2021 cigna comprehensive drug list (formulary)...sep 01, 2020 · cigna secure-essential rx (pdp)...

Plan coveredCigna Secure-Essential Rx (PDP)

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

2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

HPMS Approved Formulary File Submission ID 21119, Version 11This drug list was updated on 05/01/2021. 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 CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. 21_F_S5617_ESS_V05May 2021 INT_21_87406_C_Final_10e

1May 2021

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 both. 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 Drug List?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna Secure-Essential Rx (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of May 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

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drugs will remain available at the same cost-sharing and with no new restrictions for those customers taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the drug list for the new benefit year for any changes to drugs. The enclosed drug list is current as of May 2021. 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 18. 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 18. 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 atorvastatin 40mg. 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 108 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 18. 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:

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

• 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.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not 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 18 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., atorvastatin).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 18 along with the amount dispensed per the days supplied. (For example: atorvastatin 40mg QL 30/30; this means the drug atorvastatin 40mg 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 Cigna.com/member-resources 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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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.If you qualified for Extra Help with your drug costs, your costs may be different from those described below. Please refer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are.Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit Cigna.com/member-resources to search for a preferred retail or mail-order pharmacy near you.

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.

Cigna Secure-Essential Rx (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 / $0 $20 / $40 / $60 $20

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

Tier 4: Non-Preferred Drugs 47% 48% 47% 48% 48%

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





* 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.

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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

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Drug List Table of Contents:The drugs in the drug list are grouped into categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list below. Then look under the category name in the drug list for your drug. Page

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.LA – Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or 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 should call 711.

NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.PA – This drug requires prior authorizationQL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally 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.

ANTI - INFECTIVES ...................................................................................................................................................................18

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ........................................................................................................24

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...........................................................................................................30

CARDIOVASCULAR, HYPERTENSION / LIPIDS ....................................................................................................................38

DERMATOLOGICALS/TOPICAL THERAPY ...........................................................................................................................41

DIAGNOSTICS / MISCELLANEOUS AGENTS ........................................................................................................................44

EAR, NOSE / THROAT MEDICATIONS ....................................................................................................................................45

ENDOCRINE/DIABETES ...........................................................................................................................................................45

GASTROENTEROLOGY ...........................................................................................................................................................49

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...................................................................................................................50

MUSCULOSKELETAL / RHEUMATOLOGY ............................................................................................................................52

OBSTETRICS / GYNECOLOGY ...............................................................................................................................................53

OPHTHALMOLOGY ..................................................................................................................................................................56

RESPIRATORY AND ALLERGY ...............................................................................................................................................57

UROLOGICALS .........................................................................................................................................................................59

VITAMINS, HEMATINICS / ELECTROLYTES ..........................................................................................................................59

18

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugYou can find information on what the symbols and abbreviations on this table mean by going to page 17.

May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 4 PAAMBISOME 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 PA

fluconazole oral suspension for reconstitution

3

fluconazole oral tablet 2flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 QL (120/30)itraconazole oral solution 5 NDSketoconazole oral 2nystatin oral suspension 3nystatin oral tablet 2posaconazole oral tablet, delayed release (dr/ec)

5 QL (96/30); NDS

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

5 NDS

voriconazole oral tablet 200 mg 5 NDSvoriconazole oral tablet 50 mg 4ANTIVIRALSabacavir oral solution 3 QL (960/30)abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acyclovir 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, 300 mg

4 QL (30/30)

atazanavir oral capsule 200 mg 4 QL (60/30)ATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 NDSCABENUVA 5 NDSCIMDUO 4COMPLERA 4 QL (30/30)CRIXIVAN ORAL CAPSULE 200 MG

4 QL (270/30)

DELSTRIGO 4DESCOVY 5 QL (30/30); NDSdidanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 NDSEDURANT 3 QL (30/30)efavirenz oral capsule 200 mg 5 QL (120/30); NDSefavirenz oral capsule 50 mg 4 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDSefavirenz-emtricitabin-tenofov 5 QL (30/30); NDSefavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg

4 QL (30/30)

efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg

4

emtricitabine 3 QL (30/30)emtricitabine-tenofovir (tdf) 5 QL (30/30); NDSEMTRIVA ORAL CAPSULE 4 QL (30/30)

19



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 4MAVYRET 5 PA; QL (84/28);

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

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

4

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

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (240/30)


5 QL (60/30); NDS


4 QL (480/30)


5 QL (30/30); NDS

RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (240/30); NDS

ribavirin oral capsule 3ribavirin oral tablet 200 mg 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMTRIVA ORAL SOLUTION 4 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 ORAL PELLETS IN PACKET 33.75-150 MG

5 PA; QL (28/28); NDS

HARVONI ORAL PELLETS IN PACKET 45-200 MG

5 PA; QL (56/28); NDS

HARVONI ORAL TABLET 45-200 MG

5 PA; QL (60/30); NDS

HARVONI ORAL TABLET 90-400 MG

5 PA; QL (28/28); NDS

INTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 4 QL (120/30)ISENTRESS HD 5 NDSISENTRESS ORAL POWDER IN PACKET

4 QL (60/30)

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)

20



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

zidovudine oral capsule 4 QL (180/30)zidovudine oral syrup 4 QL (1680/28)zidovudine oral tablet 2 QL (60/30)CEPHALOSPORINScefaclor oral capsule 4cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

4

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 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

cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg

4

cefazolin intravenous 4cefdinir 4CEFEPIME IN DEXTROSE 5% 4cefepime in dextrose,iso-osm 4cefepime injection 4CEFEPIME INTRAVENOUS 4 PAcefixime 4CEFOTETAN IN DEXTROSE, ISO-OSM

4 PA

cefotetan injection 4 PAcefoxitin 4 PAcefoxitin in dextrose, iso-osm 4 PAcefpodoxime 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

rimantadine 4ritonavir 3 QL (360/30)RUKOBIA 4SELZENTRY ORAL SOLUTION

5 NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

4 QL (120/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

SOVALDI ORAL TABLET 400 MG

5 PA; QL (28/28); NDS

stavudine oral capsule 4 QL (60/30)STRIBILD 5 QL (30/30); NDSSYMFI 4SYMFI LO 4 QL (30/30)SYMTUZA 4TEMIXYS 5 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

TIVICAY PD 4 QL (180/30)TRIUMEQ 5 QL (30/30); NDSTROGARZO 5 NDSTRUVADA 5 QL (30/30); NDSvalacyclovir oral tablet 1 gram 3 QL (120/30)valacyclovir oral tablet 500 mg 3 QL (60/30)valganciclovir 5 NDSVEMLIDY 5 NDSVIRACEPT 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

21



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

5 QL (360/30); NDS

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

4 PA

ARIKAYCE 4 PA; LAatovaquone 5 NDSatovaquone-proguanil 4aztreonam 4 PAbacitracin intramuscular 4CAPASTAT 4CAYSTON 5 PA; LA; QL (84/28);

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

4 PA

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

4 PA

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

5 NDS

daptomycin intravenous recon soln 500 mg

5 NDS

EMVERM 4ertapenem 4ethambutol 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefprozil 3ceftazidime 4 PACEFTAZIDIME IN D5W 4 PAceftriaxone 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 4cefuroxime axetil oral tablet 3cefuroxime sodium injection recon soln 750 mg

4 PA

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

2

cephalexin oral suspension for reconstitution

2

tazicef 4 PATEFLARO 4 PAERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4 PAazithromycin oral packet 3azithromycin oral suspension for reconstitution

4

azithromycin oral tablet 2clarithromycin 4DIFICID ORAL SUSPENSION FOR RECONSTITUTION

5 QL (136/10); NDS

DIFICID ORAL TABLET 5 QL (20/10); NDSerythrocin (as stearate) oral tablet 250 mg

4

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4 PA

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

4

erythromycin oral capsule, delayed release(dr/ec)

4

22



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pentamidine injection 4praziquantel 4PRIFTIN 4PRIMAQUINE 4pyrazinamide 4pyrimethamine 5 PA; NDSquinine sulfate 4 PA; QL (42/7)rifabutin 4rifampin 4SIRTURO 4 PA; LASIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDSSIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 4 PASYNERCID 5 PA; NDStigecycline 5 PA; NDStobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDStobramycin sulfate 4 PATRECATOR 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 PA; QL (40/10)

vancomycin oral capsule 250 mg

4 PA; QL (80/10)

vancomycin oral recon soln 2 QL (450/10)VANCOMYCIN-WATER INJECT (PEG)

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FIRVANQ ORAL RECON SOLN 25 MG/ML

4 QL (300/10)

FIRVANQ ORAL RECON SOLN 50 MG/ML

4 QL (450/10)

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4 PA

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

4 PA

gentamicin injection solution 40 mg/ml

4 PA

gentamicin sulfate (ped) (pf) 4 PAhydroxychloroquine 2imipenem-cilastatin 4isoniazid oral solution 4isoniazid oral tablet 2ivermectin oral 3lincomycin 4 PAlinezolid in dextrose 5% 4 PAlinezolid oral suspension for reconstitution

5 QL (1800/30); NDS

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

4

metro i.v. 4 PAmetronidazole in nacl (iso-os) 4 PAmetronidazole oral tablet 2neomycin 2nitazoxanide 5 QL (20/10); NDSparomomycin 4PASER 4PENTAM 4pentamidine inhalation 3 B/D PA; QL (1/28)

23



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciprofloxacin hcl oral tablet 100 mg

4

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

2

ciprofloxacin in 5% dextrose 4 PAlevofloxacin in d5w 4 PAlevofloxacin intravenous 4 PAlevofloxacin oral solution 4levofloxacin oral tablet 2moxifloxacin oral 4MOXIFLOXACIN-SOD.ACE, SUL-WATER

4 PA

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

4 PA

sulfamethoxazole-trimethoprim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

2

TETRACYCLINESdoxy-100 4 PAdoxycycline hyclate intravenous 4 PAdoxycycline 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 oral capsule 100 mg 4NUZYRA INTRAVENOUS 4 PANUZYRA ORAL 4tetracycline 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

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 4 PAampicillin-sulbactam 4 PABICILLIN L-A 4 PAdicloxacillin 2nafcillin 4 PAnafcillin in dextrose iso-osm 4 PAoxacillin injection 4 PApenicillin g potassium 4 PApenicillin v potassium 2pfizerpen-g 4 PAPIPERACILLIN-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

QUINOLONESCIPRO ORAL SUSPENSION, MICROCAPSULE RECON

4

24



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALECENSA 5 PA; QL (240/30); NDS

ALIMTA 5 PA; NDSALIQOPA 5 PA; NDSALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

ALUNBRIG ORAL TABLETS, DOSE PACK

5 PA; QL (30/30); NDS

anastrozole 2ARRANON 4 B/D PAARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

arsenic trioxide intravenous solution 2 mg/ml

4 B/D PA

ARZERRA 4 B/D PAAYVAKIT 5 PA; LA; QL (30/30);

NDSazacitidine 4 B/D PAazathioprine 2 PAazathioprine sodium 4 PABALVERSA 5 PA; LA; NDSBAVENCIO 5 PA; NDSBELEODAQ 4 B/D PABENDEKA 5 B/D PA; NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 3BLENREP 4 PAbleomycin 4 B/D PABLINCYTO INTRAVENOUS KIT

4 B/D PA

BORTEZOMIB 5 PA; NDSBOSULIF ORAL TABLET 100 MG

5 PA; QL (90/30); NDS

BOSULIF ORAL TABLET 400 MG, 500 MG

5 PA; QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

URINARY 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

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection 4leucovorin 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 oral tablet 250 mg 4 PA; QL (120/30)abiraterone oral tablet 500 mg 4 PA; QL (60/30)ABRAXANE 5 PA; NDSADCETRIS 4 PAadriamycin intravenous recon soln 10 mg

4 B/D PA

adriamycin intravenous solution 4 B/D PAadrucil intravenous solution 2.5 gram/50 ml

4 B/D PA

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG

5 PA; QL (150/30); NDS

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG, 5 MG

5 PA; QL (56/28); NDS

AFINITOR ORAL TABLET 10 MG

5 PA; QL (30/30); NDS

25



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CYRAMZA 5 PA; NDScytarabine 4 B/D PAcytarabine (pf) injection solution 4 B/D PAdacarbazine 4 B/D PAdactinomycin 4 B/D PADANYELZA 4 PADARZALEX 5 PA; NDSDARZALEX FASPRO 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

decitabine 4 B/D PAdocetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

4 B/D PA

doxorubicin intravenous recon soln 50 mg

4 B/D PA

doxorubicin intravenous solution

4 B/D PA

doxorubicin, peg-liposomal 4 B/D PADROXIA 4ELLENCE 4 B/D PAELZONRIS 5 PA; NDSEMCYT 4EMPLICITI 4 PAENHERTU 5 PA; NDSepirubicin intravenous solution 4 B/D PAERBITUX 4 B/D PAERIVEDGE 5 PA; QL (30/30);

NDSERLEADA 4 PA; QL (120/30)erlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BRAFTOVI ORAL CAPSULE 75 MG

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

BRUKINSA 5 PA; LA; NDSbusulfan 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

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

CABOMETYX ORAL TABLET 40 MG

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

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

CAPRELSA ORAL TABLET 100 MG

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

CAPRELSA ORAL TABLET 300 MG

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

carboplatin intravenous solution 4 B/D PAcarmustine 4 B/D PAcisplatin intravenous solution 4 B/D PAcladribine 4 B/D PAclofarabine 4 B/D PACOMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

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; LA; QL (60/30); NDS

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

cyclophosphamide intravenous recon soln

5 B/D PA; NDS

CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION

5 B/D PA; NDS

cyclophosphamide oral capsule 3 B/D PAcyclosporine intravenous 4 PAcyclosporine modified 4 PAcyclosporine oral capsule 4 PA

26



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HALAVEN 5 PA; NDShydroxyurea 2IBRANCE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG

5 PA; QL (30/30); NDS

ICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

idarubicin 4 B/D PAIDHIFA 5 PA; LA; QL (30/30);

NDSifosfamide 4 B/D PAimatinib oral tablet 100 mg 5 PA; QL (180/30);

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

NDSIMBRUVICA 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);

NDSINQOVI 5 PA; QL (5/28); NDSINREBIC 5 PA; LA; QL

(120/30); NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAIXEMPRA 4 B/D PAJAKAFI 5 PA; QL (60/30);

NDSJEVTANA 4 B/D PAKADCYLA 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

ERWINAZE 4 B/D PAETOPOPHOS 4 B/D PAetoposide intravenous 3 B/D PAeverolimus (antineoplastic) 5 PA; QL (30/30);

NDSeverolimus (immunosuppressive) oral tablet 0.25 mg, 0.75 mg

5 PA; QL (60/30); NDS

everolimus (immunosuppressive) oral tablet 0.5 mg

5 PA; QL (120/30); NDS

EVOMELA 5 PA; NDSexemestane 4FARYDAK 5 PA; QL (6/21); NDSFIRMAGON KIT W DILUENT SYRINGE

4 B/D PA

floxuridine 4 B/D PAfludarabine 4 B/D PAfluorouracil intravenous 4 B/D PAflutamide 4FOLOTYN 5 B/D PA; NDSfulvestrant 5 B/D PA; NDSGAVRETO 4 PA; LA; QL (120/30)GAZYVA 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);

NDS

27



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; NDSLUPRON DEPOT (3 MONTH) 5 PA; NDSLUPRON DEPOT (4 MONTH) 5 PA; NDSLUPRON DEPOT (6 MONTH) 5 PA; NDSLUPRON DEPOT-PED 5 PA; NDSLUPRON DEPOT-PED (3 MONTH)

5 PA; NDS

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

LYSODREN 5 NDSMARQIBO 4 B/D PAMATULANE 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; LA; QL (180/30); NDS

melphalan hcl 5 B/D PA; NDSmercaptopurine 4methotrexate sodium (pf) 4 B/D PAmethotrexate sodium injection 4 B/D PAmethotrexate sodium oral 2mitomycin intravenous 4 B/D PAmitoxantrone 4 B/D PAMONJUVI 4 PAMVASI 5 PA; NDSmycophenolate mofetil (hcl) 4 PAmycophenolate mofetil oral capsule

3 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KANJINTI 5 PA; NDSKEYTRUDA INTRAVENOUS SOLUTION

5 PA; 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

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (21/28); NDS


5 PA; QL (42/28); NDS


5 PA; QL (63/28); NDS

KYPROLIS 5 B/D PA; NDSlapatinib 5 PA; QL (180/30);

NDSLENVIMA 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; 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

28



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

PORTRAZZA 4 B/D PAPOTELIGEO 5 PA; NDSPROGRAF ORAL GRANULES IN PACKET

4 PA

PURIXAN 5 NDSQINLOCK 5 PA; LA; NDSRETEVMO 5 PA; LA; NDSREVLIMID 5 PA; LA; QL (28/28);

NDSROMIDEPSIN INTRAVENOUS SOLUTION

5 PA; NDS

ROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

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

RUXIENCE 5 PA; NDSRYDAPT 5 PA; QL (240/30);

NDSSANDIMMUNE ORAL SOLUTION

4 PA

SARCLISA 4 PASIGNIFOR 5 PA; NDSSIMULECT 5 B/D PA; NDSsirolimus oral solution 5 PA; NDSsirolimus oral tablet 4 PASOLTAMOX 4SOMATULINE DEPOT 5 PA; NDSSPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG

5 PA; QL (30/30); NDS

SPRYCEL ORAL TABLET 20 MG, 70 MG

5 PA; QL (60/30); NDS

STIVARGA 5 PA; QL (84/28); NDS

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mycophenolate mofetil oral suspension for reconstitution

5 PA; NDS

mycophenolate mofetil oral tablet

4 PA

mycophenolate sodium 4 PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; LA; NDSNEXAVAR 5 PA; LA; QL

(120/30); NDSnilutamide 5 NDSNINLARO 5 PA; QL (3/28); NDSNIPENT 4 B/D PANUBEQA 4 PA; LA; 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

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

OGIVRI 5 PA; NDSONCASPAR 4ONIVYDE 4 B/D PAONUREG 4 PA; QL (14/28)OPDIVO 5 PA; QL (80/28);

NDSORGOVYX 4 PA; LA; QL (30/30)oxaliplatin 4 B/D PApaclitaxel 4 B/D PAPADCEV 4 PAPEMAZYRE 4 PA; LA; QL (14/21)PERJETA 5 PA; NDSPHESGO 5 PA; NDSPIQRAY 5 PA; NDSPOLIVY 5 PA; NDS

29



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5 PA; NDS

tretinoin (antineoplastic) 5 NDSTRIPTODUR 5 PA; NDSTRODELVY 4 PATRUXIMA 5 PA; NDSTUKYSA ORAL TABLET 150 MG

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

TUKYSA ORAL TABLET 50 MG

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

TURALIO 5 PA; LA; NDSTYKERB 5 PA; LA; QL

(180/30); NDSUNITUXIN 5 PA; NDSvalrubicin 4 B/D PAVECTIBIX 5 PA; NDSVELCADE 5 PA; NDSVENCLEXTA ORAL TABLET 10 MG

4 PA; LA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

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

VENCLEXTA ORAL TABLET 50 MG

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

VENCLEXTA STARTING PACK 5 PA; LA; QL (42/30); NDS

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

vinblastine intravenous solution 4 B/D PAvincasar pfs 4 B/D PAvincristine 4 B/D PAvinorelbine 4 B/D PAVITRAKVI ORAL CAPSULE 100 MG

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

VITRAKVI ORAL CAPSULE 25 MG

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

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNRIBO 5 PA; NDSTABLOID 4TABRECTA 5 PA; NDStacrolimus oral 4 PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; LA; QL (30/30);

NDSTALZENNA ORAL CAPSULE 0.25 MG

5 PA; QL (90/30); NDS

TALZENNA ORAL CAPSULE 1 MG

5 PA; QL (30/30); NDS

tamoxifen 2TARGRETIN TOPICAL 5 PA; NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (120/30); NDS

TAZVERIK 4 PA; LATECENTRIQ 5 PA; NDSTEMODAR INTRAVENOUS 4 B/D PAtemsirolimus 4 B/D PATEPMETKO 5 PA; LA; QL (60/30);

NDSTHALOMID 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 4 PATIBSOVO 5 PA; NDStoposar 3 B/D PAtopotecan intravenous recon soln

5 B/D PA; NDS

topotecan intravenous solution 4 mg/4 ml (1 mg/ml)

4 B/D PA

toremifene 5 NDSTRAZIMERA 5 PA; NDSTREANDA INTRAVENOUS RECON SOLN

5 B/D PA; NDS

30



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

APTIOM ORAL TABLET 600 MG, 800 MG

4 QL (60/30)

BANZEL 5 PA; NDSBRIVIACT INTRAVENOUS 4BRIVIACT ORAL SOLUTION 4 QL (600/30)BRIVIACT ORAL TABLET 4 QL (60/30)carbamazepine oral capsule, er multiphase 12 hr

4

carbamazepine oral suspension 100 mg/5 ml, 200 mg/10 ml

4

carbamazepine oral tablet 4carbamazepine oral tablet extended release 12 hr

4

carbamazepine oral tablet, chewable

4

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 4 PA; QL (480/30)clobazam oral tablet 4 PA; QL (60/30)clonazepam oral tablet 0.5 mg, 1 mg

2 QL (90/30)

clonazepam oral tablet 2 mg 2 QL (300/30)clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg

4 QL (90/30)

clonazepam oral tablet, disintegrating 2 mg

4 QL (300/30)

DIACOMIT ORAL CAPSULE 250 MG

4 PA; LA; QL (360/30)

DIACOMIT ORAL CAPSULE 500 MG

4 PA; LA; QL (180/30)

DIACOMIT ORAL POWDER IN PACKET 250 MG

4 PA; LA; QL (360/30)

DIACOMIT ORAL POWDER IN PACKET 500 MG

4 PA; LA; QL (180/30)

DIAZEPAM RECTAL 4DILANTIN 30 MG 4divalproex oral capsule, delayed rel sprinkle

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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; LA; NDSXPOVIO 5 PA; LA; NDSXTANDI ORAL CAPSULE 4 PA; QL (120/30)XTANDI ORAL TABLET 40 MG 4 PA; QL (120/30)XTANDI ORAL TABLET 80 MG 4 PA; QL (60/30)YERVOY 5 PA; NDSYONDELIS 5 PA; NDSZALTRAP 4 B/D PAZANOSAR 4 B/D PAZEJULA 5 PA; LA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZEPZELCA 4 PAZIRABEV 5 PA; NDSZOLADEX 4 B/D PAZOLINZA 5 PA; QL (120/30);

NDSZORTRESS ORAL TABLET 1 MG

5 PA; NDS

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

ZYKADIA ORAL TABLET 5 PA; QL (90/30); NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

4 QL (180/30)

APTIOM ORAL TABLET 400 MG

4 QL (90/30)

31



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

phenobarbital sodium injection solution

3

phenytoin oral suspension 2phenytoin oral tablet,chewable 3phenytoin sodium extended 2phenytoin sodium intravenous solution

3

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg

3 QL (90/30)

pregabalin oral capsule 225 mg, 300 mg

3 QL (60/30)

pregabalin oral solution 3 QL (900/30)primidone 2roweepra 2rufinamide 5 PA; NDSSPRITAM 4subvenite 3subvenite starter (blue) kit 3subvenite starter (green) kit 3subvenite starter (orange) kit 3SYMPAZAN 5 PA; QL (60/30);

NDStiagabine 4topiramate oral capsule, sprinkle

2 PA

topiramate oral tablet 2 PAvalproate sodium 3valproic acid 2valproic acid (as sodium salt) oral solution

2

VALTOCO 4 PA; QL (10/30)vigabatrin 5 PA; LA; QL

(180/30); NDSvigadrone 5 PA; LA; QL

(180/30); NDSVIMPAT INTRAVENOUS 4 QL (1200/30)VIMPAT ORAL SOLUTION 4 QL (1200/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

divalproex oral tablet extended release 24 hr

4

divalproex oral tablet,delayed release (dr/ec)

2

EPIDIOLEX 5 PA; LA; NDSepitol 4ethosuximide 4felbamate 4FINTEPLA 4 PA; LAfosphenytoin 3FYCOMPA ORAL SUSPENSION

4 PA; QL (720/30)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

4 PA; QL (30/30)

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG

4 PA; QL (60/30)

gabapentin oral capsule 100 mg, 400 mg

2 QL (270/30)

gabapentin oral capsule 300 mg

2 QL (360/30)

gabapentin oral solution 4 QL (2160/30)gabapentin oral tablet 600 mg 2 QL (180/30)gabapentin oral tablet 800 mg 2 QL (120/30)lamotrigine oral tablet 2lamotrigine oral tablet, chewable dispersible

2

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 3levetiracetam oral solution 2levetiracetam oral tablet 2levetiracetam oral tablet extended release 24 hr

4

NAYZILAM 4 PA; QL (10/30)oxcarbazepine oral suspension 4oxcarbazepine oral tablet 3phenobarbital oral elixir 4 PA; QL (1500/30)phenobarbital oral tablet 3 PA; QL (120/30)

32



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sumatriptan nasal spray,non-aerosol 5 mg/actuation

4 QL (36/28)

sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

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 THERAPYCOPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

5 PA; QL (30/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

5 PA; QL (12/28); NDS

dalfampridine 3 PA; QL (60/30)dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg

5 PA; QL (14/30); NDS

dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg (14)- 240 mg (46)

5 PA; QL (120/180); NDS

dimethyl fumarate oral capsule, delayed release(dr/ec) 240 mg

5 PA; QL (60/30); NDS

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)memantine oral capsule, sprinkle,er 24hr

4 PA

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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

4 QL (60/30)

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)XCOPRI 4 PAXCOPRI MAINTENANCE PACK

4 PA

XCOPRI TITRATION PACK 4 PAzonisamide 3 PAANTIPARKINSONISM AGENTSAPOKYN 5 PA; LA; 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 4NEUPRO 4pramipexole oral tablet 2rasagiline 4ropinirole oral tablet 2RYTARY 4 STselegiline hcl 3MIGRAINE / CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA; QL (1/30)dihydroergotamine nasal 4 PA; QL (8/28)ergotamine-caffeine 3naratriptan 4 QL (18/28)rizatriptan 4 QL (36/28)sumatriptan nasal spray,non-aerosol 20 mg/actuation

4 QL (18/28)

33



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (360/30); NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (180/30); NDS

buprenorphine hcl injection 4 NDSbuprenorphine hcl sublingual 3 PAbutalbital-acetaminophen-caff oral capsule

4 PA; QL (180/30)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

4 PA; QL (180/30)

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

4 QL (360/30); NDS

fentanyl citrate buccal lozenge on a handle

5 PA; QL (120/30); NDS

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

4 QL (10/30); NDS

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

4 NDS

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

4 QL (5550/30); NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral tablet 7.5-200 mg

4 QL (50/30); NDS

hydromorphone oral liquid 4 QL (2400/30); NDShydromorphone oral tablet 4 QL (180/30); NDSINFUMORPH P/F 4 B/D PA; NDSmethadone injection solution 4 NDSmethadone intensol 4 QL (90/30); NDSmethadone oral concentrate 4 QL (90/30); NDSmethadone oral solution 10 mg/5 ml

4 QL (600/30); NDS

methadone oral solution 5 mg/5 ml

4 QL (1200/30); NDS

methadone oral tablet 10 mg 2 QL (120/30); NDSmethadone oral tablet 5 mg 2 QL (240/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

memantine oral tablets,dose pack

3 PA; QL (98/28)

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

5 PA; LA; QL (14/30); NDS

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

5 PA; LA; QL (120/180); NDS

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

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

tetrabenazine oral tablet 12.5 mg

5 PA; QL (240/30); NDS

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

TYSABRI 5 PA; NDSMUSCLE 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 (4500/30); NDS

34



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4 QL (60/30)

buprenorphine-naloxone sublingual film 2-0.5 mg

4 QL (360/30)

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

4 QL (90/30)

buprenorphine-naloxone sublingual tablet 2-0.5 mg

2 QL (360/30)

buprenorphine-naloxone sublingual tablet 8-2 mg

2 QL (90/30)

butorphanol nasal 4 QL (10/28); NDScelecoxib 3 QL (60/30)diclofenac potassium 2diclofenac sodium topical gel 1%

3 QL (1000/28)

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 15 mg 1meloxicam oral tablet 7.5 mg 1 QL (60/30)nabumetone 2naloxone 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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

4 NDS

morphine concentrate oral solution

4 QL (900/30); NDS

MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML

4 NDS

morphine injection solution 8 mg/ml

4 NDS

MORPHINE INJECTION SYRINGE 2 MG/ML

4 NDS

morphine injection syringe 4 mg/ml, 5 mg/ml

4 NDS

morphine intravenous solution 10 mg/ml

4 NDS

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

4 NDS

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML

4 NDS

morphine intravenous syringe 2 mg/ml, 4 mg/ml

4 NDS

morphine oral solution 4 QL (900/30); NDSMORPHINE ORAL TABLET 3 QL (180/30); NDSmorphine oral tablet extended release

3 QL (120/30); NDS

oxycodone oral concentrate 4 QL (180/30); NDSoxycodone oral solution 4 QL (1200/30); NDSoxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg

3 QL (180/30); NDS

oxycodone oral tablet 5 mg 3 QL (360/30); NDSoxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

4 QL (360/30); NDS

oxycodone-aspirin 4 QL (360/30); NDSoxymorphone oral tablet extended release 12 hr

3 QL (90/30); NDS

XTAMPZA ER 3 QL (90/30); NDSzebutal oral capsule 50-325-40 mg

4 PA; QL (180/30)

35



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

chlorpromazine 4citalopram oral solution 4citalopram oral tablet 1clomipramine 4clorazepate dipotassium oral tablet 15 mg

4 QL (180/30)

clorazepate dipotassium oral tablet 3.75 mg

4 QL (90/30)

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

4

desipramine 4desvenlafaxine succinate 4 QL (30/30)dexmethylphenidate oral tablet 3dextroamphetamine oral capsule, extended release

4

dextroamphetamine oral tablet 4dextroamphetamine-amphetamine oral capsule, extended release 24hr

4 QL (60/30)

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 2diazepam intensol 2 QL (240/30)diazepam oral concentrate 2 QL (240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxaprozin 4SUBOXONE SUBLINGUAL FILM 12-3 MG

4 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG

4 QL (360/30)

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

4 QL (90/30)

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 4 QL (240/30); NDSVIVITROL 5 NDSPSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 4 QL (1/28)ADASUVE 4alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

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

5 QL (60/30); NDS

asenapine maleate 4 QL (60/30)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)

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

3 QL (60/30)

buspirone 2CAPLYTA 4 PA; QL (30/30)

36



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

haloperidol 2haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2HETLIOZ 5 PA; QL (30/30);

NDSimipramine hcl 3INVEGA 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)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML

4 QL (0.88/90)


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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3doxepin oral concentrate 3DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG

4 QL (60/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG

4 QL (90/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

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 PA; QL (60/30)FANAPT ORAL TABLETS, DOSE PACK

4 PA; QL (8/28)

FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK

4 ST; QL (28/28)

FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine oral capsule 10 mg 2 QL (30/30)fluoxetine oral capsule 20 mg 2fluoxetine oral capsule 40 mg 2 QL (60/30)fluoxetine oral solution 2fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 100 mg 3 QL (90/30)fluvoxamine oral tablet 25 mg 3 QL (30/30)fluvoxamine oral tablet 50 mg 3 QL (60/30)

37



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

perphenazine-amitriptyline 4PERSERIS 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 3 QL (30/30)REXULTI 4 QL (30/30)RISPERDAL CONSTA 4 QL (2/28)risperidone oral solution 4risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

2 QL (60/30)

risperidone oral tablet 4 mg 2 QL (120/30)risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

4 QL (60/30)

risperidone oral tablet, disintegrating 4 mg

4 QL (120/30)

SAPHRIS 4 QL (60/30)SECUADO 4 QL (30/30)sertraline oral concentrate 4sertraline oral tablet 2temazepam 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 4TRINTELLIX 4 ST; QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lorazepam oral tablet 0.5 mg, 1 mg

2 QL (90/30)

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

4

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating)

4

mirtazapine oral tablet 3MIRTAZAPINE ORAL TABLET, DISINTEGRATING

3 QL (30/30)

modafinil oral tablet 100 mg 3 PA; QL (30/30)modafinil oral tablet 200 mg 3 PA; QL (60/30)molindone 2nefazodone 4nortriptyline 2NUPLAZID ORAL CAPSULE 4 PA; QL (30/30)NUPLAZID ORAL TABLET 10 MG

4 PA; QL (30/30)

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 3olanzapine 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 PA; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 PA; QL (60/30)

paroxetine hcl oral tablet 2PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4

38



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propafenone 4quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2amiloride 2amiloride-hydrochlorothiazide 2amlodipine 1amlodipine-benazepril 2amlodipine-valsartan 2amlodipine-valsartan-hcthiazid 2atenolol 1atenolol-chlorthalidone 2benazepril 1benazepril-hydrochlorothiazide 2betaxolol oral 2BIDIL 3bisoprolol 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 sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

venlafaxine oral capsule, extended release 24hr

2

venlafaxine oral tablet 2 QL (90/30)VERSACLOZ 4VIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (30/30)

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

4 PA; QL (7/30)

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

ziprasidone hcl 4 QL (60/30)ziprasidone mesylate 4 QL (6/30)zolpidem oral tablet 2 QL (30/30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4 PA; QL (2/28)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG, 405 MG

4 PA

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 4pacerone oral tablet 100 mg, 200 mg, 400 mg

4

39



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isradipine 4labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)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 1metyrosine 5 PA; NDSminoxidil oral 2moexipril 2nadolol 4nadolol-bendroflumethiazide oral tablet 80-5 mg

4

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

3

nifedipine oral tablet extended release 24hr

3

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

4

propranolol oral solution 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clonidine 4 QL (4/28)clonidine hcl oral tablet 2DEMSER 4 PAdiltiazem hcl intravenous 4diltiazem hcl oral capsule,ext.rel 24h degradable

3

diltiazem 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

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 oral tablet 1 mg, 2 mg, 4 mg

2 QL (30/30)

doxazosin oral tablet 8 mg 2 QL (60/30)enalapril maleate 2enalapril-hydrochlorothiazide 2ethacrynate sodium 4felodipine 2fosinopril 2fosinopril-hydrochlorothiazide 2furosemide 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 1 QL (30/30)irbesartan-hydrochlorothiazide 1 QL (30/30)

40



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

verapamil oral tablet 1verapamil oral tablet extended release

2

COAGULATION THERAPYaminocaproic acid oral 4BRILINTA 4 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 4clopidogrel oral tablet 75 mg 1 QL (30/30)dipyridamole oral 3ELIQUIS 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 2prasugrel 4PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA; LA; QL (360/30); NDS

PROMACTA ORAL POWDER IN PACKET 25 MG

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propranolol oral tablet 2propranolol-hydrochlorothiazid 3quinapril 1quinapril-hydrochlorothiazide 2ramipril 1spironolactone 2spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

3

telmisartan 2telmisartan-amlodipine 2telmisartan-hydrochlorothiazid 2terazosin oral capsule 1 mg, 2 mg, 5 mg

1 QL (30/30)

terazosin oral capsule 10 mg 1 QL (60/30)tiadylt er 3timolol maleate oral 4torsemide oral 2trandolapril 2triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 4 PA; LAvalsartan 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

41



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VASCEPA 3MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PAdigitek 3digox 3digoxin oral solution 50 mcg/ml (0.05 mg/ml)

3

digoxin oral tablet 3ENTRESTO 3 QL (60/30)LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG)

4

ranolazine 4 QL (60/30)VYNDAQEL 4 PANITRATESisosorbide 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 3 QL (120/30)calcipotriene topical cream 4 QL (120/30)calcipotriene topical ointment 4 QL (120/30)selenium sulfide topical lotion 2SKYRIZI 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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG

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

PROMACTA ORAL TABLET 75 MG

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

warfarin 1XARELTO 3XARELTO DVT-PE TREAT 30D START

3

LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin 1 QL (30/30)cholestyramine (with sugar) 4cholestyramine light 4colesevelam 4colestipol 4ezetimibe 3 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral tablet 160 mg, 54 mg

3

fluvastatin oral capsule 20 mg 4 QL (30/30)fluvastatin oral capsule 40 mg 4 QL (60/30)gemfibrozil 2lovastatin oral tablet 10 mg 1 QL (30/30)lovastatin oral tablet 20 mg 1 QL (60/30)lovastatin oral tablet 40 mg 2 QL (60/30)niacin oral tablet extended release 24 hr

4

pravastatin 1 QL (30/30)prevalite 3REPATHA 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)

42



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

silver sulfadiazine 3SSD 4tacrolimus topical 4 PA; QL (100/30)VALCHLOR 5 PA; NDSZTLIDO 4 PA; QL (90/30)THERAPY FOR ACNEavita 4 PAclaravis 4clindamycin phosphate topical gel

4 QL (120/30)

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

4 QL (120/30)

clindamycin phosphate topical lotion

4 QL (120/30)

clindamycin phosphate topical solution

4 QL (120/30)

clindamycin phosphate topical swab

3 QL (60/30)

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 topical cream 4 PATAZORAC TOPICAL CREAM 0.05%

4 PA

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

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

TALTZ SYRINGE 5 PA; QL (4/28); NDSMISCELLANEOUS DERMATOLOGICALSammonium lactate 2DUPIXENT PEN 5 PA; QL (8/28); NDSDUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML

5 PA; QL (4.56/28); NDS

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML

5 PA; QL (8/28); NDS

fluorouracil topical cream 5% 3fluorouracil topical solution 3glydo 3 QL (60/30)imiquimod topical cream in packet 5%

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 4podofilox 4REGRANEX 5 PA; NDSSANTYL 4

43



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

betamethasone 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)

CLODAN 4 QL (236/28)DESONATE 4desonide topical lotion 4desonide topical ointment 4desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

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

3

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 2 QL (44/30)mupirocin calcium 4 QL (30/30)sulfacetamide sodium (acne) 4TOPICAL ANTIFUNGALSciclodan topical solution 4ciclopirox topical cream 4 QL (90/28)ciclopirox topical shampoo 4 QL (120/28)ciclopirox topical solution 4ciclopirox topical suspension 4 QL (60/28)clotrimazole topical cream 2 QL (45/28)clotrimazole 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 ANTIVIRALSacyclovir topical ointment 4 QL (30/30)DENAVIR 4TOPICAL CORTICOSTEROIDSala-cort topical cream 1% 2alclometasone topical cream 3alclometasone topical ointment 2

44



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIAGNOSTICS / MISCELLANEOUS AGENTS

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

4 B/D PA

d10%-0.45% sodium chloride 4d2.5%-0.45% sodium chloride 4d5% and 0.9% sodium chloride 4d5%-0.45% sodium chloride 4deferasirox oral tablet, dispersible

5 PA; NDS

dextrose 10% and 0.2% nacl 4DEXTROSE 10% IN WATER (D10W)

4

dextrose 25% in water (d25w) 4dextrose 30% in water (d30w) 4dextrose 40% in water (d40w) 4DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

dextrose 5%-lactated ringers 4dextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4dextrose 70% in water (d70w) 4disulfiram 4INCRELEX 4 PA; LA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 QL (120/30)

hydrocortisone butyrate topical ointment

4

hydrocortisone butyr-emollient 4 QL (120/30)hydrocortisone topical cream 1%, 2.5%

2

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 4IMPOYZ 4 QL (120/28)mometasone topical 2prednicarbate topical ointment 2triamcinolone acetonide topical cream

2

triamcinolone acetonide topical lotion

3

triamcinolone acetonide topical ointment

2

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

45



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CHANTIX CONTINUING MONTH BOX

4

CHANTIX STARTING MONTH BOX

4

NICOTROL 4NICOTROL NS 4

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (60/30)chlorhexidine gluconate mucous membrane

2

ipratropium bromide nasal 2 QL (30/30)oralone 4paroex oral rinse 2triamcinolone acetonide dental 4MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 3flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 4OTIC STEROID / ANTIBIOTICCIPRODEX 3ciprofloxacin-dexamethasone 3neomycin-polymyxin-hc otic (ear)

4

ENDOCRINE/DIABETES

ADRENAL HORMONESdexamethasone intensol 4dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 2DEXAMETHASONE SODIUM PHOS (PF) INJECTION SOLUTION

4

dexamethasone sodium phosphate injection solution

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

kionex (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

pilocarpine hcl oral 4PROLASTIN-C INTRAVENOUS RECON SOLN

5 PA; LA; NDS

PROLASTIN-C INTRAVENOUS SOLUTION

5 B/D PA; LA; NDS

riluzole 3sevelamer carbonate oral powder in packet

5 NDS

sevelamer carbonate oral tablet 4sodium chloride 0.9% intravenous

4

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

4

sps (with sorbitol) 4trientine 5 PA; QL (240/30);

NDSVELTASSA 3water for irrigation, sterile 4XIAFLEX 4 PAzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (60/30)CHANTIX 4

46



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BD PEN NEEDLE 3 QL(200/30)BYDUREON BCISE 4 QL (4/28)CYCLOSET 4 QL (180/30)diazoxide 4GAUZE 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)

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 HYPOPEN 1-PACK 3GVOKE HYPOPEN 2-PACK 3GVOKE PFS 1-PACK SYRINGE

3

GVOKE PFS 2-PACK SYRINGE

3

HUMALOG JUNIOR KWIKPEN U-100

2

HUMALOG KWIKPEN INSULIN

2

HUMALOG MIX 50-50 INSULN U-100

2

HUMALOG MIX 50-50 KWIKPEN

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4

methylprednisolone sodium succ intravenous

4

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

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

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection suspension 40 mg/ml

4

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg 2 QL (90/30)acarbose oral tablet 25 mg 2 QL (360/30)acarbose oral tablet 50 mg 2 QL (180/30)ALCOHOL PADS 3BAQSIMI 3

47



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYUMJEV KWIKPEN U-200 INSULIN

3

LYUMJEV 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)

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)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)

3 QL (1.5/28)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML)

3 QL (3/28)

pioglitazone 2 QL (30/30)PROGLYCEM 4repaglinide oral tablet 0.5 mg 4 QL (960/30)repaglinide oral tablet 1 mg 4 QL (480/30)repaglinide oral tablet 2 mg 4 QL (240/30)RYBELSUS 3 QL (30/30)SOLIQUA 100/33 3 QL (15/30)SYNJARDY 3 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMALOG MIX 75-25 KWIKPEN

2

HUMALOG MIX 75-25(U-100)INSULN

2

HUMALOG U-100 INSULIN 2HUMULIN 70/30 U-100 INSULIN

2

HUMULIN 70/30 U-100 KWIKPEN

2

HUMULIN N NPH INSULIN KWIKPEN

2

HUMULIN N NPH U-100 INSULIN

2

HUMULIN R REGULAR U-100 INSULN

2

HUMULIN R U-500 (CONC) INSULIN

5 B/D PA; NDS

HUMULIN R U-500 (CONC) KWIKPEN

5 NDS

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

3 QL (200/30)

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

2

LANTUS U-100 INSULIN 2LEVEMIR FLEXTOUCH U-100 INSULN

2

LEVEMIR U-100 INSULIN 2LYUMJEV KWIKPEN U-100 INSULIN

3

48



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 4ELAPRASE 5 PA; NDSFABRAZYME 5 NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSmiglustat 5 LA; NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; LA; 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 4paricalcitol oral 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

sapropterin 5 PA; NDSSOMAVERT 5 PA; QL (30/30);

NDSSYNAREL 4testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml)

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

2

TOUJEO SOLOSTAR U-300 INSULIN

2

TRADJENTA 4 QL (30/30)TRESIBA FLEXTOUCH U-100 2TRESIBA FLEXTOUCH U-200 2TRESIBA U-100 INSULIN 2TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG

4 QL (30/30)

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG

4 QL (60/30)

TRULICITY 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 QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDScabergoline 4calcitonin (salmon) 3calcitriol intravenous solution 1 mcg/ml

4

calcitriol oral 2CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 PA; NDS

49



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GLYCOPYRROLATE (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 2MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron 5 PA; NDSaprepitant 4 B/D PAbalsalazide 4budesonide oral 4compro 4constulose 2CORTIFOAM 4CREON 3cromolyn oral 3CYSTADANE 5 NDSdronabinol 4 B/D PA; QL (60/30)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 2GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2gavilyte-n 2generlac 2granisetron hcl oral 4 B/D PA; QL (60/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

2

lactulose oral solution 2LINZESS 3 QL (30/30)meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule, extended release 24hr

3

mesalamine rectal enema 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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)

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

zoledronic acid intravenous solution

4 B/D PA

zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml

4 B/D PA

ZOLEDRONIC AC-MANNITOL-0.9NACL

4 B/D PA

THYROID HORMONESEUTHYROX 4LEVO-T 4levothyroxine oral tablet 1levoxyl 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 4UNITHROID 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 4

50



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trilyte with flavor packets 2ursodiol oral capsule 3ursodiol oral tablet 4VIOKACE 4ULCER THERAPYDEXILANT 4 QL (30/30)esomeprazole magnesium oral capsule,delayed release(dr/ec)

4

FAMOTIDINE ORAL SUSPENSION

4

famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule, delayed release(dr/ec)

3

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

2

pantoprazole oral tablet, delayed release (dr/ec) 20 mg

2

pantoprazole oral tablet, delayed release (dr/ec) 40 mg

2 QL (60/30)

sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

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

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK 5 PA; NDSINTRON A INJECTION RECON SOLN

5 B/D PA; NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 B/D PA; NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mesalamine with cleansing wipe

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2MOVANTIK 4 QL (30/30)OCALIVA 4 PA; LA; 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 4PLENVU 4prochlorperazine 4prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 4procto-pak 2proctosol hc topical 4proctozone-hc 4RECTIV 4RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

REMICADE 5 PA; NDSSANCUSO 5 NDSscopolamine base 4 QL (10/30)sulfasalazine 2SUPREP BOWEL PREP KIT 4SUTAB 4

51



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

3

MENQUADFI (PF) 3MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3PEDIARIX (PF) 3PEDVAX HIB (PF) 3PENTACEL (PF) INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 MCG/0.5ML

3

PROQUAD (PF) 3QUADRACEL (PF) 3RABAVERT (PF) 3RECOMBIVAX HB (PF) 3 B/D PAROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 4 QL (2/999)STAMARIL (PF) 4TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3VARIZIG INTRAMUSCULAR SOLUTION

4

YF-VAX (PF) 3ZOSTAVAX (PF) 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MOZOBIL 5 B/D PA; NDSNIVESTYM 5 PA; NDSPROCRIT 4 PARETACRIT 4 PAZARXIO 5 PA; NDSZIEXTENZO 4 PAVACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3

ATGAM 4 PABCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

fomepizole 5 NDSGAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 4HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

3

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HIBERIX (PF) 3HIZENTRA 4 B/D PAIMOVAX RABIES VACCINE (PF)

4

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3

52



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

5 PA; QL (3/180); NDS

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

5 PA; QL (2/180); NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (3/180); NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (3/180); NDS

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

5 PA; QL (4/28); NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML

5 PA; QL (3/28); 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 3 QL (30/30)ORENCIA CLICKJECT 5 PA; QL (4/28); NDSORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML

5 PA; QL (1.6/28); NDS

ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML

5 PA; QL (2.8/28); NDS

penicillamine 5 NDSRINVOQ 5 PA; QL (30/30);

NDSXELJANZ ORAL SOLUTION 5 PA; QL (300/30);

NDSXELJANZ ORAL TABLET 5 PA; QL (60/30);

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

NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral tablet 4 QL (120/30)febuxostat 4 STMITIGARE 3probenecid 3probenecid-colchicine 3OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

ibandronate oral 3 QL (1/30)PROLIA 4 QL (1/180)raloxifene 3 QL (30/30)TERIPARATIDE 5 PA; QL (2.4/28);

NDSTYMLOS 5 PA; QL (1.56/30);

NDSOTHER RHEUMATOLOGICALSBENLYSTA 5 PA; NDSDEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (16/28); NDS

ENBREL SUBCUTANEOUS SOLUTION

5 PA; QL (4/28); NDS

ENBREL SUBCUTANEOUS SYRINGE

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 (6/180); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (4/180); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

53



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vandazole 4ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 4alyacen 7/7/7 (28) 3amethia 3amethyst (28) 2apri 2aranelle (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) 4charlotte 24 fe 2chateal (28) 3chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINScamila 3deblitane 3dotti 4 QL (8/28)DUAVEE 4 PAerrin 3estradiol oral 3estradiol transdermal patch semiweekly

4 QL (8/28)

estradiol transdermal patch weekly

4 QL (4/28)

estradiol vaginal tablet 4estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

heather 3hydroxyprogesterone caproate 5 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

PREMARIN VAGINAL 3progesterone micronized 2sharobel 3yuvafem 4MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 4metronidazole vaginal 4terconazole 4tranexamic acid oral 3

54



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 (28) 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) 2larin 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 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cyred 3cyred eq 3dasetta 1/35 (28) 3dasetta 7/7/7 (28) 3daysee 3desog-e.estradiol/e.estradiol 4desogestrel-ethinyl estradiol 2drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 3emoquette 4enpresse 2enskyce 2estarylla 4ethynodiol diac-eth estradiol 4falmina (28) 2fayosim 2femynor 4gemmily 2gianvi (28) 2hailey 2hailey 24 fe 3hailey fe 1.5/30 (28) 2hailey fe 1/20 (28) 2iclevia 2introvale 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 4

55



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nymyo 2ocella 2orsythia 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) 3tarina 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-nymyo 2tri-previfem (28) 4tri-sprintec (28) 4trivora (28) 2tri-vylibra 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

loryna (28) 2low-ogestrel (28) 4lo-zumandimine (28) 2lutera (28) 3marlissa (28) 2melodetta 24 fe 4merzee 3mibelas 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

norethindrone-e.estradiol-iron oral capsule

3

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) 3nylia 7/7/7 (28) 2

56



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ofloxacin ophthalmic (eye) 2polycin 2polymyxin b sulf-trimethoprim 2tobramycin ophthalmic (eye) 2ANTIVIRALStrifluridine 4ZIRGAN 3BETA-BLOCKERScarteolol 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; NDSepinastine 4EYLEA 4 PAolopatadine ophthalmic (eye) 4OXERVATE 4 PA; QL (112/999)PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

3

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

2

sulfacetamide-prednisolone 2NON-STEROIDAL ANTI-INFLAMMATORY AGENTSdiclofenac sodium ophthalmic (eye)

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-vylibra lo 4TYBLUME 4tydemy 4velivet triphasic regimen (28) 2vestura (28) 2vienva 4viorele (28) 3volnea (28) 2vyfemla (28) 2vylibra 4wera (28) 3wymzya fe 2zarah 2zovia 1/35e (28) 2zovia 1-35 (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

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

2

gentamicin ophthalmic (eye) drops

3

moxifloxacin ophthalmic (eye) 3NATACYN 4neomycin-bacitracin-polymyxin 4neomycin-polymyxin-gramicidin 3neo-polycin 4

57



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

3

apraclonidine 4brimonidine ophthalmic (eye) drops 0.15%

4

brimonidine ophthalmic (eye) drops 0.2%

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 3 QL (30/30)diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector

3 QL (2/30)

epinephrine injection solution 1 mg/ml

4

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

NDSADVAIR DISKUS 3 QL (60/30)ADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair)

3 QL (17/30)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proventil)

3 QL (13.4/30)

albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 4brinzolamide 4COMBIGAN 3dorzolamide 2dorzolamide-timolol 3latanoprost 1LUMIGAN 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 4tobramycin-dexamethasone 3STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

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

4

58



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION

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 ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

KALYDECO ORAL TABLET 5 PA; QL (60/30); NDS

metaproterenol oral syrup 4montelukast oral granules in packet

3 QL (30/30)

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

2 QL (30/30)

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

ORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (112/28); NDS

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

PULMOZYME 5 B/D PA; QL (150/30); NDS

SEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

SYMDEKO 5 PA; QL (56/28); NDS

tadalafil (pulmonary arterial hypertension) oral tablet 20 mg

5 PA; QL (60/30); NDS

terbutaline 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

albuterol sulfate oral tablet extended release 12 hr

4

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

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

ANORO ELLIPTA 3 QL (60/30)ARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)BREO ELLIPTA 3 QL (60/30)budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

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

budesonide inhalation suspension for nebulization 1 mg/2 ml

4 B/D PA; QL (60/30)

CINRYZE 5 PA; NDSCOMBIVENT RESPIMAT 4 QL (8/30)cromolyn inhalation 2 B/D PADALIRESP 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)


3 QL (24/30)

59



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RENACIDIN 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 4MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4

magnesium sulfate in water 4magnesium sulfate injection 4NORMOSOL-R 4POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4

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

4

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

4

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

4

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l

4

potassium chloride in water intravenous piggyback

4

potassium chloride intravenous 4potassium chloride oral capsule, extended release

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

theophylline oral tablet extended release 12 hr 300 mg, 450 mg

2

theophylline oral tablet extended release 24 hr

2

TRELEGY ELLIPTA 3 QL (60/30)TRIKAFTA 5 PA; NDSVENTAVIS 4 PAVENTOLIN HFA 3 QL (36/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; LA; QL (6/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML

5 PA; LA; QL (4/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML

5 PA; LA; QL (1/28); NDS

zafirlukast 4 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSMYRBETRIQ 4oxybutynin chloride oral syrup 2oxybutynin chloride oral tablet 2oxybutynin chloride oral tablet extended release 24hr

3 QL (60/30)

solifenacin 4tolterodine oral tablet 4TOVIAZ 4 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2dutasteride 2finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)MISCELLANEOUS UROLOGICALSbethanechol chloride 3CYSTAGON 4 LAELMIRON 4K-PHOS ORIGINAL 4potassium citrate 4

60



May 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX 8%-D10W(SULFITE-FREE)

4 B/D PA


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 4freamine 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-R PH 7.4 4PERIKABIVEN 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 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 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 4POTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4

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

4

POTASSIUM CHLORIDE-D5-0.9%NACL

4

ringer’s intravenous 4sodium 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 4MISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 15% 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


4 B/D PA

CLINIMIX 6%-D5W (SULFITE-FREE)

4 B/D PA

61

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

May 2021

Aabacavir-lamivudine . . . . . . . . . . . . . . . 18abacavir-lamivudine-zidovudine . . . . 18abacavir oral solution . . . . . . . . . . . . . . 18abacavir oral tablet . . . . . . . . . . . . . . . . 18ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 18ABILIFY MAINTENA . . . . . . . . . . . . . . . 35abiraterone oral tablet 250 mg . . . . . . 24abiraterone oral tablet 500 mg . . . . . . 24ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 24acamprosate . . . . . . . . . . . . . . . . . . . . . . 44acarbose oral tablet 25 mg . . . . . . . . . 46acarbose oral tablet 50 mg . . . . . . . . . 46acarbose oral tablet 100 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 . . . . . . . . . . . . 33acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . . . . . 33acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . . . . . 33acetazolamide . . . . . . . . . . . . . . . . . . . . . 57acetazolamide sodium . . . . . . . . . . . . . 57acetic acid otic (ear) . . . . . . . . . . . . . . . 45acetylcysteine . . . . . . . . . . . . . . . . . . . . . 57acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 51ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 50acyclovir oral capsule . . . . . . . . . . . . . . 18acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 18acyclovir oral tablet . . . . . . . . . . . . . . . . 18acyclovir sodium intravenous solution . . . . . . . . . . . . . . . 18acyclovir topical ointment . . . . . . . . . . 43ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 51ADASUVE . . . . . . . . . . . . . . . . . . . . . . . . 35ADCETRIS . . . . . . . . . . . . . . . . . . . . . . . . 24

ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 57adriamycin intravenous recon soln 10 mg . . . . . . . . . . . . . . . . . . 24adriamycin intravenous solution . . . . 24adrucil intravenous solution 2.5 gram/50 ml . . . . . . . . . . . . 24ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 57ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 57AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG . . . . . . . . . 24AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG, 5 MG . . . 24AFINITOR ORAL TABLET 10 MG . . 24afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 53AIMOVIG AUTOINJECTOR . . . . . . . . 32ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 56ala-cort topical cream 1% . . . . . . . . . . 43albendazole . . . . . . . . . . . . . . . . . . . . . . . 21albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair) . . . . . . . . . . . . . . . . . 57albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proventil) . . . . . . . . . . . . . . 57albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 57albuterol sulfate oral syrup . . . . . . . . . 57albuterol sulfate oral tablet . . . . . . . . . 57albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 58alclometasone topical cream . . . . . . . 43alclometasone topical ointment . . . . . 43ALCOHOL PADS . . . . . . . . . . . . . . . . . . 46ALDURAZYME . . . . . . . . . . . . . . . . . . . . 48ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 24alendronate oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 52alendronate oral tablet 35 mg, 70 mg . . . . . . . . . . . . . . . . . . . . . 52alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 59ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ALINIA ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 21

ALINIA ORAL TABLET . . . . . . . . . . . . . 21ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 24allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 52alosetron . . . . . . . . . . . . . . . . . . . . . . . . . . 49ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 57alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 35alprazolam oral tablet 2 mg . . . . . . . . 35altavera (28) . . . . . . . . . . . . . . . . . . . . . . 53ALUNBRIG ORAL TABLET 30 MG . 24ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 24ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 24alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 53alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 53alyq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58amantadine hcl . . . . . . . . . . . . . . . . . . . . 18AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 18AMBRISENTAN . . . . . . . . . . . . . . . . . . . 58amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 53amethyst (28) . . . . . . . . . . . . . . . . . . . . . 53amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml . . . . . . . . 21amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 38amiloride-hydrochlorothiazide . . . . . . 38aminocaproic acid oral . . . . . . . . . . . . . 40AMINOSYN II 15% . . . . . . . . . . . . . . . . 60AMINOSYN-PF 7% (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60amiodarone intravenous solution . . . 38amiodarone oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 38amiodarone oral tablet 400 mg . . . . . 38amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 35amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 38amlodipine-benazepril . . . . . . . . . . . . . 38amlodipine-valsartan . . . . . . . . . . . . . . . 38amlodipine-valsartan-hcthiazid . . . . . 38ammonium lactate . . . . . . . . . . . . . . . . . 42

62


Covered Drugs Index

May 2021

azithromycin oral packet . . . . . . . . . . . 21azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 21azithromycin oral tablet . . . . . . . . . . . . 21AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 57aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 21azurette (28) . . . . . . . . . . . . . . . . . . . . . . 53

Bbacitracin intramuscular . . . . . . . . . . . . 21bacitracin ophthalmic (eye) . . . . . . . . . 56bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 56baclofen oral . . . . . . . . . . . . . . . . . . . . . . 33balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 49BALVERSA . . . . . . . . . . . . . . . . . . . . . . . 24balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 53BANZEL . . . . . . . . . . . . . . . . . . . . . . . . . . 30BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 46BARACLUDE ORAL SOLUTION . . . 18BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 24BCG VACCINE, LIVE (PF) . . . . . . . . . 51BD PEN NEEDLE . . . . . . . . . . . . . . . . . 46bekyree (28) . . . . . . . . . . . . . . . . . . . . . . 53BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 24benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 38benazepril-hydrochlorothiazide . . . . . 38BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 24BENLYSTA . . . . . . . . . . . . . . . . . . . . . . . . 52benztropine injection . . . . . . . . . . . . . . . 32benztropine oral . . . . . . . . . . . . . . . . . . . 32BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 56BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 24betamethasone, augmented topical cream . . . . . . . . . . 43betamethasone, augmented topical gel . . . . . . . . . . . . . 43betamethasone, augmented topical lotion . . . . . . . . . . . 43betamethasone, augmented topical ointment . . . . . . . . 43

ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 24arsenic trioxide intravenous solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 24ARZERRA . . . . . . . . . . . . . . . . . . . . . . . . 24asenapine maleate . . . . . . . . . . . . . . . . 35ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 53atazanavir oral capsule 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . 18atazanavir oral capsule 200 mg . . . . . 18atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38atenolol-chlorthalidone . . . . . . . . . . . . . 38ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 51atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 35atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 35atorvastatin . . . . . . . . . . . . . . . . . . . . . . . 41atovaquone . . . . . . . . . . . . . . . . . . . . . . . 21atovaquone-proguanil . . . . . . . . . . . . . . 21ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 18atropine ophthalmic (eye) drops . . . . 56ATROVENT HFA . . . . . . . . . . . . . . . . . . 58aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 53aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 53aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 53aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 53aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 53aurovela fe 1-20 (28) . . . . . . . . . . . . . . 53aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 24azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 24azathioprine . . . . . . . . . . . . . . . . . . . . . . . 24azathioprine sodium . . . . . . . . . . . . . . . 24azelastine nasal . . . . . . . . . . . . . . . . . . . 45azelastine ophthalmic (eye) . . . . . . . . 56azithromycin intravenous . . . . . . . . . . . 21

amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 35amoxicillin oral capsule . . . . . . . . . . . . 23amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23amoxicillin oral tablet . . . . . . . . . . . . . . 23amoxicillin oral tablet, chewable 125 mg, 250 mg . . . . . . . . . 23amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 23amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 23amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 23amoxicillin-pot clavulanate oral tablet extended release 12 hr . . . . . . . 23amphotericin b . . . . . . . . . . . . . . . . . . . . 18ampicillin oral capsule 500 mg . . . . . . 23ampicillin sodium . . . . . . . . . . . . . . . . . . 23ampicillin-sulbactam . . . . . . . . . . . . . . . 23anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 44anastrozole . . . . . . . . . . . . . . . . . . . . . . . 24ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 58APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 32apraclonidine . . . . . . . . . . . . . . . . . . . . . . 57aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 49apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53APTIOM ORAL TABLET 200 MG . . . 30APTIOM ORAL TABLET 400 MG . . . 30APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 30APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . 18APTIVUS (WITH VITAMIN E). . . . . . . 18aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 53ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 50ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 21aripiprazole oral solution . . . . . . . . . . . 35aripiprazole oral tablet . . . . . . . . . . . . . 35aripiprazole oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 35ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 58ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 24

63


Covered Drugs Index

May 2021

butorphanol nasal . . . . . . . . . . . . . . . . . 34BYDUREON BCISE . . . . . . . . . . . . . . . 46

CCABENUVA . . . . . . . . . . . . . . . . . . . . . . . 18cabergoline . . . . . . . . . . . . . . . . . . . . . . . 48CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . 25CABOMETYX ORAL TABLET 40 MG . . . . . . . . . . . . . . . . . . . 25calcipotriene scalp . . . . . . . . . . . . . . . . . 41calcipotriene topical cream . . . . . . . . . 41calcipotriene topical ointment . . . . . . . 41calcitonin (salmon) . . . . . . . . . . . . . . . . . 48calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 48calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 48calcium acetate(phosphat bind) . . . . . 59CALQUENCE . . . . . . . . . . . . . . . . . . . . . 25camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 53camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 53candesartan-hydrochlorothiazid . . . . 38candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 38candesartan oral tablet 32 mg . . . . . . 38CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . 21CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 35CAPRELSA ORAL TABLET 100 MG . 25CAPRELSA ORAL TABLET 300 MG . 25captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 38captopril-hydrochlorothiazide . . . . . . . 38CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 44carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 30carbamazepine oral suspension 100 mg/5 ml, 200 mg/10 ml . . . . . . . . 30carbamazepine oral tablet . . . . . . . . . . 30carbamazepine oral tablet, chewable . . . . . . . . . . . . . . . . . . . . . . . . . 30

brinzolamide . . . . . . . . . . . . . . . . . . . . . . 57BRIVIACT INTRAVENOUS . . . . . . . . . 30BRIVIACT ORAL SOLUTION . . . . . . . 30BRIVIACT ORAL TABLET . . . . . . . . . . 30bromocriptine . . . . . . . . . . . . . . . . . . . . . 32BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 25budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml . . . . . . . . . . . . . . . . . . . . . . . 58budesonide inhalation suspension for nebulization 1 mg/2 ml . . . . . . . . . . 58budesonide oral . . . . . . . . . . . . . . . . . . . 49bumetanide injection . . . . . . . . . . . . . . . 38bumetanide oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 38bumetanide oral tablet 2 mg . . . . . . . . 38buprenorphine hcl injection . . . . . . . . . 33buprenorphine hcl sublingual . . . . . . . 33buprenorphine-naloxone sublingual film 2-0.5 mg . . . . . . . . . . . . 34buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg . . . . . . 34buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 34buprenorphine-naloxone sublingual tablet 2-0.5 mg . . . . . . . . . . 34buprenorphine-naloxone sublingual tablet 8-2 mg . . . . . . . . . . . . 34bupropion hcl oral tablet 75 mg . . . . . 35bupropion hcl oral tablet 100 mg . . . . 35bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . 35bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . 35bupropion hcl oral tablet sustained-release 12 hr . . . . . . . . . . . . 35bupropion hcl (smoking deter) . . . . . . 45buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 35busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 25butalbital-acetaminophen-caff oral capsule . . . . . . . . . . . . . . . . . . . . . . . 33butalbital-acetaminophen-caff oral tablet 50-325-40 mg . . . . . . . . . . . 33

betamethasone dipropionate . . . . . . . 43betamethasone valerate topical cream . . . . . . . . . . . . . . . . . . . . . . 43betamethasone valerate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 43betamethasone valerate topical ointment . . . . . . . . . . . . . . . . . . . 43BETASERON SUBCUTANEOUS KIT . . . . . . . . . . . . . 50betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 38bethanechol chloride . . . . . . . . . . . . . . . 59bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 24BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 51bicalutamide . . . . . . . . . . . . . . . . . . . . . . 24BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 23BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 18bisoprolol fumarate . . . . . . . . . . . . . . . . 38bisoprolol-hydrochlorothiazide . . . . . . 38BLENREP . . . . . . . . . . . . . . . . . . . . . . . . 24bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 24BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 56BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 56BLINCYTO INTRAVENOUS KIT . . . . 24blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 53blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 53blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 53BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 51BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 24BOSULIF ORAL TABLET 100 MG . . 24BOSULIF ORAL TABLET 400 MG, 500 MG . . . . . . . . . . . . . . . . . . 24BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51BRAFTOVI ORAL CAPSULE 75 MG . . . . . . . . . . . . . . . . . 25BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 58briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 40brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 57brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 57

64


Covered Drugs Index

May 2021

chlorothiazide sodium . . . . . . . . . . . . . . 38chlorpromazine . . . . . . . . . . . . . . . . . . . . 35chlorthalidone 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 . . . . . . . . . . . . . . . . . . . . . . . . . . 18cinacalcet oral tablet 30 mg, 60 mg . 48cinacalcet oral tablet 90 mg . . . . . . . . 48CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 58CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 45ciprofloxacin-dexamethasone . . . . . . 45ciprofloxacin hcl ophthalmic (eye) . . . 56ciprofloxacin hcl oral tablet 100 mg . 23ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 23ciprofloxacin in 5% dextrose . . . . . . . . 23CIPRO ORAL SUSPENSION, MICROCAPSULE RECON . . . . . . . . . 23cisplatin intravenous solution . . . . . . . 25citalopram oral solution . . . . . . . . . . . . 35citalopram oral tablet . . . . . . . . . . . . . . 35cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 25claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 42clarithromycin . . . . . . . . . . . . . . . . . . . . . 21clindamycin hcl . . . . . . . . . . . . . . . . . . . . 21CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . 21clindamycin in 5% dextrose . . . . . . . . 21clindamycin pediatric . . . . . . . . . . . . . . 21clindamycin phosphate injection . . . . 21

CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . 20cefotetan injection . . . . . . . . . . . . . . . . . 20cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefoxitin in dextrose, iso-osm . . . . . . . 20cefpodoxime . . . . . . . . . . . . . . . . . . . . . . 20cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 21ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 21CEFTAZIDIME IN D5W . . . . . . . . . . . . 21ceftriaxone in dextrose,iso-os . . . . . . 21ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 21CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 21ceftriaxone intravenous . . . . . . . . . . . . 21cefuroxime axetil oral tablet . . . . . . . . 21cefuroxime sodium injection recon soln 750 mg . . . . . . . . . . . . . . . . . 21cefuroxime sodium intravenous . . . . . 21celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 34CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . 30cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 21cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 21CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 48CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 45CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 45CHANTIX STARTING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 45charlotte 24 fe . . . . . . . . . . . . . . . . . . . . . 53chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 53chateal eq (28) . . . . . . . . . . . . . . . . . . . . 53CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 44chloramphenicol sod succinate . . . . . 21chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 45chloroquine phosphate . . . . . . . . . . . . . 21

carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 30carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 32carbidopa-levodopa-entacapone . . . . 32carbidopa-levodopa oral tablet . . . . . 32carbidopa-levodopa oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 32carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . . . . . . . 32carboplatin intravenous solution . . . . 25carmustine . . . . . . . . . . . . . . . . . . . . . . . . 25carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 56cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 38carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 38caspofungin . . . . . . . . . . . . . . . . . . . . . . . 18CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 21caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 53cefaclor oral capsule . . . . . . . . . . . . . . . 20cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . 20cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . 20cefadroxil oral capsule . . . . . . . . . . . . . 20cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 20cefadroxil oral tablet . . . . . . . . . . . . . . . 20cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . 20CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . 20cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg . 20cefazolin intravenous . . . . . . . . . . . . . . 20cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20CEFEPIME IN DEXTROSE 5% . . . . . 20cefepime in dextrose,iso-osm . . . . . . 20cefepime injection . . . . . . . . . . . . . . . . . 20CEFEPIME INTRAVENOUS . . . . . . . 20cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

65


Covered Drugs Index

May 2021

COMPLERA . . . . . . . . . . . . . . . . . . . . . . 18compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 49constulose . . . . . . . . . . . . . . . . . . . . . . . . 49COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML . . . . . . . . . . . . . . 32COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML . . . . . . . . . . . . . . 32COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 25CORLANOR ORAL TABLET . . . . . . . 41CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . 49COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 25CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CRESEMBA ORAL . . . . . . . . . . . . . . . . 18CRIXIVAN ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 18cromolyn inhalation . . . . . . . . . . . . . . . . 58cromolyn ophthalmic (eye) . . . . . . . . . 56cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 49cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 53cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 53cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 53cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . 33cyclophosphamide intravenous recon soln . . . . . . . . . . . . . 25CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION . . . . . . . 25cyclophosphamide oral capsule . . . . 25CYCLOSERINE . . . . . . . . . . . . . . . . . . . 21CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 46cyclosporine intravenous . . . . . . . . . . . 25cyclosporine modified . . . . . . . . . . . . . . 25cyclosporine oral capsule . . . . . . . . . . 25CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 25cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 54CYSTADANE . . . . . . . . . . . . . . . . . . . . . 49CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 59CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 56cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 25cytarabine (pf) injection solution . . . . 25

clomipramine . . . . . . . . . . . . . . . . . . . . . . 35clonazepam oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 30clonazepam oral tablet 2 mg . . . . . . . 30clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 30clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 30clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . 39clonidine hcl oral tablet . . . . . . . . . . . . . 39clopidogrel oral tablet 75 mg . . . . . . . 40clopidogrel oral tablet 300 mg . . . . . . 40clorazepate dipotassium oral tablet 3.75 mg . . . . . . . . . . . . . . . . . 35clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 35clorazepate dipotassium oral tablet 15 mg . . . . . . . . . . . . . . . . . . 35clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 43clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 43clotrimazole mucous membrane . . . . 18clotrimazole topical cream . . . . . . . . . . 43clotrimazole topical solution . . . . . . . . 43clozapine oral tablet 25 mg, 50 mg . . 35clozapine oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 35clozapine oral tablet, disintegrating . 35COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 21colchicine oral tablet . . . . . . . . . . . . . . . 52colesevelam . . . . . . . . . . . . . . . . . . . . . . . 41colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 41colistin (colistimethate na) . . . . . . . . . . 21COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 57COMBIVENT RESPIMAT . . . . . . . . . . 58COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 25COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) . 25COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) . 25

clindamycin phosphate intravenous solution 600 mg/4 ml . . . 21clindamycin 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 6%-D5W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60CLINIMIX 8%-D10W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60CLINIMIX 8%-D14W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 60CLINIMIX E 4.25%/D10W SUL FREE . . . . . . . . . . . . . . . . . . . . . . . . 60CLINISOL SF 15% . . . . . . . . . . . . . . . . 60clobazam oral suspension . . . . . . . . . . 30clobazam oral tablet . . . . . . . . . . . . . . . 30clobetasol-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 . . . . . . . . . . . 43CLODAN . . . . . . . . . . . . . . . . . . . . . . . . . . 43clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 25

66


Covered Drugs Index

May 2021

dextrose 5%-0.3% sod.chloride . . . . . 44DEXTROSE 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) . . . . . . . . . . . . . . . . 44dextrose 25% in water (d25w) . . . . . . 44dextrose 30% in water (d30w) . . . . . . 44dextrose 40% in water (d40w) . . . . . . 44dextrose 50% in water (d50w) . . . . . . 44dextrose 70% in water (d70w) . . . . . . 44DIACOMIT ORAL CAPSULE 250 MG . . . . . . . . . . . . . . . . 30DIACOMIT ORAL CAPSULE 500 MG . . . . . . . . . . . . . . . . 30DIACOMIT ORAL POWDER IN PACKET 250 MG . . . . . . . . . . . . . . . 30DIACOMIT ORAL POWDER IN PACKET 500 MG . . . . . . . . . . . . . . . 30diazepam injection . . . . . . . . . . . . . . . . . 35diazepam intensol . . . . . . . . . . . . . . . . . 35diazepam oral concentrate . . . . . . . . . 35diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 36diazepam oral tablet . . . . . . . . . . . . . . . 36DIAZEPAM RECTAL . . . . . . . . . . . . . . . 30diazoxide . . . . . . . . . . . . . . . . . . . . . . . . . 46diclofenac potassium . . . . . . . . . . . . . . 34diclofenac sodium ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 56diclofenac sodium topical gel 1% . . . 34dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 23dicyclomine oral capsule . . . . . . . . . . . 49dicyclomine oral solution . . . . . . . . . . . 49dicyclomine oral tablet . . . . . . . . . . . . . 49didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg . . . . . 18

desmopressin 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 . . . . . . . . . . 43desoximetasone topical cream . . . . . 43desoximetasone topical gel . . . . . . . . 43desoximetasone topical ointment . . . 43desvenlafaxine succinate . . . . . . . . . . 35dexamethasone intensol . . . . . . . . . . . 45dexamethasone oral elixir . . . . . . . . . . 45dexamethasone oral solution . . . . . . . 45dexamethasone oral tablet . . . . . . . . . 45DEXAMETHASONE SODIUM PHOS (PF) INJECTION SOLUTION. . . . . . . . . . . . 45dexamethasone sodium phosphate injection solution . . . . . . . . 45dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 57DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 50dexmethylphenidate oral tablet . . . . . 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 . . . . . . . . . . . . . . . . . . 35dextroamphetamine oral tablet . . . . . 35dextrose 5%-0.2% sod chloride . . . . . 44

Dd2.5%-0.45% sodium chloride . . . . . . 44d5%-0.45% sodium chloride . . . . . . . . 44d5% and 0.9% sodium chloride . . . . . 44d10%-0.45% sodium chloride . . . . . . 44dacarbazine . . . . . . . . . . . . . . . . . . . . . . . 25dactinomycin . . . . . . . . . . . . . . . . . . . . . . 25dalfampridine . . . . . . . . . . . . . . . . . . . . . . 32DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 58danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 48dantrolene oral . . . . . . . . . . . . . . . . . . . . 33DANYELZA . . . . . . . . . . . . . . . . . . . . . . . 25dapsone oral . . . . . . . . . . . . . . . . . . . . . . 21DAPTACEL (DTAP PEDIATRIC) (PF) . . . . . . . . . . . 51DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 21daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 21DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 25DARZALEX FASPRO . . . . . . . . . . . . . . 25dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 54dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 54daunorubicin intravenous solution . . 25DAURISMO ORAL TABLET 25 MG . . 25DAURISMO ORAL TABLET 100 MG . 25daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 53decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 25deferasirox oral tablet, dispersible . . . . . . . . . . . . . . . . . . . . . . . . 44DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 18DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 39DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 43DEPEN TITRATABS . . . . . . . . . . . . . . . 52DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 18desipramine . . . . . . . . . . . . . . . . . . . . . . . 35desloratadine oral tablet . . . . . . . . . . . 57desmopressin injection . . . . . . . . . . . . . 48

67


Covered Drugs Index

May 2021

dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 49drospirenone-e.estradiol-lm.fa . . . . . . 54drospirenone-ethinyl estradiol . . . . . . 54DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 25DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 53duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg, 60 mg . . . . . . . . . . . . . . 36DUPIXENT PEN . . . . . . . . . . . . . . . . . . . 42DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML . . . . . . . . . . . . . . . . . . 42DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML . . . . . . . . . . . . . . . . . . . . . 42dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 59

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 34econazole . . . . . . . . . . . . . . . . . . . . . . . . . 43EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 18efavirenz-emtricitabin-tenofov . . . . . . 18efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg . . . . . . . . . 18efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg . . . . . . . . . 18efavirenz oral capsule 50 mg . . . . . . . 18efavirenz oral capsule 200 mg . . . . . . 18efavirenz oral tablet . . . . . . . . . . . . . . . . 18ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 48electrolyte-48 in d5w . . . . . . . . . . . . . . . 60elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 40ELIQUIS DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 40ELLENCE . . . . . . . . . . . . . . . . . . . . . . . . . 25ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 59ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 25EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 25EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 49emoquette . . . . . . . . . . . . . . . . . . . . . . . . 54

docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/ 8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) . . . . . . . . . . . . . 25dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 38donepezil oral tablet 5 mg . . . . . . . . . . 32donepezil oral tablet 10 mg . . . . . . . . . 32donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 32donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 32dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 57dorzolamide-timolol . . . . . . . . . . . . . . . . 57dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 18doxazosin oral tablet 1 mg, 2 mg, 4 mg . . . . . . . . . . . . . . . . . . 39doxazosin oral tablet 8 mg . . . . . . . . . 39doxepin oral capsule . . . . . . . . . . . . . . . 36doxepin oral concentrate . . . . . . . . . . . 36doxercalciferol . . . . . . . . . . . . . . . . . . . . . 48doxorubicin intravenous recon soln 50 mg . . . . . . . . . . . . . . . . . . 25doxorubicin intravenous solution . . . . 25doxorubicin, peg-liposomal . . . . . . . . . 25doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 23doxycycline hyclate intravenous . . . . 23doxycycline hyclate oral capsule . . . . 23doxycycline hyclate oral tablet 100 mg, 20 mg . . . . . . . . . . 23doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . 23doxycycline monohydrate oral suspension for reconstitution . . . . . . . 23doxycycline monohydrate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 23DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG . 36DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG . . . . . . . . . . . . . . . . . 36

DIFICID ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 21DIFICID ORAL TABLET . . . . . . . . . . . . 21diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 34digitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41digox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41digoxin oral solution 50 mcg/ml (0.05 mg/ml) . . . . . . . . . . . . 41digoxin oral tablet . . . . . . . . . . . . . . . . . . 41dihydroergotamine nasal . . . . . . . . . . . 32DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 30diltiazem hcl intravenous . . . . . . . . . . . 39diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 39diltiazem 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 . . 39diltiazem hcl oral capsule, ext.rel 24h degradable . . . . . . . . . . . . . 39diltiazem hcl oral tablet . . . . . . . . . . . . . 39diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 39dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg . . . . . 32dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg (14)- 240 mg (46) . . . . . . . . . . . . . . . . . . 32dimethyl fumarate oral capsule, delayed release(dr/ec) 240 mg . . . . . 32diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . . . . . . . . . . 57diphenoxylate-atropine . . . . . . . . . . . . . 49dipyridamole oral . . . . . . . . . . . . . . . . . . 40disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 44divalproex oral capsule, delayed rel sprinkle . . . . . . . . . . . . . . . . 30divalproex oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 31divalproex oral tablet extended release 24 hr . . . . . . . . . . . . 31

68


Covered Drugs Index

May 2021

ethosuximide . . . . . . . . . . . . . . . . . . . . . . 31ethynodiol diac-eth estradiol . . . . . . . . 54etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 34ETOPOPHOS . . . . . . . . . . . . . . . . . . . . . 26etoposide intravenous . . . . . . . . . . . . . 26EUTHYROX . . . . . . . . . . . . . . . . . . . . . . . 49everolimus (antineoplastic) . . . . . . . . . 26everolimus (immunosuppressive) oral tablet 0.5 mg . . . . . . . . . . . . . . . . . . 26everolimus (immunosuppressive) oral tablet 0.25 mg, 0.75 mg . . . . . . . . 26EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 26EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 19exemestane . . . . . . . . . . . . . . . . . . . . . . . 26EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 41ezetimibe-simvastatin . . . . . . . . . . . . . . 41

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 48falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 54famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 19FAMOTIDINE ORAL SUSPENSION . . . . . . . . . . . . . . . . . . . . 50famotidine oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 50FANAPT ORAL TABLET . . . . . . . . . . . 36FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 36FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 26fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 54febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 52felbamate . . . . . . . . . . . . . . . . . . . . . . . . . 31felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 39femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 54fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 41fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 41fenofibrate oral tablet 160 mg, 54 mg . . . . . . . . . . . . . . . . . . . . 41

ergotamine-caffeine . . . . . . . . . . . . . . . 32ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 25ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 25erlotinib oral tablet 25 mg . . . . . . . . . . 26erlotinib oral tablet 100 mg, 150 mg . . 25errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 21ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 26ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 42erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 21ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 21erythromycin-benzoyl peroxide . . . . . 42erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . 21erythromycin ophthalmic (eye) . . . . . . 56erythromycin oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 21erythromycin oral tablet . . . . . . . . . . . . 21erythromycin 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 . . 36escitalopram oxalate oral tablet . . . . . 36esomeprazole 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 . . . . . . . . . . . . . . . . . . . . . . . . 21

EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 25EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 36emtricitabine . . . . . . . . . . . . . . . . . . . . . . 18emtricitabine-tenofovir (tdf) . . . . . . . . . 18EMTRIVA ORAL CAPSULE . . . . . . . . 18EMTRIVA ORAL SOLUTION . . . . . . . 19EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 21enalapril-hydrochlorothiazide . . . . . . . 39enalapril maleate . . . . . . . . . . . . . . . . . . 39ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 52ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 52ENBREL SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 52ENBREL SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 52ENBREL SURECLICK . . . . . . . . . . . . . 52endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg . 33ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE . . . . . . 51ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 51ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 25enoxaparin . . . . . . . . . . . . . . . . . . . . . . . . 40enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 54enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 54entacapone . . . . . . . . . . . . . . . . . . . . . . . 32entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 19ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 41enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 49EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 19EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 31epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 56epinephrine injection auto-injector . . 57epinephrine injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 57epirubicin intravenous solution . . . . . 25epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31EPIVIR HBV ORAL SOLUTION . . . . 19ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 25

69


Covered Drugs Index

May 2021

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 40fosamprenavir . . . . . . . . . . . . . . . . . . . . . 19fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 39fosinopril-hydrochlorothiazide . . . . . . 39fosphenytoin . . . . . . . . . . . . . . . . . . . . . . 31freamine iii 10% . . . . . . . . . . . . . . . . . . . 60fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 26furosemide injection . . . . . . . . . . . . . . . 39furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 39furosemide oral tablet . . . . . . . . . . . . . . 39FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 19FYCOMPA ORAL SUSPENSION . . . 31FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 31FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 31

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 31gabapentin oral capsule 300 mg . . . . 31gabapentin oral solution . . . . . . . . . . . . 31gabapentin oral tablet 600 mg . . . . . . 31gabapentin oral tablet 800 mg . . . . . . 31galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 32galantamine oral solution . . . . . . . . . . . 32galantamine oral tablet . . . . . . . . . . . . . 32GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 51GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 51GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 49GATTEX ONE-VIAL . . . . . . . . . . . . . . . 49GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 46gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 49gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 49GAVRETO . . . . . . . . . . . . . . . . . . . . . . . . 26GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 26

fluocinolone . . . . . . . . . . . . . . . . . . . . . . . 43fluocinolone acetonide oil . . . . . . . . . . 45fluocinolone and shower cap . . . . . . . 43fluocinonide topical cream 0.05% . . . 43fluocinonide 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 intravenous . . . . . . . . . . . . 26fluorouracil topical cream 5% . . . . . . . 42fluorouracil topical solution . . . . . . . . . 42fluoxetine oral capsule 10 mg . . . . . . 36fluoxetine oral capsule 20 mg . . . . . . 36fluoxetine oral capsule 40 mg . . . . . . 36fluoxetine oral solution . . . . . . . . . . . . . 36fluphenazine decanoate . . . . . . . . . . . . 36fluphenazine hcl injection . . . . . . . . . . 36fluphenazine hcl oral concentrate . . . 36fluphenazine hcl oral elixir . . . . . . . . . . 36fluphenazine hcl oral tablet . . . . . . . . . 36flurbiprofen oral tablet 100 mg . . . . . . 34flurbiprofen sodium . . . . . . . . . . . . . . . . 57flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 26fluticasone propionate nasal . . . . . . . . 58fluticasone propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 44fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 44fluvastatin oral capsule 20 mg . . . . . . 41fluvastatin oral capsule 40 mg . . . . . . 41fluvoxamine oral tablet 25 mg . . . . . . 36fluvoxamine oral tablet 50 mg . . . . . . 36fluvoxamine oral tablet 100 mg . . . . . 36FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 26fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 51fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 40

fentanyl citrate buccal lozenge on a handle . . . . . . . . . . . . . . . 33fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr . . . . 33FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 36FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK. . . . . . . 36finasteride oral tablet 5 mg . . . . . . . . . 59FINTEPLA . . . . . . . . . . . . . . . . . . . . . . . . 31FIRMAGON KIT W DILUENT SYRINGE . . . . . . . . . . . . 26FIRVANQ ORAL RECON SOLN 25 MG/ML . . . . . . . . . . 22FIRVANQ ORAL RECON SOLN 50 MG/ML . . . . . . . . . . 22flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 45flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 38FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . . . . . . . . . . . . . . 58FLOVENT 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 . . 58floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . 26fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . 18fluconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 18fluconazole oral tablet . . . . . . . . . . . . . . 18flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 18fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 26fludrocortisone . . . . . . . . . . . . . . . . . . . . 46flunisolide nasal spray, non-aerosol 25 mcg (0.025%) . . . . . . 58

70


Covered Drugs Index

May 2021

HARVONI ORAL TABLET 45-200 MG . . . . . . . . . . . . . . . 19HARVONI ORAL TABLET 90-400 MG . . . . . . . . . . . . . . . 19HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML . . . . . . . . . . . . . 51HAVRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 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% . . . . . . . . . . . . . . . . . 60HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 36HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 51HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . . 51HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 46HUMALOG KWIKPEN INSULIN . . . . 46HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 46HUMALOG MIX 50-50 KWIKPEN. . . 46HUMALOG 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 . . . . . . . . . . . . . . . . . . . . . 52

glipizide oral tablet extended release 24hr 5 mg . . . . . . . . 46glipizide oral tablet extended release 24hr 10 mg . . . . . . 46GLUCAGEN HYPOKIT . . . . . . . . . . . . 46GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 46GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 46glycopyrrolate oral . . . . . . . . . . . . . . . . . 49GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 49glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . 49glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42granisetron hcl oral . . . . . . . . . . . . . . . . 49griseofulvin microsize . . . . . . . . . . . . . . 18griseofulvin ultramicrosize . . . . . . . . . . 18GVOKE HYPOPEN 1-PACK . . . . . . . 46GVOKE HYPOPEN 2-PACK . . . . . . . 46GVOKE PFS 1-PACK SYRINGE. . . . 46GVOKE PFS 2-PACK SYRINGE. . . . 46

Hhailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 54hailey fe 1.5/30 (28) . . . . . . . . . . . . . . . 54hailey fe 1/20 (28) . . . . . . . . . . . . . . . . . 54HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 26halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 44halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 44haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 36haloperidol decanoate . . . . . . . . . . . . . 36haloperidol lactate injection . . . . . . . . 36haloperidol lactate oral . . . . . . . . . . . . . 36HARVONI ORAL PELLETS IN PACKET 33.75-150 MG . . . . . . . . . 19HARVONI ORAL PELLETS IN PACKET 45-200 MG . . . . . . . . . . . . 19

gemcitabine intravenous recon soln . 26gemcitabine 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) . . . . . . . . . 26GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 26gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 41gemmily . . . . . . . . . . . . . . . . . . . . . . . . . . 54generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 49gengraf oral capsule 100 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 26gengraf oral solution . . . . . . . . . . . . . . . 26GENOTROPIN . . . . . . . . . . . . . . . . . . . . 50GENOTROPIN MINIQUICK . . . . . . . . 50gentak ophthalmic (eye) ointment . . . 56gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . 22GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 22gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 22gentamicin ophthalmic (eye) drops . . 56gentamicin sulfate (ped) (pf) . . . . . . . . 22gentamicin topical cream . . . . . . . . . . . 43gentamicin topical ointment . . . . . . . . 43GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 19gianvi (28) . . . . . . . . . . . . . . . . . . . . . . . . 54GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 26glimepiride 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 . . . 46glipizide oral tablet 5 mg . . . . . . . . . . . 46glipizide oral tablet 10 mg . . . . . . . . . . 46glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 46

71


Covered Drugs Index

May 2021

imatinib oral tablet 400 mg . . . . . . . . . 26IMBRUVICA ORAL CAPSULE 70 MG . . . . . . . . . . . . . . . . . 26IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . 26IMBRUVICA ORAL TABLET . . . . . . . . 26IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 26imipenem-cilastatin . . . . . . . . . . . . . . . . 22imipramine hcl . . . . . . . . . . . . . . . . . . . . . 36imiquimod topical cream in packet 5% . . . . . . . . . . . . . . . . . . . . . . 42IMOVAX RABIES VACCINE (PF) . . . 51IMPOYZ . . . . . . . . . . . . . . . . . . . . . . . . . . 44incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 53INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 44INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 58indapamide . . . . . . . . . . . . . . . . . . . . . . . 39INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION . . . . . . . . . . . . . . . . . . . . 51INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 26INFUMORPH P/F. . . . . . . . . . . . . . . . . . 33INLYTA ORAL TABLET 1 MG . . . . . . . 26INLYTA ORAL TABLET 5 MG . . . . . . . 26INQOVI . . . . . . . . . . . . . . . . . . . . . . . . . . . 26INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 26INSULIN PEN NEEDLE . . . . . . . . . . . . 47INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 47INTELENCE ORAL TABLET 25 MG . . . . . . . . . . . . . . . . . . . 19INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . 19INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 60INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 50INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . 50INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . 50introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 54

hydrocodone-ibuprofen oral tablet 7.5-200 mg . . . . . . . . . . . . . . 33hydrocortisone-acetic acid . . . . . . . . . 45hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 44hydrocortisone butyr-emollient . . . . . . 44hydrocortisone oral . . . . . . . . . . . . . . . . 46hydrocortisone rectal . . . . . . . . . . . . . . 49hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 49hydrocortisone topical lotion 2.5% . . 44hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 44hydrocortisone valerate . . . . . . . . . . . . 44hydromorphone oral liquid . . . . . . . . . . 33hydromorphone oral tablet . . . . . . . . . 33hydroxychloroquine . . . . . . . . . . . . . . . . 22hydroxyprogesterone caproate . . . . . 53hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 26hydroxyzine hcl oral tablet . . . . . . . . . . 57

Iibandronate oral . . . . . . . . . . . . . . . . . . . 52IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 26ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ibuprofen oral suspension . . . . . . . . . . 34ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 34icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 58iclevia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG . . . . . . . . . . . . . 26ICLUSIG ORAL TABLET 15 MG . . . . 26idarubicin . . . . . . . . . . . . . . . . . . . . . . . . . 26IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . 26imatinib oral tablet 100 mg . . . . . . . . . 26

HUMIRA(CF) PEN CROHNS-UC-HS . . . . . . . . . . . . . . . . . . 52HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 52HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . . . . . . . . . . . . 52HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML . . . . . . 52HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 52HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 52HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 52HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 52HUMULIN 70/30 U-100 INSULIN . . . 47HUMULIN 70/30 U-100 KWIKPEN . . 47HUMULIN 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 . . . . . . . . . . 33hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 33hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . 33

72


Covered Drugs Index

May 2021

KALETRA ORAL TABLET 100-25 MG . . . . . . . . . . . . . . . 19KALETRA ORAL TABLET 200-50 MG . . . . . . . . . . . . . . . 19kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KALYDECO ORAL GRANULES IN PACKET . . . . . . . . . . . 58KALYDECO ORAL TABLET . . . . . . . . 58KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 27kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 54kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 54kelnor 1-50 (28) . . . . . . . . . . . . . . . . . . . 54ketoconazole oral . . . . . . . . . . . . . . . . . . 18ketoconazole topical cream . . . . . . . . 43ketoconazole topical shampoo . . . . . 43ketorolac ophthalmic (eye) . . . . . . . . . 57KEYTRUDA INTRAVENOUS SOLUTION . . . . . . . 27KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . 51kionex (with sorbitol) . . . . . . . . . . . . . . . 45KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 27KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 27KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) . . . . . . . . 27KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) . . . . . . . . 27klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 59KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 59KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 59klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 59klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 59KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 48K-PHOS ORIGINAL . . . . . . . . . . . . . . . 59

isoniazid oral tablet . . . . . . . . . . . . . . . . 22isosorbide dinitrate oral tablet . . . . . . 41isosorbide mononitrate . . . . . . . . . . . . . 41isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 42isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 39itraconazole oral capsule . . . . . . . . . . . 18itraconazole oral solution . . . . . . . . . . . 18ivermectin oral . . . . . . . . . . . . . . . . . . . . 22IXEMPRA . . . . . . . . . . . . . . . . . . . . . . . . . 26IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 51

Jjaimiess . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 26jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 40JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . 53JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 26jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 19junel 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 . . . . . . . . . . . . . . . . . . . . . . . . 26kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

INVEGA 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 . . . . . . . . 36INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML . . . . . . . 36INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 57INVIRASE ORAL TABLET . . . . . . . . . 19IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ipratropium-albuterol . . . . . . . . . . . . . . . 58ipratropium bromide inhalation . . . . . 58ipratropium bromide nasal . . . . . . . . . . 45irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 39irbesartan-hydrochlorothiazide . . . . . 39IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 26irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 26ISENTRESS HD . . . . . . . . . . . . . . . . . . . 19ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . 19ISENTRESS ORAL TABLET . . . . . . . 19ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . 19ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . 19isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 54isoniazid oral solution . . . . . . . . . . . . . . 22

73


Covered Drugs Index

May 2021

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month . . . . . 54levonorg-eth estrad triphasic . . . . . . . 54levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 54LEVO-T . . . . . . . . . . . . . . . . . . . . . . . . . . . 49levothyroxine oral tablet . . . . . . . . . . . . 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 . . . . . . 19LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 27lidocaine 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 . . . 42lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 42lidocaine topical ointment . . . . . . . . . . 42lidocaine viscous . . . . . . . . . . . . . . . . . . 42lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 54lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 22lindane topical shampoo . . . . . . . . . . . 44linezolid-0.9% sodium chloride . . . . . 22linezolid in dextrose 5% . . . . . . . . . . . . 22linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 22linezolid oral tablet . . . . . . . . . . . . . . . . . 22LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 49liothyronine oral . . . . . . . . . . . . . . . . . . . 49lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 39lisinopril-hydrochlorothiazide . . . . . . . 39lithium carbonate . . . . . . . . . . . . . . . . . . 36

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) . . . . . . . . . . . . . 27LENVIMA 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) . . . . . . . . . . . . . 27lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 27leucovorin calcium injection . . . . . . . . 24leucovorin calcium oral tablet 5 mg . 24leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg . . . . . . . . . . . . . . 24LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 27leuprolide subcutaneous kit . . . . . . . . 27LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 47LEVEMIR U-100 INSULIN . . . . . . . . . 47levetiracetam in nacl (iso-os) . . . . . . . 31levetiracetam intravenous . . . . . . . . . . 31levetiracetam oral solution . . . . . . . . . 31levetiracetam oral tablet . . . . . . . . . . . . 31levetiracetam oral tablet extended release 24 hr . . . . . . . . . . . . 31levobunolol 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 . . . . . . . . . . . . . . . . 23levofloxacin intravenous . . . . . . . . . . . 23levofloxacin oral solution . . . . . . . . . . . 23levofloxacin oral tablet . . . . . . . . . . . . . 23levonest (28) . . . . . . . . . . . . . . . . . . . . . . 54levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 90-20 mcg (28) . . . . . . . . . . . . . . . . . . . . 54levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg . . . . . . . . . . . . 54

kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 54KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 27

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 39lactated ringers intravenous . . . . . . . . 59lactated ringers irrigation . . . . . . . . . . . 44lactulose oral solution . . . . . . . . . . . . . . 49lamivudine oral solution . . . . . . . . . . . . 19lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . 19lamivudine oral tablet 150 mg . . . . . . 19lamivudine-zidovudine . . . . . . . . . . . . . 19lamotrigine oral tablet . . . . . . . . . . . . . . 31lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 31LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG) . . . . . . . . . . . . 41lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 50LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 47LANTUS U-100 INSULIN . . . . . . . . . . 47lapatinib . . . . . . . . . . . . . . . . . . . . . . . . . . 27larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 54larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 54larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 54larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 54larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 54larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 57LATUDA ORAL TABLET 80 MG . . . . 36LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 36layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 54leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 54leflunomide . . . . . . . . . . . . . . . . . . . . . . . 52LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 27

74


Covered Drugs Index

May 2021

MEKINIST ORAL TABLET 0.5 MG . . 27MEKINIST ORAL TABLET 2 MG . . . . 27MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 27melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 55meloxicam oral tablet 7.5 mg . . . . . . . 34meloxicam oral tablet 15 mg . . . . . . . . 34melphalan hcl . . . . . . . . . . . . . . . . . . . . . 27memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 32memantine oral solution . . . . . . . . . . . . 32memantine oral tablet 5 mg . . . . . . . . 32memantine oral tablet 10 mg . . . . . . . 32memantine oral tablets,dose pack . . 33MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 51MENQUADFI (PF) . . . . . . . . . . . . . . . . . 51MENVEO A-C-Y-W-135-DIP (PF) . . . 51mercaptopurine . . . . . . . . . . . . . . . . . . . . 27meropenem . . . . . . . . . . . . . . . . . . . . . . . 22MEROPENEM-0.9% SODIUM CHLORIDE . . . . . . . . . . . . . . 22merzee . . . . . . . . . . . . . . . . . . . . . . . . . . . 55mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 49mesalamine rectal enema . . . . . . . . . . 49mesalamine with cleansing wipe . . . . 50mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MESNEX ORAL . . . . . . . . . . . . . . . . . . . 24metaproterenol oral syrup . . . . . . . . . . 58metformin oral tablet 1,000 mg . . . . . 47metformin oral tablet 500 mg . . . . . . . 47metformin oral tablet 850 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) . . . . . . . . . 47methadone injection solution . . . . . . . 33methadone intensol . . . . . . . . . . . . . . . . 33methadone oral concentrate . . . . . . . . 33methadone oral solution 5 mg/5 ml . 33

LUPRON DEPOT (3 MONTH) . . . . . . 27LUPRON DEPOT (4 MONTH) . . . . . . 27LUPRON DEPOT (6 MONTH) . . . . . . 27LUPRON DEPOT-PED . . . . . . . . . . . . 27LUPRON DEPOT-PED (3 MONTH) . 27lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 55LYNPARZA ORAL TABLET . . . . . . . . . 27LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 27LYUMJEV KWIKPEN U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 47LYUMJEV KWIKPEN U-200 INSULIN . . . . . . . . . . . . . . . . . . . . 47LYUMJEV U-100 INSULIN . . . . . . . . . 47lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53mafenide acetate . . . . . . . . . . . . . . . . . . 43

MMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . 59magnesium sulfate injection . . . . . . . . 59magnesium sulfate in water . . . . . . . . 59malathion . . . . . . . . . . . . . . . . . . . . . . . . . 44maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 37marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 55MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 37MARQIBO . . . . . . . . . . . . . . . . . . . . . . . . 27MATULANE . . . . . . . . . . . . . . . . . . . . . . . 27matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 39MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . 19meclizine oral tablet 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 49medroxyprogesterone intramuscular . . . . . . . . . . . . . . . . . . . . . . 53medroxyprogesterone oral . . . . . . . . . 53mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 22megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 27megestrol oral tablet 20 mg . . . . . . . . 27megestrol oral tablet 40 mg . . . . . . . . 27

l 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 . . . . . . . . . . . . . . . . . . . . . . . . . 54LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . 27LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . 27loperamide oral capsule . . . . . . . . . . . . 49lopinavir-ritonavir . . . . . . . . . . . . . . . . . . 19lorazepam injection . . . . . . . . . . . . . . . . 36lorazepam intensol . . . . . . . . . . . . . . . . 36lorazepam oral concentrate . . . . . . . . 36lorazepam oral tablet 0.5 mg, 1 mg . 37lorazepam oral tablet 2 mg . . . . . . . . . 37LORBRENA ORAL TABLET 25 MG . 27LORBRENA ORAL TABLET 100 MG . 27loryna (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 . . . . . . . . . 41lovastatin oral tablet 20 mg . . . . . . . . . 41lovastatin oral tablet 40 mg . . . . . . . . . 41low-ogestrel (28) . . . . . . . . . . . . . . . . . . 55loxapine succinate . . . . . . . . . . . . . . . . . 37lo-zumandimine (28) . . . . . . . . . . . . . . . 55LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 57LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 48LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 27LUPRON DEPOT . . . . . . . . . . . . . . . . . 27

75


Covered Drugs Index

May 2021

morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . 34morphine intravenous syringe 2 mg/ml, 4 mg/ml . . . . . . . . . . 34MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML . . . . 34morphine oral solution . . . . . . . . . . . . . 34MORPHINE ORAL TABLET . . . . . . . . 34morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 34morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . 34MOVANTIK . . . . . . . . . . . . . . . . . . . . . . . 50moxifloxacin ophthalmic (eye) . . . . . . 56moxifloxacin oral . . . . . . . . . . . . . . . . . . 23MOXIFLOXACIN-SOD. ACE, SUL-WATER . . . . . . . . . . . . . . . . 23moxifloxacin-sod.chloride(iso) . . . . . . 23MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 51mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 43mupirocin calcium . . . . . . . . . . . . . . . . . 43MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27mycophenolate mofetil (hcl) . . . . . . . . 27mycophenolate mofetil oral capsule . . 27mycophenolate mofetil oral suspension for reconstitution . . . . . . . 28mycophenolate mofetil oral tablet . . . 28mycophenolate sodium . . . . . . . . . . . . 28MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 28MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 59

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 34nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 39nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . 23nafcillin in dextrose iso-osm . . . . . . . . 23NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 48naloxone injection solution . . . . . . . . . 34naloxone injection syringe 1 mg/ml . 34

microgestin 1.5/30 (21) . . . . . . . . . . . . 55microgestin 1/20 (21) . . . . . . . . . . . . . . 55microgestin fe 1.5/30 (28) . . . . . . . . . . 55microgestin fe 1/20 (28) . . . . . . . . . . . . 55midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 45miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 48mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 41minocycline oral capsule . . . . . . . . . . . 23minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 39mirtazapine oral tablet . . . . . . . . . . . . . 37MIRTAZAPINE ORAL TABLET, DISINTEGRATING . . . . . . . 37misoprostol . . . . . . . . . . . . . . . . . . . . . . . 50MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 52mitomycin intravenous . . . . . . . . . . . . . 27mitoxantrone . . . . . . . . . . . . . . . . . . . . . . 27M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 51modafinil oral tablet 100 mg . . . . . . . . 37modafinil oral tablet 200 mg . . . . . . . . 37moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 39molindone . . . . . . . . . . . . . . . . . . . . . . . . . 37mometasone topical . . . . . . . . . . . . . . . 44MONJUVI . . . . . . . . . . . . . . . . . . . . . . . . . 27mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 55montelukast oral granules in packet . . . . . . . . . . . . . . . . . . . . . . . . . . 58montelukast oral tablet . . . . . . . . . . . . . 58montelukast oral tablet, chewable . . 58morgidox oral capsule 100 mg . . . . . . 23morphine concentrate oral solution . 34morphine injection solution 8 mg/ml . . . . . . . . . . . . . . . . . . . 34MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML . . . . . 34MORPHINE INJECTION SYRINGE 2 MG/ML . . . . . . . . . . . . . . . 34morphine injection syringe 4 mg/ml, 5 mg/ml . . . . . . . . . . . . . . . . . . 34MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML . . . . 34

methadone oral solution 10 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 33methadone oral tablet 5 mg . . . . . . . . 33methadone oral tablet 10 mg . . . . . . . 33methazolamide . . . . . . . . . . . . . . . . . . . . 57methenamine hippurate . . . . . . . . . . . . 24methimazole oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 46methocarbamol oral . . . . . . . . . . . . . . . 33methotrexate sodium injection . . . . . . 27methotrexate sodium oral . . . . . . . . . . 27methotrexate sodium (pf) . . . . . . . . . . . 27methoxsalen . . . . . . . . . . . . . . . . . . . . . . 42methyldopa . . . . . . . . . . . . . . . . . . . . . . . 39methylphenidate hcl oral tablet . . . . . 37methylphenidate hcl oral tablet extended release . . . . . . . . . . . . 37methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . 37methylprednisolone . . . . . . . . . . . . . . . . 46methylprednisolone acetate . . . . . . . . 46methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . 46methylprednisolone sodium succ intravenous . . . . . . . . . . . . . . . . . . . . . . . 46metoclopramide hcl oral solution . . . . 50metoclopramide hcl oral tablet . . . . . . 50metolazone . . . . . . . . . . . . . . . . . . . . . . . 39metoprolol succinate . . . . . . . . . . . . . . . 39metoprolol ta-hydrochlorothiaz . . . . . 39metoprolol tartrate oral . . . . . . . . . . . . . 39metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 22metronidazole in nacl (iso-os) . . . . . . 22metronidazole oral tablet . . . . . . . . . . . 22metronidazole topical . . . . . . . . . . . . . . 42metronidazole vaginal . . . . . . . . . . . . . . 53metyrosine . . . . . . . . . . . . . . . . . . . . . . . . 39mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 38mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 55

76


Covered Drugs Index

May 2021

norethindrone-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-R . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . 37NORVIR ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 19NORVIR ORAL SOLUTION . . . . . . . . 19NOVOFINE PEN NEEDLE . . . . . . . . . 47NOVOTWIST PEN NEEDLE . . . . . . . 47NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 28NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 33NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 28NUPLAZID ORAL CAPSULE . . . . . . . 37NUPLAZID ORAL TABLET 10 MG . . 37NUZYRA INTRAVENOUS . . . . . . . . . . 23NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 23nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 43nylia 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . 55nymyo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55nystatin oral suspension . . . . . . . . . . . 18nystatin oral tablet . . . . . . . . . . . . . . . . . 18nystatin topical cream . . . . . . . . . . . . . . 43nystatin topical ointment . . . . . . . . . . . 43nystatin topical powder . . . . . . . . . . . . . 43nystatin-triamcinolone . . . . . . . . . . . . . . 43

nicardipine intravenous solution . . . . 39nicardipine oral . . . . . . . . . . . . . . . . . . . . 39NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 45NICOTROL NS . . . . . . . . . . . . . . . . . . . . 45nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 39nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 39nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 55nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 28nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 39NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 28NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 28nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 39nitazoxanide . . . . . . . . . . . . . . . . . . . . . . 22nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 45nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 24nitrofurantoin macrocrystal oral capsule 50 mg . . . . . . . . . . . . . . . . 24nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg . . . . . . . . 24nitrofurantoin monohyd/m-cryst . . . . . 24nitroglycerin intravenous . . . . . . . . . . . 41nitroglycerin sublingual . . . . . . . . . . . . . 41nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 41nitroglycerin translingual spray, non-aerosol . . . . . . . . . . . . . . . . . 41NIVESTYM . . . . . . . . . . . . . . . . . . . . . . . 51nora-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 capsule . . . . . . . . . . . . . . . . . . . . . . . 55

naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 34naproxen oral suspension . . . . . . . . . . 34naproxen oral tablet . . . . . . . . . . . . . . . 34naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 34naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . 34naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 32NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION . . . . . 34NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 56nateglinide oral tablet 60 mg . . . . . . . 47nateglinide oral tablet 120 mg . . . . . . 47NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 48NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 31necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 55NEEDLES, INSULIN DISP.,SAFETY . 47nefazodone . . . . . . . . . . . . . . . . . . . . . . . 37neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 22neomycin-bacitracin-poly-hc . . . . . . . . 57neomycin-bacitracin-polymyxin . . . . . 56neomycin-polymyxin b-dexameth . . . 57neomycin-polymyxin b gu . . . . . . . . . . 44neomycin-polymyxin-gramicidin . . . . 56neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 57neomycin-polymyxin-hc otic (ear) . . . 45neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 56neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 57NEPHRAMINE 5.4% . . . . . . . . . . . . . . . 60NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 28NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 32nevirapine oral suspension . . . . . . . . . 19nevirapine oral tablet . . . . . . . . . . . . . . 19nevirapine oral tablet extended release 24 hr 100 mg . . . . . 19nevirapine oral tablet extended release 24 hr 400 mg . . . . . 19NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 28niacin oral tablet extended release 24 hr . . . . . . . . . . . . 41

77


Covered Drugs Index

May 2021

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 38paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 28PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 28paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 37paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . 37pamidronate . . . . . . . . . . . . . . . . . . . . . . . 48PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 42pantoprazole oral tablet, delayed release (dr/ec) 20 mg . . . . . . 50pantoprazole oral tablet, delayed release (dr/ec) 40 mg . . . . . . 50paricalcitol oral . . . . . . . . . . . . . . . . . . . . 48paroex oral rinse . . . . . . . . . . . . . . . . . . 45paromomycin . . . . . . . . . . . . . . . . . . . . . . 22paroxetine hcl oral tablet . . . . . . . . . . . 37PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 22PAXIL ORAL SUSPENSION . . . . . . . 37PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 51PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 51peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 50peg-electrolyte . . . . . . . . . . . . . . . . . . . . 50PEMAZYRE . . . . . . . . . . . . . . . . . . . . . . . 28penicillamine . . . . . . . . . . . . . . . . . . . . . . 52penicillin g potassium . . . . . . . . . . . . . . 23penicillin v potassium . . . . . . . . . . . . . . 23PENTACEL (PF) INTRAMUSCULAR KIT 15LF- 48MCG-62DU -10 MCG/0.5ML . . . . . 51PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 22pentamidine inhalation . . . . . . . . . . . . . 22pentamidine injection . . . . . . . . . . . . . . 22PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 50pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 40PERFOROMIST . . . . . . . . . . . . . . . . . . . 58PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 60perindopril erbumine . . . . . . . . . . . . . . . 39

ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML . . . . . . . . . 52ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML . . . . . . . . . . . . . 52ORGOVYX . . . . . . . . . . . . . . . . . . . . . . . . 28ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . 58ORKAMBI ORAL TABLET . . . . . . . . . . 58orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 55oseltamivir oral capsule . . . . . . . . . . . . 19oseltamivir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 19oxacillin injection . . . . . . . . . . . . . . . . . . 23oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . . 28oxandrolone oral tablet 2.5 mg . . . . . 48oxandrolone oral tablet 10 mg . . . . . . 48oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 35oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 37oxcarbazepine oral suspension . . . . . 31oxcarbazepine oral tablet . . . . . . . . . . 31OXERVATE . . . . . . . . . . . . . . . . . . . . . . . 56oxybutynin chloride oral syrup . . . . . . 59oxybutynin chloride oral tablet . . . . . . 59oxybutynin chloride oral tablet extended release 24hr . . . . . . . . . . . . . 59oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . 34oxycodone-aspirin . . . . . . . . . . . . . . . . . 34oxycodone oral concentrate . . . . . . . . 34oxycodone oral solution . . . . . . . . . . . . 34oxycodone oral tablet 5 mg . . . . . . . . . 34oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg . . . . . . . 34oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 34OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) . . . . . . . . . . 47OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) . . . . . . . . . . . . . . . . . . . . . . 47

nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 50ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 33octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml . . . . . . . . . . . 28octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 28ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 19ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 28OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ofloxacin ophthalmic (eye) . . . . . . . . . 56OGIVRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28olanzapine intramuscular . . . . . . . . . . . 37olanzapine oral tablet . . . . . . . . . . . . . . 37olanzapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 37olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 39olmesartan-hydrochlorothiazide . . . . 39olopatadine ophthalmic (eye) . . . . . . . 56omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 50OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 47OMNIPOD DASH 5 PACK. . . . . . . . . . 47OMNIPOD STARTER KIT . . . . . . . . . . 47ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 28ondansetron . . . . . . . . . . . . . . . . . . . . . . . 50ondansetron hcl intravenous . . . . . . . 50ondansetron hcl oral solution . . . . . . . 50ondansetron hcl oral tablet . . . . . . . . . 50ondansetron hcl (pf) . . . . . . . . . . . . . . . 50ONIVYDE . . . . . . . . . . . . . . . . . . . . . . . . . 28ONUREG . . . . . . . . . . . . . . . . . . . . . . . . . 28OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 28oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ORENCIA CLICKJECT . . . . . . . . . . . . 52ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML . . . . . . . . . . . 52

78


Covered Drugs Index

May 2021

POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 28pramipexole oral tablet . . . . . . . . . . . . . 32prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 40pravastatin . . . . . . . . . . . . . . . . . . . . . . . . 41praziquantel . . . . . . . . . . . . . . . . . . . . . . . 22prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 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 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg . . . . . . . . . . . . . . 31pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 31pregabalin oral solution . . . . . . . . . . . . 31PREMARIN VAGINAL . . . . . . . . . . . . . 53PREMASOL 10% . . . . . . . . . . . . . . . . . . 60PRENATAL VITAMIN ORAL TABLET . . . . . . . . . . . . . . . . . . . . 60prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 41previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 55PREVYMIS ORAL . . . . . . . . . . . . . . . . . 19PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 19PREZISTA ORAL SUSPENSION . . . 19PREZISTA ORAL TABLET 75 MG . . 19PREZISTA ORAL TABLET 150 MG . 19

polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56polymyxin b sulf-trimethoprim . . . . . . 56POMALYST . . . . . . . . . . . . . . . . . . . . . . . 28portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 55PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 28posaconazole oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 18POTASSIUM 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- D5-0.9%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 . . . . . . . 59potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l . . . . . . . . . . . . . . . . . . 59potassium chloride intravenous . . . . . 59potassium chloride in water intravenous piggyback . . . . . . . . . . . . . 59potassium chloride oral capsule, extended release . . . . . . . . . . . . . . . . . . 59potassium chloride oral liquid . . . . . . . 60potassium chloride oral packet . . . . . 60potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 60potassium chloride oral tablet extended release . . . . . . . . . . . . . . . . . . 60potassium citrate . . . . . . . . . . . . . . . . . . 59

PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 28permethrin topical cream . . . . . . . . . . . 44perphenazine . . . . . . . . . . . . . . . . . . . . . 37perphenazine-amitriptyline . . . . . . . . . 37PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 37pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 23phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 37phenobarbital oral elixir . . . . . . . . . . . . 31phenobarbital oral tablet . . . . . . . . . . . 31phenobarbital sodium injection solution . . . . . . . . . . . . . . . . . . . 31phenytoin oral suspension . . . . . . . . . 31phenytoin oral tablet,chewable . . . . . 31phenytoin sodium extended . . . . . . . . 31phenytoin sodium intravenous solution . . . . . . . . . . . . . . . 31PHESGO . . . . . . . . . . . . . . . . . . . . . . . . . 28philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PHOSPHOLINE IODIDE . . . . . . . . . . . 56PICATO . . . . . . . . . . . . . . . . . . . . . . . . . . . 42PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 19pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 56pilocarpine hcl oral . . . . . . . . . . . . . . . . . 45pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 37pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 55pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39pioglitazone . . . . . . . . . . . . . . . . . . . . . . . 47piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 23PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 23PIQRAY . . . . . . . . . . . . . . . . . . . . . . . . . . . 28pirmella oral tablet 0.5/0.75/1 mg- 35 mcg . . . . . . . . . . . . . 55pirmella oral tablet 1-35 mg-mcg . . . . 55PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 60PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 50podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 42POLIVY . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

79


Covered Drugs Index

May 2021

RELISTOR SUBCUTANEOUS SYRINGE . . . . . . 50REMICADE . . . . . . . . . . . . . . . . . . . . . . . 50RENACIDIN IRRIGATION SOLUTION 1980.6 MG- 59.4 MG-980.4MG/30ML . . . . . . . . . . . 59repaglinide oral tablet 0.5 mg . . . . . . . 47repaglinide oral tablet 1 mg . . . . . . . . 47repaglinide oral tablet 2 mg . . . . . . . . 47REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 41REPATHA PUSHTRONEX . . . . . . . . . 41REPATHA SURECLICK . . . . . . . . . . . . 41RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 56RESTASIS MULTIDOSE . . . . . . . . . . . 56RETACRIT . . . . . . . . . . . . . . . . . . . . . . . . 51RETEVMO . . . . . . . . . . . . . . . . . . . . . . . . 28RETROVIR INTRAVENOUS . . . . . . . 19REVLIMID . . . . . . . . . . . . . . . . . . . . . . . . 28REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 37REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 19RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 57ribavirin oral capsule . . . . . . . . . . . . . . . 19ribavirin oral tablet 200 mg . . . . . . . . . 19rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 22rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 22riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45rimantadine . . . . . . . . . . . . . . . . . . . . . . . 20ringer’s intravenous . . . . . . . . . . . . . . . . 60ringer’s irrigation . . . . . . . . . . . . . . . . . . . 44RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 52RISPERDAL CONSTA . . . . . . . . . . . . . 37risperidone oral solution . . . . . . . . . . . . 37risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . 37risperidone oral tablet 4 mg . . . . . . . . 37risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . 37risperidone oral tablet, disintegrating 4 mg . . . . . . . . . . . . . . . . 37ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 51PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 60protriptyline . . . . . . . . . . . . . . . . . . . . . . . 37PULMOZYME . . . . . . . . . . . . . . . . . . . . . 58PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 22pyridostigmine bromide oral syrup . . 33pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . 33pyridostigmine bromide oral tablet extended release . . . . . . . . 33pyrimethamine . . . . . . . . . . . . . . . . . . . . 22

QQINLOCK . . . . . . . . . . . . . . . . . . . . . . . . . 28QUADRACEL (PF) . . . . . . . . . . . . . . . . 51quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . 37quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 37quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 40quinapril-hydrochlorothiazide . . . . . . . 40quinidine sulfate oral tablet . . . . . . . . . 38quinine sulfate . . . . . . . . . . . . . . . . . . . . . 22

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 51raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 52ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 37ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 41rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 32reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 55RECOMBIVAX HB (PF) . . . . . . . . . . . . 51RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 50regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 33REGRANEX . . . . . . . . . . . . . . . . . . . . . . 42RELISTOR SUBCUTANEOUS SOLUTION . . . . . 50

PREZISTA ORAL TABLET 600 MG . 19PREZISTA ORAL TABLET 800 MG . 19PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 22PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 22primidone . . . . . . . . . . . . . . . . . . . . . . . . . 31probenecid . . . . . . . . . . . . . . . . . . . . . . . . 52probenecid-colchicine . . . . . . . . . . . . . . 52PROCALAMINE 3% . . . . . . . . . . . . . . . 60prochlorperazine . . . . . . . . . . . . . . . . . . 50prochlorperazine edisylate . . . . . . . . . 50prochlorperazine maleate oral . . . . . . 50PROCRIT . . . . . . . . . . . . . . . . . . . . . . . . . 51procto-med hc . . . . . . . . . . . . . . . . . . . . . 50procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 50proctosol hc topical . . . . . . . . . . . . . . . . 50proctozone-hc . . . . . . . . . . . . . . . . . . . . . 50progesterone micronized . . . . . . . . . . . 53PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 47PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . 28PROLASTIN-C INTRAVENOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 45PROLASTIN-C INTRAVENOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 45PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 52PROMACTA ORAL POWDER IN PACKET 12.5 MG . . . . . . . . . . . . . . 40PROMACTA ORAL POWDER IN PACKET 25 MG . . . . . . . . . . . . . . . . 40PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG . . . . . . . . . . . 41PROMACTA ORAL TABLET 75 MG . 41promethazine oral syrup . . . . . . . . . . . 57promethazine oral tablet . . . . . . . . . . . 57propafenone . . . . . . . . . . . . . . . . . . . . . . 38propranolol-hydrochlorothiazid . . . . . 40propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 39propranolol oral solution . . . . . . . . . . . 39propranolol oral tablet . . . . . . . . . . . . . . 40propylthiouracil . . . . . . . . . . . . . . . . . . . . 46

80


Covered Drugs Index

May 2021

sodium polystyrene sulfonate oral powder . . . . . . . . . . . . . . 45solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 59SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 47SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 28SOLU-CORTEF ACT-O-VIAL (PF) . . 46SOMATULINE DEPOT . . . . . . . . . . . . . 28SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 48sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 38SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 38SOVALDI ORAL TABLET 400 MG . . 20spironolactone . . . . . . . . . . . . . . . . . . . . 40spironolacton-hydrochlorothiaz . . . . . 40sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 55SPRITAM . . . . . . . . . . . . . . . . . . . . . . . . . 31SPRYCEL ORAL TABLET 20 MG, 70 MG . . . . . . . . . . . . . . . . . . . . 28SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG . . . 28sps (with sorbitol) . . . . . . . . . . . . . . . . . . 45sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 51stavudine oral capsule . . . . . . . . . . . . . 20STELARA INTRAVENOUS . . . . . . . . . 41STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 41STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 41STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 42STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 28streptomycin . . . . . . . . . . . . . . . . . . . . . . 22STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 20SUBOXONE SUBLINGUAL FILM 2-0.5 MG . . . . . . . . . . . . . . . . . . . . 35SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG . . . . . . . . . . . . . 35SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 35

SELZENTRY ORAL TABLET 25 MG . . . . . . . . . . . . . . . . . . . 20SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . 20SELZENTRY ORAL TABLET 300 MG . . . . . . . . . . . . . . . . . . 20SEREVENT DISKUS . . . . . . . . . . . . . . 58sertraline oral concentrate . . . . . . . . . . 37sertraline oral tablet . . . . . . . . . . . . . . . . 37setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 55sevelamer carbonate oral powder in packet . . . . . . . . . . . . . . 45sevelamer carbonate oral tablet . . . . 45sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 53SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 51SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 28sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 58silver sulfadiazine . . . . . . . . . . . . . . . . . 42simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 55simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 55SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 28simvastatin oral tablet . . . . . . . . . . . . . . 41sirolimus oral solution . . . . . . . . . . . . . . 28sirolimus oral tablet . . . . . . . . . . . . . . . . 28SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 22SIVEXTRO INTRAVENOUS . . . . . . . . 22SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 22SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 41sodium 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) . . . . . 45

rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 33rivastigmine tartrate . . . . . . . . . . . . . . . . 33rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55rizatriptan . . . . . . . . . . . . . . . . . . . . . . . . . 32ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 57ROMIDEPSIN INTRAVENOUS SOLUTION . . . . . . . 28ropinirole oral tablet . . . . . . . . . . . . . . . . 32rosadan topical cream . . . . . . . . . . . . . 42rosadan topical gel . . . . . . . . . . . . . . . . 42rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 41ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 51ROTATEQ VACCINE . . . . . . . . . . . . . . 51roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 31ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 28ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 28RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 28rufinamide . . . . . . . . . . . . . . . . . . . . . . . . 31RUKOBIA . . . . . . . . . . . . . . . . . . . . . . . . . 20RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 28RYBELSUS . . . . . . . . . . . . . . . . . . . . . . . 47RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 28RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 32

SSAMSCA ORAL TABLET 15 MG . . . . 48SAMSCA ORAL TABLET 30 MG . . . . 48SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 50SANDIMMUNE ORAL SOLUTION . . 28SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 42SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 37sapropterin . . . . . . . . . . . . . . . . . . . . . . . . 48SARCLISA . . . . . . . . . . . . . . . . . . . . . . . . 28scopolamine base . . . . . . . . . . . . . . . . . 50SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 37selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 32selenium sulfide topical lotion . . . . . . 41SELZENTRY ORAL SOLUTION . . . . 20

81


Covered Drugs Index

May 2021

TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 120 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 33TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46) . . . . . . . . . 33TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 240 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 33TECHLITE PEN NEEDLE . . . . . . . . . . 48TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 21telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 40telmisartan-amlodipine . . . . . . . . . . . . . 40telmisartan-hydrochlorothiazid . . . . . . 40temazepam oral capsule 15 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . 37temazepam oral capsule 22.5 mg, 7.5 mg . . . . . . . . . . . . . . . . . . . 37TEMIXYS . . . . . . . . . . . . . . . . . . . . . . . . . 20TEMODAR INTRAVENOUS . . . . . . . . 29temsirolimus . . . . . . . . . . . . . . . . . . . . . . 29TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 51tenofovir disoproxil fumarate . . . . . . . 20TEPMETKO . . . . . . . . . . . . . . . . . . . . . . . 29terazosin oral capsule 1 mg, 2 mg, 5 mg . . . . . . . . . . . . . . . . . . 40terazosin oral capsule 10 mg . . . . . . . 40terbinafine hcl oral . . . . . . . . . . . . . . . . . 18terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 58terconazole . . . . . . . . . . . . . . . . . . . . . . . 53TERIPARATIDE . . . . . . . . . . . . . . . . . . . 52testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml) . . . . . . . 48testosterone 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) . . . . . . . . . . . . . . . . 49

SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 47SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 48SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 48SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 29SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 49

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 29TABRECTA . . . . . . . . . . . . . . . . . . . . . . . 29tacrolimus oral . . . . . . . . . . . . . . . . . . . . 29tacrolimus topical . . . . . . . . . . . . . . . . . . 42tadalafil (pulmonary arterial hypertension) oral tablet 20 mg . . . . . 58TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 29TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 29TALTZ SYRINGE . . . . . . . . . . . . . . . . . . 42TALZENNA ORAL CAPSULE 0.25 MG . . . . . . . . . . . . . . . . 29TALZENNA ORAL CAPSULE 1 MG . 29tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 29tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 59TARGRETIN TOPICAL . . . . . . . . . . . . 29tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 55tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 55tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 55TASIGNA ORAL CAPSULE 50 MG . 29TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 29tazarotene topical cream . . . . . . . . . . . 42tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21TAZORAC TOPICAL CREAM 0.05% . . . . . . . . . . . . . . . . . . . . 42taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . . . . . . . . . 40TAZVERIK . . . . . . . . . . . . . . . . . . . . . . . . 29TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 29

subvenite . . . . . . . . . . . . . . . . . . . . . . . . . 31subvenite starter (blue) kit . . . . . . . . . . 31subvenite starter (green) kit . . . . . . . . 31subvenite starter (orange) kit . . . . . . . 31sucralfate oral tablet . . . . . . . . . . . . . . . 50sulfacetamide-prednisolone . . . . . . . . 56sulfacetamide sodium (acne) . . . . . . . 43sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 56sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 23sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 23sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 23sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 23sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 50sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 35sumatriptan nasal spray, non-aerosol 5 mg/actuation . . . . . . . . 32sumatriptan nasal spray, non-aerosol 20 mg/actuation . . . . . . . 32sumatriptan succinate oral . . . . . . . . . 32sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 32sumatriptan succinate subcutaneous pen injector . . . . . . . . . 32sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 32sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml . . 32SUPREP BOWEL PREP KIT . . . . . . . 50SUTAB . . . . . . . . . . . . . . . . . . . . . . . . . . . 50SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 28syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55SYMDEKO . . . . . . . . . . . . . . . . . . . . . . . . 58SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 20SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 31SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 20SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 48SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 22

82


Covered Drugs Index

May 2021

triamcinolone 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% . . . . . . . . . 44trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 45tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 55tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 55trifluoperazine oral tablet 1 mg . . . . . 37trifluoperazine oral tablet 10 mg, 2 mg, 5 mg . . . . . . . . . . . . . . . . . 37trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 56TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG . . . . 48TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5- 2.5-1,000 MG, 5-2.5-1,000 MG . . . . . 48TRIKAFTA . . . . . . . . . . . . . . . . . . . . . . . . 59tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 55tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 55tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 55tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 55tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 55tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 55trilyte with flavor packets . . . . . . . . . . . 50trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 24tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55trimipramine . . . . . . . . . . . . . . . . . . . . . . . 37TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 37tri-nymyo . . . . . . . . . . . . . . . . . . . . . . . . . . 55tri-previfem (28) . . . . . . . . . . . . . . . . . . . 55TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 29tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 55TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 20trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 55

topotecan intravenous recon soln . . . 29topotecan intravenous solution 4 mg/4 ml (1 mg/ml) . . . . . . . 29toremifene . . . . . . . . . . . . . . . . . . . . . . . . 29torsemide oral . . . . . . . . . . . . . . . . . . . . . 40TOUJEO MAX U-300 SOLOSTAR . . 48TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 48TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 59TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 48tramadol-acetaminophen . . . . . . . . . . . 35tramadol oral tablet 50 mg . . . . . . . . . 35trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 40tranexamic acid oral . . . . . . . . . . . . . . . 53tranylcypromine . . . . . . . . . . . . . . . . . . . 37TRAVASOL 10% . . . . . . . . . . . . . . . . . . 60travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 57TRAZIMERA . . . . . . . . . . . . . . . . . . . . . . 29trazodone . . . . . . . . . . . . . . . . . . . . . . . . . 37TREANDA INTRAVENOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 29TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 22TRELEGY ELLIPTA . . . . . . . . . . . . . . . 59TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 29TRESIBA FLEXTOUCH U-100 . . . . . 48TRESIBA FLEXTOUCH U-200 . . . . . 48TRESIBA U-100 INSULIN . . . . . . . . . . 48tretinoin (antineoplastic) . . . . . . . . . . . . 29tretinoin microspheres topical gel 0.1% . . . . . . . . . . . . . . . . . . . 42tretinoin 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 suspension 40 mg/ml . . . . . . 46

TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . 51tetrabenazine oral tablet 12.5 mg . . . 33tetrabenazine oral tablet 25 mg . . . . . 33tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 23THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 29THALOMID ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 29theophylline oral tablet extended release 12 hr 300 mg, 450 mg . . . . . . 59theophylline oral tablet extended release 24 hr . . . . . . . . . . . . 59thioridazine . . . . . . . . . . . . . . . . . . . . . . . 37thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 29thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 37tiadylt er . . . . . . . . . . . . . . . . . . . . . . . . . . 40tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 31TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 29tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 22tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 56timolol maleate ophthalmic (eye) gel forming solution . . . . . . . . . . 56timolol maleate oral . . . . . . . . . . . . . . . . 40tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 44TIVICAY ORAL TABLET 10 MG . . . . 20TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . 20TIVICAY PD . . . . . . . . . . . . . . . . . . . . . . . 20tizanidine oral tablet . . . . . . . . . . . . . . . 33tobramycin-dexamethasone . . . . . . . . 57tobramycin in 0.225% nacl . . . . . . . . . 22tobramycin ophthalmic (eye) . . . . . . . 56tobramycin sulfate . . . . . . . . . . . . . . . . . 22tolterodine oral tablet . . . . . . . . . . . . . . 59tolvaptan oral tablet 30 mg . . . . . . . . . 49topiramate oral capsule, sprinkle . . . 31topiramate oral tablet . . . . . . . . . . . . . . 31toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

83


Covered Drugs Index

May 2021

venlafaxine oral capsule, extended release 24hr . . . . . . . . . . . . . 38venlafaxine oral tablet . . . . . . . . . . . . . . 38VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . 38VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 29vestura (28) . . . . . . . . . . . . . . . . . . . . . . . 56V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 48VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 48VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 48vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 31vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 31VIIBRYD ORAL TABLET . . . . . . . . . . . 38VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 38VIMPAT INTRAVENOUS . . . . . . . . . . . 31VIMPAT ORAL SOLUTION . . . . . . . . . 31VIMPAT ORAL TABLET 50 MG . . . . . 32VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 32vinblastine intravenous solution . . . . . 29vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 29vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 29vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 29VIOKACE . . . . . . . . . . . . . . . . . . . . . . . . . 50viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 56

valproic acid (as sodium salt) oral solution . . . . . . . . . . . . . . . . . . . . . . . 31valrubicin . . . . . . . . . . . . . . . . . . . . . . . . . 29valsartan-hydrochlorothiazide . . . . . . 40valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 40valsartan oral tablet 320 mg . . . . . . . . 40VALTOCO . . . . . . . . . . . . . . . . . . . . . . . . . 31VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . . . . . . 22VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . . . . . 22VANCOMYCIN INJECTION . . . . . . . . 22vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 22VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM. . . . . . 22vancomycin oral capsule 125 mg . . . 22vancomycin oral capsule 250 mg . . . 22vancomycin oral recon soln . . . . . . . . 22VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 22vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 53VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 51VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 51VARIZIG INTRAMUSCULAR SOLUTION . . . . 51VASCEPA . . . . . . . . . . . . . . . . . . . . . . . . . 41VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 29VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 29velivet triphasic regimen (28) . . . . . . . 56VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 45VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . 20VENCLEXTA ORAL TABLET 10 MG . . . . . . . . . . . . . . . . . . . 29VENCLEXTA ORAL TABLET 50 MG . . . . . . . . . . . . . . . . . . . 29VENCLEXTA ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 29VENCLEXTA STARTING PACK . . . . 29

tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 55tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 56TRODELVY . . . . . . . . . . . . . . . . . . . . . . . 29TROGARZO . . . . . . . . . . . . . . . . . . . . . . 20TROPHAMINE 10% . . . . . . . . . . . . . . . 60TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 48TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 51TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 20TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 29TUKYSA ORAL TABLET 50 MG . . . . 29TUKYSA ORAL TABLET 150 MG . . . 29TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 29TWINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 51TYBLUME . . . . . . . . . . . . . . . . . . . . . . . . 56tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 29TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 52TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 51TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 33

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 . . . . . . . . . . . . . . . . . . . . . . . . 29UPTRAVI . . . . . . . . . . . . . . . . . . . . . . . . . 40ursodiol oral capsule . . . . . . . . . . . . . . . 50ursodiol oral tablet . . . . . . . . . . . . . . . . . 50

Vvalacyclovir oral tablet 1 gram . . . . . . 20valacyclovir oral tablet 500 mg . . . . . 20VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 42valganciclovir . . . . . . . . . . . . . . . . . . . . . . 20valproate sodium . . . . . . . . . . . . . . . . . . 31valproic acid . . . . . . . . . . . . . . . . . . . . . . . 31

84


Covered Drugs Index

May 2021

ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 30ZEPZELCA . . . . . . . . . . . . . . . . . . . . . . . 30zidovudine oral capsule . . . . . . . . . . . . 20zidovudine oral syrup . . . . . . . . . . . . . . 20zidovudine oral tablet . . . . . . . . . . . . . . 20ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 51ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 38ziprasidone mesylate . . . . . . . . . . . . . . 38ZIRABEV . . . . . . . . . . . . . . . . . . . . . . . . . 30ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 56ZOLADEX . . . . . . . . . . . . . . . . . . . . . . . . 30zoledronic acid intravenous solution . . . . . . . . . . . . . . . 49zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 49zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 45ZOLEDRONIC AC- MANNITOL-0.9NACL . . . . . . . . . . . . . . 49ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 30zolpidem oral tablet . . . . . . . . . . . . . . . . 38zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 32ZORTRESS ORAL TABLET 1 MG . . 30ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 51zovia 1-35 (28) . . . . . . . . . . . . . . . . . . . . 56zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 56ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 42zumandimine (28) . . . . . . . . . . . . . . . . . 56ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYKADIA ORAL TABLET . . . . . . . . . . 30ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG, 405 MG . . . . . . . . . . . . . . . . . . 38

XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 30XCOPRI . . . . . . . . . . . . . . . . . . . . . . . . . . 32XCOPRI MAINTENANCE PACK . . . . 32XCOPRI TITRATION PACK . . . . . . . . 32XELJANZ ORAL SOLUTION . . . . . . . 52XELJANZ ORAL TABLET . . . . . . . . . . 52XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 52XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 24XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 45XIFAXAN ORAL TABLET 550 MG . . 23XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 59XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML . . . . . . . . . . . 59XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML . . . . . . . . . . . . . 59XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 30XPOVIO . . . . . . . . . . . . . . . . . . . . . . . . . . 30XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 34XTANDI ORAL CAPSULE . . . . . . . . . . 30XTANDI ORAL TABLET 40 MG . . . . . 30XTANDI ORAL TABLET 80 MG . . . . . 30XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 48XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

YYERVOY . . . . . . . . . . . . . . . . . . . . . . . . . . 30YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 51YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 59ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 30ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 30zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 51zebutal oral capsule 50-325-40 mg . . . . . . . . . . . . . . . . . . . . . 34ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 30

VIRACEPT ORAL TABLET 250 MG . . . . . . . . . . . . . . . . . . 20VIRACEPT ORAL TABLET 625 MG . . . . . . . . . . . . . . . . . . 20VIREAD ORAL POWDER . . . . . . . . . . 20VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . 20VITRAKVI ORAL CAPSULE 25 MG . . . . . . . . . . . . . . . . . 29VITRAKVI ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 29VITRAKVI ORAL SOLUTION . . . . . . . 29VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 35VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 30volnea (28) . . . . . . . . . . . . . . . . . . . . . . . . 56voriconazole intravenous . . . . . . . . . . . 18voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 18voriconazole oral tablet 50 mg . . . . . . 18voriconazole oral tablet 200 mg . . . . . 18VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 20VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 30VRAYLAR ORAL CAPSULE . . . . . . . . 38VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 38vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 56vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56VYNDAQEL . . . . . . . . . . . . . . . . . . . . . . . 41VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 41water for irrigation, sterile . . . . . . . . . . 45wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 56wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 56

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 30XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 41XARELTO DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 41

85

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Notes

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: − Qualified sign language interpreters − 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: − Qualified interpreters − Information written in other languages

If you need these services, contact Customer Service at 1-800-222-6700 (TTY 711), 8 a.m. to 8 p.m. 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 a.m. to 8 p.m., 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 771), 8 a.m. a 8 p.m, 7 días de la semana. Cigna® Rx (PDP) is a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna depends on contract renewal. © 2017 Cigna

INT_17_49135 v05012020 20_NDMLI_PDP

ACCEPTED 20_PDP_NDMLI

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

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

Chinese – (TTY 711)

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

Korean – : , .(TTY: 711) .

Arabic

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

).711 رقم ھاتف الصم والبكم(

Gujarati –

まで、お電話にてご連絡ください。

Navajo – ti’go Diné Bizaad, saad(TTY 711).

Urdu خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال:TTY)

توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد711)

1-800-222-6700

1-800-222-6700

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1-800-222-6700

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(01142020)

This formulary was updated on 05/01/2021. 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 CignaMedicare.com. 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. © 2020 CignaMay 2021 946458 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.

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