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2019

BlueMedicareSM Comprehensive

FormularyBlueMedicare Complete Rx (PDP) S5904-002BlueMedicare Group PPO (Employer PPO)BlueMedicare Group Rx (Employer PDP)

This formulary was updated on 02/25/2019. For more recent information or other questions, please contact Florida Blue at 1-800-926-6565 or, for TTY users, 1-800-955-8770, from 8:00 a.m. – 8:00 p.m. local time, seven days a week from October 1 – March 31, except for Thanksgiving and Christmas. From April 1 – September 30, we are open Monday – Friday, 8:00 a.m. – 8:00 p.m. local time, except for Federal holidays. Or visit www.floridablue/medicare.

Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association.

Y0011_34289_C 0818 C: 08/2018

Florida’s Blue Cross and Blue Shield Plan

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BlueMedicare Complete Rx (PDP) BlueMedicare Group PPO (Employer PPO) BlueMedicare Group Rx (Employer PDP)

2019 Formulary (List of Covered Drugs)

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

Formulary ID 00019363, Version 8

This formulary was updated on 02/25/2019. For more recent information or other questions, please contact BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx Member Services at 1-800-926-6565 or, for TTY users, 1-800-955-8770. We are open from 8:00 a.m. – 8:00 p.m. local time, seven days a week from October 1 – March31, except for Thanksgiving and Christmas. From April 1 –September 30, we are open Monday – Friday, 8:00 a.m. – 8:00 p.m. local time, except for Federal holidays. Or visit www.floridablue.com/medicare.

Florida Blue is an Rx (PDP) Plan with a Medicare contract. Florida Blue is a PPO plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-800-926-6565 (TTY: 1-800-955-8770).

Si habla español, hay servicios de traducción, libre de cargos, disponibles para usted. Llame al 1-800-926-6565 (TTY: 1-800-955-8773). The formulary may change at any time. You will receive notice when necessary.

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Florida Blue. When it refers to “plan” or “our plan,” it means BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx. This document includes a list of the drugs (formulary) for our plan which is current as of February 25, 2019. 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, 2020, and from time to time during the year.

What is the BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx Formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

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

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep thebrand name drug on our Drug List, but immediately move it to a different cost-sharing tier or addnew restrictions. If you are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on the steps you may take to request an exception, and you can also findinformation in the section below entitled “How do I request an exception to the BlueMedicareComplete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. We may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to

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the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or 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 members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 31-day supply of the drug. The enclosed formulary is current as of February 25, 2019. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx provide monthly updates of the formulary on our website (www.floridablue.com/medicare) and in print as needed. The paragraphs that follow will explain how you will be notified in the event of certain changes. BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx will only remove Part D drugs from our formulary, move covered Part D drugs to a less preferred tier status, or add utilization management requirements 30 days after the beginning of the contract year associated with the annual election period, and only if these changes are approved by CMS. If BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx should make such formulary changes, members currently taking the affected drug are exempt from the formulary change for the remainder of the contract year. Prior to removing a covered Part D drug from its formulary, or making any change in the preferred or tiered cost-sharing status of a covered Part D drug, BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx will either: • Provide direct written notice to affected enrollees at least 30 days prior to the date the change becomes

effective; or

• At the time an affected enrollee requests a refill of the Part D drug, provide such enrollee with a 31-daysupply of the Part D drug under the same terms as previously allowed and written notice of theformulary change.

How do I use the Formulary? There are two ways to find your drug within the formulary:

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

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 126. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Our plan 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.

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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: Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from our plan before you fill your prescriptions.If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. Forexample, our plan provides 30 tablets per prescription for Januvia. This may be in addition to astandard one-month or three-month supply.

• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our web site. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us 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 BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by our plan. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx.

• You can ask us to make an exception and cover your drug. See below for information about how torequest an exception.

How do I request an exception to the BlueMedicare Complete Rx, BlueMedicare Group PPO and BlueMedicare Group Rx Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level.

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

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

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Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, 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 formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply. If your prescription is written for fewer days), we’ll allow refills to provide up to a maximum of a 31-day supply of medication. After your first one month supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires. When a member is admitted to or discharged from a Long Term Care (LTC) facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the “refill too soon” edits, are provided, for each medication which would be impacted due to a member being admitted to or discharged from an LTC facility. Early refill edits are not used to limit appropriate and necessary access to a member’s Part D benefit, and such members are allowed to access a refill upon admission or discharge.

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

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Our Plan’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 126. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin).

The information in the Requirements/Limits column tells you if we have any special requirements for coverage of your drug.

The information in the second column of the chart tells you at what level (tier) your drug is covered. The third column of the chart indicates whether any special requirements apply for coverage of a drug such as "Prior Authorization," "Quantity Limits" and "Step Therapy." If Quantity Limits apply to a drug, the restriction amounts are shown in the listing beginning on page 1. All drugs included in this formulary are available through our mail services. Contact us for details.

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DOSAGE / FORM ABBREVIATIONS KEY

act Actuation mcg Microgram ad Adsorbed meq Milli-Equivalent aer, aero Aerosol mg Milligram app Applicator ml Milliliter

ba, breath act, breath activ Breath Activated mu Million Units

bau Bioequivalent Allergy Units nebu Nebules cap, caps Capsules orally disintegr tab Orally disintegrating tablets cart Cartridge op, ophth Ophthalmic chew tab Chewable Tablets osm osmotic conc Concentrate pf Preservative-Free

conj Conjugate, conjugated pfu Plaque Forming Units

crys Crystals pow, powd Powder deter Deterrent Pref, prefill Prefilled

disint disintegrating pak pack

dr Delayed-Release ptwk patch weekly

ec Enteric-Coated pttw patch twice weekly el, elu Enzyme-Linked

I b t A recomb Recombinant

er, extended, extended rel, xl, xr Extended-Release sl Sublingual

ext extract sol, soln Solution

gm Gram sr Sustained-Release

gu Genitourinary supp, suppos Suppositories

hr Hour sus, susp Suspension Ig Immunie globuline syr Syringe im Intramuscular tab, tabs Tablets inh, inhal Inhalation td Transdermal inj Injection tl Translingual ir Immediate-Release unt Unit iv Intravenous vac Vaccine

l Liter va vaginal

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Coverage Gap Stage Below is information, by plan, that explains what additional coverage each plan provides when you are in the Coverage Gap Stage. For more information, please refer to your Evidence of Coverage.

Plan(s) Additional Coverage when you are in the Coverage Gap Stage

• BlueMedicare Complete Rx This plan provides coverage of Tier 1: Preferred Generics and Tier 2: Generics when you are in the Coverage Gap Stage. You pay the same cost-sharing you paid during the Initial Coverage Stage for Tier 1 and Tier 2 drugs.

• BlueMedicare Group Rx – Option 1 & 2 This plan provides coverage of all tiers. Your cost-sharing remains the same as in the Initial Coverage Stage when you are in the Coverage Gap Stage.

• BlueMedicare Group Rx – Option 3 This plan provides coverage of Tier 1: Preferred Generics and Tier 2: Generics when you are in the Coverage Gap Stage. You pay the same cost-sharing you paid during the Initial Coverage Stage for Tier 1 and Tier 2 drugs.

Initial Coverage Stage The copayment/coinsurance amounts that you pay for a one-month (31-day) supply of drugs in each Drug Tier are shown below.

For BlueMedicare Complete Rx

Pharmacy Type

Tier 1 Preferred

Generics

Tier 2 Generics

Tier 3 Preferred

Brand

Tier 4 Non-

Preferred Brand

Tier 5 Specialty

Blue Medicare Complete Rx

Preferred Retail

$3 copay $10 copay $40 copay $93 copay

33% Standard Retail $13 copay $20 copay $47 copay $100 copay

Mail-Order $3 copay $10 copay $40 copay $93 copay

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For BlueMedicare Group Rx

Pharmacy Type

Tier 1 Preferred

Generics

Tier 2 Generics

Tier 3 Preferred

Brand

Tier 4 Non-

Preferred Brand

Tier 5 Specialty

Blue Medicare Group Rx – Option 1

Preferred Retail

N/A N/A N/A N/A




Preferred Retail

N/A N/A N/A N/A




Preferred Retail

N/A N/A N/A N/A



For Options 2 and 3, a $75 deductible applies to drugs in Tier 3, Tier 4 and Tier 5.

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Abbreviation Key

1 = Preferred Generic Drugs

2 = Generic Drugs

3 = Preferred Brand Drugs

4 = Non-Preferred Brand Drugs

5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited distribution drugs are indicated by an asterisk (*) in the drug list. These drugs may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call our Member Services at 1-800-926-6565 or, for TTY users, 1-800-955-8770. We are open from 8:00 a.m. – 8:00 p.m. local time seven days a week from October 1 – March 31, except for Thanksgiving and Christmas. From April 1 – September 30, we are open Monday – Friday 8:00 a.m. – 8:00 p.m. local time, except for Federal holidays. Or visit www.floridablue.com/medicare.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

^ = Additional coverage of this prescription drug in the coverage gap is provided by certain plans. Please refer to the table in the “Coverage Gap Stage” section on page viii to determine if your plan provides additional coverage in the gap. You can also refer to your Evidence of Coverage.

2019

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

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml^ 1 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg^ 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg^ 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg^ 2 QL (180 tablets/30 days)ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed release

50-0.2 mg4 QL (120 tablets/30 days)

ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed release75-0.2 mg

4 QL (90 tablets/30 days)

buprenorphine td patch weekly 5 mcg/hr^ 2 PA, QL (4 patches/28 days)buprenorphine td patch weekly 10 mcg/hr^ 2 PA, QL (4 patches/28 days)buprenorphine td patch weekly 15 mcg/hr^ 2 PA, QL (4 patches/28 days)buprenorphine td patch weekly 20 mcg/hr^ 2 PA, QL (4 patches/28 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml^ 2butorphanol tartrate nasal soln 10 mg/ml^ 2 QL (87.5 mls/30 days)BUTRANS - buprenorphine td patch weekly 5 mcg/hr 4 PA, QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr 4 PA, QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 10 mcg/hr 4 PA, QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 15 mcg/hr 4 PA, QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 20 mcg/hr 5 PA, QL (4 patches/28 days)CELEBREX - celecoxib cap 50 mg 4 QL (60 capsules/30 days)CELEBREX - celecoxib cap 100 mg 4 QL (60 capsules/30 days)CELEBREX - celecoxib cap 200 mg 4 QL (60 capsules/30 days)CELEBREX - celecoxib cap 400 mg 4 QL (30 capsules/30 days)celecoxib cap 50 mg^ 2 QL (60 capsules/30 days)celecoxib cap 100 mg^ 2 QL (60 capsules/30 days)celecoxib cap 200 mg^ 2 QL (60 capsules/30 days)

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitscelecoxib cap 400 mg^ 2 QL (30 capsules/30 days)codeine sulfate tab 15 mg^ 2 QL (180 tablets/30 days)codeine sulfate tab 30 mg^ 2 QL (180 tablets/30 days)codeine sulfate tab 60 mg^ 2 QL (180 tablets/30 days)DAYPRO - oxaprozin tab 600 mg 4 QL (90 tablets/30 days)diclofenac potassium tab 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium gel 1%^ 2 PAdiclofenac sodium tab delayed release 25 mg^ 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg^ 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg^ 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg^ 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg^ 2 QL (90 tablets/30 days)DOLOPHINE - methadone hcl tab 5 mg 4 QL (180 tablets/30 days)DOLOPHINE - methadone hcl tab 10 mg 4 QL (360 tablets/30 days)EC-NAPROSYN - naproxen tab ec 375 mg 4 QL (120 tablets/30 days)etodolac cap 200 mg^ 2 QL (150 capsules/30 days)etodolac cap 300 mg^ 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg^ 2 QL (30 tablets/30 days)etodolac tab 400 mg^ 2 QL (60 tablets/30 days)etodolac tab 500 mg^ 2 QL (60 tablets/30 days)FELDENE - piroxicam cap 10 mg 4 QL (60 capsules/30 days)FELDENE - piroxicam cap 20 mg 4 QL (30 capsules/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr^ 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr^ 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr^ 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr^ 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 5 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr^ 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 5 PA, QL (15 patches/30 days)

2019


3

Drug Name Drug Tier Requirements/Limitsfentanyl td patch 72hr 100 mcg/hr^ 2 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg^ 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg^ 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml^ 2 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg^ 2 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg^ 2 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg^ 2 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg^ 2 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg^ 2 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg^ 2 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg^ 2 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg^ 2 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg^ 2 QL (150 tablets/30 days)hydromorphone hcl inj 2 mg/ml^ 2 BDhydromorphone hcl liqd 1 mg/ml^ 2 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml^ 2 BDhydromorphone hcl preservative free inj 10 mg/ml^ 2 BDhydromorphone hcl tab 2 mg^ 2 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg^ 2 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg^ 2 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml^ 2ibuprofen tab 400 mg^ 1 QL (240 tablets/30 days)ibuprofen tab 600 mg^ 1 QL (150 tablets/30 days)ibuprofen tab 800 mg^ 1 QL (120 tablets/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg^ 1 QL (60 tablets/30 days)meloxicam tab 15 mg^ 1 QL (30 tablets/30 days)methadone hcl tab 5 mg^ 2 QL (180 tablets/30 days)methadone hcl tab 10 mg^ 2 QL (360 tablets/30 days)MOBIC - meloxicam tab 7.5 mg 4 QL (60 tablets/30 days)MOBIC - meloxicam tab 15 mg 4 QL (30 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml^ 2 BDmorphine sulfate inj pf 1 mg/ml^ 2 BD

2019


Drug Name Drug Tier Requirements/Limitsmorphine sulfate oral soln 10 mg/5ml^ 2 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml^ 2 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml)^ 2 QL (270 mls/30 days)morphine sulfate tab er 15 mg^ 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg^ 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg^ 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg^ 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg^ 2 PA, QL (90 tablets/30 days)nabumetone tab 500 mg^ 2 QL (120 tablets/30 days)nabumetone tab 750 mg^ 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg^ 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg^ 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml^ 2 QL (1800 mls/30 days)naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)naproxen tab 250 mg^ 1 QL (180 tablets/30 days)naproxen tab 375 mg^ 1 QL (120 tablets/30 days)naproxen tab 500 mg^ 1 QL (90 tablets/30 days)NUCYNTA - tapentadol hcl tab 50 mg 4 QL (180 tablets/30 days)NUCYNTA - tapentadol hcl tab 75 mg 4 QL (180 tablets/30 days)NUCYNTA - tapentadol hcl tab 100 mg 4 QL (180 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 50 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 100 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 150 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 200 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 250 mg 3 PA, QL (60 tablets/30 days)oxaprozin tab 600 mg^ 2 QL (90 tablets/30 days)oxycodone hcl tab 5 mg^ 2 QL (360 tablets/30 days)oxycodone hcl tab 10 mg^ 2 QL (180 tablets/30 days)oxycodone hcl tab 15 mg^ 2 QL (180 tablets/30 days)oxycodone hcl tab 20 mg^ 2 QL (180 tablets/30 days)oxycodone hcl tab 30 mg^ 2 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg^ 2 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg^ 2 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg^ 2 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg^ 2 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg^ 2 QL (360 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg 3 PA, QL (60 tablets/30 days)

2019


5

Drug Name Drug Tier Requirements/LimitsOXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg 3 PA, QL (120 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg 3 PA, QL (120 tablets/30 days)piroxicam cap 10 mg^ 2 QL (60 capsules/30 days)piroxicam cap 20 mg^ 2 QL (30 capsules/30 days)ROXICODONE - oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)ROXICODONE - oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)ROXICODONE - oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)sulindac tab 150 mg^ 2 QL (60 tablets/30 days)sulindac tab 200 mg^ 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg^ 2 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg^ 2 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg^ 2 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg^ 1 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg^ 2 QL (240 tablets/30 days)ULTRACET - tramadol-acetaminophen tab 37.5-325 mg 4 QL (240 tablets/30 days)ULTRAM - tramadol hcl tab 50 mg 4 QL (240 tablets/30 days)VOLTAREN - diclofenac sodium gel 1% 4 PAZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)









Anestheticslidocaine hcl gel 2%^ 2 PA, QL (150 mls/30 days)lidocaine hcl local inj 1%^ 1lidocaine hcl local preservative free inj 1%^ 1lidocaine hcl soln 4%^ 2 PA, QL (150 mls/30 days)

2019


Drug Name Drug Tier Requirements/Limitslidocaine hcl viscous soln 2%^ 2lidocaine oint 5%^ 2 PA, QL (100 grams/30 days)lidocaine patch 5%^ 2 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5%^ 2 PA, QL (60 grams/30 days)LIDODERM - lidocaine patch 5% 4 PA, QL (90 patches/30 days)XYLOCAINE - lidocaine hcl local inj 1% 4XYLOCAINE-MPF - lidocaine hcl local preservative free inj 1% 4Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg^ 2ANTABUSE - disulfiram tab 250 mg 4ANTABUSE - disulfiram tab 500 mg 4buprenorphine hcl sl tab 2 mg^ 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg^ 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg^ 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg^ 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg^ 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

3

disulfiram tab 250 mg^ 2disulfiram tab 500 mg^ 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 3NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3naloxone hcl inj 0.4 mg/ml^ 2naloxone hcl inj 4 mg/10ml^ 2naltrexone hcl tab 50 mg^ 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBLOCADE - buprenorphine extended release soln pref syr

100 mg/0.5ml5

SUBLOCADE - buprenorphine extended release soln pref syr300 mg/1.5ml

5

SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 3 QL (120 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 3 QL (30 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 3 QL (60 films/30 days)

2019


7

Drug Name Drug Tier Requirements/LimitsSUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 3 QL (60 films/30 days)VIVITROL - naltrexone for im extended release susp 380 mg 5ZYBAN - bupropion hcl (smoking deterrent) tab er 12hr 150 mg 4Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml)^ 2amikacin sulfate inj 1 gm/4ml (250 mg/ml)^ 2amoxicillin (trihydrate) cap 250 mg^ 1amoxicillin (trihydrate) cap 500 mg^ 1amoxicillin (trihydrate) for susp 125 mg/5ml^ 1amoxicillin (trihydrate) for susp 200 mg/5ml^ 1amoxicillin (trihydrate) for susp 250 mg/5ml^ 1amoxicillin (trihydrate) for susp 400 mg/5ml^ 1amoxicillin (trihydrate) tab 500 mg^ 1amoxicillin (trihydrate) tab 875 mg^ 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml^ 2amoxicillin & k clavulanate for susp 400-57 mg/5ml^ 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml^ 2amoxicillin & k clavulanate tab 250-125 mg^ 2amoxicillin & k clavulanate tab 500-125 mg^ 2amoxicillin & k clavulanate tab 875-125 mg^ 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

3

ampicillin & sulbactam sodium for inj 3 (2-1) gm^ 2ampicillin cap 500 mg^ 2AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg^ 2ampicillin sodium for inj 500 mg^ 2ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm^ 2ampicillin sodium for iv soln 2 gm^ 2ampicillin sodium for iv soln 10 gm^ 2AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm^2

AUGMENTIN - amoxicillin & k clavulanate tab 500-125 mg 4AUGMENTIN - amoxicillin & k clavulanate tab 875-125 mg 4AVELOX - moxifloxacin hcl tab 400 mg 4AVELOX - moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8%

inj4

2019


Drug Name Drug Tier Requirements/LimitsAZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextrose

inj 1 gm/50ml4

AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextroseinj 2 gm/50ml

4

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml^ 2azithromycin for susp 200 mg/5ml^ 2azithromycin iv for soln 500 mg^ 2azithromycin tab 250 mg^ 2azithromycin tab 500 mg^ 2azithromycin tab 600 mg^ 2aztreonam for inj 1 gm^ 2aztreonam for inj 2 gm^ 2BACTRIM - sulfamethoxazole-trimethoprim tab 400-80 mg 4BACTRIM DS - sulfamethoxazole-trimethoprim tab 800-160 mg 4BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg^ 2cefaclor cap 500 mg^ 2cefadroxil cap 500 mg^ 2cefadroxil for susp 250 mg/5ml^ 2cefadroxil for susp 500 mg/5ml^ 2cefadroxil tab 1 gm^ 2CEFAZOLIN SODIUM - cefazolin sodium for inj 20 gm 3cefazolin sodium for inj 500 mg^ 2cefazolin sodium for inj 1 gm^ 2cefazolin sodium for inj 10 gm 3cefdinir cap 300 mg^ 2cefdinir for susp 125 mg/5ml^ 2cefdinir for susp 250 mg/5ml^ 2cefepime hcl for inj 1 gm^ 2cefepime hcl for inj 2 gm^ 2CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3

2019


9

Drug Name Drug Tier Requirements/Limitscefoxitin sodium for inj 10 gm^ 2cefoxitin sodium for iv soln 1 gm^ 2cefoxitin sodium for iv soln 2 gm^ 2cefpodoxime proxetil for susp 50 mg/5ml^ 2cefpodoxime proxetil for susp 100 mg/5ml^ 2cefpodoxime proxetil tab 100 mg^ 2cefpodoxime proxetil tab 200 mg^ 2cefprozil for susp 125 mg/5ml^ 2cefprozil for susp 250 mg/5ml^ 2cefprozil tab 250 mg^ 2cefprozil tab 500 mg^ 2ceftazidime for inj 1 gm^ 2ceftazidime for inj 2 gm^ 2ceftazidime for inj 6 gm^ 2CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

3

ceftriaxone sodium for inj 250 mg^ 2ceftriaxone sodium for inj 500 mg^ 2ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm^ 2ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%3

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22%

3

cefuroxime axetil tab 250 mg^ 2cefuroxime axetil tab 500 mg^ 2cefuroxime sodium for inj 750 mg^ 2cefuroxime sodium for inj 7.5 gm^ 2cefuroxime sodium for iv soln 1.5 gm^ 2cephalexin cap 250 mg^ 1cephalexin cap 500 mg^ 1cephalexin cap 750 mg^ 1cephalexin for susp 125 mg/5ml^ 2cephalexin for susp 250 mg/5ml^ 2

2019


Drug Name Drug Tier Requirements/LimitsCHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 4CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%)

(10 gm/100ml)4

CIPRO - ciprofloxacin hcl tab 250 mg 4CIPRO - ciprofloxacin hcl tab 500 mg 4CIPRO I.V.-IN D5W - ciprofloxacin 400 mg/200ml in d5w 4ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)^ 2ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)^ 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab er 24hr 500 mg^ 2ciprofloxacin hcl tab er 24hr 1000 mg^ 2ciprofloxacin hcl tab 250 mg^ 1ciprofloxacin hcl tab 500 mg^ 1ciprofloxacin hcl tab 750 mg^ 1ciprofloxacin 200 mg/100ml in d5w^ 2ciprofloxacin 400 mg/200ml in d5w^ 2clarithromycin for susp 125 mg/5ml^ 2clarithromycin for susp 250 mg/5ml^ 2clarithromycin tab er 24hr 500 mg^ 2clarithromycin tab 250 mg^ 2clarithromycin tab 500 mg^ 2CLEOCIN - clindamycin hcl cap 75 mg 4CLEOCIN - clindamycin hcl cap 150 mg 4CLEOCIN - clindamycin hcl cap 300 mg 4CLEOCIN - clindamycin phosphate vaginal cream 2% 4CLEOCIN IN D5W - clindamycin phosphate in d5w iv soln

300 mg/50ml4

CLEOCIN IN D5W - clindamycin phosphate in d5w iv soln600 mg/50ml

4

CLEOCIN IN D5W - clindamycin phosphate in d5w iv soln900 mg/50ml

4

CLEOCIN PHOSPHATE - clindamycin phosphate in d5w iv soln300 mg/50ml

4


4


4

CLEOCIN PHOSPHATE - clindamycin phosphate inj 300 mg/2ml 4CLEOCIN PHOSPHATE - clindamycin phosphate inj 600 mg/4ml 4

2019


11

Drug Name Drug Tier Requirements/LimitsCLEOCIN PHOSPHATE - clindamycin phosphate inj 900 mg/6ml 4CLEOCIN PHOSPHATE - clindamycin phosphate inj 9 gm/60ml 4CLEOCIN PHOSPHATE - clindamycin phosphate iv soln

300 mg/2ml4

CLEOCIN PHOSPHATE - clindamycin phosphate iv soln600 mg/4ml

4

CLEOCIN PHOSPHATE - clindamycin phosphate iv soln900 mg/6ml

4

CLEOCIN-T - clindamycin phosphate gel 1% 4CLEOCIN-T - clindamycin phosphate lotion 1% 4CLEOCIN-T - clindamycin phosphate soln 1% 4CLEOCIN-T - clindamycin phosphate swab 1% 4clindamycin hcl cap 75 mg^ 2clindamycin hcl cap 150 mg^ 2clindamycin hcl cap 300 mg^ 2clindamycin phosphate gel 1%^ 2clindamycin phosphate in d5w iv soln 300 mg/50ml^ 2clindamycin phosphate in d5w iv soln 600 mg/50ml^ 2clindamycin phosphate in d5w iv soln 900 mg/50ml^ 2clindamycin phosphate inj 300 mg/2ml^ 2clindamycin phosphate inj 600 mg/4ml^ 2clindamycin phosphate inj 900 mg/6ml^ 2clindamycin phosphate inj 9 gm/60ml^ 2clindamycin phosphate iv soln 300 mg/2ml^ 2clindamycin phosphate iv soln 600 mg/4ml^ 2clindamycin phosphate iv soln 900 mg/6ml^ 2clindamycin phosphate lotion 1%^ 2clindamycin phosphate soln 1%^ 2clindamycin phosphate swab 1%^ 2clindamycin phosphate vaginal cream 2%^ 2colistimethate sod for inj 150 mg 5CUBICIN - daptomycin for iv soln 500 mg 5CUBICIN RF - daptomycin for iv soln 500 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg^ 2demeclocycline hcl tab 300 mg^ 2dicloxacillin sodium cap 250 mg^ 2dicloxacillin sodium cap 500 mg^ 2

2019


Drug Name Drug Tier Requirements/LimitsDIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj 100 mg^ 2doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2doxycycline monohydrate cap 50 mg^ 2doxycycline monohydrate cap 75 mg^ 2doxycycline monohydrate cap 100 mg^ 2doxycycline monohydrate cap 150 mg^ 2doxycycline monohydrate tab 50 mg^ 2doxycycline monohydrate tab 75 mg^ 2doxycycline monohydrate tab 100 mg^ 2doxycycline monohydrate tab 150 mg^ 2E.E.S. GRANULES - erythromycin ethylsuccinate for susp

200 mg/5ml4

ertapenem sodium for inj 1 gm^ 2ERY-TAB - erythromycin tab delayed release 250 mg 4ERY-TAB - erythromycin tab delayed release 333 mg 4ERY-TAB - erythromycin tab delayed release 500 mg 4ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg5

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml^ 2erythromycin pads 2%^ 2erythromycin soln 2%^ 2erythromycin tab 250 mg^ 2erythromycin tab 500 mg^ 2FLAGYL - metronidazole cap 375 mg 4FLAGYL - metronidazole tab 250 mg 4FLAGYL - metronidazole tab 500 mg 4gentamicin in saline inj 0.8 mg/ml^ 2gentamicin in saline inj 1 mg/ml^ 2gentamicin in saline inj 1.6 mg/ml^ 2gentamicin in saline inj 1.2 mg/ml^ 2gentamicin sulfate inj 10 mg/ml^ 2gentamicin sulfate inj 40 mg/ml^ 2

2019


13

Drug Name Drug Tier Requirements/LimitsHIPREX - methenamine hippurate tab 1 gm 4imipenem-cilastatin intravenous for soln 250 mg^ 2imipenem-cilastatin intravenous for soln 500 mg^ 2IMPAVIDO - miltefosine cap 50 mg 5INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4KLARON - sulfacetamide sodium lotion 10% 4levofloxacin in d5w iv soln 250 mg/50ml^ 2levofloxacin in d5w iv soln 500 mg/100ml^ 2levofloxacin in d5w iv soln 750 mg/150ml^ 2levofloxacin iv soln 25 mg/ml^ 2levofloxacin oral soln 25 mg/ml^ 2levofloxacin tab 250 mg^ 1levofloxacin tab 500 mg^ 1levofloxacin tab 750 mg^ 1LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%5

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 5linezolid tab 600 mg^ 2 PAmeropenem iv for soln 500 mg^ 2meropenem iv for soln 1 gm^ 2MERREM - meropenem iv for soln 500 mg 4MERREM - meropenem iv for soln 1 gm 4methenamine hippurate tab 1 gm^ 2METROGEL-VAGINAL - metronidazole vaginal gel 0.75% 4METRONIDAZOLE - metronidazole in nacl 0.74% iv soln

500 mg/100ml3

METRONIDAZOLE - metronidazole iv soln 5 mg/ml 3metronidazole cap 375 mg^ 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole tab 250 mg^ 2metronidazole tab 500 mg^ 2metronidazole vaginal gel 0.75%^ 2MINOCIN - minocycline hcl cap 50 mg 4minocycline hcl cap 50 mg^ 2minocycline hcl cap 75 mg^ 2minocycline hcl cap 100 mg^ 2minocycline hcl tab 50 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitsminocycline hcl tab 75 mg^ 2minocycline hcl tab 100 mg^ 2MOXIFLOXACIN HCL - moxifloxacin hcl iv solution 400 mg/250ml^ 2moxifloxacin hcl tab 400 mg^ 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj^ 2NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 4NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 4nafcillin sodium for inj 1 gm 4nafcillin sodium for inj 2 gm 4nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg^ 2neomycin-polymyxin b gu irrigation soln^ 2nitrofurantoin macrocrystalline cap 50 mg# 3 PAnitrofurantoin macrocrystalline cap 100 mg# 3 PAnitrofurantoin monohydrate macrocrystalline cap 100 mg# 4 PAnitrofurantoin susp 25 mg/5ml# 4 PAofloxacin tab 400 mg^ 2paromomycin sulfate cap 250 mg^ 2penicillin g potassium for inj 5000000 unit^ 2penicillin g potassium for inj 20000000 unit^ 2PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4penicillin v potassium for soln 125 mg/5ml^ 2penicillin v potassium for soln 250 mg/5ml^ 2penicillin v potassium tab 250 mg^ 1penicillin v potassium tab 500 mg^ 1PFIZERPEN - penicillin g potassium for inj 20000000 unit 4piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm)^ 2piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)^ 2piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm)^ 2SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3

2019


15

Drug Name Drug Tier Requirements/Limitssulfacetamide sodium lotion 10%^ 2SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml^ 2sulfamethoxazole-trimethoprim susp 200-40 mg/5ml^ 2sulfamethoxazole-trimethoprim tab 400-80 mg^ 1sulfamethoxazole-trimethoprim tab 800-160 mg^ 1SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm^ 2TAZICEF - ceftazidime for iv soln 2 gm^ 2TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg^ 2tetracycline hcl cap 500 mg^ 2tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml^ 2TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3trimethoprim tab 100 mg^ 2TYGACIL - tigecycline for iv soln 50 mg 5VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm^ 2vancomycin hcl cap 125 mg^ 2vancomycin hcl cap 250 mg^ 2vancomycin hcl for iv soln 500 mg^ 2vancomycin hcl for iv soln 750 mg^ 2vancomycin hcl for iv soln 1 gm^ 2vancomycin hcl for iv soln 5 gm^ 2vancomycin hcl for iv soln 10 gm^ 2VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose iv

soln 500 mg/100ml-5%4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 750 mg/150ml-5%

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 1 gm/200ml-5%

4

2019


Drug Name Drug Tier Requirements/LimitsVANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln

250 mg4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

4

VIBRAMYCIN - doxycycline hyclate cap 100 mg 4ZITHROMAX - azithromycin for susp 100 mg/5ml 4ZITHROMAX - azithromycin for susp 200 mg/5ml 4ZITHROMAX - azithromycin iv for soln 500 mg 4ZITHROMAX - azithromycin tab 250 mg 4ZITHROMAX - azithromycin tab 500 mg 4ZITHROMAX - azithromycin tab 600 mg 4ZITHROMAX TRI-PAK - azithromycin tab 500 mg 4ZITHROMAX Z-PAK - azithromycin tab 250 mg 4ZOSYN - piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)4

ZOSYN - piperacillin sod-tazobactam sod for inj 2.25 gm(2-0.25 gm)

4

ZOSYN - piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

ZYVOX - linezolid for susp 100 mg/5ml 5 PAZYVOX - linezolid iv soln 200 mg/100ml (2 mg/ml) 5ZYVOX - linezolid iv soln 600 mg/300ml (2 mg/ml) 5ZYVOX - linezolid tab 600 mg 5 PAAnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5

2019


17

Drug Name Drug Tier Requirements/LimitsBRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg^ 2carbamazepine cap er 12hr 200 mg^ 2carbamazepine cap er 12hr 300 mg^ 2carbamazepine chew tab 100 mg^ 2carbamazepine susp 100 mg/5ml^ 2carbamazepine tab er 12hr 100 mg^ 2carbamazepine tab er 12hr 200 mg^ 2carbamazepine tab er 12hr 400 mg^ 2carbamazepine tab 200 mg^ 2CARBATROL - carbamazepine cap er 12hr 100 mg 4CARBATROL - carbamazepine cap er 12hr 200 mg 4CARBATROL - carbamazepine cap er 12hr 300 mg 4CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml^ 2 PA, QL (480 mls/30 days)clobazam tab 10 mg^ 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg^ 2 PA, QL (60 tablets/30 days)DEPACON - valproate sodium inj 100 mg/ml 4DEPAKENE - valproic acid cap 250 mg 4DEPAKOTE - divalproex sodium tab delayed release 125 mg 4DEPAKOTE - divalproex sodium tab delayed release 250 mg 4DEPAKOTE - divalproex sodium tab delayed release 500 mg 4DEPAKOTE ER - divalproex sodium tab er 24 hr 250 mg 4DEPAKOTE ER - divalproex sodium tab er 24 hr 500 mg 4DEPAKOTE SPRINKLES - divalproex sodium cap delayed release

sprinkle 125 mg4

DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

2019


Drug Name Drug Tier Requirements/LimitsDIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

20 mg4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 4DILANTIN - phenytoin sodium extended cap 100 mg 4DILANTIN INFATABS - phenytoin chew tab 50 mg 4DILANTIN-125 - phenytoin susp 125 mg/5ml 4divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2EPIDIOLEX - cannabidiol soln 100 mg/ml 5 PAethosuximide cap 250 mg^ 2ethosuximide soln 250 mg/5ml^ 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg^ 2felbamate tab 600 mg^ 2fosphenytoin sodium inj 100 mg/2ml^ 2fosphenytoin sodium inj 500 mg/10ml^ 2FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg^ 1 QL (1080 capsules/30 days)gabapentin cap 300 mg^ 1 QL (360 capsules/30 days)gabapentin cap 400 mg^ 1 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml^ 2 QL (2160 mls/30 days)gabapentin tab 600 mg^ 2 QL (180 tablets/30 days)gabapentin tab 800 mg^ 2 QL (135 tablets/30 days)GABITRIL - tiagabine hcl tab 2 mg 4GABITRIL - tiagabine hcl tab 4 mg 4GABITRIL - tiagabine hcl tab 12 mg 4GABITRIL - tiagabine hcl tab 16 mg 4KEPPRA - levetiracetam inj 500 mg/5ml (100 mg/ml) 4KEPPRA - levetiracetam oral soln 100 mg/ml 4

2019


19

Drug Name Drug Tier Requirements/LimitsKEPPRA - levetiracetam tab 250 mg 4KEPPRA - levetiracetam tab 500 mg 4KEPPRA - levetiracetam tab 750 mg 4KEPPRA - levetiracetam tab 1000 mg 4LAMICTAL - lamotrigine tab 25 mg 5LAMICTAL - lamotrigine tab 100 mg 5LAMICTAL - lamotrigine tab 150 mg 5LAMICTAL - lamotrigine tab 200 mg 5LAMICTAL CHEWABLE DISPERSIBLE - lamotrigine tab chewable

dispersible 5 mg4

LAMICTAL CHEWABLE DISPERSIBLE - lamotrigine tab chewabledispersible 25 mg

5

lamotrigine tab chewable dispersible 5 mg^ 2lamotrigine tab chewable dispersible 25 mg^ 2lamotrigine tab 25 mg^ 1lamotrigine tab 100 mg^ 1lamotrigine tab 150 mg^ 1lamotrigine tab 200 mg^ 1levetiracetam in sodium chloride iv soln 500 mg/100ml^ 2levetiracetam in sodium chloride iv soln 1000 mg/100ml^ 2levetiracetam in sodium chloride iv soln 1500 mg/100ml^ 2levetiracetam inj 500 mg/5ml (100 mg/ml)^ 2levetiracetam oral soln 100 mg/ml^ 2levetiracetam tab 250 mg^ 2levetiracetam tab 500 mg^ 2levetiracetam tab 750 mg^ 2levetiracetam tab 1000 mg^ 2LYRICA - pregabalin cap 25 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 50 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 75 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 100 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 150 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 200 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 225 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin cap 300 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)MYSOLINE - primidone tab 50 mg 5MYSOLINE - primidone tab 250 mg 5NEURONTIN - gabapentin cap 100 mg 4 QL (1080 capsules/30 days)

2019


Drug Name Drug Tier Requirements/LimitsNEURONTIN - gabapentin cap 300 mg 4 QL (360 capsules/30 days)NEURONTIN - gabapentin cap 400 mg 4 QL (270 capsules/30 days)NEURONTIN - gabapentin oral soln 250 mg/5ml 4 QL (2160 mls/30 days)NEURONTIN - gabapentin tab 600 mg 4 QL (180 tablets/30 days)NEURONTIN - gabapentin tab 800 mg 4 QL (135 tablets/30 days)ONFI - clobazam suspension 2.5 mg/ml 5 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 5 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 5 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml)^ 2oxcarbazepine tab 150 mg^ 2oxcarbazepine tab 300 mg^ 2oxcarbazepine tab 600 mg^ 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 15 mg# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 30 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 60 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenobarbital tab 100 mg# 4 PAPHENYTEK - phenytoin sodium extended cap 200 mg 4PHENYTEK - phenytoin sodium extended cap 300 mg 4phenytoin chew tab 50 mg^ 2phenytoin sodium extended cap 100 mg^ 2phenytoin sodium extended cap 200 mg^ 2phenytoin sodium extended cap 300 mg^ 2phenytoin susp 125 mg/5ml^ 2primidone tab 50 mg^ 2primidone tab 250 mg^ 2SABRIL - vigabatrin powd pack 500 mg* 5SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 5

2019


21

Drug Name Drug Tier Requirements/LimitsSPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)TEGRETOL - carbamazepine susp 100 mg/5ml 4TEGRETOL - carbamazepine tab 200 mg 4TEGRETOL-XR - carbamazepine tab er 12hr 100 mg 4TEGRETOL-XR - carbamazepine tab er 12hr 200 mg 4TEGRETOL-XR - carbamazepine tab er 12hr 400 mg 4tiagabine hcl tab 2 mg^ 2tiagabine hcl tab 4 mg^ 2tiagabine hcl tab 12 mg^ 2tiagabine hcl tab 16 mg^ 2topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 1topiramate tab 50 mg^ 1topiramate tab 100 mg^ 1topiramate tab 200 mg^ 1TRILEPTAL - oxcarbazepine susp 300 mg/5ml (60 mg/ml) 5TRILEPTAL - oxcarbazepine tab 150 mg 4TRILEPTAL - oxcarbazepine tab 300 mg 4TRILEPTAL - oxcarbazepine tab 600 mg 4valproate sodium inj 100 mg/ml^ 2valproate sodium oral soln 250 mg/5ml^ 2valproic acid cap 250 mg^ 2vigabatrin powd pack 500 mg* 5vigabatrin tab 500 mg* 5VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3ZARONTIN - ethosuximide cap 250 mg 4ZONEGRAN - zonisamide cap 25 mg 5ZONEGRAN - zonisamide cap 100 mg 5zonisamide cap 25 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitszonisamide cap 50 mg^ 2zonisamide cap 100 mg^ 2Antidementia AgentsARICEPT - donepezil hydrochloride tab 5 mg 4ARICEPT - donepezil hydrochloride tab 10 mg 4donepezil hydrochloride orally disintegrating tab 5 mg^ 2donepezil hydrochloride orally disintegrating tab 10 mg^ 2donepezil hydrochloride tab 5 mg^ 1donepezil hydrochloride tab 10 mg^ 1donepezil hydrochloride tab 23 mg^ 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3 PAEXELON - rivastigmine td patch 24hr 4.6 mg/24hr 4EXELON - rivastigmine td patch 24hr 9.5 mg/24hr 4EXELON - rivastigmine td patch 24hr 13.3 mg/24hr 4GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg^ 2galantamine hydrobromide cap er 24hr 16 mg^ 2galantamine hydrobromide cap er 24hr 24 mg^ 2galantamine hydrobromide tab 4 mg^ 2galantamine hydrobromide tab 8 mg^ 2galantamine hydrobromide tab 12 mg^ 2memantine hcl oral solution 2 mg/ml^ 2 PAmemantine hcl tab 5 mg^ 2 PAmemantine hcl tab 10 mg^ 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak^ 2 PANAMENDA - memantine hcl tab 5 mg 4 PANAMENDA - memantine hcl tab 10 mg 4 PANAMENDA TITRATION PAK - memantine hcl tab 5 mg (28) &

10 mg (21) titration pak4 PA

RAZADYNE - galantamine hydrobromide tab 4 mg 4RAZADYNE - galantamine hydrobromide tab 8 mg 4RAZADYNE - galantamine hydrobromide tab 12 mg 4RAZADYNE ER - galantamine hydrobromide cap er 24hr 8 mg 4RAZADYNE ER - galantamine hydrobromide cap er 24hr 16 mg 4RAZADYNE ER - galantamine hydrobromide cap er 24hr 24 mg 4rivastigmine tartrate cap 1.5 mg^ 2rivastigmine tartrate cap 3 mg^ 2rivastigmine tartrate cap 4.5 mg^ 2

2019


23

Drug Name Drug Tier Requirements/Limitsrivastigmine tartrate cap 6 mg^ 2rivastigmine td patch 24hr 4.6 mg/24hr^ 2rivastigmine td patch 24hr 9.5 mg/24hr^ 2rivastigmine td patch 24hr 13.3 mg/24hr^ 2Antidepressantsamitriptyline hcl tab 10 mg# 4 PAamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg# 4 PAAMOXAPINE - amoxapine tab 50 mg# 4 PAAMOXAPINE - amoxapine tab 100 mg# 4 PAAMOXAPINE - amoxapine tab 150 mg# 4 PAbupropion hcl tab er 12hr 100 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg^ 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg^ 2 QL (120 tablets/30 days)CELEXA - citalopram hydrobromide tab 10 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 20 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 40 mg 4 QL (30 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml^ 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg^ 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PACYMBALTA - duloxetine hcl enteric coated pellets cap 20 mg 4 QL (60 capsules/30 days)CYMBALTA - duloxetine hcl enteric coated pellets cap 30 mg 4 QL (90 capsules/30 days)CYMBALTA - duloxetine hcl enteric coated pellets cap 60 mg 4 QL (60 capsules/30 days)desipramine hcl tab 10 mg# 3 PAdesipramine hcl tab 25 mg# 3 PAdesipramine hcl tab 50 mg# 3 PA

2019


Drug Name Drug Tier Requirements/Limitsdesipramine hcl tab 75 mg# 3 PAdesipramine hcl tab 100 mg# 3 PAdesipramine hcl tab 150 mg# 3 PAdesvenlafaxine succinate tab er 24hr 25 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg^ 2 QL (30 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 3 PAduloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)EFFEXOR XR - venlafaxine hcl cap er 24hr 37.5 mg 4 QL (60 capsules/30 days)EFFEXOR XR - venlafaxine hcl cap er 24hr 75 mg 4 QL (90 capsules/30 days)EFFEXOR XR - venlafaxine hcl cap er 24hr 150 mg 4 QL (30 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml^ 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg^ 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg^ 1 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg^ 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg^ 1 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml^ 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg^ 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg^ 2 QL (120 tablets/30 days)

2019


25

Drug Name Drug Tier Requirements/Limitsfluvoxamine maleate tab 25 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg^ 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4 PAimipramine hcl tab 25 mg# 4 PAimipramine hcl tab 50 mg# 4 PALEXAPRO - escitalopram oxalate tab 5 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 10 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 20 mg 4 QL (30 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 5mirtazapine orally disintegrating tab 15 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 15 mg^ 2 QL (45 tablets/30 days)mirtazapine tab 30 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 45 mg^ 2 QL (30 tablets/30 days)NARDIL - phenelzine sulfate tab 15 mg 4NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 50 mg^ 2nefazodone hcl tab 250 mg^ 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3NORPRAMIN - desipramine hcl tab 10 mg# 4 PANORPRAMIN - desipramine hcl tab 25 mg# 4 PAnortriptyline hcl cap 10 mg# 4 PAnortriptyline hcl cap 25 mg# 4 PAnortriptyline hcl cap 50 mg# 4 PAnortriptyline hcl cap 75 mg# 4 PAnortriptyline hcl soln 10 mg/5ml# 4 PAPARNATE - tranylcypromine sulfate tab 10 mg 5paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsPAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)PAXIL - paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)PAXIL - paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)PAXIL - paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)phenelzine sulfate tab 15 mg^ 2PRISTIQ - desvenlafaxine succinate tab er 24hr 25 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 50 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 100 mg 4 QL (30 tablets/30 days)protriptyline hcl tab 5 mg# 4 PAprotriptyline hcl tab 10 mg# 4 PAPROZAC - fluoxetine hcl cap 10 mg 4 QL (90 capsules/30 days)PROZAC - fluoxetine hcl cap 20 mg 4 QL (120 capsules/30 days)PROZAC - fluoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)REMERON - mirtazapine tab 15 mg 4 QL (45 tablets/30 days)REMERON - mirtazapine tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 4 QL (30 tablets/30 days)sertraline hcl oral concentrate for solution 20 mg/ml^ 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)SURMONTIL - trimipramine maleate cap 25 mg# 4 PASURMONTIL - trimipramine maleate cap 50 mg# 4 PASURMONTIL - trimipramine maleate cap 100 mg# 4 PAtranylcypromine sulfate tab 10 mg^ 2trazodone hcl tab 50 mg^ 1trazodone hcl tab 100 mg^ 1trazodone hcl tab 150 mg^ 1trazodone hcl tab 300 mg^ 1trimipramine maleate cap 25 mg# 4 PAtrimipramine maleate cap 50 mg# 4 PAtrimipramine maleate cap 100 mg# 4 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg^ 2 QL (60 capsules/30 days)

2019


27

Drug Name Drug Tier Requirements/Limitsvenlafaxine hcl cap er 24hr 75 mg^ 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg^ 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg^ 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg^ 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg^ 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

WELLBUTRIN SR - bupropion hcl tab er 12hr 100 mg 4 QL (90 tablets/30 days)WELLBUTRIN SR - bupropion hcl tab er 12hr 150 mg 4 QL (60 tablets/30 days)WELLBUTRIN SR - bupropion hcl tab er 12hr 200 mg 5 QL (60 tablets/30 days)WELLBUTRIN XL - bupropion hcl tab er 24hr 150 mg 5 QL (90 tablets/30 days)WELLBUTRIN XL - bupropion hcl tab er 24hr 300 mg 5 QL (30 tablets/30 days)ZOLOFT - sertraline hcl tab 25 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 50 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 100 mg 4 QL (60 tablets/30 days)AntiemeticsALOXI - palonosetron hcl iv soln 0.25 mg/5ml 5aprepitant capsule therapy pack 80 & 125 mg^ 2 BDaprepitant capsule 40 mg^ 2 BDaprepitant capsule 80 mg^ 2 BDaprepitant capsule 125 mg^ 2 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg^ 2 PAchlorpromazine hcl tab 25 mg^ 2 PAchlorpromazine hcl tab 50 mg^ 2 PAchlorpromazine hcl tab 100 mg^ 2 PAchlorpromazine hcl tab 200 mg^ 2 PAdronabinol cap 2.5 mg^ 2 BDdronabinol cap 5 mg^ 2 BDdronabinol cap 10 mg^ 2 BD

2019


Drug Name Drug Tier Requirements/LimitsEMEND - aprepitant capsule 40 mg 4 BDEMEND - aprepitant capsule 80 mg 4 BDEMEND - aprepitant capsule 125 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4EMEND TRIPACK - aprepitant capsule therapy pack 80 & 125 mg 4 BDgranisetron hcl inj 1 mg/ml^ 2granisetron hcl inj 4 mg/4ml (1 mg/ml)^ 2granisetron hcl tab 1 mg^ 2 BDmeclizine hcl tab 12.5 mg# 4meclizine hcl tab 25 mg# 4ondansetron hcl inj 4 mg/2ml (2 mg/ml)^ 2ondansetron hcl inj 40 mg/20ml (2 mg/ml)^ 2ondansetron hcl oral soln 4 mg/5ml^ 2 BDondansetron hcl tab 4 mg^ 2 BDondansetron hcl tab 8 mg^ 2 BDondansetron hcl tab 24 mg^ 2 BDondansetron orally disintegrating tab 4 mg^ 2 BDondansetron orally disintegrating tab 8 mg^ 2 BDpalonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

pref syr 0.25 mg/5ml5

PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln0.25 mg/2ml

5

perphenazine tab 2 mg^ 2 PAperphenazine tab 4 mg^ 2 PAperphenazine tab 8 mg^ 2 PAperphenazine tab 16 mg^ 2 PAprochlorperazine edisylate inj 5 mg/ml^ 2prochlorperazine maleate tab 5 mg^ 2prochlorperazine maleate tab 10 mg^ 2prochlorperazine suppos 25 mg^ 2promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAZOFRAN - ondansetron hcl oral soln 4 mg/5ml 4 BDZOFRAN - ondansetron hcl tab 4 mg 5 BD

2019


29

Drug Name Drug Tier Requirements/LimitsZOFRAN - ondansetron hcl tab 8 mg 4 BDZOFRAN ODT - ondansetron orally disintegrating tab 4 mg 4 BDZOFRAN ODT - ondansetron orally disintegrating tab 8 mg 5 BDAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for inj 50 mg 4 BDCANCIDAS - caspofungin acetate for iv soln 50 mg 5CANCIDAS - caspofungin acetate for iv soln 70 mg 5caspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77%^ 2ciclopirox olamine cream 0.77%^ 2ciclopirox olamine susp 0.77%^ 2ciclopirox shampoo 1%^ 2ciclopirox solution 8%^ 2clotrimazole cream 1%^ 2clotrimazole troche 10 mg^ 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PADIFLUCAN - fluconazole for susp 10 mg/ml 4DIFLUCAN - fluconazole for susp 40 mg/ml 4DIFLUCAN - fluconazole tab 50 mg 4DIFLUCAN - fluconazole tab 100 mg 4DIFLUCAN - fluconazole tab 150 mg 4DIFLUCAN - fluconazole tab 200 mg 4econazole nitrate cream 1%^ 2fluconazole for susp 10 mg/ml^ 2fluconazole for susp 40 mg/ml^ 2fluconazole in dextrose inj 200 mg/100ml^ 2fluconazole in dextrose inj 400 mg/200ml^ 2fluconazole in nacl 0.9% inj 200 mg/100ml^ 2fluconazole in nacl 0.9% inj 400 mg/200ml^ 2fluconazole tab 50 mg^ 2fluconazole tab 100 mg^ 2fluconazole tab 150 mg^ 2fluconazole tab 200 mg^ 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5

2019


Drug Name Drug Tier Requirements/Limitsgriseofulvin microsize susp 125 mg/5ml^ 2griseofulvin ultramicrosize tab 125 mg^ 2griseofulvin ultramicrosize tab 250 mg^ 2itraconazole cap 100 mg^ 2ketoconazole cream 2%^ 2ketoconazole shampoo 2%^ 2ketoconazole tab 200 mg^ 2LOPROX SHAMPOO - ciclopirox shampoo 1% 5MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NIZORAL - ketoconazole shampoo 2% 4NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm^ 2nystatin oint 100000 unit/gm^ 2nystatin susp 100000 unit/ml^ 2nystatin tab 500000 unit^ 2nystatin topical powder 100000 unit/gm^ 2SPORANOX - itraconazole cap 100 mg 5SPORANOX PULSEPAK - itraconazole cap 100 mg 5terbinafine hcl tab 250 mg^ 1terconazole vaginal cream 0.8%^ 2terconazole vaginal cream 0.4%^ 2terconazole vaginal suppos 80 mg^ 2VFEND IV - voriconazole for inj 200 mg 4 PAvoriconazole for inj 200 mg^ 2 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg^ 2allopurinol tab 100 mg^ 1allopurinol tab 300 mg^ 1ALOPRIM - allopurinol sodium for inj 500 mg 4colchicine w/ probenecid tab 0.5-500 mg^ 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg^ 2

2019


31

Drug Name Drug Tier Requirements/LimitsULORIC - febuxostat tab 40 mg 3 STULORIC - febuxostat tab 80 mg 3 STZYLOPRIM - allopurinol tab 100 mg 4ZYLOPRIM - allopurinol tab 300 mg 4Antimigraine AgentsAMERGE - naratriptan hcl tab 1 mg 4 QL (18 tablets/30 days)AMERGE - naratriptan hcl tab 2.5 mg 4 QL (18 tablets/30 days)IMITREX - sumatriptan nasal spray 5 mg/act 4 QL (12 units (2

packages)/30 days)IMITREX - sumatriptan nasal spray 20 mg/act 4 QL (12 units (2

packages)/30 days)IMITREX - sumatriptan succinate inj 6 mg/0.5ml 4IMITREX - sumatriptan succinate tab 25 mg 4 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 50 mg 4 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 100 mg 4 QL (18 tablets/30 days)IMITREX STATDOSE REFILL - sumatriptan succinate solution

cartridge 4 mg/0.5ml4

IMITREX STATDOSE REFILL - sumatriptan succinate solutioncartridge 6 mg/0.5ml

4

IMITREX STATDOSE SYSTEM - sumatriptan succinate solutionauto-injector 4 mg/0.5ml

4

IMITREX STATDOSE SYSTEM - sumatriptan succinate solutionauto-injector 6 mg/0.5ml

4

MAXALT - rizatriptan benzoate tab 10 mg 4 QL (18 tablets/30 days)MAXALT-MLT - rizatriptan benzoate oral disintegrating tab 5 mg 4 QL (18 tablets/30 days)MAXALT-MLT - rizatriptan benzoate oral disintegrating tab 10 mg 4 QL (18 tablets/30 days)MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg^ 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg^ 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act^ 2 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act^ 2 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml^2

sumatriptan succinate inj 6 mg/0.5ml^ 2

2019


Drug Name Drug Tier Requirements/Limitssumatriptan succinate solution auto-injector 4 mg/0.5ml^ 2sumatriptan succinate solution auto-injector 6 mg/0.5ml^ 2sumatriptan succinate solution cartridge 4 mg/0.5ml^ 2sumatriptan succinate solution cartridge 6 mg/0.5ml^ 2sumatriptan succinate tab 25 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg^ 2 QL (18 tablets/30 days)zolmitriptan orally disintegrating tab 2.5 mg^ 2 QL (12 tablets/30 days)zolmitriptan orally disintegrating tab 5 mg^ 2 QL (12 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 3MESTINON - pyridostigmine bromide syrup 60 mg/5ml 5MESTINON - pyridostigmine bromide tab 60 mg 5MESTINON TIMESPAN - pyridostigmine bromide tab er 180 mg 5pyridostigmine bromide tab er 180 mg^ 2pyridostigmine bromide tab 60 mg^ 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4cycloserine cap 250 mg 5dapsone tab 25 mg^ 2dapsone tab 100 mg^ 2ethambutol hcl tab 100 mg^ 2ethambutol hcl tab 400 mg^ 2ISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg^ 1isoniazid tab 300 mg^ 1MYCOBUTIN - rifabutin cap 150 mg 5PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg^ 2rifabutin cap 150 mg 5RIFADIN - rifampin cap 150 mg 4RIFADIN - rifampin for inj 600 mg 5rifampin cap 150 mg^ 2rifampin cap 300 mg^ 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg 5TRECATOR - ethionamide tab 250 mg 4

2019


33

Drug Name Drug Tier Requirements/LimitsAntineoplasticsabiraterone acetate tab 250 mg 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAAFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5 PAALIMTA - pemetrexed disodium for iv soln 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg^ 1ARIMIDEX - anastrozole tab 1 mg 4AROMASIN - exemestane tab 25 mg 5ARRANON - nelarabine iv soln 5 mg/ml 5arsenic trioxide inj 10 mg/10ml (1 mg/ml)^ 2ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5 PAARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5 PAAVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5 PAAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5 PABAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5 PABELEODAQ - belinostat for iv inj 500 mg* 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg 5 PAbicalutamide tab 50 mg^ 2BICNU - carmustine for inj 100 mg 4bleomycin sulfate for inj 15 unit^ 2 BDbleomycin sulfate for inj 30 unit^ 2 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsBOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 50 mg 5 PA, QL (180 capsules/30 days)BRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml^ 2carboplatin iv soln 150 mg/15ml^ 2carboplatin iv soln 450 mg/45ml^ 2carboplatin iv soln 600 mg/60ml^ 2carmustine for inj 100 mg^ 2CASODEX - bicalutamide tab 50 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml)^ 2cisplatin inj 50 mg/50ml (1 mg/ml)^ 2cisplatin inj 100 mg/100ml (1 mg/ml)^ 2cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5CLOLAR - clofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*


COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*


COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COSMEGEN - dactinomycin for inj 0.5 mg 5COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg^ 2 BDcyclophosphamide cap 50 mg^ 2 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5 PA

2019


35

Drug Name Drug Tier Requirements/LimitsCYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5 PACYTARABINE - cytarabine inj 20 mg/ml^ 2 BDcytarabine inj pf 20 mg/ml^ 2 BDcytarabine inj pf 100 mg/ml^ 2 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg^ 2dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5 PADARZALEX - daratumumab iv soln 400 mg/20ml* 5 PAdaunorubicin hcl iv soln 20 mg/4ml^ 2DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml^2

DAURISMO - glasdegib maleate tab 25 mg 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5docetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg^ 2 BDdoxorubicin hcl for inj 50 mg^ 2 BDdoxorubicin hcl inj 2 mg/ml^ 2 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PAELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg 5 PAEMPLICITI - elotuzumab for iv soln 400 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml)^ 2epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)^ 2ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5 PAERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg 5 PA, QL (120 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml)^ 2etoposide inj 500 mg/25ml (20 mg/ml)^ 2etoposide inj 1 gm/50ml (20 mg/ml)^ 2EVOMELA - melphalan hcl for inj 50 mg* 5exemestane tab 25 mg^ 2FARESTON - toremifene citrate tab 60 mg 5FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5FEMARA - letrozole tab 2.5 mg 5fludarabine phosphate for inj 50 mg^ 2fludarabine phosphate inj 25 mg/ml^ 2fluorouracil iv soln 500 mg/10ml (50 mg/ml)^ 2 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml)^ 2 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml)^ 2 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml)^ 2 BDflutamide cap 125 mg^ 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAGAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg^ 2gemcitabine hcl for inj 1 gm^ 2gemcitabine hcl for inj 2 gm^ 2gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)^ 2gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)^ 2gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)^ 2GILOTRIF - afatinib dimaleate tab 20 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 5 PA, QL (30 tablets/30 days)GLEEVEC - imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)GLEEVEC - imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 5

2019


37

Drug Name Drug Tier Requirements/LimitsHALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN - trastuzumab for iv soln 440 mg* 5 PAHYDREA - hydroxyurea cap 500 mg 4hydroxyurea cap 500 mg^ 2IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm^ 2ifosfamide iv inj 1 gm/20ml (50 mg/ml)^ 2ifosfamide iv inj 3 gm/60ml (50 mg/ml)^ 2imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml*4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml*

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml)^ 2irinotecan hcl inj 40 mg/2ml (20 mg/ml)^ 2

2019


Drug Name Drug Tier Requirements/Limitsirinotecan hcl inj 100 mg/5ml (20 mg/ml)^ 2ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5 PAKISQALI - ribociclib succinate tab 200 mg 5 PA, QL (63 tablets/28 days)KISQALI FEMARA 200 DOSE - ribociclib tab 200 mg & letrozole

tab 2.5 mg therapy pack5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 600 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack


KYPROLIS - carfilzomib for inj 10 mg 5 PAKYPROLIS - carfilzomib for inj 30 mg 5 PAKYPROLIS - carfilzomib for inj 60 mg 5 PALARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

2019


39

Drug Name Drug Tier Requirements/Limitsletrozole tab 2.5 mg^ 1LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)4

LEUCOVORIN CALCIUM - leucovorin calcium inj 500 mg/50ml(10 mg/ml)

4

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg^ 2leucovorin calcium for inj 100 mg^ 2leucovorin calcium for inj 200 mg^ 2leucovorin calcium for inj 350 mg^ 2leucovorin calcium for inj 500 mg^ 2leucovorin calcium tab 5 mg^ 2leucovorin calcium tab 25 mg^ 2LEUKERAN - chlorambucil tab 2 mg 5LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml) 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg 5 PALYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg^ 2mesna inj 100 mg/ml^ 2MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg^ 2mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)^ 2mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)^ 2mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml)^ 2

2019


Drug Name Drug Tier Requirements/LimitsMYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)NILANDRON - nilutamide tab 150 mg 5nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml* 5 PAOPDIVO - nivolumab iv soln 100 mg/10ml* 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml* 5 PAoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml^ 2oxaliplatin iv soln 100 mg/20ml^ 2paclitaxel iv conc 30 mg/5ml (6 mg/ml)^ 2paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)^ 2paclitaxel iv conc 300 mg/50ml (6 mg/ml)^ 2PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

POMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PAPROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)

2019


41

Drug Name Drug Tier Requirements/LimitsRITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml

5 PA

RUBRACA - rucaparib camsylate tab 200 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg^ 2tamoxifen citrate tab 20 mg^ 2TARCEVA - erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene cap 75 mg 5 PATARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)

2019


Drug Name Drug Tier Requirements/LimitsTASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TAXOTERE - docetaxel for inj conc 20 mg/ml 5TAXOTERE - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5TECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg^ 2topotecan hcl inj 4 mg/4ml (for infusion)^ 2toremifene citrate tab 60 mg 5TORISEL - temsirolimus soln for iv infusion 25 mg/ml 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (120 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BDvincristine sulfate iv soln 1 mg/ml^ 2 BDvinorelbine tartrate inj 10 mg/ml^ 2vinorelbine tartrate inj 50 mg/5ml (10 mg/ml)^ 2

2019


43

Drug Name Drug Tier Requirements/LimitsVITRAKVI - larotrectinib sulfate cap 25 mg 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5 PAYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5 PAYONDELIS - trabectedin for inj 1 mg 5 PAYONSA - abiraterone acetate tab 125 mg* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5 PAZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (90 capsules/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 5 PA, QL (120 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 5ALBENZA - albendazole tab 200 mg 5ALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg^ 2atovaquone-proguanil hcl tab 250-100 mg^ 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4BILTRICIDE - praziquantel tab 600 mg 5

2019


Drug Name Drug Tier Requirements/LimitsCHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg^ 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg^ 2ivermectin tab 3 mg^ 2lindane shampoo 1% 3MALARONE - atovaquone-proguanil hcl tab 62.5-25 mg 4MALARONE - atovaquone-proguanil hcl tab 250-100 mg 4malathion lotion 0.5%^ 2mefloquine hcl tab 250 mg^ 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDOVIDE - malathion lotion 0.5% 4PENTAM 300 - pentamidine isethionate for soln 300 mg 4permethrin cream 5%^ 2PLAQUENIL - hydroxychloroquine sulfate tab 200 mg 4praziquantel tab 600 mg 5PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26.3 mg 3STROMECTOL - ivermectin tab 3 mg 4Antiparkinson Agentsamantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2amantadine hcl tab 100 mg^ 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)AZILECT - rasagiline mesylate tab 0.5 mg 5AZILECT - rasagiline mesylate tab 1 mg 5benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg^ 2bromocriptine mesylate tab 2.5 mg^ 2carbidopa & levodopa orally disintegrating tab 10-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-250 mg^ 2carbidopa & levodopa tab er 25-100 mg^ 2carbidopa & levodopa tab er 50-200 mg^ 2carbidopa & levodopa tab 10-100 mg^ 2carbidopa & levodopa tab 25-100 mg^ 2

2019


45

Drug Name Drug Tier Requirements/Limitscarbidopa & levodopa tab 25-250 mg^ 2carbidopa tab 25 mg 5CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

3


3


3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

3

COMTAN - entacapone tab 200 mg 5entacapone tab 200 mg^ 2MIRAPEX - pramipexole dihydrochloride tab 0.125 mg 4MIRAPEX - pramipexole dihydrochloride tab 0.25 mg 4MIRAPEX - pramipexole dihydrochloride tab 0.5 mg 4MIRAPEX - pramipexole dihydrochloride tab 0.75 mg 4MIRAPEX - pramipexole dihydrochloride tab 1 mg 4MIRAPEX - pramipexole dihydrochloride tab 1.5 mg 4pramipexole dihydrochloride tab 0.125 mg^ 1pramipexole dihydrochloride tab 0.25 mg^ 1pramipexole dihydrochloride tab 0.5 mg^ 1pramipexole dihydrochloride tab 0.75 mg^ 1pramipexole dihydrochloride tab 1 mg^ 1pramipexole dihydrochloride tab 1.5 mg^ 1rasagiline mesylate tab 0.5 mg^ 2rasagiline mesylate tab 1 mg^ 2REQUIP - ropinirole hydrochloride tab 0.5 mg 4REQUIP - ropinirole hydrochloride tab 1 mg 4REQUIP - ropinirole hydrochloride tab 4 mg 4REQUIP - ropinirole hydrochloride tab 5 mg 4ropinirole hydrochloride tab er 24hr 2 mg^ 2ropinirole hydrochloride tab er 24hr 4 mg^ 2ropinirole hydrochloride tab er 24hr 6 mg^ 2ropinirole hydrochloride tab er 24hr 8 mg^ 2ropinirole hydrochloride tab er 24hr 12 mg^ 2ropinirole hydrochloride tab 0.25 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitsropinirole hydrochloride tab 0.5 mg^ 2ropinirole hydrochloride tab 1 mg^ 2ropinirole hydrochloride tab 2 mg^ 2ropinirole hydrochloride tab 3 mg^ 2ropinirole hydrochloride tab 4 mg^ 2ropinirole hydrochloride tab 5 mg^ 2selegiline hcl cap 5 mg^ 2selegiline hcl tab 5 mg^ 2SINEMET - carbidopa & levodopa tab 10-100 mg 4SINEMET - carbidopa & levodopa tab 25-100 mg 4SINEMET - carbidopa & levodopa tab 25-250 mg 4SINEMET CR - carbidopa & levodopa tab er 25-100 mg 4SINEMET CR - carbidopa & levodopa tab er 50-200 mg 4TASMAR - tolcapone tab 100 mg 5tolcapone tab 100 mg 5AntipsychoticsABILIFY - aripiprazole tab 2 mg 5 PA, QL (45 tablets/30 days)ABILIFY - aripiprazole tab 5 mg 5 PA, QL (45 tablets/30 days)ABILIFY - aripiprazole tab 10 mg 5 PA, QL (30 tablets/30 days)ABILIFY - aripiprazole tab 15 mg 5 PA, QL (30 tablets/30 days)ABILIFY - aripiprazole tab 20 mg 5 PA, QL (30 tablets/30 days)ABILIFY - aripiprazole tab 30 mg 5 PA, QL (30 tablets/30 days)ADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml^ 2 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg^ 2 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg^ 2 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg^ 2 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg^ 2 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg^ 2 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg^ 2 PA, QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 PA, QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 PA, QL (1 syringe/28 days)





2019


47

Drug Name Drug Tier Requirements/LimitsARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr

675 mg/2.4ml5 PA, QL (1 syringe/42 days)

clozapine orally disintegrating tab 12.5 mg^ 2 PA, QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg^ 2 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg^ 2 PA, QL (270 tablets/30 days)clozapine tab 25 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 50 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 100 mg^ 2 PA, QL (270 tablets/30 days)clozapine tab 200 mg^ 2 PA, QL (120 tablets/30 days)CLOZARIL - clozapine tab 25 mg 4 PA, QL (90 tablets/30 days)CLOZARIL - clozapine tab 100 mg 5 PA, QL (270 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)FAZACLO - clozapine orally disintegrating tab 25 mg 4 PA, QL (270 tablets/30 days)FAZACLO - clozapine orally disintegrating tab 100 mg 4 PA, QL (270 tablets/30 days)fluphenazine decanoate inj 25 mg/ml^ 2 PAFLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg^ 2 PAfluphenazine hcl tab 2.5 mg^ 2 PAfluphenazine hcl tab 5 mg^ 2 PAfluphenazine hcl tab 10 mg^ 2 PAGEODON - ziprasidone hcl cap 20 mg 5 PA, QL (90 capsules/30 days)GEODON - ziprasidone hcl cap 40 mg 5 PA, QL (90 capsules/30 days)GEODON - ziprasidone hcl cap 60 mg 5 PA, QL (60 capsules/30 days)GEODON - ziprasidone hcl cap 80 mg 5 PA, QL (60 capsules/30 days)GEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)HALDOL - haloperidol lactate inj 5 mg/ml 4 PAHALDOL DECANOATE 100 - haloperidol decanoate im soln

100 mg/ml4 PA

2019


Drug Name Drug Tier Requirements/LimitsHALDOL DECANOATE 50 - haloperidol decanoate im soln 50 mg/

ml4 PA

haloperidol decanoate im soln 50 mg/ml^ 2 PAhaloperidol decanoate im soln 100 mg/ml^ 2 PAhaloperidol lactate inj 5 mg/ml^ 2 PAhaloperidol lactate oral conc 2 mg/ml^ 2 PAhaloperidol tab 0.5 mg^ 2 PAhaloperidol tab 1 mg^ 2 PAhaloperidol tab 2 mg^ 2 PAhaloperidol tab 5 mg^ 2 PAhaloperidol tab 10 mg^ 2 PAhaloperidol tab 20 mg^ 2 PAINVEGA - paliperidone tab er 24hr 1.5 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab er 24hr 3 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab er 24hr 6 mg 5 PA, QL (60 tablets/30 days)INVEGA - paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)INVEGA SUSTENNA - paliperidone palmitate im extend-release

susp 117 mg/0.75ml5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 39 mg/0.25ml

4 PA, QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 156 mg/ml




INVEGA TRINZA - paliperidone palmitate im extend-release susp273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg^ 2 PAloxapine succinate cap 10 mg^ 2 PA

2019


49

Drug Name Drug Tier Requirements/Limitsloxapine succinate cap 25 mg^ 2 PAloxapine succinate cap 50 mg^ 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)NUPLAZID - pimavanserin tartrate tab 17 mg* 5 PA, QL (60 tablets/30 days)olanzapine for im inj 10 mg^ 2 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg^ 2 PA, QL (30 tablets/30 days)ORAP - pimozide tab 1 mg 4paliperidone tab er 24hr 1.5 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg^ 2 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 PA, QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


pimozide tab 1 mg^ 2pimozide tab 2 mg^ 2quetiapine fumarate tab er 24hr 50 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg^ 2 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg^ 2 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 25 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 PA, QL (120 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsquetiapine fumarate tab 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)RISPERDAL - risperidone soln 1 mg/ml 4 PA, QL (480 mls/30 days)RISPERDAL - risperidone tab 0.25 mg 4 PA, QL (60 tablets/30 days)RISPERDAL - risperidone tab 0.5 mg 4 PA, QL (60 tablets/30 days)RISPERDAL - risperidone tab 1 mg 4 PA, QL (60 tablets/30 days)RISPERDAL - risperidone tab 2 mg 4 PA, QL (60 tablets/30 days)RISPERDAL - risperidone tab 3 mg 5 PA, QL (60 tablets/30 days)RISPERDAL - risperidone tab 4 mg 5 PA, QL (120 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 5 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 5 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg^ 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml^ 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg^ 1 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg^ 1 PA, QL (60 tablets/30 days)risperidone tab 1 mg^ 1 PA, QL (60 tablets/30 days)risperidone tab 2 mg^ 1 PA, QL (60 tablets/30 days)risperidone tab 3 mg^ 1 PA, QL (60 tablets/30 days)risperidone tab 4 mg^ 1 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)SEROQUEL - quetiapine fumarate tab 25 mg 4 PA, QL (120 tablets/30 days)SEROQUEL - quetiapine fumarate tab 50 mg 4 PA, QL (120 tablets/30 days)SEROQUEL - quetiapine fumarate tab 100 mg 4 PA, QL (120 tablets/30 days)

2019


51

Drug Name Drug Tier Requirements/LimitsSEROQUEL - quetiapine fumarate tab 200 mg 4 PA, QL (120 tablets/30 days)SEROQUEL - quetiapine fumarate tab 300 mg 4 PA, QL (60 tablets/30 days)SEROQUEL - quetiapine fumarate tab 400 mg 4 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab er 24hr 50 mg 4 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab er 24hr 150 mg 4 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab er 24hr 200 mg 4 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab er 24hr 300 mg 4 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab er 24hr 400 mg 4 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg^ 2 PAthiothixene cap 2 mg^ 2 PAthiothixene cap 5 mg^ 2 PAthiothixene cap 10 mg^ 2 PAtrifluoperazine hcl tab 1 mg^ 2 PAtrifluoperazine hcl tab 2 mg^ 2 PAtrifluoperazine hcl tab 5 mg^ 2 PAtrifluoperazine hcl tab 10 mg^ 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg^ 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg^ 2 PA, QL (60 capsules/30 days)ZYPREXA - olanzapine for im inj 10 mg 4 PA, QL (90 vials/30 days)ZYPREXA - olanzapine tab 2.5 mg 4 PA, QL (45 tablets/30 days)ZYPREXA - olanzapine tab 5 mg 4 PA, QL (45 tablets/30 days)ZYPREXA - olanzapine tab 7.5 mg 4 PA, QL (45 tablets/30 days)ZYPREXA - olanzapine tab 10 mg 4 PA, QL (45 tablets/30 days)ZYPREXA - olanzapine tab 15 mg 4 PA, QL (30 tablets/30 days)ZYPREXA - olanzapine tab 20 mg 4 PA, QL (30 tablets/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 PA, QL (2 vials/28 days)

2019


Drug Name Drug Tier Requirements/LimitsZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 300 mg5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

ZYPREXA ZYDIS - olanzapine orally disintegrating tab 5 mg 4 PA, QL (30 tablets/30 days)ZYPREXA ZYDIS - olanzapine orally disintegrating tab 10 mg 4 PA, QL (30 tablets/30 days)ZYPREXA ZYDIS - olanzapine orally disintegrating tab 15 mg 4 PA, QL (30 tablets/30 days)ZYPREXA ZYDIS - olanzapine orally disintegrating tab 20 mg 4 PA, QL (30 tablets/30 days)Antispasticity Agentsbaclofen tab 10 mg^ 2baclofen tab 20 mg^ 2DANTRIUM - dantrolene sodium cap 25 mg 4DANTRIUM - dantrolene sodium cap 50 mg 4dantrolene sodium cap 25 mg^ 2dantrolene sodium cap 50 mg^ 2dantrolene sodium cap 100 mg^ 2tizanidine hcl cap 2 mg^ 2tizanidine hcl cap 4 mg^ 2tizanidine hcl cap 6 mg^ 2tizanidine hcl tab 2 mg^ 2tizanidine hcl tab 4 mg^ 2ZANAFLEX - tizanidine hcl tab 4 mg 4Antiviralsabacavir sulfate soln 20 mg/ml^ 2 QL (960 mls/30 days)abacavir sulfate tab 300 mg^ 2 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg^ 2 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg^ 2acyclovir oint 5%^ 2acyclovir sodium iv soln 50 mg/ml^ 2 BDacyclovir susp 200 mg/5ml^ 2acyclovir tab 400 mg^ 2acyclovir tab 800 mg^ 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)

2019


53

Drug Name Drug Tier Requirements/LimitsATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BARACLUDE - entecavir tab 0.5 mg 5BARACLUDE - entecavir tab 1 mg 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)CYTOVENE - ganciclovir sodium for inj 500 mg 4 BDDAKLINZA - daclatasvir dihydrochloride tab 30 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 60 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 90 mg 5 PADELSTRIGO - doravirine-lamivudine-tenofovir df tab


DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg^ 2 QL (30 capsules/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg^ 2 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (60 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg^ 2entecavir tab 1 mg^ 2EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR - lamivudine oral soln 10 mg/ml 4 QL (960 mls/30 days)EPIVIR - lamivudine tab 150 mg 4 QL (60 tablets/30 days)EPIVIR - lamivudine tab 300 mg 4 QL (30 tablets/30 days)EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EPIVIR HBV - lamivudine tab 100 mg (hbv) 4EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsfamciclovir tab 125 mg^ 2famciclovir tab 250 mg^ 2famciclovir tab 500 mg^ 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg^ 2 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 5 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml^ 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv)^ 2lamivudine tab 150 mg^ 2 QL (60 tablets/30 days)lamivudine tab 300 mg^ 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg^ 2 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PA

2019


55

Drug Name Drug Tier Requirements/Limitsnevirapine susp 50 mg/5ml^ 2 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg^ 2 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg^ 2 QL (30 tablets/30 days)nevirapine tab 200 mg^ 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)NORVIR - ritonavir tab 100 mg 4 QL (360 tablets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg^ 2oseltamivir phosphate cap 45 mg^ 2oseltamivir phosphate cap 75 mg^ 2oseltamivir phosphate for susp 6 mg/ml^ 2PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5PREVYMIS - letermovir tab 480 mg 5PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 100 mg 4 QL (360 tablets/30 days)RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR - zidovudine cap 100 mg 4 QL (180 capsules/30 days)RETROVIR - zidovudine syrup 10 mg/ml 4 QL (1920 mls/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 5RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5

2019


Drug Name Drug Tier Requirements/LimitsRIBASPHERE RIBAPAK - ribavirin tab 600 mg 5ribavirin cap 200 mg^ 2ribavirin tab 200 mg^ 2ritonavir tab 100 mg^ 2 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg^ 2 QL (60 capsules/30 days)stavudine cap 20 mg^ 2 QL (60 capsules/30 days)stavudine cap 30 mg^ 2 QL (60 capsules/30 days)stavudine cap 40 mg^ 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)SUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)SUSTIVA - efavirenz tab 600 mg 5 QL (30 tablets/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


TAMIFLU - oseltamivir phosphate cap 30 mg 4TAMIFLU - oseltamivir phosphate cap 45 mg 4TAMIFLU - oseltamivir phosphate cap 75 mg 4TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg 5 PAtenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


2019


57

Drug Name Drug Tier Requirements/LimitsTRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab167-250 mg


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab200-300 mg


TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg^ 2valacyclovir hcl tab 1 gm^ 2VALCYTE - valganciclovir hcl for soln 50 mg/ml 5VALCYTE - valganciclovir hcl tab 450 mg 5valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VALTREX - valacyclovir hcl tab 500 mg 4VALTREX - valacyclovir hcl tab 1 gm 4VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 400 mg 4 QL (30 capsules/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIEKIRA XR - dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIRAMUNE XR - nevirapine tab er 24hr 400 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAXOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg (80 mgdose)

4

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PA

2019


Drug Name Drug Tier Requirements/LimitsZERIT - stavudine cap 15 mg 4 QL (60 capsules/30 days)ZERIT - stavudine cap 20 mg 4 QL (60 capsules/30 days)ZERIT - stavudine cap 30 mg 4 QL (60 capsules/30 days)ZERIT - stavudine cap 40 mg 4 QL (60 capsules/30 days)ZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)ZIAGEN - abacavir sulfate tab 300 mg 4 QL (60 tablets/30 days)zidovudine cap 100 mg^ 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml^ 2 QL (1920 mls/30 days)zidovudine tab 300 mg^ 2 QL (60 tablets/30 days)ZOVIRAX - acyclovir cap 200 mg 4ZOVIRAX - acyclovir oint 5% 5ZOVIRAX - acyclovir susp 200 mg/5ml 4ZOVIRAX - acyclovir tab 400 mg 4Anxiolyticsalprazolam tab 0.25 mg^ 1 QL (120 tablets/30 days)alprazolam tab 0.5 mg^ 1 QL (120 tablets/30 days)alprazolam tab 1 mg^ 1 QL (120 tablets/30 days)alprazolam tab 2 mg^ 1 QL (150 tablets/30 days)buspirone hcl tab 5 mg^ 2buspirone hcl tab 7.5 mg^ 2buspirone hcl tab 10 mg^ 2buspirone hcl tab 15 mg^ 2buspirone hcl tab 30 mg^ 2clonazepam orally disintegrating tab 0.125 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg^ 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg^ 1 PA, QL (120 tablets/30 days)clonazepam tab 1 mg^ 1 PA, QL (120 tablets/30 days)clonazepam tab 2 mg^ 1 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg^ 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg^ 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg^ 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml^ 2 PA, QL (240 mls/30 days)diazepam tab 2 mg^ 1 PA, QL (120 tablets/30 days)diazepam tab 5 mg^ 1 PA, QL (120 tablets/30 days)

2019


59

Drug Name Drug Tier Requirements/Limitsdiazepam tab 10 mg^ 1 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAlorazepam tab 0.5 mg^ 1 PA, QL (120 tablets/30 days)lorazepam tab 1 mg^ 1 PA, QL (120 tablets/30 days)lorazepam tab 2 mg^ 1 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg^ 2lithium carbonate cap 300 mg^ 1lithium carbonate cap 600 mg^ 2lithium carbonate tab er 300 mg^ 2lithium carbonate tab er 450 mg^ 2lithium carbonate tab 300 mg^ 2LITHOBID - lithium carbonate tab er 300 mg 4Blood Glucose Regulatorsacarbose tab 25 mg^ 2 QL (360 tablets/30 days)acarbose tab 50 mg^ 2 QL (180 tablets/30 days)acarbose tab 100 mg^ 2 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 15 mg 4 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 30 mg 4 QL (30 tablets/30 days)ACTOS - pioglitazone hcl tab 45 mg 4 QL (30 tablets/30 days)ALCOHOL SWABS 3AMARYL - glimepiride tab 1 mg 4 QL (240 tablets/30 days)AMARYL - glimepiride tab 2 mg 4 QL (120 tablets/30 days)AMARYL - glimepiride tab 4 mg 4 QL (60 tablets/30 days)BASAGLAR KWIKPEN - insulin glargine soln pen-injector 100 unit/

ml4 QL (20 pens/30 days)

BYDUREON BCISE - exenatide extended release susp auto-injector 2 mg/0.85ml

3 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg^ 1 QL (240 tablets/30 days)glimepiride tab 2 mg^ 1 QL (120 tablets/30 days)glimepiride tab 4 mg^ 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg^ 2 QL (240 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsglipizide tab er 24hr 5 mg^ 2 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg^ 2 QL (60 tablets/30 days)glipizide tab 5 mg^ 1 QL (240 tablets/30 days)glipizide tab 10 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg^ 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg^ 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg^ 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3GLUCOPHAGE - metformin hcl tab 500 mg 4 QL (150 tablets/30 days)GLUCOPHAGE - metformin hcl tab 850 mg 4 QL (90 tablets/30 days)GLUCOPHAGE - metformin hcl tab 1000 mg 4 QL (75 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 500 mg 4 QL (120 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 750 mg 4 QL (60 tablets/30 days)GLUCOTROL - glipizide tab 5 mg 4 QL (240 tablets/30 days)GLUCOTROL - glipizide tab 10 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 2.5 mg 4 QL (240 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 5 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 10 mg 4 QL (60 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 3 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 3 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)3 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)

3 QL (20 pens/30 days)

HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)

3 QL (6 vials/30 days)

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml3 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)

2019


61

Drug Name Drug Tier Requirements/LimitsHUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml3 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

3 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsKOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 3 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml3 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg^ 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg^ 1 QL (60 tablets/30 days)metformin hcl tab 500 mg^ 1 QL (150 tablets/30 days)metformin hcl tab 850 mg^ 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg^ 1 QL (75 tablets/30 days)nateglinide tab 60 mg^ 2 QL (180 tablets/30 days)nateglinide tab 120 mg^ 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg^ 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg^ 2 QL (90 tablets/30 days)PRECOSE - acarbose tab 25 mg 4 QL (360 tablets/30 days)PRECOSE - acarbose tab 50 mg 4 QL (180 tablets/30 days)PRECOSE - acarbose tab 100 mg 4 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg^ 2 QL (960 tablets/30 days)repaglinide tab 1 mg^ 2 QL (480 tablets/30 days)repaglinide tab 2 mg^ 2 QL (240 tablets/30 days)STARLIX - nateglinide tab 60 mg 4 QL (180 tablets/30 days)STARLIX - nateglinide tab 120 mg 4 QL (90 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

2019


63

Drug Name Drug Tier Requirements/LimitsSYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml

(1000 mcg/ml)5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300unit/ml


TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml


TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 3 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 4 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 4 QL (4 pens/28 days), STVICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume ExpandersAGGRENOX - aspirin-dipyridamole cap er 12hr 25-200 mg 4AGRYLIN - anagrelide hcl cap 0.5 mg 5anagrelide hcl cap 0.5 mg^ 2anagrelide hcl cap 1 mg^ 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA

2019


Drug Name Drug Tier Requirements/LimitsARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

40 mcg/0.4ml4 PA


5 PA


5 PA


5 PA


5 PA


5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg^ 2azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 2cilostazol tab 100 mg^ 2clopidogrel bisulfate tab 75 mg^ 1COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4CYKLOKAPRON - tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)4

dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 4EFFIENT - prasugrel hcl tab 10 mg 4ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)

2019


65

Drug Name Drug Tier Requirements/LimitsELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml^ 2 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml^ 2 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml^ 2 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5GRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5GRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5

heparin sodium (porcine) inj 1000 unit/ml^ 2heparin sodium (porcine) inj 5000 unit/ml^ 2heparin sodium (porcine) inj 10000 unit/ml^ 2heparin sodium (porcine) inj 20000 unit/ml^ 2heparin sodium (porcine) pf inj 5000 unit/0.5ml^ 2heparin sodium (porcine) 40 unit/ml in d5w^ 2LEUKINE - sargramostim lyophilized for inj 250 mcg 5LOVENOX - enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 80 mg/0.8ml 5 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 100 mg/ml 5 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 120 mg/0.8ml 5 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 150 mg/ml 5 QL (30 syringes/90 days)LOVENOX - enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5

2019


Drug Name Drug Tier Requirements/LimitsNEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

NEUPOGEN - filgrastim inj 300 mcg/ml 5NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5PLAVIX - clopidogrel bisulfate tab 75 mg 4PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg^ 2prasugrel hcl tab 10 mg^ 2PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml)^ 2tranexamic acid tab 650 mg^ 2warfarin sodium tab 1 mg^ 1warfarin sodium tab 2 mg^ 1warfarin sodium tab 2.5 mg^ 1warfarin sodium tab 3 mg^ 1warfarin sodium tab 4 mg^ 1warfarin sodium tab 5 mg^ 1warfarin sodium tab 6 mg^ 1warfarin sodium tab 7.5 mg^ 1warfarin sodium tab 10 mg^ 1XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)

2019


67

Drug Name Drug Tier Requirements/LimitsXARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular AgentsACCUPRIL - quinapril hcl tab 5 mg 4ACCUPRIL - quinapril hcl tab 10 mg 4ACCUPRIL - quinapril hcl tab 20 mg 4ACCUPRIL - quinapril hcl tab 40 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-25 mg 4acebutolol hcl cap 200 mg^ 2acebutolol hcl cap 400 mg^ 2acetazolamide cap er 12hr 500 mg^ 2acetazolamide tab 125 mg^ 2acetazolamide tab 250 mg^ 2ADALAT CC - nifedipine tab er 24hr 30 mg 4ADALAT CC - nifedipine tab er 24hr 60 mg 4ADALAT CC - nifedipine tab er 24hr 90 mg 4ALDACTAZIDE - spironolactone & hydrochlorothiazide tab

25-25 mg4

ALDACTONE - spironolactone tab 25 mg 4ALDACTONE - spironolactone tab 50 mg 4ALDACTONE - spironolactone tab 100 mg 4ALTACE - ramipril cap 1.25 mg 4ALTACE - ramipril cap 2.5 mg 4ALTACE - ramipril cap 5 mg 4ALTACE - ramipril cap 10 mg 4amiloride & hydrochlorothiazide tab 5-50 mg^ 2amiloride hcl tab 5 mg^ 2amiodarone hcl tab 200 mg^ 2amiodarone hcl tab 400 mg^ 2amlodipine besylate tab 2.5 mg^ 1amlodipine besylate tab 5 mg^ 1amlodipine besylate tab 10 mg^ 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitsamlodipine besylate-atorvastatin calcium tab 2.5-20 mg^ 2amlodipine besylate-atorvastatin calcium tab 2.5-40 mg^ 2amlodipine besylate-atorvastatin calcium tab 5-10 mg^ 2amlodipine besylate-atorvastatin calcium tab 5-20 mg^ 2amlodipine besylate-atorvastatin calcium tab 5-40 mg^ 2amlodipine besylate-atorvastatin calcium tab 5-80 mg^ 2amlodipine besylate-atorvastatin calcium tab 10-10 mg^ 2amlodipine besylate-atorvastatin calcium tab 10-20 mg^ 2amlodipine besylate-atorvastatin calcium tab 10-40 mg^ 2amlodipine besylate-atorvastatin calcium tab 10-80 mg^ 2amlodipine besylate-benazepril hcl cap 2.5-10 mg^ 2amlodipine besylate-benazepril hcl cap 5-10 mg^ 2amlodipine besylate-benazepril hcl cap 5-20 mg^ 2amlodipine besylate-benazepril hcl cap 5-40 mg^ 2amlodipine besylate-benazepril hcl cap 10-20 mg^ 2amlodipine besylate-benazepril hcl cap 10-40 mg^ 2amlodipine besylate-olmesartan medoxomil tab 5-20 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 5-40 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-20 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-40 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg^ 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg^ 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg^ 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg^ 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg^ 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg^ 2 QL (30 tablets/30 days)ATACAND - candesartan cilexetil tab 4 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 8 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 16 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 32 mg 4 QL (30 tablets/30 days)ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab


ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg


ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-25 mg


2019


69

Drug Name Drug Tier Requirements/Limitsatenolol & chlorthalidone tab 50-25 mg^ 2atenolol & chlorthalidone tab 100-25 mg^ 2atenolol tab 25 mg^ 1atenolol tab 50 mg^ 1atenolol tab 100 mg^ 1atorvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg^ 1 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5 mg 4 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 75 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 150 mg 4 QL (60 tablets/30 days)AVAPRO - irbesartan tab 300 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 4 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg^ 2benazepril & hydrochlorothiazide tab 10-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-25 mg^ 2benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1BENICAR - olmesartan medoxomil tab 5 mg 4 QL (60 tablets/30 days)BENICAR - olmesartan medoxomil tab 20 mg 4 QL (30 tablets/30 days)BENICAR - olmesartan medoxomil tab 40 mg 4 QL (30 tablets/30 days)BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-25 mg


betaxolol hcl tab 10 mg^ 2betaxolol hcl tab 20 mg^ 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg^ 1bisoprolol & hydrochlorothiazide tab 5-6.25 mg^ 1

2019


Drug Name Drug Tier Requirements/Limitsbisoprolol & hydrochlorothiazide tab 10-6.25 mg^ 1bisoprolol fumarate tab 5 mg^ 2bisoprolol fumarate tab 10 mg^ 2bumetanide inj 0.25 mg/ml^ 2bumetanide tab 0.5 mg^ 2bumetanide tab 1 mg^ 2bumetanide tab 2 mg^ 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4CALAN - verapamil hcl tab 120 mg 4CALAN SR - verapamil hcl tab er 120 mg 4CALAN SR - verapamil hcl tab er 240 mg 4candesartan cilexetil tab 4 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg^ 2 QL (30 tablets/30 days)captopril tab 12.5 mg^ 2captopril tab 25 mg^ 2captopril tab 50 mg^ 2captopril tab 100 mg^ 2CAPTOPRIL/HYDROCHLOROTHIAZIDE - captopril &

hydrochlorothiazide tab 25-15 mg4

CAPTOPRIL/HYDROCHLOROTHIAZIDE - captopril &hydrochlorothiazide tab 25-25 mg

4


4


4

CARDIZEM - diltiazem hcl tab 30 mg 4CARDIZEM - diltiazem hcl tab 60 mg 4CARDIZEM - diltiazem hcl tab 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 180 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 240 mg 4

2019


71

Drug Name Drug Tier Requirements/LimitsCARDIZEM CD - diltiazem hcl coated beads cap er 24hr 300 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 360 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 120 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 180 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 240 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 300 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 360 mg 4CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 420 mg 4CARDURA - doxazosin mesylate tab 1 mg 4 QL (60 tablets/30 days)CARDURA - doxazosin mesylate tab 2 mg 4 QL (60 tablets/30 days)CARDURA - doxazosin mesylate tab 4 mg 4 QL (60 tablets/30 days)CARDURA - doxazosin mesylate tab 8 mg 4 QL (60 tablets/30 days)carvedilol phosphate cap er 24hr 10 mg^ 2carvedilol phosphate cap er 24hr 20 mg^ 2carvedilol phosphate cap er 24hr 40 mg^ 2carvedilol phosphate cap er 24hr 80 mg^ 2carvedilol tab 3.125 mg^ 1carvedilol tab 6.25 mg^ 1carvedilol tab 12.5 mg^ 1carvedilol tab 25 mg^ 1CATAPRES - clonidine hcl tab 0.1 mg 4CATAPRES - clonidine hcl tab 0.2 mg 4CATAPRES - clonidine hcl tab 0.3 mg 4CATAPRES-TTS-1 - clonidine td patch weekly 0.1 mg/24hr 4CATAPRES-TTS-2 - clonidine td patch weekly 0.2 mg/24hr 4CATAPRES-TTS-3 - clonidine td patch weekly 0.3 mg/24hr 4CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg^ 2chlorthalidone tab 25 mg^ 2chlorthalidone tab 50 mg^ 2cholestyramine light powder packets 4 gm^ 2cholestyramine light powder 4 gm/dose^ 2cholestyramine powder packets 4 gm^ 2cholestyramine powder 4 gm/dose^ 2choline fenofibrate cap dr 45 mg^ 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg^ 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg^ 2clonidine hcl tab 0.2 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitsclonidine hcl tab 0.3 mg^ 2clonidine td patch weekly 0.1 mg/24hr^ 2clonidine td patch weekly 0.2 mg/24hr^ 2clonidine td patch weekly 0.3 mg/24hr^ 2COLESTID - colestipol hcl granule packets 5 gm 4COLESTID - colestipol hcl granules 5 gm 4COLESTID - colestipol hcl tab 1 gm 4COLESTID FLAVORED - colestipol hcl granule packets 5 gm 4COLESTID FLAVORED - colestipol hcl granules 5 gm 4colestipol hcl granule packets 5 gm^ 2colestipol hcl granules 5 gm^ 2colestipol hcl tab 1 gm^ 2COREG - carvedilol tab 3.125 mg 4COREG - carvedilol tab 6.25 mg 4COREG - carvedilol tab 12.5 mg 4COREG - carvedilol tab 25 mg 4COREG CR - carvedilol phosphate cap er 24hr 10 mg 4COREG CR - carvedilol phosphate cap er 24hr 20 mg 4COREG CR - carvedilol phosphate cap er 24hr 40 mg 4COREG CR - carvedilol phosphate cap er 24hr 80 mg 4CORGARD - nadolol tab 20 mg 4CORGARD - nadolol tab 40 mg 4CORGARD - nadolol tab 80 mg 4CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)COZAAR - losartan potassium tab 25 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 50 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 100 mg 4 QL (30 tablets/30 days)CRESTOR - rosuvastatin calcium tab 5 mg 4 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 10 mg 4 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 20 mg 4 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 40 mg 4 QL (30 tablets/30 days)DEMADEX - torsemide tab 10 mg 4DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)#^ 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg^ 2

2019


73

Drug Name Drug Tier Requirements/Limitsdiltiazem hcl cap er 12hr 90 mg^ 2diltiazem hcl cap er 12hr 120 mg^ 2diltiazem hcl cap er 24hr 120 mg^ 2diltiazem hcl cap er 24hr 180 mg^ 2diltiazem hcl cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 120 mg^ 2diltiazem hcl coated beads cap er 24hr 180 mg^ 2diltiazem hcl coated beads cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 300 mg^ 2diltiazem hcl coated beads cap er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 180 mg^ 2diltiazem hcl coated beads tab er 24hr 240 mg^ 2diltiazem hcl coated beads tab er 24hr 300 mg^ 2diltiazem hcl coated beads tab er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 420 mg^ 2diltiazem hcl extended release beads cap er 24hr 120 mg^ 2diltiazem hcl extended release beads cap er 24hr 180 mg^ 2diltiazem hcl extended release beads cap er 24hr 240 mg^ 2diltiazem hcl extended release beads cap er 24hr 300 mg^ 2diltiazem hcl extended release beads cap er 24hr 360 mg^ 2diltiazem hcl extended release beads cap er 24hr 420 mg^ 2diltiazem hcl tab 30 mg^ 2diltiazem hcl tab 60 mg^ 2diltiazem hcl tab 90 mg^ 2diltiazem hcl tab 120 mg^ 2DIOVAN - valsartan tab 40 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 80 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 160 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 320 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25 mg 4 QL (30 tablets/30 days)dofetilide cap 125 mcg (0.125 mg)^ 2dofetilide cap 250 mcg (0.25 mg)^ 2dofetilide cap 500 mcg (0.5 mg)^ 2doxazosin mesylate tab 1 mg^ 2 QL (60 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsdoxazosin mesylate tab 2 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg^ 2 QL (60 tablets/30 days)DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25 mg 4enalapril maleate & hydrochlorothiazide tab 5-12.5 mg^ 2enalapril maleate & hydrochlorothiazide tab 10-25 mg^ 2enalapril maleate tab 2.5 mg^ 2enalapril maleate tab 5 mg^ 2enalapril maleate tab 10 mg^ 2enalapril maleate tab 20 mg^ 2ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg^ 2eplerenone tab 50 mg^ 2EXFORGE - amlodipine besylate-valsartan tab 5-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 5-320 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-320 mg 4 QL (30 tablets/30 days)EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg4 QL (30 tablets/30 days)

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg


EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg






ezetimibe tab 10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg^ 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg^ 2felodipine tab er 24hr 5 mg^ 2felodipine tab er 24hr 10 mg^ 2fenofibrate micronized cap 43 mg^ 2 QL (60 capsules/30 days)fenofibrate micronized cap 67 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 130 mg^ 2 QL (30 capsules/30 days)

2019


75

Drug Name Drug Tier Requirements/Limitsfenofibrate micronized cap 134 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg^ 2 QL (30 capsules/30 days)fenofibrate tab 48 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 54 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 145 mg^ 2 QL (30 tablets/30 days)fenofibrate tab 160 mg^ 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg^ 2flecainide acetate tab 100 mg^ 2flecainide acetate tab 150 mg^ 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg^ 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg^ 2fosinopril sodium tab 10 mg^ 1fosinopril sodium tab 20 mg^ 1fosinopril sodium tab 40 mg^ 1furosemide inj 10 mg/ml^ 2furosemide oral soln 10 mg/ml^ 2furosemide tab 20 mg^ 1furosemide tab 40 mg^ 1furosemide tab 80 mg^ 1gemfibrozil tab 600 mg^ 1 QL (60 tablets/30 days)hydralazine hcl tab 10 mg^ 2hydralazine hcl tab 25 mg^ 2hydralazine hcl tab 50 mg^ 2hydralazine hcl tab 100 mg^ 2hydrochlorothiazide cap 12.5 mg^ 1hydrochlorothiazide tab 12.5 mg^ 1hydrochlorothiazide tab 25 mg^ 1hydrochlorothiazide tab 50 mg^ 1HYZAAR - losartan potassium & hydrochlorothiazide tab


HYZAAR - losartan potassium & hydrochlorothiazide tab100-12.5 mg


HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg 4 QL (30 tablets/30 days)indapamide tab 1.25 mg^ 2indapamide tab 2.5 mg^ 2INDERAL LA - propranolol hcl cap er 24hr 60 mg 5INDERAL LA - propranolol hcl cap er 24hr 80 mg 5INDERAL LA - propranolol hcl cap er 24hr 120 mg 5INDERAL LA - propranolol hcl cap er 24hr 160 mg 5

2019


Drug Name Drug Tier Requirements/LimitsINSPRA - eplerenone tab 25 mg 4INSPRA - eplerenone tab 50 mg 4irbesartan tab 75 mg^ 2 QL (30 tablets/30 days)irbesartan tab 150 mg^ 2 QL (60 tablets/30 days)irbesartan tab 300 mg^ 2 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg^ 2 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg^ 2 QL (30 tablets/30 days)ISORDIL TITRADOSE - isosorbide dinitrate tab 5 mg 4isosorbide dinitrate tab 5 mg^ 2isosorbide dinitrate tab 10 mg^ 2isosorbide dinitrate tab 20 mg^ 2isosorbide dinitrate tab 30 mg^ 2isosorbide mononitrate tab er 24hr 30 mg^ 2isosorbide mononitrate tab er 24hr 60 mg^ 2isosorbide mononitrate tab er 24hr 120 mg^ 2isosorbide mononitrate tab 10 mg^ 2isosorbide mononitrate tab 20 mg^ 2isradipine cap 2.5 mg^ 2isradipine cap 5 mg^ 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAKYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml* 5 PAlabetalol hcl tab 100 mg^ 2labetalol hcl tab 200 mg^ 2labetalol hcl tab 300 mg^ 2LANOXIN - digoxin tab 62.5 mcg (0.0625 mg)# 4 QL (30 tablets/30 days)LANOXIN - digoxin tab 125 mcg (0.125 mg)# 4 QL (30 tablets/30 days)LANOXIN - digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)LASIX - furosemide tab 20 mg 4LASIX - furosemide tab 40 mg 4LASIX - furosemide tab 80 mg 4LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml 4LIPITOR - atorvastatin calcium tab 10 mg 4 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 20 mg 4 QL (45 tablets/30 days)

2019


77

Drug Name Drug Tier Requirements/LimitsLIPITOR - atorvastatin calcium tab 40 mg 4 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 80 mg 4 QL (30 tablets/30 days)lisinopril & hydrochlorothiazide tab 10-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-25 mg^ 1lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1LOPID - gemfibrozil tab 600 mg 4 QL (60 tablets/30 days)LOPRESSOR - metoprolol tartrate tab 50 mg 4LOPRESSOR - metoprolol tartrate tab 100 mg 4LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab

50-25 mg4

losartan potassium & hydrochlorothiazide tab 50-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg^ 1 QL (30 tablets/30 days)losartan potassium tab 25 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 50 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 100 mg^ 1 QL (30 tablets/30 days)LOTENSIN - benazepril hcl tab 10 mg 4LOTENSIN - benazepril hcl tab 20 mg 4LOTENSIN - benazepril hcl tab 40 mg 4LOTENSIN HCT - benazepril & hydrochlorothiazide tab 10-12.5 mg 4LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-12.5 mg 4LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-25 mg 4lovastatin tab 10 mg^ 1 QL (60 tablets/30 days)lovastatin tab 20 mg^ 1 QL (60 tablets/30 days)lovastatin tab 40 mg^ 1 QL (60 tablets/30 days)LOVAZA - omega-3-acid ethyl esters cap 1 gm 4MAXZIDE - triamterene & hydrochlorothiazide tab 75-50 mg 4MAXZIDE-25 - triamterene & hydrochlorothiazide tab 37.5-25 mg 4methazolamide tab 25 mg^ 2methazolamide tab 50 mg^ 2metolazone tab 2.5 mg^ 2metolazone tab 5 mg^ 2metolazone tab 10 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitsmetoprolol & hydrochlorothiazide tab 100-50 mg^ 2metoprolol & hydrochlorothiazide tab 50-25 mg^ 2metoprolol & hydrochlorothiazide tab 100-25 mg^ 2metoprolol succinate tab er 24hr 25 mg^ 2metoprolol succinate tab er 24hr 50 mg^ 2metoprolol succinate tab er 24hr 100 mg^ 2metoprolol succinate tab er 24hr 200 mg^ 2metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1mexiletine hcl cap 150 mg^ 2mexiletine hcl cap 200 mg^ 2mexiletine hcl cap 250 mg^ 2MICARDIS - telmisartan tab 20 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 40 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 80 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 40-12.5 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (60 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-25 mg 4 QL (30 tablets/30 days)midodrine hcl tab 2.5 mg^ 2midodrine hcl tab 5 mg^ 2midodrine hcl tab 10 mg^ 2MINIPRESS - prazosin hcl cap 1 mg 4MINIPRESS - prazosin hcl cap 2 mg 4MINIPRESS - prazosin hcl cap 5 mg 4minoxidil tab 2.5 mg^ 2minoxidil tab 10 mg^ 2moexipril hcl tab 7.5 mg^ 2moexipril hcl tab 15 mg^ 2moexipril-hydrochlorothiazide tab 7.5-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-25 mg^ 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg^ 2nadolol tab 40 mg^ 2nadolol tab 80 mg^ 2niacin tab er 500 mg^ 2 QL (30 tablets/30 days)niacin tab er 750 mg^ 2 QL (60 tablets/30 days)

2019


79

Drug Name Drug Tier Requirements/Limitsniacin tab er 1000 mg^ 2 QL (60 tablets/30 days)NIASPAN - niacin tab er 500 mg 4 QL (30 tablets/30 days)NIASPAN - niacin tab er 750 mg 4 QL (60 tablets/30 days)NIASPAN - niacin tab er 1000 mg 4 QL (60 tablets/30 days)nicardipine hcl cap 20 mg^ 2nicardipine hcl cap 30 mg^ 2nifedipine tab er 24hr 30 mg^ 2nifedipine tab er 24hr 60 mg^ 2nifedipine tab er 24hr 90 mg^ 2nifedipine tab er 24hr osmotic release 30 mg^ 2nifedipine tab er 24hr osmotic release 60 mg^ 2nifedipine tab er 24hr osmotic release 90 mg^ 2nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg^ 2nisoldipine tab er 24hr 17 mg^ 2nisoldipine tab er 24hr 34 mg^ 2NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg^ 2nitroglycerin sl tab 0.4 mg^ 2nitroglycerin sl tab 0.6 mg^ 2nitroglycerin td patch 24hr 0.1 mg/hr^ 2nitroglycerin td patch 24hr 0.2 mg/hr^ 2nitroglycerin td patch 24hr 0.4 mg/hr^ 2nitroglycerin td patch 24hr 0.6 mg/hr^ 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)^ 2NITROLINGUAL PUMPSPRAY - nitroglycerin tl soln 0.4 mg/spray

(400 mcg/spray)4

NITROSTAT - nitroglycerin sl tab 0.3 mg 4NITROSTAT - nitroglycerin sl tab 0.4 mg 4NITROSTAT - nitroglycerin sl tab 0.6 mg 4NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PANORVASC - amlodipine besylate tab 2.5 mg 4NORVASC - amlodipine besylate tab 5 mg 4NORVASC - amlodipine besylate tab 10 mg 4olmesartan medoxomil tab 5 mg^ 2 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg^ 2 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsolmesartan medoxomil tab 40 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg^ 2 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg^ 2 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg^ 2 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm^ 2pentoxifylline tab er 400 mg^ 2perindopril erbumine tab 2 mg^ 2perindopril erbumine tab 4 mg^ 2perindopril erbumine tab 8 mg^ 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg^ 2pindolol tab 10 mg^ 2PRAVACHOL - pravastatin sodium tab 20 mg 4 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 40 mg 4 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 80 mg 4 QL (30 tablets/30 days)pravastatin sodium tab 10 mg^ 2 QL (45 tablets/30 days)pravastatin sodium tab 20 mg^ 2 QL (45 tablets/30 days)pravastatin sodium tab 40 mg^ 2 QL (45 tablets/30 days)pravastatin sodium tab 80 mg^ 2 QL (30 tablets/30 days)prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2PRINIVIL - lisinopril tab 5 mg 4PRINIVIL - lisinopril tab 10 mg 4PRINIVIL - lisinopril tab 20 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 30 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 60 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 90 mg 4propafenone hcl cap er 12hr 225 mg^ 2propafenone hcl cap er 12hr 325 mg^ 2propafenone hcl cap er 12hr 425 mg^ 2propafenone hcl tab 150 mg^ 2propafenone hcl tab 225 mg^ 2

2019


81

Drug Name Drug Tier Requirements/Limitspropafenone hcl tab 300 mg^ 2PROPRANOLOL HCL - propranolol hcl oral soln 20 mg/5ml 4PROPRANOLOL HCL - propranolol hcl oral soln 40 mg/5ml 4propranolol hcl cap er 24hr 60 mg^ 2propranolol hcl cap er 24hr 80 mg^ 2propranolol hcl cap er 24hr 120 mg^ 2propranolol hcl cap er 24hr 160 mg^ 2propranolol hcl inj 1 mg/ml^ 2propranolol hcl tab 10 mg^ 2propranolol hcl tab 20 mg^ 2propranolol hcl tab 40 mg^ 2propranolol hcl tab 60 mg^ 2propranolol hcl tab 80 mg^ 2quinapril hcl tab 5 mg^ 1quinapril hcl tab 10 mg^ 1quinapril hcl tab 20 mg^ 1quinapril hcl tab 40 mg^ 1quinapril-hydrochlorothiazide tab 10-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-25 mg^ 2quinidine gluconate tab er 324 mg^ 2QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg^ 1ramipril cap 2.5 mg^ 1ramipril cap 5 mg^ 1ramipril cap 10 mg^ 1RANEXA - ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)RANEXA - ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml3 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

3 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

3 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg^ 2 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsRYTHMOL SR - propafenone hcl cap er 12hr 225 mg 5RYTHMOL SR - propafenone hcl cap er 12hr 325 mg 5RYTHMOL SR - propafenone hcl cap er 12hr 425 mg 5simvastatin tab 5 mg^ 1 QL (45 tablets/30 days)simvastatin tab 10 mg^ 1 QL (45 tablets/30 days)simvastatin tab 20 mg^ 1 QL (60 tablets/30 days)simvastatin tab 40 mg^ 1 QL (45 tablets/30 days)simvastatin tab 80 mg^ 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg^ 2sotalol hcl (afib/afl) tab 120 mg^ 2sotalol hcl (afib/afl) tab 160 mg^ 2sotalol hcl tab 80 mg^ 2sotalol hcl tab 120 mg^ 2sotalol hcl tab 160 mg^ 2sotalol hcl tab 240 mg^ 2spironolactone & hydrochlorothiazide tab 25-25 mg^ 2spironolactone tab 25 mg^ 1spironolactone tab 50 mg^ 1spironolactone tab 100 mg^ 1SULAR - nisoldipine tab er 24hr 8.5 mg 4SULAR - nisoldipine tab er 24hr 17 mg 4SULAR - nisoldipine tab er 24hr 34 mg 4TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg^ 2 QL (30 tablets/30 days)telmisartan tab 40 mg^ 2 QL (30 tablets/30 days)telmisartan tab 80 mg^ 2 QL (30 tablets/30 days)telmisartan-amlodipine tab 40-5 mg^ 2 QL (30 tablets/30 days)telmisartan-amlodipine tab 40-10 mg^ 2 QL (30 tablets/30 days)telmisartan-amlodipine tab 80-5 mg^ 2 QL (30 tablets/30 days)telmisartan-amlodipine tab 80-10 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg^ 2 QL (30 tablets/30 days)

2019


83

Drug Name Drug Tier Requirements/LimitsTENORETIC 100 - atenolol & chlorthalidone tab 100-25 mg 4TENORETIC 50 - atenolol & chlorthalidone tab 50-25 mg 4TENORMIN - atenolol tab 25 mg 4TENORMIN - atenolol tab 50 mg 4TENORMIN - atenolol tab 100 mg 4terazosin hcl cap 1 mg^ 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 1 QL (60 capsules/30 days)TIAZAC - diltiazem hcl extended release beads cap er 24hr 120 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 180 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 240 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 300 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 360 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 420 mg 4TIKOSYN - dofetilide cap 125 mcg (0.125 mg) 4TIKOSYN - dofetilide cap 250 mcg (0.25 mg) 4TIKOSYN - dofetilide cap 500 mcg (0.5 mg) 4TIMOLOL MALEATE - timolol maleate tab 5 mg 3TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3TOPROL XL - metoprolol succinate tab er 24hr 25 mg 4TOPROL XL - metoprolol succinate tab er 24hr 50 mg 4TOPROL XL - metoprolol succinate tab er 24hr 100 mg 4TOPROL XL - metoprolol succinate tab er 24hr 200 mg 4torsemide tab 5 mg^ 1torsemide tab 10 mg^ 1torsemide tab 20 mg^ 1torsemide tab 100 mg^ 1trandolapril tab 1 mg^ 2trandolapril tab 2 mg^ 2trandolapril tab 4 mg^ 2triamterene & hydrochlorothiazide cap 37.5-25 mg^ 1triamterene & hydrochlorothiazide tab 37.5-25 mg^ 1triamterene & hydrochlorothiazide tab 75-50 mg^ 1TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg4 QL (30 tablets/30 days)

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg


2019


Drug Name Drug Tier Requirements/LimitsTRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg


valsartan tab 40 mg^ 2 QL (60 tablets/30 days)valsartan tab 80 mg^ 2 QL (60 tablets/30 days)valsartan tab 160 mg^ 2 QL (60 tablets/30 days)valsartan tab 320 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg^ 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3VASERETIC - enalapril maleate & hydrochlorothiazide tab

10-25 mg4

VASOTEC - enalapril maleate tab 2.5 mg 4VASOTEC - enalapril maleate tab 5 mg 5VASOTEC - enalapril maleate tab 10 mg 5VASOTEC - enalapril maleate tab 20 mg 5verapamil hcl cap er 24hr 360 mg^ 2verapamil hcl cap er 24hr 100 mg^ 2verapamil hcl cap er 24hr 120 mg^ 2verapamil hcl cap er 24hr 180 mg^ 2verapamil hcl cap er 24hr 200 mg^ 2verapamil hcl cap er 24hr 240 mg^ 2verapamil hcl cap er 24hr 300 mg^ 2verapamil hcl tab er 120 mg^ 2verapamil hcl tab er 180 mg^ 2verapamil hcl tab er 240 mg^ 2verapamil hcl tab 40 mg^ 2verapamil hcl tab 80 mg^ 2verapamil hcl tab 120 mg^ 2VERELAN - verapamil hcl cap er 24hr 120 mg 4VERELAN - verapamil hcl cap er 24hr 180 mg 4VERELAN - verapamil hcl cap er 24hr 240 mg 4

2019


85

Drug Name Drug Tier Requirements/LimitsVERELAN - verapamil hcl cap er 24hr 360 mg 4VERELAN PM - verapamil hcl cap er 24hr 100 mg 4VERELAN PM - verapamil hcl cap er 24hr 200 mg 4VERELAN PM - verapamil hcl cap er 24hr 300 mg 4VYTORIN - ezetimibe-simvastatin tab 10-10 mg 4 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-20 mg 4 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-40 mg 4 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-80 mg 4 QL (30 tablets/30 days)ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 4ZESTRIL - lisinopril tab 2.5 mg 4ZESTRIL - lisinopril tab 5 mg 4ZESTRIL - lisinopril tab 10 mg 4ZESTRIL - lisinopril tab 20 mg 4ZESTRIL - lisinopril tab 30 mg 4ZESTRIL - lisinopril tab 40 mg 4ZETIA - ezetimibe tab 10 mg 4 QL (30 tablets/30 days)ZIAC - bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 4ZIAC - bisoprolol & hydrochlorothiazide tab 5-6.25 mg 4ZIAC - bisoprolol & hydrochlorothiazide tab 10-6.25 mg 4ZOCOR - simvastatin tab 5 mg 4 QL (45 tablets/30 days)ZOCOR - simvastatin tab 10 mg 4 QL (45 tablets/30 days)ZOCOR - simvastatin tab 20 mg 4 QL (60 tablets/30 days)ZOCOR - simvastatin tab 40 mg 4 QL (45 tablets/30 days)ZOCOR - simvastatin tab 80 mg 4 QL (30 tablets/30 days)Central Nervous System AgentsADDERALL XR - amphetamine-dextroamphetamine cap er 24hr

5 mg4 QL (30 capsules/30 days)

ADDERALL XR - amphetamine-dextroamphetamine cap er 24hr10 mg

4 QL (30 capsules/30 days)









amphetamine-dextroamphetamine cap er 24hr 5 mg^ 2 QL (30 capsules/30 days)

2019


Drug Name Drug Tier Requirements/Limitsamphetamine-dextroamphetamine cap er 24hr 10 mg^ 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg^ 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg^ 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg^ 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg^ 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg^ 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg^ 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg^ 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg^ 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg^ 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg^ 2 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg^ 2 QL (60 tablets/30 days)AMPYRA - dalfampridine tab er 12hr 10 mg* 5 PAatomoxetine hcl cap 10 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg^ 2 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg^ 2 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg^ 2 QL (30 capsules/30 days)AUBAGIO - teriflunomide tab 7 mg 5 PA, QL (30 tablets/30 days)AUBAGIO - teriflunomide tab 14 mg 5 PA, QL (30 tablets/30 days)AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/

vial)5 PA, QL (1 kit/28 days)

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg^ 2 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dalfampridine tab er 12hr 10 mg 5 PADEXEDRINE - dextroamphetamine sulfate cap er 24hr 5 mg 5 QL (90 capsules/30 days)DEXEDRINE - dextroamphetamine sulfate cap er 24hr 10 mg 5 QL (120 capsules/30 days)DEXEDRINE - dextroamphetamine sulfate cap er 24hr 15 mg 5 QL (120 capsules/30 days)dexmethylphenidate hcl tab 2.5 mg^ 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg^ 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg^ 2 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg^ 2 QL (90 capsules/30 days)

2019


87

Drug Name Drug Tier Requirements/Limitsdextroamphetamine sulfate cap er 24hr 10 mg^ 2 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg^ 2 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg^ 2 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg^ 2 QL (180 tablets/30 days)FOCALIN - dexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)FOCALIN - dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)FOCALIN - dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)methylphenidate hcl tab er 20 mg^ 2 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg^ 2 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg^ 2 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg^ 2 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

riluzole tab 50 mg^ 2RITALIN - methylphenidate hcl tab 5 mg 4 QL (90 tablets/30 days)RITALIN - methylphenidate hcl tab 10 mg 4 QL (90 tablets/30 days)RITALIN - methylphenidate hcl tab 20 mg 4 QL (90 tablets/30 days)STRATTERA - atomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 18 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 25 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 60 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 80 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 100 mg 4 QL (30 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PA

2019


Drug Name Drug Tier Requirements/LimitsXENAZINE - tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)XENAZINE - tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)Dental and Oral Agentscevimeline hcl cap 30 mg^ 2chlorhexidine gluconate soln 0.12%^ 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg^ 2pilocarpine hcl tab 7.5 mg^ 2SALAGEN - pilocarpine hcl tab 5 mg 4SALAGEN - pilocarpine hcl tab 7.5 mg 4triamcinolone acetonide dental paste 0.1%^ 2Dermatological Agentsacitretin cap 10 mg^ 2acitretin cap 17.5 mg^ 2acitretin cap 25 mg^ 2alclometasone dipropionate cream 0.05%^ 2alclometasone dipropionate oint 0.05%^ 2ALDARA - imiquimod cream 5% 5 PAazelaic acid gel 15%^ 2AZELEX - azelaic acid cream 20% 4BENZAMYCIN - benzoyl peroxide-erythromycin gel 5-3% 4benzoyl peroxide-erythromycin gel 5-3%^ 2betamethasone dipropionate augmented cream 0.05%^ 2betamethasone dipropionate augmented gel 0.05%^ 2betamethasone dipropionate augmented lotion 0.05%^ 2betamethasone dipropionate augmented oint 0.05%^ 2betamethasone dipropionate cream 0.05%^ 2betamethasone dipropionate lotion 0.05%^ 2betamethasone dipropionate oint 0.05%^ 2betamethasone valerate cream 0.1%^ 2betamethasone valerate lotion 0.1%^ 2betamethasone valerate oint 0.1%^ 2calcipotriene cream 0.005%^ 2calcipotriene oint 0.005%^ 2calcipotriene soln 0.005% (50 mcg/ml)^ 2CARAC - fluorouracil cream 0.5% 5clindamycin phosphate-benzoyl peroxide gel 1-5%^ 2clobetasol propionate cream 0.05%^ 2clobetasol propionate emollient base cream 0.05%^ 2

2019


89

Drug Name Drug Tier Requirements/Limitsclobetasol propionate gel 0.05%^ 2clobetasol propionate oint 0.05%^ 2clobetasol propionate soln 0.05%^ 2clotrimazole w/ betamethasone cream 1-0.05%^ 2clotrimazole w/ betamethasone lotion 1-0.05%^ 2desonide cream 0.05%^ 2desonide lotion 0.05%^ 2desonide oint 0.05%^ 2desoximetasone cream 0.05%^ 2desoximetasone cream 0.25%^ 2desoximetasone gel 0.05%^ 2desoximetasone oint 0.25%^ 2diclofenac sodium gel 3% 5diflorasone diacetate oint 0.05%^ 2DIPROLENE - betamethasone dipropionate augmented oint 0.05% 4DOVONEX - calcipotriene cream 0.005% 5ELIDEL - pimecrolimus cream 1% 4 PAELOCON - mometasone furoate cream 0.1% 4ELOCON - mometasone furoate oint 0.1% 4FINACEA - azelaic acid foam 15% 3FINACEA - azelaic acid gel 15% 3fluocinolone acetonide cream 0.01%^ 2fluocinonide cream 0.05%^ 2fluocinonide emulsified base cream 0.05%^ 2fluocinonide gel 0.05%^ 2fluocinonide oint 0.05%^ 2fluocinonide soln 0.05%^ 2FLUOROURACIL - fluorouracil soln 2%^ 2FLUOROURACIL - fluorouracil soln 5%^ 2fluorouracil cream 5%^ 2fluticasone propionate cream 0.05%^ 2fluticasone propionate oint 0.005%^ 2gentamicin sulfate cream 0.1%^ 2gentamicin sulfate oint 0.1%^ 2halobetasol propionate cream 0.05%^ 2halobetasol propionate oint 0.05%^ 2hydrocortisone butyrate cream 0.1%^ 2hydrocortisone butyrate hydrophilic lipo base cream 0.1%^ 2

2019


Drug Name Drug Tier Requirements/Limitshydrocortisone butyrate oint 0.1%^ 2hydrocortisone butyrate soln 0.1%^ 2hydrocortisone cream 1%^ 1hydrocortisone cream 2.5%^ 2hydrocortisone lotion 2.5%^ 2hydrocortisone oint 1%^ 2hydrocortisone oint 2.5%^ 2hydrocortisone valerate cream 0.2%^ 2hydrocortisone valerate oint 0.2%^ 2imiquimod cream 5%^ 2 PAisotretinoin cap 10 mg^ 2isotretinoin cap 20 mg^ 2isotretinoin cap 30 mg^ 2isotretinoin cap 40 mg^ 2lactic acid (ammonium lactate) cream 12%^ 2lactic acid (ammonium lactate) lotion 12%^ 2LOCOID - hydrocortisone butyrate cream 0.1% 4LOCOID LIPOCREAM - hydrocortisone butyrate hydrophilic lipo

base cream 0.1%4

LOTRISONE - clotrimazole w/ betamethasone cream 1-0.05% 4methoxsalen rapid cap 10 mg 5METROCREAM - metronidazole cream 0.75% 4METROGEL - metronidazole gel 1% 4METROLOTION - metronidazole lotion 0.75% 5metronidazole cream 0.75%^ 2metronidazole gel 0.75%^ 2metronidazole gel 1%^ 2metronidazole lotion 0.75%^ 2mometasone furoate cream 0.1%^ 2mometasone furoate oint 0.1%^ 2mometasone furoate solution 0.1% (lotion)^ 2mupirocin oint 2%^ 2nystatin-triamcinolone cream 100000-0.1 unit/gm-%^ 2nystatin-triamcinolone oint 100000-0.1 unit/gm-%^ 2ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)pimecrolimus cream 1%^ 2 PApodofilox soln 0.5%^ 2

2019


91

Drug Name Drug Tier Requirements/LimitsPREDNICARBATE - prednicarbate oint 0.1%^ 2prednicarbate cream 0.1%^ 2PRUDOXIN - doxepin hcl cream 5% 5 PAREGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)RETIN-A - tretinoin cream 0.025% 4RETIN-A - tretinoin cream 0.05% 4RETIN-A - tretinoin cream 0.1% 4RETIN-A - tretinoin gel 0.01% 4RETIN-A - tretinoin gel 0.025% 4SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5%^ 2SILVADENE - silver sulfadiazine cream 1% 4silver sulfadiazine cream 1%^ 2SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03%^ 2 PAtacrolimus oint 0.1%^ 2 PAtazarotene cream 0.1%^ 2TAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025%^ 2tretinoin cream 0.05%^ 2tretinoin cream 0.1%^ 2tretinoin gel 0.01%^ 2tretinoin gel 0.025%^ 2triamcinolone acetonide cream 0.025%^ 2triamcinolone acetonide cream 0.1%^ 2triamcinolone acetonide cream 0.5%^ 2triamcinolone acetonide lotion 0.025%^ 2triamcinolone acetonide lotion 0.1%^ 2triamcinolone acetonide oint 0.025%^ 2triamcinolone acetonide oint 0.1%^ 2triamcinolone acetonide oint 0.5%^ 2ULTRAVATE - halobetasol propionate cream 0.05% 4ULTRAVATE - halobetasol propionate oint 0.05% 4ZONALON - doxepin hcl cream 5% 5 PAElectrolytes/Minerals/Metals/Vitaminsamino acid infusion 6%^ 2 BD

2019


Drug Name Drug Tier Requirements/Limitsamino acid infusion 15%^ 2 BDAMINOSYN II - amino acid infusion 15% 4 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PAcalcium acetate cap 667 mg^ 2calcium acetate tab 667 mg^ 2CARBAGLU - carglumic acid tab 200 mg 5 PACARNITOR - levocarnitine oral soln 1 gm/10ml (10%) 4CARNITOR - levocarnitine tab 330 mg 4CARNITOR SF - levocarnitine oral soln 1 gm/10ml (10%) 4CHEMET - succimer cap 100 mg 4dextrose inj 5%^ 2dextrose inj 10%^ 2dextrose 2.5% w/ sodium chloride 0.45%^ 1dextrose 5% in lactated ringers^ 2dextrose 5% w/ sodium chloride 0.2%^ 1dextrose 5% w/ sodium chloride 0.33%^ 1dextrose 5% w/ sodium chloride 0.45%^ 1dextrose 5% w/ sodium chloride 0.9%^ 1EXJADE - deferasirox tab for oral susp 125 mg* 5 PAEXJADE - deferasirox tab for oral susp 250 mg* 5 PAEXJADE - deferasirox tab for oral susp 500 mg* 5 PAfat emulsion iv soln 20% 4 BDfomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate chew tab 500 mg 5FOSRENOL - lanthanum carbonate chew tab 750 mg 5FOSRENOL - lanthanum carbonate chew tab 1000 mg 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5HEPATAMINE - amino acid infusion 8% 3 BDJADENU - deferasirox tab 90 mg 5 PAJADENU - deferasirox tab 180 mg 5 PAJADENU - deferasirox tab 360 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg 5 PAK-TAB - potassium chloride tab er 10 meq 4K-TAB - potassium chloride tab er 20 meq (1500 mg) 4kcl 20 meq/l (0.15%) in nacl 0.45% inj^ 1

2019


93

Drug Name Drug Tier Requirements/Limitskcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj^ 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj^ 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj^ 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj^ 2kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj^ 2kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj^ 2lactated ringer's solution^ 2lanthanum carbonate chew tab 500 mg 5lanthanum carbonate chew tab 750 mg 5lanthanum carbonate chew tab 1000 mg 5levocarnitine oral soln 1 gm/10ml (10%)^ 2levocarnitine tab 330 mg^ 2magnesium sulfate inj 50%^ 2MICRO-K - potassium chloride cap er 8 meq 4MICRO-K - potassium chloride cap er 10 meq 4NORMOSOL-M IN D5W - electrolyte-m in d5w soln 4PHOSLYRA - calcium acetate oral soln 667 mg/5ml 3potassium chloride cap er 8 meq^ 2potassium chloride cap er 10 meq^ 2POTASSIUM CHLORIDE ER - potassium chloride tab er 20 meq

(1500 mg)4

potassium chloride inj 2 meq/ml^ 2potassium chloride microencapsulated crys er tab 10 meq^ 2potassium chloride microencapsulated crys er tab 20 meq^ 2potassium chloride oral soln 10% (20 meq/15ml)^ 2potassium chloride tab er 8 meq (600 mg)^ 2potassium chloride tab er 10 meq^ 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj^ 2POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 40 meq/l (0.3%) in d5w lactated ringers

4

potassium citrate tab er 5 meq (540 mg)^ 2potassium citrate tab er 10 meq (1080 mg)^ 2potassium citrate tab er 15 meq (1620 mg)^ 2RENVELA - sevelamer carbonate packet 0.8 gm 5RENVELA - sevelamer carbonate packet 2.4 gm 5

2019


Drug Name Drug Tier Requirements/LimitsRENVELA - sevelamer carbonate tab 800 mg 5SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5sevelamer carbonate packet 2.4 gm 5sevelamer carbonate tab 800 mg^ 2sodium chloride inj 0.45%^ 2sodium chloride irrigation soln 0.9%^ 2sodium chloride iv soln 0.9%^ 2sodium polystyrene sulfonate oral susp 15 gm/60ml^ 2sodium polystyrene sulfonate powder^ 2sodium polystyrene sulfonate rectal susp 30 gm/120ml^ 2SYPRINE - trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)TROPHAMINE - amino acid infusion 6% 4 BDVELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 4VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 4VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 4water for irrigation, sterile irrigation soln^ 2Gastrointestinal AgentsACTIGALL - ursodiol cap 300 mg 5alosetron hcl tab 0.5 mg 5alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACARAFATE - sucralfate susp 1 gm/10ml 4CARAFATE - sucralfate tab 1 gm 4CHENODAL - chenodiol tab 250 mg* 5 PACIMETIDINE HCL - cimetidine hcl soln 300 mg/5ml^ 2cimetidine tab 200 mg^ 2cimetidine tab 300 mg^ 2cimetidine tab 400 mg^ 2cimetidine tab 800 mg^ 2COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 240 gm4

cromolyn sodium oral conc 100 mg/5ml^ 2CYTOTEC - misoprostol tab 100 mcg 4CYTOTEC - misoprostol tab 200 mcg 4

2019


95

Drug Name Drug Tier Requirements/Limitsdicyclomine hcl cap 10 mg# 3 PAdicyclomine hcl tab 20 mg# 4 PAesomeprazole magnesium cap delayed release 20 mg^ 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg^ 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg3

esomeprazole sodium for intravenous soln 40 mg^ 2famotidine for susp 40 mg/5ml^ 2famotidine inj 20 mg/2ml^ 2famotidine inj 40 mg/4ml^ 2famotidine inj 200 mg/20ml^ 2famotidine tab 20 mg^ 2famotidine tab 40 mg^ 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg^ 2glycopyrrolate tab 2 mg^ 2GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate packet

227.1 gm4

GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for soln236 gm

4

lactulose (encephalopathy) solution 10 gm/15ml^ 2lactulose solution 10 gm/15ml^ 2lansoprazole cap delayed release 15 mg^ 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg^ 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg^ 1LOTRONEX - alosetron hcl tab 0.5 mg 5LOTRONEX - alosetron hcl tab 1 mg 5methscopolamine bromide tab 2.5 mg^ 2methscopolamine bromide tab 5 mg^ 2metoclopramide hcl inj 5 mg/ml^ 2metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)^ 2metoclopramide hcl tab 5 mg^ 1metoclopramide hcl tab 10 mg^ 1misoprostol tab 100 mcg^ 2misoprostol tab 200 mcg^ 2

2019


Drug Name Drug Tier Requirements/LimitsMOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium cap delayed release 20 mg 4 QL (30 capsules/30 days)NEXIUM - esomeprazole magnesium cap delayed release 40 mg 4 QL (30 capsules/30 days)NEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppack 2.5 mg


NEXIUM I.V. - esomeprazole sodium for intravenous soln 40 mg 4nizatidine cap 150 mg^ 2nizatidine cap 300 mg^ 2NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for

soln 420 gm4

omeprazole cap delayed release 10 mg^ 1 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg^ 1 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg^ 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg^ 1 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg^ 1 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg^ 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm^ 2polyethylene glycol 3350 oral packet^ 2PREVACID - lansoprazole cap delayed release 15 mg 4 QL (30 capsules/30 days)PREVACID - lansoprazole cap delayed release 30 mg 4 QL (30 capsules/30 days)PROTONIX - pantoprazole sodium ec tab 20 mg 4 QL (30 tablets/30 days)PROTONIX - pantoprazole sodium ec tab 40 mg 4 QL (60 tablets/30 days)PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg5

rabeprazole sodium ec tab 20 mg^ 2 QL (30 tablets/30 days)ranitidine hcl cap 150 mg^ 2ranitidine hcl cap 300 mg^ 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml)^ 2ranitidine hcl tab 150 mg^ 1

2019


97

Drug Name Drug Tier Requirements/Limitsranitidine hcl tab 300 mg^ 1REGLAN - metoclopramide hcl tab 5 mg 4REGLAN - metoclopramide hcl tab 10 mg 4RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAROBINUL - glycopyrrolate tab 1 mg 4ROBINUL FORTE - glycopyrrolate tab 2 mg 4sucralfate tab 1 gm^ 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg^ 2ursodiol tab 250 mg^ 2ursodiol tab 500 mg^ 2XIFAXAN - rifaximin tab 550 mg 5ZANTAC - ranitidine hcl tab 300 mg 4Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN - pegademase bovine inj 250 unit/ml* 5ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

BUPHENYL - sodium phenylbutyrate tab 500 mg 5 PACEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4 PACYSTAGON - cysteamine bitartrate cap 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml)* 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PA

2019


Drug Name Drug Tier Requirements/LimitsKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVPRIV - velaglucerase alfa for inj 400 unit 5 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

2019


99

Drug Name Drug Tier Requirements/LimitsGenitourinary Agentsalfuzosin hcl tab er 24hr 10 mg^ 1 QL (30 tablets/30 days)AVODART - dutasteride cap 0.5 mg 4 QL (30 capsules/30 days)bethanechol chloride tab 5 mg^ 2bethanechol chloride tab 10 mg^ 2bethanechol chloride tab 25 mg^ 2bethanechol chloride tab 50 mg^ 2D-PENAMINE - penicillamine tab 125 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5DETROL - tolterodine tartrate tab 1 mg 4 QL (60 tablets/30 days)DETROL - tolterodine tartrate tab 2 mg 4 QL (60 tablets/30 days)DETROL LA - tolterodine tartrate cap er 24hr 2 mg 4 QL (30 capsules/30 days)DETROL LA - tolterodine tartrate cap er 24hr 4 mg 4 QL (30 capsules/30 days)DITROPAN XL - oxybutynin chloride tab er 24hr 5 mg 4 QL (30 tablets/30 days)DITROPAN XL - oxybutynin chloride tab er 24hr 10 mg 4 QL (90 tablets/30 days)dutasteride cap 0.5 mg^ 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg^ 2 QL (30 capsules/30 days)finasteride tab 5 mg^ 1 QL (30 tablets/30 days)FLOMAX - tamsulosin hcl cap 0.4 mg 4 QL (60 capsules/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml^ 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg^ 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg^ 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg^ 2 QL (120 tablets/30 days)PROSCAR - finasteride tab 5 mg 4 QL (30 tablets/30 days)RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)silodosin cap 4 mg^ 2 QL (30 capsules/30 days)silodosin cap 8 mg^ 2 QL (30 capsules/30 days)tamsulosin hcl cap 0.4 mg^ 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg^ 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg^ 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsTOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg^ 2 QL (30 capsules/30 days)trospium chloride tab 20 mg^ 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTEF - hydrocortisone tab 5 mg 4CORTEF - hydrocortisone tab 10 mg 4CORTEF - hydrocortisone tab 20 mg 4CORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone tab 1 mg 3DEXAMETHASONE - dexamethasone tab 2 mg 3dexamethasone elixir 0.5 mg/5ml^ 2dexamethasone sodium phosphate inj 4 mg/ml^ 2dexamethasone sodium phosphate inj 20 mg/5ml^ 2dexamethasone sodium phosphate inj 120 mg/30ml^ 2dexamethasone tab 0.5 mg^ 1dexamethasone tab 0.75 mg^ 1dexamethasone tab 1.5 mg^ 1dexamethasone tab 4 mg^ 1dexamethasone tab 6 mg^ 1fludrocortisone acetate tab 0.1 mg^ 2H.P. ACTHAR - corticotropin inj gel 80 unit/ml* 5 PAhydrocortisone butyrate hydrophilic lipo base cream 0.1%^ 2hydrocortisone tab 5 mg^ 2hydrocortisone tab 10 mg^ 2hydrocortisone tab 20 mg^ 2LOCOID LIPOCREAM - hydrocortisone butyrate hydrophilic lipo

base cream 0.1%4

MEDROL - methylprednisolone tab 4 mg 4MEDROL - methylprednisolone tab 8 mg 4MEDROL - methylprednisolone tab 16 mg 4MEDROL - methylprednisolone tab 32 mg 4MEDROL DOSEPAK - methylprednisolone tab therapy pack 4 mg

(21)4

methylprednisolone sod succ for inj 40 mg^ 2methylprednisolone sod succ for inj 125 mg^ 2methylprednisolone sod succ for inj 1000 mg^ 2methylprednisolone tab therapy pack 4 mg (21)^ 2methylprednisolone tab 4 mg^ 2methylprednisolone tab 8 mg^ 2

2019


101

Drug Name Drug Tier Requirements/Limitsmethylprednisolone tab 16 mg^ 2methylprednisolone tab 32 mg^ 2prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)^ 2prednisolone sod phosphate oral soln 15 mg/5ml^ 2prednisolone syrup 15 mg/5ml^ 2PREDNISONE - prednisone oral soln 5 mg/5ml 3PREDNISONE - prednisone tab therapy pack 5 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 5 mg (48)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (48)^ 2PREDNISONE - prednisone tab 50 mg 3prednisone tab 1 mg^ 1prednisone tab 2.5 mg^ 1prednisone tab 5 mg^ 2prednisone tab 10 mg^ 2prednisone tab 20 mg^ 1SOLU-MEDROL - methylprednisolone sod succ for inj 40 mg 4SOLU-MEDROL - methylprednisolone sod succ for inj 125 mg 4SOLU-MEDROL - methylprednisolone sod succ for inj 500 mg 4SOLU-MEDROL - methylprednisolone sod succ for inj 1000 mg 4Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit^2 PA

DDAVP - desmopressin acetate nasal spray soln 0.01% 5DDAVP - desmopressin acetate tab 0.1 mg 4DDAVP - desmopressin acetate tab 0.2 mg 4desmopressin acetate inj 4 mcg/ml^ 2desmopressin acetate nasal spray soln 0.01%^ 2desmopressin acetate nasal spray soln 0.01% (refrigerated)^ 2desmopressin acetate tab 0.1 mg^ 2desmopressin acetate tab 0.2 mg^ 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit^2 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5

2019


Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 25 mg/2.5gm (1%) 4 PA, QL (90 packets/30 days)ANDROGEL - testosterone td gel 50 mg/5gm (1%) 4 PA, QL (60 units/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)AYGESTIN - norethindrone acetate tab 5 mg 4danazol cap 50 mg^ 2 PAdanazol cap 100 mg^ 2 PAdanazol cap 200 mg^ 2 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

DEPO-PROVERA CONTRACEPTIVE - medroxyprogesteroneacetate im susp prefilled syr 150 mg/ml

4

DEPO-PROVERA CONTRACEPTIVE - medroxyprogesteroneacetate im susp 150 mg/ml

4

DEPO-TESTOSTERONE - testosterone cypionate im inj in oil100 mg/ml

4 PA

DEPO-TESTOSTERONE - testosterone cypionate im inj in oil200 mg/ml

4 PA

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)^ 2desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg^ 2desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4 PADIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4 PADIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4 PADIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4 PAdrospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg^ 2drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg^ 2drospirenone-ethinyl estradiol tab 3-0.02 mg^ 2drospirenone-ethinyl estradiol tab 3-0.03 mg^ 2DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4 PAELLA - ulipristal acetate tab 30 mg 3ESTRACE - estradiol vaginal cream 0.1 mg/gm 4estradiol & norethindrone acetate tab 0.5-0.1 mg# 4 PAestradiol & norethindrone acetate tab 1-0.5 mg# 4 PAestradiol tab 0.5 mg# 4 PA

2019


103

Drug Name Drug Tier Requirements/Limitsestradiol tab 1 mg# 4 PAestradiol tab 2 mg# 4 PAestradiol td patch weekly 0.025 mg/24hr# 4 PAestradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4 PAestradiol td patch weekly 0.05 mg/24hr# 4 PAestradiol td patch weekly 0.06 mg/24hr# 4 PAestradiol td patch weekly 0.075 mg/24hr# 4 PAestradiol td patch weekly 0.1 mg/24hr# 4 PAestradiol vaginal cream 0.1 mg/gm^ 2estradiol vaginal tab 10 mcg^ 2ESTROPIPATE - estropipate tab 0.75 mg# 4 PAESTROSTEP FE - norethindrone ac-ethinyl estrad-fe tab

1-20/1-30/1-35 mg-mcg4

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg^ 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg^ 2EVISTA - raloxifene hcl tab 60 mg 4HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)^ 2levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)^ 2levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg^ 2levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg^ 2levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg^ 2levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg^ 2LOESTRIN FE 1.5/30 - norethindrone ace & ethinyl estradiol-fe tab

1.5 mg-30 mcg4

LOESTRIN FE 1/20 - norethindrone ace & ethinyl estradiol-fe tab1 mg-20 mcg

4

LOESTRIN 1.5/30-21 - norethindrone ace & ethinyl estradiol tab1.5 mg-30 mcg

4

LOESTRIN 1/20-21 - norethindrone ace & ethinyl estradiol tab1 mg-20 mcg

4

LOSEASONIQUE - levonorg-eth est tab 0.1-0.02mg(84) & eth esttab 0.01mg(7)

4

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml^ 2medroxyprogesterone acetate im susp 150 mg/ml^ 2medroxyprogesterone acetate tab 2.5 mg^ 1medroxyprogesterone acetate tab 5 mg^ 1medroxyprogesterone acetate tab 10 mg^ 1

2019


Drug Name Drug Tier Requirements/Limitsmegestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAMENEST - esterified estrogens tab 0.3 mg# 4 PAMENEST - esterified estrogens tab 0.625 mg# 4 PAMENEST - esterified estrogens tab 1.25 mg# 4 PAMETHYLTESTOSTERONE - methyltestosterone cap 10 mg 5 PAMIRCETTE - desogest-eth estrad & eth estrad tab

0.15-0.02/0.01 mg(21/5)4

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg^ 2norethindrone & ethinyl estradiol tab 1 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg^ 2norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg^ 2norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg^ 2norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)^ 2norethindrone acetate tab 5 mg^ 2norethindrone tab 0.35 mg^ 2norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg^ 2norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg^ 2norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg^ 2norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg^ 2norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg^ 2norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg^ 2NUVARING - etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr4

ORTHO MICRONOR - norethindrone tab 0.35 mg 4ORTHO TRI-CYCLEN - norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg4

ORTHO-CYCLEN - norgestimate & ethinyl estradiol tab0.25 mg-35 mcg

4

ORTHO-NOVUM 1/35 - norethindrone & ethinyl estradiol tab1 mg-35 mcg

4

ORTHO-NOVUM 7/7/7 - norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg

4

oxandrolone tab 2.5 mg^ 2 PA

2019


105

Drug Name Drug Tier Requirements/Limitsoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMARIN - estrogens, conjugated tab 0.3 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.45 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.625 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.9 mg# 4 PAPREMARIN - estrogens, conjugated tab 1.25 mg# 4 PAPREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4 PA


4 PA


4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4 PA

progesterone micronized cap 100 mg^ 2progesterone micronized cap 200 mg^ 2PROVERA - medroxyprogesterone acetate tab 2.5 mg 4PROVERA - medroxyprogesterone acetate tab 5 mg 4PROVERA - medroxyprogesterone acetate tab 10 mg 4raloxifene hcl tab 60 mg^ 2SEASONIQUE - levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)4

testosterone cypionate im inj in oil 100 mg/ml^ 2 PAtestosterone cypionate im inj in oil 200 mg/ml^ 2 PAtestosterone enanthate im inj in oil 200 mg/ml^ 2 PAtestosterone td gel 25 mg/2.5gm (1%)^ 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%)^ 2 PA, QL (60 units/30 days)testosterone td gel 12.5 mg/act (1%)^ 2 PA, QL (4 pump bottles/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%)^ 2 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%)^ 2 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%)^ 2 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act^ 2 PA, QL (2 pump bottles/30 days)TRI-NORINYL 28 - norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg4

VAGIFEM - estradiol vaginal tab 10 mcg 4YASMIN 28 - drospirenone-ethinyl estradiol tab 3-0.03 mg 4YAZ - drospirenone-ethinyl estradiol tab 3-0.02 mg 4

2019


Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Thyroid)CYTOMEL - liothyronine sodium tab 5 mcg 4CYTOMEL - liothyronine sodium tab 25 mcg 4CYTOMEL - liothyronine sodium tab 50 mcg 4levothyroxine sodium tab 25 mcg^ 2levothyroxine sodium tab 50 mcg^ 2levothyroxine sodium tab 75 mcg^ 2levothyroxine sodium tab 88 mcg^ 2levothyroxine sodium tab 100 mcg^ 2levothyroxine sodium tab 112 mcg^ 2levothyroxine sodium tab 125 mcg^ 2levothyroxine sodium tab 137 mcg^ 2levothyroxine sodium tab 150 mcg^ 2levothyroxine sodium tab 175 mcg^ 2levothyroxine sodium tab 200 mcg^ 2levothyroxine sodium tab 300 mcg^ 2liothyronine sodium tab 5 mcg^ 2liothyronine sodium tab 25 mcg^ 2liothyronine sodium tab 50 mcg^ 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4TIROSINT - levothyroxine sodium cap 13 mcg 4TIROSINT - levothyroxine sodium cap 25 mcg 4TIROSINT - levothyroxine sodium cap 50 mcg 4TIROSINT - levothyroxine sodium cap 75 mcg 4TIROSINT - levothyroxine sodium cap 88 mcg 4TIROSINT - levothyroxine sodium cap 100 mcg 4TIROSINT - levothyroxine sodium cap 112 mcg 4

2019


107

Drug Name Drug Tier Requirements/LimitsTIROSINT - levothyroxine sodium cap 125 mcg 4TIROSINT - levothyroxine sodium cap 137 mcg 4TIROSINT - levothyroxine sodium cap 150 mcg 4TIROSINT - levothyroxine sodium cap 175 mcg 4TIROSINT - levothyroxine sodium cap 200 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 5Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg^ 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 5LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)^ 2 PA

2019


Drug Name Drug Tier Requirements/Limitsoctreotide acetate inj 100 mcg/ml (0.1 mg/ml)^ 2 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml)^ 2 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml)^ 2 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASANDOSTATIN LAR DEPOT - octreotide acetate for im inj kit

10 mg5 PA

SANDOSTATIN LAR DEPOT - octreotide acetate for im inj kit20 mg

5 PA

SANDOSTATIN LAR DEPOT - octreotide acetate for im inj kit30 mg

5 PA

SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg^ 1methimazole tab 10 mg^ 1propylthiouracil tab 50 mg^ 2

2019


109

Drug Name Drug Tier Requirements/LimitsImmunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 3ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAASTAGRAF XL - tacrolimus cap er 24hr 0.5 mg 4 BDASTAGRAF XL - tacrolimus cap er 24hr 1 mg 4 BDASTAGRAF XL - tacrolimus cap er 24hr 5 mg 4 BDATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg^ 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

3

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

CELLCEPT - mycophenolate mofetil cap 250 mg 5 BDCELLCEPT - mycophenolate mofetil for oral susp 200 mg/ml 5 BDCELLCEPT - mycophenolate mofetil tab 500 mg 5 BDCELLCEPT INTRAVENOUS - mycophenolate mofetil hcl for iv soln

500 mg4 BD

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous soln prefilled syringe

150 mg/ml*5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

cyclosporine cap 25 mg^ 2 BDcyclosporine cap 100 mg^ 2 BDcyclosporine iv soln 50 mg/ml^ 2 BDCYCLOSPORINE MODIFIED - cyclosporine modified cap 50 mg^ 2 BDcyclosporine modified cap 25 mg^ 2 BD

2019


Drug Name Drug Tier Requirements/Limitscyclosporine modified cap 100 mg^ 2 BDcyclosporine modified oral soln 100 mg/ml^ 2 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 3 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 3 BDFIRAZYR - icatibant acetate inj 30 mg/3ml* 5 PA, QL (6 syringes/30 days)GAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln 5 gm 5 BD, PAGAMMAGARD S/D - immune globulin (human) iv for soln 10 gm 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

2019


111

Drug Name Drug Tier Requirements/LimitsGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

5 gm/50ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln10 gm/100ml

5 BD, PA


5 BD, PA


5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

3

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

3

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 3HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 3HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg3

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PA

2019


Drug Name Drug Tier Requirements/LimitsIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDIMURAN - azathioprine tab 50 mg 4 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 3IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 3KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 3leflunomide tab 10 mg^ 2leflunomide tab 20 mg^ 2M-M-R II - measles, mumps & rubella virus vaccines for inj 3MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj3

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 3METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)^2

methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)^ 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)^ 2methotrexate sodium inj 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium tab 2.5 mg^ 2mycophenolate mofetil cap 250 mg^ 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg^ 2 BDmycophenolate mofetil tab 500 mg^ 2 BDmycophenolate sodium tab dr 180 mg^ 2 BDmycophenolate sodium tab dr 360 mg^ 2 BDNEORAL - cyclosporine modified cap 25 mg 4 BDNEORAL - cyclosporine modified cap 100 mg 4 BDNEORAL - cyclosporine modified oral soln 100 mg/ml 4 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

2019


113

Drug Name Drug Tier Requirements/LimitsORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector

125 mg/ml5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg*

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 3PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml3

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

3

PROGRAF - tacrolimus cap 0.5 mg 4 BDPROGRAF - tacrolimus cap 1 mg 4 BDPROGRAF - tacrolimus cap 5 mg 4 BDPROGRAF - tacrolimus inj 5 mg/ml 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp3

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

3

RABAVERT - rabies vaccine, pcec for inj 3 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

3 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5ROTARIX - rotavirus vaccine, live for oral susp 3ROTATEQ - rotavirus vaccine, live oral pentavalent soln 3SANDIMMUNE - cyclosporine cap 25 mg 4 BDSANDIMMUNE - cyclosporine cap 100 mg 4 BDSANDIMMUNE - cyclosporine iv soln 50 mg/ml 4 BDSANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus tab 0.5 mg^ 2 BDsirolimus tab 1 mg^ 2 BDsirolimus tab 2 mg 5 BD

2019


Drug Name Drug Tier Requirements/LimitsSTAMARIL - yellow fever vaccine for inj suspension 3STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg^ 2 BDtacrolimus cap 1 mg^ 2 BDtacrolimus cap 5 mg^ 2 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

3

TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml

3

TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj25 mcg/0.5ml

3

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 3VAQTA - hepatitis a vaccine inj susp 50 unit/ml 3VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml3

XATMEP - methotrexate oral soln 2.5 mg/ml 5 BDXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe 150 mg/ml*

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 3ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

2019


115

Drug Name Drug Tier Requirements/LimitsInflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3AZULFIDINE - sulfasalazine tab 500 mg 4AZULFIDINE EN-TABS - sulfasalazine tab delayed release 500 mg 4balsalazide disodium cap 750 mg^ 2budesonide delayed release particles cap 3 mg^ 2CANASA - mesalamine suppos 1000 mg 3COLAZAL - balsalazide disodium cap 750 mg 5DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml^ 2hydrocortisone rectal cream 1%^ 1hydrocortisone rectal cream 2.5%^ 2LIALDA - mesalamine tab delayed release 1.2 gm 4mesalamine enema 4 gm^ 2mesalamine rectal enema 4 gm & cleanser wipe kit^ 2mesalamine suppos 1000 mg^ 2mesalamine tab delayed release 800 mg^ 2mesalamine tab delayed release 1.2 gm^ 2PENTASA - mesalamine cap er 250 mg 4PENTASA - mesalamine cap er 500 mg 4ROWASA - mesalamine rectal enema 4 gm & cleanser wipe kit 4SFROWASA - mesalamine sulfite-free enema 4 gm/60ml 4sulfasalazine tab delayed release 500 mg^ 2sulfasalazine tab 500 mg^ 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg^ 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg^ 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg^ 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg^ 1 QL (4 tablets/28 days)ATELVIA - risedronate sodium tab delayed release 35 mg 4 QL (4 tablets/28 days)BONIVA - ibandronate sodium iv soln 3 mg/3ml 4calcitonin (salmon) nasal soln 200 unit/act^ 2calcitriol cap 0.25 mcg^ 2calcitriol cap 0.5 mcg^ 2calcitriol inj 1 mcg/ml^ 2calcitriol oral soln 1 mcg/ml^ 2ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4

2019


Drug Name Drug Tier Requirements/LimitsETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAFOSAMAX - alendronate sodium tab 70 mg 4 QL (4 tablets/28 days)ibandronate sodium iv soln 3 mg/3ml^ 2ibandronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg^ 2paricalcitol cap 2 mcg^ 2paricalcitol cap 4 mcg^ 2paricalcitol iv soln 2 mcg/ml^ 2paricalcitol iv soln 5 mcg/ml^ 2PROLIA - denosumab inj 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)ROCALTROL - calcitriol cap 0.25 mcg 4ROCALTROL - calcitriol cap 0.5 mcg 4ROCALTROL - calcitriol oral soln 1 mcg/ml 4SENSIPAR - cinacalcet hcl tab 30 mg 5 PASENSIPAR - cinacalcet hcl tab 60 mg 5 PASENSIPAR - cinacalcet hcl tab 90 mg 5 PATYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAZEMPLAR - paricalcitol cap 2 mcg 4ZEMPLAR - paricalcitol iv soln 2 mcg/ml 4ZEMPLAR - paricalcitol iv soln 5 mcg/ml 4zoledronic acid inj conc for iv infusion 4 mg/5ml^ 2zoledronic acid iv soln 5 mg/100ml^ 2

2019


117

Drug Name Drug Tier Requirements/LimitsOphthalmic AgentsACULAR - ketorolac tromethamine ophth soln 0.5% 4ACULAR LS - ketorolac tromethamine ophth soln 0.4% 4ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3ALPHAGAN P - brimonidine tartrate ophth soln 0.15% 3azelastine hcl ophth soln 0.05%^ 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint^ 2bacitracin-polymyxin-neomycin-hc ophth oint 1%^ 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4BETAGAN - levobunolol hcl ophth soln 0.5% 4betaxolol hcl ophth soln 0.5%^ 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03%^ 2brimonidine tartrate ophth soln 0.15%^ 2brimonidine tartrate ophth soln 0.2%^ 2bromfenac sodium ophth soln 0.09% (once-daily)^ 2carteolol hcl ophth soln 1%^ 1CILOXAN - ciprofloxacin hcl ophth soln 0.3% 4ciprofloxacin hcl ophth soln 0.3%^ 1COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

COSOPT - dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

4

cromolyn sodium ophth soln 4%^ 1CYSTARAN - cysteamine hcl ophth soln 0.44% 5DEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1%^ 2dorzolamide hcl ophth soln 2%^ 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml^ 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05%^ 2erythromycin ophth oint 5 mg/gm^ 2fluorometholone ophth susp 0.1%^ 2flurbiprofen sodium ophth soln 0.03%^ 2FML LIQUIFILM - fluorometholone ophth susp 0.1% 4gentamicin sulfate ophth oint 0.3%^ 2

2019


Drug Name Drug Tier Requirements/Limitsgentamicin sulfate ophth soln 0.3%^ 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4%^ 2ketorolac tromethamine ophth soln 0.5%^ 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005%^ 2levobunolol hcl ophth soln 0.5%^ 1LUMIGAN - bimatoprost ophth soln 0.01% 3MAXITROL - neomycin-polymyxin-dexamethasone ophth oint 0.1% 4MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5%^ 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin^ 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml^ 2neomycin-polymyxin-dexamethasone ophth oint 0.1%^ 2neomycin-polymyxin-dexamethasone ophth susp 0.1%^ 2OCUFLOX - ofloxacin ophth soln 0.3% 4ofloxacin ophth soln 0.3%^ 2olopatadine hcl ophth soln 0.1%^ 2olopatadine hcl ophth soln 0.2%^ 2OMNIPRED - prednisolone acetate ophth susp 1% 4PATADAY - olopatadine hcl ophth soln 0.2% 4PATANOL - olopatadine hcl ophth soln 0.1% 4PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1%^ 2pilocarpine hcl ophth soln 2%^ 2pilocarpine hcl ophth soln 4%^ 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%^ 1POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%4

PRED FORTE - prednisolone acetate ophth susp 1% 4PRED MILD - prednisolone acetate ophth susp 0.12% 4prednisolone acetate ophth susp 1%^ 2PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)

2019


119

Drug Name Drug Tier Requirements/LimitsSIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10%^ 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%^ 2timolol maleate ophth gel forming soln 0.25%^ 2timolol maleate ophth gel forming soln 0.5%^ 2timolol maleate ophth soln 0.25%^ 1timolol maleate ophth soln 0.5%^ 1timolol maleate ophth soln 0.5% (once-daily)^ 2TIMOPTIC - timolol maleate ophth soln 0.25% 4TIMOPTIC - timolol maleate ophth soln 0.5% 4TIMOPTIC OCUDOSE - timolol maleate preservative free ophth

soln 0.25%4

TIMOPTIC OCUDOSE - timolol maleate preservative free ophthsoln 0.5%

4

TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4TOBRADEX - tobramycin-dexamethasone ophth susp 0.3-0.1% 4tobramycin ophth soln 0.3%^ 2tobramycin-dexamethasone ophth susp 0.3-0.1%^ 2TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1%^ 2TRUSOPT - dorzolamide hcl ophth soln 2% 4VIGAMOX - moxifloxacin hcl ophth soln 0.5% 4VIROPTIC - trifluridine ophth soln 1% 4Otic Agentsacetic acid otic soln 2% 3CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01%^ 2hydrocortisone w/ acetic acid otic soln 1-2%^ 2neomycin-polymyxin-hc otic soln 1%^ 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%^ 2ofloxacin otic soln 0.3%^ 2Respiratory Tract/Pulmonary AgentsACCOLATE - zafirlukast tab 10 mg 4ACCOLATE - zafirlukast tab 20 mg 4acetylcysteine inhal soln 10%^ 2 BDacetylcysteine inhal soln 20%^ 2 BDADCIRCA - tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)^ 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml)^ 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml^ 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml^ 2 BDalbuterol sulfate syrup 2 mg/5ml^ 2albuterol sulfate tab er 12hr 4 mg^ 2albuterol sulfate tab er 12hr 8 mg^ 2albuterol sulfate tab 2 mg^ 2albuterol sulfate tab 4 mg^ 2ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act

3 QL (30 blisters/30 days)





ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh








2019


121

Drug Name Drug Tier Requirements/LimitsASMANEX TWISTHALER 60 METERED DOSES - mometasone

furoate inhal powd 220 mcg/inh3 QL (1 canister/30 days)



ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 4 QL (2 bottles/30 days)ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/

act4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray)^ 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray)^ 2 QL (2 bottles/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml^ 2 BDbudesonide inhalation susp 0.5 mg/2ml^ 2 BDbudesonide inhalation susp 1 mg/2ml^ 2 BDcaffeine citrate oral soln 60 mg/3ml^ 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 250 mcg 4 PA, QL (30 tablets/30 days)DALIRESP - roflumilast tab 500 mcg 4 PA, QL (30 tablets/30 days)desloratadine tab 5 mg^ 2diphenhydramine hcl inj 50 mg/ml^ 2DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000)

3

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (genericfor EpiPen 2-Pak)^

2

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

2019


Drug Name Drug Tier Requirements/LimitsFLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act

(50/valve)3 QL (1 canister/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)

3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act^ 1 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act3 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act


INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh


ipratropium bromide inhal soln 0.02%^ 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray)^ 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray)^ 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg^ 1mometasone furoate nasal susp 50 mcg/act^ 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg^ 2montelukast sodium chew tab 5 mg^ 2montelukast sodium oral granules packet 4 mg^ 2montelukast sodium tab 10 mg^ 1NASONEX - mometasone furoate nasal susp 50 mcg/act 4 QL (2 bottles/30 days)OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6%^ 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PATANASE - olopatadine hcl nasal soln 0.6% 4 QL (1 bottle/30 days)

2019


123

Drug Name Drug Tier Requirements/LimitsPROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer80 mcg/act

3 QL (2 canisters/30 days)

REMODULIN - treprostinil sodium inj 1 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 2.5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 10 mg/ml* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg^ 2 PA, QL (90 tablets/30 days)SINGULAIR - montelukast sodium chew tab 4 mg 4SINGULAIR - montelukast sodium chew tab 5 mg 4SINGULAIR - montelukast sodium oral granules packet 4 mg 4SINGULAIR - montelukast sodium tab 10 mg 4SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg^ 2terbutaline sulfate tab 5 mg^ 2THEO-24 - theophylline cap er 24hr 100 mg 4THEO-24 - theophylline cap er 24hr 200 mg 4THEO-24 - theophylline cap er 24hr 300 mg 4THEO-24 - theophylline cap er 24hr 400 mg 4theophylline tab er 12hr 100 mg^ 2

2019


Drug Name Drug Tier Requirements/Limitstheophylline tab er 12hr 200 mg^ 2theophylline tab er 12hr 300 mg^ 2theophylline tab er 12hr 450 mg^ 2theophylline tab er 24hr 400 mg^ 2theophylline tab er 24hr 600 mg^ 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg(60)*

5 PA, QL (1 pack (200tablets)/28 days)

UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg^ 2zafirlukast tab 20 mg^ 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PASleep Disorder Agentsarmodafinil tab 50 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 150 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 200 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 250 mg^ 2 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)

2019


125

Drug Name Drug Tier Requirements/LimitsBELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg^ 2 PA, QL (30 tablets/30 days)modafinil tab 200 mg^ 2 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 50 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 150 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 200 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 250 mg 4 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg^ 1 QL (30 capsules/30 days)temazepam cap 30 mg^ 1 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4 PAzaleplon cap 10 mg# 4 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA

2019

126

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................52abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................52abacavir sulfate soln 20 mg/ml.................................. 52abacavir sulfate tab 300 mg.......................................52ABILIFY..........................................................................46ABILIFY..........................................................................46ABILIFY..........................................................................46ABILIFY..........................................................................46ABILIFY..........................................................................46ABILIFY..........................................................................46abiraterone acetate tab 250 mg.................................33ABRAXANE...................................................................33ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................6acarbose tab 100 mg.................................................. 59acarbose tab 25 mg.................................................... 59acarbose tab 50 mg.................................................... 59ACCOLATE.................................................................119ACCOLATE.................................................................119ACCUPRIL.................................................................... 67ACCUPRIL.................................................................... 67ACCUPRIL.................................................................... 67ACCUPRIL.................................................................... 67ACCURETIC................................................................. 67ACCURETIC................................................................. 67ACCURETIC................................................................. 67acebutolol hcl cap 200 mg..........................................67acebutolol hcl cap 400 mg..........................................67acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................67acetazolamide tab 125 mg......................................... 67acetazolamide tab 250 mg......................................... 67acetic acid otic soln 2%............................................ 119

acetylcysteine inhal soln 10%..................................119acetylcysteine inhal soln 20%..................................119acitretin cap 10 mg......................................................88acitretin cap 17.5 mg...................................................88acitretin cap 25 mg......................................................88ACTHIB........................................................................109ACTIGALL..................................................................... 94ACTIMMUNE.............................................................. 109ACTOS...........................................................................59ACTOS...........................................................................59ACTOS...........................................................................59ACULAR......................................................................117ACULAR LS................................................................117acyclovir cap 200 mg.................................................. 52acyclovir oint 5%..........................................................52acyclovir sodium iv soln 50 mg/ml.............................52acyclovir susp 200 mg/5ml......................................... 52acyclovir tab 400 mg................................................... 52acyclovir tab 800 mg................................................... 52ADACEL...................................................................... 109ADAGEN........................................................................97ADALAT CC..................................................................67ADALAT CC..................................................................67ADALAT CC..................................................................67ADASUVE..................................................................... 46ADCIRCA.................................................................... 119ADDERALL XR............................................................ 85ADDERALL XR............................................................ 85ADDERALL XR............................................................ 85ADDERALL XR............................................................ 85ADDERALL XR............................................................ 85ADDERALL XR............................................................ 85adefovir dipivoxil tab 10 mg........................................52ADEMPAS...................................................................119ADEMPAS...................................................................119ADEMPAS...................................................................120ADEMPAS...................................................................120ADEMPAS...................................................................120ADVAIR DISKUS....................................................... 120ADVAIR DISKUS....................................................... 120ADVAIR DISKUS....................................................... 120ADVAIR HFA.............................................................. 120ADVAIR HFA.............................................................. 120ADVAIR HFA.............................................................. 120AFINITOR......................................................................33AFINITOR......................................................................33AFINITOR......................................................................33AFINITOR......................................................................33AFINITOR DISPERZ................................................... 33AFINITOR DISPERZ................................................... 33AFINITOR DISPERZ................................................... 33AGGRENOX................................................................. 63

2019

127

AGRYLIN.......................................................................63albendazole tab 200 mg............................................. 43ALBENZA...................................................................... 43albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................120albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................. 120albuterol sulfate soln nebu 0.63

mg/3ml......................................................................120albuterol sulfate soln nebu 1.25

mg/3ml......................................................................120albuterol sulfate syrup 2 mg/5ml..............................120albuterol sulfate tab 2 mg.........................................120albuterol sulfate tab 4 mg.........................................120albuterol sulfate tab er 12hr 4 mg........................... 120albuterol sulfate tab er 12hr 8 mg........................... 120alclometasone dipropionate cream

0.05%..........................................................................88alclometasone dipropionate oint

0.05%..........................................................................88ALCOHOL SWABS......................................................59ALDACTAZIDE............................................................. 67ALDACTONE................................................................ 67ALDACTONE................................................................ 67ALDACTONE................................................................ 67ALDARA........................................................................ 88ALDURAZYME............................................................. 97ALECENSA................................................................... 33alendronate sodium tab 10 mg................................ 115alendronate sodium tab 35 mg................................ 115alendronate sodium tab 5 mg.................................. 115alendronate sodium tab 70 mg................................ 115alfuzosin hcl tab er 24hr 10 mg................................. 99ALIMTA.......................................................................... 33ALIMTA.......................................................................... 33ALINIA............................................................................43ALINIA............................................................................43ALIQOPA....................................................................... 33allopurinol sodium for inj 500 mg...............................30allopurinol tab 100 mg.................................................30allopurinol tab 300 mg.................................................30ALOPRIM...................................................................... 30alosetron hcl tab 0.5 mg............................................. 94alosetron hcl tab 1 mg................................................ 94ALOXI.............................................................................27ALPHAGAN P............................................................ 117ALPHAGAN P............................................................ 117alprazolam tab 0.25 mg.............................................. 58alprazolam tab 0.5 mg................................................ 58alprazolam tab 1 mg....................................................58alprazolam tab 2 mg....................................................58ALTACE......................................................................... 67

ALTACE......................................................................... 67ALTACE......................................................................... 67ALTACE......................................................................... 67ALUNBRIG....................................................................33ALUNBRIG....................................................................33ALUNBRIG....................................................................33ALUNBRIG....................................................................33amantadine hcl cap 100 mg.......................................44amantadine hcl syrup 50 mg/5ml...............................44amantadine hcl tab 100 mg........................................44AMARYL........................................................................ 59AMARYL........................................................................ 59AMARYL........................................................................ 59AMBISOME...................................................................29AMERGE....................................................................... 31AMERGE....................................................................... 31amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................7amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................7amiloride & hydrochlorothiazide tab 5-50

mg................................................................................67amiloride hcl tab 5 mg.................................................67amino acid infusion 15%.............................................92amino acid infusion 6%...............................................91AMINOSYN II............................................................... 92amiodarone hcl tab 200 mg........................................67amiodarone hcl tab 400 mg........................................67AMITIZA.........................................................................94AMITIZA.........................................................................94amitriptyline hcl tab 100 mg....................................... 23amitriptyline hcl tab 10 mg..........................................23amitriptyline hcl tab 150 mg....................................... 23amitriptyline hcl tab 25 mg..........................................23amitriptyline hcl tab 50 mg..........................................23amitriptyline hcl tab 75 mg..........................................23amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................68amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................68amlodipine besylate-atorvastatin calcium tab 2.5-10




mg................................................................................68

2019

128

amlodipine besylate-atorvastatin calcium tab 5-20mg................................................................................68



amlodipine besylate-benazepril hcl cap 10-20mg................................................................................68


amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................68




amlodipine besylate-olmesartan medoxomil tab10-20 mg....................................................................68

amlodipine besylate-olmesartan medoxomil tab10-40 mg....................................................................68

amlodipine besylate-olmesartan medoxomil tab 5-20mg................................................................................68

amlodipine besylate-olmesartan medoxomil tab 5-40mg................................................................................68

amlodipine besylate tab 10 mg..................................67amlodipine besylate tab 2.5 mg.................................67amlodipine besylate tab 5 mg.................................... 67amlodipine besylate-valsartan tab 10-160

mg................................................................................68amlodipine besylate-valsartan tab 10-320



mg................................................................................68amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................68amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................68amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................68amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................68amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 68AMOXAPINE.................................................................23AMOXAPINE.................................................................23AMOXAPINE.................................................................23AMOXAPINE.................................................................23

AMOXICILLIN/CLAVULANATEPOTASSIUM................................................................ 7

AMOXICILLIN/CLAVULANATEPOTASSIUM................................................................ 7

amoxicillin (trihydrate) cap 250 mg..............................7amoxicillin (trihydrate) cap 500 mg..............................7amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 7amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 7amoxicillin (trihydrate) tab 500 mg...............................7amoxicillin (trihydrate) tab 875 mg...............................7amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 7amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 7amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 7amoxicillin & k clavulanate tab 250-125

mg..................................................................................7amoxicillin & k clavulanate tab 500-125

mg..................................................................................7amoxicillin & k clavulanate tab 875-125

mg..................................................................................7amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................86amphetamine-dextroamphetamine cap er 24hr 15





mg................................................................................85amphetamine-dextroamphetamine tab 10

mg................................................................................86amphetamine-dextroamphetamine tab 12.5





mg................................................................................86

2019

129

amphetamine-dextroamphetamine tab 7.5mg................................................................................86

AMPHOTERICIN B......................................................29ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................7ampicillin cap 500 mg....................................................7AMPICILLIN SODIUM................................................... 7ampicillin sodium for inj 1 gm.......................................7ampicillin sodium for inj 250 mg...................................7ampicillin sodium for inj 2 gm.......................................7ampicillin sodium for inj 500 mg...................................7ampicillin sodium for iv soln 10 gm..............................7ampicillin sodium for iv soln 2 gm................................7AMPICILLIN-SULBACTAM........................................... 7AMPYRA........................................................................86ANADROL-50............................................................. 102anagrelide hcl cap 0.5 mg.......................................... 63anagrelide hcl cap 1 mg............................................. 63anastrozole tab 1 mg...................................................33ANDRODERM............................................................ 102ANDRODERM............................................................ 102ANDROGEL................................................................102ANDROGEL................................................................102ANDROGEL................................................................102ANDROGEL................................................................102ANDROGEL PUMP...................................................102ANORO ELLIPTA.......................................................120ANTABUSE..................................................................... 6ANTABUSE..................................................................... 6APOKYN........................................................................44aprepitant capsule 125 mg.........................................27aprepitant capsule 40 mg........................................... 27aprepitant capsule 80 mg........................................... 27aprepitant capsule therapy pack 80 & 125

mg................................................................................27APRISO....................................................................... 115APTIOM......................................................................... 16APTIOM......................................................................... 16APTIOM......................................................................... 16APTIOM......................................................................... 16APTIVUS....................................................................... 52APTIVUS....................................................................... 52ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................63ARANESP ALBUMIN FREE.......................................64ARANESP ALBUMIN FREE.......................................64

ARANESP ALBUMIN FREE.......................................64ARANESP ALBUMIN FREE.......................................64ARANESP ALBUMIN FREE.......................................64ARANESP ALBUMIN FREE.......................................64ARANESP ALBUMIN FREE.......................................64ARCALYST................................................................. 109ARICEPT....................................................................... 22ARICEPT....................................................................... 22ARIMIDEX..................................................................... 33aripiprazole orally disintegrating tab 10

mg................................................................................46aripiprazole orally disintegrating tab 15

mg................................................................................46aripiprazole oral solution 1 mg/ml..............................46aripiprazole tab 10 mg................................................ 46aripiprazole tab 15 mg................................................ 46aripiprazole tab 20 mg................................................ 46aripiprazole tab 2 mg...................................................46aripiprazole tab 30 mg................................................ 46aripiprazole tab 5 mg...................................................46ARISTADA.....................................................................46ARISTADA.....................................................................46ARISTADA.....................................................................46ARISTADA.....................................................................46ARISTADA INITIO........................................................47armodafinil tab 150 mg............................................. 124armodafinil tab 200 mg............................................. 124armodafinil tab 250 mg............................................. 124armodafinil tab 50 mg............................................... 124ARNUITY ELLIPTA....................................................120ARNUITY ELLIPTA....................................................120ARNUITY ELLIPTA....................................................120AROMASIN................................................................... 33ARRANON.................................................................... 33arsenic trioxide inj 10 mg/10ml (1 mg/

ml)................................................................................33ARTHROTEC 50............................................................ 1ARTHROTEC 75............................................................ 1ARZERRA..................................................................... 33ARZERRA..................................................................... 33ASACOL HD...............................................................115ASMANEX HFA..........................................................120ASMANEX HFA..........................................................120ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................120ASMANEX TWISTHALER 14 METERED



DOSES.....................................................................120

2019

130

ASMANEX TWISTHALER 60 METEREDDOSES.....................................................................121

ASMANEX TWISTHALER 7 METEREDDOSES.....................................................................121

aspirin-dipyridamole cap er 12hr 25-200mg................................................................................64

ASTAGRAF XL...........................................................109ASTAGRAF XL...........................................................109ASTAGRAF XL...........................................................109ASTEPRO................................................................... 121ATACAND......................................................................68ATACAND......................................................................68ATACAND......................................................................68ATACAND......................................................................68ATACAND HCT............................................................ 68ATACAND HCT............................................................ 68ATACAND HCT............................................................ 68atazanavir sulfate cap 150 mg...................................52atazanavir sulfate cap 200 mg...................................52atazanavir sulfate cap 300 mg...................................52ATELVIA...................................................................... 115atenolol & chlorthalidone tab 100-25

mg................................................................................69atenolol & chlorthalidone tab 50-25 mg.................... 69atenolol tab 100 mg.....................................................69atenolol tab 25 mg.......................................................69atenolol tab 50 mg.......................................................69ATGAM........................................................................ 109atomoxetine hcl cap 100 mg...................................... 86atomoxetine hcl cap 10 mg........................................ 86atomoxetine hcl cap 18 mg........................................ 86atomoxetine hcl cap 25 mg........................................ 86atomoxetine hcl cap 40 mg........................................ 86atomoxetine hcl cap 60 mg........................................ 86atomoxetine hcl cap 80 mg........................................ 86atorvastatin calcium tab 10 mg.................................. 69atorvastatin calcium tab 20 mg.................................. 69atorvastatin calcium tab 40 mg.................................. 69atorvastatin calcium tab 80 mg.................................. 69atovaquone-proguanil hcl tab 250-100

mg................................................................................43atovaquone-proguanil hcl tab 62.5-25

mg................................................................................43atovaquone susp 750 mg/5ml....................................43ATRIPLA........................................................................ 53ATROVENT HFA........................................................121AUBAGIO...................................................................... 86AUBAGIO...................................................................... 86AUGMENTIN...................................................................7AUGMENTIN...................................................................7AURYXIA.......................................................................92AVALIDE........................................................................ 69

AVALIDE........................................................................ 69AVAPRO........................................................................ 69AVAPRO........................................................................ 69AVAPRO........................................................................ 69AVASTIN........................................................................33AVASTIN........................................................................33AVELOX...........................................................................7AVELOX...........................................................................7AVODART..................................................................... 99AVONEX........................................................................ 86AVONEX........................................................................ 86AVONEX PEN.............................................................. 86AYGESTIN.................................................................. 102azacitidine for inj 100 mg............................................64AZACTAM........................................................................8AZACTAM........................................................................8AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 8AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 8AZASAN...................................................................... 109AZASAN...................................................................... 109AZATHIOPRINE......................................................... 109azathioprine tab 50 mg............................................. 109azelaic acid gel 15%................................................... 88azelastine hcl nasal spray 0.1% (137 mcg/

spray)........................................................................121azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)........................................................................121azelastine hcl ophth soln 0.05%..............................117AZELEX......................................................................... 88AZILECT........................................................................44AZILECT........................................................................44AZITHROMYCIN............................................................ 8azithromycin for susp 100 mg/5ml...............................8azithromycin for susp 200 mg/5ml...............................8azithromycin iv for soln 500 mg................................... 8azithromycin tab 250 mg...............................................8azithromycin tab 500 mg...............................................8azithromycin tab 600 mg...............................................8AZOPT.........................................................................117AZOR............................................................................. 69AZOR............................................................................. 69AZOR............................................................................. 69AZOR............................................................................. 69aztreonam for inj 1 gm.................................................. 8aztreonam for inj 2 gm.................................................. 8AZULFIDINE...............................................................115AZULFIDINE EN-TABS.............................................115BBACITRACIN.............................................................. 117bacitracin-polymyxin b ophth oint............................ 117

2019

131

bacitracin-polymyxin-neomycin-hc ophth oint1%............................................................................. 117

baclofen tab 10 mg......................................................52baclofen tab 20 mg......................................................52BACTRIM.........................................................................8BACTRIM DS..................................................................8balsalazide disodium cap 750 mg........................... 115BANZEL.........................................................................16BANZEL.........................................................................16BANZEL.........................................................................16BARACLUDE................................................................ 53BARACLUDE................................................................ 53BARACLUDE................................................................ 53BASAGLAR KWIKPEN............................................... 59BAVENCIO.................................................................... 33BCG VACCINE...........................................................109BELEODAQ.................................................................. 33BELSOMRA................................................................ 124BELSOMRA................................................................ 125BELSOMRA................................................................ 125BELSOMRA................................................................ 125benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................69benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................69benazepril & hydrochlorothiazide tab 20-25

mg................................................................................69benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................69benazepril hcl tab 10 mg............................................ 69benazepril hcl tab 20 mg............................................ 69benazepril hcl tab 40 mg............................................ 69benazepril hcl tab 5 mg.............................................. 69BENDEKA..................................................................... 33BENICAR.......................................................................69BENICAR.......................................................................69BENICAR.......................................................................69BENICAR HCT............................................................. 69BENICAR HCT............................................................. 69BENICAR HCT............................................................. 69BENLYSTA..................................................................109BENLYSTA..................................................................109BENLYSTA..................................................................109BENLYSTA..................................................................109BENZAMYCIN.............................................................. 88BENZNIDAZOLE..........................................................43BENZNIDAZOLE..........................................................43benzoyl peroxide-erythromycin gel

5-3%............................................................................88benztropine mesylate tab 0.5 mg.............................. 44benztropine mesylate tab 1 mg..................................44benztropine mesylate tab 2 mg..................................44

BESIVANCE................................................................117BESPONSA.................................................................. 33BETAGAN................................................................... 117betamethasone dipropionate augmented cream

0.05%..........................................................................88betamethasone dipropionate augmented gel

0.05%..........................................................................88betamethasone dipropionate augmented lotion

0.05%..........................................................................88betamethasone dipropionate augmented oint

0.05%..........................................................................88betamethasone dipropionate cream

0.05%..........................................................................88betamethasone dipropionate lotion

0.05%..........................................................................88betamethasone dipropionate oint

0.05%..........................................................................88betamethasone valerate cream 0.1%....................... 88betamethasone valerate lotion 0.1%.........................88betamethasone valerate oint 0.1%............................88BETASERON................................................................ 86betaxolol hcl ophth soln 0.5%..................................117betaxolol hcl tab 10 mg...............................................69betaxolol hcl tab 20 mg...............................................69bethanechol chloride tab 10 mg.................................99bethanechol chloride tab 25 mg.................................99bethanechol chloride tab 50 mg.................................99bethanechol chloride tab 5 mg...................................99BETOPTIC-S.............................................................. 117BEVYXXA......................................................................64BEVYXXA......................................................................64bexarotene cap 75 mg................................................ 33BEXSERO...................................................................109bicalutamide tab 50 mg...............................................33BICILLIN L-A...................................................................8BICILLIN L-A...................................................................8BICILLIN L-A...................................................................8BICNU............................................................................33BIKTARVY..................................................................... 53BILTRICIDE...................................................................43bimatoprost ophth soln 0.03%................................. 117bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................70bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................69bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................69bisoprolol fumarate tab 10 mg................................... 70bisoprolol fumarate tab 5 mg..................................... 70bleomycin sulfate for inj 15 unit................................. 33bleomycin sulfate for inj 30 unit................................. 33BLINCYTO.....................................................................33

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BONIVA....................................................................... 115BOOSTRIX..................................................................109BOSULIF....................................................................... 33BOSULIF....................................................................... 34BOSULIF....................................................................... 34BRAFTOVI.....................................................................34BRAFTOVI.....................................................................34BREO ELLIPTA..........................................................121BREO ELLIPTA..........................................................121BRILINTA.......................................................................64BRILINTA.......................................................................64brimonidine tartrate ophth soln 0.15%.................... 117brimonidine tartrate ophth soln 0.2%...................... 117BRIVIACT......................................................................16BRIVIACT......................................................................16BRIVIACT......................................................................16BRIVIACT......................................................................17BRIVIACT......................................................................17BRIVIACT......................................................................17BRIVIACT......................................................................17bromfenac sodium ophth soln 0.09% (once-

daily)......................................................................... 117bromocriptine mesylate cap 5 mg..............................44bromocriptine mesylate tab 2.5 mg........................... 44budesonide delayed release particles cap 3

mg............................................................................. 115budesonide inhalation susp 0.25

mg/2ml......................................................................121budesonide inhalation susp 0.5

mg/2ml......................................................................121budesonide inhalation susp 1 mg/2ml.....................121bumetanide inj 0.25 mg/ml......................................... 70bumetanide tab 0.5 mg............................................... 70bumetanide tab 1 mg.................................................. 70bumetanide tab 2 mg.................................................. 70BUPHENYL...................................................................97buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................6buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................6buprenorphine hcl sl tab 2 mg......................................6buprenorphine hcl sl tab 8 mg......................................6buprenorphine td patch weekly 10 mcg/

hr....................................................................................1buprenorphine td patch weekly 15 mcg/



hr....................................................................................1bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................6

bupropion hcl tab 100 mg...........................................23bupropion hcl tab 75 mg.............................................23bupropion hcl tab er 12hr 100 mg............................. 23bupropion hcl tab er 12hr 150 mg............................. 23bupropion hcl tab er 12hr 200 mg............................. 23bupropion hcl tab er 24hr 150 mg............................. 23bupropion hcl tab er 24hr 300 mg............................. 23buspirone hcl tab 10 mg............................................. 58buspirone hcl tab 15 mg............................................. 58buspirone hcl tab 30 mg............................................. 58buspirone hcl tab 5 mg............................................... 58buspirone hcl tab 7.5 mg............................................ 58busulfan inj 6 mg/ml.................................................... 34butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BUTRANS........................................................................1BUTRANS........................................................................1BUTRANS........................................................................1BUTRANS........................................................................1BUTRANS........................................................................1BYDUREON BCISE.....................................................59BYDUREON PEN........................................................ 59BYSTOLIC.....................................................................70BYSTOLIC.....................................................................70BYSTOLIC.....................................................................70BYSTOLIC.....................................................................70Ccabergoline tab 0.5 mg............................................. 107CABOMETYX............................................................... 34CABOMETYX............................................................... 34CABOMETYX............................................................... 34caffeine citrate oral soln 60 mg/3ml........................ 121CALAN........................................................................... 70CALAN SR.................................................................... 70CALAN SR.................................................................... 70calcipotriene cream 0.005%.......................................88calcipotriene oint 0.005%............................................88calcipotriene soln 0.005% (50 mcg/ml).....................88

2019

133

calcitonin (salmon) nasal soln 200 unit/act..............................................................................115

calcitriol cap 0.25 mcg.............................................. 115calcitriol cap 0.5 mcg................................................ 115calcitriol inj 1 mcg/ml.................................................115calcitriol oral soln 1 mcg/ml......................................115calcium acetate cap 667 mg...................................... 92calcium acetate tab 667 mg....................................... 92CALQUENCE................................................................34CANASA......................................................................115CANCIDAS....................................................................29CANCIDAS....................................................................29candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................70candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................70candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................70candesartan cilexetil tab 16 mg................................. 70candesartan cilexetil tab 32 mg................................. 70candesartan cilexetil tab 4 mg................................... 70candesartan cilexetil tab 8 mg................................... 70CAPASTAT SULFATE..................................................32CAPRELSA................................................................... 34CAPRELSA................................................................... 34CAPTOPRIL/

HYDROCHLOROTHIAZIDE....................................70CAPTOPRIL/



HYDROCHLOROTHIAZIDE....................................70captopril tab 100 mg....................................................70captopril tab 12.5 mg...................................................70captopril tab 25 mg......................................................70captopril tab 50 mg......................................................70CARAC.......................................................................... 88CARAFATE....................................................................94CARAFATE....................................................................94CARBAGLU.................................................................. 92carbamazepine cap er 12hr 100 mg......................... 17carbamazepine cap er 12hr 200 mg......................... 17carbamazepine cap er 12hr 300 mg......................... 17carbamazepine chew tab 100 mg..............................17carbamazepine susp 100 mg/5ml..............................17carbamazepine tab 200 mg........................................17carbamazepine tab er 12hr 100 mg.......................... 17carbamazepine tab er 12hr 200 mg.......................... 17carbamazepine tab er 12hr 400 mg.......................... 17CARBATROL................................................................ 17CARBATROL................................................................ 17

CARBATROL................................................................ 17CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................45CARBIDOPA/LEVODOPA/





ENTACAPONE..........................................................45carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................44carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................44carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................44carbidopa & levodopa tab 10-100 mg....................... 44carbidopa & levodopa tab 25-100 mg....................... 44carbidopa & levodopa tab 25-250 mg....................... 45carbidopa & levodopa tab er 25-100

mg................................................................................44carbidopa & levodopa tab er 50-200

mg................................................................................44carbidopa tab 25 mg................................................... 45carboplatin iv soln 150 mg/15ml................................ 34carboplatin iv soln 450 mg/45ml................................ 34carboplatin iv soln 50 mg/5ml.................................... 34carboplatin iv soln 600 mg/60ml................................ 34CARDIZEM....................................................................70CARDIZEM....................................................................70CARDIZEM....................................................................70CARDIZEM CD............................................................ 70CARDIZEM CD............................................................ 70CARDIZEM CD............................................................ 70CARDIZEM CD............................................................ 71CARDIZEM CD............................................................ 71CARDIZEM LA............................................................. 71CARDIZEM LA............................................................. 71CARDIZEM LA............................................................. 71CARDIZEM LA............................................................. 71CARDIZEM LA............................................................. 71CARDIZEM LA............................................................. 71CARDURA.....................................................................71CARDURA.....................................................................71CARDURA.....................................................................71CARDURA.....................................................................71carmustine for inj 100 mg...........................................34CARNITOR....................................................................92CARNITOR....................................................................92

2019

134

CARNITOR SF............................................................. 92carteolol hcl ophth soln 1%...................................... 117carvedilol phosphate cap er 24hr 10

mg................................................................................71carvedilol phosphate cap er 24hr 20



mg................................................................................71carvedilol tab 12.5 mg.................................................71carvedilol tab 25 mg....................................................71carvedilol tab 3.125 mg...............................................71carvedilol tab 6.25 mg.................................................71CASODEX.....................................................................34caspofungin acetate for iv soln 50 mg...................... 29caspofungin acetate for iv soln 70 mg...................... 29CATAPRES....................................................................71CATAPRES....................................................................71CATAPRES....................................................................71CATAPRES-TTS-1....................................................... 71CATAPRES-TTS-2....................................................... 71CATAPRES-TTS-3....................................................... 71cefaclor cap 250 mg......................................................8cefaclor cap 500 mg......................................................8cefadroxil cap 500 mg...................................................8cefadroxil for susp 250 mg/5ml....................................8cefadroxil for susp 500 mg/5ml....................................8cefadroxil tab 1 gm........................................................ 8CEFAZOLIN SODIUM................................................... 8cefazolin sodium for inj 10 gm..................................... 8cefazolin sodium for inj 1 gm....................................... 8cefazolin sodium for inj 500 mg................................... 8cefdinir cap 300 mg....................................................... 8cefdinir for susp 125 mg/5ml........................................8cefdinir for susp 250 mg/5ml........................................8cefepime hcl for inj 1 gm.............................................. 8cefepime hcl for inj 2 gm.............................................. 8CEFOTAXIME SODIUM................................................8cefotaxime sodium for inj 1 gm.................................... 8cefoxitin sodium for inj 10 gm...................................... 9cefoxitin sodium for iv soln 1 gm................................. 9cefoxitin sodium for iv soln 2 gm................................. 9cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 9cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 9cefpodoxime proxetil tab 100 mg.................................9cefpodoxime proxetil tab 200 mg.................................9cefprozil for susp 125 mg/5ml...................................... 9cefprozil for susp 250 mg/5ml...................................... 9cefprozil tab 250 mg......................................................9

cefprozil tab 500 mg......................................................9ceftazidime for inj 1 gm.................................................9ceftazidime for inj 2 gm.................................................9ceftazidime for inj 6 gm.................................................9CEFTRIAXONE/DEXTROSE....................................... 9CEFTRIAXONE/DEXTROSE....................................... 9CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 9CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 9ceftriaxone sodium for inj 10 gm..................................9ceftriaxone sodium for inj 1 gm....................................9ceftriaxone sodium for inj 250 mg................................9ceftriaxone sodium for inj 2 gm....................................9ceftriaxone sodium for inj 500 mg................................9ceftriaxone sodium for iv soln 1 gm.............................9ceftriaxone sodium for iv soln 2 gm.............................9cefuroxime axetil tab 250 mg....................................... 9cefuroxime axetil tab 500 mg....................................... 9cefuroxime sodium for inj 7.5 gm.................................9cefuroxime sodium for inj 750 mg................................9cefuroxime sodium for iv soln 1.5 gm..........................9CELEBREX..................................................................... 1CELEBREX..................................................................... 1CELEBREX..................................................................... 1CELEBREX..................................................................... 1celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 2celecoxib cap 50 mg......................................................1CELEXA.........................................................................23CELEXA.........................................................................23CELEXA.........................................................................23CELLCEPT..................................................................109CELLCEPT..................................................................109CELLCEPT..................................................................109CELLCEPT INTRAVENOUS....................................109CELONTIN.................................................................... 17cephalexin cap 250 mg.................................................9cephalexin cap 500 mg.................................................9cephalexin cap 750 mg.................................................9cephalexin for susp 125 mg/5ml..................................9cephalexin for susp 250 mg/5ml..................................9CEREZYME.................................................................. 97cevimeline hcl cap 30 mg...........................................88CHANTIX......................................................................... 6CHANTIX......................................................................... 6CHANTIX CONTINUING MONTH

PACK.............................................................................6CHANTIX STARTING MONTH PACK.........................6CHEMET........................................................................92CHENODAL.................................................................. 94

2019

135

CHLORAMPHENICOL SODIUMSUCCINATE.............................................................. 10

chlorhexidine gluconate soln 0.12%..........................88CHLOROQUINE PHOSPHATE................................. 44chloroquine phosphate tab 500 mg...........................44CHLOROTHIAZIDE..................................................... 71chlorothiazide tab 500 mg.......................................... 71CHLORPROMAZINE HCL..........................................27CHLORPROMAZINE HCL..........................................27chlorpromazine hcl tab 100 mg..................................27chlorpromazine hcl tab 10 mg....................................27chlorpromazine hcl tab 200 mg..................................27chlorpromazine hcl tab 25 mg....................................27chlorpromazine hcl tab 50 mg....................................27chlorthalidone tab 25 mg............................................ 71chlorthalidone tab 50 mg............................................ 71cholestyramine light powder 4 gm/

dose............................................................................ 71cholestyramine light powder packets 4

gm................................................................................71cholestyramine powder 4 gm/dose............................71cholestyramine powder packets 4 gm.......................71choline fenofibrate cap dr 135 mg............................. 71choline fenofibrate cap dr 45 mg............................... 71CHORIONIC GONADOTROPIN..............................101ciclopirox gel 0.77%.................................................... 29ciclopirox olamine cream 0.77%................................29ciclopirox olamine susp 0.77%...................................29ciclopirox shampoo 1%............................................... 29ciclopirox solution 8%..................................................29cidofovir iv inj 75 mg/ml.............................................. 53cilostazol tab 100 mg.................................................. 64cilostazol tab 50 mg.................................................... 64CILOXAN.....................................................................117CIMDUO........................................................................ 53CIMETIDINE HCL........................................................ 94cimetidine tab 200 mg.................................................94cimetidine tab 300 mg.................................................94cimetidine tab 400 mg.................................................94cimetidine tab 800 mg.................................................94CINRYZE.....................................................................109CIPRO............................................................................10CIPRO............................................................................10CIPRO............................................................................10CIPRO............................................................................10CIPRODEX................................................................. 119ciprofloxacin 200 mg/100ml in d5w........................... 10ciprofloxacin 400 mg/200ml in d5w........................... 10ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).................................................................. 10ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).................................................................. 10

CIPROFLOXACIN HCL...............................................10ciprofloxacin hcl ophth soln 0.3%............................ 117ciprofloxacin hcl tab 250 mg.......................................10ciprofloxacin hcl tab 500 mg.......................................10ciprofloxacin hcl tab 750 mg.......................................10ciprofloxacin hcl tab er 24hr 1000 mg....................... 10ciprofloxacin hcl tab er 24hr 500 mg......................... 10CIPRO I.V.-IN D5W..................................................... 10CISPLATIN.................................................................... 34cisplatin inj 100 mg/100ml (1 mg/ml).........................34cisplatin inj 50 mg/50ml (1 mg/ml).............................34citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 23citalopram hydrobromide tab 10 mg..........................23citalopram hydrobromide tab 20 mg..........................23citalopram hydrobromide tab 40 mg..........................23cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................34clarithromycin for susp 125 mg/5ml...........................10clarithromycin for susp 250 mg/5ml...........................10clarithromycin tab 250 mg.......................................... 10clarithromycin tab 500 mg.......................................... 10clarithromycin tab er 24hr 500 mg.............................10CLEMASTINE FUMARATE......................................121CLEOCIN.......................................................................10CLEOCIN.......................................................................10CLEOCIN.......................................................................10CLEOCIN.......................................................................10CLEOCIN IN D5W....................................................... 10CLEOCIN IN D5W....................................................... 10CLEOCIN IN D5W....................................................... 10CLEOCIN PHOSPHATE............................................. 10CLEOCIN PHOSPHATE............................................. 10CLEOCIN PHOSPHATE............................................. 10CLEOCIN PHOSPHATE............................................. 10CLEOCIN PHOSPHATE............................................. 10CLEOCIN PHOSPHATE............................................. 11CLEOCIN PHOSPHATE............................................. 11CLEOCIN PHOSPHATE............................................. 11CLEOCIN PHOSPHATE............................................. 11CLEOCIN PHOSPHATE............................................. 11CLEOCIN-T...................................................................11CLEOCIN-T...................................................................11CLEOCIN-T...................................................................11CLEOCIN-T...................................................................11clindamycin hcl cap 150 mg.......................................11clindamycin hcl cap 300 mg.......................................11clindamycin hcl cap 75 mg......................................... 11clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................88clindamycin phosphate gel 1%.................................. 11

2019

136

clindamycin phosphate in d5w iv soln 300mg/50ml......................................................................11



clindamycin phosphate inj 300 mg/2ml.....................11clindamycin phosphate inj 600 mg/4ml.....................11clindamycin phosphate inj 900 mg/6ml.....................11clindamycin phosphate inj 9 gm/60ml....................... 11clindamycin phosphate iv soln 300

mg/2ml........................................................................ 11clindamycin phosphate iv soln 600

mg/4ml........................................................................ 11clindamycin phosphate iv soln 900

mg/6ml........................................................................ 11clindamycin phosphate lotion 1%.............................. 11clindamycin phosphate soln 1%................................ 11clindamycin phosphate swab 1%.............................. 11clindamycin phosphate vaginal cream

2%............................................................................... 11clobazam suspension 2.5 mg/ml............................... 17clobazam tab 10 mg....................................................17clobazam tab 20 mg....................................................17clobetasol propionate cream 0.05%..........................88clobetasol propionate emollient base cream

0.05%..........................................................................88clobetasol propionate gel 0.05%................................89clobetasol propionate oint 0.05%.............................. 89clobetasol propionate soln 0.05%..............................89clofarabine iv soln 1 mg/ml.........................................34CLOLAR........................................................................ 34clomipramine hcl cap 25 mg...................................... 23clomipramine hcl cap 50 mg...................................... 23clomipramine hcl cap 75 mg...................................... 23clonazepam orally disintegrating tab 0.125

mg................................................................................58clonazepam orally disintegrating tab 0.25

mg................................................................................58clonazepam orally disintegrating tab 0.5

mg................................................................................58clonazepam orally disintegrating tab 1

mg................................................................................58clonazepam orally disintegrating tab 2

mg................................................................................58clonazepam tab 0.5 mg.............................................. 58clonazepam tab 1 mg..................................................58clonazepam tab 2 mg..................................................58clonidine hcl tab 0.1 mg..............................................71clonidine hcl tab 0.2 mg..............................................71clonidine hcl tab 0.3 mg..............................................72clonidine hcl tab er 12hr 0.1 mg................................ 86

clonidine td patch weekly 0.1 mg/24hr......................72clonidine td patch weekly 0.2 mg/24hr......................72clonidine td patch weekly 0.3 mg/24hr......................72clopidogrel bisulfate tab 75 mg..................................64clorazepate dipotassium tab 15 mg...........................58clorazepate dipotassium tab 3.75 mg....................... 58clorazepate dipotassium tab 7.5 mg......................... 58clotrimazole cream 1%................................................29clotrimazole troche 10 mg.......................................... 29clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 89clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 89clozapine orally disintegrating tab 100

mg................................................................................47clozapine orally disintegrating tab 12.5

mg................................................................................47clozapine orally disintegrating tab 25

mg................................................................................47clozapine tab 100 mg..................................................47clozapine tab 200 mg..................................................47clozapine tab 25 mg....................................................47clozapine tab 50 mg....................................................47CLOZARIL.....................................................................47CLOZARIL.....................................................................47COARTEM.....................................................................44codeine sulfate tab 15 mg............................................ 2codeine sulfate tab 30 mg............................................ 2codeine sulfate tab 60 mg............................................ 2COLAZAL....................................................................115colchicine w/ probenecid tab 0.5-500

mg................................................................................30COLCRYS..................................................................... 30COLESTID.................................................................... 72COLESTID.................................................................... 72COLESTID.................................................................... 72COLESTID FLAVORED.............................................. 72COLESTID FLAVORED.............................................. 72colestipol hcl granule packets 5 gm.......................... 72colestipol hcl granules 5 gm.......................................72colestipol hcl tab 1 gm................................................ 72colistimethate sod for inj 150 mg...............................11COLYTE-FLAVOR PACKS......................................... 94COMBIGAN................................................................ 117COMBIVENT RESPIMAT......................................... 121COMETRIQ...................................................................34COMETRIQ...................................................................34COMETRIQ...................................................................34COMPLERA.................................................................. 53COMTAN....................................................................... 45COPAXONE.................................................................. 86COPAXONE.................................................................. 86

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COPIKTRA....................................................................34COPIKTRA....................................................................34COREG..........................................................................72COREG..........................................................................72COREG..........................................................................72COREG..........................................................................72COREG CR...................................................................72COREG CR...................................................................72COREG CR...................................................................72COREG CR...................................................................72CORGARD....................................................................72CORGARD....................................................................72CORGARD....................................................................72CORLANOR..................................................................72CORLANOR..................................................................72CORTEF......................................................................100CORTEF......................................................................100CORTEF......................................................................100CORTISONE ACETATE............................................100COSENTYX................................................................ 109COSENTYX SENSOREADY PEN.......................... 109COSMEGEN................................................................. 34COSOPT..................................................................... 117COTELLIC.....................................................................34COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COUMADIN...................................................................64COZAAR........................................................................72COZAAR........................................................................72COZAAR........................................................................72CREON..........................................................................97CREON..........................................................................97CREON..........................................................................97CREON..........................................................................97CREON..........................................................................97CRESEMBA.................................................................. 29CRESEMBA.................................................................. 29CRESTOR.....................................................................72CRESTOR.....................................................................72CRESTOR.....................................................................72CRESTOR.....................................................................72CRIXIVAN......................................................................53CRIXIVAN......................................................................53cromolyn sodium ophth soln 4%..............................117cromolyn sodium oral conc 100

mg/5ml........................................................................ 94

cromolyn sodium soln nebu 20mg/2ml......................................................................121

CUBICIN........................................................................11CUBICIN RF................................................................. 11cyclobenzaprine hcl tab 10 mg................................ 124cyclobenzaprine hcl tab 5 mg.................................. 124cyclobenzaprine hcl tab 7.5 mg...............................124cyclophosphamide cap 25 mg................................... 34cyclophosphamide cap 50 mg................................... 34cyclophosphamide for inj 1 gm.................................. 34cyclophosphamide for inj 2 gm.................................. 34cyclophosphamide for inj 500 mg..............................34cycloserine cap 250 mg..............................................32CYCLOSET...................................................................59cyclosporine cap 100 mg..........................................109cyclosporine cap 25 mg............................................109cyclosporine iv soln 50 mg/ml..................................109CYCLOSPORINE MODIFIED..................................109cyclosporine modified cap 100 mg..........................110cyclosporine modified cap 25 mg............................ 109cyclosporine modified oral soln 100 mg/

ml...............................................................................110CYKLOKAPRON.......................................................... 64CYMBALTA....................................................................23CYMBALTA....................................................................23CYMBALTA....................................................................23CYRAMZA.....................................................................34CYRAMZA.....................................................................35CYSTADANE................................................................ 97CYSTAGON.................................................................. 97CYSTAGON.................................................................. 97CYSTARAN.................................................................117CYTARABINE............................................................... 35cytarabine inj pf 100 mg/ml........................................ 35cytarabine inj pf 20 mg/ml.......................................... 35CYTOMEL...................................................................106CYTOMEL...................................................................106CYTOMEL...................................................................106CYTOTEC..................................................................... 94CYTOTEC..................................................................... 94CYTOVENE...................................................................53DDACARBAZINE............................................................ 35dacarbazine for inj 200 mg.........................................35dactinomycin for inj 0.5 mg........................................ 35DAKLINZA.....................................................................53DAKLINZA.....................................................................53DAKLINZA.....................................................................53dalfampridine tab er 12hr 10 mg................................86DALIRESP.................................................................. 121DALIRESP.................................................................. 121

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DALVANCE................................................................... 11danazol cap 100 mg..................................................102danazol cap 200 mg..................................................102danazol cap 50 mg....................................................102DANTRIUM................................................................... 52DANTRIUM................................................................... 52dantrolene sodium cap 100 mg................................. 52dantrolene sodium cap 25 mg....................................52dantrolene sodium cap 50 mg....................................52dapsone tab 100 mg................................................... 32dapsone tab 25 mg......................................................32DAPTACEL................................................................. 110daptomycin for iv soln 500 mg...................................11DARAPRIM................................................................... 44DARZALEX................................................................... 35DARZALEX................................................................... 35daunorubicin hcl iv soln 20 mg/4ml........................... 35DAUNORUBICIN HYDROCHLORIDE......................35DAURISMO...................................................................35DAURISMO...................................................................35DAYPRO.......................................................................... 2DDAVP.........................................................................101DDAVP.........................................................................101DDAVP.........................................................................101decitabine for inj 50 mg.............................................. 35DELSTRIGO................................................................. 53DELZICOL...................................................................115DEMADEX.....................................................................72demeclocycline hcl tab 150 mg..................................11demeclocycline hcl tab 300 mg..................................11DEMSER....................................................................... 72DENAVIR.......................................................................53DEPACON.....................................................................17DEPAKENE...................................................................17DEPAKOTE...................................................................17DEPAKOTE...................................................................17DEPAKOTE...................................................................17DEPAKOTE ER............................................................ 17DEPAKOTE ER............................................................ 17DEPAKOTE SPRINKLES........................................... 17DEPEN TITRATABS.................................................... 99DEPO-PROVERA...................................................... 102DEPO-PROVERA

CONTRACEPTIVE................................................. 102DEPO-PROVERA

CONTRACEPTIVE................................................. 102DEPO-TESTOSTERONE......................................... 102DEPO-TESTOSTERONE......................................... 102DESCOVY.....................................................................53desipramine hcl tab 100 mg.......................................24desipramine hcl tab 10 mg......................................... 23desipramine hcl tab 150 mg.......................................24

desipramine hcl tab 25 mg......................................... 23desipramine hcl tab 50 mg......................................... 23desipramine hcl tab 75 mg......................................... 24desloratadine tab 5 mg............................................. 121desmopressin acetate inj 4 mcg/ml.........................101desmopressin acetate nasal spray soln

0.01%........................................................................101desmopressin acetate nasal spray soln 0.01%

(refrigerated)............................................................101desmopressin acetate tab 0.1 mg........................... 101desmopressin acetate tab 0.2 mg........................... 101desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)...................................................................102desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg............................................................................. 102

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg........................................................................... 102

desonide cream 0.05%............................................... 89desonide lotion 0.05%.................................................89desonide oint 0.05%....................................................89desoximetasone cream 0.05%...................................89desoximetasone cream 0.25%...................................89desoximetasone gel 0.05%........................................ 89desoximetasone oint 0.25%....................................... 89desvenlafaxine succinate tab er 24hr 100

mg................................................................................24desvenlafaxine succinate tab er 24hr 25

mg................................................................................24desvenlafaxine succinate tab er 24hr 50

mg................................................................................24DETROL........................................................................ 99DETROL........................................................................ 99DETROL LA..................................................................99DETROL LA..................................................................99DEXAMETHASONE.................................................. 100DEXAMETHASONE.................................................. 100dexamethasone elixir 0.5 mg/5ml............................100DEXAMETHASONE SODIUM

PHOSPHATE...........................................................117dexamethasone sodium phosphate inj 120

mg/30ml....................................................................100dexamethasone sodium phosphate inj 20

mg/5ml......................................................................100dexamethasone sodium phosphate inj 4 mg/

ml...............................................................................100dexamethasone tab 0.5 mg......................................100dexamethasone tab 0.75 mg................................... 100dexamethasone tab 1.5 mg......................................100dexamethasone tab 4 mg.........................................100dexamethasone tab 6 mg.........................................100DEXEDRINE................................................................. 86

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DEXEDRINE................................................................. 86DEXEDRINE................................................................. 86dexmethylphenidate hcl tab 10 mg............................86dexmethylphenidate hcl tab 2.5 mg...........................86dexmethylphenidate hcl tab 5 mg..............................86dexrazoxane for inj 250 mg........................................35dexrazoxane for inj 500 mg........................................35dextroamphetamine sulfate cap er 24hr 10

mg................................................................................87dextroamphetamine sulfate cap er 24hr 15

mg................................................................................87dextroamphetamine sulfate cap er 24hr 5

mg................................................................................86dextroamphetamine sulfate tab 10 mg......................87dextroamphetamine sulfate tab 5 mg........................87dextrose 2.5% w/ sodium chloride

0.45%..........................................................................92dextrose 5% in lactated ringers................................. 92dextrose 5% w/ sodium chloride 0.2%...................... 92dextrose 5% w/ sodium chloride

0.33%..........................................................................92dextrose 5% w/ sodium chloride

0.45%..........................................................................92dextrose 5% w/ sodium chloride 0.9%...................... 92dextrose inj 10%.......................................................... 92dextrose inj 5%.............................................................92DIASTAT ACUDIAL......................................................17DIASTAT ACUDIAL......................................................17DIASTAT PEDIATRIC..................................................17DIAZEPAM.................................................................... 17DIAZEPAM.................................................................... 17DIAZEPAM.................................................................... 17DIAZEPAM.................................................................... 58diazepam conc 5 mg/ml..............................................58DIAZEPAM RECTAL GEL.......................................... 17DIAZEPAM RECTAL GEL.......................................... 17DIAZEPAM RECTAL GEL.......................................... 18diazepam tab 10 mg....................................................59diazepam tab 2 mg......................................................58diazepam tab 5 mg......................................................58diclofenac potassium tab 50 mg.................................. 2diclofenac sodium gel 1%.............................................2diclofenac sodium gel 3%...........................................89diclofenac sodium ophth soln 0.1%.........................117diclofenac sodium tab delayed release 25

mg..................................................................................2diclofenac sodium tab delayed release 50

mg..................................................................................2diclofenac sodium tab delayed release 75

mg..................................................................................2diclofenac sodium tab er 24hr 100 mg........................2

diclofenac w/ misoprostol tab delayed release 50-0.2mg..................................................................................2

diclofenac w/ misoprostol tab delayed release 75-0.2mg..................................................................................2

dicloxacillin sodium cap 250 mg................................ 11dicloxacillin sodium cap 500 mg................................ 11dicyclomine hcl cap 10 mg......................................... 95dicyclomine hcl tab 20 mg..........................................95didanosine delayed release capsule 200

mg................................................................................53didanosine delayed release capsule 250

mg................................................................................53didanosine delayed release capsule 400

mg................................................................................53DIFICID..........................................................................12diflorasone diacetate oint 0.05%................................89DIFLUCAN.................................................................... 29DIFLUCAN.................................................................... 29DIFLUCAN.................................................................... 29DIFLUCAN.................................................................... 29DIFLUCAN.................................................................... 29DIFLUCAN.................................................................... 29DIGOXIN........................................................................72digoxin tab 125 mcg (0.125 mg)................................72digoxin tab 250 mcg (0.25 mg).................................. 72DILANTIN...................................................................... 18DILANTIN...................................................................... 18DILANTIN-125.............................................................. 18DILANTIN INFATABS.................................................. 18diltiazem hcl cap er 12hr 120 mg.............................. 73diltiazem hcl cap er 12hr 60 mg.................................72diltiazem hcl cap er 12hr 90 mg.................................73diltiazem hcl cap er 24hr 120 mg.............................. 73diltiazem hcl cap er 24hr 180 mg.............................. 73diltiazem hcl cap er 24hr 240 mg.............................. 73diltiazem hcl coated beads cap er 24hr 120

mg................................................................................73diltiazem hcl coated beads cap er 24hr 180




mg................................................................................73diltiazem hcl coated beads tab er 24hr 180



mg................................................................................73

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diltiazem hcl coated beads tab er 24hr 360mg................................................................................73

diltiazem hcl coated beads tab er 24hr 420mg................................................................................73

diltiazem hcl extended release beads cap er 24hr120 mg....................................................................... 73






diltiazem hcl tab 120 mg.............................................73diltiazem hcl tab 30 mg...............................................73diltiazem hcl tab 60 mg...............................................73diltiazem hcl tab 90 mg...............................................73DIOVAN......................................................................... 73DIOVAN......................................................................... 73DIOVAN......................................................................... 73DIOVAN......................................................................... 73DIOVAN HCT................................................................73DIOVAN HCT................................................................73DIOVAN HCT................................................................73DIOVAN HCT................................................................73DIOVAN HCT................................................................73DIPENTUM................................................................. 115diphenhydramine hcl inj 50 mg/ml...........................121DIPHTHERIA/TETANUS TOXOIDS

ADSORBED.............................................................110DIPROLENE................................................................. 89dipyridamole tab 25 mg.............................................. 64dipyridamole tab 50 mg.............................................. 64dipyridamole tab 75 mg.............................................. 64disulfiram tab 250 mg....................................................6disulfiram tab 500 mg....................................................6DITROPAN XL..............................................................99DITROPAN XL..............................................................99divalproex sodium cap delayed release sprinkle 125

mg................................................................................18divalproex sodium tab delayed release 125



mg................................................................................18divalproex sodium tab er 24 hr 250 mg.....................18divalproex sodium tab er 24 hr 500 mg.....................18DIVIGEL...................................................................... 102

DIVIGEL...................................................................... 102DIVIGEL...................................................................... 102DIVIGEL...................................................................... 102DOCETAXEL.................................................................35DOCETAXEL.................................................................35docetaxel for inj conc 20 mg/ml................................. 35docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................35docetaxel soln for iv infusion 160

mg/16ml......................................................................35docetaxel soln for iv infusion 20

mg/2ml........................................................................ 35docetaxel soln for iv infusion 80

mg/8ml........................................................................ 35dofetilide cap 125 mcg (0.125 mg)............................73dofetilide cap 250 mcg (0.25 mg).............................. 73dofetilide cap 500 mcg (0.5 mg)................................ 73DOLOPHINE................................................................... 2DOLOPHINE................................................................... 2donepezil hydrochloride orally disintegrating tab 10

mg................................................................................22donepezil hydrochloride orally disintegrating tab 5

mg................................................................................22donepezil hydrochloride tab 10 mg........................... 22donepezil hydrochloride tab 23 mg........................... 22donepezil hydrochloride tab 5 mg..............................22dorzolamide hcl ophth soln 2%................................117dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 117DOVONEX.................................................................... 89doxazosin mesylate tab 1 mg.................................... 73doxazosin mesylate tab 2 mg.................................... 74doxazosin mesylate tab 4 mg.................................... 74doxazosin mesylate tab 8 mg.................................... 74doxepin hcl cap 100 mg..............................................24doxepin hcl cap 10 mg................................................24doxepin hcl cap 150 mg..............................................24doxepin hcl cap 25 mg................................................24doxepin hcl cap 50 mg................................................24doxepin hcl cap 75 mg................................................24doxepin hcl conc 10 mg/ml.........................................24doxorubicin hcl for inj 10 mg...................................... 35doxorubicin hcl for inj 50 mg...................................... 35doxorubicin hcl inj 2 mg/ml.........................................35doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................35doxycycline hyclate cap 100 mg................................12doxycycline hyclate cap 50 mg..................................12doxycycline hyclate for inj 100 mg.............................12doxycycline hyclate tab 100 mg.................................12doxycycline hyclate tab 20 mg...................................12doxycycline monohydrate cap 100 mg......................12

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doxycycline monohydrate cap 150 mg......................12doxycycline monohydrate cap 50 mg........................12doxycycline monohydrate cap 75 mg........................12doxycycline monohydrate tab 100 mg...................... 12doxycycline monohydrate tab 150 mg...................... 12doxycycline monohydrate tab 50 mg.........................12doxycycline monohydrate tab 75 mg.........................12D-PENAMINE............................................................... 99dronabinol cap 10 mg................................................. 27dronabinol cap 2.5 mg................................................ 27dronabinol cap 5 mg....................................................27drospirenone-ethinyl estradiol tab 3-0.02

mg............................................................................. 102drospirenone-ethinyl estradiol tab 3-0.03

mg............................................................................. 102drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg..................................................... 102drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg..................................................... 102DUAVEE...................................................................... 102DULERA......................................................................121DULERA......................................................................121duloxetine hcl enteric coated pellets cap 20

mg................................................................................24duloxetine hcl enteric coated pellets cap 30

mg................................................................................24duloxetine hcl enteric coated pellets cap 60

mg................................................................................24DUPIXENT.................................................................. 110DUREZOL................................................................... 117dutasteride cap 0.5 mg............................................... 99dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................99DYAZIDE....................................................................... 74EE.E.S. GRANULES......................................................12EC-NAPROSYN............................................................. 2econazole nitrate cream 1%.......................................29EDURANT..................................................................... 53efavirenz cap 200 mg..................................................53efavirenz cap 50 mg....................................................53efavirenz tab 600 mg...................................................53EFFEXOR XR...............................................................24EFFEXOR XR...............................................................24EFFEXOR XR...............................................................24EFFIENT........................................................................64EFFIENT........................................................................64EGRIFTA..................................................................... 101ELAPRASE................................................................... 97ELELYSO.......................................................................97ELIDEL...........................................................................89

ELIGARD.....................................................................107ELIGARD.....................................................................107ELIGARD.....................................................................107ELIGARD.....................................................................107ELIQUIS.........................................................................64ELIQUIS.........................................................................64ELIQUIS STARTER PACK......................................... 65ELITEK...........................................................................35ELITEK...........................................................................35ELLA............................................................................ 102ELOCON........................................................................89ELOCON........................................................................89EMCYT.......................................................................... 35EMEND..........................................................................28EMEND..........................................................................28EMEND..........................................................................28EMEND..........................................................................28EMEND TRIPACK........................................................28EMPLICITI.....................................................................35EMPLICITI.....................................................................35EMSAM..........................................................................24EMSAM..........................................................................24EMSAM..........................................................................24EMTRIVA.......................................................................53EMTRIVA.......................................................................53enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................74enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................74enalapril maleate tab 10 mg.......................................74enalapril maleate tab 2.5 mg......................................74enalapril maleate tab 20 mg.......................................74enalapril maleate tab 5 mg.........................................74ENBREL...................................................................... 110ENBREL...................................................................... 110ENBREL...................................................................... 110ENBREL MINI............................................................ 110ENBREL SURECLICK.............................................. 110ENGERIX-B................................................................ 110ENGERIX-B................................................................ 110enoxaparin sodium inj 100 mg/ml..............................65enoxaparin sodium inj 120 mg/0.8ml........................ 65enoxaparin sodium inj 150 mg/ml..............................65enoxaparin sodium inj 300 mg/3ml............................65enoxaparin sodium inj 30 mg/0.3ml...........................65enoxaparin sodium inj 40 mg/0.4ml...........................65enoxaparin sodium inj 60 mg/0.6ml...........................65enoxaparin sodium inj 80 mg/0.8ml...........................65entacapone tab 200 mg..............................................45entecavir tab 0.5 mg....................................................53entecavir tab 1 mg.......................................................53ENTRESTO...................................................................74

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ENTRESTO...................................................................74ENTRESTO...................................................................74EPCLUSA......................................................................53EPIDIOLEX................................................................... 18epinastine hcl ophth soln 0.05%..............................117EPINEPHRINE........................................................... 121epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak).................... 121epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................35epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................35EPIVIR........................................................................... 53EPIVIR........................................................................... 53EPIVIR........................................................................... 53EPIVIR HBV..................................................................53EPIVIR HBV..................................................................53eplerenone tab 25 mg.................................................74eplerenone tab 50 mg.................................................74EPOGEN....................................................................... 65EPOGEN....................................................................... 65EPOGEN....................................................................... 65EPOGEN....................................................................... 65EPOGEN....................................................................... 65EPZICOM...................................................................... 53ERBITUX....................................................................... 35ERBITUX....................................................................... 35ERGOLOID MESYLATES...........................................22ERIVEDGE....................................................................35ERLEADA......................................................................35ertapenem sodium for inj 1 gm.................................. 12ERWINAZE................................................................... 36ERYPED 200................................................................12ERYPED 400................................................................12ERY-TAB....................................................................... 12ERY-TAB....................................................................... 12ERY-TAB....................................................................... 12ERYTHROCIN LACTOBIONATE...............................12ERYTHROCIN STEARATE........................................ 12erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 12erythromycin ophth oint 5 mg/gm............................ 117erythromycin pads 2%.................................................12erythromycin soln 2%..................................................12erythromycin tab 250 mg............................................ 12erythromycin tab 500 mg............................................ 12ESBRIET..................................................................... 121ESBRIET..................................................................... 121ESBRIET..................................................................... 121escitalopram oxalate soln 5 mg/5ml..........................24escitalopram oxalate tab 10 mg.................................24escitalopram oxalate tab 20 mg.................................24

escitalopram oxalate tab 5 mg...................................24esomeprazole magnesium cap delayed release 20

mg................................................................................95esomeprazole magnesium cap delayed release 40

mg................................................................................95ESOMEPRAZOLE SODIUM...................................... 95esomeprazole sodium for intravenous soln 40

mg................................................................................95ESTRACE................................................................... 102estradiol & norethindrone acetate tab 0.5-0.1

mg............................................................................. 102estradiol & norethindrone acetate tab 1-0.5

mg............................................................................. 102estradiol tab 0.5 mg...................................................102estradiol tab 1 mg......................................................103estradiol tab 2 mg......................................................103estradiol td patch weekly 0.025

mg/24hr.................................................................... 103estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr).................................................................103estradiol td patch weekly 0.05

mg/24hr.................................................................... 103estradiol td patch weekly 0.06

mg/24hr.................................................................... 103estradiol td patch weekly 0.075

mg/24hr.................................................................... 103estradiol td patch weekly 0.1 mg/24hr.................... 103estradiol vaginal cream 0.1 mg/gm......................... 103estradiol vaginal tab 10 mcg.................................... 103ESTROPIPATE...........................................................103ESTROSTEP FE........................................................103ethambutol hcl tab 100 mg.........................................32ethambutol hcl tab 400 mg.........................................32ethosuximide cap 250 mg...........................................18ethosuximide soln 250 mg/5ml.................................. 18ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg........................................................................... 103ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg........................................................................... 103ETHYOL........................................................................ 36ETIDRONATE DISODIUM........................................115ETIDRONATE DISODIUM........................................116etodolac cap 200 mg.....................................................2etodolac cap 300 mg.....................................................2etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 2etodolac tab er 24hr 500 mg........................................ 2etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 36etoposide inj 100 mg/5ml (20 mg/ml)........................36etoposide inj 1 gm/50ml (20 mg/ml).......................... 36

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etoposide inj 500 mg/25ml (20 mg/ml)......................36EVISTA........................................................................ 103EVOMELA..................................................................... 36EVOTAZ.........................................................................53EXELON........................................................................ 22EXELON........................................................................ 22EXELON........................................................................ 22exemestane tab 25 mg............................................... 36EXFORGE.....................................................................74EXFORGE.....................................................................74EXFORGE.....................................................................74EXFORGE.....................................................................74EXFORGE HCT........................................................... 74EXFORGE HCT........................................................... 74EXFORGE HCT........................................................... 74EXFORGE HCT........................................................... 74EXFORGE HCT........................................................... 74EXJADE.........................................................................92EXJADE.........................................................................92EXJADE.........................................................................92ezetimibe-simvastatin tab 10-10 mg..........................74ezetimibe-simvastatin tab 10-20 mg..........................74ezetimibe-simvastatin tab 10-40 mg..........................74ezetimibe-simvastatin tab 10-80 mg..........................74ezetimibe tab 10 mg....................................................74FFABRAZYME................................................................ 97FABRAZYME................................................................ 97famciclovir tab 125 mg................................................54famciclovir tab 250 mg................................................54famciclovir tab 500 mg................................................54famotidine for susp 40 mg/5ml...................................95famotidine inj 200 mg/20ml........................................ 95famotidine inj 20 mg/2ml.............................................95famotidine inj 40 mg/4ml.............................................95famotidine tab 20 mg...................................................95famotidine tab 40 mg...................................................95FANAPT.........................................................................47FANAPT.........................................................................47FANAPT.........................................................................47FANAPT.........................................................................47FANAPT.........................................................................47FANAPT.........................................................................47FANAPT.........................................................................47FANAPT TITRATION PACK....................................... 47FARESTON...................................................................36FARYDAK......................................................................36FARYDAK......................................................................36FARYDAK......................................................................36FASLODEX................................................................... 36fat emulsion iv soln 20%.............................................92

FAZACLO...................................................................... 47FAZACLO...................................................................... 47felbamate susp 600 mg/5ml....................................... 18felbamate tab 400 mg................................................. 18felbamate tab 600 mg................................................. 18FELDENE........................................................................ 2FELDENE........................................................................ 2felodipine tab er 24hr 10 mg...................................... 74felodipine tab er 24hr 2.5 mg..................................... 74felodipine tab er 24hr 5 mg........................................ 74FEMARA........................................................................36fenofibrate micronized cap 130 mg........................... 74fenofibrate micronized cap 134 mg........................... 75fenofibrate micronized cap 200 mg........................... 75fenofibrate micronized cap 43 mg............................. 74fenofibrate micronized cap 67 mg............................. 74fenofibrate tab 145 mg................................................75fenofibrate tab 160 mg................................................75fenofibrate tab 48 mg.................................................. 75fenofibrate tab 54 mg.................................................. 75fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600





mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................3fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 37.5 mcg/hr..............................2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 62.5 mcg/hr..............................2fentanyl td patch 72hr 75 mcg/hr................................. 2fentanyl td patch 72hr 87.5 mcg/hr..............................2FETZIMA....................................................................... 24FETZIMA....................................................................... 24FETZIMA....................................................................... 24FETZIMA....................................................................... 24FETZIMA TITRATION PACK......................................24FINACEA....................................................................... 89FINACEA....................................................................... 89finasteride tab 5 mg.....................................................99FIRAZYR..................................................................... 110FIRMAGON.................................................................107FIRMAGON.................................................................107FLAGYL......................................................................... 12

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FLAGYL......................................................................... 12FLAGYL......................................................................... 12flecainide acetate tab 100 mg....................................75flecainide acetate tab 150 mg....................................75flecainide acetate tab 50 mg...................................... 75FLOMAX........................................................................99FLOVENT DISKUS....................................................121FLOVENT DISKUS....................................................121FLOVENT DISKUS....................................................121FLOVENT HFA...........................................................122FLOVENT HFA...........................................................122FLOVENT HFA...........................................................122fluconazole for susp 10 mg/ml................................... 29fluconazole for susp 40 mg/ml................................... 29fluconazole in dextrose inj 200

mg/100ml....................................................................29fluconazole in dextrose inj 400

mg/200ml....................................................................29fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................29fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................29fluconazole tab 100 mg...............................................29fluconazole tab 150 mg...............................................29fluconazole tab 200 mg...............................................29fluconazole tab 50 mg.................................................29flucytosine cap 250 mg............................................... 29flucytosine cap 500 mg............................................... 29fludarabine phosphate for inj 50 mg..........................36fludarabine phosphate inj 25 mg/ml.......................... 36fludrocortisone acetate tab 0.1 mg..........................100fluocinolone acetonide (otic) oil

0.01%........................................................................119fluocinolone acetonide cream 0.01%........................ 89fluocinonide cream 0.05%.......................................... 89fluocinonide emulsified base cream

0.05%..........................................................................89fluocinonide gel 0.05%................................................89fluocinonide oint 0.05%...............................................89fluocinonide soln 0.05%..............................................89fluorometholone ophth susp 0.1%...........................117FLUOROURACIL......................................................... 89FLUOROURACIL......................................................... 89fluorouracil cream 5%................................................. 89fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................36fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................36fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................36fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................36

FLUOXETINE DR........................................................ 24fluoxetine hcl cap 10 mg.............................................24fluoxetine hcl cap 20 mg.............................................24fluoxetine hcl cap 40 mg.............................................24fluoxetine hcl solution 20 mg/5ml.............................. 24fluoxetine hcl tab 10 mg..............................................24fluoxetine hcl tab 20 mg..............................................24fluphenazine decanoate inj 25 mg/ml........................47FLUPHENAZINE HCL.................................................47FLUPHENAZINE HCL.................................................47FLUPHENAZINE HCL.................................................47fluphenazine hcl tab 10 mg........................................ 47fluphenazine hcl tab 1 mg.......................................... 47fluphenazine hcl tab 2.5 mg....................................... 47fluphenazine hcl tab 5 mg.......................................... 47flurbiprofen sodium ophth soln 0.03%.....................117flurbiprofen tab 100 mg.................................................3flurbiprofen tab 50 mg................................................... 3flutamide cap 125 mg..................................................36FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 122FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 122FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 122fluticasone propionate cream 0.05%.........................89fluticasone propionate nasal susp 50 mcg/

act..............................................................................122fluticasone propionate oint 0.005%........................... 89fluvoxamine maleate tab 100 mg...............................25fluvoxamine maleate tab 25 mg.................................25fluvoxamine maleate tab 50 mg.................................25FML LIQUIFILM......................................................... 117FOCALIN....................................................................... 87FOCALIN....................................................................... 87FOCALIN....................................................................... 87FOLOTYN......................................................................36FOLOTYN......................................................................36fomepizole inj 1 gm/ml (for iv infusion)......................92fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................65fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................65fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................65fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................65FORTEO......................................................................116FOSAMAX...................................................................116fosamprenavir calcium tab 700 mg........................... 54fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................75

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fosinopril sodium & hydrochlorothiazide tab 20-12.5mg................................................................................75

fosinopril sodium tab 10 mg....................................... 75fosinopril sodium tab 20 mg....................................... 75fosinopril sodium tab 40 mg....................................... 75fosphenytoin sodium inj 100 mg/2ml.........................18fosphenytoin sodium inj 500 mg/10ml.......................18FOSRENOL.................................................................. 92FOSRENOL.................................................................. 92FOSRENOL.................................................................. 92FOSRENOL.................................................................. 92FOSRENOL.................................................................. 92furosemide inj 10 mg/ml..............................................75furosemide oral soln 10 mg/ml...................................75furosemide tab 20 mg................................................. 75furosemide tab 40 mg................................................. 75furosemide tab 80 mg................................................. 75FUZEON........................................................................54FYCOMPA.....................................................................18FYCOMPA.....................................................................18FYCOMPA.....................................................................18FYCOMPA.....................................................................18FYCOMPA.....................................................................18FYCOMPA.....................................................................18FYCOMPA.....................................................................18Ggabapentin cap 100 mg.............................................. 18gabapentin cap 300 mg.............................................. 18gabapentin cap 400 mg.............................................. 18gabapentin oral soln 250 mg/5ml.............................. 18gabapentin tab 600 mg............................................... 18gabapentin tab 800 mg............................................... 18GABITRIL...................................................................... 18GABITRIL...................................................................... 18GABITRIL...................................................................... 18GABITRIL...................................................................... 18GALANTAMINE HYDROBROMIDE.......................... 22galantamine hydrobromide cap er 24hr 16

mg................................................................................22galantamine hydrobromide cap er 24hr 24

mg................................................................................22galantamine hydrobromide cap er 24hr 8

mg................................................................................22galantamine hydrobromide tab 12 mg...................... 22galantamine hydrobromide tab 4 mg.........................22galantamine hydrobromide tab 8 mg.........................22GAMMAGARD LIQUID............................................. 110GAMMAGARD LIQUID............................................. 110GAMMAGARD LIQUID............................................. 110GAMMAGARD LIQUID............................................. 110GAMMAGARD LIQUID............................................. 110

GAMMAGARD LIQUID............................................. 110GAMMAGARD S/D....................................................110GAMMAGARD S/D....................................................110GAMMAPLEX.............................................................110GAMMAPLEX.............................................................110GAMMAPLEX.............................................................110GAMMAPLEX.............................................................110GAMMAPLEX.............................................................110GAMMAPLEX.............................................................110GAMUNEX-C..............................................................110GAMUNEX-C..............................................................110GAMUNEX-C..............................................................111GAMUNEX-C..............................................................111GAMUNEX-C..............................................................111GAMUNEX-C..............................................................111ganciclovir sodium for inj 500 mg.............................. 54GARDASIL 9.............................................................. 111GARDASIL 9.............................................................. 111GATTEX.........................................................................95GAUZE PADS 2" X 2".................................................59GAZYVA.........................................................................36gemcitabine hcl for inj 1 gm....................................... 36gemcitabine hcl for inj 200 mg...................................36gemcitabine hcl for inj 2 gm....................................... 36gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................36gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................36gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................36gemfibrozil tab 600 mg............................................... 75gentamicin in saline inj 0.8 mg/ml............................. 12gentamicin in saline inj 1.2 mg/ml............................. 12gentamicin in saline inj 1.6 mg/ml............................. 12gentamicin in saline inj 1 mg/ml.................................12gentamicin sulfate cream 0.1%..................................89gentamicin sulfate inj 10 mg/ml................................. 12gentamicin sulfate inj 40 mg/ml................................. 12gentamicin sulfate oint 0.1%...................................... 89gentamicin sulfate ophth oint 0.3%......................... 117gentamicin sulfate ophth soln 0.3%........................ 118GENVOYA.....................................................................54GEODON.......................................................................47GEODON.......................................................................47GEODON.......................................................................47GEODON.......................................................................47GEODON.......................................................................47GILOTRIF......................................................................36GILOTRIF......................................................................36GILOTRIF......................................................................36glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................87

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146

glatiramer acetate soln prefilled syringe 40 mg/ml.................................................................................87

GLEEVEC......................................................................36GLEEVEC......................................................................36GLEOSTINE..................................................................36GLEOSTINE..................................................................36GLEOSTINE..................................................................36glimepiride tab 1 mg....................................................59glimepiride tab 2 mg....................................................59glimepiride tab 4 mg....................................................59glipizide-metformin hcl tab 2.5-250 mg.....................60glipizide-metformin hcl tab 2.5-500 mg.....................60glipizide-metformin hcl tab 5-500 mg........................ 60glipizide tab 10 mg...................................................... 60glipizide tab 5 mg.........................................................60glipizide tab er 24hr 10 mg.........................................60glipizide tab er 24hr 2.5 mg........................................59glipizide tab er 24hr 5 mg...........................................60GLUCAGEN HYPOKIT............................................... 60GLUCAGON EMERGENCY KIT............................... 60GLUCOPHAGE............................................................ 60GLUCOPHAGE............................................................ 60GLUCOPHAGE............................................................ 60GLUCOPHAGE XR..................................................... 60GLUCOPHAGE XR..................................................... 60GLUCOTROL................................................................60GLUCOTROL................................................................60GLUCOTROL XL......................................................... 60GLUCOTROL XL......................................................... 60GLUCOTROL XL......................................................... 60glycopyrrolate tab 1 mg.............................................. 95glycopyrrolate tab 2 mg.............................................. 95GLYXAMBI.................................................................... 60GLYXAMBI.................................................................... 60GOLYTELY....................................................................95GOLYTELY....................................................................95granisetron hcl inj 1 mg/ml......................................... 28granisetron hcl inj 4 mg/4ml (1 mg/ml)......................28granisetron hcl tab 1 mg.............................................28GRANIX......................................................................... 65GRANIX......................................................................... 65GRANIX......................................................................... 65GRANIX......................................................................... 65griseofulvin microsize susp 125

mg/5ml........................................................................ 30griseofulvin ultramicrosize tab 125 mg......................30griseofulvin ultramicrosize tab 250 mg......................30GUANIDINE HCL.........................................................32HH.P. ACTHAR............................................................. 100HAEGARDA................................................................111

HAEGARDA................................................................111HALAVEN...................................................................... 37HALDOL........................................................................ 47HALDOL DECANOATE 100.......................................47HALDOL DECANOATE 50......................................... 48halobetasol propionate cream 0.05%........................89halobetasol propionate oint 0.05%............................ 89haloperidol decanoate im soln 100 mg/

ml.................................................................................48haloperidol decanoate im soln 50 mg/

ml.................................................................................48haloperidol lactate inj 5 mg/ml................................... 48haloperidol lactate oral conc 2 mg/ml........................48haloperidol tab 0.5 mg................................................ 48haloperidol tab 10 mg................................................. 48haloperidol tab 1 mg....................................................48haloperidol tab 20 mg................................................. 48haloperidol tab 2 mg....................................................48haloperidol tab 5 mg....................................................48HARVONI...................................................................... 54HAVRIX........................................................................111HAVRIX........................................................................111heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................65heparin sodium (porcine) inj 10000 unit/

ml.................................................................................65heparin sodium (porcine) inj 1000 unit/



ml.................................................................................65heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................65HEPATAMINE............................................................... 92HERCEPTIN................................................................. 37HERCEPTIN................................................................. 37HETLIOZ..................................................................... 125HIBERIX...................................................................... 111HIPREX..........................................................................13HUMALOG.................................................................... 60HUMALOG.................................................................... 60HUMALOG JUNIOR KWIKPEN.................................60HUMALOG KWIKPEN.................................................60HUMALOG KWIKPEN.................................................60HUMALOG MIX 50/50.................................................60HUMALOG MIX 50/50 KWIKPEN............................. 60HUMALOG MIX 75/25.................................................60HUMALOG MIX 75/25 KWIKPEN............................. 60HUMIRA...................................................................... 111HUMIRA...................................................................... 111HUMIRA...................................................................... 111

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HUMIRA...................................................................... 111HUMIRA...................................................................... 111HUMIRA...................................................................... 111HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................111HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................111HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................111HUMIRA PEN.............................................................111HUMIRA PEN.............................................................111HUMIRA PEN-CD/UC/HS STARTER..................... 111HUMIRA PEN-CD/UC/HS STARTER..................... 111HUMIRA PEN-PS/UV STARTER.............................111HUMIRA PEN-PS/UV STARTER.............................111HUMULIN 70/30...........................................................61HUMULIN 70/30 KWIKPEN....................................... 61HUMULIN N..................................................................60HUMULIN N KWIKPEN.............................................. 60HUMULIN R..................................................................60HUMULIN R U-500 (CONCENTRATE).....................61HUMULIN R U-500 KWIKPEN...................................61hydralazine hcl tab 100 mg........................................ 75hydralazine hcl tab 10 mg.......................................... 75hydralazine hcl tab 25 mg.......................................... 75hydralazine hcl tab 50 mg.......................................... 75HYDREA........................................................................37hydrochlorothiazide cap 12.5 mg...............................75hydrochlorothiazide tab 12.5 mg................................75hydrochlorothiazide tab 25 mg...................................75hydrochlorothiazide tab 50 mg...................................75hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 3hydrocodone-acetaminophen tab 10-300

mg..................................................................................3hydrocodone-acetaminophen tab 10-325



mg..................................................................................3hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................3hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................3hydrocodone-ibuprofen tab 10-200 mg.......................3hydrocodone-ibuprofen tab 5-200 mg......................... 3hydrocodone-ibuprofen tab 7.5-200 mg......................3hydrocortisone butyrate cream 0.1%........................ 89hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................89

hydrocortisone butyrate hydrophilic lipo base cream0.1%..........................................................................100

hydrocortisone butyrate oint 0.1%.............................90hydrocortisone butyrate soln 0.1%............................ 90hydrocortisone cream 1%...........................................90hydrocortisone cream 2.5%........................................90hydrocortisone enema 100 mg/60ml.......................115hydrocortisone lotion 2.5%......................................... 90hydrocortisone oint 1%............................................... 90hydrocortisone oint 2.5%............................................ 90hydrocortisone rectal cream 1%.............................. 115hydrocortisone rectal cream 2.5%...........................115hydrocortisone tab 10 mg.........................................100hydrocortisone tab 20 mg.........................................100hydrocortisone tab 5 mg...........................................100hydrocortisone valerate cream 0.2%.........................90hydrocortisone valerate oint 0.2%............................. 90hydrocortisone w/ acetic acid otic soln

1-2%..........................................................................119hydromorphone hcl inj 2 mg/ml....................................3hydromorphone hcl liqd 1 mg/ml..................................3hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 3hydromorphone hcl preservative free inj 2 mg/

ml................................................................................... 3hydromorphone hcl tab 2 mg....................................... 3hydromorphone hcl tab 4 mg....................................... 3hydromorphone hcl tab 8 mg....................................... 3hydroxychloroquine sulfate tab 200 mg.................... 44HYDROXYPROGESTERONE

CAPROATE............................................................. 103hydroxyurea cap 500 mg............................................ 37hydroxyzine hcl syrup 10 mg/5ml.............................. 59hydroxyzine hcl tab 10 mg..........................................59hydroxyzine hcl tab 25 mg..........................................59hydroxyzine hcl tab 50 mg..........................................59HYZAAR........................................................................ 75HYZAAR........................................................................ 75HYZAAR........................................................................ 75Iibandronate sodium iv soln 3 mg/3ml..................... 116ibandronate sodium tab 150 mg..............................116IBRANCE.......................................................................37IBRANCE.......................................................................37IBRANCE.......................................................................37ibuprofen susp 100 mg/5ml.......................................... 3ibuprofen tab 400 mg.................................................... 3ibuprofen tab 600 mg.................................................... 3ibuprofen tab 800 mg.................................................... 3ICLUSIG........................................................................ 37ICLUSIG........................................................................ 37

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idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)................................................................................37

idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)................................................................................37

idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................37IDHIFA............................................................................37IDHIFA............................................................................37IFEX............................................................................... 37IFOSFAMIDE................................................................ 37ifosfamide for inj 1 gm.................................................37ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 37ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 37ILARIS..........................................................................111ILEVRO........................................................................118imatinib mesylate tab 100 mg.................................... 37imatinib mesylate tab 400 mg.................................... 37IMBRUVICA.................................................................. 37IMBRUVICA.................................................................. 37IMBRUVICA.................................................................. 37IMBRUVICA.................................................................. 37IMBRUVICA.................................................................. 37IMBRUVICA.................................................................. 37IMFINZI..........................................................................37IMFINZI..........................................................................37imipenem-cilastatin intravenous for soln 250

mg................................................................................13imipenem-cilastatin intravenous for soln 500

mg................................................................................13imipramine hcl tab 10 mg........................................... 25imipramine hcl tab 25 mg........................................... 25imipramine hcl tab 50 mg........................................... 25imiquimod cream 5%...................................................90IMITREX........................................................................ 31IMITREX........................................................................ 31IMITREX........................................................................ 31IMITREX........................................................................ 31IMITREX........................................................................ 31IMITREX........................................................................ 31IMITREX STATDOSE REFILL....................................31IMITREX STATDOSE REFILL....................................31IMITREX STATDOSE SYSTEM.................................31IMITREX STATDOSE SYSTEM.................................31IMLYGIC........................................................................ 37IMLYGIC........................................................................ 37IMOVAX RABIES (H.D.C.V.).................................... 112IMPAVIDO..................................................................... 13IMURAN...................................................................... 112INCRELEX.................................................................. 101INCRUSE ELLIPTA................................................... 122indapamide tab 1.25 mg............................................. 75indapamide tab 2.5 mg............................................... 75INDERAL LA.................................................................75

INDERAL LA.................................................................75INDERAL LA.................................................................75INDERAL LA.................................................................75INFANRIX....................................................................112INLYTA...........................................................................37INLYTA...........................................................................37INSPRA..........................................................................76INSPRA..........................................................................76INSULIN INJECTION DEVICE...................................61INSULIN SYRINGE/NEEDLE.....................................61INTELENCE.................................................................. 54INTELENCE.................................................................. 54INTELENCE.................................................................. 54INTRON A.....................................................................54INTRON A.....................................................................54INTRON A.....................................................................54INTRON A.....................................................................54INTRON A.....................................................................54INTRON A W/DILUENT..............................................54INTRON A W/DILUENT..............................................54INTRON A W/DILUENT..............................................54INVANZ.......................................................................... 13INVANZ.......................................................................... 13INVEGA......................................................................... 48INVEGA......................................................................... 48INVEGA......................................................................... 48INVEGA......................................................................... 48INVEGA SUSTENNA.................................................. 48INVEGA SUSTENNA.................................................. 48INVEGA SUSTENNA.................................................. 48INVEGA SUSTENNA.................................................. 48INVEGA SUSTENNA.................................................. 48INVEGA TRINZA..........................................................48INVEGA TRINZA..........................................................48INVEGA TRINZA..........................................................48INVEGA TRINZA..........................................................48INVIRASE......................................................................54INVOKAMET.................................................................61INVOKAMET.................................................................61INVOKAMET.................................................................61INVOKAMET.................................................................61INVOKAMET XR..........................................................61INVOKAMET XR..........................................................61INVOKAMET XR..........................................................61INVOKAMET XR..........................................................61INVOKANA....................................................................61INVOKANA....................................................................61IPOL INACTIVATED IPV.......................................... 112ipratropium bromide inhal soln 0.02%.....................122ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................122

2019

149

ipratropium bromide nasal soln 0.06% (42 mcg/spray)........................................................................122

irbesartan-hydrochlorothiazide tab 150-12.5mg................................................................................76

irbesartan-hydrochlorothiazide tab 300-12.5mg................................................................................76

irbesartan tab 150 mg.................................................76irbesartan tab 300 mg.................................................76irbesartan tab 75 mg................................................... 76IRESSA..........................................................................37IRINOTECAN................................................................37irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................38irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 37ISENTRESS..................................................................54ISENTRESS..................................................................54ISENTRESS..................................................................54ISENTRESS..................................................................54ISENTRESS HD...........................................................54ISONIAZID.................................................................... 32isoniazid tab 100 mg................................................... 32isoniazid tab 300 mg................................................... 32ISORDIL TITRADOSE................................................ 76isosorbide dinitrate tab 10 mg....................................76isosorbide dinitrate tab 20 mg....................................76isosorbide dinitrate tab 30 mg....................................76isosorbide dinitrate tab 5 mg......................................76isosorbide mononitrate tab 10 mg............................. 76isosorbide mononitrate tab 20 mg............................. 76isosorbide mononitrate tab er 24hr 120

mg................................................................................76isosorbide mononitrate tab er 24hr 30

mg................................................................................76isosorbide mononitrate tab er 24hr 60

mg................................................................................76isotretinoin cap 10 mg.................................................90isotretinoin cap 20 mg.................................................90isotretinoin cap 30 mg.................................................90isotretinoin cap 40 mg.................................................90isradipine cap 2.5 mg..................................................76isradipine cap 5 mg..................................................... 76ISTALOL...................................................................... 118ISTODAX (OVERFILL)................................................38itraconazole cap 100 mg............................................ 30ivermectin tab 3 mg.....................................................44IXEMPRA KIT...............................................................38IXEMPRA KIT...............................................................38IXIARO.........................................................................112JJADENU........................................................................ 92JADENU........................................................................ 92

JADENU........................................................................ 92JADENU SPRINKLE................................................... 92JADENU SPRINKLE................................................... 92JADENU SPRINKLE................................................... 92JAKAFI...........................................................................38JAKAFI...........................................................................38JAKAFI...........................................................................38JAKAFI...........................................................................38JAKAFI...........................................................................38JANUMET......................................................................61JANUMET......................................................................61JANUMET XR...............................................................61JANUMET XR...............................................................61JANUMET XR...............................................................61JANUVIA........................................................................61JANUVIA........................................................................61JANUVIA........................................................................61JARDIANCE..................................................................61JARDIANCE..................................................................61JENTADUETO.............................................................. 61JENTADUETO.............................................................. 61JENTADUETO.............................................................. 61JENTADUETO XR....................................................... 61JENTADUETO XR....................................................... 61JEVTANA.......................................................................38JULUCA.........................................................................54JUXTAPID..................................................................... 76JUXTAPID..................................................................... 76JUXTAPID..................................................................... 76JUXTAPID..................................................................... 76JUXTAPID..................................................................... 76JUXTAPID..................................................................... 76KKADCYLA......................................................................38KADCYLA......................................................................38KALETRA...................................................................... 54KALETRA...................................................................... 54KALETRA...................................................................... 54KALYDECO.................................................................122KALYDECO.................................................................122KALYDECO.................................................................122kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 93kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%



inj................................................................................. 93kcl 20 meq/l (0.15%) in nacl 0.45% inj......................92kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%

inj................................................................................. 93

2019

150

kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45%inj................................................................................. 93

KEPIVANCE..................................................................88KEPPRA........................................................................ 18KEPPRA........................................................................ 18KEPPRA........................................................................ 19KEPPRA........................................................................ 19KEPPRA........................................................................ 19KEPPRA........................................................................ 19ketoconazole cream 2%..............................................30ketoconazole shampoo 2%........................................ 30ketoconazole tab 200 mg........................................... 30ketorolac tromethamine ophth soln

0.4%..........................................................................118ketorolac tromethamine ophth soln

0.5%..........................................................................118KEYTRUDA...................................................................38KINERET.....................................................................112KINRIX.........................................................................112KISQALI.........................................................................38KISQALI FEMARA 200 DOSE...................................38KISQALI FEMARA 400 DOSE...................................38KISQALI FEMARA 600 DOSE...................................38KLARON........................................................................13KOMBIGLYZE XR........................................................62KOMBIGLYZE XR........................................................62KOMBIGLYZE XR........................................................62KORLYM......................................................................107K-TAB.............................................................................92K-TAB.............................................................................92KUVAN...........................................................................97KUVAN...........................................................................97KUVAN...........................................................................98KYNAMRO.................................................................... 76KYPROLIS.................................................................... 38KYPROLIS.................................................................... 38KYPROLIS.................................................................... 38Llabetalol hcl tab 100 mg..............................................76labetalol hcl tab 200 mg..............................................76labetalol hcl tab 300 mg..............................................76LACRISERT................................................................118lactated ringer's solution............................................. 93lactic acid (ammonium lactate) cream

12%............................................................................. 90lactic acid (ammonium lactate) lotion

12%............................................................................. 90lactulose (encephalopathy) solution 10

gm/15ml......................................................................95lactulose solution 10 gm/15ml....................................95LAMICTAL..................................................................... 19LAMICTAL..................................................................... 19

LAMICTAL..................................................................... 19LAMICTAL..................................................................... 19LAMICTAL CHEWABLE

DISPERSIBLE........................................................... 19LAMICTAL CHEWABLE

DISPERSIBLE........................................................... 19lamivudine oral soln 10 mg/ml................................... 54lamivudine tab 100 mg (hbv)......................................54lamivudine tab 150 mg................................................54lamivudine tab 300 mg................................................54lamivudine-zidovudine tab 150-300 mg.................... 54lamotrigine tab 100 mg............................................... 19lamotrigine tab 150 mg............................................... 19lamotrigine tab 200 mg............................................... 19lamotrigine tab 25 mg................................................. 19lamotrigine tab chewable dispersible 25

mg................................................................................19lamotrigine tab chewable dispersible 5

mg................................................................................19LANOXIN.......................................................................76LANOXIN.......................................................................76LANOXIN.......................................................................76lansoprazole cap delayed release 15

mg................................................................................95lansoprazole cap delayed release 30

mg................................................................................95lanthanum carbonate chew tab 1000



mg................................................................................93LANTUS.........................................................................62LANTUS SOLOSTAR..................................................62LARTRUVO...................................................................38LARTRUVO...................................................................38LASIX............................................................................. 76LASIX............................................................................. 76LASIX............................................................................. 76latanoprost ophth soln 0.005%................................ 118LATUDA.........................................................................48LATUDA.........................................................................48LATUDA.........................................................................48LATUDA.........................................................................48LATUDA.........................................................................48LAZANDA........................................................................ 3LAZANDA........................................................................ 3LAZANDA........................................................................ 3leflunomide tab 10 mg.............................................. 112leflunomide tab 20 mg.............................................. 112LENVIMA 10 MG DAILY DOSE.................................38LENVIMA 12MG DAILY DOSE..................................38

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LENVIMA 14 MG DAILY DOSE.................................38LENVIMA 18 MG DAILY DOSE.................................38LENVIMA 20 MG DAILY DOSE.................................38LENVIMA 24 MG DAILY DOSE.................................38LENVIMA 4 MG DAILY DOSE...................................38LENVIMA 8 MG DAILY DOSE...................................38LETAIRIS.....................................................................122LETAIRIS.....................................................................122letrozole tab 2.5 mg.....................................................39LEUCOVORIN CALCIUM...........................................39LEUCOVORIN CALCIUM...........................................39LEUCOVORIN CALCIUM...........................................39LEUCOVORIN CALCIUM...........................................39leucovorin calcium for inj 100 mg.............................. 39leucovorin calcium for inj 200 mg.............................. 39leucovorin calcium for inj 350 mg.............................. 39leucovorin calcium for inj 500 mg.............................. 39leucovorin calcium for inj 50 mg................................ 39leucovorin calcium tab 25 mg.................................... 39leucovorin calcium tab 5 mg.......................................39LEUKERAN...................................................................39LEUKINE....................................................................... 65leuprolide acetate inj kit 5 mg/ml............................. 107LEVEMIR.......................................................................62LEVEMIR FLEXTOUCH..............................................62levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................19levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................19levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................19levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................19levetiracetam oral soln 100 mg/ml.............................19levetiracetam tab 1000 mg......................................... 19levetiracetam tab 250 mg........................................... 19levetiracetam tab 500 mg........................................... 19levetiracetam tab 750 mg........................................... 19levobunolol hcl ophth soln 0.5%..............................118levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 93levocarnitine tab 330 mg............................................ 93levocetirizine dihydrochloride tab 5

mg............................................................................. 122levofloxacin in d5w iv soln 250

mg/50ml......................................................................13levofloxacin in d5w iv soln 500

mg/100ml....................................................................13levofloxacin in d5w iv soln 750

mg/150ml....................................................................13levofloxacin iv soln 25 mg/ml..................................... 13levofloxacin oral soln 25 mg/ml..................................13

levofloxacin tab 250 mg..............................................13levofloxacin tab 500 mg..............................................13levofloxacin tab 750 mg..............................................13levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg........................................................... 103levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg........................................................................... 103levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg........................................................................... 103levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg..................... 103levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg................................................................103levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7).................................................................103levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7).................................................................103levorphanol tartrate tab 2 mg....................................... 3levothyroxine sodium tab 100 mcg..........................106levothyroxine sodium tab 112 mcg..........................106levothyroxine sodium tab 125 mcg..........................106levothyroxine sodium tab 137 mcg..........................106levothyroxine sodium tab 150 mcg..........................106levothyroxine sodium tab 175 mcg..........................106levothyroxine sodium tab 200 mcg..........................106levothyroxine sodium tab 25 mcg............................106levothyroxine sodium tab 300 mcg..........................106levothyroxine sodium tab 50 mcg............................106levothyroxine sodium tab 75 mcg............................106levothyroxine sodium tab 88 mcg............................106LEXAPRO......................................................................25LEXAPRO......................................................................25LEXAPRO......................................................................25LEXIVA...........................................................................54LEXIVA...........................................................................54LIALDA........................................................................ 115LIBTAYO........................................................................ 39LIDOCAINE HCL..........................................................76lidocaine hcl gel 2%.......................................................5lidocaine hcl local inj 1%...............................................5lidocaine hcl local preservative free inj

1%..................................................................................5lidocaine hcl soln 4%.....................................................5lidocaine hcl viscous soln 2%.......................................6lidocaine oint 5%............................................................6lidocaine patch 5%.........................................................6lidocaine-prilocaine cream 2.5-2.5%........................... 6LIDODERM......................................................................6lindane shampoo 1%...................................................44LINEZOLID....................................................................13linezolid for susp 100 mg/5ml.................................... 13

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linezolid iv soln 600 mg/300ml (2 mg/ml)................................................................................13

linezolid tab 600 mg.................................................... 13LINZESS........................................................................95LINZESS........................................................................95LINZESS........................................................................95liothyronine sodium tab 25 mcg...............................106liothyronine sodium tab 50 mcg...............................106liothyronine sodium tab 5 mcg.................................106LIPITOR.........................................................................76LIPITOR.........................................................................76LIPITOR.........................................................................77LIPITOR.........................................................................77lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................77lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................77lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................77lisinopril tab 10 mg...................................................... 77lisinopril tab 2.5 mg..................................................... 77lisinopril tab 20 mg...................................................... 77lisinopril tab 30 mg...................................................... 77lisinopril tab 40 mg...................................................... 77lisinopril tab 5 mg.........................................................77LITHIUM........................................................................ 59lithium carbonate cap 150 mg....................................59lithium carbonate cap 300 mg....................................59lithium carbonate cap 600 mg....................................59lithium carbonate tab 300 mg.....................................59lithium carbonate tab er 300 mg................................59lithium carbonate tab er 450 mg................................59LITHOBID......................................................................59LOCOID......................................................................... 90LOCOID LIPOCREAM................................................ 90LOCOID LIPOCREAM.............................................. 100LOESTRIN 1/20-21................................................... 103LOESTRIN 1.5/30-21................................................ 103LOESTRIN FE 1/20...................................................103LOESTRIN FE 1.5/30................................................103LONSURF..................................................................... 39LONSURF..................................................................... 39loperamide hcl cap 2 mg............................................ 95LOPID............................................................................ 77lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................54LOPRESSOR................................................................77LOPRESSOR................................................................77LOPRESSOR HCT...................................................... 77LOPROX SHAMPOO.................................................. 30lorazepam tab 0.5 mg................................................. 59lorazepam tab 1 mg.................................................... 59

lorazepam tab 2 mg.................................................... 59LORBRENA.................................................................. 39LORBRENA.................................................................. 39losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 77losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................77losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................77losartan potassium tab 100 mg..................................77losartan potassium tab 25 mg....................................77losartan potassium tab 50 mg....................................77LOSEASONIQUE.......................................................103LOTENSIN.................................................................... 77LOTENSIN.................................................................... 77LOTENSIN.................................................................... 77LOTENSIN HCT...........................................................77LOTENSIN HCT...........................................................77LOTENSIN HCT...........................................................77LOTRISONE................................................................. 90LOTRONEX.................................................................. 95LOTRONEX.................................................................. 95lovastatin tab 10 mg....................................................77lovastatin tab 20 mg....................................................77lovastatin tab 40 mg....................................................77LOVAZA.........................................................................77LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65LOVENOX..................................................................... 65loxapine succinate cap 10 mg....................................48loxapine succinate cap 25 mg....................................49loxapine succinate cap 50 mg....................................49loxapine succinate cap 5 mg......................................48LUMIGAN....................................................................118LUMIZYME....................................................................98LUMOXITI......................................................................39LUPRON DEPOT (1-MONTH).................................107LUPRON DEPOT (1-MONTH).................................107LUPRON DEPOT (3-MONTH).................................107LUPRON DEPOT (3-MONTH).................................107LUPRON DEPOT (4-MONTH).................................107LUPRON DEPOT (6-MONTH).................................107LUPRON DEPOT-PED (1-MONTH)....................... 107LUPRON DEPOT-PED (1-MONTH)....................... 107LUPRON DEPOT-PED (1-MONTH)....................... 107LUPRON DEPOT-PED (3-MONTH)....................... 107LUPRON DEPOT-PED (3-MONTH)....................... 107

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LYNPARZA....................................................................39LYNPARZA....................................................................39LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYRICA.......................................................................... 19LYSODREN.................................................................107Mmagnesium sulfate inj 50%........................................ 93MALARONE.................................................................. 44MALARONE.................................................................. 44malathion lotion 0.5%..................................................44MAPROTILINE HCL.................................................... 25MAPROTILINE HCL.................................................... 25MAPROTILINE HCL.................................................... 25MARPLAN..................................................................... 25MARQIBO......................................................................39MATULANE...................................................................39MAVYRET..................................................................... 54MAXALT.........................................................................31MAXALT-MLT................................................................31MAXALT-MLT................................................................31MAXITROL..................................................................118MAXZIDE.......................................................................77MAXZIDE-25.................................................................77meclizine hcl tab 12.5 mg...........................................28meclizine hcl tab 25 mg..............................................28MEDROL..................................................................... 100MEDROL..................................................................... 100MEDROL..................................................................... 100MEDROL..................................................................... 100MEDROL DOSEPAK.................................................100medroxyprogesterone acetate im susp 150 mg/

ml...............................................................................103medroxyprogesterone acetate im susp prefilled syr

150 mg/ml................................................................103medroxyprogesterone acetate tab 10

mg............................................................................. 103medroxyprogesterone acetate tab 2.5

mg............................................................................. 103medroxyprogesterone acetate tab 5

mg............................................................................. 103mefloquine hcl tab 250 mg......................................... 44megestrol acetate susp 40 mg/ml........................... 104megestrol acetate tab 20 mg................................... 104megestrol acetate tab 40 mg................................... 104MEKINIST......................................................................39

MEKINIST......................................................................39MEKTOVI.......................................................................39meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 39memantine hcl oral solution 2 mg/ml.........................22memantine hcl tab 10 mg...........................................22memantine hcl tab 5 mg............................................. 22memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................22MENACTRA................................................................112MENEST......................................................................104MENEST......................................................................104MENEST......................................................................104MENVEO.....................................................................112mercaptopurine tab 50 mg......................................... 39meropenem iv for soln 1 gm...................................... 13meropenem iv for soln 500 mg.................................. 13MERREM.......................................................................13MERREM.......................................................................13mesalamine enema 4 gm.........................................115mesalamine rectal enema 4 gm & cleanser wipe

kit...............................................................................115mesalamine suppos 1000 mg..................................115mesalamine tab delayed release 1.2

gm............................................................................. 115mesalamine tab delayed release 800

mg............................................................................. 115mesna inj 100 mg/ml...................................................39MESNEX........................................................................39MESTINON................................................................... 32MESTINON................................................................... 32MESTINON TIMESPAN.............................................. 32metformin hcl tab 1000 mg.........................................62metformin hcl tab 500 mg...........................................62metformin hcl tab 850 mg...........................................62metformin hcl tab er 24hr 500 mg............................. 62metformin hcl tab er 24hr 750 mg............................. 62methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 77methazolamide tab 50 mg.......................................... 77methenamine hippurate tab 1 gm..............................13methimazole tab 10 mg............................................ 108methimazole tab 5 mg.............................................. 108methocarbamol tab 500 mg..................................... 124methocarbamol tab 750 mg..................................... 124METHOTREXATE SODIUM.....................................112methotrexate sodium for inj 1 gm............................112methotrexate sodium inj 50 mg/2ml (25 mg/

ml)............................................................................. 112

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methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)............................................................................. 112



methotrexate sodium tab 2.5 mg.............................112methoxsalen rapid cap 10 mg....................................90methscopolamine bromide tab 2.5 mg......................95methscopolamine bromide tab 5 mg......................... 95methylergonovine maleate tab 0.2 mg......................99methylphenidate hcl tab 10 mg..................................87methylphenidate hcl tab 20 mg..................................87methylphenidate hcl tab 5 mg....................................87methylphenidate hcl tab er 20 mg............................. 87methylprednisolone sod succ for inj 1000

mg............................................................................. 100methylprednisolone sod succ for inj 125

mg............................................................................. 100methylprednisolone sod succ for inj 40

mg............................................................................. 100methylprednisolone tab 16 mg.................................101methylprednisolone tab 32 mg.................................101methylprednisolone tab 4 mg...................................100methylprednisolone tab 8 mg...................................100methylprednisolone tab therapy pack 4 mg

(21)............................................................................100METHYLTESTOSTERONE......................................104metoclopramide hcl inj 5 mg/ml................................. 95metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................95metoclopramide hcl tab 10 mg...................................95metoclopramide hcl tab 5 mg.....................................95metolazone tab 10 mg................................................ 77metolazone tab 2.5 mg............................................... 77metolazone tab 5 mg...................................................77metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................78metoprolol & hydrochlorothiazide tab 100-50

mg................................................................................78metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................78metoprolol succinate tab er 24hr 100




mg................................................................................78metoprolol tartrate tab 100 mg...................................78metoprolol tartrate tab 25 mg.....................................78

metoprolol tartrate tab 50 mg.....................................78METROCREAM............................................................90METROGEL.................................................................. 90METROGEL-VAGINAL................................................13METROLOTION........................................................... 90METRONIDAZOLE...................................................... 13METRONIDAZOLE...................................................... 13metronidazole cap 375 mg.........................................13metronidazole cream 0.75%.......................................90metronidazole gel 0.75%............................................ 90metronidazole gel 1%..................................................90metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................13metronidazole lotion 0.75%........................................ 90metronidazole tab 250 mg..........................................13metronidazole tab 500 mg..........................................13metronidazole vaginal gel 0.75%...............................13mexiletine hcl cap 150 mg..........................................78mexiletine hcl cap 200 mg..........................................78mexiletine hcl cap 250 mg..........................................78MIACALCIN................................................................ 116MICARDIS.....................................................................78MICARDIS.....................................................................78MICARDIS.....................................................................78MICARDIS HCT........................................................... 78MICARDIS HCT........................................................... 78MICARDIS HCT........................................................... 78MICRO-K....................................................................... 93MICRO-K....................................................................... 93midodrine hcl tab 10 mg............................................. 78midodrine hcl tab 2.5 mg............................................ 78midodrine hcl tab 5 mg............................................... 78MIGERGOT...................................................................31miglustat cap 100 mg..................................................98MIGRANAL....................................................................31MINIPRESS.................................................................. 78MINIPRESS.................................................................. 78MINIPRESS.................................................................. 78MINOCIN....................................................................... 13minocycline hcl cap 100 mg.......................................13minocycline hcl cap 50 mg......................................... 13minocycline hcl cap 75 mg......................................... 13minocycline hcl tab 100 mg........................................14minocycline hcl tab 50 mg..........................................13minocycline hcl tab 75 mg..........................................14minoxidil tab 10 mg..................................................... 78minoxidil tab 2.5 mg.................................................... 78MIRAPEX...................................................................... 45MIRAPEX...................................................................... 45MIRAPEX...................................................................... 45MIRAPEX...................................................................... 45MIRAPEX...................................................................... 45

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MIRAPEX...................................................................... 45MIRCETTE..................................................................104mirtazapine orally disintegrating tab 15

mg................................................................................25mirtazapine orally disintegrating tab 30

mg................................................................................25mirtazapine orally disintegrating tab 45

mg................................................................................25mirtazapine tab 15 mg................................................ 25mirtazapine tab 30 mg................................................ 25mirtazapine tab 45 mg................................................ 25mirtazapine tab 7.5 mg............................................... 25misoprostol tab 100 mcg............................................ 95misoprostol tab 200 mcg............................................ 95mitomycin for iv soln 20 mg....................................... 39mitomycin for iv soln 40 mg....................................... 39mitomycin for iv soln 5 mg..........................................39mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................39mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................39mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................39M-M-R II...................................................................... 112MOBIC............................................................................. 3MOBIC............................................................................. 3modafinil tab 100 mg.................................................125modafinil tab 200 mg.................................................125moexipril hcl tab 15 mg...............................................78moexipril hcl tab 7.5 mg..............................................78moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................78moexipril-hydrochlorothiazide tab 15-25

mg................................................................................78moexipril-hydrochlorothiazide tab 7.5-12.5

mg................................................................................78MOLINDONE HYDROCHLORIDE............................ 49MOLINDONE HYDROCHLORIDE............................ 49MOLINDONE HYDROCHLORIDE............................ 49mometasone furoate cream 0.1%............................. 90mometasone furoate nasal susp 50 mcg/

act..............................................................................122mometasone furoate oint 0.1%..................................90mometasone furoate solution 0.1%

(lotion).........................................................................90montelukast sodium chew tab 4 mg........................122montelukast sodium chew tab 5 mg........................122montelukast sodium oral granules packet 4

mg............................................................................. 122montelukast sodium tab 10 mg................................122MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3

morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................4morphine sulfate oral soln 10 mg/5ml......................... 4morphine sulfate oral soln 20 mg/5ml......................... 4morphine sulfate tab er 100 mg...................................4morphine sulfate tab er 15 mg..................................... 4morphine sulfate tab er 200 mg...................................4morphine sulfate tab er 30 mg..................................... 4morphine sulfate tab er 60 mg..................................... 4MOVIPREP................................................................... 96MOXEZA..................................................................... 118MOXIFLOXACIN HCL................................................. 14moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................14moxifloxacin hcl ophth soln 0.5%............................ 118moxifloxacin hcl tab 400 mg.......................................14MOZOBIL...................................................................... 65MULTAQ........................................................................ 78mupirocin oint 2%........................................................ 90MYALEPT...................................................................... 96MYCAMINE...................................................................30MYCAMINE...................................................................30MYCOBUTIN................................................................ 32mycophenolate mofetil cap 250 mg........................ 112mycophenolate mofetil for oral susp 200 mg/

ml...............................................................................112mycophenolate mofetil hcl for iv soln 500

mg............................................................................. 112mycophenolate mofetil tab 500 mg......................... 112mycophenolate sodium tab dr 180

mg............................................................................. 112mycophenolate sodium tab dr 360

mg............................................................................. 112MYLOTARG.................................................................. 40MYRBETRIQ.................................................................99MYRBETRIQ.................................................................99MYSOLINE....................................................................19MYSOLINE....................................................................19Nnabumetone tab 500 mg...............................................4nabumetone tab 750 mg...............................................4nadolol tab 20 mg........................................................78nadolol tab 40 mg........................................................78nadolol tab 80 mg........................................................78NAFCILLIN SODIUM...................................................14NAFCILLIN SODIUM...................................................14NAFCILLIN SODIUM...................................................14nafcillin sodium for inj 1 gm........................................14nafcillin sodium for inj 2 gm........................................14

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nafcillin sodium for iv soln 10 gm.............................. 14NAGLAZYME................................................................98NALOXONE HCL........................................................... 6NALOXONE HCL........................................................... 6naloxone hcl inj 0.4 mg/ml............................................6naloxone hcl inj 4 mg/10ml...........................................6naltrexone hcl tab 50 mg.............................................. 6NAMENDA.................................................................... 22NAMENDA.................................................................... 22NAMENDA TITRATION PAK......................................22naproxen sodium tab 275 mg.......................................4naproxen sodium tab 550 mg.......................................4naproxen susp 125 mg/5ml.......................................... 4naproxen tab 250 mg.................................................... 4naproxen tab 375 mg.................................................... 4naproxen tab 500 mg.................................................... 4naproxen tab ec 375 mg...............................................4naproxen tab ec 500 mg...............................................4naratriptan hcl tab 1 mg..............................................31naratriptan hcl tab 2.5 mg...........................................31NARCAN..........................................................................6NARDIL..........................................................................25NASONEX...................................................................122NATACYN....................................................................118nateglinide tab 120 mg............................................... 62nateglinide tab 60 mg..................................................62NATPARA....................................................................116NATPARA....................................................................116NATPARA....................................................................116NATPARA....................................................................116NEBUPENT...................................................................44NEFAZODONE HCL....................................................25NEFAZODONE HCL....................................................25nefazodone hcl tab 250 mg........................................25nefazodone hcl tab 50 mg..........................................25NEFAZODONE HYDROCHLORIDE.........................25neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin........................118neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml...........................118neomycin-polymyxin b gu irrigation

soln..............................................................................14neomycin-polymyxin-dexamethasone ophth oint

0.1%..........................................................................118neomycin-polymyxin-dexamethasone ophth susp

0.1%..........................................................................118neomycin-polymyxin-hc otic soln 1%...................... 119neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 119neomycin sulfate tab 500 mg.....................................14NEORAL......................................................................112NEORAL......................................................................112

NEORAL......................................................................112NERLYNX......................................................................40NEULASTA....................................................................66NEULASTA ONPRO KIT............................................ 66NEUPOGEN..................................................................66NEUPOGEN..................................................................66NEURONTIN.................................................................19NEURONTIN.................................................................20NEURONTIN.................................................................20NEURONTIN.................................................................20NEURONTIN.................................................................20NEURONTIN.................................................................20nevirapine susp 50 mg/5ml........................................ 55nevirapine tab 200 mg................................................ 55nevirapine tab er 24hr 100 mg...................................55nevirapine tab er 24hr 400 mg...................................55NEXAVAR......................................................................40NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM.........................................................................96NEXIUM I.V...................................................................96niacin tab er 1000 mg................................................. 79niacin tab er 500 mg................................................... 78niacin tab er 750 mg................................................... 78NIASPAN....................................................................... 79NIASPAN....................................................................... 79NIASPAN....................................................................... 79nicardipine hcl cap 20 mg...........................................79nicardipine hcl cap 30 mg...........................................79NICOTROL INHALER................................................... 6NICOTROL NS............................................................... 6nifedipine tab er 24hr 30 mg...................................... 79nifedipine tab er 24hr 60 mg...................................... 79nifedipine tab er 24hr 90 mg...................................... 79nifedipine tab er 24hr osmotic release 30

mg................................................................................79nifedipine tab er 24hr osmotic release 60

mg................................................................................79nifedipine tab er 24hr osmotic release 90

mg................................................................................79NILANDRON.................................................................40nilutamide tab 150 mg.................................................40nimodipine cap 30 mg.................................................79NINLARO.......................................................................40NINLARO.......................................................................40NINLARO.......................................................................40NIPENT..........................................................................40NISOLDIPINE ER........................................................ 79

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nisoldipine tab er 24hr 17 mg.................................... 79nisoldipine tab er 24hr 34 mg.................................... 79nisoldipine tab er 24hr 8.5 mg................................... 79NITRO-BID....................................................................79nitrofurantoin macrocrystalline cap 100

mg................................................................................14nitrofurantoin macrocrystalline cap 50

mg................................................................................14nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................14nitrofurantoin susp 25 mg/5ml....................................14nitroglycerin sl tab 0.3 mg.......................................... 79nitroglycerin sl tab 0.4 mg.......................................... 79nitroglycerin sl tab 0.6 mg.......................................... 79nitroglycerin td patch 24hr 0.1 mg/hr.........................79nitroglycerin td patch 24hr 0.2 mg/hr.........................79nitroglycerin td patch 24hr 0.4 mg/hr.........................79nitroglycerin td patch 24hr 0.6 mg/hr.........................79nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................79NITROLINGUAL PUMPSPRAY................................. 79NITROSTAT.................................................................. 79NITROSTAT.................................................................. 79NITROSTAT.................................................................. 79nizatidine cap 150 mg.................................................96nizatidine cap 300 mg.................................................96NIZORAL....................................................................... 30norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg...............................................................104norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg...............................................................104norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg........................................................................... 104norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg........................................................................... 104norethindrone & ethinyl estradiol tab 1 mg-35

mcg........................................................................... 104norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg...............................................................104norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg........................................................................... 104norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg........................................................................... 104norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg........................................................................... 104norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24)...................................................................104norethindrone acetate tab 5 mg...............................104norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.....................................................................104norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.....................................................................104

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35mg-mcg.....................................................................104

norethindrone tab 0.35 mg....................................... 104norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg........................................................................... 104norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.......................104norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.......................104norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg........................................................................... 104NORMOSOL-M IN D5W............................................. 93NORPRAMIN................................................................ 25NORPRAMIN................................................................ 25NORTHERA.................................................................. 79NORTHERA.................................................................. 79NORTHERA.................................................................. 79nortriptyline hcl cap 10 mg......................................... 25nortriptyline hcl cap 25 mg......................................... 25nortriptyline hcl cap 50 mg......................................... 25nortriptyline hcl cap 75 mg......................................... 25nortriptyline hcl soln 10 mg/5ml................................. 25NORVASC..................................................................... 79NORVASC..................................................................... 79NORVASC..................................................................... 79NORVIR.........................................................................55NORVIR.........................................................................55NORVIR.........................................................................55NOXAFIL....................................................................... 30NOXAFIL....................................................................... 30NOXAFIL....................................................................... 30NUCYNTA........................................................................4NUCYNTA........................................................................4NUCYNTA........................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUEDEXTA...................................................................87NULOJIX..................................................................... 112NULYTELY/FLAVOR PACKS..................................... 96NUPLAZID.....................................................................49NUPLAZID.....................................................................49NUPLAZID.....................................................................49NUVARING................................................................. 104NUVIGIL...................................................................... 125NUVIGIL...................................................................... 125NUVIGIL...................................................................... 125NUVIGIL...................................................................... 125nystatin cream 100000 unit/gm..................................30nystatin oint 100000 unit/gm...................................... 30

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nystatin susp 100000 unit/ml......................................30nystatin tab 500000 unit..............................................30nystatin topical powder 100000 unit/

gm................................................................................30nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................90nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................90OOCALIVA....................................................................... 98OCALIVA....................................................................... 98octreotide acetate inj 1000 mcg/ml (1 mg/

ml)............................................................................. 108octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)............................................................................. 107OCUFLOX...................................................................118ODEFSEY..................................................................... 55ODOMZO...................................................................... 40OFEV........................................................................... 122OFEV........................................................................... 122ofloxacin ophth soln 0.3%........................................ 118ofloxacin otic soln 0.3%............................................ 119ofloxacin tab 400 mg...................................................14olanzapine for im inj 10 mg........................................ 49olanzapine orally disintegrating tab 10

mg................................................................................49olanzapine orally disintegrating tab 15



mg................................................................................49olanzapine tab 10 mg..................................................49olanzapine tab 15 mg..................................................49olanzapine tab 2.5 mg.................................................49olanzapine tab 20 mg..................................................49olanzapine tab 5 mg....................................................49olanzapine tab 7.5 mg.................................................49olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg............................................................. 80olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg...........................................................80olmesartan-amlodipine-hydrochlorothiazide tab

40-10-25 mg.............................................................. 80

olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg............................................................. 80

olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg................................................................ 80

olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg.................................................................80

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg.................................................................80

olmesartan medoxomil-hydrochlorothiazide tab40-25 mg....................................................................80

olmesartan medoxomil tab 20 mg............................. 79olmesartan medoxomil tab 40 mg............................. 80olmesartan medoxomil tab 5 mg............................... 79olopatadine hcl nasal soln 0.6%..............................122olopatadine hcl ophth soln 0.1%..............................118olopatadine hcl ophth soln 0.2%..............................118omega-3-acid ethyl esters cap 1 gm.........................80omeprazole cap delayed release 10

mg................................................................................96omeprazole cap delayed release 20

mg................................................................................96omeprazole cap delayed release 40

mg................................................................................96OMNIPRED.................................................................118OMNITROPE.............................................................. 101OMNITROPE.............................................................. 101OMNITROPE.............................................................. 101ONCASPAR.................................................................. 40ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................28ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................28ondansetron hcl oral soln 4 mg/5ml.......................... 28ondansetron hcl tab 24 mg.........................................28ondansetron hcl tab 4 mg...........................................28ondansetron hcl tab 8 mg...........................................28ondansetron orally disintegrating tab 4

mg................................................................................28ondansetron orally disintegrating tab 8

mg................................................................................28ONFI...............................................................................20ONFI...............................................................................20ONFI...............................................................................20ONGLYZA......................................................................62ONGLYZA......................................................................62ONIVYDE...................................................................... 40OPDIVO.........................................................................40OPDIVO.........................................................................40OPDIVO.........................................................................40OPSUMIT....................................................................122ORACEA........................................................................90ORALAIR.....................................................................122

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ORAP............................................................................. 49ORENCIA....................................................................112ORENCIA....................................................................112ORENCIA....................................................................112ORENCIA....................................................................112ORENCIA CLICKJECT............................................. 113ORFADIN.......................................................................98ORFADIN.......................................................................98ORFADIN.......................................................................98ORFADIN.......................................................................98ORFADIN.......................................................................98ORKAMBI....................................................................122ORKAMBI....................................................................122ORKAMBI....................................................................122ORKAMBI....................................................................122ORTHO-CYCLEN...................................................... 104ORTHO MICRONOR................................................ 104ORTHO-NOVUM 1/35...............................................104ORTHO-NOVUM 7/7/7..............................................104ORTHO TRI-CYCLEN...............................................104oseltamivir phosphate cap 30 mg..............................55oseltamivir phosphate cap 45 mg..............................55oseltamivir phosphate cap 75 mg..............................55oseltamivir phosphate for susp 6 mg/

ml.................................................................................55OTEZLA.......................................................................113OTEZLA.......................................................................113OVIDE............................................................................44oxaliplatin for iv inj 100 mg.........................................40oxaliplatin for iv inj 50 mg...........................................40oxaliplatin iv soln 100 mg/20ml..................................40oxaliplatin iv soln 50 mg/10ml....................................40oxandrolone tab 10 mg.............................................105oxandrolone tab 2.5 mg............................................104oxaprozin tab 600 mg....................................................4oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................20oxcarbazepine tab 150 mg.........................................20oxcarbazepine tab 300 mg.........................................20oxcarbazepine tab 600 mg.........................................20oxybutynin chloride syrup 5 mg/5ml..........................99oxybutynin chloride tab 5 mg..................................... 99oxybutynin chloride tab er 24hr 10 mg......................99oxybutynin chloride tab er 24hr 15 mg......................99oxybutynin chloride tab er 24hr 5 mg........................99oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................4oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................4

oxycodone w/ acetaminophen tab 10-325mg..................................................................................4

oxycodone w/ acetaminophen tab 2.5-325mg..................................................................................4

oxycodone w/ acetaminophen tab 5-325mg..................................................................................4

oxycodone w/ acetaminophen tab 7.5-325mg..................................................................................4

OXYCONTIN...................................................................4OXYCONTIN...................................................................5OXYCONTIN...................................................................5OXYCONTIN...................................................................5OXYCONTIN...................................................................5OXYCONTIN...................................................................5OXYCONTIN...................................................................5OZEMPIC...................................................................... 62OZEMPIC...................................................................... 62Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................40paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................40paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................40paliperidone tab er 24hr 1.5 mg.................................49paliperidone tab er 24hr 3 mg....................................49paliperidone tab er 24hr 6 mg....................................49paliperidone tab er 24hr 9 mg....................................49palonosetron hcl iv soln 0.25 mg/5ml........................28PALONOSETRON

HYDROCHLORIDE.................................................. 28PALONOSETRON

HYDROCHLORIDE.................................................. 28PALYNZIQ..................................................................... 98PALYNZIQ..................................................................... 98PALYNZIQ..................................................................... 98PANRETIN.....................................................................40pantoprazole sodium ec tab 20 mg........................... 96pantoprazole sodium ec tab 40 mg........................... 96pantoprazole sodium for iv soln 40 mg..................... 96paricalcitol cap 1 mcg............................................... 116paricalcitol cap 2 mcg............................................... 116paricalcitol cap 4 mcg............................................... 116paricalcitol iv soln 2 mcg/ml..................................... 116paricalcitol iv soln 5 mcg/ml..................................... 116PARNATE...................................................................... 25paromomycin sulfate cap 250 mg..............................14paroxetine hcl tab 10 mg............................................ 25paroxetine hcl tab 20 mg............................................ 25paroxetine hcl tab 30 mg............................................ 25paroxetine hcl tab 40 mg............................................ 25PASER........................................................................... 32

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PATADAY.....................................................................118PATANASE..................................................................122PATANOL.................................................................... 118PAXIL............................................................................. 26PAXIL............................................................................. 26PAXIL............................................................................. 26PAXIL............................................................................. 26PAXIL............................................................................. 26PAZEO.........................................................................118PEDIARIX....................................................................113PEDVAX HIB.............................................................. 113peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................96peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................96peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................96PEGANONE..................................................................20PEGASYS..................................................................... 55PEGASYS..................................................................... 55PEGASYS PROCLICK................................................55penicillin g potassium for inj 20000000

unit...............................................................................14penicillin g potassium for inj 5000000

unit...............................................................................14PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 14PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 14PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 14PENICILLIN G SODIUM............................................. 14penicillin v potassium for soln 125

mg/5ml........................................................................ 14penicillin v potassium for soln 250

mg/5ml........................................................................ 14penicillin v potassium tab 250 mg............................. 14penicillin v potassium tab 500 mg............................. 14PENTACEL................................................................. 113PENTAM 300................................................................44PENTASA....................................................................115PENTASA....................................................................115pentoxifylline tab er 400 mg....................................... 80perindopril erbumine tab 2 mg................................... 80perindopril erbumine tab 4 mg................................... 80perindopril erbumine tab 8 mg................................... 80PERJETA.......................................................................40permethrin cream 5%..................................................44perphenazine tab 16 mg.............................................28perphenazine tab 2 mg............................................... 28perphenazine tab 4 mg............................................... 28perphenazine tab 8 mg............................................... 28

PERSERIS.................................................................... 49PERSERIS.................................................................... 49PFIZERPEN.................................................................. 14phenelzine sulfate tab 15 mg.....................................26phenobarbital elixir 20 mg/5ml...................................20PHENOBARBITAL SODIUM...................................... 20PHENOBARBITAL SODIUM...................................... 20phenobarbital tab 100 mg...........................................20phenobarbital tab 15 mg.............................................20phenobarbital tab 16.2 mg..........................................20phenobarbital tab 30 mg.............................................20phenobarbital tab 32.4 mg..........................................20phenobarbital tab 60 mg.............................................20phenobarbital tab 64.8 mg..........................................20phenobarbital tab 97.2 mg..........................................20phenoxybenzamine hcl cap 10 mg............................80PHENYTEK...................................................................20PHENYTEK...................................................................20phenytoin chew tab 50 mg......................................... 20phenytoin sodium extended cap 100

mg................................................................................20phenytoin sodium extended cap 200

mg................................................................................20phenytoin sodium extended cap 300

mg................................................................................20phenytoin susp 125 mg/5ml....................................... 20PHOSLYRA...................................................................93PHOSPHOLINE IODIDE.......................................... 118PICATO..........................................................................90PICATO..........................................................................90PIFELTRO..................................................................... 55pilocarpine hcl ophth soln 1%..................................118pilocarpine hcl ophth soln 2%..................................118pilocarpine hcl ophth soln 4%..................................118pilocarpine hcl tab 5 mg..............................................88pilocarpine hcl tab 7.5 mg.......................................... 88pimecrolimus cream 1%..............................................90pimozide tab 1 mg....................................................... 49pimozide tab 2 mg....................................................... 49pindolol tab 10 mg....................................................... 80pindolol tab 5 mg......................................................... 80pioglitazone hcl-glimepiride tab 30-2

mg................................................................................62pioglitazone hcl-glimepiride tab 30-4

mg................................................................................62pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................62pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................62pioglitazone hcl tab 15 mg..........................................62pioglitazone hcl tab 30 mg..........................................62pioglitazone hcl tab 45 mg..........................................62

2019

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piperacillin sod-tazobactam na for inj 3.375 gm(3-0.375 gm)..............................................................14

piperacillin sod-tazobactam sod for inj 2.25 gm(2-0.25 gm)................................................................ 14

piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5gm).............................................................................. 14

piroxicam cap 10 mg..................................................... 5piroxicam cap 20 mg..................................................... 5PLAQUENIL.................................................................. 44PLAVIX...........................................................................66PLEGRIDY.................................................................... 87PLEGRIDY.................................................................... 87PLEGRIDY STARTER PACK..................................... 87PLEGRIDY STARTER PACK..................................... 87podofilox soln 0.5%..................................................... 90polyethylene glycol 3350 oral packet........................ 96polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 118POLYTRIM.................................................................. 118POMALYST...................................................................40POMALYST...................................................................40POMALYST...................................................................40POMALYST...................................................................40PORTRAZZA................................................................ 40POTASSIUM CHLORIDE/DEXTROSE.....................93POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................93POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................93potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 93potassium chloride cap er 10 meq............................ 93potassium chloride cap er 8 meq...............................93POTASSIUM CHLORIDE ER.....................................93potassium chloride inj 2 meq/ml................................ 93potassium chloride microencapsulated crys er tab 10

meq............................................................................. 93potassium chloride microencapsulated crys er tab 20

meq............................................................................. 93potassium chloride oral soln 10% (20

meq/15ml).................................................................. 93potassium chloride tab er 10 meq............................. 93potassium chloride tab er 8 meq (600

mg).............................................................................. 93potassium citrate tab er 10 meq (1080



mg).............................................................................. 93POTELIGEO................................................................. 40PRADAXA..................................................................... 66

PRADAXA..................................................................... 66PRADAXA..................................................................... 66pramipexole dihydrochloride tab 0.125

mg................................................................................45pramipexole dihydrochloride tab 0.25




mg................................................................................45pramipexole dihydrochloride tab 1 mg...................... 45prasugrel hcl tab 10 mg..............................................66prasugrel hcl tab 5 mg................................................ 66PRAVACHOL................................................................ 80PRAVACHOL................................................................ 80PRAVACHOL................................................................ 80pravastatin sodium tab 10 mg....................................80pravastatin sodium tab 20 mg....................................80pravastatin sodium tab 40 mg....................................80pravastatin sodium tab 80 mg....................................80praziquantel tab 600 mg............................................. 44prazosin hcl cap 1 mg.................................................80prazosin hcl cap 2 mg.................................................80prazosin hcl cap 5 mg.................................................80PRECOSE.....................................................................62PRECOSE.....................................................................62PRECOSE.....................................................................62PRED FORTE............................................................ 118PRED MILD................................................................ 118PREDNICARBATE.......................................................91prednicarbate cream 0.1%......................................... 91prednisolone acetate ophth susp 1%......................118prednisolone sod phosphate oral soln 15

mg/5ml......................................................................101prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).......................................................... 101prednisolone syrup 15 mg/5ml.................................101PREDNISONE............................................................101PREDNISONE............................................................101PREDNISONE............................................................101PREDNISONE............................................................101PREDNISONE............................................................101PREDNISONE............................................................101prednisone tab 10 mg............................................... 101prednisone tab 1 mg................................................. 101prednisone tab 2.5 mg..............................................101prednisone tab 20 mg............................................... 101prednisone tab 5 mg................................................. 101PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL........................................................................ 101

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PREMARIN................................................................. 105PREMARIN................................................................. 105PREMARIN................................................................. 105PREMARIN................................................................. 105PREMARIN................................................................. 105PREMARIN................................................................. 105PREMPHASE............................................................. 105PREMPRO.................................................................. 105PREMPRO.................................................................. 105PREMPRO.................................................................. 105PREMPRO.................................................................. 105PREVACID.................................................................... 96PREVACID.................................................................... 96PREVYMIS....................................................................55PREVYMIS....................................................................55PREZCOBIX................................................................. 55PREZISTA..................................................................... 55PREZISTA..................................................................... 55PREZISTA..................................................................... 55PREZISTA..................................................................... 55PREZISTA..................................................................... 55PRIFTIN.........................................................................32PRIMAQUINE PHOSPHATE......................................44primidone tab 250 mg................................................. 20primidone tab 50 mg................................................... 20PRINIVIL........................................................................80PRINIVIL........................................................................80PRINIVIL........................................................................80PRISTIQ........................................................................ 26PRISTIQ........................................................................ 26PRISTIQ........................................................................ 26PROAIR HFA..............................................................123PROAIR RESPICLICK..............................................123probenecid tab 500 mg............................................... 30PROCARDIA XL.......................................................... 80PROCARDIA XL.......................................................... 80PROCARDIA XL.......................................................... 80prochlorperazine edisylate inj 5 mg/ml......................28prochlorperazine maleate tab 10 mg.........................28prochlorperazine maleate tab 5 mg...........................28prochlorperazine suppos 25 mg................................ 28PROCRIT...................................................................... 66PROCRIT...................................................................... 66PROCRIT...................................................................... 66PROCRIT...................................................................... 66PROCRIT...................................................................... 66PROCRIT...................................................................... 66progesterone micronized cap 100 mg.....................105progesterone micronized cap 200 mg.....................105PROGLYCEM............................................................... 62PROGRAF.................................................................. 113PROGRAF.................................................................. 113

PROGRAF.................................................................. 113PROGRAF.................................................................. 113PROLASTIN-C..............................................................98PROLASTIN-C..............................................................98PROLENSA................................................................ 118PROLEUKIN................................................................. 40PROLIA........................................................................116PROMACTA.................................................................. 66PROMACTA.................................................................. 66PROMACTA.................................................................. 66PROMACTA.................................................................. 66PROMACTA.................................................................. 66promethazine hcl suppos 12.5 mg............................ 28promethazine hcl suppos 25 mg................................28promethazine hcl syrup 6.25 mg/5ml........................ 28promethazine hcl tab 12.5 mg....................................28promethazine hcl tab 25 mg.......................................28promethazine hcl tab 50 mg.......................................28propafenone hcl cap er 12hr 225 mg........................ 80propafenone hcl cap er 12hr 325 mg........................ 80propafenone hcl cap er 12hr 425 mg........................ 80propafenone hcl tab 150 mg...................................... 80propafenone hcl tab 225 mg...................................... 80propafenone hcl tab 300 mg...................................... 81PROPRANOLOL HCL.................................................81PROPRANOLOL HCL.................................................81propranolol hcl cap er 24hr 120 mg.......................... 81propranolol hcl cap er 24hr 160 mg.......................... 81propranolol hcl cap er 24hr 60 mg.............................81propranolol hcl cap er 24hr 80 mg.............................81propranolol hcl inj 1 mg/ml......................................... 81propranolol hcl tab 10 mg...........................................81propranolol hcl tab 20 mg...........................................81propranolol hcl tab 40 mg...........................................81propranolol hcl tab 60 mg...........................................81propranolol hcl tab 80 mg...........................................81propylthiouracil tab 50 mg........................................ 108PROQUAD.................................................................. 113PROSCAR.....................................................................99PROTONIX....................................................................96PROTONIX....................................................................96protriptyline hcl tab 10 mg.......................................... 26protriptyline hcl tab 5 mg............................................ 26PROVERA...................................................................105PROVERA...................................................................105PROVERA...................................................................105PROZAC........................................................................26PROZAC........................................................................26PROZAC........................................................................26PRUDOXIN................................................................... 91PULMOZYME.............................................................123PURIXAN.......................................................................40

2019

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PYLERA.........................................................................96pyrazinamide tab 500 mg........................................... 32pyridostigmine bromide tab 60 mg............................ 32pyridostigmine bromide tab er 180 mg......................32QQUADRACEL............................................................. 113quetiapine fumarate tab 100 mg................................49quetiapine fumarate tab 200 mg................................49quetiapine fumarate tab 25 mg..................................49quetiapine fumarate tab 300 mg................................50quetiapine fumarate tab 400 mg................................50quetiapine fumarate tab 50 mg..................................49quetiapine fumarate tab er 24hr 150

mg................................................................................49quetiapine fumarate tab er 24hr 200



mg................................................................................49quetiapine fumarate tab er 24hr 50 mg.....................49quinapril hcl tab 10 mg............................................... 81quinapril hcl tab 20 mg............................................... 81quinapril hcl tab 40 mg............................................... 81quinapril hcl tab 5 mg..................................................81quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................81quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................81quinapril-hydrochlorothiazide tab 20-25

mg................................................................................81quinidine gluconate tab er 324 mg............................ 81QUINIDINE SULFATE................................................. 81QUINIDINE SULFATE................................................. 81QVAR REDIHALER................................................... 123QVAR REDIHALER................................................... 123RRABAVERT................................................................. 113rabeprazole sodium ec tab 20 mg............................. 96raloxifene hcl tab 60 mg........................................... 105ramipril cap 1.25 mg....................................................81ramipril cap 10 mg.......................................................81ramipril cap 2.5 mg......................................................81ramipril cap 5 mg.........................................................81RANEXA........................................................................81RANEXA........................................................................81ranitidine hcl cap 150 mg........................................... 96ranitidine hcl cap 300 mg........................................... 96ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................96ranitidine hcl tab 150 mg............................................ 96

ranitidine hcl tab 300 mg............................................ 97RAPAFLO...................................................................... 99RAPAFLO...................................................................... 99RAPAMUNE................................................................113rasagiline mesylate tab 0.5 mg.................................. 45rasagiline mesylate tab 1 mg..................................... 45RAZADYNE...................................................................22RAZADYNE...................................................................22RAZADYNE...................................................................22RAZADYNE ER............................................................22RAZADYNE ER............................................................22RAZADYNE ER............................................................22REBETOL......................................................................55RECOMBIVAX HB..................................................... 113RECOMBIVAX HB..................................................... 113RECOMBIVAX HB..................................................... 113REGLAN........................................................................97REGLAN........................................................................97REGRANEX.................................................................. 91RELENZA DISKHALER.............................................. 55RELISTOR.....................................................................97RELISTOR.....................................................................97RELISTOR.....................................................................97REMERON....................................................................26REMERON....................................................................26REMERON SOLTAB....................................................26REMERON SOLTAB....................................................26REMERON SOLTAB....................................................26REMODULIN.............................................................. 123REMODULIN.............................................................. 123REMODULIN.............................................................. 123REMODULIN.............................................................. 123RENFLEXIS................................................................ 113RENVELA......................................................................93RENVELA......................................................................93RENVELA......................................................................94repaglinide tab 0.5 mg................................................ 62repaglinide tab 1 mg....................................................62repaglinide tab 2 mg....................................................62REPATHA...................................................................... 81REPATHA PUSHTRONEX SYSTEM........................81REPATHA SURECLICK.............................................. 81REQUIP......................................................................... 45REQUIP......................................................................... 45REQUIP......................................................................... 45REQUIP......................................................................... 45RESCRIPTOR.............................................................. 55RESCRIPTOR.............................................................. 55RESTASIS...................................................................118RESTASIS MULTIDOSE...........................................118RETACRIT.....................................................................66RETACRIT.....................................................................66

2019

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RETACRIT.....................................................................66RETACRIT.....................................................................66RETACRIT.....................................................................66RETIN-A........................................................................ 91RETIN-A........................................................................ 91RETIN-A........................................................................ 91RETIN-A........................................................................ 91RETIN-A........................................................................ 91RETROVIR....................................................................55RETROVIR....................................................................55RETROVIR IV INFUSION...........................................55REVLIMID......................................................................40REVLIMID......................................................................40REVLIMID......................................................................40REVLIMID......................................................................40REVLIMID......................................................................40REVLIMID......................................................................40REXULTI........................................................................50REXULTI........................................................................50REXULTI........................................................................50REXULTI........................................................................50REXULTI........................................................................50REXULTI........................................................................50REYATAZ.......................................................................55REYATAZ.......................................................................55REYATAZ.......................................................................55REYATAZ.......................................................................55RIBASPHERE...............................................................55RIBASPHERE...............................................................55RIBASPHERE RIBAPAK.............................................55RIBASPHERE RIBAPAK.............................................56ribavirin cap 200 mg....................................................56ribavirin for inhal soln 6 gm......................................123ribavirin tab 200 mg.....................................................56RIDAURA.................................................................... 113rifabutin cap 150 mg....................................................32RIFADIN.........................................................................32RIFADIN.........................................................................32rifampin cap 150 mg....................................................32rifampin cap 300 mg....................................................32rifampin for inj 600 mg................................................ 32riluzole tab 50 mg........................................................ 87risedronate sodium tab 150 mg...............................116risedronate sodium tab 30 mg................................. 116risedronate sodium tab 35 mg................................. 116risedronate sodium tab 5 mg................................... 116risedronate sodium tab delayed release 35

mg............................................................................. 116RISPERDAL..................................................................50RISPERDAL..................................................................50RISPERDAL..................................................................50RISPERDAL..................................................................50

RISPERDAL..................................................................50RISPERDAL..................................................................50RISPERDAL..................................................................50RISPERDAL CONSTA................................................ 50RISPERDAL CONSTA................................................ 50RISPERDAL CONSTA................................................ 50RISPERDAL CONSTA................................................ 50risperidone orally disintegrating tab 0.25

mg................................................................................50risperidone orally disintegrating tab 0.5

mg................................................................................50risperidone orally disintegrating tab 1




mg................................................................................50risperidone soln 1 mg/ml............................................ 50risperidone tab 0.25 mg..............................................50risperidone tab 0.5 mg................................................ 50risperidone tab 1 mg................................................... 50risperidone tab 2 mg................................................... 50risperidone tab 3 mg................................................... 50risperidone tab 4 mg................................................... 50RITALIN......................................................................... 87RITALIN......................................................................... 87RITALIN......................................................................... 87ritonavir tab 100 mg.................................................... 56RITUXAN.......................................................................41RITUXAN.......................................................................41RITUXAN HYCELA......................................................41RITUXAN HYCELA......................................................41rivastigmine tartrate cap 1.5 mg................................ 22rivastigmine tartrate cap 3 mg....................................22rivastigmine tartrate cap 4.5 mg................................ 22rivastigmine tartrate cap 6 mg....................................23rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 23rivastigmine td patch 24hr 4.6 mg/24hr.....................23rivastigmine td patch 24hr 9.5 mg/24hr.....................23rizatriptan benzoate oral disintegrating tab 10

mg................................................................................31rizatriptan benzoate oral disintegrating tab 5

mg................................................................................31rizatriptan benzoate tab 10 mg.................................. 31rizatriptan benzoate tab 5 mg.................................... 31ROBINUL.......................................................................97ROBINUL FORTE........................................................97ROCALTROL.............................................................. 116ROCALTROL.............................................................. 116

2019

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ROCALTROL.............................................................. 116ropinirole hydrochloride tab 0.25 mg.........................45ropinirole hydrochloride tab 0.5 mg...........................46ropinirole hydrochloride tab 1 mg.............................. 46ropinirole hydrochloride tab 2 mg.............................. 46ropinirole hydrochloride tab 3 mg.............................. 46ropinirole hydrochloride tab 4 mg.............................. 46ropinirole hydrochloride tab 5 mg.............................. 46ropinirole hydrochloride tab er 24hr 12

mg................................................................................45ropinirole hydrochloride tab er 24hr 2




mg................................................................................45rosuvastatin calcium tab 10 mg................................. 81rosuvastatin calcium tab 20 mg................................. 81rosuvastatin calcium tab 40 mg................................. 81rosuvastatin calcium tab 5 mg................................... 81ROTARIX.....................................................................113ROTATEQ....................................................................113ROWASA.....................................................................115ROXICODONE............................................................... 5ROXICODONE............................................................... 5ROXICODONE............................................................... 5RUBRACA.....................................................................41RUBRACA.....................................................................41RUBRACA.....................................................................41RYDAPT........................................................................ 41RYTHMOL SR..............................................................82RYTHMOL SR..............................................................82RYTHMOL SR..............................................................82SSABRIL.......................................................................... 20SABRIL.......................................................................... 20SALAGEN......................................................................88SALAGEN......................................................................88SAMSCA........................................................................94SAMSCA........................................................................94SANDIMMUNE...........................................................113SANDIMMUNE...........................................................113SANDIMMUNE...........................................................113SANDIMMUNE...........................................................113SANDOSTATIN LAR DEPOT...................................108SANDOSTATIN LAR DEPOT...................................108SANDOSTATIN LAR DEPOT...................................108SANTYL.........................................................................91SAPHRIS.......................................................................50SAPHRIS.......................................................................50

SAPHRIS.......................................................................50SEASONIQUE............................................................105selegiline hcl cap 5 mg............................................... 46selegiline hcl tab 5 mg................................................ 46selenium sulfide lotion 2.5%.......................................91SELZENTRY.................................................................56SELZENTRY.................................................................56SELZENTRY.................................................................56SELZENTRY.................................................................56SELZENTRY.................................................................56SENSIPAR.................................................................. 116SENSIPAR.................................................................. 116SENSIPAR.................................................................. 116SEREVENT DISKUS.................................................123SEROQUEL.................................................................. 50SEROQUEL.................................................................. 50SEROQUEL.................................................................. 50SEROQUEL.................................................................. 51SEROQUEL.................................................................. 51SEROQUEL.................................................................. 51SEROQUEL XR........................................................... 51SEROQUEL XR........................................................... 51SEROQUEL XR........................................................... 51SEROQUEL XR........................................................... 51SEROQUEL XR........................................................... 51sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................26sertraline hcl tab 100 mg............................................ 26sertraline hcl tab 25 mg.............................................. 26sertraline hcl tab 50 mg.............................................. 26sevelamer carbonate packet 0.8 gm......................... 94sevelamer carbonate packet 2.4 gm......................... 94sevelamer carbonate tab 800 mg..............................94SFROWASA................................................................115SHINGRIX...................................................................113SIGNIFOR...................................................................108SIGNIFOR...................................................................108SIGNIFOR...................................................................108SIGNIFOR LAR..........................................................108SIGNIFOR LAR..........................................................108SIGNIFOR LAR..........................................................108SIGNIFOR LAR..........................................................108SIGNIFOR LAR..........................................................108sildenafil citrate tab 20 mg....................................... 123SILENOR.....................................................................125SILENOR.....................................................................125silodosin cap 4 mg.......................................................99silodosin cap 8 mg.......................................................99SILVADENE...................................................................91silver sulfadiazine cream 1%......................................91SIMBRINZA................................................................ 119SIMULECT.................................................................. 113

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SIMULECT.................................................................. 113simvastatin tab 10 mg.................................................82simvastatin tab 20 mg.................................................82simvastatin tab 40 mg.................................................82simvastatin tab 5 mg................................................... 82simvastatin tab 80 mg.................................................82SINEMET.......................................................................46SINEMET.......................................................................46SINEMET.......................................................................46SINEMET CR............................................................... 46SINEMET CR............................................................... 46SINGULAIR.................................................................123SINGULAIR.................................................................123SINGULAIR.................................................................123SINGULAIR.................................................................123sirolimus tab 0.5 mg..................................................113sirolimus tab 1 mg..................................................... 113sirolimus tab 2 mg..................................................... 113SIRTURO.......................................................................32SIVEXTRO.................................................................... 14SIVEXTRO.................................................................... 14sodium chloride inj 0.45%...........................................94sodium chloride irrigation soln 0.9%......................... 94sodium chloride iv soln 0.9%..................................... 94sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................98sodium phenylbutyrate tab 500 mg........................... 98sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................94sodium polystyrene sulfonate powder.......................94sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................94SOLTAMOX...................................................................41SOLU-MEDROL.........................................................101SOLU-MEDROL.........................................................101SOLU-MEDROL.........................................................101SOLU-MEDROL.........................................................101SOMATULINE DEPOT..............................................108SOMATULINE DEPOT..............................................108SOMATULINE DEPOT..............................................108SOMAVERT................................................................ 108SOMAVERT................................................................ 108SOMAVERT................................................................ 108SOMAVERT................................................................ 108SOMAVERT................................................................ 108SOOLANTRA................................................................91sotalol hcl (afib/afl) tab 120 mg..................................82sotalol hcl (afib/afl) tab 160 mg..................................82sotalol hcl (afib/afl) tab 80 mg....................................82sotalol hcl tab 120 mg.................................................82sotalol hcl tab 160 mg.................................................82sotalol hcl tab 240 mg.................................................82

sotalol hcl tab 80 mg...................................................82SOVALDI....................................................................... 56SPIRIVA HANDIHALER............................................123SPIRIVA RESPIMAT................................................. 123SPIRIVA RESPIMAT................................................. 123spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................82spironolactone tab 100 mg.........................................82spironolactone tab 25 mg........................................... 82spironolactone tab 50 mg........................................... 82SPORANOX..................................................................30SPORANOX PULSEPAK............................................30SPRITAM.......................................................................20SPRITAM.......................................................................20SPRITAM.......................................................................20SPRITAM.......................................................................21SPRYCEL......................................................................41SPRYCEL......................................................................41SPRYCEL......................................................................41SPRYCEL......................................................................41SPRYCEL......................................................................41SPRYCEL......................................................................41STAMARIL...................................................................114STARLIX........................................................................ 62STARLIX........................................................................ 62stavudine cap 15 mg...................................................56stavudine cap 20 mg...................................................56stavudine cap 30 mg...................................................56stavudine cap 40 mg...................................................56STELARA....................................................................114STELARA....................................................................114STELARA....................................................................114STELARA....................................................................114STIMATE..................................................................... 101STIOLTO RESPIMAT................................................ 123STIVARGA.....................................................................41STRATTERA.................................................................87STRATTERA.................................................................87STRATTERA.................................................................87STRATTERA.................................................................87STRATTERA.................................................................87STRATTERA.................................................................87STRATTERA.................................................................87STRENSIQ....................................................................98STRENSIQ....................................................................98STRENSIQ....................................................................98STRENSIQ....................................................................98STREPTOMYCIN SULFATE...................................... 14STRIBILD...................................................................... 56STROMECTOL.............................................................44SUBLOCADE.................................................................. 6SUBLOCADE.................................................................. 6

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SUBOXONE....................................................................6SUBOXONE....................................................................6SUBOXONE....................................................................6SUBOXONE....................................................................7sucralfate tab 1 gm......................................................97SULAR........................................................................... 82SULAR........................................................................... 82SULAR........................................................................... 82sulfacetamide sodium lotion 10%.............................. 15sulfacetamide sodium ophth soln

10%...........................................................................119sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 119SULFADIAZINE............................................................ 15sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 15sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 15sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................15sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................15sulfasalazine tab 500 mg..........................................115sulfasalazine tab delayed release 500

mg............................................................................. 115sulindac tab 150 mg...................................................... 5sulindac tab 200 mg...................................................... 5sumatriptan nasal spray 20 mg/act........................... 31sumatriptan nasal spray 5 mg/act..............................31SUMATRIPTAN SUCCINATE.....................................31sumatriptan succinate inj 6 mg/0.5ml........................31sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................32sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................32sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................32sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................32sumatriptan succinate tab 100 mg............................ 32sumatriptan succinate tab 25 mg...............................32sumatriptan succinate tab 50 mg...............................32SUPRAX........................................................................15SUPRAX........................................................................15SUPRAX........................................................................15SUPREP BOWEL PREP KIT.....................................97SURMONTIL.................................................................26SURMONTIL.................................................................26SURMONTIL.................................................................26SUSTIVA........................................................................56SUSTIVA........................................................................56SUSTIVA........................................................................56

SUTENT........................................................................ 41SUTENT........................................................................ 41SUTENT........................................................................ 41SUTENT........................................................................ 41SYLATRON................................................................... 56SYLATRON................................................................... 56SYLATRON................................................................... 56SYLVANT.....................................................................114SYLVANT.....................................................................114SYMBICORT...............................................................123SYMBICORT...............................................................123SYMDEKO.................................................................. 123SYMFI............................................................................ 56SYMFI LO..................................................................... 56SYMLINPEN 120......................................................... 62SYMLINPEN 60............................................................63SYMPAZAN...................................................................21SYMPAZAN...................................................................21SYMPAZAN...................................................................21SYMTUZA..................................................................... 56SYNAGIS.................................................................... 114SYNAGIS.................................................................... 114SYNAREL....................................................................108SYNERCID....................................................................15SYNJARDY................................................................... 63SYNJARDY................................................................... 63SYNJARDY................................................................... 63SYNJARDY................................................................... 63SYNJARDY XR............................................................ 63SYNJARDY XR............................................................ 63SYNJARDY XR............................................................ 63SYNJARDY XR............................................................ 63SYNRIBO...................................................................... 41SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYNTHROID...............................................................106SYPRINE.......................................................................94TTABLOID........................................................................41tacrolimus cap 0.5 mg...............................................114tacrolimus cap 1 mg..................................................114tacrolimus cap 5 mg..................................................114tacrolimus oint 0.03%..................................................91

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tacrolimus oint 0.1%.................................................... 91tadalafil tab 20 mg (pah)...........................................123TAFINLAR..................................................................... 41TAFINLAR..................................................................... 41TAGRISSO.................................................................... 41TAGRISSO.................................................................... 41TALZENNA....................................................................41TALZENNA....................................................................41TAMIFLU........................................................................56TAMIFLU........................................................................56TAMIFLU........................................................................56TAMIFLU........................................................................56tamoxifen citrate tab 10 mg........................................41tamoxifen citrate tab 20 mg........................................41tamsulosin hcl cap 0.4 mg..........................................99TARCEVA...................................................................... 41TARCEVA...................................................................... 41TARCEVA...................................................................... 41TARGRETIN..................................................................41TARGRETIN..................................................................41TASIGNA....................................................................... 41TASIGNA....................................................................... 41TASIGNA....................................................................... 42TASMAR........................................................................ 46TAXOTERE................................................................... 42TAXOTERE................................................................... 42tazarotene cream 0.1%...............................................91TAZICEF........................................................................ 15TAZICEF........................................................................ 15TAZORAC......................................................................91TAZORAC......................................................................91TAZORAC......................................................................91TDVAX......................................................................... 114TECENTRIQ................................................................. 42TECFIDERA..................................................................87TECFIDERA..................................................................87TECFIDERA STARTER PACK...................................87TECHNIVIE................................................................... 56TEFLARO......................................................................15TEFLARO......................................................................15TEGRETOL...................................................................21TEGRETOL...................................................................21TEGRETOL-XR............................................................ 21TEGRETOL-XR............................................................ 21TEGRETOL-XR............................................................ 21TEKTURNA...................................................................82TEKTURNA...................................................................82TEKTURNA HCT......................................................... 82TEKTURNA HCT......................................................... 82TEKTURNA HCT......................................................... 82TEKTURNA HCT......................................................... 82telmisartan-amlodipine tab 40-10 mg........................82

telmisartan-amlodipine tab 40-5 mg..........................82telmisartan-amlodipine tab 80-10 mg........................82telmisartan-amlodipine tab 80-5 mg..........................82telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................82telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................82telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................82telmisartan tab 20 mg................................................. 82telmisartan tab 40 mg................................................. 82telmisartan tab 80 mg................................................. 82temazepam cap 15 mg............................................. 125temazepam cap 30 mg............................................. 125TEMODAR.................................................................... 42temsirolimus soln for iv infusion 25 mg/

ml.................................................................................42TENCON..........................................................................5TENIVAC..................................................................... 114tenofovir disoproxil fumarate tab 300

mg................................................................................56TENORETIC 100......................................................... 83TENORETIC 50............................................................83TENORMIN................................................................... 83TENORMIN................................................................... 83TENORMIN................................................................... 83terazosin hcl cap 10 mg..............................................83terazosin hcl cap 1 mg................................................83terazosin hcl cap 2 mg................................................83terazosin hcl cap 5 mg................................................83terbinafine hcl tab 250 mg..........................................30terbutaline sulfate tab 2.5 mg.................................. 123terbutaline sulfate tab 5 mg......................................123terconazole vaginal cream 0.4%................................30terconazole vaginal cream 0.8%................................30terconazole vaginal suppos 80 mg............................30testosterone cypionate im inj in oil 100 mg/

ml...............................................................................105testosterone cypionate im inj in oil 200 mg/

ml...............................................................................105testosterone enanthate im inj in oil 200 mg/

ml...............................................................................105testosterone td gel 12.5 mg/act (1%)...................... 105testosterone td gel 20.25 mg/1.25gm

(1.62%).....................................................................105testosterone td gel 20.25 mg/act

(1.62%).....................................................................105testosterone td gel 25 mg/2.5gm

(1%).......................................................................... 105testosterone td gel 40.5 mg/2.5gm

(1.62%).....................................................................105testosterone td gel 50 mg/5gm (1%).......................105

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testosterone td soln 30 mg/act.................................105tetrabenazine tab 12.5 mg..........................................87tetrabenazine tab 25 mg.............................................87tetracycline hcl cap 250 mg........................................15tetracycline hcl cap 500 mg........................................15THALOMID....................................................................42THALOMID....................................................................42THALOMID....................................................................42THALOMID....................................................................42THEO-24..................................................................... 123THEO-24..................................................................... 123THEO-24..................................................................... 123THEO-24..................................................................... 123theophylline tab er 12hr 100 mg..............................123theophylline tab er 12hr 200 mg..............................124theophylline tab er 12hr 300 mg..............................124theophylline tab er 12hr 450 mg..............................124theophylline tab er 24hr 400 mg..............................124theophylline tab er 24hr 600 mg..............................124thioridazine hcl tab 100 mg........................................ 51thioridazine hcl tab 10 mg.......................................... 51thioridazine hcl tab 25 mg.......................................... 51thioridazine hcl tab 50 mg.......................................... 51thiotepa for inj 15 mg.................................................. 42thiothixene cap 10 mg.................................................51thiothixene cap 1 mg...................................................51thiothixene cap 2 mg...................................................51thiothixene cap 5 mg...................................................51THYMOGLOBULIN....................................................114tiagabine hcl tab 12 mg.............................................. 21tiagabine hcl tab 16 mg.............................................. 21tiagabine hcl tab 2 mg.................................................21tiagabine hcl tab 4 mg.................................................21TIAZAC.......................................................................... 83TIAZAC.......................................................................... 83TIAZAC.......................................................................... 83TIAZAC.......................................................................... 83TIAZAC.......................................................................... 83TIAZAC.......................................................................... 83TIBSOVO.......................................................................42tigecycline for iv soln 50 mg.......................................15TIKOSYN.......................................................................83TIKOSYN.......................................................................83TIKOSYN.......................................................................83TIMOLOL MALEATE................................................... 83TIMOLOL MALEATE................................................... 83TIMOLOL MALEATE................................................... 83timolol maleate ophth gel forming soln

0.25%........................................................................119timolol maleate ophth gel forming soln

0.5%..........................................................................119timolol maleate ophth soln 0.25%........................... 119

timolol maleate ophth soln 0.5%..............................119timolol maleate ophth soln 0.5% (once-

daily)......................................................................... 119TIMOPTIC................................................................... 119TIMOPTIC................................................................... 119TIMOPTIC OCUDOSE..............................................119TIMOPTIC OCUDOSE..............................................119TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................106TIROSINT....................................................................107TIROSINT....................................................................107TIROSINT....................................................................107TIROSINT....................................................................107TIROSINT....................................................................107TIVICAY......................................................................... 56TIVICAY......................................................................... 56TIVICAY......................................................................... 56tizanidine hcl cap 2 mg............................................... 52tizanidine hcl cap 4 mg............................................... 52tizanidine hcl cap 6 mg............................................... 52tizanidine hcl tab 2 mg................................................52tizanidine hcl tab 4 mg................................................52TOBRADEX................................................................ 119TOBRADEX................................................................ 119tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................119tobramycin nebu soln 300 mg/5ml.......................... 124tobramycin ophth soln 0.3%.....................................119TOBRAMYCIN SULFATE........................................... 15TOBRAMYCIN SULFATE........................................... 15tobramycin sulfate for inj 1.2 gm................................15tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................15tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................15tolcapone tab 100 mg................................................. 46TOLMETIN SODIUM..................................................... 5tolterodine tartrate cap er 24hr 2 mg.........................99tolterodine tartrate cap er 24hr 4 mg.........................99tolterodine tartrate tab 1 mg.......................................99tolterodine tartrate tab 2 mg.......................................99topiramate sprinkle cap 15 mg...................................21topiramate sprinkle cap 25 mg...................................21topiramate tab 100 mg................................................21topiramate tab 200 mg................................................21topiramate tab 25 mg.................................................. 21topiramate tab 50 mg.................................................. 21

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topotecan hcl for inj 4 mg........................................... 42topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 42TOPROL XL..................................................................83TOPROL XL..................................................................83TOPROL XL..................................................................83TOPROL XL..................................................................83toremifene citrate tab 60 mg...................................... 42TORISEL....................................................................... 42torsemide tab 100 mg................................................. 83torsemide tab 10 mg................................................... 83torsemide tab 20 mg................................................... 83torsemide tab 5 mg......................................................83TOUJEO MAX SOLOSTAR........................................63TOUJEO SOLOSTAR..................................................63TOVIAZ.......................................................................... 99TOVIAZ........................................................................100TRACLEER.................................................................124TRACLEER.................................................................124TRACLEER.................................................................124TRADJENTA................................................................. 63tramadol-acetaminophen tab 37.5-325

mg..................................................................................5tramadol hcl tab 50 mg................................................. 5tramadol hcl tab er 24hr 100 mg..................................5tramadol hcl tab er 24hr 200 mg..................................5tramadol hcl tab er 24hr 300 mg..................................5trandolapril tab 1 mg................................................... 83trandolapril tab 2 mg................................................... 83trandolapril tab 4 mg................................................... 83tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................66tranexamic acid tab 650 mg.......................................66tranylcypromine sulfate tab 10 mg............................ 26TRAVATAN Z.............................................................. 119trazodone hcl tab 100 mg...........................................26trazodone hcl tab 150 mg...........................................26trazodone hcl tab 300 mg...........................................26trazodone hcl tab 50 mg.............................................26TREANDA..................................................................... 42TREANDA..................................................................... 42TRECATOR...................................................................32TRELEGY ELLIPTA...................................................124TRELSTAR..................................................................108TRELSTAR..................................................................108TRELSTAR MIXJECT............................................... 108TRELSTAR MIXJECT............................................... 108TRELSTAR MIXJECT............................................... 108TRESIBA....................................................................... 63TRESIBA FLEXTOUCH.............................................. 63TRESIBA FLEXTOUCH.............................................. 63tretinoin cap 10 mg......................................................42

tretinoin cream 0.025%............................................... 91tretinoin cream 0.05%................................................. 91tretinoin cream 0.1%................................................... 91tretinoin gel 0.01%.......................................................91tretinoin gel 0.025%.....................................................91triamcinolone acetonide cream

0.025%........................................................................91triamcinolone acetonide cream 0.1%........................91triamcinolone acetonide cream 0.5%........................91triamcinolone acetonide dental paste

0.1%............................................................................88triamcinolone acetonide lotion 0.025%..................... 91triamcinolone acetonide lotion 0.1%..........................91triamcinolone acetonide oint 0.025%........................ 91triamcinolone acetonide oint 0.1%.............................91triamcinolone acetonide oint 0.5%.............................91triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................83triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................83triamterene & hydrochlorothiazide tab 75-50

mg................................................................................83TRIBENZOR................................................................. 83TRIBENZOR................................................................. 83TRIBENZOR................................................................. 84TRIBENZOR................................................................. 84TRIBENZOR................................................................. 84trientine hcl cap 250 mg............................................. 94trifluoperazine hcl tab 10 mg......................................51trifluoperazine hcl tab 1 mg........................................51trifluoperazine hcl tab 2 mg........................................51trifluoperazine hcl tab 5 mg........................................51trifluridine ophth soln 1%.......................................... 119TRILEPTAL................................................................... 21TRILEPTAL................................................................... 21TRILEPTAL................................................................... 21TRILEPTAL................................................................... 21trimethoprim tab 100 mg.............................................15trimipramine maleate cap 100 mg............................. 26trimipramine maleate cap 25 mg............................... 26trimipramine maleate cap 50 mg............................... 26TRI-NORINYL 28.......................................................105TRINTELLIX..................................................................26TRINTELLIX..................................................................26TRINTELLIX..................................................................26TRISENOX....................................................................42TRIUMEQ......................................................................56TROGARZO..................................................................56TROPHAMINE..............................................................94trospium chloride cap er 24hr 60 mg...................... 100trospium chloride tab 20 mg.....................................100TRULICITY....................................................................63

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TRULICITY....................................................................63TRUMENBA................................................................114TRUSOPT................................................................... 119TRUVADA......................................................................56TRUVADA......................................................................57TRUVADA......................................................................57TRUVADA......................................................................57TWINRIX..................................................................... 114TYBOST........................................................................ 57TYGACIL....................................................................... 15TYKERB........................................................................ 42TYMLOS......................................................................116TYPHIM VI..................................................................114TYSABRI....................................................................... 87UULORIC......................................................................... 31ULORIC......................................................................... 31ULTRACET......................................................................5ULTRAM.......................................................................... 5ULTRAVATE.................................................................. 91ULTRAVATE.................................................................. 91UNITUXIN......................................................................42UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124UPTRAVI..................................................................... 124ursodiol cap 300 mg....................................................97ursodiol tab 250 mg.....................................................97ursodiol tab 500 mg.....................................................97VVAGIFEM.....................................................................105valacyclovir hcl tab 1 gm............................................ 57valacyclovir hcl tab 500 mg........................................57VALCHLOR................................................................... 42VALCYTE.......................................................................57VALCYTE.......................................................................57valganciclovir hcl for soln 50 mg/ml.......................... 57valganciclovir hcl tab 450 mg.....................................57valproate sodium inj 100 mg/ml.................................21valproate sodium oral soln 250 mg/5ml.................... 21valproic acid cap 250 mg............................................21valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................84valsartan-hydrochlorothiazide tab 160-25

mg................................................................................84

valsartan-hydrochlorothiazide tab 320-12.5mg................................................................................84

valsartan-hydrochlorothiazide tab 320-25mg................................................................................84

valsartan-hydrochlorothiazide tab 80-12.5mg................................................................................84

valsartan tab 160 mg...................................................84valsartan tab 320 mg...................................................84valsartan tab 40 mg.....................................................84valsartan tab 80 mg.....................................................84VALTREX.......................................................................57VALTREX.......................................................................57VANCOMYCIN HCL.................................................... 15vancomycin hcl cap 125 mg.......................................15vancomycin hcl cap 250 mg.......................................15vancomycin hcl for iv soln 10 gm.............................. 15vancomycin hcl for iv soln 1 gm.................................15vancomycin hcl for iv soln 500 mg............................ 15vancomycin hcl for iv soln 5 gm.................................15vancomycin hcl for iv soln 750 mg............................ 15VANCOMYCIN HCL IN DEXTROSE.........................15VANCOMYCIN HCL IN DEXTROSE.........................15VANCOMYCIN HCL IN DEXTROSE.........................15VANCOMYCIN HYDROCHLORIDE..........................16VANCOMYCIN HYDROCHLORIDE..........................16VANCOMYCIN HYDROCHLORIDE..........................16VAQTA......................................................................... 114VAQTA......................................................................... 114VARIVAX..................................................................... 114VASCEPA...................................................................... 84VASCEPA...................................................................... 84VASERETIC.................................................................. 84VASOTEC......................................................................84VASOTEC......................................................................84VASOTEC......................................................................84VASOTEC......................................................................84VECTIBIX...................................................................... 42VECTIBIX...................................................................... 42VELCADE......................................................................42VELPHORO.................................................................. 94VELTASSA.................................................................... 94VELTASSA.................................................................... 94VELTASSA.................................................................... 94VENCLEXTA.................................................................42VENCLEXTA.................................................................42VENCLEXTA.................................................................42VENCLEXTA STARTING PACK................................ 42venlafaxine hcl cap er 24hr 150 mg.......................... 27venlafaxine hcl cap er 24hr 37.5 mg......................... 26venlafaxine hcl cap er 24hr 75 mg............................ 27venlafaxine hcl tab 100 mg........................................ 27venlafaxine hcl tab 25 mg...........................................27

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venlafaxine hcl tab 37.5 mg....................................... 27venlafaxine hcl tab 50 mg...........................................27venlafaxine hcl tab 75 mg...........................................27venlafaxine hcl tab er 24hr 150 mg........................... 27venlafaxine hcl tab er 24hr 37.5 mg..........................27venlafaxine hcl tab er 24hr 75 mg............................. 27VENTAVIS................................................................... 124VENTAVIS................................................................... 124VENTOLIN HFA......................................................... 124verapamil hcl cap er 24hr 100 mg.............................84verapamil hcl cap er 24hr 120 mg.............................84verapamil hcl cap er 24hr 180 mg.............................84verapamil hcl cap er 24hr 200 mg.............................84verapamil hcl cap er 24hr 240 mg.............................84verapamil hcl cap er 24hr 300 mg.............................84verapamil hcl cap er 24hr 360 mg.............................84verapamil hcl tab 120 mg........................................... 84verapamil hcl tab 40 mg............................................. 84verapamil hcl tab 80 mg............................................. 84verapamil hcl tab er 120 mg.......................................84verapamil hcl tab er 180 mg.......................................84verapamil hcl tab er 240 mg.......................................84VERELAN......................................................................84VERELAN......................................................................84VERELAN......................................................................84VERELAN......................................................................85VERELAN PM.............................................................. 85VERELAN PM.............................................................. 85VERELAN PM.............................................................. 85VERSACLOZ................................................................ 51VERZENIO....................................................................42VERZENIO....................................................................42VERZENIO....................................................................42VERZENIO....................................................................42VFEND IV......................................................................30VIBRAMYCIN................................................................16VICTOZA....................................................................... 63VIDEX............................................................................ 57VIDEX............................................................................ 57VIDEX EC..................................................................... 57VIDEX EC..................................................................... 57VIDEX EC..................................................................... 57VIDEX EC..................................................................... 57VIEKIRA PAK................................................................57VIEKIRA XR..................................................................57vigabatrin powd pack 500 mg.................................... 21vigabatrin tab 500 mg................................................. 21VIGAMOX....................................................................119VIIBRYD.........................................................................27VIIBRYD.........................................................................27VIIBRYD.........................................................................27VIIBRYD STARTER PACK......................................... 27

VIMPAT.......................................................................... 21VIMPAT.......................................................................... 21VIMPAT.......................................................................... 21VIMPAT.......................................................................... 21VIMPAT.......................................................................... 21VIMPAT.......................................................................... 21VINBLASTINE SULFATE............................................42vincristine sulfate iv soln 1 mg/ml..............................42vinorelbine tartrate inj 10 mg/ml.................................42vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................42VIRACEPT.................................................................... 57VIRACEPT.................................................................... 57VIRAMUNE................................................................... 57VIRAMUNE XR............................................................ 57VIREAD..........................................................................57VIREAD..........................................................................57VIREAD..........................................................................57VIREAD..........................................................................57VIREAD..........................................................................57VIROPTIC................................................................... 119VITRAKVI...................................................................... 43VITRAKVI...................................................................... 43VITRAKVI...................................................................... 43VIVITROL........................................................................ 7VIZIMPRO..................................................................... 43VIZIMPRO..................................................................... 43VIZIMPRO..................................................................... 43VOLTAREN......................................................................5voriconazole for inj 200 mg........................................ 30voriconazole for susp 40 mg/ml.................................30voriconazole tab 200 mg............................................ 30voriconazole tab 50 mg...............................................30VOSEVI..........................................................................57VOTRIENT.................................................................... 43VPRIV............................................................................ 98VRAYLAR...................................................................... 51VRAYLAR...................................................................... 51VRAYLAR...................................................................... 51VRAYLAR...................................................................... 51VYTORIN.......................................................................85VYTORIN.......................................................................85VYTORIN.......................................................................85VYTORIN.......................................................................85VYXEOS........................................................................43Wwarfarin sodium tab 10 mg.........................................66warfarin sodium tab 1 mg...........................................66warfarin sodium tab 2.5 mg........................................66warfarin sodium tab 2 mg...........................................66warfarin sodium tab 3 mg...........................................66warfarin sodium tab 4 mg...........................................66

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warfarin sodium tab 5 mg...........................................66warfarin sodium tab 6 mg...........................................66warfarin sodium tab 7.5 mg........................................66water for irrigation, sterile irrigation

soln..............................................................................94WELLBUTRIN SR........................................................27WELLBUTRIN SR........................................................27WELLBUTRIN SR........................................................27WELLBUTRIN XL........................................................ 27WELLBUTRIN XL........................................................ 27XXALKORI....................................................................... 43XALKORI....................................................................... 43XARELTO...................................................................... 66XARELTO...................................................................... 67XARELTO...................................................................... 67XARELTO...................................................................... 67XARELTO STARTER PACK.......................................67XATMEP...................................................................... 114XENAZINE.................................................................... 88XENAZINE.................................................................... 88XGEVA.........................................................................116XIFAXAN........................................................................97XOFLUZA......................................................................57XOFLUZA......................................................................57XOLAIR........................................................................114XOLAIR........................................................................114XOLAIR........................................................................114XOPENEX HFA..........................................................124XOSPATA...................................................................... 43XTANDI.......................................................................... 43XYLOCAINE....................................................................6XYLOCAINE-MPF.......................................................... 6XYREM........................................................................125YYASMIN 28................................................................. 105YAZ...............................................................................105YERVOY........................................................................43YERVOY........................................................................43YF-VAX........................................................................ 114YONDELIS.................................................................... 43YONSA.......................................................................... 43Zzafirlukast tab 10 mg.................................................124zafirlukast tab 20 mg.................................................124zaleplon cap 10 mg...................................................125zaleplon cap 5 mg..................................................... 125ZALTRAP.......................................................................43ZALTRAP.......................................................................43ZANAFLEX....................................................................52

ZANOSAR..................................................................... 43ZANTAC.........................................................................97ZARONTIN....................................................................21ZEJULA..........................................................................43ZELBORAF................................................................... 43ZEMPLAR................................................................... 116ZEMPLAR................................................................... 116ZEMPLAR................................................................... 116ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZENPEP........................................................................ 98ZEPATIER..................................................................... 57ZERIT.............................................................................58ZERIT.............................................................................58ZERIT.............................................................................58ZERIT.............................................................................58ZESTORETIC............................................................... 85ZESTORETIC............................................................... 85ZESTORETIC............................................................... 85ZESTRIL........................................................................85ZESTRIL........................................................................85ZESTRIL........................................................................85ZESTRIL........................................................................85ZESTRIL........................................................................85ZESTRIL........................................................................85ZETIA............................................................................. 85ZIAC............................................................................... 85ZIAC............................................................................... 85ZIAC............................................................................... 85ZIAGEN..........................................................................58ZIAGEN..........................................................................58zidovudine cap 100 mg...............................................58zidovudine syrup 10 mg/ml.........................................58zidovudine tab 300 mg................................................58ziprasidone hcl cap 20 mg..........................................51ziprasidone hcl cap 40 mg..........................................51ziprasidone hcl cap 60 mg..........................................51ziprasidone hcl cap 80 mg..........................................51ZITHROMAX.................................................................16ZITHROMAX.................................................................16ZITHROMAX.................................................................16ZITHROMAX.................................................................16ZITHROMAX.................................................................16ZITHROMAX.................................................................16ZITHROMAX TRI-PAK................................................ 16ZITHROMAX Z-PAK.................................................... 16ZOCOR..........................................................................85ZOCOR..........................................................................85

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ZOCOR..........................................................................85ZOCOR..........................................................................85ZOCOR..........................................................................85ZOFRAN........................................................................28ZOFRAN........................................................................28ZOFRAN........................................................................29ZOFRAN ODT.............................................................. 29ZOFRAN ODT.............................................................. 29ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5zoledronic acid inj conc for iv infusion 4

mg/5ml......................................................................116zoledronic acid iv soln 5 mg/100ml......................... 116ZOLINZA........................................................................43zolmitriptan orally disintegrating tab 2.5

mg................................................................................32zolmitriptan orally disintegrating tab 5

mg................................................................................32ZOLOFT.........................................................................27ZOLOFT.........................................................................27ZOLOFT.........................................................................27zolpidem tartrate tab 10 mg..................................... 125zolpidem tartrate tab 5 mg....................................... 125ZONALON..................................................................... 91ZONEGRAN..................................................................21ZONEGRAN..................................................................21zonisamide cap 100 mg..............................................22zonisamide cap 25 mg................................................21zonisamide cap 50 mg................................................22ZONTIVITY....................................................................67ZORTRESS.................................................................114ZORTRESS.................................................................114ZORTRESS.................................................................114ZORTRESS.................................................................114ZOSTAVAX..................................................................114ZOSYN...........................................................................16ZOSYN...........................................................................16ZOSYN...........................................................................16ZOSYN...........................................................................16ZOSYN...........................................................................16ZOSYN...........................................................................16ZOVIRAX.......................................................................58ZOVIRAX.......................................................................58ZOVIRAX.......................................................................58ZOVIRAX.......................................................................58ZYBAN............................................................................. 7ZYDELIG....................................................................... 43ZYDELIG....................................................................... 43

ZYKADIA....................................................................... 43ZYLOPRIM....................................................................31ZYLOPRIM....................................................................31ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA......................................................................51ZYPREXA RELPREVV............................................... 51ZYPREXA RELPREVV............................................... 52ZYPREXA RELPREVV............................................... 52ZYPREXA ZYDIS.........................................................52ZYPREXA ZYDIS.........................................................52ZYPREXA ZYDIS.........................................................52ZYPREXA ZYDIS.........................................................52ZYTIGA..........................................................................43ZYTIGA..........................................................................43ZYVOX...........................................................................16ZYVOX...........................................................................16ZYVOX...........................................................................16ZYVOX...........................................................................16

This formulary was updated on 02/25/2019. For more recent information or other questions, please contact Florida Blue at 1-800-926-6565 or, for TTY users, 1-800-955-8770, from 8:00 a.m. – 8:00 p.m. local time, seven days a week from October 1 – March 31, except for Thanksgiving and Christmas. From April 1 – September 30, we are open Monday – Friday, 8:00 a.m. – 8:00 p.m. local time, except for Federal holidays. Or visit www.floridablue/medicare.

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