preferred drug list (pdl) - uhcprovider.com...this preferred drug list ( pdl) to be used when...

© 2020 United HealthCare Services, Inc. All rights reserved.

Preferred Drug List (PDL)New Jersey Effective Date: 7/1/20

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, 24 hours a day, 7 days a week.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card.

We provide free services to help you communicate with us, such as letters in other languages or large print. You can also ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, 24 hours a day, 7 days a week.

CSNJ19MC4421731_000

UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad u origen nacional.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o origen nacional, puede enviar una queja a:


[email protected]

Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro.

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad u origen nacional.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o origen nacional, puede enviar una queja a:


[email protected]

Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro.

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

CSNJ19MC4421730_000

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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare Community Plan PDL have been reviewed and approved by the Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at http://www.guideline.gov. PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the P&T Committee. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received the PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site.

Preferred Drug List

http://www.guideline.gov/

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OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following:

• Safety • Efficacy • Comparison studies • Approved indications • Adverse effects • Contraindications/Warnings/Precautions • Pharmacokinetics

• Patient administration/compliance considerations • Medical outcome and pharmacoeconomic studies

When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited brand name product. carvedilol Coreg All strengths of Coreg would be covered by this listing. Extended-release and delayed-release products require their own entry.

diltiazem sustained release CARDIZEM SR

Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymyxin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not citalopram 40 mg tabs Celexa tabs DRUG TIERS The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available. Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column. If a brand name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare Community Plan MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval:

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1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand name product.

2. The FDA has given the generic an “A” rating compared

to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare Community Plan’s PDL does not cover DESI “less than fully effective” drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare Community Plan PDL.

• DESI drugs • Anti-obesity agents • Experimental / research drugs

• Cosmetic drugs • Nutritional / diet supplements • Blood and blood plasma products • Agents used to promote fertility • Agents used for erectile dysfunction • Agents used for cosmetic hair growth • Drugs from manufacturers that do not participate

in the FFS Medicaid Drug Rebate Program • Diagnostic products • Medical supplies and DME except as listed:

insulin syringes, insulin needles, lancets, alcohol swabs, spacers, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air brands, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years)

DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members may receive up to a one- month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when ninety percent (90%) of the medication has been utilized for a controlled substance and eighty-five percent (85%) of the medication has been utilized for a non-controlled substance. If a claim is submitted before 90% of the medication has been used for a controlled substance or submitted before 85% of the medication has been used for a non-controlled substance, based on the original day supply submitted on the claim, the claim will reject with a “refill too soon” message. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be either made in writing by the physician and faxed or called into:

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UnitedHealthcare Community Plan Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan Pharmacy Prior Notification Service at 800-310-6826 with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY TEMPORARY SUPPLY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-PDL drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of “00000000120”. Please note that non-preferred drugs are available for a 5-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310-6826. The pharmacy should contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare Community Plan at 800-310-6826. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars.

The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Community Plan Pharmacy Department via fax at 866-940-7328. The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or provider. Drugs that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826. MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits or with the drug class name on the PDL. The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim. If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328. STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process.

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While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP Drug First-Line Agent(s) .Amerge Trial at a minimum dose of 50mg of

sumatriptan tablets. Aricept 23mg 90 day trial of Aricept 10mg daily calcipotriene Trial of two medium to high potency cream & oint corticosteroids 0.005% calcitriol Trial of two medium to high potency 3mcg/gm corticosteroids

DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Nesina, metformin. Kazano, Oseni) Elidel Minimum age of 2. Trial of one topical

corticosteroid. Eucrisa Trial of a topical steroid AND one of the

following: Elidel cream or tacrolimus ointment

fenofibrate Fill of a statin or 90 days of gemfibrozil

within the previous 180 days. GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Adlyxin, metformin Trulicity, Victoza 2 pen pack) GLP-1/Insulin Trial of one drug from the following Combinations classes: GLP-1 or Basal Insulin (Soliqua) Optivar 14 day trial of ketotifen within previous

90 days required first. Ranexa Trial of one drug from the following

classes: beta blockers, calcium channel blockers, long acting nitrates

Renvela 8 week trial of calcium acetate SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Steglatro, Segluromet) tacrolimus 0.03% Minimum age of 2.Trial of one

topical corticosteroid. tacrolimus 0.1% Minimum age of 16. Trial of one

topical corticosteroid.

tolterodine 30 day trial of oxybutynin immediate or extended release. Step Therapy only applies to members less than 65 years of age.

tretinoin Cream Trial of Differin OTC Gel 0.1%. (tretinoin cream 0.025%, 0.05%, 0.1%, and Avita cream 0.025%) trospium 30 day trial of oxybutynin immediate or

extended release. Step Therapy only applies to members less than 65 years of age.

Uloric 8 week trial of up to 600mg of

allopurinol required first. Xopenex Respules 30 day trial of Albuterol .083% or .5%

respules. PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Community Plan Director of Pharmacy Services by either mail or fax.

Attn: Director of Pharmacy Services UnitedHealthcare Community Plan 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826 Email: [email protected]

Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:

UnitedHealthcare Community Plan by UnitedHealthcare

Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212

Phone: 800-310-6826

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LEGEND # Only the dosage forms/strengths of the brand

name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustained-

release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V-VI for details SP Specialty Pharmaceuticals, see pages IV-V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

Table of Contents

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions......................................................................................................3Anesthetics - Drugs for Numbing.................................................................................................................................................................................. 9Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence........................................................................................... 9Antibacterials - Drugs to Treat Bacterial Infections.....................................................................................................................................................11Anticonvulsants - Drugs to Treat Seizures..................................................................................................................................................................15Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia................................................................................................................18Antidepressants - Drugs to Treat Depression.............................................................................................................................................................19Antiemetics - Drugs to Treat Nausea and Vomiting....................................................................................................................................................20Antifungals - Drugs to Treat Fungal Infections............................................................................................................................................................21Antigout Agents - Drugs to Treat Gout........................................................................................................................................................................22Antimigraine Agents - Drugs to Treat Migraines......................................................................................................................................................... 22Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis...................................................................................................................................... 23Antimycobacterials - Drugs to Treat Infections........................................................................................................................................................... 23Antineoplastics - Drugs to Treat Cancer..................................................................................................................................................................... 24Antiparasitics - Drugs to Treat Parasitic Infections..................................................................................................................................................... 28Antiparkinson Agents - Drugs to Treat Parkinson's Disease...................................................................................................................................... 29Antipsychotics - Drugs to Treat Mood Disorders........................................................................................................................................................ 30Antivirals - Drugs to Treat Viral Infections...................................................................................................................................................................32Anxiolytics - Drugs to Treat Anxiety............................................................................................................................................................................ 36Bipolar Agents - Drugs to Treat Mood Disorders........................................................................................................................................................ 37Blood Glucose Regulators - Drugs to Regulate Blood Sugar..................................................................................................................................... 38Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders........................................................................................................43Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions.................................................................................................................45Central Nervous System Agents - Drugs to Treat Nerve Conditions.......................................................................................................................... 51Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions..................................................................................................................... 53Dermatological Agents - Drugs to Treat Skin Conditions............................................................................................................................................54Electrolytes/Minerals/Metals/Vitamins........................................................................................................................................................................ 59Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions.................................................................................................. 67Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment.............................................................................................................................74Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions........................................................................................................ 74Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones............................................................................... 76Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones.............................................................................. 77Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones....................................................................77Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones.................................................... 78Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones....................................................................85Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones................................................................................................................ 85Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones................................................................................................................86Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones................................................................................................... 86

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Immunological Agents - Drugs that Stimulate or Suppress the Immune System....................................................................................................... 87Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease................................................................................................. 91Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions........................................................................................................................... 92Metabolic Bone Disease Agents - Other.....................................................................................................................................................................92Miscellaneous Therapeutic Agents............................................................................................................................................................................. 93Ophthalmic Agents - Drugs to Treat Eye Conditions.................................................................................................................................................. 96Otic Agents - Drugs to Treat Ear Conditions.............................................................................................................................................................100Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions....................................................................... 101Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm................................................................................................................ 109Sleep Disorder Agents - Drugs for Sedation and Sleep............................................................................................................................................110

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Preferred Agents Non-Preferred Agents

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Analgesics - Miscellaneous Analgesics

8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QLacetaminophen childrens - Tier 1; QLacetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QLacetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QLacetaminophen oral solution - Tier 1; QLacetaminophen oral tablet (generic for TYLENOL) - Tier 1; QLacetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QLacetaminophen rectal (generic for FEVERALL CHILDRENS) - Tier 1; QLapap (generic for MEDI-TABS CHILDRENS) - Tier 1; QLaurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QLbutalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1; QLbutalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1; QLbutalbital-apap-caffeine oral tablet (generic for ESGIC) - Tier 1; QLbutalbital-aspirin-caffeine (generic for FIORINAL) - Tier 1; QLcapsaicin external cream 0.025 % - Tier 1; QLchildrens acetaminophen oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QLchildrens apap (generic for CHILDRENS MEDI-TABS) - Tier 1; QLchildrens non-aspirin oral tablet chewable (generic for CHILDRENS MEDI-TABS) - Tier 1; QLcvs acetaminophen ex st oral tablet (generic for PANADOL EXTRA STRENGTH) - Tier 1; QLheadache relief (generic for BAYER MIGRAINE) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy

3


liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QLmigraine relief (generic for BAYER MIGRAINE) - Tier 1m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QLpain & fever childrens oral suspension (generic for PANADOL CHILDRENS) - Tier 1; QLpain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QLpain relief childrens oral elixir (generic for MEDI-TABS CHILDRENS) - Tier 1; QLpain relief extra strength oral capsule - Tier 1; QLpain relief oral liquid (generic for CHLORASEPTIC SORE THROAT) - Tier 1pain relief oral tablet 325 mg (generic for TYLENOL) - Tier 1; QLpain relief regular strength (generic for TYLENOL) - Tier 1; QLPANADOL CHILDRENS (brand for ra fever reducer/pain reliever) - Tier 2; QLPANADOL EXTRA STRENGTH (brand for hm pain relief extra strength) - Tier 2; QLPANADOL INFANTS (brand for ra fever reducer/pain reliever) - Tier 2; QLtencon (generic for TENCON) - Tier 1; QLTYLENOL 8 HOUR (brand for arthritis pain reliever) - Tier 2; QLTYLENOL EXTRA STRENGTH (brand for hm pain relief extra strength) - Tier 2; QLTYLENOL INFANTS PAIN+FEVER (brand for ra fever reducer/pain reliever) - Tier 2; QLTYLENOL ORAL TABLET (brand for pain reliever) - Tier 2; QL


4


Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs

adult aspirin regimen (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLADVIL JUNIOR STRENGTH (brand for sm ibuprofen jr) - Tier 2; QLADVIL ORAL TABLET (brand for tgt ibuprofen) - Tier 2; QLALEVE ORAL TABLET (brand for ra naproxen sodium) - Tier 2; QLaspirin adult (generic for BAYER ASPIRIN) - Tier 1; QLaspirin adult low strength oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLaspirin childrens (generic for BAYER LOW DOSE) - Tier 1; QLaspirin ec (generic for BAYER ASPIRIN) - Tier 1; QLaspirin ec low dose (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLaspirin ec low strength (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLaspirin low dose (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLaspirin oral tablet (generic for BAYER ASPIRIN) - Tier 1; QLaspirin oral tablet delayed release (generic for BAYER ASPIRIN) - Tier 1; QLaspirin rectal - Tier 1BAYER ASPIRIN (brand for sb aspirin) - Tier 2; QLBAYER ASPIRIN EC LOW DOSE (brand for sb aspirin) - Tier 2; QLcelecoxib oral (generic for CELEBREX) - Tier 1; PA; QLdiclofenac potassium - Tier 1; QLdiclofenac sodium er - Tier 1; QLdiclofenac sodium oral - Tier 1; QLdiclofenac sodium transdermal gel 1 % (generic for VOLTAREN) - Tier 1; PA; QLec-naproxen - Tier 1; QL


5


etodolac - Tier 1; QLgnp all day pain relief (generic for ALEVE) - Tier 1; QLgoodsense aspirin low dose (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLgoodsense naproxen sodium (generic for ALEVE) - Tier 1; QLibu (generic for IBU) - Tier 1; QLibuprofen infants (generic for MOTRIN INFANTS DROPS) - Tier 1; QLibuprofen oral suspension (generic for CHILDRENS ADVIL) - Tier 1; QLibuprofen oral tablet (generic for ADVIL) - Tier 1; QLindomethacin oral capsule 25 mg, 50 mg - Tier 1; QLketoprofen oral - Tier 1; QLketorolac tromethamine oral - Tier 1; QLmeloxicam oral (generic for MOBIC) - Tier 1; QLMOTRIN INFANTS DROPS (brand for tgt infants ibuprofen) - Tier 2; QLnabumetone oral - Tier 1; QLnaproxen dr (generic for EC-NAPROSYN) - Tier 1; QLnaproxen oral (generic for NAPROSYN) - Tier 1; QLnaproxen sodium oral tablet 220 mg (generic for ALEVE) - Tier 1; QLoxaprozin (generic for DAYPRO) - Tier 1; QLpiroxicam oral (generic for FELDENE) - Tier 1; QLqc aspirin low dose oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QLsalsalate oral - Tier 1; QLST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE (brand for sb aspirin) - Tier 2; QLsulindac oral - Tier 1; QL


6


Opioid Analgesics, Long-acting - Opioid Pain Relievers

buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QLfentanyl transdermal patch 72 hour 100 mcg/hr (generic forDURAGESIC-100) - Tier 1; PA; QLfentanyl transdermal patch 72 hour 12 mcg/hr (generic forDURAGESIC-12) - Tier 1; PA; QLfentanyl transdermal patch 72 hour 25 mcg/hr (generic forDURAGESIC-25) - Tier 1; PA; QLfentanyl transdermal patch 72 hour 50 mcg/hr (generic forDURAGESIC-50) - Tier 1; PA; QLfentanyl transdermal patch 72 hour 75 mcg/hr (generic forDURAGESIC-75) - Tier 1; PA; QLhydrocodone bitartrate er (generic for ZOHYDRO ER) - Tier 1; PA; QLmethadone hcl oral tablet soluble (generic for METHADOSE) - Tier 1;DX2RX; QLmethadose oral tablet soluble (generic for METHADOSE) - Tier 1;DX2RX; QLmorphine sulfate er oral tablet extended release (generic for MSCONTIN) - Tier 1; PA; QLoxymorphone hcl er - Tier 1; PA; QL

HYSINGLA ER - Tier 2; PA; QLNUCYNTA ER - Tier 2; PA; QLOXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QLZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL


7


Opioid Analgesics, Short-acting - Opioid Pain Relievers

acetaminophen-codeine - Tier 1; QLacetaminophen-codeine #2 - Tier 1; QLacetaminophen-codeine #3 (generic for TYLENOL WITH CODEINE #3) - Tier 1; QLacetaminophen-codeine #4 - Tier 1; QLascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QLbutalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QLbutalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; QLbutorphanol tartrate nasal - Tier 1; QLcodeine sulfate oral tablet 30 mg, 60 mg - Tier 1; QLendocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QLhydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QLhydrocodone-acetaminophen oral tablet 10-325 mg (generic for LORCET HD) - Tier 1; QLhydrocodone-acetaminophen oral tablet 5-325 mg (generic for LORCET) - Tier 1; QLhydrocodone-acetaminophen oral tablet 7.5-325 mg (generic for LORCET PLUS) - Tier 1; QLhydromorphone hcl oral (generic for DILAUDID) - Tier 1; QLhydromorphone hcl rectal - Tier 1; QLlorcet (generic for LORCET) - Tier 1; QLlorcet hd (generic for LORCET HD) - Tier 1; QLlorcet plus (generic for LORCET PLUS) - Tier 1; QLmorphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier 1; QLmorphine sulfate oral - Tier 1; QL

apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA;QLKADIAN (brand for morphine sulfate er) - Tier 2; PA; QLTREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL


8


morphine sulfate rectal - Tier 1; QLoxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QLoxycodone hcl oral solution - Tier 1; QLoxycodone hcl oral tablet - Tier 1; QLoxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325mg (generic for ENDOCET) - Tier 1; QLoxycodone-aspirin - Tier 1; QLpentazocine-naloxone hcl - Tier 1; QLtramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL

Anesthetics - Drugs for Numbing

Local Anesthetics

7T LIDO - Tier 2; QLlidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QLlidocaine external patch 5 % (generic for LIDODERM) - Tier 1; DX2RX; QLlidocaine hcl external cream 3 % - Tier 1; QLlidocaine hcl urethral/mucosal (generic for GLYDO) - Tier 1; QLlidocaine viscous hcl - Tier 1; QLlidocaine-prilocaine external cream - Tier 1; QLlidopin external cream 3 % - Tier 1; QL

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants

acamprosate calcium - Tier 1; QLdisulfiram oral tablet 250 mg (generic for ANTABUSE) - Tier 1; QLdisulfiram oral tablet 500 mg (generic for ANTABUSE) - Tier 1naltrexone hcl oral - Tier 1


9


Opioid Dependence Treatments - Antidotes/Deterrents/Protectants

buprenorphine hcl sublingual - Tier 1; QLbuprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4-1 mg(generic for SUBOXONE) - Tier 1; ^; QLbuprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg (generic forSUBOXONE) - Tier 1; QLbuprenorphine hcl-naloxone hcl sublingual film 8-2 mg (generic forSUBOXONE) - Tier 1; DX2RX; QLbuprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1; ^;QLSUBOXONE SUBLINGUAL FILM 2-0.5 MG (brand for buprenorphinehcl-naloxone hcl) - Tier 2; QLSUBOXONE SUBLINGUAL FILM 8-2 MG (brand for buprenorphinehcl-naloxone hcl) - Tier 2; DX2RX; QL

BUNAVAIL - Tier 2; PA; ^; QLSUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG (brand for buprenorphine hcl-naloxone hcl) - Tier 2; PA; ^; QLZUBSOLV - Tier 2; PA; ^; QL

Opioid Reversal Agents - Antidotes/Deterrents/Protectants

naloxone hcl injection solution - Tier 1; QLnaloxone hcl injection solution cartridge - Tier 1; QLnaloxone hcl injection solution prefilled syringe - Tier 1; ^; QLNARCAN - Tier 2; QL

EVZIO (brand for naloxone hcl) - Tier 2; PA; ^; QL


10


Smoking Cessation Agents - Deterrents

bupropion hcl er (smoking det) - Tier 1CHANTIX - Tier 2; QLCHANTIX CONTINUING MONTH PAK - Tier 2; QLCHANTIX STARTING MONTH PAK - Tier 2; QLgoodsense nicotine mouth/throat gum (generic for KLS QUIT4) - Tier 1; QLNICORETTE MOUTH/THROAT GUM 2 MG (brand for sm nicotine polacrilex) - Tier 2; QLnicotine polacrilex mouth/throat (generic for NICORETTE) - Tier 1; QLnicotine step 1 (generic for NICODERM CQ) - Tier 1; QLnicotine step 2 (generic for NICODERM CQ) - Tier 1; QLnicotine step 3 (generic for NICODERM CQ) - Tier 1; QLNICOTROL - Tier 2; QLNICOTROL NS - Tier 2; QL

Antibacterials - Drugs to Treat Bacterial Infections

Aminoglycosides - Antibiotics

gentamicin sulfate external - Tier 1; QLneomycin sulfate oral - Tier 1; QLparomomycin sulfate oral - Tier 1; QL


11


Antibacterials, Other - Antibiotics

bacitracin external (generic for BACIGUENT) - Tier 1; QLbacitracin zinc external - Tier 1; QLclindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) -Tier 1; QLclindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QLclindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QLFIRVANQ - Tier 2; DX2RX; QLlinezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1;PA; QLlinezolid oral tablet (generic for ZYVOX) - Tier 1; PAmethenamine hippurate (generic for HIPREX) - Tier 1; QLmetronidazole external (generic for ROSADAN) - Tier 1; QLmetronidazole oral tablet (generic for FLAGYL) - Tier 1; QLmetronidazole vaginal (generic for VANDAZOLE) - Tier 1; QLmupirocin external (generic for CENTANY) - Tier 1; QLNEOSPORIN ORIGINAL EXTERNAL OINTMENT 3.5-400-5000(brand for hm triple antibiotic) - Tier 2; QLnitrofurantoin - Tier 1; QL; ALnitrofurantoin macrocrystal oral (generic for MACRODANTIN) - Tier 1;QLnitrofurantoin monohydrate macrocrystals (generic for MACROBID) -Tier 1; QLPOLYSPORIN (brand for bacitracin-polymyxin b) - Tier 2rosadan external cream (generic for ROSADAN) - Tier 1; QLrosadan external gel (generic for ROSADAN) - Tier 1; QLSCRUB CARE POVIDONE-IODINE (brand for cvs povidone-iodine) -Tier 2trimethoprim oral - Tier 1; QLtriple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL

CLEOCIN VAGINAL SUPPOSITORY - Tier 2; PA; QLCLINDESSE - Tier 2; PA; QLFLAGYL (brand for metronidazole) - Tier 2; PA; QLMETROGEL (brand for metronidazole) - Tier 2; PA; QLNORITATE - Tier 2; PAVANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QLXENLETA ORAL - Tier 2; PA; QL


12


vandazole (generic for VANDAZOLE) - Tier 1; QL

Beta-Lactam, Cephalosporins - Antibiotics

cefaclor - Tier 1; QLcefadroxil - Tier 1; QLcefdinir - Tier 1; QLcefixime oral capsule (generic for SUPRAX) - Tier 1; QLcefprozil - Tier 1; QLcefuroxime axetil - Tier 1; QLcephalexin oral capsule (generic for KEFLEX) - Tier 1; QLcephalexin oral suspension reconstituted - Tier 1; QL

Beta-Lactam, Penicillins - Antibiotics

amoxicillin oral capsule - Tier 1; QLamoxicillin oral suspension reconstituted - Tier 1; QLamoxicillin oral tablet 875 mg - Tier 1; QLamoxicillin oral tablet chewable - Tier 1; QLamoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier 1; QLampicillin - Tier 1; QLdicloxacillin sodium - Tier 1; QLpenicillin v potassium - Tier 1; QL


13


Macrolides - Antibiotics

azithromycin oral suspension reconstituted (generic for ZITHROMAX) - Tier 1; QLazithromycin oral tablet - Tier 1; QLclarithromycin er - Tier 1; QLclarithromycin oral - Tier 1; QLDIFICID - Tier 2; PA; QLE.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; QLE.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; QLERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; QLERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; QLerythromycin base - Tier 1; QLerythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QLerythromycin oral (generic for ERY-TAB) - Tier 1; QL

Quinolones - Antibiotics

CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QLciprofloxacin hcl oral - Tier 1; QLlevofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QLofloxacin oral - Tier 1; QL

MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QLVIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QLXEPI - Tier 2; PA; QL

Sulfonamides - Antibiotics

silver sulfadiazine external (generic for SSD) - Tier 1; QLssd (generic for SSD) - Tier 1; QLsulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1; QLsulfamethoxazole-trimethoprim oral (generic for BACTRIM DS) - Tier 1; QLsulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL


14


Tetracyclines - Antibiotics

doxycycline monohydrate oral capsule 100 mg (generic forMONDOXYNE NL) - Tier 1; QLdoxycycline monohydrate oral capsule 50 mg - Tier 1; QLminocycline hcl oral capsule 100 mg, 50 mg (generic for MINOCIN) -Tier 1; QLmondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) -Tier 1; QLNUZYRA ORAL - Tier 2; PA; QL

ORACEA (brand for doxycycline) - Tier 2; PASOLODYN (brand for minocycline hcl er) - Tier 2; PAXIMINO (brand for minocycline hcl er) - Tier 2; PA; QL

Anticonvulsants - Drugs to Treat Seizures

Anticonvulsants, Other - Seizure Control Drugs

levetiracetam oral solution (generic for KEPPRA) - Tier 1; QL; ALlevetiracetam oral tablet (generic for ROWEEPRA) - Tier 1; QLNAYZILAM - Tier 2; PA; QLphenobarbital oral tablet - Tier 1; QLroweepra (generic for ROWEEPRA) - Tier 1; QL

Calcium Channel Modifying Agents - Seizure Control Drugs

CELONTIN - Tier 2; QLethosuximide oral (generic for ZARONTIN) - Tier 1; QLzonisamide oral (generic for ZONEGRAN) - Tier 1; QL


15


Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs

clobazam (generic for ONFI) - Tier 1; DX2RX; QLdiazepam rectal gel 10 mg, 20 mg (generic for DIASTAT ACUDIAL) - Tier 1diazepam rectal gel 2.5 mg (generic for DIASTAT PEDIATRIC) - Tier 1; QLgabapentin oral capsule (generic for NEURONTIN) - Tier 1; QLgabapentin oral tablet (generic for NEURONTIN) - Tier 1; QLphenobarbital oral elixir - Tier 1; QLphenobarbital oral solution - Tier 1; QLprimidone oral (generic for MYSOLINE) - Tier 1; QLtiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; ALvalproic acid oral - Tier 1; QLvigabatrin oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QLvigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL

SYMPAZAN - Tier 2; PA; QL


16


Glutamate Reducing Agents - Seizure Control Drugs

felbamate oral suspension (generic for FELBATOL) - Tier 1; QL; ALfelbamate oral tablet (generic for FELBATOL) - Tier 1; QLlamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QLlamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; QL; ALlamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE) - Tier 1; *; QLlamotrigine starter kit-green (generic for SUBVENITE STARTER KIT-GREEN) - Tier 1; *; QLlamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT-ORANGE) - Tier 1; *; QLsubvenite (generic for SUBVENITE) - Tier 1; QLsubvenite starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE) - Tier 1; *; QLsubvenite starter kit-green (generic for SUBVENITE STARTER KIT-GREEN) - Tier 1; *; QLsubvenite starter kit-orange (generic for SUBVENITE STARTER KIT-ORANGE) - Tier 1; *; QLtopiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier 1; QL; ALtopiramate oral tablet (generic for TOPAMAX) - Tier 1; QL


17


Sodium Channel Agents - Seizure Control Drugs

BANZEL - Tier 2; DX2RX; QLcarbamazepine er (generic for CARBATROL) - Tier 1; QLcarbamazepine oral - Tier 1; QLDILANTIN ORAL CAPSULE 30 MG - Tier 2epitol (generic for EPITOL) - Tier 1; QLoxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; QL; ALoxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QLphenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QLphenytoin oral (generic for DILANTIN) - Tier 1; QLphenytoin sodium extended (generic for DILANTIN) - Tier 1; QLVIMPAT ORAL TABLET - Tier 2; PA; QL; AL

Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia

Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs

donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1; QL; ALdonepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST; QL; ALgalantamine hydrobromide (generic for RAZADYNE) - Tier 1; QL; ALrivastigmine (generic for EXELON) - Tier 1; QL; ALrivastigmine tartrate - Tier 1; QL; AL

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs

memantine hcl oral solution 2 mg/ml - Tier 1; QLmemantine hcl oral tablet (generic for NAMENDA) - Tier 1; QL; AL


18


Antidepressants - Drugs to Treat Depression

Antidepressants, Other - Antidepressants

bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QLbupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg (generic for WELLBUTRIN XL) - Tier 1; ^; QLbupropion hcl oral - Tier 1; QLmirtazapine oral tablet (generic for REMERON) - Tier 1; QLperphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50 mg - Tier 1perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; QL

Monoamine Oxidase Inhibitors - Antidepressants

tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

citalopram hydrobromide (generic for CELEXA) - Tier 1; QLescitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QLfluoxetine hcl oral capsule 10 mg, 20 mg (generic for PROZAC) - Tier1; QLfluoxetine hcl oral solution - Tier 1fluvoxamine maleate - Tier 1; QLmaprotiline hcl oral tablet 25 mg - Tier 1maprotiline hcl oral tablet 50 mg, 75 mg - Tier 1; QLparoxetine hcl (generic for PAXIL) - Tier 1; QLsertraline hcl oral (generic for ZOLOFT) - Tier 1; QLtrazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QLvenlafaxine hcl - Tier 1; QLvenlafaxine hcl er oral capsule extended release 24 hour (generic forEFFEXOR XR) - Tier 1; QL

FETZIMA - Tier 2; PA; ^; QLPRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; ^; QLtrazodone hcl oral tablet 300 mg - Tier 1; PA; ^; QLTRINTELLIX - Tier 2; PA; ^; QLVIIBRYD - Tier 2; PA; ^; QL


19


Tricyclics - Antidepressants

amitriptyline hcl oral - Tier 1; QLamoxapine - Tier 1; QLdesipramine hcl oral (generic for NORPRAMIN) - Tier 1; QLdoxepin hcl oral capsule - Tier 1; QLdoxepin hcl oral concentrate - Tier 1; QLimipramine hcl oral - Tier 1; QLnortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL

Antiemetics - Drugs to Treat Nausea and Vomiting

Antiemetics, Other - Nausea and Vomiting Drugs

compro (generic for COMPRO) - Tier 1; QLcvs motion sickness (generic for DRAMAMINE) - Tier 1goodsense motion sickness (generic for DRAMAMINE) - Tier 1goodsense nausea relief (generic for EMETROL) - Tier 1meclizine hcl oral tablet - Tier 1; QLmetoclopramide hcl oral solution 5 mg/5ml - Tier 1; QLmotion sickness relief (generic for DRAMAMINE) - Tier 1perphenazine oral - Tier 1; DX2RX; QLprochlorperazine (generic for COMPRO) - Tier 1; QLtravel sickness oral tablet chewable (generic for BONINE) - Tier 1trimethobenzamide hcl oral (generic for TIGAN) - Tier 1; QL

Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs

aprepitant (generic for EMEND) - Tier 1; QLdronabinol (generic for MARINOL) - Tier 1; PA; QLondansetron hcl oral tablet (generic for ZOFRAN) - Tier 1; QLondansetron odt - Tier 1; QL

AKYNZEO ORAL - Tier 2; PA; QLEMEND ORAL CAPSULE 80 MG (brand for aprepitant) - Tier 2; PA; QLEMEND ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; QLVARUBI (180 MG DOSE) - Tier 2; PA; QL


20


Antifungals - Drugs to Treat Fungal Infections

Antifungals - Fungal Infection Drugs

antifungal external aerosol (generic for TINACTIN) - Tier 1athletes foot external cream (generic for LAMISIL AT) - Tier 1; QLciclodan (generic for CICLODAN) - Tier 1; QLciclopirox external solution (generic for CICLODAN) - Tier 1; QLclotrimazole external (generic for CLOTRIMAZOLE GRX) - Tier 1; QLclotrimazole mouth/throat - Tier 1; QLclotrimazole vaginal cream 1 % (generic for GYNE-LOTRIMIN) - Tier 1; QLcvs clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1fluconazole oral (generic for DIFLUCAN) - Tier 1; QLgriseofulvin microsize oral - Tier 1; QLgriseofulvin ultramicrosize - Tier 1; QLitraconazole oral (generic for SPORANOX) - Tier 1; PA; QLketoconazole external cream - Tier 1; QLketoconazole external shampoo - Tier 1; QLketoconazole oral - Tier 1; QLmicaderm (generic for CARRINGTON ANTIFUNGAL) - Tier 1miconazole 3 vaginal suppository - Tier 1; QLmiconazole 7 vaginal suppository - Tier 1miconazole nitrate external (generic for CARRINGTON ANTIFUNGAL) - Tier 1nyamyc (generic for NYAMYC) - Tier 1; QLnystatin external - Tier 1; QLnystatin mouth/throat - Tier 1; QLnystatin oral - Tier 1; QLnystop (generic for NYAMYC) - Tier 1; QLpodactin external cream (generic for CARRINGTON ANTIFUNGAL) - Tier 1terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL

DIFLUCAN (brand for fluconazole) - Tier 2; PA; QLGYNAZOLE-1 - Tier 2; PA; QL


21


terconazole vaginal cream - Tier 1; QLtolnaftate antifungal (generic for FUNGOID-D) - Tier 1voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL

Antigout Agents - Drugs to Treat Gout

Antigout Agents - Gout Drugs

allopurinol oral (generic for ZYLOPRIM) - Tier 1; QLfebuxostat (generic for ULORIC) - Tier 1; ST; QLMITIGARE (brand for colchicine) - Tier 2; QLprobenecid - Tier 1; QL

COLCHICINE ORAL CAPSULE - Tier 2; PA; QLcolchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QLCOLCRYS (brand for colchicine) - Tier 2; PA; QL

Antimigraine Agents - Drugs to Treat Migraines

Ergot Alkaloids - Migraine Drugs

dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; QLergotamine-caffeine (generic for CAFERGOT) - Tier 1; QLMIGERGOT - Tier 2; QL

Prophylactic - Migraine Drugs

AIMOVIG - Tier 2; PA; QLEMGALITY - Tier 2; PA; QLEMGALITY (300 MG DOSE) - Tier 2; PA; QL

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA;QL

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs

naratriptan hcl (generic for AMERGE) - Tier 1; ST; QLrizatriptan benzoate - Tier 1; QLsumatriptan nasal (generic for IMITREX) - Tier 1; QLsumatriptan succinate oral (generic for IMITREX) - Tier 1; QLsumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - Tier 1; QLsumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL


22


Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis

Parasympathomimetics - Myasthenia Gravis Drugs

pyridostigmine bromide er (generic for MESTINON) - Tier 1; QLpyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; QLpyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL

Antimycobacterials - Drugs to Treat Infections

Antimycobacterials, Other - Miscellaneous Anti-Infectives

dapsone oral - Tier 1; QLrifabutin (generic for MYCOBUTIN) - Tier 1; QL

Antituberculars - Tuberculosis Drugs

cycloserine oral - Tier 1; QLethambutol hcl oral tablet 100 mg - Tier 1ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QLisoniazid oral syrup - Tier 1; QLISONIAZID ORAL TABLET 100 MG - Tier 2; QLisoniazid oral tablet 300 mg - Tier 1; QLPASER - Tier 2; QLPRIFTIN - Tier 2; QLpyrazinamide oral - Tier 1; QLrifampin oral (generic for RIFADIN) - Tier 1; QLSIRTURO - Tier 2; QLTRECATOR - Tier 2; QL


23


Antineoplastics - Drugs to Treat Cancer

Alkylating Agents - Chemotherapy Agents

cyclophosphamide oral - Tier 1GLEOSTINE - Tier 2LEUKERAN - Tier 2MATULANE - Tier 2; SP; QLmelphalan (generic for ALKERAN) - Tier 1MYLERAN - Tier 2temozolomide (generic for TEMODAR) - Tier 1; PA; SP; QL

Antiandrogens - Hormone Suppressants

abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QLbicalutamide (generic for CASODEX) - Tier 1; QLERLEADA - Tier 2; PA; SP; QLflutamide - Tier 1; QL

NUBEQA - Tier 2; PA; SP; QLXTANDI - Tier 2; PA; SP; QLYONSA - Tier 2; PA; SP; QLZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL

Antiangiogenic Agents - Chemotherapy Agents

POMALYST - Tier 2; PA; SP; QLREVLIMID - Tier 2; PA; SP; QLTHALOMID - Tier 2; PA; SP; QL

Antiestrogens/Modifiers - Chemotherapy Agents

tamoxifen citrate oral - Tier 1; QLtoremifene citrate (generic for FARESTON) - Tier 1; QL

Antimetabolites - Chemotherapy Agents

capecitabine (generic for XELODA) - Tier 1; SP; QLDROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2DROXIA ORAL CAPSULE 400 MG - Tier 2; QLhydroxyurea oral (generic for HYDREA) - Tier 1; QLmercaptopurine oral - Tier 1; QLTABLOID - Tier 2

XELODA (brand for capecitabine) - Tier 2; PA; SP; QL


24


Antineoplastics, Other - Chemotherapy Agents

leucovorin calcium oral tablet 10 mg - Tier 1leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; QLLONSURF - Tier 2; PA; SP; QLNINLARO - Tier 2; PA; SP; QLPIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QLPIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QLPIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QLVERZENIO - Tier 2; PA; SP; QLZOLINZA - Tier 2; PA; SP; QL

KISQALI (200 MG DOSE) - Tier 2; PA; SP; QLKISQALI (400 MG DOSE) - Tier 2; PA; SP; QLKISQALI (600 MG DOSE) - Tier 2; PA; SP; QL

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents

anastrozole oral (generic for ARIMIDEX) - Tier 1; QLexemestane (generic for AROMASIN) - Tier 1; QLletrozole oral (generic for FEMARA) - Tier 1; QL

Enzyme Inhibitors - Chemotherapy Agents

BALVERSA - Tier 2; PA; SP; QLetoposide oral - Tier 1HYCAMTIN ORAL - Tier 2; PA; SP; QLRUBRACA - Tier 2; PA; SP; QLZEJULA - Tier 2; PA; SP; QL


25


Molecular Target Inhibitors - Chemotherapy Agents

AFINITOR DISPERZ - Tier 2; PA; SP; QLAFINITOR ORAL TABLET 10 MG - Tier 2; PA; SP; QLALECENSA - Tier 2; PA; SP; QLALUNBRIG - Tier 2; PA; SP; QLBOSULIF - Tier 2; PA; SP; QLBRUKINSA - Tier 2; PA; SPCABOMETYX - Tier 2; PA; SP; QLCALQUENCE - Tier 2; PA; SP; QLCAPRELSA - Tier 2; PA; SP; QLCOMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG - Tier 2; PA; SP; QLCOMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG - Tier 2; PA; SP; QLCOMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QLCOTELLIC - Tier 2; PA; SP; QLDAURISMO - Tier 2; PA; SP; QLERIVEDGE - Tier 2; PA; SP; QLerlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QLeverolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP; QLFARYDAK - Tier 2; PA; SP; QLGILOTRIF - Tier 2; PA; SP; QLIBRANCE ORAL CAPSULE - Tier 2; PA; SP; QLIBRANCE ORAL TABLET - Tier 2; PA; QLICLUSIG - Tier 2; PA; SP; QLIDHIFA - Tier 2; PA; SP; QLimatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QLIMBRUVICA - Tier 2; PA; SP; QLINLYTA - Tier 2; PA; SP; QL


26


IRESSA - Tier 2; PA; SP; QLJAKAFI - Tier 2; PA; SP; QLLENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QLLENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QLLYNPARZA - Tier 2; PA; SP; QLMEKINIST - Tier 2; PA; SP; QLNEXAVAR - Tier 2; PA; SP; QLODOMZO - Tier 2; PA; SP; QLRYDAPT - Tier 2; PA; SP; QLSPRYCEL - Tier 2; PA; SP; QLSTIVARGA - Tier 2; PA; SP; QLSUTENT - Tier 2; PA; SP; QLTAFINLAR - Tier 2; PA; SP; QLTASIGNA - Tier 2; PA; SP; QLTIBSOVO - Tier 2; PA; SP; QLTYKERB - Tier 2; PA; SP; QLVENCLEXTA - Tier 2; PA; SP; QLVENCLEXTA STARTING PACK - Tier 2; PA; SP; QLVITRAKVI - Tier 2; PA; SP; QLVOTRIENT - Tier 2; PA; SP; QLXALKORI - Tier 2; PA; SP; QLZELBORAF - Tier 2; PA; SP; QLZYDELIG - Tier 2; PA; SP; QLZYKADIA - Tier 2; PA; SP; QL


27


Retinoids - Chemotherapy Agents

bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QLPANRETIN - Tier 2; PATARGRETIN EXTERNAL - Tier 2; PA; SP; QLtretinoin oral - Tier 1; SP; QL

Treatment Adjuncts - Supportive Chemotherapy Drugs

MESNEX ORAL - Tier 2; SP; QL

Antiparasitics - Drugs to Treat Parasitic Infections

Anthelmintics - Worm Infection Drugs

albendazole oral (generic for ALBENZA) - Tier 1; DX2RX; QLivermectin oral (generic for STROMECTOL) - Tier 1; QLpraziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL

Antiprotozoals - Protozoal Infection Drugs

ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; QL; ALALINIA ORAL TABLET - Tier 2; DX2RX; QLatovaquone oral (generic for MEPRON) - Tier 1; PA; QLBENZNIDAZOLE - Tier 2; DX2RX; QLchloroquine phosphate oral - Tier 1; DX2RX; QLhydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; DX2RX; QLIMPAVIDO - Tier 2; PA; QLKRINTAFEL - Tier 2; QLmefloquine hcl - Tier 1; QLpentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1primaquine phosphate - Tier 1pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL

ARAKODA - Tier 2; PA; QL


28


Pediculicides/Scabicides - Scabies and Lice Drugs

crotan - Tier 1; QLlice killing (generic for LICIDE) - Tier 1lice treatment external liquid (generic for NIX CREME RINSE) - Tier 1malathion (generic for OVIDE) - Tier 1; QLpermethrin external (generic for ELIMITE) - Tier 1; QLspinosad (generic for NATROBA) - Tier 1; QL

Antiparkinson Agents - Drugs to Treat Parkinson's Disease

Anticholinergics - Parkinson's Disease Drugs

benztropine mesylate oral - Tier 1; QLtrihexyphenidyl hcl oral tablet - Tier 1; QL

Antiparkinson Agents, Other - Parkinson's Disease Drugs

amantadine hcl oral capsule - Tier 1; QLamantadine hcl oral syrup - Tier 1; QLentacapone (generic for COMTAN) - Tier 1; QLtolcapone (generic for TASMAR) - Tier 1; QL

Dopamine Agonists - Parkinson's Disease Drugs

pramipexole dihydrochloride oral tablet 0.125 mg, 0.5 mg, 1 mg (generic for MIRAPEX) - Tier 1; QLpramipexole dihydrochloride oral tablet 0.25 mg, 1.5 mg - Tier 1; QLpramipexole dihydrochloride oral tablet 0.75 mg (generic for MIRAPEX) - Tier 1ropinirole hcl - Tier 1; QL

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs

carbidopa-levodopa er - Tier 1; QLcarbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL


29


Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs

selegiline hcl oral - Tier 1; QL

Antipsychotics - Drugs to Treat Mood Disorders

1st Generation/Typical - Mood Disorder Drugs

chlorpromazine hcl oral - Tier 1; DX2RX; QLfluphenazine decanoate injection - Tier 1; DX2RX; QLfluphenazine hcl injection - Tier 1; DX2RXfluphenazine hcl oral concentrate - Tier 1; DX2RXfluphenazine hcl oral elixir - Tier 1; DX2RXfluphenazine hcl oral tablet - Tier 1; DX2RX; QLhaloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; DX2RX; QLhaloperidol oral - Tier 1; DX2RX; QLloxapine succinate - Tier 1; DX2RX; QLpimozide - Tier 1; DX2RX; QL; ALprochlorperazine maleate oral - Tier 1; QLthioridazine hcl oral - Tier 1; DX2RX; QLthiothixene - Tier 1; DX2RX; QLtrifluoperazine hcl - Tier 1; DX2RX; QL


30


2nd Generation/Atypical - Mood Disorder Drugs

ABILIFY MAINTENA - Tier 2; DX2RX; ^; QL; ALaripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg (generic forABILIFY) - Tier 1; DX2RX; QL; ALaripiprazole oral tablet 2 mg (generic for ABILIFY) - Tier 1; DX2RX; QLARISTADA - Tier 2; DX2RX; ^; QL; ALINVEGA SUSTENNA - Tier 2; DX2RX; ^; QL; ALINVEGA TRINZA - Tier 2; DX2RX; ^; QL; ALolanzapine oral tablet (generic for ZYPREXA) - Tier 1; DX2RX; QL; ALPERSERIS - Tier 2; DX2RX; ^; QL; ALquetiapine fumarate (generic for SEROQUEL) - Tier 1; DX2RX; QL; ALRISPERDAL CONSTA - Tier 2; DX2RX; ^; QL; ALrisperidone oral solution (generic for RISPERDAL) - Tier 1; DX2RX;QL; ALrisperidone oral tablet (generic for RISPERDAL) - Tier 1; DX2RX; QL;ALziprasidone hcl (generic for GEODON) - Tier 1; DX2RX; QL; AL

ABILIFY ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG, 5 MG (brand for aripiprazole) - Tier 2; DX2RX; QL; ALABILIFY ORAL TABLET 2 MG (brand for aripiprazole) - Tier 2; DX2RX; QLaripiprazole oral solution - Tier 1; DX2RX; ^; QL; ALaripiprazole oral tablet dispersible - Tier 1; DX2RX; ^; QL; ALARISTADA INITIO - Tier 2; DX2RX; ^; QL; ALFANAPT - Tier 2; DX2RX; ^; QL; ALGEODON INTRAMUSCULAR (brand for ziprasidone mesylate) - Tier 2; PA; ^; QLGEODON ORAL (brand for ziprasidone hcl) - Tier 2; DX2RX; QL; ALINVEGA (brand for paliperidone er) - Tier 2; DX2RX; ^; QL; ALLATUDA - Tier 2; DX2RX; ^; QL; ALolanzapine intramuscular (generic for ZYPREXA) - Tier 1; DX2RX; ^; QLolanzapine oral tablet dispersible (generic for ZYPREXA ZYDIS) - Tier 1; DX2RX; ^; QL; ALpaliperidone er (generic for INVEGA) - Tier 1; DX2RX; ^; QL; ALquetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; DX2RX; ^; QL; ALREXULTI - Tier 2; DX2RX; ^; QL; ALRISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; DX2RX; QL; ALRISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; DX2RX; QL; ALrisperidone oral tablet dispersible - Tier 1; DX2RX; ^; QL; ALSAPHRIS - Tier 2; DX2RX; ^; QL; ALSEROQUEL (brand for quetiapine fumarate) - Tier 2; DX2RX; QL; ALSEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; DX2RX; ^; QL; AL


31


VRAYLAR - Tier 2; DX2RX; ^; QL; ALZYPREXA INTRAMUSCULAR (brand for olanzapine) - Tier 2; DX2RX; ^; QLZYPREXA ORAL (brand for olanzapine) - Tier 2; DX2RX; QL; ALZYPREXA RELPREVV - Tier 2; PA; ^; QLZYPREXA ZYDIS (brand for olanzapine) - Tier 2; DX2RX; ^; QL; AL

Treatment-Resistant - Mood Disorder Drugs

clozapine oral tablet 100 mg, 25 mg, 50 mg (generic for CLOZARIL) -Tier 1; DX2RX; QL; AL

CLOZARIL ORAL TABLET 100 MG, 25 MG, 50 MG (brand for clozapine) - Tier 2; DX2RX; QL; ALCLOZARIL ORAL TABLET 200 MG (brand for clozapine) - Tier 2; DX2RX; ^; QL; AL

Antivirals - Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs

valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL

Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs

BARACLUDE ORAL SOLUTION - Tier 2; SP; QLentecavir (generic for BARACLUDE) - Tier 1; SP; QLEPIVIR HBV ORAL SOLUTION - Tier 2; SP; QLlamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; QL


32


Anti-hepatitis C (HCV) Agents, Direct Acting Agents - Hepatitis C Drugs

MAVYRET - Tier 2; PA; SP; QLSOFOSBUVIR-VELPATASVIR - Tier 2; PA; SP; QLZEPATIER - Tier 2; PA; SP; QL

EPCLUSA (brand for sofosbuvir-velpatasvir) - Tier 2; PA; SP; QLHARVONI ORAL TABLET (brand for ledipasvir-sofosbuvir) - Tier 2; PA;SP; QLSOVALDI ORAL TABLET - Tier 2; PA; SP; QLVIEKIRA PAK - Tier 2; PA; SP; QLVOSEVI - Tier 2; PA; SP; QL

Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs

INTRON A - Tier 2; PA; SP; QLPEGASYS - Tier 2; PA; SP; QLPEGASYS PROCLICK - Tier 2; PA; SP; QLribavirin oral - Tier 1; QLSYLATRON - Tier 2; PA; SP; QL

Antiherpetic Agents - Herpes Drugs

acyclovir oral - Tier 1; QLdocosanol external (generic for ABREVA) - Tier 1; QLtrifluridine - Tier 1; QLvalacyclovir hcl oral (generic for VALTREX) - Tier 1; QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs

DOVATO - Tier 2; DX2RX; QLGENVOYA - Tier 2; PA; QLISENTRESS HD - Tier 2; DX2RX; QLISENTRESS ORAL PACKET - Tier 2; DX2RX; QL; ALISENTRESS ORAL TABLET - Tier 2; DX2RX; QLISENTRESS ORAL TABLET CHEWABLE - Tier 2; DX2RX; QLSTRIBILD - Tier 2; PA; QLTIVICAY - Tier 2; DX2RX; QLTRIUMEQ - Tier 2; DX2RX; QLTYBOST - Tier 2; DX2RX; QL


33


Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs

COMPLERA - Tier 2; PA; QLDELSTRIGO - Tier 2; DX2RX; QLEDURANT - Tier 2; DX2RX; QLefavirenz (generic for SUSTIVA) - Tier 1; DX2RX; QLINTELENCE - Tier 2; DX2RX; QLJULUCA - Tier 2; DX2RX; QLnevirapine (generic for VIRAMUNE) - Tier 1; DX2RX; QLnevirapine er (generic for VIRAMUNE XR) - Tier 1; DX2RX; QLODEFSEY - Tier 2; DX2RX; QLSYMFI - Tier 2; DX2RX; QLSYMFI LO - Tier 2; DX2RX; QLVIRAMUNE ORAL SUSPENSION (brand for nevirapine) - Tier 2; DX2RX; QL

ATRIPLA - Tier 2; PA; QL


34


Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs

abacavir sulfate (generic for ZIAGEN) - Tier 1; DX2RX; QLabacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; DX2RX; QLabacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; DX2RX; QLBIKTARVY - Tier 2; PA; QLDESCOVY - Tier 2; DX2RX; QLdidanosine - Tier 1; DX2RX; QLEMTRIVA - Tier 2; DX2RX; QLlamivudine oral solution (generic for EPIVIR) - Tier 1; DX2RX; QLlamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; DX2RX; QLlamivudine-zidovudine (generic for COMBIVIR) - Tier 1; DX2RX; QLstavudine - Tier 1; DX2RX; QLTEMIXYS - Tier 2; DX2RX; QLtenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; DX2RX; QLTRUVADA - Tier 2; DX2RX; QLVIREAD ORAL POWDER - Tier 2; DX2RX; QLVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; DX2RX; QLzidovudine (generic for RETROVIR) - Tier 1; DX2RX; QL

CIMDUO - Tier 2; DX2RX; QL

Anti-HIV Agents, Other - HIV Drugs

FUZEON - Tier 2; DX2RX; QLSELZENTRY - Tier 2; DX2RX; QL


35


Anti-HIV Agents, Protease Inhibitors - HIV Drugs

APTIVUS - Tier 2; DX2RX; QLatazanavir sulfate (generic for REYATAZ) - Tier 1; DX2RX; QLCRIXIVAN - Tier 2; DX2RX; QLEVOTAZ - Tier 2; DX2RX; QLfosamprenavir calcium (generic for LEXIVA) - Tier 1; DX2RX; QLINVIRASE - Tier 2; DX2RX; QLLEXIVA ORAL SUSPENSION - Tier 2; DX2RX; QLlopinavir-ritonavir (generic for KALETRA) - Tier 1; DX2RX; QLNORVIR ORAL PACKET - Tier 2; DX2RX; QLNORVIR ORAL SOLUTION - Tier 2; DX2RX; QLPREZCOBIX - Tier 2; DX2RX; QLPREZISTA - Tier 2; DX2RX; QLREYATAZ ORAL PACKET - Tier 2; DX2RX; QL; ALritonavir (generic for NORVIR) - Tier 1; DX2RX; QLVIRACEPT - Tier 2; DX2RX; QL

KALETRA (brand for lopinavir-ritonavir) - Tier 2; DX2RX; QLREYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2;DX2RX; QLSYMTUZA - Tier 2; PA; QL

Anti-Influenza Agents - Flu Drugs

oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QLoseltamivir phosphate oral suspension reconstituted (generic forTAMIFLU) - Tier 1; QL; ALRELENZA DISKHALER - Tier 2; QLrimantadine hcl - Tier 1; QL

TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA; QLTAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir phosphate) - Tier 2; PA; QL; ALXOFLUZA (40 MG DOSE) - Tier 2; PA; QLXOFLUZA (80 MG DOSE) - Tier 2; PA; QL

Anxiolytics - Drugs to Treat Anxiety

Anxiolytics, Other - Anxiety Drugs

buspirone hcl oral - Tier 1; QLhydroxyzine hcl oral - Tier 1; QL


36


Benzodiazepines - Anxiety Drugs

alprazolam oral tablet (generic for XANAX) - Tier 1; QLchlordiazepoxide hcl - Tier 1; QLclonazepam oral tablet (generic for KLONOPIN) - Tier 1; QLclorazepate dipotassium - Tier 1; QLdiazepam oral solution - Tier 1; QLdiazepam oral tablet (generic for VALIUM) - Tier 1; QLlorazepam oral tablet (generic for ATIVAN) - Tier 1; QLoxazepam - Tier 1; QLtriazolam - Tier 1; QL

Bipolar Agents - Drugs to Treat Mood Disorders

Mood Stabilizers - Mood Disorder Drugs

divalproex sodium oral capsule delayed release sprinkle (generic for DEPAKOTE SPRINKLES) - Tier 1; QL; ALdivalproex sodium oral tablet delayed release (generic for DEPAKOTE) - Tier 1; QLlithium - Tier 1; QLlithium carbonate er (generic for LITHOBID) - Tier 1; QLlithium carbonate oral - Tier 1; QL


37


Blood Glucose Regulators - Drugs to Regulate Blood Sugar

Antidiabetic Agents - Diabetic Drugs

acarbose oral (generic for PRECOSE) - Tier 1; QLADLYXIN - Tier 2; ST; QLADLYXIN STARTER PACK - Tier 2; ST; QLALOGLIPTIN BENZOATE - Tier 2; ST; QLALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QLALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QLglimepiride (generic for AMARYL) - Tier 1; QLglipizide er (generic for GLUCOTROL XL) - Tier 1; QLglipizide ir (generic for GLUCOTROL) - Tier 1; QLglipizide xl (generic for GLUCOTROL XL) - Tier 1; QLglyburide micronized (generic for GLYNASE) - Tier 1; QLglyburide oral - Tier 1; QLglyburide-metformin - Tier 1; QLmetformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA; QLmetformin hcl er oral tablet extended release 24 hour 500 mg - Tier 1;QLmetformin hcl er oral tablet extended release 24 hour 750 mg - Tier 1metformin hcl oral tablet - Tier 1; QLnateglinide (generic for STARLIX) - Tier 1; QLpioglitazone hcl (generic for ACTOS) - Tier 1; QLrepaglinide - Tier 1; QLSEGLUROMET - Tier 2; ST; QLSOLIQUA - Tier 2; ST; QLSTEGLATRO - Tier 2; ST; QLSYMLINPEN 120 - Tier 2; PA; QLSYMLINPEN 60 - Tier 2; PA; QLTRULICITY - Tier 2; ST; QLVICTOZA SOLUTION PEN-INJECTOR 18 MG/3MLSUBCUTANEOUS - Tier 2; PA; ST; QL

BYDUREON - Tier 2; PA; QLBYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QLBYETTA 10 MCG PEN - Tier 2; PA; QLBYETTA 5 MCG PEN - Tier 2; PA; QLFARXIGA - Tier 2; PA; QLGLYXAMBI - Tier 2; PAINVOKAMET - Tier 2; PA; QLINVOKAMET XR - Tier 2; PA; QLINVOKANA - Tier 2; PA; QLJANUMET - Tier 2; PA; QLJANUMET XR - Tier 2; PA; QLJANUVIA - Tier 2; PA; QLJARDIANCE - Tier 2; PA; QLJENTADUETO - Tier 2; PA; QLJENTADUETO XR - Tier 2; PA; QLKAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; QLKOMBIGLYZE XR - Tier 2; PA; QLNESINA (brand for alogliptin benzoate) - Tier 2; PA; QLONGLYZA - Tier 2; PA; QLOSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; QLOZEMPIC - Tier 2; PA; QLQTERN - Tier 2; PA; QLRYBELSUS - Tier 2; PA; QLSTEGLUJAN - Tier 2; PA; QLSYNJARDY - Tier 2; PA; QLSYNJARDY XR - Tier 2; PA; QLTRADJENTA - Tier 2; PA; QLVICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS - Tier 2; PA; QL


38


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG - Tier 2; PAXIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG - Tier 2; PA; QLXULTOPHY - Tier 2; PA; QL


39


Glycemic Agents - Diabetic Drugs

BAQSIMI ONE PACK - Tier 2; QLBAQSIMI TWO PACK - Tier 2; QLGLUCAGEN HYPOKIT - Tier 2; QLGLUCAGON EMERGENCY INJECTION KIT - Tier 2GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - Tier 2; QLGVOKE HYPOPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML - Tier 2; QLGVOKE PFS - Tier 2; QL


40


Insulins - Diabetic Drugs

ADMELOG (brand for insulin lispro) - Tier 2; QLADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2;PA; QLBASAGLAR KWIKPEN - Tier 2; QLHUMALOG MIX 50/50 VIAL - Tier 2; QLHUMALOG MIX 75/25 VIAL - Tier 2; QLHUMULIN 70/30 VIAL - Tier 2; QLHUMULIN N VIAL - Tier 2; QLHUMULIN R VIAL - Tier 2; QLINSULIN ASPART PROT & ASPART - Tier 2; QLNOVOLIN 70/30 RELION - Tier 2; QLNOVOLIN 70/30 VIAL - Tier 2; QLNOVOLIN N RELION - Tier 2; QLNOVOLIN N VIAL - Tier 2; QLNOVOLIN R RELION - Tier 2; QLNOVOLIN R VIAL - Tier 2; QL

AFREZZA - Tier 2; PA; QLAPIDRA SOLOSTAR - Tier 2; PA; QLAPIDRA VIAL - Tier 2; PA; QLFIASP - Tier 2; PA; QLFIASP FLEXTOUCH - Tier 2; PA; QLHUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QLHUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QLHUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - Tier 2; PA; QLHUMALOG U-100 JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - Tier 2; PA; QLHUMALOG U-100 VIAL AND CARTRIDGE (brand for insulin lispro) - Tier 2; PA; QLHUMULIN 70/30 KWIKPEN - Tier 2; PA; QLHUMULIN N KWIKPEN - Tier 2; PA; QLHUMULIN R U-500 KWIKPEN - Tier 2; PA; QLHUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QLINSULIN LISPRO - Tier 2; PA; QLINSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QLLANTUS SOLOSTAR - Tier 2; PA; QLLANTUS U-100 VIAL - Tier 2; PA; QLLEVEMIR U-100 FLEXTOUCH - Tier 2; PA; QLLEVEMIR U-100 VIAL - Tier 2; PA; QLNOVOLIN 70/30 FLEXPEN - Tier 2; PA; QLNOVOLIN N FLEXPEN - Tier 2; PA; QLNOVOLIN R FLEXPEN - Tier 2; PA; QLNOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL


41


NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; PA; QLNOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; PA; QLNOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QLNOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QLTOUJEO MAX SOLOSTAR - Tier 2; PA; QLTOUJEO SOLOSTAR - Tier 2; PA; QLTRESIBA - Tier 2; PA; QLTRESIBA FLEXTOUCH - Tier 2; PA; QL


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Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders

Anticoagulants - Blood Thinners

BEVYXXA ORAL CAPSULE 40 MG, 80 MG - Tier 2; QLELIQUIS - Tier 2; QLELIQUIS DVT/PE STARTER PACK - Tier 2; QLenoxaparin sodium (generic for LOVENOX) - Tier 1; QLheparin sodium (porcine) injection solution 1000 unit/ml, 20000 unit/ml- Tier 1; QLheparin sodium (porcine) injection solution 10000 unit/ml, 5000 unit/ml- Tier 1heparin sodium (porcine) injection solution prefilled syringe - Tier 1; QLheparin sodium (porcine) pf - Tier 1jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5mg (generic for JANTOVEN) - Tier 1; QLjantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1SAVAYSA - Tier 2; QLwarfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QLwarfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1

PRADAXA - Tier 2; PA; QLXARELTO - Tier 2; PA; QLXARELTO STARTER PACK - Tier 2; PA; QL


43


Blood Formation Modifiers - Blood Formation Drugs

anagrelide hcl (generic for AGRYLIN) - Tier 1ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QLLEUKINE - Tier 2; PA; SP; QLMOZOBIL - Tier 2; PA; SP; QLMULPLETA - Tier 2; PA; SP; QLNEULASTA - Tier 2; PA; SP; QLNEULASTA ONPRO - Tier 2; PA; SP; QLPROMACTA ORAL TABLET - Tier 2; PA; SP; QLRETACRIT - Tier 2; PA; SP; QLZARXIO - Tier 2; PA; SP; QL

DOPTELET - Tier 2; PA; SP; QLEPOGEN - Tier 2; PA; SP; QLFULPHILA - Tier 2; PA; SP; QLGRANIX - Tier 2; PA; SP; QLMIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2;PANEUPOGEN - Tier 2; PA; SP; QLNIVESTYM - Tier 2; PA; SP; QLPROCRIT - Tier 2; PA; SP; QLUDENYCA - Tier 2; PA; SP; QL

Hemostasis Agents - Drugs to Stop Bleeding

aminocaproic acid oral (generic for AMICAR) - Tier 1; QLHEMLIBRA - Tier 2; PA; SP; QLtranexamic acid oral (generic for LYSTEDA) - Tier 1; DX2RX; QL

Platelet Modifying Agents - Platelet Modifying Drugs

BRILINTA - Tier 2; DX2RX; QLCABLIVI - Tier 2; PA; SP; QLcilostazol - Tier 1; QLclopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QLdipyridamole oral - Tier 1; QLprasugrel hcl (generic for EFFIENT) - Tier 1; DX2RX; QL


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Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions

Alpha-adrenergic Agonists - Blood Pressure Drugs

clonidine hcl oral (generic for CATAPRES) - Tier 1; QLguanfacine hcl - Tier 1; QLmethyldopa - Tier 1; QLmidodrine hcl - Tier 1; QL

Alpha-adrenergic Blocking Agents - Blood Pressure Drugs

doxazosin mesylate oral (generic for CARDURA) - Tier 1; QLprazosin hcl oral (generic for MINIPRESS) - Tier 1; QL

Angiotensin II Receptor Antagonists - Blood Pressure Drugs

losartan potassium oral (generic for COZAAR) - Tier 1; QL EDARBI - Tier 2; PA; QL

Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs

benazepril hcl oral (generic for LOTENSIN) - Tier 1; QLcaptopril oral - Tier 1; QLenalapril maleate oral (generic for VASOTEC) - Tier 1; QLEPANED - Tier 2; QL; ALfosinopril sodium - Tier 1; QLlisinopril oral (generic for PRINIVIL) - Tier 1; QLquinapril hcl (generic for ACCUPRIL) - Tier 1; QLramipril (generic for ALTACE) - Tier 1; QLtrandolapril - Tier 1; QL


45


Antiarrhythmics - Heart Regulation Drugs

amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) -Tier 1; QLdisopyramide phosphate (generic for NORPACE) - Tier 1; QLdofetilide (generic for TIKOSYN) - Tier 1; QLflecainide acetate - Tier 1; QLmexiletine hcl oral - Tier 1; QLNORPACE CR - Tier 2pacerone oral tablet 200 mg (generic for PACERONE) - Tier 1; QLpropafenone hcl - Tier 1; QLquinidine gluconate er - Tier 1; QLquinidine sulfate - Tier 1; QLsotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QLsotalol hcl oral (generic for BETAPACE) - Tier 1; QL

BETAPACE (brand for sotalol hcl) - Tier 2; PA; QLBETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QLMULTAQ - Tier 2; PA; QLNORPACE (brand for disopyramide phosphate) - Tier 2; PA; QLPACERONE ORAL TABLET 100 MG, 400 MG (brand for amiodarone hcl) - Tier 2; PA; QLRYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG (brand for propafenone hcl er) - Tier 2; PA; QLRYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 425 MG (brand for propafenone hcl er) - Tier 2; PATIKOSYN (brand for dofetilide) - Tier 2; PA; QL

Beta-adrenergic Blocking Agents - Blood Pressure Drugs

acebutolol hcl oral - Tier 1; QLatenolol oral (generic for TENORMIN) - Tier 1; QLbetaxolol hcl oral - Tier 1; QLbisoprolol fumarate - Tier 1; QLcarvedilol (generic for COREG) - Tier 1; QLlabetalol hcl oral - Tier 1; QLmetoprolol succinate er (generic for TOPROL XL) - Tier 1; QLmetoprolol tartrate oral tablet 100 mg, 50 mg (generic for LOPRESSOR) - Tier 1; QLmetoprolol tartrate oral tablet 25 mg - Tier 1; QLpropranolol hcl er (generic for INDERAL LA) - Tier 1; DX2RX; QLpropranolol hcl oral solution 20 mg/5ml - Tier 1; QLpropranolol hcl oral solution 40 mg/5ml - Tier 1propranolol hcl oral tablet - Tier 1; QL

HEMANGEOL - Tier 2; PA; QL


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Calcium Channel Blocking Agents - Blood Pressure Drugs

amlodipine besylate oral (generic for NORVASC) - Tier 1; QLcartia xt (generic for CARTIA XT) - Tier 1; QLdiltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QLdiltiazem hcl er coated beads oral capsule extended release 24 hour (generic for CARTIA XT) - Tier 1; QLdiltiazem hcl er oral capsule extended release 12 hour - Tier 1; QLdiltiazem hcl oral (generic for CARDIZEM) - Tier 1; QLdilt-xr - Tier 1; QLfelodipine er - Tier 1; QLnifedipine er (generic for AFEDITAB CR) - Tier 1; QLnifedipine er osmotic release (generic for NIFEDICAL XL) - Tier 1; QLnifedipine oral (generic for PROCARDIA) - Tier 1; QLnimodipine oral - Tier 1; QLNYMALIZE - Tier 2; QLtaztia xt (generic for TAZTIA XT) - Tier 1; QLtiadylt er (generic for TAZTIA XT) - Tier 1; QLverapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QLverapamil hcl er oral tablet extended release (generic for CALAN SR) - Tier 1; QLverapamil hcl oral - Tier 1; QL


47


Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs

amiloride-hydrochlorothiazide - Tier 1; QLatenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QLbenazepril-hydrochlorothiazide - Tier 1; QLbisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QLcaptopril-hydrochlorothiazide - Tier 1; QLdigitek (generic for DIGITEK) - Tier 1; QLdigox (generic for DIGITEK) - Tier 1; QLdigoxin oral solution - Tier 1digoxin oral tablet (generic for DIGITEK) - Tier 1; QLenalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QLENTRESTO - Tier 2; PA; QLfosinopril sodium-hctz - Tier 1; QLlisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QLlosartan potassium-hctz (generic for HYZAAR) - Tier 1; QLmethyldopa-hydrochlorothiazide - Tier 1; QLpentoxifylline er - Tier 1; QLpropranolol-hctz - Tier 1; QLquinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QLranolazine er (generic for RANEXA) - Tier 1; ST; QLspironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QLtriamterene-hctz (generic for MAXZIDE-25) - Tier 1; QLVYNDAMAX - Tier 2; PA; SP; QLVYNDAQEL - Tier 2; PA; SP; QL

BIDIL - Tier 2; PA; QLCORLANOR - Tier 2; PA; QLEDARBYCLOR - Tier 2; PA; QL

Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs

methazolamide oral - Tier 1; QL

Diuretics, Loop - Cardiac Drugs

bumetanide oral (generic for BUMEX) - Tier 1; QLfurosemide oral solution 10 mg/ml - Tier 1; QLfurosemide oral tablet (generic for LASIX) - Tier 1; QLtorsemide - Tier 1; QL


48


Diuretics, Potassium-sparing - Cardiac Drugs

amiloride hcl oral - Tier 1; QLspironolactone oral (generic for ALDACTONE) - Tier 1; QL

Diuretics, Thiazide - Cardiac Drugs

chlorothiazide oral - Tier 1; QLchlorthalidone - Tier 1; QLDIURIL - Tier 2; QLhydrochlorothiazide oral capsule - Tier 1; QLhydrochlorothiazide oral tablet 12.5 mg - Tier 1hydrochlorothiazide oral tablet 25 mg, 50 mg - Tier 1; QLindapamide - Tier 1; QLmetolazone - Tier 1; QL

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QLfenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QLfenofibrate oral tablet 160 mg (generic for TRIGLIDE) - Tier 1; ST; QLfenofibrate oral tablet 54 mg - Tier 1; ST; QLgemfibrozil oral (generic for LOPID) - Tier 1; QL

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs

atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QLlovastatin - Tier 1; QL; ALsimvastatin oral (generic for ZOCOR) - Tier 1; QL


49


Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs

cholestyramine light oral powder (generic for PREVALITE) - Tier 1; QLcholestyramine oral powder (generic for QUESTRAN) - Tier 1; QLezetimibe (generic for ZETIA) - Tier 1; PA; QLniacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QLniacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QLniacor (generic for NIACOR) - Tier 1; QLomega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QLPRALUENT - Tier 2; PA; SP; QLprevalite oral powder (generic for PREVALITE) - Tier 1; QLREPATHA - Tier 2; PA; SP; QL

Vasodilators, Direct-acting Arterial - Chest Pain Drugs

hydralazine hcl oral - Tier 1; QLminoxidil oral - Tier 1; QL

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs

isosorbide dinitrate - Tier 1; QLisosorbide mononitrate - Tier 1; QLisosorbide mononitrate er - Tier 1; QLminitran (generic for MINITRAN) - Tier 1; QLNITRO-BID - Tier 2; QLNITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR - Tier 2; QLnitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QLnitroglycerin transdermal (generic for MINITRAN) - Tier 1; QLnitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QLRECTIV - Tier 2; DX2RX; QL


50


Central Nervous System Agents - Drugs to Treat Nerve Conditions

Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs

ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2;DX2RX; QL; ALamphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1;DX2RX; QL; ALamphetamine-dextroamphetamine er (generic for ADDERALL XR) -Tier 1; DX2RX; QL; ALVYVANSE - Tier 2; QL; AL

ADZENYS XR-ODT - Tier 2; DX2RX; ^; QL; ALDYANAVEL XR - Tier 2; DX2RX; ^; QL; ALEVEKEO (brand for amphetamine sulfate) - Tier 2; DX2RX; ^; QL; ALEVEKEO ODT - Tier 2; PA; ^; QL; ALMYDAYIS - Tier 2; DX2RX; ^; QL; ALZENZEDI - Tier 2; DX2RX; ^; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs

atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; QL; ALguanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; QL; ALmetadate er (generic for METADATE ER) - Tier 1; DX2RX; QL; ALmethylphenidate hcl er (cd) - Tier 1; DX2RX; QL; ALmethylphenidate hcl er (la) oral capsule extended release 24 hour 20mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX; QL; ALmethylphenidate hcl er oral tablet extended release 10 mg - Tier 1;DX2RX; QL; ALmethylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36mg, 54 mg (generic for CONCERTA) - Tier 1; DX2RX; ^; QL; ALmethylphenidate hcl er oral tablet extended release 20 mg (generic forMETADATE ER) - Tier 1; DX2RX; QL; ALmethylphenidate hcl er oral tablet extended release 24 hour - Tier 1;DX2RX; QL; ALmethylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX;QL; AL

ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG - Tier 2; PA; ^; QLADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 45 MG, 55 MG, 70 MG, 85 MG - Tier 2; PA; ^; QL; ALAPTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; DX2RX; ^; QL; ALCONCERTA (brand for methylphenidate hcl er) - Tier 2; DX2RX; ^; QL; ALCOTEMPLA XR-ODT - Tier 2; DX2RX; ^; QL; ALDAYTRANA - Tier 2; DX2RX; ^; QL; ALFOCALIN (brand for dexmethylphenidate hcl) - Tier 2; DX2RX; ^; QL; ALINTUNIV (brand for guanfacine hcl er) - Tier 2; DX2RX; QL; ALJORNAY PM - Tier 2; PA; ^; QL; ALKAPVAY (brand for clonidine hcl er) - Tier 2; DX2RX; ^; QL; ALMETHYLIN (brand for methylphenidate hcl) - Tier 2; DX2RX; ^; QL; ALRITALIN (brand for methylphenidate hcl) - Tier 2; DX2RX; QL; ALSTRATTERA (brand for atomoxetine hcl) - Tier 2; DX2RX; QL; AL


51


Central Nervous System, Other - Miscellaneous Central Nervous System Drugs

caffeine citrate oral - Tier 1; QL; ALINGREZZA - Tier 2; PA; SP; QLNUEDEXTA - Tier 2; DX2RX; QLriluzole (generic for RILUTEK) - Tier 1; QLtetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; QL

Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg (generic for CYMBALTA) - Tier 1; QLpregabalin oral (generic for LYRICA) - Tier 1; QL

CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL

Multiple Sclerosis Agents - Multiple Sclerosis Drugs

AUBAGIO - Tier 2; DX2RX; SP; QLGILENYA - Tier 2; DX2RX; SP; QLglatiramer acetate (generic for GLATOPA) - Tier 1; DX2RX; SP; QLglatopa (generic for GLATOPA) - Tier 1; DX2RX; SP; QLMAYZENT - Tier 2; PA; SP; QLMAYZENT STARTER PACK - Tier 2; PA; SP; QLPLEGRIDY - Tier 2; DX2RX; SP; QLPLEGRIDY STARTER PACK - Tier 2; DX2RX; SP; QLTECFIDERA - Tier 2; DX2RX; SP; QL

AVONEX PEN - Tier 2; PA; SP; QLAVONEX PREFILLED - Tier 2; PA; SP; QLBETASERON - Tier 2; PA; SP; QLCOPAXONE (brand for glatiramer acetate) - Tier 2; DX2RX; SP; QLEXTAVIA - Tier 2; PA; SP; QLMAVENCLAD (10 TABS) - Tier 2; PA; SP; QLMAVENCLAD (4 TABS) - Tier 2; PA; SP; QLMAVENCLAD (5 TABS) - Tier 2; PA; SP; QLMAVENCLAD (6 TABS) - Tier 2; PA; SP; QLMAVENCLAD (7 TABS) - Tier 2; PA; SP; QLMAVENCLAD (8 TABS) - Tier 2; PA; SP; QLMAVENCLAD (9 TABS) - Tier 2; PA; SP; QLREBIF - Tier 2; PA; SP; QLREBIF REBIDOSE - Tier 2; PA; SP; QLREBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QLREBIF TITRATION PACK - Tier 2; PA; SP; QLVUMERITY - Tier 2; PA; SP; QLVUMERITY (STARTER) - Tier 2; PA; SP; QL


52


Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions

cavarest (generic for CAVAREST) - Tier 1chlorhexidine gluconate mouth/throat (generic for PAROEX) - Tier 1; QLdenta 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QLdentagel (generic for CAVAREST) - Tier 1easygel - Tier 1fluoridex daily renewal - Tier 1oralone (generic for ORALONE) - Tier 1; QLparoex (generic for PAROEX) - Tier 1; QLperiogard (generic for PAROEX) - Tier 1; QLpilocarpine hcl oral tablet 5 mg (generic for SALAGEN) - Tier 1; QLpilocarpine hcl oral tablet 7.5 mg (generic for SALAGEN) - Tier 1PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2PREVIDENT 5000 PLUS (brand for sodium fluoride) - Tier 2; QLPREVIDENT DENTAL (brand for sf) - Tier 2sf (generic for CAVAREST) - Tier 1sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QLsodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QLsodium fluoride 5000 ppm dental cream (generic for DENTA 5000 PLUS) - Tier 1; QLsodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; QLsodium fluoride dental gel (generic for CAVAREST) - Tier 1triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL


53


Dermatological Agents - Drugs to Treat Skin Conditions

acitretin (generic for SORIATANE) - Tier 1; PA; QLala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QLalclometasone dipropionate external ointment - Tier 1; QLamcinonide external ointment - Tier 1ammonium lactate external (generic for AL12) - Tier 1; QLamnesteem (generic for AMNESTEEM) - Tier 1; PA; QLAQUAPHILIC (brand for advanced healing/baby) - Tier 2AVAR-E EMOLLIENT (brand for sulfacetamide sodium-sulfur) - Tier 2AVAR-E GREEN (brand for sulfacetamide sodium-sulfur) - Tier 2avita external cream (generic for AVITA) - Tier 1; ST; QL; ALazelaic acid external (generic for FINACEA) - Tier 1; QLBENZAC AC WASH (brand for cvs advanced 3-in-1 cleanser) - Tier 2;QLBENZIQ WASH - Tier 2betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier1; QLbetamethasone dipropionate external lotion - Tier 1betamethasone dipropionate external ointment - Tier 1; QLbetamethasone valerate external cream - Tier 1; QLbetamethasone valerate external lotion - Tier 1betamethasone valerate external ointment - Tier 1; QLbp 10-1 - Tier 1bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1calcipotriene external cream (generic for DOVONEX) - Tier 1; ST; QLcalcipotriene external ointment (generic for CALCITRENE) - Tier 1;ST; QLcalcipotriene external solution - Tier 1; QLcalcitriol external (generic for VECTICAL) - Tier 1; ST; QLcapzix (generic for CAPZASIN-HP) - Tier 1; QL

ABSORICA (brand for isotretinoin) - Tier 2; PA; QLABSORICA LD - Tier 2; PA; QLACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QLACZONE (brand for dapsone) - Tier 2; PA; QLALDARA (brand for imiquimod) - Tier 2; PA; QLATRALIN (brand for tretinoin) - Tier 2; PA; QL; ALBENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QLBENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QLBENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QLCARAC (brand for fluorouracil) - Tier 2; PA; QLCLOBEX (brand for clobetasol propionate) - Tier 2; PA; QLCLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QLDIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QLDIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QLDIFFERIN EXTERNAL LOTION - Tier 2; PA; QLDOVONEX (brand for calcipotriene) - Tier 2; PA; ST; QLDUPIXENT - Tier 2; PA; SP; QLEFUDEX (brand for fluorouracil) - Tier 2; PA; QLELIDEL (brand for pimecrolimus) - Tier 2; PA; ST; QL; ALENSTILAR - Tier 2; PA; QLEPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QLEPIDUO FORTE - Tier 2; PA; QLFABIOR - Tier 2; PA; QLFINACEA (brand for azelaic acid) - Tier 2; PA; QLILUMYA - Tier 2; PA; SP; QLLUXIQ (brand for betamethasone valerate) - Tier 2; PA; QLOLUX (brand for clobetasol propionate) - Tier 2; PA; QLOLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL


54


cerovel (generic for CEROVEL) - Tier 1; QLclaravis (generic for AMNESTEEM) - Tier 1; PA; QLclindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QLclindacin-p (generic for CLINDACIN ETZ) - Tier 1; QLclindamycin phosphate external gel (generic for CLEOCIN-T) - Tier 1; QLclindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; QLclindamycin phosphate external solution - Tier 1; QLclindamycin phosphate external swab (generic for CLINDACIN ETZ) - Tier 1; QLclobetasol prop emollient base - Tier 1; QLclobetasol propionate e - Tier 1; QLclobetasol propionate external solution - Tier 1; QLclotrimazole-betamethasone - Tier 1; QLcorn & callus remover (generic for COMPOUND W) - Tier 1COSENTYX - Tier 2; PA; SP; QLdiaper rash external ointment (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QLerythromycin external (generic for ERYGEL) - Tier 1; QLEUCRISA - Tier 2; ST; QLfluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; QLfluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - Tier 1; QLfluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; QLfluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; QL

ONEXTON - Tier 2; PA; QLPICATO - Tier 2; PA; QLPROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % (brand for tacrolimus)- Tier 2; PA; ST; QL; ALQBREXZA - Tier 2; PA; QLRETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL;ALRETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL; ALRETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) -Tier 2; PA; QL; ALRETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; ALRHOFADE - Tier 2; PA; QLSERNIVO - Tier 2; PA; QLSILIQ - Tier 2; PA; SP; QLSOOLANTRA - Tier 2; PA; QLSORILUX - Tier 2; PA; QLTACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QLTALTZ - Tier 2; PA; SP; QLTAZORAC - Tier 2; PA; QLTEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QLTOLAK - Tier 2; PA; QLTOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QLTREMFYA - Tier 2; PA; SP; QLVANOS (brand for fluocinonide) - Tier 2; PA; QLVECTICAL (brand for calcitriol) - Tier 2; PA; ST; QLVELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QLZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QLZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL


55


fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FSSCALP) - Tier 1; QLfluocinonide emulsified base - Tier 1; QLfluocinonide external solution - Tier 1; QLfluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QLfluorouracil external solution - Tier 1fluticasone propionate external cream - Tier 1; QLfluticasone propionate external ointment - Tier 1; QLgnp acne treatment (generic for CLEAN & CLEAR CONTINUOUS) -Tier 1gnp hydrocortisone - Tier 1; QLhalobetasol propionate external cream - Tier 1; QLhydrocortisone butyrate external ointment - Tier 1; QLhydrocortisone butyrate external solution (generic for LOCOID) - Tier1; QLhydrocortisone external cream - Tier 1; QLhydrocortisone external lotion 2.5 % - Tier 1; QLhydrocortisone external ointment 0.5 % - Tier 1hydrocortisone external ointment 1 % (generic for CORTIZONE-10) -Tier 1; QLhydrocortisone external ointment 2.5 % - Tier 1; QLimiquimod external (generic for ALDARA) - Tier 1; QLisotretinoin oral (generic for AMNESTEEM) - Tier 1; PA; QLlactic acid external - Tier 1methoxsalen rapid (generic for OXSORALEN ULTRA) - Tier 1MIRVASO - Tier 2; PA; QLmometasone furoate external - Tier 1; QLmyorisan (generic for AMNESTEEM) - Tier 1; PA; QL


56


OVACE PLUS WASH EXTERNAL LIQUID (brand for sulfacetamide sodium) - Tier 2OVACE WASH (brand for sulfacetamide sodium) - Tier 2pimecrolimus (generic for ELIDEL) - Tier 1; ST; QL; ALpodofilox external - Tier 1; QLprednicarbate external cream - Tier 1; QLREGRANEX - Tier 2; DX2RX; QLSANTYL - Tier 2; QLselenium sulfide external lotion - Tier 1; QLsodium sulfacetamide wash - Tier 1sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1sulfacetamide sodium external liquid (generic for OVACE PLUS WASH) - Tier 1sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR-E EMOLLIENT) - Tier 1sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QLsulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; QLsulfamez wash - Tier 1SUMADAN WASH (brand for sulfacetamide sodium-sulfur) - Tier 2; QLtacrolimus external ointment 0.03 %, 0.1 % (generic for PROTOPIC) - Tier 1; ST; QL; ALtretinoin external cream (generic for AVITA) - Tier 1; ST; QL; ALtriamcinolone acetonide external cream - Tier 1; QLtriamcinolone acetonide external lotion 0.025 % - Tier 1triamcinolone acetonide external lotion 0.1 % - Tier 1; QLtriamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier 1; QL


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triderm (generic for TRIDERM) - Tier 1; QLurea external lotion (generic for CEROVEL) - Tier 1; QLurea-c40 (generic for CEROVEL) - Tier 1; QLureacin-10 (generic for AQUA CARE) - Tier 1; QLureacin-20 - Tier 1; QLzaclir cleansing - Tier 1zenatane (generic for AMNESTEEM) - Tier 1; PA; QL


58


Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs

calcitrate oral tablet 950 mg - Tier 1calcium carbonate oral tablet 600 mg (generic for HIGH POTENCY CALCIUM) - Tier 1; QLcalcium carbonate-vitamin d tablet 600-400 mg-unit oral - Tier 1calcium carbonate-vitamin d tablet 600-400 mg-unit oral - Tier 1; QLCALTRATE 600 (brand for calcium 600) - Tier 2; QLCARBAGLU - Tier 2; PA; SP; QLeffer-k oral tablet effervescent 25 meq (generic for EFFER-K) - Tier 1; QLferocon (generic for TRICON) - Tier 1ferotrinsic (generic for TRICON) - Tier 1ferrous sulfate oral solution (generic for BPROTECTED PEDIA IRON) - Tier 1; QLferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QLferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg - Tier 1; QLfluoritab (generic for LUDENT) - Tier 1; QLFLURA-DROPS - Tier 2; QLfolic acid oral tablet 1 mg - Tier 1; QLfolic acid oral tablet 800 mcg (generic for FA-8) - Tier 1foltrin (generic for TRICON) - Tier 1gnp folic acid - Tier 1iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1klor-con (generic for KLOR-CON) - Tier 1; QLklor-con 10 (generic for KLOR-CON 10) - Tier 1; QLklor-con m10 (generic for KLOR-CON M10) - Tier 1; QLklor-con m20 (generic for KLOR-CON M20) - Tier 1; QL


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klor-con sprinkle oral capsule extended release 10 meq (generic for KLOR-CON SPRINKLE) - Tier 1; QLklor-con/ef (generic for EFFER-K) - Tier 1; QLK-PHOS - Tier 2; QLK-PHOS-NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QLk-prime (generic for EFFER-K) - Tier 1; QLludent (generic for LUDENT) - Tier 1; QLmagnesium oxide oral tablet 400 (241.3 mg) mg (generic for MAGNESIUM-OXIDE) - Tier 1magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1nafrinse (generic for LUDENT) - Tier 1; QLnafrinse drops (generic for NAFRINSE DROPS) - Tier 1; QLneutral sodium fluoride (generic for PREVIDENT) - Tier 1oyster shell calcium oral tablet 500 mg (generic for OYSTERCAL) - Tier 1; QLoyster shell calcium/d oral tablet 250-250 mg-unit, 500-400 mg-unit - Tier 1oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1; QLoyster shell calcium/vitamin d oral tablet 500-200 mg-unit (generic for OS-CAL CALCIUM + D3) - Tier 1; QLPEDIALYTE ORAL SOLUTION (brand for ra pediatric electrolyte) - Tier 2; QLpediatric electrolyte oral solution (generic for PEDIALYTE) - Tier 1; QLphospha 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; QLphosphorous (generic for PHOSPHA 250 NEUTRAL) - Tier 1; QLphospho-trin 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; QL


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poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1potassium bicarbonate oral (generic for EFFER-K) - Tier 1; QLpotassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QLpotassium chloride er oral capsule extended release 10 meq (generic for KLOR-CON SPRINKLE) - Tier 1; QLpotassium chloride er oral tablet extended release (generic for KLOR-CON 10) - Tier 1; QLpotassium chloride oral (generic for KLOR-CON) - Tier 1; QLpotassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QLpotassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1potassium citrate-citric acid - Tier 1PREVIDENT MOUTH/THROAT (brand for neutral sodium fluoride) - Tier 2ra iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QLsod citrate-citric acid - Tier 1sodium fluoride oral solution - Tier 1; QLsodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1sodium fluoride oral tablet chewable (generic for LUDENT) - Tier 1; QLtricon (generic for TRICON) - Tier 1virt-phos 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; QL


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Electrolyte/Mineral/Metal Modifiers

CHEMET - Tier 2; QLdeferasirox (generic for EXJADE) - Tier 1; PA; SP; QLJADENU SPRINKLE - Tier 2; PA; SP; QLkionex (generic for KIONEX) - Tier 1; QLLOKELMA - Tier 2; PA; QLsodium polystyrene sulfonate oral suspension (generic for KIONEX) - Tier 1; QLsodium polystyrene sulfonate rectal - Tier 1sps (generic for KIONEX) - Tier 1; QLVELTASSA - Tier 2; PA; QL

Phosphate Binders - Phosphate-Removing Agents

calcium acetate (phos binder) oral tablet (generic for CALPHRON) -Tier 1; QLcalcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1;QLsevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; ST;QL

AURYXIA - Tier 2; PA; QLVELPHORO - Tier 2; PA; QL


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Vitamins

adc/f (0.5mg/ml) - Tier 1animal shapes (generic for ANIMAL SHAPES) - Tier 1; QLATABEX OB - Tier 2; QLBACMIN (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLb-complex/b-12 oral - Tier 1biocel (generic for LYSIPLEX PLUS) - Tier 1; QLb-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QLcalcidol (generic for CALCIDOL) - Tier 1; QLchildrens chewable vitamins (generic for ANIMAL SHAPES) - Tier 1; QLcvs vitamin e oral capsule 1000 unit - Tier 1cyanocobalamin injection solution 1000 mcg/ml - Tier 1; QLCYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML - Tier 2; QLd3 high potency oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1d3 super strength - Tier 1; QLdecara oral capsule 1.25 mg (50000 ut) - Tier 1; QLdecara oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QLergocalciferol oral (generic for DRISDOL) - Tier 1; QLFORTAVIT ORAL CAPSULE (brand for multi for her) - Tier 2; QLgnp daily prenatal (generic for ONE-A-DAY WOMENS PRENATAL) - Tier 1; QLlysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QLM-NATAL PLUS - Tier 2; QLmultiple vitamin-folic acid (generic for ESTROFACTORS) - Tier 1


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MULTIPRO - Tier 2; QLmulti-vit/iron/fluoride - Tier 1; QLmulti-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QLmultivitamin/fluoride oral solution (generic for FLORIVA PLUS) - Tier 1; QLmultivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg (generic for MVC-FLUORIDE) - Tier 1; QLmultivitamin/fluoride/iron - Tier 1; QLmulti-vitamin/fluoride/iron - Tier 1; QLmultivitamins/fluoride (generic for MVC-FLUORIDE) - Tier 1; QLmvc-fluoride (generic for MVC-FLUORIDE) - Tier 1; QLmynephrocaps (generic for MYNEPHRON) - Tier 1mynephron (generic for MYNEPHRON) - Tier 1NEONATAL COMPLETE - Tier 2; QLNEONATAL PLUS (brand for prenatal vitamin plus low iron) - Tier 2; QLNEOVITE - Tier 2; QLNESTABS - Tier 2; QLniacin er oral capsule extended release 250 mg - Tier 1; QLniacin oral tablet 100 mg - Tier 1NICADAN (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLNICAZEL (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLNICAZEL FORTE (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLnovamv pediatric multi-vitamin - Tier 1; QLNUTRICAP (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLnutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QLone daily (generic for ESTROFACTORS) - Tier 1ONEVITE - Tier 2; QL


64


pediavit - Tier 1; QLphytonadione oral (generic for MEPHYTON) - Tier 1; QLpoly-vite pediatric (generic for BPROTECTED PEDIA POLY-VITE) - Tier 1; QLprenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier 1; QLprenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; QLprenatal oral tablet 28-0.8 mg - Tier 1; QLprenatal plus iron (generic for PRENATABS RX) - Tier 1; QLPRENATVITE RX - Tier 2; QLQUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML (brand for multivitamin/fluoride) - Tier 2; QLQUFLORA PEDIATRIC ORAL TABLET CHEWABLE (brand for multivitamin/fluoride) - Tier 2; QLra one daily (generic for ONE-A-DAY WOMENS PRENATAL) - Tier 1; QLrenal (generic for MYNEPHRON) - Tier 1RENAL MULTIVITAMIN FORMULA (brand for renal vitamin) - Tier 2; QLrena-vite (generic for RENAL MULTIVITAMIN FORMULA) - Tier 1; QLREQ 49+ (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLSELECT-OB ORAL TABLET CHEWABLE 29-1 MG - Tier 2; QLSIDEROL (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLSTROVITE FORTE ORAL TABLET (brand for ra one daily mens 50+ w/vit d3) - Tier 2; PA; QLSTROVITE ONE (brand for ra one daily mens 50+ w/vit d3) - Tier 2; PA; QLsupport (generic for BPROTECTED MULTI-VITE) - Tier 1; QL


65


trinate - Tier 1; QLtriphrocaps (generic for MYNEPHRON) - Tier 1tri-vitamin/fluoride oral solution 0.25 mg/ml - Tier 1; QLtri-vitamin/fluoride oral solution 0.5 mg/ml - Tier 1tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QLtri-vite/fluoride oral solution 0.5 mg/ml - Tier 1UDAMIN SP (brand for onevite) - Tier 2; QLv-c forte (generic for VIC-FORTE) - Tier 1; QLvic-forte (generic for VIC-FORTE) - Tier 1; QLvirt-caps (generic for MYNEPHRON) - Tier 1vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QLvitacel (generic for LYSIPLEX PLUS) - Tier 1; QLvita-min (generic for VIC-FORTE) - Tier 1; QLvitamin b-6 - Tier 1; QLvitamin c oral tablet 1000 mg - Tier 1; QLvitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QLvitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QLvitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QLvitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; QLvitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QLvitamin e oral capsule 1000 unit - Tier 1


66


vitamins acd-fluoride - Tier 1; QLVITAROCA PLUS (brand for ra one daily mens 50+ w/vit d3) - Tier 2; QLVITATHELY WITH GINGER (brand for prenatal vitamin plus low iron) - Tier 2; QLweekly-d - Tier 1; QL

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions

Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs

ANASPAZ (brand for ed-spaz) - Tier 2; QLdicyclomine hcl oral capsule - Tier 1; QLdicyclomine hcl oral solution - Tier 1dicyclomine hcl oral tablet - Tier 1; QLed-spaz (generic for ANASPAZ) - Tier 1; QLglycopyrrolate oral tablet 1 mg, 2 mg - Tier 1hyoscyamine sulfate er (generic for SYMAX-SR) - Tier 1; QLhyoscyamine sulfate oral - Tier 1; QLhyoscyamine sulfate sl (generic for SYMAX-SL) - Tier 1; QLhyoscyamine sulfate sublingual (generic for SYMAX-SL) - Tier 1; QLhyosyne - Tier 1; QLLEVBID (brand for oscimin sr) - Tier 2; QLLEVSIN ORAL (brand for hyoscyamine sulfate) - Tier 2; QLLEVSIN/SL (brand for hyoscyamine sulfate) - Tier 2; QLNULEV (brand for ed-spaz) - Tier 2; QLoscimin (generic for LEVSIN) - Tier 1; QLoscimin sr (generic for SYMAX-SR) - Tier 1; QLsymax-sl (generic for SYMAX-SL) - Tier 1; QLsymax-sr (generic for SYMAX-SR) - Tier 1; QL


67


Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs

antacid anti-gas max strength (generic for MAALOX MULTI SYMPTOM MAX ST) - Tier 1; QLantacid calcium (generic for CAL-GEST ANTACID) - Tier 1antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1antacid extra strength oral tablet chewable 750 mg (generic for TUMS CHEWY BITES) - Tier 1antacid maximum (generic for TUMS ULTRA 1000) - Tier 1antacid maximum strength (generic for MAALOX MULTI SYMPTOM MAX ST) - Tier 1; QLantacid oral suspension 200-200-20 mg/5ml (generic for MI-ACID) - Tier 1; QLantacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1antacid regular strength oral suspension (generic for MI-ACID) - Tier 1; QLantacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1anti-diarrheal oral liquid 1 mg/5ml - Tier 1anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1cvs antacid extra strength (generic for TUMS CHEWY BITES) - Tier 1diotame instydose (generic for SOOTHE) - Tier 1diphenoxylate-atropine - Tier 1; QLGAS-X (brand for cvs gas relief) - Tier 2GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for eq gas relief) - Tier 2GATTEX - Tier 2; PA; SP; QL

OMECLAMOX-PAK - Tier 2; PAPYLERA - Tier 2; PARELISTOR - Tier 2; PA; QLSYMPROIC - Tier 2; PA; QL


68


GELUSIL - Tier 2gnp antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1goodsense antacid (generic for CAL-GEST ANTACID) - Tier 1goodsense stomach relief oral suspension 1050 mg/30ml (generic for KAOPECTATE EXTRA STRENGTH) - Tier 1high potency probiotic (generic for ACIDOPHILUS HIGH-POTENCY) - Tier 1; QLhm gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1hm stomach relief oral suspension 525 mg/30ml (generic for SOOTHE) - Tier 1IMODIUM A-D ORAL TABLET (brand for qc anti-diarrheal) - Tier 2IMODIUM MULTI-SYMPTOM RELIEF (brand for hm anti-diarrheal anti-gas) - Tier 2infants gas relief oral suspension 20 mg/0.3ml (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QLMAALOX MULTI SYMPTOM MAX ST (brand for ra antacid/anti-gas max st) - Tier 2; QLmagnesium oxide oral tablet 400 mg - Tier 1magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QLmi-acid (generic for MI-ACID) - Tier 1; QLmi-acid maximum strength (generic for MAALOX MULTI SYMPTOM MAX ST) - Tier 1; QLmintox regular strength (generic for MI-ACID) - Tier 1; QLMOTEGRITY - Tier 2; QLMOVANTIK - Tier 2; DX2RX; QL


69


MYTESI - Tier 2; DX2RX; QLpink bismuth maximum strength (generic for KAOPECTATE EXTRA STRENGTH) - Tier 1RESTORA RX - Tier 2saccharomyces boulardii (generic for FLORASTOR) - Tier 1simethicone oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier 1simethicone oral suspension (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1simethicone oral tablet chewable 80 mg (generic for GAS-X) - Tier 1sodium bicarbonate oral tablet - Tier 1soothe oral suspension 525 mg/30ml (generic for SOOTHE) - Tier 1soothe oral tablet - Tier 1stomach relief oral suspension 525 mg/30ml (generic for SOOTHE) - Tier 1stomach relief oral tablet chewable (generic for PEPTO-BISMOL) - Tier 1; QLTRULANCE - Tier 2; DX2RX; QLTUMS CHEWY BITES (brand for hm calcium antacid) - Tier 2ursodiol oral capsule (generic for ACTIGALL) - Tier 1; QLursodiol oral tablet (generic for URSO 250) - Tier 1ZELAC - Tier 2; QL

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs

cimetidine hcl - Tier 1cimetidine oral tablet 200 mg (generic for TAGAMET HB) - Tier 1cimetidine oral tablet 300 mg, 400 mg, 800 mg - Tier 1; QLfamotidine oral (generic for PEPCID) - Tier 1; QLheartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1


70


Irritable Bowel Syndrome Agents - Bowel Treatment Drugs

AMITIZA - Tier 2; PA; QLLINZESS - Tier 2; PA; QL

Laxatives - Drugs to treat Constipation

bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1; QLbisacodyl rectal (generic for DULCOLAX) - Tier 1; QLcitroma (generic for CITROMA) - Tier 1clearlax (generic for CLEARLAX) - Tier 1; QLconstulose - Tier 1; QLcvs gentle laxative rectal (generic for DULCOLAX) - Tier 1; QLcvs stool softener oral capsule 250 mg - Tier 1; QLdocusate mini (generic for DOCUSOL MINI) - Tier 1; QLdocusate sodium oral capsule 250 mg - Tier 1; QLdocusate sodium oral liquid 150 mg/15ml - Tier 1; QLdocusate sodium oral syrup - Tier 1docuzen (generic for DOK PLUS) - Tier 1dok plus (generic for DOK PLUS) - Tier 1enulose - Tier 1; QLEX-LAX ULTRA (brand for gentle laxative) - Tier 2; QLfiber laxative (generic for FIBERCON) - Tier 1gavilax oral powder (generic for CLEARLAX) - Tier 1; QLgavilyte-c - Tier 1; QLgavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QLgenerlac - Tier 1; QLgentle laxative (generic for EX-LAX ULTRA) - Tier 1; QLgeri-kot (generic for DR EDWARDS OLIVE LAXATIVE) - Tier 1glycolax (generic for CLEARLAX) - Tier 1; QLgnp senna lax (generic for DR EDWARDS OLIVE LAXATIVE) - Tier 1GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM - Tier 2; QLgoodsense enema (generic for FLEET ENEMA) - Tier 1


71


hm stool softener oral capsule 100 mg (generic for COLACE) - Tier 1; QLlactulose encephalopathy - Tier 1; QLlactulose oral solution - Tier 1; QLlaxative max str - Tier 1laxative regular strength (generic for SENNA SMOOTH) - Tier 1magnesium citrate oral solution (generic for CITROMA) - Tier 1milk of magnesia oral suspension 1200 mg/15ml, 400 mg/5ml (generic for DULCOLAX MILK OF MAGNESIA) - Tier 1mineral oil heavy oral - Tier 1mm stool softener laxative (generic for COLACE) - Tier 1; QLnatural fiber laxative oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QLnatural senna laxative (generic for DR EDWARDS OLIVE LAXATIVE) - Tier 1peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QLPERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2qc magnesium citrate (generic for CITROMA) - Tier 1senexon-s (generic for DOK PLUS) - Tier 1senna oral liquid - Tier 1senna oral syrup 8.8 mg/5ml - Tier 1senna oral tablet (generic for DR EDWARDS OLIVE LAXATIVE) - Tier 1senna plus oral tablet (generic for DOK PLUS) - Tier 1senna s (generic for DOK PLUS) - Tier 1senna smooth (generic for SENNA SMOOTH) - Tier 1senna-docusate sodium (generic for DOK PLUS) - Tier 1senna-plus (generic for DOK PLUS) - Tier 1


72


SENOKOT S (brand for sb docusate sodium/senna) - Tier 2stimulant laxative oral tablet (generic for DOK PLUS) - Tier 1stool softener laxative oral capsule 100 mg (generic for COLACE) - Tier 1; QLstool softener oral capsule 100 mg (generic for COLACE) - Tier 1; QLstool softener oral capsule 250 mg - Tier 1; QLstool softener plus laxative (generic for DOK PLUS) - Tier 1stool softener/laxative oral tablet (generic for DOK PLUS) - Tier 1trilyte (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QLvegetable lax+stool softener (generic for DOK PLUS) - Tier 1

Protectants - Ulcer and Stomach Acid Drugs

CARAFATE ORAL SUSPENSION (brand for sucralfate) - Tier 2; QLmisoprostol oral (generic for CYTOTEC) - Tier 1; QLsucralfate oral tablet (generic for CARAFATE) - Tier 1; QL

Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs

esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1;QL; ALgnp lansoprazole (generic for PREVACID) - Tier 1; QLheartburn treatment 24 hour (generic for PREVACID) - Tier 1; QLlansoprazole oral capsule delayed release (generic for PREVACID) -Tier 1; QLlansoprazole oral tablet delayed release dispersible (generic forPREVACID SOLUTAB) - Tier 1; QL; ALNEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; QL; ALomeprazole oral capsule delayed release - Tier 1; QLpantoprazole sodium oral (generic for PROTONIX) - Tier 1; QLPREVACID 24HR (brand for gnp lansoprazole) - Tier 2; QL

ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QLDEXILANT - Tier 2; PA; QLesomeprazole magnesium oral capsule delayed release (generic for NEXIUM) - Tier 1; PA; QLNEXIUM ORAL CAPSULE DELAYED RELEASE (brand for esomeprazole magnesium) - Tier 2; PA; QLNEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG (brand for esomeprazole magnesium) - Tier 2; PA; QL; ALomeprazole magnesium oral tablet delayed release (generic for PRILOSEC OTC) - Tier 1; PA; QLomeprazole oral tablet delayed release - Tier 1; PA; QLPREVACID (brand for gnp lansoprazole) - Tier 2; PA; QLPRILOSEC - Tier 2; PA; QLZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL


73


Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

CHOLBAM - Tier 2; PA; SP; QLCREON - Tier 2CYSTAGON - Tier 2; SP; QLKUVAN - Tier 2; DX2RX; SP; QLNITYR - Tier 2; DX2RX; SP; QLRAVICTI - Tier 2; PA; SP; QLsodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1;DX2RX; SP; QLSTRENSIQ - Tier 2; PA; SP; QLTEGSEDI - Tier 2; PA; SP; QL

CERDELGA - Tier 2; PA; SP; QLORFADIN (brand for nitisinone) - Tier 2; PA; SP; QLPANCREAZE - Tier 2; PAVIOKACE - Tier 2; PAZAVESCA (brand for miglustat) - Tier 2; PA; SP; QLZENPEP - Tier 2; PA

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions

Antispasmodics, Urinary - Bladder Control Drugs

oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QLoxybutynin chloride oral - Tier 1; QLphosphasal (generic for PHOSPHASAL) - Tier 1; QLtolterodine tartrate (generic for DETROL) - Tier 1; ST; QLtrospium chloride - Tier 1; ST; QLuretron d/s (generic for PHOSPHASAL) - Tier 1; QLurin ds (generic for PHOSPHASAL) - Tier 1; QLutira-c (generic for PHOSPHASAL) - Tier 1; QLutrona-c (generic for PHOSPHASAL) - Tier 1; QL

DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QLDETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QLDITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QLENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG (brand for darifenacin hydrobromide er) - Tier 2; PA; QLMYRBETRIQ - Tier 2; PA; QLTOVIAZ - Tier 2; PA; QLVESICARE (brand for solifenacin succinate) - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents - Prostate Drugs

alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QLfinasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QLtamsulosin hcl (generic for FLOMAX) - Tier 1; QLterazosin hcl - Tier 1; QL


74


Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs

azo tabs (generic for AZO URINARY PAIN RELIEF) - Tier 1bethanechol chloride oral - Tier 1ELMIRON - Tier 2; DX2RX; QLpenicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1; DX2RX; SP; QLphenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QLphenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1; QLphenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; QLPYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QLurinary pain relief oral tablet 95 mg (generic for AZO URINARY PAIN RELIEF) - Tier 1

CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QLDEPEN TITRATABS (brand for penicillamine) - Tier 2; DX2RX; SP; QL


75


Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs

cortisone acetate oral - Tier 1; QLDECADRON ORAL TABLET 0.5 MG, 0.75 MG (brand for dexamethasone) - Tier 2DECADRON ORAL TABLET 4 MG, 6 MG (brand for dexamethasone) - Tier 2; QLdexamethasone intensol - Tier 1dexamethasone oral elixir - Tier 1; QLdexamethasone oral solution - Tier 1; QLdexamethasone oral tablet 0.5 mg, 0.75 mg (generic for DECADRON) - Tier 1dexamethasone oral tablet 1 mg, 2 mg - Tier 1dexamethasone oral tablet 1.5 mg - Tier 1; QLdexamethasone oral tablet 4 mg, 6 mg (generic for DECADRON) - Tier 1; QLfludrocortisone acetate oral - Tier 1; QLhydrocortisone oral (generic for CORTEF) - Tier 1; QLMEDROL ORAL TABLET 2 MG - Tier 2methylprednisolone oral (generic for MEDROL) - Tier 1; QLprednisolone oral solution - Tier 1; QLprednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml (generic for PEDIAPRED) - Tier 1; QLprednisone oral solution - Tier 1; QLprednisone oral tablet - Tier 1; QLprednisone oral tablet therapy pack 10 mg (21) - Tier 1; QLprednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) - Tier 1


76


Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs

chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; DX2RXDDAVP RHINAL TUBE - Tier 2; QLdesmopressin ace spray refrig - Tier 1; QLdesmopressin acetate oral (generic for DDAVP) - Tier 1; QLdesmopressin acetate spray (generic for DDAVP) - Tier 1; QLINCRELEX - Tier 2; PA; SP; QLNOCDURNA - Tier 2; PA; QLnovarel intramuscular solution reconstituted 10000 unit (generic for NOVAREL) - Tier 1; DX2RXNOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT - Tier 2; DX2RXOVIDREL - Tier 2; DX2RXpregnyl (generic for NOVAREL) - Tier 1; DX2RXZOMACTON - Tier 2; PA; SP; QL

GENOTROPIN - Tier 2; PA; SP; QLHUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24MG, 6 MG - Tier 2; PA; SP; QLNORDITROPIN FLEXPRO - Tier 2; PA; SP; QLNUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QLNUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QLNUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QLOMNITROPE - Tier 2; PA; SP; QLSAIZEN - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs

KORLYM - Tier 2; PA; SP; QL


77


Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones

Androgens - Hormone Replacement/Modifying Drugs

danazol oral - Tier 1; QLtestosterone cypionate intramuscular (generic for DEPO-TESTOSTERONE) - Tier 1; QLtestosterone enanthate intramuscular - Tier 1; QLtestosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; QLtestosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; QL


78


Estrogens - Hormone Replacement/Modifying Drugs

afirmelle (generic for AFIRMELLE) - Tier 1; QL; GEaltavera (generic for ALTAVERA) - Tier 1; QL; GEalyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GEalyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GEapri (generic for APRI) - Tier 1; QL; GEaranelle - Tier 1; QL; GEaubra (generic for AFIRMELLE) - Tier 1; QL; GEaubra eq (generic for AFIRMELLE) - Tier 1; QL; GEaurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GEaurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GEaurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GEaurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GEaviane (generic for AFIRMELLE) - Tier 1; QL; GEayuna (generic for ALTAVERA) - Tier 1; QL; GEazurette (generic for AZURETTE) - Tier 1; QL; GEbalziva (generic for BALZIVA) - Tier 1; QL; GEbekyree (generic for AZURETTE) - Tier 1; QL; GEblisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GEblisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GEbriellyn (generic for BALZIVA) - Tier 1; QL; GEcaziant - Tier 1; QLchateal (generic for ALTAVERA) - Tier 1; QL; GEchateal eq (generic for ALTAVERA) - Tier 1; QL; GEcryselle-28 - Tier 1; QL; GEcyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GEcyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GEcyred (generic for APRI) - Tier 1; QL; GEcyred eq (generic for APRI) - Tier 1; QL; GEdasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE

ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QLALORA (brand for estradiol) - Tier 2; PA; QLANGELIQ - Tier 2; PACLIMARA (brand for estradiol) - Tier 2; PA; QLCLIMARA PRO - Tier 2; PACOMBIPATCH - Tier 2; PA; QLDIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25MG/1.25GM - Tier 2; PA; QLDIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM - Tier 2; PAELESTRIN - Tier 2; PAESTRACE (brand for estradiol) - Tier 2; PA; QLestradiol transdermal patch twice weekly (generic for ALORA) - Tier 1;PA; QLestradiol-norethindrone acet oral tablet 1-0.5 mg (generic for MIMVEY) -Tier 1; PA; QLESTRING - Tier 2; PA; QLESTROGEL - Tier 2; PAEVAMIST - Tier 2; PAFEMHRT LOW DOSE (brand for norethindrone-eth estradiol) - Tier 2; PAFEMRING - Tier 2; PA; QLfyavolv oral tablet 0.5-2.5 mg-mcg - Tier 1; PAfyavolv oral tablet 1-5 mg-mcg - Tier 1; PA; QLjinteli - Tier 1; PA; QLMENEST - Tier 2; PA; QLMENOSTAR - Tier 2; PA; QLmimvey (generic for MIMVEY) - Tier 1; PA; QLMINIVELLE (brand for estradiol) - Tier 2; PA; QLPREFEST - Tier 2; PA; QLPREMARIN VAGINAL - Tier 2; PA; QL


79


dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GEdelyla (generic for AFIRMELLE) - Tier 1; QL; GEDEPO-ESTRADIOL - Tier 2; QLdesogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GEDUAVEE - Tier 2; QLelinest - Tier 1; QL; GEeluryng (generic for ELURYNG) - Tier 1; QL; GEemoquette (generic for APRI) - Tier 1; QL; GEenpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GEenskyce (generic for APRI) - Tier 1; QL; GEestarylla (generic for ESTARYLLA) - Tier 1; QL; GEestradiol oral (generic for ESTRACE) - Tier 1; QLestradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QLestradiol vaginal (generic for ESTRACE) - Tier 1; QLethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL; GEetonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GEfalmina (generic for AFIRMELLE) - Tier 1; QL; GEfemynor (generic for ESTARYLLA) - Tier 1; QL; GEhailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GEintrovale (generic for INTROVALE) - Tier 1; QLisibloom (generic for APRI) - Tier 1; QL; GEjolessa (generic for INTROVALE) - Tier 1; QLjuleber (generic for APRI) - Tier 1; QL; GEjunel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GEjunel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GEjunel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

VAGIFEM (brand for estradiol) - Tier 2; PA; QLVIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL


80


junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) - Tier 1; QL; GEkalliga (generic for APRI) - Tier 1; QL; GEkariva (generic for AZURETTE) - Tier 1; QL; GEkelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GEkelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GEkurvelo (generic for ALTAVERA) - Tier 1; QL; GElarin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GElarin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GElarin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GElarin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GElarissia (generic for AFIRMELLE) - Tier 1; QL; GEleena - Tier 1; QL; GElessina (generic for AFIRMELLE) - Tier 1; QL; GElevonest (generic for ENPRESSE-28) - Tier 1; QL; GElevonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg (generic for INTROVALE) - Tier 1; QLlevonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1; QL; GElevonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1; QL; GElevonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL; GElevora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GElillow (generic for ALTAVERA) - Tier 1; QL; GElow-ogestrel - Tier 1; QL; GElutera (generic for AFIRMELLE) - Tier 1; QL; GEmarlissa (generic for ALTAVERA) - Tier 1; QL; GEmicrogestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE


81


microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GEmicrogestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GEmicrogestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GEmili (generic for ESTARYLLA) - Tier 1; QL; GEmono-linyah (generic for ESTARYLLA) - Tier 1; QL; GEnecon 0.5/35 (28) - Tier 1; QL; GEnorethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL; GEnorethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL; GEnorgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GEnorgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg (generic for TRI FEMYNOR) - Tier 1; QL; GEnortrel 0.5/35 (28) - Tier 1; QL; GEnortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL; GEnortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL; GEnortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GEorsythia (generic for AFIRMELLE) - Tier 1; QL; GEphilith (generic for BALZIVA) - Tier 1; QL; GEpimtrea (generic for AZURETTE) - Tier 1; QL; GEpirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GEpirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GEportia-28 (generic for ALTAVERA) - Tier 1; QL; GEPREMARIN ORAL - Tier 2; QLPREMPHASE - Tier 2; QLPREMPRO - Tier 2; QLprevifem (generic for ESTARYLLA) - Tier 1; QL; GEreclipsen (generic for APRI) - Tier 1; QL; GE


82


setlakin (generic for INTROVALE) - Tier 1; QLsimliya (generic for AZURETTE) - Tier 1; QL; GEsprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GEsronyx (generic for AFIRMELLE) - Tier 1; QL; GEtarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GEtarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GEtilia fe - Tier 1; QL; GEtri femynor (generic for TRI FEMYNOR) - Tier 1; QL; GEtri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL; GEtri-legest fe - Tier 1; QL; GEtri-linyah (generic for TRI FEMYNOR) - Tier 1; QL; GEtri-mili (generic for TRI FEMYNOR) - Tier 1; QL; GEtri-previfem (generic for TRI FEMYNOR) - Tier 1; QL; GEtri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL; GEtrivora (28) (generic for ENPRESSE-28) - Tier 1; QL; GEtri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL; GEvelivet - Tier 1; QLvienva (generic for AFIRMELLE) - Tier 1; QL; GEviorele (generic for AZURETTE) - Tier 1; QL; GEvolnea (generic for AZURETTE) - Tier 1; QL; GEvyfemla (generic for BALZIVA) - Tier 1; QL; GEvylibra (generic for ESTARYLLA) - Tier 1; QL; GEwera - Tier 1; QL; GExulane - Tier 1; QL; GEyuvafem (generic for YUVAFEM) - Tier 1; QLzovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL; GE


83


Progestins - Hormone Replacement/Modifying Drugs

camila (generic for CAMILA) - Tier 1; QL; GEdeblitane (generic for CAMILA) - Tier 1; QL; GEerrin (generic for CAMILA) - Tier 1; QL; GEheather (generic for CAMILA) - Tier 1; QL; GEincassia (generic for CAMILA) - Tier 1; QL; GEjencycla (generic for CAMILA) - Tier 1; QL; GElevonorgestrel (generic for PLAN B ONE-STEP) - Tier 1; QL; GElyza (generic for CAMILA) - Tier 1; QL; GEmedroxyprogesterone acetate intramuscular (generic for DEPO-PROVERA) - Tier 1; QL; GEmedroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QLmegestrol acetate oral suspension 40 mg/ml - Tier 1; QLmegestrol acetate oral tablet 20 mg - Tier 1megestrol acetate oral tablet 40 mg - Tier 1; QLnora-be (generic for CAMILA) - Tier 1; QL; GEnorethindrone acetate oral (generic for AYGESTIN) - Tier 1; QLnorethindrone oral (generic for CAMILA) - Tier 1; QL; GEnorlyda (generic for CAMILA) - Tier 1; QL; GEnorlyroc (generic for CAMILA) - Tier 1; QL; GEPLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GEprogesterone micronized oral (generic for PROMETRIUM) - Tier 1; DX2RX; QLsharobel (generic for CAMILA) - Tier 1; QL; GEtulana (generic for CAMILA) - Tier 1; QL; GE

DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs

raloxifene hcl (generic for EVISTA) - Tier 1; QL OSPHENA - Tier 2; PA; QL; GE


84


Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs

euthyrox (generic for EUTHYROX) - Tier 1; QLlevo-t (generic for EUTHYROX) - Tier 1; QLlevothyroxine sodium oral (generic for EUTHYROX) - Tier 1; QLlevoxyl (generic for EUTHYROX) - Tier 1; QLliothyronine sodium oral (generic for CYTOMEL) - Tier 1; QLunithroid (generic for EUTHYROX) - Tier 1; QL

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants

LYSODREN - Tier 2; QL


85


Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants

cabergoline - Tier 1; QLEGRIFTA - Tier 2; DX2RX; SP; QLEGRIFTA SV - Tier 2; DX2RX; SP; QLleuprolide acetate injection - Tier 1; PA; SP; QLLUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QLLUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QLLUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2;PA; SP; QLLUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2;PA; SP; QLLUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QLLUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QLoctreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QLORILISSA - Tier 2; PA; QLSIGNIFOR - Tier 2; PA; SP; QLSOMAVERT - Tier 2; PA; SP; QL

LUPANETA PACK - Tier 2; PA; SP; QLSYNAREL - Tier 2; PA

Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones

Antithyroid Agents - Thyroid Suppressing Drugs

methimazole oral (generic for TAPAZOLE) - Tier 1; QLpropylthiouracil oral - Tier 1; QL


86


Immunological Agents - Drugs that Stimulate or Suppress the Immune System

Angioedema Agents - Drugs to Treat Swelling Underneath the Skin

BERINERT - Tier 2; PA; SP; QLHAEGARDA - Tier 2; PA; SP; QLicatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL

CINRYZE - Tier 2; PA; SP; QLFIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QLRUCONEST - Tier 2; PA; SP; QLTAKHZYRO - Tier 2; PA; SP; QL


87


Immune Suppressants - Immune System Drugs

azathioprine oral (generic for IMURAN) - Tier 1; QLCIMZIA - Tier 2; PA; SP; QLcyclosporine modified oral capsule 100 mg (generic for GENGRAF) - Tier 1; QLcyclosporine modified oral capsule 25 mg (generic for GENGRAF) - Tier 1cyclosporine modified oral capsule 50 mg - Tier 1; QLcyclosporine modified oral solution (generic for GENGRAF) - Tier 1cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QLENBREL - Tier 2; PA; SP; QLeverolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for ZORTRESS) - Tier 1gengraf oral capsule 100 mg (generic for GENGRAF) - Tier 1; QLgengraf oral capsule 25 mg (generic for GENGRAF) - Tier 1HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT - Tier 2; PA; SP; QLHUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT - Tier 2; PA; SP; QLKINERET - Tier 2; PA; SP; QLmethotrexate oral - Tier 1methotrexate sodium - Tier 1methotrexate sodium (pf) - Tier 1mycophenolate mofetil (generic for CELLCEPT) - Tier 1; QLmycophenolate sodium (generic for MYFORTIC) - Tier 1; QLOLUMIANT - Tier 2; PA; SP; QLsirolimus oral solution (generic for RAPAMUNE) - Tier 1; QLsirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; QLsirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1

ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QLOTREXUP - Tier 2; PA; QLRASUVO - Tier 2; PA; QLSIMPONI - Tier 2; PA; SP; QLSKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QLSTELARA SUBCUTANEOUS - Tier 2; PA; SP; QLXELJANZ - Tier 2; PA; SP; QLXELJANZ XR - Tier 2; PA; SP; QL


88


tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QLZORTRESS ORAL TABLET 1 MG - Tier 2

Immunomodulators - Immune System Drugs

ACTIMMUNE - Tier 2; PA; SP; QLILARIS - Tier 2; PA; SP; QLKEVZARA - Tier 2; PA; SP; QLleflunomide oral (generic for ARAVA) - Tier 1; QLOTEZLA - Tier 2; PA; SP; QLSYNAGIS - Tier 2; PA; SP; QLXOLAIR - Tier 2; PA; SP; QL

ACTEMRA ACTPEN - Tier 2; PA; SP; QLACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QLRINVOQ - Tier 2; PA; SP; QL


89


Vaccines

ADACEL - Tier 2; QLAFLURIA QUADRIVALENT - Tier 2; QLBEXSERO - Tier 2; QLBOOSTRIX - Tier 2; QLDAPTACEL - Tier 2; QLDIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QLENGERIX-B - Tier 2; QLFLUAD - Tier 2; QLFLUARIX QUADRIVALENT - Tier 2; QLFLULAVAL QUADRIVALENT - Tier 2; QLFLUZONE HIGH-DOSE - Tier 2; QLFLUZONE QUADRIVALENT - Tier 2; QLGARDASIL 9 - Tier 2; QLHAVRIX - Tier 2; QLHEPLISAV-B - Tier 2; QL; ALHYPERTET S/D - Tier 2; QLINFANRIX - Tier 2; QLMENACTRA - Tier 2; QLMENVEO - Tier 2; QLM-M-R II - Tier 2; QLPNEUMOVAX 23 - Tier 2; QLPREVNAR 13 - Tier 2; QLRECOMBIVAX HB - Tier 2; QLSHINGRIX - Tier 2; QL; ALTDVAX - Tier 2; QLTENIVAC - Tier 2; QLTRUMENBA - Tier 2; QLTWINRIX - Tier 2; QLVAQTA - Tier 2; QLVARIVAX - Tier 2; QLZOSTAVAX - Tier 2; QL; AL


90


Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease

Aminosalicylates - Inflammatory Bowel Disease Drugs

balsalazide disodium (generic for COLAZAL) - Tier 1; QLmesalamine oral capsule delayed release (generic for DELZICOL) - Tier 1; QLmesalamine rectal - Tier 1; QLSFROWASA - Tier 2; QL

APRISO (brand for mesalamine er) - Tier 2; PA; QLASACOL HD (brand for mesalamine) - Tier 2; PA; QLCOLAZAL (brand for balsalazide disodium) - Tier 2; PA; QLDELZICOL (brand for mesalamine) - Tier 2; PA; QLDIPENTUM - Tier 2; PA; QLLIALDA (brand for mesalamine) - Tier 2; PA; QLPENTASA - Tier 2; PA; QL

Glucocorticoids - Drugs to Treat Inflammation

budesonide oral (generic for ENTOCORT EC) - Tier 1; DX2RX; QLcolocort (generic for COLOCORT) - Tier 1hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO-MED HC) - Tier 1; QLhydrocortisone rectal (generic for COLOCORT) - Tier 1procto-med hc (generic for PROCTO-MED HC) - Tier 1; QLproctosol hc (generic for PROCTO-MED HC) - Tier 1; QLproctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL

CORTIFOAM - Tier 2; PA; QLPROCTOFOAM HC - Tier 2; PA

Sulfonamides - Antibiotics

sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL


91


Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs

alendronate sodium - Tier 1; QLcalcitonin (salmon) (generic for MIACALCIN) - Tier 1; QLcinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QLTYMLOS - Tier 2; PA; SP; QL

ATELVIA (brand for risedronate sodium) - Tier 2; PABINOSTO - Tier 2; PA; QLFORTEO - Tier 2; PA; SP; QL

Metabolic Bone Disease Agents - Other

calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QLcalcitriol oral solution (generic for ROCALTROL) - Tier 1; AL


92


Miscellaneous Therapeutic Agents

ACCU-CHEK AVIVA IN VITRO (brand for element compact control 2) - Tier 2; QLACCU-CHEK COMPACT PLUS CONTROL (brand for element compact control 2) - Tier 2; QLACCU-CHEK GUIDE CONTROL (brand for element compact control 2) - Tier 2; QLACCU-CHEK MULTICLIX LANCETS (brand for drug mart lancets thin 26g) - Tier 2; QLACCU-CHEK SMARTVIEW CONTROL (brand for element compact control 2) - Tier 2; QLALCOHOL PREP PADS PAD , 70 % - Tier 2; QLBD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier 2; QLBD ULTRA-FINE INSULIN SYRINGES - Tier 2; QLBD ULTRA-FINE PEN NEEDLES (brand for sure comfort pen needles) - Tier 2; QLBREATHE EASE HUMIDIFIER - Tier 2; QLCARETOUCH CONTROL SOL LEVEL 2 (brand for element compact control 2) - Tier 2; QLCAYA - Tier 2; QLCHEMSTRIP UGK - Tier 2; QLCONDOMS - Tier 2; QLDESENEX EXTERNAL POWDER (brand for gnp miconazorb af) - Tier 2; QLEASIVENT (brand for procare spacer/child mask) - Tier 2; QLINSPIREASE RESERVOIR BAGS - Tier 2; QLKETONE TEST - Tier 2; QLKETOSTIX (brand for ketone test) - Tier 2; QLLANCETS (brand for drug mart lancets thin 26g) - Tier 2; QL

ACCU-CHEK AVIVA CONNECT (brand for meijer blood glucose) - Tier 2;PA; QLACCU-CHEK AVIVA PLUS KIT W/DEVICE (brand for meijer bloodglucose test) - Tier 2; PA; QLACCU-CHEK COMPACT PLUS (brand for meijer blood glucose test) -Tier 2; PA; QLACCU-CHEK COMPACT PLUS CARE - Tier 2; PA; QLACCU-CHEK FASTCLIX LANCET KIT (brand for select-litedevice/lancets) - Tier 2; PA; QLACCU-CHEK GUIDE KIT W/DEVICE (brand for meijer blood glucose) -Tier 2; PA; QLACCU-CHEK MULTICLIX LANCET DEVICE KIT (brand for select-litedevice/lancets) - Tier 2; PA; QLACCU-CHEK MULTICLIX LANCETS (brand for drug mart lancets thin26g) - Tier 2; PA; QLACCU-CHEK NANO SMARTVIEW (brand for meijer blood glucose) - Tier2; PA; QLACCU-CHEK SMARTVIEW (brand for meijer blood glucose test) - Tier 2;PA; QLACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-litedevice/lancets) - Tier 2; PA; QLAJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;PA; QLCONTOUR NEXT TEST (brand for meijer blood glucose test) - Tier 2; PA;QLCONTOUR TEST (brand for meijer blood glucose test) - Tier 2; PA; QLFREESTYLE PRECISION NEO TEST (brand for meijer blood glucosetest) - Tier 2; PA; QLNOVOEIGHT - Tier 2; PA; QL


93


LOTRIMIN AF EXTERNAL POWDER (brand for gnp miconazorb af) - Tier 2; QLMASK VORTEX - Tier 2; QLmethergine (generic for METHERGINE) - Tier 1; QLmethylergonovine maleate oral (generic for METHERGINE) - Tier 1; QLONETOUCH ULTRA 2 KIT W/DEVICE (brand for meijer blood glucose) - Tier 2; QLONETOUCH ULTRA BLUE IN VITRO STRIP (brand for meijer blood glucose test) - Tier 2; QLONETOUCH ULTRA MINI KIT W/DEVICE (brand for meijer blood glucose) - Tier 2; QLONETOUCH VERIO KIT W/DEVICE (brand for meijer blood glucose) - Tier 2; QLONETOUCH VERIO FLEX SYSTEM (brand for meijer blood glucose) - Tier 2; QLONETOUCH VERIO TEST STRIPS (brand for meijer blood glucose test) - Tier 2; QLONETOUCH VERIO IQ SYSTEM (brand for meijer blood glucose) - Tier 2; QLONETOUCH VERIO SYNC SYSTEM (brand for meijer blood glucose) - Tier 2; QLPREMIUM CONDOMS LUBRICATED - Tier 2; QLRUZURGI - Tier 2; PA; SP; QLtolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) - Tier 1VISTOGARD - Tier 2; QLVORTEX HOLDING CHAMBER/MASK (brand for nebulizer) - Tier 2WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL

NOVOFINE AUTOCOVER PEN NEEDLE (brand for pen needles 5/16") -Tier 2; PA; QLNOVOFINE PEN NEEDLE (brand for sure comfort pen needles) - Tier 2;PA; QLNOVOFINE PLUS PEN NEEDLE (brand for wegmans unifine pentipsplus) - Tier 2; PA; QLNOVOTWIST PEN NEEDLE (brand for pro comfort pen needles) - Tier 2;PA; QLPRECISION LINK (brand for meijer blood glucose) - Tier 2; PA; QLPRECISION PCX PLUS TEST (brand for meijer blood glucose test) - Tier2; PA; QLPRECISION QID MONITOR (brand for diatrue plus blood glucose) - Tier2; PA; QLPRECISION QID TEST (brand for meijer blood glucose test) - Tier 2; PA;QLPRECISION SOF-TACT MONITOR (brand for diatrue plus blood glucose)- Tier 2; PA; QLPRECISION SOF-TACT TEST (brand for meijer blood glucose test) - Tier2; PA; QLPRECISION XTRA BLOOD GLUCOSE (brand for meijer blood glucosetest) - Tier 2; PA; QLPRECISION XTRA DEVICE (brand for diatrue plus blood glucose) - Tier2; PA; QLPRECISION XTRA MONITOR (brand for diatrue plus blood glucose) -Tier 2; PA; QLTRUETRACK TEST (brand for meijer blood glucose test) - Tier 2; PA; QL


94


WIDE-SEAL DIAPHRAGM 65 - Tier 2; QLWIDE-SEAL DIAPHRAGM 70 - Tier 2; QLWIDE-SEAL DIAPHRAGM 75 - Tier 2; QLWIDE-SEAL DIAPHRAGM 80 - Tier 2; QLWIDE-SEAL DIAPHRAGM 85 - Tier 2; QLWIDE-SEAL DIAPHRAGM 90 - Tier 2; QLWIDE-SEAL DIAPHRAGM 95 - Tier 2; QLZEASORB-AF (brand for gnp miconazorb af) - Tier 2; QL


95


Ophthalmic Agents - Drugs to Treat Eye Conditions

Ophthalmic Agents, Other - Miscellaneous Eye Drugs

ak-poly-bac (generic for POLYCIN) - Tier 1altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QLaltafrin (generic for ALTAFRIN) - Tier 1artificial tears ophthalmic solution 1.4 % - Tier 1atropine sulfate ophthalmic ointment - Tier 1atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE) - Tier 1; QLbacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; QLBLEPHAMIDE S.O.P. - Tier 2; QLcvs lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QLcyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - Tier 1; QLCYSTARAN - Tier 2; DX2RX; SP; QLGENTEAL TEARS NIGHT-TIME (brand for for sty relief) - Tier 2; QLGENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.3 % (brand for artificial tears) - Tier 2goodsense relief eye drops (generic for VISINE-AC) - Tier 1; QLgoodsense ultra lubricant drop (generic for SYSTANE) - Tier 1; QLISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QLlubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QLlubricant pm (generic for PURALUBE) - Tier 1; QLlubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QLlubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1

CEQUA - Tier 2; PA; QLLASTACAFT - Tier 2; PARESTASIS - Tier 2; PA; QLRESTASIS MULTIDOSE - Tier 2; PA; QLRHOPRESSA - Tier 2; PA; QL


96


MURO 128 OPHTHALMIC OINTMENT (brand for cvs sodium chloride) - Tier 2MURO 128 OPHTHALMIC SOLUTION 5 % (brand for cvs sodium chloride) - Tier 2; QLneomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1; QLneomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1; QLneomycin-polymyxin-gramicidin - Tier 1; QLneomycin-polymyxin-hc ophthalmic - Tier 1; QLneo-polycin (generic for NEO-POLYCIN) - Tier 1neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QLphenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1polycin (generic for POLYCIN) - Tier 1polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QLPRED-G - Tier 2; QLPRED-G S.O.P. - Tier 2puralube (generic for PURALUBE) - Tier 1; QLsodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QLsulfacetamide-prednisolone ophthalmic solution - Tier 1SYSTANE COMPLETE (brand for cvs lubricant drops) - Tier 2; QLSYSTANE HYDRATION PF (brand for goodsense lubricant eye drops) - Tier 2; QLSYSTANE ULTRA PF (brand for goodsense lubricant eye drops) - Tier 2; QL


97


TOBRADEX OPHTHALMIC OINTMENT - Tier 2; QLtobramycin-dexamethasone (generic for TOBRADEX) - Tier 1ultra fresh pm - Tier 1; QLultra lubricating eye drops (generic for SYSTANE) - Tier 1; QLXIIDRA - Tier 2; PA; QL

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs

azelastine hcl ophthalmic - Tier 1; STcromolyn sodium ophthalmic - Tier 1; QL

BEPREVE - Tier 2; PA; QLOPTIVAR OPHTHALMIC SOLUTION 0.05 % (brand for azelastine hcl) - Tier 2; PA; STPAZEO - Tier 2; PA; QL

Ophthalmic Antibiotics - Drugs to treat Eye Infections

bacitracin ophthalmic - Tier 1; QLCILOXAN OPHTHALMIC OINTMENT - Tier 2; QLciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QLerythromycin ophthalmic - Tier 1; QLgentak - Tier 1; QLgentamicin sulfate ophthalmic - Tier 1; QLofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QLtobramycin ophthalmic (generic for TOBREX) - Tier 1; QLTOBREX OPHTHALMIC OINTMENT - Tier 2; QL

AZASITE - Tier 2; PA; QLBESIVANCE - Tier 2; PA; QLCILOXAN OPHTHALMIC SOLUTION (brand for ciprofloxacin hcl) - Tier 2; PA; QLZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL


98


Ophthalmic Antiglaucoma Agents - Glaucoma Drugs

acetazolamide er - Tier 1; QLacetazolamide oral - Tier 1; QLALPHAGAN P OPHTHALMIC SOLUTION 0.1 % - Tier 2; QLapraclonidine hcl - Tier 1; QLbetaxolol hcl ophthalmic - Tier 1; QLBETIMOL - Tier 2; QLbrimonidine tartrate ophthalmic - Tier 1; QLcarteolol hcl - Tier 1DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QLdorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier1; QLdorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QLlevobunolol hcl - Tier 1; QLPHOSPHOLINE IODIDE - Tier 2pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1timolol maleate ophthalmic gel forming solution (generic forTIMOPTIC-XE) - Tier 1; QLtimolol maleate ophthalmic solution 0.25 %, 0.5 % (generic forTIMOPTIC) - Tier 1; QLTIMOPTIC OCUDOSE - Tier 2; QL

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brand for brimonidine tartrate) - Tier 2; PA; QLAZOPT - Tier 2; PABETOPTIC-S - Tier 2; PA; QLCOMBIGAN - Tier 2; PA; QLCOSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QLCOSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PAISTALOL (brand for timolol maleate) - Tier 2; PA; QLSIMBRINZA - Tier 2; PA; QLTIMOPTIC (brand for timolol maleate) - Tier 2; PA; QLTIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QLTRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL


99


Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs

dexamethasone sodium phosphate ophthalmic - Tier 1diclofenac sodium ophthalmic - Tier 1; QLeye itch relief (generic for ZADITOR) - Tier 1; QLfluorometholone (generic for FML LIQUIFILM) - Tier 1flurbiprofen sodium - Tier 1; QLketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1ketorolac tromethamine ophthalmic solution 0.5 % (generic for ACULAR) - Tier 1; QLprednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; QLprednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QLprednisolone sodium phosphate ophthalmic - Tier 1ZADITOR (brand for kp ketotifen fumarate) - Tier 2; QL

ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PAACUVAIL - Tier 2; PA; QLILEVRO - Tier 2; PA; QLNEVANAC - Tier 2; PA; QLPROLENSA - Tier 2; PA; QL

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs

latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QLTRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QLXALATAN (brand for latanoprost) - Tier 2; PA; QLZIOPTAN - Tier 2; PA; QL

Otic Agents - Drugs to Treat Ear Conditions

ofloxacin otic - Tier 1; QL CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA; QLOTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA; QL


100


Otic Agents - Drugs for the Ear

acetic acid otic - Tier 1; QLCIPRODEX - Tier 2; DX2RX; QLgoodsense ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1neomycin-polymyxin-hc otic - Tier 1; QL

CIPRO HC - Tier 2; PA; QL

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions

Antihistamines - Allergy Drugs

chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1; QL


101


Antihistamines - Drugs to Treat Allergies

allergy 24hour indoor/outdoor (generic for WAL-ZYR) - Tier 1; QLallergy childrens (generic for BANOPHEN) - Tier 1; QLallergy relief cetirizine (generic for WAL-ZYR) - Tier 1; QLallergy relief childrens oral liquid (generic for BANOPHEN) - Tier 1; QLallergy relief oral tablet 10 mg (generic for CLARITIN) - Tier 1; QLallergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QLallergy relief oral tablet dispersible (generic for CLARITIN REDITABS) - Tier 1; QLallergy relief/indoor/outdoor (generic for WAL-ZYR) - Tier 1; QLaurodryl allergy childrens (generic for BANOPHEN) - Tier 1; QLazelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1; QLbanophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QLbanophen oral tablet (generic for BANOPHEN) - Tier 1; QLcetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) - Tier 1; QLcetirizine hcl oral tablet (generic for WAL-ZYR) - Tier 1; QLCLARITIN ORAL TABLET (brand for px allergy relief loratadine) - Tier 2; QLCLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for allergy relief) - Tier 2; QLclemastine fumarate oral tablet 2.68 mg - Tier 1; QLcyproheptadine hcl oral - Tier 1; QLdayhist allergy 12 hour relief - Tier 1; QLdiphen oral elixir - Tier 1; QLdiphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; QLdiphenhydramine hcl oral elixir - Tier 1; QLdiphenhydramine hcl oral liquid 12.5 mg/5ml (generic for BANOPHEN) - Tier 1; QL


102


diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QLgeri-dryl oral liquid (generic for BANOPHEN) - Tier 1; QLhm loratadine (generic for CLARITIN) - Tier 1; QLhydroxyzine pamoate oral - Tier 1; QLlevocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1; QLloratadine oral syrup (generic for CLARITIN) - Tier 1; QLloratadine oral tablet (generic for CLARITIN) - Tier 1; QLm-dryl (generic for BANOPHEN) - Tier 1; QLpromethazine hcl oral - Tier 1; QLpromethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QLpromethegan - Tier 1; QLwal-zyr oral tablet (generic for WAL-ZYR) - Tier 1; QL

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs

ARNUITY ELLIPTA - Tier 2; QLASMANEX HFA - Tier 2; QL; ALbudesonide inhalation (generic for PULMICORT) - Tier 1; QL; ALfluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QLNASACORT ALLERGY 24HR (brand for gnp 24 hour nasal allergy) -Tier 2; QLQVAR REDIHALER - Tier 2; QL

ALVESCO - Tier 2; PAASMANEX (120 METERED DOSES) - Tier 2; PA; QLASMANEX (14 METERED DOSES) - Tier 2; PA; QLASMANEX (30 METERED DOSES) - Tier 2; PA; QLASMANEX (60 METERED DOSES) - Tier 2; PA; QLASMANEX (7 METERED DOSES) - Tier 2; PA; QLFLOVENT DISKUS - Tier 2; PA; QLFLOVENT HFA - Tier 2; PA; QLOMNARIS - Tier 2; PA; QLPULMICORT FLEXHALER - Tier 2; PA; QLZETONNA - Tier 2; PA; QL

Antileukotrienes - Asthma/Lung Drugs

montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL


103


Bronchodilators, Anticholinergic - Asthma/Lung Drugs

ATROVENT HFA - Tier 2; QLINCRUSE ELLIPTA - Tier 2; QLipratropium bromide inhalation - Tier 1; QLipratropium bromide nasal - Tier 1; QL

SEEBRI NEOHALER - Tier 2; PA; QLSPIRIVA HANDIHALER - Tier 2; PA; QLSPIRIVA RESPIMAT - Tier 2; PA; QLTUDORZA PRESSAIR - Tier 2; PA; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs

ALBUTEROL SULFATE HFA - Tier 2; QLalbuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%,(5 mg/ml) 0.5%, 2.5 mg/0.5ml - Tier 1; QLalbuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25mg/3ml - Tier 1; QL; ALalbuterol sulfate oral syrup - Tier 1; QLARCAPTA NEOHALER - Tier 2; QLepinephrine injection solution auto-injector (generic for AUVI-Q) - Tier1; QLlevalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; ST; QLSTRIVERDI RESPIMAT - Tier 2; QLSYMJEPI - Tier 2; QL

AUVI-Q (brand for epinephrine) - Tier 2; PA; QLBROVANA - Tier 2; PA; QLEPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QLEPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QLPERFOROMIST - Tier 2; PA; QLPROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QLPROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QLVENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QLXOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis

BETHKIS - Tier 2; DX2RX; SP; QLCAYSTON - Tier 2; DX2RX; SP; QLKALYDECO - Tier 2; PA; SP; QLORKAMBI - Tier 2; PA; SP; QLSYMDEKO - Tier 2; PA; SP; QLTRIKAFTA - Tier 2; PA; SP; QL

KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QLTOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QLTOBI PODHALER - Tier 2; PA; SP; QLtobramycin nebulization solution 300 mg/5ml inhalation (generic forKITABIS PAK) - Tier 1; PA; SP; QLTOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION -Tier 2; PA; SP; QL

Mast Cell Stabilizers - Drugs for the Lungs

cromolyn sodium inhalation - Tier 1; QL


104


Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs

ELIXOPHYLLIN - Tier 2; QLTHEO-24 - Tier 2theophylline - Tier 1; QLtheophylline er oral tablet extended release 12 hour 300 mg - Tier 1; QLtheophylline er oral tablet extended release 12 hour 450 mg - Tier 1theophylline er oral tablet extended release 24 hour 400 mg - Tier 1; QLtheophylline er oral tablet extended release 24 hour 600 mg - Tier 1

Pulmonary Antihypertensives - Asthma/Lung Drugs

ADEMPAS - Tier 2; DX2RX; SP; QLambrisentan (generic for LETAIRIS) - Tier 1; DX2RX; SP; QLbosentan (generic for TRACLEER) - Tier 1; DX2RX; SP; QLOPSUMIT - Tier 2; DX2RX; SP; QLsildenafil citrate oral suspension reconstituted (generic for REVATIO) -Tier 1; DX2RX; SP; QLsildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1;DX2RX; SP; QL

LETAIRIS (brand for ambrisentan) - Tier 2; DX2RX; SP; QLTRACLEER (brand for bosentan) - Tier 2; DX2RX; SP; QL

Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis

ESBRIET - Tier 2; PA; SP; QLOFEV - Tier 2; PA; SP; QL


105


Respiratory Tract Agents, Other - Asthma/Lung Drugs

12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL12 hour nasal decongestant nasal (generic for AFRIN NASAL SPRAY) - Tier 1acetylcysteine inhalation solution 10 % - Tier 1; QLacetylcysteine inhalation solution 20 % - Tier 1AFRIN NASAL SPRAY (brand for ra 12 hour nasal spray) - Tier 2all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL; ALallergy relief/nasal decongest oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; ALallergy relief-d oral tablet extended release 12 hour (generic for CLARITIN-D 12 HOUR) - Tier 1; ALbenzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; ALbenzonatate oral capsule 200 mg - Tier 1; QL; ALbromfed dm (generic for BROMFED DM) - Tier 1; QL; ALCLARITIN-D 12 HOUR (brand for allergy/congestion relief) - Tier 2; ALCOMBIVENT RESPIMAT - Tier 2; QLcough dm (generic for ROBITUSSIN 12 HOUR COUGH CHILD) - Tier 1; QL; ALcough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; ALdimaphen dm cold/cough - Tier 1; QL; ALfluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QLFLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; QLguaiatussin ac - Tier 1; QL; AL

ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QLADVAIR HFA - Tier 2; PA; QLAIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2;PA; QLAIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2;PA; QLAIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2;PA; QLANORO ELLIPTA - Tier 2; PA; QLBEVESPI AEROSPHERE - Tier 2; PA; QLBREO ELLIPTA - Tier 2; PA; QLDULERA - Tier 2; PA; QLNUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA;SP; QLNUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;PA; SP; QLSYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA;QL; ALTRELEGY ELLIPTA - Tier 2; PA; QLUTIBRON NEOHALER - Tier 2; PA; QL


106


guaifenesin ac - Tier 1; QL; ALguaifenesin oral tablet 400 mg (generic for BIDEX) - Tier 1guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; ALhm adult tussin cough & chest (generic for ROBITUSSIN COUGH+CHEST CONG DM) - Tier 1hydrocodone-homatropine - Tier 1; QL; ALhydromet - Tier 1; QL; ALHYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for sodium chloride) - Tier 2ipratropium-albuterol - Tier 1; QLloratadine-d 12hr (generic for CLARITIN-D 12 HOUR) - Tier 1; ALloratadine-d 24hr (generic for CLARITIN-D 24 HOUR) - Tier 1; ALMUCINEX DM (brand for eq mucus relief dm) - Tier 2; QL; ALmucus dm (generic for MUCINEX DM) - Tier 1; QL; ALmucus relief d oral tablet extended release 12 hour (generic for MUCINEX D) - Tier 1; ALmucus relief dm oral liquid (generic for ROBITUSSIN COUGH+CHEST CONG DM) - Tier 1mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; ALmucus-d (generic for MUCINEX D) - Tier 1; ALmucus-er max (generic for EQ MUCUS ER) - Tier 1; QL; ALnasal decongestant (generic for SUDOGEST) - Tier 1; QLnasal decongestant pe (generic for SUDOGEST PE) - Tier 1nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1nasal spray 12 hour (generic for AFRIN NASAL SPRAY) - Tier 1nebusal inhalation nebulization solution 3 % (generic for NEBUSAL) - Tier 1


107


NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for gnp nose drops extra strength) - Tier 2NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2promethazine-codeine - Tier 1; QL; ALpromethazine-dm - Tier 1; QL; ALpromethazine-phenyleph-codeine - Tier 1; QL; ALpromethazine-phenylephrine - Tier 1; QL; ALpseudoephedrine hcl er (generic for SHOPKO NASAL DECONGESTANT) - Tier 1pseudoephedrine-bromphen-dm (generic for BROMFED DM) - Tier 1; QL; ALpseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1; ALpulmosal (generic for PULMOSAL) - Tier 1PULMOZYME - Tier 2; DX2RX; SP; QLrobafen (generic for DIABETIC TUSSIN EX) - Tier 1; ALROBITUSSIN 12 HOUR COUGH CHILD (brand for gnp cough dm er) - Tier 2; QL; ALROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for sm mucus relief cough children) - Tier 2sinus 12 hour (generic for SHOPKO NASAL DECONGESTANT) - Tier 1sm cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; ALsodium chloride inhalation - Tier 1STIOLTO RESPIMAT - Tier 2; QLSUDAFED CONGESTION (brand for decongestant) - Tier 2; QLsudogest 12 hour (generic for SHOPKO NASAL DECONGESTANT) - Tier 1sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL


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sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QLsudogest pe (generic for SUDOGEST PE) - Tier 1tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1; ALtussin dm max adult oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; ALtussin dm max adult oral liquid 5-100 mg/5ml (generic for ROBITUSSIN COUGH+CHEST CONG DM) - Tier 1tussin dm max oral liquid 20-400 mg/20ml (generic for ROBITUSSIN COUGH+CHEST CONG DM) - Tier 1tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; ALvirtussin ac w/alc - Tier 1; QL; ALwal-tap cold/allergy oral elixir - Tier 1; ALwixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL

Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral - Tier 1; QLchlorzoxazone oral tablet 500 mg - Tier 1; QLcyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QLdantrolene sodium oral - Tier 1; QLmethocarbamol oral - Tier 1; QLorphenadrine citrate er - Tier 1; QLtizanidine hcl oral tablet - Tier 1; QL


109


Sleep Disorder Agents - Drugs for Sedation and Sleep

GABA Receptor Modulators - Drugs for Sleeping

temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier1; QLzaleplon - Tier 1; QLzolpidem tartrate oral (generic for AMBIEN) - Tier 1; QL

AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QLAMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PALUNESTA ORAL TABLET 1 MG (brand for eszopiclone) - Tier 2; PA; QLLUNESTA ORAL TABLET 2 MG, 3 MG (brand for eszopiclone) - Tier 2; PAzolpidem tartrate sublingual (generic for INTERMEZZO) - Tier 1; PA; QL

Sleep Disorders, Other - Drugs for Sleeping

armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QLSILENOR (brand for doxepin hcl) - Tier 2; PA; QL


110

Prior Authorization / Class Criteria


111

Index of Drugs12 hour allergy-d........................................ 10612 hour nasal decongestant nasal............. 1067T LIDO..........................................................98 hr arthritis pain relief....................................3abacavir sulfate............................................ 35abacavir sulfate-lamivudine..........................35abacavir-lamivudine-zidovudine...................35ABILIFY MAINTENA.................................... 31ABILIFY ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG, 5 MG...................................31ABILIFY ORAL TABLET 2 MG.....................31abiraterone acetate...................................... 24ABSORICA...................................................54ABSORICA LD............................................. 54acamprosate calcium..................................... 9ACANYA...................................................... 54acarbose oral............................................... 38ACCU-CHEK AVIVA CONNECT................. 93ACCU-CHEK AVIVA IN VITRO....................93ACCU-CHEK AVIVA PLUS KIT W/DEVICE 93ACCU-CHEK COMPACT PLUS.................. 93ACCU-CHEK COMPACT PLUS CARE....... 93ACCU-CHEK COMPACT PLUS CONTROL....................................................93ACCU-CHEK FASTCLIX LANCET KIT........93ACCU-CHEK GUIDE CONTROL.................93ACCU-CHEK GUIDE KIT W/DEVICE.......... 93ACCU-CHEK MULTICLIX LANCET DEVICE KIT................................................. 93ACCU-CHEK MULTICLIX LANCETS.......... 93ACCU-CHEK NANO SMARTVIEW..............93ACCU-CHEK SMARTVIEW......................... 93ACCU-CHEK SMARTVIEW CONTROL...... 93ACCU-CHEK SOFTCLIX LANCET DEVICE KIT................................................. 93acebutolol hcl oral........................................ 46acetaminophen childrens............................... 3acetaminophen er.......................................... 3

acetaminophen extra strength........................3acetaminophen oral solution.......................... 3acetaminophen oral tablet..............................3acetaminophen oral tablet chewable 160 mg.................................................................. 3acetaminophen rectal.....................................3acetaminophen-codeine.................................8acetaminophen-codeine #2............................8acetaminophen-codeine #3............................8acetaminophen-codeine #4............................8acetazolamide er..........................................99acetazolamide oral....................................... 99acetic acid otic............................................101acetylcysteine inhalation solution 10 %......106acetylcysteine inhalation solution 20 %......106ACIPHEX..................................................... 73acitretin.........................................................54ACTEMRA ACTPEN.................................... 89ACTEMRA SUBCUTANEOUS.....................89ACTIMMUNE............................................... 89ACTIVELLA..................................................79ACULAR LS............................................... 100ACUVAIL....................................................100acyclovir oral................................................ 33ACZONE...................................................... 54ADACEL.......................................................90adc/f (0.5mg/ml)........................................... 63ADDERALL XR............................................ 51ADEMPAS..................................................105ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG....51ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 45 MG, 55 MG, 70 MG, 85 MG.................... 51ADLYXIN......................................................38ADLYXIN STARTER PACK......................... 38ADMELOG................................................... 41ADMELOG SOLOSTAR...............................41

adult aspirin regimen......................................5ADVAIR DISKUS....................................... 106ADVAIR HFA..............................................106ADVIL JUNIOR STRENGTH..........................5ADVIL ORAL TABLET................................... 5ADZENYS XR-ODT..................................... 51AFINITOR DISPERZ....................................26AFINITOR ORAL TABLET 10 MG............... 26afirmelle........................................................79AFLURIA QUADRIVALENT......................... 90AFREZZA.....................................................41AFRIN NASAL SPRAY.............................. 106AIMOVIG......................................................22AIRDUO RESPICLICK 113/14...................106AIRDUO RESPICLICK 232/14...................106AIRDUO RESPICLICK 55/14.....................106AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR........................................ 22AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE................................ 93ak-poly-bac...................................................96AKYNZEO ORAL......................................... 20ala-cort......................................................... 54albendazole oral...........................................28ALBUTEROL SULFATE HFA.................... 104albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 2.5 mg/0.5ml.................................... 104albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml............ 104albuterol sulfate oral syrup......................... 104alclometasone dipropionate external ointment....................................................... 54ALCOHOL PREP PADS PAD , 70 %..........93ALDARA.......................................................54ALECENSA.................................................. 26alendronate sodium......................................92ALEVE ORAL TABLET.................................. 5

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alfuzosin hcl er............................................. 74ALINIA ORAL SUSPENSION RECONSTITUTED.......................................28ALINIA ORAL TABLET................................ 28all day allergy d-12..................................... 106allergy 24hour indoor/outdoor.................... 102allergy childrens......................................... 102allergy relief cetirizine.................................102allergy relief childrens oral liquid................ 102allergy relief oral tablet 10 mg.................... 102allergy relief oral tablet 25 mg.................... 102allergy relief oral tablet dispersible.............102allergy relief/indoor/outdoor........................102allergy relief/nasal decongest oral tablet extended release 12 hour.......................... 106allergy relief-d oral tablet extended release 12 hour....................................................... 106allopurinol oral..............................................22ALOGLIPTIN BENZOATE............................38ALOGLIPTIN-METFORMIN HCL.................38ALOGLIPTIN-PIOGLITAZONE.................... 38ALORA......................................................... 79ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %............................................................ 99ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %.......................................................... 99alprazolam oral tablet...................................37altachlore ophthalmic ointment.................... 96altachlore ophthalmic solution......................96altafrin.......................................................... 96altavera........................................................ 79ALUNBRIG...................................................26ALVESCO.................................................. 103alyacen 1/35.................................................79alyacen 7/7/7................................................79amantadine hcl oral capsule........................ 29amantadine hcl oral syrup............................ 29AMBIEN..................................................... 110AMBIEN CR............................................... 110

ambrisentan............................................... 105amcinonide external ointment...................... 54amiloride hcl oral.......................................... 49amiloride-hydrochlorothiazide...................... 48aminocaproic acid oral................................. 44amiodarone hcl oral tablet 200 mg, 400 mg.46AMITIZA....................................................... 71amitriptyline hcl oral..................................... 20amlodipine besylate oral.............................. 47ammonium lactate external.......................... 54amnesteem.................................................. 54amoxapine....................................................20amoxicillin oral capsule................................ 13amoxicillin oral suspension reconstituted.....13amoxicillin oral tablet 875 mg.......................13amoxicillin oral tablet chewable....................13amoxicillin-potassium clavulanate oral.........13amphetamine-dextroamphetamine.............. 51amphetamine-dextroamphetamine er.......... 51ampicillin...................................................... 13anagrelide hcl...............................................44ANASPAZ.................................................... 67anastrozole oral............................................25ANGELIQ..................................................... 79animal shapes.............................................. 63ANORO ELLIPTA.......................................106antacid anti-gas max strength...................... 68antacid calcium............................................ 68antacid extra strength oral tablet chewable 160-105 mg.................................................. 68antacid extra strength oral tablet chewable 750 mg......................................................... 68antacid maximum......................................... 68antacid maximum strength........................... 68antacid oral suspension 200-200-20 mg/5ml......................................................... 68antacid oral tablet chewable 500 mg............68antacid regular strength oral suspension..... 68

antacid regular strength oral tablet chewable...................................................... 68antacid ultra strength oral tablet chewable 1000 mg....................................................... 68anti-diarrheal oral liquid 1 mg/5ml................ 68anti-diarrheal oral tablet............................... 68antifungal external aerosol........................... 21apap............................................................... 3apap-caff-dihydrocodeine oral capsule.......... 8APIDRA SOLOSTAR................................... 41APIDRA VIAL............................................... 41apraclonidine hcl.......................................... 99aprepitant..................................................... 20apri............................................................... 79APRISO........................................................91APTENSIO XR............................................. 51APTIVUS......................................................36AQUAPHILIC............................................... 54ARAKODA....................................................28aranelle........................................................ 79ARANESP (ALBUMIN FREE)...................... 44ARCAPTA NEOHALER............................. 104aripiprazole oral solution.............................. 31aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg.......................................... 31aripiprazole oral tablet 2 mg.........................31aripiprazole oral tablet dispersible................31ARISTADA................................................... 31ARISTADA INITIO........................................31armodafinil ..................................................110ARNUITY ELLIPTA.................................... 103artificial tears ophthalmic solution 1.4 %...... 96ASACOL HD................................................ 91ascomp-codeine.............................................8ASMANEX (120 METERED DOSES)........ 103ASMANEX (14 METERED DOSES).......... 103ASMANEX (30 METERED DOSES).......... 103ASMANEX (60 METERED DOSES).......... 103ASMANEX (7 METERED DOSES)............ 103

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ASMANEX HFA......................................... 103aspirin adult....................................................5aspirin adult low strength oral tablet delayed release..............................................5aspirin childrens............................................. 5aspirin ec........................................................5aspirin ec low dose.........................................5aspirin ec low strength................................... 5aspirin low dose............................................. 5aspirin oral tablet............................................5aspirin oral tablet delayed release................. 5aspirin rectal...................................................5ATABEX OB.................................................63atazanavir sulfate......................................... 36ATELVIA...................................................... 92atenolol oral..................................................46atenolol-chlorthalidone................................. 48athletes foot external cream.........................21atomoxetine hcl............................................ 51atorvastatin calcium oral.............................. 49atovaquone oral........................................... 28ATRALIN...................................................... 54ATRIPLA...................................................... 34atropine sulfate ophthalmic ointment........... 96atropine sulfate ophthalmic solution 1 %......96ATROVENT HFA....................................... 104AUBAGIO.....................................................52aubra............................................................ 79aubra eq....................................................... 79aurodryl allergy childrens........................... 102aurophen childrens.........................................3aurovela 1.5/30............................................ 79aurovela 1/20............................................... 79aurovela fe 1.5/30........................................ 79aurovela fe 1/20........................................... 79AURYXIA..................................................... 62AUVI-Q.......................................................104AVAR-E EMOLLIENT.................................. 54AVAR-E GREEN.......................................... 54

aviane...........................................................79avita external cream.....................................54AVONEX PEN..............................................52AVONEX PREFILLED..................................52ayuna........................................................... 79AZASITE...................................................... 98azathioprine oral...........................................88azelaic acid external.....................................54azelastine hcl nasal solution 0.1 %, 137 mcg/spray...................................................102azelastine hcl ophthalmic............................. 98azithromycin oral suspension reconstituted. 14azithromycin oral tablet................................ 14azo tabs........................................................75AZOPT......................................................... 99azurette........................................................ 79bacitracin external........................................ 12bacitracin ophthalmic................................... 98bacitracin zinc external.................................12bacitracin-polymyxin b ophthalmic............... 96bacitra-neomycin-polymyxin-hc....................96baclofen oral...............................................109BACMIN....................................................... 63balsalazide disodium....................................91BALVERSA.................................................. 25balziva.......................................................... 79banophen oral capsule 25 mg....................102banophen oral tablet.................................. 102BANZEL....................................................... 18BAQSIMI ONE PACK...................................40BAQSIMI TWO PACK.................................. 40BARACLUDE ORAL SOLUTION................. 32BASAGLAR KWIKPEN................................ 41BAYER ASPIRIN............................................5BAYER ASPIRIN EC LOW DOSE................. 5b-complex/b-12 oral..................................... 63BD AUTOSHIELD DUO PEN NEEDLES..... 93BD ULTRA-FINE INSULIN SYRINGES....... 93BD ULTRA-FINE PEN NEEDLES................93

bekyree........................................................ 79benazepril hcl oral........................................ 45benazepril-hydrochlorothiazide.................... 48BENZAC AC WASH.....................................54BENZACLIN................................................. 54BENZACLIN WITH PUMP........................... 54BENZAMYCIN..............................................54BENZIQ WASH............................................ 54BENZNIDAZOLE..........................................28benzonatate oral capsule 100 mg.............. 106benzonatate oral capsule 200 mg.............. 106benztropine mesylate oral............................ 29BEPREVE.................................................... 98BERINERT................................................... 87BESIVANCE.................................................98betamethasone dipropionate aug.................54betamethasone dipropionate external lotion 54betamethasone dipropionate external ointment....................................................... 54betamethasone valerate external cream......54betamethasone valerate external lotion....... 54betamethasone valerate external ointment.. 54BETAPACE.................................................. 46BETAPACE AF............................................ 46BETASERON............................................... 52betaxolol hcl ophthalmic...............................99betaxolol hcl oral.......................................... 46bethanechol chloride oral............................. 75BETHKIS....................................................104BETIMOL..................................................... 99BETOPTIC-S................................................99BEVESPI AEROSPHERE..........................106BEVYXXA ORAL CAPSULE 40 MG, 80 MG............................................................... 43bexarotene................................................... 28BEXSERO....................................................90bicalutamide................................................. 24BIDIL............................................................ 48BIKTARVY................................................... 35

114

BINOSTO..................................................... 92biocel............................................................63bisacodyl ec................................................. 71bisacodyl rectal............................................ 71bisoprolol fumarate.......................................46bisoprolol-hydrochlorothiazide..................... 48BLEPHAMIDE S.O.P................................... 96blisovi fe 1.5/30............................................ 79blisovi fe 1/20............................................... 79BOOSTRIX...................................................90bosentan.................................................... 105BOSULIF......................................................26bp 10-1......................................................... 54bp wash external liquid 2.5 %...................... 54b-plex plus....................................................63BREATHE EASE HUMIDIFIER....................93BREO ELLIPTA..........................................106briellyn..........................................................79BRILINTA..................................................... 44brimonidine tartrate ophthalmic....................99bromfed dm................................................ 106BROVANA..................................................104BRUKINSA...................................................26budesonide inhalation................................ 103budesonide oral............................................91bumetanide oral........................................... 48BUNAVAIL................................................... 10buprenorphine hcl sublingual....................... 10buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4-1 mg.................................... 10buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg................................................ 10buprenorphine hcl-naloxone hcl sublingual film 8-2 mg................................................... 10buprenorphine hcl-naloxone hcl sublingual tablet sublingual........................................... 10buprenorphine transdermal............................ 7bupropion hcl er (smoking det).....................11bupropion hcl er (sr)..................................... 19

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg................. 19bupropion hcl oral.........................................19buspirone hcl oral.........................................36butalbital-acetaminophen oral tablet 50-325 mg........................................................... 3butalbital-apap-caff-cod oral capsule 50-325-40-30 mg.................................................8butalbital-apap-caffeine oral capsule 50-325-40 mg...................................................... 3butalbital-apap-caffeine oral tablet................. 3butalbital-asa-caff-codeine............................. 8butalbital-aspirin-caffeine............................... 3butorphanol tartrate nasal.............................. 8BYDUREON.................................................38BYDUREON BCISE AUTOINJECTOR........ 38BYETTA 10 MCG PEN................................ 38BYETTA 5 MCG PEN.................................. 38cabergoline...................................................86CABLIVI....................................................... 44CABOMETYX...............................................26caffeine citrate oral.......................................52calcidol......................................................... 63calcipotriene external cream........................ 54calcipotriene external ointment.................... 54calcipotriene external solution......................54calcitonin (salmon)....................................... 92calcitrate oral tablet 950 mg......................... 59calcitriol external.......................................... 54calcitriol oral capsule....................................92calcitriol oral solution....................................92calcium acetate (phos binder) oral tablet..... 62calcium acetate oral tablet 667 mg.............. 62calcium carbonate oral tablet 600 mg.......... 59calcium carbonate-vitamin d tablet 600-400 mg-unit oral.................................................. 59CALQUENCE...............................................26CALTRATE 600........................................... 59camila...........................................................84

capecitabine................................................. 24CAPRELSA.................................................. 26capsaicin external cream 0.025 %................. 3captopril oral.................................................45captopril-hydrochlorothiazide....................... 48capzix........................................................... 54CARAC.........................................................54CARAFATE ORAL SUSPENSION...............73CARBAGLU................................................. 59carbamazepine er........................................ 18carbamazepine oral......................................18carbidopa-levodopa er................................. 29carbidopa-levodopa oral tablet.....................29CARETOUCH CONTROL SOL LEVEL 2.... 93carteolol hcl.................................................. 99cartia xt.........................................................47carvedilol...................................................... 46cavarest........................................................53CAYA........................................................... 93CAYSTON..................................................104caziant..........................................................79cefaclor.........................................................13cefadroxil ......................................................13cefdinir..........................................................13cefixime oral capsule....................................13cefprozil ........................................................13cefuroxime axetil .......................................... 13celecoxib oral................................................. 5CELONTIN................................................... 15cephalexin oral capsule................................13cephalexin oral suspension reconstituted.... 13CEQUA........................................................ 96CERDELGA................................................. 74cerovel..........................................................54cetirizine hcl oral solution........................... 102cetirizine hcl oral tablet...............................102CETRAXAL................................................ 100CHANTIX..................................................... 11CHANTIX CONTINUING MONTH PAK....... 11

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CHANTIX STARTING MONTH PAK............11chateal..........................................................79chateal eq.....................................................79CHEMET...................................................... 62CHEMSTRIP UGK....................................... 93childrens acetaminophen oral suspension 160 mg/5ml.................................................... 3childrens apap................................................3childrens chewable vitamins........................ 63childrens non-aspirin oral tablet chewable..... 3chlordiazepoxide hcl.....................................37chlorhexidine gluconate mouth/throat.......... 53chloroquine phosphate oral..........................28chlorothiazide oral........................................ 49chlorpheniramine maleate er......................101chlorpromazine hcl oral................................ 30chlorthalidone...............................................49chlorzoxazone oral tablet 500 mg.............. 109CHOLBAM................................................... 74cholestyramine light oral powder..................50cholestyramine oral powder......................... 50chorionic gonadotropin intramuscular.......... 77ciclodan........................................................ 21ciclopirox external solution........................... 21cilostazol...................................................... 44CILOXAN OPHTHALMIC OINTMENT......... 98CILOXAN OPHTHALMIC SOLUTION......... 98CIMDUO.......................................................35cimetidine hcl............................................... 70cimetidine oral tablet 200 mg....................... 70cimetidine oral tablet 300 mg, 400 mg, 800 mg................................................................ 70CIMZIA......................................................... 88cinacalcet hcl................................................92CINRYZE..................................................... 87CIPRO HC..................................................101CIPRO ORAL SUSPENSION RECONSTITUTED.......................................14CIPRODEX................................................ 101

ciprofloxacin hcl ophthalmic......................... 98ciprofloxacin hcl oral.....................................14citalopram hydrobromide..............................19citroma......................................................... 71claravis......................................................... 55clarithromycin er...........................................14clarithromycin oral........................................ 14CLARITIN ORAL TABLET......................... 102CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG................................102CLARITIN-D 12 HOUR.............................. 106clearlax.........................................................71clemastine fumarate oral tablet 2.68 mg.... 102CLEOCIN VAGINAL SUPPOSITORY..........12CLIMARA..................................................... 79CLIMARA PRO............................................ 79clindacin etz external swab.......................... 55clindacin-p.................................................... 55clindamycin hcl oral capsule 150 mg, 300 mg................................................................ 12clindamycin palmitate hcl............................. 12clindamycin phosphate external gel............. 55clindamycin phosphate external lotion......... 55clindamycin phosphate external solution..... 55clindamycin phosphate external swab......... 55clindamycin phosphate vaginal.................... 12CLINDESSE.................................................12clobazam......................................................16clobetasol prop emollient base.....................55clobetasol propionate e................................ 55clobetasol propionate external solution........55CLOBEX.......................................................55CLOBEX SPRAY......................................... 55clonazepam oral tablet................................. 37clonidine hcl oral.......................................... 45clopidogrel bisulfate oral.............................. 44clorazepate dipotassium.............................. 37clotrimazole external.................................... 21clotrimazole mouth/throat.............................21

clotrimazole vaginal cream 1 %................... 21clotrimazole-betamethasone........................ 55clozapine oral tablet 100 mg, 25 mg, 50 mg 32CLOZARIL ORAL TABLET 100 MG, 25 MG, 50 MG...................................................32CLOZARIL ORAL TABLET 200 MG............ 32codeine sulfate oral tablet 30 mg, 60 mg....... 8COLAZAL.....................................................91COLCHICINE ORAL CAPSULE.................. 22colchicine oral tablet.....................................22COLCRYS....................................................22colocort.........................................................91COMBIGAN..................................................99COMBIPATCH............................................. 79COMBIVENT RESPIMAT.......................... 106COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG...............................26COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG...............................26COMETRIQ (60 MG DAILY DOSE)............. 26COMPLERA................................................. 34compro......................................................... 20CONCERTA................................................. 51CONDOMS.................................................. 93constulose.................................................... 71CONTOUR NEXT TEST.............................. 93CONTOUR TEST.........................................93COPAXONE.................................................52CORLANOR.................................................48corn & callus remover.................................. 55CORTIFOAM................................................91cortisone acetate oral...................................76COSENTYX................................................. 55COSOPT...................................................... 99COSOPT PF................................................ 99COTELLIC....................................................26COTEMPLA XR-ODT...................................51cough dm................................................... 106cough/chest congestion dm....................... 106

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CREON........................................................ 74CRIXIVAN.................................................... 36cromolyn sodium inhalation........................104cromolyn sodium ophthalmic........................98crotan........................................................... 29cryselle-28....................................................79CUPRIMINE................................................. 75cvs acetaminophen ex st oral tablet...............3cvs antacid extra strength............................ 68cvs clotrimazole 3.........................................21cvs gentle laxative rectal.............................. 71cvs lubricant eye drops ophthalmic solution 0.4-0.3 %......................................................96cvs motion sickness..................................... 20cvs stool softener oral capsule 250 mg........71cvs vitamin e oral capsule 1000 unit............ 63cyanocobalamin injection solution 1000 mcg/ml..........................................................63CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML.......................... 63cyclafem 1/35............................................... 79cyclafem 7/7/7.............................................. 79cyclobenzaprine hcl oral tablet 10 mg, 5 mg.............................................................. 109cyclopentolate hcl ophthalmic solution 1 %..96cyclophosphamide oral................................ 24cycloserine oral............................................ 23cyclosporine modified oral capsule 100 mg. 88cyclosporine modified oral capsule 25 mg... 88cyclosporine modified oral capsule 50 mg... 88cyclosporine modified oral solution.............. 88cyclosporine oral.......................................... 88CYMBALTA..................................................52cyproheptadine hcl oral.............................. 102cyred............................................................ 79cyred eq....................................................... 79CYSTAGON................................................. 74CYSTARAN..................................................96

d3 high potency oral capsule 25 mcg (1000 ut)................................................................. 63d3 super strength......................................... 63danazol oral..................................................78dantrolene sodium oral...............................109dapsone oral................................................ 23DAPTACEL.................................................. 90dasetta 1/35................................................. 79dasetta 7/7/7................................................ 79DAURISMO..................................................26dayhist allergy 12 hour relief...................... 102DAYTRANA..................................................51DDAVP RHINAL TUBE................................ 77deblitane.......................................................84DECADRON ORAL TABLET 0.5 MG, 0.75 MG............................................................... 76DECADRON ORAL TABLET 4 MG, 6 MG...76decara oral capsule 1.25 mg (50000 ut)...... 63decara oral capsule 250 mcg (10000 ut)......63DECARA ORAL CAPSULE 625 MCG (25000 UT)................................................... 63deferasirox................................................... 62DELSTRIGO................................................ 34delyla............................................................80DELZICOL....................................................91denta 5000 plus............................................53dentagel....................................................... 53DEPEN TITRATABS.................................... 75DEPO-ESTRADIOL..................................... 80DEPO-SUBQ PROVERA 104...................... 84DESCOVY....................................................35DESENEX EXTERNAL POWDER...............93desipramine hcl oral..................................... 20desmopressin ace spray refrig..................... 77desmopressin acetate oral........................... 77desmopressin acetate spray........................ 77desogestrel-ethinyl estradiol........................ 80DETROL.......................................................74DETROL LA................................................. 74

dexamethasone intensol.............................. 76dexamethasone oral elixir............................ 76dexamethasone oral solution....................... 76dexamethasone oral tablet 0.5 mg, 0.75 mg................................................................ 76dexamethasone oral tablet 1 mg, 2 mg........76dexamethasone oral tablet 1.5 mg...............76dexamethasone oral tablet 4 mg, 6 mg........76dexamethasone sodium phosphate ophthalmic..................................................100DEXILANT....................................................73diaper rash external ointment.......................55diazepam oral solution................................. 37diazepam oral tablet.....................................37diazepam rectal gel 10 mg, 20 mg............... 16diazepam rectal gel 2.5 mg.......................... 16diclofenac potassium......................................5diclofenac sodium er...................................... 5diclofenac sodium ophthalmic.................... 100diclofenac sodium oral................................... 5diclofenac sodium transdermal gel 1 %......... 5dicloxacillin sodium...................................... 13dicyclomine hcl oral capsule........................ 67dicyclomine hcl oral solution........................ 67dicyclomine hcl oral tablet............................ 67didanosine....................................................35DIFFERIN EXTERNAL CREAM...................55DIFFERIN EXTERNAL GEL 0.3 %.............. 55DIFFERIN EXTERNAL LOTION.................. 55DIFICID........................................................ 14DIFLUCAN................................................... 21digitek...........................................................48digox.............................................................48digoxin oral solution..................................... 48digoxin oral tablet......................................... 48dihydroergotamine mesylate injection..........22DILANTIN ORAL CAPSULE 30 MG............ 18diltiazem hcl er beads.................................. 47

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diltiazem hcl er coated beads oral capsule extended release 24 hour............................ 47diltiazem hcl er oral capsule extended release 12 hour............................................ 47diltiazem hcl oral.......................................... 47dilt-xr............................................................ 47dimaphen dm cold/cough........................... 106diotame instydose........................................ 68DIPENTUM.................................................. 91diphen oral elixir......................................... 102diphenhydramine hcl oral capsule..............102diphenhydramine hcl oral elixir...................102diphenhydramine hcl oral liquid 12.5 mg/5ml....................................................... 102diphenhydramine hcl oral tablet................. 102diphenoxylate-atropine.................................68DIPHTHERIA-TETANUS TOXOIDS DT...... 90dipyridamole oral..........................................44disopyramide phosphate.............................. 46disulfiram oral tablet 250 mg.......................... 9disulfiram oral tablet 500 mg.......................... 9DITROPAN XL............................................. 74DIURIL......................................................... 49divalproex sodium oral capsule delayed release sprinkle............................................ 37divalproex sodium oral tablet delayed release......................................................... 37DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25 MG/1.25GM..................................................80DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM.................................. 80docosanol external....................................... 33docusate mini............................................... 71docusate sodium oral capsule 250 mg.........71docusate sodium oral liquid 150 mg/15ml....71docusate sodium oral syrup......................... 71docuzen........................................................71dofetilide.......................................................46

dok plus........................................................71donepezil hcl oral tablet 10 mg, 5 mg.......... 18donepezil hcl oral tablet 23 mg.................... 18DOPTELET.................................................. 44DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC..............................................99dorzolamide hcl solution 2 % ophthalmic..... 99dorzolamide hcl-timolol mal..........................99DOVATO...................................................... 33DOVONEX................................................... 55doxazosin mesylate oral...............................45doxepin hcl oral capsule...............................20doxepin hcl oral concentrate........................ 20doxycycline monohydrate oral capsule 100 mg................................................................ 15doxycycline monohydrate oral capsule 50 mg................................................................ 15dronabinol.................................................... 20DROXIA ORAL CAPSULE 200 MG, 300 MG............................................................... 24DROXIA ORAL CAPSULE 400 MG............. 24DUAVEE...................................................... 80DULERA.....................................................106duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg.....................52DUPIXENT................................................... 55d-vite pediatric..............................................63DYANAVEL XR............................................ 51E.E.S. 400.................................................... 14E.E.S. GRANULES...................................... 14EASIVENT................................................... 93easygel.........................................................53ec-naproxen................................................... 5EDARBI........................................................45EDARBYCLOR............................................ 48ed-spaz........................................................ 67EDURANT....................................................34efavirenz.......................................................34effer-k oral tablet effervescent 25 meq.........59

EFUDEX.......................................................55EGRIFTA......................................................86EGRIFTA SV................................................86ELESTRIN....................................................80ELIDEL.........................................................55elinest...........................................................80ELIQUIS....................................................... 43ELIQUIS DVT/PE STARTER PACK............ 43ELIXOPHYLLIN..........................................105ELMIRON.....................................................75eluryng......................................................... 80EMEND ORAL CAPSULE 80 MG................20EMEND ORAL SUSPENSION RECONSTITUTED.......................................20EMGALITY................................................... 22EMGALITY (300 MG DOSE)........................22emoquette.................................................... 80EMTRIVA..................................................... 35ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG....................... 74enalapril maleate oral...................................45enalapril-hydrochlorothiazide....................... 48ENBREL.......................................................88endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg..................................................... 8ENGERIX-B................................................. 90enoxaparin sodium.......................................43enpresse-28................................................. 80enskyce........................................................ 80ENSTILAR....................................................55entacapone.................................................. 29entecavir.......................................................32ENTRESTO..................................................48enulose.........................................................71EPANED...................................................... 45EPCLUSA.................................................... 33EPIDUO....................................................... 55EPIDUO FORTE.......................................... 55epinephrine injection solution auto-injector 104

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EPIPEN 2-PAK...........................................104EPIPEN JR 2-PAK..................................... 104epitol.............................................................18EPIVIR HBV ORAL SOLUTION...................32EPOGEN......................................................44ergocalciferol oral.........................................63ergotamine-caffeine..................................... 22ERIVEDGE...................................................26ERLEADA.................................................... 24erlotinib hcl................................................... 26errin.............................................................. 84ERYPED 200............................................... 14ERYTHROCIN STEARATE......................... 14erythromycin base........................................14erythromycin ethylsuccinate oral..................14erythromycin external...................................55erythromycin ophthalmic.............................. 98erythromycin oral..........................................14ESBRIET....................................................105escitalopram oxalate oral tablet................... 19esomeprazole magnesium oral capsule delayed release............................................73esomeprazole magnesium oral packet........ 73estarylla........................................................80ESTRACE.................................................... 80estradiol oral.................................................80estradiol transdermal patch twice weekly.....80estradiol transdermal patch weekly..............80estradiol vaginal........................................... 80estradiol-norethindrone acet oral tablet 1-0.5 mg.......................................................... 80ESTRING..................................................... 80ESTROGEL..................................................80ethambutol hcl oral tablet 100 mg................ 23ethambutol hcl oral tablet 400 mg................ 23ethosuximide oral......................................... 15ethynodiol diac-eth estradiol........................ 80etodolac..........................................................5etonogestrel-ethinyl estradiol....................... 80

etoposide oral...............................................25EUCRISA..................................................... 55euthyrox....................................................... 85EVAMIST..................................................... 80EVEKEO...................................................... 51EVEKEO ODT..............................................51everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg........................................................ 88everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg................................................................ 26EVOTAZ.......................................................36EVZIO.......................................................... 10exemestane..................................................25EX-LAX ULTRA............................................71EXTAVIA...................................................... 52eye itch relief.............................................. 100ezetimibe......................................................50FABIOR........................................................55falmina..........................................................80famotidine oral..............................................70FANAPT....................................................... 31FARXIGA..................................................... 38FARYDAK.................................................... 26febuxostat.....................................................22felbamate oral suspension........................... 17felbamate oral tablet.....................................17felodipine er..................................................47FEMHRT LOW DOSE..................................80FEMRING.....................................................80femynor........................................................ 80fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg...................................... 49fenofibrate oral capsule 134 mg, 200 mg, 67 mg........................................................... 49fenofibrate oral tablet 160 mg...................... 49fenofibrate oral tablet 54 mg........................ 49fentanyl transdermal patch 72 hour 100 mcg/hr............................................................ 7

fentanyl transdermal patch 72 hour 12 mcg/hr............................................................ 7fentanyl transdermal patch 72 hour 25 mcg/hr............................................................ 7fentanyl transdermal patch 72 hour 50 mcg/hr............................................................ 7fentanyl transdermal patch 72 hour 75 mcg/hr............................................................ 7ferocon......................................................... 59ferotrinsic......................................................59ferrous sulfate oral solution.......................... 59ferrous sulfate oral tablet 325 (65 fe) mg..... 59ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg.................... 59FETZIMA......................................................19FIASP...........................................................41FIASP FLEXTOUCH.................................... 41fiber laxative................................................. 71FINACEA......................................................55finasteride oral tablet 5 mg...........................74FIRAZYR......................................................87FIRVANQ..................................................... 12FLAGYL....................................................... 12flecainide acetate......................................... 46FLOVENT DISKUS.................................... 103FLOVENT HFA.......................................... 103FLUAD......................................................... 90FLUARIX QUADRIVALENT......................... 90fluconazole oral............................................ 21fludrocortisone acetate oral..........................76FLULAVAL QUADRIVALENT...................... 90fluocinolone acetonide body.........................55fluocinolone acetonide external cream 0.025 %........................................................ 55fluocinolone acetonide external ointment.....55fluocinolone acetonide external solution...... 55fluocinolone acetonide scalp........................ 55fluocinonide emulsified base........................ 56fluocinonide external solution.......................56

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fluoridex daily renewal..................................53fluoritab........................................................ 59fluorometholone......................................... 100fluorouracil external cream 5 %....................56fluorouracil external solution........................ 56fluoxetine hcl oral capsule 10 mg, 20 mg.....19fluoxetine hcl oral solution............................19fluphenazine decanoate injection.................30fluphenazine hcl injection............................. 30fluphenazine hcl oral concentrate................ 30fluphenazine hcl oral elixir............................30fluphenazine hcl oral tablet.......................... 30FLURA-DROPS........................................... 59flurbiprofen sodium.....................................100flutamide.......................................................24fluticasone propionate external cream......... 56fluticasone propionate external ointment..... 56fluticasone propionate nasal...................... 103fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose..........106FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT..........106fluvoxamine maleate.................................... 19FLUZONE HIGH-DOSE............................... 90FLUZONE QUADRIVALENT....................... 90FOCALIN......................................................51folic acid oral tablet 1 mg............................. 59folic acid oral tablet 800 mcg........................59foltrin............................................................ 59FORTAVIT ORAL CAPSULE.......................63FORTEO...................................................... 92fosamprenavir calcium................................. 36fosinopril sodium.......................................... 45fosinopril sodium-hctz.................................. 48FREESTYLE PRECISION NEO TEST........ 93FULPHILA.................................................... 44

furosemide oral solution 10 mg/ml............... 48furosemide oral tablet...................................48FUZEON...................................................... 35fyavolv oral tablet 0.5-2.5 mg-mcg............... 80fyavolv oral tablet 1-5 mg-mcg..................... 80gabapentin oral capsule............................... 16gabapentin oral tablet...................................16galantamine hydrobromide...........................18GARDASIL 9................................................ 90GAS-X.......................................................... 68GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE.................................. 68GATTEX.......................................................68gavilax oral powder...................................... 71gavilyte-c...................................................... 71gavilyte-n with flavor pack............................ 71GELUSIL...................................................... 68gemfibrozil oral.............................................49generlac....................................................... 71gengraf oral capsule 100 mg........................88gengraf oral capsule 25 mg..........................88GENOTROPIN............................................. 77gentak.......................................................... 98gentamicin sulfate external.......................... 11gentamicin sulfate ophthalmic......................98GENTEAL TEARS NIGHT-TIME................. 96GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.3 %.................................. 96gentle laxative.............................................. 71GENVOYA................................................... 33GEODON INTRAMUSCULAR..................... 31GEODON ORAL.......................................... 31geri-dryl oral liquid......................................103geri-kot......................................................... 71GILENYA......................................................52GILOTRIF.....................................................26glatiramer acetate........................................ 52glatopa......................................................... 52GLEOSTINE.................................................24

glimepiride....................................................38glipizide er.................................................... 38glipizide ir..................................................... 38glipizide xl.....................................................38GLUCAGEN HYPOKIT................................ 40GLUCAGON EMERGENCY INJECTION KIT................................................................40GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED................... 40glyburide micronized.................................... 38glyburide oral................................................38glyburide-metformin..................................... 38glycolax........................................................ 71glycopyrrolate oral tablet 1 mg, 2 mg........... 67GLYXAMBI...................................................38gnp acne treatment...................................... 56gnp all day pain relief..................................... 6gnp antacid extra strength oral tablet chewable 160-105 mg..................................69gnp daily prenatal.........................................63gnp folic acid................................................ 59gnp hydrocortisone.......................................56gnp lansoprazole..........................................73gnp senna lax...............................................71GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM......................71goodsense antacid....................................... 69goodsense aspirin low dose...........................6goodsense ear wax kit ............................... 101goodsense enema........................................71goodsense motion sickness......................... 20goodsense naproxen sodium......................... 6goodsense nausea relief.............................. 20goodsense nicotine mouth/throat gum......... 11goodsense relief eye drops.......................... 96goodsense stomach relief oral suspension 1050 mg/30ml.............................................. 69goodsense ultra lubricant drop.....................96GRANIX....................................................... 44

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griseofulvin microsize oral............................21griseofulvin ultramicrosize............................21guaiatussin ac............................................ 106guaifenesin ac............................................ 106guaifenesin oral tablet 400 mg................... 107guaifenesin-dm oral syrup..........................107guanfacine hcl.............................................. 45guanfacine hcl er..........................................51GVOKE HYPOPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML...............................40GVOKE PFS................................................ 40GYNAZOLE-1.............................................. 21HAEGARDA................................................. 87hailey 1.5/30.................................................80halobetasol propionate external cream........ 56haloperidol decanoate intramuscular........... 30haloperidol oral.............................................30HARVONI ORAL TABLET........................... 33HAVRIX........................................................90headache relief...............................................3heartburn relief oral tablet 200 mg............... 70heartburn treatment 24 hour........................ 73heather......................................................... 84HEMANGEOL.............................................. 46HEMLIBRA...................................................44heparin sodium (porcine) injection solution 1000 unit/ml, 20000 unit/ml.......................... 43heparin sodium (porcine) injection solution 10000 unit/ml, 5000 unit/ml.......................... 43heparin sodium (porcine) injection solution prefilled syringe............................................ 43heparin sodium (porcine) pf......................... 43HEPLISAV-B................................................ 90high potency probiotic.................................. 69hm adult tussin cough & chest................... 107hm gas relief oral tablet chewable 125 mg...69hm loratadine............................................. 103

hm stomach relief oral suspension 525 mg/30ml....................................................... 69hm stool softener oral capsule 100 mg........ 71HUMALOG KWIKPEN................................. 41HUMALOG MIX 50/50 KWIKPEN................ 41HUMALOG MIX 50/50 VIAL.........................41HUMALOG MIX 75/25 KWIKPEN................ 41HUMALOG MIX 75/25 VIAL.........................41HUMALOG U-100 JUNIOR KWIKPEN........ 41HUMALOG U-100 VIAL AND CARTRIDGE.41HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 6 MG... 77HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT.............................................88HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT.............................................. 88HUMULIN 70/30 KWIKPEN......................... 41HUMULIN 70/30 VIAL.................................. 41HUMULIN N KWIKPEN................................41HUMULIN N VIAL........................................ 41HUMULIN R U-500 KWIKPEN.....................41HUMULIN R U-500 VIAL (CONCENTRATED).....................................41HUMULIN R VIAL........................................ 41HYCAMTIN ORAL........................................25hydralazine hcl oral...................................... 50hydrochlorothiazide oral capsule..................49hydrochlorothiazide oral tablet 12.5 mg....... 49hydrochlorothiazide oral tablet 25 mg, 50 mg................................................................ 49hydrocodone bitartrate er............................... 7hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml............................................ 8hydrocodone-acetaminophen oral tablet 10-325 mg...................................................... 8hydrocodone-acetaminophen oral tablet 5-325 mg........................................................... 8hydrocodone-acetaminophen oral tablet 7.5-325 mg..................................................... 8

hydrocodone-homatropine......................... 107hydrocortisone (perianal) external cream 2.5 %............................................................ 91hydrocortisone butyrate external ointment... 56hydrocortisone butyrate external solution.... 56hydrocortisone external cream.....................56hydrocortisone external lotion 2.5 %............ 56hydrocortisone external ointment 0.5 %.......56hydrocortisone external ointment 1 %..........56hydrocortisone external ointment 2.5 %.......56hydrocortisone oral.......................................76hydrocortisone rectal....................................91hydrocortisone-acetic acid......................... 101hydromet.................................................... 107hydromorphone hcl oral................................. 8hydromorphone hcl rectal...............................8hydroxychloroquine sulfate oral................... 28hydroxyurea oral.......................................... 24hydroxyzine hcl oral..................................... 36hydroxyzine pamoate oral.......................... 103hyoscyamine sulfate er................................ 67hyoscyamine sulfate oral..............................67hyoscyamine sulfate sl................................. 67hyoscyamine sulfate sublingual................... 67hyosyne........................................................67HYPERSAL INHALATION NEBULIZATION SOLUTION 7 %..........................................107HYPERTET S/D........................................... 90HYSINGLA ER............................................... 7IBRANCE ORAL CAPSULE.........................26IBRANCE ORAL TABLET............................26ibu.................................................................. 6ibuprofen infants.............................................6ibuprofen oral suspension.............................. 6ibuprofen oral tablet....................................... 6icatibant acetate........................................... 87ICLUSIG.......................................................26IDHIFA......................................................... 26iferex 150 forte............................................. 59

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ILARIS..........................................................89ILEVRO...................................................... 100ILUMYA........................................................56imatinib mesylate......................................... 26IMBRUVICA................................................. 26imipramine hcl oral....................................... 20imiquimod external....................................... 56IMODIUM A-D ORAL TABLET.....................69IMODIUM MULTI-SYMPTOM RELIEF........ 69IMPAVIDO....................................................28incassia........................................................ 84INCRELEX................................................... 77INCRUSE ELLIPTA....................................104indapamide...................................................49indomethacin oral capsule 25 mg, 50 mg...... 6INFANRIX.................................................... 90infants gas relief oral suspension 20 mg/0.3ml...................................................... 69INGREZZA................................................... 52INLYTA.........................................................26INSPIREASE RESERVOIR BAGS.............. 93INSULIN ASPART PROT & ASPART..........41INSULIN LISPRO.........................................41INSULIN LISPRO (1 UNIT DIAL)................. 41INTELENCE................................................. 34INTRON A.................................................... 33introvale........................................................80INTUNIV.......................................................51INVEGA........................................................31INVEGA SUSTENNA................................... 31INVEGA TRINZA..........................................31INVIRASE.................................................... 36INVOKAMET................................................ 38INVOKAMET XR.......................................... 38INVOKANA...................................................38ipratropium bromide inhalation...................104ipratropium bromide nasal..........................104ipratropium-albuterol.................................. 107IRESSA........................................................ 26

ISENTRESS HD...........................................33ISENTRESS ORAL PACKET.......................33ISENTRESS ORAL TABLET....................... 33ISENTRESS ORAL TABLET CHEWABLE.. 33isibloom........................................................ 80isoniazid oral syrup...................................... 23ISONIAZID ORAL TABLET 100 MG............ 23isoniazid oral tablet 300 mg......................... 23ISOPTO ATROPINE.................................... 96isosorbide dinitrate....................................... 50isosorbide mononitrate.................................50isosorbide mononitrate er.............................50isotretinoin oral.............................................56ISTALOL...................................................... 99itraconazole oral...........................................21ivermectin oral..............................................28JADENU SPRINKLE.................................... 62JAKAFI......................................................... 27jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg..................... 43jantoven oral tablet 6 mg..............................43JANUMET.................................................... 38JANUMET XR.............................................. 38JANUVIA...................................................... 38JARDIANCE.................................................38jencycla........................................................ 84JENTADUETO............................................. 38JENTADUETO XR....................................... 38jinteli ............................................................. 80jolessa.......................................................... 80JORNAY PM................................................ 51juleber.......................................................... 80JULUCA....................................................... 34junel 1.5/30...................................................80junel 1/20......................................................80junel fe oral tablet 1.5-30 mg-mcg................80junel fe oral tablet 1-20 mg-mcg...................80KADIAN..........................................................8KALETRA.....................................................36

kalliga........................................................... 81KALYDECO................................................104KAPVAY.......................................................51kariva............................................................81KAZANO...................................................... 38kelnor 1/35................................................... 81kelnor 1/50................................................... 81ketoconazole external cream....................... 21ketoconazole external shampoo.................. 21ketoconazole oral......................................... 21KETONE TEST............................................ 93ketoprofen oral............................................... 6ketorolac tromethamine ophthalmic solution 0.4 %.............................................100ketorolac tromethamine ophthalmic solution 0.5 %.............................................100ketorolac tromethamine oral...........................6KETOSTIX................................................... 93KEVZARA.................................................... 89KINERET......................................................88kionex...........................................................62KISQALI (200 MG DOSE)............................25KISQALI (400 MG DOSE)............................25KISQALI (600 MG DOSE)............................25KITABIS PAK............................................. 104klor-con........................................................ 59klor-con 10................................................... 59klor-con m10................................................ 59klor-con m20................................................ 59klor-con sprinkle oral capsule extended release 10 meq............................................ 59klor-con/ef.................................................... 60KOMBIGLYZE XR........................................38KORLYM...................................................... 77K-PHOS....................................................... 60K-PHOS-NEUTRAL..................................... 60k-prime......................................................... 60KRINTAFEL................................................. 28kurvelo..........................................................81

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KUVAN.........................................................74labetalol hcl oral........................................... 46lactic acid external........................................56lactulose encephalopathy.............................72lactulose oral solution...................................72lamivudine oral solution................................35lamivudine oral tablet 100 mg...................... 32lamivudine oral tablet 150 mg, 300 mg........ 35lamivudine-zidovudine..................................35lamotrigine oral tablet...................................17lamotrigine oral tablet chewable...................17lamotrigine starter kit-blue............................17lamotrigine starter kit-green......................... 17lamotrigine starter kit-orange....................... 17LANCETS.....................................................93lansoprazole oral capsule delayed release.. 73lansoprazole oral tablet delayed release dispersible.................................................... 73LANTUS SOLOSTAR.................................. 41LANTUS U-100 VIAL................................... 41larin 1.5/30................................................... 81larin 1/20...................................................... 81larin fe 1.5/30............................................... 81larin fe 1/20.................................................. 81larissia.......................................................... 81LASTACAFT................................................ 96latanoprost ophthalmic............................... 100LATUDA....................................................... 31laxative max str............................................ 72laxative regular strength...............................72leena............................................................ 81leflunomide oral............................................89LENVIMA (10 MG DAILY DOSE).................27LENVIMA (12 MG DAILY DOSE).................27LENVIMA (14 MG DAILY DOSE).................27LENVIMA (18 MG DAILY DOSE).................27LENVIMA (20 MG DAILY DOSE).................27LENVIMA (24 MG DAILY DOSE).................27LENVIMA (4 MG DAILY DOSE)...................27

LENVIMA (8 MG DAILY DOSE)...................27lessina.......................................................... 81LETAIRIS................................................... 105letrozole oral.................................................25leucovorin calcium oral tablet 10 mg............25leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg...................................................... 25LEUKERAN..................................................24LEUKINE......................................................44leuprolide acetate injection...........................86levalbuterol hcl inhalation...........................104LEVBID........................................................ 67LEVEMIR U-100 FLEXTOUCH....................41LEVEMIR U-100 VIAL..................................41levetiracetam oral solution........................... 15levetiracetam oral tablet............................... 15levobunolol hcl............................................. 99levocetirizine dihydrochloride oral tablet.... 103levofloxacin oral tablet..................................14levonest........................................................81levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg................................................ 81levonorgestrel...............................................84levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg............................................. 81levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg........................................... 81levonorg-eth estrad triphasic........................81levora 0.15/30 (28)....................................... 81levo-t............................................................ 85levothyroxine sodium oral............................ 85levoxyl.......................................................... 85LEVSIN ORAL..............................................67LEVSIN/SL................................................... 67LEXIVA ORAL SUSPENSION..................... 36LIALDA.........................................................91lice killing......................................................29lice treatment external liquid........................ 29lidocaine external cream 4 %......................... 9

lidocaine external patch 5 %.......................... 9lidocaine hcl external cream 3 %................... 9lidocaine hcl urethral/mucosal........................9lidocaine viscous hcl...................................... 9lidocaine-prilocaine external cream................9lidopin external cream 3 %.............................9lillow............................................................. 81linezolid oral suspension reconstituted........ 12linezolid oral tablet....................................... 12LINZESS...................................................... 71liothyronine sodium oral............................... 85liquid acetaminophen..................................... 3lisinopril oral................................................. 45lisinopril-hydrochlorothiazide........................48lithium...........................................................37lithium carbonate er......................................37lithium carbonate oral...................................37LOKELMA.................................................... 62LONSURF.................................................... 25loperamide hcl oral capsule......................... 69lopinavir-ritonavir..........................................36loratadine oral syrup...................................103loratadine oral tablet...................................103loratadine-d 12hr........................................ 107loratadine-d 24hr........................................ 107lorazepam oral tablet....................................37lorcet.............................................................. 8lorcet hd......................................................... 8lorcet plus.......................................................8losartan potassium oral................................ 45losartan potassium-hctz............................... 48LOTRIMIN AF EXTERNAL POWDER......... 93lovastatin...................................................... 49low-ogestrel..................................................81loxapine succinate........................................30lubricant eye drops ophthalmic solution 0.4-0.3 %......................................................96lubricant pm..................................................96

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lubricating eye drops ophthalmic solution 0.4-0.3 %......................................................96lubricating plus eye drops............................ 96ludent........................................................... 60LUMIGAN...................................................100LUNESTA ORAL TABLET 1 MG............... 110LUNESTA ORAL TABLET 2 MG, 3 MG.....110LUPANETA PACK....................................... 86LUPRON DEPOT (1-MONTH)..................... 86LUPRON DEPOT (3-MONTH)..................... 86LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG.....................86LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG.....................86LUPRON DEPOT-PED (1-MONTH)............ 86LUPRON DEPOT-PED (3-MONTH)............ 86lutera............................................................ 81LUXIQ.......................................................... 56LYNPARZA.................................................. 27lysiplex plus oral tablet................................. 63LYSODREN................................................. 85lyza...............................................................84MAALOX MULTI SYMPTOM MAX ST.........69magnesium citrate oral solution................... 72magnesium oxide oral tablet 400 (241.3 mg) mg......................................................... 60magnesium oxide oral tablet 400 mg........... 69magnesium oxide oral tablet 420 mg........... 69magnesium-oxide.........................................60malathion......................................................29maprotiline hcl oral tablet 25 mg.................. 19maprotiline hcl oral tablet 50 mg, 75 mg...... 19marlissa........................................................81MASK VORTEX........................................... 94MATULANE..................................................24MAVENCLAD (10 TABS)............................. 52MAVENCLAD (4 TABS)............................... 52MAVENCLAD (5 TABS)............................... 52MAVENCLAD (6 TABS)............................... 52

MAVENCLAD (7 TABS)............................... 52MAVENCLAD (8 TABS)............................... 52MAVENCLAD (9 TABS)............................... 52MAVYRET....................................................33MAYZENT.................................................... 52MAYZENT STARTER PACK....................... 52m-dryl......................................................... 103meclizine hcl oral tablet................................20MEDROL ORAL TABLET 2 MG...................76medroxyprogesterone acetate intramuscular................................................84medroxyprogesterone acetate oral.............. 84mefloquine hcl.............................................. 28megestrol acetate oral suspension 40 mg/ml........................................................... 84megestrol acetate oral tablet 20 mg.............84megestrol acetate oral tablet 40 mg.............84MEKINIST.................................................... 27meloxicam oral............................................... 6melphalan.....................................................24memantine hcl oral solution 2 mg/ml............18memantine hcl oral tablet............................. 18MENACTRA................................................. 90MENEST...................................................... 81MENOSTAR.................................................81MENVEO......................................................90mercaptopurine oral..................................... 24mesalamine oral capsule delayed release... 91mesalamine rectal........................................ 91MESNEX ORAL........................................... 28metadate er.................................................. 51metformin hcl er (osm)................................. 38metformin hcl er oral tablet extended release 24 hour 500 mg............................... 38metformin hcl er oral tablet extended release 24 hour 750 mg............................... 38metformin hcl oral tablet...............................38methadone hcl oral tablet soluble.................. 7methadose oral tablet soluble........................ 7

methazolamide oral......................................48methenamine hippurate............................... 12methergine................................................... 94methimazole oral..........................................86methocarbamol oral................................... 109methotrexate oral......................................... 88methotrexate sodium....................................88methotrexate sodium (pf)............................. 88methoxsalen rapid........................................56methyldopa...................................................45methyldopa-hydrochlorothiazide.................. 48methylergonovine maleate oral.................... 94METHYLIN................................................... 51methylphenidate hcl er (cd)..........................51methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg........................................................... 51methylphenidate hcl er oral tablet extended release 10 mg.............................................. 51methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg.......... 51methylphenidate hcl er oral tablet extended release 20 mg.............................................. 51methylphenidate hcl er oral tablet extended release 24 hour............................................ 51methylphenidate hcl oral tablet.................... 51methylprednisolone oral............................... 76metoclopramide hcl oral solution 5 mg/5ml..20metoclopramide hcl oral tablet..................... 69metolazone...................................................49metoprolol succinate er................................ 46metoprolol tartrate oral tablet 100 mg, 50 mg................................................................ 46metoprolol tartrate oral tablet 25 mg............ 46METROGEL................................................. 12metronidazole external.................................12metronidazole oral tablet..............................12metronidazole vaginal.................................. 12mexiletine hcl oral........................................ 46

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mi-acid..........................................................69mi-acid maximum strength........................... 69micaderm..................................................... 21miconazole 3 vaginal suppository................ 21miconazole 7 vaginal suppository................ 21miconazole nitrate external.......................... 21microgestin 1.5/30........................................81microgestin 1/20...........................................81microgestin fe 1.5/30....................................82microgestin fe 1/20.......................................82midodrine hcl................................................45MIGERGOT..................................................22migraine relief.................................................4mili ................................................................82milk of magnesia oral suspension 1200 mg/15ml, 400 mg/5ml...................................72mimvey.........................................................82mineral oil heavy oral................................... 72minitran........................................................ 50MINIVELLE.................................................. 82minocycline hcl oral capsule 100 mg, 50 mg................................................................ 15minoxidil oral................................................ 50mintox regular strength................................ 69MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML..................................................44mirtazapine oral tablet..................................19MIRVASO.....................................................56misoprostol oral............................................73MITIGARE....................................................22mm stool softener laxative........................... 72M-M-R II....................................................... 90M-NATAL PLUS........................................... 63mometasone furoate external...................... 56mondoxyne nl oral capsule 100 mg............. 15mono-linyah..................................................82montelukast sodium oral............................ 103

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml...................... 8morphine sulfate er oral tablet extended release........................................................... 7morphine sulfate oral......................................8morphine sulfate rectal...................................8MOTEGRITY................................................69motion sickness relief...................................20MOTRIN INFANTS DROPS...........................6MOVANTIK.................................................. 69MOXEZA...................................................... 14MOZOBIL..................................................... 44m-pap............................................................. 4MUCINEX DM............................................ 107mucus dm...................................................107mucus relief d oral tablet extended release 12 hour....................................................... 107mucus relief dm oral liquid......................... 107mucus relief max st.................................... 107mucus-d..................................................... 107mucus-er max............................................ 107MULPLETA.................................................. 44MULTAQ...................................................... 46multiple vitamin-folic acid............................. 63MULTIPRO...................................................63multi-vit/iron/fluoride..................................... 64multi-vitamin/fluoride.................................... 64multivitamin/fluoride oral solution................. 64multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg................................. 64multivitamin/fluoride/iron.............................. 64multi-vitamin/fluoride/iron............................. 64multivitamins/fluoride....................................64mupirocin external........................................12MURO 128 OPHTHALMIC OINTMENT.......96MURO 128 OPHTHALMIC SOLUTION 5 %.................................................................. 97mvc-fluoride..................................................64mycophenolate mofetil ................................. 88

mycophenolate sodium................................ 88MYDAYIS..................................................... 51MYLERAN....................................................24mynephrocaps..............................................64mynephron................................................... 64myorisan.......................................................56MYRBETRIQ................................................74MYTESI........................................................69nabumetone oral............................................ 6nafrinse........................................................ 60nafrinse drops.............................................. 60naloxone hcl injection solution..................... 10naloxone hcl injection solution cartridge...... 10naloxone hcl injection solution prefilled syringe..........................................................10naltrexone hcl oral..........................................9naproxen dr.................................................... 6naproxen oral................................................. 6naproxen sodium oral tablet 220 mg..............6naratriptan hcl.............................................. 22NARCAN...................................................... 10NASACORT ALLERGY 24HR................... 103nasal decongestant.................................... 107nasal decongestant pe............................... 107nasal moisturizing spray.............................107nasal spray 12 hour....................................107nateglinide....................................................38natural fiber laxative oral powder 28.3 %..... 72natural senna laxative.................................. 72NAYZILAM................................................... 15nebusal inhalation nebulization solution 3 %................................................................ 107necon 0.5/35 (28)......................................... 82neomycin sulfate oral................................... 11neomycin-bacitracin zn-polymyx.................. 97neomycin-polymyxin-dexameth ophthalmic ointment....................................................... 97neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1............................97

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neomycin-polymyxin-gramicidin................... 97neomycin-polymyxin-hc ophthalmic............. 97neomycin-polymyxin-hc otic....................... 101NEONATAL COMPLETE............................. 64NEONATAL PLUS....................................... 64neo-polycin...................................................97neo-polycin hc.............................................. 97NEOSPORIN ORIGINAL EXTERNAL OINTMENT 3.5-400-5000............................ 12NEO-SYNEPHRINE COLD/ALLRG MILD. 107NEO-SYNEPHRINE COLD/ALLRGY EXT.108NEO-SYNEPHRINE COLD/ALLRGY REG 108NEOVITE..................................................... 64NESINA........................................................38NESTABS.................................................... 64NEULASTA.................................................. 44NEULASTA ONPRO.................................... 44NEUPOGEN.................................................44neutral sodium fluoride.................................60NEVANAC..................................................100nevirapine.....................................................34nevirapine er................................................ 34NEXAVAR.................................................... 27NEXIUM ORAL CAPSULE DELAYED RELEASE.....................................................73NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG.......................................................... 73NEXIUM ORAL PACKET 2.5 MG, 5 MG..... 73niacin (antihyperlipidemic)............................50niacin er (antihyperlipidemic)....................... 50niacin er oral capsule extended release 250 mg......................................................... 64niacin oral tablet 100 mg.............................. 64niacor........................................................... 50NICADAN..................................................... 64NICAZEL...................................................... 64NICAZEL FORTE.........................................64NICORETTE MOUTH/THROAT GUM 2 MG............................................................... 11

nicotine polacrilex mouth/throat................... 11nicotine step 1.............................................. 11nicotine step 2.............................................. 11nicotine step 3.............................................. 11NICOTROL...................................................11NICOTROL NS.............................................11nifedipine er..................................................47nifedipine er osmotic release....................... 47nifedipine oral...............................................47nimodipine oral.............................................47NINLARO..................................................... 25NITRO-BID...................................................50NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR....................50nitrofurantoin................................................ 12nitrofurantoin macrocrystal oral....................12nitrofurantoin monohydrate macrocrystals... 12nitroglycerin sublingual.................................50nitroglycerin transdermal..............................50nitroglycerin translingual.............................. 50NITYR.......................................................... 74NIVESTYM...................................................44NOCDURNA................................................ 77nora-be.........................................................84NORDITROPIN FLEXPRO.......................... 77norethin ace-eth estrad-fe oral tablet........... 82norethindrone acetate oral........................... 84norethindrone acet-ethinyl est......................82norethindrone oral........................................ 84norgestimate-eth estradiol............................82norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg............... 82NORITATE................................................... 12norlyda......................................................... 84norlyroc........................................................ 84NORPACE................................................... 46NORPACE CR............................................. 46nortrel 0.5/35 (28).........................................82nortrel 1/35 (21)............................................82

nortrel 1/35 (28)............................................82nortrel 7/7/7.................................................. 82nortriptyline hcl oral...................................... 20NORVIR ORAL PACKET............................. 36NORVIR ORAL SOLUTION......................... 36novamv pediatric multi-vitamin.....................64novarel intramuscular solution reconstituted 10000 unit...............................77NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT.................... 77NOVOEIGHT................................................94NOVOFINE AUTOCOVER PEN NEEDLE...94NOVOFINE PEN NEEDLE...........................94NOVOFINE PLUS PEN NEEDLE................ 94NOVOLIN 70/30 FLEXPEN..........................41NOVOLIN 70/30 RELION.............................41NOVOLIN 70/30 VIAL.................................. 41NOVOLIN N FLEXPEN................................ 41NOVOLIN N RELION................................... 41NOVOLIN N VIAL.........................................41NOVOLIN R FLEXPEN................................ 41NOVOLIN R RELION................................... 41NOVOLIN R VIAL.........................................41NOVOLOG FLEXPEN..................................41NOVOLOG MIX 70/30 FLEXPEN................ 41NOVOLOG MIX 70/30 VIAL.........................42NOVOLOG PENFILL................................... 42NOVOLOG U-100 VIAL............................... 42NOVOTWIST PEN NEEDLE........................94NUBEQA...................................................... 24NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR...................................... 108NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.............................. 108NUCYNTA ER................................................7NUEDEXTA..................................................52NULEV......................................................... 67NUTRICAP...................................................64nutrifac zx.....................................................64

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NUTROPIN AQ NUSPIN 10.........................77NUTROPIN AQ NUSPIN 20.........................77NUTROPIN AQ NUSPIN 5...........................77NUZYRA ORAL............................................15nyamyc.........................................................21NYMALIZE................................................... 47nystatin external........................................... 21nystatin mouth/throat....................................21nystatin oral..................................................21nystop...........................................................21octreotide acetate.........................................86ODEFSEY.................................................... 34ODOMZO..................................................... 27OFEV......................................................... 105ofloxacin ophthalmic.....................................98ofloxacin oral................................................ 14ofloxacin otic.............................................. 100olanzapine intramuscular............................. 31olanzapine oral tablet................................... 31olanzapine oral tablet dispersible.................31OLUMIANT...................................................88OLUX........................................................... 56OLUX-E........................................................56OMECLAMOX-PAK..................................... 70omega-3-acid ethyl esters............................50omeprazole magnesium oral tablet delayed release......................................................... 73omeprazole oral capsule delayed release....73omeprazole oral tablet delayed release....... 73OMNARIS.................................................. 103OMNITROPE............................................... 77ondansetron hcl oral tablet...........................20ondansetron odt........................................... 20one daily.......................................................64ONETOUCH ULTRA 2 KIT W/DEVICE....... 94ONETOUCH ULTRA BLUE IN VITRO STRIP...........................................................94ONETOUCH ULTRA MINI KIT W/DEVICE..94ONETOUCH VERIO FLEX SYSTEM...........94

ONETOUCH VERIO IQ SYSTEM................94ONETOUCH VERIO KIT W/DEVICE........... 94ONETOUCH VERIO SYNC SYSTEM..........94ONETOUCH VERIO TEST STRIPS............ 94ONEVITE..................................................... 64ONEXTON................................................... 56ONGLYZA.................................................... 38OPSUMIT...................................................105OPTIVAR OPHTHALMIC SOLUTION 0.05 %.................................................................. 98ORACEA...................................................... 15oralone......................................................... 53ORENCIA SUBCUTANEOUS......................88ORFADIN..................................................... 74ORILISSA.....................................................86ORKAMBI...................................................104orphenadrine citrate er............................... 109orsythia.........................................................82oscimin......................................................... 67oscimin sr..................................................... 67oseltamivir phosphate oral capsule..............36oseltamivir phosphate oral suspension reconstituted.................................................36OSENI.......................................................... 38OSPHENA....................................................84OTEZLA....................................................... 89OTOVEL.....................................................100OTREXUP....................................................88OVACE PLUS WASH EXTERNAL LIQUID. 56OVACE WASH.............................................57OVIDREL..................................................... 77oxaprozin........................................................6oxazepam.....................................................37oxcarbazepine oral suspension....................18oxcarbazepine oral tablet............................. 18oxybutynin chloride er.................................. 74oxybutynin chloride oral............................... 74oxycodone hcl oral concentrate 100 mg/5ml........................................................... 9

oxycodone hcl oral solution............................9oxycodone hcl oral tablet............................... 9oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg......................9oxycodone-aspirin.......................................... 9OXYCONTIN..................................................7oxymorphone hcl er........................................7oyster shell calcium oral tablet 500 mg........ 60oyster shell calcium/d oral tablet 250-250 mg-unit, 500-400 mg-unit............................. 60oyster shell calcium/d oral tablet 500-200 mg-unit......................................................... 60oyster shell calcium/vitamin d oral tablet 500-200 mg-unit........................................... 60OZEMPIC.....................................................38PACERONE ORAL TABLET 100 MG, 400 MG............................................................... 46pacerone oral tablet 200 mg........................ 46pain & fever childrens oral suspension.......... 4pain & fever infants........................................ 4pain relief childrens oral elixir.........................4pain relief extra strength oral capsule............ 4pain relief oral liquid....................................... 4pain relief oral tablet 325 mg..........................4pain relief regular strength............................. 4paliperidone er............................................. 31PANADOL CHILDRENS................................ 4PANADOL EXTRA STRENGTH.................... 4PANADOL INFANTS......................................4PANCREAZE............................................... 74PANRETIN................................................... 28pantoprazole sodium oral.............................73paroex.......................................................... 53paromomycin sulfate oral............................. 11paroxetine hcl...............................................19PASER......................................................... 23PAZEO......................................................... 98PEDIALYTE ORAL SOLUTION................... 60pediatric electrolyte oral solution..................60

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pediavit.........................................................64peg 3350-kcl-na bicarb-nacl.........................72PEGASYS.................................................... 33PEGASYS PROCLICK.................................33penicillamine oral tablet................................75penicillin v potassium................................... 13pentamidine isethionate inhalation...............28PENTASA.................................................... 91pentazocine-naloxone hcl.............................. 9pentoxifylline er............................................ 48PERDIEM OVERNIGHT RELIEF.................72PERFOROMIST.........................................104periogard...................................................... 53permethrin external...................................... 29perphenazine oral........................................ 20perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50 mg...................19perphenazine-amitriptyline oral tablet 2-25 mg................................................................ 19PERSERIS................................................... 31phenazo oral tablet 200 mg..........................75phenazopyridine hcl oral tablet 100 mg....... 75phenazopyridine hcl oral tablet 200 mg....... 75phenobarbital oral elixir................................ 16phenobarbital oral solution........................... 16phenobarbital oral tablet...............................15phenylephrine hcl ophthalmic.......................97phenytoin infatabs........................................ 18phenytoin oral...............................................18phenytoin sodium extended......................... 18philith............................................................82phospha 250 neutral.................................... 60phosphasal...................................................74PHOSPHOLINE IODIDE..............................99phosphorous................................................ 60phospho-trin 250 neutral.............................. 60phytonadione oral.........................................65PICATO........................................................57pilocarpine hcl ophthalmic............................99

pilocarpine hcl oral tablet 5 mg.................... 53pilocarpine hcl oral tablet 7.5 mg................. 53pimecrolimus................................................ 57pimozide.......................................................30pimtrea......................................................... 82pink bismuth maximum strength.................. 70pioglitazone hcl............................................ 38PIQRAY (200 MG DAILY DOSE).................25PIQRAY (250 MG DAILY DOSE).................25PIQRAY (300 MG DAILY DOSE).................25pirmella 1/35.................................................82pirmella 7/7/7................................................82piroxicam oral.................................................6PLAN B ONE-STEP..................................... 84PLEGRIDY................................................... 52PLEGRIDY STARTER PACK...................... 52PNEUMOVAX 23......................................... 90podactin external cream...............................21podofilox external......................................... 57polycin.......................................................... 97poly-iron 150 forte........................................ 60polymyxin b-trimethoprim............................. 97POLYSPORIN..............................................12poly-vite pediatric......................................... 65POMALYST..................................................24portia-28....................................................... 82potassium bicarbonate oral.......................... 61potassium chloride crys er........................... 61potassium chloride er oral capsule extended release 10 meq.............................61potassium chloride er oral tablet extended release......................................................... 61potassium chloride oral................................ 61potassium citrate er oral tablet extended release 10 meq (1080 mg)........................... 61potassium citrate er oral tablet extended release 15 meq (1620 mg)........................... 61potassium citrate er oral tablet extended release 5 meq (540 mg)............................... 61

potassium citrate-citric acid..........................61PRADAXA.................................................... 43PRALUENT.................................................. 50pramipexole dihydrochloride oral tablet 0.125 mg, 0.5 mg, 1 mg............................... 29pramipexole dihydrochloride oral tablet 0.25 mg, 1.5 mg........................................... 29pramipexole dihydrochloride oral tablet 0.75 mg........................................................ 29prasugrel hcl.................................................44praziquantel oral...........................................28prazosin hcl oral........................................... 45PRECISION LINK........................................ 94PRECISION PCX PLUS TEST.................... 94PRECISION QID MONITOR........................ 94PRECISION QID TEST................................94PRECISION SOF-TACT MONITOR............ 94PRECISION SOF-TACT TEST.................... 94PRECISION XTRA BLOOD GLUCOSE.......94PRECISION XTRA DEVICE........................ 94PRECISION XTRA MONITOR.....................94PRED-G....................................................... 97PRED-G S.O.P.............................................97prednicarbate external cream...................... 57prednisolone acetate ophthalmic............... 100prednisolone acetate p-f.............................100prednisolone oral solution............................ 76prednisolone sodium phosphate ophthalmic..................................................100prednisolone sodium phosphate oral solution 15 mg/5ml....................................... 76prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml........................76prednisone oral solution............................... 76prednisone oral tablet...................................76prednisone oral tablet therapy pack 10 mg (21)...............................................................76prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48)............................ 76

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PREFEST.....................................................82pregabalin oral............................................. 52pregnyl......................................................... 77PREMARIN ORAL....................................... 82PREMARIN VAGINAL..................................82PREMIUM CONDOMS LUBRICATED.........94PREMPHASE...............................................82PREMPRO................................................... 82prenatal oral tablet 27-0.8 mg...................... 65prenatal oral tablet 27-1 mg......................... 65prenatal oral tablet 28-0.8 mg...................... 65prenatal plus iron..........................................65PRENATVITE RX.........................................65PREVACID...................................................73PREVACID 24HR.........................................73prevalite oral powder....................................50PREVIDENT 5000 DRY MOUTH.................53PREVIDENT 5000 PLUS............................. 53PREVIDENT DENTAL................................. 53PREVIDENT MOUTH/THROAT...................61previfem....................................................... 82PREVNAR 13...............................................90PREZCOBIX................................................ 36PREZISTA....................................................36PRIFTIN....................................................... 23PRILOSEC................................................... 73primaquine phosphate..................................28primidone oral.............................................. 16PRISTIQ.......................................................19PROAIR HFA............................................. 104probenecid................................................... 22prochlorperazine.......................................... 20prochlorperazine maleate oral......................30PROCRIT..................................................... 44PROCTOFOAM HC..................................... 91procto-med hc.............................................. 91proctosol hc..................................................91proctozone-hc.............................................. 91progesterone micronized oral.......................84

PROLENSA................................................100PROMACTA ORAL TABLET....................... 44promethazine hcl oral.................................103promethazine hcl rectal.............................. 103promethazine-codeine................................108promethazine-dm....................................... 108promethazine-phenyleph-codeine..............108promethazine-phenylephrine......................108promethegan.............................................. 103propafenone hcl........................................... 46propranolol hcl er......................................... 46propranolol hcl oral solution 20 mg/5ml....... 46propranolol hcl oral solution 40 mg/5ml....... 46propranolol hcl oral tablet.............................46propranolol-hctz........................................... 48propylthiouracil oral...................................... 86PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 %.......................................................57PROVENTIL HFA.......................................104pseudoephedrine hcl er..............................108pseudoephedrine-bromphen-dm................108pseudoephedrine-guaifenesin er................108PULMICORT FLEXHALER........................ 103pulmosal.....................................................108PULMOZYME............................................ 108puralube....................................................... 97PYLERA....................................................... 70pyrazinamide oral.........................................23PYRIDIUM....................................................75pyridostigmine bromide er............................23pyridostigmine bromide oral solution............23pyridostigmine bromide oral tablet 60 mg.... 23pyrimethamine oral.......................................28QBREXZA.................................................... 57qc aspirin low dose oral tablet delayed release........................................................... 6qc magnesium citrate................................... 72QTERN.........................................................38quetiapine fumarate..................................... 31

quetiapine fumarate er................................. 31QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML................................................... 65QUFLORA PEDIATRIC ORAL TABLET CHEWABLE................................................. 65quinapril hcl.................................................. 45quinapril-hydrochlorothiazide....................... 48quinidine gluconate er.................................. 46quinidine sulfate........................................... 46QVAR REDIHALER................................... 103ra iron oral tablet 325 (65 fe) mg..................61ra one daily...................................................65raloxifene hcl................................................ 84ramipril ......................................................... 45ranolazine er................................................ 48RASUVO...................................................... 88RAVICTI....................................................... 74REBIF...........................................................52REBIF REBIDOSE....................................... 52REBIF REBIDOSE TITRATION PACK........ 52REBIF TITRATION PACK............................52reclipsen.......................................................82RECOMBIVAX HB....................................... 90RECTIV........................................................ 50REGRANEX................................................. 57RELENZA DISKHALER............................... 36RELISTOR................................................... 70renal............................................................. 65RENAL MULTIVITAMIN FORMULA............ 65rena-vite....................................................... 65repaglinide....................................................38REPATHA.................................................... 50REQ 49+...................................................... 65RESTASIS................................................... 97RESTASIS MULTIDOSE............................. 97RESTORA RX..............................................70RETACRIT................................................... 44RETIN-A EXTERNAL CREAM.....................57RETIN-A EXTERNAL GEL...........................57

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RETIN-A MICRO GEL 0.04 %, 0.1 %.......... 57RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %.......................................................... 57REVLIMID.................................................... 24REXULTI...................................................... 31REYATAZ ORAL CAPSULE........................ 36REYATAZ ORAL PACKET.......................... 36RHOFADE....................................................57RHOPRESSA...............................................97ribavirin oral..................................................33rifabutin........................................................ 23rifampin oral................................................. 23riluzole..........................................................52rimantadine hcl.............................................36RINVOQ....................................................... 89RISPERDAL CONSTA.................................31RISPERDAL ORAL SOLUTION...................31RISPERDAL ORAL TABLET....................... 31risperidone oral solution............................... 31risperidone oral tablet...................................31risperidone oral tablet dispersible................ 31RITALIN....................................................... 51ritonavir........................................................ 36rivastigmine.................................................. 18rivastigmine tartrate......................................18rizatriptan benzoate......................................22robafen....................................................... 108ROBITUSSIN 12 HOUR COUGH CHILD.. 108ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML.........108ropinirole hcl.................................................29rosadan external cream............................... 12rosadan external gel.....................................12roweepra...................................................... 15ROZEREM................................................. 110RUBRACA....................................................25RUCONEST................................................. 87RUZURGI.....................................................94RYBELSUS.................................................. 38

RYDAPT.......................................................27RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG........................................................ 46RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 425 MG..46saccharomyces boulardii ..............................70SAIZEN........................................................ 77salsalate oral.................................................. 6SANTYL....................................................... 57SAPHRIS..................................................... 31SAVAYSA.................................................... 43SCRUB CARE POVIDONE-IODINE............ 12SEEBRI NEOHALER................................. 104SEGLUROMET............................................ 38SELECT-OB ORAL TABLET CHEWABLE 29-1 MG....................................................... 65selegiline hcl oral..........................................30selenium sulfide external lotion.................... 57SELZENTRY................................................ 35senexon-s.....................................................72senna oral liquid........................................... 72senna oral syrup 8.8 mg/5ml........................72senna oral tablet...........................................72senna plus oral tablet................................... 72senna s.........................................................72senna smooth...............................................72senna-docusate sodium............................... 72senna-plus....................................................72SENOKOT S................................................ 72SERNIVO..................................................... 57SEROQUEL................................................. 31SEROQUEL XR........................................... 31sertraline hcl oral..........................................19setlakin......................................................... 82sevelamer carbonate oral tablet...................62sf.................................................................. 53sf 5000 plus..................................................53SFROWASA.................................................91

sharobel....................................................... 84SHINGRIX....................................................90SIDEROL..................................................... 65SIGNIFOR....................................................86sildenafil citrate oral suspension reconstituted...............................................105sildenafil citrate oral tablet 20 mg...............105SILENOR................................................... 110SILIQ............................................................ 57silver sulfadiazine external........................... 14SIMBRINZA..................................................99simethicone oral capsule..............................70simethicone oral suspension........................70simethicone oral tablet chewable 80 mg...... 70simliya.......................................................... 83SIMPONI...................................................... 88simvastatin oral............................................ 49sinus 12 hour..............................................108sirolimus oral solution...................................88sirolimus oral tablet 0.5 mg, 1 mg................ 88sirolimus oral tablet 2 mg............................. 88SIRTURO..................................................... 23SKYRIZI (150 MG DOSE)............................88sm cold & allergy childrens oral elixir 1-15 mg/5ml....................................................... 108sod citrate-citric acid.................................... 61sodium bicarbonate oral tablet..................... 70sodium chloride (hypertonic) ophthalmic ointment....................................................... 97sodium chloride (hypertonic) ophthalmic solution.........................................................97sodium chloride inhalation..........................108sodium fluoride 5000 plus............................ 53sodium fluoride 5000 ppm dental cream...... 53sodium fluoride dental cream....................... 53sodium fluoride dental gel............................ 53sodium fluoride oral solution........................ 61sodium fluoride oral tablet 1.1 (0.5 f) mg......61sodium fluoride oral tablet chewable............61

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sodium phenylbutyrate oral powder............. 74sodium polystyrene sulfonate oral suspension................................................... 62sodium polystyrene sulfonate rectal.............62sodium sulfacetamide wash......................... 57SOFOSBUVIR-VELPATASVIR....................33SOLIQUA..................................................... 38SOLODYN....................................................15SOMAVERT................................................. 86SOOLANTRA............................................... 57soothe oral suspension 525 mg/30ml.......... 70soothe oral tablet..........................................70SORILUX..................................................... 57sotalol hcl (af)...............................................46sotalol hcl oral.............................................. 46SOVALDI ORAL TABLET............................ 33spinosad.......................................................29SPIRIVA HANDIHALER.............................104SPIRIVA RESPIMAT..................................104spironolactone oral.......................................49spironolactone-hctz...................................... 48sprintec 28....................................................83SPRYCEL.................................................... 27sps................................................................62sronyx...........................................................83ssd................................................................14sss 10-5 external cream...............................57ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE.....................................6stavudine......................................................35STEGLATRO............................................... 38STEGLUJAN................................................ 38STELARA SUBCUTANEOUS......................88stimulant laxative oral tablet.........................73STIOLTO RESPIMAT................................ 108STIVARGA................................................... 27stomach relief oral suspension 525 mg/30ml....................................................... 70stomach relief oral tablet chewable..............70

stool softener laxative oral capsule 100 mg. 73stool softener oral capsule 100 mg.............. 73stool softener oral capsule 250 mg.............. 73stool softener plus laxative...........................73stool softener/laxative oral tablet..................73STRATTERA................................................51STRENSIQ...................................................74STRIBILD..................................................... 33STRIVERDI RESPIMAT.............................104STROVITE FORTE ORAL TABLET.............65STROVITE ONE.......................................... 65SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG................................................. 10SUBOXONE SUBLINGUAL FILM 2-0.5 MG............................................................... 10SUBOXONE SUBLINGUAL FILM 8-2 MG...10subvenite......................................................17subvenite starter kit-blue.............................. 17subvenite starter kit-green............................17subvenite starter kit-orange..........................17sucralfate oral tablet.....................................73SUDAFED CONGESTION.........................108sudogest 12 hour....................................... 108sudogest maximum strength...................... 108sudogest oral tablet 30 mg.........................108sudogest pe................................................109sulfacetamide sodium external liquid........... 57sulfacetamide sodium ophthalmic................ 14sulfacetamide sodium-sulfur external cream 10-5 %...............................................57sulfacetamide sodium-sulfur external liquid 9-4.5 %.........................................................57sulfacetamide sodium-sulfur external lotion 10-5 %..........................................................57sulfacetamide sodium-sulfur external suspension 10-5 %.......................................57sulfacetamide-prednisolone ophthalmic solution.........................................................97sulfamethoxazole-trimethoprim oral............. 14

sulfamez wash............................................. 57sulfasalazine oral......................................... 91sulfatrim pediatric......................................... 14sulindac oral................................................... 6SUMADAN WASH....................................... 57sumatriptan nasal.........................................22sumatriptan succinate oral........................... 22sumatriptan succinate refill ...........................22sumatriptan succinate subcutaneous...........22support......................................................... 65SUTENT.......................................................27SYLATRON..................................................33symax-sl....................................................... 67symax-sr.......................................................67SYMBICORT..............................................109SYMDEKO................................................. 104SYMFI.......................................................... 34SYMFI LO.................................................... 34SYMJEPI....................................................104SYMLINPEN 120......................................... 38SYMLINPEN 60........................................... 38SYMPAZAN................................................. 16SYMPROIC.................................................. 70SYMTUZA.................................................... 36SYNAGIS..................................................... 89SYNAREL.................................................... 86SYNJARDY.................................................. 38SYNJARDY XR............................................ 38SYSTANE COMPLETE................................97SYSTANE HYDRATION PF.........................97SYSTANE ULTRA PF.................................. 97TABLOID......................................................24TACLONEX..................................................57tacrolimus external ointment 0.03 %, 0.1 %.57tacrolimus oral capsule 0.5 mg, 5 mg.......... 88tacrolimus oral capsule 1 mg....................... 88TAFINLAR....................................................27TAKHZYRO..................................................87TALTZ.......................................................... 57

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TAMIFLU ORAL CAPSULE......................... 36TAMIFLU ORAL SUSPENSION RECONSTITUTED.......................................36tamoxifen citrate oral....................................24tamsulosin hcl.............................................. 74TARGRETIN EXTERNAL............................ 28tarina fe 1/20................................................ 83tarina fe 1/20 eq........................................... 83TASIGNA..................................................... 27TAZORAC.................................................... 57taztia xt.........................................................47TDVAX......................................................... 90TECFIDERA.................................................52TEGSEDI..................................................... 74temazepam oral capsule 15 mg, 30 mg..... 110TEMIXYS..................................................... 35TEMOVATE................................................. 57temozolomide...............................................24tencon............................................................ 4TENIVAC......................................................90tenofovir disoproxil fumarate........................ 35terazosin hcl................................................. 74terbinafine hcl oral........................................21terconazole vaginal cream........................... 21testosterone cypionate intramuscular.......... 78testosterone enanthate intramuscular..........78testosterone transdermal gel 12.5 mg/act (1%)..............................................................78testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%)................................. 78tetrabenazine............................................... 52THALOMID...................................................24THEO-24.................................................... 105theophylline................................................ 105theophylline er oral tablet extended release 12 hour 300 mg.......................................... 105theophylline er oral tablet extended release 12 hour 450 mg.......................................... 105

theophylline er oral tablet extended release 24 hour 400 mg.......................................... 105theophylline er oral tablet extended release 24 hour 600 mg.......................................... 105thioridazine hcl oral...................................... 30thiothixene....................................................30tiadylt er........................................................47tiagabine hcl................................................. 16TIBSOVO..................................................... 27TIKOSYN..................................................... 46tilia fe............................................................83timolol maleate ophthalmic gel forming solution.........................................................99timolol maleate ophthalmic solution 0.25 %, 0.5 %.......................................................99TIMOPTIC.................................................... 99TIMOPTIC OCUDOSE.................................99TIMOPTIC-XE.............................................. 99TIVICAY....................................................... 33tizanidine hcl oral tablet..............................109TOBI NEBULIZER......................................104TOBI PODHALER...................................... 104TOBRADEX OPHTHALMIC OINTMENT..... 97tobramycin nebulization solution 300 mg/5ml inhalation....................................... 104TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION.... 104tobramycin ophthalmic................................. 98tobramycin-dexamethasone.........................98TOBREX OPHTHALMIC OINTMENT.......... 98TOLAK......................................................... 57tolcapone......................................................29tolnaftate antifungal......................................22tolnaftate external powder............................94tolterodine tartrate........................................ 74TOPICORT SPRAY..................................... 57topiramate oral capsule sprinkle.................. 17topiramate oral tablet................................... 17toremifene citrate......................................... 24

torsemide..................................................... 48TOUJEO MAX SOLOSTAR......................... 42TOUJEO SOLOSTAR.................................. 42TOVIAZ........................................................ 74TRACLEER................................................ 105TRADJENTA................................................ 38tramadol hcl oral tablet 50 mg........................9trandolapril ................................................... 45tranexamic acid oral..................................... 44tranylcypromine sulfate................................ 19TRAVATAN Z.............................................100travel sickness oral tablet chewable.............20trazodone hcl oral tablet 100 mg, 150 mg, 50 mg........................................................... 19trazodone hcl oral tablet 300 mg..................19TRECATOR................................................. 23TRELEGY ELLIPTA................................... 109TREMFYA.................................................... 57TRESIBA......................................................42TRESIBA FLEXTOUCH............................... 42tretinoin external cream................................57tretinoin oral................................................. 28TREZIX.......................................................... 9tri femynor.................................................... 83triamcinolone acetonide external cream...... 57triamcinolone acetonide external lotion 0.025 %........................................................ 57triamcinolone acetonide external lotion 0.1 %.................................................................. 57triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %..................................57triamcinolone acetonide mouth/throat.......... 53triamterene-hctz........................................... 48triazolam.......................................................37tricon............................................................ 61triderm.......................................................... 57tri-estarylla....................................................83trifluoperazine hcl......................................... 30trifluridine......................................................33

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trihexyphenidyl hcl oral tablet.......................29TRIKAFTA..................................................104tri-legest fe................................................... 83tri-linyah........................................................83trilyte.............................................................73trimethobenzamide hcl oral.......................... 20trimethoprim oral.......................................... 12tri-mili ............................................................83trinate........................................................... 65TRINTELLIX.................................................19triphrocaps................................................... 66triple antibiotic.............................................. 12tri-previfem................................................... 83tri-sprintec.................................................... 83TRIUMEQ.....................................................33tri-vitamin/fluoride oral solution 0.25 mg/ml..66tri-vitamin/fluoride oral solution 0.5 mg/ml....66tri-vite/fluoride oral solution 0.25 mg/ml....... 66tri-vite/fluoride oral solution 0.5 mg/ml......... 66trivora (28)....................................................83tri-vylibra.......................................................83trospium chloride..........................................74TRUETRACK TEST..................................... 94TRULANCE..................................................70TRULICITY...................................................38TRUMENBA................................................. 90TRUSOPT.................................................... 99TRUVADA.................................................... 35TUDORZA PRESSAIR...............................104tulana........................................................... 84TUMS CHEWY BITES................................. 70tussin cf multi-symptom cold...................... 109tussin dm max adult oral liquid 10-200 mg/5ml....................................................... 109tussin dm max adult oral liquid 5-100 mg/5ml....................................................... 109tussin dm max oral liquid 20-400 mg/20ml.109tussin dm oral syrup 100-10 mg/5ml.......... 109TWINRIX...................................................... 90

TYBOST.......................................................33TYKERB.......................................................27TYLENOL 8 HOUR........................................ 4TYLENOL EXTRA STRENGTH..................... 4TYLENOL INFANTS PAIN+FEVER...............4TYLENOL ORAL TABLET............................. 4TYMLOS...................................................... 92UDAMIN SP................................................. 66UDENYCA....................................................44ultra fresh pm............................................... 98ultra lubricating eye drops............................ 98unithroid....................................................... 85urea external lotion.......................................58urea-c40....................................................... 58ureacin-10.................................................... 58ureacin-20.................................................... 58uretron d/s.................................................... 74urin ds.......................................................... 74urinary pain relief oral tablet 95 mg..............75ursodiol oral capsule.................................... 70ursodiol oral tablet........................................70UTIBRON NEOHALER.............................. 109utira-c........................................................... 74utrona-c........................................................ 74VAGIFEM..................................................... 83valacyclovir hcl oral...................................... 33valganciclovir hcl oral tablet......................... 32valproic acid oral.......................................... 16VANCOCIN.................................................. 12vandazole.....................................................12VANOS.........................................................58VAQTA......................................................... 90VARIVAX......................................................90VARUBI (180 MG DOSE)............................ 20v-c forte........................................................ 66VECTICAL....................................................58vegetable lax+stool softener........................ 73velivet........................................................... 83VELPHORO................................................. 62

VELTASSA...................................................62VELTIN.........................................................58VENCLEXTA................................................27VENCLEXTA STARTING PACK..................27venlafaxine hcl............................................. 19venlafaxine hcl er oral capsule extended release 24 hour............................................ 19VENTOLIN HFA......................................... 104verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg......................................................... 47verapamil hcl er oral tablet extended release......................................................... 47verapamil hcl oral......................................... 47VERZENIO...................................................25VESICARE................................................... 74vic-forte........................................................ 66VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS........................ 38VIEKIRA PAK...............................................33vienva...........................................................83vigabatrin oral packet................................... 16vigadrone..................................................... 16VIGAMOX.................................................... 14VIIBRYD.......................................................19VIMPAT ORAL TABLET.............................. 18VIOKACE..................................................... 74viorele...........................................................83VIRACEPT................................................... 36VIRAMUNE ORAL SUSPENSION...............34VIREAD ORAL POWDER............................35VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG........................................................ 35virt-caps........................................................66virt-phos 250 neutral.................................... 61virtussin ac w/alc........................................ 109VISTOGARD................................................ 94vita s forte.....................................................66vitacel........................................................... 66

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vita-min.........................................................66vitamin b-6....................................................66vitamin c oral tablet 1000 mg....................... 66vitamin c oral tablet 500 mg......................... 66vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut)............................................... 66vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)...............................................66vitamin d3 oral capsule 250 mcg (10000 ut) 66vitamin d3 oral capsule 50 mcg (2000 ut).... 66vitamin d3 oral tablet 10 mcg (400 unit)....... 66vitamin d3 oral tablet 125 mcg (5000 ut)......66vitamin d3 oral tablet 50 mcg (2000 ut)........66vitamin e oral capsule 1000 unit...................66vitamins acd-fluoride.................................... 66VITAROCA PLUS........................................ 67VITATHELY WITH GINGER........................ 67VITRAKVI.....................................................27VIVELLE-DOT..............................................83volnea...........................................................83voriconazole oral tablet................................ 22VORTEX HOLDING CHAMBER/MASK.......94VOSEVI........................................................33VOTRIENT................................................... 27VRAYLAR.................................................... 31VUMERITY...................................................52VUMERITY (STARTER).............................. 52vyfemla.........................................................83vylibra...........................................................83VYNDAMAX................................................. 48VYNDAQEL..................................................48VYVANSE.................................................... 51wal-tap cold/allergy oral elixir..................... 109wal-zyr oral tablet....................................... 103warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg........ 43warfarin sodium oral tablet 6 mg.................. 43weekly-d....................................................... 67wera............................................................. 83

WIDE-SEAL DIAPHRAGM 60......................94WIDE-SEAL DIAPHRAGM 65......................94WIDE-SEAL DIAPHRAGM 70......................95WIDE-SEAL DIAPHRAGM 75......................95WIDE-SEAL DIAPHRAGM 80......................95WIDE-SEAL DIAPHRAGM 85......................95WIDE-SEAL DIAPHRAGM 90......................95WIDE-SEAL DIAPHRAGM 95......................95wixela inhub............................................... 109XALATAN...................................................100XALKORI......................................................27XARELTO.................................................... 43XARELTO STARTER PACK........................43XELJANZ..................................................... 89XELJANZ XR............................................... 89XELODA.......................................................24XENLETA ORAL.......................................... 13XEPI............................................................. 14XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG............................................. 38XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG............................................................... 39XIIDRA......................................................... 98XIMINO........................................................ 15XOFLUZA (40 MG DOSE)........................... 36XOFLUZA (80 MG DOSE)........................... 36XOLAIR........................................................ 89XOPENEX HFA..........................................104XTANDI........................................................ 24xulane...........................................................83XULTOPHY..................................................39YONSA.........................................................24yuvafem........................................................83zaclir cleansing.............................................58ZADITOR................................................... 100zaleplon......................................................110ZARXIO........................................................44

ZAVESCA.................................................... 74ZEASORB-AF.............................................. 95ZEGERID..................................................... 73ZEJULA........................................................25ZELAC..........................................................70ZELBORAF.................................................. 27zenatane...................................................... 58ZENPEP.......................................................74ZENZEDI......................................................51ZEPATIER....................................................33ZETONNA.................................................. 103ZIANA...........................................................58zidovudine.................................................... 35ZIOPTAN....................................................100ziprasidone hcl............................................. 32ZOHYDRO ER............................................... 7ZOLINZA...................................................... 25zolpidem tartrate oral................................. 110zolpidem tartrate sublingual....................... 110ZOMACTON.................................................77zonisamide oral............................................ 15ZORTRESS ORAL TABLET 1 MG.............. 89ZOSTAVAX.................................................. 90zovia 1/35e (28)........................................... 83ZUBSOLV.................................................... 10ZYCLARA.....................................................58ZYDELIG......................................................27ZYKADIA......................................................27ZYMAXID..................................................... 98ZYPREXA INTRAMUSCULAR.................... 32ZYPREXA ORAL..........................................32ZYPREXA RELPREVV................................ 32ZYPREXA ZYDIS.........................................32ZYTIGA........................................................ 24

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