2020 Prescription Drug List
UnitedHealthcare & Affiliated Companies
2020 Prescription Drug List
Introduction1 The UnitedHealthcare Prescription Drug List (PDL) provides
a list of of the most commonly prescribed medications in various therapeutic classes. This list is intended for use with UnitedHealthcare health plans and affiliated companies’ pharmacy benefit plan designs. The PDL applies only to prescription medications dispensed to outpatients and does not include inpatient medications or medications obtained or administered in a physician’s office. The PDL does not define benefit coverage. Benefit coverage is decided by the
2 member’s pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered under a particular member’s pharmacy benefit plan.
You may also access PDL information by visiting our website at UHCprovider.com.
Prescription Drug List Medication OverviewTier decisions are made by our PDL Management Committee based on clinical, economic, and other factors. The PDL Management Committee is comprised of senior UnitedHealth Group physician and business leaders. The UnitedHealthcare Pharmacy & Therapeutics (P&T) Committee, comprised of physicians and pharmacists, reviews new and existing medications and provides clinical guidance to the PDL Management Committee. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition.
The tier placement of a medication on the PDL may change. While medications change tiers infrequently, such changes generally occur two times per calendar year. Additionally, when a brand-name medication becomes available as a generic, the tier status and coverage of the brand-name medication and its corresponding generic will be evaluated. When a medication changes tiers, your patient may be required to pay more or less for that medication. These changes may occur without prior notice to you or your patient. However, you may visit our
® website at UHCprovider.com or use the PreCheck MyScript app for the most up-to-date information for a particular medication. Your patient can also find the most up-to-date tier
3, 8 status and cost information for a particular medication by ® visiting our member website at myuhc.com and/or calling the
toll-free member phone number located on his or her health plan ID card.
2
Tier DesignationsPrescription medications are categorized within 3 tiers on the
4 PDL. Each tier is assigned a cost,³ which is determined by the member’s pharmacy benefit plan. You may refer to the PDL as a guide to select the most appropriate medication with the lowest member cost for your patients.
Tier 1 Tier 2 Tier 3 Lowest cost Mid-range cost Highest cost medications
Tier 1 Tier 1 medications are your patient’s lowest cost option. Members can maximize their cost savings when you prescribe Tier 1 medications, if you decide they are appropriate for your patient’s treatment.
Tier 2 Tier 2 medications are your patient’s mid-range cost option. Consider Tier 2 medications if no Tier 1 medication is appropriate to treat your patient’s condition.
Tier 3 Tier 3 medications are your patient’s highest cost option. If your patient is currently taking a medication in Tier 3, you may want to determine if there is an appropriate alternative in Tier 1 or Tier 2.
You and your patient make decisions about health care and medication treatments.
If the member has a “closed” pharmacy benefit (a two-tier pharmacy benefit plan that does not cover medications classified in Tier 3 of this PDL), medications in Tier 3 are generally not covered, except under certain processes consistent with applicable law.
Some members have a four-tier prescription plan, and these medications are noted as T4 throughout the document. Members with a four-tier prescription plan should refer to their enrollment materials, check the Medication Pricing / Coverage information on our member website or call the toll-free member phone number provided on their ID card for more information about their benefit plan.
Not all medications are represented in this PDL. Only the most commonly prescribed medications are included.
3
Over-the-Counter and Therapeutically Equivalent MedicationsFor some conditions, you and your patient may decide that an over-the-counter (OTC) medication is the most appropriate treatment. According to UnitedHealthcare benefit design, OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. In some instances, OTC medications are listed on the PDL for reference purposes only. OTC medications may cost less than the member’s out-of-pocket expense for prescription medications.
Therapeutically Equivalent means that medications can be expected to produce essentially the same efficacy or adverse event profile. Our benefit designs allow us to exclude a medication if determined to be Therapeutically Equivalent to another covered product or OTC option.
If the patient or physician requests a medication we have excluded based on determination of Therapeutic Equivalent, the patient may be required to pay the entire cost of the medication as it may not be covered under the member’s pharmacy benefit. Please refer to the member’s pharmacy benefit plan.
Symbols
E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York.
5H May be part of health care reform preventiveH-PA May be part of health care reform preventive with prior
5 authorization MC Multiple copay
6PA Prior authorization requiredRS May be eligible for the Refill and Save ProgramSL Supply limitSP Specialty medication
7ST Step therapyT4 May be covered on Tier 4 in select benefits
Generic Medication Policy Many generic medications are included on the PDL in Tier 1; however, generic medications can be placed into any tier of the PDL. When a generic medication does not offer significant financial savings, it may be placed in the same tier or a higher tier than the brand medication. Generic medications are noted in italic font.
Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher tier or be excluded from coverage by the member’s plan. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. The member’s cost share is determined by the pharmacy benefit plan. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescribing physician or other health care professional to substitute the generic equivalent.
Specialty MedicationsSome members may have coverage for self-administered injectable and oral specialty medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories. UnitedHealthcare has a specialty pharmacy program that requires most specialty medications to be obtained through a designated specialty pharmacy. These medications are noted by SP throughout the document. The specialty pharmacy program includes designated specialty pharmacies, each selected based on their clinical expertise for the targeted therapeutic classes, quality of services, and cost. Their pharmacists are trained to help educate patients for these specialty medications, which may help improve treatment adherence.
Participating members should be instructed to call the toll-free member number on their ID card where a representative will answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty medication prescription.
Medications Requiring Prior Authorization and Other Pharmacy Programs Select medications may require prior authorization to be eligible for coverage under the member’s pharmacy benefit plan. Such medications are noted with a PA. Depending on your patients’ benefit and/or medication, a coverage review may apply to determine coverage under the pharmacy benefit. The pharmacy benefit may exclude coverage of medications for certain uses.
Clinical criteria for PA medications are available on our website at UHCprovider.com. The criteria reflect UnitedHealthcare’s P&T Committee decisions.
7 Some benefit plans may include our Step Therapy program. Step Therapy requires prior authorization and offers a “stepwise” approach to therapy for certain high-cost medications and requires that a member first try a more cost-effective medication before another high-cost medication. Step Therapy medications are noted as ST.
Supply limits define the maximum supply of medication per copayment or period of time. Supply limits are based on several factors that may include FDA-approved dosing guidelines as defined in the product package insert, medical literature, guidelines, or supportive data. Supply limit medications are noted as SL.
The Refill and Save Program encourages members to adhere to their treatment regimens by rewarding them with a discounted copayment/coinsurance for refilling their prescription within the defined time period. Eligible medications are noted as RS.
1 In certain documents the Prescription Drug List (PDL) was referred to as the “Preferred Dru coverage.
2 Where differences are noted, the benefit plan documents will govern. 3 UnitedHealthcare operates a wide number of benefit programs and products, and some ben
member’s specific benefit prior to prescribing medications. 4 In certain documents Tier 1 was referred to as “generics;” Tier 2 was referred to as “preferr
brands,” “not on the PDL,” or “brand-name not on the PDL.” These changes in descriptive te
5 Health Care Reform drug lists may vary by plan; your patient can find the most up-to-date ti calling the toll-free member phone number on their health plan ID card.
6 Depending on your patients’ benefit and/or medication, notification or medical necessity crit 7 For New Jersey fully insured members, this program is referred to as First Start. 8 In accordance with HCR/ACA requirements, providers may request a zero dollar coverage e
List and Pharmacy>Additional Resources> Patient Protection and Affordable Care Act $0 call the toll-free number on the member’s health plan ID card.
4
How to Obtain AuthorizationUse the PreCheck MyScript app on Link. By using the PreCheck MyScript app, you can now run a pharmacy trial claim and get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members. This will allow you to check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at their selected pharmacy, as well as:
• Get information on lower-cost prescription alternatives, if available, to help save members money.
• See which prescriptions currently require prior authorization, or are non-covered or non-preferred.
• Request prior authorization and receive status and results.
The app is now available to all Link users; to access, sign in to UHCprovider.com, then select the Link Marketplace from your Link dashboard and search for the PreCheck MyScript app. Add the app to your dashboard and start using it.
Below are also options to obtain authorization:
• Online: Use the online prior authorization tool (available through UHCprovider.com). Most online prior authorizations are approved in real-time, and an autopopulation feature provides 95 percent of a member’s information. Prior authorizations can also be submitted online by signing in to optumrx.com > Healthcare Professionals > Prior Authorizations.
• By Phone: Call the OptumRx prior authorization team at 1-800-711-4555.
g List (PDL).” This change in descriptive terms does not affect your patient’s benefit
efit programs may have alternative benefit designs. Physicians should always check the
ed brands” or “brand-name” on the PDL; and Tier 3 was referred to as “non-preferred rms do not affect your patient’s benefit coverage.
er status and cost information for a particular medication by visiting myuhc.com and/or
eria will be applied to determine if covered under the pharmacy benefit.
xception review for preventive medications. Please access uhcprovider.com>Drug Cost-share Preventive Medications Exemption Requests (Commercial members) or
Table of Contents
Analgesics - Drugs for Pain.............................. 6
Analgesics - Drugs for Pain and Inflammation. 9
Anti-Addiction / Substance Abuse Treatment
Agents.......................................................... 10
Antibacterials - Drugs for Infections................10
Anticoagulants - Drugs to Treat or Prevent
Blood Clots...................................................13
Anticonvulsants - Drugs for Seizures............. 14
Antidementia Agents - Drugs for Alzheimer's
Disease and Dementia................................. 15
Antidepressants - Drugs for Depression.........16
Antiemetics - Drugs for Nausea and Vomiting17
Antifungals - Drugs for Fungal Infections....... 18
Antigout Agents - Drugs for Gout................... 19
Antimigraine Agents - Drugs for Migraines.....19
Antimyasthenic Agents - Drugs to Treat
Myasthenia Gravis........................................20
Antimycobacterials - Drugs to Treat
Infections......................................................21
Antineoplastics - Drugs for Cancer.................21
Antiparasitics - Drugs for Parasitic Infections. 23
Antiparkinson Agents - Drugs for Parkinson's
Disease........................................................ 24
Antiplatelets - Drugs for Heart Attack and
Stroke Prevention.........................................25
Antipsychotics - Drugs for Mood Disorders.... 25
Antivirals - Drugs for Viral Infections.............. 26
Anxiolytics - Drugs for Anxiety........................28
Bipolar Agents - Drugs for Mood Disorders....28
Cardiovascular Agents - Drugs for Heart and
Circulation Conditions.................................. 29
Central Nervous System Agents - Drugs for
Attention Deficit Disorder..............................34
Central Nervous System Agents - Drugs for
Multiple Sclerosis......................................... 35
Central Nervous System Agents -
Miscellaneous...............................................36
Dental and Oral Agents - Drugs for Mouth
and Throat Conditions.................................. 36
Dermatological Agents - Drugs for Skin
Conditions.................................................... 37
Diabetes - Glucose Monitoring....................... 45
Diabetes - Insulin............................................47
Diabetes - Non-Insulin Agents........................48
Drugs for Blood Disorders.............................. 49
Drugs for Sexual Dysfunction......................... 51
Electrolytes / Vitamins.................................... 51
Gastrointestinal Agents - Drugs for Acid
Reflux and Ulcer...........................................53
Gastrointestinal Agents - Drugs for Bowel,
Intestine and Stomach Conditions................54
Genetic or Enzyme Disorder - Drugs for
Replacement, Modification, Treatment.........56
Genitourinary Agents - Drugs for Bladder,
Genital and Kidney Conditions.....................57
Genitourinary Agents - Drugs for Prostate
Conditions.................................................... 58
Hormonal Agents - Hormone Replacement
and Birth Control.......................................... 58
Hormonal Agents - Oral Steroids....................63
Hormonal Agents - Other................................64
Hormonal Agents - Testosterone
Replacement................................................ 64
Hormonal Agents - Thyroid.............................65
Immunological Agents - Drugs for Immune
System Stimulation or Suppression............. 65
Immunological Agents - Drugs for
Vaccination...................................................67
Infertility Agents.............................................. 68
Inflammatory Bowel Disease Agents..............68
Metabolic Bone Disease Agents - Drugs for
Osteoporosis................................................ 69
Metabolic Bone Disease Agents - Other........ 69
Ophthalmic Agents - Drugs for Eye Allergy,
Infection and Inflammation........................... 69
Ophthalmic Agents - Drugs for Glaucoma......71
Ophthalmic Agents - Drugs for Miscellaneous
Eye Conditions............................................. 72
Otic Agents - Drugs for Ear Conditions.......... 72
Respiratory - Drugs for Anaphylaxis...............72
Respiratory Tract / Pulmonary Agents -
Drugs for Allergies, Cough, Cold..................73
Respiratory Tract / Pulmonary Agents -
Drugs for Asthma and COPD.......................74
Respiratory Tract / Pulmonary Agents -
Drugs for Cystic Fibrosis.............................. 76
Respiratory Tract / Pulmonary Agents -
Drugs for Pulmonary Fibrosis.......................76
Respiratory Tract / Pulmonary Agents -
Drugs for Pulmonary Hypertension.............. 76
Skeletal Muscle Relaxants - Drugs for
Muscle Pain and Spasm...............................77
Sleep Disorder Agents....................................77
Index of Drugs................................................ 79
5
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
Analgesics - Drugs for
Pain
ABSTRAL SUBLINGUAL
TABLET SUBLINGUAL
400 MCG, 600 MCG, 800E PA; QL
MCG
acetaminophen-codeine 1
acetaminophen-codeine
#21
acetaminophen-codeine
#31
acetaminophen-codeine
#41
ACTIQ E PA; QL
ALLZITAL E
APADAZ E
apap-caff-dihydrocodeine
oral capsule4 QL
apap-caff-dihydrocodeine
oral tablet1 QL
ARYMO ER E PA; ST; QL
ascomp-codeine 1
BELBUCA 3 PA; QL
BENZHYDROCODONE-
ACETAMINOPHEN3
BUPAP 4
buprenorphine
transdermalE PA; ST; QL
butalbital-acetaminophen
capsule 50-300 mg oralE QL
BUTALBITAL-
ACETAMINOPHEN
CAPSULE 50-300 MG E QL
ORAL
butalbital-acetaminophen
oral tablet 25-325 mgE
butalbital-acetaminophen
oral tablet 50-300 mg3
butalbital-acetaminophen
oral tablet 50-325 mg1
butalbital-apap-caff-cod
oral capsule 50-300-40- E QL
30 mg
butalbital-apap-caff-cod
oral capsule 50-325-40- 1 QL
30 mg
butalbital-apap-caffeine
oral capsule 50-300-40 3 QL
mg
butalbital-apap-caffeine
oral capsule 50-325-40 1 QL
mg
butalbital-apap-caffeine
oral tablet1 QL
butalbital-asa-caff-
codeine1
butalbital-aspirin-caffeine 1
butorphanol tartrate
nasal2 QL
BUTRANS E PA; ST; QL
carisoprodol-aspirin-
codeine1
codeine sulfate oral
tablet 30 mg, 60 mg1
CONZIP ORAL
CAPSULE EXTENDED
RELEASE 24 HOUR 100
MG
E
(generic for
Conzip);
QL
CONZIP ORAL
CAPSULE EXTENDED
RELEASE 24 HOUR 200 E QL
MG, 300 MG
DILAUDID ORAL 4
DOLOPHINE 3 PA; QL
DURAGESIC-100 E PA; ST; QL
DURAGESIC-12 E PA; ST; QL
DURAGESIC-25 E PA; ST; QL
DURAGESIC-50 E PA; ST; QL
DURAGESIC-75 E PA; ST; QL
duraxin 1
6
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
DVORAH E QL
endocet 1
ESGIC 4 QL
fentanyl citrate buccal
lozenge on a handle2 PA; QL
FENTANYL CITRATE
BUCCAL TABLETE PA; QL
fentanyl transdermal
patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 2 PA; QL
mcg/hr, 50 mcg/hr, 75
mcg/hr
fentanyl transdermal
patch 72 hour 37.5
mcg/hr, 62.5 mcg/hr, E PA; ST; QL
87.5 mcg/hr
FENTORA E PA; QL
FIORICET 4 QL
FIORICET/CODEINE E QL
FIORINAL 4
FIORINAL/CODEINE #3 4
hydrocodone bitartrate er 3 PA; ST; QL
hydrocodone-
acetaminophen oral 1
solution 10-325 mg/15ml
hydrocodone-
acetaminophen oral 2
solution 7.5-325 mg/15ml
hydrocodone-
acetaminophen oral
tablet 10-300 mg, 5-300 E
mg, 7.5-300 mg
hydrocodone-
acetaminophen oral
tablet 10-325 mg, 5-325 1
mg, 7.5-325 mg
hydrocodone-ibuprofen 1
hydromorphone hcl er 4 PA; ST; QL
hydromorphone hcl oral 1
hydromorphone hcl rectal 1
HYSINGLA ER E PA; ST; QL
KADIAN E PA; ST; QL
LAZANDA 4 PA; QL
levorphanol tartrate oral 4 QL
lidocaine external
ointment2 QL
lidocaine external patch 5
%3 PA; QL
lidocaine hcl external
solution1
lidocaine hcl
urethral/mucosal1
lidocaine-prilocaine
external cream1
LIDODERM E PA; QL
lorcet 1
lorcet hd 1
lorcet plus oral tablet 7.5-
325 mg1
LORTAB 4
meperidine hcl oral 1
methadone hcl intensol 1 QL
methadone hcl oral
concentrate1 QL
methadone hcl oral
solution1 PA; QL
methadone hcl oral tablet 1 PA; QL
methadone hcl oral tablet
soluble1 QL
methadose oral
concentrate 10 mg/ml1 QL
methadose oral tablet
soluble1 QL
methadose sugar-free 1 QL
morphine sulfate
(concentrate) oral
solution 100 mg/5ml, 20 1
mg/ml
7
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
morphine sulfate er
beads4 PA; ST; QL
morphine sulfate er oral
capsule extended E PA; ST; QL
release 24 hour
morphine sulfate er oral
tablet extended release1 PA; QL
morphine sulfate oral 1
morphine sulfate rectal 1
MS CONTIN 3 PA; ST; QL
NALOCET E QL
NORCO 4
NUCYNTA 4 QL
NUCYNTA ER 3 PA; QL
OXAYDO E QL
OXYCODONE HCL ER E PA; ST; QL
oxycodone hcl oral
capsule1
oxycodone hcl oral
concentrate 100 mg/5ml1
oxycodone hcl oral
solution1
oxycodone hcl oral tablet 1
oxycodone-
acetaminophen oral
tablet 10-325 mg, 2.5- 1
325 mg, 5-325 mg, 7.5-
325 mg
oxycodone-
acetaminophen oral E QL
tablet 2.5-300 mg
oxycodone-aspirin 1
OXYCONTIN E PA; ST; QL
oxymorphone hcl 2 QL
oxymorphone hcl er 4 PA; ST; QL
pentazocine-naloxone hcl 1
PERCOCET E
pramox 1
premium lidocaine 2 QL
PRIMLEV E
PROLATE E
ROXICODONE ORAL
TABLET 15 MG, 30 MG4
ROXICODONE ORAL
TABLET 5 MG3
SUBSYS E PA; QL
tencon 1
tramadol hcl er (biphasic)E
(generic for
Ryzolt); QL
TRAMADOL HCL ER
ORAL CAPSULE (generic for
EXTENDED RELEASE E Conzip);
24 HOUR 100 MG, 200 QL
MG, 300 MG
tramadol hcl er oral
capsule extended 1 QL
release 24 hour 150 mg
(generic for
tramadol hcl er oral tablet 2 Ultram
extended release 24 hour ER); QL
tramadol hcl oral tablet
100 mgE QL
tramadol hcl oral tablet
50 mg1
tramadol-acetaminophen 1 QL
TREZIX 4 QL
TYLENOL WITH
CODEINE #3 ORAL 4
TABLET 300-30 MG
ULTRACET 4 QL
ULTRAM 4
VANATOL LQ 2 PA; QL
VANATOL S 2 PA; QL
VTOL LQ 2 PA; QL
XTAMPZA ER 2 PA; QL
ZEBUTAL 4 QL
ZILACAINE PATCH 3
ZOHYDRO ER 4 PA; ST; QL
8
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ZTLIDO E PA; QL
Analgesics - Drugs for
Pain and Inflammation
ARTHROTEC 3
CELEBREX E QL
celecoxib oral 2 QL
DAYPRO 4
DICLOFENAC
EPOLAMINEE
diclofenac potassium 1
diclofenac sodium er 1
diclofenac sodium oral 1
diclofenac sodium
transdermal gel 1 %2
diclofenac sodium
transdermal solutionE
diclofenac-misoprostol 3
diflunisal oral 1
DUEXIS E QL
EC-NAPROSYN 3
ec-naproxen 1
etodolac 1
etodolac er 1
FELDENE 4
fenoprofen calcium oral E
fenortho E
FLECTOR E
flurbiprofen oral 1
ibu 1
ibuprofen oral
suspensionE
ibuprofen oral tablet 400
mg, 600 mg, 800 mg1
INDOCIN 3
indomethacin er 1
INDOMETHACIN ORAL
CAPSULE 20 MGE
indomethacin oral
capsule 25 mg, 50 mg1
ketoprofen er E ST; QL
ketoprofen oral capsule
25 mgE ST; QL
ketorolac tromethamine
oral1
LODINE E
meclofenamate sodium
oral1
mefenamic acid oral 3
meloxicam oral 1
MOBIC 4
nabumetone oral 1
NALFON E
NAPRELAN E
NAPROSYN ORAL
SUSPENSION4 PA
naproxen dr 1
naproxen oral
suspension1 PA
naproxen oral tablet 1
naproxen sodium er E
naproxen sodium oral
tablet 275 mg, 550 mg1
naproxen-esomeprazole E QL
oxaprozin 1
PENNSAID E
piroxicam oral 1
QMIIZ ODT E
RELAFEN DS E
salsalate oral 1
SPRIX 4 ST; QL
sulindac oral 1
TIVORBEX E
tolmetin sodium 2
VIMOVO E QL
9
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
VIVLODEX E QL
ZIPSOR E
ZORVOLEX E
Anti-Addiction /
Substance Abuse
Treatment Agents
acamprosate calcium 1
ANTABUSE 4
BUNAVAIL E PA; QL
buprenorphine hcl
sublingual1 QL
buprenorphine hcl-
naloxone hcl2 QL
bupropion hcl er
(smoking det)1 H
CHANTIX 4 PA; H
CHANTIX CONTINUING
MONTH PAK4 PA; H
CHANTIX STARTING
MONTH PAK4 PA; H
disulfiram oral 1
EVZIO E PA; QL
LUCEMYRA 4 PA; QL
naloxone hcl injection
solution1
NALOXONE HCL
INJECTION SOLUTION E PA; QL
AUTO-INJECTOR
naloxone hcl injection
solution cartridge1
naloxone hcl injection
solution prefilled syringe1
naltrexone hcl oral 1
NARCAN 2 QL
NICOTROL 4 PA; H
NICOTROL NS 4 PA; H
SUBOXONE E PA; QL
ZUBSOLV 2 QL
Antibacterials - Drugs
for Infections
ACTICLATE E
AEMCOLO E QL
ALCOHOL PREP PADS
EXTERNAL 70 %3
ALTABAX 3 QL
amoxicillin 1
amoxicillin-potassium
clavulanate erE
amoxicillin-potassium
clavulanate oral1
ampicillin 1
ARIKAYCE 4 PA; QL; SP
arzol silver nit applicators 1
AUGMENTIN E
AUGMENTIN ES-600 E
avidoxy 1
AVIDOXY DK 3
azithromycin oral 1
BACTRIM 4
BACTRIM DS 4
BAXDELA ORAL 3
BENZALKONIUM
CHLORIDE EXTERNAL 2
SOLUTION
benzalkonium chloride
external solution 50 %1
cefaclor 1
cefaclor er 1
cefadroxil 1
cefdinir 1
cefditoren pivoxil 1
cefixime 3
cefpodoxime proxetil 1
cefprozil 1
cefuroxime axetil 1
10
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
CENTANY 4 QL
CENTANY AT E
cephalexin 1
CIPRO ORAL
SUSPENSION 3
RECONSTITUTED
CIPRO ORAL TABLET 4
ciprofloxacin hcl oral 1
clarithromycin er 2
clarithromycin oral
suspension reconstituted2
clarithromycin oral tablet 1
CLEOCIN ORAL
CAPSULE 150 MG, 300 4
MG
CLEOCIN ORAL
CAPSULE 75 MG2
CLEOCIN ORAL
SOLUTION 4
RECONSTITUTED
CLEOCIN VAGINAL
CREAM4
CLEOCIN VAGINAL
SUPPOSITORY2
clindamycin hcl oral 1
clindamycin palmitate hcl 2
clindamycin phosphate
vaginal2
CLINDESSE 2
colistimethate sodium
(cba)1
COLY-MYCIN M 4
coremino E PA
demeclocycline hcl 1
dicloxacillin sodium 1
DIFICID 3 QL
DORYX E
DORYX MPC E
doxycycline hyclate oral
capsule2
doxycycline hyclate oral
tablet 100 mg2
doxycycline hyclate oral
tablet 150 mg, 50 mg, 75 E
mg
doxycycline hyclate oral
tablet 20 mg1
doxycycline hyclate oral
tablet delayed releaseE
doxycycline monohydrate
oral capsule 100 mg, 50 1
mg
doxycycline monohydrate
oral capsule 150 mg, 75 E
mg
doxycycline monohydrate
oral suspension 3
reconstituted
doxycycline monohydrate
oral tablet1
E.E.S. 400 E
E.E.S. GRANULES 3
ERYPED 200 3
ERYPED 400 4
ERY-TAB 4
ERYTHROCIN
STEARATE2
erythromycin base oral
capsule delayed release 1
particles
erythromycin base oral
tablet1
erythromycin base oral
tablet delayed release3
erythromycin
ethylsuccinate oral
suspension reconstituted 1
200 mg/5ml
11
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
erythromycin
ethylsuccinate oral
suspension reconstituted 3
400 mg/5ml
erythromycin
ethylsuccinate oral tablet1
erythromycin oral 3
FEM PH 4
FIRVANQ 1
FLAGYL 4
gentamicin sulfate
external1 QL
GLUTARALDEHYDE
EXTERNAL3
grafco silver nit applicator 1
HIPREX 4
iodine tincture external
tincture 2 %1
KEFLEX 4
levofloxacin oral 1
linezolid oral 2 QL
MACROBID 4
MACRODANTIN 4
mafenide acetate
external3
methenamine hippurate 1
methenamine mandelate
oral1
metronidazole oral 1
metronidazole vaginal 2
MINOCIN ORAL
CAPSULE 50 MGE
MINOCYCLINE HCL ER
ORAL CAPSULE
EXTENDED RELEASE E PA
24 HOUR
minocycline hcl er oral
tablet extended release
24 hour 105 mg, 115 mg, E PA
55 mg, 65 mg, 80 mg
minocycline hcl er oral
tablet extended release
24 hour 135 mg, 45 mg, E PA
90 mg
minocycline hcl oral
capsule1
minocycline hcl oral
tabletE
MINOLIRA E PA
mondoxyne nl oral
capsule 100 mg1
mondoxyne nl oral
capsule 75 mgE
MONUROL 3
MORGIDOX
COMBINATIONE
morgidox oral 2
moxifloxacin hcl oral 3
mupirocin calcium 3 QL
mupirocin external 1 QL
neomycin sulfate oral 1
NEO-SYNALAR
EXTERNAL KITE
nitrofurantoin 1
nitrofurantoin
macrocrystal oral1
nitrofurantoin
monohydrate 1
macrocrystals
NUTRIDOX 3
NUVESSA E
NUZYRA ORAL 4 QL
ofloxacin oral 1
paromomycin sulfate oral 1
penicillin v potassium 1
PRIMSOL 3
SEYSARA E
SILVADENE 4
silver nitrate external 1
12
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
silver sulfadiazine
external1
SIVEXTRO ORAL 3 QL
SOLODYN E PA
SOLOSEC 4 ST; QL
SPECTRACEF ORAL
TABLET 400 MG4
ssd 1
sulfadiazine oral 1
sulfamethoxazole-
trimethoprim oral1
SULFAMYLON
EXTERNAL CREAM3
SULFAMYLON
EXTERNAL PACKET4
sulfatrim pediatric 1
SUPRAX 4
TARGADOX E
tetracycline hcl oral 3
tinidazole oral 3
trimethoprim oral 1
VANCOCIN 4 QL
VANCOCIN HCL 4 QL
vancomycin hcl oral
capsule1 QL
vancomycin hcl oral
solution reconstituted3
vandazole 2
VIBRAMYCIN ORAL
CAPSULE4
VIBRAMYCIN ORAL
SUSPENSION 4
RECONSTITUTED
VIBRAMYCIN ORAL
SYRUP3
XENLETA ORAL 3
XEPI 3 QL
XIFAXAN 3 PA; QL
XIMINO E PA
ZITHROMAX ORAL 4
ZITHROMAX TRI-PAK 4
ZITHROMAX Z-PAK 4
ZYVOX ORAL
SUSPENSION 4 QL
RECONSTITUTED
ZYVOX ORAL TABLET E QL
Anticoagulants - Drugs
to Treat or Prevent
Blood Clots
ARIXTRA 4 QL
COUMADIN ORAL
TABLET 1 MG, 2.5 MG, 3
5 MG
ELIQUIS 2 QL
ELIQUIS DVT/PE
STARTER PACK2 QL
enoxaparin sodium 2 QL
fondaparinux sodium 2 QL
FRAGMIN
SUBCUTANEOUS
SOLUTION 10000
UNIT/ML, 12500
UNIT/0.5ML, 15000
UNIT/0.6ML, 18000 4 QL
UNT/0.72ML, 2500
UNIT/0.2ML, 5000
UNIT/0.2ML, 7500
UNIT/0.3ML
FRAGMIN
SUBCUTANEOUS
SOLUTION 95000 4
UNIT/3.8ML
heparin sodium (porcine) 1
heparin sodium (porcine)
pf1
jantoven 1
LOVENOX E QL
PRADAXA 2 QL
SAVAYSA 4 QL
13
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
warfarin sodium oral 1
XARELTO 2 QL
XARELTO STARTER
PACK2 QL
Anticonvulsants -
Drugs for Seizures
APTIOM 3 PA
BANZEL ORAL
SUSPENSION3
BANZEL ORAL TABLET 3 PA
BRIVIACT ORAL
SOLUTION4 PA
BRIVIACT ORAL
TABLET3 PA
carbamazepine er oral
capsule extended 2
release 12 hour
carbamazepine er oral
tablet extended release 3
12 hour
carbamazepine oral 1
CARBATROL 4
CELONTIN 2
clobazam oral
suspension3 PA
clobazam oral tablet 2 PA
DEPAKOTE 4 PA
DEPAKOTE ER 4 PA; ST
DEPAKOTE SPRINKLES 4 PA; ST
DIACOMIT 3 PA; SP
DIASTAT ACUDIAL 4 QL
DIASTAT PEDIATRIC 2 QL
diazepam rectal 1 QL
DILANTIN 3
DILANTIN INFATABS 3
divalproex sodium er 2
divalproex sodium oral
capsule delayed release 2
sprinkle
divalproex sodium oral
tablet delayed release1
EPIDIOLEX 3 PA; SP
epitol 1
ethosuximide oral 1
felbamate 1
FELBATOL 4 PA; ST
FYCOMPA ORAL
SUSPENSION4 PA
FYCOMPA ORAL
TABLET3 PA
gabapentin oral 1
GABITRIL 4
KEPPRA ORAL 4 PA; ST
KEPPRA XR 4 PA; ST
LAMICTAL 4 PA; ST
LAMICTAL ODT ORAL
KIT3 PA; ST
LAMICTAL ODT ORAL
TABLET DISPERSIBLE4 PA; ST
LAMICTAL STARTER 4 PA; ST
LAMICTAL XR 3 PA; ST
lamotrigine er 3 PA; ST
lamotrigine oral tablet 1
lamotrigine oral tablet
chewable1
lamotrigine oral tablet
dispersible3 PA; ST
lamotrigine starter kit-
blue1
lamotrigine starter kit-
green1
lamotrigine starter kit-
orange1
levetiracetam er 2
levetiracetam oral 1
MYSOLINE 2 PA; ST
NAYZILAM 3 PA; QL
14
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
NEURONTIN 4 PA; ST
ONFI 4 PA; ST
oxcarbazepine 1
OXTELLAR XR E PA; ST
PEGANONE 2
phenobarbital oral 1
PHENYTEK 4
phenytoin infatabs 1
phenytoin oral
suspension 125 mg/5ml1
phenytoin oral tablet
chewable1
phenytoin sodium
extended1
primidone oral 1
QUDEXY XR E PA; ST
roweepra 1
roweepra xr 2
SABRIL ORAL PACKET E PA; QL; SP
SABRIL ORAL TABLET 4 PA; QL; SP
SPRITAM E PA; ST
subvenite 1
subvenite starter kit-blue 1
subvenite starter kit-
green1
subvenite starter kit-
orange1
SYMPAZAN E PA
TEGRETOL 3
TEGRETOL-XR 4
tiagabine hcl 1
TOPAMAX 4 PA; ST
TOPAMAX SPRINKLE 4 PA; ST
topiramate er E PA; ST
topiramate oral 1
TRILEPTAL 4 PA; ST
TROKENDI XR E PA; ST
valproic acid oral 1
VALTOCO 10 MG DOSE 3 PA; QL
VALTOCO 15 MG DOSE 3 PA; QL
VALTOCO 20 MG DOSE 3 PA; QL
VALTOCO 5 MG DOSE 3 PA; QL
vigabatrin 2 PA; QL; SP
vigadrone 2 PA; QL; SP
VIMPAT ORAL 3 PA
ZARONTIN 4
ZONEGRAN 4 PA; ST
zonisamide oral 1
Antidementia Agents -
Drugs for Alzheimer's
Disease and Dementia
ARICEPT ORAL
TABLET 10 MG, 5 MG3
ARICEPT ORAL
TABLET 23 MGE
donepezil hcl oral tablet
10 mg, 5 mg1
donepezil hcl oral tablet
23 mgE
donepezil hcl oral tablet
dispersible1
EXELON E
galantamine
hydrobromide1
galantamine
hydrobromide er1
memantine hcl er E
memantine hcl oral
solution 2 mg/ml3
memantine hcl oral tablet 2
NAMENDA 4
NAMENDA TITRATION
PAK4
NAMENDA XR E
NAMENDA XR
TITRATION PACKE
15
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
NAMZARIC E
RAZADYNE 4
RAZADYNE ER 4
rivastigmine 3
rivastigmine tartrate 1
Antidepressants -
Drugs for Depression
amitriptyline hcl oral 1
amoxapine 1
ANAFRANIL E
APLENZIN E QL
BRISDELLE E QL
bupropion hcl er (sr) 1
bupropion hcl er (xl) oral
tablet extended release 1
24 hour 150 mg, 300 mg
BUPROPION HCL ER
(XL) ORAL TABLET
EXTENDED RELEASE E QL
24 HOUR 450 MG
bupropion hcl oral 1
CELEXA E
chlordiazepoxide-
amitriptyline1
citalopram hydrobromide 1
clomipramine hcl oral 4
CYMBALTA E QL
desipramine hcl oral 1
DESVENLAFAXINE ER E QL
desvenlafaxine succinate
er3 QL
doxepin hcl oral capsule 1
doxepin hcl oral
concentrate1
DRIZALMA SPRINKLE 4 PA; QL
duloxetine hcl oral
capsule delayed release
particles 20 mg, 30 mg, 2 QL
60 mg
duloxetine hcl oral
capsule delayed release E
particles 40 mg
EFFEXOR XR E
EMSAM 3
escitalopram oxalate oral
solution3
escitalopram oxalate oral
tablet1
FETZIMA 4 ST; QL
FETZIMA TITRATION 4 ST; QL
fluoxetine hcl (pmdd) E
fluoxetine hcl oral
capsule1
fluoxetine hcl oral
capsule delayed release3 QL
fluoxetine hcl oral
solution1
fluoxetine hcl oral tablet
10 mg3 QL
fluoxetine hcl oral tablet
20 mg3
fluoxetine hcl oral tablet
60 mgE
fluvoxamine maleate 1
fluvoxamine maleate er 3 QL
FORFIVO XL E QL
imipramine hcl oral 1
imipramine pamoate 1
LEXAPRO E
maprotiline hcl 1
MARPLAN 3
mirtazapine oral 1
NARDIL 4
nefazodone hcl 1
NORPRAMIN 4
nortriptyline hcl oral 1
olanzapine-fluoxetine hcl 2 QL
16
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
PAMELOR 4
PARNATE 4
paroxetine hcl 1
paroxetine hcl er 3 QL
paroxetine mesylate E QL
PAXIL CR 4 QL
PAXIL ORAL
SUSPENSION3
PAXIL ORAL TABLET 4
perphenazine-
amitriptyline1
PEXEVA E QL
phenelzine sulfate oral 1
PRISTIQ E QL
protriptyline hcl 1
PROZAC E
REMERON 4
REMERON SOLTAB 4
SARAFEM E
sertraline hcl oral 1
SPRAVATO (56 MG
DOSE)4 PA; QL
SPRAVATO (84 MG
DOSE)4 PA; QL
SYMBYAX 4 QL
tranylcypromine sulfate 1
trazodone hcl oral 1
trimipramine maleate oral 3
TRINTELLIX 4 ST; QL
venlafaxine hcl 1
venlafaxine hcl er oral
capsule extended 1
release 24 hour
venlafaxine hcl er oral
tablet extended release E QL
24 hour
VIIBRYD 4 QL
VIIBRYD STARTER
PACK4
WELLBUTRIN SR E
WELLBUTRIN XL E
ZOLOFT E
Antiemetics - Drugs for
Nausea and Vomiting
AKYNZEO ORAL 4 QL
ANZEMET 3 QL
aprepitant 2 QL
BONJESTA E PA
compro 1
DICLEGIS E PA
doxylamine-pyridoxine E PA
dronabinol 1
EMEND ORAL
CAPSULE 80 MG4 QL
EMEND ORAL
SUSPENSION 2 QL
RECONSTITUTED
EMEND TRI-PACK 4 QL
granisetron hcl oral 2
MARINOL 4
meclizine hcl oral tablet E
metoclopramide hcl oral
solution 5 mg/5ml1
metoclopramide hcl oral
tablet1
metoclopramide hcl oral
tablet dispersibleE
ondansetron hcl oral 1
ondansetron odt 1
perphenazine oral 1
prochlorperazine 1
prochlorperazine maleate
oral1
promethazine hcl oral 1
promethazine hcl rectal 1
17
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
promethegan 1
REGLAN 4
SANCUSO E QL
scopolamine 3
SYNDROS 4 PA; QL
TIGAN ORAL 4
TRANSDERM-SCOP
(1.5 MG)4
trimethobenzamide hcl
oral1
VARUBI (180 MG DOSE) 2 QL
ZOFRAN 4
ZUPLENZ E QL
Antifungals - Drugs for
Fungal Infections
ANCOBON ORAL
CAPSULE 250 MG4
ANCOBON ORAL
CAPSULE 500 MG3
BIO-STATIN ORAL
CAPSULE3
bio-statin oral powder 1
ciclodan 1
ciclopirox external gel 1
ciclopirox external
shampoo2
ciclopirox external
solution1
ciclopirox olamine
external1
ciclopirox treatment E
clotrimazole external E
clotrimazole mouth/throat 1
clotrimazole mouth/throat
lozenge 10 mg1
CRESEMBA ORAL 3
dermazene 1
DIFLUCAN ORAL
SUSPENSION 4
RECONSTITUTED
DIFLUCAN ORAL
TABLET 100 MG, 150 4
MG, 200 MG
DIFLUCAN ORAL
TABLET 50 MG3
econazole nitrate
external2 QL
ECOZA E
ERTACZO E
EXELDERM 3
exoderm external lotion 1
EXTINA 4 QL
fluconazole oral 1
flucytosine oral 1
griseofulvin microsize
oral1
griseofulvin
ultramicrosize1
GYNAZOLE-1 3
hydrocortisone-
iodoquinol1
itraconazole oral capsule 1 QL
itraconazole oral solution 2 QL
JUBLIA 4 PA; ST; QL
KERYDIN 4 PA; ST; QL
ketoconazole external
cream1 QL
ketoconazole external
foam3 QL
ketoconazole external
shampoo1
ketoconazole oral 1
ketodan external foam 3 QL
LOPROX EXTERNAL
CREAME
18
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
LOPROX EXTERNAL
KIT 0.77 %E
LOPROX EXTERNAL
SHAMPOOE
LOPROX EXTERNAL
SUSPENSIONE
LULICONAZOLE E
LUZU E
MENTAX 3
miconazole 3 vaginal
suppository1
MICONAZOLE-ZINC
OXIDE-PETROLATE
naftifine hcl E
NAFTIN E
NOXAFIL ORAL
SUSPENSION2
NOXAFIL ORAL TABLET
DELAYED RELEASEE
nyamyc 1 QL
nystatin external 1 QL
nystatin mouth/throat 1
nystatin oral 1
nystatin-triamcinolone E
nystop 1 QL
ORAVIG 3
oxiconazole nitrate 3 PA; QL
OXISTAT EXTERNAL
CREAM4 PA; QL
OXISTAT EXTERNAL
LOTIONE
PEDIZOLPAK E
posaconazole 2
SPORANOX 4 QL
SPORANOX PULSEPAK 4 QL
SULCONAZOLE
NITRATE3
terbinafine hcl oral 1 QL
terconazole 1
TOLSURA E
VFEND ORAL
SUSPENSION 4
RECONSTITUTED
VFEND ORAL TABLET
200 MG4 QL
VFEND ORAL TABLET
50 MG3 QL
voriconazole oral
suspension reconstituted1
voriconazole oral tablet 1 QL
VUSION E
XOLEGEL 3
XOLEGEL COREPAK 3
XOLEGEL DUO/HEAD &
SHOULDERS3
XOLEGEL DUO/XOLEX 3
Antigout Agents -
Drugs for Gout
allopurinol oral 1
COLCHICINE ORAL
CAPSULEE
colchicine oral tablet E
colchicine-probenecid 1
COLCRYS E
febuxostat 3 ST; QL
GLOPERBA 4 PA
MITIGARE 2
probenecid 1
ULORIC E ST; QL
ZYLOPRIM 4
Antimigraine Agents -
Drugs for Migraines
AIMOVIG 2 PA; ST; QL
AJOVY E PA; ST; QL
almotriptan malate 3 QL
AMERGE 4 QL
19
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
CAFERGOT 4
CAMBIA E QL
D.H.E. 45 E
dihydroergotamine
mesylate injection1
dihydroergotamine
mesylate nasal4 PA; QL
eletriptan hydrobromide 2 QL
EMGALITY 2 PA; ST; QL
EMGALITY (300 MG
DOSE)2 PA; ST; QL
ERGOMAR 4 PA; QL
ergotamine-caffeine 3
FROVA 4 QL
frovatriptan succinate 3 QL
IMITREX NASAL 4 QL
IMITREX ORAL E QL
IMITREX STATDOSE
REFILLE QL
IMITREX STATDOSE
SYSTEME QL
IMITREX
SUBCUTANEOUSE QL
MAXALT E QL
MAXALT-MLT E QL
MIGERGOT 3
MIGRANAL E PA; QL
naratriptan hcl 1 QL
NURTEC E PA; QL
ONZETRA XSAIL E QL
RELPAX E QL
REYVOW E PA; QL
rizatriptan benzoate 1 QL
sumatriptan nasal 2 QL
sumatriptan succinate
oral1 QL
sumatriptan succinate
refill1 QL
sumatriptan succinate
subcutaneous1 QL
sumatriptan-naproxen
sodiumE QL
TOSYMRA E QL
TREXIMET E QL
UBRELVY E PA; QL
ZEMBRACE
SYMTOUCHE QL
zolmitriptan oral tablet 2 QL
zolmitriptan oral tablet
dispersible3 QL
ZOMIG NASAL
SOLUTION 2.5 MG3 ST; QL
ZOMIG NASAL
SOLUTION 5 MG4 ST; QL
ZOMIG ORAL 4 QL
ZOMIG ZMT 4 QL
Antimyasthenic Agents
- Drugs to Treat
Myasthenia Gravis
GUANIDINE HCL 3
MESTINON ORAL
SOLUTION4
MESTINON ORAL
TABLET4
MESTINON ORAL
TABLET EXTENDED 3
RELEASE
pyridostigmine bromide
er1
pyridostigmine bromide
oral solution3
pyridostigmine bromide
oral tablet 30 mgE
pyridostigmine bromide
oral tablet 60 mg1
20
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
Antimycobacterials -
Drugs to Treat
Infections
cycloserine oral 1
dapsone oral 2
ethambutol hcl oral 1
isoniazid oral 1
MYAMBUTOL 4
MYCOBUTIN 4
PASER 3
PRETOMANID 4
PRIFTIN 2
pyrazinamide oral 1
rifabutin 1
RIFADIN ORAL
CAPSULE 150 MG3
RIFADIN ORAL
CAPSULE 300 MG4
RIFAMATE ORAL
CAPSULE 150-300 MG3
rifampin oral 1
RIFATER ORAL TABLET
50-120-300 MG2
SIRTURO ORAL
TABLET 100 MG2
TRECATOR 2
Antineoplastics - Drugs
for Cancer
abiraterone acetate E PA; QL; SP
AFINITOR DISPERZ 2 PA; QL; SP
AFINITOR ORAL
TABLET 10 MG2 PA; QL; SP
AFINITOR ORAL
TABLET 2.5 MG, 5 MG, 4 PA; QL; SP
7.5 MG
ALECENSA 2 PA; QL; SP
ALKERAN ORAL 4 SP
ALUNBRIG 2 PA; QL; SP
anastrozole oral 1
ARIMIDEX E
AROMASIN 4
AYVAKIT 4 PA; QL; SP
BALVERSA 2 PA; QL; SP
bexarotene E SP
bicalutamide 1
BOSULIF2
PA; ST;
QL; SP
BRAFTOVI4
PA; ST;
QL; SP
BRUKINSA 2 PA; QL
CABOMETYX 2 PA; QL; SP
CALQUENCE 2 PA; QL; SP
capecitabine E QL; SP
CAPRELSA 2 PA; QL; SP
CASODEX 4
COMETRIQ (100 MG
DAILY DOSE) ORAL KIT 2 PA; QL; SP
1 X 80 & 1 X 20 MG
COMETRIQ (140 MG
DAILY DOSE) ORAL KIT 2 PA; QL; SP
1 X 80 & 3 X 20 MG
COMETRIQ (60 MG
DAILY DOSE)2 PA; QL; SP
COPIKTRA 4 PA; QL; SP
COTELLIC 2 PA; QL; SP
cyclophosphamide oral 2
DAURISMO 2 PA; QL; SP
DROXIA 2
EMCYT 2
ERIVEDGE 2 PA; QL; SP
ERLEADA 2 PA; QL; SP
erlotinib hcl 2 PA; QL; SP
etoposide oral 1 SP
everolimus oral tablet 2.5
mg, 5 mg, 7.5 mg2 PA; QL; SP
exemestane 2
21
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
FARESTON 4
FARYDAK 2 PA; QL; SP
FEMARA E
flutamide 1
GILOTRIF 3 PA; QL; SP
GLEEVEC E PA; QL; SP
GLEOSTINE 2 SP
HYCAMTIN ORAL 2 PA; QL; SP
HYDREA 4
hydroxyurea oral 1
IBRANCE 2 PA; QL; SP
ICLUSIG 3 PA; QL; SP
IDHIFA 2 PA; QL; SP
imatinib mesylate 1 PA; QL; SP
IMBRUVICA 2 PA; QL; SP
INLYTA 3 PA; QL; SP
INREBIC4
PA; ST;
QL; SP
IRESSA 3 PA; QL; SP
JAKAFI 2 PA; QL; SP
KISQALI (200 MG
DOSE)4
PA; ST;
QL; SP
KISQALI (400 MG
DOSE)4
PA; ST;
QL; SP
KISQALI (600 MG
DOSE)4
PA; ST;
QL; SP
KISQALI FEMARA (400
MG DOSE)4 PA; ST; SP
KISQALI FEMARA (600
MG DOSE)4 PA; ST; SP
KISQALI FEMARA(200
MG DOSE)4
PA; ST;
QL; SP
LENVIMA (10 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (12 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (14 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (18 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (20 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (24 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (4 MG DAILY
DOSE)3 PA; QL; SP
LENVIMA (8 MG DAILY
DOSE)3 PA; QL; SP
letrozole oral 1
leucovorin calcium oral 1
LEUKERAN 2
LONSURF 2 PA; QL; SP
LORBRENA 3 PA; SP
LYNPARZA 2 PA; QL; SP
LYSODREN 2
MATULANE 2 SP
MEKINIST 3 PA; QL; SP
MEKTOVI4
PA; ST;
QL; SP
melphalan 2 SP
mercaptopurine oral 1
MESNEX ORAL 3
MYLERAN 2
NERLYNX 2 PA; QL; SP
NEXAVAR 2 PA; QL; SP
nilutamide 3 SP
NINLARO 2 PA; QL; SP
NUBEQA 2 PA; QL; SP
ODOMZO 2 PA; QL; SP
PANRETIN 3
PIQRAY (200 MG DAILY
DOSE)2 PA; QL; SP
PIQRAY (250 MG DAILY
DOSE)2 PA; QL; SP
PIQRAY (300 MG DAILY
DOSE)2 PA; QL; SP
22
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
POMALYST 3 PA; QL; SP
PURIXAN 4 PA; SP
REVLIMID 2 PA; QL; SP
ROZLYTREK 2 PA; QL; SP
RUBRACA3
PA; ST;
QL; SP
RYDAPT 2 PA; QL; SP
SIKLOS E
SOLTAMOX E
SPRYCEL4
PA; ST;
QL; SP
STIVARGA 2 PA; QL; SP
SUTENT 2 PA; QL; SP
SYNRIBO 2 PA; QL; SP
TABLOID 2 SP
TAFINLAR 3 PA; QL; SP
TAGRISSO 3 PA; QL; SP
TALZENNA4
PA; ST;
QL; SP
tamoxifen citrate oral
tablet 10 mg1
tamoxifen citrate oral
tablet 20 mg1 H-PA
TARCEVA 4 PA; QL; SP
TARGRETIN EXTERNAL 3 QL; SP
TARGRETIN ORAL 2 SP
TASIGNA2
PA; ST;
QL; SP
TAZVERIK 4 PA; QL
TEMODAR ORAL 4 PA; SP
temozolomide 1 PA; SP
THALOMID 2 PA; QL; SP
TIBSOVO 2 PA; QL; SP
toremifene citrate 2
tretinoin oral 2 QL; SP
TURALIO 2 PA; QL; SP
TYKERB 2 PA; QL; SP
VALCHLOR 2 PA; QL; SP
VENCLEXTA 2 PA; QL; SP
VENCLEXTA STARTING
PACK2 PA; QL; SP
VERZENIO 2 PA; QL; SP
VITRAKVI 2 PA; QL; SP
VIZIMPRO 3 PA; QL; SP
VOTRIENT 2 PA; QL; SP
XALKORI 2 PA; QL; SP
XELODA 1 QL; SP
XOSPATA 3 PA; QL; SP
XPOVIO (100 MG ONCE
WEEKLY)4 PA; QL; SP
XPOVIO (60 MG ONCE
WEEKLY)4 PA; QL; SP
XPOVIO (80 MG ONCE
WEEKLY)4 PA; QL; SP
XPOVIO (80 MG TWICE
WEEKLY)4 PA; QL; SP
XTANDI4
PA; ST;
QL; SP
YONSAE
PA; ST;
QL; SP
ZEJULA 2 PA; QL; SP
ZELBORAF 2 PA; QL; SP
ZOLINZA 2 QL; SP
ZYDELIG 4 PA; QL; SP
ZYKADIA 2 PA; QL; SP
ZYTIGA ORAL TABLET
250 MG2 PA; QL; SP
ZYTIGA ORAL TABLET
500 MG2 PA; SP
Antiparasitics - Drugs
for Parasitic Infections
albendazole oral 3 PA; QL
ALBENZA 4 PA; QL
ALINIA 2 QL
ARAKODA 4 QL
23
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
atovaquone oral 2
atovaquone-proguanil hcl 2
BENZNIDAZOLE 2 PA; QL
BILTRICIDE 4
chloroquine phosphate
oral1
COARTEM 2
crotan 2
DARAPRIM 4 PA; SP
EGATEN 3
ELIMITE 4
EMVERM 4 PA; QL
hydroxychloroquine
sulfate oral1
IMPAVIDO 2 PA; QL
ivermectin oral 1
KRINTAFEL 1 QL
lindane 1 QL
MALARONE 4
malathion 1
mefloquine hcl 1
MEPRON E
NATROBA E
NEBUPENT 4
OVIDE 4
pentamidine isethionate
inhalation2
permethrin external 1
PLAQUENIL E
praziquantel oral 2
primaquine phosphate 1
pyrimethamine oral 2 PA; SP
QUALAQUIN 4
quinine sulfate oral 1
SKLICE 4 QL
spinosad 3
STROMECTOL 4
SULFURATED LIME 3
Antiparkinson Agents -
Drugs for Parkinson's
Disease
amantadine hcl oral 1
APOKYN 2 SP
AZILECT E
benztropine mesylate
oral1
bromocriptine mesylate
oral1
carbidopa oral 1
carbidopa-levodopa 1
carbidopa-levodopa er 1
carbidopa-levodopa-
entacapone1
COMTAN 4
DUOPA 4 PA
entacapone 1
GOCOVRI E QL
INBRIJA 3 PA; QL; SP
LODOSYN E
MIRAPEX 4
MIRAPEX ER E
NEUPRO 3
NOURIANZ E PA; QL
OSMOLEX ER ORAL
TABLET EXTENDED E
RELEASE 24 HOUR
PARLODEL E
pramipexole
dihydrochloride1
pramipexole
dihydrochloride erE
rasagiline mesylate oral 3
REQUIP XL E
ropinirole hcl 1
24
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ropinirole hcl er E
RYTARY E
selegiline hcl oral 1
SINEMET 4
STALEVO 100 4
STALEVO 125 4
STALEVO 150 4
STALEVO 200 4
STALEVO 50 4
STALEVO 75 4
TASMAR E
tolcapone 2
trihexyphenidyl hcl 1
XADAGO E
ZELAPAR 3
Antiplatelets - Drugs
for Heart Attack and
Stroke Prevention
AGGRENOX 4
aspirin-dipyridamole er 3
ASPIRIN-OMEPRAZOLE E
BRILINTA 4 QL
cilostazol 1
clopidogrel bisulfate oral 1
dipyridamole oral 1
DURLAZA E QL
EFFIENT E QL
PLAVIX E
prasugrel hcl 3 QL
YOSPRALA E
ZONTIVITY 4 QL
Antipsychotics - Drugs
for Mood Disorders
ABILIFY E QL
aripiprazole oral solution 3
aripiprazole oral tablet 2 QL
aripiprazole oral tablet
dispersible2 QL
CAPLYTA 4 PA; ST; QL
chlorpromazine hcl oral 1
clozapine 1
CLOZARIL 4
FANAPT 4 QL
FANAPT TITRATION
PACK3 QL
fluphenazine hcl oral 1
GEODON ORAL E QL
haloperidol lactate oral 1
haloperidol oral 1
INVEGA E QL
LATUDA 4 QL
loxapine succinate 1
molindone hcl 3
NUPLAZID 4 PA
olanzapine oral tablet 1 QL
olanzapine oral tablet
dispersible2 QL
paliperidone er 3 QL
pimozide 2
quetiapine fumarate 1
quetiapine fumarate er 3 QL
REXULTI 4 PA; ST; QL
RISPERDAL E
risperidone 1
SAPHRIS 3 QL
SECUADO E QL
SEROQUEL E
SEROQUEL XR E QL
thioridazine hcl oral 1
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ E
25
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
VRAYLAR 4 ST; QL
ziprasidone hcl 2 QL
ZYPREXA ORAL E QL
ZYPREXA ZYDIS E QL
Antivirals - Drugs for
Viral Infections
abacavir sulfate 1 SP
abacavir sulfate-
lamivudine2 QL; SP
abacavir-lamivudine-
zidovudine1 SP
acyclovir external cream E QL
acyclovir external
ointment4 PA; ST; QL
acyclovir oral 1
adefovir dipivoxil 2 SP
APTIVUS ORAL
CAPSULE2 SP
APTIVUS ORAL
SOLUTION3 SP
atazanavir sulfate 2 SP
ATRIPLA E ST; QL; SP
BARACLUDE ORAL
SOLUTION2 SP
BARACLUDE ORAL
TABLETE SP
BIKTARVY 4 QL; SP
CIMDUO 2 QL; SP
COMBIVIR 4 SP
COMPLERA 4 QL; SP
CRIXIVAN 2 SP
DELSTRIGO 2 QL; SP
DENAVIR E
DESCOVY E ST; QL; SP
didanosine 1 SP
DOVATO 2 QL; SP
EDURANT 2 SP
efavirenz 2 SP
EMTRIVA 2 SP
entecavir 1 SP
EPCLUSA 2 PA; QL; SP
EPIVIR 4 SP
EPIVIR HBV ORAL
SOLUTION2 SP
EPIVIR HBV ORAL
TABLET4 SP
EPZICOM E QL; SP
EVOTAZ 2 SP
famciclovir oral tablet 125
mg, 500 mg2
famciclovir oral tablet 250
mg2 QL
fosamprenavir calcium 2 SP
FUZEON 2 SP
GENVOYA 4 QL; SP
HARVONI ORAL
PACKET3
HARVONI ORAL
TABLET2
PA; ST;
QL; SP
HEPSERA 4 SP
INTELENCE 2 SP
INTRON A 4 PA; SP
INVIRASE 2 SP
ISENTRESS 2 SP
ISENTRESS HD 2 SP
JULUCA 2 QL; SP
KALETRA ORAL
SOLUTION4 SP
KALETRA ORAL
TABLET2 SP
lamivudine 1 SP
lamivudine-zidovudine 1 SP
LEDIPASVIR-
SOFOSBUVIR2
PA; ST;
QL; SP
LEXIVA ORAL
SUSPENSION2 SP
26
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
LEXIVA ORAL TABLET 4 SP
lopinavir-ritonavir 2 SP
MAVYRET 2 PA; QL; SP
nevirapine 1 SP
nevirapine er E SP
NORVIR ORAL PACKET 2 SP
NORVIR ORAL
SOLUTION2 SP
NORVIR ORAL TABLET E SP
ODEFSEY 4 QL; SP
oseltamivir phosphate
oral capsule2
oseltamivir phosphate
oral suspension 2 QL
reconstituted
PEGASYS 2 PA; QL; SP
PEGASYS PROCLICK 2 PA; QL; SP
PEGINTRON 4 PA; QL; SP
PIFELTRO 3 SP
PREVYMIS ORAL 2 PA
PREZCOBIX 2 SP
PREZISTA 2 SP
RELENZA DISKHALER 3
RETROVIR ORAL
CAPSULE4 SP
RETROVIR ORAL
SYRUP3 SP
REYATAZ ORAL
CAPSULEE SP
REYATAZ ORAL
PACKET2 SP
ribavirin inhalation 3
ribavirin oral 1
rimantadine hcl 1
ritonavir 2 SP
SELZENTRY 2 PA; SP
SITAVIG E QL
SOFOSBUVIR-
VELPATASVIR2 PA; QL; SP
SOVALDI ORAL
PACKET3 PA; ST
SOVALDI ORAL
TABLET 200 MG4 PA; ST; QL
SOVALDI ORAL
TABLET 400 MG4
PA; ST;
QL; SP
stavudine 1 SP
STRIBILD 4 QL; SP
SUSTIVA 4 SP
SYLATRON
SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 2 PA; QL; SP
MCG
SYMFI 2 QL; SP
SYMFI LO 2 QL; SP
SYMTUZA E QL; SP
TAMIFLU ORAL
CAPSULEE
TAMIFLU ORAL
SUSPENSION E QL
RECONSTITUTED
TEMIXYS E QL; SP
tenofovir disoproxil
fumarate2 SP
TIVICAY 3 SP
TRIUMEQ 2 QL; SP
TRIZIVIR 4 SP
TRUVADA 4 QL; SP
TYBOST 2 SP
valacyclovir hcl oral 1 QL
VALCYTE ORAL
SOLUTION 4
RECONSTITUTED
VALCYTE ORAL
TABLETE QL
valganciclovir hcl oral
solution reconstituted1
27
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
valganciclovir hcl oral
tablet1 QL
VALTREX E QL
VEMLIDY 4 ST; SP
VIEKIRA PAK4
PA; ST;
QL; SP
VIRACEPT 2 SP
VIRAMUNE ORAL
SUSPENSION4 SP
VIRAMUNE ORAL
TABLETE SP
VIRAMUNE XR E SP
VIRAZOLE 4
VIREAD ORAL
POWDER3 SP
VIREAD ORAL TABLET
150 MG, 200 MG, 250 2 SP
MG
VIREAD ORAL TABLET
300 MGE SP
VOSEVI 2 PA; QL; SP
XERESE E
XOFLUZA (40 MG
DOSE)3 QL
XOFLUZA (80 MG
DOSE)3 QL
ZEPATIER 2 PA; QL; SP
ZIAGEN 4 SP
zidovudine 1 SP
ZOVIRAX EXTERNAL
CREAME QL
ZOVIRAX EXTERNAL
OINTMENTE PA; ST; QL
ZOVIRAX ORAL
SUSPENSION4
Anxiolytics - Drugs for
Anxiety
alprazolam er 1
alprazolam intensol 1
alprazolam oral 1
alprazolam xr 1
ATIVAN ORAL E
buspirone hcl oral 1
chlordiazepoxide hcl 1
clonazepam oral 1
clorazepate dipotassium 1
diazepam intensol 1
diazepam oral 1
DORAL 3
estazolam 1
HALCION 4
hydroxyzine hcl oral 1
hydroxyzine pamoate
oral1
KLONOPIN E
lorazepam intensol 1
lorazepam oral
concentrate 2 mg/ml1
lorazepam oral tablet 1
meprobamate 1
midazolam hcl oral 1
oxazepam 1
quazepam 1
TRANXENE-T 4
triazolam 1
VALIUM E
VISTARIL 4
XANAX E
XANAX XR E
Bipolar Agents - Drugs
for Mood Disorders
EQUETRO 3
lithium 1
lithium carbonate er 1
lithium carbonate oral 1
28
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
LITHOBID 4
Cardiovascular Agents
- Drugs for Heart and
Circulation Conditions
ACCUPRIL 4
ACCURETIC 4
acebutolol hcl oral 1
acetazolamide er 1
acetazolamide oral 1
ADALAT CC ORAL
TABLET EXTENDED
RELEASE 24 HOUR 60 4
MG
ALDACTAZIDE ORAL
TABLET 25-25 MG4
ALDACTAZIDE ORAL
TABLET 50-50 MG2
ALDACTONE 4
aliskiren fumarate 3
ALTACE 4
ALTOPREV E
amiloride hcl oral 1
amiloride-
hydrochlorothiazide1
amiodarone hcl oral 1
amlodipine besylate oral 1
amlodipine besylate-
benazepril hcl1
amlodipine besylate-
valsartan2
amlodipine-atorvastatin
oral tablet 10-10 mg, 10-
20 mg, 10-40 mg, 10-80 E
mg, 5-10 mg, 5-20 mg, 5-
40 mg, 5-80 mg
amlodipine-atorvastatin
oral tablet 2.5-10 mg, E QL
2.5-20 mg, 2.5-40 mg
amlodipine-olmesartan E
amlodipine-valsartan-
hctzE
ANTARA E
ATACAND 4
ATACAND HCT 4
atenolol oral 1
atenolol-chlorthalidone 1
atorvastatin calcium oral
tablet 10 mg, 20 mg1 QL; H-PA
atorvastatin calcium oral
tablet 40 mg, 80 mg1 QL
AVALIDE 4
AVAPRO 4
AZOR E
benazepril hcl oral 1
benazepril-
hydrochlorothiazide1
BENICAR E
BENICAR HCT E
BETAPACE E
BETAPACE AF 4
betaxolol hcl oral 1
BIDIL 2
bisoprolol fumarate 1
bisoprolol-
hydrochlorothiazide1
bumetanide oral 1
BUMEX 3
BYSTOLIC 2
CADUET E
CALAN SR 4
candesartan cilexetil 3
candesartan cilexetil-hctz 3
captopril oral 1
captopril-
hydrochlorothiazide1
CARDIZEM E
29
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
CARDIZEM CD E
CARDIZEM LA E
CARDURA 4
CAROSPIR 4 PA
cartia xt 2
carvedilol 1
carvedilol phosphate er E
CATAPRES 4
CATAPRES-TTS-1 4
CATAPRES-TTS-2 4
CATAPRES-TTS-3 4
chlorothiazide oral 1
chlorthalidone 1
cholestyramine light 1
cholestyramine oral 1
clonidine 3 (Patch)
clonidine hcl oral 1
colesevelam hcl E
COLESTID FLAVORED
ORAL GRANULES3
COLESTID FLAVORED
ORAL PACKET4
COLESTID ORAL
GRANULES3
COLESTID ORAL
PACKET4
COLESTID ORAL
TABLET4
colestipol hcl 1
CONSENSI E QL
COREG 4
COREG CR E
CORGARD 4
CORLANOR 3 PA; QL
COZAAR 4
CRESTOR E QL
DEMSER 3
DIBENZYLINE E
digitek 1
digox 1
digoxin oral 1
DILATRATE-SR 3
diltiazem hcl er beads 2
diltiazem hcl er coated
beads2
diltiazem hcl er oral
capsule extended 1
release 12 hour
diltiazem hcl oral 1
dilt-xr 1
DIOVAN E
DIOVAN HCT E
disopyramide phosphate 1
DIURIL 2
dofetilide 2
doxazosin mesylate oral 1
DUTOPROL ORAL
TABLET EXTENDED
RELEASE 24 HOUR E QL
100-12.5 MG, 50-12.5
MG
DUTOPROL ORAL
TABLET EXTENDED
RELEASE 24 HOUR 25-E
12.5 MG
DYAZIDE 4
DYRENIUM 4
EDARBI 3
EDARBYCLOR 3
EDECRIN 4
enalapril maleate oral 1
enalapril-
hydrochlorothiazide1
ENTRESTO 4 PA; QL
EPANED 4 PA
30
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
eplerenone 2
ethacrynic acid 3
EXFORGE E
EXFORGE HCT E
EZALLOR SPRINKLE 3 PA
ezetimibe 2
ezetimibe-simvastatin 3
felodipine er 1
fenofibrate micronized E
fenofibrate oral capsule E
fenofibrate oral tablet 120
mg, 40 mg, 48 mgE
fenofibrate oral tablet 145
mg, 160 mg, 54 mg2
fenofibric acid E
FENOGLIDE E
FIBRICOR E
flecainide acetate 1
FLOLIPID 4 PA
fluvastatin sodium 1
fluvastatin sodium er 3 ST
fosinopril sodium 1
fosinopril sodium-hctz 1
furosemide oral 1
gemfibrozil oral 1
GONITRO E QL
guanfacine hcl 1
HEMANGEOL E
hydralazine hcl oral 1
hydrochlorothiazide oral 1
HYZAAR 4
indapamide 1
INDERAL LA E
INDERAL XL 3
INNOPRAN XL 3
INSPRA 4
irbesartan 1
irbesartan-
hydrochlorothiazide1
ISORDIL TITRADOSE 4
isosorbide dinitrate oral
tablet 10 mg, 20 mg, 30 1
mg, 5 mg
isosorbide dinitrate oral
tablet 40 mg2
isosorbide mononitrate 1
isosorbide mononitrate er 1
isoxsuprine hcl oral 1
isradipine 1
JUXTAPID4
PA; ST;
QL; SP
KAPSPARGO
SPRINKLE4
KATERZIA 4 PA
KEVEYIS 2 PA; QL; SP
labetalol hcl oral 1
LANOXIN ORAL 3
LASIX 4
LESCOL XL E ST
LIPITOR E QL
LIPOFEN E
lisinopril oral 1
lisinopril-
hydrochlorothiazide1
LIVALO E ST; QL
LOPID 4
LOPRESSOR 4
LOPRESSOR HCT 4
losartan potassium oral 1
losartan potassium-hctz 1
LOTENSIN 4
LOTENSIN HCT 4
LOTREL 4
31
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
lovastatin 1 H
LOVAZA E
matzim la 2
MAXZIDE 4
MAXZIDE-25 4
methazolamide oral 1
methyldopa 1
methyldopa-
hydrochlorothiazide1
metolazone 1
metoprolol succinate er
oral tablet extended
release 24 hour 100 mg, 2
200 mg, 50 mg
metoprolol succinate er
oral tablet extended 1
release 24 hour 25 mg
metoprolol tartrate oral
tablet 100 mg, 25 mg, 50 1
mg
metoprolol tartrate oral
tablet 37.5 mg, 75 mgE
metoprolol-
hydrochlorothiazide1
mexiletine hcl oral 1
MICARDIS E
MICARDIS HCT E
midodrine hcl 1
MINIPRESS 4
minitran 1
minoxidil oral 1
moexipril hcl 1
MULTAQ 4 PA
nadolol oral 1
NEXLETOL E PA; QL
NEXLIZET E
niacin
(antihyperlipidemic)2
niacin er
(antihyperlipidemic)4
niacor 2
NIASPAN 2
nicardipine hcl oral 1
nifedipine er 1
nifedipine er osmotic
release1
nifedipine oral 1
nimodipine oral 1
nisoldipine er 2
NITRO-BID 2
NITRO-DUR 3
nitroglycerin sublingual 1
nitroglycerin transdermal 1
nitroglycerin translingual E QL
NITROLINGUAL E QL
NITROMIST 4 QL
NITROSTAT 4
nitro-time 1
NORPACE 4
NORPACE CR 2
NORTHERA 4 PA; QL; SP
NORVASC E
olmesartan medoxomil
oral2
olmesartan medoxomil-
hctz2
olmesartan-amlodipine-
hctzE
omega-3-acid ethyl
esters3
PACERONE ORAL
TABLET 100 MG, 400 3
MG
pacerone oral tablet 200
mg1
pentoxifylline er 1
32
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
perindopril erbumine 2
phenoxybenzamine hcl
oral2
pindolol 1
PRALUENT 2 PA; ST; QL
PRAVACHOL 4
pravastatin sodium 1
prazosin hcl oral 1
PRESTALIA E QL
prevalite 1
PRINIVIL 4
PROCARDIA 4
PROCARDIA XL 4
propafenone hcl 1
propafenone hcl er 3
propranolol hcl er 2
propranolol hcl oral 1
propranolol-hctz 1
QBRELIS 4 PA
QUESTRAN 4
QUESTRAN LIGHT 4
quinapril hcl 1
quinapril-
hydrochlorothiazide2
quinidine gluconate er 1
quinidine sulfate 1
ramipril 1
RANEXA E
ranolazine er 2
RECTIV 3 QL
REPATHA 2 PA; ST; QL
REPATHA
PUSHTRONEX SYSTEM2 PA; ST; QL
REPATHA SURECLICK 2 PA; ST; QL
rosuvastatin calcium 2 QL
RYTHMOL SR 4
simvastatin oral tablet 10
mg, 20 mg, 40 mg, 5 mg1 H-PA
simvastatin oral tablet 80
mg1
sotalol hcl (af) 1
sotalol hcl oral 1
SOTYLIZE 4 PA
spironolactone oral 1
spironolactone-hctz 1
SULAR 4
TARKA 4
taztia xt 2
TEKTURNA 3
TEKTURNA HCT 3
telmisartan 2
telmisartan-amlodipine E
telmisartan-hctz 2
TENORETIC 100 E
TENORETIC 50 E
TENORMIN E
tiadylt er 2
TIAZAC 4
TIKOSYN 4
timolol maleate oral 1
TOPROL XL 4
torsemide 1
trandolapril 1
trandolapril-verapamil hcl
er3
triamterene oral 3
triamterene-hctz 1
TRIBENZOR E
TRICOR E
TRILIPIX E
TWYNSTA E
valsartan 2
33
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
valsartan-
hydrochlorothiazide1
VASCEPA ORAL
CAPSULE 0.5 GM4 PA
VASCEPA ORAL
CAPSULE 1 GM3 PA
VASERETIC E
VASOTEC E
VECAMYL 4 PA
verapamil hcl er oral
capsule extended
release 24 hour 100 mg, 3
200 mg, 300 mg
verapamil hcl er oral
capsule extended
release 24 hour 120 mg, 1
180 mg, 240 mg, 360 mg
verapamil hcl er oral
tablet extended release1
verapamil hcl oral 1
VERELAN 4
VERELAN PM 4
VYNDAMAX 2 PA; QL; SP
VYNDAQEL 2 PA; QL; SP
VYTORIN E
WELCHOL 2
ZESTORETIC E
ZESTRIL E
ZETIA E
ZIAC ORAL TABLET 10-
6.25 MG, 2.5-6.25 MG3
ZIAC ORAL TABLET 5-
6.25 MG4
ZOCOR ORAL TABLET
10 MG, 20 MG, 40 MG, 4
80 MG
ZYPITAMAG E ST; QL
Central Nervous
System Agents - Drugs
for Attention Deficit
Disorder
ADDERALL E PA
ADDERALL XR 2 QL
ADHANSIA XR E PA; QL
ADZENYS ER E PA; QL
ADZENYS XR-ODT E PA; QL
AMPHETAMINE ER 4 PA; QL
amphetamine sulfate E PA
amphetamine-
dextroamphetamine1 PA
amphetamine-
dextroamphetamine erE QL
APTENSIO XR E PA; QL
atomoxetine hcl 3 QL
clonidine hcl er E
CONCERTA 2 PA; QL
COTEMPLA XR-ODT E PA; QL
DAYTRANA E PA; QL
DESOXYN 4 PA
DEXEDRINE E PA
dexmethylphenidate hcl 1 PA
dexmethylphenidate hcl
er3 PA; QL
dextroamphetamine
sulfate er3 PA
dextroamphetamine
sulfate oral solution1 PA
dextroamphetamine
sulfate oral tablet3 PA
DYANAVEL XR E PA; QL
EVEKEO E PA
EVEKEO ODT E PA; QL
FOCALIN 4 PA
FOCALIN XR E PA; QL
guanfacine hcl er 2 QL
34
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
INTUNIV E QL
JORNAY PM E PA; QL
KAPVAY E
metadate er 4 PA; QL
methamphetamine hcl 1 PA
METHYLIN 4 PA
methylphenidate hcl er
(cd)2 PA; QL
methylphenidate hcl er
(la) oral capsule
extended release 24 hour 2 PA; QL
10 mg, 20 mg, 30 mg, 40
mg
methylphenidate hcl er
(la) oral capsule
extended release 24 hour2 PA
60 mg
METHYLPHENIDATE
HCL ER (XR)E PA; QL
methylphenidate hcl er
oral tablet extended 4 PA; QL
release 10 mg, 20 mg
methylphenidate hcl er
oral tablet extended
release 18 mg, 27 mg, 36E
PA; QL
mg, 54 mg, 72 mg
methylphenidate hcl oral
solution1 PA
methylphenidate hcl oral
tablet1 PA
methylphenidate hcl oral
tablet chewable3 PA
MYDAYIS E PA; QL
PROCENTRA 3 PA
QUILLICHEW ER E PA; QL
QUILLIVANT XR E PA; QL
relexxii E PA; QL
RITALIN 4 PA
RITALIN LA E PA; QL
STRATTERA E QL
VYVANSE 3 PA; QL
ZENZEDI E PA
Central Nervous
System Agents - Drugs
for Multiple Sclerosis
AMPYRA E PA; QL; SP
AUBAGIO 3 PA; QL; SP
AVONEX PEN 2 PA; QL; SP
AVONEX PREFILLED 2 PA; QL; SP
BETASERON 2 PA; QL; SP
COPAXONE E PA; QL; SP
dalfampridine er 2 PA; QL; SP
EXTAVIAE
PA; ST;
QL; SP
GILENYA 3 PA; QL; SP
glatiramer acetate 2 PA; QL; SP
glatopa 2 PA; QL; SP
MAVENCLAD (10 TABS)3
PA; ST;
QL; SP
MAVENCLAD (4 TABS)3
PA; ST;
QL; SP
MAVENCLAD (5 TABS)3
PA; ST;
QL; SP
MAVENCLAD (6 TABS)3
PA; ST;
QL; SP
MAVENCLAD (7 TABS)3
PA; ST;
QL; SP
MAVENCLAD (8 TABS)3
PA; ST;
QL; SP
MAVENCLAD (9 TABS)3
PA; ST;
QL; SP
MAYZENT 3 PA; QL; SP
MAYZENT STARTER
PACK3 PA; QL; SP
PLEGRIDY 3 PA; QL; SP
PLEGRIDY STARTER
PACK3 PA; QL; SP
REBIF4
PA; ST;
QL; SP
35
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
REBIF REBIDOSE4
PA; ST;
QL; SP
REBIF REBIDOSE
TITRATION PACK4
PA; ST;
QL; SP
REBIF TITRATION
PACK4
PA; ST;
QL; SP
TECFIDERA 2 PA; QL; SP
VUMERITYE
PA; ST;
QL; SP
VUMERITY (STARTER)E
PA; ST;
QL; SP
Central Nervous
System Agents -
Miscellaneous
AUSTEDO 2 PA; QL; SP
caffeine citrate oral 1
GRALISE E QL
GRALISE STARTER
ORAL 300 & 600 MGE QL
HORIZANT E QL
INGREZZA4
PA; ST;
QL; SP
LYRICA 4 PA; ST; QL
LYRICA CR E ST; QL
NUEDEXTA 2 PA
pregabalin oral capsule 2 QL
pregabalin oral solution 3 QL
RILUTEK 4 SP
riluzole 1 SP
SAVELLA 4 QL
SAVELLA TITRATION
PACK4 QL
tetrabenazine 2 PA; SP
TIGLUTIK 4 PA
XENAZINE E PA; SP
Dental and Oral Agents
- Drugs for Mouth and
Throat Conditions
cavarest 1
cevimeline hcl 1
chlorhexidine gluconate
mouth/throat1
clinpro 5000 1
DEBACTEROL 2
denta 5000 plus 1
dentagel 1
easygel 1
EVOXAC 4
fluoridex 1
fluoridex daily renewal 1
fluoridex enhanced
whitening1
fluoridex sensitivity relief 1
lidocaine hcl
mouth/throat1
lidocaine viscous hcl 1
MUCOSITISRX 3
NAFRINSE DAILY
ACIDULATED2
NAFRINSE
DAILY/NEUTRAL2
NAFRINSE WEEKLY 4
neutral sodium fluoride 1
oralone 1
paroex 1
PERIDEX 4
periogard 1
pilocarpine hcl oral 1
PREVIDENT 5000
BOOSTER PLUS3
PREVIDENT 5000 DRY
MOUTH4
PREVIDENT 5000
ENAMEL PROTECT3
PREVIDENT 5000
ORTHO DEFENSE3
PREVIDENT 5000 PLUS 4
36
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
PREVIDENT 5000
SENSITIVE3
PREVIDENT DENTAL 4
PREVIDENT
MOUTH/THROAT3
SALAGEN 4
sf 1
sf 5000 plus 1
sodium fluoride 5000
plus1
sodium fluoride 5000
ppm1
sodium fluoride 5000
sensitive1
sodium fluoride dental 1
TOPEX TOPICAL
ANESTHETIC3
triamcinolone acetonide
mouth/throat1
Dermatological Agents
- Drugs for Skin
Conditions
ABSORICA E PA
ABSORICA LD E PA
ACANYA E QL
acitretin 1
ACZONE EXTERNAL
GEL 5 %4 QL
ACZONE EXTERNAL
GEL 7.5 %3 QL
adapalene external
creamE PA; QL
adapalene external gel E PA; QL
ADAPALENE
EXTERNAL PADE PA
ADAPALENE
EXTERNAL SOLUTION4 PA
adapalene-benzoyl
peroxideE QL
AKLIEF E PA; QL
ALA SCALP 4
ala-cort external cream 1
%E
ala-cort external cream
2.5 %1
alclometasone
dipropionate1
ALDARA 4 QL
ALTRENO E PA; QL
amcinonide external
cream3
amcinonide external
lotion3
amcinonide external
ointment1
AMELUZ 3
ammonium lactate
externalE
amnesteem 2
AMZEEQ 4 PA; QL
APEXICON E 2 QL
ATRALIN E PA; QL
avar cleanser 1
AVAR LS CLEANSER E
AVAR-E EMOLLIENT 3
AVAR-E GREEN 3
AVAR-E LS 3
avita E PA; QL
azelaic acid external 3
AZELEX 3 QL
balsam peru-castor oil 1
BENZAC AC WASH E
BENZACLIN E QL
BENZACLIN WITH
PUMPE QL
BENZAMYCIN 2 QL
benzepro creamy wash E QL
37
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
BENZEPRO EXTERNAL E
BENZEPRO EXTERNAL
FOAM 5.2 %, 9.7 %4
benzepro external foam
5.3 %E
BENZEPRO EXTERNAL
LIQUID4
benzepro foaming cloths E
BENZEPRO SHORT
CONTACTE
BENZIQ E
BENZIQ LS E
BENZIQ WASH 4
BENZOIN 3
benzoin compound 1
benzoyl peroxide
external foam 9.8 %E
BENZOYL PEROXIDE
EXTERNAL GEL 6.5 %E
benzoyl peroxide-
erythromycin1 QL
beser external lotion 3 ST; QL
betamethasone
dipropionate aug external 1
cream
betamethasone
dipropionate aug external 1
gel
betamethasone
dipropionate aug external 3
lotion
betamethasone
dipropionate aug external 3
ointment
betamethasone
dipropionate external 2
cream
betamethasone
dipropionate external 1
lotion
betamethasone
dipropionate external 2
ointment
betamethasone valerate
external cream1
betamethasone valerate
external foamE QL
betamethasone valerate
external lotion1
betamethasone valerate
external ointment1
bp 10-1 1
bp cleansing wash 1
bp wash external liquid
2.5 %, 7 %E
BRYHALI E ST; QL
calcipotriene external
cream2 QL
calcipotriene external
ointment2
calcipotriene external
solution1 QL
calcipotriene-betameth
diprop external ointment3 QL
calcipotriene-betameth
diprop external E QL
suspension
CALCITRENE 3
calcitriol external 1 QL
CAPEX 2
CARAC 2
cerovel 1
claravis 2
CLEOCIN-T EXTERNAL
GEL4 QL
CLEOCIN-T EXTERNAL
LOTION4
CLINDACIN ETZ
EXTERNAL KITE
38
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
clindacin etz external
swab1
CLINDACIN PAC E
clindacin-p 1
CLINDAGEL E QL
clindamycin phos-
benzoyl perox external 3 QL
gel 1.2-5 %
clindamycin phos-
benzoyl perox external E QL
gel 1-5 %, 1.2-2.5 %
clindamycin phosphate
external foam3
clindamycin phosphate
external lotion3
clindamycin phosphate
external solution1 QL
clindamycin phosphate
external swab1
CLINDAMYCIN
PHOSPHATE GEL 1 % E
EXTERNAL
clindamycin phosphate
gel 1 % external3 QL
clindamycin-tretinoin E QL
clobetasol prop emollient
base2 QL
clobetasol propionate e 2 QL
clobetasol propionate
emulsionE QL
clobetasol propionate
external cream2 QL
clobetasol propionate
external foamE QL
clobetasol propionate
external gel2 QL
clobetasol propionate
external liquid1 QL
clobetasol propionate
external lotionE QL
clobetasol propionate
external ointment2 QL
clobetasol propionate
external shampooE QL
clobetasol propionate
external solution1 QL
CLOBEX E QL
CLOBEX SPRAY E QL
clocortolone pivalate 3 ST; QL
clodan external shampoo E QL
CLODERM E ST; QL
clotrimazole-
betamethasone external 1 QL
cream
clotrimazole-
betamethasone external 1
lotion
COAL TAR EXTERNAL 3
CONDYLOX 3
CORDRAN EXTERNAL
CREAM 0.025 %E QL
CORDRAN EXTERNAL
CREAM 0.05 %E ST; QL
CORDRAN EXTERNAL
LOTIONE ST; QL
CORDRAN EXTERNAL
OINTMENT4 ST
CORDRAN EXTERNAL
TAPE3 QL
CORTANE-B 4
CORTISPORIN
EXTERNAL CREAM2
CORTISPORIN
EXTERNAL OINTMENT3
CUTIVATE 3 ST; QL
dapsone external gel 5 % E QL
DAPSONE EXTERNAL
GEL 7.5 %E QL
DERMA-SMOOTHE/FS
BODY4 QL
39
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
DERMA-SMOOTHE/FS
SCALP4
DESONATE 3 ST; QL
desonide external cream 3 QL
desonide external gel 1 ST; QL
desonide external lotion 3 QL
desonide external
ointment3 QL
DESOWEN 3 QL
desoximetasone external
cream1 QL
desoximetasone external
gel3 QL
desoximetasone external
liquidE
desoximetasone external
ointment3 QL
diclofenac sodium
transdermal gel 3 %3 PA; QL
DIFFERIN EXTERNAL
CREAME PA; QL
DIFFERIN EXTERNAL
GEL 0.3 %E PA; QL
DIFFERIN EXTERNAL
LOTIONE PA; QL
diflorasone diacetate
external cream3 QL
diflorasone diacetate
external ointmentE QL
DIPROLENE 4
DIPROLENE AF 4
DOVONEX 4 QL
doxepin hcl external 1 PA; QL
doxycycline E
DRYSOL 4
DUOBRII E QL
DUPIXENT
SUBCUTANEOUS
SOLUTION PREFILLED 4
PA; ST;
QL; SP
SYRINGE
EFUDEX 4
ELIDEL 4 ST; QL
ENSTILAR 4 QL
ENZOCLEAR E
EPIDUO E QL
EPIDUO FORTE E QL
EPIFOAM 2
ery 1
ERYGEL 3
erythromycin external 1
ESKATA E
EUCRISA 3 ST; QL
EVOCLIN 4
FABIOR E PA; QL
FINACEA 4
fluocinolone acetonide
body3 QL
fluocinolone acetonide
external cream3 QL
fluocinolone acetonide
external ointment2 QL
fluocinolone acetonide
external solution3 QL
fluocinolone acetonide
scalp3
fluocinonide emulsified
base1
fluocinonide external
cream 0.05 %1
fluocinonide external
cream 0.1 %E QL
fluocinonide external gel 1
fluocinonide external
ointment1
40
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
fluocinonide external
solution1
FLUOROPLEX 4
FLUOROURACIL
EXTERNAL CREAM 0.5 4
%
fluorouracil external
cream 5 %1
fluorouracil external
solution1
flurandrenolide external
cream3 ST; QL
flurandrenolide external
lotion3 ST; QL
flurandrenolide external
ointment3 ST
fluticasone propionate
external cream1
fluticasone propionate
external lotion3 ST; QL
fluticasone propionate
external ointment1
formaldehyde external
solution 10 %1
FORMALDEHYDE
EXTERNAL SOLUTION 3
37 %
GORDOFILM 2
halcinonide 3 ST; QL
halobetasol propionate
external cream2 QL
HALOBETASOL
PROPIONATE E QL
EXTERNAL FOAM
halobetasol propionate
external ointment2 QL
HALOG EXTERNAL
CREAM4 ST; QL
HALOG EXTERNAL
OINTMENT3 ST; QL
HALUCORT 3
HYDRO 40 3
hydrocortisone ace-
pramoxine external 1
cream 2.5-1 %
hydrocortisone butyr lipo
baseE QL
hydrocortisone butyrate
external cream1
hydrocortisone butyrate
external lotionE QL
hydrocortisone butyrate
external ointment1
hydrocortisone butyrate
external solution1
hydrocortisone external
cream 1 %E
hydrocortisone external
cream 2.5 %1
hydrocortisone external
lotion 2.5 %1
hydrocortisone external
ointment 1 %, 2.5 %1
hydrocortisone valerate 3 QL
ILUMYAE
PA; ST;
QL; SP
imiquimod external 1 QL
IMIQUIMOD PUMP E QL
IMPOYZ E QL
INOVA 3
INOVA 4/1 ACNE
CONTROL THERAPY3
INOVA 8/2 ACNE
CONTROL THERAPY3
isotretinoin oral 2
KENALOG EXTERNAL E QL
KERALAC E
KERALYT SCALP E
KLARON 4
LEVULAN KERASTICK 3
41
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
LEXETTE E QL
LIDOCAINE-
HYDROCORTISONE E
ACE EXTERNAL
LOCOID EXTERNAL
CREAM 0.1 %4
LOCOID EXTERNAL
LOTIONE QL
LOCOID EXTERNAL
SOLUTION 0.1 %4
LOCOID LIPOCREAM E QL
LUXIQ E QL
methoxsalen rapid 1
methyl salicylate external
liquid1
METROCREAM 4
METROGEL E
METROLOTION 4
metronidazole external
cream1
metronidazole external
gel 0.75 %1
metronidazole external
gel 1 %E
metronidazole external
lotion1
MIRVASO 4 PA; QL
mometasone furoate
external1
myorisan 2
NEO-SYNALAR
EXTERNAL CREAME QL
neuac external gel 3 QL
NEUAC EXTERNAL KIT E
nolix 3 ST; QL
NORITATE E
NUCORT 3
NUVAIL 3
OLUX E QL
OLUX-E E QL
ONEXTON E QL
ORACEA E
OVACE PLUS
EXTERNAL CREAM3
OVACE PLUS
EXTERNAL LOTIONE
OVACE PLUS
EXTERNAL SHAMPOO3
OVACE PLUS WASH
EXTERNAL GEL3
OVACE PLUS WASH
EXTERNAL LIQUID4
OVACE WASH 4
OXSORALEN ULTRA 3
PANDEL 3
PICATO 3 QL
pimecrolimus 3 ST; QL
PLEXION E
PLEXION CLEANSER E
PLEXION CLEANSING
CLOTHE
podocon 1
podofilox external 1
PR BENZOYL
PEROXIDE4
pr benzoyl peroxide wash E
pramosone external
cream 1-1 %1
PRAMOSONE
EXTERNAL CREAM 1- 3
2.5 %
PRAMOSONE
EXTERNAL LOTION2
PRAMOSONE
EXTERNAL OINTMENT 2
1-1 %
42
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
PRAMOSONE
EXTERNAL OINTMENT 4
1-2.5 %
prednicarbate 1
PROMISEB CREAM
EXTERNAL4
PROMISEB CREAM
EXTERNAL4 PA
PROTOPIC E ST; QL
PRUDOXIN 4 PA; QL
PSORCON 3 QL
PYROGALLIC ACID 2
REGRANEX 2 PA; QL
RETIN-A E PA; QL
RETIN-A MICRO GEL
0.04 %, 0.1 %E PA; QL
RETIN-A MICRO PUMP E PA; QL
RHOFADE 4 PA; QL
RIAX E
rosadan external cream 1
rosadan external gel 1
ROSADAN EXTERNAL
KITE
salicylic acid er E
salicylic acid external
cream1
salicylic acid external
liquidE
salicylic acid external
lotion1
salicylic acid external
solution1
salicylic acid wart
removerE
salimez 1
SALVAX DUO PLUS 3
SANTYL 3 QL
SCALACORT DK 3
selenium sulfide external
lotion1
selenium sulfide external
shampoo 2.25 %4
selenium sulfide external
shampoo 2.3 %E
SELRX E
SERNIVO E QL
sodium hyaluronate
external1
sodium sulfacetamide 1
sodium sulfacetamide
wash1
SOOLANTRA 4 ST; QL
SORIATANE 4
SORILUX E QL
sss 10-5 1
sulfacetamide sodium
(acne)1
sulfacetamide sodium
external1
sulfacetamide sodium-
sulfur external cream 10- 1
2 %, 10-5 %
sulfacetamide sodium-
sulfur external cream 9.8- E
4.8 %
sulfacetamide sodium-
sulfur external emulsion1
sulfacetamide sodium-
sulfur external liquid 10-2 E
%, 9.8-4.8 %
sulfacetamide sodium-
sulfur external liquid 9-4 1
%, 9-4.5 %
sulfacetamide sodium-
sulfur external lotion 10-5 1
%
sulfacetamide sodium-
sulfur external lotion 9.8- E
4.8 %
43
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
sulfacetamide sodium-
sulfur external pad1
sulfacetamide sodium-
sulfur external 1
suspension 10-5 %
sulfacetamide sodium-
sulfur external E
suspension 8-4 %
sulfacetamide sod-sulfur
washE
sulfacetamide-sulfur in
urea1
sulfacleanse 8/4 E
sulfamez wash 1
SUMADAN E
SUMADAN WASH E
SUMADAN XLT E
SUMAXIN 4
SUMAXIN CP E
SUMAXIN WASH 3
SYNALAR E QL
SYNALAR (CREAM) E
SYNALAR (OINTMENT) E
SYNALAR TS E
TACLONEX EXTERNAL
OINTMENTE QL
TACLONEX EXTERNAL
SUSPENSION3 QL
tacrolimus external
ointment2 ST; QL
tazarotene external 3 PA; QL
TAZORAC 4 PA; QL
TEMOVATE 4 QL
TEXACORT 2
TOLAK E
TOPICORT 4 QL
TOPICORT SPRAY E
tovet external foam E QL
tretinoin external cream 3 PA; QL
tretinoin external gel 0.01
%, 0.05 %E PA; QL
tretinoin external gel
0.025 %E PA
tretinoin microsphere E PA; QL
tretinoin microsphere
pumpE PA; QL
triamcinolone acetonide
external aerosol solution2 QL
triamcinolone acetonide
external cream 0.025 %, 1
0.1 %
triamcinolone acetonide
external cream 0.5 %1 QL
triamcinolone acetonide
external lotion1
triamcinolone acetonide
external ointment 0.025 1
%, 0.1 %, 0.5 %
triamcinolone acetonide
external ointment 0.05 %E
trianex E
TRI-CHLOR 2
triderm external cream
0.1 %1
triderm external cream
0.5 %1 QL
TRIDESILON 3 QL
ULTRASAL-ER E
ULTRAVATE E PA; ST; QL
UMECTA MOUSSE E
URAMAXIN E
urea external cream 40
%, 45 %1
urea external cream 41
%, 47 %E
urea external lotion 1
urea external suspension 1
44
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
urea nail 1
urea-c40 1
uremez-40 1
UTOPIC E
VANOS E QL
VECTICAL E QL
VELTIN E QL
VENELEX 3
VERDESO E QL
VEREGEN 3 QL
VIRASAL E
ZACARE 3
zaclir cleansing 1
zenatane 2
ZIANA E QL
ZONALON 4 PA; QL
ZYCLARA E QL
ZYCLARA PUMP E QL
Diabetes - Glucose
Monitoring
ACCU-CHEK AVIVA
DEVICEE
ACCU-CHEK AVIVA
CONNECT KIT E
W/DEVICE
ACCU-CHEK AVIVA
PLUS KIT W/DEVICEE
ACCU-CHEK AVIVA
PLUS TEST STRIPSE QL
ACCU-CHEK COMPACT
PLUS CARE KITE
ACCU-CHEK COMPACT
PLUS TEST STRIPSE QL
ACCU-CHEK GUIDE KIT
W/DEVICEE
ACCU-CHEK GUIDE
TEST STRIPSE QL
ACCU-CHEK NANO
SMARTVIEW KIT E
W/DEVICE
ACCU-CHEK
SMARTVIEW TEST E QL
STRIPS
ACCU-CHEK SOFTCLIX
LANCET DEVICE KIT1
bd autoshield duo pen
needles2
bd ultra-fine insulin
syringes2
bd ultra-fine pen needles 2
CARETOUCH TEST E QL
CEQUR SIMPLICITY 2U 3
CONTOUR NEXT
MONITOR KIT
W/DEVICE
2(Contour
Next EZ)
CONTOUR NEXT
MONITOR KIT E
W/DEVICE
CONTOUR NEXT TEST 2 QL
CONTOUR TEST E QL
DEXCOM G4 / G5 / G6
RECEIVER,
TRANSMITTER,
SENSOR (INCLUDING 3 PA; QL
PLATINUM, PLATINUM
PEDIATRIC)
DEXCOM G4 / G5 / G6
RECEIVER,
TRANSMITTER,
SENSOR (INCLUDING 3 PA; QL
PLATINUM, PLATINUM
PEDIATRIC) DEVICE
diazoxide oral 3
ENLITE GLUCOSE
SENSOR3 PA; QL
FORTISCARE
GLUCOSE SYSTEM 3
DEVICE
45
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
FORTISCARE T1
GLUCOSE SYSTEM3
FREESTYLE LIBRE 14
DAY READER3 PA
FREESTYLE LIBRE 14
DAY SENSOR3 PA; QL
FREESTYLE LIBRE
READER3 PA; QL
FREESTYLE LIBRE
SENSOR SYSTEM3 PA; QL
FREESTYLE
PRECISION NEO TESTE QL
GLUCAGEN HYPOKIT 2 QL
GLUCAGON
EMERGENCY KIT2
GUARDIAN CONNECT
TRANSMITTER3
GUARDIAN CONNECT
TRANSMITTER3 PA; QL
GUARDIAN LINK 3
TRANSMITTER3
GUARDIAN SENSOR (3) 3 PA; QL
INSULIN SYRINGES 2
LANCETS 1
MICRODOT TEST E QL
NOVOFINE
AUTOCOVER PEN 2
NEEDLE
NOVOFINE PEN
NEEDLE2
NOVOFINE PLUS PEN
NEEDLE2
NOVOPEN ECHO 3
ONETOUCH ULTRA 2
KIT W/DEVICE1
ONETOUCH ULTRA
BLUE TEST STRIPS IN 1 QL
VITRO STRIP
ONETOUCH ULTRA
MINI KIT W/DEVICE1
ONETOUCH VERIO KIT
W/DEVICE1
ONETOUCH VERIO
FLEX SYSTEM KIT 1
W/DEVICE
ONETOUCH VERIO
TEST STRIPS1 QL
ONETOUCH VERIO IQ
SYSTEM1
ONETOUCH VERIO
REFLECT1
ONETOUCH VERIO
SYNC SYSTEM KIT 1
W/DEVICE
PRECISION LINK E
PRECISION PCX PLUS
TESTE QL
PRECISION QID
MONITORE
PRECISION QID TEST E QL
PRECISION SOF-TACT
MONITORE
PRECISION SOF-TACT
TESTE QL
PRECISION XTRA
BLOOD GLUCOSEE QL
PRECISION XTRA
DEVICEE
PRECISION XTRA KIT E
PRECISION XTRA
MONITORE
PROGLYCEM 4
RELION BLOOD
GLUCOSE TESTE QL
RELION ULTIMA TEST 3 QL
SOF-SENSOR 3 PA; QL
TRUE METRIX BLOOD
GLUCOSE TESTE QL
TRUE METRIX PRO
BLOOD GLUCOSEE QL
46
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
TRUETRACK TEST E QL
Diabetes - Insulin
ADMELOG E QL
ADMELOG SOLOSTAR E QL
AFREZZA INHALATION
POWDER 12 UNITE PA; QL
AFREZZA INHALATION
POWDER 4 & 8 & 12
UNIT, 4 UNIT, 8 UNIT,
90 X 4 UNIT & 90X8 E PA
UNIT, 90 X 8 UNIT &
90X12 UNIT
APIDRA SOLOSTAR E ST; QL
APIDRA VIAL E ST; QL
BASAGLAR KWIKPEN E QL
FIASP E ST; QL
FIASP FLEXTOUCH E ST; QL
FIASP PENFILL E QL
HUMALOG KWIKPEN 2 QL
HUMALOG MIX 50/50
KWIKPEN2 QL
HUMALOG MIX 50/50
VIAL1 QL
HUMALOG MIX 75/25
KWIKPEN2 QL
HUMALOG MIX 75/25
VIAL1 QL
HUMALOG U-100
JUNIOR KWIKPEN2 QL
HUMALOG VIAL
SUBCUTANEOUS 1 QL
SOLUTION 100 UNIT/ML
HUMALOG VIAL
SUBCUTANEOUS
SOLUTION CARTRIDGE 2 QL
100 UNIT/ML
HUMULIN 70/30
KWIKPEN2 QL
HUMULIN 70/30 VIAL 1 QL
HUMULIN N KWIKPEN 2 QL
HUMULIN N VIAL 1 QL
HUMULIN R U-500
KWIKPEN2 QL
HUMULIN R U-500 VIAL 1 QL
HUMULIN R VIAL 1 QL
INSULIN ASP PROT &
ASP FLEXPENE ST; QL
INSULIN ASPART E ST; QL
INSULIN ASPART
FLEXPENE ST; QL
INSULIN ASPART
PENFILLE ST; QL
INSULIN ASPART PROT
& ASPARTE ST; QL
INSULIN LISPRO (1
UNIT DIAL) SOLUTION
PEN-INJECTOR 100 2 QL
UNIT/ML
SUBCUTANEOUS
INSULIN LISPRO (1
UNIT DIAL) SOLUTION
PEN-INJECTOR 100 E QL
UNIT/ML
SUBCUTANEOUS
INSULIN LISPRO
JUNIOR KWIKPENE QL
INSULIN LISPRO PROT
& LISPROE QL
INSULIN LISPRO
SOLUTION 100 UNIT/ML 2 QL
SUBCUTANEOUS
INSULIN LISPRO
SOLUTION 100 UNIT/ML E QL
SUBCUTANEOUS
LANTUS SOLOSTAR 1 QL
LANTUS U-100 VIAL 1 QL
LEVEMIR U-100
FLEXTOUCHE QL
LEVEMIR U-100 VIAL E QL
NOVOLIN 70/30
FLEXPENE ST; QL
47
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
NOVOLIN 70/30
FLEXPEN RELIONE ST; QL
NOVOLIN 70/30 RELION E ST; QL
NOVOLIN 70/30 VIAL E ST; QL
NOVOLIN N FLEXPEN E ST; QL
NOVOLIN N FLEXPEN
RELIONE ST; QL
NOVOLIN N RELION E ST; QL
NOVOLIN N VIAL E ST; QL
NOVOLIN R FLEXPEN E ST; QL
NOVOLIN R FLEXPEN
RELIONE ST; QL
NOVOLIN R RELION E ST; QL
NOVOLIN R VIAL E ST; QL
NOVOLOG FLEXPEN E ST; QL
NOVOLOG MIX 70/30
FLEXPENE ST; QL
NOVOLOG MIX 70/30
VIALE ST; QL
NOVOLOG PENFILL E ST; QL
NOVOLOG U-100 VIAL E ST; QL
TOUJEO MAX
SOLOSTAR2 QL
TOUJEO SOLOSTAR 2 QL
TRESIBA E QL
TRESIBA FLEXTOUCH E QL
Diabetes - Non-Insulin
Agents
acarbose oral 1
ACTOPLUS MET 4 QL
ACTOS E QL
ADLYXIN 4 ST; QL
ADLYXIN STARTER
PACK4 ST; QL
ALOGLIPTIN
BENZOATEE QL
ALOGLIPTIN-
METFORMIN HCLE QL
ALOGLIPTIN-
PIOGLITAZONEE QL
AMARYL 4
AVANDIA 3 QL
BAQSIMI ONE PACK 2 QL
BAQSIMI TWO PACK 2 QL
BYDUREON 2 ST; QL
BYDUREON BCISE
AUTOINJECTOR2 ST; QL
BYETTA 10 MCG PEN 2 ST; QL
BYETTA 5 MCG PEN 2 ST; QL
CYCLOSET 3
DUETACT 3 QL
FARXIGA E ST; QL
FORTAMET E PA
glimepiride 1
glipizide er 1
glipizide ir 1
glipizide xl 1
glipizide-metformin hcl 2
GLUCAGON
EMERGENCY KIT2 QL
GLUCOTROL 4
GLUCOTROL XL 4
GLUCOVANCE ORAL
TABLET 5-500 MG4
GLUMETZA E PA
glyburide micronized 1
glyburide oral 1
glyburide-metformin 1
GLYNASE ORAL
TABLET 1.5 MG3
GLYNASE ORAL
TABLET 3 MG, 6 MG4
GLYSET 4
GLYXAMBI 2 ST; QL
48
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
GVOKE HYPOPEN
SUBCUTANEOUS
SOLUTION AUTO- 2
INJECTOR 0.5
MG/0.1ML, 1 MG/0.2ML
GVOKE PFS 2 QL
INVOKAMET E ST; QL
INVOKAMET XR E ST; QL
INVOKANA E ST; QL
JANUMET E ST; QL
JANUMET XR E ST; QL
JANUVIA E ST; QL
JARDIANCE 2 ST; QL
JENTADUETO 2 QL
JENTADUETO XR 2 QL
KAZANO 2 QL
KOMBIGLYZE XR 2 QL
metformin hcl er 1
metformin hcl er (mod) E PA
metformin hcl er (osm) E PA
metformin hcl oral
solution3
metformin hcl oral tablet 1
miglitol 2
nateglinide 2 QL
NESINA 2 QL
ONGLYZA 2 QL
OSENI 2 QL
OZEMPIC 2 ST; QL
pioglitazone hcl 1 QL
pioglitazone hcl-
glimepiride1 QL
pioglitazone hcl-
metformin hcl2 QL
PRECOSE 4
QTERN E ST; QL
repaglinide 2 QL
RIOMET 4
RIOMET ER 3
RYBELSUS 2 ST; QL
SEGLUROMET E ST; QL
SOLIQUA 2 QL
STARLIX 4 QL
STEGLATRO E ST; QL
STEGLUJAN E ST; QL
SYMLINPEN 120 3 QL
SYMLINPEN 60 3 QL
SYNJARDY 2 QL
SYNJARDY XR 2 QL
tolbutamide 1
TRADJENTA 2 QL
TRIJARDY XR 2 QL
TRULICITY 2 ST; QL
VICTOZA SOLUTION
PEN-INJECTOR 18
MG/3ML 2
ST; (2
Pak); QL
SUBCUTANEOUS
VICTOZA SOLUTION
PEN-INJECTOR 18
MG/3ML 3
ST; (3
Pak); QL
SUBCUTANEOUS
XIGDUO XR E ST; QL
XULTOPHY E QL
Drugs for Blood
Disorders
ADVATE 4 PA; ST; SP
ADYNOVATE E PA; ST; SP
AFSTYLA
INTRAVENOUS KIT
1000 UNIT, 2000 UNIT, 4 PA
250 UNIT, 3000 UNIT,
500 UNIT
AFSTYLA
INTRAVENOUS KIT 4 PA; SP
1500 UNIT, 2500 UNIT
AGRYLIN 4
49
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ALPHANATE/VWF
COMPLEX/HUMAN2 SP
ALPHANINE SD 2 SP
ALPROLIX 3 SP
AMICAR ORAL
SOLUTION4
AMICAR ORAL TABLET
1000 MG3
AMICAR ORAL TABLET
500 MG4
aminocaproic acid oral 3
anagrelide hcl 1
ARANESP (ALBUMIN
FREE)2 QL; SP
ARTISS 3
BENEFIX 2 SP
CABLIVI 2 PA; QL; SP
COAGADEX 2 SP
CORIFACT 2 SP
DOPTELET4
PA; ST;
QL; SP
ELOCTATE 4 PA; SP
EPOGEN E QL; SP
ESPEROCT E PA; SP
FEIBA 2 SP
FULPHILA E SP
GRANIX E SP
HEMLIBRA 2 PA; SP
HEMOFIL M 2 SP
HUMATE-P 2 SP
IDELVION 4 SP
IXINITY E ST; SP
JIVI 4 PA; SP
KOATE 2 SP
KOATE-DVI 2 SP
KOGENATE FS 2 SP
KOVALTRY 2 SP
LEUKINE 2 SP
LYSTEDA 3 QL
MONONINE 2 SP
monsels ferric subsulfate 1
MOZOBIL 2 SP
MULPLETA 2 PA; QL; SP
NEULASTA 3 SP
NEUPOGEN E SP
NIVESTYM E SP
NOVOEIGHT 2 SP
NOVOSEVEN RT 2 SP
NUWIQ 2 SP
OXBRYTA 4 PA; QL; SP
PROCRIT E QL; SP
PROFILNINE 2 SP
PROFILNINE SD 2 SP
PROMACTA ORAL
PACKET 12.5 MG4 PA; SP
PROMACTA ORAL
TABLET4 PA; SP
REBINYN E PA; SP
RECOMBINATE 4 PA; ST; SP
RECOTHROM 3
RECOTHROM SPRAY
KIT3
RETACRIT 2 QL; SP
RIXUBIS 2 SP
TAVALISSE4
PA; ST;
QL; SP
THROMBOGEN 3
TISSEEL 3
tranexamic acid oral 2 QL
TRETTEN 3 SP
UDENYCA E SP
VONVENDI 2 SP
WILATE 2
XYNTHA 4 PA; ST; SP
50
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
XYNTHA SOLOFUSE 4 PA; ST; SP
ZARXIO 2 SP
ZIEXTENZO E SP
Drugs for Sexual
Dysfunction
ADDYI 4 PA; QL
CAVERJECT 3 QL
CAVERJECT IMPULSE 3 QL
CIALIS ORAL TABLET
10 MG, 20 MGE QL
CIALIS ORAL TABLET
2.5 MG, 5 MGE ST; QL
EDEX 3 QL
IMVEXXY
MAINTENANCE PACK3 QL
IMVEXXY STARTER
PACK3 QL
INTRAROSA 3 QL
LEVITRA E QL
MUSE 3 QL
OSPHENA 3 PA; QL
sildenafil citrate oral
tablet 100 mg, 25 mg, 50 2 QL
mg
STAXYN E QL
STENDRA 4 PA; QL
tadalafil oral tablet 10
mg, 20 mg2 QL
tadalafil oral tablet 2.5
mg, 5 mg2 ST; QL
vardenafil hcl oral tablet 3 QL
vardenafil hcl oral tablet
dispersibleE QL
VIAGRA E QL
VYLEESI 4 PA; QL
Electrolytes / Vitamins
adc/f (0.5mg/ml) 1
aminoamrms 1
aminobenzoate
potassium1
aminoreliefrms 1
ATABEX OB 3
AZESCO E
CALCIFOL 3
calcium-folic acid plus d 1
CARDIOVID PLUS 3
CARNITOR ORAL 4
CARNITOR SF 4
CHEMET 2
CITRANATAL BLOOM 3
CITRANATAL MEDLEY 3
cyanocobalamin injection
solution 1000 mcg/ml1
CYANOCOBALAMIN
INJECTION SOLUTION 3
2000 MCG/ML
cytra k crystals 1
DRISDOL 4
EFFER-K ORAL TABLET
EFFERVESCENT 10 2
MEQ, 20 MEQ
effer-k oral tablet
effervescent 25 meq1
ELITE-OB 3
ENBRACE HR 3
ERGOCAL 3
ergocalciferol oral
capsule1
FLORIVA ORAL LIQUID 3
FLORIVA PLUS 3
FLUORABON 2 H
fluoritab 1 H
FLURA-DROPS 3 H
folic acid oral tablet 1 mg 1
GALZIN 3
hematinic/folic acid 1
51
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
hemocyte-f 1
IODINE STRONG ORAL 2
kionex 1
klor-con 1
klor-con 10 1
klor-con m10 1
KLOR-CON M15 3
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 1
K-PHOS 2
K-PHOS NO 2 2
K-PHOS-NEUTRAL 2
k-prime 1
K-TAB 3
L-CYSTINE 3
levocarnitine oral solution 1
levocarnitine oral tablet 1
levocarnitine sf 1
LOKELMA 3 PA; QL
ludent 1 H
MAGNEBIND 400 2
MEPHYTON 4 QL
M-NATAL PLUS 3
multi-vit/iron/fluoride 1
multi-vitamin/fluoride 1
multivitamin/fluoride oral
solution1
multivitamin/fluoride oral
tablet chewable 0.25 mg, 1
0.5 mg, 1 mg
multivitamin/fluoride/iron 1
multi-vitamin/fluoride/iron 1
multivitamins/fluoride 1
mvc-fluoride 1
n-acetyl-l-cysteine oral 1
nafrinse 1 H
nafrinse drops 1 H
NASCOBAL 3
NEONATAL COMPLETE 3
NEONATAL PLUS 3
NESTABS 3
NESTABS ONE E
ORACIT 2
phospha 250 neutral 1
phosphorous 1
phospho-trin 250 neutral 1
phytonadione oral 3 QL
pnv prenatal plus
multivit+dha1
POLY-VI-FLOR 3
POLY-VI-FLOR/IRON 3
pot bicarb-pot chloride 1
POTABA 4
potassium bicarbonate
oral1
potassium chloride crys
er1
potassium chloride er 1
potassium chloride oral 1
potassium citrate er 1
potassium citrate-citric
acid1
PREGENNA E
PREMESISRX 3
PRENAISSANCE 2
PRENATA 3
prenatal oral tablet 27-1
mg1
prenatal plus iron 1
PRENATE 3
PRENATE DHA 3
PRENATE ELITE 3
52
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
PRENATE ENHANCE 3
PRENATE ESSENTIAL 3
PRENATE MINI 3
PRENATE PIXIE 3
PRENATE RESTORE 3
PRIMACARE 3
QUFLORA PEDIATRIC 3
RELNATE DHA 3
SELECT-OB ORAL
TABLET CHEWABLE 4
29-1 MG
sod citrate-citric acid 1
sodium fluoride oral
solution1 H
sodium fluoride oral
tablet1
sodium fluoride oral
tablet chewable1 H
sodium polystyrene
sulfonate1
sps 1
taron-crystals 1
TRICARE PRENATAL
DHA ONE3
tricitrates 1
trinate 1
TRINAZ E
TRISTART ONE 3
TRI-VI-FLOR 3
TRI-VI-FLORO 3
tri-vitamin/fluoride 1
tri-vite/fluoride 1
TRYPTOPHAN ORAL 3
UROCIT-K 10 4
UROCIT-K 15 4
UROCIT-K 5 4
VELTASSA 3 PA; QL
virt-phos 250 neutral 1
VITAFOL FE+ 3
VITAFOL STRIPS 3
VITAFOL-OB+DHA 3
vitamin d (ergocalciferol)
oral capsule 1.25 mg 1
(50000 ut)
vitamins acd-fluoride 1
VITATHELY WITH
GINGER3
vp-pnv-dha 1
WHEAT GERM OIL 3
ZALVIT E
Gastrointestinal Agents
- Drugs for Acid Reflux
and Ulcer
ACIPHEX E QL
ACIPHEX SPRINKLE E QL
amoxicill-clarithro-
lansoprazE QL
CARAFATE 4
cimetidine hcl 1
cimetidine oral 1
CYTOTEC 4
DEXILANT 3 QL
esomeprazole
magnesium oral capsule E QL
delayed release
esomeprazole
magnesium oral packet3 PA; ST; QL
ESOMEPRAZOLE
STRONTIUME
famotidine oral
suspension reconstituted1
famotidine oral tablet 20
mg, 40 mgE
lansoprazole oral capsule
delayed releaseE QL
53
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
lansoprazole oral tablet
delayed release 3 PA; ST; QL
dispersible
misoprostol oral 1
NEXIUM ORAL
CAPSULE DELAYED E QL
RELEASE
NEXIUM ORAL PACKET 4 PA; ST; QL
nizatidine oral capsule E
nizatidine oral solution 2
OMECLAMOX-PAK 3 QL
omeprazole oral capsule
delayed release1
omeprazole-sodium
bicarbonate oral capsuleE QL
omeprazole-sodium
bicarbonate oral packetE ST; QL
pantoprazole sodium
tablet delayed release 20 1
mg oral
pantoprazole sodium
tablet delayed release 20 E (Camber)
mg oral
pantoprazole sodium
tablet delayed release 40 E
mg oral
pantoprazole sodium
tablet delayed release 40 1
mg oral
pantoprazole sodium
tablet delayed release 40 E (Camber)
mg oral
PEPCID E
PREVACID E QL
PREVACID SOLUTAB 4 PA; ST; QL
PRILOSEC E
PROTONIX ORAL E
PYLERA 3 QL
RABEPRAZOLE
SODIUM ORAL E QL
CAPSULE SPRINKLE
rabeprazole sodium oral
tablet delayed release2 QL
sucralfate oral
suspension3
sucralfate oral tablet 1
TALICIA E QL
ZEGERID ORAL
CAPSULEE QL
ZEGERID ORAL
PACKETE ST; QL
Gastrointestinal Agents
- Drugs for Bowel,
Intestine and Stomach
Conditions
ACTIGALL 4
alosetron hcl 2 PA; QL
AMITIZA 4 PA; ST; QL
ANASPAZ 2
belladonna alkaloids-
opium1
cascara sagrada oral
fluid extract1
CHENODAL 3 SP
chlordiazepoxide-
clidinium4
CHOLBAM 2 PA; QL; SP
CLENPIQ 3
constulose 1
cromolyn sodium oral 1
CUVPOSA 3
dicyclomine hcl oral 1
diphenoxylate-atropine 1
ed-spaz 1
ENTEREG 3
enulose 1
GASTROCROM 4
54
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
GATTEX 2 PA; QL; SP
gavilyte-c 1 H
gavilyte-g 1 QL; H
gavilyte-h 1
gavilyte-n with flavor
pack1 QL; H
generlac 1
GLYCATE E
glycopyrrolate oral tablet
1 mg, 2 mg1
GLYCOPYRROLATE
ORAL TABLET 1.5 MGE
GOLYTELY ORAL
SOLUTION
RECONSTITUTED 227.12 QL
GM
GOLYTELY ORAL
SOLUTION
RECONSTITUTED 236 4 QL
GM
hyoscyamine sulfate er 1
hyoscyamine sulfate oral 1
hyoscyamine sulfate sl 1
hyoscyamine sulfate
sublingual1
hyosyne 1
KRISTALOSE ORAL
PACKET 20 GM3
lactulose encephalopathy 1
lactulose oral packet E
lactulose oral solution 1
LEVBID 4
LEVSIN ORAL 4
LEVSIN/SL 4
LIBRAX E
LINZESS 2 PA; QL
LOMOTIL 4
loperamide hcl oral
capsuleE
LOTRONEX E PA; QL
methscopolamine
bromide oral1
mineral oil heavy oral 1
MOTEGRITY 3 PA; QL
MOTOFEN E
MOVANTIK E PA; QL
MOVIPREP 3 QL
MYTESI 4 PA; QL
NULEV 4
NULYTELY WITH
FLAVOR PACKS4 QL
OCALIVA4
PA; ST;
QL; SP
opium 1
oscimin 1
oscimin sr 1
OSMOPREP 3
PCP 100 E
peg 3350-kcl-na bicarb-
nacl1 QL; H
peg-3350/electrolytes 1 QL; H
peg-prep 1
PLENVU 3 QL
propantheline bromide
oral1
RELISTOR ORAL E PA; QL
RELISTOR
SUBCUTANEOUS4 PA; QL
SODIUM
BICARBONATE ORAL 3
POWDER
SUPREP BOWEL PREP
KIT3 QL
SYMAX DUOTAB 3
symax-sl 1
symax-sr 1
SYMPROIC 2 PA; QL
55
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
trilyte 1 QL; H
TRULANCE 4 PA; ST; QL
URSO 250 4
URSO FORTE 4
ursodiol oral 1
VIBERZI 4 PA; QL
XERMELO 3 PA; QL; SP
ZELNORM 3 PA; ST; QL
Genetic or Enzyme
Disorder - Drugs for
Replacement,
Modification, Treatment
BUPHENYL 4 PA; SP
CARBAGLU 2 PA; SP
CERDELGA 2 PA; SP
clovique E PA; SP
CREON 2
CUPRIMINE 4 SP
CYSTADANE 2 SP
CYSTAGON 2 SP
deferasirox 2 PA; SP
DEPEN TITRATABS 2 SP
ENDARI 4 PA; QL
EXJADE E PA; SP
FERRIPROX ORAL
SOLUTION2 PA; SP
FERRIPROX ORAL
TABLET 1000 MG4
FERRIPROX ORAL
TABLET 500 MG4 PA; SP
FIRDAPSEE
PA; ST;
QL; SP
GALAFOLD 4 PA; QL; SP
JADENU 4 PA; SP
JADENU SPRINKLE 2 PA; SP
JYNARQUE ORAL
TABLET2 PA; QL; SP
JYNARQUE ORAL
TABLET THERAPY
PACK 45 & 15 MG, 60 & 2 PA; QL; SP
30 MG, 90 & 30 MG
KUVAN 2 PA; QL; SP
miglustat 3 SP
MYALEPT 3 PA; QL; SP
nitisinone E PA; SP
NITYR 2 PA; SP
ORFADIN E PA; SP
PALYNZIQ
SUBCUTANEOUS
SOLUTION PREFILLED 3 PA; QL; SP
SYRINGE 10 MG/0.5ML,
20 MG/ML
PALYNZIQ
SUBCUTANEOUS
SOLUTION PREFILLED 3 PA; SP
SYRINGE 2.5 MG/0.5ML
PANCREAZE 3 ST
penicillamine oral
capsule4 SP
penicillamine oral tablet 2 SP
PERTZYE 4 ST
PROCYSBI ORAL
CAPSULE DELAYED 4 PA; ST; SP
RELEASE
RAVICTI4
PA; ST;
QL; SP
RUZURGI 2 PA; QL; SP
SAMSCA ORAL TABLET
15 MG2 PA; QL; SP
SAMSCA ORAL TABLET
30 MG4 PA; QL; SP
sodium phenylbutyrate
oral powder1 PA; SP
sodium phenylbutyrate
oral tablet3 PA; SP
STRENSIQ 2 PA; QL; SP
SUCRAID 2 PA; SP
56
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
SYPRINE 3 PA; SP
TEGSEDI 2 PA; QL; SP
tolvaptan 2 PA; SP
trientine hcl E PA; SP
VIOKACE 4 ST
VISTOGARD 2 QL
XURIDEN 2 PA; QL; SP
ZAVESCA E SP
ZENPEP 2
Genitourinary Agents -
Drugs for Bladder,
Genital and Kidney
Conditions
AURYXIA 3
bethanechol chloride oral 1
calcium acetate (phos
binder)1
calcium acetate oral
tablet 667 mg1
darifenacin hydrobromide
erE
DETROL E
DETROL LA E
DITROPAN XL 3
ELMIRON 2
ENABLEX ORAL
TABLET EXTENDED
RELEASE 24 HOUR 7.5 E
MG
flavoxate hcl 1
FOSRENOL ORAL
PACKET3
FOSRENOL ORAL
TABLET CHEWABLEE
GELNIQUE E
hyophen 1
lanthanum carbonate 3
LITHOSTAT 3
me/naphos/mb/hyo1 1
MYRBETRIQ E
oxybutynin chloride er 2
oxybutynin chloride oral 1
OXYTROL E
phenazo oral tablet 200
mg1
phenazopyridine hcl oral
tablet 100 mg, 200 mg1
PHOSLYRA 3
phosphasal 1
PYRIDIUM 3
RENAGEL 4
RENVELA ORAL
PACKET4
RENVELA ORAL
TABLETE
sevelamer carbonate 2
sevelamer hcl 3
solifenacin succinate E
THIOLA 3 SP
THIOLA EC 3 SP
tolterodine tartrate E
tolterodine tartrate er E
TOVIAZ 3
trospium chloride E
trospium chloride er E
URECHOLINE ORAL
TABLET 25 MG4
URECHOLINE ORAL
TABLET 50 MG3
URELLE 3
uretron d/s 1
URIBEL 3
URIMAR-T 2
urin ds 1
URO-458 3
57
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
UROGESIC-BLUE 2
uro-mp 1
URYL 2
ustell 1
uticap 1
utira-c 1
utrona-c 1
VELPHORO 2
VESICARE E
vilamit mb 1
VILEVEV MB 3
Genitourinary Agents -
Drugs for Prostate
Conditions
alfuzosin hcl er 1
AVODART E
CARDURA XL 3
dutasteride oral 3
dutasteride-tamsulosin
hclE
finasteride oral tablet 5
mg1
FLOMAX E
JALYN E
PROSCAR 4
RAPAFLO E
silodosin 3
tamsulosin hcl 1
terazosin hcl 1
UROXATRAL 4
Hormonal Agents -
Hormone Replacement
and Birth Control
ACTIVELLA 4
afirmelle 1 H
ALORA 3 QL
altavera 1 H
alyacen 1/35 1 H
alyacen 7/7/7 1 H
amabelz 2
amethia 3
amethia lo 3
amethyst 3
ANGELIQ 3
ANNOVERA E QL
apri 1 H
aranelle 1 H
ashlyna 3
aubra 1 H
aubra eq 1 H
aurovela 1.5/30 2
aurovela 1/20 2
aurovela 24 fe 3
aurovela fe 1.5/30 1 H
aurovela fe 1/20 1 H
aviane 1 H
AYGESTIN 4
ayuna 1 H
azurette 2
BALCOLTRA E
balziva 2
bekyree 2
BEYAZ E
BIJUVA 3
blisovi 24 fe 3
blisovi fe 1.5/30 1 H
blisovi fe 1/20 1 H
briellyn 2
camila 1 H
camrese 3
camrese lo 3
caziant 1 H
chateal 1 H
58
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
chateal eq 1 H
CLIMARA E QL
CLIMARA PRO 3 QL
COMBIPATCH 3 QL
covaryx 1
covaryx hs 1
cryselle-28 1 H
cyclafem 1/35 1 H
cyclafem 7/7/7 1 H
cyred 1 H
cyred eq 1 H
dasetta 1/35 1 H
dasetta 7/7/7 1 H
daysee 3
deblitane 1 H
DELESTROGEN 4
delyla 1 H
DEPO-ESTRADIOL 3
DEPO-PROVERA
INTRAMUSCULAR
SUSPENSION 150 4 QL
MG/ML
DEPO-PROVERA
INTRAMUSCULAR
SUSPENSION 4
PREFILLED SYRINGE
DEPO-SUBQ PROVERA
1042 QL
desogestrel-ethinyl
estradiol oral tablet 0.15- 2
0.02/0.01 mg (21/5)
desogestrel-ethinyl
estradiol oral tablet 0.15- 1 H
30 mg-mcg
DIVIGEL 3
dotti E QL
drospiren-eth estrad-
levomefolE
drospirenone-ethinyl
estradiol3
DUAVEE 3 QL
eemt 1
eemt hs 1
ELESTRIN 3
elinest 1 H
ELLA 1 QL
eluryng E
emoquette 1 H
enpresse-28 1 H
enskyce 1 H
errin 1 H
est estrogens-methyltest 1
est estrogens-methyltest
ds1
est estrogens-methyltest
hs1
estarylla 1 H
ESTRACE ORAL 4
ESTRACE VAGINAL 3
estradiol oral 1
estradiol patch twice (generic for
weekly 0.025 mg/24hr 2 Minivelle);
transdermal QL
estradiol patch twice (generic for
weekly 0.025 mg/24hr E Vivelle-
transdermal Dot); QL
estradiol patch twice (generic for
weekly 0.0375 mg/24hr 2 Minivelle);
transdermal QL
estradiol patch twice (generic for
weekly 0.0375 mg/24hr E Vivelle-
transdermal Dot); QL
estradiol patch twice (generic for
weekly 0.05 mg/24hr 2 Minivelle);
transdermal QL
59
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
estradiol patch twice (generic for
weekly 0.05 mg/24hr E Vivelle-
transdermal Dot); QL
estradiol patch twice (generic for
weekly 0.075 mg/24hr 2 Minivelle);
transdermal QL
estradiol patch twice (generic for
weekly 0.075 mg/24hr E Vivelle-
transdermal Dot); QL
estradiol patch twice (generic for
weekly 0.1 mg/24hr 2 Minivelle);
transdermal QL
estradiol patch twice (generic for
weekly 0.1 mg/24hr E Vivelle-
transdermal Dot); QL
(generic for
estradiol transdermal 1 Climara);
patch weekly QL
estradiol vaginal cream E
estradiol vaginal tablet 2
estradiol valerate
intramuscular1
estradiol-norethindrone
acet2
ESTRING 2 QL
ESTROGEL 3 QL
ESTROSTEP FE 4
ethynodiol diac-eth
estradiol1 H
etonogestrel-ethinyl
estradiolE
EVAMIST 2
falmina 1 H
fayosim E
FEMHRT LOW DOSE 3
FEMRING 3 QL
femynor 1 H
fyavolv 3
GENERESS FE E
gianvi 3
hailey 1.5/30 2
hailey 24 fe 3
hailey fe 1.5/30 1 H
hailey fe 1/20 1 H
heather 1 H
incassia 1 H
introvale 2 H
isibloom 1 H
jaimiess 3
jasmiel 3
jencycla 1 H
jinteli 3
jolessa 2 H
juleber 1 H
junel 1.5/30 2
junel 1/20 2
junel fe 1.5/30 1 H
junel fe 1/20 1 H
junel fe 24 3
kaitlib fe E
kalliga 1 H
kariva 2
kelnor 1/35 1 H
kelnor 1/50 1 H
kurvelo 1 H
larin 1.5/30 2
larin 1/20 2
larin 24 fe 3
larin fe 1.5/30 1 H
larin fe 1/20 1 H
larissia 1 H
layolis fe E
leena 1 H
lessina 1 H
levonest 1 H
60
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
levonorgest-eth est & eth
estE
levonorgest-eth estrad
91-day oral tablet 0.1-
0.02 & 0.01 mg, 0.15-3
0.03 &0.01 mg
levonorgest-eth estrad
91-day oral tablet 0.15- 2 H
0.03 mg
levonorgestrel-ethinyl
estrad oral tablet 0.1-20
mg-mcg, 0.15-30 mg-1 H
mcg
levonorgestrel-ethinyl
estrad oral tablet 90-20 3
mcg
levonorg-eth estrad
triphasic1 H
levora 0.15/30 (28) 1 H
lillow 1 H
LO LOESTRIN FE 3
LOESTRIN 1.5/30 (21) 4
LOESTRIN 1/20 (21) 4
LOESTRIN FE 1.5/30 4
LOESTRIN FE 1/20 4
lojaimiess 3
lopreeza 2
loryna 3
LOSEASONIQUE 4
low-ogestrel 1 H
lo-zumandimine 3
lutera 1 H
lyza 1 H
marlissa 1 H
medroxyprogesterone
acetate intramuscular 1 QL; H
suspension
medroxyprogesterone
acetate intramuscular
suspension prefilled 1 H
syringe
medroxyprogesterone
acetate oral1
megestrol acetate oral
suspension 40 mg/ml1
megestrol acetate oral
suspension 625 mg/5ml3
megestrol acetate oral
tablet1
melodetta 24 fe E
MENEST 3
MENOSTAR 3 QL
mibelas 24 fe E
microgestin 1.5/30 2
microgestin 1/20 2
microgestin fe 1.5/30 1 H
microgestin fe 1/20 1 H
mili 1 H
mimvey 2
MINASTRIN 24 FE E
MINIVELLE E QL
MIRCETTE 4
mono-linyah 1 H
NATAZIA 2
necon 0.5/35 (28) 1 H
nikki 3
nora-be 1 H
norethin ace-eth estrad-
fe oral tablet1 H
norethin ace-eth estrad-
fe oral tablet chewableE
norethindrone acetate
oral1
norethindrone acet-
ethinyl est2
61
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
norethindrone oral 1 H
norethindrone-eth
estradiol3
norethin-eth estradiol-fe
oral tablet chewable 0.4- 3
35 mg-mcg
norethin-eth estradiol-fe
oral tablet chewable 0.8- E
25 mg-mcg
norgestimate-eth
estradiol1 H
norgestimate-ethinyl
estradiol triphasic oral
tablet 0.18/0.215/0.25 2
mg-25 mcg
norgestimate-ethinyl
estradiol triphasic oral
tablet 0.18/0.215/0.25 1 H
mg-35 mcg
norlyda 1 H
norlyroc 1 H
nortrel 0.5/35 (28) 1 H
nortrel 1/35 (21) 1 H
nortrel 1/35 (28) 1 H
nortrel 7/7/7 1 H
NUVARING 1 H
ocella 3
ORIAHNN E
orsythia 1 H
ORTHO MICRONOR 4
philith 2
pimtrea 2
pirmella 1/35 1 H
pirmella 7/7/7 1 H
portia-28 1 H
PREFEST 2
PREMARIN ORAL 3
PREMARIN VAGINAL 3
PREMPHASE 3
PREMPRO 3
previfem 1 H
progesterone
intramuscular1
progesterone micronized
oral2
PROMETRIUM E
PROVERA 4
QUARTETTE E
reclipsen 1 H
rivelsa E
SAFYRAL E
SEASONIQUE 4
setlakin 2 H
sharobel 1 H
simliya 2
simpesse 3
SLYND 4 PA; ST
sprintec 28 1 H
sronyx 1 H
syeda 3
tarina 24 fe 3
tarina fe 1/20 1 H
tarina fe 1/20 eq 1 H
TAYTULLA E
tilia fe 3
tri femynor 1 H
tri-estarylla 1 H
tri-legest fe 3
tri-linyah 1 H
tri-lo-estarylla 2
tri-lo-marzia 2
tri-lo-mili 2
tri-lo-sprintec 2
tri-mili 1 H
tri-previfem 1 H
62
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
tri-sprintec 1 H
trivora (28) 1 H
tri-vylibra 1 H
tri-vylibra lo 2
tulana 1 H
tydemy E
VAGIFEM E
velivet 1 H
vienva 1 H
viorele 2
VIVELLE-DOT 2 QL
volnea 2
vyfemla 2
vylibra 1 H
wera 1 H
wymzya fe 3
xulane 3 H
YASMIN 28 2
YAZ 2
yuvafem 2
zarah 3
zovia 1/35e (28) 1 H
zumandimine 3
Hormonal Agents - Oral
Steroids
CORTEF 4
cortisone acetate oral 1
DECADRON E
DEXABLISS E
dexamethasone intensol 1
dexamethasone oral
elixir1
dexamethasone oral
solution1
dexamethasone oral
tablet1
dexamethasone oral
tablet therapy pack3
DEXPAK 10 DAY ORAL
TABLET THERAPY 4
PACK 1.5 MG (35)
DEXPAK 13 DAY ORAL
TABLET THERAPY 4
PACK 1.5 MG (51)
DEXPAK 6 DAY ORAL
TABLET THERAPY 4
PACK 1.5 MG (21)
DXEVO 11-DAY E
EMFLAZA E PA; ST; SP
fludrocortisone acetate
oral1
HIDEX 6-DAY E
hydrocortisone oral 1
MEDROL ORAL TABLET
16 MG, 4 MG, 8 MG4
MEDROL ORAL TABLET
2 MG2
MEDROL ORAL TABLET
32 MG3
MEDROL ORAL TABLET
THERAPY PACK4
methylprednisolone oral 1
MILLIPRED 2
MILLIPRED DP 12-DAY 2
MILLIPRED DP ORAL
TABLET THERAPY
PACK 5 MG (21), 5 MG 2
(48)
ORAPRED ODT 4
PEDIAPRED 2
prednisolone oral
solution1
prednisolone sodium
phosphate oral1
prednisone intensol 1
prednisone oral 1
63
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
RAYOS E
TAPERDEX 12-DAY 3
TAPERDEX 6-DAY
ORAL TABLET 4
THERAPY PACK 1.5 MG
TAPERDEX 6-DAY
ORAL TABLET
THERAPY PACK 1.5 MG 3
(21)
TAPERDEX 7-DAY 3
Hormonal Agents -
Other
PA; ST; 4
ACTHAR QL; SP
cabergoline 2
CERVIDIL 3
CETROTIDE E PA; ST; SP
cinacalcet hcl 3 PA
DDAVP 4
DDAVP RHINAL TUBE 3
desmopressin ace spray
refrig1
desmopressin acetate
injection1
desmopressin acetate
oral1
desmopressin acetate
spray1
EGRIFTA 4 PA; SP
EGRIFTA SV 4 SP
ELIGARD 3 PA
FENSOLVI
SUBCUTANEOUS KIT 3 PA
45 MG
FIRMAGON 3 SP
FIRMAGON (240 MG
DOSE)3 SP
GENOTROPIN E PA; QL; SP
GENOTROPIN
MINIQUICKE PA; QL; SP
HUMATROPE E PA; QL; SP
INCRELEX 2 PA; QL; SP
KORLYM 3 PA; SP
leuprolide acetate
injection1 PA
NOCDURNA 3 PA; QL
NORDITROPIN
FLEXPROE PA; QL; SP
NUTROPIN AQ NUSPIN
102 PA; QL; SP
NUTROPIN AQ NUSPIN
202 PA; QL; SP
NUTROPIN AQ NUSPIN
52 PA; QL; SP
octreotide acetate 1 PA; SP
OMNITROPE E PA; QL; SP
ORILISSA 4 PA; QL
PREPIDIL 3
PROSTIN E2 3
SAIZEN E PA; QL; SP
SAIZENPREP E PA; QL; SP
SANDOSTATIN E PA; SP
SENSIPAR 4 PA
SEROSTIM 4 PA; QL; SP
SIGNIFOR 2 PA; QL; SP
SOMATULINE DEPOT 4 SP
SOMAVERT 3 PA; QL; SP
STIMATE 3
SYNAREL 2
ZOMACTON E PA; QL; SP
ZORBTIVE 3 PA; QL; SP
Hormonal Agents -
Testosterone
Replacement
ANADROL-50 3
ANDRODERM 2 PA; QL
64
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ANDROGEL E PA; QL
ANDROGEL PUMP E PA; QL
danazol oral 1
DEPO-TESTOSTERONE
INTRAMUSCULAR 3
SOLUTION 100 MG/ML
DEPO-TESTOSTERONE
INTRAMUSCULAR 4
SOLUTION 200 MG/ML
FORTESTA E PA; QL
JATENZO E QL
METHITEST 2
methyltestosterone oral 2
NATESTO E PA; QL
oxandrolone oral 2
TESTIM 2 PA; QL
testosterone cypionate
intramuscular1
testosterone enanthate
intramuscular1
testosterone transdermal E PA; QL
VOGELXO E PA; QL
VOGELXO PUMP E PA; QL
XYOSTED E PA
Hormonal Agents -
Thyroid
ARMOUR THYROID 3
CYTOMEL E
euthyrox 1
levo-t 1
levothyroxine sodium oral 1
levoxyl 2
liothyronine sodium oral 2
methimazole oral 1
NATURE-THROID 3
np thyroid 1
propylthiouracil oral 1
SYNTHROID E
TAPAZOLE 4
TIROSINT E
TIROSINT-SOL 4 PA
unithroid 1
WESTHROID 3
WP THYROID 3
Immunological Agents -
Drugs for Immune
System Stimulation or
Suppression
PA; ST; 3
ACTEMRA ACTPEN QL; SP
ACTEMRA
SUBCUTANEOUS3
PA; ST;
QL; SP
ACTIMMUNE 2 PA; QL; SP
ALFERON N 2
ARAVA 4
ARCALYST 2 PA; QL; SP
ASTAGRAF XL E SP
AZASAN 3 SP
azathioprine oral 1 SP
BENLYSTA
SUBCUTANEOUS2 PA; QL; SP
CELLCEPT E SP
CIMZIA PREFILLED KIT 2 PA; QL; SP
CIMZIA STARTER KIT 2 PA; QL; SP
COSENTYX (300 MG
DOSE)3
PA; ST;
QL; SP
COSENTYX 150 MG/ML3
PA; ST;
QL; SP
COSENTYX
SENSOREADY (300
MG)
3PA; ST;
QL; SP
COSENTYX
SENSOREADY PEN3
PA; ST;
QL; SP
cyclosporine modified 1 SP
cyclosporine oral 1 SP
65
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ENBREL MINI4
PA; ST;
QL; SP
ENBREL
SUBCUTANEOUS
SOLUTION PREFILLED 4
PA; ST;
QL; SP
SYRINGE
ENBREL
SUBCUTANEOUS
SOLUTION 4
PA; ST;
QL; SP
RECONSTITUTED
ENBREL SURECLICK4
PA; ST;
QL; SP
ENVARSUS XR E SP
everolimus oral tablet
0.25 mg, 0.5 mg, 0.75 3 SP
mg
FIRAZYR 2 PA; QL; SP
gengraf 1 SP
HAEGARDA 2 PA; QL; SP
HUMIRA 2 PA; QL; SP
HUMIRA PEDIATRIC
CROHNS START2 PA; QL; SP
HUMIRA PEN 2 PA; QL; SP
HUMIRA PEN-
CD/UC/HS STARTER2 PA; QL; SP
HUMIRA PEN-
PS/UV/ADOL HS START2 PA; QL; SP
icatibant acetate E PA; QL; SP
IMURAN E SP
KEVZARA4
PA; ST;
QL; SP
KINERET 3 PA; QL; SP
leflunomide oral 1
methotrexate oral 1
methotrexate sodium oral 1
mycophenolate mofetil 1 SP
mycophenolate sodium 2 SP
MYFORTIC E SP
NEORAL E SP
OLUMIANT 2 PA; QL; SP
ORENCIA CLICKJECT3
PA; ST;
QL; SP
ORENCIA
SUBCUTANEOUS3
PA; ST;
QL; SP
OTEZLA 2 PA; QL; SP
OTREXUP E ST; QL
PALFORZIA (12 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (120 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (160 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (20 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (200 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (240 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (3 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (300 MG
MAINTENANCE)E PA; QL; SP
PALFORZIA (300 MG
TITRATION)E PA; QL; SP
PALFORZIA (40 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (6 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA (80 MG
DAILY DOSE)E PA; QL; SP
PALFORZIA INITIAL
ESCALATIONE PA; QL; SP
PROGRAF ORAL
CAPSULE4 SP
PROGRAF ORAL
PACKET4 PA; SP
RAPAMUNE ORAL
SOLUTION4 SP
66
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
RAPAMUNE ORAL
TABLETE SP
RASUVO 2 ST; QL
RIDAURA 3 SP
RINVOQ 2 PA; QL; SP
SANDIMMUNE ORAL
CAPSULEE SP
SANDIMMUNE ORAL
SOLUTION4 SP
SILIQ E PA; ST; QL
SIMPONI 2 PA; QL; SP
sirolimus oral solution 2 SP
sirolimus oral tablet 1 SP
SKYRIZI (150 MG
DOSE)2 PA; QL; SP
STELARA
SUBCUTANEOUS2 PA; QL; SP
tacrolimus oral 1 SP
TAKHZYRO 2 PA; QL; SP
TALTZE
PA; ST;
QL; SP
TREMFYA 2 PA; QL; SP
TREXALL 2
XATMEP 4 PA; QL
XELJANZ2
PA; ST;
QL; SP
XELJANZ XR2
PA; ST;
QL; SP
ZORTRESS ORAL
TABLET 0.25 MG, 0.5 4 SP
MG, 0.75 MG
ZORTRESS ORAL
TABLET 1 MG3 SP
Immunological Agents -
Drugs for Vaccination
ACTHIB 2 H
ADACEL 3 H
AFLURIA
QUADRIVALENT3 H
BEXSERO 3 H
BOOSTRIX 2 H
ENGERIX-B INJECTION 2 H
ENGERIX-B
INTRAMUSCULAR3 H
FLUAD 3 H
FLUARIX
QUADRIVALENT3 H
FLULAVAL
QUADRIVALENT
INTRAMUSCULAR 3 H
SUSPENSION
FLUZONE HIGH-DOSE
INTRAMUSCULAR
SUSPENSION 3 H
PREFILLED SYRINGE
0.5 ML
FLUZONE
QUADRIVALENT3 H
GARDASIL 9 3 H
HAVRIX 3 H
HEPLISAV-B 3 H
HIBERIX 3 H
IPOL 2 H
MENACTRA 3 H
MENVEO 3 H
M-M-R II 2 H
PEDVAX HIB 2 H
PNEUMOVAX 23 2 H
PREVNAR 13 3 H
RECOMBIVAX HB 2 H
SHINGRIX 3 H
TENIVAC 3 H
TRUMENBA 3 H
TWINRIX 3 H
VAQTA 2 H
VARIVAX 3 H
67
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ZOSTAVAX
SUBCUTANEOUS
SUSPENSION 3 H
RECONSTITUTED
19400 UNT/0.65ML
Infertility Agents
CRINONE VAGINAL
GEL 4 %4 ST
CRINONE VAGINAL
GEL 8 %4 PA; ST
ENDOMETRIN 2 PA
GONAL-F E ST; SP
GONAL-F RFF E ST; SP
GONAL-F RFF
REDIJECTE ST; SP
OVIDREL E SP
Inflammatory Bowel
Disease Agents
ANALPRAM HC 4
ANALPRAM HC
SINGLES4
ANALPRAM-HC
EXTERNAL CREAM4
ANALPRAM-HC
EXTERNAL LOTION3
anucort-hc 2
ANUSOL-HC
EXTERNAL4
ANUSOL-HC RECTAL E
APRISO 2
ASACOL HD E
AZULFIDINE 4
AZULFIDINE EN-TABS 4
balsalazide disodium 1
budesonide er E
budesonide oral 2
CANASA E
COLAZAL E
colocort 1
CORTENEMA 4
CORTIFOAM 2
DELZICOL E
DIPENTUM 3
ENTOCORT EC E
hemmorex-hc 2
hemorrhoidal-hc rectal
suppository 25 mg2
hydrocortisone (perianal) 1
hydrocortisone ace-
pramoxine external 1
cream 1-1 %
hydrocortisone acetate
rectal2
hydrocortisone rectal 1
hydrocort-pramoxine
(perianal)1
LIALDA 2
mesalamine er E
mesalamine oral E
mesalamine rectal
enema1
mesalamine rectal
suppository2
mesalamine-cleanser 1 QL
PENTASA E
PROCORT E
PROCTOCORT E
PROCTOFOAM HC 2
procto-med hc 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
ROWASA 4 QL
SFROWASA 4
sulfasalazine oral 1
UCERIS ORAL 3
68
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
UCERIS RECTAL 2
Metabolic Bone
Disease Agents - Drugs
for Osteoporosis
ACTONEL ORAL
TABLET 150 MG, 35 MG4 QL
ACTONEL ORAL
TABLET 30 MG, 5 MG4
alendronate sodium 1
ATELVIA E QL
BINOSTO E QL
BONIVA ORAL 4
calcitonin (salmon) 2
EVISTA E
FORTEO 3 PA; SP
FOSAMAX 4
FOSAMAX PLUS D 3
ibandronate sodium oral 2
MIACALCIN INJECTION 3
raloxifene hcl 2 H
RAYALDEE E
risedronate sodium oral
tablet 150 mg, 35 mg3 QL
risedronate sodium oral
tablet 30 mg, 5 mg3
risedronate sodium oral
tablet delayed releaseE QL
TYMLOS 3 PA; SP
Metabolic Bone
Disease Agents - Other
calcitriol oral 1
doxercalciferol oral 1
NATPARA 4 PA; QL; SP
paricalcitol oral 1
ROCALTROL 4
ZEMPLAR ORAL 4
Ophthalmic Agents -
Drugs for Eye Allergy,
Infection and
Inflammation
ACULAR 4
ACULAR LS 4
ACUVAIL E
ak-poly-bac 1
ALREX 4 QL
AZASITE 3
azelastine hcl ophthalmic 1
bacitracin ophthalmic 1
bacitracin-polymyxin b
ophthalmic1
bacitra-neomycin-
polymyxin-hc1
BEPREVE E QL
BESIVANCE 3
BETADINE
OPHTHALMIC PREP3
BLEPH-10 3
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 2
bromfenac sodium (once-
daily)3
BROMSITE E QL
CILOXAN OPHTHALMIC
OINTMENT3
CILOXAN OPHTHALMIC
SOLUTION4
ciprofloxacin hcl
ophthalmic1
dexamethasone sodium
phosphate ophthalmic1
diclofenac sodium
ophthalmic1
epinastine hcl E QL
erythromycin ophthalmic 1 H
FLAREX 2
69
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
fluorometholone 1
flurbiprofen sodium 1
FML 3
FML FORTE 3
FML LIQUIFILM 4
gatifloxacin ophthalmic 3
gentak 1
gentamicin sulfate
ophthalmic1 QL
ILEVRO E
INVELTYS 3
ketorolac tromethamine
ophthalmic1
LASTACAFT 3 QL
levofloxacin ophthalmic 1
LOTEMAX
OPHTHALMIC GELE
LOTEMAX
OPHTHALMIC 3
OINTMENT
LOTEMAX
OPHTHALMIC 4 QL
SUSPENSION
LOTEMAX SM 3 QL
loteprednol etabonate 3 QL
MAXIDEX 2
MAXITROL 4
MOXEZA 4
moxifloxacin hcl (2x day) 3
moxifloxacin hcl
ophthalmic3
NATACYN 3
neomycin-bacitracin zn-
polymyx1
neomycin-polymyxin-
dexameth ophthalmic 1
ointment
neomycin-polymyxin-
dexameth ophthalmic
suspension 3.5-10000-1
0.1
neomycin-polymyxin-
gramicidin1
neomycin-polymyxin-hc
ophthalmic1
neo-polycin 1
neo-polycin hc 1
NEVANAC 4
OCUFLOX 4
ofloxacin ophthalmic 1
olopatadine hcl
ophthalmic solution 0.1 3 QL
%
olopatadine hcl
ophthalmic solution 0.2 E QL
%
PAZEO E QL
polycin 1
polymyxin b-trimethoprim 1
POLYTRIM 4
PRED FORTE 4
PRED MILD 3
PRED-G 3
PRED-G S.O.P. 3
prednisolone acetate
ophthalmic1
prednisolone sodium
phosphate ophthalmic1
PROLENSA E
sulfacetamide sodium
ophthalmic1
sulfacetamide-
prednisolone ophthalmic 1
solution
TOBRADEX
OPHTHALMIC 3
OINTMENT
70
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
TOBRADEX
OPHTHALMIC 4
SUSPENSION
TOBRADEX ST E
tobramycin ophthalmic 1
tobramycin-
dexamethasone2
TOBREX OPHTHALMIC
OINTMENT3
TOBREX OPHTHALMIC
SOLUTION4
trifluridine 1
VIGAMOX E
ZIRGAN 3
ZYLET 3
ZYMAXID 4
Ophthalmic Agents -
Drugs for Glaucoma
ALPHAGAN P
OPHTHALMIC 2 QL
SOLUTION 0.1 %
ALPHAGAN P
OPHTHALMIC 4 QL
SOLUTION 0.15 %
AZOPT 2 QL
betaxolol hcl ophthalmic 1
BETIMOL 2 QL
BETOPTIC-S 3
bimatoprost ophthalmic E QL
brimonidine tartrate
ophthalmic solution 0.15 2 QL
%
brimonidine tartrate
ophthalmic solution 0.2 1
%
carteolol hcl 1
COMBIGAN 2 QL
COSOPT 4
COSOPT PF E QL
DORZOLAMIDE HCL
SOLUTION 2 % 4
OPHTHALMIC
dorzolamide hcl solution
2 % ophthalmic1
dorzolamide hcl-timolol
mal2
dorzolamide hcl-timolol
mal pfE QL
ISTALOL 4
latanoprost ophthalmic 1
levobunolol hcl 1
LUMIGAN 2
RHOPRESSA 3 QL
ROCKLATAN 3 QL
SIMBRINZA E QL
timolol maleate
ophthalmic gel forming 1
solution
timolol maleate
ophthalmic solution 0.25 1
%, 0.5 %
timolol maleate
ophthalmic solution 0.5 3
% (daily)
TIMOPTIC 4
TIMOPTIC OCUDOSE 2
TIMOPTIC-XE 4
TRAVATAN Z 4 QL
travoprost (bak free) 2 QL
TRUSOPT 4
VYZULTA E ST; QL
XALATAN E
XELPROS 3 QL
ZIOPTAN 3 ST; QL
71
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
Ophthalmic Agents -
Drugs for
Miscellaneous Eye
Conditions
AKTEN 3
ALCAINE 3
ALOCRIL 3
ALOMIDE 3
altacaine 1
altafrin 1
apraclonidine hcl 1
atropine sulfate
ophthalmic ointment1
CEQUA E PA; QL
cromolyn sodium
ophthalmic1
CYCLOGYL 4
CYCLOMYDRIL 3
cyclopentolate hcl
ophthalmic1
CYSTARAN 2 PA; QL; SP
DUREZOL 4
GELFILM OPHTHALMIC 2
homatropaire 1
HYPOCYN 3
IOPIDINE 3
ISOPTO CARPINE
OPHTHALMIC 4
SOLUTION 1 %, 2 %
ISOPTO CARPINE
OPHTHALMIC 3
SOLUTION 4 %
LACRISERT 2
MITOSOL 3
OXERVATE 4 PA; QL; SP
phenylephrine hcl
ophthalmic1
PHOSPHOLINE IODIDE 2
PHOTREXA-PHOTREXA
VISCOUS KIT3
pilocarpine hcl
ophthalmic1
proparacaine hcl
ophthalmic1
RESTASIS 4 PA; QL
RESTASIS MULTIDOSE E PA; QL
tetracaine hcl ophthalmic 1
XIIDRA 4 PA; QL
Otic Agents - Drugs for
Ear Conditions
acetic acid otic 1
CETRAXAL 3
CIPRO HC 3
CIPRODEX 3
ciprofloxacin hcl otic 1
CIPROFLOXACIN-
FLUOCINOLONE PFE
cortic-nd 1
DERMOTIC 4
exotic-hc 1
flac 1
fluocinolone acetonide
otic1
hydrocortisone-acetic
acid1
neomycin-polymyxin-hc
otic1
ofloxacin otic 2
OTICIN HC NR 2
OTOVEL E
PRAMOTIC 3
Respiratory - Drugs for
Anaphylaxis
AUVI-Q E QL
72
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
epinephrine injection (generic for
solution auto-injector E Adrenaclic
0.15 mg/0.15ml k); QL
(generic for
epinephrine solution
auto-injector 0.15 E
EpiPen-
Single
mg/0.3ml injection Pack); QL
epinephrine solution (generic for
auto-injector 0.15 2 EpiPen);
mg/0.3ml injection QL
epinephrine solution (generic for
auto-injector 0.3 E Adrenaclic
mg/0.3ml injection k); QL
(generic for
epinephrine solution
auto-injector 0.3 E
EpiPen-
Single
mg/0.3ml injection Pack); QL
epinephrine solution (generic for
auto-injector 0.3 2 EpiPen);
mg/0.3ml injection QL
EPIPEN 2-PAK E QL
EPIPEN JR 2-PAK E QL
SYMJEPI 2 QL
Respiratory Tract /
Pulmonary Agents -
Drugs for Allergies,
Cough, Cold
ADRENALIN NASAL 2
azelastine hcl nasal
solution 0.1 %, 137 3
mcg/spray
azelastine hcl nasal
solution 0.15 %E
azelastine-fluticasone E QL
BECONASE AQ E QL
benzonatate oral capsule
100 mg, 200 mg1
benzonatate oral capsule
150 mgE
bromfed dm 1
brompheniramine
tannate1
carbinoxamine maleate
oral solution1
carbinoxamine maleate
oral tablet 4 mg1
carbinoxamine maleate
oral tablet 6 mgE
cetirizine hcl oral solution E
CLARINEX E
CLARINEX-D 12 HOUR E
clemastine fumarate oral
tablet 2.68 mg1
cyproheptadine hcl oral 1
desloratadine oral tablet E
desloratadine oral tablet
dispersible 5 mgE
dexchlorpheniramine
maleate oralE
diphen oral elixir 1
diphenhydramine hcl oral
elixir1
DYMISTA E QL
flunisolide nasal 3
fluticasone propionate
nasal2 QL
GILPHEX TR 3
GILTUSS TR 3
GRASTEK 4 PA; QL
hydrocodone polst-cpm
polst er3 PA; QL
hydrocodone-
homatropine oral syrup1 PA; QL
hydrocodone-
homatropine oral tablet1 PA
hydromet 1 PA; QL
HYPERSAL 2
ipratropium bromide
nasal1
73
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
KARBINAL ER E
levocetirizine
dihydrochloride oral 3
solution
levocetirizine
dihydrochloride oral 1
tablet
mometasone furoate
nasalE QL
NASONEX E QL
nebusal inhalation
nebulization solution 3 %1
NEBUSAL INHALATION
NEBULIZATION 3
SOLUTION 6 %
NEOTUSS PLUS 3
ODACTRA 4 PA; QL
olopatadine hcl nasal 3 QL
OMNARIS E QL
ORALAIR 4 PA; QL
ORALAIR ADULT
SAMPLE KIT4 PA; QL
ORALAIR ADULT
STARTER PACK4 PA; QL
ORALAIR CHILDRENS
SAMPLE KIT4
ORALAIR CHILDRENS
STARTER PACK4 PA; QL
PATANASE 4 QL
promethazine-codeine 1 PA; QL
promethazine-dm 1
promethazine-phenyleph-
codeine1 PA; QL
promethazine-
phenylephrine1
pseudoephedrine-
bromphen-dm oral syrup1
pulmosal 1
QNASL E QL
QNASL CHILDRENS E QL
RAGWITEK 4 PA; QL
RYCLORA E
ryvent E
SEMPREX-D 3
sodium chloride
inhalation1
TESSALON PERLES 4
TUSSICAPS 3 PA; QL
TUXARIN ER 3 PA; QL
TUZISTRA XR E PA; QL
XHANCE E QL
ZETONNA 3 QL
Respiratory Tract /
Pulmonary Agents -
Drugs for Asthma and
COPD
ACCOLATE 4
acetylcysteine inhalation 1
ADVAIR DISKUS 3 QL; RS
ADVAIR HFA 3 QL; RS
AIRDUO RESPICLICK
113/14E QL
AIRDUO RESPICLICK
232/14E QL
AIRDUO RESPICLICK
55/14E QL
albuterol sulfate er 1
(ProAir
albuterol sulfate hfa
aerosol solution 108 (90 3
HFA or
Proventil
base) mcg/act inhalation HFA); QL
ALBUTEROL SULFATE
HFA AEROSOL
SOLUTION 108 (90
BASE) MCG/ACT
E(Ventolin
HFA); QL
INHALATION
albuterol sulfate
inhalation1
74
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
albuterol sulfate oral 1
ALVESCO E QL
ANORO ELLIPTA 3 QL
ARNUITY ELLIPTA 1 QL
ASMANEX (120
METERED DOSES)E QL
ASMANEX (14
METERED DOSES)E QL
ASMANEX (30
METERED DOSES)E QL
ASMANEX (60
METERED DOSES)E QL
ASMANEX (7 METERED
DOSES)E QL
ASMANEX HFA E QL
ATROVENT HFA 3 QL
BEVESPI
AEROSPHERE2 QL
BREO ELLIPTA 3 QL; RS
BROVANA 3 QL
budesonide inhalation 2 QL
BUDESONIDE-
FORMOTEROL E QL; RS
FUMARATE
COMBIVENT RESPIMAT 3 QL
cromolyn sodium
inhalation1
DALIRESP 3 PA; QL
difil-g forte 1
DUAKLIR PRESSAIR E QL
DULERA E ST; QL
ELIXOPHYLLIN 3
FASENRA PEN 4 PA
FLOVENT DISKUS 1 QL
FLOVENT HFA 1 QL
fluticasone-salmeterol
inhalation aerosol
powder breath activated
100-50 mcg/dose, 250-E QL; RS
50 mcg/dose, 500-50
mcg/dose
FLUTICASONE-
SALMETEROL
INHALATION AEROSOL
POWDER BREATH
ACTIVATED 113-14 2 QL
MCG/ACT, 232-14
MCG/ACT, 55-14
MCG/ACT
INCRUSE ELLIPTA 2 QL
ipratropium bromide
inhalation1
ipratropium-albuterol 2
levalbuterol hcl inhalation 3 QL
LEVALBUTEROL HFA
INHALATION AEROSOL 3 QL
45 MCG/ACT
LONHALA MAGNAIR
REFILL KITE PA; QL
LONHALA MAGNAIR
STARTER KITE PA; QL
metaproterenol sulfate
oral1
montelukast sodium oral
packet2
montelukast sodium oral
tablet1
montelukast sodium oral
tablet chewable1
NUCALA
SUBCUTANEOUS
SOLUTION AUTO-4 PA; QL; SP
INJECTOR
NUCALA
SUBCUTANEOUS
SOLUTION PREFILLED 4 PA; QL; SP
SYRINGE
75
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
PERFOROMIST 3 QL
PROAIR DIGIHALER E QL
PROAIR HFA 3 QL
PROAIR RESPICLICK 3 QL
PROVENTIL HFA 3 QL
PULMICORT
FLEXHALER1 QL
PULMICORT
SUSPENSIONE QL
QVAR REDIHALER E QL
SEREVENT DISKUS 3 QL
SINGULAIR ORAL
PACKET3
SINGULAIR ORAL
TABLETE
SINGULAIR ORAL
TABLET CHEWABLEE
SPIRIVA HANDIHALER 2 QL
SPIRIVA RESPIMAT 2 QL
STIOLTO RESPIMAT E QL
STRIVERDI RESPIMAT 2 QL
SYMBICORT 3 QL; RS
terbutaline sulfate oral 1
THEO-24 3
theophylline 1
theophylline er 1
TRELEGY ELLIPTA 3 QL; RS
TUDORZA PRESSAIR E QL
VENTOLIN HFA 2 QL
wixela inhub E QL; RS
XOPENEX E QL
XOPENEX
CONCENTRATEE QL
XOPENEX HFA 3 QL
YUPELRI 4 PA; QL
zafirlukast 1
zileuton er 3 ST
ZYFLO 4 ST
Respiratory Tract /
Pulmonary Agents -
Drugs for Cystic
Fibrosis
BETHKIS 2 PA; QL; SP
CAYSTON 2 PA; QL; SP
KALYDECO 2 PA; QL; SP
KITABIS PAK E PA; QL; SP
ORKAMBI 2 PA; QL; SP
PULMOZYME 2 PA; QL; SP
SYMDEKO 2 PA; QL; SP
TOBI NEBULIZER E PA; QL; SP
TOBI PODHALER 3 PA; QL; SP
tobramycin nebulization
solution 300 mg/5ml E PA; QL; SP
inhalation
TOBRAMYCIN
NEBULIZATION
SOLUTION 300 MG/5ML E PA; QL; SP
INHALATION
TRIKAFTA 2 PA; QL; SP
Respiratory Tract /
Pulmonary Agents -
Drugs for Pulmonary
Fibrosis
ESBRIET 2 PA; QL; SP
OFEV 4 PA; QL; SP
Respiratory Tract /
Pulmonary Agents -
Drugs for Pulmonary
Hypertension
ADCIRCA E PA; QL; SP
ADEMPAS 2 PA; QL; SP
alyq 3 PA; QL; SP
ambrisentan 2 PA; QL; SP
bosentan 2 PA; QL; SP
LETAIRIS 4 PA; QL; SP
OPSUMIT 2 PA; QL; SP
76
RequiremDrug
Drug Name ents & Tier
Limits
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
ORENITRAM 4 PA; QL; SP
REVATIO ORAL
SUSPENSION 4 PA; QL; SP
RECONSTITUTED
REVATIO ORAL
TABLETE QL
sildenafil citrate oral
suspension reconstituted3 PA; QL; SP
sildenafil citrate oral
tablet 20 mg1 QL
tadalafil (pah) 3 PA; QL; SP
TRACLEER 62.5 MG,
125 MG2 PA; QL; SP
TRACLEER 32 MG 2 PA; SP
TYVASO 2 PA; SP
TYVASO REFILL 2 PA; SP
TYVASO STARTER 2 PA; SP
UPTRAVI 4 PA; QL
VENTAVIS 2 PA; SP
Skeletal Muscle
Relaxants - Drugs for
Muscle Pain and
Spasm
AMRIX E
baclofen oral 1
carisoprodol oral tablet
250 mgE
carisoprodol oral tablet
350 mg1
carisoprodol-aspirin 1
chlorzoxazone oral tablet
250 mg, 375 mg, 750 mgE
chlorzoxazone oral tablet
500 mg1
cyclobenzaprine hcl er E
cyclobenzaprine hcl oral 1
DANTRIUM ORAL 4
dantrolene sodium oral 1
FEXMID 4
LORZONE E
metaxalone 3
methocarbamol oral 1
NORGESIC FORTE E
orphenadrine citrate er 2
OZOBAX 4 PA
ROBAXIN-750 4
SKELAXIN E
SOMA ORAL TABLET
250 MGE
SOMA ORAL TABLET
350 MG3
tizanidine hcl oral
capsule3
tizanidine hcl oral tablet 1
VANADOM 3
ZANAFLEX 4
Sleep Disorder Agents
AMBIEN E QL
AMBIEN CR E QL
armodafinil 2 PA; QL
BELSOMRA 4 ST; QL
doxepin hcl oral tablet E QL
EDLUAR E QL
eszopiclone 2 QL
flurazepam hcl 1
HETLIOZ 4 PA; QL; SP
INTERMEZZO E QL
LUNESTA E QL
modafinil 2 PA; QL
NUVIGIL E PA; QL
PROVIGIL E PA; QL
ramelteon 3 ST; QL
RESTORIL 4
ROZEREM 4 ST; QL
SECONAL 3
77
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
Drug NameDrug
Tier
Requirem
ents &
Limits
SILENOR E QL
SUNOSI 3 PA; QL
temazepam 1
WAKIX 4 PA; QL; SP
XYREM 4 PA; QL; SP
zaleplon 1 QL
zolpidem tartrate er 3 QL
zolpidem tartrate oral 1 QL
zolpidem tartrate
sublingualE QL
ZOLPIMIST 4 ST; QL
78
Index of Drugs
abacavir sulfate...................26
abacavir sulfate-lamivudine 26
abacavir-lamivudine-
zidovudine...........................26
ABILIFY.............................. 25
abiraterone acetate.............21
ABSORICA......................... 37
ABSORICA LD....................37
ABSTRAL............................. 6
acamprosate calcium..........10
ACANYA............................. 37
acarbose............................. 48
ACCOLATE........................ 74
ACCU-CHEK AVIVA
CONNECT KIT W/DEVICE.45
ACCU-CHEK AVIVA
DEVICE.............................. 45
ACCU-CHEK AVIVA PLUS
KIT W/DEVICE................... 45
ACCU-CHEK COMPACT
PLUS CARE KIT.................45
ACCU-CHEK COMPACT
PLUS TEST STRIPS.......... 45
ACCU-CHEK GUIDE KIT
W/DEVICE.......................... 45
ACCU-CHEK NANO
SMARTVIEW KIT
W/DEVICE.......................... 45
ACCU-CHEK
SMARTVIEW TEST
STRIPS...............................45
ACCU-CHEK SOFTCLIX
LANCET DEVICE KIT.........45
ACCUPRIL..........................29
ACCURETIC.......................29
acebutolol hcl ......................29
acetaminophen-codeine....... 6
acetaminophen-codeine #2.. 6
acetaminophen-codeine #3.. 6
acetaminophen-codeine #4.. 6
acetazolamide.....................29
acetazolamide er................ 29
acetic acid...........................72
acetylcysteine..................... 74
ACIPHEX............................ 53
ACIPHEX SPRINKLE......... 53
acitretin............................... 37
ACTEMRA.......................... 65
ACTEMRA ACTPEN...........65
ACTHAR............................. 64
ACTHIB...............................67
ACTICLATE........................ 10
ACTIGALL.......................... 54
ACTIMMUNE...................... 65
ACTIQ...................................6
ACTIVELLA........................ 58
ACTONEL...........................69
ACTOPLUS MET................48
ACTOS............................... 48
ACULAR............................. 69
ACULAR LS........................69
ACUVAIL............................ 69
acyclovir..............................26
ACZONE.............................37
ADACEL............................. 67
ADALAT CC........................29
adapalene........................... 37
ADAPALENE...................... 37
adapalene-benzoyl
peroxide.............................. 37
adc/f (0.5mg/ml)..................51
ADCIRCA............................76
ADDERALL.........................34
ADDERALL XR...................34
ADDYI.................................51
adefovir dipivoxil................. 26
ADEMPAS.......................... 76
ADHANSIA XR................... 34
ADLYXIN............................ 48
ADLYXIN STARTER
PACK.................................. 48
ADMELOG..........................47
ADMELOG SOLOSTAR..... 47
ADRENALIN....................... 73
ADVAIR DISKUS................ 74
ADVAIR HFA...................... 74
ADVATE............................. 49
ADYNOVATE......................49
ADZENYS ER.....................34
ADZENYS XR-ODT............ 34
AEMCOLO..........................10
AFINITOR........................... 21
AFINITOR DISPERZ.......... 21
afirmelle.............................. 58
AFLURIA
QUADRIVALENT................67
AFREZZA........................... 47
AFSTYLA............................49
AGGRENOX....................... 25
AGRYLIN............................ 49
AIMOVIG............................ 19
AIRDUO RESPICLICK
113/14.................................74
AIRDUO RESPICLICK
232/14.................................74
AIRDUO RESPICLICK
55/14...................................74
AJOVY................................ 19
AKLIEF............................... 37
ak-poly-bac......................... 69
AKTEN................................72
AKYNZEO...........................17
ALA SCALP........................ 37
ala-cort ................................37
albendazole........................ 23
ALBENZA........................... 23
albuterol sulfate............ 74, 75
albuterol sulfate er.............. 74
albuterol sulfate hfa............ 74
ALBUTEROL SULFATE
HFA.....................................74
ALCAINE............................ 72
alclometasone
dipropionate........................ 37
ALCOHOL PREP PADS..... 10
ALDACTAZIDE................... 29
ALDACTONE......................29
ALDARA............................. 37
ALECENSA.........................21
alendronate sodium............ 69
ALFERON N....................... 65
alfuzosin hcl er....................58
ALINIA................................ 23
aliskiren fumarate............... 29
ALKERAN........................... 21
allopurinol........................... 19
ALLZITAL..............................6
almotriptan malate.............. 19
ALOCRIL............................ 72
ALOGLIPTIN BENZOATE.. 48
ALOGLIPTIN-
METFORMIN HCL..............48
ALOGLIPTIN-
PIOGLITAZONE................. 48
ALOMIDE............................72
ALORA................................58
alosetron hcl....................... 54
ALPHAGAN P.....................71
ALPHANATE/VWF
COMPLEX/HUMAN............ 50
ALPHANINE SD................. 50
alprazolam.......................... 28
alprazolam er...................... 28
alprazolam intensol.............28
alprazolam xr...................... 28
ALPROLIX.......................... 50
ALREX................................ 69
ALTABAX............................10
79
altacaine............................. 72
ALTACE..............................29
altafrin................................. 72
altavera............................... 58
ALTOPREV.........................29
ALTRENO...........................37
ALUNBRIG......................... 21
ALVESCO...........................75
alyacen 1/35....................... 58
alyacen 7/7/7...................... 58
alyq..................................... 76
amabelz.............................. 58
amantadine hcl................... 24
AMARYL............................. 48
AMBIEN.............................. 77
AMBIEN CR........................77
ambrisentan........................ 76
amcinonide......................... 37
AMELUZ............................. 37
AMERGE............................ 19
amethia............................... 58
amethia lo........................... 58
amethyst............................. 58
AMICAR..............................50
amiloride hcl........................29
amiloride-
hydrochlorothiazide.............29
aminoamrms....................... 51
aminobenzoate potassium..51
aminocaproic acid...............50
aminoreliefrms.................... 51
amiodarone hcl ................... 29
AMITIZA..............................54
amitriptyline hcl................... 16
amlodipine besylate............ 29
amlodipine besylate-
benazepril hcl......................29
amlodipine besylate-
valsartan............................. 29
amlodipine-atorvastatin.......29
amlodipine-olmesartan....... 29
amlodipine-valsartan-hctz...29
ammonium lactate.............. 37
amnesteem......................... 37
amoxapine.......................... 16
amoxicill-clarithro-
lansopraz............................ 53
amoxicillin........................... 10
amoxicillin-potassium
clavulanate..........................10
amoxicillin-potassium
clavulanate er..................... 10
AMPHETAMINE ER........... 34
amphetamine sulfate.......... 34
amphetamine-
dextroamphetamine............ 34
amphetamine-
dextroamphetamine er........34
ampicillin............................. 10
AMPYRA.............................35
AMRIX................................ 77
AMZEEQ.............................37
ANADROL-50..................... 64
ANAFRANIL........................16
anagrelide hcl..................... 50
ANALPRAM HC..................68
ANALPRAM HC SINGLES. 68
ANALPRAM-HC..................68
ANASPAZ........................... 54
anastrozole......................... 21
ANCOBON..........................18
ANDRODERM.................... 64
ANDROGEL........................65
ANDROGEL PUMP............ 65
ANGELIQ............................58
ANNOVERA........................58
ANORO ELLIPTA............... 75
ANTABUSE........................ 10
ANTARA............................. 29
anucort-hc...........................68
ANUSOL-HC.......................68
ANZEMET...........................17
APADAZ............................... 6
apap-caff-dihydrocodeine..... 6
APEXICON E......................37
APIDRA SOLOSTAR..........47
APIDRA VIAL......................47
APLENZIN.......................... 16
APOKYN.............................24
apraclonidine hcl.................72
aprepitant............................17
apri......................................58
APRISO.............................. 68
APTENSIO XR....................34
APTIOM.............................. 14
APTIVUS............................ 26
ARAKODA.......................... 23
aranelle............................... 58
ARANESP (ALBUMIN
FREE)................................. 50
ARAVA................................65
ARCALYST.........................65
ARICEPT............................ 15
ARIKAYCE..........................10
ARIMIDEX.......................... 21
aripiprazole......................... 25
ARIXTRA............................ 13
armodafinil .......................... 77
ARMOUR THYROID...........65
ARNUITY ELLIPTA.............75
AROMASIN.........................21
ARTHROTEC....................... 9
ARTISS...............................50
ARYMO ER...........................6
arzol silver nit applicators... 10
ASACOL HD....................... 68
ascomp-codeine................... 6
ashlyna............................... 58
ASMANEX (120
METERED DOSES)........... 75
ASMANEX (14 METERED
DOSES).............................. 75
ASMANEX (30 METERED
DOSES).............................. 75
ASMANEX (60 METERED
DOSES).............................. 75
ASMANEX (7 METERED
DOSES).............................. 75
ASMANEX HFA.................. 75
aspirin-dipyridamole er ....... 25
ASPIRIN-OMEPRAZOLE... 25
ASTAGRAF XL................... 65
ATABEX OB....................... 51
ATACAND...........................29
ATACAND HCT.................. 29
atazanavir sulfate................26
ATELVIA............................. 69
atenolol ............................... 29
atenolol-chlorthalidone........29
ATIVAN...............................28
atomoxetine hcl ...................34
atorvastatin calcium............ 29
atovaquone......................... 24
atovaquone-proguanil hcl ... 24
ATRALIN.............................37
ATRIPLA.............................26
atropine sulfate................... 72
ATROVENT HFA................ 75
AUBAGIO........................... 35
aubra...................................58
aubra eq..............................58
AUGMENTIN...................... 10
AUGMENTIN ES-600......... 10
aurovela 1.5/30................... 58
aurovela 1/20...................... 58
aurovela 24 fe..................... 58
aurovela fe 1.5/30............... 58
aurovela fe 1/20.................. 58
AURYXIA............................ 57
80
AUSTEDO.......................... 36
AUVI-Q............................... 72
AVALIDE.............................29
AVANDIA............................ 48
AVAPRO.............................29
avar cleanser...................... 37
AVAR LS CLEANSER........ 37
AVAR-E EMOLLIENT......... 37
AVAR-E GREEN.................37
AVAR-E LS......................... 37
aviane................................. 58
avidoxy................................10
AVIDOXY DK......................10
avita.................................... 37
AVODART.......................... 58
AVONEX PEN.................... 35
AVONEX PREFILLED........ 35
AYGESTIN..........................58
ayuna.................................. 58
AYVAKIT.............................21
AZASAN............................. 65
AZASITE.............................69
azathioprine........................ 65
azelaic acid......................... 37
azelastine hcl................ 69, 73
azelastine-fluticasone......... 73
AZELEX.............................. 37
AZESCO............................. 51
AZILECT............................. 24
azithromycin........................10
AZOPT................................71
AZOR..................................29
AZULFIDINE.......................68
AZULFIDINE EN-TABS...... 68
azurette...............................58
bacitracin............................ 69
bacitracin-polymyxin b........ 69
bacitra-neomycin-
polymyxin-hc.......................69
baclofen.............................. 77
BACTRIM............................10
BACTRIM DS......................10
BALCOLTRA...................... 58
balsalazide disodium.......... 68
balsam peru-castor oil ........ 37
BALVERSA.........................21
balziva.................................58
BANZEL..............................14
BAQSIMI ONE PACK......... 48
BAQSIMI TWO PACK.........48
BARACLUDE......................26
BASAGLAR KWIKPEN.......47
BAXDELA........................... 10
bd autoshield duo pen
needles............................... 45
bd ultra-fine insulin
syringes.............................. 45
bd ultra-fine pen needles.... 45
BECONASE AQ..................73
bekyree............................... 58
BELBUCA............................. 6
belladonna alkaloids-opium 54
BELSOMRA........................77
benazepril hcl......................29
benazepril-
hydrochlorothiazide.............29
BENEFIX............................ 50
BENICAR............................29
BENICAR HCT................... 29
BENLYSTA......................... 65
BENZAC AC WASH........... 37
BENZACLIN........................37
BENZACLIN WITH PUMP.. 37
BENZALKONIUM
CHLORIDE......................... 10
benzalkonium chloride........ 10
BENZAMYCIN.................... 37
BENZEPRO........................ 38
benzepro.............................38
benzepro creamy wash.......37
benzepro foaming cloths.....38
BENZEPRO SHORT
CONTACT.......................... 38
BENZHYDROCODONE-
ACETAMINOPHEN.............. 6
BENZIQ.............................. 38
BENZIQ LS......................... 38
BENZIQ WASH...................38
BENZNIDAZOLE................ 24
BENZOIN............................38
benzoin compound............. 38
benzonatate........................ 73
benzoyl peroxide.................38
BENZOYL PEROXIDE....... 38
benzoyl peroxide-
erythromycin....................... 38
benztropine mesylate..........24
BEPREVE...........................69
beser...................................38
BESIVANCE....................... 69
BETADINE OPHTHALMIC
PREP.................................. 69
betamethasone
dipropionate........................ 38
betamethasone
dipropionate aug................. 38
betamethasone valerate..... 38
BETAPACE.........................29
BETAPACE AF................... 29
BETASERON......................35
betaxolol hcl ..................29, 71
bethanechol chloride...........57
BETHKIS............................ 76
BETIMOL............................ 71
BETOPTIC-S...................... 71
BEVESPI AEROSPHERE.. 75
bexarotene..........................21
BEXSERO.......................... 67
BEYAZ................................ 58
bicalutamide........................21
BIDIL...................................29
BIJUVA............................... 58
BIKTARVY.......................... 26
BILTRICIDE........................ 24
bimatoprost......................... 71
BINOSTO............................69
BIO-STATIN........................18
bio-statin............................. 18
bisoprolol fumarate............. 29
bisoprolol-
hydrochlorothiazide.............29
BLEPH-10...........................69
BLEPHAMIDE.....................69
BLEPHAMIDE S.O.P.......... 69
blisovi 24 fe.........................58
blisovi fe 1.5/30...................58
blisovi fe 1/20......................58
BONIVA.............................. 69
BONJESTA.........................17
BOOSTRIX......................... 67
bosentan............................. 76
BOSULIF............................ 21
bp 10-1................................38
bp cleansing wash.............. 38
bp wash.............................. 38
BRAFTOVI..........................21
BREO ELLIPTA.................. 75
briellyn................................ 58
BRILINTA............................25
brimonidine tartrate.............71
BRISDELLE........................ 16
BRIVIACT........................... 14
bromfed dm.........................73
bromfenac sodium (once-
daily)................................... 69
bromocriptine mesylate.......24
brompheniramine tannate...73
BROMSITE......................... 69
BROVANA.......................... 75
81
BRUKINSA......................... 21
BRYHALI............................ 38
budesonide................... 68, 75
budesonide er..................... 68
BUDESONIDE-
FORMOTEROL
FUMARATE........................ 75
bumetanide......................... 29
BUMEX............................... 29
BUNAVAIL.......................... 10
BUPAP..................................6
BUPHENYL........................ 56
buprenorphine.......................6
buprenorphine hcl............... 10
buprenorphine hcl-
naloxone hcl........................10
bupropion hcl ...................... 16
bupropion hcl er (smoking
det)......................................10
bupropion hcl er (sr) ............16
bupropion hcl er (xl)............ 16
BUPROPION HCL ER (XL) 16
buspirone hcl...................... 28
butalbital-acetaminophen......6
BUTALBITAL-
ACETAMINOPHEN.............. 6
butalbital-apap-caff-cod........ 6
butalbital-apap-caffeine........ 6
butalbital-asa-caff-codeine....6
butalbital-aspirin-caffeine......6
butorphanol tartrate.............. 6
BUTRANS.............................6
BYDUREON....................... 48
BYDUREON BCISE
AUTOINJECTOR................48
BYETTA 10 MCG PEN....... 48
BYETTA 5 MCG PEN......... 48
BYSTOLIC.......................... 29
cabergoline......................... 64
CABLIVI.............................. 50
CABOMETYX..................... 21
CADUET............................. 29
CAFERGOT........................20
caffeine citrate.................... 36
CALAN SR..........................29
CALCIFOL.......................... 51
calcipotriene........................38
calcipotriene-betameth
diprop..................................38
calcitonin (salmon)..............69
CALCITRENE..................... 38
calcitriol.........................38, 69
calcium acetate...................57
calcium acetate (phos
binder).................................57
calcium-folic acid plus d......51
CALQUENCE..................... 21
CAMBIA.............................. 20
camila................................. 58
camrese.............................. 58
camrese lo.......................... 58
CANASA............................. 68
candesartan cilexetil........... 29
candesartan cilexetil-hctz... 29
capecitabine........................21
CAPEX................................38
CAPLYTA........................... 25
CAPRELSA.........................21
captopril.............................. 29
captopril-
hydrochlorothiazide.............29
CARAC............................... 38
CARAFATE.........................53
CARBAGLU........................ 56
carbamazepine................... 14
carbamazepine er............... 14
CARBATROL......................14
carbidopa............................ 24
carbidopa-levodopa............ 24
carbidopa-levodopa er........ 24
carbidopa-levodopa-
entacapone......................... 24
carbinoxamine maleate.......73
CARDIOVID PLUS............. 51
CARDIZEM......................... 29
CARDIZEM CD...................30
CARDIZEM LA....................30
CARDURA.......................... 30
CARDURA XL.....................58
CARETOUCH TEST...........45
carisoprodol........................ 77
carisoprodol-aspirin............ 77
carisoprodol-aspirin-
codeine................................. 6
CARNITOR......................... 51
CARNITOR SF................... 51
CAROSPIR......................... 30
carteolol hcl.........................71
cartia xt............................... 30
carvedilol.............................30
carvedilol phosphate er.......30
cascara sagrada................. 54
CASODEX.......................... 21
CATAPRES........................ 30
CATAPRES-TTS-1............. 30
CATAPRES-TTS-2............. 30
CATAPRES-TTS-3............. 30
cavarest .............................. 36
CAVERJECT...................... 51
CAVERJECT IMPULSE......51
CAYSTON.......................... 76
caziant................................ 58
cefaclor ............................... 10
cefaclor er........................... 10
cefadroxil ............................ 10
cefdinir ................................ 10
cefditoren pivoxil ................. 10
cefixime...............................10
cefpodoxime proxetil ...........10
cefprozil .............................. 10
cefuroxime axetil .................10
CELEBREX...........................9
celecoxib...............................9
CELEXA..............................16
CELLCEPT......................... 65
CELONTIN..........................14
CENTANY...........................11
CENTANY AT..................... 11
cephalexin...........................11
CEQUA............................... 72
CEQUR SIMPLICITY 2U.... 45
CERDELGA........................ 56
cerovel ................................ 38
CERVIDIL........................... 64
cetirizine hcl........................ 73
CETRAXAL.........................72
CETROTIDE....................... 64
cevimeline hcl ..................... 36
CHANTIX............................ 10
CHANTIX CONTINUING
MONTH PAK...................... 10
CHANTIX STARTING
MONTH PAK...................... 10
chateal ................................ 58
chateal eq........................... 59
CHEMET.............................51
CHENODAL........................54
chlordiazepoxide hcl........... 28
chlordiazepoxide-
amitriptyline.........................16
chlordiazepoxide-clidinium..54
chlorhexidine gluconate...... 36
chloroquine phosphate....... 24
chlorothiazide......................30
chlorpromazine hcl ..............25
chlorthalidone..................... 30
chlorzoxazone.....................77
CHOLBAM.......................... 54
cholestyramine....................30
82
cholestyramine light............ 30
CIALIS................................ 51
ciclodan...............................18
ciclopirox.............................18
ciclopirox olamine............... 18
ciclopirox treatment.............18
cilostazol............................. 25
CILOXAN............................ 69
CIMDUO............................. 26
cimetidine............................53
cimetidine hcl...................... 53
CIMZIA PREFILLED KIT.... 65
CIMZIA STARTER KIT....... 65
cinacalcet hcl ...................... 64
CIPRO................................ 11
CIPRO HC.......................... 72
CIPRODEX......................... 72
ciprofloxacin hcl ...... 11, 69, 72
CIPROFLOXACIN-
FLUOCINOLONE PF..........72
citalopram hydrobromide.... 16
CITRANATAL BLOOM....... 51
CITRANATAL MEDLEY......51
claravis................................38
CLARINEX..........................73
CLARINEX-D 12 HOUR..... 73
clarithromycin......................11
clarithromycin er................. 11
clemastine fumarate........... 73
CLENPIQ............................ 54
CLEOCIN............................11
CLEOCIN-T........................ 38
CLIMARA............................59
CLIMARA PRO................... 59
CLINDACIN ETZ.................38
clindacin etz........................ 39
CLINDACIN PAC................ 39
clindacin-p...........................39
CLINDAGEL....................... 39
clindamycin hcl................... 11
clindamycin palmitate hcl....11
clindamycin phosphate. 11, 39
CLINDAMYCIN
PHOSPHATE......................39
clindamycin phosphate-
benzoyl peroxide.................39
clindamycin-tretinoin........... 39
CLINDESSE....................... 11
clinpro 5000........................ 36
clobazam............................ 14
clobetasol prop emollient
base.................................... 39
clobetasol propionate..........39
clobetasol propionate e.......39
clobetasol propionate
emulsion............................. 39
CLOBEX............................. 39
CLOBEX SPRAY................ 39
clocortolone pivalate........... 39
clodan................................. 39
CLODERM..........................39
clomipramine hcl.................16
clonazepam........................ 28
clonidine..............................30
clonidine hcl........................ 30
clonidine hcl er....................34
clopidogrel bisulfate............ 25
clorazepate dipotassium..... 28
clotrimazole.........................18
clotrimazole-
betamethasone................... 39
clovique...............................56
clozapine.............................25
CLOZARIL.......................... 25
COAGADEX....................... 50
COAL TAR..........................39
COARTEM..........................24
codeine sulfate......................6
COLAZAL........................... 68
COLCHICINE......................19
colchicine............................ 19
colchicine-probenecid......... 19
COLCRYS.......................... 19
colesevelam hcl.................. 30
COLESTID..........................30
COLESTID FLAVORED..... 30
colestipol hcl....................... 30
colistimethate sodium
(cba)....................................11
colocort............................... 68
COLY-MYCIN M................. 11
COMBIGAN........................ 71
COMBIPATCH....................59
COMBIVENT RESPIMAT... 75
COMBIVIR.......................... 26
COMETRIQ (100 MG
DAILY DOSE)..................... 21
COMETRIQ (140 MG
DAILY DOSE)..................... 21
COMETRIQ (60 MG
DAILY DOSE)..................... 21
COMPLERA........................26
compro................................17
COMTAN............................ 24
CONCERTA........................34
CONDYLOX........................39
CONSENSI......................... 30
constulose...........................54
CONTOUR NEXT
MONITOR...........................45
CONTOUR NEXT TEST.....45
CONTOUR TEST............... 45
CONZIP................................ 6
COPAXONE....................... 35
COPIKTRA......................... 21
CORDRAN..........................39
COREG...............................30
COREG CR........................ 30
coremino............................. 11
CORGARD......................... 30
CORIFACT......................... 50
CORLANOR....................... 30
CORTANE-B.......................39
CORTEF............................. 63
CORTENEMA.....................68
cortic-nd.............................. 72
CORTIFOAM...................... 68
cortisone acetate................ 63
CORTISPORIN...................39
COSENTYX (300 MG
DOSE)................................ 65
COSENTYX 150 MG/ML.... 65
COSENTYX
SENSOREADY (300 MG)...65
COSENTYX
SENSOREADY PEN.......... 65
COSOPT.............................71
COSOPT PF....................... 71
COTELLIC.......................... 21
COTEMPLA XR-ODT......... 34
COUMADIN........................ 13
covaryx............................... 59
covaryx hs...........................59
COZAAR.............................30
CREON...............................56
CRESEMBA........................18
CRESTOR.......................... 30
CRINONE........................... 68
CRIXIVAN...........................26
cromolyn sodium.....54, 72, 75
crotan..................................24
cryselle-28.......................... 59
CUPRIMINE........................56
CUTIVATE.......................... 39
CUVPOSA.......................... 54
cyanocobalamin..................51
CYANOCOBALAMIN..........51
cyclafem 1/35......................59
cyclafem 7/7/7.....................59
83
cyclobenzaprine hcl............ 77
cyclobenzaprine hcl er........ 77
CYCLOGYL........................ 72
CYCLOMYDRIL..................72
cyclopentolate hcl ............... 72
cyclophosphamide.............. 21
cycloserine..........................21
CYCLOSET........................ 48
cyclosporine........................65
cyclosporine modified......... 65
CYMBALTA........................ 16
cyproheptadine hcl ..............73
cyred................................... 59
cyred eq.............................. 59
CYSTADANE......................56
CYSTAGON........................56
CYSTARAN........................ 72
CYTOMEL.......................... 65
CYTOTEC...........................53
cytra k crystals.................... 51
D.H.E. 45............................ 20
dalfampridine er.................. 35
DALIRESP.......................... 75
danazol............................... 65
DANTRIUM.........................77
dantrolene sodium.............. 77
dapsone........................ 21, 39
DAPSONE.......................... 39
DARAPRIM.........................24
darifenacin hydrobromide
er.........................................57
dasetta 1/35........................ 59
dasetta 7/7/7....................... 59
DAURISMO........................ 21
DAYPRO...............................9
daysee................................ 59
DAYTRANA........................ 34
DDAVP............................... 64
DDAVP RHINAL TUBE.......64
DEBACTEROL................... 36
deblitane............................. 59
DECADRON....................... 63
deferasirox.......................... 56
DELESTROGEN.................59
DELSTRIGO....................... 26
delyla.................................. 59
DELZICOL.......................... 68
demeclocycline hcl..............11
DEMSER............................ 30
DENAVIR............................26
denta 5000 plus.................. 36
dentagel.............................. 36
DEPAKOTE........................ 14
DEPAKOTE ER.................. 14
DEPAKOTE SPRINKLES... 14
DEPEN TITRATABS...........56
DEPO-ESTRADIOL............ 59
DEPO-PROVERA...............59
DEPO-SUBQ PROVERA
104......................................59
DEPO-TESTOSTERONE... 65
DERMA-SMOOTHE/FS
BODY..................................39
DERMA-SMOOTHE/FS
SCALP................................ 40
dermazene..........................18
DERMOTIC.........................72
DESCOVY.......................... 26
desipramine hcl...................16
desloratadine...................... 73
desmopressin ace spray
refrig....................................64
desmopressin acetate.........64
desmopressin acetate
spray................................... 64
desogestrel-ethinyl
estradiol.............................. 59
DESONATE........................ 40
desonide............................. 40
DESOWEN......................... 40
desoximetasone..................40
DESOXYN.......................... 34
DESVENLAFAXINE ER......16
desvenlafaxine succinate
er.........................................16
DETROL............................. 57
DETROL LA........................57
DEXABLISS........................63
dexamethasone.................. 63
dexamethasone intensol.....63
dexamethasone sodium
phosphate........................... 69
dexchlorpheniramine
maleate............................... 73
DEXCOM G4 / G5 / G6
RECEIVER,
TRANSMITTER, SENSOR
(INCLUDING PLATINUM,
PLATINUM PEDIATRIC).... 45
DEXEDRINE.......................34
DEXILANT.......................... 53
dexmethylphenidate hcl...... 34
dexmethylphenidate hcl er..34
DEXPAK 10 DAY................63
DEXPAK 13 DAY................63
DEXPAK 6 DAY..................63
dextroamphetamine sulfate 34
dextroamphetamine sulfate
er.........................................34
DIACOMIT.......................... 14
DIASTAT ACUDIAL............ 14
DIASTAT PEDIATRIC........ 14
diazepam...................... 14, 28
diazepam intensol...............28
diazoxide.............................45
DIBENZYLINE.................... 30
DICLEGIS........................... 17
DICLOFENAC
EPOLAMINE.........................9
diclofenac potassium............ 9
diclofenac sodium..... 9, 40, 69
diclofenac sodium er.............9
diclofenac-misoprostol .......... 9
dicloxacillin sodium............. 11
dicyclomine hcl................... 54
didanosine.......................... 26
DIFFERIN........................... 40
DIFICID...............................11
difil-g forte........................... 75
diflorasone diacetate...........40
DIFLUCAN..........................18
diflunisal ................................9
digitek................................. 30
digox................................... 30
digoxin................................ 30
dihydroergotamine
mesylate............................. 20
DILANTIN........................... 14
DILANTIN INFATABS.........14
DILATRATE-SR..................30
DILAUDID............................. 6
diltiazem hcl........................ 30
diltiazem hcl er....................30
diltiazem hcl er beads......... 30
diltiazem hcl er coated
beads.................................. 30
dilt-xr................................... 30
DIOVAN.............................. 30
DIOVAN HCT......................30
DIPENTUM......................... 68
diphen................................. 73
diphenhydramine hcl ...........73
diphenoxylate-atropine....... 54
DIPROLENE....................... 40
DIPROLENE AF................. 40
dipyridamole....................... 25
disopyramide phosphate.....30
disulfiram............................ 10
DITROPAN XL....................57
84
DIURIL................................ 30
divalproex sodium...............14
divalproex sodium er...........14
DIVIGEL..............................59
dofetilide............................. 30
DOLOPHINE.........................6
donepezil hcl .......................15
DOPTELET.........................50
DORAL............................... 28
DORYX............................... 11
DORYX MPC...................... 11
DORZOLAMIDE HCL......... 71
dorzolamide hcl...................71
dorzolamide hcl-timolol mal 71
dorzolamide hcl-timolol mal
pf.........................................71
dotti ..................................... 59
DOVATO.............................26
DOVONEX..........................40
doxazosin mesylate............ 30
doxepin hcl..............16, 40, 77
doxercalciferol.....................69
doxycycline......................... 40
doxycycline hyclate.............11
doxycycline monohydrate... 11
doxylamine-pyridoxine........ 17
DRISDOL............................51
DRIZALMA SPRINKLE.......16
dronabinol........................... 17
drospiren-eth estrad-
levomefol............................ 59
drospirenone-ethinyl
estradiol.............................. 59
DROXIA.............................. 21
DRYSOL............................. 40
DUAKLIR PRESSAIR......... 75
DUAVEE............................. 59
DUETACT...........................48
DUEXIS................................ 9
DULERA............................. 75
duloxetine hcl......................16
DUOBRII.............................40
DUOPA............................... 24
DUPIXENT..........................40
DURAGESIC-100................. 6
DURAGESIC-12................... 6
DURAGESIC-25................... 6
DURAGESIC-50................... 6
DURAGESIC-75................... 6
duraxin.................................. 6
DUREZOL...........................72
DURLAZA........................... 25
dutasteride.......................... 58
dutasteride-tamsulosin hcl.. 58
DUTOPROL........................30
DVORAH.............................. 7
DXEVO 11-DAY..................63
DYANAVEL XR...................34
DYAZIDE............................ 30
DYMISTA............................73
DYRENIUM.........................30
E.E.S. 400...........................11
E.E.S. GRANULES.............11
easygel............................... 36
EC-NAPROSYN................... 9
ec-naproxen..........................9
econazole nitrate................ 18
ECOZA............................... 18
EDARBI.............................. 30
EDARBYCLOR................... 30
EDECRIN............................30
EDEX.................................. 51
EDLUAR............................. 77
ed-spaz............................... 54
EDURANT.......................... 26
eemt....................................59
eemt hs............................... 59
efavirenz............................. 26
EFFER-K............................ 51
effer-k..................................51
EFFEXOR XR.....................16
EFFIENT.............................25
EFUDEX............................. 40
EGATEN............................. 24
EGRIFTA............................ 64
EGRIFTA SV...................... 64
ELESTRIN.......................... 59
eletriptan hydrobromide...... 20
ELIDEL............................... 40
ELIGARD............................ 64
ELIMITE..............................24
elinest................................. 59
ELIQUIS..............................13
ELIQUIS DVT/PE
STARTER PACK................ 13
ELITE-OB........................... 51
ELIXOPHYLLIN.................. 75
ELLA................................... 59
ELMIRON........................... 57
ELOCTATE.........................50
eluryng................................ 59
EMCYT............................... 21
EMEND...............................17
EMEND TRI-PACK............. 17
EMFLAZA........................... 63
EMGALITY..........................20
EMGALITY (300 MG
DOSE)................................ 20
emoquette...........................59
EMSAM...............................16
EMTRIVA............................26
EMVERM............................ 24
ENABLEX........................... 57
enalapril maleate................ 30
enalapril-
hydrochlorothiazide.............30
ENBRACE HR.................... 51
ENBREL............................. 66
ENBREL MINI.....................66
ENBREL SURECLICK........66
ENDARI.............................. 56
endocet................................. 7
ENDOMETRIN....................68
ENGERIX-B........................ 67
ENLITE GLUCOSE
SENSOR.............................45
enoxaparin sodium............. 13
enpresse-28........................59
enskyce...............................59
ENSTILAR.......................... 40
entacapone......................... 24
entecavir ............................. 26
ENTEREG.......................... 54
ENTOCORT EC..................68
ENTRESTO........................ 30
enulose............................... 54
ENVARSUS XR.................. 66
ENZOCLEAR......................40
EPANED............................. 30
EPCLUSA........................... 26
EPIDIOLEX.........................14
EPIDUO.............................. 40
EPIDUO FORTE.................40
EPIFOAM............................40
epinastine hcl......................69
epinephrine......................... 73
EPIPEN 2-PAK................... 73
EPIPEN JR 2-PAK..............73
epitol ................................... 14
EPIVIR................................ 26
EPIVIR HBV........................26
eplerenone..........................31
EPOGEN............................ 50
EPZICOM........................... 26
EQUETRO.......................... 28
ERGOCAL.......................... 51
ergocalciferol...................... 51
ERGOMAR......................... 20
ergotamine-caffeine............ 20
85
ERIVEDGE......................... 21
ERLEADA........................... 21
erlotinib hcl..........................21
errin.....................................59
ERTACZO...........................18
ery.......................................40
ERYGEL............................. 40
ERYPED 200...................... 11
ERYPED 400...................... 11
ERY-TAB............................ 11
ERYTHROCIN
STEARATE.........................11
erythromycin........... 12, 40, 69
erythromycin base.............. 11
erythromycin
ethylsuccinate............... 11, 12
ESBRIET............................ 76
escitalopram oxalate...........16
ESGIC...................................7
ESKATA..............................40
esomeprazole magnesium..53
ESOMEPRAZOLE
STRONTIUM...................... 53
ESPEROCT........................ 50
est estrogens-methyltest.....59
est estrogens-methyltest
ds........................................ 59
est estrogens-methyltest
hs........................................ 59
estarylla.............................. 59
estazolam........................... 28
ESTRACE...........................59
estradiol........................ 59, 60
estradiol valerate................ 60
estradiol-norethindrone
acet..................................... 60
ESTRING............................60
ESTROGEL........................ 60
ESTROSTEP FE................ 60
eszopiclone.........................77
ethacrynic acid....................31
ethambutol hcl.................... 21
ethosuximide.......................14
ethynodiol diac-eth
estradiol.............................. 60
etodolac................................ 9
etodolac er............................ 9
etonogestrel-ethinyl
estradiol.............................. 60
etoposide............................ 21
EUCRISA............................40
euthyrox.............................. 65
EVAMIST............................ 60
EVEKEO............................. 34
EVEKEO ODT.................... 34
everolimus.................... 21, 66
EVISTA............................... 69
EVOCLIN............................ 40
EVOTAZ............................. 26
EVOXAC.............................36
EVZIO................................. 10
EXELDERM........................ 18
EXELON............................. 15
exemestane........................ 21
EXFORGE.......................... 31
EXFORGE HCT..................31
EXJADE..............................56
exoderm..............................18
exotic-hc............................. 72
EXTAVIA.............................35
EXTINA...............................18
EZALLOR SPRINKLE.........31
ezetimibe............................ 31
ezetimibe-simvastatin......... 31
FABIOR.............................. 40
falmina................................ 60
famciclovir...........................26
famotidine........................... 53
FANAPT..............................25
FANAPT TITRATION
PACK.................................. 25
FARESTON........................ 22
FARXIGA............................ 48
FARYDAK...........................22
FASENRA PEN.................. 75
fayosim............................... 60
febuxostat........................... 19
FEIBA................................. 50
felbamate............................ 14
FELBATOL......................... 14
FELDENE............................. 9
felodipine er........................ 31
FEM PH.............................. 12
FEMARA.............................22
FEMHRT LOW DOSE........ 60
FEMRING........................... 60
femynor...............................60
fenofibrate...........................31
fenofibrate micronized........ 31
fenofibric acid......................31
FENOGLIDE....................... 31
fenoprofen calcium............... 9
fenortho.................................9
FENSOLVI.......................... 64
fentanyl................................. 7
fentanyl citrate...................... 7
FENTANYL CITRATE...........7
FENTORA.............................7
FERRIPROX.......................56
FETZIMA............................ 16
FETZIMA TITRATION........ 16
FEXMID.............................. 77
FIASP................................. 47
FIASP FLEXTOUCH...........47
FIASP PENFILL..................47
FIBRICOR...........................31
FINACEA............................ 40
finasteride........................... 58
FIORICET............................. 7
FIORICET/CODEINE............7
FIORINAL............................. 7
FIORINAL/CODEINE #3.......7
FIRAZYR............................ 66
FIRDAPSE..........................56
FIRMAGON........................ 64
FIRMAGON (240 MG
DOSE)................................ 64
FIRVANQ............................12
flac...................................... 72
FLAGYL.............................. 12
FLAREX..............................69
flavoxate hcl ........................57
flecainide acetate................31
FLECTOR............................. 9
FLOLIPID............................31
FLOMAX............................. 58
FLORIVA............................ 51
FLORIVA PLUS.................. 51
FLOVENT DISKUS.............75
FLOVENT HFA................... 75
FLUAD................................ 67
FLUARIX
QUADRIVALENT................67
fluconazole..........................18
flucytosine...........................18
fludrocortisone acetate....... 63
FLULAVAL
QUADRIVALENT................67
flunisolide............................73
fluocinolone acetonide.. 40, 72
fluocinolone acetonide
body.................................... 40
fluocinolone acetonide
scalp................................... 40
fluocinonide...................40, 41
fluocinonide emulsified
base.................................... 40
FLUORABON..................... 51
fluoridex.............................. 36
86
fluoridex daily renewal........ 36
fluoridex enhanced
whitening.............................36
fluoridex sensitivity relief.....36
fluoritab............................... 51
fluorometholone.................. 70
FLUOROPLEX....................41
FLUOROURACIL................41
fluorouracil.......................... 41
fluoxetine hcl.......................16
fluoxetine hcl (pmdd).......... 16
fluphenazine hcl..................25
FLURA-DROPS.................. 51
flurandrenolide.................... 41
flurazepam hcl.................... 77
flurbiprofen............................9
flurbiprofen sodium............. 70
flutamide............................. 22
fluticasone propionate...41, 73
fluticasone-salmeterol.........75
FLUTICASONE-
SALMETEROL....................75
fluvastatin sodium............... 31
fluvastatin sodium er...........31
fluvoxamine maleate...........16
fluvoxamine maleate er.......16
FLUZONE HIGH-DOSE......67
FLUZONE
QUADRIVALENT................67
FML.....................................70
FML FORTE....................... 70
FML LIQUIFILM.................. 70
FOCALIN............................ 34
FOCALIN XR...................... 34
folic acid..............................51
fondaparinux sodium.......... 13
FORFIVO XL...................... 16
formaldehyde...................... 41
FORMALDEHYDE..............41
FORTAMET........................ 48
FORTEO.............................69
FORTESTA.........................65
FORTISCARE GLUCOSE
SYSTEM............................. 45
FORTISCARE T1
GLUCOSE SYSTEM.......... 46
FOSAMAX.......................... 69
FOSAMAX PLUS D............ 69
fosamprenavir calcium........26
fosinopril sodium.................31
fosinopril sodium-hctz......... 31
FOSRENOL........................ 57
FRAGMIN........................... 13
FREESTYLE LIBRE 14
DAY READER.................... 46
FREESTYLE LIBRE 14
DAY SENSOR.................... 46
FREESTYLE LIBRE
READER.............................46
FREESTYLE LIBRE
SENSOR SYSTEM.............46
FREESTYLE PRECISION
NEO TEST..........................46
FROVA............................... 20
frovatriptan succinate..........20
FULPHILA...........................50
furosemide.......................... 31
FUZEON............................. 26
fyavolv.................................60
FYCOMPA.......................... 14
gabapentin.......................... 14
GABITRIL........................... 14
GALAFOLD.........................56
galantamine hydrobromide. 15
galantamine hydrobromide
er.........................................15
GALZIN...............................51
GARDASIL 9.......................67
GASTROCROM..................54
gatifloxacin..........................70
GATTEX............................. 55
gavilyte-c.............................55
gavilyte-g............................ 55
gavilyte-h............................ 55
gavilyte-n with flavor pack...55
GELFILM............................ 72
GELNIQUE......................... 57
gemfibrozil.......................... 31
GENERESS FE.................. 60
generlac.............................. 55
gengraf................................66
GENOTROPIN....................64
GENOTROPIN
MINIQUICK.........................64
gentak................................. 70
gentamicin sulfate.........12, 70
GENVOYA.......................... 26
GEODON............................25
gianvi.................................. 60
GILENYA............................ 35
GILOTRIF........................... 22
GILPHEX TR...................... 73
GILTUSS TR.......................73
glatiramer acetate............... 35
glatopa................................ 35
GLEEVEC...........................22
GLEOSTINE....................... 22
glimepiride.......................... 48
glipizide er...........................48
glipizide ir ............................48
glipizide xl ........................... 48
glipizide-metformin hcl ........ 48
GLOPERBA........................ 19
GLUCAGEN HYPOKIT.......46
GLUCAGON
EMERGENCY KIT........ 46, 48
GLUCOTROL..................... 48
GLUCOTROL XL................ 48
GLUCOVANCE...................48
GLUMETZA........................ 48
GLUTARALDEHYDE..........12
glyburide............................. 48
glyburide micronized...........48
glyburide-metformin............ 48
GLYCATE........................... 55
glycopyrrolate..................... 55
GLYCOPYRROLATE......... 55
GLYNASE...........................48
GLYSET..............................48
GLYXAMBI......................... 48
GOCOVRI...........................24
GOLYTELY.........................55
GONAL-F............................68
GONAL-F RFF....................68
GONAL-F RFF REDIJECT. 68
GONITRO........................... 31
GORDOFILM...................... 41
grafco silver nit applicator... 12
GRALISE............................ 36
GRALISE STARTER.......... 36
granisetron hcl .................... 17
GRANIX.............................. 50
GRASTEK...........................73
griseofulvin microsize......... 18
griseofulvin ultramicrosize.. 18
guanfacine hcl .....................31
guanfacine hcl er................ 34
GUANIDINE HCL................20
GUARDIAN CONNECT
TRANSMITTER.................. 46
GUARDIAN LINK 3
TRANSMITTER.................. 46
GUARDIAN SENSOR (3)... 46
GVOKE HYPOPEN............ 49
GVOKE PFS....................... 49
GYNAZOLE-1..................... 18
HAEGARDA........................66
hailey 1.5/30....................... 60
hailey 24 fe......................... 60
87
hailey fe 1.5/30................... 60
hailey fe 1/20...................... 60
halcinonide..........................41
HALCION............................28
halobetasol propionate....... 41
HALOBETASOL
PROPIONATE.................... 41
HALOG............................... 41
haloperidol.......................... 25
haloperidol lactate...............25
HALUCORT........................ 41
HARVONI........................... 26
HAVRIX.............................. 67
heather................................60
HEMANGEOL.....................31
hematinic/folic acid............. 51
HEMLIBRA......................... 50
hemmorex-hc......................68
hemocyte-f.......................... 52
HEMOFIL M........................50
hemorrhoidal-hc..................68
heparin sodium (porcine).... 13
heparin sodium (porcine)
pf.........................................13
HEPLISAV-B.......................67
HEPSERA...........................26
HETLIOZ.............................77
HIBERIX............................. 67
HIDEX 6-DAY..................... 63
HIPREX.............................. 12
homatropaire.......................72
HORIZANT......................... 36
HUMALOG KWIKPEN........ 47
HUMALOG MIX 50/50
KWIKPEN........................... 47
HUMALOG MIX 50/50
VIAL.................................... 47
HUMALOG MIX 75/25
KWIKPEN........................... 47
HUMALOG MIX 75/25
VIAL.................................... 47
HUMALOG U-100 JUNIOR
KWIKPEN........................... 47
HUMALOG VIAL.................47
HUMATE-P......................... 50
HUMATROPE.....................64
HUMIRA..............................66
HUMIRA PEDIATRIC
CROHNS START............... 66
HUMIRA PEN..................... 66
HUMIRA PEN-CD/UC/HS
STARTER........................... 66
HUMIRA PEN-
PS/UV/ADOL HS START... 66
HUMULIN 70/30
KWIKPEN........................... 47
HUMULIN 70/30 VIAL.........47
HUMULIN N KWIKPEN...... 47
HUMULIN N VIAL............... 47
HUMULIN R U-500
KWIKPEN........................... 47
HUMULIN R U-500 VIAL.... 47
HUMULIN R VIAL............... 47
HYCAMTIN......................... 22
hydralazine hcl....................31
HYDREA.............................22
HYDRO 40..........................41
hydrochlorothiazide.............31
hydrocodone bitartrate er......7
hydrocodone polst-cpm
polst er................................ 73
hydrocodone-
acetaminophen..................... 7
hydrocodone-homatropine..73
hydrocodone-ibuprofen.........7
hydrocortisone........ 41, 63, 68
hydrocortisone (perianal).... 68
hydrocortisone ace-
pramoxine..................... 41, 68
hydrocortisone acetate....... 68
hydrocortisone butyr lipo
base.................................... 41
hydrocortisone butyrate...... 41
hydrocortisone valerate...... 41
hydrocortisone-acetic acid.. 72
hydrocortisone-iodoquinol...18
hydrocort-pramoxine
(perianal).............................68
hydromet.............................73
hydromorphone hcl............... 7
hydromorphone hcl er...........7
hydroxychloroquine sulfate. 24
hydroxyurea........................ 22
hydroxyzine hcl................... 28
hydroxyzine pamoate..........28
hyophen.............................. 57
hyoscyamine sulfate........... 55
hyoscyamine sulfate er....... 55
hyoscyamine sulfate sl........55
hyosyne.............................. 55
HYPERSAL.........................73
HYPOCYN.......................... 72
HYSINGLA ER......................7
HYZAAR............................. 31
ibandronate sodium............ 69
IBRANCE............................22
ibu......................................... 9
ibuprofen...............................9
icatibant acetate..................66
ICLUSIG............................. 22
IDELVION........................... 50
IDHIFA................................ 22
ILEVRO...............................70
ILUMYA.............................. 41
imatinib mesylate................ 22
IMBRUVICA........................22
imipramine hcl .....................16
imipramine pamoate........... 16
imiquimod........................... 41
IMIQUIMOD PUMP.............41
IMITREX............................. 20
IMITREX STATDOSE
REFILL................................20
IMITREX STATDOSE
SYSTEM............................. 20
IMPAVIDO.......................... 24
IMPOYZ.............................. 41
IMURAN..............................66
IMVEXXY MAINTENANCE
PACK.................................. 51
IMVEXXY STARTER
PACK.................................. 51
INBRIJA.............................. 24
incassia...............................60
INCRELEX..........................64
INCRUSE ELLIPTA............ 75
indapamide......................... 31
INDERAL LA.......................31
INDERAL XL.......................31
INDOCIN...............................9
INDOMETHACIN.................. 9
indomethacin........................ 9
indomethacin er.................... 9
INGREZZA..........................36
INLYTA............................... 22
INNOPRAN XL................... 31
INOVA.................................41
INOVA 4/1 ACNE
CONTROL THERAPY........ 41
INOVA 8/2 ACNE
CONTROL THERAPY........ 41
INREBIC............................. 22
INSPRA.............................. 31
INSULIN ASP PROT &
ASP FLEXPEN................... 47
INSULIN ASPART.............. 47
INSULIN ASPART
FLEXPEN........................... 47
88
INSULIN ASPART
PENFILL............................. 47
INSULIN ASPART PROT
& ASPART.......................... 47
INSULIN LISPRO............... 47
INSULIN LISPRO (1 UNIT
DIAL)...................................47
INSULIN LISPRO JUNIOR
KWIKPEN........................... 47
INSULIN LISPRO PROT &
LISPRO...............................47
INSULIN PEN NEEDLES... 46
INTELENCE........................26
INTERMEZZO.................... 77
INTRAROSA.......................51
INTRON A...........................26
introvale.............................. 60
INTUNIV............................. 35
INVEGA.............................. 25
INVELTYS.......................... 70
INVIRASE........................... 26
INVOKAMET.......................49
INVOKAMET XR.................49
INVOKANA......................... 49
IODINE STRONG............... 52
iodine tincture..................... 12
IOPIDINE............................ 72
IPOL....................................67
ipratropium bromide......73, 75
ipratropium-albuterol...........75
irbesartan............................31
irbesartan-
hydrochlorothiazide.............31
IRESSA...............................22
ISENTRESS....................... 26
ISENTRESS HD................. 26
isibloom...............................60
isoniazid..............................21
ISOPTO CARPINE............. 72
ISORDIL TITRADOSE........31
isosorbide dinitrate..............31
isosorbide mononitrate....... 31
isosorbide mononitrate er... 31
isotretinoin.......................... 41
isoxsuprine hcl.................... 31
isradipine............................ 31
ISTALOL............................. 71
itraconazole........................ 18
ivermectin........................... 24
IXINITY............................... 50
JADENU............................. 56
JADENU SPRINKLE...........56
jaimiess...............................60
JAKAFI................................22
JALYN.................................58
jantoven.............................. 13
JANUMET...........................49
JANUMET XR.....................49
JANUVIA.............................49
JARDIANCE....................... 49
jasmiel.................................60
JATENZO........................... 65
jencycla...............................60
JENTADUETO....................49
JENTADUETO XR..............49
jinteli ....................................60
JIVI......................................50
jolessa.................................60
JORNAY PM.......................35
JUBLIA................................18
juleber................................. 60
JULUCA..............................26
junel 1.5/30......................... 60
junel 1/20............................ 60
junel fe 1.5/30..................... 60
junel fe 1/20........................ 60
junel fe 24........................... 60
JUXTAPID.......................... 31
JYNARQUE........................ 56
KADIAN................................ 7
kaitlib fe...............................60
KALETRA........................... 26
kalliga..................................60
KALYDECO........................ 76
KAPSPARGO SPRINKLE.. 31
KAPVAY............................. 35
KARBINAL ER.................... 74
kariva.................................. 60
KATERZIA.......................... 31
KAZANO............................. 49
KEFLEX.............................. 12
kelnor 1/35.......................... 60
kelnor 1/50.......................... 60
KENALOG.......................... 41
KEPPRA............................. 14
KEPPRA XR....................... 14
KERALAC........................... 41
KERALYT SCALP...............41
KERYDIN............................18
ketoconazole.......................18
ketodan............................... 18
ketoprofen.............................9
ketoprofen er.........................9
ketorolac tromethamine.. 9, 70
KEVEYIS............................ 31
KEVZARA........................... 66
KINERET............................ 66
kionex................................. 52
KISQALI (200 MG DOSE).. 22
KISQALI (400 MG DOSE).. 22
KISQALI (600 MG DOSE).. 22
KISQALI FEMARA (400
MG DOSE)..........................22
KISQALI FEMARA (600
MG DOSE)..........................22
KISQALI FEMARA(200
MG DOSE)..........................22
KITABIS PAK......................76
KLARON............................. 41
KLONOPIN......................... 28
klor-con............................... 52
klor-con 10.......................... 52
klor-con m10....................... 52
KLOR-CON M15.................52
klor-con m20....................... 52
klor-con sprinkle..................52
klor-con/ef........................... 52
KOATE................................50
KOATE-DVI........................ 50
KOGENATE FS.................. 50
KOMBIGLYZE XR.............. 49
KORLYM.............................64
KOVALTRY.........................50
K-PHOS.............................. 52
K-PHOS NO 2.....................52
K-PHOS-NEUTRAL............ 52
k-prime................................52
KRINTAFEL........................ 24
KRISTALOSE..................... 55
K-TAB................................. 52
kurvelo................................ 60
KUVAN............................... 56
labetalol hcl .........................31
LACRISERT........................72
lactulose..............................55
lactulose encephalopathy... 55
LAMICTAL.......................... 14
LAMICTAL ODT..................14
LAMICTAL STARTER........ 14
LAMICTAL XR.................... 14
lamivudine...........................26
lamivudine-zidovudine........ 26
lamotrigine.......................... 14
lamotrigine er...................... 14
lamotrigine starter kit-blue.. 14
lamotrigine starter kit-
green...................................14
lamotrigine starter kit-
orange.................................14
89
LANCETS........................... 46
LANOXIN............................ 31
lansoprazole................. 53, 54
lanthanum carbonate.......... 57
LANTUS SOLOSTAR......... 47
LANTUS U-100 VIAL.......... 47
larin 1.5/30.......................... 60
larin 1/20............................. 60
larin 24 fe............................ 60
larin fe 1.5/30...................... 60
larin fe 1/20......................... 60
larissia.................................60
LASIX..................................31
LASTACAFT....................... 70
latanoprost.......................... 71
LATUDA..............................25
layolis fe..............................60
LAZANDA............................. 7
L-CYSTINE......................... 52
LEDIPASVIR-
SOFOSBUVIR.................... 26
leena................................... 60
leflunomide......................... 66
LENVIMA (10 MG DAILY
DOSE)................................ 22
LENVIMA (12 MG DAILY
DOSE)................................ 22
LENVIMA (14 MG DAILY
DOSE)................................ 22
LENVIMA (18 MG DAILY
DOSE)................................ 22
LENVIMA (20 MG DAILY
DOSE)................................ 22
LENVIMA (24 MG DAILY
DOSE)................................ 22
LENVIMA (4 MG DAILY
DOSE)................................ 22
LENVIMA (8 MG DAILY
DOSE)................................ 22
LESCOL XL........................ 31
lessina.................................60
LETAIRIS............................76
letrozole.............................. 22
leucovorin calcium.............. 22
LEUKERAN........................ 22
LEUKINE............................ 50
leuprolide acetate............... 64
levalbuterol hcl ....................75
LEVALBUTEROL HFA....... 75
LEVBID............................... 55
LEVEMIR U-100
FLEXTOUCH...................... 47
LEVEMIR U-100 VIAL........ 47
levetiracetam...................... 14
levetiracetam er.................. 14
LEVITRA.............................51
levobunolol hcl.................... 71
levocarnitine........................52
levocarnitine sf....................52
levocetirizine
dihydrochloride................... 74
levofloxacin................... 12, 70
levonest.............................. 60
levonorgest-eth est & eth
est....................................... 61
levonorgest-eth estrad 91-
day...................................... 61
levonorgestrel-ethinyl
estrad..................................61
levonorg-eth estrad
triphasic.............................. 61
levora 0.15/30 (28)..............61
levorphanol tartrate...............7
levo-t................................... 65
levothyroxine sodium.......... 65
levoxyl.................................65
LEVSIN............................... 55
LEVSIN/SL..........................55
LEVULAN KERASTICK...... 41
LEXAPRO...........................16
LEXETTE............................42
LEXIVA......................... 26, 27
LIALDA............................... 68
LIBRAX............................... 55
lidocaine................................7
lidocaine hcl.................... 7, 36
lidocaine hcl
urethral/mucosal................... 7
lidocaine viscous hcl........... 36
LIDOCAINE-
HYDROCORTISONE ACE. 42
lidocaine-prilocaine............... 7
LIDODERM...........................7
lillow.................................... 61
lindane................................ 24
linezolid...............................12
LINZESS.............................55
liothyronine sodium.............65
LIPITOR..............................31
LIPOFEN............................ 31
lisinopril...............................31
lisinopril-
hydrochlorothiazide.............31
lithium................................. 28
lithium carbonate................ 28
lithium carbonate er............ 28
LITHOBID........................... 29
LITHOSTAT........................ 57
LIVALO............................... 31
LO LOESTRIN FE.............. 61
LOCOID.............................. 42
LOCOID LIPOCREAM........42
LODINE................................ 9
LODOSYN.......................... 24
LOESTRIN 1.5/30 (21)....... 61
LOESTRIN 1/20 (21) .......... 61
LOESTRIN FE 1.5/30......... 61
LOESTRIN FE 1/20............ 61
lojaimiess............................ 61
LOKELMA...........................52
LOMOTIL............................ 55
LONHALA MAGNAIR
REFILL KIT......................... 75
LONHALA MAGNAIR
STARTER KIT.................... 75
LONSURF...........................22
loperamide hcl.................... 55
LOPID................................. 31
lopinavir-ritonavir................ 27
lopreeza.............................. 61
LOPRESSOR..................... 31
LOPRESSOR HCT............. 31
LOPROX.......................18, 19
lorazepam........................... 28
lorazepam intensol ..............28
LORBRENA........................ 22
lorcet..................................... 7
lorcet hd................................ 7
lorcet plus............................. 7
LORTAB............................... 7
loryna.................................. 61
LORZONE.......................... 77
losartan potassium..............31
losartan potassium-hctz......31
LOSEASONIQUE............... 61
LOTEMAX...........................70
LOTEMAX SM.................... 70
LOTENSIN..........................31
LOTENSIN HCT................. 31
loteprednol etabonate......... 70
LOTREL..............................31
LOTRONEX........................ 55
lovastatin.............................32
LOVAZA..............................32
LOVENOX.......................... 13
low-ogestrel........................ 61
loxapine succinate.............. 25
lo-zumandimine.................. 61
LUCEMYRA........................10
90
ludent.................................. 52
LULICONAZOLE................ 19
LUMIGAN........................... 71
LUNESTA........................... 77
lutera...................................61
LUXIQ................................. 42
LUZU.................................. 19
LYNPARZA.........................22
LYRICA...............................36
LYRICA CR.........................36
LYSODREN........................ 22
LYSTEDA........................... 50
lyza..................................... 61
MACROBID........................ 12
MACRODANTIN................. 12
mafenide acetate................ 12
MAGNEBIND 400............... 52
MALARONE........................24
malathion............................ 24
maprotiline hcl.....................16
MARINOL........................... 17
marlissa.............................. 61
MARPLAN.......................... 16
MATULANE........................ 22
matzim la............................ 32
MAVENCLAD (10 TABS)....35
MAVENCLAD (4 TABS)......35
MAVENCLAD (5 TABS)......35
MAVENCLAD (6 TABS)......35
MAVENCLAD (7 TABS)......35
MAVENCLAD (8 TABS)......35
MAVENCLAD (9 TABS)......35
MAVYRET.......................... 27
MAXALT............................. 20
MAXALT-MLT..................... 20
MAXIDEX............................70
MAXITROL......................... 70
MAXZIDE............................32
MAXZIDE-25.......................32
MAYZENT...........................35
MAYZENT STARTER
PACK.................................. 35
me/naphos/mb/hyo1........... 57
meclizine hcl....................... 17
meclofenamate sodium.........9
MEDROL............................ 63
medroxyprogesterone
acetate................................ 61
mefenamic acid.....................9
mefloquine hcl.....................24
megestrol acetate............... 61
MEKINIST...........................22
MEKTOVI............................22
melodetta 24 fe................... 61
meloxicam.............................9
melphalan........................... 22
memantine hcl.................... 15
memantine hcl er................ 15
MENACTRA........................67
MENEST.............................61
MENOSTAR....................... 61
MENTAX.............................19
MENVEO............................ 67
meperidine hcl...................... 7
MEPHYTON....................... 52
meprobamate......................28
MEPRON............................ 24
mercaptopurine...................22
mesalamine........................ 68
mesalamine er.................... 68
mesalamine-cleanser..........68
MESNEX.............................22
MESTINON.........................20
metadate er.........................35
metaproterenol sulfate........ 75
metaxalone......................... 77
metformin hcl er.................. 49
metformin hcl er (mod)........49
metformin hcl er (osm)........49
metformin hcl ir................... 49
methadone hcl...................... 7
methadone hcl intensol.........7
methadose............................ 7
methadose sugar-free...........7
methamphetamine hcl........ 35
methazolamide................... 32
methenamine hippurate...... 12
methenamine mandelate.... 12
methimazole....................... 65
METHITEST....................... 65
methocarbamol................... 77
methotrexate.......................66
methotrexate sodium.......... 66
methoxsalen rapid.............. 42
methscopolamine bromide..55
methyl salicylate................. 42
methyldopa......................... 32
methyldopa-
hydrochlorothiazide.............32
METHYLIN..........................35
methylphenidate hcl............35
methylphenidate hcl er........35
methylphenidate hcl er (cd) 35
methylphenidate hcl er (la). 35
METHYLPHENIDATE HCL
ER (XR).............................. 35
methylprednisolone.............63
methyltestosterone............. 65
metoclopramide hcl .............17
metolazone......................... 32
metoprolol succinate er.......32
metoprolol tartrate...............32
metoprolol-
hydrochlorothiazide.............32
METROCREAM..................42
METROGEL........................42
METROLOTION................. 42
metronidazole............... 12, 42
mexiletine hcl...................... 32
MIACALCIN........................ 69
mibelas 24 fe...................... 61
MICARDIS.......................... 32
MICARDIS HCT..................32
miconazole 3.......................19
MICONAZOLE-ZINC
OXIDE-PETROLAT............ 19
MICRODOT TEST.............. 46
microgestin 1.5/30.............. 61
microgestin 1/20................. 61
microgestin fe 1.5/30.......... 61
microgestin fe 1/20............. 61
midazolam hcl.....................28
midodrine hcl...................... 32
MIGERGOT........................ 20
miglitol.................................49
miglustat............................. 56
MIGRANAL......................... 20
mili ...................................... 61
MILLIPRED.........................63
MILLIPRED DP...................63
MILLIPRED DP 12-DAY..... 63
mimvey............................... 61
MINASTRIN 24 FE............. 61
mineral oil heavy.................55
MINIPRESS........................ 32
minitran............................... 32
MINIVELLE......................... 61
MINOCIN............................ 12
minocycline hcl................... 12
MINOCYCLINE HCL ER.....12
minocycline hcl er............... 12
MINOLIRA.......................... 12
minoxidil ..............................32
MIRAPEX............................24
MIRAPEX ER......................24
MIRCETTE......................... 61
mirtazapine......................... 16
MIRVASO........................... 42
misoprostol......................... 54
91
MITIGARE.......................... 19
MITOSOL............................72
M-M-R II..............................67
M-NATAL PLUS..................52
MOBIC.................................. 9
modafinil ............................. 77
moexipril hcl ........................32
molindone hcl......................25
mometasone furoate.....42, 74
mondoxyne nl..................... 12
mono-linyah........................ 61
MONONINE........................ 50
monsels ferric subsulfate.... 50
montelukast sodium............75
MONUROL......................... 12
MORGIDOX........................12
morgidox............................. 12
morphine sulfate................... 8
morphine sulfate
(concentrate).........................7
morphine sulfate er............... 8
morphine sulfate er beads.... 8
MOTEGRITY...................... 55
MOTOFEN..........................55
MOVANTIK......................... 55
MOVIPREP.........................55
MOXEZA.............................70
moxifloxacin hcl............ 12, 70
moxifloxacin hcl (2x day).... 70
MOZOBIL............................50
MS CONTIN..........................8
MUCOSITISRX...................36
MULPLETA.........................50
MULTAQ.............................32
multi-vit/iron/fluoride............52
multivitamin/fluoride............ 52
multi-vitamin/fluoride...........52
multivitamin/fluoride/iron..... 52
multi-vitamin/fluoride/iron....52
multivitamins/fluoride.......... 52
mupirocin............................ 12
mupirocin calcium............... 12
MUSE................................. 51
mvc-fluoride........................ 52
MYALEPT........................... 56
MYAMBUTOL..................... 21
MYCOBUTIN...................... 21
mycophenolate mofetil ........66
mycophenolate sodium.......66
MYDAYIS............................35
MYFORTIC......................... 66
MYLERAN.......................... 22
myorisan............................. 42
MYRBETRIQ...................... 57
MYSOLINE......................... 14
MYTESI.............................. 55
nabumetone..........................9
n-acetyl-l-cysteine...............52
nadolol................................ 32
nafrinse............................... 52
NAFRINSE DAILY
ACIDULATED..................... 36
NAFRINSE
DAILY/NEUTRAL................36
nafrinse drops..................... 52
NAFRINSE WEEKLY..........36
naftifine hcl..........................19
NAFTIN...............................19
NALFON............................... 9
NALOCET.............................8
naloxone hcl........................10
NALOXONE HCL................10
naltrexone hcl..................... 10
NAMENDA..........................15
NAMENDA TITRATION
PAK.....................................15
NAMENDA XR....................15
NAMENDA XR
TITRATION PACK.............. 15
NAMZARIC......................... 16
NAPRELAN.......................... 9
NAPROSYN..........................9
naproxen...............................9
naproxen dr...........................9
naproxen sodium.................. 9
naproxen sodium er.............. 9
naproxen-esomeprazole....... 9
naratriptan hcl..................... 20
NARCAN.............................10
NARDIL...............................16
NASCOBAL........................ 52
NASONEX.......................... 74
NATACYN...........................70
NATAZIA.............................61
nateglinide.......................... 49
NATESTO...........................65
NATPARA...........................69
NATROBA.......................... 24
NATURE-THROID.............. 65
NAYZILAM..........................14
NEBUPENT........................ 24
nebusal............................... 74
NEBUSAL........................... 74
necon 0.5/35 (28)................61
nefazodone hcl................... 16
neomycin sulfate.................12
neomycin-bacitracin zn-
polymyx...............................70
neomycin-polymyxin-
dexameth............................ 70
neomycin-polymyxin-
gramicidin........................... 70
neomycin-polymyxin-hc 70, 72
NEONATAL COMPLETE....52
NEONATAL PLUS.............. 52
neo-polycin......................... 70
neo-polycin hc.....................70
NEORAL............................. 66
NEO-SYNALAR............ 12, 42
NEOTUSS PLUS................ 74
NERLYNX...........................22
NESINA.............................. 49
NESTABS........................... 52
NESTABS ONE.................. 52
neuac.................................. 42
NEUAC............................... 42
NEULASTA.........................50
NEUPOGEN....................... 50
NEUPRO............................ 24
NEURONTIN...................... 15
neutral sodium fluoride....... 36
NEVANAC.......................... 70
nevirapine........................... 27
nevirapine er....................... 27
NEXAVAR...........................22
NEXIUM..............................54
NEXLETOL......................... 32
NEXLIZET...........................32
niacin (antihyperlipidemic).. 32
niacin er
(antihyperlipidemic).............32
niacor.................................. 32
NIASPAN............................ 32
nicardipine hcl.....................32
NICOTROL......................... 10
NICOTROL NS................... 10
nifedipine............................ 32
nifedipine er........................ 32
nifedipine er osmotic
release................................ 32
nikki.....................................61
nilutamide........................... 22
nimodipine.......................... 32
NINLARO............................22
nisoldipine er .......................32
nitisinone.............................56
NITRO-BID......................... 32
NITRO-DUR........................32
nitrofurantoin.......................12
92
nitrofurantoin macrocrystal. 12
nitrofurantoin monohydrate
macrocrystals......................12
nitroglycerin........................ 32
NITROLINGUAL................. 32
NITROMIST........................ 32
NITROSTAT....................... 32
nitro-time.............................32
NITYR................................. 56
NIVESTYM......................... 50
nizatidine.............................54
NOCDURNA....................... 64
nolix.................................... 42
nora-be............................... 61
NORCO................................ 8
NORDITROPIN FLEXPRO.64
norethin ace-eth estrad-fe...61
norethindrone......................62
norethindrone acetate.........61
norethindrone acet-ethinyl
est....................................... 61
norethindrone-eth estradiol.62
norethin-eth estradiol-fe......62
NORGESIC FORTE........... 77
norgestimate-eth estradiol.. 62
norgestimate-ethinyl
estradiol triphasic................62
NORITATE..........................42
norlyda................................ 62
norlyroc............................... 62
NORPACE.......................... 32
NORPACE CR....................32
NORPRAMIN......................16
NORTHERA........................32
nortrel 0.5/35 (28)............... 62
nortrel 1/35 (21).................. 62
nortrel 1/35 (28).................. 62
nortrel 7/7/7.........................62
nortriptyline hcl....................16
NORVASC.......................... 32
NORVIR..............................27
NOURIANZ......................... 24
NOVOEIGHT...................... 50
NOVOFINE AUTOCOVER
PEN NEEDLE..................... 46
NOVOFINE PEN NEEDLE. 46
NOVOFINE PLUS PEN
NEEDLE............................. 46
NOVOLIN 70/30 FLEXPEN 47
NOVOLIN 70/30 FLEXPEN
RELION.............................. 48
NOVOLIN 70/30 RELION... 48
NOVOLIN 70/30 VIAL.........48
NOVOLIN N FLEXPEN.......48
NOVOLIN N FLEXPEN
RELION.............................. 48
NOVOLIN N RELION..........48
NOVOLIN N VIAL............... 48
NOVOLIN R FLEXPEN.......48
NOVOLIN R FLEXPEN
RELION.............................. 48
NOVOLIN R RELION..........48
NOVOLIN R VIAL............... 48
NOVOLOG FLEXPEN........ 48
NOVOLOG MIX 70/30
FLEXPEN........................... 48
NOVOLOG MIX 70/30
VIAL.................................... 48
NOVOLOG PENFILL.......... 48
NOVOLOG U-100 VIAL...... 48
NOVOPEN ECHO.............. 46
NOVOSEVEN RT............... 50
NOXAFIL............................ 19
np thyroid............................ 65
NUBEQA.............................22
NUCALA............................. 75
NUCORT............................ 42
NUCYNTA............................ 8
NUCYNTA ER...................... 8
NUEDEXTA........................ 36
NULEV................................55
NULYTELY WITH
FLAVOR PACKS................ 55
NUPLAZID.......................... 25
NURTEC.............................20
NUTRIDOX......................... 12
NUTROPIN AQ NUSPIN
10........................................64
NUTROPIN AQ NUSPIN
20........................................64
NUTROPIN AQ NUSPIN 5. 64
NUVAIL...............................42
NUVARING.........................62
NUVESSA...........................12
NUVIGIL............................. 77
NUWIQ............................... 50
NUZYRA............................. 12
nyamyc............................... 19
nystatin............................... 19
nystatin-triamcinolone.........19
nystop................................. 19
OCALIVA............................ 55
ocella.................................. 62
octreotide acetate............... 64
OCUFLOX.......................... 70
ODACTRA.......................... 74
ODEFSEY...........................27
ODOMZO............................22
OFEV.................................. 76
ofloxacin..................12, 70, 72
olanzapine.......................... 25
olanzapine-fluoxetine hcl.... 16
olmesartan medoxomil ........32
olmesartan medoxomil-
hctz..................................... 32
olmesartan-amlodipine-
hctz..................................... 32
olopatadine hcl ..............70, 74
OLUMIANT......................... 66
OLUX.................................. 42
OLUX-E.............................. 42
OMECLAMOX-PAK............ 54
omega-3-acid ethyl esters.. 32
omeprazole......................... 54
omeprazole-sodium
bicarbonate......................... 54
OMNARIS........................... 74
OMNITROPE...................... 64
ondansetron hcl .................. 17
ondansetron odt..................17
ONETOUCH ULTRA 2 KIT
W/DEVICE.......................... 46
ONETOUCH ULTRA
BLUE TEST STRIPS.......... 46
ONETOUCH ULTRA MINI
KIT W/DEVICE................... 46
ONETOUCH VERIO FLEX
SYSTEM KIT W/DEVICE....46
ONETOUCH VERIO IQ
SYSTEM............................. 46
ONETOUCH VERIO KIT
W/DEVICE.......................... 46
ONETOUCH VERIO
REFLECT........................... 46
ONETOUCH VERIO
SYNC SYSTEM KIT
W/DEVICE.......................... 46
ONEXTON.......................... 42
ONFI................................... 15
ONGLYZA...........................49
ONZETRA XSAIL............... 20
opium.................................. 55
OPSUMIT........................... 76
ORACEA.............................42
ORACIT.............................. 52
ORALAIR............................ 74
ORALAIR ADULT
SAMPLE KIT.......................74
93
ORALAIR ADULT
STARTER PACK................ 74
ORALAIR CHILDRENS
SAMPLE KIT.......................74
ORALAIR CHILDRENS
STARTER PACK................ 74
oralone................................36
ORAPRED ODT................. 63
ORAVIG..............................19
ORENCIA........................... 66
ORENCIA CLICKJECT.......66
ORENITRAM...................... 77
ORFADIN............................56
ORIAHNN........................... 62
ORILISSA........................... 64
ORKAMBI........................... 76
orphenadrine citrate er........77
orsythia............................... 62
ORTHO MICRONOR..........62
oscimin................................55
oscimin sr............................55
oseltamivir phosphate.........27
OSENI.................................49
OSMOLEX ER.................... 24
OSMOPREP....................... 55
OSPHENA.......................... 51
OTEZLA..............................66
OTICIN HC NR................... 72
OTOVEL............................. 72
OTREXUP.......................... 66
OVACE PLUS.....................42
OVACE PLUS WASH......... 42
OVACE WASH................... 42
OVIDE.................................24
OVIDREL............................ 68
oxandrolone........................ 65
oxaprozin.............................. 9
OXAYDO.............................. 8
oxazepam........................... 28
OXBRYTA...........................50
oxcarbazepine.................... 15
OXERVATE........................ 72
oxiconazole nitrate..............19
OXISTAT............................ 19
OXSORALEN ULTRA.........42
OXTELLAR XR................... 15
oxybutynin chloride............. 57
oxybutynin chloride er.........57
oxycodone hcl.......................8
OXYCODONE HCL ER........ 8
oxycodone-acetaminophen...8
oxycodone-aspirin.................8
OXYCONTIN........................ 8
oxymorphone hcl.................. 8
oxymorphone hcl er.............. 8
OXYTROL...........................57
OZEMPIC........................... 49
OZOBAX.............................77
PACERONE........................32
pacerone.............................32
PALFORZIA (12 MG
DAILY DOSE)..................... 66
PALFORZIA (120 MG
DAILY DOSE)..................... 66
PALFORZIA (160 MG
DAILY DOSE)..................... 66
PALFORZIA (20 MG
DAILY DOSE)..................... 66
PALFORZIA (200 MG
DAILY DOSE)..................... 66
PALFORZIA (240 MG
DAILY DOSE)..................... 66
PALFORZIA (3 MG DAILY
DOSE)................................ 66
PALFORZIA (300 MG
MAINTENANCE)................ 66
PALFORZIA (300 MG
TITRATION)........................66
PALFORZIA (40 MG
DAILY DOSE)..................... 66
PALFORZIA (6 MG DAILY
DOSE)................................ 66
PALFORZIA (80 MG
DAILY DOSE)..................... 66
PALFORZIA INITIAL
ESCALATION..................... 66
paliperidone er.................... 25
PALYNZIQ.......................... 56
PAMELOR.......................... 17
PANCREAZE......................56
PANDEL............................. 42
PANRETIN..........................22
pantoprazole sodium.......... 54
paricalcitol...........................69
PARLODEL.........................24
PARNATE...........................17
paroex.................................36
paromomycin sulfate...........12
paroxetine hcl..................... 17
paroxetine hcl er................. 17
paroxetine mesylate............17
PASER................................21
PATANASE.........................74
PAXIL..................................17
PAXIL CR........................... 17
PAZEO................................70
PCP 100............................. 55
PEDIAPRED....................... 63
PEDIZOLPAK..................... 19
PEDVAX HIB...................... 67
peg 3350-kcl-na bicarb-
nacl..................................... 55
peg-3350/electrolytes......... 55
PEGANONE....................... 15
PEGASYS...........................27
PEGASYS PROCLICK....... 27
PEGINTRON...................... 27
peg-prep............................. 55
penicillamine....................... 56
penicillin v potassium..........12
PENNSAID........................... 9
pentamidine isethionate......24
PENTASA........................... 68
pentazocine-naloxone hcl ..... 8
pentoxifylline er...................32
PEPCID.............................. 54
PERCOCET..........................8
PERFOROMIST................. 76
PERIDEX............................ 36
perindopril erbumine........... 33
periogard.............................36
permethrin...........................24
perphenazine...................... 17
perphenazine-amitriptyline..17
PERTZYE........................... 56
PEXEVA............................. 17
phenazo.............................. 57
phenazopyridine hcl............57
phenelzine sulfate...............17
phenobarbital ...................... 15
phenoxybenzamine hcl ....... 33
phenylephrine hcl ................72
PHENYTEK........................ 15
phenytoin............................ 15
phenytoin infatabs...............15
phenytoin sodium
extended............................. 15
philith.................................. 62
PHOSLYRA........................ 57
phospha 250 neutral ........... 52
phosphasal......................... 57
PHOSPHOLINE IODIDE.... 72
phosphorous....................... 52
phospho-trin 250 neutral .....52
PHOTREXA-PHOTREXA
VISCOUS KIT..................... 72
phytonadione...................... 52
PICATO.............................. 42
PIFELTRO.......................... 27
94
pilocarpine hcl...............36, 72
pimecrolimus.......................42
pimozide............................. 25
pimtrea................................62
pindolol ............................... 33
pioglitazone hcl................... 49
pioglitazone hcl-glimepiride 49
pioglitazone hcl-metformin
hcl....................................... 49
PIQRAY (200 MG DAILY
DOSE)................................ 22
PIQRAY (250 MG DAILY
DOSE)................................ 22
PIQRAY (300 MG DAILY
DOSE)................................ 22
pirmella 1/35....................... 62
pirmella 7/7/7...................... 62
piroxicam.............................. 9
PLAQUENIL........................24
PLAVIX............................... 25
PLEGRIDY..........................35
PLEGRIDY STARTER
PACK.................................. 35
PLENVU............................. 55
PLEXION............................ 42
PLEXION CLEANSER........42
PLEXION CLEANSING
CLOTH................................42
PNEUMOVAX 23................67
pnv prenatal plus
multivit+dha.........................52
podocon.............................. 42
podofilox............................. 42
polycin.................................70
polymyxin b-trimethoprim....70
POLYTRIM......................... 70
POLY-VI-FLOR...................52
POLY-VI-FLOR/IRON.........52
POMALYST........................ 23
portia-28..............................62
posaconazole......................19
pot bicarb-pot chloride........ 52
POTABA............................. 52
potassium bicarbonate........52
potassium chloride..............52
potassium chloride crys er.. 52
potassium chloride er..........52
potassium citrate er............ 52
potassium citrate-citric acid 52
PR BENZOYL PEROXIDE. 42
pr benzoyl peroxide wash... 42
PRADAXA...........................13
PRALUENT.........................33
pramipexole
dihydrochloride................... 24
pramipexole
dihydrochloride er............... 24
pramosone..........................42
PRAMOSONE.............. 42, 43
PRAMOTIC.........................72
pramox..................................8
prasugrel hcl....................... 25
PRAVACHOL......................33
pravastatin sodium..............33
praziquantel........................ 24
prazosin hcl.........................33
PRECISION LINK............... 46
PRECISION PCX PLUS
TEST...................................46
PRECISION QID
MONITOR...........................46
PRECISION QID TEST...... 46
PRECISION SOF-TACT
MONITOR...........................46
PRECISION SOF-TACT
TEST...................................46
PRECISION XTRA............. 46
PRECISION XTRA
BLOOD GLUCOSE.............46
PRECISION XTRA
MONITOR...........................46
PRECOSE.......................... 49
PRED FORTE.....................70
PRED MILD........................ 70
PRED-G..............................70
PRED-G S.O.P................... 70
prednicarbate......................43
prednisolone....................... 63
prednisolone acetate.......... 70
prednisolone sodium
phosphate..................... 63, 70
prednisone.......................... 63
prednisone intensol.............63
PREFEST........................... 62
pregabalin........................... 36
PREGENNA........................52
PREMARIN.........................62
PREMESISRX.................... 52
premium lidocaine.................8
PREMPHASE..................... 62
PREMPRO..........................62
PRENAISSANCE................52
PRENATA...........................52
prenatal...............................52
prenatal plus iron................ 52
PRENATE...........................52
PRENATE DHA.................. 52
PRENATE ELITE................52
PRENATE ENHANCE........ 53
PRENATE ESSENTIAL...... 53
PRENATE MINI.................. 53
PRENATE PIXIE.................53
PRENATE RESTORE........ 53
PREPIDIL........................... 64
PRESTALIA........................ 33
PRETOMANID....................21
PREVACID......................... 54
PREVACID SOLUTAB........54
prevalite.............................. 33
PREVIDENT....................... 37
PREVIDENT 5000
BOOSTER PLUS................36
PREVIDENT 5000 DRY
MOUTH...............................36
PREVIDENT 5000
ENAMEL PROTECT...........36
PREVIDENT 5000 ORTHO
DEFENSE...........................36
PREVIDENT 5000 PLUS....36
PREVIDENT 5000
SENSITIVE......................... 37
previfem.............................. 62
PREVNAR 13..................... 67
PREVYMIS......................... 27
PREZCOBIX....................... 27
PREZISTA.......................... 27
PRIFTIN..............................21
PRILOSEC..........................54
PRIMACARE...................... 53
primaquine phosphate........ 24
primidone............................ 15
PRIMLEV.............................. 8
PRIMSOL............................12
PRINIVIL.............................33
PRISTIQ............................. 17
PROAIR DIGIHALER..........76
PROAIR HFA......................76
PROAIR RESPICLICK........76
probenecid.......................... 19
PROCARDIA...................... 33
PROCARDIA XL................. 33
PROCENTRA..................... 35
prochlorperazine................. 17
prochlorperazine maleate... 17
PROCORT..........................68
PROCRIT............................50
PROCTOCORT.................. 68
PROCTOFOAM HC............68
procto-med hc.....................68
95
procto-pak...........................68
proctosol hc........................ 68
proctozone-hc..................... 68
PROCYSBI......................... 56
PROFILNINE...................... 50
PROFILNINE SD................ 50
progesterone.......................62
progesterone micronized.... 62
PROGLYCEM.....................46
PROGRAF.......................... 66
PROLATE............................. 8
PROLENSA........................ 70
PROMACTA....................... 50
promethazine hcl................ 17
promethazine-codeine........ 74
promethazine-dm................74
promethazine-phenyleph-
codeine............................... 74
promethazine-
phenylephrine..................... 74
promethegan.......................18
PROMETRIUM................... 62
PROMISEB.........................43
propafenone hcl.................. 33
propafenone hcl er..............33
propantheline bromide........ 55
proparacaine hcl ................. 72
propranolol hcl .................... 33
propranolol hcl er................ 33
propranolol-hctz.................. 33
propylthiouracil....................65
PROSCAR.......................... 58
PROSTIN E2...................... 64
PROTONIX......................... 54
PROTOPIC......................... 43
protriptyline hcl....................17
PROVENTIL HFA............... 76
PROVERA.......................... 62
PROVIGIL...........................77
PROZAC.............................17
PRUDOXIN.........................43
pseudoephedrine-
bromphen-dm..................... 74
PSORCON..........................43
PULMICORT FLEXHALER.76
PULMICORT
SUSPENSION.................... 76
pulmosal............................. 74
PULMOZYME..................... 76
PURIXAN............................23
PYLERA..............................54
pyrazinamide...................... 21
PYRIDIUM.......................... 57
pyridostigmine bromide.......20
pyridostigmine bromide er.. 20
pyrimethamine.................... 24
PYROGALLIC ACID........... 43
QBRELIS............................ 33
QMIIZ ODT........................... 9
QNASL................................74
QNASL CHILDRENS..........74
QTERN............................... 49
QUALAQUIN.......................24
QUARTETTE...................... 62
quazepam........................... 28
QUDEXY XR.......................15
QUESTRAN........................33
QUESTRAN LIGHT............ 33
quetiapine fumarate............ 25
quetiapine fumarate er........25
QUFLORA PEDIATRIC...... 53
QUILLICHEW ER............... 35
QUILLIVANT XR.................35
quinapril hcl.........................33
quinapril-
hydrochlorothiazide.............33
quinidine gluconate er.........33
quinidine sulfate..................33
quinine sulfate.....................24
QVAR REDIHALER............ 76
RABEPRAZOLE SODIUM..54
rabeprazole sodium............ 54
RAGWITEK.........................74
raloxifene hcl.......................69
ramelteon............................77
ramipril................................ 33
RANEXA............................. 33
ranolazine er....................... 33
RAPAFLO........................... 58
RAPAMUNE................. 66, 67
rasagiline mesylate............. 24
RASUVO.............................67
RAVICTI..............................56
RAYALDEE.........................69
RAYOS............................... 64
RAZADYNE........................ 16
RAZADYNE ER.................. 16
REBIF................................. 35
REBIF REBIDOSE..............36
REBIF REBIDOSE
TITRATION PACK.............. 36
REBIF TITRATION PACK.. 36
REBINYN............................50
reclipsen............................. 62
RECOMBINATE................. 50
RECOMBIVAX HB..............67
RECOTHROM.................... 50
RECOTHROM SPRAY KIT 50
RECTIV...............................33
REGLAN............................. 18
REGRANEX........................43
RELAFEN DS....................... 9
RELENZA DISKHALER......27
relexxii .................................35
RELION BLOOD
GLUCOSE TEST................ 46
RELION ULTIMA TEST...... 46
RELISTOR..........................55
RELNATE DHA...................53
RELPAX..............................20
REMERON......................... 17
REMERON SOLTAB.......... 17
RENAGEL...........................57
RENVELA........................... 57
repaglinide.......................... 49
REPATHA...........................33
REPATHA PUSHTRONEX
SYSTEM............................. 33
REPATHA SURECLICK..... 33
REQUIP XL.........................24
RESTASIS.......................... 72
RESTASIS MULTIDOSE.... 72
RESTORIL..........................77
RETACRIT..........................50
RETIN-A............................. 43
RETIN-A MICRO GEL 0.04
%, 0.1 %............................. 43
RETIN-A MICRO PUMP..... 43
RETROVIR......................... 27
REVATIO............................ 77
REVLIMID...........................23
REXULTI.............................25
REYATAZ........................... 27
REYVOW............................20
RHOFADE.......................... 43
RHOPRESSA..................... 71
RIAX................................... 43
ribavirin ............................... 27
RIDAURA............................67
rifabutin............................... 21
RIFADIN............................. 21
RIFAMATE..........................21
rifampin............................... 21
RIFATER............................ 21
RILUTEK.............................36
riluzole................................ 36
rimantadine hcl................... 27
RINVOQ..............................67
RIOMET..............................49
96
RIOMET ER........................49
risedronate sodium............. 69
RISPERDAL....................... 25
risperidone.......................... 25
RITALIN.............................. 35
RITALIN LA.........................35
ritonavir............................... 27
rivastigmine.........................16
rivastigmine tartrate............ 16
rivelsa................................. 62
RIXUBIS............................. 50
rizatriptan benzoate............ 20
ROBAXIN-750.................... 77
ROCALTROL......................69
ROCKLATAN......................71
ropinirole hcl....................... 24
ropinirole hcl er................... 25
rosadan...............................43
ROSADAN.......................... 43
rosuvastatin calcium........... 33
ROWASA............................68
roweepra.............................15
roweepra xr.........................15
ROXICODONE..................... 8
ROZEREM..........................77
ROZLYTREK...................... 23
RUBRACA.......................... 23
RUZURGI........................... 56
RYBELSUS.........................49
RYCLORA.......................... 74
RYDAPT............................. 23
RYTARY............................. 25
RYTHMOL SR.................... 33
ryvent.................................. 74
SABRIL............................... 15
SAFYRAL........................... 62
SAIZEN...............................64
SAIZENPREP..................... 64
SALAGEN...........................37
salicylic acid........................43
salicylic acid er....................43
salicylic acid wart remover..43
salimez................................43
salsalate................................9
SALVAX DUO PLUS.......... 43
SAMSCA.............................56
SANCUSO.......................... 18
SANDIMMUNE................... 67
SANDOSTATIN.................. 64
SANTYL..............................43
SAPHRIS............................ 25
SARAFEM.......................... 17
SAVAYSA........................... 13
SAVELLA............................36
SAVELLA TITRATION
PACK.................................. 36
SCALACORT DK................43
scopolamine........................18
SEASONIQUE.................... 62
SECONAL...........................77
SECUADO.......................... 25
SEGLUROMET...................49
SELECT-OB....................... 53
selegiline hcl....................... 25
selenium sulfide.................. 43
SELRX................................ 43
SELZENTRY.......................27
SEMPREX-D...................... 74
SENSIPAR..........................64
SEREVENT DISKUS.......... 76
SERNIVO............................43
SEROQUEL........................25
SEROQUEL XR..................25
SEROSTIM......................... 64
sertraline hcl....................... 17
setlakin................................62
sevelamer carbonate.......... 57
sevelamer hcl......................57
SEYSARA...........................12
sf......................................... 37
sf 5000 plus........................ 37
SFROWASA....................... 68
sharobel.............................. 62
SHINGRIX.......................... 67
SIGNIFOR.......................... 64
SIKLOS...............................23
sildenafil citrate............. 51, 77
SILENOR............................ 78
SILIQ...................................67
silodosin..............................58
SILVADENE........................12
silver nitrate........................ 12
silver sulfadiazine............... 13
SIMBRINZA........................ 71
simliya.................................62
simpesse.............................62
SIMPONI.............................67
simvastatin..........................33
SINEMET............................25
SINGULAIR........................ 76
sirolimus..............................67
SIRTURO............................21
SITAVIG..............................27
SIVEXTRO..........................13
SKELAXIN.......................... 77
SKLICE............................... 24
SKYRIZI (150 MG DOSE).. 67
SLYND................................62
sod citrate-citric acid........... 53
SODIUM BICARBONATE...55
sodium chloride...................74
sodium fluoride............. 37, 53
sodium fluoride 5000 plus...37
sodium fluoride 5000 ppm.. 37
sodium fluoride 5000
sensitive..............................37
sodium hyaluronate............ 43
sodium phenylbutyrate........56
sodium polystyrene
sulfonate............................. 53
sodium sulfacetamide......... 43
sodium sulfacetamide
wash................................... 43
SOFOSBUVIR-
VELPATASVIR................... 27
SOF-SENSOR.................... 46
solifenacin succinate...........57
SOLIQUA............................49
SOLODYN.......................... 13
SOLOSEC.......................... 13
SOLTAMOX........................23
SOMA................................. 77
SOMATULINE DEPOT....... 64
SOMAVERT........................64
SOOLANTRA......................43
SORIATANE....................... 43
SORILUX............................ 43
sotalol hcl ............................33
sotalol hcl (af)..................... 33
SOTYLIZE.......................... 33
SOVALDI............................ 27
SPECTRACEF....................13
spinosad............................. 24
SPIRIVA HANDIHALER..... 76
SPIRIVA RESPIMAT.......... 76
spironolactone.................... 33
spironolactone-hctz.............33
SPORANOX....................... 19
SPORANOX PULSEPAK... 19
SPRAVATO (56 MG
DOSE)................................ 17
SPRAVATO (84 MG
DOSE)................................ 17
sprintec 28.......................... 62
SPRITAM............................15
SPRIX................................... 9
SPRYCEL........................... 23
sps...................................... 53
sronyx................................. 62
97
ssd...................................... 13
sss 10-5.............................. 43
STALEVO 100.................... 25
STALEVO 125.................... 25
STALEVO 150.................... 25
STALEVO 200.................... 25
STALEVO 50...................... 25
STALEVO 75...................... 25
STARLIX.............................49
stavudine............................ 27
STAXYN............................. 51
STEGLATRO...................... 49
STEGLUJAN.......................49
STELARA........................... 67
STENDRA...........................51
STIMATE............................ 64
STIOLTO RESPIMAT......... 76
STIVARGA..........................23
STRATTERA...................... 35
STRENSIQ......................... 56
STRIBILD............................27
STRIVERDI RESPIMAT..... 76
STROMECTOL...................24
SUBOXONE....................... 10
SUBSYS............................... 8
subvenite............................ 15
subvenite starter kit-blue.....15
subvenite starter kit-green.. 15
subvenite starter kit-orange 15
SUCRAID............................56
sucralfate............................ 54
SULAR................................33
SULCONAZOLE NITRATE.19
sulfacetamide sodium... 43, 70
sulfacetamide sodium
(acne)..................................43
sulfacetamide sodium-
sulfur............................. 43, 44
sulfacetamide sod-sulfur
wash................................... 44
sulfacetamide-
prednisolone....................... 70
sulfacetamide-sulfur in
urea.....................................44
sulfacleanse 8/4..................44
sulfadiazine.........................13
sulfamethoxazole-
trimethoprim........................13
sulfamez wash.................... 44
SULFAMYLON................... 13
sulfasalazine....................... 68
sulfatrim pediatric................13
SULFURATED LIME.......... 24
sulindac.................................9
SUMADAN..........................44
SUMADAN WASH.............. 44
SUMADAN XLT.................. 44
sumatriptan......................... 20
sumatriptan succinate.........20
sumatriptan succinate refill . 20
sumatriptan-naproxen
sodium................................ 20
SUMAXIN........................... 44
SUMAXIN CP..................... 44
SUMAXIN WASH................44
SUNOSI.............................. 78
SUPRAX............................. 13
SUPREP BOWEL PREP
KIT...................................... 55
SUSTIVA............................ 27
SUTENT............................. 23
syeda.................................. 62
SYLATRON........................ 27
SYMAX DUOTAB............... 55
symax-sl..............................55
symax-sr............................. 55
SYMBICORT...................... 76
SYMBYAX.......................... 17
SYMDEKO..........................76
SYMFI.................................27
SYMFI LO........................... 27
SYMJEPI............................ 73
SYMLINPEN 120................ 49
SYMLINPEN 60.................. 49
SYMPAZAN........................ 15
SYMPROIC.........................55
SYMTUZA...........................27
SYNALAR........................... 44
SYNALAR (CREAM)...........44
SYNALAR (OINTMENT).....44
SYNALAR TS..................... 44
SYNAREL........................... 64
SYNDROS.......................... 18
SYNJARDY.........................49
SYNJARDY XR...................49
SYNRIBO............................23
SYNTHROID.......................65
SYPRINE............................ 57
TABLOID............................ 23
TACLONEX........................ 44
tacrolimus..................... 44, 67
tadalafil............................... 51
tadalafil (pah)...................... 77
TAFINLAR.......................... 23
TAGRISSO......................... 23
TAKHZYRO........................ 67
TALICIA.............................. 54
TALTZ.................................67
TALZENNA......................... 23
TAMIFLU............................ 27
tamoxifen citrate................. 23
tamsulosin hcl..................... 58
TAPAZOLE......................... 65
TAPERDEX 12-DAY...........64
TAPERDEX 6-DAY.............64
TAPERDEX 7-DAY.............64
TARCEVA...........................23
TARGADOX........................13
TARGRETIN....................... 23
tarina 24 fe..........................62
tarina fe 1/20.......................62
tarina fe 1/20 eq..................62
TARKA................................33
taron-crystals...................... 53
TASIGNA............................ 23
TASMAR.............................25
TAVALISSE........................ 50
TAYTULLA..........................62
tazarotene...........................44
TAZORAC...........................44
taztia xt ............................... 33
TAZVERIK.......................... 23
TECFIDERA....................... 36
TEGRETOL........................ 15
TEGRETOL-XR.................. 15
TEGSEDI............................ 57
TEKTURNA........................ 33
TEKTURNA HCT................ 33
telmisartan.......................... 33
telmisartan-amlodipine........33
telmisartan-hctz.................. 33
temazepam......................... 78
TEMIXYS............................ 27
TEMODAR..........................23
TEMOVATE........................ 44
temozolomide..................... 23
tencon................................... 8
TENIVAC............................ 67
tenofovir disoproxil
fumarate..............................27
TENORETIC 100................ 33
TENORETIC 50.................. 33
TENORMIN.........................33
terazosin hcl ........................58
terbinafine hcl..................... 19
terbutaline sulfate............... 76
terconazole......................... 19
TESSALON PERLES......... 74
TESTIM...............................65
98
testosterone........................ 65
testosterone cypionate........65
testosterone enanthate....... 65
tetrabenazine...................... 36
tetracaine hcl...................... 72
tetracycline hcl.................... 13
TEXACORT........................ 44
THALOMID......................... 23
THEO-24.............................76
theophylline.........................76
theophylline er.................... 76
THIOLA...............................57
THIOLA EC.........................57
thioridazine hcl....................25
thiothixene.......................... 25
THROMBOGEN..................50
tiadylt er.............................. 33
tiagabine hcl........................15
TIAZAC............................... 33
TIBSOVO............................23
TIGAN.................................18
TIGLUTIK............................36
TIKOSYN............................ 33
tilia fe.................................. 62
timolol maleate..............33, 71
TIMOPTIC...........................71
TIMOPTIC OCUDOSE....... 71
TIMOPTIC-XE.....................71
tinidazole.............................13
TIROSINT........................... 65
TIROSINT-SOL...................65
TISSEEL............................. 50
TIVICAY..............................27
TIVORBEX............................9
tizanidine hcl....................... 77
TOBI NEBULIZER.............. 76
TOBI PODHALER...............76
TOBRADEX.................. 70, 71
TOBRADEX ST.................. 71
tobramycin.................... 71, 76
TOBRAMYCIN....................76
tobramycin-
dexamethasone.................. 71
TOBREX............................. 71
TOLAK................................ 44
tolbutamide......................... 49
tolcapone............................ 25
tolmetin sodium.....................9
TOLSURA...........................19
tolterodine tartrate...............57
tolterodine tartrate er.......... 57
tolvaptan............................. 57
TOPAMAX.......................... 15
TOPAMAX SPRINKLE....... 15
TOPEX TOPICAL
ANESTHETIC..................... 37
TOPICORT......................... 44
TOPICORT SPRAY............ 44
topiramate...........................15
topiramate er.......................15
TOPROL XL........................33
toremifene citrate................ 23
torsemide............................ 33
TOSYMRA.......................... 20
TOUJEO MAX
SOLOSTAR........................ 48
TOUJEO SOLOSTAR.........48
tovet.................................... 44
TOVIAZ...............................57
TRACLEER.........................77
TRADJENTA.......................49
TRAMADOL HCL ER............8
tramadol hcl er...................... 8
tramadol hcl er (biphasic)..... 8
tramadol hcl ir....................... 8
tramadol-acetaminophen...... 8
trandolapril .......................... 33
trandolapril-verapamil hcl
er.........................................33
tranexamic acid...................50
TRANSDERM-SCOP (1.5
MG).....................................18
TRANXENE-T.....................28
tranylcypromine sulfate.......17
TRAVATAN Z..................... 71
travoprost (bak free)........... 71
trazodone hcl...................... 17
TRECATOR........................ 21
TRELEGY ELLIPTA............76
TREMFYA...........................67
TRESIBA............................ 48
TRESIBA FLEXTOUCH......48
tretinoin......................... 23, 44
tretinoin microsphere.......... 44
tretinoin microsphere pump 44
TRETTEN........................... 50
TREXALL............................67
TREXIMET..........................20
TREZIX................................. 8
tri femynor...........................62
triamcinolone acetonide 37, 44
triamterene..........................33
triamterene-hctz..................33
trianex................................. 44
triazolam............................. 28
TRIBENZOR....................... 33
TRICARE PRENATAL
DHA ONE........................... 53
TRI-CHLOR........................ 44
tricitrates............................. 53
TRICOR.............................. 33
triderm.................................44
TRIDESILON...................... 44
trientine hcl......................... 57
tri-estarylla.......................... 62
trifluoperazine hcl ................25
trifluridine............................ 71
trihexyphenidyl hcl .............. 25
TRIJARDY XR.................... 49
TRIKAFTA.......................... 76
tri-legest fe.......................... 62
TRILEPTAL.........................15
tri-linyah.............................. 62
TRILIPIX............................. 33
tri-lo-estarylla...................... 62
tri-lo-marzia.........................62
tri-lo-mili .............................. 62
tri-lo-sprintec....................... 62
trilyte................................... 56
trimethobenzamide hcl ........18
trimethoprim........................13
tri-mili .................................. 62
trimipramine maleate.......... 17
trinate..................................53
TRINAZ...............................53
TRINTELLIX....................... 17
tri-previfem..........................62
tri-sprintec........................... 63
TRISTART ONE................. 53
TRIUMEQ........................... 27
TRI-VI-FLOR.......................53
TRI-VI-FLORO....................53
tri-vitamin/fluoride............... 53
tri-vite/fluoride..................... 53
trivora (28).......................... 63
tri-vylibra............................. 63
tri-vylibra lo......................... 63
TRIZIVIR.............................27
TROKENDI XR................... 15
trospium chloride................ 57
trospium chloride er............ 57
TRUE METRIX BLOOD
GLUCOSE TEST................ 46
TRUE METRIX PRO
BLOOD GLUCOSE.............46
TRUETRACK TEST............47
TRULANCE........................ 56
TRULICITY......................... 49
TRUMENBA........................67
99
TRUSOPT...........................71
TRUVADA...........................27
TRYPTOPHAN................... 53
TUDORZA PRESSAIR....... 76
tulana.................................. 63
TURALIO............................ 23
TUSSICAPS....................... 74
TUXARIN ER...................... 74
TUZISTRA XR.................... 74
TWINRIX.............................67
TWYNSTA.......................... 33
TYBOST............................. 27
tydemy................................ 63
TYKERB............................. 23
TYLENOL WITH
CODEINE #3........................ 8
TYMLOS............................. 69
TYVASO............................. 77
TYVASO REFILL................ 77
TYVASO STARTER........... 77
UBRELVY........................... 20
UCERIS........................ 68, 69
UDENYCA.......................... 50
ULORIC.............................. 19
ULTRACET...........................8
ULTRAM............................... 8
ULTRASAL-ER................... 44
ULTRAVATE.......................44
UMECTA MOUSSE............ 44
unithroid.............................. 65
UPTRAVI............................ 77
URAMAXIN.........................44
urea.....................................44
urea nail .............................. 45
urea-c40..............................45
URECHOLINE.................... 57
URELLE..............................57
uremez-40...........................45
uretron d/s...........................57
URIBEL...............................57
URIMAR-T.......................... 57
urin ds................................. 57
URO-458.............................57
UROCIT-K 10..................... 53
UROCIT-K 15..................... 53
UROCIT-K 5....................... 53
UROGESIC-BLUE.............. 58
uro-mp................................ 58
UROXATRAL......................58
URSO 250.......................... 56
URSO FORTE.................... 56
ursodiol............................... 56
URYL.................................. 58
ustell................................... 58
uticap.................................. 58
utira-c..................................58
UTOPIC.............................. 45
utrona-c...............................58
VAGIFEM............................63
valacyclovir hcl....................27
VALCHLOR........................ 23
VALCYTE........................... 27
valganciclovir hcl...........27, 28
VALIUM.............................. 28
valproic acid........................15
valsartan............................. 33
valsartan-
hydrochlorothiazide.............34
VALTOCO 10 MG DOSE....15
VALTOCO 15 MG DOSE....15
VALTOCO 20 MG DOSE....15
VALTOCO 5 MG DOSE......15
VALTREX........................... 28
VANADOM..........................77
VANATOL LQ....................... 8
VANATOL S..........................8
VANCOCIN.........................13
VANCOCIN HCL.................13
vancomycin hcl................... 13
vandazole........................... 13
VANOS............................... 45
VAQTA................................67
vardenafil hcl.......................51
VARIVAX............................ 67
VARUBI (180 MG DOSE)... 18
VASCEPA...........................34
VASERETIC....................... 34
VASOTEC...........................34
VECAMYL...........................34
VECTICAL.......................... 45
velivet..................................63
VELPHORO........................58
VELTASSA......................... 53
VELTIN............................... 45
VEMLIDY............................ 28
VENCLEXTA...................... 23
VENCLEXTA STARTING
PACK.................................. 23
VENELEX........................... 45
venlafaxine hcl.................... 17
venlafaxine hcl er................17
VENTAVIS.......................... 77
VENTOLIN HFA..................76
verapamil hcl.......................34
verapamil hcl er.................. 34
VERDESO.......................... 45
VEREGEN.......................... 45
VERELAN........................... 34
VERELAN PM.....................34
VERSACLOZ...................... 25
VERZENIO......................... 23
VESICARE..........................58
VFEND................................19
VIAGRA.............................. 51
VIBERZI..............................56
VIBRAMYCIN..................... 13
VICTOZA............................ 49
VIEKIRA PAK..................... 28
vienva................................. 63
vigabatrin............................ 15
vigadrone............................ 15
VIGAMOX........................... 71
VIIBRYD............................. 17
VIIBRYD STARTER PACK.17
vilamit mb............................58
VILEVEV MB...................... 58
VIMOVO............................... 9
VIMPAT.............................. 15
VIOKACE............................57
viorele................................. 63
VIRACEPT..........................28
VIRAMUNE.........................28
VIRAMUNE XR...................28
VIRASAL.............................45
VIRAZOLE.......................... 28
VIREAD.............................. 28
virt-phos 250 neutral ........... 53
VISTARIL............................28
VISTOGARD.......................57
VITAFOL FE+..................... 53
VITAFOL STRIPS...............53
VITAFOL-OB+DHA.............53
vitamin d (ergocalciferol) .....53
vitamins acd-fluoride...........53
VITATHELY WITH
GINGER..............................53
VITRAKVI........................... 23
VIVELLE-DOT.................... 63
VIVLODEX..........................10
VIZIMPRO.......................... 23
VOGELXO.......................... 65
VOGELXO PUMP...............65
volnea................................. 63
VONVENDI......................... 50
voriconazole........................19
VOSEVI.............................. 28
VOTRIENT..........................23
vp-pnv-dha..........................53
VRAYLAR........................... 26
100
VTOL LQ...............................8
VUMERITY......................... 36
VUMERITY (STARTER)..... 36
VUSION.............................. 19
vyfemla............................... 63
VYLEESI.............................51
vylibra................................. 63
VYNDAMAX........................34
VYNDAQEL........................ 34
VYTORIN............................34
VYVANSE...........................35
VYZULTA............................71
WAKIX................................ 78
warfarin sodium.................. 14
WELCHOL.......................... 34
WELLBUTRIN SR...............17
WELLBUTRIN XL............... 17
wera.................................... 63
WESTHROID......................65
WHEAT GERM OIL............ 53
WILATE.............................. 50
wixela inhub........................ 76
WP THYROID.....................65
wymzya fe...........................63
XADAGO............................ 25
XALATAN........................... 71
XALKORI............................ 23
XANAX................................28
XANAX XR..........................28
XARELTO........................... 14
XARELTO STARTER
PACK.................................. 14
XATMEP............................. 67
XELJANZ............................ 67
XELJANZ XR...................... 67
XELODA............................. 23
XELPROS...........................71
XENAZINE..........................36
XENLETA........................... 13
XEPI....................................13
XERESE............................. 28
XERMELO.......................... 56
XHANCE.............................74
XIFAXAN............................ 13
XIGDUO XR........................49
XIIDRA................................72
XIMINO............................... 13
XOFLUZA (40 MG DOSE)..28
XOFLUZA (80 MG DOSE)..28
XOLEGEL........................... 19
XOLEGEL COREPAK........ 19
XOLEGEL DUO/HEAD &
SHOULDERS..................... 19
XOLEGEL DUO/XOLEX..... 19
XOPENEX.......................... 76
XOPENEX
CONCENTRATE................ 76
XOPENEX HFA.................. 76
XOSPATA...........................23
XPOVIO (100 MG ONCE
WEEKLY)............................23
XPOVIO (60 MG ONCE
WEEKLY)............................23
XPOVIO (80 MG ONCE
WEEKLY)............................23
XPOVIO (80 MG TWICE
WEEKLY)............................23
XTAMPZA ER.......................8
XTANDI...............................23
xulane................................. 63
XULTOPHY........................ 49
XURIDEN............................57
XYNTHA............................. 50
XYNTHA SOLOFUSE.........51
XYOSTED...........................65
XYREM............................... 78
YASMIN 28......................... 63
YAZ.....................................63
YONSA............................... 23
YOSPRALA........................ 25
YUPELRI............................ 76
yuvafem.............................. 63
ZACARE............................. 45
zaclir cleansing................... 45
zafirlukast............................76
zaleplon.............................. 78
ZALVIT................................53
ZANAFLEX......................... 77
zarah...................................63
ZARONTIN......................... 15
ZARXIO.............................. 51
ZAVESCA........................... 57
ZEBUTAL..............................8
ZEGERID............................54
ZEJULA.............................. 23
ZELAPAR........................... 25
ZELBORAF.........................23
ZELNORM.......................... 56
ZEMBRACE SYMTOUCH.. 20
ZEMPLAR...........................69
zenatane............................. 45
ZENPEP............................. 57
ZENZEDI............................ 35
ZEPATIER.......................... 28
ZESTORETIC..................... 34
ZESTRIL............................. 34
ZETIA..................................34
ZETONNA...........................74
ZIAC....................................34
ZIAGEN.............................. 28
ZIANA................................. 45
zidovudine...........................28
ZIEXTENZO........................51
ZILACAINE PATCH.............. 8
zileuton er........................... 76
ZIOPTAN............................ 71
ziprasidone hcl....................26
ZIPSOR.............................. 10
ZIRGAN.............................. 71
ZITHROMAX.......................13
ZITHROMAX TRI-PAK....... 13
ZITHROMAX Z-PAK........... 13
ZOCOR...............................34
ZOFRAN............................. 18
ZOHYDRO ER......................8
ZOLINZA.............................23
zolmitriptan......................... 20
ZOLOFT..............................17
zolpidem tartrate................. 78
zolpidem tartrate er.............78
ZOLPIMIST.........................78
ZOMACTON....................... 64
ZOMIG................................ 20
ZOMIG ZMT........................20
ZONALON.......................... 45
ZONEGRAN....................... 15
zonisamide..........................15
ZONTIVITY......................... 25
ZORBTIVE..........................64
ZORTRESS........................ 67
ZORVOLEX........................ 10
ZOSTAVAX.........................68
zovia 1/35e (28).................. 63
ZOVIRAX............................ 28
ZTLIDO................................. 9
ZUBSOLV........................... 10
zumandimine...................... 63
ZUPLENZ........................... 18
ZYCLARA........................... 45
ZYCLARA PUMP................45
ZYDELIG............................ 23
ZYFLO................................ 76
ZYKADIA............................ 23
ZYLET.................................71
ZYLOPRIM......................... 19
ZYMAXID............................71
ZYPITAMAG....................... 34
ZYPREXA........................... 26
ZYPREXA ZYDIS............... 26
101
ZYTIGA...............................23
ZYVOX................................13
102
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UnitedHealthcare Physician PDL Booklet 9/20 Revised June 2020WF2352478 © 2020 UnitedHealthCare Services, Inc. All rights reserved.