2019 cigna-healthspring comprehensive drug list …then look under the category name for your drug....

Plans coveredCigna-HealthSpring Primary (HMO)Cigna-HealthSpring TotalCare (HMO SNP)Cigna-HealthSpring TotalCare AR (HMO SNP)Cigna-HealthSpring TotalCare ETN (HMO SNP)Cigna-HealthSpring TotalCare Direct (HMO SNP)Cigna-HealthSpring Traditions (HMO SNP)

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

2019 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 19145, Version Number 18 INT_19_65288_C_Final_3n Populated Template 07312018

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

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2019 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic equivalent of the drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect customers currently taking the drug.) Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect customers currently taking the drug:• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before

we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the following section entitled “How do I request an exception to the Cigna-HealthSpring Drug List?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug. Or we may make changes based on new clinical guidelines and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug.

The enclosed drug list is current as of December 2019. To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Primary (HMO), Cigna-HealthSpring TotalCare (HMO SNP), Cigna-HealthSpring TotalCare AR (HMO SNP), Cigna-HealthSpring TotalCare ETN (HMO SNP), Cigna-HealthSpring TotalCare Direct (HMO SNP), Cigna-HealthSpring Traditions (HMO SNP). This document includes a list of the drugs (formulary) for our plans, which is current as of December 2019. For an updated drug list, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

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changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 10. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 55. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

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

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

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

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

• Step Therapy: In some cases, Cigna-HealthSpring requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For

example, if Drug A and Drug B both treat your medical condition, Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not “opioid naïve”) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

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

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

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

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

cost generic alternatives available for any of your current medications.

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

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

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

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

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

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

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

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

Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included in our drug list or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a drug list or utilization restriction exception. When you request a drug list or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days).

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Cigna-HealthSpring’s Drug ListThe comprehensive drug list that begins on page 10, provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 55. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug.

We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 10 along with the amount dispensed per the days supplied. (For example: simvastatin 10mg QL 30/30; this means the drug simvastatin 10mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Your plan has one tier named “Covered Drugs”. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.

For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

For more information

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

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Service Area: Alabama H4513-044 – Cigna-HealthSpring TotalCare (HMO SNP): Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama

Drug Tier

Standard Retail Cost-Sharing*

Standard Mail Order Cost-Sharing*

30, 60, 90 Days 30, 60, 90 DaysTier 1: Covered Drugs 25% or 25% or

$0 / $1.25 / $3.40 / 15% (generics) $0 / $1.25 / $3.40 / 15% (generics)$0 / $3.80 / $8.50 / 15% (all other drugs) $0 / $3.80 / $8.50 / 15% (all other drugs)

Service Area: Arkansas H4513-039 – Cigna-HealthSpring TotalCare AR (HMO SNP): Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, Arkansas

Drug Tier





Service Area: Florida H5410-013 – Cigna-HealthSpring TotalCare (HMO SNP): Bay, Escambia, Okaloosa, Santa Rosa and Walton, FloridaH5410-025 – Cigna-HealthSpring TotalCare (HMO SNP): Lake, Orange, Osceola, Polk and Seminole, Florida

Drug Tier





*Cost-sharing is based on your level of “Extra Help”

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.

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

Drug Tier





Service Area: Illinois H1415-024 – Cigna-HealthSpring Primary (HMO): Cook, DuPage, Kane and Will, Illinois

Drug Tier





Service Area: Mid-Atlantic H2108-001 – Cigna-HealthSpring TotalCare (HMO SNP): District of Columbia; Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery and Prince George’s, Maryland; Kent, New Castle and Sussex, Delaware

Drug Tier





Service Area: Mid-Atlantic H2108-020 – Cigna-HealthSpring Traditions (HMO SNP): District of Columbia; Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery and Prince George’s, Maryland; Kent, New Castle and Sussex, Delaware

Drug Tier



30, 60, 90 Days 30, 60, 90 DaysTier 1: Covered Drugs 25% or Not covered

$0 / $1.25 / $3.40 / 15% (generics)$0 / $3.80 / $8.50 / 15% (all other drugs)


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Service Area: Mississippi H4407-004 – Cigna-HealthSpring TotalCare (HMO SNP): Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi

Drug Tier





Service Area: North Carolina H9725-003 – Cigna-HealthSpring TotalCare Direct (HMO SNP): Alexander, Cabarrus, Cleveland, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Lincoln, Polk, Rowan, Stokes, Yadkin and Union, North Carolina

Drug Tier





Service Area: Pennsylvania H3949-009 – Cigna-HealthSpring TotalCare (HMO SNP): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania

Drug Tier





Service Area: Pennsylvania H3949-016 – Cigna-HealthSpring Traditions (HMO SNP): Bucks, Chester, Delaware, Montgomery and Philadelphia, Pennsylvania

Drug Tier



30, 60, 90 Days 30, 60, 90 DaysTier 1: Covered Drugs 25% or Not covered

$0 / $1.25 / $3.40 / 15% (generics)$0 / $3.80 / $8.50 / 15% (all other drugs)


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Service Area: Tennessee H4513-034 – Cigna-HealthSpring TotalCare (HMO SNP): Bedford, Benton, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marshall, Maury, McNairy, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, TennesseeH4513-040 – Cigna-HealthSpring TotalCare ETN (HMO SNP): Bledsoe, Bradley, Grundy, Hamilton, Marion, Polk and Sequatchie, TennesseeH4513-035 – Cigna-HealthSpring Primary (HMO): Anderson, Blount, Bradley, Cocke, Grainger, Grundy, Hamblen, Hamilton, Jefferson, Knox, Loudon, Marion, Morgan, Sequatchie, Sevier and Union, Tennessee

Drug Tier





Service Area: Texas H4513-010 – Cigna-HealthSpring TotalCare (HMO SNP): Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591 and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, TexasH4513-027 – Cigna-HealthSpring TotalCare (HMO SNP): Henderson, Rusk, Smith, Upshur and Van Zandt, TexasH4513-029 – Cigna-HealthSpring TotalCare (HMO SNP): Bexar, Collin, Dallas, Denton, Hood, Johnson, Parker, Tarrant and Wise, Texas

Drug Tier






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

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring

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

NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

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

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Covered Drugs By Category

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsacetaminophen/codeine oral soln

1 NDS QL(2700/30)

butalbital/acetaminophen/caffeine caps

1 PA QL(180/30)

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

1 PA QL(180/30)

butalbital/acetaminophen/caffeine/codeine

1 PA NDS QL(180/30)

butalbital/aspirin/caffeine caps 1 PA QL(180/30)butalbital/aspirin/caffeine/codeine

1 PA NDS QL(180/30)

esgic caps 1 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

1 PA QL(180/30)

NonsteroidalAnti-inflammatoryDrugscelecoxib caps 400mg 1 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

1 QL(60/30)

diclofenac potassium 1diclofenac sodium dr 1diclofenac sodium er 1diflunisal 1etodolac 1etodolac er 1flurbiprofen 1ibu tabs 600mg, 800mg 1ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

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

1

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

salsalate 1sulindac 1Opioid Analgesics, Long-actingbuprenorphine hcl inj 1 QL(150/30)BUPRENORPHINE PTWK 10MCG/HR, 15MCG/HR, 20MCG/HR, 5MCG/HR

1 NDS QL(4/28)

buprenorphine ptwk 7.5mcg/hr 1 NDS QL(4/28)DURAMORPH 1 B/D PA NDS

QL(180/30)fentanyl 1 NDS QL(10/30)INFUMORPH 200 1 NDS QL(200/30)INFUMORPH 500 1 NDS QL(200/30)methadone hcl conc 1 NDS QL(500/30)methadone hcl inj 1 NDS QL(150/30)methadone hcl intensol 1 NDS QL(500/30)methadone hcl oral soln 10mg/5ml

1 NDS QL(450/30)

methadone hcl oral soln 5mg/5ml

1 NDS QL(600/30)

methadone hcl tabs 10mg 1 NDS QL(120/30)methadone hcl tabs 5mg 1 NDS QL(180/30)mitigo 1 NDS QL(200/30)morphine sulfate er tbcr 1 NDS QL(90/30)XTAMPZA ER 1 NDS QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine tabs 300mg; 60mg

1 NDS QL(180/30)

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

1 NDS QL(360/30)

ascomp/codeine 1 PA NDS QL(180/30)butorphanol tartrate inj 2mg/ml 1 NDS QL(240/30)butorphanol tartrate inj 1mg/ml 1 NDS QL(480/30)butorphanol tartrate nasal soln 1 NDS QL(5/30)endocet tabs 325mg; 10mg 1 NDS QL(180/30)endocet tabs 325mg; 7.5mg 1 NDS QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

1 NDS QL(360/30)

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

1 B/D PA NDS

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CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 9.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 PA NDS QL(120/30)

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

1 PA NDS QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln 325mg/15ml; 7.5mg/15ml

1 NDS QL(2700/30)

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

1 NDS QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg

1 NDS QL(360/30)

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

1 NDS QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

1 NDS QL(360/30)

hydrocodone/ibuprofen 1 NDS QL(150/30)hydromorphone hcl dosette 1 NDShydromorphone hcl inj 1 NDShydromorphone hcl liqd 1 NDS QL(1200/30)hydromorphone hcl tabs 8mg 1 NDS QL(120/30)hydromorphone hcl tabs 2mg, 4mg

1 NDS QL(180/30)

lorcet 1 NDS QL(360/30)lorcet hd 1 NDS QL(180/30)lorcet plus tabs 325mg; 7.5mg 1 NDS QL(180/30)MORPHINE SULFATE INJ 5MG/ML

1 B/D PA NDS

morphine sulfate inj 1mg/ml, 50mg/ml

1 B/D PA NDS

morphine sulfate inj 0.5mg/ml, 1mg/ml

1 B/D PA NDS QL(180/30)

MORPHINE SULFATE INJ 10MG/ML

1 B/D PA NDS QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


1 B/D PA NDS QL(250/30)


1 B/D PA NDS QL(480/30)


1 B/D PA NDS QL(1200/30)

morphine sulfate oral soln 100mg/5ml

1 NDS QL(240/30)


1 NDS QL(700/30)


1 NDS QL(900/30)

MORPHINE SULFATE TABS 1 NDS QL(120/30)nalbuphine hcl inj 20mg/ml 1 NDS QL(90/30)nalbuphine hcl inj 10mg/ml 1 NDS QL(180/30)oxycodone hcl caps 1 NDS QL(180/30)oxycodone hcl conc 1 NDS QL(120/30)oxycodone hcl tabs 1 NDS QL(180/30)oxycodone hydrochloride oral soln

1 NDS QL(1200/30)

oxycodone hydrochloride tabs 1 NDS QL(180/30)oxycodone/acetaminophen tabs 325mg; 10mg

1 NDS QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

1 NDS QL(240/30)

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

1 NDS QL(360/30)

oxycodone/aspirin 1 NDS QL(180/30)oxycodone/ibuprofen 1 NDS QL(28/30)tramadol hcl 1 NDS QL(240/30)tramadol hydrochloride/acetaminophen

1 NDS QL(240/30)

vicodin es tabs 300mg; 7.5mg 1 NDS QL(180/30)vicodin hp tabs 300mg; 10mg 1 NDS QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CHANTIX STARTING MONTH PAK

1 QL(56/28)

NICOTROL INHALER 1 QL(1008/90)NICOTROL NS 1 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 1gentak 1gentamicin sulfate crea 1gentamicin sulfate inj 1gentamicin sulfate oint 1gentamicin sulfate ophthalmic soln

1

gentamicin sulfate pediatric 1gentamicin sulfate/0.9% sodium chloride

1

isotonic gentamicin 1neomycin sulfate 1paromomycin sulfate 1streptomycin sulfate 1tobramycin ophthalmic soln 1tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

1

tobramycin sulfate ophthalmic soln

1

TOBREX OINT 1ZYLET 1Antibacterials, OtherALCOHOL PREP PADS 1bacitracin inj 1bacitracin ophthalmic oint 1bacitracin/polymyxin b 1chloramphenicol sodium succinate

1

clindacin etz pledgets 1clindacin-p 1clindamycin hcl caps 1clindamycin phosphate crea 1clindamycin phosphate external soln

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anesthetics

Local Anestheticsglydo 1 PAlidocaine hcl external soln 1 PAlidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

1

lidocaine hcl jelly gel 1 PAlidocaine hcl mouth/throat soln 1lidocaine hcl prsy 1 PAlidocaine hcl viscous 1lidocaine oint 1 PA QL(50/30)lidocaine ptch 1 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 1 PA

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 1disulfiram 1naltrexone hcl 1Opioid Dependence Treatmentsbuprenorphine hcl subl 1 PA QL(90/30)buprenorphine hcl/naloxone hcl 1 QL(90/30)buprenorphine hydrochloride/naloxone hydrochloride film

1 QL(90/30)

SUBOXONE 1 QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

1 QL(30/30)

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

1 QL(90/30)

Opioid Reversal Agentsnaloxone hcl 1NARCAN 1 QL(4/30)Smoking Cessation Agentsbupropion hydrochloride er (sr) 1 QL(60/30)CHANTIX 1 QL(56/28)CHANTIX CONTINUING MONTH PAK

1 QL(56/28)

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin 1nitrofurantoin macrocrystals 1nitrofurantoin monohydrate 1nitrofurantoin monohydrate/macrocrystals

1

polycin 1polymyxin b sulfate 1polymyxin b sulfate/trimethoprim sulfate

1

rosadan 1silver sulfadiazine 1SIVEXTRO TABS 1 NDS QL(6/30)ssd 1SYNERCID 1 NDStigecycline 1 NDStrimethoprim 1trimethoprim sulfate/polymyxin b sulfate

1

vancomycin 1vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg

1

vancomycin hydrochloride caps 125mg

1 QL(40/10)

vancomycin hydrochloride caps 250mg

1 QL(80/10)

VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML

1

vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg

1

vancomycin hydrochloride/dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate gel 1clindamycin phosphate in d5w 1clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml

1

clindamycin phosphate lotn 1clindamycin phosphate swab 1clindamycin/sodium chloride 1colistimethate sodium 1DAPTOMYCIN INJ 350MG 1 B/D PA NDSdaptomycin inj 500mg 1 B/D PA NDSFIRVANQ 1 QL(300/10)lincomycin hcl 1linezolid inj 1linezolid susr 1 NDS QL(1800/30)linezolid tabs 1 NDS QL(60/30)methenamine hippurate 1metronidazole crea 1metronidazole gel 1metronidazole in nacl 0.79% 1metronidazole inj 500mg/100ml; 0.79%

1

metronidazole lotn 1metronidazole tabs 1metronidazole vaginal 1MONUROL 1mupirocin crea 1mupirocin oint 1neo-polycin 1neo-polycin hc 1neomycin/bacitracin/polymyxin 1neomycin/polymyxin/bacitracin/hydrocortisone

1

neomycin/polymyxin/gramicidin 1neomycin/polymyxin/hydrocortisone ophthalmic susp

1

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, OtherAZACTAM 1aztreonam inj 1gm 1AZTREONAM INJ 2GM 1 NDScefotetan 1ertapenem 1ertapenem sodium 1imipenem/cilastatin inj 500mg; 500mg

1

imipenem/cilastatin inj 250mg; 250mg

1

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

1

amoxicillin/clavulanate potassium er

1

ampicillin 1ampicillin sodium 1ampicillin-sulbactam 1AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

1

BICILLIN L-A 1dicloxacillin sodium 1nafcillin sodium 1oxacillin sodium 1penicillin g potassium 1penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

1

pfizerpen inj 20000000unit, 5000000unit

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1

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

1

cefazolin sodium/dextrose inj 2gm; 3%

1

cefdinir caps 1cefdinir susr 1cefepime 1cefepime/dextrose 1cefixime caps 1 QL(30/30)cefixime susr 1cefotaxime sodium inj 1gm, 500mg

1

cefoxitin sodium inj 10gm, 1gm, 2gm

1

cefpodoxime proxetil 1cefprozil 1ceftazidime 1ceftazidime/dextrose 1ceftriaxone in iso-osmotic dextrose

1

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

1

cefuroxime axetil 1cefuroxime sodium 1cephalexin caps 250mg, 500mg 1cephalexin susr 1SUPRAX SUSR 500MG/5ML 1tazicef inj 1gm, 2gm, 6gm 1TEFLARO 1 NDS

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erythromycin gel 1erythromycin oint 1QuinolonesBAXDELA 1BESIVANCE 1CILOXAN OINT 1CIPRO HC 1CIPRODEX 1ciprofloxacin hcl tabs 100mg 1ciprofloxacin hcl tabs 750mg 1ciprofloxacin hydrochloride ophthalmic soln

1

ciprofloxacin hydrochloride tabs 1ciprofloxacin i.v.-in d5w 1ciprofloxacin susr 1levofloxacin in d5w 1levofloxacin inj 1levofloxacin oral soln 1levofloxacin tabs 500mg 1levofloxacin tabs 250mg, 750mg

1 QL(30/30)

moxifloxacinhydrochloride/sodium hydrochloride

1

moxifloxacin hcl 1moxifloxacin hydrochloride ophthalmic soln

1

moxifloxacin hydrochloride tabs 1ofloxacin 1SulfonamidesBLEPHAMIDE 1BLEPHAMIDE S.O.P. 1sodium sulfacetamide ophthalmic soln

1

sulfacetamide sodium lotn 1sulfacetamide sodium ophthalmic soln

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm

1

piperacillin/tazobactam 1ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

1

MacrolidesAZASITE 1azithromycin inj 1azithromycin pack 1azithromycin susr 200mg/5ml 1 QL(90/30)azithromycin susr 100mg/5ml 1 QL(150/30)azithromycin tabs 250mg, 500mg

1 QL(12/28)

azithromycin tabs 600mg 1 QL(60/30)clarithromycin er 1clarithromycin susr 1clarithromycin tabs 1DIFICID 1 PA NDS QL(20/10)e.e.s. 400 1ery 1ERY-TAB 1ERYPED 400 1 NDSERYTHROCIN LACTOBIONATE

1

erythrocin stearate 1erythromycin base 1erythromycin dr 1erythromycin ethylsuccinate susr 200mg/5ml

1

ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML

1 NDS

erythromycin ethylsuccinate tabs

1

erythromycin external soln 1

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

1 NDS QL(60/30)

BRIVIACT TABS 100MG 1 NDS QL(120/30)EPIDIOLEX 1 PA NDSFYCOMPA SUSP 1 QL(720/30)FYCOMPA TABS 1 QL(30/30)levetiracetam er tb24 750mg 1 QL(120/30)levetiracetam er tb24 500mg 1 QL(180/30)levetiracetam inj 1levetiracetam oral soln 1levetiracetam tabs 1levetiracetam/sodium chloride 1magnesium sulfate in d5w 1 B/D PANAYZILAM 1 PA NDS QL(10/30)roweepra 1roweepra xr tb24 750mg 1 QL(120/30)roweepra xr tb24 500mg 1 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

1 QL(60/30)

SPRITAM TB3D 750MG 1 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 1ethosuximide 1LYRICA CAPS 225MG, 300MG 1 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

1 QL(90/30)

LYRICA ORAL SOLN 1 QL(900/30)pregabalin caps 225mg, 300mg 1 QL(60/30)pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg

1 QL(90/30)

pregabalin oral soln 1 QL(900/30)zonisamide 1Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam susp 1 NDS QL(480/30)clobazam tabs 20mg 1 NDS QL(60/30)clobazam tabs 10mg 1 QL(60/30)clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

1 QL(90/30)

clonazepam odt tbdp 1mg 1 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfacetamide sodium/prednisolone sodium phosphate

1

sulfadiazine 1sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

1

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

Tetracyclinesdemeclocycline hcl 1doxy 100 1doxycycline hyclate caps 1doxycycline hyclate tabs 100mg 1doxycycline hyclate tabs 20mg 1doxycycline monohydrate caps 100mg, 50mg

1 QL(60/30)

doxycycline monohydrate tabs 1doxycycline susr 1minocycline hcl 1minocycline hydrochloride caps 100mg, 50mg

1

mondoxyne nl caps 100mg 1 QL(60/30)mondoxyne nl caps 75mg 1 QL(60/30)morgidox 1x100mg caps 1morgidox 1x50mg 1morgidox 2x100mg caps 1NUZYRA INJ 1 QL(15/14)NUZYRA TABS 1 QL(30/14)tetracycline hydrochloride 1

Anticonvulsants

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

1 NDS QL(30/30)

APTIOM TABS 600MG 1 NDS QL(60/30)BRIVIACT INJ 1 NDS QL(600/30)BRIVIACT ORAL SOLN 1 NDS QL(1200/30)

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

valproate sodium inj 100mg/ml 1valproic acid 1vigabatrin pack 1 PA NDS QL(200/30)vigabatrin tabs 1 PA NDS QL(180/30)vigadrone 1 PA NDS QL(200/30)Glutamate Reducing Agentsfelbamate susp 1 NDSfelbamate tabs 1lamotrigine 1lamotrigine er 1lamotrigine odt 1topiramate 1TROKENDI XR CP24 100MG, 25MG, 50MG

1 QL(30/30)

TROKENDI XR CP24 200MG 1 NDS QL(60/30)Sodium Channel AgentsBANZEL SUSP 1 PA NDS

QL(2400/30)BANZEL TABS 200MG 1 PA NDS QL(60/30)BANZEL TABS 400MG 1 PA NDS QL(240/30)carbamazepine 1carbamazepine er 1DILANTIN CAPS 30MG 1epitol 1fosphenytoin sodium 1oxcarbazepine 1PEGANONE 1phenytoin 1phenytoin infatabs 1phenytoin sodium 1phenytoin sodium extended 1VIMPAT INJ 1 QL(1200/30)VIMPAT ORAL SOLN 1 QL(1200/30)VIMPAT TABS 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clonazepam odt tbdp 2mg 1 QL(300/30)clonazepam tabs 0.5mg 1 QL(90/30)clonazepam tabs 1mg 1 QL(120/30)clonazepam tabs 2mg 1 QL(300/30)DIACOMIT CAPS 500MG 1 PA NDS QL(180/30)DIACOMIT CAPS 250MG 1 PA NDS QL(360/30)DIACOMIT PACK 500MG 1 PA NDS QL(180/30)DIACOMIT PACK 250MG 1 PA NDS QL(360/30)DIASTAT ACUDIAL GEL 10MG 1 QL(20/30)DIASTAT ACUDIAL GEL 20MG 1 QL(40/30)DIASTAT PEDIATRIC 1 QL(5/30)diazepam rectal gel gel 2.5mg 1 QL(5/30)diazepam rectal gel gel 10mg 1 QL(20/30)diazepam rectal gel gel 20mg 1 QL(40/30)divalproex sodium 1divalproex sodium dr 1divalproex sodium er 1gabapentin caps 100mg 1 QL(180/30)gabapentin caps 300mg, 400mg

1 QL(270/30)

gabapentin oral soln 1 QL(2160/30)gabapentin tabs 800mg 1gabapentin tabs 600mg 1 QL(180/30)GABITRIL TABS 12MG, 16MG 1GRALISE 1GRALISE STARTER 1 QL(156/365)ONFI SUSP 1 NDS QL(480/30)ONFI TABS 20MG 1 NDS QL(60/30)ONFI TABS 10MG 1 QL(60/30)phenobarbital elix 1 QL(1500/30)phenobarbital tabs 1 QL(120/30)primidone 1SABRIL TABS 1 PA NDS QL(180/30)tiagabine hydrochloride 1

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trazodone hydrochloride tabs 300mg

1

trazodone hydrochloride tabs 100mg, 150mg, 50mg

1

TRINTELLIX 1 QL(30/30) STMonoamine Oxidase InhibitorsEMSAM 1 NDS QL(30/30)MARPLAN 1 QL(180/30)phenelzine sulfate 1tranylcypromine sulfate 1SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 10mg

1


1 QL(30/30)


1 QL(60/30)

desvenlafaxine er 1 QL(30/30)duloxetine hcl cpep 20mg 1 QL(60/30)duloxetine hydrochloride cpep 60mg

1 QL(60/30)

duloxetine hydrochloride cpep 30mg

1 QL(90/30)

escitalopram oxalate oral soln 1 QL(600/30)escitalopram oxalate tabs 5mg 1 QL(30/30)escitalopram oxalate tabs 10mg 1 QL(60/30)escitalopram oxalate tabs 20mg 1 QL(90/30)FETZIMA 1 QL(30/30) STFETZIMA TITRATION PACK 1 QL(56/365) STfluoxetine dr 1 QL(4/28)fluoxetine hcl caps 40mg 1 QL(60/30)fluoxetine hcl caps 20mg 1 QL(120/30)fluoxetine hydrochloride caps 10mg

1 QL(30/30)

fluoxetine hydrochloride oral soln

1 QL(600/30)

fluoxetine hydrochloride tabs 10mg

1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antidementia Agents

Cholinesterase Inhibitorsdonepezil hcl tabs 10mg 1 QL(60/30)donepezil hcl tabs 23mg 1 QL(30/30)donepezil hcl tbdp 5mg 1 QL(30/30)donepezil hcl tbdp 10mg 1 QL(60/30)donepezil hydrochloride tabs 5mg

1 QL(30/30)

donepezil hydrochloride tabs 10mg

1 QL(60/30)

galantamine hydrobromide er 1 QL(30/30)galantamine hydrobromide oral soln

1 QL(200/30)

galantamine hydrobromide tabs 1 QL(60/30)rivastigmine tartrate 1 QL(60/30)rivastigmine transdermal system

1 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 1 PA QL(60/30)memantine hcl tabs 5mg 1 PA QL(90/30)memantine hcl titration pak 1 PA QL(49/28)memantine hydrochloride er 1 PA QL(30/30)memantine hydrochloride oral soln

1 PA QL(360/30)

Antidepressants

Antidepressants, Otherbupropion hcl tabs 100mg 1 QL(120/30)bupropion hydrochloride er (sr) 1 QL(60/30)bupropion hydrochloride er (xl) tb24 150mg, 300mg

1 QL(30/30)

bupropion hydrochloride tabs 75mg

1 QL(180/30)

maprotiline hcl 1 QL(90/30)mirtazapine 1 QL(30/30)mirtazapine odt 1 QL(30/30)nefazodone hcl 1 QL(60/30)nefazodone hydrochloride 1 QL(60/30)SPRAVATO 56MG DOSE 1 PA NDSSPRAVATO 84MG DOSE 1 PA NDS

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imipramine hcl tabs 25mg, 50mg

1 PA

imipramine hydrochloride 1 PAnortriptyline hcl 1nortriptyline hydrochloride 1perphenazine/amitriptyline 1 PAprotriptyline hcl 1trimipramine maleate 1 PA

Antiemetics

Antiemetics, Othercompro 1meclizine hcl tabs 1phenadoz 1prochlorperazine 1promethazine hcl supp 1promethazine hcl syrp 1 PApromethazine hcl tabs 12.5mg 1 PApromethazine hydrochloride tabs 25mg, 50mg

1 PA

promethegan 1scopolamine 1 QL(10/30)TRANSDERM-SCOP 1 QL(10/30)Emetogenic Therapy AdjunctsALOXI 1 B/D PA NDSaprepitant caps 40mg 1 B/D PA QL(1/30)aprepitant caps 125mg 1 B/D PA QL(2/28)aprepitant caps 80mg 1 B/D PA QL(4/28)aprepitant caps pack 1 B/D PA QL(6/28)dronabinol 1 PA QL(60/30)EMEND SUSR 1 B/D PA QL(6/28)granisetron hcl inj 1mg/ml 1 B/D PAgranisetron hcl tabs 1 B/D PA QL(30/30)granisetron hydrochloride 1 B/D PAondansetron hcl oral soln 1 B/D PA QL(450/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluoxetine hydrochloride tabs 20mg

1 QL(120/30)

fluvoxamine maleate er 1 QL(60/30)fluvoxamine maleate tabs 25mg, 50mg

1 QL(30/30)

fluvoxamine maleate tabs 100mg

1 QL(90/30)

olanzapine/fluoxetine 1 QL(30/30)paroxetine hcl er tb24 12.5mg 1 QL(30/30)paroxetine hcl er tb24 25mg, 37.5mg

1 QL(60/30)

paroxetine hcl tabs 30mg, 40mg

1 QL(60/30)

paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hydrochloride tabs 20mg

1 QL(90/30)

PAXIL SUSP 1 QL(900/30) STPRISTIQ 1 QL(30/30)sertraline hcl conc 1 QL(300/30)sertraline hcl tabs 25mg 1 QL(30/30)sertraline hcl tabs 50mg 1 QL(120/30)sertraline hydrochloride tabs 100mg

1 QL(60/30)

venlafaxine hcl 1 QL(90/30)venlafaxine hcl er cp24 37.5mg 1 QL(30/30)venlafaxine hcl er cp24 150mg 1 QL(60/30)venlafaxine hcl er cp24 75mg 1 QL(90/30)VIIBRYD 1 QL(30/30) STVIIBRYD STARTER PACK 1 QL(30/30) STTricyclicsamitriptyline hcl 1 PAamitriptyline hydrochloride tabs 10mg, 50mg

1 PA

amoxapine 1clomipramine hcl 1 PAdesipramine hcl 1

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NOXAFIL TBEC 1 PA NDS QL(96/30)nyamyc 1nystatin 1nystatin/triamcinolone 1nystop 1POSACONAZOLE DR 1 PA NDS QL(96/30)SPORANOX ORAL SOLN 1 PA NDSterbinafine hcl tabs 1 QL(90/365)terconazole 1voriconazole inj 1 PA NDSvoriconazole susr 1 PA NDS QL(300/30)voriconazole tabs 1 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 1colchicine caps 1 QL(60/30)colchicine tabs 1 QL(120/30)febuxostat 1 QL(30/30) STMITIGARE 1 QL(60/30)probenecid 1probenecid/colchicine 1ULORIC 1 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 1 QL(30/28)dihydroergotamine mesylate nasal soln

1 PA QL(8/30)

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

1 QL(4/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ondansetron hcl tabs 1 B/D PA QL(15/30)ondansetron hydrochloride inj 1ondansetron hydrochloride tabs 1 B/D PA QL(90/30)ondansetron odt 1 B/D PA QL(90/30)palonosetron hydrochloride inj 0.25mg/5ml

1 B/D PA NDS

SANCUSO 1 NDS QL(4/28)

Antifungals

AntifungalsABELCET 1 PA NDSAMBISOME 1 PA NDSamphotericin b 1 PAcaspofungin acetate 1 PA NDSciclodan 1ciclopirox nail lacquer 1ciclopirox olamine 1ciclopirox sham 1ciclopirox susp 1clotrimazole external crea 1clotrimazole external soln 1clotrimazole lozg 1clotrimazole/betamethasone dipropionate

1

econazole nitrate 1fluconazole 1fluconazole in nacl 1flucytosine 1 NDSgriseofulvin microsize 1griseofulvin ultramicrosize 1itraconazole caps 1 PA QL(120/30)itraconazole oral soln 1 PA NDSketoconazole crea 1ketoconazole sham 1ketoconazole tabs 1naftifine hcl 1naftifine hydrochloride 1NAFTIN GEL 1NATACYN 1NOXAFIL SUSP 1 PA NDS QL(600/30)

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antineoplastics

Alkylating AgentsBENDEKA 1 B/D PA NDS

QL(8/21)BICNU 1 B/D PAbusulfan 1 B/D PA NDSBUSULFEX 1 B/D PA NDScarmustine 1 B/D PAcyclophosphamide caps 1 B/D PAcyclophosphamide inj 1 B/D PA NDSdacarbazine 1 B/D PAEVOMELA 1 PA NDSGLEOSTINE CAPS 10MG, 40MG

1

GLEOSTINE CAPS 100MG 1ifosfamide inj 1gm, 3gm 1 B/D PAKISQALI FEMARA 200 DOSE 1 PA NDS QL(49/28)KISQALI FEMARA 400 DOSE 1 PA NDS QL(70/28)KISQALI FEMARA 600 DOSE 1 PA NDS QL(91/28)LEUKERAN 1MATULANE 1 NDSmelphalan hydrochloride 1 B/D PA NDSthiotepa 1 PATREANDA INJ 100MG 1 B/D PA NDSTREANDA INJ 25MG 1 B/D PA NDS

QL(8/21)VALCHLOR 1 PA NDS QL(60/30)YONDELIS 1 PA NDSZANOSAR 1 B/D PAAntiandrogensabiraterone acetate 1 PA NDS QL(120/30)bicalutamide 1 QL(30/30)ERLEADA 1 PA NDS QL(120/30)flutamide 1nilutamide 1 NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sumatriptan succinate inj 4mg/0.5ml

1 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

1 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

1 QL(8/30)

sumatriptan succinate tabs 1 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 1pyridostigmine bromide er 1pyridostigmine bromide tabs 60mg

1

REGONOL 1

Antimycobacterials

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

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

1 B/D PA NDS

hydroxyurea 1INFUGEM 1 B/D PA NDSLONSURF TABS 8.19MG; 20MG

1 PA NDS QL(80/28)

LONSURF TABS 6.14MG; 15MG

1 PA NDS QL(100/28)

mercaptopurine 1NIPENT 1 B/D PA NDSPURIXAN 1 PA NDS QL(300/30)TABLOID 1VYXEOS 1 B/D PA NDSAntineoplasticsXPOVIO 100 MG ONCE WEEKLY

1 PA NDS QL(20/28)

XPOVIO 60 MG ONCE WEEKLY

1 PA NDS QL(12/28)

XPOVIO 80 MG ONCE WEEKLY

1 PA NDS QL(16/28)

XPOVIO 80 MG TWICE WEEKLY

1 PA NDS QL(32/28)

Antineoplastics, OtherABRAXANE 1 PA NDSADRIAMYCIN INJ 50MG 1 B/D PAadriamycin inj 2mg/ml 1 B/D PAarsenic trioxide 1 B/D PAazacitidine 1 B/D PA NDSBELEODAQ 1 PA NDSbleomycin 1 B/D PAbleomycin sulfate 1 B/D PABORTEZOMIB 1 PA NDS QL(14/21)BRAFTOVI 1 PA NDS QL(180/30)carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

1 B/D PA

cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

1 B/D PA

COPIKTRA 1 PA NDS QL(60/30)COSMEGEN 1 B/D PA NDSdactinomycin 1 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUBEQA 1 PA NDS QL(120/30)XTANDI 1 PA NDS QL(120/30)YONSA 1 PA NDS QL(120/30)ZYTIGA TABS 500MG 1 PA NDS QL(60/30)ZYTIGA TABS 250MG 1 PA NDS QL(120/30)Antiangiogenic AgentsPOMALYST 1 PA NDS QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

1 PA NDS QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

1 PA NDS QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

1 PA NDS QL(28/28)

THALOMID CAPS 200MG 1 PA NDS QL(56/28)Antiestrogens/ModifiersEMCYT 1FARESTON 1 NDS QL(30/30)FASLODEX 1 B/D PA NDS

QL(30/30)fulvestrant 1 B/D PA NDS

QL(30/30)SOLTAMOX 1 NDStamoxifen citrate 1toremifene citrate 1 NDS QL(30/30)Antimetabolitesadrucil 1 B/D PAALIMTA 1 PA NDSARRANON 1cladribine 1 B/D PAclofarabine 1 B/D PAcytarabine 1 B/D PAcytarabine aqueous 1 B/D PADROXIA 1ELITEK 1 B/D PA NDSfluorouracil inj 1 B/D PAFOLOTYN 1 B/D PA NDSgemcitabine 1 B/D PAgemcitabine hcl 1 B/D PAgemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml

1 B/D PA

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LARTRUVO 1 PA NDSleucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg

1

leucovorin calcium tabs 1levoleucovorin 1 NDSlevoleucovorin calcium 1 NDSLORBRENA TABS 100MG 1 PA NDS QL(30/30)LORBRENA TABS 25MG 1 PA NDS QL(90/30)LYNPARZA 1 PA NDS QL(120/30)MEKTOVI 1 PA NDS QL(180/30)mesna 1 B/D PAMESNEX TABS 1 NDSmitomycin inj 40mg 1 B/D PA NDSmitomycin inj 20mg, 5mg 1 B/D PAmitoxantrone hcl 1 B/D PANERLYNX 1 PA NDS QL(180/30)NINLARO 1 PA NDS QL(3/28)ODOMZO 1 PA NDS QL(30/30)ONCASPAR 1 B/D PA NDSoxaliplatin inj 100mg 1 B/D PA NDSoxaliplatin inj 100mg/20ml, 50mg/10ml

1 B/D PA

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

1 B/D PA

PIQRAY 200MG DAILY DOSE 1 PA NDS QL(28/28)PIQRAY 250MG DAILY DOSE 1 PA NDS QL(56/28)PIQRAY 300MG DAILY DOSE 1 PA NDS QL(56/28)PORTRAZZA 1 PA NDS QL(100/21)PROLEUKIN 1 B/D PA NDSromidepsin 1 PA NDSROZLYTREK CAPS 200MG 1 PA NDS QL(90/30)ROZLYTREK CAPS 100MG 1 PA NDS QL(150/30)RUBRACA 1 PA NDS QL(120/30)RYDAPT 1 PA NDS QL(224/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

daunorubicin hcl 1 B/D PADAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

1 B/D PA

daunorubicin hydrochloride inj 20mg/4ml

1 B/D PA

DAURISMO TABS 100MG 1 PA NDS QL(30/30)DAURISMO TABS 25MG 1 PA NDS QL(60/30)decitabine 1 NDSdexrazoxane 1 B/D PADOCETAXEL INJ 200MG/10ML 1 B/D PA NDSdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

1 B/D PA NDS

doxorubicin hydrochloride liposomal

1 B/D PA NDS

doxorubicin hydrochloride liposome

1 B/D PA NDS

ELZONRIS 1 PA NDSepirubicin hcl inj 200mg/100ml 1 B/D PAERWINAZE 1 B/D PA NDS

QL(60/28)ETHYOL 1 B/D PA NDSfludarabine phosphate inj 50mg 1 B/D PAFUSILEV 1 NDSHALAVEN 1 PA NDSidarubicin hcl inj 10mg/10ml 1 B/D PA NDSidarubicin hydrochloride inj 10mg/10ml

1 B/D PA NDS

INREBIC 1 PA NDS QL(120/30)irinotecan hcl 1 B/D PAirinotecan hydrochloride 1 B/D PAirinotecan inj 100mg/5ml, 500mg/25ml

1 B/D PA

ISTODAX (OVERFILL) 1 PA NDSJEVTANA 1 PA NDSKISQALI 1 PA NDS QL(63/28)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AFINITOR TABS 10MG 1 PA NDS QL(56/28)ALECENSA 1 PA NDS QL(240/30)ALIQOPA 1 PA NDS QL(3/28)ALUNBRIG TABS 180MG, 90MG

1 PA NDS QL(30/30)

ALUNBRIG TABS 30MG 1 PA NDS QL(180/30)ALUNBRIG TBPK 1 PA NDS QL(60/365)BOSULIF TABS 400MG, 500MG

1 PA NDS QL(30/30)

BOSULIF TABS 100MG 1 PA NDS QL(120/30)CABOMETYX TABS 20MG, 60MG

1 PA NDS QL(30/30)

CABOMETYX TABS 40MG 1 PA NDS QL(60/30)CALQUENCE 1 PA NDS QL(60/30)CAPRELSA TABS 300MG 1 PA NDS QL(30/30)CAPRELSA TABS 100MG 1 PA NDS QL(60/30)COMETRIQ 100MG DAILY DOSE KIT

1 PA NDS QL(56/28)

COMETRIQ 60MG DAILY DOSE KIT

1 PA NDS QL(84/28)

COMETRIQ 140MG DAILY DOSE KIT

1 PA NDS QL(112/28)

COTELLIC 1 PA NDS QL(63/28)ERIVEDGE 1 PA NDS QL(28/28)erlotinib hydrochloride tabs 100mg, 150mg

1 PA NDS QL(30/30)

erlotinib hydrochloride tabs 25mg

1 PA NDS QL(60/30)

FARYDAK 1 PA NDS QL(6/21)GILOTRIF 1 PA NDS QL(30/30)IBRANCE 1 PA NDS QL(21/28)ICLUSIG TABS 45MG 1 PA NDS QL(30/30)ICLUSIG TABS 15MG 1 PA NDS QL(60/30)IDHIFA 1 PA NDS QL(30/30)imatinib mesylate 1 PA NDS QL(60/30)IMBRUVICA CAPS 70MG 1 PA NDS QL(30/30)IMBRUVICA CAPS 140MG 1 PA NDS QL(120/30)IMBRUVICA TABS 1 PA NDS QL(30/30)INLYTA 1 PA NDS QL(120/30)IRESSA 1 PA NDS QL(30/30)JAKAFI 1 PA NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYLATRON 1 PA NDS QL(4/28)SYNRIBO 1 PA NDS QL(28/28)TALZENNA 1 PA NDS QL(90/30)TRISENOX 1 B/D PAVELCADE 1 PA NDS QL(14/21)VENCLEXTA STARTING PACK 1 PA NDS QL(84/365)VENCLEXTA TABS 100MG 1 PA NDS QL(120/30)VENCLEXTA TABS 50MG 1 PA QL(30/30)VENCLEXTA TABS 10MG 1 PA QL(60/30)VERZENIO 1 PA NDS QL(60/30)vinblastine sulfate 1 B/D PAvincristine sulfate 1 B/D PAvinorelbine tartrate inj 50mg/5ml

1 B/D PA

VITRAKVI CAPS 100MG 1 PA NDS QL(60/30)VITRAKVI CAPS 25MG 1 PA NDS QL(180/30)VITRAKVI ORAL SOLN 1 PA NDS QL(300/30)ZEJULA 1 PA NDS QL(90/30)ZOLINZA 1 NDS QL(120/30)ZYKADIA 1 PA NDS QL(140/28)Aromatase Inhibitors, 3rd Generationanastrozole 1 QL(30/30)exemestane 1 QL(60/30)letrozole 1 QL(30/30)Enzyme InhibitorsBALVERSA TABS 5MG 1 PA NDS QL(30/30)BALVERSA TABS 4MG 1 PA NDS QL(60/30)BALVERSA TABS 3MG 1 PA NDS QL(90/30)etoposide inj 1 B/D PAirinotecan hydrochloride 1 B/D PAKYPROLIS 1 B/D PA NDStoposar 1 B/D PAtopotecan hcl inj 4mg 1 NDSMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

1 PA NDS QL(56/28)

AFINITOR DISPERZ TBSO 5MG

1 PA NDS QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

1 PA NDS QL(28/28)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 1 PA NDSBAVENCIO 1 PA NDSBESPONSA 1 PA NDSCYRAMZA 1 PA NDSDARZALEX 1 PA NDSEMPLICITI 1 PA NDSERBITUX 1 PA NDSGAZYVA 1 PA NDSHERCEPTIN HYLECTA 1 PA NDSIMFINZI 1 PA NDSKADCYLA 1 PA NDSKANJINTI INJ 420MG 1 PA NDSKEYTRUDA 1 PA NDSLIBTAYO 1 PA NDS QL(7/21)LUMOXITI 1 PA NDSMVASI 1 PA NDSMYLOTARG 1 PA NDSOPDIVO 1 PA NDS QL(80/28)PERJETA 1 PA NDSPOTELIGEO 1 PA NDSRITUXAN 1 PA NDSRITUXAN HYCELA 1 PA NDSTECENTRIQ INJ 1200MG/20ML

1 PA NDS QL(20/21)

TECENTRIQ INJ 840MG/14ML 1 PA NDS QL(28/28)UNITUXIN 1 PA NDSVECTIBIX 1 PA NDSYERVOY INJ 50MG/10ML 1 PA NDSYERVOY INJ 200MG/40ML 1 PA NDS QL(80/21)Retinoidsbexarotene 1 NDSPANRETIN 1 NDSTARGRETIN GEL 1 NDS QL(60/30)tretinoin caps 1 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LENVIMA 10 MG DAILY DOSE 1 PA NDS QL(30/30)LENVIMA 12MG DAILY DOSE 1 PA NDS QL(90/30)LENVIMA 14 MG DAILY DOSE 1 PA NDS QL(60/30)LENVIMA 18 MG DAILY DOSE 1 PA NDS QL(90/30)LENVIMA 20 MG DAILY DOSE 1 PA NDS QL(60/30)LENVIMA 24 MG DAILY DOSE 1 PA NDS QL(90/30)LENVIMA 4 MG DAILY DOSE 1 PA NDS QL(30/30)LENVIMA 8 MG DAILY DOSE 1 PA NDS QL(60/30)MEKINIST TABS 2MG 1 PA NDS QL(30/30)MEKINIST TABS 0.5MG 1 PA NDS QL(90/30)NEXAVAR 1 PA NDS QL(120/30)SPRYCEL 1 PA NDS QL(30/30)STIVARGA 1 PA NDSSUTENT 1 PA NDS QL(28/28)TAFINLAR 1 PA NDS QL(120/30)TAGRISSO 1 PA NDS QL(30/30)TARCEVA TABS 100MG, 150MG

1 PA NDS QL(30/30)

TARCEVA TABS 25MG 1 PA NDS QL(60/30)TASIGNA CAPS 150MG, 200MG

1 PA NDS QL(112/28)

TASIGNA CAPS 50MG 1 PA NDS QL(420/30)temsirolimus 1 B/D PA NDS

QL(4/28)TIBSOVO 1 PA NDS QL(60/30)TURALIO 1 PA NDS QL(120/30)TYKERB 1 PA NDS QL(180/30)VIZIMPRO 1 PA NDS QL(30/30)VOTRIENT 1 PA NDS QL(120/30)XALKORI 1 PA NDS QL(60/30)XOSPATA 1 PA NDS QL(90/30)ZALTRAP 1 PA NDS QL(40/28)ZELBORAF 1 PA NDS QL(240/30)ZYDELIG 1 PA NDS QL(60/30)ZYKADIA 1 PA NDS QL(140/28)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bromocriptine mesylate 1NEUPRO 1 QL(30/30)pramipexole dihydrochloride 1 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

1 QL(30/30)

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

1 QL(90/30)

ropinirole hcl 1ropinirole hydrochloride tabs 0.25mg, 3mg

1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 1carbidopa/levodopa 1carbidopa/levodopa er 1carbidopa/levodopa odt 1carbidopa/levodopa/entacapone

1

RYTARY 1 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 1 QL(30/30)selegiline hcl 1

Antipsychotics

1st Generation/Typicalchlorpromazine hcl inj 1chlorpromazine hcl tabs 1fluphenazine decanoate 1fluphenazine hcl conc 1fluphenazine hcl inj 1fluphenazine hcl tabs 1fluphenazine hydrochloride 1haloperidol conc 1haloperidol decanoate 1haloperidol lactate 1haloperidol tabs 10mg, 20mg 1haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1

loxapine 1loxapine succinate 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiparasitics

Anthelminticsalbendazole 1 NDSALBENZA 1 NDSBILTRICIDE 1ivermectin tabs 1praziquantel 1AntiprotozoalsALINIA SUSR 1 NDS QL(150/30)ALINIA TABS 1 NDS QL(20/30)atovaquone 1atovaquone/proguanil hcl 1chloroquine phosphate 1COARTEM 1 QL(24/30)DARAPRIM 1 NDS QL(90/30)hydroxychloroquine sulfate 1mefloquine hcl 1NEBUPENT 1 B/D PA QL(6/28)PENTAM 300 1pentamidine isethionate 1PRIMAQUINE PHOSPHATE 1quinine sulfate 1 QL(42/7)Pediculicides/Scabicideslindane 1malathion 1permethrin 1

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 1benztropine mesylate tabs 1 PAtrihexyphenidyl hcl 1 PAtrihexyphenidyl hydrochloride 1 PAAntiparkinson Agents, Otheramantadine hcl 1entacapone 1 QL(240/30)tolcapone 1 NDSDopamine AgonistsAPOKYN 1 PA NDS QL(60/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA TRINZA INJ 273MG/0.875ML

1 QL(0.88/90)


1 QL(1.32/90)


1 QL(1.75/90)


1 QL(2.63/90)

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

1 NDS QL(30/30)

LATUDA TABS 80MG 1 NDS QL(60/30)NUPLAZID 1 PA NDS QL(30/30)olanzapine inj 1 QL(30/30)olanzapine odt 1 QL(30/30)olanzapine tabs 1 QL(30/30)paliperidone er tb24 1.5mg, 3mg

1 QL(30/30) ST

paliperidone er tb24 6mg 1 QL(60/30) STpaliperidone er tb24 9mg 1 NDS QL(30/30) STPERSERIS 1 NDS QL(1/30)quetiapine fumarate 1 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

1 QL(30/30)

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

1 QL(60/30)

REXULTI 1 NDS QL(30/30)RISPERDAL CONSTA INJ 50MG

1 NDS QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

1 QL(2/28)

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

1 QL(60/30)

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

1 QL(60/30)

risperidone tabs 4mg 1 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

molindone hydrochloride 1perphenazine 1pimozide 1prochlorperazine edisylate inj 10mg/2ml

1

prochlorperazine maleate 1thioridazine hcl 1thiothixene 1trifluoperazine hcl 12nd Generation/AtypicalABILIFY MAINTENA 1 NDS QL(1/28)aripiprazole odt 1 NDS QL(60/30)aripiprazole oral soln 1 QL(900/30)aripiprazole tabs 1 QL(30/30)ARISTADA INITIO 1 NDS QL(4.8/365)ARISTADA INJ 441MG/1.6ML 1 NDS QL(1.6/28)ARISTADA INJ 662MG/2.4ML 1 NDS QL(2.4/28)ARISTADA INJ 882MG/3.2ML 1 NDS QL(3.2/28)ARISTADA INJ 1064MG/3.9ML 1 QL(3.9/56)FANAPT TABS 1MG, 2MG, 4MG

1 QL(60/30) ST

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

1 NDS QL(60/30) ST

FANAPT TITRATION PACK 1 QL(16/365) STGEODON INJ 1 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

1 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

1 NDS QL(0.5/28)


1 NDS QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

1 NDS QL(1/28)


1 NDS QL(1.5/28)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BARACLUDE ORAL SOLN 1 QL(630/30)entecavir 1 QL(30/30)EPIVIR HBV ORAL SOLN 1INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU

1 NDS

INTRON A INJ 6000000UNIT/ML

1

lamivudine tabs 100mg 1Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 1 PA QL(28/28)HARVONI 1 QL(28/28)VOSEVI 1 PA NDS QL(30/30)Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 1 PA NDS QL(2/28)PEGASYS INJ 180MCG/ML 1 PA NDS QL(4/28)PEGASYS PROCLICK 1 PA NDS QL(2/28)ribavirin caps 1 QL(168/28)ribavirin tabs 1 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 1 NDS QL(30/30)DELSTRIGO 1 NDS QL(30/30)DOVATO 1 NDS QL(30/30)GENVOYA 1 NDS QL(30/30)ISENTRESS CHEW 100MG 1 NDS QL(180/30)ISENTRESS CHEW 25MG 1 QL(180/30)ISENTRESS HD 1 NDS QL(60/30)ISENTRESS PACK 1 NDS QL(180/30)ISENTRESS TABS 1 NDS QL(60/30)JULUCA 1 NDS QL(30/30)TIVICAY TABS 25MG, 50MG 1 NDS QL(60/30)TIVICAY TABS 10MG 1 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 1 NDS QL(30/30)EDURANT 1 NDS QL(30/30)efavirenz caps 200mg 1 QL(60/30)efavirenz caps 50mg 1 QL(90/30)efavirenz tabs 1 NDS QL(30/30)INTELENCE TABS 100MG, 200MG

1 NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SAPHRIS 1 QL(60/30)VRAYLAR CAPS 1 NDS QL(30/30) STVRAYLAR CPPK 1 QL(14/365) STziprasidone hcl 1 QL(60/30)ZYPREXA RELPREVV INJ 210MG

1 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

1 NDS QL(1/28)

ZYPREXA RELPREVV INJ 300MG

1 NDS QL(2/28)

Treatment-Resistantclozapine odt tbdp 200mg 1 NDS QL(120/30)clozapine odt tbdp 12.5mg, 25mg

1

clozapine odt tbdp 150mg 1 QL(180/30)clozapine odt tbdp 100mg 1 QL(270/30)clozapine tabs 25mg, 50mg 1clozapine tabs 200mg 1 QL(120/30)clozapine tabs 100mg 1 QL(270/30)VERSACLOZ 1 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 10mg, 5mg 1baclofen tabs 20mg 1dantrolene sodium caps 1tizanidine hcl caps 1tizanidine hcl tabs 1tizanidine hydrochloride tabs 4mg

1

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 1 NDSganciclovir inj 500mg, 500mg/10ml

1 B/D PA

valganciclovir 1 NDSvalganciclovir hydrochlorde 1 NDSZIRGAN 1Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 1 NDS QL(30/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIREAD POWD 1 NDS QL(240/30)VIREAD TABS 150MG, 200MG, 250MG

1 NDS QL(30/30)

zidovudine caps 1 QL(180/30)zidovudine syrp 1 QL(1680/28)zidovudine tabs 1 QL(60/30)Anti-HIV Agents, OtherATRIPLA 1 NDS QL(30/30)FUZEON 1 NDS QL(60/30)SELZENTRY ORAL SOLN 1 NDS QL(1610/26)SELZENTRY TABS 150MG, 75MG

1 NDS QL(60/30)

SELZENTRY TABS 300MG 1 NDS QL(120/30)SELZENTRY TABS 25MG 1 QL(240/30)TROGARZO 1 B/D PA NDSTYBOST 1 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 1 NDS QL(120/30)APTIVUS ORAL SOLN 1 NDS QL(285/28)atazanavir sulfate caps 300mg 1 NDS QL(30/30)atazanavir sulfate caps 200mg 1 NDS QL(60/30)atazanavir sulfate caps 150mg 1 QL(30/30)CRIXIVAN CAPS 400MG 1 QL(180/30)CRIXIVAN CAPS 200MG 1 QL(270/30)EVOTAZ 1 NDS QL(30/30)fosamprenavir calcium 1 NDS QL(120/30)INVIRASE 1 NDS QL(120/30)KALETRA TABS 200MG; 50MG

1 NDS QL(120/30)

KALETRA TABS 100MG; 25MG

1 QL(300/30)

LEXIVA SUSP 1 QL(1575/28)lopinavir/ritonavir 1 QL(480/30)NORVIR ORAL SOLN 1 QL(480/30)NORVIR PACK 1 QL(360/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTELENCE TABS 25MG 1 QL(120/30)nevirapine er tb24 400mg 1 QL(30/30)nevirapine er tb24 100mg 1 QL(90/30)nevirapine susp 1 QL(1200/30)nevirapine tabs 1 QL(60/30)ODEFSEY 1 NDS QL(30/30)PIFELTRO 1 NDS QL(30/30)RESCRIPTOR 1 QL(180/30)STRIBILD 1 NDS QL(30/30)SYMFI 1 NDS QL(30/30)SYMFI LO 1 NDS QL(30/30)VIRAMUNE SUSP 1 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 1 QL(960/30)abacavir sulfate/lamivudine 1 NDS QL(30/30)abacavir sulfate/lamivudine/zidovudine

1 NDS QL(60/30)

abacavir tabs 1 QL(60/30)CIMDUO 1 NDS QL(30/30)DESCOVY 1 NDS QL(30/30)didanosine 1 QL(30/30)EMTRIVA CAPS 1 QL(30/30)EMTRIVA ORAL SOLN 1 QL(680/28)lamivudine oral soln 1 QL(900/30)lamivudine tabs 300mg 1 QL(30/30)lamivudine tabs 150mg 1 QL(60/30)lamivudine/zidovudine 1 QL(60/30)RETROVIR IV INFUSION 1stavudine 1 QL(60/30)tenofovir disoproxil fumarate 1 NDS QL(30/30)TRIUMEQ 1 NDS QL(30/30)TRUVADA 1 NDS QL(30/30)VIDEX EC CPDR 125MG 1VIDEX PEDIATRIC 1 QL(1200/30)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Benzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

1 QL(90/30)

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

1 QL(90/30)

alprazolam tabs 2mg 1 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

1 QL(90/30)

clorazepate dipotassium tabs 15mg

1 QL(180/30)

diazepam inj 5mg/ml 1diazepam oral soln 1 QL(1200/30)diazepam tabs 1 QL(120/30)lorazepam conc 1 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 1lorazepam intensol 1 QL(150/30)lorazepam tabs 0.5mg, 1mg 1 QL(90/30)lorazepam tabs 2mg 1 QL(150/30)oxazepam 1 QL(120/30)

Bipolar Agents

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

1

lithium carbonate er 1lithium carbonate tabs 1

Blood Glucose Regulators

Antidiabetic Agentsacarbose 1 QL(90/30)BYDUREON BCISE 1 QL(4/28)BYDUREON PEN 1 QL(4/28)CYCLOSET 1 QL(180/30)FARXIGA 1 QL(30/30)glimepiride tabs 4mg 1 QL(60/30)glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 1 QL(60/30)glipizide er tb24 5mg 1 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NORVIR TABS 1 QL(360/30)PREZCOBIX 1 NDS QL(30/30)PREZISTA SUSP 1 NDS QL(400/30)PREZISTA TABS 800MG 1 NDS QL(30/30)PREZISTA TABS 600MG 1 NDS QL(60/30)PREZISTA TABS 150MG 1 QL(180/30)PREZISTA TABS 75MG 1 QL(210/30)REYATAZ PACK 1 NDS QL(180/30)ritonavir 1 QL(360/30)SYMTUZA 1 NDS QL(30/30)VIRACEPT TABS 625MG 1 NDS QL(120/30)VIRACEPT TABS 250MG 1 NDS QL(270/30)Anti-influenzaAgentsoseltamivir phosphate 1rimantadine hcl 1XOFLUZA 1Antiherpetic Agentsacyclovir caps 1acyclovir crea 1 QL(5/30)acyclovir oint 1 QL(30/30)acyclovir sodium 1 B/D PAacyclovir susp 1acyclovir tabs 1DENAVIR 1 NDS QL(5/30)famciclovir 1 QL(60/30)trifluridine 1valacyclovir hcl 1 QL(30/30)valacyclovir hydrochloride 1 QL(30/30)ZOVIRAX CREA 1 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl 1buspirone hydrochloride tabs 7.5mg

1

buspirone hydrochloride tabs 10mg, 5mg

1

doxepin hcl 1 PAdoxepin hydrochloride caps 25mg

1 PA

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metformin hydrochloride tabs 1000mg

1 QL(60/30)


1 QL(90/30)


1 QL(150/30)

miglitol 1 QL(90/30)nateglinide 1 QL(90/30)OZEMPIC 1 QL(3/28)pioglitazone hcl 1 QL(30/30)pioglitazone hcl/metformin hcl 1 QL(90/30)pioglitazone hydrochloride tabs 15mg, 30mg

1 QL(30/30)

repaglinide tabs 0.5mg, 1mg 1 QL(120/30)repaglinide tabs 2mg 1 QL(240/30)RIOMET 1 QL(750/30)SYMLINPEN 120 1 PA NDS

QL(10.8/28)SYMLINPEN 60 1 PA NDS QL(6/30)SYNJARDY 1 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

1 QL(30/30)

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

1 QL(60/30)

TRADJENTA 1 QL(30/30)TRULICITY 1 QL(2/28)VICTOZA 1 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

1 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

1 QL(60/30)

Glycemic AgentsBAQSIMI ONE PACK 1 QL(2/30)BAQSIMI TWO PACK 1 QL(2/30)GLUCAGEN HYPOKIT 1 QL(4/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide er tb24 2.5mg 1 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide xl tb24 5mg 1 QL(120/30)glipizide xl tb24 2.5mg 1 QL(240/30)glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hydrochloride tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 1 QL(30/30)INVOKAMET 1 QL(60/30)INVOKAMET XR 1 QL(60/30)INVOKANA 1 QL(30/30)JANUMET 1 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

1 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

1 QL(60/30)

JANUVIA 1 QL(30/30)JARDIANCE 1 QL(30/30)JENTADUETO 1 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

1 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

1 QL(60/30)

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

1 QL(60/30)

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

1 QL(120/30)

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

1 QL(60/30)

metformin hydrochloride oral soln

1 QL(750/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fondaparinux sodium inj 7.5mg/0.6ml

1 NDS QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

1 NDS QL(24/90)

fondaparinux sodium inj 2.5mg/0.5ml

1 QL(15/90)

heparin sodium inj 5000unit/0.5ml, 5000unit/ml

1

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

1

heparin sodium/d5w 1heparin sodium/dextrose 1heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

1

heparin sodium/nacl 0.9% 1heparin sodium/sodium chloride 0.9%

1

heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9%

1

heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

1

jantoven 1PRADAXA 1 QL(60/30)warfarin sodium 1XARELTO STARTER PACK 1 QL(102/365)XARELTO TABS 10MG, 20MG 1 QL(30/30)XARELTO TABS 15MG, 2.5MG 1 QL(60/30)BloodFormationModifiersanagrelide hydrochloride 1ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

1 PA QL(1.2/28)

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

1 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

1 PA QL(1.68/28)

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

1 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

1 PA NDS QL(1/21)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GLUCAGON EMERGENCY KIT

1 QL(4/30)

PROGLYCEM 1InsulinsHUMALOG 1HUMALOG JUNIOR KWIKPEN 1HUMALOG KWIKPEN 1HUMALOG MIX 50/50 1HUMALOG MIX 50/50 KWIKPEN

1

HUMALOG MIX 75/25 1HUMALOG MIX 75/25 KWIKPEN

1

HUMULIN 70/30 1HUMULIN 70/30 KWIKPEN 1HUMULIN N 1HUMULIN N KWIKPEN 1HUMULIN R 1HUMULIN R U-500 (CONCENTRATED)

1

HUMULIN R U-500 KWIKPEN 1LANTUS 1LANTUS SOLOSTAR 1LEVEMIR 1LEVEMIR FLEXTOUCH 1SOLIQUA 100/33 1 QL(18/30) STTOUJEO MAX SOLOSTAR 1TOUJEO SOLOSTAR 1TRESIBA 1TRESIBA FLEXTOUCH 1XULTOPHY 100/3.6 1 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 1ELIQUIS STARTER PACK 1 QL(74/30)ELIQUIS TABS 2.5MG 1 QL(60/30)ELIQUIS TABS 5MG 1 QL(74/30)enoxaparin sodium 1fondaparinux sodium inj 5mg/0.4ml

1 NDS QL(12/90)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Cardiovascular Agents

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

1 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 1 QL(8/28)clonidine hcl tabs 0.3mg 1clonidine hcl tabs 0.1mg 1clonidine hydrochloride tabs 1midodrine hcl 1Alpha-adrenergic Blocking Agentsdoxazosin mesylate tabs 1mg, 2mg, 4mg

1 QL(30/30)

doxazosin mesylate tabs 8mg 1 QL(60/30)phenoxybenzamine hydrochloride

1 NDS

prazosin hcl 1prazosin hydrochloride caps 2mg

1

terazosin hcl caps 1mg, 5mg 1terazosin hcl caps 10mg 1 QL(60/30)terazosin hydrochloride 1Angiotensin II Receptor Antagonistscandesartan cilexetil tabs 32mg 1 QL(30/30)candesartan cilexetil tabs 16mg, 4mg, 8mg

1 QL(60/30)

candesartan cilexetil/hydrochlorothiazide

1

EDARBI 1 QL(30/30) STEDARBYCLOR 1 STENTRESTO 1 QL(60/30)irbesartan tabs 300mg 1 QL(30/30)irbesartan tabs 150mg, 75mg 1 QL(60/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


1 PA NDS QL(1.2/28)


1 PA NDS QL(1.6/28)


1 PA NDS QL(2/28)


1 PA NDS QL(2.4/28)

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

1 PA NDS QL(4/28)

LEUKINE INJ 250MCG 1 PA NDSMOZOBIL 1 NDS QL(9.6/30)PROCRIT INJ 40000UNIT/ML 1 PA NDS QL(6/28)PROCRIT INJ 20000UNIT/ML 1 PA NDS QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

1 PA QL(12/28)

PROMACTA PACK 1 PA NDS QL(360/30)PROMACTA TABS 1 PA NDS QL(30/30)ZARXIO 1 PA NDSHemostasis AgentsRETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

1 PA QL(12/28)

RETACRIT INJ 40000UNIT/ML 1 PA NDS QL(6/28)tranexamic acid inj 1tranexamic acid tabs 1 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 1 QL(60/30)BRILINTA 1 QL(60/30)cilostazol 1clopidogrel tabs 300mg 1 QL(2/365)clopidogrel tabs 75mg 1 QL(30/30)prasugrel 1 QL(30/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

perindopril erbumine 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril hydrochloride tabs 10mg

1 QL(60/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

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

1 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 1 QL(30/30)trandolapril tabs 2mg, 4mg 1 QL(60/30)trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg

1 QL(30/30)

trandolapril/verapamil hcl er tbcr 4mg; 240mg

1 QL(60/30)

Antiarrhythmicsamiodarone hcl inj 50mg/ml, 900mg/18ml

1

amiodarone hcl tabs 1amiodarone hydrochloride inj 1dofetilide 1 QL(60/30)flecainide acetate 1lidocaine hcl inj 100mg/5ml, 50mg/5ml

1

mexiletine hcl 1MULTAQ 1 QL(60/30)pacerone 1propafenone hcl 1propafenone hydrochloride er 1quinidine sulfate 1sorine 1sotalol hcl 1sotalol hcl (af) 1sotalol hcl af 1sotalol hydrochloride (af) tabs 80mg

1

sotalol hydrochloride af 1sotalol hydrochloride tabs 120mg, 80mg

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 1olmesartan medoxomil/hydrochlorothiazide

1

telmisartan tabs 20mg, 40mg 1 QL(30/30)telmisartan tabs 80mg 1 QL(60/30)telmisartan/amlodipine 1 QL(30/30)telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg

1 QL(30/30)

telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg

1 QL(60/30)

valsartan tabs 320mg 1 QL(30/30)valsartan tabs 160mg, 40mg, 80mg

1 QL(60/30)

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

1 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

1 QL(60/30)

benazepril hydrochloride 1 QL(60/30)enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide

1

fosinopril sodium 1 QL(60/30)fosinopril sodium/hydrochlorothiazide

1 QL(120/30)

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

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 1

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Calcium Channel Blocking Agentsamlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hcl caps 5mg; 40mg

1 QL(60/30)

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

1 QL(30/30)

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

1 QL(60/30)

amlodipine besylate/valsartan 1amlodipine/valsartan/hctz 1amlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg

1

cartia xt 1dilt-xr 1diltiazem cd cp24 180mg 1diltiazem hcl er cp12 1diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg

1

diltiazem hcl er tb24 1diltiazem hcl inj 1diltiazem hcl tabs 1diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg

1

felodipine er 1 QL(60/30)isradipine 1matzim la 1nicardipine hcl caps 1nicardipine hcl inj 1nifedipine er tb24 90mg 1 QL(30/30)nifedipine er tb24 30mg, 60mg 1 QL(60/30)nimodipine 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-adrenergic Blocking Agentsacebutolol hcl caps 200mg 1acebutolol hydrochloride caps 400mg

1

atenolol 1atenolol/chlorthalidone 1betaxolol hcl tabs 1bisoprolol fumarate 1bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

1 QL(30/30)

BYSTOLIC TABS 20MG 1 QL(60/30)carvedilol 1carvedilol phosphate 1 QL(30/30)labetalol hydrochloride inj 5mg/ml

1

labetalol hydrochloride tabs 1metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 1metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 1nadolol 1nadolol/bendroflumethiazide 1pindolol 1propranolol hcl er 1propranolol hcl inj 1propranolol hcl oral soln 1propranolol hcl tabs 40mg, 80mg

1

propranolol hydrochloride er 1propranolol hydrochloride tabs 10mg, 20mg, 60mg

1

propranolol/hydrochlorothiazide 1timolol maleate tabs 1

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bumetanide tabs 0.5mg, 1mg 1bumetanide tabs 2mg 1ethacrynate sodium 1furosemide inj 1furosemide oral soln 1furosemide tabs 1torsemide 1Diuretics, Potassium-sparingamiloride hcl 1amiloride/hydrochlorothiazide 1spironolactone 1spironolactone/hydrochlorothiazide

1

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 1chlorothiazide sodium 1chlorthalidone 1hydrochlorothiazide 1indapamide 1metolazone 1Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 1 QL(30/30)fenofibrate caps 43mg, 50mg 1 QL(60/30)fenofibrate caps 134mg, 200mg 1 QL(30/30)fenofibrate caps 67mg 1 QL(60/30)fenofibrate micronized caps 134mg, 200mg

1 QL(30/30)

fenofibrate micronized caps 67mg

1 QL(60/30)

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nisoldipine er tb24 20mg, 30mg, 40mg

1

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

1 QL(30/30)

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

1

verapamil hcl 1verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

1 QL(30/30)

verapamil hcl er cp24 200mg 1 QL(60/30)verapamil hcl er tbcr 1VERAPAMIL HCL SR CP24 360MG

1 QL(30/30)

verapamil hydrochloride inj 1verapamil hydrochloride tabs 1Cardiovascular Agents, Otheraliskiren 1 QL(30/30)atropine sulfate inj 0.5mg/5ml 1CORLANOR TABS 1 PA QL(60/30)DEMSER 1 NDSdigitek tabs 0.125mg 1 QL(30/30)digitek tabs 0.25mg 1 PAdigox tabs 125mcg 1 QL(30/30)digox tabs 250mcg 1 PAdigoxin inj 1 PAdigoxin tabs 125mcg 1 QL(30/30)digoxin tabs 250mcg 1 PANORTHERA CAPS 100MG 1 PA NDS QL(90/30)NORTHERA CAPS 200MG, 300MG

1 PA NDS QL(180/30)

pentoxifylline er 1RANEXA 1 QL(60/30)ranolazine er 1 QL(60/30)TEKTURNA 1 QL(30/30)TEKTURNA HCT 1 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 1acetazolamide sodium 1methazolamide 1Diuretics, Loopbumetanide inj 1

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isosorbide dinitrate er 1isosorbide dinitrate tabs 1isosorbide mononitrate 1isosorbide mononitrate er 1minitran 1 QL(30/30)nitroglycerin inj 1nitroglycerin lingual 1nitroglycerin subl 1nitroglycerin transdermal 1 QL(30/30)

Central Nervous System Agents

AttentionDeficitHyperactivityDisorderAgents,Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

1 QL(30/30)

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

1 QL(60/30)

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

1 QL(60/30)

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

1 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 PA NDS

REPATHA SURECLICK 1 PA NDSVASCEPA CAPS 1GM 1 QL(120/30)VASCEPA CAPS 0.5GM 1 QL(240/30)WELCHOL 1Vasodilators, Direct-acting Arterialhydralazine hcl inj 1hydralazine hcl tabs 1hydralazine hydrochloride tabs 100mg, 25mg, 50mg

1

minoxidil 1Vasodilators, Direct-acting Arterial/VenousBIDIL 1 QL(180/30)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUEDEXTA 1 PA QL(60/30)riluzole 1tetrabenazine tabs 12.5mg 1 PA NDS QL(90/30)tetrabenazine tabs 25mg 1 PA NDS QL(120/30)Multiple Sclerosis AgentsAMPYRA 1 PA NDS QL(60/30)AVONEX 1 PA NDS QL(4/28)AVONEX PEN 1 PA NDS QL(4/28)BETASERON 1 PA NDS QL(14/28)COPAXONE INJ 40MG/ML 1 PA NDS QL(12/28)COPAXONE INJ 20MG/ML 1 PA NDS QL(30/30)dalfampridine er 1 PA QL(60/30)GILENYA 1 PA NDS QL(30/30)REBIF 1 PA NDS QL(6/28)REBIF REBIDOSE 1 PA NDS QL(6/28)REBIF REBIDOSE TITRATION PACK

1 PA NDS QL(4.2/28)

REBIF TITRATION PACK 1 PA NDS QL(4.2/28)TECFIDERA CPDR 120MG 1 PA NDS QL(14/30)TECFIDERA CPDR 240MG 1 PA NDS QL(60/30)TECFIDERA STARTER PACK 1 PA NDS

QL(120/365)TYSABRI 1 PA NDS QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 1paroex 1pilocarpine hcl 1pilocarpine hydrochloride tabs 5mg

1

triamcinolone acetonide dental paste

1

Dermatological Agents

Dermatological Agentsacitretin 1 PAammonium lactate 1amnesteem 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


1 QL(90/30)


1 QL(120/30)

dextroamphetamine sulfate oral soln

1 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

1 QL(60/30)

dextroamphetamine sulfate tabs 10mg

1 QL(180/30)

AttentionDeficitHyperactivityDisorderAgents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

1 QL(30/30)

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

1 QL(60/30)

clonidine hcl er 1 QL(120/30)dexmethylphenidate hcl tabs 10mg

1 QL(60/30)

dexmethylphenidate hydrochloride tabs 2.5mg, 5mg

1 QL(60/30)

metadate er 1 QL(90/30)methylphenidate hydrochloride er tb24 27mg, 54mg

1 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

1 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

1 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg

1 QL(30/30)


1 QL(60/30)


1 QL(90/30)

methylphenidate hydrochloride tabs

1 QL(90/30)

Central Nervous System, OtherHETLIOZ 1 PA NDS QL(30/30)LYRICA CR TB24 330MG 1 QL(60/30)LYRICA CR TB24 165MG, 82.5MG

1 QL(90/30)

NAMZARIC C4PK 1 PA QL(56/365)NAMZARIC CP24 1 PA QL(30/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tretinoin crea 1 PA QL(45/30)tretinoin gel 0.025% 1 PAtretinoin gel 0.05% 1 PA QL(45/30)tretinoin gel 0.01% 1 PA QL(45/30)tretinoin microsphere 1 PAtretinoin microsphere pump gel 0.1%

1 PA

zenatane 1ZYCLARA 1 NDS QL(56/30)ZYCLARA PUMP CREA 2.5% 1 NDS QL(15/30)ZYCLARA PUMP CREA 3.75% 1 NDS QL(56/30)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN II 1 B/D PAAMINOSYN-PF 1 B/D PAAMINOSYN-PF 7% 1 B/D PACARBAGLU 1 PA NDSCLINIMIX 4.25%/DEXTROSE 10%

1 B/D PA

CLINIMIX 4.25%/DEXTROSE 25%

1 B/D PA

CLINIMIX 4.25%/DEXTROSE 5%

1 B/D PA

CLINIMIX 5%/DEXTROSE 15% 1 B/D PACLINIMIX 5%/DEXTROSE 20% 1 B/D PACLINIMIX 5%/DEXTROSE 25% 1 B/D PACLINIMIX E 4.25%/DEXTROSE 10%

1 B/D PA

CLINISOL SF 15% 1 B/D PAdextrose 1 B/D PAdextrose10%/nacl 0.45% 1 B/D PAdextrose5% /electrolyte #48 viaflex

1 B/D PA

DEXTROSE 10% 1 B/D PAdextrose 10%/nacl 0.2% 1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

avita crea 1 PA QL(45/30)avita gel 1 PAcalcipotriene crea 1 QL(120/30)calcipotriene external soln 1 QL(60/30)calcipotriene oint 1 QL(120/30)calcitrene 1 QL(120/30)calcitriol oint 1 QL(800/30)claravis 1CURITY GAUZE PADS 2”X2” 1diclofenac sodium gel 1% 1 QL(1000/30)diclofenac sodium transdermal soln

1 QL(1050/30)

ELIDEL 1 QL(100/90)erythromycin/benzoyl peroxide 1fluorouracil crea 5% 1fluorouracil crea 0.5% 1 NDSfluorouracil external soln 1imiquimod 1 QL(12/30)imiquimod pump 1 NDS QL(56/30)isotretinoin 1methoxsalen 1myorisan 1PICATO GEL 0.05% 1 QL(2/56)PICATO GEL 0.015% 1 QL(3/56)pimecrolimus 1 QL(100/90)podofilox 1RECTIV 1 QL(30/30)REGRANEX 1 PA NDS QL(15/30)SANTYL 1selenium sulfide lotn 1tacrolimus oint 1 QL(100/90)tazarotene 1TAZORAC CREA 1TAZORAC GEL 1 QL(100/30)TOLAK 1

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KLOR-CON 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 1LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

1 B/D PA

LACTATED RINGERS VIAFLEX

1 B/D PA

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

1 B/D PA

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

1 B/D PA

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

1 B/D PA

potassium chloride oral soln 1potassium chloride pack 1potassium chloride sr 1potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

1 B/D PA

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

1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 B/D PA

HEPATAMINE 1 B/D PAKABIVEN 1 B/D PAKCL 0.075%/D5W/NACL 0.45% 1 B/D PAKCL 0.15%/D5W/NACL 0.2% 1 B/D PAKCL 0.15%/D5W/NACL 0.225% 1 B/D PAKCL 0.15%/D5W/NACL 0.45% 1 B/D PAKCL 0.15%/D5W/NACL 0.9% 1 B/D PAKCL 0.3%/D5W/NACL 0.45% 1 B/D PAKCL 0.3%/D5W/NACL 0.9% 1 B/D PAklor-con 1KLOR-CON 10 1

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium fluoride chew 0.25mg, 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

1 B/D PA

TPN ELECTROLYTES 1 B/D PATRAVASOL 1 B/D PATROPHAMINE 1 B/D PAElectrolyte/Mineral/MetalModifiersCHEMET 1 NDSCUPRIMINE 1 NDSDEPEN TITRATABS 1 NDSFERRIPROX 1 PA NDSJADENU 1 NDSJADENU SPRINKLE 1 NDSkionex 1penicillamine 1 NDSSAMSCA TABS 15MG 1 PA NDS QL(30/30)SAMSCA TABS 30MG 1 PA NDS QL(60/30)sodium polystyrene sulfonate powd

1

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

1

sps 1SYPRINE 1 NDStrientine hydrochloride 1 NDSVELTASSA 1Phosphate BindersAURYXIA 1 PA QL(360/30)calcium acetate caps 1calcium acetate tabs 667mg 1PHOSLYRA 1RENVELA PACK 1 QL(180/30)RENVELA TABS 1 QL(540/30)SEVELAMER CARBONATE PACK

1 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 B/D PA

potassium chloride/dextrose/sodium chloride

1 B/D PA

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

1 B/D PA

potassium citrate er 1PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

1 B/D PA

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

1 B/D PA

PROCALAMINE 1 B/D PAPROSOL 1 B/D PAringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l

1 B/D PA

sodium bicarbonate inj 1sodium chloride 0.45% 1sodium chloride inj 0.45%, 0.9%, 3%, 5%

1

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RELISTOR INJ 12MG/0.6ML 1 PA NDS QL(16.8/28)

TRULANCE 1 QL(30/30)ursodiol 1Histamine2 (H2) Receptor Antagonistscimetidine 1cimetidine hcl 1famotidine inj 1famotidine premixed 1famotidine tabs 20mg, 40mg 1nizatidine caps 1ranitidine hcl inj 1ranitidine hcl syrp 1ranitidine hcl tabs 150mg, 300mg

1

ranitidine hydrochloride caps 1ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml

1

Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 1mg

1 PA NDS QL(60/30)

alosetron hydrochloride tabs 0.5mg

1 PA QL(60/30)

AMITIZA 1 QL(60/30)LINZESS 1 QL(30/30)VIBERZI 1 PA QL(60/30)Laxativesconstulose 1enulose 1gavilyte-c 1gavilyte-g 1gavilyte-n/flavor pack 1generlac 1lactulose oral soln 1MOVIPREP 1peg 3350/electrolytes 1peg-3350/electrolytes 1peg-3350/nacl/na bicarbonate/kcl

1

SUPREP BOWEL PREP KIT 1trilyte 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SEVELAMER CARBONATE TABS

1 QL(540/30)

VELPHORO 1 QL(180/30)Vitaminsmultivitamin with fluoride chew 1VP-PNV-DHA 1

Gastrointestinal Agents

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

1

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

1

glycopyrrolate tabs 1mg, 2mg 1hyoscyamine sulfate elix 1hyoscyamine sulfate subl 1hyoscyamine sulfate tabs 1hyoscyamine sulfate tbdp 1methscopolamine bromide 1nulev 1oscimin 1propantheline bromide 1Gastrointestinal Agents, Othercromolyn sodium conc 1diphenoxylate/atropine liqd 1diphenoxylate/atropine tabs 1GATTEX 1 PA NDSloperamide hcl caps 1metoclopramide hcl inj 1metoclopramide hcl oral soln 1metoclopramide hcl tabs 1metoclopramide hydrochloride 1OSMOPREP 1RELISTOR INJ 8MG/0.4ML 1 PA NDS

QL(11.2/28)

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxybutynin chloride er tb24 5mg

1 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

1 QL(60/30)

oxybutynin chloride syrp 1 QL(600/30)oxybutynin chloride tabs 1 QL(120/30)solifenacin succinate 1 QL(30/30)tolterodine tartrate 1 QL(60/30)tolterodine tartrate er 1 QL(30/30)VESICARE 1 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 1 QL(30/30)dutasteride 1 QL(30/30)dutasteride/tamsulosin hydrochloride

1 QL(30/30)

finasteride tabs 5mg 1 QL(30/30)tamsulosin hydrochloride 1 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 1ELMIRON 1phenazopyridine hydrochloride 1phenazopyridine hydrocholride 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

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

1

betamethasone dipropionate 1betamethasone valerate crea 1betamethasone valerate foam 1betamethasone valerate lotn 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ProtectantsCARAFATE SUSP 1misoprostol 1sucralfate 1Proton Pump Inhibitorsesomeprazole magnesium 1 QL(60/30)omeprazole cpdr 1 QL(60/30)pantoprazole sodium tbec 1 QL(60/30)

GeneticorEnzymeDisorder:Replacement,Modifiers,Treatment

GeneticorEnzymeDisorder:Replacement,Modifiers,TreatmentALDURAZYME 1 PA NDSCEREZYME 1 B/D PA NDSCREON 1CYSTADANE 1 NDSCYSTAGON 1ELAPRASE 1 PA NDSFABRAZYME 1 B/D PA NDSKUVAN 1 PA NDSLUMIZYME 1 PA NDSmiglustat 1 NDS QL(90/30)NAGLAZYME 1 PA NDSNITISINONE CAPS 2MG 1 NDSnitisinone caps 10mg, 5mg 1 NDSORFADIN 1 NDSsodium phenylbutyrate 1 PA NDSZENPEP 1

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 1 QL(30/30)flavoxate hcl 1MYRBETRIQ 1 QL(30/30)

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluocinonide gel 1fluocinonide oint 1fluticasone propionate crea 1fluticasone propionate oint 1halobetasol propionate crea 1halobetasol propionate oint 1hydrocortisone butyrate (lipid) 1hydrocortisone butyrate (lipophilic)

1

hydrocortisone butyrate crea 1hydrocortisone butyrate external soln

1

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

1

methylprednisolone dose pack 1methylprednisolone sodiumsuccinate inj 125mg, 40mg

1

methylprednisolone tabs 1mometasone furoate crea 1mometasone furoate external soln

1

mometasone furoate oint 1prednicarbate oint 1prednisolone 1prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

1

prednisone intensol 1prednisone oral soln 1prednisone tabs 50mg 1prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

betamethasone valerate oint 1clobetasol propionate crea 1clobetasol propionate emollient crea

1

clobetasol propionate emollient foam

1

clobetasol propionate external soln

1

clobetasol propionate foam 1clobetasol propionate gel 1clobetasol propionate oint 1clobetasol propionate sham 1clodan 1cortisone acetate 1DEPO-MEDROL INJ 20MG/ML 1desonide lotn 1desonide oint 1desoximetasone crea 1desoximetasone gel 1desoximetasone oint 1dexamethasone elix 1dexamethasone intensol 1dexamethasone oral soln 1dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

1

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

1

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

fludrocortisone acetate 1fluocinolone acetonide body 1fluocinolone acetonide crea 1fluocinolone acetonide external soln

1

fluocinolone acetonide oint 1fluocinolone acetonide scalp 1fluocinonide crea 0.1% 1fluocinonide crea 0.05% 1fluocinonide external soln 1

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)

Anabolic SteroidsANADROL-50 1 PA NDSoxandrolone tabs 2.5mg 1 PA QL(120/30)oxandrolone tabs 10mg 1 PA QL(60/30)Androgensdanazol caps 50mg 1danazol caps 100mg, 200mg 1testosterone cypionate 1testosterone enanthate 1 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

1 PA QL(300/30)

testosterone pump gel 1% 1 PA QL(300/30)EstrogensALORA 1 PA QL(8/28)altavera 1alyacen 1/35 1alyacen 7/7/7 1amethia 1 QL(91/91)amethia lo 1 QL(91/91)apri 1aranelle 1ashlyna 1 QL(91/91)aubra 1aviane 1azurette 1balziva 1blisovi fe 1.5/30 1briellyn 1camrese 1 QL(91/91)camrese lo 1 QL(91/91)caziant 1cesia 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1

triamcinolone acetonide crea 0.025%, 0.5%

1

triamcinolone acetonide inj 40mg/ml

1

triamcinolone acetonide lotn 1triamcinolone acetonide oint 1trianex 1 NDStriderm crea 0.1% 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)desmopressin acetate inj 1desmopressin acetate nasal soln

1 QL(15/30)

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

1 PA NDS

GENOTROPIN MINIQUICK INJ 0.2MG

1 PA

INCRELEX 1 PASTIMATE 1 NDS

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1 QL(91/91)

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

1

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

1 QL(91/91)

levora 0.15/30-28 1low-ogestrel 1lutera 1marlissa 1melodetta 24 fe 1MENEST 1 PAMENOSTAR 1 PA QL(4/28)mibelas 24 fe 1microgestin 1.5/30 1microgestin 1/20 1microgestin fe 1microgestin fe 1.5/30 1mili 1MINIVELLE 1 PA QL(8/28)mono-linyah 1necon 0.5/35-28 1norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

1

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

1 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

1

falmina 1femynor 1fyavolv tabs 2.5mcg; 0.5mg 1 PAhailey 24 fe 1introvale 1 QL(91/91)isibloom 1jolessa 1 QL(91/91)juleber 1junel 1.5/30 1junel 1/20 1junel fe 1.5/30 1

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

wera 1yuvafem 1 QL(18/28)zovia 1/35e 1Progesterone Agonists/AntagonistsELLA 1MAKENA 1 PA NDSProgestinscamila 1deblitane 1DEPO-PROVERA 1 QL(10/28)errin 1heather 1hydroxyprogesterone caproate 1 PA NDSincassia 1jencycla 1lyza 1MAKENA 1 PA NDSmedroxyprogesterone acetate inj 150mg/ml

1 QL(1/90)

medroxyprogesterone acetate inj 150mg/ml

1 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

1 PA

megestrol acetate tabs 1 PAnora-be 1norethindrone 1norethindrone acetate 1norlyroc 1progesterone caps 1sharobel 1Selective Estrogen Receptor Modifying AgentsDUAVEE 1 PA QL(30/30)raloxifene hydrochloride 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SIGNIFOR 1 PA NDS QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

1 PA NDS QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

1 PA NDS QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

1 PA NDS QL(0.5/28)

SOMAVERT 1 PA NDS QL(30/30)SYNAREL 1 PA NDSTRELSTAR MIXJECT INJ 22.5MG

1 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

1 PA NDS QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

1 PA QL(1/84)

TRIPTODUR 1 PA NDS QL(1/168)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 1propylthiouracil 1

Immunological Agents

Angioedema AgentsCINRYZE 1 PA NDS QL(20/30)FIRAZYR 1 PA NDS QL(18/30)icatibant acetate 1 PA NDS QL(18/30)RUCONEST 1 PA NDS QL(8/30)Immune SuppressantsASTAGRAF XL 1 PAAZASAN 1 PAazathioprine inj 1 PAazathioprine tabs 1 PAcyclosporine 1 PAcyclosporine modified 1 PAENBREL INJ 25MG/0.5ML 1 PA NDS

QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 1 PA NDS QL(8/28)ENBREL MINI 1 PA NDS QL(8/28)ENBREL SURECLICK 1 PA NDS QL(8/28)ENVARSUS XR TB24 4MG 1 PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

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

1

levoxyl tabs 100mcg, 112mcg, 175mcg

1

liothyronine sodium inj 1liothyronine sodium tabs 1SYNTHROID 1UNITHROID 1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 1 NDS

Hormonal Agents, Suppressant (Pituitary)

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

QL(4/365)FIRMAGON INJ 80MG 1 B/D PA QL(1/28)leuprolide acetate 1 PALUPRON DEPOT (1-MONTH) 1 PA NDS QL(1/30)LUPRON DEPOT (3-MONTH) 1 PA QL(1/84)LUPRON DEPOT (4-MONTH) 1 PA QL(1/112)LUPRON DEPOT (6-MONTH) 1 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

1 PA NDS QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

1 PA QL(1/84)

octreotide acetate 1 PASANDOSTATIN LAR DEPOT 1 PA NDS

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sirolimus oral soln 1 PA NDSsirolimus tabs 1 PASKYRIZI 1 PA NDS QL(2/28)tacrolimus caps 1 PATORISEL 1 B/D PA NDS

QL(4/28)XATMEP 1 PAZORTRESS TABS 0.25MG 1 PA QL(60/30)ZORTRESS TABS 0.75MG, 1MG

1 PA NDS QL(60/30)

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

1 B/D PA NDS

GAMMAKED INJ 1GM/10ML 1 B/D PAGAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

1 B/D PA NDS

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

1 PA NDS QL(40/28)

ACTIMMUNE 1 PA NDSARCALYST 1 PA NDSBENLYSTA INJ 400MG 1 PA NDS QL(9/28)BENLYSTA INJ 120MG 1 PA NDS QL(30/28)leflunomide 1 QL(30/30)RIDAURA 1RINVOQ 1 PA NDS QL(30/30)SIMULECT 1 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENVARSUS XR TB24 0.75MG, 1MG

1 PA

gengraf 1 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

1 PA NDS QL(2/28)

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

1 PA NDS QL(4/28)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH)

1 PA NDS QL(4/365)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK)

1 PA NDS QL(6/365)

HUMIRA PEN 1 PA NDS QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

1 PA NDS QL(6/365)

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

1 PA NDS QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

1 PA NDS QL(6/365)

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

1 PA NDS QL(8/365)

methotrexate sodium 1methotrexate tabs 1mycophenolate mofetil caps 1 PAmycophenolate mofetil inj 1 PAmycophenolate mofetil susr 1 PA NDSmycophenolate mofetil tabs 1 PAmycophenolic acid dr 1 PANULOJIX 1 PA NDS QL(150/30)PROGRAF INJ 1 PAPROGRAF PACK 1 PARAPAMUNE ORAL SOLN 1 PA NDSRENFLEXIS 1 PA NDSSANDIMMUNE ORAL SOLN 1 PA

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VAQTA 1VARIVAX 1 QL(1/365)VARIZIG 1 QL(12/30)VAXCHORA 1YF-VAX 1ZOSTAVAX 1 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 1 QL(120/30)balsalazide disodium 1mesalamine dr tbec 1.2gm 1 QL(120/30)mesalamine enem 1mesalamine kit 1Glucocorticoidsbudesonide cpep 1colocort 1hydrocortisone enem 1Sulfonamidessulfasalazine 1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

BINOSTO 1calcitonin-salmon 1 QL(3.7/30)calcitriol caps 1calcitriol inj 1calcitriol oral soln 1doxercalciferol caps 0.5mcg 1 QL(90/30)doxercalciferol caps 2.5mcg 1 QL(120/30)doxercalciferol caps 1mcg 1 QL(240/30)etidronate disodium 1FORTEO 1 PA NDS QL(2.4/28)ibandronate sodium tabs 1 QL(1/28)MIACALCIN 1 NDSpamidronate disodium 1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNAGIS 1 PA NDSVaccinesACTHIB 1ADACEL 1 QL(0.5/365)BCG VACCINE 1BEXSERO 1BOOSTRIX 1 QL(0.5/365)DAPTACEL 1DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

1

ENGERIX-B INJ 10MCG/0.5ML 1 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 1 B/D PA QL(8/365)GARDASIL 9 1 QL(1.5/365)HAVRIX 1HEPLISAV-B 1 B/D PA QL(3/365)HIBERIX 1IMOVAX RABIES (H.D.C.V.) 1 B/D PAINFANRIX 1IPOL INACTIVATED IPV 1IXIARO 1KINRIX 1M-M-R II 1 QL(2/365)MENACTRA 1MENVEO 1PEDIARIX 1PEDVAX HIB 1PROQUAD 1 QL(2/365)QUADRACEL 1RABAVERT 1 B/D PARECOMBIVAX HB 1 B/D PA QL(3/365)ROTARIX 1ROTATEQ 1SHINGRIX 1 QL(2/999)STAMARIL 1 QL(1/999)TDVAX 1TENIVAC 1 QL(0.5/28)TRUMENBA 1TWINRIX 1TYPHIM VI 1

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTRALIPID 1 B/D PAKORLYM 1 PA NDS QL(120/30)LACTATED RINGERS IRRIGATION

1

levocarnitine 1LIPOSYN III 1 B/D PANATPARA 1 PA NDS QL(2/28)NOVOFINE 31 1 QL(200/30)NOVOFINE 32GX6MM 1 QL(200/30)NOVOFINE AUTOCOVER 30GX8MM

1 QL(200/30)

NOVOTWIST 32GX5MM 1 QL(200/30)NUTRILIPID 1 B/D PAOMNIPOD 5 PACK 1 QL(30/30)OMNIPOD DASH 5 PACK 1 QL(30/30)OMNIPOD STARTER KIT 1 QL(1/365)PHYSIOLYTE 1physiosol irrigation 1RINGERS IRRIGATION 1sodium chloride irrigation 0.9% 1sterile water irrigation 1sterile water irrigation plastic bottle

1

sterile water irrigation w/hanger 1TECHLITE PEN NEEDLES/31G X 6 MM

1 QL(200/30)

TECHLITE PEN NEEDLES/31G X 8MM

1 QL(200/30)


1 QL(200/30)


1 QL(200/30)


1 QL(200/30)

TIS-U-SOL 1V-GO 20 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

paricalcitol caps 4mcg 1 QL(60/30)paricalcitol caps 1mcg, 2mcg 1 QL(90/30)PROLIA 1 QL(1/180)risedronate sodium tabs 150mg 1 QL(1/30)risedronate sodium tabs 35mg 1 QL(4/28)risedronate sodium tabs 30mg, 5mg

1 QL(30/30)

SENSIPAR TABS 30MG, 60MG 1 NDS QL(60/30)SENSIPAR TABS 90MG 1 NDS QL(120/30)TYMLOS 1 PA NDS

QL(1.56/30)XGEVA 1 PA NDS QL(1.7/28)zoledronic acid inj 5mg/100ml 1 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAMINO ACID 1 B/D PABD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2”

1 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM

1 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM

1 QL(200/30)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”

1 QL(200/30)

BD PEN NEEDLE/MINI/ULTRA-FINE/31G X 5MM

1 QL(200/30)

BD PEN NEEDLE/NANO/ULTRA -FINE/32G X 4MM

1 QL(200/30)

BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM

1 QL(200/30)

CARNITOR INJ 1 B/D PAFERRIPROX 1 PA NDSFIRDAPSE 1 PA NDS

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LOTEMAX 1LOTEMAX SM 1neomycin/polymyxin/dexamethasone

1

PRED MILD 1PRED-G 1PRED-G S.O.P. 1prednisolone acetate 1prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 1TOBRADEX OINT 1tobramycin/dexamethasone 1Ophthalmic Antiglaucoma Agentsacetazolamide er 1ALPHAGAN P OPHTHALMIC SOLN 0.1%

1

apraclonidine 1AZOPT 1betaxolol hcl ophthalmic soln 1brimonidine tartrate ophthalmic soln 0.15%

1

brimonidine tartrate ophthalmic soln 0.2%

1

carteolol hcl 1dorzolamide hcl 1 QL(10/30)dorzolamide hcl/timolol maleate 1 QL(10/30)levobunolol hcl 1PHOSPHOLINE IODIDE 1pilocarpine hcl 1ROCKLATAN 1 STSIMBRINZA 1TIMOLOL MALEATE OPHTHALMIC GEL FORMING

1

timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetic acid 1COLY-MYCIN S 1CORTISPORIN-TC 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

V-GO 30 1V-GO 40 1

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 1 QL(5/30)COMBIGAN 1latanoprost 1 QL(5/30)LUMIGAN 1 QL(5/30) STTRAVATAN Z 1 QL(5/30)ZIOPTAN 1 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 1CYSTARAN 1 PA NDS QL(60/28)LACRISERT 1proparacaine hcl 1RESTASIS 1 QL(60/30)RHOPRESSA 1 STtropicamide 1Ophthalmic Anti-allergy Agentsazelastine hcl ophthalmic soln 1cromolyn sodium ophthalmic soln

1

epinastine hcl 1olopatadine hcl ophthalmic soln 1 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

1

PAZEO 1 QL(2.5/30)OphthalmicAnti-inflammatoriesbromfenac 1dexamethasone sodium phosphate ophthalmic soln

1

diclofenac sodium ophthalmic soln

1

DUREZOL 1fluorometholone 1flurbiprofen sodium 1ILEVRO 1INVELTYS 1ketorolac tromethamine ophthalmic soln

1

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diphenhydramine hcl inj 1diphenhydramine hydrochloride inj

1

levocetirizine dihydrochloride oral soln

1 QL(300/30)

levocetirizine dihydrochloride tabs

1 QL(30/30)

Antileukotrienesmontelukast sodium 1 QL(30/30)zafirlukast 1 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 1 QL(25.8/30)COMBIVENT RESPIMAT 1 QL(8/30)INCRUSE ELLIPTA 1 QL(30/30)ipratropium bromide inhalation soln

1 B/D PA QL(300/30)

ipratropium bromide nasal soln 1 QL(30/30)ipratropium bromide/albuterol sulfate

1 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 1albuterol sulfate hfa aers 108mcg/act (generic for ProAir)

1 QL(17/30)

albuterol sulfate hfa aers 108mcg/act (generic for Ventolin)

1 QL(36/30)

albuterol sulfate nebu 0.5% 1 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

1 B/D PA QL(360/30)

albuterol sulfate syrp 1albuterol sulfate tabs 1ANORO ELLIPTA 1 QL(60/30)epinephrine hcl inj 1mg/10ml 1epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

1 QL(2/30)

EPIPEN 2-PAK 1 QL(2/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

flac 1fluocinolone acetonide ear drops

1

fluocinolone acetonide oil 1hydrocortisone/acetic acid 1neomycin/polymyxin/hc 1neomycin/polymyxin/hydrocortisone otic soln

1

neomycin/polymyxin/hydrocortisone otic susp

1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories,InhaledCorticosteroidsADVAIR DISKUS 1 QL(60/30)ADVAIR HFA 1 QL(12/30)ARNUITY ELLIPTA 1 QL(30/30)BREO ELLIPTA 1 QL(60/30)budesonide susp 1 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

1 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

1 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

1 QL(10.6/30)


1 QL(12/30)


1 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 1 QL(16/30)mometasone furoate susp 1 QL(34/30)XHANCE 1 QL(16/30) STAntihistaminesazelastine hcl nasal soln 1 QL(30/25)azelastine hydrochloride nasal soln

1 QL(30/25)

desloratadine 1 QL(30/30)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Pulmonary Fibrosis AgentsESBRIET CAPS 1 PA NDS QL(270/30)ESBRIET TABS 801MG 1 PA NDS QL(90/30)ESBRIET TABS 267MG 1 PA NDS QL(270/30)OFEV 1 PA NDS QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 1 B/D PAARALAST NP 1 B/D PA NDSPROLASTIN-C 1 B/D PA NDSribavirin inhalation soln 1 B/D PA NDSTRELEGY ELLIPTA 1 QL(60/30)XOLAIR INJ 75MG/0.5ML 1 PA NDS QL(2/28)XOLAIR INJ 150MG/ML 1 PA NDS QL(4/28)XOLAIR VIAL INJ 150MG 1 PA NDS QL(6/28)ZEMAIRA 1 B/D PA NDS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hydrochloride tabs 10mg, 5mg

1 PA QL(90/30)

methocarbamol tabs 1 PAorphenadrine citrate er 1 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam caps 15mg, 30mg 1 QL(60/365)temazepam caps 22.5mg, 7.5mg

1 QL(60/365)

zaleplon 1 QL(30/30)zolpidem tartrate tabs 1 QL(30/30)Sleep Disorders, Otherarmodafinil 1 PA QL(30/30)ramelteon 1 QL(30/30)ROZEREM 1 QL(30/30)SILENOR 1 QL(30/30)XYREM 1 PA NDS QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EPIPEN-JR 2-PAK 1 QL(2/30)levalbuterol tartrate hfa 1 QL(30/30)metaproterenol sulfate 1PERFOROMIST 1 B/D PA QL(120/30)PROAIR HFA 1 QL(17/30)PROAIR RESPICLICK 1 QL(2/30)SEREVENT DISKUS 1 QL(60/30)terbutaline sulfate 1VENTOLIN HFA 1 QL(36/30)Cystic Fibrosis AgentsCAYSTON 1 PA NDS QL(84/56)KALYDECO 1 PA NDS QL(60/30)ORKAMBI PACK 1 PA NDS QL(56/28)ORKAMBI TABS 1 PA NDS QL(120/30)PULMOZYME 1 B/D PA NDS

QL(150/30)TOBI PODHALER 1 NDS QL(1568/365)tobramycin nebu 1 B/D PA NDSMast Cell Stabilizerscromolyn sodium nebu 1 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 1DALIRESP TABS 500MCG 1 PA QL(30/30)DALIRESP TABS 250MCG 1 PA QL(60/365)THEO-24 1theophylline er tb12 300mg 1theophylline er tb24 1Pulmonary AntihypertensivesADEMPAS 1 PA NDS QL(90/30)ambrisentan 1 PA NDS QL(30/30)bosentan 1 PA NDS QL(60/30)LETAIRIS 1 PA NDS QL(30/30)OPSUMIT 1 PA NDS QL(30/30)REMODULIN 1 B/D PA NDSsildenafil citrate tabs 20mg 1 PA QL(90/30)TRACLEER TABS 1 PA NDS QL(60/30)TRACLEER TBSO 1 PA NDStreprostinil 1 B/D PA NDSVENTAVIS 1 PA NDS QL(270/30)

55

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir oral soln . . . . . . . . . . . . . . . . . 29abacavir sulfate/lamivudine . . . . . . . . 29abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 29abacavir tabs . . . . . . . . . . . . . . . . . . . . . 29ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 20ABILIFY MAINTENA . . . . . . . . . . . . . . . 27abiraterone acetate . . . . . . . . . . . . . . . . 21ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 22acamprosate calcium dr . . . . . . . . . . . . 12acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 30acebutolol hcl caps 200mg . . . . . . . . . 35acebutolol hydrochloride caps 400mg . . . . . . . . . . . . . . . . . . . . . . . 35acetaminophen/codeine oral soln . . . 10acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 10acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 10acetazolamide . . . . . . . . . . . . . . . . . . . . . 36acetazolamide er . . . . . . . . . . . . . . . . . . 52acetazolamide sodium . . . . . . . . . . . . . 36acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 52acetylcysteine inhalation soln . . . . . . 54acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ACTEMRA ACTPEN . . . . . . . . . . . . . . . 49ACTEMRA INJ 162MG/0.9ML . . . . . . 49ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 49ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 49acyclovir caps . . . . . . . . . . . . . . . . . . . . 30acyclovir crea . . . . . . . . . . . . . . . . . . . . . 30acyclovir oint . . . . . . . . . . . . . . . . . . . . . 30acyclovir sodium . . . . . . . . . . . . . . . . . . . 30acyclovir susp . . . . . . . . . . . . . . . . . . . . 30acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 30ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 50adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 28

ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 54adriamycin inj 2mg/ml . . . . . . . . . . . . . . 22ADRIAMYCIN INJ 50MG . . . . . . . . . . . 22adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 53ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 53AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . 24AFINITOR DISPERZ TBSO 5MG . . . 24AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 24AFINITOR TABS 10MG . . . . . . . . . . . . 24ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 43albendazole . . . . . . . . . . . . . . . . . . . . . . . 26ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 26albuterol sulfate er . . . . . . . . . . . . . . . . . 53albuterol sulfate hfa aers 108mcg/act (generic for ProAir) . . . . . 53albuterol sulfate hfa aers 108mcg/act (generic for Ventolin) . . 53albuterol sulfate nebu 0.5% . . . . . . . . 53albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 53albuterol sulfate syrp . . . . . . . . . . . . . . 53albuterol sulfate tabs . . . . . . . . . . . . . . 53alclometasone dipropionate . . . . . . . . 43ALCOHOL PREP PADS . . . . . . . . . . . . 12ALDURAZYME . . . . . . . . . . . . . . . . . . . . 43ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 24alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 50alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 50alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 43ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 26ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 26ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 24aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 36allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 20allopurinol sodium . . . . . . . . . . . . . . . . . 20

ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 45alosetron hydrochloride tabs 0.5mg . . . . . . . . . . . . . . . . . . . . . . . . 42alosetron hydrochloride tabs 1mg . . . 42ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 52alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 30alprazolam odt tbdp 2mg . . . . . . . . . . . 30alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 30alprazolam tabs 2mg . . . . . . . . . . . . . . 30altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ALUNBRIG TABS 30MG . . . . . . . . . . . 24ALUNBRIG TABS 180MG, 90MG . . . 24ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 24alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 45alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 45amantadine hcl . . . . . . . . . . . . . . . . . . . . 26AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 20ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 54a-methapred . . . . . . . . . . . . . . . . . . . . . . 43amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 45amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 45amikacin sulfate . . . . . . . . . . . . . . . . . . . 12amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 36amiloride/hydrochlorothiazide . . . . . . 36AMINO ACID . . . . . . . . . . . . . . . . . . . . . . 51aminophylline . . . . . . . . . . . . . . . . . . . . . 54AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 39AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 39AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 39amiodarone hcl inj 50mg/ml, 900mg/18ml . . . . . . . . . . . . . 34amiodarone hcl tabs . . . . . . . . . . . . . . 34amiodarone hydrochloride inj . . . . . . 34AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 42amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 19amitriptyline hydrochloride tabs 10mg, 50mg . . . . . . . . . . . . . . . . . . 19

56


Covered Drugs Index

ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 33ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 32ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 49aripiprazole odt . . . . . . . . . . . . . . . . . . . . 27aripiprazole oral soln . . . . . . . . . . . . . . 27aripiprazole tabs . . . . . . . . . . . . . . . . . . 27ARISTADA INITIO . . . . . . . . . . . . . . . . . 27ARISTADA INJ 441MG/1.6ML . . . . . . 27ARISTADA INJ 662MG/2.4ML . . . . . . 27ARISTADA INJ 882MG/3.2ML . . . . . . 27ARISTADA INJ 1064MG/3.9ML . . . . . 27armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 54ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 53ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 22arsenic trioxide . . . . . . . . . . . . . . . . . . . . 22ascomp/codeine . . . . . . . . . . . . . . . . . . . 10ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 45aspirin/dipyridamole . . . . . . . . . . . . . . . 33ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 48atazanavir sulfate caps 150mg . . . . . 29atazanavir sulfate caps 200mg . . . . . 29atazanavir sulfate caps 300mg . . . . . 29atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 35atenolol/chlorthalidone . . . . . . . . . . . . . 35ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 49atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 38atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 38atorvastatin calcium . . . . . . . . . . . . . . . 36atovaquone . . . . . . . . . . . . . . . . . . . . . . . 26atovaquone/proguanil hcl . . . . . . . . . . 26ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 29atropine sulfate inj 0.5mg/5ml . . . . . . 36atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . 42atropine sulfate ophthalmic soln . . . . 52ATROVENT HFA . . . . . . . . . . . . . . . . . . 53aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

amphotericin b . . . . . . . . . . . . . . . . . . . . 20ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 14ampicillin sodium . . . . . . . . . . . . . . . . . . 14ampicillin-sulbactam . . . . . . . . . . . . . . . 14AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 38ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 45anagrelide hydrochloride . . . . . . . . . . . 32anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 42anastrozole . . . . . . . . . . . . . . . . . . . . . . . 24ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 53APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 26apraclonidine . . . . . . . . . . . . . . . . . . . . . . 52aprepitant caps 40mg . . . . . . . . . . . . . . 19aprepitant caps 80mg . . . . . . . . . . . . . . 19aprepitant caps 125mg . . . . . . . . . . . . . 19aprepitant caps pack . . . . . . . . . . . . . . . 19apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 50APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 16APTIOM TABS 600MG . . . . . . . . . . . . . 16APTIVUS CAPS . . . . . . . . . . . . . . . . . . 29APTIVUS ORAL SOLN . . . . . . . . . . . . 29ARALAST NP . . . . . . . . . . . . . . . . . . . . . 54aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 32ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 32ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 32ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 32ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 33ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 33ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 33ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 33

amlodipine besylate/benazepril hcl caps 5mg; 40mg . . . . . . . . . . . . . . . 35amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 35amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 35amlodipine besylate tabs 2.5mg . . . . 35amlodipine besylate tabs 5mg . . . . . . 35amlodipine besylate tabs 10mg . . . . . 35amlodipine besylate/valsartan . . . . . . 35amlodipine/valsartan/hctz . . . . . . . . . . 35amlodipine/valsartan/ hydrochlorothiazide tabs 5mg; 12.5mg; 160mg . . . . . . . . . . . . . . 35ammonium lactate . . . . . . . . . . . . . . . . . 38amnesteem . . . . . . . . . . . . . . . . . . . . . . . 38amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 19amoxicillin caps . . . . . . . . . . . . . . . . . . . 14amoxicillin chew . . . . . . . . . . . . . . . . . . 14amoxicillin/clavulanate potassium . . . 14amoxicillin/clavulanate potassium er . 14amoxicillin susr . . . . . . . . . . . . . . . . . . . 14amoxicillin tabs . . . . . . . . . . . . . . . . . . . 14amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 37amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . . . . . . . . 37amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 37amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 37

57


Covered Drugs Index

betamethasone valerate crea . . . . . . 43betamethasone valerate foam . . . . . 43betamethasone valerate lotn . . . . . . . 43betamethasone valerate oint . . . . . . . 44BETASERON . . . . . . . . . . . . . . . . . . . . . 38betaxolol hcl ophthalmic soln . . . . . . 52betaxolol hcl tabs . . . . . . . . . . . . . . . . . 35bethanechol chloride . . . . . . . . . . . . . . . 43bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 25BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 50bicalutamide . . . . . . . . . . . . . . . . . . . . . . 21BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 14BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 28BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 26bimatoprost ophthalmic soln . . . . . . . 52BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 50bisoprolol fumarate . . . . . . . . . . . . . . . . 35bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 35bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 22bleomycin sulfate . . . . . . . . . . . . . . . . . . 22BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 15BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 15blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 45BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 50BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 22bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 54BOSULIF TABS 100MG . . . . . . . . . . . . 24BOSULIF TABS 400MG, 500MG . . . 24BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 22BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 53briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 33brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 52brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 52BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 16

BALVERSA TABS 4MG . . . . . . . . . . . . 24BALVERSA TABS 5MG . . . . . . . . . . . . 24balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45BANZEL SUSP . . . . . . . . . . . . . . . . . . . 17BANZEL TABS 200MG . . . . . . . . . . . . 17BANZEL TABS 400MG . . . . . . . . . . . . 17BAQSIMI ONE PACK . . . . . . . . . . . . . . 31BAQSIMI TWO PACK . . . . . . . . . . . . . . 31BARACLUDE ORAL SOLN . . . . . . . . 28BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 25BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 15BCG VACCINE . . . . . . . . . . . . . . . . . . . . 50BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” . . . . 51BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” . . . . 51BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM . . . . . . . . 51BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM . . . . . . . . . . . . . 51BD PEN NEEDLE/MINI/ ULTRA-FINE/31G X 5MM . . . . . . . . . . 51BD PEN NEEDLE/NANO/ ULTRA -FINE/32G X 4MM . . . . . . . . . 51BD PEN NEEDLE/ORIGINAL/ ULTRA-FINE/29G X 12.7MM . . . . . . . 51BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 22benazepril hcl . . . . . . . . . . . . . . . . . . . . . 34benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 34benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 34benazepril hydrochloride . . . . . . . . . . . 34BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 21BENLYSTA INJ 120MG . . . . . . . . . . . . 49BENLYSTA INJ 400MG . . . . . . . . . . . . 49benztropine mesylate inj . . . . . . . . . . . 26benztropine mesylate tabs . . . . . . . . . 26BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 15BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 25betamethasone dipropionate . . . . . . . 43

augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 43AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 14AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 41AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 25aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45avita crea . . . . . . . . . . . . . . . . . . . . . . . . . 39avita gel . . . . . . . . . . . . . . . . . . . . . . . . . . 39AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 38AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 38azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 22AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 14AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 48AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 15azathioprine inj . . . . . . . . . . . . . . . . . . . 48azathioprine tabs . . . . . . . . . . . . . . . . . 48azelastine hcl nasal soln . . . . . . . . . . . 53azelastine hcl ophthalmic soln . . . . . 52azelastine hydrochloride nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 53azithromycin inj . . . . . . . . . . . . . . . . . . . 15azithromycin pack . . . . . . . . . . . . . . . . . 15azithromycin susr 100mg/5ml . . . . . . 15azithromycin susr 200mg/5ml . . . . . . 15azithromycin tabs 250mg, 500mg . . . 15azithromycin tabs 600mg . . . . . . . . . . . 15AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 52aztreonam inj 1gm . . . . . . . . . . . . . . . . . 14AZTREONAM INJ 2GM . . . . . . . . . . . . 14azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Bbacitracin inj . . . . . . . . . . . . . . . . . . . . . . 12bacitracin ophthalmic oint . . . . . . . . . . 12bacitracin/polymyxin b . . . . . . . . . . . . . 12baclofen tabs 10mg, 5mg . . . . . . . . . . 28baclofen tabs 20mg . . . . . . . . . . . . . . . . 28balsalazide disodium . . . . . . . . . . . . . . 50BALVERSA TABS 3MG . . . . . . . . . . . . 24

58


Covered Drugs Index

carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 26carbidopa/levodopa . . . . . . . . . . . . . . . . 26carbidopa/levodopa/entacapone . . . . 26carbidopa/levodopa er . . . . . . . . . . . . . 26carbidopa/levodopa odt . . . . . . . . . . . . 26carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 22carmustine . . . . . . . . . . . . . . . . . . . . . . . . 21CARNITOR INJ . . . . . . . . . . . . . . . . . . . 51carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 52cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 35carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 35carvedilol phosphate . . . . . . . . . . . . . . . 35caspofungin acetate . . . . . . . . . . . . . . . 20CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 54caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45cefaclor caps . . . . . . . . . . . . . . . . . . . . . 14cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 14cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 14cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 14CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 14cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 14cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 14cefdinir caps . . . . . . . . . . . . . . . . . . . . . . 14cefdinir susr . . . . . . . . . . . . . . . . . . . . . . 14cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 14cefepime/dextrose . . . . . . . . . . . . . . . . . 14cefixime caps . . . . . . . . . . . . . . . . . . . . . 14cefixime susr . . . . . . . . . . . . . . . . . . . . . 14cefotaxime sodium inj 1gm, 500mg . . 14cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 14cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 14cefpodoxime proxetil . . . . . . . . . . . . . . . 14cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 14ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 14ceftazidime/dextrose . . . . . . . . . . . . . . . 14ceftriaxone in iso-osmotic dextrose . . . . . . . . . . . . . . . 14

butorphanol tartrate inj 1mg/ml . . . . . 10butorphanol tartrate inj 2mg/ml . . . . . 10butorphanol tartrate nasal soln . . . . . 10BYDUREON BCISE . . . . . . . . . . . . . . . 30BYDUREON PEN . . . . . . . . . . . . . . . . . 30BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 35BYSTOLIC TABS 20MG . . . . . . . . . . . 35

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 48CABOMETYX TABS 20MG, 60MG . . 24CABOMETYX TABS 40MG . . . . . . . . 24calcipotriene crea . . . . . . . . . . . . . . . . . 39calcipotriene external soln . . . . . . . . . 39calcipotriene oint . . . . . . . . . . . . . . . . . . 39calcitonin-salmon . . . . . . . . . . . . . . . . . . 50calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 39calcitriol caps . . . . . . . . . . . . . . . . . . . . . 50calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 50calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 39calcitriol oral soln . . . . . . . . . . . . . . . . . 50calcium acetate caps . . . . . . . . . . . . . . 41calcium acetate tabs 667mg . . . . . . . . 41CALQUENCE . . . . . . . . . . . . . . . . . . . . . 24camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 45camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 45candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 33candesartan cilexetil tabs 16mg, 4mg, 8mg . . . . . . . . . . . . . . . . . . 33candesartan cilexetil tabs 32mg . . . . 33CAPASTAT SULFATE . . . . . . . . . . . . . . 21CAPRELSA TABS 100MG . . . . . . . . . 24CAPRELSA TABS 300MG . . . . . . . . . 24CARAFATE SUSP . . . . . . . . . . . . . . . . 43CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 39carbamazepine . . . . . . . . . . . . . . . . . . . . 17carbamazepine er . . . . . . . . . . . . . . . . . 17

BRIVIACT ORAL SOLN . . . . . . . . . . . 16BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 16BRIVIACT TABS 100MG . . . . . . . . . . . 16bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 52bromocriptine mesylate . . . . . . . . . . . . 26budesonide cpep . . . . . . . . . . . . . . . . . 50budesonide susp . . . . . . . . . . . . . . . . . . 53bumetanide inj . . . . . . . . . . . . . . . . . . . . 36bumetanide tabs 0.5mg, 1mg . . . . . . . 36bumetanide tabs 2mg . . . . . . . . . . . . . . 36buprenorphine hcl inj . . . . . . . . . . . . . . 10buprenorphine hcl/naloxone hcl . . . . . 12buprenorphine hcl subl . . . . . . . . . . . . 12buprenorphine hydrochloride/ naloxone hydrochloride film . . . . . . . . 12buprenorphine ptwk 7.5mcg/hr . . . . . 10BUPRENORPHINE PTWK 10MCG/HR, 15MCG/HR, 20MCG/HR, 5MCG/HR . . . . . . . . . . . . 10bupropion hcl tabs 100mg . . . . . . . . . . 18bupropion hydrochloride er (sr) . . . . . 12bupropion hydrochloride er (sr) . . . . . 18bupropion hydrochloride er (xl) tb24 150mg, 300mg . . . . . . . . . . . . . . . 18bupropion hydrochloride tabs 75mg . . . . . . . . . . . . . . . . . . . . . . . . 18buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 30buspirone hydrochloride tabs 7.5mg . . . . . . . . . . . . . . . . . . . . . . . . 30buspirone hydrochloride tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 30busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 21BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 21butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 10butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 10butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 10butalbital/aspirin/caffeine caps . . . . . 10butalbital/aspirin/caffeine/codeine . . . 10

59


Covered Drugs Index

CLINIMIX 5%/DEXTROSE 15% . . . . 39CLINIMIX 5%/DEXTROSE 20% . . . . 39CLINIMIX 5%/DEXTROSE 25% . . . . 39CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 39CLINISOL SF 15% . . . . . . . . . . . . . . . . 39clobazam susp . . . . . . . . . . . . . . . . . . . . 16clobazam tabs 10mg . . . . . . . . . . . . . . . 16clobazam tabs 20mg . . . . . . . . . . . . . . . 16clobetasol propionate crea . . . . . . . . . 44clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 44clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 44clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 44clobetasol propionate foam . . . . . . . . 44clobetasol propionate gel . . . . . . . . . . 44clobetasol propionate oint . . . . . . . . . 44clobetasol propionate sham . . . . . . . . 44clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 22clomipramine hcl . . . . . . . . . . . . . . . . . . 19clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 16clonazepam odt tbdp 1mg . . . . . . . . . . 16clonazepam odt tbdp 2mg . . . . . . . . . . 17clonazepam tabs 0.5mg . . . . . . . . . . . . 17clonazepam tabs 1mg . . . . . . . . . . . . . 17clonazepam tabs 2mg . . . . . . . . . . . . . 17clonidine hcl er . . . . . . . . . . . . . . . . . . . . 38clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 33clonidine hcl ptwk 0.3mg/24hr . . . . . . 33clonidine hcl tabs 0.1mg . . . . . . . . . . . 33clonidine hcl tabs 0.3mg . . . . . . . . . . . 33clonidine hydrochloride tabs . . . . . . . 33clopidogrel tabs 75mg . . . . . . . . . . . . . 33clopidogrel tabs 300mg . . . . . . . . . . . . 33clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 30

CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 48CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 15ciprofloxacin hcl tabs 100mg . . . . . . . 15ciprofloxacin hcl tabs 750mg . . . . . . . 15ciprofloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 15ciprofloxacin hydrochloride tabs . . . . 15ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 15ciprofloxacin susr . . . . . . . . . . . . . . . . . 15CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 15cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml . . . . . . . . . . 22citalopram hydrobromide oral soln . . 18citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 18citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 18citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 18cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 22claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 39clarithromycin er . . . . . . . . . . . . . . . . . . . 15clarithromycin susr . . . . . . . . . . . . . . . . 15clarithromycin tabs . . . . . . . . . . . . . . . . 15clindacin etz pledgets . . . . . . . . . . . . . . 12clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 12clindamycin hcl caps . . . . . . . . . . . . . . . 12clindamycin phosphate crea . . . . . . . 12clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 12clindamycin phosphate gel . . . . . . . . 13clindamycin phosphate in d5w . . . . . . 13clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml . . . . . . . . . . . . . 13clindamycin phosphate lotn . . . . . . . . 13clindamycin phosphate swab . . . . . . 13clindamycin/sodium chloride . . . . . . . . 13CLINIMIX 4.25%/DEXTROSE 5% . . 39CLINIMIX 4.25%/DEXTROSE 10% . . 39CLINIMIX 4.25%/DEXTROSE 25% . . 39

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 14cefuroxime axetil . . . . . . . . . . . . . . . . . . 14cefuroxime sodium . . . . . . . . . . . . . . . . 14celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 10celecoxib caps 400mg . . . . . . . . . . . . . 10CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 16cephalexin caps 250mg, 500mg . . . . 14cephalexin susr . . . . . . . . . . . . . . . . . . . 14CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 43cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 12CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 12CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 12chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 41chloramphenicol sodium succinate . . 12chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 38chloroquine phosphate . . . . . . . . . . . . . 26chlorothiazide . . . . . . . . . . . . . . . . . . . . . 36chlorothiazide sodium . . . . . . . . . . . . . . 36chlorpromazine hcl inj . . . . . . . . . . . . . 26chlorpromazine hcl tabs . . . . . . . . . . . 26chlorthalidone . . . . . . . . . . . . . . . . . . . . . 36cholestyramine . . . . . . . . . . . . . . . . . . . . 37cholestyramine light . . . . . . . . . . . . . . . 37ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 20ciclopirox nail lacquer . . . . . . . . . . . . . . 20ciclopirox olamine . . . . . . . . . . . . . . . . . 20ciclopirox sham . . . . . . . . . . . . . . . . . . . 20ciclopirox susp . . . . . . . . . . . . . . . . . . . . 20cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 28cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 33CILOXAN OINT . . . . . . . . . . . . . . . . . . . 15CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 29cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 42cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 42

60


Covered Drugs Index

DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 50DAPTOMYCIN INJ 350MG . . . . . . . . . 13daptomycin inj 500mg . . . . . . . . . . . . . . 13DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 26darifenacin hydrobromide er . . . . . . . . 43DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 25dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 46dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 46daunorubicin hcl . . . . . . . . . . . . . . . . . . . 23daunorubicin hydrochloride inj 20mg/4ml . . . . . . . . . . . . . . . . . . . . . . 23DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML . . . . . . . . . . . . . . . . . . . 23DAURISMO TABS 25MG . . . . . . . . . . 23DAURISMO TABS 100MG . . . . . . . . . 23daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 47decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 23DELESTROGEN INJ 10MG/ML . . . . 46DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 28delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46demeclocycline hcl . . . . . . . . . . . . . . . . 16DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 36DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 30DEPEN TITRATABS . . . . . . . . . . . . . . . 41DEPO-ESTRADIOL . . . . . . . . . . . . . . . 46DEPO-MEDROL INJ 20MG/ML . . . . . 44DEPO-PROVERA . . . . . . . . . . . . . . . . . 47DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 29desipramine hcl . . . . . . . . . . . . . . . . . . . 19desloratadine . . . . . . . . . . . . . . . . . . . . . . 53desmopressin acetate inj . . . . . . . . . . 45desmopressin acetate nasal soln . . . 45desmopressin acetate tabs . . . . . . . . 45desogestrel/ethinyl estradiol . . . . . . . . 46desonide lotn . . . . . . . . . . . . . . . . . . . . . 44desonide oint . . . . . . . . . . . . . . . . . . . . . 44desoximetasone crea . . . . . . . . . . . . . 44desoximetasone gel . . . . . . . . . . . . . . . 44

CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 36CRIXIVAN CAPS 200MG . . . . . . . . . . 29CRIXIVAN CAPS 400MG . . . . . . . . . . 29cromolyn sodium conc . . . . . . . . . . . . 42cromolyn sodium nebu . . . . . . . . . . . . 54cromolyn sodium ophthalmic soln . . . 52cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 46CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 41CURITY GAUZE PADS 2”X2” . . . . . . 39cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 46cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 46cyclobenzaprine hydrochloride tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 54cyclophosphamide caps . . . . . . . . . . . 21cyclophosphamide inj . . . . . . . . . . . . . 21cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 21CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 30cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 48cyclosporine modified . . . . . . . . . . . . . . 48CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 25cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 46CYSTADANE . . . . . . . . . . . . . . . . . . . . . 43CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 43CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 52cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 22cytarabine aqueous . . . . . . . . . . . . . . . . 22

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 21dactinomycin . . . . . . . . . . . . . . . . . . . . . . 22dalfampridine er . . . . . . . . . . . . . . . . . . . 38DALIRESP TABS 250MCG . . . . . . . . . 54DALIRESP TABS 500MCG . . . . . . . . . 54danazol caps 50mg . . . . . . . . . . . . . . . . 45danazol caps 100mg, 200mg . . . . . . . 45dantrolene sodium caps . . . . . . . . . . . 28dapsone tabs . . . . . . . . . . . . . . . . . . . . . 21

clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 30clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 20clotrimazole external crea . . . . . . . . . 20clotrimazole external soln . . . . . . . . . . 20clotrimazole lozg . . . . . . . . . . . . . . . . . . 20clozapine odt tbdp 12.5mg, 25mg . . . 28clozapine odt tbdp 100mg . . . . . . . . . . 28clozapine odt tbdp 150mg . . . . . . . . . . 28clozapine odt tbdp 200mg . . . . . . . . . . 28clozapine tabs 25mg, 50mg . . . . . . . . 28clozapine tabs 100mg . . . . . . . . . . . . . . 28clozapine tabs 200mg . . . . . . . . . . . . . . 28COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 26colchicine caps . . . . . . . . . . . . . . . . . . . 20colchicine tabs . . . . . . . . . . . . . . . . . . . . 20colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 37colistimethate sodium . . . . . . . . . . . . . . 13colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 50COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 52COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 52COMBIVENT RESPIMAT . . . . . . . . . . 53COMETRIQ 60MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 24COMETRIQ 100MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 24COMETRIQ 140MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 24COMPLERA . . . . . . . . . . . . . . . . . . . . . . 28compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 19constulose . . . . . . . . . . . . . . . . . . . . . . . . 42COPAXONE INJ 20MG/ML . . . . . . . . . 38COPAXONE INJ 40MG/ML . . . . . . . . . 38COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 22CORLANOR TABS . . . . . . . . . . . . . . . . 36cortisone acetate . . . . . . . . . . . . . . . . . . 44CORTISPORIN-TC . . . . . . . . . . . . . . . . 52COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 22COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 24COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 32

61


Covered Drugs Index

digoxin tabs 250mcg . . . . . . . . . . . . . . . 36digox tabs 125mcg . . . . . . . . . . . . . . . . 36digox tabs 250mcg . . . . . . . . . . . . . . . . 36dihydroergotamine mesylate inj . . . . 20dihydroergotamine mesylate nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 20DILANTIN CAPS 30MG . . . . . . . . . . . . 17diltiazem cd cp24 180mg . . . . . . . . . . . 35diltiazem hcl er cp12 . . . . . . . . . . . . . . 35diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg . . . . . 35diltiazem hcl er tb24 . . . . . . . . . . . . . . . 35diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 35diltiazem hcl tabs . . . . . . . . . . . . . . . . . 35diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg . . . . . 35dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35diphenhydramine hcl inj . . . . . . . . . . . 53diphenhydramine hydrochloride inj . . . 53diphenoxylate/atropine liqd . . . . . . . . 42diphenoxylate/atropine tabs . . . . . . . . 42DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 50disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 12divalproex sodium . . . . . . . . . . . . . . . . . 17divalproex sodium dr . . . . . . . . . . . . . . . 17divalproex sodium er . . . . . . . . . . . . . . . 17docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 23DOCETAXEL INJ 200MG/10ML . . . . 23dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 34donepezil hcl tabs 10mg . . . . . . . . . . . 18donepezil hcl tabs 23mg . . . . . . . . . . . 18donepezil hcl tbdp 5mg . . . . . . . . . . . . 18donepezil hcl tbdp 10mg . . . . . . . . . . . 18donepezil hydrochloride tabs 5mg . . 18donepezil hydrochloride tabs 10mg . . 18dorzolamide hcl . . . . . . . . . . . . . . . . . . . 52dorzolamide hcl/timolol maleate . . . . 52dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

dextrose 10%/nacl 0.2% . . . . . . . . . . . 39dextrose10%/nacl 0.45% . . . . . . . . . . . 39DEXTROSE 20% . . . . . . . . . . . . . . . . . . 40DEXTROSE 25% . . . . . . . . . . . . . . . . . . 40DEXTROSE 30% . . . . . . . . . . . . . . . . . . 40DEXTROSE 40% . . . . . . . . . . . . . . . . . . 40DEXTROSE 50% . . . . . . . . . . . . . . . . . . 40DEXTROSE 70% . . . . . . . . . . . . . . . . . . 40DIACOMIT CAPS 250MG . . . . . . . . . . 17DIACOMIT CAPS 500MG . . . . . . . . . . 17DIACOMIT PACK 250MG . . . . . . . . . . 17DIACOMIT PACK 500MG . . . . . . . . . . 17DIASTAT ACUDIAL GEL 10MG . . . . . 17DIASTAT ACUDIAL GEL 20MG . . . . . 17DIASTAT PEDIATRIC . . . . . . . . . . . . . . 17diazepam inj 5mg/ml . . . . . . . . . . . . . . . 30diazepam oral soln . . . . . . . . . . . . . . . . 30diazepam rectal gel gel 2.5mg . . . . . . 17diazepam rectal gel gel 10mg . . . . . . 17diazepam rectal gel gel 20mg . . . . . . 17diazepam tabs . . . . . . . . . . . . . . . . . . . . 30diclofenac potassium . . . . . . . . . . . . . . 10diclofenac sodium dr . . . . . . . . . . . . . . . 10diclofenac sodium er . . . . . . . . . . . . . . . 10diclofenac sodium gel 1% . . . . . . . . . . 39diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 52diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 39dicloxacillin sodium . . . . . . . . . . . . . . . . 14dicyclomine hcl oral soln . . . . . . . . . . . 42dicyclomine hydrochloride caps . . . . 42dicyclomine hydrochloride tabs . . . . 42didanosine . . . . . . . . . . . . . . . . . . . . . . . . 29DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 15diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 10digitek tabs 0.25mg . . . . . . . . . . . . . . . . 36digitek tabs 0.125mg . . . . . . . . . . . . . . . 36digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 36digoxin tabs 125mcg . . . . . . . . . . . . . . . 36

desoximetasone oint . . . . . . . . . . . . . . 44desvenlafaxine er . . . . . . . . . . . . . . . . . . 18dexamethasone elix . . . . . . . . . . . . . . . 44dexamethasone intensol . . . . . . . . . . . 44dexamethasone oral soln . . . . . . . . . . 44dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 44dexamethasone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 52dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 44dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 44dexmethylphenidate hcl tabs 10mg . . 38dexmethylphenidate hydrochloride tabs 2.5mg, 5mg . . . . . 38dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 23dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 37dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 38dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 38dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 38dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 38dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 38dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 39dextrose 2.5%/nacl 0.45% . . . . . . . . . 40DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 40dextrose5% /electrolyte #48 viaflex . . 39dextrose 5%/lactated ringers . . . . . . . 40dextrose 5%/nacl 0.2% . . . . . . . . . . . . 40DEXTROSE 5%/NACL 0.3% . . . . . . . 40dextrose 5%/nacl 0.9% . . . . . . . . . . . . 40dextrose 5%/nacl 0.33% . . . . . . . . . . . 40dextrose 5%/nacl 0.45% . . . . . . . . . . . 40dextrose 5%/nacl 0.225% . . . . . . . . . . 40DEXTROSE 10% . . . . . . . . . . . . . . . . . . 39

62


Covered Drugs Index

enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 46entacapone . . . . . . . . . . . . . . . . . . . . . . . 26entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 28ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 33enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 49ENVARSUS XR TB24 4MG . . . . . . . . 48EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 28EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 16epinastine hcl . . . . . . . . . . . . . . . . . . . . . 52epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . . . . . . . . . . . . . . . . 53epinephrine hcl inj 1mg/10ml . . . . . . . 53EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 53EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 54epirubicin hcl inj 200mg/100ml . . . . . 23epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17EPIVIR HBV ORAL SOLN . . . . . . . . . 28ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 25ergotamine tartrate/caffeine . . . . . . . . 20ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 24ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 21erlotinib hydrochloride tabs 25mg . . . 24erlotinib hydrochloride tabs 100mg, 150mg . . . . . . . . . . . . . . . . . . . . 24errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 14ertapenem sodium . . . . . . . . . . . . . . . . . 14ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 23ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 15ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 15ERYTHROCIN LACTOBIONATE . . . 15erythrocin stearate . . . . . . . . . . . . . . . . . 15erythromycin base . . . . . . . . . . . . . . . . . 15erythromycin/benzoyl peroxide . . . . . 39erythromycin dr . . . . . . . . . . . . . . . . . . . . 15erythromycin ethylsuccinate susr 200mg/5ml . . . . . . . . . . . . . . . . . . . 15

e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 15efavirenz caps 50mg . . . . . . . . . . . . . . . 28efavirenz caps 200mg . . . . . . . . . . . . . 28efavirenz tabs . . . . . . . . . . . . . . . . . . . . 28ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 43ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 39ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 48ELIGARD INJ 22.5MG . . . . . . . . . . . . . 48ELIGARD INJ 30MG . . . . . . . . . . . . . . . 48ELIGARD INJ 45MG . . . . . . . . . . . . . . . 48elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ELIQUIS STARTER PACK . . . . . . . . . 32ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 32ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 32ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 43ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 23EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EMEND SUSR . . . . . . . . . . . . . . . . . . . . 19emoquette . . . . . . . . . . . . . . . . . . . . . . . . 46EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 25EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 29EMTRIVA ORAL SOLN . . . . . . . . . . . . 29enalapril maleate . . . . . . . . . . . . . . . . . . 34enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 34ENBREL INJ 25MG/0.5ML . . . . . . . . . 48ENBREL INJ 25MG, 50MG/ML . . . . . 48ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 48ENBREL SURECLICK . . . . . . . . . . . . . 48endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 10endocet tabs 325mg; 7.5mg . . . . . . . . 10endocet tabs 325mg; 10mg . . . . . . . . 10ENGERIX-B INJ 10MCG/0.5ML . . . . 50ENGERIX-B INJ 20MCG/ML . . . . . . . 50enoxaparin sodium . . . . . . . . . . . . . . . . 32enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 46

DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 28doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 33doxazosin mesylate tabs 8mg . . . . . . 33doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 30doxepin hydrochloride caps 25mg . . 30doxercalciferol caps 0.5mcg . . . . . . . . 50doxercalciferol caps 1mcg . . . . . . . . . . 50doxercalciferol caps 2.5mcg . . . . . . . . 50doxorubicin hydrochloride liposomal . . . . . . . . . . . . . . . . . . . . . . . . . 23doxorubicin hydrochloride liposome . . . . . . . . . . . . . . . . . . . . . . . . . . 23doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 16doxycycline hyclate caps . . . . . . . . . . 16doxycycline hyclate tabs 20mg . . . . . 16doxycycline hyclate tabs 100mg . . . . 16doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 16doxycycline monohydrate tabs . . . . . 16doxycycline susr . . . . . . . . . . . . . . . . . . 16dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 19DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 22DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 47duloxetine hcl cpep 20mg . . . . . . . . . . 18duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 18duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 18DURAMORPH . . . . . . . . . . . . . . . . . . . . 10DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 52dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 43dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 43

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 20EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 33EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 33ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 42EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 28

63


Covered Drugs Index

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 11FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 41FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 51FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 18FETZIMA TITRATION PACK . . . . . . . 18finasteride tabs 5mg . . . . . . . . . . . . . . . 43FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 48FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 51FIRMAGON INJ 80MG . . . . . . . . . . . . . 48FIRMAGON INJ 120MG . . . . . . . . . . . 48FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 13flac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 43flecainide acetate . . . . . . . . . . . . . . . . . . 34FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 53FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 53FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 53FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 53FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 53fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 20fluconazole in nacl . . . . . . . . . . . . . . . . . 20flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 20fludarabine phosphate inj 50mg . . . . 23fludrocortisone acetate . . . . . . . . . . . . . 44flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 53fluocinolone acetonide body . . . . . . . . 44fluocinolone acetonide crea . . . . . . . . 44fluocinolone acetonide ear drops . . . 53fluocinolone acetonide external soln . . . . . . . . . . . . . . . . . . . . . . 44fluocinolone acetonide oil . . . . . . . . . . 53fluocinolone acetonide oint . . . . . . . . 44fluocinolone acetonide scalp . . . . . . . 44fluocinonide crea 0.1% . . . . . . . . . . . . . 44fluocinonide crea 0.05% . . . . . . . . . . . 44

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 43falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 30famotidine inj . . . . . . . . . . . . . . . . . . . . . 42famotidine premixed . . . . . . . . . . . . . . . 42famotidine tabs 20mg, 40mg . . . . . . . 42FANAPT TABS 1MG, 2MG, 4MG . . . 27FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 27FANAPT TITRATION PACK . . . . . . . . 27FARESTON . . . . . . . . . . . . . . . . . . . . . . . 22FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 30FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 24FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 22febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 20felbamate susp . . . . . . . . . . . . . . . . . . . 17felbamate tabs . . . . . . . . . . . . . . . . . . . . 17felodipine er . . . . . . . . . . . . . . . . . . . . . . . 35femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 46fenofibrate caps 43mg, 50mg . . . . . . . 36fenofibrate caps 67mg . . . . . . . . . . . . . 36fenofibrate caps 130mg, 150mg . . . . 36fenofibrate caps 134mg, 200mg . . . . 36fenofibrate micronized caps 67mg . . 36fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 36fenofibrate tabs 48mg . . . . . . . . . . . . . . 36fenofibrate tabs 54mg . . . . . . . . . . . . . . 36fenofibrate tabs 145mg . . . . . . . . . . . . 36fenofibrate tabs 160mg . . . . . . . . . . . . 36fenofibric acid dr cpdr 45mg . . . . . . . . 36fenofibric acid dr cpdr 135mg . . . . . . . 36fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 10fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 10fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 11

ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML . . . . . . . . . . . . . . . . 15erythromycin ethylsuccinate tabs . . . 15erythromycin external soln . . . . . . . . . 15erythromycin gel . . . . . . . . . . . . . . . . . . 15erythromycin oint . . . . . . . . . . . . . . . . . 15ESBRIET CAPS . . . . . . . . . . . . . . . . . . 54ESBRIET TABS 267MG . . . . . . . . . . . . 54ESBRIET TABS 801MG . . . . . . . . . . . . 54escitalopram oxalate oral soln . . . . . 18escitalopram oxalate tabs 5mg . . . . . 18escitalopram oxalate tabs 10mg . . . . 18escitalopram oxalate tabs 20mg . . . . 18esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 10esomeprazole magnesium . . . . . . . . . 43estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 46estradiol crea . . . . . . . . . . . . . . . . . . . . . 46estradiol pttw . . . . . . . . . . . . . . . . . . . . . 46estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 46estradiol tabs 0.5mg, 1mg, 2mg . . . . 46estradiol tabs 10mcg . . . . . . . . . . . . . . . 46estradiol valerate . . . . . . . . . . . . . . . . . . 46ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 46ethacrynate sodium . . . . . . . . . . . . . . . . 36ethambutol hcl . . . . . . . . . . . . . . . . . . . . 21ethambutol hydrochloride . . . . . . . . . . 21ethosuximide . . . . . . . . . . . . . . . . . . . . . . 16ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 46ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 23etidronate disodium . . . . . . . . . . . . . . . . 50etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 10etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 10etoposide inj . . . . . . . . . . . . . . . . . . . . . . 24EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 21EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 29exemestane . . . . . . . . . . . . . . . . . . . . . . . 24ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 37ezetimibe/simvastatin . . . . . . . . . . . . . . 37

64


Covered Drugs Index

GAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 49GAMUNEX-C INJ 1GM/10ML . . . . . . 49GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 49ganciclovir inj 500mg, 500mg/10ml . 28GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 50GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 42gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 42gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 42gavilyte-n/flavor pack . . . . . . . . . . . . . . 42GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 25gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 22gemcitabine hcl . . . . . . . . . . . . . . . . . . . . 22gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 22gemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml . . . . . . . . . . . . . . . . . . . . . . . 22gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 36generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 42gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 49GENOTROPIN . . . . . . . . . . . . . . . . . . . . 45GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 45GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 45gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 12gentamicin sulfate crea . . . . . . . . . . . . 12gentamicin sulfate inj . . . . . . . . . . . . . . 12gentamicin sulfate oint . . . . . . . . . . . . 12gentamicin sulfate ophthalmic soln . . 12gentamicin sulfate pediatric . . . . . . . . 12GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 28GEODON INJ . . . . . . . . . . . . . . . . . . . . 27GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 38GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 24

fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 32FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 50fosamprenavir calcium . . . . . . . . . . . . . 29fosinopril sodium . . . . . . . . . . . . . . . . . . 34fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 34fosphenytoin sodium . . . . . . . . . . . . . . . 17FREAMINE HBC 6.9% . . . . . . . . . . . . . 40FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 40fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 22furosemide inj . . . . . . . . . . . . . . . . . . . . 36furosemide oral soln . . . . . . . . . . . . . . 36furosemide tabs . . . . . . . . . . . . . . . . . . . 36FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 23FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 29fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 46FYCOMPA SUSP . . . . . . . . . . . . . . . . . 16FYCOMPA TABS . . . . . . . . . . . . . . . . . 16

Ggabapentin caps 100mg . . . . . . . . . . . 17gabapentin caps 300mg, 400mg . . . . 17gabapentin oral soln . . . . . . . . . . . . . . 17gabapentin tabs 600mg . . . . . . . . . . . . 17gabapentin tabs 800mg . . . . . . . . . . . . 17GABITRIL TABS 12MG, 16MG . . . . . 17galantamine hydrobromide er . . . . . . 18galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 18galantamine hydrobromide tabs . . . . 18GAMMAKED INJ 1GM/10ML . . . . . . . 49

fluocinonide external soln . . . . . . . . . . 44fluocinonide gel . . . . . . . . . . . . . . . . . . . 44fluocinonide oint . . . . . . . . . . . . . . . . . . 44fluoride chew 0.25mg . . . . . . . . . . . . . . 40fluoritab chew 0.5mg, 1mg . . . . . . . . . 40fluorometholone . . . . . . . . . . . . . . . . . . . 52fluorouracil crea 0.5% . . . . . . . . . . . . . . 39fluorouracil crea 5% . . . . . . . . . . . . . . . 39fluorouracil external soln . . . . . . . . . . . 39fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 22fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 18fluoxetine hcl caps 20mg . . . . . . . . . . . 18fluoxetine hcl caps 40mg . . . . . . . . . . . 18fluoxetine hydrochloride caps 10mg . . . . . . . . . . . . . . . . . . . . . . . . 18fluoxetine hydrochloride oral soln . . 18fluoxetine hydrochloride tabs 10mg . . 18fluoxetine hydrochloride tabs 20mg . . 19fluphenazine decanoate . . . . . . . . . . . . 26fluphenazine hcl conc . . . . . . . . . . . . . 26fluphenazine hcl inj . . . . . . . . . . . . . . . . 26fluphenazine hcl tabs . . . . . . . . . . . . . . 26fluphenazine hydrochloride . . . . . . . . . 26flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 10flurbiprofen sodium . . . . . . . . . . . . . . . . 52flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 21fluticasone propionate crea . . . . . . . . 44fluticasone propionate oint . . . . . . . . . 44fluticasone propionate susp . . . . . . . . 53fluvoxamine maleate er . . . . . . . . . . . . 19fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 19fluvoxamine maleate tabs 100mg . . . 19FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 22fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 32fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 32fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 32

65


Covered Drugs Index

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK) . . . . . . . . . . . . . 49HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH) . . . . . . . . . . . . . . . . . 49HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 49HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 49HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 49HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 49HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 49HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 32HUMULIN 70/30 KWIKPEN . . . . . . . . 32HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 32HUMULIN N KWIKPEN . . . . . . . . . . . . 32HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 32HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 32HUMULIN R U-500 KWIKPEN. . . . . . 32hydralazine hcl inj . . . . . . . . . . . . . . . . . 37hydralazine hcl tabs . . . . . . . . . . . . . . . 37hydralazine hydrochloride tabs 100mg, 25mg, 50mg . . . . . . . . . . 37hydrochlorothiazide . . . . . . . . . . . . . . . . 36hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . 11hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . 11hydrocodone bitartrate/ acetaminophen oral soln 325mg/15ml; 7.5mg/15ml . . . . . . . . . . 11hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg . . 11hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . . . . . . . . . 11hydrocodone/ibuprofen . . . . . . . . . . . . 11hydrocortisone/acetic acid . . . . . . . . . . 53

haloperidol lactate . . . . . . . . . . . . . . . . . 26haloperidol tabs 0.5mg, 1mg, 2mg, 5mg . . . . . . . . . . . . 26haloperidol tabs 10mg, 20mg . . . . . . . 26HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 28HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 50heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 47heparin sodium/d5w . . . . . . . . . . . . . . . 32heparin sodium/dextrose . . . . . . . . . . . 32heparin sodium inj 5000unit/0.5ml, 5000unit/ml . . . . . . . . 32heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml . . . . . . . . . . 32heparin sodium/nacl 0.9% . . . . . . . . . . 32heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 32heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 32heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9% . . . . . . . . . . . . . . 32heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 32HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 40HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 50HERCEPTIN HYLECTA . . . . . . . . . . . . 25HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 38HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 50HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 32HUMALOG JUNIOR KWIKPEN . . . . 32HUMALOG KWIKPEN . . . . . . . . . . . . . 32HUMALOG MIX 50/50 . . . . . . . . . . . . . 32HUMALOG MIX 50/50 KWIKPEN . . . 32HUMALOG MIX 75/25 . . . . . . . . . . . . . 32HUMALOG MIX 75/25 KWIKPEN . . . 32HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 49HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 49

GLEOSTINE CAPS 10MG, 40MG . . 21GLEOSTINE CAPS 100MG . . . . . . . . 21glimepiride tabs 1mg . . . . . . . . . . . . . . . 30glimepiride tabs 2mg . . . . . . . . . . . . . . . 30glimepiride tabs 4mg . . . . . . . . . . . . . . . 30glipizide er tb24 2.5mg . . . . . . . . . . . . . 31glipizide er tb24 5mg . . . . . . . . . . . . . . . 30glipizide er tb24 10mg . . . . . . . . . . . . . 30glipizide/metformin hydrochloride tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . 31glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg . . . 31glipizide tabs 5mg . . . . . . . . . . . . . . . . . 31glipizide tabs 10mg . . . . . . . . . . . . . . . . 31glipizide xl tb24 2.5mg . . . . . . . . . . . . . 31glipizide xl tb24 5mg . . . . . . . . . . . . . . . 31glipizide xl tb24 10mg . . . . . . . . . . . . . . 31GLUCAGEN HYPOKIT . . . . . . . . . . . . 31GLUCAGON EMERGENCY KIT . . . . 32glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 42glycopyrrolate tabs 1mg, 2mg . . . . . . 42glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 31GRALISE . . . . . . . . . . . . . . . . . . . . . . . . . 17GRALISE STARTER . . . . . . . . . . . . . . . 17granisetron hcl inj 1mg/ml . . . . . . . . . . 19granisetron hcl tabs . . . . . . . . . . . . . . . 19granisetron hydrochloride . . . . . . . . . . 19griseofulvin microsize . . . . . . . . . . . . . . 20griseofulvin ultramicrosize . . . . . . . . . . 20GUANIDINE HCL . . . . . . . . . . . . . . . . . . 21

Hhailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 46HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 23halobetasol propionate crea . . . . . . . 44halobetasol propionate oint . . . . . . . . 44haloperidol conc . . . . . . . . . . . . . . . . . . 26haloperidol decanoate . . . . . . . . . . . . . 26

66


Covered Drugs Index

INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 27INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 27INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 27INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 27INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 27INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 52INVIRASE . . . . . . . . . . . . . . . . . . . . . . . . 29INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 31INVOKAMET XR . . . . . . . . . . . . . . . . . . 31INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 31IPOL INACTIVATED IPV . . . . . . . . . . . 50ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 53ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 53ipratropium bromide nasal soln . . . . 53irbesartan/hydrochlorothiazide . . . . . . 33irbesartan tabs 150mg, 75mg . . . . . . 33irbesartan tabs 300mg . . . . . . . . . . . . . 33IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 23irinotecan hydrochloride . . . . . . . . . . . . 23irinotecan hydrochloride . . . . . . . . . . . . 24irinotecan inj 100mg/5ml, 500mg/25ml . . . . . . . . . . . 23ISENTRESS CHEW 25MG . . . . . . . . . 28ISENTRESS CHEW 100MG . . . . . . . 28ISENTRESS HD . . . . . . . . . . . . . . . . . . . 28ISENTRESS PACK . . . . . . . . . . . . . . . 28ISENTRESS TABS . . . . . . . . . . . . . . . . 28isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 46isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 21isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 21isoniazid tabs . . . . . . . . . . . . . . . . . . . . . 21isosorbide dinitrate er . . . . . . . . . . . . . . 37

ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 21ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 52imatinib mesylate . . . . . . . . . . . . . . . . . . 24IMBRUVICA CAPS 70MG . . . . . . . . . . 24IMBRUVICA CAPS 140MG. . . . . . . . . 24IMBRUVICA TABS . . . . . . . . . . . . . . . . 24IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 25imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 14imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 14imipramine hcl tabs 25mg, 50mg . . . 19imipramine hydrochloride . . . . . . . . . . 19imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 39imiquimod pump . . . . . . . . . . . . . . . . . . . 39IMOVAX RABIES (H.D.C.V.) . . . . . . . 50incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 45INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 53indapamide . . . . . . . . . . . . . . . . . . . . . . . 36INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 50INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 22INFUMORPH 200 . . . . . . . . . . . . . . . . . 10INFUMORPH 500 . . . . . . . . . . . . . . . . . 10INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 23INTELENCE TABS 25MG . . . . . . . . . . 29INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 28INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 51INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 28INTRON A INJ 6000000UNIT/ML . . . 28introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 46INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 14INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 27

hydrocortisone butyrate crea . . . . . . . 44hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone butyrate (lipid) . . . . . . 44hydrocortisone butyrate (lipophilic) . . 44hydrocortisone butyrate oint . . . . . . . 44hydrocortisone enem . . . . . . . . . . . . . . 50hydrocortisone external crea . . . . . . . 44hydrocortisone lotn 2.5% . . . . . . . . . . . 44hydrocortisone oint 1%, 2.5% . . . . . . 44hydrocortisone rectal crea . . . . . . . . . 44hydrocortisone tabs . . . . . . . . . . . . . . . 44hydrocortisone valerate . . . . . . . . . . . . 44hydromorphone hcl dosette . . . . . . . . 11hydromorphone hcl inj . . . . . . . . . . . . . 11hydromorphone hcl liqd . . . . . . . . . . . 11hydromorphone hcl tabs 2mg, 4mg . . 11hydromorphone hcl tabs 8mg . . . . . . . 11hydroxychloroquine sulfate . . . . . . . . . 26hydroxyprogesterone caproate . . . . . 47hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 22hyoscyamine sulfate elix . . . . . . . . . . . 42hyoscyamine sulfate subl . . . . . . . . . . 42hyoscyamine sulfate tabs . . . . . . . . . . 42hyoscyamine sulfate tbdp . . . . . . . . . . 42

Iibandronate sodium tabs . . . . . . . . . . 50IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 24ibuprofen susp . . . . . . . . . . . . . . . . . . . . 10ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 10ibu tabs 600mg, 800mg . . . . . . . . . . . . 10icatibant acetate . . . . . . . . . . . . . . . . . . . 48ICLUSIG TABS 15MG . . . . . . . . . . . . . 24ICLUSIG TABS 45MG . . . . . . . . . . . . . 24idarubicin hcl inj 10mg/10ml . . . . . . . . 23idarubicin hydrochloride inj 10mg/10ml . . . . . . . . . . . . . . . . . . . . . 23IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

67


Covered Drugs Index

Llabetalol hydrochloride inj 5mg/ml . . 35labetalol hydrochloride tabs . . . . . . . . 35LACRISERT . . . . . . . . . . . . . . . . . . . . . . 52LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 40LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 51LACTATED RINGERS VIAFLEX . . . . 40lactulose oral soln . . . . . . . . . . . . . . . . . 42lamivudine oral soln . . . . . . . . . . . . . . . 29lamivudine tabs 100mg . . . . . . . . . . . . 28lamivudine tabs 150mg . . . . . . . . . . . . 29lamivudine tabs 300mg . . . . . . . . . . . . 29lamivudine/zidovudine . . . . . . . . . . . . . 29lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 17lamotrigine er . . . . . . . . . . . . . . . . . . . . . 17lamotrigine odt . . . . . . . . . . . . . . . . . . . . 17LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 32LANTUS SOLOSTAR . . . . . . . . . . . . . . 32larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 46larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 46larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 46larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 46larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 23latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 52LATUDA TABS 80MG . . . . . . . . . . . . . . 27LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 27leflunomide . . . . . . . . . . . . . . . . . . . . . . . 49LENVIMA 4 MG DAILY DOSE . . . . . . 25LENVIMA 8 MG DAILY DOSE . . . . . . 25LENVIMA 10 MG DAILY DOSE . . . . . 25LENVIMA 12MG DAILY DOSE . . . . . 25LENVIMA 14 MG DAILY DOSE . . . . . 25LENVIMA 18 MG DAILY DOSE . . . . . 25LENVIMA 20 MG DAILY DOSE . . . . . 25LENVIMA 24 MG DAILY DOSE . . . . . 25

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 40KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 25KALETRA TABS 100MG; 25MG . . . . 29KALETRA TABS 200MG; 50MG . . . . 29KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 54KANJINTI INJ 420MG . . . . . . . . . . . . . 25kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 40KCL 0.3%/D5W/NACL 0.45% . . . . . . 40KCL 0.15%/D5W/NACL 0.2% . . . . . . 40KCL 0.15%/D5W/NACL 0.9% . . . . . . 40KCL 0.15%/D5W/NACL 0.45% . . . . . 40KCL 0.15%/D5W/NACL 0.225% . . . . 40KCL 0.075%/D5W/NACL 0.45% . . . . 40kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 46kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 46ketoconazole crea . . . . . . . . . . . . . . . . 20ketoconazole sham . . . . . . . . . . . . . . . 20ketoconazole tabs . . . . . . . . . . . . . . . . . 20ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 52KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 25KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 50kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 23KISQALI FEMARA 200 DOSE . . . . . . 21KISQALI FEMARA 400 DOSE . . . . . . 21KISQALI FEMARA 600 DOSE . . . . . . 21klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 40KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 40KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 40klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 40klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 40klor-con sprinkle . . . . . . . . . . . . . . . . . . . 40KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 51kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 43KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 24

isosorbide dinitrate tabs . . . . . . . . . . . 37isosorbide mononitrate . . . . . . . . . . . . . 37isosorbide mononitrate er . . . . . . . . . . 37isotonic gentamicin . . . . . . . . . . . . . . . . 12isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 39isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 35ISTODAX (OVERFILL) . . . . . . . . . . . . . 23itraconazole caps . . . . . . . . . . . . . . . . . 20itraconazole oral soln . . . . . . . . . . . . . . 20ivermectin tabs . . . . . . . . . . . . . . . . . . . 26IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 41JADENU SPRINKLE . . . . . . . . . . . . . . . 41JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 24jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 32JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 31JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 31JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 31JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 31JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 31jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 47JENTADUETO . . . . . . . . . . . . . . . . . . . . 31JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 31JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 31JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 23jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 28junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 46junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 46junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 46junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 46

68


Covered Drugs Index

LONSURF TABS 8.19MG; 20MG . . . 22loperamide hcl caps . . . . . . . . . . . . . . . 42lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 29lorazepam conc . . . . . . . . . . . . . . . . . . . 30lorazepam inj 2mg/ml, 4mg/ml . . . . . . 30lorazepam intensol . . . . . . . . . . . . . . . . 30lorazepam tabs 0.5mg, 1mg . . . . . . . . 30lorazepam tabs 2mg . . . . . . . . . . . . . . . 30LORBRENA TABS 25MG . . . . . . . . . . 23LORBRENA TABS 100MG . . . . . . . . . 23lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 11lorcet plus tabs 325mg; 7.5mg . . . . . . 11losartan potassium . . . . . . . . . . . . . . . . 33losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 34losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 34LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 52LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 52lovastatin tabs 10mg, 20mg . . . . . . . . 37lovastatin tabs 40mg . . . . . . . . . . . . . . . 37low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 46loxapine . . . . . . . . . . . . . . . . . . . . . . . . . . 26loxapine succinate . . . . . . . . . . . . . . . . . 26ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 52LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 43LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 25LUPRON DEPOT (1-MONTH) . . . . . . 48LUPRON DEPOT (3-MONTH) . . . . . . 48LUPRON DEPOT (4-MONTH) . . . . . . 48LUPRON DEPOT (6-MONTH) . . . . . . 48LUPRON DEPOT-PED (1-MONTH) . . 48LUPRON DEPOT-PED (3-MONTH) . . 48lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 23LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 16

levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 48LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . 48LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 29LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 25lidocaine hcl external soln . . . . . . . . . 12lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% . . . . . . . . . . . 12lidocaine hcl inj 100mg/5ml, 50mg/5ml . . . . . . . . . . . . . 34lidocaine hcl jelly gel . . . . . . . . . . . . . . 12lidocaine hcl mouth/throat soln . . . . . 12lidocaine hcl prsy . . . . . . . . . . . . . . . . . 12lidocaine hcl viscous . . . . . . . . . . . . . . . 12lidocaine oint . . . . . . . . . . . . . . . . . . . . . 12lidocaine/prilocaine crea . . . . . . . . . . . 12lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 12lidocaine viscous . . . . . . . . . . . . . . . . . . 12lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 13lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 13linezolid susr . . . . . . . . . . . . . . . . . . . . . 13linezolid tabs . . . . . . . . . . . . . . . . . . . . . 13LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 42liothyronine sodium inj . . . . . . . . . . . . . 48liothyronine sodium tabs . . . . . . . . . . . 48LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 51lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 34lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 34lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 34lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 30lithium carbonate caps 300mg . . . . . . 30lithium carbonate er . . . . . . . . . . . . . . . . 30lithium carbonate tabs . . . . . . . . . . . . . 30LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 37LONSURF TABS 6.14MG; 15MG . . . 22

lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 54letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 24leucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg . . . . . . . . 23leucovorin calcium tabs . . . . . . . . . . . 23LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 21LEUKINE INJ 250MCG . . . . . . . . . . . . 33leuprolide acetate . . . . . . . . . . . . . . . . . 48levalbuterol tartrate hfa . . . . . . . . . . . . 54LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 32LEVEMIR FLEXTOUCH . . . . . . . . . . . 32levetiracetam er tb24 500mg . . . . . . . 16levetiracetam er tb24 750mg . . . . . . . 16levetiracetam inj . . . . . . . . . . . . . . . . . . 16levetiracetam oral soln . . . . . . . . . . . . 16levetiracetam/sodium chloride . . . . . . 16levetiracetam tabs . . . . . . . . . . . . . . . . 16levobunolol hcl . . . . . . . . . . . . . . . . . . . . 52levocarnitine . . . . . . . . . . . . . . . . . . . . . . 51levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 53levocetirizine dihydrochloride tabs . . 53levofloxacin in d5w . . . . . . . . . . . . . . . . 15levofloxacin inj . . . . . . . . . . . . . . . . . . . . 15levofloxacin oral soln . . . . . . . . . . . . . . 15levofloxacin tabs 250mg, 750mg . . . . 15levofloxacin tabs 500mg . . . . . . . . . . . 15levoleucovorin . . . . . . . . . . . . . . . . . . . . . 23levoleucovorin calcium . . . . . . . . . . . . . 23levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 46levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 46levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 46levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 46levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 46levothyroxine sodium tabs . . . . . . . . . 48

69


Covered Drugs Index

methimazole . . . . . . . . . . . . . . . . . . . . . . 48methocarbamol tabs . . . . . . . . . . . . . . 54methotrexate sodium . . . . . . . . . . . . . . 49methotrexate tabs . . . . . . . . . . . . . . . . . 49methoxsalen . . . . . . . . . . . . . . . . . . . . . . 39methscopolamine bromide . . . . . . . . . 42methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 38methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 38methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 38methylphenidate hydrochloride er tbcr 10mg . . . . . . . . . . . . . . . . . . . . . . 38methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 38methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 38methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 38methylprednisolone acetate inj 80mg/ml . . . . . . . . . . . . . . . . . . . . . . . 44methylprednisolone dose pack . . . . . 44methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 44methylprednisolone tabs . . . . . . . . . . . 44metoclopramide hcl inj . . . . . . . . . . . . 42metoclopramide hcl oral soln . . . . . . 42metoclopramide hcl tabs . . . . . . . . . . . 42metoclopramide hydrochloride . . . . . . 42metolazone . . . . . . . . . . . . . . . . . . . . . . . 36metoprolol/hydrochlorothiazide . . . . . 35metoprolol succinate er . . . . . . . . . . . . 35metoprolol tartrate inj . . . . . . . . . . . . . . 35metoprolol tartrate tabs . . . . . . . . . . . . 35metronidazole crea . . . . . . . . . . . . . . . . 13metronidazole gel . . . . . . . . . . . . . . . . . 13metronidazole inj 500mg/100ml; 0.79% . . . . . . . . . . . . . . 13metronidazole in nacl 0.79% . . . . . . . 13metronidazole lotn . . . . . . . . . . . . . . . . 13metronidazole tabs . . . . . . . . . . . . . . . . 13

memantine hcl tabs 5mg . . . . . . . . . . . 18memantine hcl tabs 10mg . . . . . . . . . . 18memantine hcl titration pak . . . . . . . . . 18memantine hydrochloride er . . . . . . . . 18memantine hydrochloride oral soln . . 18MENACTRA . . . . . . . . . . . . . . . . . . . . . . 50MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 46MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 46MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 50mercaptopurine . . . . . . . . . . . . . . . . . . . . 22meropenem . . . . . . . . . . . . . . . . . . . . . . . 14meropenem/sodium chloride . . . . . . . 14mesalamine dr tbec 1.2gm . . . . . . . . . 50mesalamine enem . . . . . . . . . . . . . . . . 50mesalamine kit . . . . . . . . . . . . . . . . . . . . 50mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23MESNEX TABS . . . . . . . . . . . . . . . . . . . 23metadate er . . . . . . . . . . . . . . . . . . . . . . . 38metaproterenol sulfate . . . . . . . . . . . . . 54metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 31metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 31metformin hcl er tb24 1000mg, 500mg (generic for Fortamet) . . . . . . 31metformin hydrochloride oral soln . . . 31metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 31metformin hydrochloride tabs 850mg . . . . . . . . . . . . . . . . . . . . . . . 31metformin hydrochloride tabs 1000mg . . . . . . . . . . . . . . . . . . . . . . 31methadone hcl conc . . . . . . . . . . . . . . . 10methadone hcl inj . . . . . . . . . . . . . . . . . 10methadone hcl intensol . . . . . . . . . . . . 10methadone hcl oral soln 5mg/5ml . . . 10methadone hcl oral soln 10mg/5ml . . 10methadone hcl tabs 5mg . . . . . . . . . . . 10methadone hcl tabs 10mg . . . . . . . . . . 10methazolamide . . . . . . . . . . . . . . . . . . . . 36methenamine hippurate . . . . . . . . . . . . 13

LYRICA CAPS 225MG, 300MG . . . . . 16LYRICA CR TB24 165MG, 82.5MG . . 38LYRICA CR TB24 330MG . . . . . . . . . . 38LYRICA ORAL SOLN . . . . . . . . . . . . . . 16LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 48lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Mmagnesium sulfate in d5w . . . . . . . . . . 16MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML . . . . . . . . . . . . . . . . . . . . . . . . 40magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 40MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 47MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 47malathion . . . . . . . . . . . . . . . . . . . . . . . . . 26maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 18marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 46MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 18MATULANE . . . . . . . . . . . . . . . . . . . . . . . 21matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 35meclizine hcl tabs . . . . . . . . . . . . . . . . . 19MEDROL TABS 2MG . . . . . . . . . . . . . . 44medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 47medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 47medroxyprogesterone acetate tabs . . 47mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 26megestrol acetate susp 40mg/ml . . . 47megestrol acetate tabs . . . . . . . . . . . . 47MEKINIST TABS 0.5MG . . . . . . . . . . . 25MEKINIST TABS 2MG . . . . . . . . . . . . . 25MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 23melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 46meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 10melphalan hydrochloride . . . . . . . . . . . 21

70


Covered Drugs Index

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 10nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35nadolol/bendroflumethiazide . . . . . . . . 35nafcillin sodium . . . . . . . . . . . . . . . . . . . . 14naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 20naftifine hydrochloride . . . . . . . . . . . . . 20NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 20NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 43nalbuphine hcl inj 10mg/ml . . . . . . . . . 11nalbuphine hcl inj 20mg/ml . . . . . . . . . 11naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 12naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 12NAMZARIC C4PK . . . . . . . . . . . . . . . . 38NAMZARIC CP24 . . . . . . . . . . . . . . . . . 38naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 10naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 10naproxen susp . . . . . . . . . . . . . . . . . . . . 10naproxen tabs 250mg . . . . . . . . . . . . . . 10naproxen tabs 375mg, 500mg . . . . . . 10naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 20NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 12NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 20nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 31NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 51NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 16NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 26necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 46nefazodone hcl . . . . . . . . . . . . . . . . . . . . 18nefazodone hydrochloride . . . . . . . . . . 18neomycin/bacitracin/polymyxin . . . . . 13neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 13neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 52neomycin/polymyxin/gramicidin . . . . . 13neomycin/polymyxin/hc . . . . . . . . . . . . 53neomycin/polymyxin/ hydrocortisone ophthalmic susp . . . . 13

morgidox 1x100mg caps . . . . . . . . . . 16morgidox 2x100mg caps . . . . . . . . . . 16morphine sulfate er tbcr . . . . . . . . . . . 10morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 11morphine sulfate inj 1mg/ml, 50mg/ml . . . . . . . . . . . . . . . . . . 11MORPHINE SULFATE INJ 2MG/ML . . 11MORPHINE SULFATE INJ 4MG/ML . . 11MORPHINE SULFATE INJ 5MG/ML . . 11MORPHINE SULFATE INJ 8MG/ML . . 11MORPHINE SULFATE INJ 10MG/ML . 11morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 11morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 11morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 11MORPHINE SULFATE TABS . . . . . . 11MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 42moxifloxacin hcl . . . . . . . . . . . . . . . . . . . 15moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 15moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 15moxifloxacin hydrochloride tabs . . . . 15MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 33MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 34multivitamin with fluoride chew . . . . . 42mupirocin crea . . . . . . . . . . . . . . . . . . . . 13mupirocin oint . . . . . . . . . . . . . . . . . . . . 13MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25mycophenolate mofetil caps . . . . . . . 49mycophenolate mofetil inj . . . . . . . . . . 49mycophenolate mofetil susr . . . . . . . . 49mycophenolate mofetil tabs . . . . . . . . 49mycophenolic acid dr . . . . . . . . . . . . . . 49MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 25myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 39MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 43

metronidazole vaginal . . . . . . . . . . . . . . 13mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 34MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 50mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 46microgestin 1.5/30 . . . . . . . . . . . . . . . . . 46microgestin 1/20 . . . . . . . . . . . . . . . . . . . 46microgestin fe . . . . . . . . . . . . . . . . . . . . . 46microgestin fe 1.5/30 . . . . . . . . . . . . . . 46midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 33migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 20miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 43mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 37MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 46minocycline hcl . . . . . . . . . . . . . . . . . . . . 16minocycline hydrochloride caps 100mg, 50mg . . . . . . . . . . . . . . . . 16minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 37mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 18mirtazapine odt . . . . . . . . . . . . . . . . . . . . 18misoprostol . . . . . . . . . . . . . . . . . . . . . . . 43MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 20mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10mitomycin inj 20mg, 5mg . . . . . . . . . . . 23mitomycin inj 40mg . . . . . . . . . . . . . . . . 23mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 23M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 50moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 34molindone hydrochloride . . . . . . . . . . . 27mometasone furoate crea . . . . . . . . . 44mometasone furoate external soln . . 44mometasone furoate oint . . . . . . . . . . 44mometasone furoate susp . . . . . . . . . 53mondoxyne nl caps 75mg . . . . . . . . . . 16mondoxyne nl caps 100mg . . . . . . . . . 16mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 46montelukast sodium . . . . . . . . . . . . . . . 53MONUROL . . . . . . . . . . . . . . . . . . . . . . . 13morgidox 1x50mg . . . . . . . . . . . . . . . . . 16

71


Covered Drugs Index

NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 27NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 51NUZYRA INJ . . . . . . . . . . . . . . . . . . . . . 16NUZYRA TABS . . . . . . . . . . . . . . . . . . . 16nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 20nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 20nystatin/triamcinolone . . . . . . . . . . . . . . 20nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ooctreotide acetate . . . . . . . . . . . . . . . . . 48ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 29ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 23OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 15ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 47olanzapine/fluoxetine . . . . . . . . . . . . . . 19olanzapine inj . . . . . . . . . . . . . . . . . . . . . 27olanzapine odt . . . . . . . . . . . . . . . . . . . . 27olanzapine tabs . . . . . . . . . . . . . . . . . . . 27olmesartan medoxomil . . . . . . . . . . . . . 34olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 34olopatadine hcl ophthalmic soln . . . . 52olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 52omega-3-acid ethyl esters . . . . . . . . . . 37omeprazole cpdr . . . . . . . . . . . . . . . . . . 43OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 51OMNIPOD DASH 5 PACK. . . . . . . . . . 51OMNIPOD STARTER KIT . . . . . . . . . . 51ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 23ondansetron hcl oral soln . . . . . . . . . . 19ondansetron hcl tabs . . . . . . . . . . . . . . 20ondansetron hydrochloride inj . . . . . . 20ondansetron hydrochloride tabs . . . . 20ondansetron odt . . . . . . . . . . . . . . . . . . . 20ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 17ONFI TABS 10MG . . . . . . . . . . . . . . . . . 17ONFI TABS 20MG . . . . . . . . . . . . . . . . . 17

nitroglycerin lingual . . . . . . . . . . . . . . . . 37nitroglycerin subl . . . . . . . . . . . . . . . . . . 37nitroglycerin transdermal . . . . . . . . . . . 37nizatidine caps . . . . . . . . . . . . . . . . . . . . 42nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 47norethindrone . . . . . . . . . . . . . . . . . . . . . 47norethindrone acetate . . . . . . . . . . . . . . 47norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 46norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 46norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 46norgestimate/ethinyl estradiol . . . . . . 47norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 47NORMOSOL-M IN D5W . . . . . . . . . . . 40NORMOSOL -R . . . . . . . . . . . . . . . . . . . 40NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 40NORMOSOL-R IN D5W. . . . . . . . . . . . 40NORTHERA CAPS 100MG . . . . . . . . 36NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 36nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 47nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 47nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 47nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 19nortriptyline hydrochloride . . . . . . . . . . 19NORVIR ORAL SOLN . . . . . . . . . . . . . 29NORVIR PACK . . . . . . . . . . . . . . . . . . . 29NORVIR TABS . . . . . . . . . . . . . . . . . . . . 30NOVOFINE 31 . . . . . . . . . . . . . . . . . . . . 51NOVOFINE 32GX6MM . . . . . . . . . . . . 51NOVOFINE AUTOCOVER 30GX8MM . . . . . . . . . . . . . . . . . . . . . . . . 51NOVOTWIST 32GX5MM . . . . . . . . . . . 51NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 20NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 20NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 22NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 38nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 49

neomycin/polymyxin/ hydrocortisone otic soln . . . . . . . . . . . 53neomycin/polymyxin/ hydrocortisone otic susp . . . . . . . . . . . 53neomycin sulfate . . . . . . . . . . . . . . . . . . 12neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 13neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 13NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 40NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 23NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 26nevirapine er tb24 100mg . . . . . . . . . . 29nevirapine er tb24 400mg . . . . . . . . . . 29nevirapine susp . . . . . . . . . . . . . . . . . . . 29nevirapine tabs . . . . . . . . . . . . . . . . . . . 29NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 25niacin er tbcr 500mg . . . . . . . . . . . . . . . 37niacin er tbcr 1000mg, 750mg . . . . . . 37niacin tabs 500mg . . . . . . . . . . . . . . . . . 37niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37nicardipine hcl caps . . . . . . . . . . . . . . . 35nicardipine hcl inj . . . . . . . . . . . . . . . . . 35NICOTROL INHALER. . . . . . . . . . . . . . 12NICOTROL NS . . . . . . . . . . . . . . . . . . . . 12nifedipine er tb24 30mg, 60mg . . . . . 35nifedipine er tb24 90mg . . . . . . . . . . . . 35nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 21nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 35NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 23NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 22nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg . . . . . . . 36nisoldipine er tb24 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 36NITISINONE CAPS 2MG . . . . . . . . . . 43nitisinone caps 10mg, 5mg . . . . . . . . . 43nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 13nitrofurantoin macrocrystals . . . . . . . . 13nitrofurantoin monohydrate . . . . . . . . . 13nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 13nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 37

72


Covered Drugs Index

PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 26pentamidine isethionate . . . . . . . . . . . . 26pentoxifylline er . . . . . . . . . . . . . . . . . . . . 36PERFOROMIST . . . . . . . . . . . . . . . . . . . 54PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 40perindopril erbumine . . . . . . . . . . . . . . . 34PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 25permethrin . . . . . . . . . . . . . . . . . . . . . . . . 26perphenazine . . . . . . . . . . . . . . . . . . . . . 27perphenazine/amitriptyline . . . . . . . . . 19PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 27pfizerpen inj 20000000unit, 5000000unit . . . . . . . . 14phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 19phenazopyridine hydrochloride . . . . . 43phenazopyridine hydrocholride . . . . . 43phenelzine sulfate . . . . . . . . . . . . . . . . . 18phenobarbital elix . . . . . . . . . . . . . . . . . 17phenobarbital tabs . . . . . . . . . . . . . . . . 17phenoxybenzamine hydrochloride . . 33phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 17phenytoin infatabs . . . . . . . . . . . . . . . . . 17phenytoin sodium . . . . . . . . . . . . . . . . . . 17phenytoin sodium extended . . . . . . . . 17philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 41PHOSPHOLINE IODIDE . . . . . . . . . . . 52PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 51physiosol irrigation . . . . . . . . . . . . . . . . . 51PICATO GEL 0.05% . . . . . . . . . . . . . . . 39PICATO GEL 0.015% . . . . . . . . . . . . . . 39PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 29pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 38pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 52pilocarpine hydrochloride tabs 5mg . . 38pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 39pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 27pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 47pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 35pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 31

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 34paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 23paliperidone er tb24 1.5mg, 3mg . . . 27paliperidone er tb24 6mg . . . . . . . . . . . 27paliperidone er tb24 9mg . . . . . . . . . . . 27palonosetron hydrochloride inj 0.25mg/5ml . . . . . . . . . . . . . . . . . . . . . . . 20pamidronate disodium . . . . . . . . . . . . . 50PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 25pantoprazole sodium tbec . . . . . . . . . 43paricalcitol caps 1mcg, 2mcg . . . . . . . 51paricalcitol caps 4mcg . . . . . . . . . . . . . 51paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38paromomycin sulfate . . . . . . . . . . . . . . . 12paroxetine hcl er tb24 12.5mg . . . . . . 19paroxetine hcl er tb24 25mg, 37.5mg . . . . . . . . . . . . . . . . . . . . . 19paroxetine hcl tabs 10mg . . . . . . . . . . 19paroxetine hcl tabs 30mg, 40mg . . . . 19paroxetine hydrochloride tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 19PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 21PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 19PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 52PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 50PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 50peg 3350/electrolytes . . . . . . . . . . . . . . 42peg-3350/electrolytes . . . . . . . . . . . . . . 42peg-3350/nacl/na bicarbonate/kcl . . . 42PEGANONE . . . . . . . . . . . . . . . . . . . . . . 17PEGASYS INJ 180MCG/0.5ML . . . . . 28PEGASYS INJ 180MCG/ML . . . . . . . . 28PEGASYS PROCLICK . . . . . . . . . . . . . 28penicillamine . . . . . . . . . . . . . . . . . . . . . . 41penicillin g potassium . . . . . . . . . . . . . . 14penicillin v potassium oral soln . . . . . 14penicillin v potassium tabs 250mg . . 14penicillin v potassium tabs 500mg . . 14

OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 25OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 54oralone dental paste . . . . . . . . . . . . . . . 38ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 43ORKAMBI PACK . . . . . . . . . . . . . . . . . . 54ORKAMBI TABS . . . . . . . . . . . . . . . . . . 54orphenadrine citrate er . . . . . . . . . . . . . 54orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 42oseltamivir phosphate . . . . . . . . . . . . . . 30OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 42oxacillin sodium . . . . . . . . . . . . . . . . . . . 14oxaliplatin inj 100mg . . . . . . . . . . . . . . . 23oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 23oxandrolone tabs 2.5mg . . . . . . . . . . . 45oxandrolone tabs 10mg . . . . . . . . . . . . 45oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 10oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 30oxcarbazepine . . . . . . . . . . . . . . . . . . . . 17oxybutynin chloride er tb24 5mg . . . . 43oxybutynin chloride er tb24 10mg, 15mg . . . . . . . . . . . . . . . . . . . . . . . 43oxybutynin chloride syrp . . . . . . . . . . . 43oxybutynin chloride tabs . . . . . . . . . . . 43oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 11oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 11oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 11oxycodone/aspirin . . . . . . . . . . . . . . . . . 11oxycodone hcl caps . . . . . . . . . . . . . . . 11oxycodone hcl conc . . . . . . . . . . . . . . . 11oxycodone hcl tabs . . . . . . . . . . . . . . . 11oxycodone hydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 11oxycodone hydrochloride tabs . . . . . 11oxycodone/ibuprofen . . . . . . . . . . . . . . 11OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 31

73


Covered Drugs Index

PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . 41premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml . . . . . . . 41prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 37previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 47PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 30PREZISTA SUSP . . . . . . . . . . . . . . . . . 30PREZISTA TABS 75MG . . . . . . . . . . . . 30PREZISTA TABS 150MG . . . . . . . . . . . 30PREZISTA TABS 600MG . . . . . . . . . . . 30PREZISTA TABS 800MG . . . . . . . . . . . 30PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 21PRIMAQUINE PHOSPHATE . . . . . . . 26primidone . . . . . . . . . . . . . . . . . . . . . . . . . 17PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 19PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 54PROAIR RESPICLICK . . . . . . . . . . . . . 54probenecid . . . . . . . . . . . . . . . . . . . . . . . . 20probenecid/colchicine . . . . . . . . . . . . . . 20PROCALAMINE . . . . . . . . . . . . . . . . . . . 41prochlorperazine . . . . . . . . . . . . . . . . . . 19prochlorperazine edisylate inj 10mg/2ml . . . . . . . . . . . . . . . . . . . . . . 27prochlorperazine maleate . . . . . . . . . . 27PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 33

potassium chloride sr . . . . . . . . . . . . . . 40potassium citrate er . . . . . . . . . . . . . . . . 41POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 25PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 32PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 37pramipexole dihydrochloride . . . . . . . . 26pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 26pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . . . . . . . . . . . . . . . . . . . . . . 26prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 33pravastatin sodium . . . . . . . . . . . . . . . . 37praziquantel . . . . . . . . . . . . . . . . . . . . . . . 26prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 33prazosin hydrochloride caps 2mg . . . 33PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 52PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 52PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 52prednicarbate oint . . . . . . . . . . . . . . . . . 44prednisolone . . . . . . . . . . . . . . . . . . . . . . 44prednisolone acetate . . . . . . . . . . . . . . 52prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 52prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 44prednisone intensol . . . . . . . . . . . . . . . . 44prednisone oral soln . . . . . . . . . . . . . . 44prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 44prednisone tabs 50mg . . . . . . . . . . . . . 44prednisone tbpk . . . . . . . . . . . . . . . . . . . 45pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg . . . . . . . . . . . . . . . . 16pregabalin caps 225mg, 300mg . . . . 16pregabalin oral soln . . . . . . . . . . . . . . . 16PREMARIN CREA . . . . . . . . . . . . . . . . 47PREMARIN INJ . . . . . . . . . . . . . . . . . . . 47PREMARIN TABS . . . . . . . . . . . . . . . . 47

pioglitazone hcl/metformin hcl . . . . . . 31pioglitazone hydrochloride tabs 15mg, 30mg . . . . . . . . . . . . . . . . . . 31piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm . . . . . . . . . . 15piperacillin/tazobactam . . . . . . . . . . . . . 15PIQRAY 200MG DAILY DOSE . . . . . . 23PIQRAY 250MG DAILY DOSE . . . . . . 23PIQRAY 300MG DAILY DOSE . . . . . . 23pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 47pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 47PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 40podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 39polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13polymyxin b sulfate . . . . . . . . . . . . . . . . 13polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 13POMALYST . . . . . . . . . . . . . . . . . . . . . . . 22portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 47PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 23POSACONAZOLE DR . . . . . . . . . . . . . 20potassium chloride cr . . . . . . . . . . . . . . 40potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . 40potassium chloride/dextrose/ lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l . . . . 41POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L . . . . 40potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 41potassium chloride er cpcr . . . . . . . . . 40potassium chloride er tbcr . . . . . . . . . 40potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 40potassium chloride oral soln . . . . . . . 40potassium chloride pack . . . . . . . . . . . 40potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 41

74


Covered Drugs Index

reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 47RECOMBIVAX HB . . . . . . . . . . . . . . . . . 50RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 39REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 21REGRANEX . . . . . . . . . . . . . . . . . . . . . . 39RELISTOR INJ 8MG/0.4ML . . . . . . . . 42RELISTOR INJ 12MG/0.6ML . . . . . . . 42REMODULIN . . . . . . . . . . . . . . . . . . . . . . 54RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 49RENVELA PACK . . . . . . . . . . . . . . . . . . 41RENVELA TABS . . . . . . . . . . . . . . . . . . 41repaglinide tabs 0.5mg, 1mg . . . . . . . 31repaglinide tabs 2mg . . . . . . . . . . . . . . 31REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 37REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 37REPATHA SURECLICK . . . . . . . . . . . . 37RESCRIPTOR . . . . . . . . . . . . . . . . . . . . 29RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 52RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . . . . . . . . . . . . . . . . 33RETACRIT INJ 40000UNIT/ML . . . . . 33RETROVIR IV INFUSION . . . . . . . . . . 29REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 22REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 22REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 27REYATAZ PACK . . . . . . . . . . . . . . . . . . 30RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 52ribavirin caps . . . . . . . . . . . . . . . . . . . . . 28ribavirin inhalation soln . . . . . . . . . . . . 54ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 28RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 49rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21rifampin caps . . . . . . . . . . . . . . . . . . . . . 21rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 21RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 21riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38rimantadine hcl . . . . . . . . . . . . . . . . . . . . 30

pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 21pyridostigmine bromide er . . . . . . . . . . 21pyridostigmine bromide tabs 60mg . . 21

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 50quetiapine fumarate . . . . . . . . . . . . . . . 27quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 27quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 27quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 34quinapril hydrochloride tabs 10mg . . 34quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 34quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 34quinidine sulfate . . . . . . . . . . . . . . . . . . . 34quinine sulfate . . . . . . . . . . . . . . . . . . . . . 26

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 50raloxifene hydrochloride . . . . . . . . . . . . 47ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 54ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 34RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 36ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 42ranitidine hcl syrp . . . . . . . . . . . . . . . . . 42ranitidine hcl tabs 150mg, 300mg . . . 42ranitidine hydrochloride caps . . . . . . 42ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml . . . . . . . . . . . . . 42ranolazine er . . . . . . . . . . . . . . . . . . . . . . 36RAPAMUNE ORAL SOLN . . . . . . . . . 49rasagiline mesylate . . . . . . . . . . . . . . . . 26REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38REBIF REBIDOSE . . . . . . . . . . . . . . . . 38REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 38REBIF TITRATION PACK . . . . . . . . . . 38

PROCRIT INJ 20000UNIT/ML . . . . . . 33PROCRIT INJ 40000UNIT/ML . . . . . . 33procto-med hc . . . . . . . . . . . . . . . . . . . . . 45procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 45proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 45proctozone-hc . . . . . . . . . . . . . . . . . . . . . 45progesterone caps . . . . . . . . . . . . . . . . 47PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 32PROGRAF INJ . . . . . . . . . . . . . . . . . . . 49PROGRAF PACK . . . . . . . . . . . . . . . . . 49PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 54PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 52PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 23PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 51PROMACTA PACK . . . . . . . . . . . . . . . . 33PROMACTA TABS . . . . . . . . . . . . . . . . 33promethazine hcl supp . . . . . . . . . . . . 19promethazine hcl syrp . . . . . . . . . . . . . 19promethazine hcl tabs 12.5mg . . . . . . 19promethazine hydrochloride tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 19promethegan . . . . . . . . . . . . . . . . . . . . . . 19propafenone hcl . . . . . . . . . . . . . . . . . . . 34propafenone hydrochloride er . . . . . . 34propantheline bromide . . . . . . . . . . . . . 42proparacaine hcl . . . . . . . . . . . . . . . . . . . 52propranolol hcl er . . . . . . . . . . . . . . . . . . 35propranolol hcl inj . . . . . . . . . . . . . . . . . 35propranolol hcl oral soln . . . . . . . . . . . 35propranolol hcl tabs 40mg, 80mg . . . 35propranolol hydrochloride er . . . . . . . . 35propranolol hydrochloride tabs 10mg, 20mg, 60mg . . . . . . . . . . . 35propranolol/hydrochlorothiazide . . . . 35propylthiouracil . . . . . . . . . . . . . . . . . . . . 48PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 50PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 41protriptyline hcl . . . . . . . . . . . . . . . . . . . . 19PULMOZYME . . . . . . . . . . . . . . . . . . . . . 54PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 22

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Covered Drugs Index

SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 52SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 49simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 37sirolimus oral soln . . . . . . . . . . . . . . . . . 49sirolimus tabs . . . . . . . . . . . . . . . . . . . . . 49SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 21SIVEXTRO TABS . . . . . . . . . . . . . . . . . 13SKYRIZI . . . . . . . . . . . . . . . . . . . . . . . . . . 49sodium bicarbonate inj . . . . . . . . . . . . 41sodium chloride 0.45% . . . . . . . . . . . . . 41sodium chloride inj 0.45%, 0.9%, 3%, 5% . . . . . . . . . . . . . . 41sodium chloride irrigation 0.9% . . . . . 51sodium fluoride chew 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 41SODIUM LACTATE INJ 5MEQ/ML . . 41sodium phenylbutyrate . . . . . . . . . . . . . 43sodium polystyrene sulfonate powd . . 41sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 41sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 15solifenacin succinate . . . . . . . . . . . . . . . 43SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 32SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 22SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 45SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 48SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 48SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 48SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 48sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 34sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 34sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 34sotalol hydrochloride af . . . . . . . . . . . . 34sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 34sotalol hydrochloride tabs 120mg, 80mg . . . . . . . . . . . . . . . . . . . . . 34

RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 23RUCONEST . . . . . . . . . . . . . . . . . . . . . . 48RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 23RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 26

SSABRIL TABS . . . . . . . . . . . . . . . . . . . . 17salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 10SAMSCA TABS 15MG . . . . . . . . . . . . . 41SAMSCA TABS 30MG . . . . . . . . . . . . . 41SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 20SANDIMMUNE ORAL SOLN . . . . . . 49SANDOSTATIN LAR DEPOT . . . . . . . 48SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 39SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 28scopolamine . . . . . . . . . . . . . . . . . . . . . . 19selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 26selenium sulfide lotn . . . . . . . . . . . . . . 39SELZENTRY ORAL SOLN . . . . . . . . 29SELZENTRY TABS 25MG . . . . . . . . . 29SELZENTRY TABS 150MG, 75MG . . . . . . . . . . . . . . . . . . . . 29SELZENTRY TABS 300MG . . . . . . . . 29SENSIPAR TABS 30MG, 60MG . . . . 51SENSIPAR TABS 90MG . . . . . . . . . . . 51SEREVENT DISKUS . . . . . . . . . . . . . . 54sertraline hcl conc . . . . . . . . . . . . . . . . . 19sertraline hcl tabs 25mg . . . . . . . . . . . . 19sertraline hcl tabs 50mg . . . . . . . . . . . . 19sertraline hydrochloride tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 19setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 47SEVELAMER CARBONATE PACK . . 41SEVELAMER CARBONATE TABS . . 42sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 47SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 50SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 48sildenafil citrate tabs 20mg . . . . . . . . . 54SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 54silver sulfadiazine . . . . . . . . . . . . . . . . . 13

ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l . . . . . . . . 41RINGERS IRRIGATION . . . . . . . . . . . . 51RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 49RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 31risedronate sodium tabs 30mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 51risedronate sodium tabs 35mg . . . . . 51risedronate sodium tabs 150mg . . . . 51RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 27RISPERDAL CONSTA INJ 50MG . . . 27risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 27risperidone odt tbdp 4mg . . . . . . . . . . . 27risperidone oral soln . . . . . . . . . . . . . . 27risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 27risperidone tabs 4mg . . . . . . . . . . . . . . 27ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 30RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 25RITUXAN HYCELA . . . . . . . . . . . . . . . . 25rivastigmine tartrate . . . . . . . . . . . . . . . . 18rivastigmine transdermal system . . . . 18rizatriptan benzoate . . . . . . . . . . . . . . . . 20rizatriptan benzoate odt . . . . . . . . . . . . 20ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 52romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 23ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 26ropinirole hydrochloride tabs 0.25mg, 3mg . . . . . . . . . . . . . . . . . 26rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 13rosuvastatin calcium . . . . . . . . . . . . . . . 37ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 50ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 50roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 16roweepra xr tb24 500mg . . . . . . . . . . . 16roweepra xr tb24 750mg . . . . . . . . . . . 16ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 54ROZLYTREK CAPS 100MG . . . . . . . . 23ROZLYTREK CAPS 200MG . . . . . . . . 23

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Covered Drugs Index

tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 47TASIGNA CAPS 50MG . . . . . . . . . . . . 25TASIGNA CAPS 150MG, 200MG . . . 25tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 39tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 14TAZORAC CREA . . . . . . . . . . . . . . . . . 39TAZORAC GEL . . . . . . . . . . . . . . . . . . . 39taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 36TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 50TECENTRIQ INJ 840MG/14ML . . . . . 25TECENTRIQ INJ 1200MG/20ML . . . 25TECFIDERA CPDR 120MG . . . . . . . . 38TECFIDERA CPDR 240MG . . . . . . . . 38TECFIDERA STARTER PACK . . . . . . 38TECHLITE PEN NEEDLES/ 31G X 6 MM . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 31G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 4MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 6MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 51TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 14TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 36TEKTURNA HCT . . . . . . . . . . . . . . . . . . 36telmisartan/amlodipine . . . . . . . . . . . . . 34telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg . . . 34telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg . . . . . . . . . . . . . . . . 34telmisartan tabs 20mg, 40mg . . . . . . . 34telmisartan tabs 80mg . . . . . . . . . . . . . 34temazepam caps 15mg, 30mg . . . . . 54temazepam caps 22.5mg, 7.5mg . . . 54temsirolimus . . . . . . . . . . . . . . . . . . . . . . 25TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 50tenofovir disoproxil fumarate . . . . . . . 29terazosin hcl caps 1mg, 5mg . . . . . . . 33

sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 20sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 21sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 21sumatriptan succinate tabs . . . . . . . . 21SUPRAX SUSR 500MG/5ML . . . . . . . 14SUPREP BOWEL PREP KIT . . . . . . . 42SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 25SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 24SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 29SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 31SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 31SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 30SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 50SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 48SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 13SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 31SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 31SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 31SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 24SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 48SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 41

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 22tacrolimus caps . . . . . . . . . . . . . . . . . . . 49tacrolimus oint . . . . . . . . . . . . . . . . . . . . 39TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 25TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 25TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 24tamoxifen citrate . . . . . . . . . . . . . . . . . . . 22tamsulosin hydrochloride . . . . . . . . . . . 43TARCEVA TABS 25MG . . . . . . . . . . . . 25TARCEVA TABS 100MG, 150MG . . . 25TARGRETIN GEL . . . . . . . . . . . . . . . . . 25

spironolactone . . . . . . . . . . . . . . . . . . . . 36spironolactone/hydrochlorothiazide . . 36SPORANOX ORAL SOLN . . . . . . . . . 20SPRAVATO 56MG DOSE . . . . . . . . . . 18SPRAVATO 84MG DOSE . . . . . . . . . . 18sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 47SPRITAM TB3D 750MG . . . . . . . . . . . 16SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 16SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 25sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 50stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 29sterile water irrigation . . . . . . . . . . . . . . 51sterile water irrigation plastic bottle . . 51sterile water irrigation w/hanger . . . . . 51STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 45STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 25streptomycin sulfate . . . . . . . . . . . . . . . 12STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 29SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 12sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 43sulfacetamide sodium lotn . . . . . . . . . 15sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 15sulfacetamide sodium/ prednisolone sodium phosphate . . . . 16sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 16sulfamethoxazole/trimethoprim ds . . 16sulfamethoxazole/trimethoprim inj . . 16sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 16sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 16sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 50sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 10sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 20sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 21

77


Covered Drugs Index

trazodone hydrochloride tabs 300mg . . . . . . . . . . . . . . . . . . . . . . . 18TREANDA INJ 25MG . . . . . . . . . . . . . . 21TREANDA INJ 100MG . . . . . . . . . . . . . 21TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 21TRELEGY ELLIPTA . . . . . . . . . . . . . . . 54TRELSTAR MIXJECT INJ 3.75MG . . 48TRELSTAR MIXJECT INJ 11.25MG . . 48TRELSTAR MIXJECT INJ 22.5MG . . 48treprostinil . . . . . . . . . . . . . . . . . . . . . . . . . 54TRESIBA . . . . . . . . . . . . . . . . . . . . . . . . . 32TRESIBA FLEXTOUCH . . . . . . . . . . . . 32tretinoin caps . . . . . . . . . . . . . . . . . . . . . 25tretinoin crea . . . . . . . . . . . . . . . . . . . . . 39tretinoin gel 0.01% . . . . . . . . . . . . . . . . . 39tretinoin gel 0.05% . . . . . . . . . . . . . . . . . 39tretinoin gel 0.025% . . . . . . . . . . . . . . . 39tretinoin microsphere . . . . . . . . . . . . . . 39tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 39triamcinolone acetonide crea 0.1% . . . . . . . . . . . . . . . . . . . . . . . . . 45triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 45triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 38triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 45triamcinolone acetonide lotn . . . . . . . 45triamcinolone acetonide oint . . . . . . . 45triamterene/hydrochlorothiazide . . . . 36trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45triderm crea 0.1% . . . . . . . . . . . . . . . . . 45trientine hydrochloride . . . . . . . . . . . . . 41tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 47trifluoperazine hcl . . . . . . . . . . . . . . . . . . 27trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 30trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 26trihexyphenidyl hydrochloride . . . . . . . 26tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 47tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 47

tobramycin nebu . . . . . . . . . . . . . . . . . . 54tobramycin ophthalmic soln . . . . . . . . 12tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 12tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . . 12TOBREX OINT . . . . . . . . . . . . . . . . . . . 12TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 39tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 26tolterodine tartrate . . . . . . . . . . . . . . . . . 43tolterodine tartrate er . . . . . . . . . . . . . . 43topiramate . . . . . . . . . . . . . . . . . . . . . . . . 17toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 24topotecan hcl inj 4mg . . . . . . . . . . . . . . 24toremifene citrate . . . . . . . . . . . . . . . . . . 22TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 49torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 36TOUJEO MAX SOLOSTAR . . . . . . . . 32TOUJEO SOLOSTAR . . . . . . . . . . . . . . 32TPN ELECTROLYTES . . . . . . . . . . . . . 41TRACLEER TABS . . . . . . . . . . . . . . . . 54TRACLEER TBSO . . . . . . . . . . . . . . . . 54TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 31tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 11tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 11trandolapril tabs 1mg . . . . . . . . . . . . . . 34trandolapril tabs 2mg, 4mg . . . . . . . . . 34trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg . . . . . . . . . . . . . . . 34trandolapril/verapamil hcl er tbcr 4mg; 240mg . . . . . . . . . . . . . . . . 34tranexamic acid inj . . . . . . . . . . . . . . . . 33tranexamic acid tabs . . . . . . . . . . . . . . 33TRANSDERM-SCOP . . . . . . . . . . . . . . 19tranylcypromine sulfate . . . . . . . . . . . . 18TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 41TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 52trazodone hydrochloride tabs 100mg, 150mg, 50mg . . . . . . . . . 18

terazosin hcl caps 10mg . . . . . . . . . . . 33terazosin hydrochloride . . . . . . . . . . . . 33terbinafine hcl tabs . . . . . . . . . . . . . . . . 20terbutaline sulfate . . . . . . . . . . . . . . . . . 54terconazole . . . . . . . . . . . . . . . . . . . . . . . 20testosterone cypionate . . . . . . . . . . . . . 45testosterone enanthate . . . . . . . . . . . . 45testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 45testosterone pump gel 1% . . . . . . . . . 45tetrabenazine tabs 12.5mg . . . . . . . . . 38tetrabenazine tabs 25mg . . . . . . . . . . . 38tetracycline hydrochloride . . . . . . . . . . 16TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 45THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 22THALOMID CAPS 200MG . . . . . . . . . 22THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 54theophylline er tb12 300mg . . . . . . . . 54theophylline er tb24 . . . . . . . . . . . . . . . 54thioridazine hcl . . . . . . . . . . . . . . . . . . . . 27thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 21thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 27THYMOGLOBULIN . . . . . . . . . . . . . . . . 49tiagabine hydrochloride . . . . . . . . . . . . 17TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 25tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 13TIMOLOL MALEATE OPHTHALMIC GEL FORMING . . . . . 52timolol maleate ophthalmic soln . . . . 52timolol maleate tabs . . . . . . . . . . . . . . . 35TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 51TIVICAY TABS 10MG . . . . . . . . . . . . . . 28TIVICAY TABS 25MG, 50MG . . . . . . . 28tizanidine hcl caps . . . . . . . . . . . . . . . . 28tizanidine hcl tabs . . . . . . . . . . . . . . . . . 28tizanidine hydrochloride tabs 4mg . . 28TOBI PODHALER . . . . . . . . . . . . . . . . . 54TOBRADEX OINT . . . . . . . . . . . . . . . . 52tobramycin/dexamethasone . . . . . . . . 52

78


Covered Drugs Index

VENCLEXTA STARTING PACK . . . . 24VENCLEXTA TABS 10MG . . . . . . . . . 24VENCLEXTA TABS 50MG . . . . . . . . . 24VENCLEXTA TABS 100MG . . . . . . . . 24venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 19venlafaxine hcl er cp24 37.5mg . . . . . 19venlafaxine hcl er cp24 75mg . . . . . . 19venlafaxine hcl er cp24 150mg . . . . . 19VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 54VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 54verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 36verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 36verapamil hcl er cp24 200mg . . . . . . . 36verapamil hcl er tbcr . . . . . . . . . . . . . . 36VERAPAMIL HCL SR CP24 360MG . . . . . . . . . . . . . . . . . . 36verapamil hydrochloride inj . . . . . . . . 36verapamil hydrochloride tabs . . . . . . 36VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 28VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 24VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 43V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 52V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 52VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 42vicodin es tabs 300mg; 7.5mg . . . . . . 11vicodin hp tabs 300mg; 10mg . . . . . . 11VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 31VIDEX EC CPDR 125MG . . . . . . . . . . 29VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 29vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47vigabatrin pack . . . . . . . . . . . . . . . . . . . 17vigabatrin tabs . . . . . . . . . . . . . . . . . . . . 17vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 17VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 19VIIBRYD STARTER PACK . . . . . . . . . 19VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 17VIMPAT ORAL SOLN . . . . . . . . . . . . . 17VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 17

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 30valacyclovir hydrochloride . . . . . . . . . . 30VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 21valganciclovir . . . . . . . . . . . . . . . . . . . . . . 28valganciclovir hydrochlorde . . . . . . . . 28valproate sodium inj 100mg/ml . . . . . 17valproic acid . . . . . . . . . . . . . . . . . . . . . . . 17valsartan/hydrochlorothiazide . . . . . . 34valsartan tabs 160mg, 40mg, 80mg . 34valsartan tabs 320mg . . . . . . . . . . . . . . 34vancomycin . . . . . . . . . . . . . . . . . . . . . . . 13vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg . . . . 13vancomycin hydrochloride caps 125mg . . . . . . . . . . . . . . . . . . . . . . . 13vancomycin hydrochloride caps 250mg . . . . . . . . . . . . . . . . . . . . . . . 13vancomycin hydrochloride/ dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml . . . 13VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML . . . . . . . . . . . . . . . . . . . 13vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg . . . . . . . 13vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 14vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 14VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 50VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 50VASCEPA CAPS 0.5GM . . . . . . . . . . . 37VASCEPA CAPS 1GM . . . . . . . . . . . . . 37VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 50VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 25VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 24velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 42VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 41

trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 13trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 13tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47trimipramine maleate . . . . . . . . . . . . . . 19TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 18tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 47TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 48TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 24tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 47TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 29trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 47tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 47TROGARZO . . . . . . . . . . . . . . . . . . . . . . 29TROKENDI XR CP24 100MG, 25MG, 50MG . . . . . . . . . . . . . 17TROKENDI XR CP24 200MG . . . . . . 17TROPHAMINE . . . . . . . . . . . . . . . . . . . . 41tropicamide . . . . . . . . . . . . . . . . . . . . . . . 52TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 42TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 31TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 50TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 29TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 25TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 50TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 29tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 25TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 51TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 50TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 38

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 20UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 48UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 25ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

79


Covered Drugs Index

zidovudine caps . . . . . . . . . . . . . . . . . . 29zidovudine syrp . . . . . . . . . . . . . . . . . . . 29zidovudine tabs . . . . . . . . . . . . . . . . . . . 29ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 52ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 28ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 28zoledronic acid inj 5mg/100ml . . . . . . 51ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 24zolpidem tartrate tabs . . . . . . . . . . . . . 54zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 16ZORTRESS TABS 0.5MG . . . . . . . . . . 49ZORTRESS TABS 0.25MG . . . . . . . . 49ZORTRESS TABS 0.75MG, 1MG . . . 49ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 50ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 15zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 47ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 30ZUBSOLV SUBL 0.7MG; 0.18MG . . 12ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 12ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 39ZYCLARA PUMP CREA 2.5% . . . . . . 39ZYCLARA PUMP CREA 3.75% . . . . . 39ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 25ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 25ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ZYPREXA RELPREVV INJ 210MG . . 28ZYPREXA RELPREVV INJ 300MG . . 28ZYPREXA RELPREVV INJ 405MG . . 28ZYTIGA TABS 250MG . . . . . . . . . . . . . 22ZYTIGA TABS 500MG . . . . . . . . . . . . . 22

XIFAXAN TABS 550MG . . . . . . . . . . . . 14XIGDUO XR TB24 5MG; 1000MG . . 31XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 31XOFLUZA . . . . . . . . . . . . . . . . . . . . . . . . . 30XOLAIR INJ 75MG/0.5ML . . . . . . . . . . 54XOLAIR INJ 150MG/ML . . . . . . . . . . . 54XOLAIR VIAL INJ 150MG . . . . . . . . . . 54XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 25XPOVIO 60 MG ONCE WEEKLY . . . 22XPOVIO 80 MG ONCE WEEKLY . . . 22XPOVIO 80 MG TWICE WEEKLY . . 22XPOVIO 100 MG ONCE WEEKLY . . 22XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 10XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 22XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 32XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

YYERVOY INJ 50MG/10ML . . . . . . . . . 25YERVOY INJ 200MG/40ML . . . . . . . . 25YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 50YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 21YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 22yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 53zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 54ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 25ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 21ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 33zebutal caps 325mg; 50mg; 40mg . . 10ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 24ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 25ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 54zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 39ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 43

vinblastine sulfate . . . . . . . . . . . . . . . . . 24vincristine sulfate . . . . . . . . . . . . . . . . . . 24vinorelbine tartrate inj 50mg/5ml . . . . 24viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47VIRACEPT TABS 250MG . . . . . . . . . . 30VIRACEPT TABS 625MG . . . . . . . . . . 30VIRAMUNE SUSP . . . . . . . . . . . . . . . . 29VIREAD POWD . . . . . . . . . . . . . . . . . . . 29VIREAD TABS 150MG, 200MG, 250MG . . . . . . . . . . . 29VITRAKVI CAPS 25MG . . . . . . . . . . . . 24VITRAKVI CAPS 100MG . . . . . . . . . . . 24VITRAKVI ORAL SOLN . . . . . . . . . . . 24VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 25voriconazole inj . . . . . . . . . . . . . . . . . . . 20voriconazole susr . . . . . . . . . . . . . . . . . 20voriconazole tabs . . . . . . . . . . . . . . . . . 20VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 28VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 25VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 42VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 28VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 28vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 47vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 32WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 37wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 25XARELTO STARTER PACK . . . . . . . . 32XARELTO TABS 10MG, 20MG . . . . . 32XARELTO TABS 15MG, 2.5MG . . . . 32XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 49XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 51XHANCE . . . . . . . . . . . . . . . . . . . . . . . . . . 53

80

Notes

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaHealthSpring.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. © 2018 Cigna 926063 j

1-800-668-3813 (TTY 711) October 1 – March 31, 8 a.m. – 8 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday 8 a.m. – 8 p.m. local time; Saturday 8 a.m. – 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

CignaHealthSpring.com

2019 cigna-healthspring comprehensive drug list …then look under the category name for your drug....

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