2020 cigna comprehensive drug list (formulary) · this drug list was updated in may 2020. for more...

This drug list was updated in May 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-222-6700, or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.Cigna.com/part-d. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring® Rx is a Medicare Prescription Drug Plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 20083, Version Number 13 INT_20_76977_C_Final_9e

Plan coveredCigna-HealthSpring Rx Secure-Essential (PDP)

Please read: This document contains information about all of the drugs we cover in this plan.

2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna 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 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 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?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.Changes that can affect you this year. In the below cases, you will be affected by coverage changes during the year:• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and

you can also find information in the section entitled “How do I request an exception to the Cigna 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 move it to a different cost-sharing tier.). 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 or move a drug to a higher cost-sharing tier, 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. – If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Cigna’s Drug List?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with

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. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Rx Secure-Essential (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of May 2020. 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, 2021, and from time to time during the year.

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no new restrictions for those customers taking them for the remainder of the coverage year. The enclosed drug list is current as of May 2020. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 17. 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, HYPERTENSION / LIPIDS”. If you know what your drug is used for, look for the category name in the list that begins on page 17. 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 that begins on page 61. The Covered Drugs Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna 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 requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill these prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for candesartan 32mg. 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 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 may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna 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 17. 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 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 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

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your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

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

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

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

cost generic alternatives available for any of your current medications.

• Some plans may offer a $0 copay for Tier 1 and 2 generic drugs filled at a preferred retail and/or mail-order pharmacies. Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings.

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

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

What if my drug is not on 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 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. 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.

• You can ask Cigna 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 Drug List?You can ask Cigna to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not on our 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 limits the

amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.

– If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

– If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

These exceptions would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

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

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

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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 on 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 will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list that begins on page 17, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 61

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., candesartan).The information in the Requirements/Limits column tells you if Cigna 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 17 along with the amount dispensed per the days supplied. (For example: candesartan 32mg QL 30/30; this means the drug candesartan 32mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. If you need help finding a network pharmacy, please call Customer Service at 1-800-222-6700 (TTY 711), or you can visit www.Cigna.com/part-d for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna, 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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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears on the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4, or Tier 5. Keep in mind that

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

To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in which you are currently enrolled or would like to enroll. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.Cigna.com/part-d to search for a preferred retail or mail-order pharmacy near you.

* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billed charge and our typical Standard Retail pharmacy billed costs.

Cigna Medicare Prescription Drug Secure-Essential (PDP)

Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing

Preferred Mail-Order

Cost-Sharing

Standard Mail-Order

Cost-Sharing

Long-term Care 31 days

Out-of-network 30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

ALABAMATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19

Tier 2: Generic Drugs $2 / $4 / $6 $20 / $40 / $60 $2 / $4 / $4 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs 18% 20% 18% 20% 20%

Tier 4: Non-Preferred Drugs 41% 50% 41% 50% 50%

Tier 5: Specialty Tier 25% (30 days) 25% (30 days) 25% (30 days) 25% (30 days) 25%

ALASKATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



ARIZONATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





ARKANSASTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





CALIFORNIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





COLORADOTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





CONNECTICUTTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



DELAWARETier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





DISTRICT OF COLUMBIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





FLORIDATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





GEORGIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





HAWAIITier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



IDAHOTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





ILLINOISTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





INDIANATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





IOWATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





KANSASTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



KENTUCKYTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





LOUISIANATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MAINETier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MARYLANDTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MASSACHUSETTSTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



MICHIGANTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MINNESOTATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MISSISSIPPITier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MISSOURITier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





MONTANATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



NEBRASKATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NEVADATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NEW HAMPSHIRETier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NEW JERSEYTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NEW MEXICOTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



NEW YORKTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NORTH CAROLINATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





NORTH DAKOTATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





OHIOTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





OKLAHOMATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



OREGONTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





PENNSYLVANIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





RHODE ISLANDTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





SOUTH CAROLINATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





SOUTH DAKOTA Tier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



TENNESSEETier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





TEXASTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





UTAHTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





VERMONTTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





VIRGINIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



WASHINGTONTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





WEST VIRGINIATier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





WISCONSINTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





WYOMINGTier 1: Preferred Generic Drugs $0 / $0 / $0 $19 / $38 / $57 $0 / $0 / $0 $19 / $38 / $57 $19





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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 1-800-222-6700, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30. TTY users can call 711.

My Medications Page Number in the Drug List Cost-Share through Cigna

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

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 16.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 5 PA; NDSAMBISOME 5 PA; NDSamphotericin b 4 PAcaspofungin 5 PA; NDSclotrimazole mucous membrane

2

CRESEMBA ORAL 4fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

4

fluconazole oral suspension for reconstitution

3

fluconazole oral tablet 2flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 PA; QL (120/30)itraconazole oral solution 5 PA; NDSketoconazole oral 2NOXAFIL ORAL SUSPENSION 5 PA; QL (600/30);

NDSNOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

nystatin oral suspension 3nystatin oral tablet 2posaconazole oral tablet,delayed release (dr/ec)

5 PA; QL (96/30); NDS

terbinafine hcl oral 2voriconazole intravenous 4 PAvoriconazole oral suspension for reconstitution

5 PA; QL (300/30); NDS

voriconazole oral tablet 4 PAANTIVIRALSabacavir oral solution 3 QL (960/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2acyclovir oral suspension 200 mg/5 ml

4

acyclovir oral tablet 2acyclovir sodium intravenous solution

4 B/D PA

amantadine hcl 3APTIVUS 4 QL (120/30)APTIVUS (WITH VITAMIN E) 4 QL (285/28)atazanavir oral capsule 150 mg 4 QL (30/30)atazanavir oral capsule 200 mg 5 QL (60/30); NDSatazanavir oral capsule 300 mg 5 QL (30/30); NDSATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 QL (30/30); NDSCIMDUO 5 QL (30/30); NDSCOMPLERA 4 QL (30/30)CRIXIVAN ORAL CAPSULE 200 MG

4 QL (270/30)

CRIXIVAN ORAL CAPSULE 400 MG

4 QL (180/30)

DELSTRIGO 5 QL (30/30); NDSDESCOVY 5 QL (30/30); NDSdidanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 QL (30/30); NDSEDURANT 3 QL (30/30)efavirenz oral capsule 200 mg 3 QL (120/30)efavirenz oral capsule 50 mg 3 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDSEMTRIVA ORAL CAPSULE 3 QL (30/30)

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nevirapine oral tablet extended release 24 hr 100 mg

4 QL (90/30)

nevirapine oral tablet extended release 24 hr 400 mg

4 QL (30/30)

NORVIR ORAL POWDER IN PACKET

4 QL (360/30)

NORVIR ORAL SOLUTION 3 QL (480/30)ODEFSEY 5 QL (30/30); NDSoseltamivir oral capsule 3oseltamivir oral suspension for reconstitution

4

PIFELTRO 5 QL (30/30); NDSPREZCOBIX 4 QL (30/30)PREZISTA ORAL SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (180/30)


5 QL (60/30); NDS


4 QL (210/30)


5 QL (30/30); NDS

RESCRIPTOR ORAL TABLET 4 QL (180/30)RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (180/30); NDS

ribavirin oral capsule 3 QL (168/28)ribavirin oral tablet 200 mg 3rimantadine 4ritonavir 3 QL (360/30)SELZENTRY ORAL SOLUTION

5 QL (1610/26); NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

4 QL (240/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

stavudine oral capsule 4 QL (60/30)STRIBILD 5 QL (30/30); NDSSYMFI 5 QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMTRIVA ORAL SOLUTION 3 QL (680/28)entecavir 4 QL (30/30)EPCLUSA 5 PA; QL (28/28);

NDSEPIVIR HBV ORAL SOLUTION 3EVOTAZ 4 QL (30/30)famciclovir 4 QL (60/30)fosamprenavir 5 QL (120/30); NDSFUZEON SUBCUTANEOUS RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDSHARVONI 5 PA; QL (28/28);

NDSINTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 5 QL (120/30); NDSISENTRESS HD 5 QL (60/30); NDSISENTRESS ORAL POWDER IN PACKET

5 QL (60/30); NDS

ISENTRESS ORAL TABLET 5 QL (120/30); NDSISENTRESS ORAL TABLET,CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

4 QL (300/30)

KALETRA ORAL TABLET 200-50 MG

5 QL (120/30); NDS

lamivudine oral solution 3 QL (900/30)lamivudine oral tablet 100 mg, 300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)lamivudine-zidovudine 3 QL (60/30)LEXIVA ORAL SUSPENSION 4 QL (1575/28)lopinavir-ritonavir 4 QL (480/30)MAVYRET 5 PA; QL (84/28);

NDSnevirapine oral suspension 4 QL (1200/30)nevirapine oral tablet 3 QL (60/30)

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefaclor oral tablet extended release 12 hr

4

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3

cefadroxil oral tablet 3cefazolin 4cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4

cefdinir 4CEFEPIME IN DEXTROSE 5% 4cefepime in dextrose,iso-osm 4cefepime injection 4cefixime oral capsule 4 QL (30/30)cefixime oral suspension for reconstitution

4

cefotetan 4CEFOTETAN IN DEXTROSE, ISO-OSM

4

cefoxitin 4cefoxitin in dextrose, iso-osm 4cefpodoxime 4cefprozil 3ceftazidime 4CEFTAZIDIME IN D5W 4ceftriaxone in dextrose,iso-os 4ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

4

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYMFI LO 5 QL (30/30); NDSSYMTUZA 5 QL (30/30); NDSSYNAGIS 5 PA; NDStenofovir disoproxil fumarate 4 QL (30/30)TIVICAY ORAL TABLET 10 MG 4 QL (60/30)TIVICAY ORAL TABLET 25 MG, 50 MG

5 QL (60/30); NDS

TRIUMEQ 5 QL (30/30); NDSTROGARZO 5 B/D PA; NDSTRUVADA 5 QL (30/30); NDSTYBOST 3 QL (30/30)valacyclovir oral tablet 1 gram 3 QL (120/30)valacyclovir oral tablet 500 mg 3 QL (60/30)valganciclovir 5 NDSVEMLIDY 4VIDEX 2 GRAM PEDIATRIC 4 QL (1200/30)VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG

4

VIRACEPT ORAL TABLET 250 MG

4 QL (270/30)

VIRACEPT ORAL TABLET 625 MG

4 QL (120/30)

VIREAD ORAL POWDER 5 QL (240/30); NDSVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (30/30); NDS

zidovudine oral capsule 4 QL (180/30)zidovudine oral syrup 4 QL (1680/28)zidovudine oral tablet 4 QL (60/30)CEPHALOSPORINScefaclor oral capsule 4cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

4

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAPASTAT 4CAYSTON 5 PA; QL (84/56);

NDSchloramphenicol sod succinate 4chloroquine phosphate 2clindamycin hcl 2CLINDAMYCIN IN 0.9% SOD CHLOR

4

clindamycin in 5% dextrose 4clindamycin palmitate hcl 4clindamycin pediatric 4clindamycin phosphate injection 4clindamycin phosphate intravenous solution 600 mg/4 ml

4

COARTEM 4 QL (24/30)colistin (colistimethate na) 4CUBICIN 4 B/D PACUBICIN RF 4 B/D PACYCLOSERINE 4dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 B/D PA; NDS

daptomycin intravenous recon soln 500 mg

5 B/D PA; NDS

DARAPRIM 5 QL (90/30); NDSEMVERM 4ertapenem 4ethambutol 4FIRVANQ 4gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

4

gentamicin injection solution 40 mg/ml

4

gentamicin sulfate (ped) (pf) 4hydroxychloroquine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefuroxime axetil oral tablet 3cefuroxime sodium injection recon soln 750 mg

4

cefuroxime sodium intravenous 4cephalexin oral capsule 250 mg, 500 mg

2

cephalexin oral suspension for reconstitution

2

tazicef 4TEFLARO 4ERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4azithromycin oral packet 3azithromycin oral suspension for reconstitution

4

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack)

2

azithromycin oral tablet 600 mg 2 QL (60/30)clarithromycin 4erythrocin (as stearate) oral tablet 250 mg

4

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

4

erythromycin oral capsule,delayed release(dr/ec)

4

erythromycin oral tablet 4MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSALINIA ORAL SUSPENSION FOR RECONSTITUTION

5 QL (180/30); NDS

ALINIA ORAL TABLET 5 QL (20/10); NDSamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

4

ARIKAYCE 4 PAatovaquone 4atovaquone-proguanil 4aztreonam 4bacitracin intramuscular 4

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 4SYNERCID 5 NDStigecycline 5 NDStobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDStobramycin sulfate 4TRECATOR 3VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK

4

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK

4

VANCOMYCIN INJECTION 4vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

4

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM

4

vancomycin oral capsule 125 mg

4 QL (40/10)

vancomycin oral capsule 250 mg

4 QL (80/10)

vancomycin oral recon soln 2VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA; QL (90/30); NDS

PENICILLINSamoxicillin oral capsule 2amoxicillin oral suspension for reconstitution

2

amoxicillin oral tablet 2amoxicillin oral tablet,chewable 125 mg, 250 mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imipenem-cilastatin 4INVANZ INJECTION 4isoniazid oral solution 4isoniazid oral tablet 2ivermectin oral 3lincomycin 4linezolid in dextrose 5% 4linezolid oral suspension for reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)linezolid-0.9% sodium chloride 4mefloquine 2meropenem 4MEROPENEM-0.9% SODIUM CHLORIDE

4

metro i.v. 4metronidazole in nacl (iso-os) 4metronidazole oral tablet 2NEBUPENT 3 B/D PA; QL (1/28)neomycin 2paromomycin 4PASER 4PENTAM 4pentamidine inhalation 3 B/D PA; QL (1/28)pentamidine injection 4praziquantel 4PRIFTIN 4PRIMAQUINE 4pyrazinamide 4quinine sulfate 4 PA; QL (42/7)rifabutin 4rifampin 4SIRTURO 4 PA; QL (188/365)SIVEXTRO INTRAVENOUS 5 B/D PA; QL (6/28);

NDS

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

moxifloxacin oral 4MOXIFLOXACIN-SOD.ACE,SUL-WATER

4

moxifloxacin-sod.chloride(iso) 4SULFAS / RELATED AGENTSsulfadiazine 4sulfamethoxazole-trimethoprim intravenous

4

sulfamethoxazole-trimethoprim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

2

sulfatrim 4TETRACYCLINESdoxy-100 4doxycycline hyclate intravenous 4doxycycline hyclate oral capsule

4

doxycycline hyclate oral tablet 100 mg, 20 mg

4

doxycycline monohydrate oral capsule 100 mg, 50 mg

3

doxycycline monohydrate oral suspension for reconstitution

4

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2morgidox 4NUZYRA INTRAVENOUS 4 QL (15/14)NUZYRA ORAL 4 QL (30/14)tetracycline 4URINARY TRACT AGENTSmethenamine hippurate 4nitrofurantoin 4nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg

4

nitrofurantoin macrocrystal oral capsule 50 mg

3

nitrofurantoin monohyd/m-cryst 4trimethoprim 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule 500 mg 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

4

BICILLIN L-A 4dicloxacillin 2nafcillin 4nafcillin in dextrose iso-osm 4oxacillin injection 4penicillin g potassium 4penicillin v potassium 2pfizerpen-g 4PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4

QUINOLONESBAXDELA 4 QL (28/14)ciprofloxacin 4ciprofloxacin hcl oral tablet 100 mg

4

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

2

ciprofloxacin in 5% dextrose 4levofloxacin in d5w 4levofloxacin intravenous 4levofloxacin oral solution 4levofloxacin oral tablet 2

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AVASTIN 5 PA; NDSAYVAKIT 4 PA; QL (30/30)azathioprine 2 PAazathioprine sodium 4 PABALVERSA ORAL TABLET 3 MG

5 PA; QL (90/30); NDS

BALVERSA ORAL TABLET 4 MG

5 PA; QL (60/30); NDS

BALVERSA ORAL TABLET 5 MG

5 PA; QL (30/30); NDS

BAVENCIO 5 PA; NDSBENDEKA 5 B/D PA; QL (8/21);

NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 3BORTEZOMIB 5 PA; QL (14/21);

NDSBOSULIF 5 PA; NDSBRAFTOVI 5 PA; QL (180/30);

NDSBRUKINSA 4 PAbusulfan 5 B/D PA; NDSBUSULFEX 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

5 PA; QL (30/30); NDS

CABOMETYX ORAL TABLET 40 MG

5 PA; QL (60/30); NDS

CALQUENCE 5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 100 MG

5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 300 MG

5 PA; QL (30/30); NDS

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection recon soln

4

leucovorin calcium injection solution 10 mg/ml

4

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg

4

leucovorin calcium oral tablet 5 mg

3

mesna 4 B/D PAMESNEX ORAL 5 NDSXGEVA 5 PA; QL (1.7/28);

NDSANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSabiraterone 4 PA; QL (120/30)ABRAXANE 5 PA; NDSAFINITOR 5 PA; QL (28/28);

NDSAFINITOR DISPERZ 5 PA; QL (56/28);

NDSALECENSA 5 PA; QL (240/30);

NDSALIMTA 5 PA; NDSALIQOPA 5 PA; QL (3/28); NDSALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (180/30); NDS

ALUNBRIG ORAL TABLETS,DOSE PACK

5 PA; QL (60/365); NDS

anastrozole 2ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

arsenic trioxide intravenous solution 2 mg/ml

4 B/D PA

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

4 B/D PA; QL (4/365)

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 B/D PA; QL (1/28)

fludarabine 4 B/D PAflutamide 4FOLOTYN 5 B/D PA; NDSfulvestrant 5 B/D PA; QL (30/30);

NDSGAZYVA 5 PA; NDSgemcitabine intravenous recon soln

4 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA; NDS

gengraf oral capsule 100 mg, 25 mg

4 PA

gengraf oral solution 4 PAGILOTRIF 5 PA; QL (30/30);

NDSGLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

4

HALAVEN 5 PA; NDSHERCEPTIN HYLECTA 5 PA; NDSHERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA; NDS

hydroxyurea 2IBRANCE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

ICLUSIG ORAL TABLET 45 MG

5 PA; QL (30/30); NDS

IDHIFA 5 PA; QL (30/30); NDS

imatinib oral tablet 100 mg 5 PA; QL (180/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

5 PA; QL (112/28); NDS

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28); NDS

COPIKTRA 5 PA; QL (60/30); NDS

COTELLIC 5 PA; QL (63/28); NDS

cyclophosphamide intravenous 5 B/D PA; NDScyclophosphamide oral capsule 3 B/D PAcyclosporine intravenous 4 PAcyclosporine modified 4 PAcyclosporine oral capsule 4 PACYRAMZA 5 PA; NDSDARZALEX 5 PA; NDSdaunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

DAURISMO ORAL TABLET 25 MG

5 PA; QL (60/30); NDS

DROXIA 4ELZONRIS 5 B/D PA; NDSEMCYT 4ENHERTU 5 PA; NDSERIVEDGE 5 PA; QL (28/28);

NDSERLEADA 4 PAerlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30); NDS

etoposide intravenous 3 B/D PAeverolimus (antineoplastic) 5 PA; QL (28/28);

NDSEVOMELA 5 PA; NDSexemestane 4 QL (60/30)FARYDAK ORAL CAPSULE 10 MG, 20 MG

5 PA; QL (6/21); NDS

FASLODEX 5 B/D PA; QL (30/30); NDS

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30); NDS

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; QL (90/30); NDS

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)

5 PA; QL (60/30); NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 4 PALIBTAYO 5 PA; QL (7/21); NDSLONSURF ORAL TABLET 15-6.14 MG

5 PA; QL (100/28); NDS

LONSURF ORAL TABLET 20-8.19 MG

5 PA; QL (80/28); NDS

LORBRENA ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; QL (1/30); NDSLUPRON DEPOT (3 MONTH) 5 PA; QL (1/84); NDSLUPRON DEPOT (4 MONTH) 5 PA; QL (1/112);

NDSLUPRON DEPOT (6 MONTH) 5 PA; QL (1/168);

NDSLUPRON DEPOT-PED 5 PA; QL (1/30); NDSLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

5 PA; QL (1/84); NDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 PA; QL (1/112); NDS

LYNPARZA ORAL TABLET 5 PA; QL (120/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imatinib oral tablet 400 mg 5 PA; QL (60/30); NDS

IMBRUVICA ORAL CAPSULE 140 MG

5 PA; QL (120/30); NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA; QL (30/30); NDS

IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS

IMFINZI 5 PA; NDSINFUGEM 5 B/D PA; NDSINLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDSINLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDSINREBIC 5 PA; QL (120/30);

NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAISTODAX 5 PA; NDSJAKAFI 5 PA; QL (60/30);

NDSKADCYLA 5 PA; NDSKANJINTI 5 PA; NDSKEYTRUDA INTRAVENOUS SOLUTION

5 PA; NDS

KISQALI 5 PA; QL (63/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28); NDS


5 PA; QL (70/28); NDS


5 PA; QL (91/28); NDS

KYPROLIS 5 B/D PA; NDS

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ODOMZO 5 PA; QL (30/30); NDS

OGIVRI 5 PA; NDSOPDIVO 5 PA; QL (80/28);

NDSpaclitaxel 4 B/D PAPADCEV 4 PAPERJETA 5 PA; NDSPIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (28/28); NDS

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

5 PA; QL (56/28); NDS

POMALYST 5 PA; QL (21/28); NDS

POTELIGEO 5 PA; NDSPROGRAF ORAL GRANULES IN PACKET

4 PA

PURIXAN 5 PA; QL (300/30); NDS

RAPAMUNE ORAL SOLUTION 5 PA; NDSREVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

5 PA; QL (28/28); NDS

REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG

5 PA; QL (21/28); NDS

RITUXAN 5 PA; NDSRITUXAN HYCELA 5 PA; NDSROMIDEPSIN 5 PA; NDSROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

RUBRACA 5 PA; QL (120/30); NDS

RUXIENCE 5 B/D PA; NDSRYDAPT 5 PA; QL (224/28);

NDSSANDIMMUNE ORAL SOLUTION

4 PA

SIGNIFOR 5 PA; QL (60/30); NDS

SIMULECT 5 B/D PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYSODREN 5 NDSMATULANE 5 NDSmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

4 PA

megestrol oral tablet 20 mg 4 PAmegestrol oral tablet 40 mg 3 PAMEKINIST ORAL TABLET 0.5 MG

5 PA; QL (90/30); NDS

MEKINIST ORAL TABLET 2 MG

5 PA; QL (30/30); NDS

MEKTOVI 5 PA; QL (180/30); NDS

melphalan hcl 5 B/D PA; NDSmercaptopurine 4methotrexate sodium (pf) 4methotrexate sodium injection 4methotrexate sodium oral 2MVASI 5 PA; NDSmycophenolate mofetil (hcl) 4 PAmycophenolate mofetil oral capsule

3 PA

mycophenolate mofetil oral suspension for reconstitution

5 PA; NDS

mycophenolate mofetil oral tablet

4 PA

mycophenolate sodium 4 PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; QL (180/30);

NDSNEXAVAR 5 PA; QL (120/30);

NDSnilutamide 5 QL (60/30); NDSNINLARO 5 PA; QL (3/28); NDSNUBEQA 4 PA; QL (120/30)NULOJIX 5 PA; QL (26/28);

NDSoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

4 PA

octreotide acetate injection solution 50 mcg/ml

3 PA

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML)

5 PA; QL (28/28); NDS

temsirolimus 5 B/D PA; QL (4/28); NDS

THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG

5 PA; QL (28/28); NDS

THALOMID ORAL CAPSULE 200 MG

5 PA; QL (56/28); NDS

thiotepa injection recon soln 100 mg

4 B/D PA

thiotepa injection recon soln 15 mg

4 PA

TIBSOVO 5 PA; QL (60/30); NDS

toposar 3 B/D PAtopotecan intravenous recon soln

5 NDS

toremifene 5 QL (30/30); NDSTORISEL 5 B/D PA; QL (4/28);

NDSTRAZIMERA 5 PA; NDSTREANDA INTRAVENOUS RECON SOLN 100 MG

5 B/D PA; NDS

TREANDA INTRAVENOUS RECON SOLN 25 MG

5 B/D PA; QL (8/21); NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG

5 PA; QL (1/84); NDS


5 PA; QL (1/168); NDS


5 PA; QL (1/28); NDS

tretinoin (chemotherapy) 5 NDSTRIPTODUR 5 PA; QL (1/168);

NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sirolimus oral solution 5 PA; NDSsirolimus oral tablet 4 PASOLTAMOX 4SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML

5 PA; QL (0.5/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

5 PA; QL (0.2/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML

5 PA; QL (0.3/28); NDS

SPRYCEL 5 PA; QL (30/30); NDS

STIVARGA 5 PA; QL (120/28); NDS

SUTENT 5 PA; QL (28/28); NDS

SYNRIBO 5 PA; QL (28/28); NDS

TABLOID 4tacrolimus oral 4 PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; QL (30/30);

NDSTALZENNA 5 PA; QL (90/30);

NDStamoxifen 2TARGRETIN TOPICAL 5 PA; QL (60/30);

NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (420/30); NDS

TAZVERIK 4 PATECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

5 PA; QL (20/21); NDS

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3)

5 PA; QL (12/28); NDS


5 PA; QL (16/28); NDS

XTANDI 4 PA; QL (120/30)YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML)

5 PA; QL (80/21); NDS

YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML)

5 PA; NDS

YONDELIS 5 PA; NDSZEJULA 5 PA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZIRABEV 5 PA; NDSZOLINZA 5 QL (120/30); NDSZORTRESS ORAL TABLET 0.25 MG

4 PA; QL (60/30)

ZORTRESS ORAL TABLET 0.5 MG

5 PA; QL (120/30); NDS

ZORTRESS ORAL TABLET 0.75 MG, 1 MG

5 PA; QL (60/30); NDS

ZYDELIG 5 PA; QL (60/30); NDS

ZYKADIA ORAL TABLET 5 PA; QL (140/28); NDS

ZYTIGA ORAL TABLET 250 MG

4 PA; QL (120/30)

ZYTIGA ORAL TABLET 500 MG

4 PA; QL (60/30)

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

4 ST; QL (180/30)

APTIOM ORAL TABLET 400 MG

4 ST; QL (90/30)

APTIOM ORAL TABLET 600 MG, 800 MG

4 ST; QL (60/30)

BANZEL ORAL SUSPENSION 5 PA; QL (2400/30); NDS

BANZEL ORAL TABLET 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRISENOX INTRAVENOUS SOLUTION 2 MG/ML

4 B/D PA

TRUXIMA 5 B/D PA; NDSTYKERB 5 PA; QL (180/30);

NDSUNITUXIN 5 PA; NDSVECTIBIX 5 PA; NDSVELCADE 5 PA; QL (14/21);

NDSVENCLEXTA ORAL TABLET 10 MG

4 PA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

5 PA; QL (120/30); NDS

VENCLEXTA ORAL TABLET 50 MG

5 PA; QL (30/30); NDS

VENCLEXTA STARTING PACK 5 PA; QL (84/365); NDS

VERZENIO 5 PA; QL (60/30); NDS

vincasar pfs intravenous solution 1 mg/ml

4 B/D PA

vincristine 4 B/D PAvinorelbine 4 B/D PAVITRAKVI ORAL CAPSULE 100 MG

5 PA; QL (60/30); NDS

VITRAKVI ORAL CAPSULE 25 MG

5 PA; QL (180/30); NDS

VITRAKVI ORAL SOLUTION 5 PA; QL (300/30); NDS

VIZIMPRO 5 PA; QL (30/30); NDS

VOTRIENT 5 PA; QL (120/30); NDS

VYXEOS 5 B/D PA; NDSXALKORI 5 PA; QL (60/30);

NDSXATMEP 4 PAXOSPATA 5 PA; QL (90/30);

NDSXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5)

5 PA; QL (20/28); NDS


5 PA; QL (32/28); NDS

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

divalproex oral capsule, delayed rel sprinkle

4

divalproex oral tablet extended release 24 hr

4

divalproex oral tablet,delayed release (dr/ec)

2

EPIDIOLEX 5 PA; NDSepitol 4ethosuximide 4felbamate 4FYCOMPA ORAL SUSPENSION

4 PA; QL DILANTIN 30 MG 4

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vigabatrin 5 PA; QL (180/30); NDS

vigadrone 5 PA; QL (180/30); NDS

VIMPAT INTRAVENOUS 4 QL (1200/30)VIMPAT ORAL SOLUTION 4 QL (1200/30)VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

4 QL (60/30)

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)zonisamide 3ANTIPARKINSONISM AGENTSAPOKYN 5 PA; QL (60/30);

NDSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 5 NDScarbidopa-levodopa oral tablet 2carbidopa-levodopa oral tablet extended release

3

carbidopa-levodopa oral tablet,disintegrating

4

carbidopa-levodopa-entacapone

4

entacapone 4 QL (240/30)NEUPRO 4pramipexole oral tablet 2rasagiline 4ropinirole oral tablet 2selegiline hcl 3MIGRAINE / CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA; QL (1/30)dihydroergotamine nasal 4 PA; QL (8/30)ergotamine-caffeine 3 QL (40/28)naratriptan 4 QL (18/28)rizatriptan 4 QL (36/28)sumatriptan 4 QL (18/28)sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

4 QL (90/30)

LYRICA ORAL CAPSULE 225 MG, 300 MG

4 QL (60/30)

LYRICA ORAL CAPSULE 75 MG

4 QL (120/30)

LYRICA ORAL SOLUTION 4 QL (900/30)NAYZILAM 4 PA; QL (10/30)oxcarbazepine oral suspension 4oxcarbazepine oral tablet 3PEGANONE 4phenobarbital oral elixir 4 QL (1500/30)phenobarbital oral tablet 3 QL (120/30)phenytoin oral suspension 2phenytoin oral tablet,chewable 3phenytoin sodium extended 2pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

3 QL (90/30)

pregabalin oral capsule 225 mg, 300 mg

3 QL (60/30)

pregabalin oral capsule 75 mg 3 QL (120/30)pregabalin oral solution 3 QL (900/30)primidone 2roweepra 2roweepra xr 4SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG

4 QL (60/30)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG

4 QL (120/30)

SYMPAZAN 5 PA; QL (60/30); NDS

tiagabine 4 STtopiramate oral capsule, sprinkle

2

topiramate oral tablet 2valproic acid 2valproic acid (as sodium salt) oral solution

2

VALTOCO 4 PA; QL (10/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OCREVUS 4 PArivastigmine 4 QL (30/30)rivastigmine tartrate 4 QL (60/30)TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG

5 PA; QL (14/30); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

5 PA; QL (120/365); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 240 MG

5 PA; QL (60/30); NDS

tetrabenazine oral tablet 12.5 mg

5 PA; QL (90/30); NDS

tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS

TYSABRI 5 PA; QL (15/28); NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPYbaclofen oral 2cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA

dantrolene oral 4methocarbamol oral 2 PApyridostigmine bromide oral syrup

4

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

3

regonol 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 QL (2700/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sumatriptan succinate subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate subcutaneous solution

4 QL (8/28)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG, 9 MG

5 PA; QL (120/30); NDS

AUSTEDO ORAL TABLET 6 MG

5 PA; QL (60/30); NDS

dalfampridine 3 PA; QL (60/30)donepezil oral tablet 10 mg 2 QL (60/30)donepezil oral tablet 5 mg 2 QL (30/30)donepezil oral tablet,disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet,disintegrating 5 mg

2 QL (30/30)

galantamine oral capsule,ext rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)galantamine oral tablet 4 QL (60/30)GILENYA ORAL CAPSULE 0.5 MG

5 PA; QL (30/30); NDS

glatiramer subcutaneous syringe 20 mg/ml

5 PA; QL (30/30); NDS

glatiramer subcutaneous syringe 40 mg/ml

5 PA; QL (12/28); NDS

memantine oral capsule,sprinkle,er 24hr

4 PA; QL (30/30)

memantine oral solution 4 PA; QL (300/30)memantine oral tablet 10 mg 3 PA; QL (60/30)memantine oral tablet 5 mg 3 PA; QL (90/30)memantine oral tablets,dose pack

3 PA; QL (98/365)

NUEDEXTA 4 PA; QL (60/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

4 NDS

hydromorphone oral liquid 4 QL ; NDS

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml

4 NDS

hydromorphone injection solution 2 mg/ml

4 NDS

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxycodone-acetaminophen oral tablet 7.5-325 mg

4 QL (240/30); NDS

oxycodone-aspirin 4 QL (180/30); NDSoxymorphone oral tablet extended release 12 hr

3 QL (90/30); NDS

XTAMPZA ER 3 QL (60/30); NDSzebutal oral capsule 50-325-40 mg

4 PA; QL (180/30)

NON-NARCOTIC ANALGESICSbuprenorphine-naloxone sublingual film 12-3 mg

4 QL (60/30)

buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg

4 QL (90/30)

buprenorphine-naloxone sublingual tablet

2 QL (90/30)

butorphanol tartrate injection solution 1 mg/ml

4 QL (480/30); NDS

butorphanol tartrate injection solution 2 mg/ml

4 QL (240/30); NDS

butorphanol tartrate nasal 4 QL (5/30); NDScelecoxib 4 QL (60/30)diclofenac potassium 2diclofenac sodium topical drops 4 QL (450/28)diclofenac sodium topical gel 1%

3 QL (1000/30)

diflunisal 4ec-naproxen 2etodolac 4flurbiprofen oral tablet 100 mg 2ibu 1ibuprofen oral suspension 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

meloxicam oral tablet 1nabumetone 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


4 B/D PA; QL (1200/30); NDS


4 B/D PA; QL (480/30); NDS


4 B/D PA; NDS


4 B/D PA; QL (250/30); NDS

morphine intravenous solution 10 mg/ml

4 B/D PA; QL (240/30); NDS

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SOLUTION 8 MG/ML

4 B/D PA; QL (250/30); NDS

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML

4 B/D PA; QL (240/30); NDS

morphine intravenous syringe 2 mg/ml

4 B/D PA; QL (1200/30); NDS

morphine intravenous syringe 4 mg/ml

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SYRINGE 8 MG/ML

4 B/D PA; QL (250/30); NDS

morphine oral solution 10 mg/5 ml

3 QL (700/30); NDS

morphine oral solution 20 mg/5 ml (4 mg/ml)

3 QL (900/30); NDS

MORPHINE ORAL TABLET 3 QL (120/30); NDSmorphine oral tablet extended release

3 QL (90/30); NDS

oxycodone oral concentrate 4 QL (120/30); NDSoxycodone oral solution 4 QL (1200/30); NDSoxycodone oral tablet 3 QL (180/30); NDSoxycodone-acetaminophen oral tablet 10-325 mg

4 QL (180/30); NDS

oxycodone-acetaminophen oral tablet 2.5-300 mg

4 NDS

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg

4 QL (360/30); NDS

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARISTADA INITIO 4 QL (4.8/365)ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

4 QL (3.9/56)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML

4 QL (1.6/28)


4 QL (2.4/28)


4 QL (3.2/28)

armodafinil 4 PA; QL (30/30)atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

4 QL (30/30)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG

3 QL (30/30)

BELSOMRA ORAL TABLET 5 MG

3 QL (60/30)

bupropion hcl oral tablet 100 mg

3 QL (120/30)

bupropion hcl oral tablet 75 mg 3 QL (180/30)bupropion hcl oral tablet extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg

3 QL (60/30)

bupropion hcl oral tablet sustained-release 12 hr 150 mg

3 QL (90/30)

buspirone 2CAPLYTA 4 ST; QL (30/30)chlorpromazine 4citalopram oral solution 4 QL (600/30)citalopram oral tablet 10 mg 1 QL (120/30)citalopram oral tablet 20 mg 1 QL (60/30)citalopram oral tablet 40 mg 1 QL (90/30)clomipramine 4 PAclorazepate dipotassium oral tablet 15 mg, 3.75 mg

4 QL (180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nalbuphine injection solution 10 mg/ml

4 QL (180/30); NDS

nalbuphine injection solution 20 mg/ml

4 QL (90/30); NDS

naloxone injection solution 2naloxone injection syringe 1 mg/ml

2

naltrexone 3naproxen oral suspension 4naproxen oral tablet 1naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

4

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3 QL (4/30)

oxaprozin 4SUBOXONE SUBLINGUAL FILM 12-3 MG

3 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG

3 QL (90/30)

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 4 QL (240/30); NDSVIVITROL 4 PAZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3 QL (90/30)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 4 QL (1/28)alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)amitriptyline 2 PAamoxapine 4aripiprazole oral solution 4 QL (900/30)aripiprazole oral tablet 4 QL (30/30)aripiprazole oral tablet,disintegrating

5 QL (60/30); NDS

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextroamphetamine-amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg

3 QL (60/30)


3 QL (120/30)


3 QL (90/30)


3 QL (360/30)

diazepam injection syringe 2diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3 PAdoxepin oral concentrate 3 PAdoxepin oral tablet 3 QL (30/30)DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG

4 QL (180/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG

4 QL (90/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG

4 QL (60/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg

2 QL (180/30)


2 QL (90/30)


2 QL (60/30)

EMSAM 4 QL (30/30)escitalopram oxalate oral solution

4 QL (600/30)

escitalopram oxalate oral tablet 2FANAPT ORAL TABLET 4 ST; QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clorazepate dipotassium oral tablet 7.5 mg

4 QL (360/30)

clozapine oral tablet 100 mg, 200 mg

4

clozapine oral tablet 25 mg, 50 mg

3

clozapine oral tablet,disintegrating 100 mg

4 QL (270/30)

clozapine oral tablet,disintegrating 12.5 mg, 25 mg

4


4 QL (180/30)


4 QL (120/30)

desipramine 4desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

4 QL (120/30)

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

4 QL (30/30)

dexmethylphenidate oral tablet 10 mg, 2.5 mg

3 QL (60/30)

dexmethylphenidate oral tablet 5 mg

3 QL (120/30)

dextroamphetamine oral capsule, extended release 10 mg

4 QL (180/30)


4 QL (120/30)


4 QL (60/30)

dextroamphetamine oral tablet 4 QL (180/30)dextroamphetamine-amphetamine oral capsule,extended release 24hr

4 QL (60/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML

4 QL (1.32/90)


4 QL (1.75/90)


4 QL (2.63/90)

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

4 QL (30/30)

LATUDA ORAL TABLET 80 MG 4 QL (60/30)lithium carbonate 2lorazepam injection 4lorazepam intensol 4 QL (150/30)lorazepam oral concentrate 4 QL (150/30)lorazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

lorazepam oral tablet 2 mg 2 QL (150/30)loxapine succinate 4maprotiline 4MARPLAN 4 QL (180/30)metadate er 4 QL (90/30)methylphenidate hcl oral tablet 4 QL (90/30)methylphenidate hcl oral tablet extended release

4 QL (90/30)

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating)

4 QL (120/30)

methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating)

4 QL (30/30)

methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating)

4 QL (60/30)

mirtazapine oral tablet 2MIRTAZAPINE ORAL TABLET,DISINTEGRATING

3 QL (30/30)

molindone 2nefazodone 4nortriptyline 2NUPLAZID ORAL CAPSULE 4 PA; QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FANAPT ORAL TABLETS,DOSE PACK

4 ST; QL (16/365)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4 ST; QL (56/365)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine oral capsule 2fluoxetine oral solution 2 QL (600/30)fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 3GEODON INTRAMUSCULAR 4 QL (6/30)haloperidol 2haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2HETLIOZ 5 PA; QL (30/30);

NDSimipramine hcl 3 PAINVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

4 QL (0.75/28)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML

4 QL (1/28)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML

4 QL (1.5/28)


4 QL (0.25/28)


4 QL (0.5/28)


4 QL (0.88/90)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg

4 QL (60/30)

risperidone oral tablet,disintegrating 0.5 mg, 4 mg

4 QL (120/30)

SAPHRIS 4 QL (60/30)SECUADO 4 QL (30/30)sertraline oral concentrate 2 QL (300/30)sertraline oral tablet 100 mg, 25 mg

2 QL (60/30)

sertraline oral tablet 50 mg 2 QL (120/30)SILENOR 3 QL (30/30)temazepam oral capsule 15 mg, 30 mg

2 QL (60/365)

temazepam oral capsule 22.5 mg, 7.5 mg

4 QL (60/365)

thioridazine 4thiothixene 4tranylcypromine 4trazodone 2trifluoperazine oral tablet 1 mg 3trifluoperazine oral tablet 10 mg, 2 mg, 5 mg

4

trimipramine 4 PATRINTELLIX 4 ST; QL (30/30)venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg

2 QL (60/30)

venlafaxine oral capsule,extended release 24hr 75 mg

2 QL (90/30)

venlafaxine oral tablet 2VERSACLOZ 4 QL (540/30)VIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (60/365)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUPLAZID ORAL TABLET 10 MG

4 PA; QL (30/30)

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 10 mg, 2.5 mg, 5 mg

3 QL (120/30)

olanzapine oral tablet 15 mg, 20 mg

3 QL (60/30)

olanzapine oral tablet 7.5 mg 3 QL (30/30)olanzapine oral tablet,disintegrating

4 QL (30/30)

oxazepam 4 QL (120/30)paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

4 ST; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 ST; QL (60/30)

paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg

2 QL (60/30)

paroxetine hcl oral tablet 20 mg 2 QL (90/30)PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4perphenazine-amitriptyline 4 PAPERSERIS 4 QL (1/30)phenelzine 3pimozide 4protriptyline 4quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 QL (90/30)

quetiapine oral tablet 300 mg, 400 mg

2 QL (60/30)

ramelteon 3REXULTI 4 QL (30/30)RISPERDAL CONSTA 4 QL (2/28)risperidone oral solution 4 QL (240/30)risperidone oral tablet 2

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amlodipine-benazepril 2amlodipine-valsartan 2amlodipine-valsartan-hcthiazid 2atenolol 1atenolol-chlorthalidone 2benazepril 1benazepril-hydrochlorothiazide 2betaxolol oral 2BIDIL 3 QL (180/30)bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4bumetanide oral tablet 0.5 mg, 1 mg

2

bumetanide oral tablet 2 mg 3candesartan oral tablet 16 mg, 4 mg, 8 mg

2 QL (60/30)

candesartan oral tablet 32 mg 2 QL (30/30)candesartan-hydrochlorothiazid 2captopril 4captopril-hydrochlorothiazide 4cartia xt 3carvedilol 1chlorothiazide oral tablet 500 mg

2

chlorothiazide sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

clonidine hcl oral tablet 2clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr

4 QL (4/28)

clonidine transdermal patch weekly 0.3 mg/24 hr

4 QL (8/28)

DEMSER 4 PAdiltiazem hcl intravenous 4diltiazem hcl oral capsule,extended release 12 hr

3

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VRAYLAR ORAL CAPSULE 4 ST; QL (30/30)VRAYLAR ORAL CAPSULE,DOSE PACK

4 ST; QL (14/365)

XYREM 5 PA; QL (540/30); NDS

ziprasidone hcl 4 QL (60/30)zolpidem oral tablet 2 QL (30/30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG

4 QL (2/28)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG

4 QL (1/28)

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 B/D PA

amiodarone oral tablet 100 mg, 200 mg

2

amiodarone oral tablet 400 mg 4dofetilide 4flecainide 4lidocaine (pf) intravenous syringe

4

mexiletine 4MULTAQ 3 QL (60/30)pacerone oral tablet 100 mg, 200 mg, 400 mg

4

propafenone 4quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2amiloride 2amiloride-hydrochlorothiazide 2amlodipine 1

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 3methyldopa 4metolazone 3metoprolol succinate 2metoprolol ta-hydrochlorothiaz 2metoprolol tartrate oral 1minoxidil oral 2moexipril 2nadolol 4nadolol-bendroflumethiazide oral tablet 80-5 mg

4

nicardipine intravenous solution 4nicardipine oral 4nifedipine oral tablet extended release

3 QL (60/30)

nifedipine oral tablet extended release 24hr

3 QL (60/30)

nimodipine 4nisoldipine 4olmesartan 3olmesartan-hydrochlorothiazide 3perindopril erbumine 2pindolol 3prazosin 4propranolol oral capsule,extended release 24 hr

4

propranolol oral solution 4propranolol oral tablet 2propranolol-hydrochlorothiazid 3quinapril 1quinapril-hydrochlorothiazide 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

3

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

3

dilt-xr 3doxazosin 2EDARBI 4 ST; QL (30/30)EDARBYCLOR 4 STenalapril maleate 2enalapril-hydrochlorothiazide 2ethacrynate sodium 4felodipine 2fosinopril 2 QL (60/30)fosinopril-hydrochlorothiazide 2 QL (120/30)furosemide injection 4furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 2irbesartan oral tablet 150 mg 1 QL (60/30)irbesartan oral tablet 300 mg, 75 mg

1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)isradipine 4labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COAGULATION THERAPYaminocaproic acid oral 4aspirin-dipyridamole 4 QL (60/30)BRILINTA 4 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 2 QL (2/365)clopidogrel oral tablet 75 mg 2COUMADIN ORAL 4dipyridamole oral 3 PAELIQUIS 3ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin 4fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

4

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4

jantoven 1pentoxifylline 2PRADAXA 4 QL (60/30)prasugrel 4 QL (30/30)PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA; QL (360/30); NDS

PROMACTA ORAL POWDER IN PACKET 25 MG

5 PA; NDS

PROMACTA ORAL TABLET 5 PA; QL (30/30); NDS

warfarin 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ramipril 1REMODULIN 5 B/D PA; NDSspironolactone 2spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

3

telmisartan oral tablet 20 mg, 40 mg

2 QL (30/30)

telmisartan oral tablet 80 mg 2 QL (60/30)telmisartan-amlodipine 2 QL (30/30)telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg

2 QL (30/30)

telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg

2 QL (60/30)

terazosin 1tiadylt er 3timolol maleate oral 4torsemide oral 2trandolapril 2treprostinil sodium 5 B/D PA; NDStriamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 4 PA; NDSvalsartan oral tablet 160 mg, 40 mg, 80 mg

2 QL (60/30)

valsartan oral tablet 320 mg 2 QL (30/30)valsartan-hydrochlorothiazide 2 QL (30/30)verapamil intravenous solution 4verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2

VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG

3

verapamil oral tablet 1verapamil oral tablet extended release

2

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REPATHA 3 PA; QL (3/28)REPATHA PUSHTRONEX 3 PA; QL (3.5/28)REPATHA SURECLICK 3 PA; QL (3/28)rosuvastatin 2 QL (30/30)simvastatin oral tablet 1 QL (30/30)VASCEPA ORAL CAPSULE 0.5 GRAM

4 QL (240/30)

VASCEPA ORAL CAPSULE 1 GRAM

4 QL (120/30)

MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PA; QL (60/30)digitek 3digox 3digoxin oral solution 50 mcg/ml (0.05 mg/ml)

3 QL (150/30)

digoxin oral tablet 3ENTRESTO 3 QL (60/30)ranolazine 4 QL (60/30)NITRATESisosorbide dinitrate oral tablet 4isosorbide mononitrate 2minitran 4nitroglycerin intravenous 4 B/D PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual spray,non-aerosol

4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3calcipotriene topical cream 4 QL (120/30)calcipotriene topical ointment 4 QL (120/30)selenium sulfide topical lotion 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XARELTO 3LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

atorvastatin oral tablet 40 mg 1 QL (60/30)cholestyramine (with sugar) 4cholestyramine light 4colesevelam 3colestipol 4ezetimibe 3 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 130 mg, 43 mg

4

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral capsule 4fenofibrate oral tablet 160 mg, 54 mg

3

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg

4 QL (30/30)

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg

4 QL (60/30)

gemfibrozil 2lovastatin oral tablet 10 mg, 20 mg

1 QL (60/30)

lovastatin oral tablet 40 mg 2 QL (60/30)niacin oral tablet extended release 24 hr

4

pravastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

pravastatin oral tablet 40 mg 1 QL (60/30)prevalite 4

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SANTYL 4silver sulfadiazine 4SSD 4tacrolimus topical 4 QL (100/90)VALCHLOR 5 PA; QL (60/30);

NDSZTLIDO 3 PA; QL (90/30)THERAPY FOR ACNEavita 4 PAclaravis 4clindamycin phosphate topical gel

4

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

4

clindamycin phosphate topical lotion

4

clindamycin phosphate topical solution

4

clindamycin phosphate topical swab

3

ery pads 4erythromycin with ethanol topical gel

4

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4isotretinoin 4metronidazole topical 4rosadan topical cream 4rosadan topical gel 4tazarotene 4TAZORAC TOPICAL CREAM 0.05%

4

tretinoin microspheres topical gel 0.1%

4 PA

tretinoin microspheres topical gel with pump 0.1%

4 PA

tretinoin topical cream 0.025%, 0.05%, 0.1%

4 PA

tretinoin topical topical gel 0.01%

3 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA; QL (2/28); NDS

STELARA INTRAVENOUS 5 PA; NDSSTELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

MISCELLANEOUS DERMATOLOGICALSacyclovir topical cream 5 QL (5/30); NDSacyclovir topical ointment 4 QL (30/30)ammonium lactate 2DUPIXENT 4 PAfluorouracil topical cream 0.5% 5 NDSfluorouracil topical cream 5% 3fluorouracil topical solution 3glydo 3 QL (60/30)imiquimod topical cream in packet

3

lidocaine (pf) injection solution 4lidocaine hcl injection solution 4lidocaine hcl laryngotracheal 3lidocaine hcl mucous membrane jelly

3 QL (60/30)

lidocaine hcl mucous membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

3

lidocaine topical adhesive patch,medicated 5%

4 PA; QL (90/30)

lidocaine topical ointment 4 QL (50/30)lidocaine viscous 2lidocaine-prilocaine topical cream

4 QL (30/30)

methoxsalen 4PANRETIN 5 NDSPICATO TOPICAL GEL 0.015% 4 QL (3/56)PICATO TOPICAL GEL 0.05% 4 QL (2/56)podofilox 4REGRANEX 5 PA; NDS

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alclometasone topical ointment 2betamethasone dipropionate 4betamethasone valerate topical cream

3

betamethasone valerate topical lotion

4

betamethasone valerate topical ointment

3

betamethasone, augmented topical cream

2

betamethasone, augmented topical gel

4

betamethasone, augmented topical lotion

4

betamethasone, augmented topical ointment

4

clobetasol scalp 4 QL (100/28)clobetasol topical cream 4 QL (120/28)clobetasol topical foam 4 QL (100/28)clobetasol topical gel 4 QL (120/28)CLOBETASOL TOPICAL LOTION

4 QL (118/28)

clobetasol topical ointment 4 QL (120/28)clobetasol topical shampoo 4 QL (236/28)CLOBETASOL TOPICAL SPRAY,NON-AEROSOL

4 QL (125/28)

clobetasol-emollient topical cream

4 QL (120/28)

CLOBEX TOPICAL LOTION 4 QL (118/28)CLOBEX TOPICAL SHAMPOO 4 QL (236/28)CLOBEX TOPICAL SPRAY,NON-AEROSOL

4 QL (125/28)

CLOCORTOLONE PIVALATE 4CLODAN 4 QL (236/28)DESONATE 4desonide topical lotion 4desonide topical ointment 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tretinoin topical topical gel 0.025%, 0.05%

4 PA

TOPICAL ANTIBACTERIALSgentamicin topical cream 4gentamicin topical ointment 3mafenide acetate 4mupirocin 2mupirocin calcium 4sulfacetamide sodium (acne) 4SULFAMYLON TOPICAL PACKET

4

TOPICAL ANTIFUNGALSciclodan topical solution 4ciclopirox topical cream 4 QL (90/28)ciclopirox topical shampoo 4 QL (120/28)ciclopirox topical solution 4ciclopirox topical suspension 4clotrimazole topical cream 2clotrimazole topical solution 3 QL (30/28)clotrimazole-betamethasone topical cream

4 QL (45/28)

clotrimazole-betamethasone topical lotion

4 QL (60/28)

econazole 4 QL (85/28)ketoconazole topical cream 2 QL (60/28)ketoconazole topical shampoo 2 QL (120/28)nyamyc 4nystatin topical cream 2 QL (30/28)nystatin topical ointment 2 QL (30/28)nystatin topical powder 3nystatin-triamcinolone 4 QL (60/28)nystop 4TOPICAL CORTICOSTEROIDSala-cort topical cream 1% 2alclometasone topical cream 3

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

triamcinolone acetonide topical ointment

2

triderm topical cream 0.1% 2tridesilon 4TOPICAL SCABICIDES / PEDICULICIDESlindane topical shampoo 4malathion 4permethrin topical cream 3

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4PHYSIOLYTE 4PHYSIOSOL IRRIGATION 4ringer’s irrigation 4tis-u-sol pentalyte 4MISCELLANEOUS AGENTSacamprosate 4anagrelide 3CARBAGLU 5 PA; NDSCHEMET 4CLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10%-0.45% sodium chloride 4 B/D PAd2.5%-0.45% sodium chloride 4 B/D PAd5% and 0.9% sodium chloride 4d5%-0.45% sodium chloride 4dextrose 10% and 0.2% nacl 4 B/D PADEXTROSE 10% IN WATER (D10W)

4 B/D PA

dextrose 20% in water (d20w) 4 B/D PAdextrose 25% in water (d25w) 4 B/D PAdextrose 30% in water (d30w) 4 B/D PAdextrose 40% in water (d40w) 4 B/D PADEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

dextrose 5%-lactated ringers 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

desowen topical cream 4DESOWEN TOPICAL LOTION 4desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone 4fluocinolone and shower cap 4fluocinonide topical cream 0.05%

3

fluocinonide topical gel 4 QL (120/30)fluocinonide topical ointment 4 QL (120/30)fluocinonide topical solution 4 QL (120/30)fluticasone propionate topical cream

2

fluticasone propionate topical ointment

3

halobetasol propionate topical cream

4

halobetasol propionate topical ointment

4

hydrocortisone butyrate topical cream

4

hydrocortisone butyrate topical ointment

4

hydrocortisone butyr-emollient 4hydrocortisone topical cream 1%, 2.5%

2

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 4hydrocortisone-min oil-wht pet 2IMPOYZ 4 QL (120/28)mometasone topical 2OLUX 4 QL (100/28)prednicarbate topical ointment 2triamcinolone acetonide topical cream

2

triamcinolone acetonide topical lotion

3

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sps (with sorbitol) 4trientine 5 QL (240/30); NDSVELTASSA 3water for irrigation, sterile 4XIAFLEX 4 PAzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA; QL (100/365)

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (60/30)CHANTIX 3CHANTIX CONTINUING MONTH BOX

3

CHANTIX STARTING MONTH BOX

3

NICOTROL 4NICOTROL NS 4 QL (30/30)

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (30/25)chlorhexidine gluconate mucous membrane

2

ipratropium bromide nasal spray,non-aerosol 0.03%

2 QL (30/30)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06%)

2 QL (45/30)

oralone 4paroex oral rinse 2triamcinolone acetonide dental 4MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 3flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4 B/D PAdextrose 70% in water (d70w) 4dextrose with sodium chloride 4disulfiram 4EXJADE 5 PA; NDSINCRELEX 4 PAkionex (with sorbitol) 4levocarnitine (with sugar) 4levocarnitine oral solution 100 mg/ml

4

levocarnitine oral tablet 4midodrine 4nitisinone 5 NDSNORTHERA ORAL CAPSULE 100 MG

5 PA; QL (90/30); NDS

NORTHERA ORAL CAPSULE 200 MG, 300 MG

5 PA; QL (180/30); NDS

ORFADIN 5 NDSpilocarpine hcl oral 4PROLASTIN-C 5 B/D PA; NDSRENVELA ORAL POWDER IN PACKET

3 QL (180/30)

RENVELA ORAL TABLET 3 QL (540/30)riluzole 3sevelamer carbonate oral powder in packet

4 QL (180/30)

sevelamer carbonate oral tablet 4 QL (540/30)sodium chloride 0.9% intravenous

4

sodium chloride irrigation 4sodium phenylbutyrate 5 PA; NDSsodium polystyrene (sorb free) 4sodium polystyrene sulfonate oral powder

4

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prednisone oral tablets,dose pack 5 mg, 5 mg (48 pack)

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection

4

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg, 25 mg

2 QL (90/30)

acarbose oral tablet 50 mg 2 QL (180/30)ALCOHOL PADS 3BAQSIMI 3BD PEN NEEDLE 3 QL(200/30)BYDUREON BCISE 4 QL (4/28)BYDUREON SUBCUTANEOUS PEN INJECTOR

4 QL (4/28)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

4 QL (2.4/30)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML

4 QL (1.2/30)

CYCLOSET 4 QL (180/30)GAUZE PADS 2 X 2 3glimepiride oral tablet 1 mg 1 QL (240/30)glimepiride oral tablet 2 mg 1 QL (120/30)glimepiride oral tablet 4 mg 1 QL (60/30)glipizide oral tablet 10 mg 1 QL (120/30)glipizide oral tablet 5 mg 1 QL (240/30)glipizide oral tablet extended release 24hr 10 mg

2 QL (60/30)

glipizide oral tablet extended release 24hr 2.5 mg

2 QL (240/30)

glipizide oral tablet extended release 24hr 5 mg

2 QL (120/30)

glipizide-metformin oral tablet 2.5-250 mg

1 QL (240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OTIC STEROID / ANTIBIOTICCIPRODEX 3neomycin-polymyxin-hc otic (ear)

4

ENDOCRINE/DIABETES

ADRENAL HORMONEScortisone 4dexamethasone intensol 4dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 2dexamethasone sodium phos (pf) injection solution

4

dexamethasone sodium phosphate injection solution

4

fludrocortisone 2hydrocortisone oral 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

4

methylprednisolone sodium succ intravenous recon soln 1,000 mg

4 QL (8/30)

methylprednisolone sodium succ intravenous recon soln 500 mg

4 QL (12/30)

prednisolone oral solution 15 mg/5 ml

4

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 5 mg base/5 ml (6.7 mg/5 ml)

4

prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml)

3

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 2 B/D PAprednisone oral tablets,dose pack 10 mg, 10 mg (48 pack)

2

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JANUMET 3 QL (60/30)JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)JARDIANCE 3 QL (30/30)LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN 3LEVEMIR FLEXTOUCH U-100 INSULN

3

LEVEMIR U-100 INSULIN 3metformin oral tablet 1,000 mg 1 QL (75/30)metformin oral tablet 500 mg 1 QL (150/30)metformin oral tablet 850 mg 1 QL (90/30)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (120/30)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (60/30)

metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet)

4 QL (60/30)

metformin oral tablet,er gast.retention 24 hr 1,000 mg

4 ST; QL (60/30)

metformin oral tablet,er gast.retention 24 hr 500 mg

4 ST; QL (120/30)

nateglinide oral tablet 120 mg 2 QL (90/30)nateglinide oral tablet 60 mg 2 QL (180/30)NEEDLES, INSULIN DISP.,SAFETY

3 QL (200/30)

NOVOFINE PEN NEEDLE 3 QL(200/30)NOVOTWIST PEN NEEDLE 3 QL(200/30)OMNIPOD 5 PACK 3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

GVOKE SYRINGE 3HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN INSULIN

3

HUMALOG MIX 50-50 INSULN U-100

3

HUMALOG MIX 50-50 KWIKPEN

3

HUMALOG MIX 75-25 KWIKPEN

3

HUMALOG MIX 75-25(U-100)INSULN

3

HUMALOG U-100 INSULIN 3HUMULIN 70/30 U-100 INSULIN

3

HUMULIN 70/30 U-100 KWIKPEN

3

HUMULIN N NPH INSULIN KWIKPEN

3

HUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

HUMULIN R U-500 (CONC) INSULIN

4 B/D PA

HUMULIN R U-500 (CONC) KWIKPEN

4

INSULIN PEN NEEDLE 3 QL (200/30)INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

3 QL (200/30)

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

calcitonin (salmon) 3calcitriol intravenous solution 1 mcg/ml

4

calcitriol oral 2CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 B/D PA; NDS

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg, 60 mg

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)danazol 4desmopressin injection 4desmopressin nasal spray with pump

4

desmopressin nasal spray,non-aerosol

4

desmopressin oral 3doxercalciferol intravenous 4doxercalciferol oral capsule 0.5 mcg

4 QL (90/30)

doxercalciferol oral capsule 1 mcg

4 QL (240/30)

doxercalciferol oral capsule 2.5 mcg

4 QL (120/30)

ELAPRASE 5 PA; NDSFABRAZYME 5 B/D PA; NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSmiglustat 5 QL (90/30); NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; QL (2/28); NDSoxandrolone oral tablet 10 mg 4 PA; QL (60/30)oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30)pamidronate 4 B/D PAparicalcitol oral 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC 3 QL (3/28)pioglitazone oral tablet 15 mg 2 QL (90/30)pioglitazone oral tablet 30 mg, 45 mg

2 QL (30/30)

PROGLYCEM 4repaglinide oral tablet 0.5 mg, 1 mg

4 QL (120/30)

repaglinide oral tablet 2 mg 4 QL (240/30)SOLIQUA 100/33 3 ST; QL (18/30)SYMLINPEN 120 4 PA; QL (10.8/28)SYMLINPEN 60 4 PA; QL (6/30)SYNJARDY 3 QL (60/30)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

3 QL (60/30)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG

3 QL (30/30)

TECHLITE PEN NEEDLE 3 QL(200/30)TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

TRADJENTA 4 QL (30/30)TRESIBA FLEXTOUCH U-100 3TRESIBA FLEXTOUCH U-200 3TRESIBA U-100 INSULIN 3TRULICITY 3 QL (2/28)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 2-PAK 3 QL (9/30)VICTOZA 3-PAK 3 QL (9/30)XULTOPHY 100/3.6 3 ST; QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDSANADROL-50 4 PAcabergoline 4

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

4

unithroid oral tablet 137 mcg 4

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICSdicyclomine oral capsule 2dicyclomine oral solution 4dicyclomine oral tablet 2diphenoxylate-atropine 4GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate oral 4loperamide oral capsule 2propantheline 4MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron oral tablet 0.5 mg 4 PA; QL (60/30)alosetron oral tablet 1 mg 5 PA; QL (60/30);

NDSAMITIZA 3 QL (60/30)aprepitant 4 B/D PAAPRISO 3 QL (120/30)balsalazide 4budesonide oral 4compro 4constulose 2CREON 3cromolyn oral 3CYSTADANE 5 NDSdronabinol 4 PA; QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

SENSIPAR ORAL TABLET 30 MG, 60 MG

4 QL (60/30)

SENSIPAR ORAL TABLET 90 MG

4 QL (120/30)

SOMAVERT 5 PA; QL (30/30); NDS

STIMATE 5 NDSSYNAREL 4 PAtestosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml)

3

testosterone enanthate 4testosterone transdermal gel 4 PA; QL (300/30)testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram)

4 PA; QL (300/30)

zoledronic acid intravenous solution

4 B/D PA; QL (15/21)

THYROID HORMONESlevothyroxine oral 2levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

4

liothyronine oral 2SYNTHROID 4THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

procto-pak 2proctosol hc topical 4proctozone-hc 4RECTIV 4 QL (30/30)RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

RENFLEXIS 5 PA; NDSSANCUSO 5 QL (4/28); NDSscopolamine base 4 QL (10/30)sulfasalazine 2trilyte with flavor packets 2ursodiol oral capsule 3ursodiol oral tablet 4VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT

4

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT

4 NDS

ULCER THERAPYDEXILANT 4 QL (30/30)esomeprazole magnesium oral capsule,delayed release(dr/ec)

4 QL (60/30)

FAMOTIDINE ORAL SUSPENSION

4

famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

3 QL (60/30)

misoprostol 3omeprazole oral capsule,delayed release(dr/ec)

2 QL (60/30)

pantoprazole oral 2 QL (60/30)PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

4

ranitidine hcl oral capsule 4ranitidine hcl oral syrup 3ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral tablet 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 2GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2gavilyte-g 2gavilyte-n 2generlac 2granisetron hcl oral 4 B/D PA; QL (30/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

2

lactulose oral solution 2meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule,extended release 24hr

3 QL (120/30)

mesalamine rectal enema 4mesalamine with cleansing wipe

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2OCALIVA 4 PA; QL (30/30)ondansetron 2 B/D PAondansetron hcl (pf) 4ondansetron hcl intravenous 4ondansetron hcl oral solution 4 B/D PA; QL

(450/30)ondansetron hcl oral tablet 2 B/D PApeg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte 2PENTASA 3PLENVU 4prochlorperazine 4prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 4

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3 QL (0.5/365)

BCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3 QL (0.5/365)BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (8/365)

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

fomepizole 5 NDSGAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 4 QL (1.5/365)HAVRIX (PF) 3HIBERIX (PF) 3HIZENTRA SUBCUTANEOUS SOLUTION

4 B/D PA

IMOVAX RABIES VACCINE (PF)

4 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3IXIARO (PF) 4KINRIX (PF) 3MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3 QL (2/365)PEDIARIX (PF) 3PEDVAX HIB (PF) 3PROQUAD (PF) 3 QL (2/365)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA; NDSARCALYST 5 PA; NDSBETASERON SUBCUTANEOUS KIT

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA; NDS

INTRON A INJECTION RECON SOLN

5 NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4

MOZOBIL 5 QL (9.6/30); NDSNEULASTA 4 PARETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4 PA; QL (12/28)

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

5 PA; QL (6/28); NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5 PA; QL (4/28); NDS

ZARXIO 5 PA; NDSZIEXTENZO 4 PA

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

FORTEO 5 PA; QL (2.4/28); NDS

ibandronate oral 3 QL (1/28)PROLIA 4 QL (1/180)raloxifene 3 QL (30/30)TYMLOS 5 PA; QL (1.56/30);

NDSOTHER RHEUMATOLOGICALSBENLYSTA INTRAVENOUS RECON SOLN 120 MG

5 PA; QL (30/28); NDS

BENLYSTA INTRAVENOUS RECON SOLN 400 MG

5 PA; QL (9/28); NDS

DEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

5 PA; QL (4.08/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDSHUMIRA PEN 5 PA; QL (4/28); NDSHUMIRA PEN CROHNS-UC-HS START

5 PA; QL (12/365); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (8/365); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML

5 PA; QL (2/28); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (6/365); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (4/365); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

QUADRACEL (PF) 3RABAVERT (PF) 3 B/D PARECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

3 B/D PA; QL (3/365)

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

3 B/D PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

ROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 4 QL (2/999)STAMARIL (PF) 4 QL (1/999)TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 QL (0.5/28)

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3 QL (1/365)VARIZIG INTRAMUSCULAR SOLUTION

4 QL (12/30)

YF-VAX (PF) 3ZOSTAVAX (PF) 4 QL (1/999)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral capsule 3 QL (60/30)colchicine oral tablet 4 QL (120/30)febuxostat 4 ST; QL (30/30)MITIGARE 3 QL (60/30)probenecid 3probenecid-colchicine 3

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

fyavolv 4 PAheather 3hydroxyprogesterone caproate 5 PA; NDSincassia 3jencycla 3lyza 3medroxyprogesterone intramuscular

4

medroxyprogesterone oral 2nora-be 3norethindrone (contraceptive) 3norethindrone acetate 4norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg

4 PA

PREMARIN VAGINAL 3progesterone micronized 2sharobel 3yuvafem 4 QL (18/28)MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 4metronidazole vaginal 4terconazole 4tranexamic acid oral 3vandazole 4ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 4alyacen 7/7/7 (28) 3amethia 3amethia lo 4amethyst (28) 2apri 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML

5 PA; QL (2/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

leflunomide 3ORENCIA 5 PA; QL (4/28); NDSORENCIA CLICKJECT 5 PA; QL (4/28); NDSpenicillamine 5 NDSRINVOQ 5 PA; QL (30/30);

NDSXELJANZ 5 PA; QL (60/30);

NDSXELJANZ XR 5 PA; QL (30/30);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINScamila 3deblitane 3dotti 4 PA; QL (8/28)DUAVEE 4 PA; QL (30/30)errin 3estradiol oral 3 PAestradiol transdermal patch semiweekly

4 PA; QL (8/28)

estradiol transdermal patch weekly

4 PA; QL (4/28)

estradiol vaginal tablet 4 QL (18/28)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

estarylla 4ethynodiol diac-eth estradiol 4falmina (28) 2fayosim 2femynor 4gianvi (28) 2hailey 2hailey 24 fe 3introvale 4isibloom 3jaimiess 2jasmiel (28) 2jolessa 3juleber 4junel 1.5/30 (21) 4junel 1/20 (21) 4junel fe 1.5/30 (28) 4junel fe 1/20 (28) 4junel fe 24 4kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 4kurvelo (28) 2l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

3

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

2

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

4

larin 1.5/30 (21) 2larin 1/20 (21) 2larin 24 fe 2larin fe 1.5/30 (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

aranelle (28) 4ashlyna 4aubra 3aubra eq 3aurovela 1.5/30 (21) 2aurovela 1/20 (21) 2aurovela 24 fe 2aurovela fe 1.5/30 (28) 2aurovela fe 1-20 (28) 2aviane 2ayuna 2azurette (28) 3balziva (28) 2bekyree (28) 4blisovi 24 fe 2blisovi fe 1.5/30 (28) 4blisovi fe 1/20 (28) 4briellyn 2camrese 3camrese lo 4caziant (28) 4chateal (28) 3chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 3cyred 3cyred eq 3dasetta 1/35 (28) 3dasetta 7/7/7 (28) 3daysee 3desog-e.estradiol/e.estradiol 4desogestrel-ethinyl estradiol 4drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 3emoquette 4enpresse 2enskyce 2

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

3

norethindrone-e.estradiol-iron oral tablet,chewable

3

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)

4

norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

3

nortrel 0.5/35 (28) 2nortrel 1/35 (21) 2nortrel 1/35 (28) 2nortrel 7/7/7 (28) 3ocella 2ogestrel (28) 3orsythia 2philith 3pimtrea (28) 3pirmella oral tablet 0.5/0.75/1 mg- 35 mcg

3

pirmella oral tablet 1-35 mg-mcg

2

portia 28 2previfem 4reclipsen (28) 2rivelsa 2setlakin 4simliya (28) 2simpesse 2sprintec (28) 4sronyx 2syeda 2tarina 24 fe 3tarina fe 1/20 (28) 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

larin fe 1/20 (28) 2larissia 4layolis fe 2leena 28 2lessina 2levonest (28) 2levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 90-20 mcg (28)

4

levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg

3

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

4

levonorg-eth estrad triphasic 4levora-28 2lillow (28) 2lojaimiess 2loryna (28) 2low-ogestrel (28) 4lo-zumandimine (28) 2lutera (28) 3marlissa (28) 2melodetta 24 fe 4mibelas 24 fe 4microgestin 1.5/30 (21) 4microgestin 1/20 (21) 4microgestin fe 1.5/30 (28) 4microgestin fe 1/20 (28) 4mili 4mono-linyah 3necon 0.5/35 (28) 3nikki (28) 2noreth-ethinyl estradiol-iron 2norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

4

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erythromycin ophthalmic (eye) 2gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

3

moxifloxacin ophthalmic (eye) drops

3

NATACYN 4neomycin-bacitracin-polymyxin 4neomycin-polymyxin-gramicidin 3neo-polycin 4ofloxacin ophthalmic (eye) 2polycin 2polymyxin b sulf-trimethoprim 2tobramycin 2ANTIVIRALStrifluridine 4ZIRGAN 3BETA-BLOCKERSbetaxolol ophthalmic (eye) 4carteolol 2levobunolol ophthalmic (eye) drops 0.5%

2

timolol maleate ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) gel forming solution

4

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3azelastine ophthalmic (eye) 4BLEPHAMIDE 4BLEPHAMIDE S.O.P. 4cromolyn ophthalmic (eye) 2CYSTARAN 5 PA; QL (60/28);

NDSepinastine 4EYLEA 4 PAolopatadine ophthalmic (eye) 4PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tarina fe 1-20 eq (28) 3tilia fe 3tri femynor 2tri-estarylla 4tri-legest fe 3tri-linyah 4tri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 4tri-previfem (28) 4tri-sprintec (28) 4trivora (28) 2tri-vylibra 4tri-vylibra lo 4tydemy 4velivet triphasic regimen (28) 2vienva 4viorele (28) 3volnea (28) 2vyfemla (28) 2vylibra 4wera (28) 3wymzya fe 2zarah 2zovia 1/35e (28) 2zumandimine (28) 2

OPHTHALMOLOGY

ANTIBIOTICSak-poly-bac 2bacitracin ophthalmic (eye) 4bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye)

2

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tobramycin-dexamethasone 3STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

DUREZOL 3fluorometholone 3INVELTYS 4LOTEMAX 4LOTEMAX SM 4prednisolone acetate 3prednisolone sodium phosphate ophthalmic (eye)

2

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

4

apraclonidine 4brimonidine ophthalmic (eye) drops 0.15%

4

brimonidine ophthalmic (eye) drops 0.2%

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 3diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector

3 QL (2/30)

hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4 QL (300/30)levocetirizine oral tablet 2 QL (120/30)promethazine oral syrup 4 PApromethazine oral tablet 2 PAPULMONARY AGENTSacetylcysteine 4 B/D PAADEMPAS 5 PA; QL (90/30);

NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RESTASIS 3 QL (60/30)RESTASIS MULTIDOSE 3 QL (11/30)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 3COMBIGAN 3dorzolamide 2dorzolamide-timolol 3latanoprost 2LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

3

RHOPRESSA 4 STROCKLATAN 4 STtravoprost 3STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 4neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-hc ophthalmic (eye)

4

neo-polycin hc 4TOBRADEX OPHTHALMIC (EYE) OINTMENT

3

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION

3 QL (24/30)


3 QL (10.6/30)

flunisolide nasal spray,non-aerosol 25 mcg (0.025%)

3 QL (50/30)

fluticasone propionate nasal 2 QL (16/30)icatibant 5 PA; QL (18/30);

NDSINCRUSE ELLIPTA 3 QL (30/30)ipratropium bromide inhalation 2 B/D PAipratropium-albuterol 2 B/D PAKALYDECO 5 PA; QL (60/30);

NDSLETAIRIS 5 PA; QL (30/30);

NDSlevalbuterol tartrate 4 QL (30/30)metaproterenol oral syrup 4mometasone nasal 4 ST; QL (34/30)montelukast oral granules in packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)montelukast oral tablet,chewable

2 QL (30/30)

nasonex 4 ST; QL (34/30)OFEV 5 PA; QL (60/30);

NDSORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (120/30); NDS

PERFOROMIST 4 B/D PA; QL (120/30)

PROAIR HFA 3 QL (17/30)PROAIR RESPICLICK 3 QL (2/30)PULMOZYME 5 B/D PA; QL

(150/30); NDSRUCONEST 5 PA; QL (8/30); NDSSEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ADVAIR DISKUS 3 QL (60/30)ADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 4albuterol sulfate oral tablet extended release 12 hr

4

AMBRISENTAN 5 PA; QL (30/30); NDS

ANORO ELLIPTA 3 QL (60/30)ARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)bosentan 5 PA; QL (60/30);

NDSBREO ELLIPTA 3 QL (60/30)BROVANA 4 B/D PA; QL

(120/30)budesonide inhalation 4 B/D PACINRYZE 5 PA; QL (20/30);

NDSCOMBIVENT RESPIMAT 4 QL (8/30)cromolyn inhalation 2 B/D PA; QL

(240/30)DALIRESP 4 PA; QL (30/30)ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDSESBRIET ORAL TABLET 267 MG

5 PA; QL (270/30); NDS

ESBRIET ORAL TABLET 801 MG

5 PA; QL (90/30); NDS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL (60/30)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

3 QL (240/30)


3 QL (12/30)

59



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MISCELLANEOUS UROLOGICALSbethanechol chloride 3CYSTAGON 4ELMIRON 4K-PHOS ORIGINAL 4potassium citrate 4RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 3klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 2klor-con m20 2lactated ringers intravenous 4 B/D PAMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4 B/D PA

magnesium sulfate in water 4 B/D PAmagnesium sulfate injection 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN 5% DEXTROSE

4 B/D PA

POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4 B/D PA

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l

4 B/D PA

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

terbutaline 4theophylline oral tablet extended release 12 hr

2

theophylline oral tablet extended release 24 hr

2

TRACLEER ORAL TABLET FOR SUSPENSION

5 PA; NDS

TRELEGY ELLIPTA 3 QL (60/30)VENTAVIS 4 PA; QL (270/30)VENTOLIN HFA 4 QL (36/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; QL (6/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE

5 PA; QL (5/28); NDS

zafirlukast 4 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSMYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG

4 QL (60/30)

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

4 QL (30/30)

oxybutynin chloride oral syrup 2 QL (600/30)oxybutynin chloride oral tablet 2oxybutynin chloride oral tablet extended release 24hr

3 QL (60/30)

solifenacin 3 QL (30/30)tolterodine oral tablet 4TOVIAZ 4 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2 QL (30/30)dutasteride 2 QL (30/30)finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)

60


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMINOSYN-PF 10% 4 B/D PAAMINOSYN-PF 7% (SULFITE-FREE)

4 B/D PA

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15% 4 B/D PAelectrolyte-48 in d5w 4 B/D PAFREAMINE HBC 6.9% 4 B/D PAfreamine iii 10% 4 B/D PAHEPATAMINE 8% 4 B/D PAINTRALIPID INTRAVENOUS EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PANEPHRAMINE 5.4% 4 B/D PANORMOSOL-M IN 5% DEXTROSE

4 B/D PA

NORMOSOL-R PH 7.4 4 B/D PANUTRILIPID 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PAPREMASOL 10% 4 B/D PAPROCALAMINE 3% 4 B/D PAPROSOL 20% 4 B/D PATRAVASOL 10% 4 B/D PATROPHAMINE 10% 4 B/D PATROPHAMINE 6% 4 B/D PAVITAMINS / HEMATINICSfluoride (sodium) oral tablet 1fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

PRENATAL VITAMIN ORAL TABLET

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride in lr-d5 4 B/D PApotassium chloride in water intravenous piggyback

4 B/D PA

potassium chloride intravenous 4 B/D PApotassium chloride oral capsule, extended release

4

potassium chloride oral liquid 4potassium chloride oral packet 2potassium chloride oral tablet extended release

2

potassium chloride oral tablet,er particles/crystals

2

potassium chloride-0.45% nacl 4 B/D PAPOTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4 B/D PA

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

4 B/D PA

POTASSIUM CHLORIDE-D5-0.9%NACL

4 B/D PA

ringer’s intravenous 4 B/D PAsodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml)

4

sodium chloride 0.45% intravenous parenteral solution

4

sodium chloride 3% 4sodium chloride 5% 4sodium chloride intravenous 4TPN ELECTROLYTES 4 B/D PAMISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 10% 4 B/D PAAMINOSYN II 15% 4 B/D PA

61

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir-lamivudine . . . . . . . . . . . . . . . 17abacavir-lamivudine-zidovudine . . . . 17abacavir oral solution . . . . . . . . . . . . . . 17abacavir oral tablet . . . . . . . . . . . . . . . . 17ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 17ABILIFY MAINTENA . . . . . . . . . . . . . . . 34abiraterone . . . . . . . . . . . . . . . . . . . . . . . . 23ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 23acamprosate . . . . . . . . . . . . . . . . . . . . . . 44acarbose oral tablet 50 mg . . . . . . . . . 46acarbose oral tablet 100 mg, 25 mg . 46acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . 38acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml . . . . . . . . . . . . 31acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . . . . . 32acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . . . . . 32acetazolamide . . . . . . . . . . . . . . . . . . . . . 57acetazolamide sodium . . . . . . . . . . . . . 57acetic acid otic (ear) . . . . . . . . . . . . . . . 45acetylcysteine . . . . . . . . . . . . . . . . . . . . . 57acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 51ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 51acyclovir oral capsule . . . . . . . . . . . . . . 17acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 17acyclovir oral tablet . . . . . . . . . . . . . . . . 17acyclovir sodium intravenous solution . . . . . . . . . . . . . . . 17acyclovir topical cream . . . . . . . . . . . . . 42acyclovir topical ointment . . . . . . . . . . 42ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 51ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 57ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 58ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 58

AFINITOR . . . . . . . . . . . . . . . . . . . . . . . . 23AFINITOR DISPERZ . . . . . . . . . . . . . . . 23afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 53AIMOVIG AUTOINJECTOR . . . . . . . . 30ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 56ala-cort topical cream 1% . . . . . . . . . . 43albendazole . . . . . . . . . . . . . . . . . . . . . . . 20albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 58albuterol sulfate oral syrup . . . . . . . . . 58albuterol sulfate oral tablet . . . . . . . . . 58albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 58alclometasone topical cream . . . . . . . 43alclometasone topical ointment . . . . . 43ALCOHOL PADS . . . . . . . . . . . . . . . . . . 46ALDURAZYME . . . . . . . . . . . . . . . . . . . . 48ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 23alendronate oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 52alendronate oral tablet 35 mg, 70 mg . . . . . . . . . . . . . . . . . . . . . 52alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 59ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ALINIA ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 20ALINIA ORAL TABLET . . . . . . . . . . . . . 20ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 23allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 52alosetron oral tablet 0.5 mg . . . . . . . . 49alosetron oral tablet 1 mg . . . . . . . . . . 49ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 57alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 34alprazolam oral tablet 2 mg . . . . . . . . 34altavera (28) . . . . . . . . . . . . . . . . . . . . . . 53ALUNBRIG ORAL TABLET 30 MG . 23ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 23ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 23

alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 53alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 53amantadine hcl . . . . . . . . . . . . . . . . . . . . 17AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 17AMBRISENTAN . . . . . . . . . . . . . . . . . . . 58amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 53amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 53amethyst (28) . . . . . . . . . . . . . . . . . . . . . 53amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml . . . . . . . . 20amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 38amiloride-hydrochlorothiazide . . . . . . 38aminocaproic acid oral . . . . . . . . . . . . . 40AMINOSYN II 10% . . . . . . . . . . . . . . . . 60AMINOSYN II 15% . . . . . . . . . . . . . . . . 60AMINOSYN-PF 7% (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60AMINOSYN-PF 10% . . . . . . . . . . . . . . . 60amiodarone intravenous solution . . . 38amiodarone oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 38amiodarone oral tablet 400 mg . . . . . 38AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 49amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 34amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 38amlodipine-benazepril . . . . . . . . . . . . . 38amlodipine-valsartan . . . . . . . . . . . . . . . 38amlodipine-valsartan-hcthiazid . . . . . 38ammonium lactate . . . . . . . . . . . . . . . . . 42amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 34amoxicillin oral capsule . . . . . . . . . . . . 21amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 21amoxicillin oral tablet . . . . . . . . . . . . . . 21amoxicillin oral tablet,chewable 125 mg, 250 mg . . . . . . . . . . . . . . . . . . . 21amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 22amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 22

62


Covered Drugs Index

ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 23azathioprine . . . . . . . . . . . . . . . . . . . . . . . 23azathioprine sodium . . . . . . . . . . . . . . . 23azelastine nasal . . . . . . . . . . . . . . . . . . . 45azelastine ophthalmic (eye) . . . . . . . . 56azithromycin intravenous . . . . . . . . . . . 20azithromycin oral packet . . . . . . . . . . . 20azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 20azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack) . . . . . . . . . . . 20azithromycin oral tablet 600 mg . . . . . 20AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 57aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 20azurette (28) . . . . . . . . . . . . . . . . . . . . . . 54

Bbacitracin intramuscular . . . . . . . . . . . . 20bacitracin ophthalmic (eye) . . . . . . . . . 56bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 56baclofen oral . . . . . . . . . . . . . . . . . . . . . . 31balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 49BALVERSA ORAL TABLET 3 MG . . . 23BALVERSA ORAL TABLET 4 MG . . . 23BALVERSA ORAL TABLET 5 MG . . . 23balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 54BANZEL ORAL SUSPENSION . . . . . 28BANZEL ORAL TABLET . . . . . . . . . . . 28BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 46BARACLUDE ORAL SOLUTION . . . 17BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 23BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 22BCG VACCINE, LIVE (PF) . . . . . . . . . 51BD PEN NEEDLE . . . . . . . . . . . . . . . . . 46bekyree (28) . . . . . . . . . . . . . . . . . . . . . . 54BELSOMRA ORAL TABLET 5 MG . . 34

armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 34ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 58ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 23arsenic trioxide intravenous solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 23ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 54aspirin-dipyridamole . . . . . . . . . . . . . . . 40atazanavir oral capsule 150 mg . . . . . 17atazanavir oral capsule 200 mg . . . . . 17atazanavir oral capsule 300 mg . . . . . 17atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38atenolol-chlorthalidone . . . . . . . . . . . . . 38atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 34atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 34atorvastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 41atorvastatin oral tablet 40 mg . . . . . . . 41atovaquone . . . . . . . . . . . . . . . . . . . . . . . 20atovaquone-proguanil . . . . . . . . . . . . . . 20ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 17atropine ophthalmic (eye) drops . . . . 56ATROVENT HFA . . . . . . . . . . . . . . . . . . 58aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 54AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML . . . . . . . . . . . . . . . . . 22aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 54aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 54aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 54aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 54aurovela fe 1-20 (28) . . . . . . . . . . . . . . 54AUSTEDO ORAL TABLET 6 MG . . . 31AUSTEDO ORAL TABLET 12 MG, 9 MG . . . . . . . . . . . . . . . . . . . . . . 31AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 23aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 22amoxicillin-pot clavulanate oral tablet extended release 12 hr . . . . . . . 22amphotericin b . . . . . . . . . . . . . . . . . . . . 17ampicillin oral capsule 500 mg . . . . . . 22ampicillin sodium . . . . . . . . . . . . . . . . . . 22ampicillin-sulbactam . . . . . . . . . . . . . . . 22ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 48anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 44anastrozole . . . . . . . . . . . . . . . . . . . . . . . 23ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 58APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 30apraclonidine . . . . . . . . . . . . . . . . . . . . . . 57aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 49apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 49APTIOM ORAL TABLET 200 MG . . . 28APTIOM ORAL TABLET 400 MG . . . 28APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 28APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . 17APTIVUS (WITH VITAMIN E). . . . . . . 17aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 54ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 51ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 20aripiprazole oral solution . . . . . . . . . . . 34aripiprazole oral tablet . . . . . . . . . . . . . 34aripiprazole oral tablet,disintegrating . 34ARISTADA INITIO . . . . . . . . . . . . . . . . . 34ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML . . . . . . . . . 34ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML . . . . . . . . . . . 34ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML . . . . . . . . . . . 34ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML . . . . . . . . . . . 34

63


Covered Drugs Index

bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . . . . . . . . . . 34bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg . . . . . . 34bupropion hcl oral tablet sustained-release 12 hr 150 mg . . . . . . . . . . . . . . 34bupropion hcl (smoking deter) . . . . . . 45buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 34busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 23BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 23butalbital-acetaminophen-caff oral capsule . . . . . . . . . . . . . . . . . . . . . . . 32butalbital-acetaminophen-caff oral tablet 50-325-40 mg . . . . . . . . . . . 32butorphanol tartrate injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 33butorphanol tartrate injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 33butorphanol tartrate nasal . . . . . . . . . . 33BYDUREON BCISE . . . . . . . . . . . . . . . 46BYDUREON SUBCUTANEOUS PEN INJECTOR . . . . . . . . . . . . . . . . . . . 46BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML . . . . . . . . . . . . . 46BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE (250 MCG/ML) 2.4 ML . . . . . . . . . . . . . 46

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 48CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . . . . . . . . . 23CABOMETYX ORAL TABLET 40 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23calcipotriene scalp . . . . . . . . . . . . . . . . . 41calcipotriene topical cream . . . . . . . . . 41calcipotriene topical ointment . . . . . . . 41calcitonin (salmon) . . . . . . . . . . . . . . . . . 48calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 48calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 48

blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 54blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 54blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 54BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 51BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 23bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 58BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . 23BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 23BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 58briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 40brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 57brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 57BRIVIACT ORAL SOLUTION . . . . . . . 29BRIVIACT ORAL TABLET . . . . . . . . . . 29bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 57bromocriptine . . . . . . . . . . . . . . . . . . . . . 30BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 58BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 23budesonide inhalation . . . . . . . . . . . . . . 58budesonide oral . . . . . . . . . . . . . . . . . . . 49bumetanide injection . . . . . . . . . . . . . . . 38bumetanide oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 38bumetanide oral tablet 2 mg . . . . . . . . 38buprenorphine hcl injection solution . . 32buprenorphine hcl injection syringe . 32buprenorphine hcl sublingual . . . . . . . 32buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg . . . . . . 33buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 33buprenorphine-naloxone sublingual tablet . . . . . . . . . . . . . . . . . . . 33bupropion hcl oral tablet 75 mg . . . . . 34bupropion hcl oral tablet 100 mg . . . . 34bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . 34

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG . . . . . . . . . . . . . 34benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 38benazepril-hydrochlorothiazide . . . . . 38BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 23BENLYSTA INTRAVENOUS RECON SOLN 120 MG . . . . . . . . . . . . 52BENLYSTA INTRAVENOUS RECON SOLN 400 MG . . . . . . . . . . . . 52benztropine injection . . . . . . . . . . . . . . . 30benztropine oral . . . . . . . . . . . . . . . . . . . 30BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 56BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 23betamethasone, augmented topical cream . . . . . . . . . . . . . . . . . . . . . . 43betamethasone, augmented topical gel . . . . . . . . . . . . . . . . . . . . . . . . . 43betamethasone, augmented topical lotion . . . . . . . . . . . . . . . . . . . . . . . 43betamethasone, augmented topical ointment . . . . . . . . . . . . . . . . . . . 43betamethasone dipropionate . . . . . . . 43betamethasone valerate topical cream . . . . . . . . . . . . . . . . . . . . . . 43betamethasone valerate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 43betamethasone valerate topical ointment . . . . . . . . . . . . . . . . . . . 43BETASERON SUBCUTANEOUS KIT 51betaxolol ophthalmic (eye) . . . . . . . . . 56betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 38bethanechol chloride . . . . . . . . . . . . . . . 59bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 23BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 51bicalutamide . . . . . . . . . . . . . . . . . . . . . . 23BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 22BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 17bisoprolol fumarate . . . . . . . . . . . . . . . . 38bisoprolol-hydrochlorothiazide . . . . . . 38BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 56BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 56

64


Covered Drugs Index

CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . 29cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 20cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 20CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 48CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 45CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 45CHANTIX STARTING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 45chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 54chateal eq (28) . . . . . . . . . . . . . . . . . . . . 54CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 44chloramphenicol sod succinate . . . . . 20chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 45chloroquine phosphate . . . . . . . . . . . . . 20chlorothiazide oral tablet 500 mg . . . 38chlorothiazide sodium . . . . . . . . . . . . . . 38chlorpromazine . . . . . . . . . . . . . . . . . . . . 34chlorthalidone oral tablet 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 38cholestyramine light . . . . . . . . . . . . . . . 41cholestyramine (with sugar) . . . . . . . . 41CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR . . . . . . . 48ciclodan topical solution . . . . . . . . . . . . 43ciclopirox topical cream . . . . . . . . . . . . 43ciclopirox topical shampoo . . . . . . . . . 43ciclopirox topical solution . . . . . . . . . . . 43ciclopirox topical suspension . . . . . . . 43cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 40CILOXAN OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 56CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 17cinacalcet oral tablet 30 mg, 60 mg . 48cinacalcet oral tablet 90 mg . . . . . . . . 48CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 58CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 46

cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . 19cefadroxil oral capsule . . . . . . . . . . . . . 19cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 19cefadroxil oral tablet . . . . . . . . . . . . . . . 19cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 19cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . 19CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . 19cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19CEFEPIME IN DEXTROSE 5% . . . . . 19cefepime in dextrose,iso-osm . . . . . . 19cefepime injection . . . . . . . . . . . . . . . . . 19cefixime oral capsule . . . . . . . . . . . . . . 19cefixime oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . . . 19cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 19CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . 19cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . 19cefoxitin in dextrose, iso-osm . . . . . . . 19cefpodoxime . . . . . . . . . . . . . . . . . . . . . . 19cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 19ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 19CEFTAZIDIME IN D5W . . . . . . . . . . . . 19ceftriaxone in dextrose,iso-os . . . . . . 19ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . 19CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 19ceftriaxone intravenous . . . . . . . . . . . . 19cefuroxime axetil oral tablet . . . . . . . . 20cefuroxime sodium injection recon soln 750 mg . . . . . . . . . . . . . . . . . 20cefuroxime sodium intravenous . . . . . 20celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 33

calcium acetate(phosphat bind) . . . . . 59CALQUENCE . . . . . . . . . . . . . . . . . . . . . 23camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 54camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 54candesartan-hydrochlorothiazid . . . . 38candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 38candesartan oral tablet 32 mg . . . . . . 38CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . 20CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 34CAPRELSA ORAL TABLET 100 MG . 23CAPRELSA ORAL TABLET 300 MG . 23captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 38captopril-hydrochlorothiazide . . . . . . . 38CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 44carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 29carbamazepine oral suspension 100 mg/5 ml . . . . . . . . . . . 29carbamazepine oral tablet . . . . . . . . . . 29carbamazepine oral tablet, chewable . . . . . . . . . . . . . . . . . . . . . . . . . 29carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 29carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 30carbidopa-levodopa-entacapone . . . . 30carbidopa-levodopa oral tablet . . . . . 30carbidopa-levodopa oral tablet,disintegrating . . . . . . . . . . . . . . . . 30carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . 30carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 56cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 38carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 38caspofungin . . . . . . . . . . . . . . . . . . . . . . . 17CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 20caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 54cefaclor oral capsule . . . . . . . . . . . . . . . 19cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . 19

65


Covered Drugs Index

clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 43clotrimazole mucous membrane . . . . 17clotrimazole topical cream . . . . . . . . . . 43clotrimazole topical solution . . . . . . . . 43clozapine oral tablet 25 mg, 50 mg . . 35clozapine oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 35clozapine oral tablet, disintegrating 12.5 mg, 25 mg . . . . . . 35clozapine oral tablet, disintegrating 100 mg . . . . . . . . . . . . . . 35clozapine oral tablet, disintegrating 150 mg . . . . . . . . . . . . . . 35clozapine oral tablet, disintegrating 200 mg . . . . . . . . . . . . . . 35COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 20colchicine oral capsule . . . . . . . . . . . . . 52colchicine oral tablet . . . . . . . . . . . . . . . 52colesevelam . . . . . . . . . . . . . . . . . . . . . . . 41colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 41colistin (colistimethate na) . . . . . . . . . . 20COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 57COMBIVENT RESPIMAT . . . . . . . . . . 58COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 24COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) . . 23COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) . . 24COMPLERA . . . . . . . . . . . . . . . . . . . . . . 17compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 49constulose . . . . . . . . . . . . . . . . . . . . . . . . 49COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 24CORLANOR ORAL TABLET . . . . . . . 41cortisone . . . . . . . . . . . . . . . . . . . . . . . . . . 46COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 24COUMADIN ORAL . . . . . . . . . . . . . . . . 40CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CRESEMBA ORAL . . . . . . . . . . . . . . . . 17CRIXIVAN ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 17

clobazam oral suspension . . . . . . . . . . 29clobazam oral tablet . . . . . . . . . . . . . . . 29clobetasol-emollient topical cream . . 43clobetasol scalp . . . . . . . . . . . . . . . . . . . 43clobetasol topical cream . . . . . . . . . . . 43clobetasol topical foam . . . . . . . . . . . . . 43clobetasol topical gel . . . . . . . . . . . . . . 43CLOBETASOL TOPICAL LOTION . . 43clobetasol topical ointment . . . . . . . . . 43clobetasol topical shampoo . . . . . . . . 43CLOBETASOL TOPICAL SPRAY,NON-AEROSOL . . . . . . . . . . . 43CLOBEX TOPICAL LOTION . . . . . . . 43CLOBEX TOPICAL SHAMPOO . . . . 43CLOBEX TOPICAL SPRAY, NON-AEROSOL . . . . . . . . . . . . . . . . . . . 43CLOCORTOLONE PIVALATE . . . . . . 43CLODAN . . . . . . . . . . . . . . . . . . . . . . . . . . 43clomipramine . . . . . . . . . . . . . . . . . . . . . . 34clonazepam oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 29clonazepam oral tablet 2 mg . . . . . . . 29clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg . . . . . . . . . . . . . . . . . . . 29clonazepam oral tablet, disintegrating 1 mg . . . . . . . . . . . . . . . . 29clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 29clonidine hcl oral tablet . . . . . . . . . . . . . 38clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr . . 38clonidine transdermal patch weekly 0.3 mg/24 hr . . . . . . . . . . . . . . . 38clopidogrel oral tablet 75 mg . . . . . . . 40clopidogrel oral tablet 300 mg . . . . . . 40clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 35clorazepate dipotassium oral tablet 15 mg, 3.75 mg . . . . . . . . . 34clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 43

ciprofloxacin . . . . . . . . . . . . . . . . . . . . . . . 22ciprofloxacin hcl ophthalmic (eye) . . . 56ciprofloxacin hcl oral tablet 100 mg . 22ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 22ciprofloxacin in 5% dextrose . . . . . . . . 22citalopram oral solution . . . . . . . . . . . . 34citalopram oral tablet 10 mg . . . . . . . . 34citalopram oral tablet 20 mg . . . . . . . . 34citalopram oral tablet 40 mg . . . . . . . . 34claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 42clarithromycin . . . . . . . . . . . . . . . . . . . . . 20clindamycin hcl . . . . . . . . . . . . . . . . . . . . 20CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . . . . . . . 20clindamycin in 5% dextrose . . . . . . . . 20clindamycin palmitate hcl . . . . . . . . . . . 20clindamycin pediatric . . . . . . . . . . . . . . 20clindamycin phosphate injection . . . . 20clindamycin phosphate intravenous solution 600 mg/4 ml . . . 20clindamycin phosphate topical gel . . 42CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . . . . 42clindamycin phosphate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 42clindamycin phosphate topical solution . . . . . . . . . . . . . . . . . . . . 42clindamycin phosphate topical swab . . . . . . . . . . . . . . . . . . . . . . . 42clindamycin phosphate vaginal . . . . . 53CLINIMIX 4.25%/D5W SULFIT FREE . . . . . . . . . . . . . . . . . . . . . 44CLINIMIX 4.25%/D10W SULF FREE . . . . . . . . . . . . . . . . . . . . . . . 60CLINIMIX 5%/D15W SULFITE FREE . . . . . . . . . . . . . . . . . . . 60CLINIMIX 5%-D20W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60CLINIMIX E 4.25%/D10W SUL FREE . . . . . . . . . . . . . . . . . . . . . . . . 60CLINISOL SF 15% . . . . . . . . . . . . . . . . 60

66


Covered Drugs Index

dexamethasone oral solution . . . . . . . 46dexamethasone oral tablet . . . . . . . . . 46dexamethasone sodium phos (pf) injection solution . . . . . . . . . . . . . . . 46dexamethasone sodium phosphate injection solution . . . . . . . . 46dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 57DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 50dexmethylphenidate oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 35dexmethylphenidate oral tablet 10 mg, 2.5 mg . . . . . . . . . . . . . . . 35dextroamphetamine-amphetamine oral capsule,extended release 24hr . 35dextroamphetamine-amphetamine oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine-amphetamine oral tablet 10 mg . . . . . . . . . . . . . . . . . . 35dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg . . 35dextroamphetamine-amphetamine oral tablet 15 mg . . . . . . . . . . . . . . . . . . 35dextroamphetamine-amphetamine oral tablet 20 mg . . . . . . . . . . . . . . . . . . 35dextroamphetamine oral capsule, extended release 5 mg . . . . . . . . . . . . . 35dextroamphetamine oral capsule, extended release 10 mg . . . . . . . . . . . 35dextroamphetamine oral capsule, extended release 15 mg . . . . . . . . . . . 35dextroamphetamine oral tablet . . . . . 35dextrose 5%-0.2% sod chloride . . . . . 45dextrose 5%-0.3% sod.chloride . . . . . 45DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION . . . . . . . . . 44dextrose 5% in water (d5w) intravenous piggyback . . . . . . . . . . . . . 44dextrose 5%-lactated ringers . . . . . . . 44dextrose 10% and 0.2% nacl . . . . . . . 44DEXTROSE 10% IN WATER (D10W) . . . . . . . . . . . . . . . . 44

daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 20DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 20DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 24dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 54dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 54daunorubicin intravenous solution . . 24DAURISMO ORAL TABLET 25 MG . 24DAURISMO ORAL TABLET 100 MG . 24daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 53DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 17DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 38DEPEN TITRATABS . . . . . . . . . . . . . . . 52DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 17desipramine . . . . . . . . . . . . . . . . . . . . . . . 35desloratadine oral tablet . . . . . . . . . . . 57desmopressin injection . . . . . . . . . . . . . 48desmopressin nasal spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 48desmopressin nasal spray with pump . . . . . . . . . . . . . . . . . . . . . . . . . 48desmopressin oral . . . . . . . . . . . . . . . . . 48desog-e.estradiol/e.estradiol . . . . . . . 54desogestrel-ethinyl estradiol . . . . . . . . 54DESONATE . . . . . . . . . . . . . . . . . . . . . . . 43desonide topical lotion . . . . . . . . . . . . . 43desonide topical ointment . . . . . . . . . . 43desowen topical cream . . . . . . . . . . . . 44DESOWEN TOPICAL LOTION . . . . . 44desoximetasone topical cream . . . . . 44desoximetasone topical gel . . . . . . . . 44desoximetasone topical ointment . . . 44desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 35desvenlafaxine succinate oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . 35dexamethasone intensol . . . . . . . . . . . 46dexamethasone oral elixir . . . . . . . . . . 46

CRIXIVAN ORAL CAPSULE 400 MG . . . . . . . . . . . . . . . . 17cromolyn inhalation . . . . . . . . . . . . . . . . 58cromolyn ophthalmic (eye) . . . . . . . . . 56cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 49cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 54CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . 20CUBICIN RF . . . . . . . . . . . . . . . . . . . . . . 20cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 54cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 54cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . 31cyclophosphamide intravenous . . . . . 24cyclophosphamide oral capsule . . . . 24CYCLOSERINE . . . . . . . . . . . . . . . . . . . 20CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 46cyclosporine intravenous . . . . . . . . . . . 24cyclosporine modified . . . . . . . . . . . . . . 24cyclosporine oral capsule . . . . . . . . . . 24CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 24cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 54CYSTADANE . . . . . . . . . . . . . . . . . . . . . 49CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 59CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 56

Dd2.5%-0.45% sodium chloride . . . . . . 44d5%-0.45% sodium chloride . . . . . . . . 44d5% and 0.9% sodium chloride . . . . . 44d10%-0.45% sodium chloride . . . . . . 44dalfampridine . . . . . . . . . . . . . . . . . . . . . . 31DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 58danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 48dantrolene oral . . . . . . . . . . . . . . . . . . . . 31dapsone oral . . . . . . . . . . . . . . . . . . . . . . 20DAPTACEL (DTAP PEDIATRIC) (PF) . . . . . . . . . . . 51DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 20

67


Covered Drugs Index

doxercalciferol oral capsule 2.5 mcg . . . . . . . . . . . . . . . . . . . 48doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 22doxycycline hyclate intravenous . . . . 22doxycycline hyclate oral capsule . . . . 22doxycycline hyclate oral tablet 100 mg, 20 mg . . . . . . . . . . . . . . . . . . . . 22doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . . . . . 22doxycycline monohydrate oral suspension for reconstitution . . . . . . . 22doxycycline monohydrate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 22DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG . . . . . . . . . . . . 35DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG . . . . 35DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG . . . . . . . . . . . . 35dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 49drospirenone-e.estradiol-lm.fa . . . . . . 54drospirenone-ethinyl estradiol . . . . . . 54DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 24DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 53duloxetine oral capsule,delayed release(dr/ec) 20 mg . . . . . . . . . . . . . . . 35duloxetine oral capsule,delayed release(dr/ec) 30 mg . . . . . . . . . . . . . . . 35duloxetine oral capsule,delayed release(dr/ec) 60 mg . . . . . . . . . . . . . . . 35DUPIXENT . . . . . . . . . . . . . . . . . . . . . . . . 42DURAMORPH (PF) . . . . . . . . . . . . . . . . 32DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 57dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 59

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 33econazole . . . . . . . . . . . . . . . . . . . . . . . . . 43EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 39

diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 38diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . 39diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg . . 38diltiazem hcl oral tablet . . . . . . . . . . . . . 39diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 39dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . 57diphenoxylate-atropine . . . . . . . . . . . . . 49dipyridamole oral . . . . . . . . . . . . . . . . . . 40disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 45divalproex oral capsule, delayed rel sprinkle . . . . . . . . . . . . . . . . 29divalproex oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 29divalproex oral tablet extended release 24 hr . . . . . . . . . . . . 29dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 38donepezil oral tablet 5 mg . . . . . . . . . . 31donepezil oral tablet 10 mg . . . . . . . . . 31donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 31donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 31dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 57dorzolamide-timolol . . . . . . . . . . . . . . . . 57dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 17doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 39doxepin oral capsule . . . . . . . . . . . . . . . 35doxepin oral concentrate . . . . . . . . . . . 35doxepin oral tablet . . . . . . . . . . . . . . . . . 35doxercalciferol intravenous . . . . . . . . . 48doxercalciferol oral capsule 0.5 mcg . . . . . . . . . . . . . . . . . . . 48doxercalciferol oral capsule 1 mcg . . 48

dextrose 20% in water (d20w) . . . . . . 44dextrose 25% in water (d25w) . . . . . . 44dextrose 30% in water (d30w) . . . . . . 44dextrose 40% in water (d40w) . . . . . . 44dextrose 50% in water (d50w) . . . . . . 45dextrose 70% in water (d70w) . . . . . . 45dextrose with sodium chloride . . . . . . 45DIASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 29DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG . . . . . . . . . . 29DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG . . 29diazepam injection syringe . . . . . . . . . 35diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 35diazepam oral tablet . . . . . . . . . . . . . . . 35DIAZEPAM RECTAL KIT 2.5 MG . . . 29DIAZEPAM RECTAL KIT 5-7.5-10 MG . . . . . . . . . . . . . . . . . . 29DIAZEPAM RECTAL KIT 12.5-15-17.5-20 MG . . . . . . . . . . . 29diclofenac potassium . . . . . . . . . . . . . . 33diclofenac sodium ophthalmic (eye) . . 57diclofenac sodium topical drops . . . . 33diclofenac sodium topical gel 1% . . . 33dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 22dicyclomine oral capsule . . . . . . . . . . . 49dicyclomine oral solution . . . . . . . . . . . 49dicyclomine oral tablet . . . . . . . . . . . . . 49didanosine oral capsule, delayed release(dr/ec) 200 mg, 250 mg, 400 mg . . . . . . . . . . . 17diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 33digitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41digox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41digoxin oral solution 50 mcg/ml (0.05 mg/ml) . . . . . . . . . . . . 41digoxin oral tablet . . . . . . . . . . . . . . . . . . 41dihydroergotamine nasal . . . . . . . . . . . 30DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 29diltiazem hcl intravenous . . . . . . . . . . . 38

68


Covered Drugs Index

esomeprazole magnesium oral capsule,delayed release(dr/ec) . . . . . 50estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 54estradiol oral . . . . . . . . . . . . . . . . . . . . . . 53estradiol transdermal patch semiweekly . . . . . . . . . . . . . . . . . . . . . . . 53estradiol transdermal patch weekly . 53estradiol vaginal tablet . . . . . . . . . . . . . 53estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml . . . . . . . . . . . . . 53ethacrynate sodium . . . . . . . . . . . . . . . . 39ethambutol . . . . . . . . . . . . . . . . . . . . . . . . 20ethosuximide . . . . . . . . . . . . . . . . . . . . . . 29ethynodiol diac-eth estradiol . . . . . . . . 54etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 33etoposide intravenous . . . . . . . . . . . . . 24everolimus (antineoplastic) . . . . . . . . . 24EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 24EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 18exemestane . . . . . . . . . . . . . . . . . . . . . . . 24EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 45EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 41ezetimibe-simvastatin . . . . . . . . . . . . . . 41

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 48falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 54famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 18FAMOTIDINE ORAL SUSPENSION . . 50famotidine oral tablet 20 mg, 40 mg . . 50FANAPT ORAL TABLET . . . . . . . . . . . 35FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 36FARYDAK ORAL CAPSULE 10 MG, 20 MG . . . . . . . . . . . . . . . . . . . . 24FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 24fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 54febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 52felbamate . . . . . . . . . . . . . . . . . . . . . . . . . 29

enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 54enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 54entacapone . . . . . . . . . . . . . . . . . . . . . . . 30entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 18ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 41enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 50EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 18EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 29epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 56epinephrine injection auto-injector . . 57epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29EPIVIR HBV ORAL SOLUTION . . . . 18ergotamine-caffeine . . . . . . . . . . . . . . . 30ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 24ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 24erlotinib oral tablet 25 mg . . . . . . . . . . 24erlotinib oral tablet 100 mg, 150 mg . . 24errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 20ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 42erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 20ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 20erythromycin-benzoyl peroxide . . . . . 42erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . 20erythromycin ophthalmic (eye) . . . . . . 56erythromycin oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 20erythromycin oral tablet . . . . . . . . . . . . 20erythromycin with ethanol topical gel . . . . . . . . . . . . . . . . . . . . . . . . . 42erythromycin with ethanol topical solution . . . . . . . . . . . . . . . . . . . . 42ESBRIET ORAL CAPSULE . . . . . . . . 58ESBRIET ORAL TABLET 267 MG . . 58ESBRIET ORAL TABLET 801 MG . . 58escitalopram oxalate oral solution . . 35escitalopram oxalate oral tablet . . . . . 35

EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 39EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 17efavirenz oral capsule 50 mg . . . . . . . 17efavirenz oral capsule 200 mg . . . . . . 17efavirenz oral tablet . . . . . . . . . . . . . . . . 17ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 48electrolyte-48 in d5w . . . . . . . . . . . . . . . 60elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 40ELIQUIS DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 40ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 59ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 24EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 50emoquette . . . . . . . . . . . . . . . . . . . . . . . . 54EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 35EMTRIVA ORAL CAPSULE . . . . . . . . 17EMTRIVA ORAL SOLUTION . . . . . . . 18EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 20enalapril-hydrochlorothiazide . . . . . . . 39enalapril maleate . . . . . . . . . . . . . . . . . . 39ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 52ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 52ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) . . . . . . 52ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) . . . . . . . 52ENBREL SURECLICK . . . . . . . . . . . . . 52endocet oral tablet 2.5-325 mg, 5-325 mg . . . . . . . . . . . . . 32endocet oral tablet 7.5-325 mg . . . . . 32endocet oral tablet 10-325 mg . . . . . . 32ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE . . . . . . 51ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 51ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 24enoxaparin . . . . . . . . . . . . . . . . . . . . . . . . 40

69


Covered Drugs Index

flurbiprofen oral tablet 100 mg . . . . . . 33flurbiprofen sodium . . . . . . . . . . . . . . . . 57flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 24fluticasone propionate nasal . . . . . . . . 58fluticasone propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 44fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 44fluvoxamine oral tablet . . . . . . . . . . . . . 36FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 24fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 51fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 40fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 40FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 52fosamprenavir . . . . . . . . . . . . . . . . . . . . . 18fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 39fosinopril-hydrochlorothiazide . . . . . . 39FREAMINE HBC 6.9% . . . . . . . . . . . . . 60freamine iii 10% . . . . . . . . . . . . . . . . . . . 60fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 24furosemide injection . . . . . . . . . . . . . . . 39furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 39furosemide oral tablet . . . . . . . . . . . . . . 39FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 18fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53FYCOMPA ORAL SUSPENSION . . . 29FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 29FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 29

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 29gabapentin oral capsule 300 mg . . . . 29gabapentin oral solution . . . . . . . . . . . . 29

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION . . . . . . . . . . . . 58FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION . . . . 58FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION . . . 58FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION . . 58fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . 17fluconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 17fluconazole oral tablet . . . . . . . . . . . . . . 17flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 17fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 24fludrocortisone . . . . . . . . . . . . . . . . . . . . 46flunisolide nasal spray, non-aerosol 25 mcg (0.025%) . . . . . . 58fluocinolone . . . . . . . . . . . . . . . . . . . . . . . 44fluocinolone acetonide oil . . . . . . . . . . 45fluocinolone and shower cap . . . . . . . 44fluocinonide topical cream 0.05% . . . 44fluocinonide topical gel . . . . . . . . . . . . . 44fluocinonide topical ointment . . . . . . . 44fluocinonide topical solution . . . . . . . . 44fluoride (sodium) oral tablet . . . . . . . . 60fluoride (sodium) oral tablet, chewable 1 mg (2.2 mg sod. fluoride) . . . . . . . . . . . . . . 60fluorometholone . . . . . . . . . . . . . . . . . . . 57fluorouracil topical cream 0.5% . . . . . 42fluorouracil topical cream 5% . . . . . . . 42fluorouracil topical solution . . . . . . . . . 42fluoxetine oral capsule . . . . . . . . . . . . . 36fluoxetine oral solution . . . . . . . . . . . . . 36fluphenazine decanoate . . . . . . . . . . . . 36fluphenazine hcl injection . . . . . . . . . . 36fluphenazine hcl oral concentrate . . . 36fluphenazine hcl oral elixir . . . . . . . . . . 36fluphenazine hcl oral tablet . . . . . . . . . 36

felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 39femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 54fenofibrate micronized oral capsule 130 mg, 43 mg . . . . . . . . . . . . 41fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 41fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 41fenofibrate oral capsule . . . . . . . . . . . . 41fenofibrate oral tablet 160 mg, 54 mg . . . . . . . . . . . . . . . . . . . . 41fenofibric acid (choline) oral capsule,delayed release (dr/ec) 45 mg . . . . . . . . . . . . . . . . . . . . . . 41fenofibric acid (choline) oral capsule,delayed release (dr/ec) 135 mg . . . . . . . . . . . . . . . . . . . . 41fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg . . . . . . . . . . . . . . . 32fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg . . . . . . . . . . . . . . . . . 32fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr . . . . 32FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 36FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK. . . . . . . 36finasteride oral tablet 5 mg . . . . . . . . . 59FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG . . . . . . . . . . . . . 24FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG . . . . . . . . . . . . 24FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 20flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 45flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 38FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . . . . . . . . . . . . . . 58

70


Covered Drugs Index

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . 49glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42granisetron hcl oral . . . . . . . . . . . . . . . . 50griseofulvin microsize . . . . . . . . . . . . . . 17griseofulvin ultramicrosize . . . . . . . . . . 17GVOKE SYRINGE . . . . . . . . . . . . . . . . . 47

Hhailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 54HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 24halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 44halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 44haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 36haloperidol decanoate . . . . . . . . . . . . . 36haloperidol lactate injection . . . . . . . . 36haloperidol lactate oral . . . . . . . . . . . . . 36HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 18HAVRIX (PF) . . . . . . . . . . . . . . . . . . . . . . 51heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 53heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml . . . . . . . . . . . . . . . . . 40heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) . . . . . 40heparin (porcine) injection solution . . 40heparin (porcine) in nacl (pf) . . . . . . . . 40heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml . . . . . . . . . . . 40HEPATAMINE 8% . . . . . . . . . . . . . . . . . 60HERCEPTIN HYLECTA . . . . . . . . . . . . 24HERCEPTIN INTRAVENOUS RECON SOLN 150 MG . . . . . . . . . . . . 24HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 36

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 20gentamicin ophthalmic (eye) drops . . 56gentamicin sulfate (ped) (pf) . . . . . . . . 20gentamicin topical cream . . . . . . . . . . . 43gentamicin topical ointment . . . . . . . . 43GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 18GEODON INTRAMUSCULAR . . . . . . 36gianvi (28) . . . . . . . . . . . . . . . . . . . . . . . . 54GILENYA ORAL CAPSULE 0.5 MG . . . . . . . . . . . . . . . . . 31GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 24glatiramer subcutaneous syringe 20 mg/ml . . . . . . . . . . . . . . . . . . 31glatiramer subcutaneous syringe 40 mg/ml . . . . . . . . . . . . . . . . . . 31GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG . . . . . . . . . . . 24glimepiride oral tablet 1 mg . . . . . . . . . 46glimepiride oral tablet 2 mg . . . . . . . . . 46glimepiride oral tablet 4 mg . . . . . . . . . 46glipizide-metformin oral tablet 2.5-250 mg . . . . . . . . . . . . . . . . . . 46glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg . . . . . . . 47glipizide oral tablet 5 mg . . . . . . . . . . . 46glipizide oral tablet 10 mg . . . . . . . . . . 46glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 46glipizide oral tablet extended release 24hr 5 mg . . . . . . . . . . . . . . . . . 46glipizide oral tablet extended release 24hr 10 mg . . . . . . . . . . . . . . . . 46GLUCAGEN HYPOKIT . . . . . . . . . . . . 47GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 47GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 47glycopyrrolate oral . . . . . . . . . . . . . . . . . 49GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 49

gabapentin oral tablet 600 mg . . . . . . 29gabapentin oral tablet 800 mg . . . . . . 29galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 31galantamine oral solution . . . . . . . . . . . 31galantamine oral tablet . . . . . . . . . . . . . 31GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 51GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 51GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 50GATTEX ONE-VIAL . . . . . . . . . . . . . . . 50GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 46gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 50gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 50gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 50GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 24gemcitabine intravenous recon soln . 24gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) . . . . . . . . . 24GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 24gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 41generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 50gengraf oral capsule 100 mg, 25 mg . . 24gengraf oral solution . . . . . . . . . . . . . . . 24GENOTROPIN . . . . . . . . . . . . . . . . . . . . 51GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . 51GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . . 51gentak ophthalmic (eye) ointment . . . 56gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . 20GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 20

71


Covered Drugs Index

hydromorphone oral liquid . . . . . . . . . . 32hydromorphone oral tablet 2 mg, 4 mg . . . . . . . . . . . . . . . . . . . . . . . . 32hydromorphone oral tablet 8 mg . . . . 32hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml . . . . . . . . . . . . . . . . . 32hydroxychloroquine . . . . . . . . . . . . . . . . 20hydroxyprogesterone caproate . . . . . 53hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 24hydroxyzine hcl oral tablet . . . . . . . . . . 57

Iibandronate oral . . . . . . . . . . . . . . . . . . . 52IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 24ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ibuprofen oral suspension . . . . . . . . . . 33ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 33icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 58ICLUSIG ORAL TABLET 15 MG . . . . 24ICLUSIG ORAL TABLET 45 MG . . . . 24IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24imatinib oral tablet 100 mg . . . . . . . . . 24imatinib oral tablet 400 mg . . . . . . . . . 25IMBRUVICA ORAL CAPSULE 70 MG . . . . . . . . . . . . . . . . . 25IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . 25IMBRUVICA ORAL TABLET . . . . . . . . 25IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 25imipenem-cilastatin . . . . . . . . . . . . . . . . 21imipramine hcl . . . . . . . . . . . . . . . . . . . . . 36imiquimod topical cream in packet . . 42IMOVAX RABIES VACCINE (PF) . . . 51IMPOYZ . . . . . . . . . . . . . . . . . . . . . . . . . . 44incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 53INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 45INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 58indapamide . . . . . . . . . . . . . . . . . . . . . . . 39

HUMULIN N NPH INSULIN KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . . . 47HUMULIN N NPH U-100 INSULIN . . 47HUMULIN R REGULAR U-100 INSULN . . . . . . . . . . . . . . . . . . . . 47HUMULIN R U-500 (CONC) INSULIN . . . . . . . . . . . . . . . . . . 47HUMULIN R U-500 (CONC) KWIKPEN . . . . . . . . . . . . . . . . 47hydralazine injection . . . . . . . . . . . . . . . 39hydralazine oral . . . . . . . . . . . . . . . . . . . 39hydrochlorothiazide . . . . . . . . . . . . . . . . 39hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml . . . . . . . . . . 32hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 32hydrocodone-acetaminophen oral tablet 5-325 mg . . . . . . . . . . . . . . . 32hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg . . 32hydrocodone-ibuprofen oral tablet 7.5-200 mg . . . . . . . . . . . . . . 32hydrocortisone-acetic acid . . . . . . . . . 45hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 44hydrocortisone butyr-emollient . . . . . . 44hydrocortisone-min oil-wht pet . . . . . . 44hydrocortisone oral . . . . . . . . . . . . . . . . 46hydrocortisone rectal . . . . . . . . . . . . . . 50hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 50hydrocortisone topical lotion 2.5% . . 44hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . 44hydrocortisone valerate . . . . . . . . . . . . 44hydromorphone injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 32hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml . . . . . . . . . 32

HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 51HIZENTRA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 51HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 47HUMALOG KWIKPEN INSULIN . . . . 47HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 47HUMALOG MIX 50-50 KWIKPEN. . . 47HUMALOG MIX 75-25 KWIKPEN. . . 47HUMALOG MIX 75-25 (U-100)INSULN . . . . . . . . . . . . . . . . . . . 47HUMALOG U-100 INSULIN . . . . . . . . 47HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML . . . . . . . 52HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML- 40 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 52HUMIRA(CF) PEN CROHNS-UC-HS . . . . . . . . . . . . . . . . . . 53HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 53HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . . . . . . . . . . . . 53HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 53HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 53HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 52HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 52HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 52HUMULIN 70/30 U-100 INSULIN . . . 47HUMULIN 70/30 U-100 KWIKPEN . . 47

72


Covered Drugs Index

JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 47JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG . . . . . . . . . . 47JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG . 47JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 47JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 47jasmiel (28) . . . . . . . . . . . . . . . . . . . . . . . 54jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 53jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 18junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 54junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 54junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 54junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . 54junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 54

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 60KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 25kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KALETRA ORAL TABLET 100-25 MG . . . . . . . . . . . . . . . 18KALETRA ORAL TABLET 200-50 MG . . . . . . . . . . . . . . . 18kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 58KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 25kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 54kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 54kelnor 1-50 . . . . . . . . . . . . . . . . . . . . . . . . 54ketoconazole oral . . . . . . . . . . . . . . . . . . 17ketoconazole topical cream . . . . . . . . 43ketoconazole topical shampoo . . . . . 43ketorolac ophthalmic (eye) . . . . . . . . . 57KEYTRUDA INTRAVENOUS SOLUTION . . . . . . . 25KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . 51kionex (with sorbitol) . . . . . . . . . . . . . . . 45

INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML . . . . . . . 36INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 57INVIRASE ORAL TABLET . . . . . . . . . 18IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ipratropium-albuterol . . . . . . . . . . . . . . . 58ipratropium bromide inhalation . . . . . 58ipratropium bromide nasal spray, non-aerosol 0.03% . . . . . . . . . . . . . . . . 45ipratropium bromide nasal spray, non-aerosol 42 mcg (0.06%) . . . . . . . 45irbesartan-hydrochlorothiazide . . . . . 39irbesartan oral tablet 150 mg . . . . . . . 39irbesartan oral tablet 300 mg, 75 mg . 39IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 25irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 25ISENTRESS HD . . . . . . . . . . . . . . . . . . . 18ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 18ISENTRESS ORAL TABLET . . . . . . . 18ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . 18ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . 18isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 54isoniazid oral solution . . . . . . . . . . . . . . 21isoniazid oral tablet . . . . . . . . . . . . . . . . 21isosorbide dinitrate oral tablet . . . . . . 41isosorbide mononitrate . . . . . . . . . . . . . 41isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 42isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 39ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . 25itraconazole oral capsule . . . . . . . . . . . 17itraconazole oral solution . . . . . . . . . . . 17ivermectin oral . . . . . . . . . . . . . . . . . . . . 21IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 51

Jjaimiess . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 25jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 40

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION . 51INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 25INFUMORPH P/F. . . . . . . . . . . . . . . . . . 32INLYTA ORAL TABLET 1 MG . . . . . . . 25INLYTA ORAL TABLET 5 MG . . . . . . . 25INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 25INSULIN PEN NEEDLE . . . . . . . . . . . . 47INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 47INTELENCE ORAL TABLET 25 MG 18INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . . . . . . . . . . 18INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 60INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 51INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . 51INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . 51introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 54INVANZ INJECTION . . . . . . . . . . . . . . . 21INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML . . . . . . . . . . . . . . . . . . . . . . . 36INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML . . . . . . . . . . . . . . . . . . . . 36INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML . . . . . . . 36INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML . . . . . . . 36INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML . . . . . . . . 36

73


Covered Drugs Index

levetiracetam oral tablet extended release 24 hr . . . . . . . . . . . . 29levobunolol ophthalmic (eye) drops 0.5% . . . . . . . . . . . . . . . . . . 56levocarnitine oral solution 100 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . 45levocarnitine oral tablet . . . . . . . . . . . . 45levocarnitine (with sugar) . . . . . . . . . . . 45levocetirizine oral solution . . . . . . . . . . 57levocetirizine oral tablet . . . . . . . . . . . . 57levofloxacin in d5w . . . . . . . . . . . . . . . . 22levofloxacin intravenous . . . . . . . . . . . 22levofloxacin oral solution . . . . . . . . . . . 22levofloxacin oral tablet . . . . . . . . . . . . . 22levonest (28) . . . . . . . . . . . . . . . . . . . . . . 55levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 90-20 mcg (28) . . . . . . . . . . . . . . . . . . . . 55levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg . . . . . . . . . . . . 55levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month . . . . . 55levonorg-eth estrad triphasic . . . . . . . 55levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 55levothyroxine oral . . . . . . . . . . . . . . . . . . 49levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg . . . 49LEXIVA ORAL SUSPENSION . . . . . . 18LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 25lidocaine hcl injection solution . . . . . . 42lidocaine hcl laryngotracheal . . . . . . . 42lidocaine hcl mucous membrane jelly . . . . . . . . . . . . . . . . . . . . 42lidocaine hcl mucous membrane jelly in applicator . . . . . . . . 42lidocaine hcl mucous membrane solution 4% (40 mg/ml) . . 42lidocaine (pf) injection solution . . . . . . 42lidocaine (pf) intravenous syringe . . . 38lidocaine-prilocaine topical cream . . . 42

larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 54larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 54larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 55larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 57LATUDA ORAL TABLET 80 MG . . . . 36LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 36layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 55leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 55leflunomide . . . . . . . . . . . . . . . . . . . . . . . 53LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 25LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY (10 MG X 2-4 MG X 1) . . . . . . . . . . . . . 25LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) . . . . . . . . . . . . . 25lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 58letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 25leucovorin calcium injection recon soln . . . . . . . . . . . . . . . . . . . . . . . . . 23leucovorin calcium injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 23leucovorin calcium oral tablet 5 mg . 23leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg . . . . . . . . . . . . . . 23LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 25leuprolide subcutaneous kit . . . . . . . . 25levalbuterol tartrate . . . . . . . . . . . . . . . . 58LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 47LEVEMIR U-100 INSULIN . . . . . . . . . 47levetiracetam in nacl (iso-os) . . . . . . . 29levetiracetam intravenous . . . . . . . . . . 29levetiracetam oral solution . . . . . . . . . 29levetiracetam oral tablet . . . . . . . . . . . . 29

KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 25KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 25KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 25KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 25klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 59KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 59KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 59klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 59klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 59KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 48K-PHOS ORIGINAL . . . . . . . . . . . . . . . 59kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 54KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 25

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 39lactated ringers intravenous . . . . . . . . 59lactated ringers irrigation . . . . . . . . . . . 44lactulose oral solution . . . . . . . . . . . . . . 50lamivudine oral solution . . . . . . . . . . . . 18lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . 18lamivudine oral tablet 150 mg . . . . . . 18lamivudine-zidovudine . . . . . . . . . . . . . 18lamotrigine oral tablet . . . . . . . . . . . . . . 29lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 29lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 50LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 47LANTUS U-100 INSULIN . . . . . . . . . . 47larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 54larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 54

74


Covered Drugs Index

LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 26lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Mmafenide acetate . . . . . . . . . . . . . . . . . . 43MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . 59magnesium sulfate injection . . . . . . . . 59magnesium sulfate in water . . . . . . . . 59malathion . . . . . . . . . . . . . . . . . . . . . . . . . 44maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 36marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 55MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 36MATULANE . . . . . . . . . . . . . . . . . . . . . . . 26matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 39MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . 18meclizine oral tablet 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 50medroxyprogesterone intramuscular . . . . . . . . . . . . . . . . . . . . . . 53medroxyprogesterone oral . . . . . . . . . 53mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 21megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 26megestrol oral tablet 20 mg . . . . . . . . 26megestrol oral tablet 40 mg . . . . . . . . 26MEKINIST ORAL TABLET 0.5 MG . . 26MEKINIST ORAL TABLET 2 MG . . . . 26MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 26melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 55meloxicam oral tablet . . . . . . . . . . . . . . 33melphalan hcl . . . . . . . . . . . . . . . . . . . . . 26memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 31memantine oral solution . . . . . . . . . . . . 31memantine oral tablet 5 mg . . . . . . . . 31memantine oral tablet 10 mg . . . . . . . 31memantine oral tablets,dose pack . . 31

loryna (28) . . . . . . . . . . . . . . . . . . . . . . . . 55losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . 39losartan-hydrochlorothiazide oral tablet 50-12.5 mg . . . . . . . . . . . . . . 39losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg . . . . . 39LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 57LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 57lovastatin oral tablet 10 mg, 20 mg . . 41lovastatin oral tablet 40 mg . . . . . . . . . 41low-ogestrel (28) . . . . . . . . . . . . . . . . . . 55loxapine succinate . . . . . . . . . . . . . . . . . 36lo-zumandimine (28) . . . . . . . . . . . . . . . 55LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 57LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 48LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 25LUPRON DEPOT . . . . . . . . . . . . . . . . . 25LUPRON DEPOT (3 MONTH) . . . . . . 25LUPRON DEPOT (4 MONTH) . . . . . . 25LUPRON DEPOT (6 MONTH) . . . . . . 25LUPRON DEPOT-PED . . . . . . . . . . . . 25LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG . . . . . . . . . . . 25LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG . . . . . . . . . . . . . . 25lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 55LYNPARZA ORAL TABLET . . . . . . . . . 25LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG . . . . . . . . . . . 29LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG . . . . . . . . . . . . . . . . . . . . 29LYRICA ORAL CAPSULE 75 MG . . . 30LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG . . . 30LYRICA ORAL CAPSULE 225 MG, 300 MG . . . . . . . . . . . . . . . . . . 30LYRICA ORAL SOLUTION . . . . . . . . . 30

lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 42lidocaine topical ointment . . . . . . . . . . 42lidocaine viscous . . . . . . . . . . . . . . . . . . 42lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 55lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 21lindane topical shampoo . . . . . . . . . . . 44linezolid-0.9% sodium chloride . . . . . 21linezolid in dextrose 5% . . . . . . . . . . . . 21linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . . . 21linezolid oral tablet . . . . . . . . . . . . . . . . . 21liothyronine oral . . . . . . . . . . . . . . . . . . . 49lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 39lisinopril-hydrochlorothiazide . . . . . . . 39lithium carbonate . . . . . . . . . . . . . . . . . . 36l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) . . . . 54l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg . . 54l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) . . . . 54lojaimiess . . . . . . . . . . . . . . . . . . . . . . . . . 55LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . . . . . . . . . 25LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . . . . . . . . . 25loperamide oral capsule . . . . . . . . . . . . 49lopinavir-ritonavir . . . . . . . . . . . . . . . . . . 18lorazepam injection . . . . . . . . . . . . . . . . 36lorazepam intensol . . . . . . . . . . . . . . . . 36lorazepam oral concentrate . . . . . . . . 36lorazepam oral tablet 0.5 mg, 1 mg . 36lorazepam oral tablet 2 mg . . . . . . . . . 36LORBRENA ORAL TABLET 25 MG . 25LORBRENA ORAL TABLET 100 MG . 25lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 32lorcet (hydrocodone) . . . . . . . . . . . . . . . 32lorcet plus oral tablet 7.5-325 mg . . . 32

75


Covered Drugs Index

microgestin fe 1.5/30 (28) . . . . . . . . . . 55microgestin fe 1/20 (28) . . . . . . . . . . . . 55midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 45miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 48mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 41minocycline oral capsule . . . . . . . . . . . 22minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 39mirtazapine oral tablet . . . . . . . . . . . . . 36MIRTAZAPINE ORAL TABLET,DISINTEGRATING . . . . . . . . 36misoprostol . . . . . . . . . . . . . . . . . . . . . . . 50MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 52MITIGO (PF) . . . . . . . . . . . . . . . . . . . . . . 32M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 51moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 39molindone . . . . . . . . . . . . . . . . . . . . . . . . . 36mometasone nasal . . . . . . . . . . . . . . . . 58mometasone topical . . . . . . . . . . . . . . . 44mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 55montelukast oral granules in packet . 58montelukast oral tablet . . . . . . . . . . . . . 58montelukast oral tablet,chewable . . . 58morgidox . . . . . . . . . . . . . . . . . . . . . . . . . . 22morphine concentrate oral solution . 32MORPHINE INJECTION SOLUTION 2 MG/ML . . . . . . . . . . . . . . 32MORPHINE INJECTION SOLUTION 4 MG/ML . . . . . . . . . . . . . . 32MORPHINE INJECTION SOLUTION 5 MG/ML . . . . . . . . . . . . . . 32morphine injection solution 8 mg/ml . 32MORPHINE INJECTION SOLUTION 10 MG/ML . . . . . . . . . . . . . 32morphine injection syringe 2 mg/ml . 33morphine injection syringe 4 mg/ml . 33morphine injection syringe 5 mg/ml . 33morphine injection syringe 8 mg/ml . 33morphine injection syringe 10 mg/ml . 32MORPHINE INTRAVENOUS SOLUTION 4 MG/ML . . . . . . . . . . . . . . 33

methocarbamol oral . . . . . . . . . . . . . . . 31methotrexate sodium injection . . . . . . 26methotrexate sodium oral . . . . . . . . . . 26methotrexate sodium (pf) . . . . . . . . . . . 26methoxsalen . . . . . . . . . . . . . . . . . . . . . . 42methyldopa . . . . . . . . . . . . . . . . . . . . . . . 39methylphenidate hcl oral tablet . . . . . 36methylphenidate hcl oral tablet extended release . . . . . . . . . . . . . . . . . . 36methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating) . . . . . . . . . . . 36methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . 36methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating) . . . . . . . . . . . 36methylprednisolone . . . . . . . . . . . . . . . . 46methylprednisolone acetate . . . . . . . . 46methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . 46methylprednisolone sodium succ intravenous recon soln 1,000 mg . . . 46methylprednisolone sodium succ intravenous recon soln 500 mg . . . . . 46metoclopramide hcl oral solution . . . . 50metoclopramide hcl oral tablet . . . . . . 50metolazone . . . . . . . . . . . . . . . . . . . . . . . 39metoprolol succinate . . . . . . . . . . . . . . . 39metoprolol ta-hydrochlorothiaz . . . . . 39metoprolol tartrate oral . . . . . . . . . . . . . 39metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 21metronidazole in nacl (iso-os) . . . . . . 21metronidazole oral tablet . . . . . . . . . . . 21metronidazole topical . . . . . . . . . . . . . . 42metronidazole vaginal . . . . . . . . . . . . . . 53mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 38mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 55microgestin 1.5/30 (21) . . . . . . . . . . . . 55microgestin 1/20 (21) . . . . . . . . . . . . . . 55

MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 51MENVEO A-C-Y-W-135-DIP (PF) . . . 51mercaptopurine . . . . . . . . . . . . . . . . . . . . 26meropenem . . . . . . . . . . . . . . . . . . . . . . . 21MEROPENEM-0.9% SODIUM CHLORIDE . . . . . . . . . . . . . . 21mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 50mesalamine rectal enema . . . . . . . . . . 50mesalamine with cleansing wipe . . . . 50mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23MESNEX ORAL . . . . . . . . . . . . . . . . . . . 23metadate er . . . . . . . . . . . . . . . . . . . . . . . 36metaproterenol oral syrup . . . . . . . . . . 58metformin oral tablet 1,000 mg . . . . . 47metformin oral tablet 500 mg . . . . . . . 47metformin oral tablet 850 mg . . . . . . . 47metformin oral tablet,er gast.retention 24 hr 1,000 mg . . . . . . 47metformin oral tablet,er gast.retention 24 hr 500 mg . . . . . . . . 47metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) . . . . . . . . . 47metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr) . . . . . . . . . 47metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet) . . . . . . . 47methadone injection solution . . . . . . . 32methadone intensol . . . . . . . . . . . . . . . . 32methadone oral concentrate . . . . . . . . 32methadone oral solution 5 mg/5 ml . 32methadone oral solution 10 mg/5 ml . 32methadone oral tablet 5 mg . . . . . . . . 32methadone oral tablet 10 mg . . . . . . . 32methazolamide . . . . . . . . . . . . . . . . . . . . 57methenamine hippurate . . . . . . . . . . . . 22methimazole oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 46

76


Covered Drugs Index

neomycin-polymyxin b-dexameth . . . 57neomycin-polymyxin b gu . . . . . . . . . . 44neomycin-polymyxin-gramicidin . . . . 56neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 57neomycin-polymyxin-hc otic (ear) . . . 46neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 56neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 57NEPHRAMINE 5.4% . . . . . . . . . . . . . . . 60NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 26NEULASTA . . . . . . . . . . . . . . . . . . . . . . . 51NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 30nevirapine oral suspension . . . . . . . . . 18nevirapine oral tablet . . . . . . . . . . . . . . 18nevirapine oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . 18nevirapine oral tablet extended release 24 hr 400 mg . . . . . . . . . . . . . . 18NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 26niacin oral tablet extended release 24 hr . . . . . . . . . . . . . . . . . . . . . . 41nicardipine intravenous solution . . . . 39nicardipine oral . . . . . . . . . . . . . . . . . . . . 39NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 45NICOTROL NS . . . . . . . . . . . . . . . . . . . . 45nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 39nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 39nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 55nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 26nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 39NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 26nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 39nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 45nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 22nitrofurantoin macrocrystal oral capsule 50 mg . . . . . . . . . . . . . . . . 22nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg . . . . . . . . 22nitrofurantoin monohyd/m-cryst . . . . . 22

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG . . . . . . . . . . . . . . . . . . . . . 59

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 33nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 39nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . 22nafcillin in dextrose iso-osm . . . . . . . . 22NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 48nalbuphine injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 34nalbuphine injection solution 20 mg/ml . . . . . . . . . . . . . . . . . . 34naloxone injection solution . . . . . . . . . 34naloxone injection syringe 1 mg/ml . 34naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 34naproxen oral suspension . . . . . . . . . . 34naproxen oral tablet . . . . . . . . . . . . . . . 34naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 34naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . 34naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 30NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION . . . . . 34nasonex . . . . . . . . . . . . . . . . . . . . . . . . . . 58NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 56nateglinide oral tablet 60 mg . . . . . . . 47nateglinide oral tablet 120 mg . . . . . . 47NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 48NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 30NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 21necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 55NEEDLES, INSULIN DISP.,SAFETY . 47nefazodone . . . . . . . . . . . . . . . . . . . . . . . 36neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 21neomycin-bacitracin-poly-hc . . . . . . . . 57neomycin-bacitracin-polymyxin . . . . . 56

MORPHINE INTRAVENOUS SOLUTION 8 MG/ML . . . . . . . . . . . . . . 33morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . 33morphine intravenous syringe 2 mg/ml . . . . . . . . . . . . . . . . . . . 33morphine intravenous syringe 4 mg/ml . . . . . . . . . . . . . . . . . . . 33MORPHINE INTRAVENOUS SYRINGE 8 MG/ML . . . . . . . . . . . . . . . 33MORPHINE INTRAVENOUS SYRINGE 10 MG/ML . . . . . . . . . . . . . . 33morphine oral solution 10 mg/5 ml . . 33morphine oral solution 20 mg/5 ml (4 mg/ml) . . . . . . . . . . . . . . 33MORPHINE ORAL TABLET . . . . . . . . 33morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 33morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . 32morphine (pf) intravenous patient control.analgesia soln . . . . . . . 32moxifloxacin ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 56moxifloxacin oral . . . . . . . . . . . . . . . . . . 22MOXIFLOXACIN-SOD.ACE,SUL-WATER . . . . . . . . . . . . . . . . . . . . . . . . . . . 22moxifloxacin-sod.chloride(iso) . . . . . . 22MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 51MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 38mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 43mupirocin calcium . . . . . . . . . . . . . . . . . 43MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26mycophenolate mofetil (hcl) . . . . . . . . 26mycophenolate mofetil oral capsule . . 26mycophenolate mofetil oral suspension for reconstitution . . . . . . . 26mycophenolate mofetil oral tablet . . . 26mycophenolate sodium . . . . . . . . . . . . 26MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 26MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG . . . . . . . . . . . . . . . . . . . . . 59

77


Covered Drugs Index

olanzapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 37olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 39olmesartan-hydrochlorothiazide . . . . 39olopatadine ophthalmic (eye) . . . . . . . 56OLUX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 50OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 47OMNIPOD DASH 5 PACK. . . . . . . . . . 48OMNIPOD STARTER KIT . . . . . . . . . . 48ondansetron . . . . . . . . . . . . . . . . . . . . . . . 50ondansetron hcl intravenous . . . . . . . 50ondansetron hcl oral solution . . . . . . . 50ondansetron hcl oral tablet . . . . . . . . . 50ondansetron hcl (pf) . . . . . . . . . . . . . . . 50OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 26oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ORENCIA . . . . . . . . . . . . . . . . . . . . . . . . . 53ORENCIA CLICKJECT . . . . . . . . . . . . 53ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 45ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 58ORKAMBI ORAL TABLET . . . . . . . . . . 58orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 55oseltamivir oral capsule . . . . . . . . . . . . 18oseltamivir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 18oxacillin injection . . . . . . . . . . . . . . . . . . 22oxandrolone oral tablet 2.5 mg . . . . . 48oxandrolone oral tablet 10 mg . . . . . . 48oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 34oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 37oxcarbazepine oral suspension . . . . . 30oxcarbazepine oral tablet . . . . . . . . . . 30oxybutynin chloride oral syrup . . . . . . 59oxybutynin chloride oral tablet . . . . . . 59oxybutynin chloride oral tablet extended release 24hr . . . . . . . . . . . . . 59oxycodone-acetaminophen oral tablet 2.5-300 mg . . . . . . . . . . . . . . 33

NOXAFIL ORAL SUSPENSION . . . . 17NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC) . . . . . 17NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 26NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 31NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 26NUPLAZID ORAL CAPSULE . . . . . . . 36NUPLAZID ORAL TABLET 10 MG . . 37NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 60NUZYRA INTRAVENOUS . . . . . . . . . . 22NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 22nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 43nystatin oral suspension . . . . . . . . . . . 17nystatin oral tablet . . . . . . . . . . . . . . . . . 17nystatin topical cream . . . . . . . . . . . . . . 43nystatin topical ointment . . . . . . . . . . . 43nystatin topical powder . . . . . . . . . . . . . 43nystatin-triamcinolone . . . . . . . . . . . . . . 43nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 50ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 31octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml . . . . . . . . . . . 26octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 26ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 18ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 26OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ofloxacin ophthalmic (eye) . . . . . . . . . 56ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . 55OGIVRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 26olanzapine intramuscular . . . . . . . . . . . 37olanzapine oral tablet 7.5 mg . . . . . . . 37olanzapine oral tablet 10 mg, 2.5 mg, 5 mg . . . . . . . . . . . . . . . 37olanzapine oral tablet 15 mg, 20 mg . 37

nitroglycerin intravenous . . . . . . . . . . . 41nitroglycerin sublingual . . . . . . . . . . . . . 41nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 41nitroglycerin translingual spray,non-aerosol . . . . . . . . . . . . . . . . . 41nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 53noreth-ethinyl estradiol-iron . . . . . . . . 55norethindrone acetate . . . . . . . . . . . . . . 53norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg . . . . . . . . . 53norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg . 55norethindrone (contraceptive) . . . . . . 53norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) . . . . . . 55norethindrone-e.estradiol-iron oral tablet,chewable . . . . . . . . . . . . . . . 55norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28) . . . . 55norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg . . . . . . . . . 55NORMOSOL-M IN 5% DEXTROSE 60NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 59NORMOSOL-R IN 5% DEXTROSE . 59NORMOSOL-R PH 7.4 . . . . . . . . . . . . 60NORTHERA ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 45NORTHERA ORAL CAPSULE 200 MG, 300 MG . . . . . . . 45nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 55nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . 55nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . 55nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . 55nortriptyline . . . . . . . . . . . . . . . . . . . . . . . 36NORVIR ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 18NORVIR ORAL SOLUTION . . . . . . . . 18NOVOFINE PEN NEEDLE . . . . . . . . . 47NOVOTWIST PEN NEEDLE . . . . . . . 47

78


Covered Drugs Index

PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 22PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 26PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) . . . . . . . . 26pirmella oral tablet 0.5/0.75/1 mg- 35 mcg . . . . . . . . . . . . . 55pirmella oral tablet 1-35 mg-mcg . . . . 55PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 60PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 50podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 42polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56polymyxin b sulf-trimethoprim . . . . . . 56POMALYST . . . . . . . . . . . . . . . . . . . . . . . 26portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 55posaconazole oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 17POTASSIUM CHLORID- D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L . . . 59potassium chlorid-d5- 0.45%nacl intravenous parenteral solution 30 meq/l . . . . . . . . 59potassium chloride-0.45% nacl . . . . . 60POTASSIUM CHLORIDE-D5-0.2% NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L . . . . . . . . . . . . . 60potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l . . . . . . . . . . . . . . . . . 60potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l . . . . . . . . . . . . . . . . . . . . . . . . . . 60POTASSIUM CHLORIDE- D5-0.9%NACL . . . . . . . . . . . . . . . . . . . . 60potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l . . . . . . . . . . . . . . . . . 59potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l . . . . . . . 60

penicillin g potassium . . . . . . . . . . . . . . 22penicillin v potassium . . . . . . . . . . . . . . 22PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 21pentamidine inhalation . . . . . . . . . . . . . 21pentamidine injection . . . . . . . . . . . . . . 21PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 50pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 40PERFOROMIST . . . . . . . . . . . . . . . . . . . 58PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 60perindopril erbumine . . . . . . . . . . . . . . . 39PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 26permethrin topical cream . . . . . . . . . . . 44perphenazine . . . . . . . . . . . . . . . . . . . . . 37perphenazine-amitriptyline . . . . . . . . . 37PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 37pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 22phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 37phenobarbital oral elixir . . . . . . . . . . . . 30phenobarbital oral tablet . . . . . . . . . . . 30phenytoin oral suspension . . . . . . . . . 30phenytoin oral tablet,chewable . . . . . 30phenytoin sodium extended . . . . . . . . 30philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PHOSPHOLINE IODIDE . . . . . . . . . . . 56PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 44PHYSIOSOL IRRIGATION . . . . . . . . . 44PICATO TOPICAL GEL 0.05% . . . . . 42PICATO TOPICAL GEL 0.015% . . . . 42PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 18pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 56pilocarpine hcl oral . . . . . . . . . . . . . . . . . 45pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 37pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 55pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39pioglitazone oral tablet 15 mg . . . . . . 48pioglitazone oral tablet 30 mg, 45 mg . 48piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 22

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg . . . . . . . 33oxycodone-acetaminophen oral tablet 7.5-325 mg . . . . . . . . . . . . . . 33oxycodone-acetaminophen oral tablet 10-325 mg . . . . . . . . . . . . . . 33oxycodone-aspirin . . . . . . . . . . . . . . . . . 33oxycodone oral concentrate . . . . . . . . 33oxycodone oral solution . . . . . . . . . . . . 33oxycodone oral tablet . . . . . . . . . . . . . . 33oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 33OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 48

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 38paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 26PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 26paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 37paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . . . . . . . . . . 37pamidronate . . . . . . . . . . . . . . . . . . . . . . . 48PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 42pantoprazole oral . . . . . . . . . . . . . . . . . . 50paricalcitol oral . . . . . . . . . . . . . . . . . . . . 48paroex oral rinse . . . . . . . . . . . . . . . . . . 45paromomycin . . . . . . . . . . . . . . . . . . . . . . 21paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg . . . . . . . . . . . . . . 37paroxetine hcl oral tablet 20 mg . . . . 37PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 21PAXIL ORAL SUSPENSION . . . . . . . 37PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 51PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 51peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 50PEGANONE . . . . . . . . . . . . . . . . . . . . . . 30peg-electrolyte . . . . . . . . . . . . . . . . . . . . 50penicillamine . . . . . . . . . . . . . . . . . . . . . . 53

79


Covered Drugs Index

PROMACTA ORAL POWDER IN PACKET 12.5 MG . . . . . . . . . . . . . . 40PROMACTA ORAL POWDER IN PACKET 25 MG . . . . . . . . . . . . . . . . 40PROMACTA ORAL TABLET . . . . . . . . 40promethazine oral syrup . . . . . . . . . . . 57promethazine oral tablet . . . . . . . . . . . 57propafenone . . . . . . . . . . . . . . . . . . . . . . 38propantheline . . . . . . . . . . . . . . . . . . . . . 49propranolol-hydrochlorothiazid . . . . . 39propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 39propranolol oral solution . . . . . . . . . . . 39propranolol oral tablet . . . . . . . . . . . . . . 39propylthiouracil . . . . . . . . . . . . . . . . . . . . 46PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 51PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 60protriptyline . . . . . . . . . . . . . . . . . . . . . . . 37PULMOZYME . . . . . . . . . . . . . . . . . . . . . 58PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 26pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 21pyridostigmine bromide oral syrup . . 31pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . . . . . . 31pyridostigmine bromide oral tablet extended release . . . . . . . . . . . . 31

QQUADRACEL (PF) . . . . . . . . . . . . . . . . 52quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . 37quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 37quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 39quinapril-hydrochlorothiazide . . . . . . . 39quinidine sulfate oral tablet . . . . . . . . . 38quinine sulfate . . . . . . . . . . . . . . . . . . . . . 21

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 52

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg . . . . . 30pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 30pregabalin oral solution . . . . . . . . . . . . 30PREMARIN VAGINAL . . . . . . . . . . . . . 53PREMASOL 10% . . . . . . . . . . . . . . . . . . 60PRENATAL VITAMIN ORAL TABLET . . . . . . . . . . . . . . . . . . . . 60prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 41previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 55PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 18PREZISTA ORAL SUSPENSION . . . 18PREZISTA ORAL TABLET 75 MG . . 18PREZISTA ORAL TABLET 150 MG . 18PREZISTA ORAL TABLET 600 MG . 18PREZISTA ORAL TABLET 800 MG . 18PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 21PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON . . . . . . . . . . . 50PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 21primidone . . . . . . . . . . . . . . . . . . . . . . . . . 30PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 58PROAIR RESPICLICK . . . . . . . . . . . . . 58probenecid . . . . . . . . . . . . . . . . . . . . . . . . 52probenecid-colchicine . . . . . . . . . . . . . . 52PROCALAMINE 3% . . . . . . . . . . . . . . . 60prochlorperazine . . . . . . . . . . . . . . . . . . 50prochlorperazine edisylate . . . . . . . . . 50prochlorperazine maleate oral . . . . . . 50procto-med hc . . . . . . . . . . . . . . . . . . . . . 50procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 50proctosol hc topical . . . . . . . . . . . . . . . . 50proctozone-hc . . . . . . . . . . . . . . . . . . . . . 50progesterone micronized . . . . . . . . . . . 53PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 48PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 26PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 45PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 57PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

potassium chloride in lr-d5 . . . . . . . . . 60potassium chloride intravenous . . . . . 60potassium chloride in water intravenous piggyback . . . . . . . 60potassium chloride oral capsule, extended release . . . . . . . . . . . . . . . . . . 60potassium chloride oral liquid . . . . . . . 60potassium chloride oral packet . . . . . 60potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 60potassium chloride oral tablet extended release . . . . . . . . . . . . 60potassium citrate . . . . . . . . . . . . . . . . . . 59POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 26PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 40pramipexole oral tablet . . . . . . . . . . . . . 30prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 40pravastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 41pravastatin oral tablet 40 mg . . . . . . . 41praziquantel . . . . . . . . . . . . . . . . . . . . . . . 21prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 39prednicarbate topical ointment . . . . . . 44prednisolone acetate . . . . . . . . . . . . . . 57prednisolone oral solution 15 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 46prednisolone sodium phosphate ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 57prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 5 mg base/5 ml (6.7 mg/5 ml) . . . . . . . . . . . . . . . . . . . . . . 46prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml) . . 46prednisone intensol . . . . . . . . . . . . . . . . 46prednisone oral solution . . . . . . . . . . . . 46prednisone oral tablet . . . . . . . . . . . . . . 46prednisone oral tablets,dose pack 5 mg, 5 mg (48 pack) . . . . . . . . . 46prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack) . . . . . . . 46pregabalin oral capsule 75 mg . . . . . . 30

80


Covered Drugs Index

rosadan topical gel . . . . . . . . . . . . . . . . 42rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 41ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 52ROTATEQ VACCINE . . . . . . . . . . . . . . 52roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 30roweepra xr . . . . . . . . . . . . . . . . . . . . . . . 30ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 26ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 26RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 26RUCONEST . . . . . . . . . . . . . . . . . . . . . . 58RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 26RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 26

SSAMSCA ORAL TABLET 15 MG . . . . 48SAMSCA ORAL TABLET 30 MG . . . . 49SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 50SANDIMMUNE ORAL SOLUTION . . 26SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 42SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 37scopolamine base . . . . . . . . . . . . . . . . . 50SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 37selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 30selenium sulfide topical lotion . . . . . . 41SELZENTRY ORAL SOLUTION . . . . 18SELZENTRY ORAL TABLET 25 MG 18SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . . . . . . . . . 18SELZENTRY ORAL TABLET 300 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 18SENSIPAR ORAL TABLET 30 MG, 60 MG . . . . . . . . . . . . . . . . . . . . 49SENSIPAR ORAL TABLET 90 MG . . 49SEREVENT DISKUS . . . . . . . . . . . . . . 58sertraline oral concentrate . . . . . . . . . . 37sertraline oral tablet 50 mg . . . . . . . . . 37sertraline oral tablet 100 mg, 25 mg . 37setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML . . . . 51RETACRIT INJECTION SOLUTION 40,000 UNIT/ML . . . . . . . 51RETROVIR INTRAVENOUS . . . . . . . 18REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG . . . . . . . . . . . . . 26REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG . . . . . . . . . . . . . 26REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 37REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 18RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 57ribavirin oral capsule . . . . . . . . . . . . . . . 18ribavirin oral tablet 200 mg . . . . . . . . . 18rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45rimantadine . . . . . . . . . . . . . . . . . . . . . . . 18ringer’s intravenous . . . . . . . . . . . . . . . . 60ringer’s irrigation . . . . . . . . . . . . . . . . . . . 44RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 53RISPERDAL CONSTA . . . . . . . . . . . . . 37risperidone oral solution . . . . . . . . . . . . 37risperidone oral tablet . . . . . . . . . . . . . . 37risperidone oral tablet, disintegrating 0.5 mg, 4 mg . . . . . . . . 37risperidone oral tablet, disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . . . . . . . . . 37ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 18RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 26RITUXAN HYCELA . . . . . . . . . . . . . . . . 26rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 31rivastigmine tartrate . . . . . . . . . . . . . . . . 31rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55rizatriptan . . . . . . . . . . . . . . . . . . . . . . . . . 30ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 57ROMIDEPSIN . . . . . . . . . . . . . . . . . . . . . 26ropinirole oral tablet . . . . . . . . . . . . . . . . 30rosadan topical cream . . . . . . . . . . . . . 42

raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 52ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 37ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ranitidine hcl oral capsule . . . . . . . . . . 50ranitidine hcl oral syrup . . . . . . . . . . . . 50ranitidine hcl oral tablet 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . 50ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 41RAPAMUNE ORAL SOLUTION . . . . 26rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 30reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 55RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML . . . . . . . . . . . . . . . . . . . . 52RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML . . . . . . . . . . 52RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE . . . . . . 52RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 50regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 31REGRANEX . . . . . . . . . . . . . . . . . . . . . . 42RELISTOR SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 50RELISTOR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 50REMODULIN . . . . . . . . . . . . . . . . . . . . . . 40RENACIDIN IRRIGATION SOLUTION 1980.6 MG- 59.4 MG-980.4MG/30ML . . . . . . . . . . . 59RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 50RENVELA ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 45RENVELA ORAL TABLET . . . . . . . . . . 45repaglinide oral tablet 0.5 mg, 1 mg . 48repaglinide oral tablet 2 mg . . . . . . . . 48REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 41REPATHA PUSHTRONEX . . . . . . . . . 41REPATHA SURECLICK . . . . . . . . . . . . 41RESCRIPTOR ORAL TABLET . . . . . 18RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 57RESTASIS MULTIDOSE . . . . . . . . . . . 57

81


Covered Drugs Index

sulfacetamide sodium (acne) . . . . . . . 43sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 57sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 22sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 22sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 22sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 22SULFAMYLON TOPICAL PACKET . 43sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 50sulfatrim . . . . . . . . . . . . . . . . . . . . . . . . . . 22sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 34sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 30sumatriptan succinate oral . . . . . . . . . 30sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 30sumatriptan succinate subcutaneous pen injector . . . . . . . . . 31sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 31sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml . . 31SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 27syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG . . . . . . . . . . . 51SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 19SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 48SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 48SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 30SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 19SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 19SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 49SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 21SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 48SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 48

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML . . . . . . . . . . . . . . . . . . . . . 27SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . 27SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 49sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 38SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 38spironolactone . . . . . . . . . . . . . . . . . . . . 40spironolacton-hydrochlorothiaz . . . . . 40sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 55SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG . . . . . . . 30SPRITAM ORAL TABLET FOR SUSPENSION 750 MG . . . . . . . 30SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 27sps (with sorbitol) . . . . . . . . . . . . . . . . . . 45sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 52stavudine oral capsule . . . . . . . . . . . . . 18STELARA INTRAVENOUS . . . . . . . . . 42STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 42STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 42STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 42STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 49STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 27streptomycin . . . . . . . . . . . . . . . . . . . . . . 21STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 18SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG . . . 34SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 34sucralfate oral tablet . . . . . . . . . . . . . . . 50sulfacetamide-prednisolone . . . . . . . . 57

sevelamer carbonate oral powder in packet . . . . . . . . . . . . . . 45sevelamer carbonate oral tablet . . . . 45sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 53SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 52SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 26sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 58SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 37silver sulfadiazine . . . . . . . . . . . . . . . . . 42simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 55simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 55SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 26simvastatin oral tablet . . . . . . . . . . . . . . 41sirolimus oral solution . . . . . . . . . . . . . . 27sirolimus oral tablet . . . . . . . . . . . . . . . . 27SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 21SIVEXTRO INTRAVENOUS . . . . . . . . 21SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 21SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 42sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . . . 60sodium chloride 0.9% intravenous . . 45sodium chloride 0.45% intravenous parenteral solution . . . . . . . . . . . . . . . . . 60sodium chloride 3% . . . . . . . . . . . . . . . . 60sodium chloride 5% . . . . . . . . . . . . . . . . 60sodium chloride intravenous . . . . . . . . 60sodium chloride irrigation . . . . . . . . . . . 45sodium phenylbutyrate . . . . . . . . . . . . . 45sodium polystyrene (sorb free) . . . . . 45sodium polystyrene sulfonate oral powder . . . . . . . . . . . . . . . . . . . . . . . 45solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 59SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 48SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 27SOLU-CORTEF ACT-O-VIAL (PF) . . 46SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 27

82


Covered Drugs Index

THALOMID ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 27theophylline oral tablet extended release 12 hr . . . . . . . . . . . . 59theophylline oral tablet extended release 24 hr . . . . . . . . . . . . 59thioridazine . . . . . . . . . . . . . . . . . . . . . . . 37thiotepa injection recon soln 15 mg . 27thiotepa injection recon soln 100 mg . 27thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 37THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 49THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 49THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 49THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 49THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 49tiadylt er . . . . . . . . . . . . . . . . . . . . . . . . . . 40tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 30TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 27tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 21tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 56timolol maleate ophthalmic (eye) gel forming solution . . . . . . . . . . 56timolol maleate oral . . . . . . . . . . . . . . . . 40tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 44TIVICAY ORAL TABLET 10 MG . . . . 19TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . 19tizanidine oral tablet . . . . . . . . . . . . . . . 31TOBRADEX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 57tobramycin . . . . . . . . . . . . . . . . . . . . . . . . 56tobramycin-dexamethasone . . . . . . . . 57tobramycin in 0.225% nacl . . . . . . . . . 21tobramycin sulfate . . . . . . . . . . . . . . . . . 21tolterodine oral tablet . . . . . . . . . . . . . . 59topiramate oral capsule, sprinkle . . . 30topiramate oral tablet . . . . . . . . . . . . . . 30toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 27topotecan intravenous recon soln . . . 27

TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 240 MG . . . . . . . . . . . . . . . . . . 31TECHLITE PEN NEEDLE . . . . . . . . . . 48TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 20telmisartan-amlodipine . . . . . . . . . . . . . 40telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg . . . 40telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg . . . . . . . . . . . . . . 40telmisartan oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 40telmisartan oral tablet 80 mg . . . . . . . 40temazepam oral capsule 15 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . 37temazepam oral capsule 22.5 mg, 7.5 mg . . . . . . . . . . . . . . . . . . . 37temsirolimus . . . . . . . . . . . . . . . . . . . . . . 27TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 52tenofovir disoproxil fumarate . . . . . . . 19terazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 40terbinafine hcl oral . . . . . . . . . . . . . . . . . 17terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 59terconazole . . . . . . . . . . . . . . . . . . . . . . . 53testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml) . . . . . . . 49testosterone enanthate . . . . . . . . . . . . 49testosterone transdermal gel . . . . . . . 49testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%) . . . . . . . . . . . 49testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) . . . . . . . . . . . . . . . . 49TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . 52tetrabenazine oral tablet 12.5 mg . . . 31tetrabenazine oral tablet 25 mg . . . . . 31tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 22THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 27

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 48SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 27SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 49

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 27tacrolimus oral . . . . . . . . . . . . . . . . . . . . 27tacrolimus topical . . . . . . . . . . . . . . . . . . 42TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 27TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 27TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 27tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 27tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 59TARGRETIN TOPICAL . . . . . . . . . . . . 27tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 55tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 55tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 56TASIGNA ORAL CAPSULE 50 MG . 27TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 27tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 42tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20TAZORAC TOPICAL CREAM 0.05% . . . . . . . . . . . . . . . . . . . . 42taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . . . . . . . . . 40TAZVERIK . . . . . . . . . . . . . . . . . . . . . . . . 27TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 52TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 27TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 27TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG . . . . . . . . . . . . . . . . . . 31TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG (14)- 240 MG (46) 31

83


Covered Drugs Index

TRISENOX INTRAVENOUS SOLUTION 2 MG/ML . . . . . . . . . . . . . . 28tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 56TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 19trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 56tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 56tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 56TROGARZO . . . . . . . . . . . . . . . . . . . . . . 19TROPHAMINE 6% . . . . . . . . . . . . . . . . 60TROPHAMINE 10% . . . . . . . . . . . . . . . 60TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 48TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 52TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 19TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 28TWINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 52TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 19tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 28TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 52TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 52TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 31

UUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 49unithroid oral tablet 137 mcg . . . . . . . 49UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 28UPTRAVI . . . . . . . . . . . . . . . . . . . . . . . . . 40ursodiol oral capsule . . . . . . . . . . . . . . . 50ursodiol oral tablet . . . . . . . . . . . . . . . . . 50

Vvalacyclovir oral tablet 1 gram . . . . . . 19valacyclovir oral tablet 500 mg . . . . . 19VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 42valganciclovir . . . . . . . . . . . . . . . . . . . . . . 19

tretinoin microspheres topical gel with pump 0.1% . . . . . . . . . . . . . . . . 42tretinoin topical cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . 42tretinoin topical topical gel 0.01% . . . 42tretinoin topical topical gel 0.025%, 0.05% . . . . . . . . . . . . . . . . . . . . 43triamcinolone acetonide dental . . . . . 45triamcinolone acetonide injection . . . 46triamcinolone acetonide topical cream . . . . . . . . . . . . . . . . . . . . . . 44triamcinolone acetonide topical lotion . . . . . . . . . . . . . . . . . . . . . . . 44triamcinolone acetonide topical ointment . . . . . . . . . . . . . . . . . . . 44triamterene-hydrochlorothiazid oral capsule 37.5-25 mg . . . . . . . . . . . 40triamterene-hydrochlorothiazid oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 40triderm topical cream 0.1% . . . . . . . . . 44tridesilon . . . . . . . . . . . . . . . . . . . . . . . . . . 44trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 45tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 56tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 56trifluoperazine oral tablet 1 mg . . . . . 37trifluoperazine oral tablet 10 mg, 2 mg, 5 mg . . . . . . . . . . . . . . . . . 37trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 56tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 56tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 56tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 56tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 56tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 56tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 56trilyte with flavor packets . . . . . . . . . . . 50trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 22tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56trimipramine . . . . . . . . . . . . . . . . . . . . . . . 37TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 37tri-previfem (28) . . . . . . . . . . . . . . . . . . . 56TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 27

toremifene . . . . . . . . . . . . . . . . . . . . . . . . 27TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 27torsemide oral . . . . . . . . . . . . . . . . . . . . . 40TOUJEO MAX U-300 SOLOSTAR . . 48TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 48TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 59TPN ELECTROLYTES . . . . . . . . . . . . . 60TRACLEER ORAL TABLET FOR SUSPENSION . . . . . . . . . . . . . . . 59TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 48tramadol-acetaminophen . . . . . . . . . . . 34tramadol oral tablet 50 mg . . . . . . . . . 34trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 40tranexamic acid oral . . . . . . . . . . . . . . . 53tranylcypromine . . . . . . . . . . . . . . . . . . . 37TRAVASOL 10% . . . . . . . . . . . . . . . . . . 60travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 57TRAZIMERA . . . . . . . . . . . . . . . . . . . . . . 27trazodone . . . . . . . . . . . . . . . . . . . . . . . . . 37TREANDA INTRAVENOUS RECON SOLN 25 MG . . . . . . . . . . . . . 27TREANDA INTRAVENOUS RECON SOLN 100 MG . . . . . . . . . . . . 27TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 21TRELEGY ELLIPTA . . . . . . . . . . . . . . . 59TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG . . . . . . 27TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG . . . . . 27TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG . . . . . . 27treprostinil sodium . . . . . . . . . . . . . . . . . 40TRESIBA FLEXTOUCH U-100 . . . . . 48TRESIBA FLEXTOUCH U-200 . . . . . 48TRESIBA U-100 INSULIN . . . . . . . . . . 48tretinoin (chemotherapy) . . . . . . . . . . . 27tretinoin microspheres topical gel 0.1% . . . . . . . . . . . . . . . . . . . 42

84


Covered Drugs Index

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 30vincasar pfs intravenous solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 28vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 28vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 28VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT . . . . . . . 50VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT . . . . . . . 50viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 56VIRACEPT ORAL TABLET 250 MG . 19VIRACEPT ORAL TABLET 625 MG . 19VIREAD ORAL POWDER . . . . . . . . . . 19VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . 19VITRAKVI ORAL CAPSULE 25 MG . 28VITRAKVI ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 28VITRAKVI ORAL SOLUTION . . . . . . . 28VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 34VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 28volnea (28) . . . . . . . . . . . . . . . . . . . . . . . . 56voriconazole intravenous . . . . . . . . . . . 17voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 17voriconazole oral tablet . . . . . . . . . . . . 17VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 19VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 28VRAYLAR ORAL CAPSULE . . . . . . . . 38VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 38vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 56vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 40water for irrigation, sterile . . . . . . . . . . 45wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 56wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 56

VENCLEXTA ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 28VENCLEXTA STARTING PACK . . . . 28venlafaxine oral capsule,extended release 24hr 75 mg . . . . . . . . . . . . . . . . 37venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg . . . . . . 37venlafaxine oral tablet . . . . . . . . . . . . . . 37VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 59VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 59verapamil intravenous solution . . . . . 40verapamil oral capsule, 24 hr er pellet ct . . . . . . . . . . . . . . . . . . . 40verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg . . . . . . . . . . . . . . . . . . . 40VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG . . . . . 40verapamil oral tablet . . . . . . . . . . . . . . . 40verapamil oral tablet extended release . . . . . . . . . . . . . . . . . . 40VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 37VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 28V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 48VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 48VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 48VIDEX 2 GRAM PEDIATRIC . . . . . . . 19VIDEX EC ORAL CAPSULE, DELAYED RELEASE (DR/EC) 125 MG . . . . . . . . . . . . . . . . . . 19vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 30vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 30VIIBRYD ORAL TABLET . . . . . . . . . . . 37VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 37VIMPAT INTRAVENOUS . . . . . . . . . . . 30VIMPAT ORAL SOLUTION . . . . . . . . . 30VIMPAT ORAL TABLET 50 MG . . . . . 30

valproic acid . . . . . . . . . . . . . . . . . . . . . . . 30valproic acid (as sodium salt) oral solution . . . . . . . . . . . . . . . . . . . . . . . 30valsartan-hydrochlorothiazide . . . . . . 40valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 40valsartan oral tablet 320 mg . . . . . . . . 40VALTOCO . . . . . . . . . . . . . . . . . . . . . . . . . 30VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . 21VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . . . . . 21VANCOMYCIN INJECTION . . . . . . . . 21vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 21VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 21vancomycin oral capsule 125 mg . . . 21vancomycin oral capsule 250 mg . . . 21vancomycin oral recon soln . . . . . . . . 21VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 21vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 53VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 52VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 52VARIZIG INTRAMUSCULAR SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 52VASCEPA ORAL CAPSULE 0.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 41VASCEPA ORAL CAPSULE 1 GRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 41VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 28VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 28velivet triphasic regimen (28) . . . . . . . 56VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 45VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . 19VENCLEXTA ORAL TABLET 10 MG . . . . . . . . . . . . . . . . . . . 28VENCLEXTA ORAL TABLET 50 MG . . . . . . . . . . . . . . . . . . . 28

85


Covered Drugs Index

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG . . 38ZYTIGA ORAL TABLET 250 MG . . . . 28ZYTIGA ORAL TABLET 500 MG . . . . 28

zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 51zebutal oral capsule 50-325-40 mg . 33ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 28zidovudine oral capsule . . . . . . . . . . . . 19zidovudine oral syrup . . . . . . . . . . . . . . 19zidovudine oral tablet . . . . . . . . . . . . . . 19ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 51ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 38ZIRABEV . . . . . . . . . . . . . . . . . . . . . . . . . 28ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 56zoledronic acid intravenous solution . . . . . . . . . . . . . . . 49zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 45ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 28zolpidem oral tablet . . . . . . . . . . . . . . . . 38zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 30ZORTRESS ORAL TABLET 0.5 MG . . . . . . . . . . . . . . . . . . . 28ZORTRESS ORAL TABLET 0.25 MG . . . . . . . . . . . . . . . . . . 28ZORTRESS ORAL TABLET 0.75 MG, 1 MG . . . . . . . . . . . 28ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 52zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 56ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG . . . . . . . . . 34ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG . . . . . . . . . . . . 34zumandimine (28) . . . . . . . . . . . . . . . . . 56ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYKADIA ORAL TABLET . . . . . . . . . . 28ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG . . . . . . . . . . . . . . . . . . 38

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 28XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 41XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 28XELJANZ . . . . . . . . . . . . . . . . . . . . . . . . . 53XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 53XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 23XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 45XIFAXAN ORAL TABLET 550 MG . . 21XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 59XOLAIR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 59XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 28XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3) . . . . . . . . . 28XPOVIO ORAL TABLET 80 MG/WEEK (20 MG X 4) . . . . . . . . . 28XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) . . . . . . . . 28XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8) . . . . . . . . 28XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 33XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 48XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

YYERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 28YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 28YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 52YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 28yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 59

86

Notice of Nondiscrimination: Discrimination is Against the Law

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact Customer Service at 1-800-222-6700 (TTY 711), 8 am – 8 pm local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 - September 30.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Cigna - Grievance PO Box 269005 Weston, FL 33326-9927 Phone: 1-800-222-6700 (TTY 711), Fax: 1-800-735-1469

You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711), 8 am – 8 pm, 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711), 8 a.m. – 8 p.m, 7 días de la semana. Cigna HealthSpring® Rx (PDP) is a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal.

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Notificación Contra la Discriminación: La Discriminación es Contra la Ley

Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Cigna no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Cigna: • Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Customer Service, al 1-800-222-6700 (TTY 711), de 8 a.m. a 8 p.m., hora local, los siete días de la semana. Puede que nuestro sistema telefónico automático conteste sus llamadas durante los fines de semana del 1 de abril al 30 de septiembre.

Si considera que Cigna no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Cigna – Grievance PO Box 269005 Weston, FL 33326-9927 Teléfono: 1-800-222-6700 (TTY 711) Fax: 1-800-735-1469.

Puede presentar el reclamo escrito por correo postal o fax. Si necesita ayuda para hacerlo, Customer Service está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal (Oficina de Derechos Civiles portal de quejas), disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711), 8 am – 8 pm, 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711), 8 a.m.– 8 p.m , 7 días de la semana. Cigna-HealthSpring® Rx (PDP) es un plan de medicamentos con receta (PDP, por sus siglas en inglés) de Medicare con un contrato con Medicare. La inscripción en Cigna-HealthSpring depende de la renovación de los contratos.

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S5617_17_50212 ACCEPTED 17_MLI_PDP

English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711).

Chinese – 1-800-222-6700 (TTY 711)

Vietnamese – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-222-6700 (TTY 711).

French Creole – ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-222-6700 (TTY 711).

Korean – 1-800-222-6700 (TTY 711)

Polish – UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-222-6700 (TTY 711).

French – ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-222-6700 (ATS 711).

Arabic – 1-800-222-6700 اتصل برقم. ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجاناللغة العربیةإذا كنت تتحدث : ملحوظة)TTY 711.(

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-222-6700 (телетайп 711).

Tagalog – PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-222-6700 (TTY 711).

Farsi/Persian – . توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد . تماس بگیرید (711 :TTY) 1-800-222-6700 با

German – ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-222-6700 (TTY 711).

Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-222-6700 (TTY 711).

Italian – ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-222-6700 (TTY 711).

Japanese – 1-800-222-6700 (TTY 711)

Navajo – D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-222-6700 (TTY 711).

Gujarati – �યાન આપો: જો તમે�જુરાતી બોલતા હો તો િન:��ુક ભાષા સહાય સેવાઓ તમારા માટ� �પલ�� છે. ફોન કરો 1-800-222-6700 (TTY 711).

Urdu توجہ دیں: اگرآپ اردو زبان بولتے ہیں تو آپ کےلئے زبان معاون خدمات مفت میں دستیاب ہیں۔ کال کریں 1-800-222-6700 (TTY 711)

This drug list was updated in May 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.Cigna.com/part-d. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2019 Cigna 929085 e

1-800-222-6700 (TTY 711) 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30.

Cigna.com/part-d

2020 cigna comprehensive drug list (formulary) · this drug list was updated in may 2020. for more...

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