your 2020-2021 prescription drug list

44
Maricopa County OptumRx® HDHP Prescription Plan – effective July 1, 2020 Your 2020-2021 Prescription Drug List Maricopa County OptumRx® HDHP Prescription Plan

Upload: others

Post on 27-Dec-2021

7 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Your 2020-2021 Prescription Drug List

Maricopa County OptumRx® HDHP Prescription Plan – effective July 1, 2020

Your 2020-2021 Prescription Drug List

Maricopa CountyOptumRx® HDHP Prescription Plan

Page 2: Your 2020-2021 Prescription Drug List

Your Prescription Drug ListThis Prescription Drug List (PDL) outlines the most commonly prescribed medications for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to myuhc.com® for complete drug informationSince the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your prescription benefit covers, possible lower-cost options, and cost comparisons.

At UnitedHealthcare, we want to help you …

Table of contentsDrug Tiers and Cost . . . . . . . . . . . 1

Programs and Limits . . . . . . . . . . 2

Drugs by Category . . . . . . . . . . . . 5

AntibioticsAntibiotics . . . . . . . . . . . . . . . . . . . . . 5Antifungals . . . . . . . . . . . . . . . . . . . . 5Antivirals/Hepatitis C. . . . . . . . . . . . 6

Anxiety . . . . . . . . . . . . . . . . . . . . . . . 6

Blood Disorders . . . . . . . . . . . . . . . 6

Breast Cancer Prevention . . . . . . 6

Cancer . . . . . . . . . . . . . . . . . . . . . . . 7

Cardiovascular/Heart DiseaseBlood Clot/Platlet Therapy . . . . . . . 7Coagulation Therapy. . . . . . . . . . . . 7High Blood Pressure . . . . . . . . . . . . 7High Cholesterol . . . . . . . . . . . . . . . 10

Central Nervous SystemAttention Deficit Disorder . . . . . . . . 10Depression . . . . . . . . . . . . . . . . . . . . 11Mental Health . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . 12Other . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . 12Seizure Disorders. . . . . . . . . . . . . . . 12

Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . 13

Dermatology . . . . . . . . . . . . . . . . . . 13

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . 15Insulin . . . . . . . . . . . . . . . . . . . . . . . . 15Non-Insulin . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone. . . . . . . . . . . . . . . 16Other . . . . . . . . . . . . . . . . . . . . . . . . . 16Thyroid Hormone Replacement . . 17

Eye ConditionsAllergies, Antibiotics and Others . . 17Glaucoma . . . . . . . . . . . . . . . . . . . . . 17

GastrointestinalAcid Suppression . . . . . . . . . . . . . . 18Nausea/Vomiting . . . . . . . . . . . . . . . 18Other . . . . . . . . . . . . . . . . . . . . . . . . . 18

Genitourinary . . . . . . . . . . . . . . . . . 19

Gout . . . . . . . . . . . . . . . . . . . . . . . . . 19

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . 19

Infertility. . . . . . . . . . . . . . . . . . . . . . 20

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative Colitis. . . . . . . 20

Miscellaneous . . . . . . . . . . . . . . . . 20

MusculoskeletalMuscle Spasms . . . . . . . . . . . . . . . . 20Osteoporosis . . . . . . . . . . . . . . . . . . 21Pain Relief . . . . . . . . . . . . . . . . . . . . . 21

Overactive Bladder . . . . . . . . . . . . 22

Parkinson’s Disease . . . . . . . . . . . 22

RespiratoryAllergies. . . . . . . . . . . . . . . . . . . . . . . 22Anaphlaxis . . . . . . . . . . . . . . . . . . . . 22Asthma/COPD . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension . 23

Smoking Cessation . . . . . . . . . . . . 24

Transplant . . . . . . . . . . . . . . . . . . . . 24

Vitamins/Electrolytes . . . . . . . . . . 24

Women’s Health:Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . 24

Page 3: Your 2020-2021 Prescription Drug List

Understand your medications optionsYour prescription benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your prescription benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List.

What is a Prescription Drug List (PDL)?This document is a list of commonly prescribed medications. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications. You may also log on to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.

How do I use my Prescription Drug List?When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special programs apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific prescription plan costs.

Drug Tier DescriptionTier 1 Lowest Cost

Lower-cost drugs. Some brands and generics are also included.Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2 Mid-range Cost

Mix of brands and generics.Use Tier 2 drugs, instead of Tier 3 to help reduce your out-of-pocket costs.

Tier 3 Highest Cost

Mostly higher-cost brand as well as select generic drugs.Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Please note: If you have a high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.

Please read: This document contains information about commonly prescribed medications.

For additional information:Call us toll-free at 1-888-876-7098, TTY 711 Habla Español? Podemos ayudar.

Visit myuhc.com®• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

1

Maricopa CountyPrescription Drug List

Page 4: Your 2020-2021 Prescription Drug List

When does the Prescription Drug List change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic becomes available.

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1.

When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the number on your ID card.

Why are some medications excluded from coverage?Medications may be excluded from coverage under your prescription benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

Should I talk to my doctor about over-the-counter (OTC) medications?An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug? The drug list shows brand-name drugs in blue type (for example, Invokana) and generic drugs in plain type (for example, Metformin).

Programs and LimitsSome medications are noted with letters next to them. The letters refer to our prescription benefit programs. Your benefit plan determines how these medications are covered. Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage.

Code Pharmacy Benefit Programs

DSPDesignated Specialty ProgramSpecialty medications need to be filled at a designated specialty pharmacy for in-network coverage. Call the number on your ID card or call Optum Specialty Pharmacy at 1-855-427-4682 for more information.

H Health Care Reform PreventiveThis medication is part of a health care reform preventive and may be available at no cost to you.

PPreventive MedicationMedications are not subject to the deductible. Medications listed in Tier 1 and Tier 2 are not subject to coinsurance. Medications listed in Tier 3 are subject to 50% coinsurance.

PA Prior Authorization Required*Your doctor is required to provide additional information to us to determine coverage.

QL Quantity LimitsSpecifies the largest quantity of medication covered per copayment or in a defined period of time.

ST Step TherapyTrial of a different medication is required before another medication may be covered.

*Depending on your benefit you may have notification or prior authorization requirements for select medications.

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.

2

Page 5: Your 2020-2021 Prescription Drug List

What if my doctor writes a brand-name prescription?The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For your benefit plan if a brand-name drug is prescribed and a generic equivalent is available, your cost share will be the coinsurance for the brand-name drug PLUS the cost difference between the brand-name drug and generic equivalent.

Are you taking a specialty medication?Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For your plan, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on Tier 3, call the toll-free number on your health plan ID card to talk with a pharmacist about finding a lower-cost one.

How do I get updated information about my prescription benefit?Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log on to myuhc.com for the following prescription information and tools:

• Prescription benefit and coverage information

• Possible lower-cost medication options

• Medication interactions and side effects

• Participating retail pharmacies by ZIP code

• Your prescription history

Mail Service is included in your prescription benefit, you can also:

• Refill prescriptions

• Check the status of your order

• Set-up e-mail reminders for refills

• Manage your account

Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines coverage for these medications .

For more informationCall the toll-free member phone number on your health plan ID card.

Or, visit myuhc.com®

3

Maricopa CountyPrescription Drug List

Page 6: Your 2020-2021 Prescription Drug List

“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of medicine and strength

Drug Tier

I take this medicine for Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr . Johnson

4

Page 7: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

AntibioticsAmoxicillin 1Amoxicillin-Potassium Clavulanate Oral 1Arakoda 3 QLAtovaquone-Proguanil HCL 2Avidoxy 1Azithromycin Oral 1Bactrim 3Bactrim DS 3Cefadroxil 1Cefdinir 1Cefuroxime Axetil 1Centany 3 QLCephalexin 1Cipro Oral Tablet 3Ciprodex 3Ciprofloxacin HCL Oral 1Clarithromycin ER 2Clarithromycin Oral Suspension Reconstituted

2

Clarithromycin Oral Tablet 1Cleocin Oral Capsule 150 mg, 300 mg

3

Cleocin Oral Capsule 75 mg 2Clindamycin HCL Oral 1Clindesse 2Dificid 3 QLDoxycycline Hyclate Oral Capsule 2Doxycycline Hyclate Oral Tablet 100 mg 2Doxycycline Hyclate Oral Tablet 20 mg 1Doxycycline Monohydrate Oral Capsule 100 mg, 50 mg

1

Doxycycline Monohydrate Oral Suspension Reconstituted

3

Doxycycline Monohydrate Oral Tablet 1Elimite 3Flagyl 3Hydroxychloroquine Sulfate Oral 1Keflex 3Krintafel 1 QLLevaquin Oral Tablet 500 mg, 750 mg 3Levofloxacin Oral 1Macrobid 3Macrodantin 3Malarone 3

Drug NameDrug Tier

Requirement and Limits

Metronidazole Oral 1Metronidazole Vaginal 2Minocycline HCL Oral Capsule 1Mondoxyne Nl Oral Capsule 100 mg 1Morgidox Oral 2Mupirocin Calcium 3 QLMupirocin External 1 QLNeomycin-Polymyxin-HC Otic 1Nitrofurantoin Macrocrystal Oral 1Nitrofurantoin Monohydrate Macrocrystals

1

Ofloxacin Otic 2Penicillin V Potassium 1Permethrin External 1Sulfamethoxazole-Trimethoprim Oral 1Sulfatrim Pediatric 1Vandazole 2Vibramycin Oral Capsule 3Vibramycin Oral Suspension Reconstituted

3

Xepi 3 QLZithromax Oral Packet 3Zithromax Oral Suspension Reconstituted

3

Zithromax Oral Tablet 250 mg, 500 mg

3

Zithromax Oral Tablet 600 mg 3Zithromax Tri-Pak 3Zithromax Z-Pak 3

AntifungalsCiclodan 1Ciclopirox External Gel 1Ciclopirox External Shampoo 2Ciclopirox External Solution 1Cresemba Oral 3Diflucan Oral Suspension Reconstituted

3

Diflucan Oral Tablet 100 mg, 150 mg, 200 mg

3

Diflucan Oral Tablet 50 mg 3Extina 3 QLFluconazole Oral 1Gynazole-1 3Ketoconazole External Cream 1 QL

2020-2021 Prescription Drug List

5

Maricopa CountyPrescription Drug List

Page 8: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Ketoconazole External Foam 3 QLKetoconazole External Shampoo 1Nizoral 3Nyamyc 1Nystatin External 1Nystatin Mouth/Throat 1Nystop 1Terbinafine HCL Oral 1 QLTerconazole 1Xolegel 3

Antivirals /Hepatitis CAcyclovir Oral 1Baraclude Oral Solution 2 DSPCimduo 2 QLDescovy 3 ST, QLDovato 2 QLEntecavir 1 DSPEpclusa 2 PA, QL, DSPGenvoya 3 QLHarvoni Oral Tablet  2 PA, QL, DSPIsentress 2Isentress HD 2Juluca 2 QLLedipasvir-Sofosbuvir 2 PA, QL, DSPMavyret 2 PA, QL, DSPNorvir Oral Packet 2Norvir Oral Solution 2Odefsey 3 QLOseltamivir Phosphate Oral Capsule 2Oseltamivir Phosphate Oral Suspension Reconstituted

2 QL

Prezcobix 2Prezista 2Ritonavir 2Sofosbuvir-Velpatasvir 2 PA, QL, DSPStribild 3 QLSymfi 2 QLSymfi Lo 2 QLTenofovir Disoproxil Fumarate 2Tivicay 3Triumeq 2 QLTruvada 3 QLValacyclovir HCL Oral 1 QLVemlidy 3 ST, DSPViread Oral Powder 3

Drug NameDrug Tier

Requirement and Limits

Viread Oral Tablet 150 mg, 200 mg, 250 mg

2

Vosevi 2 PA, QL, DSPXofluza 3 QLZepatier 2 PA, QL, DSPZovirax Oral 3

AnxietyAfstyla Intravenous Kit  3 PA, DSPAlprazolam ER 1Alprazolam Intensol 1Alprazolam Oral 1Alprazolam XR 1Aranesp (Albumin Free) 2 QL, DSP

Blood DisordersBuspirone HCL Oral 1Clonazepam Oral 1Diazepam Intensol 1Diazepam Oral 1Eloctate 3 PA, DSPHydroxyzine HCL Oral 1Hydroxyzine Pamoate Oral 1Jivi 3 PA, DSPKogenate Fs 2 DSPKovaltry 2 DSPLorazepam Intensol 1Lorazepam Oral Concentrate 2 mg/mi 1Lorazepam Oral Tablet 1Mulpleta 2 PA, QL, DSPNeulasta 3 DSPNovoeight 2 DSPNuwiq 2 DSPRecombinate 3 PA, ST, DSPRetacrit 2 QL, DSPTriazolam 1Vistaril 3Zarxio 2 DSPBreast Cancer PreventionAnastrozole 1 PAromasin 3 PExemestane 2 PFareston 3 PLetrozole 1 PTamoxifen 2 PToremifene 2 P

6

Page 9: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

CancerAnastrozole Oral 1ERleada 2 PA, QL, DSPIbrance 2 PA, QL, DSPIdhifa 2 PA, QL, DSPImatinib Mesylate 1 PA, QL, DSPLetrozole Oral 1Lynparza 2 PA, QL, DSPMercaptopurine Oral 1Nubeqa 2 PA, QL, DSPPurixan 3 PA, DSPRevlimid 2 PA, QL, DSPTamoxifen Citrate Oral Tablet 10 mg 1Tamoxifen Citrate Oral Tablet 20 mg 1 H, PATargretin External 3 QL, DSPTargretin Oral 2 DSPTasigna 2 PA, ST, QL, DSPVerzenio 2 PA, QL, DSPXeloda 1 QL, DSPZejula 2 PA, QL, DSPZytiga 2 PA, QL, DSP

Cardiovascular/Heart Disease: Blood Clot/Platelet TherapyAggrenox 3 PArixtra 2 PAspirin-Dipyridamole 1 PBevyxxa 3 PBrilinta 3 QL, PCilostazol 1 PClopidogrel 1 PClopidogrel Bisulfate Oral 1Coumadin 3 PDipyridamole 1 PEliquis 2 PEnoxaparin 2 PFondaparinux 3 PFragmin 2 PHeparin 1 PJantoven 1 PPletal 1 PPradaxa 2 PPrasugrel 3 PSavaysa 3 PWarfarin 1 PXarelto 2 PZontivity 3 QL, P

Drug NameDrug Tier

Requirement and Limits

Cardiovascular/Heart Disease: Coagulation Therapy Bevyxxa 3 QLCoumadin 3Eliquis 2 QLEnoxaparin Sodium 2 QLJantoven 1Pradaxa 2 QLWarfarin Sodium Oral 1Xarelto 2 QL

Cardiovascular/Heart Disease: High Blood PressureAccupril 3 PAccuretic 3 PAcebutolol 1 PAcetazolamide ER 1Acetazolamide Oral 1Adalat Cc 3 PAfeditab 1 PAldactazide 3 PAldactone 3 PAliskiren 3 PAliskiren Fumarate Oral Tablet  3 QLAltace 3 PAmiloride 1 PAmiloride-Hydrochlorothiazide 1 PAmiodarone HCL Oral 1Amlodipine 1 PAmlodipine Besylate Oral 1Amlodipine Besylate-Benazepril HCL 1Amlodipine Besylate-Valsartan 2Amlodipine-Benazepril 1 PAmlodipine-Valsartan 2 PAtacand 3 PAtacand Hct 3 PAtenolol 1 PAtenolol Oral 1Atenolol-Chlorthalidone 1 PAtorvastatin Calcium Oral Tablet 10 mg, 20 mg

1 QL, H, PA

Atorvastatin Calcium Oral Tablet 40 mg, 80 mg

1 QL

Avalide 3 PAvapro 3 PBenazepril 3 PBenazepril HCL Oral 1Benazepril-Hydrochlorothiazide 1 PBetaxolol* 1 P

7

Maricopa CountyPrescription Drug List

Page 10: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Bidil 2 PBisoprolol 1 PBisoprolol Fumarate 1Bisoprolol-Hydrochlorothiazide 1 PBumetanide 1 PBystolic 2 PByvalson 2 PCalan 2 PCalan Sr 3 PCandesartan 3 PCandesartan-Hydrochlorothiazide 3 PCaptopril 1 PCaptopril-Hydrochlorothiazide 1 PCardura 3 PCarospir 3 PA, PCartia Xt 3 PCarvedilol 1 PCatapres 3 PCatapres TTS 3 PChlorothiazide 1 PChlorthalidone 1Clonidine 1 PClonidine HCL Oral 1Clonidine Patch 3 PCoreg 3 PCorgard 3 PCorlanor 3 PA, QLCorzide 3 PCozaar 3 PDemadex 3 PDilacor XR 3 PDilt XR 1 PDiltiazem 1 PDiltiazem ER 1 PDiltiazem HCL ER Coated Beads 2Diltiazem HCL ER Oral Capsule Extended Release 12 Hour

1

Diltiazem HCL Oral 1Dilt-XR 1Diuril 2 PDoxazosin 1 PDoxazosin Mesylate Oral 1Dyazide 3 PDyrenium 3 PEdarbi 3 PEdarbyclor 3 P

Drug NameDrug Tier

Requirement and Limits

Edecrin 3 PEnalapril 1 PEnalapril Maleate Oral 1Enalapril-Hydrochlorothiazide 1 PEpaned 3 PA, PEplerenone 2 PEprosartan 3 PEthacrynic Acid 3 PEzetimibe 2Ezetimibe-Simvastatin 3Felodipine ER 1 PFenofibrate Oral Tablet 160 mg, 54 mg 2Flecainide Acetate 1Flolipid 3 PAFosinopril 1 PFosinopril-Hydrochlorothiazide 1 PFurosemide 1 PFurosemide Oral 1Gemfibrozil Oral 1Guanfacine 2 PGuanfacine HCL 1Hydralazine 1 PHydralazine HCL Oral 1Hydrochlorothiazide 1 PHydrochlorothiazide Oral 1Hyzaar 3 PIndapamide 1 PInderal 2 PInnopran Xl 3 PInspra 3 PIrbesartan 1 PIrbesartan - Hydrochlorothiazide 1 PIrbesartan-Hydrochlorothiazide 1Isosorbide Mononitrate 1Isosorbide Mononitrate ER 1Isradipine 2 PKapspargo 3 PKapspargo Sprinkle 3Labetalol 1 PLabetalol HCL Oral 1Lasix 3 PLisinopril 2 PLisinopril Oral 1Lisinopril-Hydrochlorothiazide 1 PLopid 3Lopressor 1 P

8

Page 11: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Losartan Potassium 1Losartan Potassium-HCTZ 1Lotensin 1 PLotensin Hct 1 PLotrel 1 PLovastatin 1 HMatzim La 2 PMavik 1 PMaxzide 3 PMaxzide-25 3Methyclothiazide 1 PMethyldopa 1 PMethyldopa-Hydrochlorothiazide 1 PMetolazone 1 PMetoprolol Succinate 2 PMetoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg, 200 mg, 50 mg

2

Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 mg

1

Metoprolol Tartrate 1 PMetoprolol Tartrate Oral Tablet 100 mg, 25 mg, 50 mg

1

Metoprolol-Hydrochlorothiazide 1 PMicrozide 1 PMidamor 1 PMinipress 3 PMinitran 1Minoxidil 1 PMoexipril 1 PMoexipril-Hydrochlorothiazide 1 PMultaq 3 PANadolol 1 PNadolol Oral 1Nadolol-Bendroflumethazide 1 PNiacin (Antihyperlipidemic) 2Niacin ER (Antihyperlipidemic) 3Niacor 2Niaspan 2Nicardipine 1 PNifedipine 1 PNifedipine ER 1 PNifedipine ER Osmotic Release 1Nifedipine Oral 1Nimodipine 1 PNisoldipine 2 PNitro-Bid 2

Drug NameDrug Tier

Requirement and Limits

Nitro-Dur 3Nitroglycerin Sublingual 1Nitroglycerin Transdermal 1Nitromist 3 QLNitrostat 3Nitro-Time 1Olmesartan 2 POlmesartan Medoxomil Oral 2Olmesartan Medoxomil-HCTZ 2Olmesartan-Hydrochlorothiazide 2 POmega-3-Acid Ethyl Esters 3Pacerone Oral Tablet 100 mg, 400 mg 3Pacerone Oral Tablet 200 mg 1Perindopril 2 PPindolol 1 PPraluent Subcutaneous Solution Auto-Injector 75 mg/mi

2 PA, ST, QL

Praluent Subcutaneous Solution Pen-Injector 150 mg/mi, 75 mg/mi

2 PA, ST, QL

Pravachol 3Pravastatin Sodium 1Prazosin 1 PPrazosin HCL Oral 1Prinivil 3 PProcardia 3 PProcardia Xl 3 PPropranolol 1 PPropranolol HCL ER 2Propranolol HCL Oral 1Propranolol-Hydrochlorothiazide 1 PQbrelis 3 PAQuinapril 1 PQuinapril HCL 1Quinapril-Hydrochlorothiazide 1 PRamipril 1 PRanolazine ER 2Repatha 2 PA, ST, QLRepatha Pushtronex System 2 PA, ST, QLRepatha Sureclick 2 PA, ST, QLRosuvastatin Calcium 2 QLSimvastatin Oral Tablet 10 mg, 20 mg, 40 mg, 5 mg

1 H, PA

Simvastatin Oral Tablet 80 mg 1Sotalol HCL Oral 1Sotylize 3 PASpironolactone 1 PSpironolactone Oral 1

9

Maricopa CountyPrescription Drug List

Page 12: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Spironolactone-Hydrochlorothiazide 1 PSular 3 PTarka 3 PTaztia Xt 2 PTekturna 2 PTekturna Hct 3 QL, PTekturna Oral Tablet 3 QLTelmisartan 2 PTelmisartan-Hydrochlorothiazide 2 PTerazosin 1 PTiazac 1 PTimolol* 3 PToprol Xl 3 PTorsemide 2 PTrandolapril 3 PTrandolapril-Verapamil 3 PTriamterene 3 PTriamterene-Hctz 1Triamterene-Hydrochlorothiazide 1 PValsartan 2 PValsartan-Hydrochlorothiazide 1 PVascepa Oral Capsule 3 PAVerapamil 1 PVerapamil ER 3 PVerapamil HCL ER Oral Capsule Extended Release 24 Hour 100 mg, 200 mg, 300 mg

3

Verapamil HCL ER Oral Capsule Extended Release 24 Hour 120 mg, 180 mg, 240 mg, 360 mg

1

Verapamil HCL ER Oral Tablet Extended Release

1

Verapamil HCL Oral 1Verelan 3 PVerelan Pm 3 PWelchol 2Ziac 3 PZiac Oral Tablet 10-6.25 mg, 5-6.25 mg, 2.5-6.25 mg

3

Zocor Oral Tablet 10 mg, 20 mg, 40 mg, 80 mg

3

Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1 PCholestyramine 1 PCholestyramine Light 1 PColestid 3 PColestipol 1 P

Drug NameDrug Tier

Requirement and Limits

Ezetimibe 2 PFenofibrate 54, 160 mg Tablet 2 PFlolipid 3 PFluvastatin 1 PFluvastatin ER 3 PGemfibrozil 1 PLescol 3 PLopid 3 PLovastatin 1 PMevacor 1 PNiacin Extended-Release 3 PNiacor 2 PNiaspan 2 POmega-3 Acid Ethyl Esters 3 PPravachol 3 PPravastatin 1 PPrevalite 1 PQuestran 3 PQuestran Light 3 PRosuvastatin 2 PSimvastatin 1 PSimvastatin/Ezetimibe 3 PWelchol 2 PZocor 3 P

Central Nervous System: Attention Deficit DisorderAdderall XR 2 QLAmphetamine-Dextroamphetamine 1 PAAtomoxetine HCL 3 QLConcerta 2 PA, QLDexmethylphenidate HCL 1 PADexmethylphenidate HCL ER 3 PA, QLDextroamphetamine Sulfate ER 3 PA, QLDextroamphetamine Sulfate Oral Solution

1 PA

Dextroamphetamine Sulfate Oral Tablet

3 PA

Focalin 3 PAGuanfacine HCL ER 2 QLMetadate ER 3 PA, QLMethylin 3 PAMethylphenidate HCL ER (Cd) 2 PA, QLMethylphenidate HCL ER (La) Oral Capsule Extended Release 24 Hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

2 PA, QL

Methylphenidate HCL ER Oral Tablet Extended Release 10 mg, 20 mg

3 PA, QL

10

Page 13: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Methylphenidate HCL Oral Solution 1 PAMethylphenidate HCL Oral Tablet 1 PAMethylphenidate HCL Oral Tablet Chewable

3 PA

Procentra 3 PARitalin 3 PAVyvanse (Starting 7/1/2020) 3 PA, QLVyvanse (Until 7/1/2020) 2 PA, QL

Central Nervous System: DepressionAmitriptyline HCL Oral 1Bupropion HCL ER (Sr) 1Bupropion HCL ER (Xl) Oral Tablet Extended Release 24 Hour 150 mg, 300 mg

1

Bupropion HCL Oral 1Celexa 3 PCitalopram 1 PCitalopram Hydrobromide 1Desvenlafaxine Succinate ER 2 QLDoxepin HCL Oral Capsule 1Doxepin HCL Oral Concentrate 1Duloxetine HCL Oral Capsule Delayed Release Particles 20 mg, 30 mg, 60 mg

2 QL

Escitalopram 1 PEscitalopram Oxalate Oral Solution 3Escitalopram Oxalate Oral Tablet 1Fluoxetine 3 PFluoxetine 10 mg, 20 mg Tablets 3 PFluoxetine Capsules 1 PFluoxetine HCL Oral Capsule 1Fluoxetine HCL Oral Capsule Delayed Release

3 QL

Fluoxetine HCL Oral Solution 1Fluoxetine HCL Oral Tablet 10 mg 3 QLFluoxetine HCL Oral Tablet 20 mg 3Fluvoxamine 1 PFluvoxamine Extended-Release 3 PFluvoxamine Maleate 1Fluvoxamine Maleate ER 3 QLLexapro 3 PMirtazapine Oral 1Nortriptyline HCL Oral 1Pamelor 3Paroxetine 1 PParoxetine Extended-Release 3 PParoxetine HCL 1

Drug NameDrug Tier

Requirement and Limits

Paroxetine HCL ER 3 QLPaxil 3 PPaxil Cr 3 QL, PPaxil Oral Suspension 3Paxil Oral Tablet 3Pexeva 3 PProzac 3 PRemeron 3Remeron Soltab 3Sertraline 1 PSertraline HCL Oral 1Trazodone HCL Oral 1Trintellix 3 ST, QLVenlafaxine HCL 1Venlafaxine HCL ER Oral Capsule Extended Release 24 Hour

1

Viibryd 3 QLZoloft 3 P

Central Nervous System: Mental Health Aripiprazole 2 PAripiprazole Oral Solution 3Aripiprazole Oral Tablet 2 QLAripiprazole Oral Tablet Dispersible 2 QLChlorpromazine 1 PClozapine 1 PClozaril 1 PFanapt 3 PFazaclo 3 PFluphenazine 2 PHaloperidol 1 PLatuda 3 QL, PLoxapine 1 PMolindone 3 POlanzapine 1 POlanzapine Oral Tablet 1 QLOlanzapine Oral Tablet Dispersible 2 QLPaliperidone ER 3 PPerphenazine 1 PQuetiapine 1 PQuetiapine ER 3 PQuetiapine Fumarate 1Quetiapine Fumarate ER 3 QLRexulti 3 PRisperidone 1 PSaphris 3 QL, PThioridazine 1 P

11

Maricopa CountyPrescription Drug List

Page 14: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Thiothixene 1 PTrifluoperazine 1 PVraylar 3 PZiprasidone 2 PZiprasidone HCL 2 QL

Central Nervous System: MigraineAimovig 2 PA, ST, QLAmerge 3 QLEletriptan Hydrobromide 2 QLEmgality 2 PA, ST, QLNaratriptan HCL 1 QLRizatriptan Benzoate 1 QLSumatriptan Succinate Oral 1 QLSumatriptan Succinate Subcutaneous 1 QLCentral Nervous System: Multiple SclerosisAubagio 3 PA, QL, DSP, PAvonex 2 PAvonex Pen 2 PA, QL, DSPAvonex Prefilled 2 PA, QL, DSPBetaseron 2 PA, QL, DSP, PDalfampridine ER 2 PA, QL, DSPGilenya 3 PGilenya Oral Capsule  3 PA, QL, DSPGlatiramer Acetate 2 PA, QL, DSPGlatiramer Acetate [Mylan Only (Generic Copaxone)]

2 P

Mavenclad  3 PA, ST, QL, DSPMayzent 3 PA, QL, DSPPlegridy 3 PA, QL, DSP, PRebif 3 PA, ST, QL, DSP, PRebif Rebidose 3 PA, ST, QL, DSPTecfidera 2 PA, QL, DSP, P

Central Nervous System: OtherAricept Oral Tablet 10 mg, 5 mg 3Austedo 2 PA, QL, DSPBuprenorphine HCL Sublingual 1 QLBuprenorphine HCL-Naloxone HCL 2 QLCarbidopa-Levodopa 1Carbidopa-Levodopa ER 1Chantix 3 PA, HChantix Continuing Month Pak 3 PA, HChantix Starting Month Pak 3 PA, HDonepezil HCL Oral Tablet 10 mg, 5 mg 1Donepezil HCL Oral Tablet Dispersible 1

Drug NameDrug Tier

Requirement and Limits

Duopa 3 PAInbrija 3 PA, QL, DSPLithium Carbonate ER 1Lithium Carbonate Oral 1Lithobid 3Mirapex 3Naloxone HCL Injection 1Naltrexone HCL Oral 1Narcan 2 QLNuedexta 2 PAPramipexole Dihydrochloride 1Pregabalin Oral Capsule 2 QLPregabalin Oral Solution 3 QLRilutek 3 DSPRiluzole 1 DSPRopinirole HCL 1Sinemet 3Sinemet Cr 3Tiglutik 3 PAZubsolv 2 QL

Central Nervous System: Sedatives/Hypnotics Eszopiclone 2 QLModafinil 2 PA, QLRestoril 3Sunosi 3 PA, QLTemazepam 1Wakix 3 PA, QL, DSPXyrem 3 PA, QL, DSPZolpidem Tartrate Oral 1 QL

Central Nervous System: Seizure DisordersCarbamazepine ER Oral Capsule Extended Release 12 Hour

2

Carbamazepine ER Oral Tablet Extended Release 12 Hour

3

Carbamazepine Oral 1Carbatrol 3Depakote 3 PADepakote ER 3 PA, STDepakote Sprinkles 3 PA, STDivalproex Sodium ER 2Divalproex Sodium Oral Capsule Delayed Release Sprinkle

2

Divalproex Sodium Oral Tablet Delayed Release

1

Epitol 1

12

Page 15: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Gabapentin Oral Capsule 1Gabapentin Oral Solution 250 mg/5ml 1Gabapentin Oral Tablet 1Keppra Oral 3 PA, STKeppra XR 3 PA, STLamictal 3 PA, STLamictal Odt Oral Tablet Dispersible

3 PA, ST

Lamictal XR 3 PA, STLamotrigine ER 3 PA, STLamotrigine Oral Tablet 1Lamotrigine Oral Tablet Chewable 1Lamotrigine Oral Tablet Dispersible 3 PA, STLevetiracetam ER 2Levetiracetam Oral 1Neurontin 3 PA, STOxcarbazepine 1Roweepra 1Roweepra XR 2Tegretol 3Tegretol-XR 3Topamax 3 PA, STTopiramate Oral 1Trileptal 3 PA, STVimpat Oral 3 PAZonegran 3 PA, STZonisamide Oral 1

Drugs for Mouth and Throat ConditionsCavarest 1Chlorhexidine Gluconate Mouth/Throat

1

Clinpro 5000 1Denta 5000 Plus 1Dentagel 1Fluoridex 1Fluoridex Enhanced Whitening 1Lidocaine HCL Mouth/Throat 1Lidocaine Viscous Mouth/Throat Solution 2%

1

Nafrinse Daily/Neutral 2Nafrinse Weekly 3Neutral Sodium Fluoride 1Paroex 1Peridex 3Periogard 1

Drug NameDrug Tier

Requirement and Limits

Prevident 5000 Booster Plus 3Prevident 5000 Dry Mouth 3Prevident 5000 Ortho Defense 3Prevident 5000 Plus 3Prevident Dental 3Prevident Mouth/Throat 3SF 1SF 5000 Plus 1Sodium Fluoride 5000 Plus 1Sodium Fluoride Dental 1

DermatologyAczone 3 QLAla Scalp 3Ala-Cort External Cream 2.5% 1Aldara 3 QLAmnesteem 2Avar Cleanser 1Azelaic Acid External 3Betamethasone Dipropionate Aug External Cream

1

Betamethasone Dipropionate Aug External Gel

1

Betamethasone Dipropionate Aug External Lotion

3

Betamethasone Dipropionate Aug External Ointment

3

Betamethasone Dipropionate External Cream

2

Betamethasone Dipropionate External Lotion

1

Betamethasone Dipropionate External Ointment

2

BP 10-1 1Calcipotriene-Betameth Diprop 3 QLCalcitriol External 1 QLCapex 2Carac 2Claravis 2Cleocin-T External Gel 3 QLCleocin-T External Lotion 3Clindacin Etz External Swab 1Clindacin-P 1Clindamycin Phos-Benzoyl Perox External Gel 1.2-5%

3 QL

Clindamycin Phosphate External Foam 3Clindamycin Phosphate External Lotion 3

13

Maricopa CountyPrescription Drug List

Page 16: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Clindamycin Phosphate External Solution 1 QLClindamycin Phosphate External Swab 1Clindamycin Phosphate Gel 1% External 3 QLClobetasol Propionate External Cream 2 QLClobetasol Propionate External Gel 2 QLClobetasol Propionate External Liquid 1 QLClobetasol Propionate External Ointment 2 QLClobetasol Propionate External Solution 1 QLClotrimazole-Betamethasone External Cream

1 QL

Clotrimazole-Betamethasone External Lotion

1

Derma-Smoothe/Fs Body 3 QLDerma-Smoothe/Fs Scalp 3Desonate 3 ST, QLDesonide External 3 QLDesowen 3 QLDiprolene 3Diprolene Af 3Dupixent 3 PA, ST, QL, DSPEfudex 3Elocon 3Enstilar 3 QLEucrisa 3 ST, QLEvoclin 3Finacea 3Fluocinolone Acetonide Body 3 QLFluocinolone Acetonide External Cream 3 QLFluocinolone Acetonide External Ointment

2 QL

Fluocinolone Acetonide External Solution

3 QL

Fluocinolone Acetonide Scalp 3Fluocinonide External Cream 0.05% 1Fluocinonide External Gel 1Fluocinonide External Ointment 1Fluocinonide External Solution 1Fluoroplex 3Fluorouracil External Cream 0.5% 3Fluorouracil External Cream 5% 1Fluorouracil External Solution 1Hydrocortisone External Cream 2.5% 1Hydrocortisone External Lotion 2.5% 1Hydrocortisone External Ointment 1%, 2.5%

1

Imiquimod External 1 QLIsotretinoin Oral 2

Drug NameDrug Tier

Requirement and Limits

Lotrisone 3 QLMetrocream 3Metrolotion 3Metronidazole External Cream 1Metronidazole External Gel 0.75% 1Metronidazole External Lotion 1Mirvaso 3 QLMometasone Furoate External 1Myorisan 2Neuac External Gel 3 QLPicato 3 QLRosadan External Cream 1Rosadan External Gel 1SSS 10-5 1Sulfacetamide Sodium-Sulfur External Cream 10-2%, 10-5%

1

Sulfacetamide Sodium-Sulfur External Emulsion

1

Sulfacetamide Sodium-Sulfur External Liquid 9-4%, 9-4.5%

1

Sulfacetamide Sodium-Sulfur External Lotion 10-5%

1

Sulfacetamide Sodium-Sulfur External Pad

1

Sulfacetamide Sodium-Sulfur External Suspension 10-5%

1

Sulfamez Wash 1Sumaxin 3Sumaxin Wash 3Taclonex External Suspension 3 QLTazorac 3 PA, QLTemovate 3 QLTexacort 2Tretinoin Cream 0.025% External 3 PA, QLTretinoin External Cream 0.05%, 0.1% 3 PA, QLTriamcinolone Acetonide External Aerosol Solution

2 QL

Triamcinolone Acetonide External Cream 0.025%, 0.1%

1

Triamcinolone Acetonide External Cream 0.5%

1 QL

Triamcinolone Acetonide External Lotion 1Triamcinolone Acetonide External Ointment 0.025%, 0.1%, 0.5%

1

Triderm External Cream 0.1% 1Triderm External Cream 0.5% 1 QLTridesilon 3 QLZenatane 2

14

Page 17: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Diabetes: Blood Glucose MonitoringBd Autoshield Duo Pen Needles 2Bd Ultra-Fine Insulin Syringes 2Bd Ultra-Fine Pen Needles 2Contour Next Ez Meters 2 PContour Next Meters 2 PContour Next Monitor 2Contour Next One Meters 2 PContour Next Test Strips 2 QL, PDexcom G4 / G5 / G6 Receiver, Transmitter, Sensor (Including Platinum, Platinum Pediatric)

3 PA, QL

Dexcom G4 / G5 / G6 Receiver, Transmitter, Sensor (Including Platinum, Platinum Pediatric) Device

3 PA, QL

Diabetic Testing - Lancets 3 PEasyplus Blood Glucose Test 3 QLFastclix 1Freestyle Libre 14 Day Reader 3 PA, QLFreestyle Libre 14 Day Sensor 3 PA, QLFreestyle Libre Reader 3 PA, QLFreestyle Libre Sensor System 3 PA, QLInsulin Needles/Syringes 2 PInsulin Syringes 2Novofine Autocover Pen Needle 2Novofine Pen Needle 2Novofine Plus Pen Needle 2One Touch Verio Kit W/Device 1Onetouch Diabetic Meters 1 POnetouch Diabetic Test Strips 1 POnetouch Ultra 2 1Onetouch Ultra Blue Test Strips 1 QLOnetouch Ultra Mini 1Onetouch Verio Flex System Kit W/Device

1

Onetouch Verio IQ System 1Onetouch Verio Sync System Kit W/Device

1

Onetouch Verio Test Strips 1 QLSoft Touch 1Softclix 1

Diabetes: InsulinHumalog 2 PHumalog Junior 2 PHumalog Kwikpen 2 QLHumalog Mix 50/50 2 P

Drug NameDrug Tier

Requirement and Limits

Humalog Mix 50/50 Kwikpen 2 QLHumalog Mix 50/50 Vial 1 QLHumalog Mix 75/25 2 PHumalog Mix 75/25 Kwikpen 2 QLHumalog Mix 75/25 Vial 1 QLHumalog Subcutaneous Solution 1 QLHumalog Subcutaneous Solution Cartridge

2 QL

Humalog U-100 Junior Kwikpen 2 QLHumulin 50/50 2 PHumulin 70/30 2 PHumulin 70/30 Kwikpen 2 QLHumulin 70/30 Vial 1 QLHumulin N 2 PHumulin N Kwikpen 2 QLHumulin N Vial 1 QLHumulin R 2 PHumulin R U-500 Kwikpen 2 QLHumulin R U-500 Vial (Concentrated) 1 QLHumulin R Vial 1 QLLantus 1 PLantus Solostar 1 QLLantus U-100 Vial 1 QLSoliqua 2 PToujeo 2 PToujeo Max Solostar 2 QLToujeo Solostar 2 QL

Diabetes: Non-InsulinAcarbose 1 PActoplus Met 3 PActoplus Met XR 3 PAdlyxin 3 ST, QL, PAmaryl 3 PAvandia 3 PBaqsimi One Pack 2 QLBaqsimi Two Pack 2 QLBydureon 2 ST, QL, PBydureon Bcise 2 PBydureon Bcise Autoinjector 2 ST, QLByetta 2 PByetta 10 mcg Pen 2 ST, QLByetta 5 mcg Pen 2 ST, QLCycloset 3 PDuetact 3 PGlimepiride 1 P

15

Maricopa CountyPrescription Drug List

Page 18: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Glipizide 1 PGlipizide ER 1 PGlipizide Ir 1Glipizide Xl 1Glipizide-Metformin 1 PGlucagon Emergency Injection Kit 2 QLGlucophage 3 PGlucophage XR 3 PA, PGlucotrol 3 PGlucotrol Xl 3 PGlucovance 3 PGlucovance Oral Tablet 5-500 mg 3Glyburide 3 PGlyburide Micronized 1 PGlyburide Oral 1Glyburide-Metformin 1 PGlynase 3 PGlyset 3 PGlyxambi 2 ST, QL, PGvoke Pfs 2 QLInvokamet 2 QL, PInvokamet XR 2 QL, PInvokana 2 ST, QL, PJardiance 2 ST, QL, PJentadueto 2 QL, PJentadueto XR 2 QL, PKazano 2 QL, PKombiglyze XR 2 QL, PMetformin 3 PMetformin ER (Generic Glucophage XR) 1 PMetformin HCL ER 1Metformin HCL Oral Solution 3Metformin HCL Oral Tablet 1Miglitol 2 PNateglinide 1 PNesina 2 QL, POnglyza 2 QL, POseni 2 QL, POzempic 2 ST, QL, PPioglitazone 1 PPioglitazone HCL 1 QLPioglitazone-Glimepiride 1 PPioglitazone-Metformin 2 PPrandin 3 PPrecose 3 PRepaglinide 2 P

Drug NameDrug Tier

Requirement and Limits

Repaglinide-Metformin 3 PRiomet 3 PRybelsus 2 ST, QL, PSoliqua 2 QLStarlix 3 PSymlinpen 3 PSynjardy 2 QL, PSynjardy XR 2 QL, PTolbutamide 1 PTradjenta 2 QL, PTrulicity 2 ST, QL, PVictoza 2 PVictoza Solution Pen-Injector 18 mg/3ml Subcutaneous (2 Pak)

2 ST, QL

Victoza Solution Pen-Injector 18 mg/3ml Subcutaneous (3 Pak)

3 ST, QL

Endocrine: Growth HormoneCabergoline 2Ddavp Injection 3Ddavp Oral 3Desmopressin Acetate Injection 1Desmopressin Acetate Oral 1Nocdurna 3 PA, QLNutropin AQ Nuspin 10 2 PA, QL, DSPNutropin AQ Nuspin 20 2 PA, QL, DSPNutropin AQ Nuspin 5 2 PA, QL, DSPOrilissa 3 PA, QLStimate 3

Endocrine: OtherAndroderm 2 PA, QLCortef 3Depo-Testosterone Intramuscular Solution 100 mg/mi

3

Depo-Testosterone Intramuscular Solution 200 mg/mi

3

Dexamethasone Intensol 1Dexamethasone Oral Elixir 1Dexamethasone Oral Solution 1Dexamethasone Oral Tablet 1Hydrocortisone Oral 1Medrol Oral Tablet 16 mg, 32 mg, 4 mg, 8 mg

3

Medrol Oral Tablet 2 mg 2Methylprednisolone Oral 1Millipred 2

16

Page 19: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Millipred DP 2Orapred ODT 3Pediapred 2Prednisolone Oral Solution 1Prednisolone Sodium Phosphate Oral 1Prednisone Intensol 1Prednisone Oral 1Striant 3 PA, QLTestim 2 PA, QLTestosterone Cypionate Injection 3Testosterone Cypionate Intramuscular 1Testosterone Enanthate Intramuscular 1

Endocrine: Thyroid Hormone ReplacementArmour Thyroid 3Euthyrox 1Levo-T 1Levothyroxine Sodium Oral 1Levothyroxine-Liothyronine Oral Tablet 30 mg, 60 mg, 90 mg

1

Levoxyl 2Liothyronine Sodium Oral 2Methimazole Oral 1Nature-Throid 3NP Thyroid 1Synthroid 2Tapazole 3Thyroid Oral Tablet 120 mg, 15 mg 1Tirosint-Sol 3 PAUnithroid 1Westhroid 3WP Thyroid 3

Eye Conditions: Allergies, Antibiotics and OthersAcular 3Acular LS 3Alrex 3 QLAzasite 3Azelastine HCL Ophthalmic 1Besivance 3Ciloxan Ophthalmic Ointment 3Ciloxan Ophthalmic Solution 3Ciprofloxacin HCL Ophthalmic 1ERythromycin Ophthalmic 1 HInveltys 3Ketorolac Tromethamine Ophthalmic 1

Drug NameDrug Tier

Requirement and Limits

Lastacaft 3 QLLotemax Ophthalmic Ointment 3Lotemax Ophthalmic Suspension 3 QLLotemax SM 3 QLLoteprednol Etabonate 3 QLMaxitrol 3Moxeza 3Moxifloxacin HCL Ophthalmic 3Neomycin-Polymyxin-Dexameth Ophthalmic Ointment

1

Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 3.5-10000-0.1

1

Nevanac 3Ocuflox 3Ofloxacin Ophthalmic 1Olopatadine HCL Ophthalmic Solution 0.1%

3 QL

Polymyxin B-Trimethoprim 1Polytrim 3Pred Forte 3Pred Mild 3Prednisolone Acetate Ophthalmic 1Restasis 3 PA, QLTobradex Ophthalmic Ointment 3Tobradex Ophthalmic Suspension 3Tobramycin Ophthalmic 1Tobramycin-Dexamethasone 2Tobrex Ophthalmic Ointment 3Tobrex Ophthalmic Solution 3Xiidra 3 PA, QL

Eye Conditions: GlaucomaAlphagan P Ophthalmic Solution 0.1%

2 QL

Alphagan P Ophthalmic Solution 0.15%

3 QL

Azopt 2 QLBetimol 2 QLBrimonidine Tartrate Ophthalmic Solution 0.15%

2 QL

Brimonidine Tartrate Ophthalmic Solution 0.2%

1

Combigan 2 QLCosopt 3Dorzolamide HCL-Timolol Mal 2Istalol 3Latanoprost Ophthalmic 1

17

Maricopa CountyPrescription Drug List

Page 20: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Lumigan 2Rhopressa 3 QLRocklatan 3 QLTimolol Maleate Ophthalmic Gel Forming Solution

1

Timolol Maleate Ophthalmic Solution 0.25%, 0.5%

1

Timolol Maleate Ophthalmic Solution 0.5% (Daily)

3

Timoptic 3Timoptic Ocudose 2Timoptic-XE 3Travatan Z 3 QLTravoprost (Bak Free) 2 QLXelpros 3 QL

Gastrointestinal: Acid SuppressionCarafate Oral Suspension 3Carafate Oral Tablet 3Cytotec 3Dexilant 3 QLMisoprostol Oral 1Omeclamox-Pak 3 QLOmeprazole Oral Capsule Delayed Release

1

Pantoprazole Sodium Tablet Delayed Release 20 mg, 40 mg Oral

1

Pylera 3 QLRabeprazole Sodium Oral Tablet Delayed Release

2 QL

Ranitidine HCL Oral Syrup 1Sucralfate Oral Tablet 1

Gastrointestinal: Nausea/VomitingCerdelga 2 PA, DSPCreon 2Endari 3 PA, QLMetoclopramide HCL Oral Solution 5 mg/5ml

1

Metoclopramide HCL Oral Tablet 1Nityr 2 PA, DSPOndansetron HCL Oral 1Ondansetron ODT 1Pancreaze 3 STPertzye 3 STPhenadoz 1Prochlorperazine Maleate Oral 1

Drug NameDrug Tier

Requirement and Limits

Promethazine HCL Oral Syrup 1Promethazine HCL Oral Tablet 1Promethazine HCL Rectal 1Promethegan 1Reglan 3Scopolamine 3Strensiq 2 PA, QL, DSPTegsedi 2 PA, QL, DSPTransderm Scop (1.5 mg) 3Varubi 2 QLViokace 3 STZenpep 2Zofran 3

Gastrointestinal: OtherActigall 3Anaspaz 2Apriso 2Azulfidine 3Azulfidine En-Tabs 3Budesonide Oral 2Clenpiq 3Colyte With Flavor Packs 3Cortifoam 2Dicyclomine HCL Oral 1Dipentum 3Diphenoxylate-Atropine 1Ed-Spaz 1Gavilyte-C 1 HGolytely Oral Solution Reconstituted 227.1 Gm

2 QL

Golytely Oral Solution Reconstituted 236 Gm

3 QL

Hydrocortisone Ace-Pramoxine 1Hyoscyamine Sulfate ER 1Hyoscyamine Sulfate Oral 1Hyoscyamine Sulfate SL 1Hyoscyamine Sulfate Sublingual 1Hyosyne 1Levbid 3Levsin Oral 3Levsin/SL 3Lialda 2Linzess 2 PA, QLLomotil 3Mesalamine Rectal Enema 1

18

Page 21: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Mesalamine Rectal Suppository 2Motegrity 3 PA, QLMoviprep 3 QLNulev 3Oscimin 1Oscimin Sr 1Peg-3350/Electrolytes 1 QL, HPlenvu 3Prepopik 3 QLProctofoam HC 2Sfrowasa 3Sulfasalazine Oral 1Suprep Bowel Prep Kit 3 QLSymax Duotab 3Symax-SL 1Symax-SR 1Symproic 2 PA, QLUceris Oral 3Uceris Rectal 2Urso 250 3Urso Forte 3Ursodiol Oral 1Viberzi 3 PA, QLZelnorm 3 PA, QL

Genitourinary: Prostate ConditionsAlfuzosin HCL ER 1Finasteride Oral Tablet 5 mg 1Proscar 3Tamsulosin HCL 1Terazosin HCL 1Uroxatral 3

GoutAllopurinol Oral 1Febuxostat 3 ST, QLMitigare 2Zyloprim 3

HIV / AidsAbacavir 1 PAbacavir-Lamivudine 2 PAbacavir-Lamivudine-Zidovudine 1 PAptivus 2 PAtazanavir 2 PBiktarvy 3 P

Drug NameDrug Tier

Requirement and Limits

Cimduo 2 PCombivir 3 PComplera 3 PCrixivan 2 PDelstrigo 2 PDescovy 3 PDidanosine 1 PDovato 2 PEdurant 2 PEfavirenz 2 PEmtriva 2 PEpivir 3 PEvotaz 2 PFosamprenavir 2 PFuzeon 2 PGenvoya 3 PInvirase 2 PIsentress 2 PIsentress HD 2 PJuluca 2 PKaletra 3 PLamivudine 1 PLamivudine-Zidovudine 1 PLexiva 3 PNevirapine 1 POdefsey 3 PPifeltro 3 PPrezcobix 2 PPrezista 2 PRescriptor 2 PRetrovir 3 PRitonavir 2 PSelzentry 2 PStavudine 1 PStribild 3 PSustiva 3 PSymfi 2 PSymfi Lo 2 PTenofovir 2 PTivicay 3 PTriumeq 2 PTrizivir 3 PTruvada 2 PVidex 3 PVidex EC 3 PViracept 2 P

19

Maricopa CountyPrescription Drug List

Page 22: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Zerit 3 PZiagen 3 PZidovudine 3 P

InfertilityChorionic Gonadotropin Intramuscular 3 DSPCrinone Vaginal Gel 4% 3 PA, STCrinone Vaginal Gel 8% 3 PA, STEndometrin 2 PAFollistim AQ 2 DSPGanirelix Acetate Solution Prefilled Syringe 250 mcg/0.5ml Subcutaneous (Ferring)

3 DSP

Ganirelix Acetate Solution Prefilled Syringe 250 mcg/0.5ml Subcutaneous (Merck/Organon)

2 DSP

Gonal-F 3 DSP, STGonal-F RFF 3 DSP, STNovarel Intramuscular Solution Reconstituted 5000 Unit

3 DSP

Ovidrel 3 DSPPregnyl 1 DSP

Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra Actpen 3 PA, ST, QL, DSPActemra Subcutaneous 3 PA, ST, QL, DSPAzasan 3Azathioprine Oral 1Cimzia Prefilled Kit 2 PA, QL, DSPCosentyx (300 mg Dose) 3 PA, ST, QL, DSPCosentyx 150 mg/Ml 3 PA, ST, QL, DSPCosentyx Sensoready (300 mg) 3 PA, ST, QL, DSPCosentyx Sensoready Pen 3 PA, ST, QL, DSPCyclosporine Modified 1Enbrel 3 PA, ST, QL, DSPEnbrel Mini 3 PA, ST, QL, DSPEnbrel Sureclick 3 PA, ST, QL, DSPFirazyr 3 PA, QL, DSPGengraf 1Haegarda 2 PA, QL, DSPHumira 2 PA, QL, DSPHumira Pen 2 PA, QL, DSPMethotrexate Oral 1Methotrexate Sodium Oral 1Mycophenolate Mofetil 1Mycophenolate Sodium 2

Drug NameDrug Tier

Requirement and Limits

Olumiant Oral Tablet 2 PA, QL, DSPOrencia 3 PA, QL, DSPOtezla 2 PA, QL, DSPPrograf Oral Packet 3Rapamune Oral Solution 3Rasuvo 3 ST, QLRinvoq 2 PA, QL, DSPRuconest 3 PA, QL, DSPSimponi 2 PA, QL, DSPSirolimus Oral Solution 2Sirolimus Oral Tablet 1Skyrizi (150 mg Dose) 2 PA, QL, DSPStelara Subcutaneous Solution 2 PA, QL, DSPStelara Subcutaneous Solution Prefilled Syringe

2 PA, QL, DSP

Tacrolimus Oral 1Takhzyro 2 PA, QL, DSPTremfya 2 PA, QL, DSPTrexall 2Xeljanz 2 PA, ST, QL, DSPXeljanz XR 2 PA, ST, QL, DSP

MiscellaneousAddyi 3 PA, QLImvexxy Maintenance Pack 3 QLIntrarosa 3 QLOsphena 3 PA, QLSildenafil Citrate Oral Tablet 100 mg, 25 mg, 50 mg

2 QL

Stendra 3 PA, QLTadalafil Oral Tablet 10 mg, 20 mg 2 QLTadalafil Oral Tablet 2.5 mg, 5 mg 2 ST, QLVyleesi 3 PA, QL

Musculoskeletal: Muscle SpasmsBaclofen Oral 1Carisoprodol Oral Tablet 350 mg 1Cyclobenzaprine HCL Oral 1Fexmid 3Metaxalone 3Methocarbamol Oral 1Robaxin-750 3Soma Oral Tablet 350 mg 3Tizanidine HCL Oral Capsule 3Tizanidine HCL Oral Tablet 1Zanaflex 3

20

Page 23: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Musculoskeletal: OsteoporosisActonel 3 PAlendronate 1 PAlendronate Sodium 1Boniva 3 PBoniva Oral 3Calcitonin (Salmon) 2 PCalcitriol Oral 1Didronel 2 PEtidronate 1 PForteo 3 PA, DSP, PFosamax 3 PFosamax Plus D 3 PIbandronate 2 PIbandronate Sodium Oral 2Miacalcin 1 PRaloxifene 2 PRisedronate 1 PRocaltrol 3Tymlos 3 PA, DSP, P

Musculoskeletal: Pain ReliefAcetaminophen-Codeine 1Acetaminophen-Codeine #2 1Acetaminophen-Codeine #3 1Acetaminophen-Codeine #4 1Apap-Caff-Dihydrocodeine 3 QLBelbuca 3 PA, QLButalbital-Apap-Caffeine Oral Capsule 50-300-40 mg

3 QL

Butalbital-Apap-Caffeine Oral Capsule 50-325-40 mg

1 QL

Butalbital-Apap-Caffeine Oral Tablet 1 QLCelecoxib Oral 2 QLDiclofenac Potassium 1Diclofenac Sodium ER 1Diclofenac Sodium Oral 1Diclofenac Sodium Transdermal Gel 1% 2Dilaudid Oral 3EC-Naprosyn 3EC-Naproxen 1Endocet 1Esgic 3 QLEtodolac 1Etodolac ER 1

Drug NameDrug Tier

Requirement and Limits

Fentanyl Transdermal Patch 72 Hour 100 mcg/Hr, 12 mcg/Hr, 25 mcg/Hr, 50 mcg/Hr, 75 mcg/Hr

2 PA, QL

Fioricet 3 QLHydrocodone-Acetaminophen Oral Solution 10-325 mg/15ml

1

Hydrocodone-Acetaminophen Oral Solution 7.5-325 mg/15ml

2

Hydrocodone-Acetaminophen Oral Tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1

Hydromorphone HCL ER 3 PA, ST, QLHydromorphone HCL Oral 1Hydromorphone HCL Rectal 1Ibu 1Ibuprofen Oral Tablet 400 mg, 600 mg, 800 mg

1

Indocin 3Indomethacin ER 1Indomethacin Oral 1Ketorolac Tromethamine Oral 1Lidocaine External Ointment 2 QLLidocaine External Patch 3 PA, QLLidocaine-Prilocaine External Cream 1Lorcet 1Lorcet HD 1Lorcet Plus 1Lortab 3Meloxicam Oral 1Mobic 3Morphine Sulfate (Concentrate) Oral Solution 100 mg/5ml, 20 mg/mi

1

Morphine Sulfate ER Oral Tablet Extended Release

1 PA, QL

Morphine Sulfate Oral 1Morphine Sulfate Rectal 1MS Contin 3 PA, ST, QLNabumetone Oral 1Naprosyn Oral Suspension 3 PANaproxen DR 1Naproxen Oral Suspension 1 PANaproxen Oral Tablet 1Naproxen Sodium Oral Tablet 275 mg, 550 mg

1

Norco 3Nucynta 3 QLNucynta ER 3 PA, QL, STOxycodone HCL Oral Capsule 1

21

Maricopa CountyPrescription Drug List

Page 24: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Oxycodone HCL Oral Concentrate 100 mg/5ml

1

Oxycodone HCL Oral Solution 1Oxycodone HCL Oral Tablet 1Oxycodone-Acetaminophen 1Premium Lidocaine 2 QLRoxicodone Oral Tablet 15 mg, 30 mg 3Roxicodone Oral Tablet 5 mg 3Sprix 3Tramadol HCL ER Oral Capsule Extended Release 24 Hour 150 mg

1 QL

Tramadol HCL ER Oral Tablet Extended Release 24 Hour

2 QL

Tramadol HCL LR 1Trezix 3 QLTylenol With Codeine #3 3Tylenol With Codeine #4 3Ultram 3Vanatol LQ 2 PA, QLVanatol S 2 PA, QLVoltaren 1% Gel 2Xtampza ER 2 PA, QLZebutal 1 QLZohydro ER 3 PA, ST, QL

Overactive BladderAuryxia 3Cuprimine 3 DSPD-Penamine 2 DSPDepen Titratabs 2 DSPDitropan XL 3Oxybutynin Chloride ER 2Oxybutynin Chloride Oral 1Penicillamine Oral 3 DSPPhenazo Oral Tablet 200 mg 1Phenazopyridine HCL Oral Tablet 100 mg, 200 mg

1

Pyridium 3Toviaz 3Velphoro 2

Parkinson’s DiseaseCarbidopa-Levodopa 1Carbidopa-Levodopa ER 1Duopa 3 PAInbrija 3 PA, QL, DSPMirapex 3

Drug NameDrug Tier

Requirement and Limits

Pramipexole Dihydrochloride 1Ropinirole HCL 1Sinemet 3Sinemet CR 3

Respiratory: AllergiesAzelastine HCL Nasal Solution 0.1%, 137 mcg/Spray

3

Benzonatate Oral Capsule 100 mg, 200 mg

1

Bromfed DM 1Cyproheptadine HCL Oral 1Fluticasone Propionate Nasal 2 QLGuaifenesin-Codeine Soln 100-10 mg/5ml

1

Hydrocodone Polst-Cpm Polst ER 3 PA, QLIpratropium Bromide Nasal 1Levocetirizine Dihydrochloride Oral Solution

3

Levocetirizine Dihydrochloride Oral Tablet

1

Promethazine-Codeine 1 PA, QLPromethazine-DM 1Pseudoephedrine-Bromphen-DM 1Tessalon Perles 3Tussicaps 3 PA, QLZetonna 3 QL

Respiratory: AnaphylaxisAzelastine HCL Nasal Solution 0.1%, 137 mcg/Spray

3

Benzonatate Oral Capsule 100 mg, 200 mg

1

Bethkis 2 PA, QL, DSPEpinephrine Solution Auto-Injector 0.15 mg/0.3ml Injection (Generic Epipen Jr.)

2 QL

Epinephrine Solution Auto-Injector 0.3 mg/0.3ml Injection (Generic Epipen)

2 QL

Pulmozyme 2 PA, QL, DSPSymjepi 2 QLTobi Podhaler 3 PA, QL, DSP

Respiratory: Asthma / COPDAccolate 3 PAccuneb 3 PAdvair Diskus 3 QL, PAdvair HFA 3 QL, P

22

Page 25: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Albuterol HFA (Proair Hfa, Proventil HFA Authorized Generic)

3 P

Albuterol Nebulized Solution 1 PAlbuterol Oral Tablet 1 PAlbuterol Sulfate ER 1Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg/act Inhalation (Generic Proair HFA Or Proventil HFA)

3 QL

Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3ml) 0.083%, (5 mg/Ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

1

Albuterol Sulfate Oral 1Alvesco 1 QL, PAnoro Ellipta 3 QL, PArcapta Neohaler 3 QL, PArnuity Ellipta 3 QLAsmanex HFA 1 QL, PAsmanex Twisthaler 1 QL, PAtrovent HFA 3 QL, PBevespi Aerosphere 2 QL, PBreo Ellipta 3 QL, RS, PBrovana 3 PBudesonide Inhalation 2 QLBudesonide Nebulized Solution 2 PCombivent Respimat 3 QL, PCromolyn 1 PDaliresp 3 PElixophyllin 3 PFasenra 3 PA, QL, DSPFasenra Pen 3 PA, DSPFlovent Diskus 3 QLFlovent HFA 3 QLFluticasone/Salmeterol Respiclick 2 PFluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act

2 QL

Gastrocrom 3 PIncruse Ellipta 2 QL, PIpratropium 1 PIpratropium/Albuterol 2 PIpratropium-Albuterol 2Levalbuterol HFA 3 PLevalbuterol HFA Inhalation Aerosol 45 mcg/act

3 QL

Levalbuterol Nebulized Solution  3 PMetaproterenol 1 P

Drug NameDrug Tier

Requirement and Limits

Montelukast 1 PMontelukast Sodium Oral Packet 2Montelukast Sodium Oral Tablet 1Montelukast Sodium Oral Tablet Chewable

1

Nucala 3 PA, QL, DSPPerforomist 3 QL, PProair HFA 3 QL, PProair Respiclick 3 QL, PProventil HFA 3 QL, PPulmicort Flexhaler 3 QL, STQvar Redihaler 1 QL, PSeebri Neohaler 3 PSerevent Diskus 3 PSingulair Oral Packet 3Spiriva Handihaler 2 QL, PSpiriva Respimat 2 QL, PStriverdi Respimat 2 QL, PSymbicort 3 QL, RS, PTerbutaline 1 PTheo-24 3 PTheophylline 1 PTheophylline/Guaifenesin 1 PTrelegy Ellipta 3 QL, RS, PVentolin HFA 2 QL, PXopenex HFA 3 QL, PYupelri 3 PA, QL,PZafirlukast 1 PZyflo 3 PZyflo CR 3 P

Respiratory: Pulmonary Arterial HypertensionAdempas 2 PA, QL, DSPAzasan 3 PAzathioprine 1 PBosentan 2 PA, QL, DSPCellcept E 1 PCyclosporine 1 PGengraf 1 PMycophenolate 1 PMycophenolic Acid 2 POpsumit 2 PA, QL, DSPOrenitram 3 PA, QL, DSPSirolimus 2 PTacrolimus 2 PTracleer  2 PA, QL, DSP

23

Maricopa CountyPrescription Drug List

Page 26: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Smoking CessationBupropion Sustained-Release Tablet 1 H, PAChantix Tablet 3 H, PANicoderm CQ 3 H, PANicorette Gum 3 H, PANicorette Lozenge 3 H, PANicorette Mini-Lozenge 3 H, PANicotine Gum 1 H, PANicotine Lozenge 1 H, PANicotine Patch 1 H, PANicotrol Inhaler 3 H, PANicotrol Nasal Spray 3 H, PAThrive Gum 3 H, PA

TransplantTyvaso 2 PA, DSPZortress 3 P

Vitamins / ElectrolytesCyanocobalamin Injection 1Drisdol 3ERgocal 3ERgocalciferol Oral Capsule 1Floriva Plus 3Folic Acid Oral Tablet 1 mg 1Klor-Con 1Klor-Con 10 1Klor-Con M10 1Klor-Con M15 3Klor-Con M20 1Klor-Con Sprinkle 1K-Tab 3Lokelma 3 PA, QLMulti-Vitamin/Fluoride 1Multivitamin/Fluoride Oral Solution 1Multivitamin/Fluoride Oral Tablet Chewable 0.25 mg, 0.5 mg, 1 mg

1

Multivitamins/Fluoride 1MVC-Fluoride 1Nascobal 3Poly-Vi-Flor 3Potassium Chloride Crys ER 1Potassium Chloride ER 1Potassium Chloride Oral 1Potassium Citrate ER 1Quflora Pediatric 3

Drug NameDrug Tier

Requirement and Limits

Syprine 3 PA, DSPUrocit-K 10 3Urocit-K 15 3Urocit-K 5 3Veltassa 3 PA, QLVitamin D (ERgocalciferol) Oral Capsule 1.25 mg (50000 Ut)

1

Vitapearl Cap 3

Women’s Health: Hormone Replacement and Birth ControlAfirmelle 1 HAlora 3 QLAltavera 1 HAlyacen 1/35 1 HAmethia 3Amethia Lo 3Apri 1 HAshlyna 3Aubra 1 HAubra EQ 1 HAurovela 1.5/30 2Aurovela 1/20 2Aurovela 24 Fe 3Aurovela Fe 1.5/30 1 HAurovela Fe 1/20 1 HAviane 1 HAygestin 3Ayuna 1 HAzurette 2Balziva 2Bekyree 2Bijuva 3Blisovi 24 Fe 3Blisovi Fe 1.5/30 1 HBlisovi Fe 1/20 1 HBriellyn 2Camila 1 HCamrese 3Camrese Lo 3Chateal 1 HChateal EQ 1 HClimara Pro 3 QLCryselle-28 1 HCyclafem 1/35 1 HCyred 1 HCyred EQ 1 H

24

Page 27: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Dasetta 1/35 1 HDaysee 3Deblitane 1 HDelyla 1 HDepo-Provera Intramuscular Suspension 150 mg/Ml

3 QL

Depo-Provera Intramuscular Suspension Prefilled Syringe

3 QL

Depo-Subq Provera 104 2 QLDesogestrel-Ethinyl Estradiol Oral Tablet 0.15-0.02/0.01 mg (21/5)

2

Desogestrel-Ethinyl Estradiol Oral Tablet 0.15-30 mg-mcg

1 H

Divigel Transdermal Gel 0.25 mg/0.25gm, 0.5 mg/0.5gm, 0.75 mg/0.75gm, 1 mg/Gm

3

Drospirenone-Ethinyl Estradiol 3Duavee 3 QLElestrin 3Elinest 1 HEmoquette 1 HEnskyce 1 HERrin 1 HEstarylla 1 HEstrace Oral 3Estrace Vaginal 3Estradiol Oral 1Estradiol Patch Twice Weekly 0.025 mg/24hr Transdermal (Generic For Minivelle)

2 QL

Estradiol Patch Twice Weekly 0.0375 mg/24hr Transdermal (Generic For Minivelle)

2 QL

Estradiol Patch Twice Weekly 0.05 mg/24hr Transdermal (Generic For Minivelle)

2 QL

Estradiol Patch Twice Weekly 0.075 mg/24hr Transdermal (Generic For Minivelle)

2 QL

Estradiol Patch Twice Weekly 0.1 mg/24hr Transdermal (Generic For Minivelle)

2 QL

Estradiol Transdermal Patch Weekly (Generic Climara)

1 QL

Estradiol Vaginal Tablet 2Estring 2 QLEstrogel 3 QLEvamist 2Falmina 1 H

Drug NameDrug Tier

Requirement and Limits

Femynor 1 HGianvi 3Hailey 1.5/30 2Hailey 24 FE 3Heather 1 HIncassia 1 HIntrovale 2 HIsibloom 1 HJasmiel 3Jencycla 1 HJolessa 2 HJuleber 1 HJunel 1.5/30 2Junel 1/20 2Junel FE 1.5/30 1 HJunel FE 1/20 1 HJunel FE 24 3Kalliga 1 HKariva 2Kurvelo 1 HLarin 1.5/30 2Larin 1/20 2Larin 24 FE 3Larin FE 1.5/30 1 HLarin FE 1/20 1 HLarissia 1 HLessina 1 HLevonorgest-Eth Estrad 91-Day Oral Tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg

3

Levonorgest-Eth Estrad 91-Day Oral Tablet 0.15-0.03 mg

2 H

Levonorgestrel-Ethinyl Estrad Oral Tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1 H

Levora 0.15/30 (28) 1 HLillow 1 HLo Loestrin FE 3Loryna 3Loseasonique 3Low-Ogestrel 1 HLo-Zumandimine 3Lutera 1 HLyza 1 HMarlissa 1 HMedroxyprogesterone Acetate Intramuscular Suspension

1 QL, H

25

Maricopa CountyPrescription Drug List

Page 28: Your 2020-2021 Prescription Drug List

Blue type = Brand-name drugPlain type = Generic drug

DSP = Designated specialty programP = Preventive medicationH = Health care reform preventive

PA = Prior authorization requiredQL = Quantity limitsST = Step therapy

Drug NameDrug Tier

Requirement and Limits

Medroxyprogesterone Acetate Intramuscular Suspension Prefilled Syringe

1 QL, H

Medroxyprogesterone Acetate Oral 1Menostar 3 QLMicrogestin 1.5/30 2Microgestin 1/20 2Microgestin FE 1.5/30 1 HMicrogestin FE 1/20 1 HMili 1 HMircette 3Mono-Linyah 1 HNatazia 2Necon 0.5/35 (28) 1 HNikki 3Nora-Be 1 HNorethin Ace-Eth Estrad-Fe Oral Tablet 1-20 mg-mcg(24)

3

Norethin Ace-Eth Estrad-Fe Oral Tablet 1-20 mg-mcg, 1.5-30 mg-mcg

1 H

Norethindrone Acetate Oral 1Norethindrone Acet-Ethinyl Est 2Norethindrone Oral 1 HNorgestimate-Eth Estradiol 1 HNorgestimate-Ethinyl Estradiol Triphasic Oral Tablet 0.18/0.215/0.25 mg-25 mcg

2

Norgestimate-Ethinyl Estradiol Triphasic Oral Tablet 0.18/0.215/0.25 mg-35 mcg

1 H

Norlyda 1 HNorlyroc 1 HNortrel 0.5/35 (28) 1 HNortrel 1/35 (21) 1 HNortrel 1/35 (28) 1 HNuvaring 1 HOcella 3Ogestrel 2Orsythia 1 HPhilith 2Pimtrea 2Pirmella 1/35 1 HPortia-28 1 HPremarin Oral 3Premarin Vaginal 3Premphase 3Prempro 3Previfem 1 H

Drug NameDrug Tier

Requirement and Limits

Progesterone Micronized Oral 2Provera 3Reclipsen 1 HSeasonique 3Setlakin 2 HSharobel 1 HSimliya 2Simpesse 3Sprintec 28 1 HSronyx 1 HSyeda 3Tarina 24 FE 3Tarina FE 1/20 1 HTarina FE 1/20 EQ 1 HTri Femynor 1 HTri-Estarylla 1 HTri-Linyah 1 HTri-Lo-Estarylla 2Tri-Lo-Marzia 2Tri-Lo-Mili 2Tri-Lo-Sprintec 2Tri-Mili 1 HTri-Previfem 1 HTri-Sprintec 1 HTri-Vylibra 1 HTri-Vylibra Lo 2Tulana 1 HVienva 1 HViorele 2Vivelle-Dot 2 QLVyfemla 2Vylibra 1 HWera 1 HXulane 3 HYasmin 28 2Yaz 2Yuvafem 2Zarah 3Zumandimine 3

26

Page 29: Your 2020-2021 Prescription Drug List

IndexAAbacavir . . . . . . . . . . . . . . . . . . . . . . . 19Abacavir-Lamivudine. . . . . . . . . . . . . 19Abacavir-Lamivudine-Zidovudine . . 19Acarbose. . . . . . . . . . . . . . . . . . . . . . . 15Accolate . . . . . . . . . . . . . . . . . . . . . . . 22Accuneb . . . . . . . . . . . . . . . . . . . . . . . 22Accupril . . . . . . . . . . . . . . . . . . . . . . . . 7Accuretic . . . . . . . . . . . . . . . . . . . . . . . 7Acebutolol. . . . . . . . . . . . . . . . . . . . . . 7Acetaminophen-Codeine . . . . . . . . . 21Acetazolamide ER . . . . . . . . . . . . . . . 7Acetazolamide Oral . . . . . . . . . . . . . . 7Actemra Actpen . . . . . . . . . . . . . . . . . 20Actemra Subcutaneous . . . . . . . . . . 20Actigall. . . . . . . . . . . . . . . . . . . . . . . . . 18Actonel . . . . . . . . . . . . . . . . . . . . . . . . 21Actoplus Met . . . . . . . . . . . . . . . . . . . 15Actoplus Met XR . . . . . . . . . . . . . . . . 15Acular . . . . . . . . . . . . . . . . . . . . . . . . . 17Acular LS. . . . . . . . . . . . . . . . . . . . . . . 17Acyclovir Oral . . . . . . . . . . . . . . . . . . . 6Aczone . . . . . . . . . . . . . . . . . . . . . . . . 13Adalat Cc . . . . . . . . . . . . . . . . . . . . . . 7Adderall XR. . . . . . . . . . . . . . . . . . . . . 10Addyi . . . . . . . . . . . . . . . . . . . . . . . . . . 20Adempas. . . . . . . . . . . . . . . . . . . . . . . 23Adlyxin. . . . . . . . . . . . . . . . . . . . . . . . . 15Advair Diskus . . . . . . . . . . . . . . . . . . . 22Advair HFA . . . . . . . . . . . . . . . . . . . . . 22Afeditab. . . . . . . . . . . . . . . . . . . . . . . . 7Afirmelle . . . . . . . . . . . . . . . . . . . . . . . 24Afstyla Intravenous Kit. . . . . . . . . . . . 6Aggrenox. . . . . . . . . . . . . . . . . . . . . . . 7Aimovig . . . . . . . . . . . . . . . . . . . . . . . . 12Ala-Cort External Cream 2.5%. . . . . 13Ala Scalp . . . . . . . . . . . . . . . . . . . . . . . 13Albuterol HFA . . . . . . . . . . . . . . . . . . . 23Albuterol Nebulized Solution . . . . . . 23Albuterol Oral Tablet . . . . . . . . . . . . . 23Albuterol Sulfate ER. . . . . . . . . . . . . . 23Albuterol Sulfate HFA Aerosol Solution 108. . . . . . . . . . . . . . . . . . . . 23Albuterol Sulfate Inhalation Nebulization Solution . . . . . . . . . . . . 23Albuterol Sulfate Oral. . . . . . . . . . . . . 23Aldactazide. . . . . . . . . . . . . . . . . . . . . 7Aldactone . . . . . . . . . . . . . . . . . . . . . . 7Aldara . . . . . . . . . . . . . . . . . . . . . . . . . 13Alendronate . . . . . . . . . . . . . . . . . . . . 21Alendronate Sodium . . . . . . . . . . . . . 21Alfuzosin HCL ER . . . . . . . . . . . . . . . 19

Aliskiren. . . . . . . . . . . . . . . . . . . . . . . . 7Aliskiren Fumarate Oral Tablet . . . . . 7Allopurinol Oral . . . . . . . . . . . . . . . . . 19Alora . . . . . . . . . . . . . . . . . . . . . . . . . . 24Alphagan P Ophthalmic Solution . . 17Alprazolam ER . . . . . . . . . . . . . . . . . . 6Alprazolam Intensol . . . . . . . . . . . . . . 6Alprazolam Oral . . . . . . . . . . . . . . . . . 6Alprazolam XR . . . . . . . . . . . . . . . . . . 6Alrex. . . . . . . . . . . . . . . . . . . . . . . . . . . 17Altace. . . . . . . . . . . . . . . . . . . . . . . . . . 7Altavera . . . . . . . . . . . . . . . . . . . . . . . . 24Alvesco . . . . . . . . . . . . . . . . . . . . . . . . 23Alyacen 1/35 . . . . . . . . . . . . . . . . . . . 24Amaryl . . . . . . . . . . . . . . . . . . . . . . . . . 15Amerge . . . . . . . . . . . . . . . . . . . . . . . . 12Amethia . . . . . . . . . . . . . . . . . . . . . . . . 24Amethia Lo . . . . . . . . . . . . . . . . . . . . . 24Amiloride. . . . . . . . . . . . . . . . . . . . . . . 7Amiloride-Hydrochlorothiazide . . . . 7Amiodarone HCL Oral. . . . . . . . . . . . 7Amitriptyline HCL Oral . . . . . . . . . . . 11Amlodipine . . . . . . . . . . . . . . . . . . . . . 7Amlodipine-Benazepril . . . . . . . . . . . 7Amlodipine Besylate-Benazepril HCL . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Amlodipine Besylate Oral . . . . . . . . . 7Amlodipine Besylate-Valsartan . . . . 7Amlodipine-Valsartan . . . . . . . . . . . . 7Amnesteem . . . . . . . . . . . . . . . . . . . . 13Amoxicillin. . . . . . . . . . . . . . . . . . . . . . 5Amoxicillin-Potassium Clavulanate Oral. . . . . . . . . . . . . . . . . 5Amphetamine-Dextroamphetamine . . 10Anaspaz . . . . . . . . . . . . . . . . . . . . . . . 18Anastrozole . . . . . . . . . . . . . . . . . . . . . 6Anastrozole Oral. . . . . . . . . . . . . . . . . 7Androderm . . . . . . . . . . . . . . . . . . . . . 16Anoro Ellipta . . . . . . . . . . . . . . . . . . . . 23Antibiotics . . . . . . . . . . . . . . . . . . . . . . 5Antibiotics and Others. . . . . . . . . . . . 17Antifungals . . . . . . . . . . . . . . . . . . . . . 5Antivirals /Hepatitis C . . . . . . . . . . . . 6Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . 6Apap-Caff-Dihydrocodeine . . . . . . . . 21Apri . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Apriso . . . . . . . . . . . . . . . . . . . . . . . . . 18Aptivus. . . . . . . . . . . . . . . . . . . . . . . . . 19Arakoda. . . . . . . . . . . . . . . . . . . . . . . . 5Aranesp (Albumin Free) . . . . . . . . . . 6Arcapta Neohaler. . . . . . . . . . . . . . . . 23Aricept Oral Tablet . . . . . . . . . . . . . . . 12

Aripiprazole. . . . . . . . . . . . . . . . . . . . . 11Aripiprazole Oral Solution. . . . . . . . . 11Aripiprazole Oral Tablet. . . . . . . . . . . 11Aripiprazole Oral Tablet Dispersible . . 11Arixtra . . . . . . . . . . . . . . . . . . . . . . . . . 7Armour Thyroid . . . . . . . . . . . . . . . . . 17Arnuity Ellipta . . . . . . . . . . . . . . . . . . . 23Aromasin. . . . . . . . . . . . . . . . . . . . . . . 6Ashlyna . . . . . . . . . . . . . . . . . . . . . . . . 24Asmanex HFA. . . . . . . . . . . . . . . . . . . 23Asmanex Twisthaler. . . . . . . . . . . . . . 23Aspirin-Dipyridamole . . . . . . . . . . . . . 7Atacand. . . . . . . . . . . . . . . . . . . . . . . . 7Atacand Hct . . . . . . . . . . . . . . . . . . . . 7Atazanavir . . . . . . . . . . . . . . . . . . . . . . 19Atenolol . . . . . . . . . . . . . . . . . . . . . . . . 7Atenolol-Chlorthalidone . . . . . . . . . . 7Atenolol Oral . . . . . . . . . . . . . . . . . . . . 7Atomoxetine HCL. . . . . . . . . . . . . . . . 10Atorvastatin . . . . . . . . . . . . . . . . . . . . . 10Atorvastatin Calcium Oral Tablet . . . 7Atovaquone-Proguanil HCL . . . . . . . 5Atrovent HFA. . . . . . . . . . . . . . . . . . . . 23Aubagio. . . . . . . . . . . . . . . . . . . . . . . . 12Aubra. . . . . . . . . . . . . . . . . . . . . . . . . . 24Aubra EQ . . . . . . . . . . . . . . . . . . . . . . 24Aurovela 1.5/30 . . . . . . . . . . . . . . . . . 24Aurovela 1/20. . . . . . . . . . . . . . . . . . . 24Aurovela 24 Fe . . . . . . . . . . . . . . . . . . 24Aurovela Fe 1.5/30 . . . . . . . . . . . . . . 24Aurovela Fe 1/20 . . . . . . . . . . . . . . . . 24Auryxia. . . . . . . . . . . . . . . . . . . . . . . . . 22Austedo . . . . . . . . . . . . . . . . . . . . . . . . 12Avalide. . . . . . . . . . . . . . . . . . . . . . . . . 7Avandia . . . . . . . . . . . . . . . . . . . . . . . . 15Avapro . . . . . . . . . . . . . . . . . . . . . . . . . 7Avar Cleanser . . . . . . . . . . . . . . . . . . . 13Aviane . . . . . . . . . . . . . . . . . . . . . . . . . 24Avidoxy . . . . . . . . . . . . . . . . . . . . . . . . 5Avonex. . . . . . . . . . . . . . . . . . . . . . . . . 12Avonex Pen. . . . . . . . . . . . . . . . . . . . . 12Avonex Prefilled . . . . . . . . . . . . . . . . . 12Aygestin. . . . . . . . . . . . . . . . . . . . . . . . 24Ayuna. . . . . . . . . . . . . . . . . . . . . . . . . . 24Azasan. . . . . . . . . . . . . . . . . . . . . . 20, 23Azasite. . . . . . . . . . . . . . . . . . . . . . . . . 17Azathioprine . . . . . . . . . . . . . . . . . . . . 23Azathioprine Oral . . . . . . . . . . . . . . . . 20Azelaic Acid External. . . . . . . . . . . . . 13Azelastine HCL Nasal Solution . . . . 22Azelastine HCL Ophthalmic . . . . . . . 17Azithromycin Oral . . . . . . . . . . . . . . . 5

27

Maricopa CountyPrescription Drug List

Page 30: Your 2020-2021 Prescription Drug List

Azopt . . . . . . . . . . . . . . . . . . . . . . . . . . 17Azulfidine . . . . . . . . . . . . . . . . . . . . . . 18Azulfidine En-Tabs . . . . . . . . . . . . . . . 18Azurette. . . . . . . . . . . . . . . . . . . . . . . . 24

BBaclofen Oral . . . . . . . . . . . . . . . . . . . 20Bactrim . . . . . . . . . . . . . . . . . . . . . . . . 5Bactrim DS . . . . . . . . . . . . . . . . . . . . . 5Balziva . . . . . . . . . . . . . . . . . . . . . . . . . 24Baqsimi One Pack. . . . . . . . . . . . . . . 15Baqsimi Two Pack . . . . . . . . . . . . . . . 15Baraclude Oral Solution . . . . . . . . . . 6Bd Autoshield Duo Pen Needles. . . 15Bd Ultra-Fine Insulin Syringes . . . . . 15Bd Ultra-Fine Pen Needles . . . . . . . . 15Bekyree . . . . . . . . . . . . . . . . . . . . . . . . 24Belbuca. . . . . . . . . . . . . . . . . . . . . . . . 21Benazepril . . . . . . . . . . . . . . . . . . . . . . 7Benazepril HCL Oral . . . . . . . . . . . . . 7Benazepril-Hydrochlorothiazide. . . . 7Benzonatate Oral Capsule . . . . . . . . 22Besivance . . . . . . . . . . . . . . . . . . . . . . 17Betamethasone . . . . . . . . . . . . . . . . . 13Betamethasone Dipropionate Aug External Cream . . . . . . . . . . . . . 13Betamethasone Dipropionate Aug External Gel . . . . . . . . . . . . . . . . 13Betamethasone Dipropionate Aug External Ointment . . . . . . . . . . . 13Betamethasone Dipropionate External . . . . . . . . . . . . . . . . . . . . . . . . 13Betamethasone Dipropionate External Cream. . . . . . . . . . . . . . . . . . 13Betaseron . . . . . . . . . . . . . . . . . . . . . . 12Betaxolol . . . . . . . . . . . . . . . . . . . . . . . 7Bethkis. . . . . . . . . . . . . . . . . . . . . . . . . 22Betimol . . . . . . . . . . . . . . . . . . . . . . . . 17Bevespi Aerosphere . . . . . . . . . . . . . 23Bevyxxa . . . . . . . . . . . . . . . . . . . . . . . . 7Bidil . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Bijuva . . . . . . . . . . . . . . . . . . . . . . . . . . 24Biktarvy . . . . . . . . . . . . . . . . . . . . . . . . 19Bisoprolol . . . . . . . . . . . . . . . . . . . . . . 8Bisoprolol Fumarate . . . . . . . . . . . . . 8Bisoprolol-Hydrochlorothiazide . . . . 8Blisovi 24 Fe . . . . . . . . . . . . . . . . . . . . 24Blisovi Fe 1.5/30 . . . . . . . . . . . . . . . . 24Blisovi Fe 1/20 . . . . . . . . . . . . . . . . . . 24Blood Disorders . . . . . . . . . . . . . . . . . 6Boniva . . . . . . . . . . . . . . . . . . . . . . . . . 21Boniva Oral . . . . . . . . . . . . . . . . . . . . . 21Bosentan. . . . . . . . . . . . . . . . . . . . . . . 23BP 10-1 . . . . . . . . . . . . . . . . . . . . . . . . 13Breast Cancer Prevention. . . . . . . . . 6Breo Ellipta . . . . . . . . . . . . . . . . . . . . . 23

Briellyn. . . . . . . . . . . . . . . . . . . . . . . . . 24Brilinta . . . . . . . . . . . . . . . . . . . . . . . . . 7Brimonidine Tartrate Ophthalmic Solution . . . . . . . . . . . . . 17Bromfed DM . . . . . . . . . . . . . . . . . . . . 22Brovana . . . . . . . . . . . . . . . . . . . . . . . . 23Budesonide Inhalation . . . . . . . . . . . 23Budesonide Nebulized Solution . . . 23Budesonide Oral . . . . . . . . . . . . . . . . 18Bumetanide . . . . . . . . . . . . . . . . . . . . 8Buprenorphine HCL-Naloxone HCL 12Buprenorphine HCL Sublingual . . . 12Bupropion HCL ER (Sr) . . . . . . . . . . 11Bupropion HCL ER (Xl) Oral Tablet Extended Release 24 Hour . . . . . . . 11Bupropion HCL Oral . . . . . . . . . . . . . 11Bupropion Sustained-Release Tablet . . . . . . . . . . . . . . . . . . . . . . . . . . 24Buspirone HCL Oral . . . . . . . . . . . . . 6Butalbital-Apap-Caffeine Oral Capsule. . . . . . . . . . . . . . . . . . . . 21Butalbital-Apap-Caffeine Oral Tablet . . 21Bydureon . . . . . . . . . . . . . . . . . . . . . . 15Bydureon Bcise . . . . . . . . . . . . . . . . . 15Bydureon Bcise Autoinjector . . . . . . 15Byetta . . . . . . . . . . . . . . . . . . . . . . . . . 15Byetta 5 mcg Pen . . . . . . . . . . . . . . . 15Byetta 10 mcg Pen . . . . . . . . . . . . . . 15Bystolic . . . . . . . . . . . . . . . . . . . . . . . . 8Byvalson . . . . . . . . . . . . . . . . . . . . . . . 8

CCabergoline . . . . . . . . . . . . . . . . . . . . 16Calan . . . . . . . . . . . . . . . . . . . . . . . . . . 8Calan Sr. . . . . . . . . . . . . . . . . . . . . . . . 8Calcipotriene-Betameth Diprop . . . . 13Calcitonin (Salmon) . . . . . . . . . . . . . . 21Calcitriol External . . . . . . . . . . . . . . . . 13Calcitriol Oral . . . . . . . . . . . . . . . . . . . 21Camila . . . . . . . . . . . . . . . . . . . . . . . . . 24Camrese . . . . . . . . . . . . . . . . . . . . . . . 24Camrese Lo . . . . . . . . . . . . . . . . . . . . 24Cancer. . . . . . . . . . . . . . . . . . . . . . . . . 7Candesartan. . . . . . . . . . . . . . . . . . . . 8Candesartan-Hydrochlorothiazide. . . 8Capex . . . . . . . . . . . . . . . . . . . . . . . . . 13Captopril . . . . . . . . . . . . . . . . . . . . . . . 8Captopril-Hydrochlorothiazide . . . . . 8Carac . . . . . . . . . . . . . . . . . . . . . . . . . . 13Carafate Oral Suspension. . . . . . . . . 18Carafate Oral Tablet. . . . . . . . . . . . . . 18Carbamazepine ER Oral Capsule Extended Release 12 Hour . . . . . . . 12Carbamazepine ER Oral Tablet Extended Release 12 Hour . . . . . . . 12Carbamazepine Oral . . . . . . . . . . . . . 12

Carbatrol . . . . . . . . . . . . . . . . . . . . . . . 12Carbidopa-Levodopa. . . . . . . . . . 12, 22Carbidopa-Levodopa ER . . . . . . 12, 22Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy . . . . . . . 7Cardiovascular/Heart Disease: Coagulation Therapy. . . . . . . . . . . . . 7Cardiovascular/Heart Disease: High Blood Pressure . . . . . . . . . . . . . 7Cardiovascular/Heart Disease: High Cholesterol . . . . . . . . . . . . . . . . 10Cardura . . . . . . . . . . . . . . . . . . . . . . . . 8Carisoprodol Oral Tablet 350 mg . . 20Carospir. . . . . . . . . . . . . . . . . . . . . . . . 8Cartia Xt. . . . . . . . . . . . . . . . . . . . . . . . 8Carvedilol . . . . . . . . . . . . . . . . . . . . . . 8Catapres . . . . . . . . . . . . . . . . . . . . . . . 8Catapres TTS . . . . . . . . . . . . . . . . . . . 8Cavarest . . . . . . . . . . . . . . . . . . . . . . . 13Cefadroxil . . . . . . . . . . . . . . . . . . . . . . 5Cefdinir . . . . . . . . . . . . . . . . . . . . . . . . 5Cefuroxime Axetil . . . . . . . . . . . . . . . . 5Celecoxib Oral . . . . . . . . . . . . . . . . . . 21Celexa . . . . . . . . . . . . . . . . . . . . . . . . . 11Cellcept E . . . . . . . . . . . . . . . . . . . . . . 23Centany . . . . . . . . . . . . . . . . . . . . . . . . 5Central Nervous System: Attention Deficit Disorder . . . . . . . . . 10Central Nervous System: Depression . . . . . . . . . . . . . . . . . . . . . 11Central Nervous System: Mental Health . . . . . . . . . . . . . . . . . . . 11Central Nervous System: Migraine . . 12Central Nervous System: Multiple . . 12Central Nervous System: Other . . . . 12Central Nervous System: Sedatives/Hypnotics . . . . . . . . . . . . . 12Central Nervous System: Seizure Disorders. . . . . . . . . . . . . . . . 12Cephalexin . . . . . . . . . . . . . . . . . . . . . 5Cerdelga . . . . . . . . . . . . . . . . . . . . . . . 18Chantix . . . . . . . . . . . . . . . . . . . . . . . . 12Chantix Continuing Month Pak . . . . 12Chantix Starting Month Pak . . . . . . . 12Chantix Tablet. . . . . . . . . . . . . . . . . . . 24Chateal . . . . . . . . . . . . . . . . . . . . . . . . 24Chateal EQ . . . . . . . . . . . . . . . . . . . . . 24Chlorhexidine Gluconate Mouth/Throat . . . . . . . . . . . . . . . . . . . 13Chlorothiazide . . . . . . . . . . . . . . . . . . 8Chlorpromazine . . . . . . . . . . . . . . . . . 11Chlorthalidone . . . . . . . . . . . . . . . . . . 8Cholestyramine . . . . . . . . . . . . . . . . . 10Cholestyramine Light . . . . . . . . . . . . 10Chorionic Gonadotropin Intramuscular . . . . . . . . . . . . . . . . . . . 20

28

Page 31: Your 2020-2021 Prescription Drug List

Ciclodan . . . . . . . . . . . . . . . . . . . . . . . 5Ciclopirox External Gel . . . . . . . . . . . 5Ciclopirox External Shampoo. . . . . . 5Ciclopirox External Solution . . . . . . . 5Cilostazol. . . . . . . . . . . . . . . . . . . . . . . 7Ciloxan Ophthalmic Ointment . . . . . 17Ciloxan Ophthalmic Solution . . . . . . 17Cimduo . . . . . . . . . . . . . . . . . . . . . 6, 19Cimzia Prefilled Kit. . . . . . . . . . . . . . . 20Ciprodex . . . . . . . . . . . . . . . . . . . . . . . 5Ciprofloxacin HCL Ophthalmic . . . . 17Ciprofloxacin HCL Oral . . . . . . . . . . . 5Cipro Oral Tablet . . . . . . . . . . . . . . . . 5Citalopram . . . . . . . . . . . . . . . . . . . . . 11Citalopram Hydrobromide . . . . . . . . 11Claravis . . . . . . . . . . . . . . . . . . . . . . . . 13Clarithromycin ER . . . . . . . . . . . . . . . 5Clarithromycin Oral Suspension Reconstituted . . . . . . . . 5Clarithromycin Oral Tablet . . . . . . . . 5Clenpiq . . . . . . . . . . . . . . . . . . . . . . . . 18Cleocin Oral Capsule . . . . . . . . . . . . 5Cleocin-T External Gel. . . . . . . . . . . . 13Cleocin-T External Lotion . . . . . . . . . 13Climara Pro. . . . . . . . . . . . . . . . . . . . . 24Clindacin Etz External Swab . . . . . . 13Clindacin-P . . . . . . . . . . . . . . . . . . . . . 13Clindamycin HCL Oral . . . . . . . . . . . 5Clindamycin Phos-Benzoyl Perox External Gel 1.2-5% . . . . . . . . 13Clindamycin Phosphate External Foam . . . . . . . . . . . . . . . . . . 13Clindamycin Phosphate External Lotion . . . . . . . . . . . . . . . . . . 13Clindamycin Phosphate External Solution . . . . . . . . . . . . . . . . 14Clindamycin Phosphate External Swab. . . . . . . . . . . . . . . . . . . 14Clindamycin Phosphate Gel 1% External . . . . . . . . . . . . . . . . . 14Clindesse . . . . . . . . . . . . . . . . . . . . . . 5Clinpro 5000 . . . . . . . . . . . . . . . . . . . 13Clobetasol Propionate External Cream. . . . . . . . . . . . . . . . . . 14Clobetasol Propionate External Gel . . 14Clobetasol Propionate External Liquid . . . . . . . . . . . . . . . . . . 14Clobetasol Propionate External Ointment . . . . . . . . . . . . . . . 14Clobetasol Propionate External Solution . . . . . . . . . . . . . . . . 14Clonazepam Oral . . . . . . . . . . . . . . . . 6Clonidine. . . . . . . . . . . . . . . . . . . . . . . 8Clonidine HCL Oral . . . . . . . . . . . . . . 8Clonidine Patch . . . . . . . . . . . . . . . . . 8Clopidogrel . . . . . . . . . . . . . . . . . . . . . 7

Clopidogrel Bisulfate Oral. . . . . . . . . 7Clotrimazole-Betamethasone External Cream. . . . . . . . . . . . . . . . . . 14Clotrimazole-Betamethasone External Lotion . . . . . . . . . . . . . . . . . . 14Clozapine . . . . . . . . . . . . . . . . . . . . . . 11Clozaril. . . . . . . . . . . . . . . . . . . . . . . . . 11Colestid . . . . . . . . . . . . . . . . . . . . . . . . 10Colestipol . . . . . . . . . . . . . . . . . . . . . . 10Colyte With Flavor Packs . . . . . . . . . 18Combigan . . . . . . . . . . . . . . . . . . . . . . 17Combivent Respimat. . . . . . . . . . . . . 23Combivir . . . . . . . . . . . . . . . . . . . . . . . 19Complera . . . . . . . . . . . . . . . . . . . . . . 19Concerta . . . . . . . . . . . . . . . . . . . . . . . 10Contour Next Ez Meters . . . . . . . . . . 15Contour Next Meters . . . . . . . . . . . . . 15Contour Next Monitor . . . . . . . . . . . . 15Contour Next One Meters. . . . . . . . . 15Contour Next Test Strips. . . . . . . . . . 15Coreg. . . . . . . . . . . . . . . . . . . . . . . . . . 8Corgard . . . . . . . . . . . . . . . . . . . . . . . . 8Corlanor . . . . . . . . . . . . . . . . . . . . . . . 8Cortef. . . . . . . . . . . . . . . . . . . . . . . . . . 16Cortifoam . . . . . . . . . . . . . . . . . . . . . . 18Corzide . . . . . . . . . . . . . . . . . . . . . . . . 8Cosentyx . . . . . . . . . . . . . . . . . . . . . . . 20Cosentyx Sensoready (300 mg) . . . 20Cosentyx Sensoready Pen . . . . . . . . 20Cosopt. . . . . . . . . . . . . . . . . . . . . . . . . 17Coumadin . . . . . . . . . . . . . . . . . . . . . . 7Cozaar . . . . . . . . . . . . . . . . . . . . . . . . . 8Creon. . . . . . . . . . . . . . . . . . . . . . . . . . 18Cresemba Oral . . . . . . . . . . . . . . . . . . 5Crinone Vaginal Gel. . . . . . . . . . . . . . 20Crixivan . . . . . . . . . . . . . . . . . . . . . . . . 19Crohn’s Disease. . . . . . . . . . . . . . . . . 20Cromolyn. . . . . . . . . . . . . . . . . . . . . . . 23Cryselle-28 . . . . . . . . . . . . . . . . . . . . . 24Cuprimine . . . . . . . . . . . . . . . . . . . . . . 22Cyanocobalamin Injection . . . . . . . . 24Cyclafem 1/35 . . . . . . . . . . . . . . . . . . 24Cyclobenzaprine HCL Oral . . . . . . . 20Cycloset. . . . . . . . . . . . . . . . . . . . . . . . 15Cyclosporine. . . . . . . . . . . . . . . . . . . . 23Cyclosporine Modified . . . . . . . . . . . 20Cyproheptadine HCL Oral . . . . . . . . 22Cyred . . . . . . . . . . . . . . . . . . . . . . . . . . 24Cyred EQ . . . . . . . . . . . . . . . . . . . . . . 24Cytotec . . . . . . . . . . . . . . . . . . . . . . . . 18

DDalfampridine ER. . . . . . . . . . . . . . . . 12Daliresp . . . . . . . . . . . . . . . . . . . . . . . . 23Dasetta 1/35 . . . . . . . . . . . . . . . . . . . 25

Daysee. . . . . . . . . . . . . . . . . . . . . . . . . 25Ddavp Injection . . . . . . . . . . . . . . . . . 16Ddavp Oral . . . . . . . . . . . . . . . . . . . . . 16Deblitane. . . . . . . . . . . . . . . . . . . . . . . 25Delstrigo . . . . . . . . . . . . . . . . . . . . . . . 19Delyla. . . . . . . . . . . . . . . . . . . . . . . . . . 25Demadex. . . . . . . . . . . . . . . . . . . . . . . 8Denta 5000 Plus . . . . . . . . . . . . . . . . 13Dentagel . . . . . . . . . . . . . . . . . . . . . . . 13Depakote. . . . . . . . . . . . . . . . . . . . . . . 12Depakote ER . . . . . . . . . . . . . . . . . . . 12Depakote Sprinkles . . . . . . . . . . . . . . 12Depen Titratabs . . . . . . . . . . . . . . . . . 22Depo-Provera Intramuscular Suspension. . . . . . . . . . . . . . . . . . . . . 25Depo-Provera Intramuscular Suspension Prefilled Syringe . . . . . . 25Depo-Subq Provera 104. . . . . . . . . . 25Depo-Testosterone Intramuscular Solution . . . . . . . . . . . 16Derma-Smoothe/Fs Body. . . . . . . . . 14Derma-Smoothe/Fs Scalp . . . . . . . . 14Dermatology . . . . . . . . . . . . . . . . . . . . 13Descovy. . . . . . . . . . . . . . . . . . . . . 6, 19Desmopressin Acetate Injection . . . 16Desmopressin Acetate Oral . . . . . . . 16Desogestrel-Ethinyl Estradiol Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 25Desonate. . . . . . . . . . . . . . . . . . . . . . . 14Desonide External . . . . . . . . . . . . . . . 14Desowen . . . . . . . . . . . . . . . . . . . . . . . 14Desvenlafaxine Succinate ER . . . . . 11Dexamethasone Intensol . . . . . . . . . 16Dexamethasone Oral Elixir . . . . . . . . 16Dexamethasone Oral Solution . . . . . 16Dexamethasone Oral Tablet . . . . . . . 16Dexcom G4 / G5 / G6 Receiver . . . 15Dexilant . . . . . . . . . . . . . . . . . . . . . . . . 18Dexmethylphenidate HCL. . . . . . . . . 10Dexmethylphenidate HCL ER . . . . . 10Dextroamphetamine Sulfate ER. . . . 10Dextroamphetamine Sulfate Oral Solution. . . . . . . . . . . . . . . . . . . . 10Dextroamphetamine Sulfate Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 10Diabetes: Blood Glucose Monitoring . 15Diabetes: Insulin. . . . . . . . . . . . . . . . . 15Diabetes: Non-Insulin . . . . . . . . . . . . 15Diabetic Testing - Lancets. . . . . . . . . 15Diazepam Intensol . . . . . . . . . . . . . . . 6Diazepam Oral . . . . . . . . . . . . . . . . . . 6Diclofenac Potassium . . . . . . . . . . . . 21Diclofenac Sodium ER . . . . . . . . . . . 21Diclofenac Sodium Oral . . . . . . . . . . 21Diclofenac Sodium Transdermal Gel 1% . . . . . . . . . . . . . 21

29

Maricopa CountyPrescription Drug List

Page 32: Your 2020-2021 Prescription Drug List

Dicyclomine HCL Oral. . . . . . . . . . . . 18Didanosine . . . . . . . . . . . . . . . . . . . . . 19Didronel. . . . . . . . . . . . . . . . . . . . . . . . 21Dificid. . . . . . . . . . . . . . . . . . . . . . . . . . 5Diflucan Oral Suspension Reconstituted . . . . . . . . . . . . . . . . . . . 5Diflucan Oral Tablet . . . . . . . . . . . . . . 5Dilacor XR. . . . . . . . . . . . . . . . . . . . . . 8Dilaudid Oral. . . . . . . . . . . . . . . . . . . . 21Diltiazem . . . . . . . . . . . . . . . . . . . . . . . 8Diltiazem ER . . . . . . . . . . . . . . . . . . . . 8Diltiazem HCL ER Coated Beads . . 8Diltiazem HCL ER Oral Capsule Extended Release 12 Hour . . . . . . . 8Diltiazem HCL Oral . . . . . . . . . . . . . . 8Dilt XR . . . . . . . . . . . . . . . . . . . . . . . . . 8Dilt-XR . . . . . . . . . . . . . . . . . . . . . . . . . 8Dipentum . . . . . . . . . . . . . . . . . . . . . . 18Diphenoxylate-Atropine. . . . . . . . . . . 18Diprolene. . . . . . . . . . . . . . . . . . . . . . . 14Diprolene Af . . . . . . . . . . . . . . . . . . . . 14Dipyridamole . . . . . . . . . . . . . . . . . . . 7Ditropan XL. . . . . . . . . . . . . . . . . . . . . 22Diuril. . . . . . . . . . . . . . . . . . . . . . . . . . . 8Divalproex Sodium ER . . . . . . . . . . . 12Divalproex Sodium Oral Capsule Delayed Release Sprinkle. . . . . . . . . 12Divalproex Sodium Oral Tablet Delayed Release . . . . . . . . . . . . . . . . 12Divigel Transdermal Gel . . . . . . . . . . 25Donepezil HCL Oral Tablet. . . . . . . . 12Donepezil HCL Oral Tablet Dispersible . . . . . . . . . . . . . . . . . . . . . 12Dorzolamide HCL-Timolol Mal . . . . . 17Dovato . . . . . . . . . . . . . . . . . . . . . . 6, 19Doxazosin . . . . . . . . . . . . . . . . . . . . . . 8Doxazosin Mesylate Oral. . . . . . . . . . 8Doxepin HCL Oral Capsule . . . . . . . 11Doxepin HCL Oral Concentrate . . . . 11Doxycycline Hyclate Oral Capsule. . 5Doxycycline Hyclate Oral Tablet. . . . 5Doxycycline Monohydrate Oral Capsule. . . . . . . . . . . . . . . . . . . . 5Doxycycline Monohydrate Oral Suspension Reconstituted . . . . 5Doxycycline Monohydrate Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 5D-Penamine . . . . . . . . . . . . . . . . . . . . 22Drisdol . . . . . . . . . . . . . . . . . . . . . . . . . 24Drospirenone-Ethinyl Estradiol. . . . . 25Drugs for Mouth and Throat Conditions. . . . . . . . . . . . . . . . . . . . . . 13Duavee . . . . . . . . . . . . . . . . . . . . . . . . 25Duetact . . . . . . . . . . . . . . . . . . . . . . . . 15Duloxetine HCL Oral Capsule Delayed Release Particles . . . . . . . . 11

Duopa . . . . . . . . . . . . . . . . . . . . . . 12, 22Dupixent . . . . . . . . . . . . . . . . . . . . . . . 14Dyazide . . . . . . . . . . . . . . . . . . . . . . . . 8Dyrenium. . . . . . . . . . . . . . . . . . . . . . . 8

EEasyplus Blood Glucose Test . . . . . 15EC-Naprosyn . . . . . . . . . . . . . . . . . . . 21EC-Naproxen . . . . . . . . . . . . . . . . . . . 21Edarbi . . . . . . . . . . . . . . . . . . . . . . . . . 8Edarbyclor. . . . . . . . . . . . . . . . . . . . . . 8Edecrin . . . . . . . . . . . . . . . . . . . . . . . . 8Ed-Spaz. . . . . . . . . . . . . . . . . . . . . . . . 18Edurant . . . . . . . . . . . . . . . . . . . . . . . . 19Efavirenz . . . . . . . . . . . . . . . . . . . . . . . 19Efudex . . . . . . . . . . . . . . . . . . . . . . . . . 14Electrolytes . . . . . . . . . . . . . . . . . . . . . 24Elestrin. . . . . . . . . . . . . . . . . . . . . . . . . 25Eletriptan Hydrobromide. . . . . . . . . . 12Elimite . . . . . . . . . . . . . . . . . . . . . . . . . 5Elinest . . . . . . . . . . . . . . . . . . . . . . . . . 25Eliquis . . . . . . . . . . . . . . . . . . . . . . . . . 7Elixophyllin . . . . . . . . . . . . . . . . . . . . . 23Elocon . . . . . . . . . . . . . . . . . . . . . . . . . 14Eloctate . . . . . . . . . . . . . . . . . . . . . . . . 6Emgality. . . . . . . . . . . . . . . . . . . . . . . . 12Emoquette . . . . . . . . . . . . . . . . . . . . . 25Emtriva. . . . . . . . . . . . . . . . . . . . . . . . . 19Enalapril . . . . . . . . . . . . . . . . . . . . . . . 8Enalapril-Hydrochlorothiazide . . . . . 8Enalapril Maleate Oral . . . . . . . . . . . . 8Enbrel . . . . . . . . . . . . . . . . . . . . . . . . . 20Enbrel Mini . . . . . . . . . . . . . . . . . . . . . 20Enbrel Sureclick . . . . . . . . . . . . . . . . . 20Endari . . . . . . . . . . . . . . . . . . . . . . . . . 18Endocet. . . . . . . . . . . . . . . . . . . . . . . . 21Endocrine: Growth Hormone. . . . . . 16Endocrine: Other . . . . . . . . . . . . . . . . 16Endocrine: Thyroid Hormone Replacement . . . . . . . . . . . . . . . . . . . 17Endometrin . . . . . . . . . . . . . . . . . . . . . 20Enoxaparin . . . . . . . . . . . . . . . . . . . . . 7Enoxaparin Sodium. . . . . . . . . . . . . . 7Enskyce. . . . . . . . . . . . . . . . . . . . . . . . 25Enstilar. . . . . . . . . . . . . . . . . . . . . . . . . 14Entecavir . . . . . . . . . . . . . . . . . . . . . . . 6Epaned . . . . . . . . . . . . . . . . . . . . . . . . 8Epclusa . . . . . . . . . . . . . . . . . . . . . . . . 6Epinephrine Solution Auto-Injector 0.3 mg/0.3ml Injection (Generic Epipen) . . . . . . . . 22Epinephrine Solution Auto-Injector 0.15 mg/0.3ml Injection (Generic Epipen Jr.). . . . . . 22Epitol . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Epivir . . . . . . . . . . . . . . . . . . . . . . . . . . 19Eplerenone . . . . . . . . . . . . . . . . . . . . . 8Eprosartan . . . . . . . . . . . . . . . . . . . . . 8ERgocal. . . . . . . . . . . . . . . . . . . . . . . . 24ERgocalciferol Oral Capsule . . . . . . 24ERleada. . . . . . . . . . . . . . . . . . . . . . . . 7ERrin . . . . . . . . . . . . . . . . . . . . . . . . . . 25ERythromycin Ophthalmic . . . . . . . . 17Escitalopram. . . . . . . . . . . . . . . . . . . . 11Escitalopram Oxalate Oral Solution. 11Escitalopram Oxalate Oral Tablet . . 11Esgic . . . . . . . . . . . . . . . . . . . . . . . . . . 21Estarylla. . . . . . . . . . . . . . . . . . . . . . . . 25Estrace Oral . . . . . . . . . . . . . . . . . . . . 25Estrace Vaginal. . . . . . . . . . . . . . . . . . 25Estradiol Oral . . . . . . . . . . . . . . . . . . . 25Estradiol Patch Twice Weekly . . . . . 25Estradiol Transdermal Patch Weekly (Generic Climara) . . . . . . . . . 25Estradiol Vaginal Tablet. . . . . . . . . . . 25Estring . . . . . . . . . . . . . . . . . . . . . . . . . 25Estrogel . . . . . . . . . . . . . . . . . . . . . . . . 25Eszopiclone . . . . . . . . . . . . . . . . . . . . 12Ethacrynic Acid . . . . . . . . . . . . . . . . . 8Etidronate . . . . . . . . . . . . . . . . . . . . . . 21Etodolac . . . . . . . . . . . . . . . . . . . . . . . 21Etodolac ER . . . . . . . . . . . . . . . . . . . . 21Eucrisa. . . . . . . . . . . . . . . . . . . . . . . . . 14Euthyrox . . . . . . . . . . . . . . . . . . . . . . . 17Evamist . . . . . . . . . . . . . . . . . . . . . . . . 25Evoclin . . . . . . . . . . . . . . . . . . . . . . . . . 14Evotaz . . . . . . . . . . . . . . . . . . . . . . . . . 19Exemestane . . . . . . . . . . . . . . . . . . . . 6Extina. . . . . . . . . . . . . . . . . . . . . . . . . . 5Eye Conditions: Allergies. . . . . . . . . 17Eye Conditions: Glaucoma. . . . . . . . 17Ezetimibe . . . . . . . . . . . . . . . . . . . 8, 10Ezetimibe-Simvastatin . . . . . . . . . . . . 8

FFalmina . . . . . . . . . . . . . . . . . . . . . . . . 25Fanapt . . . . . . . . . . . . . . . . . . . . . . . . . 11Fareston . . . . . . . . . . . . . . . . . . . . . . . 6Fasenra . . . . . . . . . . . . . . . . . . . . . . . . 23Fasenra Pen . . . . . . . . . . . . . . . . . . . . 23Fastclix. . . . . . . . . . . . . . . . . . . . . . . . . 15Fazaclo . . . . . . . . . . . . . . . . . . . . . . . . 11Febuxostat . . . . . . . . . . . . . . . . . . . . . 19Felodipine ER. . . . . . . . . . . . . . . . . . . 8Femynor . . . . . . . . . . . . . . . . . . . . . . . 25Fenofibrate 54 . . . . . . . . . . . . . . . . . . 10Fenofibrate Oral Tablet . . . . . . . . . . . 8Fentanyl Transdermal Patch 72 Hour . . . . . . . . . . . . . . . . . . . . . . . . 21Fexmid. . . . . . . . . . . . . . . . . . . . . . . . . 20

30

Page 33: Your 2020-2021 Prescription Drug List

Finacea . . . . . . . . . . . . . . . . . . . . . . . . 14Finasteride Oral Tablet 5 mg . . . . . . 19Fioricet. . . . . . . . . . . . . . . . . . . . . . . . . 21Firazyr . . . . . . . . . . . . . . . . . . . . . . . . . 20Flagyl . . . . . . . . . . . . . . . . . . . . . . . . . . 5Flecainide Acetate . . . . . . . . . . . . . . . 8Flolipid. . . . . . . . . . . . . . . . . . . . . . 8, 10Floriva Plus . . . . . . . . . . . . . . . . . . . . . 24Flovent Diskus . . . . . . . . . . . . . . . . . . 23Flovent HFA . . . . . . . . . . . . . . . . . . . . 23Fluconazole Oral . . . . . . . . . . . . . . . . 5Fluocinolone Acetonide Body . . . . . 14Fluocinolone Acetonide External Cream. . . . . . . . . . . . . . . . . . 14Fluocinolone Acetonide External Ointment . . . . . . . . . . . . . . . 14Fluocinolone Acetonide External Solution . . . . . . . . . . . . . . . . 14Fluocinolone Acetonide Scalp . . . . . 14Fluocinonide External Cream 0.05% . 14Fluocinonide External Gel. . . . . . . . . 14Fluocinonide External Ointment . . . 14Fluocinonide External Solution . . . . 14Fluoridex . . . . . . . . . . . . . . . . . . . . . . . 13Fluoridex Enhanced Whitening . . . . 13Fluoroplex . . . . . . . . . . . . . . . . . . . . . . 14Fluorouracil External Cream 0.5%. . 14Fluorouracil External Cream 5% . . . 14Fluorouracil External Solution . . . . . 14Fluoxetine . . . . . . . . . . . . . . . . . . . . . . 11Fluoxetine Capsules . . . . . . . . . . . . . 11Fluoxetine HCL Oral Capsule. . . . . . 11Fluoxetine HCL Oral Capsule Delayed Release . . . . . . . . . . . . . . . . 11Fluoxetine HCL Oral Solution. . . . . . 11Fluoxetine HCL Oral Tablet. . . . . . . . 11Fluphenazine . . . . . . . . . . . . . . . . . . . 11Fluticasone Propionate Nasal . . . . . 22Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated . . 23Fluticasone/Salmeterol Respiclick . . 23Fluvastatin . . . . . . . . . . . . . . . . . . . . . . 10Fluvastatin ER. . . . . . . . . . . . . . . . . . . 10Fluvoxamine . . . . . . . . . . . . . . . . . . . . 11Fluvoxamine Extended-Release. . . . 11Fluvoxamine Maleate. . . . . . . . . . . . . 11Fluvoxamine Maleate ER . . . . . . . . . 11Focalin. . . . . . . . . . . . . . . . . . . . . . . . . 10Folic Acid Oral Tablet 1 mg . . . . . . . 24Follistim AQ. . . . . . . . . . . . . . . . . . . . . 20Fondaparinux . . . . . . . . . . . . . . . . . . . 7Forteo . . . . . . . . . . . . . . . . . . . . . . . . . 21Fosamax . . . . . . . . . . . . . . . . . . . . . . . 21Fosamax Plus D . . . . . . . . . . . . . . . . . 21Fosamprenavir . . . . . . . . . . . . . . . . . . 19

Fosinopril . . . . . . . . . . . . . . . . . . . . . . 8Fosinopril-Hydrochlorothiazide . . . . 8Fragmin . . . . . . . . . . . . . . . . . . . . . . . . 7Freestyle Libre 14 Day Reader . . . . 15Freestyle Libre 14 Day Sensor. . . . . 15Freestyle Libre Reader . . . . . . . . . . . 15Freestyle Libre Sensor System. . . . . 15Furosemide. . . . . . . . . . . . . . . . . . . . . 8Furosemide Oral . . . . . . . . . . . . . . . . 8Fuzeon. . . . . . . . . . . . . . . . . . . . . . . . . 19

GGabapentin Oral Capsule . . . . . . . . . 13Gabapentin Oral Solution . . . . . . . . . 13Gabapentin Oral Tablet . . . . . . . . . . . 13Ganirelix Acetate Solution Prefilled Syringe 250 mcg/0.5ml Subcutaneous (Ferring) . . . . . . . . . . 20Ganirelix Acetate Solution Prefilled Syringe 250 mcg/0.5ml Subcutaneous (Merck/Organon) . . 20Gastrocrom. . . . . . . . . . . . . . . . . . . . . 23Gastrointestinal: Acid Suppression . . 18Gastrointestinal: Nausea/Vomiting . . 18Gastrointestinal: Other. . . . . . . . . . . . 18Gavilyte-C . . . . . . . . . . . . . . . . . . . . . . 18Gemfibrozil . . . . . . . . . . . . . . . . . . . . . 10Gemfibrozil Oral . . . . . . . . . . . . . . . . . 8Gengraf . . . . . . . . . . . . . . . . . . . . . 20, 23Genitourinary: Prostate Conditions . . . 19Genvoya . . . . . . . . . . . . . . . . . . . . 6, 19Gianvi. . . . . . . . . . . . . . . . . . . . . . . . . . 25Gilenya. . . . . . . . . . . . . . . . . . . . . . . . . 12Gilenya Oral Capsule. . . . . . . . . . . . . 12Glatiramer Acetate . . . . . . . . . . . . . . . 12Glatiramer Acetate [Mylan Only (Generic Copaxone)]. . . . . . . . . . . . . 12Glimepiride . . . . . . . . . . . . . . . . . . . . . 15Glipizide . . . . . . . . . . . . . . . . . . . . . . . 16Glipizide ER . . . . . . . . . . . . . . . . . . . . 16Glipizide Ir . . . . . . . . . . . . . . . . . . . . . . 16Glipizide-Metformin . . . . . . . . . . . . . . 16Glipizide Xl . . . . . . . . . . . . . . . . . . . . . 16Glucagon Emergency Injection Kit . . 16Glucophage . . . . . . . . . . . . . . . . . . . . 16Glucophage XR . . . . . . . . . . . . . . . . . 16Glucotrol . . . . . . . . . . . . . . . . . . . . . . . 16Glucotrol Xl . . . . . . . . . . . . . . . . . . . . . 16Glucovance. . . . . . . . . . . . . . . . . . . . . 16Glucovance Oral Tablet. . . . . . . . . . . 16Glyburide. . . . . . . . . . . . . . . . . . . . . . . 16Glyburide-Metformin . . . . . . . . . . . . . 16Glyburide Micronized . . . . . . . . . . . . 16Glyburide Oral . . . . . . . . . . . . . . . . . . 16Glynase . . . . . . . . . . . . . . . . . . . . . . . . 16

Glyset. . . . . . . . . . . . . . . . . . . . . . . . . . 16Glyxambi . . . . . . . . . . . . . . . . . . . . . . . 16Golytely Oral Solution Reconstituted. . 18Gonal-F . . . . . . . . . . . . . . . . . . . . . . . . 20Gonal-F RFF . . . . . . . . . . . . . . . . . . . . 20Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . 19Guaifenesin-Codeine Soln . . . . . . . . 22Guanfacine . . . . . . . . . . . . . . . . . . . . . 8Guanfacine HCL . . . . . . . . . . . . . . . . 8Guanfacine HCL ER . . . . . . . . . . . . . 10Gvoke Pfs . . . . . . . . . . . . . . . . . . . . . . 16Gynazole-1 . . . . . . . . . . . . . . . . . . . . . 5

HHaegarda . . . . . . . . . . . . . . . . . . . . . . 20Hailey 1.5/30 . . . . . . . . . . . . . . . . . . . 25Hailey 24 Fe . . . . . . . . . . . . . . . . . . . . 25Haloperidol . . . . . . . . . . . . . . . . . . . . . 11Harvoni Oral Tablet . . . . . . . . . . . . . . 6Heather . . . . . . . . . . . . . . . . . . . . . . . . 25Heparin . . . . . . . . . . . . . . . . . . . . . . . . 7Hiv / Aids . . . . . . . . . . . . . . . . . . . . . . 19Humalog . . . . . . . . . . . . . . . . . . . . . . . 15Humalog Junior . . . . . . . . . . . . . . . . . 15Humalog Kwikpen . . . . . . . . . . . . . . . 15Humalog Mix 50/50 . . . . . . . . . . . . . 15Humalog Mix 50/50 Kwikpen . . . . . 15Humalog Mix 50/50 Vial. . . . . . . . . . 15Humalog Mix 75/25 . . . . . . . . . . . . . 15Humalog Mix 75/25 Kwikpen . . . . . 15Humalog Mix 75/25 Vial. . . . . . . . . . 15Humalog Subcutaneous Solution . . 15Humalog Subcutaneous Solution Cartridge . . . . . . . . . . . . . . . 15Humalog U-100 Junior Kwikpen . . . 15Humira. . . . . . . . . . . . . . . . . . . . . . . . . 20Humira Pen. . . . . . . . . . . . . . . . . . . . . 20Humulin 50/50 . . . . . . . . . . . . . . . . . 15Humulin 70/30 . . . . . . . . . . . . . . . . . 15Humulin 70/30 Kwikpen . . . . . . . . . 15Humulin 70/30 Vial . . . . . . . . . . . . . . 15Humulin N. . . . . . . . . . . . . . . . . . . . . . 15Humulin N Kwikpen. . . . . . . . . . . . . . 15Humulin N Vial . . . . . . . . . . . . . . . . . . 15Humulin R. . . . . . . . . . . . . . . . . . . . . . 15Humulin R U-500 Kwikpen. . . . . . . . 15Humulin R U-500 Vial (Concentrated) . . . . . . . . . . . . . . . . . . 15Humulin R Vial . . . . . . . . . . . . . . . . . . 15Hydralazine. . . . . . . . . . . . . . . . . . . . . 8Hydralazine HCL Oral . . . . . . . . . . . . 8Hydrochlorothiazide . . . . . . . . . . . . . 8Hydrochlorothiazide Oral . . . . . . . . . 8Hydrocodone-Acetaminophen Oral Solution. . . . . . . . . . . . . . . . . . . . 21

31

Maricopa CountyPrescription Drug List

Page 34: Your 2020-2021 Prescription Drug List

Hydrocodone-Acetaminophen Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 21Hydrocodone Polst-Cpm Polst ER . . 22Hydrocortisone Ace-Pramoxine. . . . 18Hydrocortisone External Cream 2.5% . . . . . . . . . . . . . . . . . . . . 14Hydrocortisone External Lotion 2.5%. . . . . . . . . . . . . . . . . . . . . 14Hydrocortisone External Ointment . . 14Hydrocortisone Oral . . . . . . . . . . . . . 16Hydromorphone HCL ER . . . . . . . . . 21Hydromorphone HCL Oral . . . . . . . . 21Hydromorphone HCL Rectal . . . . . . 21Hydroxychloroquine Sulfate Oral . . . 5Hydroxyzine HCL Oral. . . . . . . . . . . . 6Hydroxyzine Pamoate Oral . . . . . . . . 6Hyoscyamine Sulfate ER. . . . . . . . . . 18Hyoscyamine Sulfate Oral. . . . . . . . . 18Hyoscyamine Sulfate Sl. . . . . . . . . . . 18Hyoscyamine Sulfate Sublingual . . . 18Hyosyne. . . . . . . . . . . . . . . . . . . . . . . . 18Hyzaar . . . . . . . . . . . . . . . . . . . . . . . . . 8

IIbandronate . . . . . . . . . . . . . . . . . . . . 21Ibandronate Sodium Oral . . . . . . . . . 21Ibrance . . . . . . . . . . . . . . . . . . . . . . . . 7Ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Ibuprofen Oral Tablet. . . . . . . . . . . . . 21Idhifa . . . . . . . . . . . . . . . . . . . . . . . . . . 7Imatinib Mesylate . . . . . . . . . . . . . . . . 7Imiquimod External . . . . . . . . . . . . . . 14Imvexxy Maintenance Pack . . . . . . . 20Inbrija. . . . . . . . . . . . . . . . . . . . . . . 12, 22Incassia . . . . . . . . . . . . . . . . . . . . . . . . 25Incruse Ellipta . . . . . . . . . . . . . . . . . . . 23Indapamide. . . . . . . . . . . . . . . . . . . . . 8Inderal . . . . . . . . . . . . . . . . . . . . . . . . . 8Indocin. . . . . . . . . . . . . . . . . . . . . . . . . 21Indomethacin ER . . . . . . . . . . . . . . . . 21Indomethacin Oral . . . . . . . . . . . . . . . 21Infertility . . . . . . . . . . . . . . . . . . . . . . . . 20Inflammatory Conditions: Rheumatoid Arthritis . . . . . . . . . . . . . 20Innopran Xl . . . . . . . . . . . . . . . . . . . . . 8Inspra. . . . . . . . . . . . . . . . . . . . . . . . . . 8Insulin Needles/Syringes . . . . . . . . . 15Insulin Syringes . . . . . . . . . . . . . . . . . 15Intrarosa . . . . . . . . . . . . . . . . . . . . . . . 20Introvale. . . . . . . . . . . . . . . . . . . . . . . . 25Inveltys. . . . . . . . . . . . . . . . . . . . . . . . . 17Invirase . . . . . . . . . . . . . . . . . . . . . . . . 19Invokamet . . . . . . . . . . . . . . . . . . . . . . 16Invokamet XR . . . . . . . . . . . . . . . . . . . 16Invokana . . . . . . . . . . . . . . . . . . . . . . . 16

Ipratropium . . . . . . . . . . . . . . . . . . . . . 23Ipratropium-Albuterol. . . . . . . . . . . . . 23Ipratropium/Albuterol . . . . . . . . . . . . 23Ipratropium Bromide Nasal . . . . . . . 22Irbesartan . . . . . . . . . . . . . . . . . . . . . . 8Irbesartan - Hydrochlorothiazide . . . 8Irbesartan-Hydrochlorothiazide . . . . 8Isentress . . . . . . . . . . . . . . . . . . . . 6, 19Isentress HD . . . . . . . . . . . . . . . . . 6, 19Isibloom. . . . . . . . . . . . . . . . . . . . . . . . 25Isosorbide Mononitrate . . . . . . . . . . . 8Isosorbide Mononitrate ER. . . . . . . . 8Isotretinoin Oral . . . . . . . . . . . . . . . . . 14Isradipine . . . . . . . . . . . . . . . . . . . . . . 8Istalol . . . . . . . . . . . . . . . . . . . . . . . . . . 17

JJantoven . . . . . . . . . . . . . . . . . . . . . . . 7Jardiance . . . . . . . . . . . . . . . . . . . . . . 16Jasmiel . . . . . . . . . . . . . . . . . . . . . . . . 25Jencycla . . . . . . . . . . . . . . . . . . . . . . . 25Jentadueto . . . . . . . . . . . . . . . . . . . . . 16Jentadueto XR . . . . . . . . . . . . . . . . . . 16Jivi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Jolessa . . . . . . . . . . . . . . . . . . . . . . . . 25Juleber. . . . . . . . . . . . . . . . . . . . . . . . . 25Juluca . . . . . . . . . . . . . . . . . . . . . . 6, 19Junel 1.5/30. . . . . . . . . . . . . . . . . . . . 25Junel 1/20 . . . . . . . . . . . . . . . . . . . . . 25Junel FE 1.5/30 . . . . . . . . . . . . . . . . . 25Junel FE 1/20 . . . . . . . . . . . . . . . . . . 25Junel FE 24. . . . . . . . . . . . . . . . . . . . . 25

KKaletra . . . . . . . . . . . . . . . . . . . . . . . . . 19Kalliga . . . . . . . . . . . . . . . . . . . . . . . . . 25Kapspargo . . . . . . . . . . . . . . . . . . . . . 8Kapspargo Sprinkle. . . . . . . . . . . . . . 8Kariva. . . . . . . . . . . . . . . . . . . . . . . . . . 25Kazano . . . . . . . . . . . . . . . . . . . . . . . . 16Keflex. . . . . . . . . . . . . . . . . . . . . . . . . . 5Keppra Oral . . . . . . . . . . . . . . . . . . . . 13Keppra XR . . . . . . . . . . . . . . . . . . . . . 13Ketoconazole External Cream . . . . . 5Ketoconazole External Foam . . . . . . 6Ketoconazole External Shampoo . . 6Ketorolac Tromethamine Ophthalmic . . . . . . . . . . . . . . . . . . . . . 17Ketorolac Tromethamine Oral . . . . . 21Klor-Con . . . . . . . . . . . . . . . . . . . . . . . 24Klor-Con 10 . . . . . . . . . . . . . . . . . . . . 24Klor-Con M10. . . . . . . . . . . . . . . . . . . 24Klor-Con M15. . . . . . . . . . . . . . . . . . . 24Klor-Con M20. . . . . . . . . . . . . . . . . . . 24Klor-Con Sprinkle . . . . . . . . . . . . . . . 24

Kogenate Fs . . . . . . . . . . . . . . . . . . . . 6Kombiglyze XR. . . . . . . . . . . . . . . . . . 16Kovaltry . . . . . . . . . . . . . . . . . . . . . . . . 6Krintafel . . . . . . . . . . . . . . . . . . . . . . . . 5K-Tab . . . . . . . . . . . . . . . . . . . . . . . . . . 24Kurvelo . . . . . . . . . . . . . . . . . . . . . . . . 25

LLabetalol . . . . . . . . . . . . . . . . . . . . . . . 8Labetalol HCL Oral . . . . . . . . . . . . . . 8Lamictal. . . . . . . . . . . . . . . . . . . . . . . . 13Lamictal Odt Oral Tablet Dispersible . 13Lamictal XR . . . . . . . . . . . . . . . . . . . . 13Lamivudine . . . . . . . . . . . . . . . . . . . . . 19Lamivudine-Zidovudine . . . . . . . . . . 19Lamotrigine ER . . . . . . . . . . . . . . . . . 13Lamotrigine Oral Tablet. . . . . . . . . . . 13Lamotrigine Oral Tablet Chewable . . 13Lamotrigine Oral Tablet Dispersible . . 13Lantus . . . . . . . . . . . . . . . . . . . . . . . . . 15Lantus Solostar . . . . . . . . . . . . . . . . . 15Lantus U-100 Vial . . . . . . . . . . . . . . . 15Larin 1.5/30 . . . . . . . . . . . . . . . . . . . . 25Larin 1/20. . . . . . . . . . . . . . . . . . . . . . 25Larin 24 FE . . . . . . . . . . . . . . . . . . . . . 25Larin FE 1.5/30 . . . . . . . . . . . . . . . . . 25Larin FE 1/20 . . . . . . . . . . . . . . . . . . . 25Larissia . . . . . . . . . . . . . . . . . . . . . . . . 25Lasix. . . . . . . . . . . . . . . . . . . . . . . . . . . 8Lastacaft . . . . . . . . . . . . . . . . . . . . . . . 17Latanoprost Ophthalmic . . . . . . . . . . 17Latuda . . . . . . . . . . . . . . . . . . . . . . . . . 11Ledipasvir-Sofosbuvir . . . . . . . . . . . . 6Lescol . . . . . . . . . . . . . . . . . . . . . . . . . 10Lessina . . . . . . . . . . . . . . . . . . . . . . . . 25Letrozole . . . . . . . . . . . . . . . . . . . . . . . 6Letrozole Oral . . . . . . . . . . . . . . . . . . . 7Levalbuterol HFA . . . . . . . . . . . . . . . . 23Levalbuterol HFA Inhalation Aerosol 45 mcg/act. . . . . . . . . . . . . . 23Levalbuterol Nebulized Solution . . . 23Levaquin Oral Tablet . . . . . . . . . . . . . 5Levbid . . . . . . . . . . . . . . . . . . . . . . . . . 18Levetiracetam ER. . . . . . . . . . . . . . . . 13Levetiracetam Oral. . . . . . . . . . . . . . . 13Levocetirizine Dihydrochloride Oral Solution. . . . . . . . . . . . . . . . . . . . 22Levocetirizine Dihydrochloride Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 22Levofloxacin Oral . . . . . . . . . . . . . . . . 5Levonorgest-Eth Estrad 91-Day Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 25Levonorgestrel-Ethinyl Estrad Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 25Levora 0.15/30 (28) . . . . . . . . . . . . . 25

32

Page 35: Your 2020-2021 Prescription Drug List

Levo-T . . . . . . . . . . . . . . . . . . . . . . . . . 17Levothyroxine-Liothyronine Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 17Levothyroxine Sodium Oral . . . . . . . 17Levoxyl. . . . . . . . . . . . . . . . . . . . . . . . . 17Levsin Oral . . . . . . . . . . . . . . . . . . . . . 18Levsin/SL . . . . . . . . . . . . . . . . . . . . . . 18Lexapro . . . . . . . . . . . . . . . . . . . . . . . . 11Lexiva. . . . . . . . . . . . . . . . . . . . . . . . . . 19Lialda . . . . . . . . . . . . . . . . . . . . . . . . . . 18Lidocaine External Ointment . . . . . . 21Lidocaine External Patch . . . . . . . . . 21Lidocaine HCL Mouth/Throat . . . . . 13Lidocaine-Prilocaine External Cream. . . . . . . . . . . . . . . . . . 21Lidocaine Viscous Mouth/Throat Solution 2%. . . . . . . . . . . . . . . . . . . . . 13Lillow . . . . . . . . . . . . . . . . . . . . . . . . . . 25Linzess . . . . . . . . . . . . . . . . . . . . . . . . 18Liothyronine Sodium Oral. . . . . . . . . 17Lisinopril . . . . . . . . . . . . . . . . . . . . . . . 8Lisinopril-Hydrochlorothiazide . . . . . 8Lisinopril Oral . . . . . . . . . . . . . . . . . . . 8Lithium Carbonate ER. . . . . . . . . . . . 12Lithium Carbonate Oral. . . . . . . . . . . 12Lithobid . . . . . . . . . . . . . . . . . . . . . . . . 12Lokelma. . . . . . . . . . . . . . . . . . . . . . . . 24Lo Loestrin FE . . . . . . . . . . . . . . . . . . 25Lomotil. . . . . . . . . . . . . . . . . . . . . . . . . 18Lopid . . . . . . . . . . . . . . . . . . . . . . . 8, 10Lopressor . . . . . . . . . . . . . . . . . . . . . . 8Lorazepam Intensol . . . . . . . . . . . . . . 6Lorazepam Oral Concentrate. . . . . . 6Lorazepam Oral Tablet . . . . . . . . . . . 6Lorcet . . . . . . . . . . . . . . . . . . . . . . . . . 21Lorcet HD . . . . . . . . . . . . . . . . . . . . . . 21Lorcet Plus . . . . . . . . . . . . . . . . . . . . . 21Lortab . . . . . . . . . . . . . . . . . . . . . . . . . 21Loryna . . . . . . . . . . . . . . . . . . . . . . . . . 25Losartan Potassium. . . . . . . . . . . . . . 9Losartan Potassium-HCTZ . . . . . . . . 9Loseasonique. . . . . . . . . . . . . . . . . . . 25Lotemax Ophthalmic Ointment . . . . 17Lotemax Ophthalmic Suspension . . 17Lotemax SM . . . . . . . . . . . . . . . . . . . . 17Lotensin. . . . . . . . . . . . . . . . . . . . . . . . 9Lotensin Hct . . . . . . . . . . . . . . . . . . . . 9Loteprednol Etabonate . . . . . . . . . . . 17Lotrel . . . . . . . . . . . . . . . . . . . . . . . . . . 9Lotrisone . . . . . . . . . . . . . . . . . . . . . . . 14Lovastatin . . . . . . . . . . . . . . . . . . . 9, 10Low-Ogestrel . . . . . . . . . . . . . . . . . . . 25Loxapine . . . . . . . . . . . . . . . . . . . . . . . 11Lo-Zumandimine . . . . . . . . . . . . . . . . 25Lumigan . . . . . . . . . . . . . . . . . . . . . . . 18

Lutera. . . . . . . . . . . . . . . . . . . . . . . . . . 25Lynparza . . . . . . . . . . . . . . . . . . . . . . . 7Lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

MMacrobid. . . . . . . . . . . . . . . . . . . . . . . 5Macrodantin . . . . . . . . . . . . . . . . . . . . 5Malarone . . . . . . . . . . . . . . . . . . . . . . . 5Marlissa . . . . . . . . . . . . . . . . . . . . . . . . 25Matzim La . . . . . . . . . . . . . . . . . . . . . . 9Mavenclad. . . . . . . . . . . . . . . . . . . . . . 12Mavik . . . . . . . . . . . . . . . . . . . . . . . . . . 9Mavyret . . . . . . . . . . . . . . . . . . . . . . . . 6Maxitrol . . . . . . . . . . . . . . . . . . . . . . . . 17Maxzide. . . . . . . . . . . . . . . . . . . . . . . . 9Maxzide-25. . . . . . . . . . . . . . . . . . . . . 9Mayzent . . . . . . . . . . . . . . . . . . . . . . . . 12Medrol Oral Tablet . . . . . . . . . . . . . . . 16Medroxyprogesterone Acetate Intramuscular Suspension . . . . . . . . 25Medroxyprogesterone Acetate Intramuscular Suspension Prefilled Syringe . . . . . . . . . . . . . . . . . 26Medroxyprogesterone Acetate Oral . . 26Meloxicam Oral . . . . . . . . . . . . . . . . . 21Menostar . . . . . . . . . . . . . . . . . . . . . . . 26Mercaptopurine Oral . . . . . . . . . . . . . 7Mesalamine Rectal Enema. . . . . . . . 18Mesalamine Rectal Suppository . . . 19Metadate ER. . . . . . . . . . . . . . . . . . . . 10Metaproterenol . . . . . . . . . . . . . . . . . . 23Metaxalone . . . . . . . . . . . . . . . . . . . . . 20Metformin . . . . . . . . . . . . . . . . . . . . . . 16Metformin ER (Generic Glucophage XR) . . . . . . . . 16Metformin HCL ER . . . . . . . . . . . . . . 16Metformin HCL Oral Solution. . . . . . 16Metformin HCL Oral Tablet. . . . . . . . 16Methimazole Oral. . . . . . . . . . . . . . . . 17Methocarbamol Oral . . . . . . . . . . . . . 20Methotrexate Oral . . . . . . . . . . . . . . . 20Methotrexate Sodium Oral . . . . . . . . 20Methyclothiazide . . . . . . . . . . . . . . . . 9Methyldopa. . . . . . . . . . . . . . . . . . . . . 9Methyldopa-Hydrochlorothiazide. . . 9Methylin. . . . . . . . . . . . . . . . . . . . . . . . 10Methylphenidate HCL ER (Cd) . . . . 10Methylphenidate HCL ER (La) Oral Capsule Extended Release 24 Hour. . 10Methylphenidate HCL ER Oral Tablet Extended Release . . . . . . . . . 10Methylphenidate HCL Oral Solution . . 11Methylphenidate HCL Oral Tablet . . 11Methylphenidate HCL Oral Tablet Chewable . . . . . . . . . . . . . . . . 11

Methylprednisolone Oral. . . . . . . . . . 16Metoclopramide HCL Oral Solution 5 mg/5ml. . . . . . . . . . . . . . . 18Metoclopramide HCL Oral Tablet . . 18Metolazone . . . . . . . . . . . . . . . . . . . . . 9Metoprolol-Hydrochlorothiazide. . . . 9Metoprolol Succinate . . . . . . . . . . . . 9Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour . . 9Metoprolol Tartrate . . . . . . . . . . . . . . 9Metoprolol Tartrate Oral Tablet . . . . 9Metrocream . . . . . . . . . . . . . . . . . . . . 14Metrolotion . . . . . . . . . . . . . . . . . . . . . 14Metronidazole External Cream. . . . . 14Metronidazole External Gel 0.75% . 14Metronidazole External Lotion . . . . . 14Metronidazole Oral . . . . . . . . . . . . . . 5Metronidazole Vaginal. . . . . . . . . . . . 5Mevacor . . . . . . . . . . . . . . . . . . . . . . . 10Miacalcin. . . . . . . . . . . . . . . . . . . . . . . 21Microgestin 1.5/30 . . . . . . . . . . . . . . 26Microgestin 1/20 . . . . . . . . . . . . . . . . 26Microgestin FE 1.5/30 . . . . . . . . . . . 26Microgestin FE 1/20 . . . . . . . . . . . . . 26Microzide. . . . . . . . . . . . . . . . . . . . . . . 9Midamor . . . . . . . . . . . . . . . . . . . . . . . 9Miglitol . . . . . . . . . . . . . . . . . . . . . . . . . 16Mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Millipred. . . . . . . . . . . . . . . . . . . . . . . . 16Millipred DP . . . . . . . . . . . . . . . . . . . . 17Minipress. . . . . . . . . . . . . . . . . . . . . . . 9Minitran . . . . . . . . . . . . . . . . . . . . . . . . 9Minocycline HCL Oral Capsule . . . . 5Minoxidil . . . . . . . . . . . . . . . . . . . . . . . 9Mirapex . . . . . . . . . . . . . . . . . . . . . 12, 22Mircette . . . . . . . . . . . . . . . . . . . . . . . . 26Mirtazapine Oral . . . . . . . . . . . . . . . . 11Mirvaso . . . . . . . . . . . . . . . . . . . . . . . . 14Miscellaneous . . . . . . . . . . . . . . . . . . 20Misoprostol Oral. . . . . . . . . . . . . . . . . 18Mitigare . . . . . . . . . . . . . . . . . . . . . . . . 19Mobic. . . . . . . . . . . . . . . . . . . . . . . . . . 21Modafinil . . . . . . . . . . . . . . . . . . . . . . . 12Moexipril . . . . . . . . . . . . . . . . . . . . . . . 9Moexipril-Hydrochlorothiazide . . . . . 9Molindone. . . . . . . . . . . . . . . . . . . . . . 11Mometasone Furoate External . . . . . 14Mondoxyne Nl Oral Capsule . . . . . . 5Mono-Linyah. . . . . . . . . . . . . . . . . . . . 26Montelukast . . . . . . . . . . . . . . . . . . . . 23Montelukast Sodium Oral Packet . . 23Montelukast Sodium Oral Tablet . . . 23Montelukast Sodium Oral Tablet Chewable . . . . . . . . . . . . . . . . 23Morgidox Oral. . . . . . . . . . . . . . . . . . . 5

33

Maricopa CountyPrescription Drug List

Page 36: Your 2020-2021 Prescription Drug List

Morphine Sulfate (Concentrate) Oral Solution. . . . . . . . . . . . . . . . . . . . 21Morphine Sulfate ER Oral Tablet Extended Release . . . . . . . . . . . . . . . 21Morphine Sulfate Oral . . . . . . . . . . . . 21Morphine Sulfate Rectal . . . . . . . . . . 21Motegrity . . . . . . . . . . . . . . . . . . . . . . . 19Moviprep . . . . . . . . . . . . . . . . . . . . . . . 19Moxeza . . . . . . . . . . . . . . . . . . . . . . . . 17Moxifloxacin HCL Ophthalmic . . . . . 17MS Contin . . . . . . . . . . . . . . . . . . . . . . 21Mulpleta . . . . . . . . . . . . . . . . . . . . . . . 6Multaq . . . . . . . . . . . . . . . . . . . . . . . . . 9Multi-Vitamin/Fluoride. . . . . . . . . . . . 24Multivitamin/Fluoride Oral Solution. . 24Multivitamin/Fluoride Oral Tablet Chewable . . . . . . . . . . . . . . . . 24Multivitamins/Fluoride. . . . . . . . . . . . 24Mupirocin Calcium . . . . . . . . . . . . . . 5Mupirocin External. . . . . . . . . . . . . . . 5Musculoskeletal: Muscle Spasms . . 20Musculoskeletal: Osteoporosis . . . . 21Musculoskeletal: Pain Relief. . . . . . . 21MVC-Fluoride . . . . . . . . . . . . . . . . . . . 24Mycophenolate. . . . . . . . . . . . . . . . . . 23Mycophenolate Mofetil . . . . . . . . . . . 20Mycophenolate Sodium . . . . . . . . . . 20Mycophenolic Acid . . . . . . . . . . . . . . 23Myorisan . . . . . . . . . . . . . . . . . . . . . . . 14

NNabumetone Oral . . . . . . . . . . . . . . . 21Nadolol . . . . . . . . . . . . . . . . . . . . . . . . 9Nadolol-Bendroflumethazide . . . . . . 9Nadolol Oral . . . . . . . . . . . . . . . . . . . . 9Nafrinse Daily/Neutral . . . . . . . . . . . . 13Nafrinse Weekly . . . . . . . . . . . . . . . . . 13Naloxone HCL Injection . . . . . . . . . . 12Naltrexone HCL Oral . . . . . . . . . . . . . 12Naprosyn Oral Suspension. . . . . . . . 21Naproxen DR . . . . . . . . . . . . . . . . . . . 21Naproxen Oral Suspension . . . . . . . 21Naproxen Oral Tablet . . . . . . . . . . . . 21Naproxen Sodium Oral Tablet . . . . . 21Naratriptan HCL. . . . . . . . . . . . . . . . . 12Narcan. . . . . . . . . . . . . . . . . . . . . . . . . 12Nascobal . . . . . . . . . . . . . . . . . . . . . . . 24Natazia . . . . . . . . . . . . . . . . . . . . . . . . 26Nateglinide . . . . . . . . . . . . . . . . . . . . . 16Nature-Throid . . . . . . . . . . . . . . . . . . . 17Necon 0.5/35 (28). . . . . . . . . . . . . . . 26Neomycin-Polymyxin-Dexameth Ophthalmic Ointment . . . . . . . . . . . . 17Neomycin-Polymyxin-Dexameth Ophthalmic Suspension . . . . . . . . . . 17Neomycin-Polymyxin-HC Otic . . . . . 5

Nesina . . . . . . . . . . . . . . . . . . . . . . . . . 16Neuac External Gel . . . . . . . . . . . . . . 14Neulasta . . . . . . . . . . . . . . . . . . . . . . . 6Neurontin . . . . . . . . . . . . . . . . . . . . . . 13Neutral Sodium Fluoride. . . . . . . . . . 13Nevanac . . . . . . . . . . . . . . . . . . . . . . . 17Nevirapine. . . . . . . . . . . . . . . . . . . . . . 19Niacin (Antihyperlipidemic). . . . . . . . 9Niacin ER (Antihyperlipidemic) . . . . 9Niacin Extended-Release . . . . . . . . . 10Niacor . . . . . . . . . . . . . . . . . . . . . . 9, 10Niaspan . . . . . . . . . . . . . . . . . . . . . 9, 10Nicardipine . . . . . . . . . . . . . . . . . . . . . 9Nicoderm CQ . . . . . . . . . . . . . . . . . . . 24Nicorette Gum . . . . . . . . . . . . . . . . . . 24Nicorette Lozenge . . . . . . . . . . . . . . . 24Nicorette Mini-Lozenge . . . . . . . . . . . 24Nicotine Gum . . . . . . . . . . . . . . . . . . . 24Nicotine Lozenge. . . . . . . . . . . . . . . . 24Nicotine Patch . . . . . . . . . . . . . . . . . . 24Nicotrol Inhaler . . . . . . . . . . . . . . . . . . 24Nicotrol Nasal Spray . . . . . . . . . . . . . 24Nifedipine . . . . . . . . . . . . . . . . . . . . . . 9Nifedipine ER . . . . . . . . . . . . . . . . . . . 9Nifedipine Oral . . . . . . . . . . . . . . . . . . 9Nikki. . . . . . . . . . . . . . . . . . . . . . . . . . . 26Nimodipine . . . . . . . . . . . . . . . . . . . . . 9Nisoldipine . . . . . . . . . . . . . . . . . . . . . 9Nitro-Bid . . . . . . . . . . . . . . . . . . . . . . . 9Nitro-Dur . . . . . . . . . . . . . . . . . . . . . . . 9Nitrofurantoin Macrocrystal Oral . . . 5Nitrofurantoin Monohydrate Macrocrystals . . . . . . . . . . . . . . . . . . . 5Nitroglycerin Sublingual . . . . . . . . . . 9Nitroglycerin Transdermal. . . . . . . . . 9Nitromist . . . . . . . . . . . . . . . . . . . . . . . 9Nitrostat . . . . . . . . . . . . . . . . . . . . . . . . 9Nitro-Time . . . . . . . . . . . . . . . . . . . . . . 9Nityr . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nizoral . . . . . . . . . . . . . . . . . . . . . . . . . 6Nocdurna . . . . . . . . . . . . . . . . . . . . . . 16Nora-Be . . . . . . . . . . . . . . . . . . . . . . . . 26Norco. . . . . . . . . . . . . . . . . . . . . . . . . . 21Norethin Ace-Eth Estrad-Fe Oral Tablet. . . . . . . . . . . . . . . . . . . . . . 26Norethindrone Acetate Oral . . . . . . . 26Norethindrone Acet-Ethinyl Est . . . . 26Norethindrone Oral . . . . . . . . . . . . . . 26Norgestimate-Eth Estradiol. . . . . . . . 26Norgestimate-Ethinyl Estradiol Triphasic Oral Tablet . . . . . . . . . . . . . 26Norlyda . . . . . . . . . . . . . . . . . . . . . . . . 26Norlyroc. . . . . . . . . . . . . . . . . . . . . . . . 26Nortrel 0.5/35 (28) . . . . . . . . . . . . . . 26Nortrel 1/35 (21) . . . . . . . . . . . . . . . . 26Nortrel 1/35 (28) . . . . . . . . . . . . . . . . 26

Nortriptyline HCL Oral. . . . . . . . . . . . 11Norvir Oral Packet . . . . . . . . . . . . . . . 6Norvir Oral Solution . . . . . . . . . . . . . . 6Novarel Intramuscular Solution Reconstituted 5000 Unit. . . . . . . . . . 20Novoeight . . . . . . . . . . . . . . . . . . . . . . 6Novofine Autocover Pen Needle . . . 15Novofine Pen Needle . . . . . . . . . . . . 15Novofine Plus Pen Needle . . . . . . . . 15NP Thyroid . . . . . . . . . . . . . . . . . . . . . 17Nubeqa . . . . . . . . . . . . . . . . . . . . . . . . 7Nucala . . . . . . . . . . . . . . . . . . . . . . . . . 23Nucynta . . . . . . . . . . . . . . . . . . . . . . . . 21Nucynta ER. . . . . . . . . . . . . . . . . . . . . 21Nuedexta. . . . . . . . . . . . . . . . . . . . . . . 12Nulev . . . . . . . . . . . . . . . . . . . . . . . . . . 19Nutropin AQ Nuspin 5. . . . . . . . . . . . 16Nutropin AQ Nuspin 10 . . . . . . . . . . 16Nutropin AQ Nuspin 20 . . . . . . . . . . 16Nuvaring . . . . . . . . . . . . . . . . . . . . . . . 26Nuwiq . . . . . . . . . . . . . . . . . . . . . . . . . 6Nyamyc . . . . . . . . . . . . . . . . . . . . . . . . 6Nystatin External . . . . . . . . . . . . . . . . 6Nystatin Mouth/Throat . . . . . . . . . . . 6Nystop . . . . . . . . . . . . . . . . . . . . . . . . . 6

OOcella . . . . . . . . . . . . . . . . . . . . . . . . . 26Ocuflox . . . . . . . . . . . . . . . . . . . . . . . . 17Odefsey . . . . . . . . . . . . . . . . . . . . . 6, 19Ofloxacin Ophthalmic . . . . . . . . . . . . 17Ofloxacin Otic . . . . . . . . . . . . . . . . . . . 5Ogestrel. . . . . . . . . . . . . . . . . . . . . . . . 26Olanzapine . . . . . . . . . . . . . . . . . . . . . 11Olanzapine Oral Tablet . . . . . . . . . . . 11Olanzapine Oral Tablet Dispersible . . 11Olmesartan . . . . . . . . . . . . . . . . . . . . . 9Olmesartan-Hydrochlorothiazide. . . 9Olmesartan Medoxomil-HCTZ . . . . . 9Olmesartan Medoxomil Oral . . . . . . 9Olopatadine HCL Ophthalmic Solution 0.1% . . . . . . . . . . . . . . . . . . . 17Olumiant Oral Tablet . . . . . . . . . . . . . 20Omeclamox-Pak. . . . . . . . . . . . . . . . . 18Omega-3 Acid Ethyl Esters. . . . . . . . 10Omega-3-Acid Ethyl Esters. . . . . . . . 9Omeprazole Oral Capsule Delayed Release . . . . . . . . . . . . . . . . 18Ondansetron HCL Oral . . . . . . . . . . . 18Ondansetron ODT . . . . . . . . . . . . . . . 18Onetouch Diabetic Meters . . . . . . . . 15Onetouch Diabetic Test Strips . . . . . 15Onetouch Ultra 2 . . . . . . . . . . . . . . . . 15Onetouch Ultra Blue Test Strips. . . . 15Onetouch Ultra Mini. . . . . . . . . . . . . . 15

34

Page 37: Your 2020-2021 Prescription Drug List

Onetouch Verio Flex System Kit W/Device. . . . . . . . . . . . . . . . . . . . 15Onetouch Verio IQ System . . . . . . . . 15One Touch Verio Kit W/Device . . . . 15Onetouch Verio Sync System Kit W/Device. . . . . . . . . . . . . . . . . . . . 15Onetouch Verio Test Strips. . . . . . . . 15Onglyza . . . . . . . . . . . . . . . . . . . . . . . . 16Opsumit. . . . . . . . . . . . . . . . . . . . . . . . 23Orapred ODT . . . . . . . . . . . . . . . . . . . 17Orencia . . . . . . . . . . . . . . . . . . . . . . . . 20Orenitram . . . . . . . . . . . . . . . . . . . . . . 23Orilissa. . . . . . . . . . . . . . . . . . . . . . . . . 16Orsythia . . . . . . . . . . . . . . . . . . . . . . . . 26Oscimin . . . . . . . . . . . . . . . . . . . . . . . . 19Oscimin Sr . . . . . . . . . . . . . . . . . . . . . 19Oseltamivir Phosphate Oral Capsule . 6Oseltamivir Phosphate Oral Suspension Reconstituted . . . . . . . . 6Oseni . . . . . . . . . . . . . . . . . . . . . . . . . . 16Osphena . . . . . . . . . . . . . . . . . . . . . . . 20Otezla. . . . . . . . . . . . . . . . . . . . . . . . . . 20Overactive Bladder . . . . . . . . . . . . . . 22Ovidrel . . . . . . . . . . . . . . . . . . . . . . . . . 20Oxcarbazepine . . . . . . . . . . . . . . . . . . 13Oxybutynin Chloride ER . . . . . . . . . . 22Oxybutynin Chloride Oral . . . . . . . . . 22Oxycodone-Acetaminophen . . . . . . 22Oxycodone HCL Oral Capsule . . . . 21Oxycodone HCL Oral Concentrate . . 22Oxycodone HCL Oral Solution . . . . 22Oxycodone HCL Oral Tablet . . . . . . 22Ozempic . . . . . . . . . . . . . . . . . . . . . . . 16

PPacerone Oral Tablet. . . . . . . . . . . . . 9Paliperidone ER . . . . . . . . . . . . . . . . . 11Pamelor . . . . . . . . . . . . . . . . . . . . . . . . 11Pancreaze . . . . . . . . . . . . . . . . . . . . . . 18Pantoprazole Sodium Tablet Delayed Release . . . . . . . . . . . . . . . . 18Parkinson’s Disease . . . . . . . . . . . . . 22Paroex . . . . . . . . . . . . . . . . . . . . . . . . . 13Paroxetine . . . . . . . . . . . . . . . . . . . . . . 11Paroxetine Extended-Release . . . . . 11Paroxetine HCL . . . . . . . . . . . . . . . . . 11Paroxetine HCL ER . . . . . . . . . . . . . . 11Paxil . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Paxil Cr . . . . . . . . . . . . . . . . . . . . . . . . 11Paxil Oral Suspension . . . . . . . . . . . . 11Paxil Oral Tablet . . . . . . . . . . . . . . . . . 11Pediapred . . . . . . . . . . . . . . . . . . . . . . 17Peg-3350/Electrolytes . . . . . . . . . . . 19Penicillamine Oral . . . . . . . . . . . . . . . 22Penicillin V Potassium. . . . . . . . . . . . 5

Perforomist . . . . . . . . . . . . . . . . . . . . . 23Peridex . . . . . . . . . . . . . . . . . . . . . . . . 13Perindopril . . . . . . . . . . . . . . . . . . . . . 9Periogard . . . . . . . . . . . . . . . . . . . . . . 13Permethrin External . . . . . . . . . . . . . . 5Perphenazine . . . . . . . . . . . . . . . . . . . 11Pertzye . . . . . . . . . . . . . . . . . . . . . . . . 18Pexeva . . . . . . . . . . . . . . . . . . . . . . . . . 11Phenadoz . . . . . . . . . . . . . . . . . . . . . . 18Phenazo Oral Tablet 200 mg . . . . . . 22Phenazopyridine HCL Oral Tablet . . 22Philith. . . . . . . . . . . . . . . . . . . . . . . . . . 26Picato. . . . . . . . . . . . . . . . . . . . . . . . . . 14Pifeltro . . . . . . . . . . . . . . . . . . . . . . . . . 19Pimtrea . . . . . . . . . . . . . . . . . . . . . . . . 26Pindolol . . . . . . . . . . . . . . . . . . . . . . . . 9Pioglitazone . . . . . . . . . . . . . . . . . . . . 16Pioglitazone-Glimepiride . . . . . . . . . 16Pioglitazone HCL . . . . . . . . . . . . . . . . 16Pioglitazone-Metformin . . . . . . . . . . . 16Pirmella 1/35 . . . . . . . . . . . . . . . . . . . 26Plegridy . . . . . . . . . . . . . . . . . . . . . . . . 12Plenvu . . . . . . . . . . . . . . . . . . . . . . . . . 19Pletal . . . . . . . . . . . . . . . . . . . . . . . . . . 7Polymyxin B-Trimethoprim . . . . . . . . 17Polytrim . . . . . . . . . . . . . . . . . . . . . . . . 17Poly-Vi-Flor . . . . . . . . . . . . . . . . . . . . . 24Portia-28 . . . . . . . . . . . . . . . . . . . . . . . 26Potassium Chloride Crys ER . . . . . . 24Potassium Chloride ER. . . . . . . . . . . 24Potassium Chloride Oral. . . . . . . . . . 24Potassium Citrate ER . . . . . . . . . . . . 24Pradaxa . . . . . . . . . . . . . . . . . . . . . . . . 7Praluent Subcutaneous Solution Auto-Injector . . . . . . . . . . . . 9Praluent Subcutaneous Solution Pen-Injector . . . . . . . . . . . . . 9Pramipexole Dihydrochloride. . . 12, 22Prandin . . . . . . . . . . . . . . . . . . . . . . . . 16Prasugrel . . . . . . . . . . . . . . . . . . . . . . . 7Pravachol . . . . . . . . . . . . . . . . . . . 9, 10Pravastatin . . . . . . . . . . . . . . . . . . . . . 10Pravastatin Sodium . . . . . . . . . . . . . . 9Prazosin . . . . . . . . . . . . . . . . . . . . . . . 9Prazosin HCL Oral . . . . . . . . . . . . . . . 9Precose . . . . . . . . . . . . . . . . . . . . . . . . 16Pred Forte . . . . . . . . . . . . . . . . . . . . . . 17Pred Mild. . . . . . . . . . . . . . . . . . . . . . . 17Prednisolone Acetate Ophthalmic. . . 17Prednisolone Oral Solution. . . . . . . . 17Prednisolone Sodium Phosphate Oral . . . . . . . . . . . . . . . . . 17Prednisone Intensol. . . . . . . . . . . . . . 17Prednisone Oral . . . . . . . . . . . . . . . . . 17Pregabalin Oral Capsule. . . . . . . . . . 12

Pregabalin Oral Solution. . . . . . . . . . 12Pregnyl . . . . . . . . . . . . . . . . . . . . . . . . 20Premarin Oral . . . . . . . . . . . . . . . . . . . 26Premarin Vaginal . . . . . . . . . . . . . . . . 26Premium Lidocaine . . . . . . . . . . . . . . 22Premphase . . . . . . . . . . . . . . . . . . . . . 26Prempro . . . . . . . . . . . . . . . . . . . . . . . 26Prepopik . . . . . . . . . . . . . . . . . . . . . . . 19Prevalite. . . . . . . . . . . . . . . . . . . . . . . . 10Prevident 5000 Booster Plus . . . . . . 13Prevident 5000 Dry Mouth. . . . . . . . 13Prevident 5000 Ortho Defense . . . . 13Prevident 5000 Plus . . . . . . . . . . . . . 13Prevident Dental. . . . . . . . . . . . . . . . . 13Prevident Mouth/Throat . . . . . . . . . . 13Previfem . . . . . . . . . . . . . . . . . . . . . . . 26Prezcobix . . . . . . . . . . . . . . . . . . . 6, 19Prezista . . . . . . . . . . . . . . . . . . . . . 6, 19Prinivil . . . . . . . . . . . . . . . . . . . . . . . . . 9Proair HFA. . . . . . . . . . . . . . . . . . . . . . 23Proair Respiclick . . . . . . . . . . . . . . . . 23Procardia. . . . . . . . . . . . . . . . . . . . . . . 9Procardia Xl . . . . . . . . . . . . . . . . . . . . 9Procentra . . . . . . . . . . . . . . . . . . . . . . 11Prochlorperazine Maleate Oral . . . . 18Proctofoam HC . . . . . . . . . . . . . . . . . 19Progesterone Micronized Oral . . . . . 26Prograf Oral Packet . . . . . . . . . . . . . . 20Promethazine-Codeine. . . . . . . . . . . 22Promethazine-DM . . . . . . . . . . . . . . . 22Promethazine HCL Oral Syrup . . . . 18Promethazine HCL Oral Tablet . . . . 18Promethazine HCL Rectal . . . . . . . . 18Promethegan . . . . . . . . . . . . . . . . . . . 18Propranolol . . . . . . . . . . . . . . . . . . . . . 9Propranolol HCL ER . . . . . . . . . . . . . 9Propranolol HCL Oral . . . . . . . . . . . . 9Propranolol-Hydrochlorothiazide. . . 9Proscar . . . . . . . . . . . . . . . . . . . . . . . . 19Proventil HFA . . . . . . . . . . . . . . . . . . . 23Provera . . . . . . . . . . . . . . . . . . . . . . . . 26Prozac . . . . . . . . . . . . . . . . . . . . . . . . . 11Pseudoephedrine-Bromphen-DM . . 22Psoriasis . . . . . . . . . . . . . . . . . . . . . . . 20Pulmicort Flexhaler . . . . . . . . . . . . . . 23Pulmozyme. . . . . . . . . . . . . . . . . . . . . 22Purixan . . . . . . . . . . . . . . . . . . . . . . . . 7Pylera. . . . . . . . . . . . . . . . . . . . . . . . . . 18Pyridium . . . . . . . . . . . . . . . . . . . . . . . 22

QQbrelis . . . . . . . . . . . . . . . . . . . . . . . . . 9Questran . . . . . . . . . . . . . . . . . . . . . . . 10Questran Light . . . . . . . . . . . . . . . . . . 10Quetiapine . . . . . . . . . . . . . . . . . . . . . 11

35

Maricopa CountyPrescription Drug List

Page 38: Your 2020-2021 Prescription Drug List

Quetiapine ER . . . . . . . . . . . . . . . . . . 11Quetiapine Fumarate. . . . . . . . . . . . . 11Quetiapine Fumarate ER. . . . . . . . . . 11Quflora Pediatric . . . . . . . . . . . . . . . . 24Quinapril . . . . . . . . . . . . . . . . . . . . . . . 9Quinapril HCL. . . . . . . . . . . . . . . . . . . 9Quinapril-Hydrochlorothiazide . . . . . 9Qvar Redihaler . . . . . . . . . . . . . . . . . . 23

RRabeprazole Sodium Oral Tablet Delayed Release . . . . . . . . . . . . . . . . 18Raloxifene . . . . . . . . . . . . . . . . . . . . . . 21Ramipril . . . . . . . . . . . . . . . . . . . . . . . . 9Ranitidine HCL Oral Syrup . . . . . . . . 18Ranolazine ER . . . . . . . . . . . . . . . . . . 9Rapamune Oral Solution . . . . . . . . . 20Rasuvo . . . . . . . . . . . . . . . . . . . . . . . . 20Rebif . . . . . . . . . . . . . . . . . . . . . . . . . . 12Rebif Rebidose . . . . . . . . . . . . . . . . . 12Reclipsen . . . . . . . . . . . . . . . . . . . . . . 26Recombinate . . . . . . . . . . . . . . . . . . . 6Reglan . . . . . . . . . . . . . . . . . . . . . . . . . 18Remeron . . . . . . . . . . . . . . . . . . . . . . . 11Remeron Soltab . . . . . . . . . . . . . . . . . 11Repaglinide. . . . . . . . . . . . . . . . . . . . . 16Repaglinide-Metformin . . . . . . . . . . . 16Repatha. . . . . . . . . . . . . . . . . . . . . . . . 9Repatha Pushtronex System . . . . . . 9Repatha Sureclick . . . . . . . . . . . . . . . 9Rescriptor . . . . . . . . . . . . . . . . . . . . . . 19Respiratory: Allergies . . . . . . . . . . . . 22Respiratory: Anaphylaxis . . . . . . . . . 22Respiratory: Asthma / COPD. . . . . . 22Respiratory: Pulmonary Arterial Hypertension. . . . . . . . . . . . . 23Restasis. . . . . . . . . . . . . . . . . . . . . . . . 17Restoril . . . . . . . . . . . . . . . . . . . . . . . . 12Retacrit . . . . . . . . . . . . . . . . . . . . . . . . 6Retrovir . . . . . . . . . . . . . . . . . . . . . . . . 19Revlimid. . . . . . . . . . . . . . . . . . . . . . . . 7Rexulti . . . . . . . . . . . . . . . . . . . . . . . . . 11Rhopressa . . . . . . . . . . . . . . . . . . . . . 18Rilutek . . . . . . . . . . . . . . . . . . . . . . . . . 12Riluzole . . . . . . . . . . . . . . . . . . . . . . . . 12Rinvoq . . . . . . . . . . . . . . . . . . . . . . . . . 20Riomet . . . . . . . . . . . . . . . . . . . . . . . . . 16Risedronate . . . . . . . . . . . . . . . . . . . . 21Risperidone . . . . . . . . . . . . . . . . . . . . 11Ritalin. . . . . . . . . . . . . . . . . . . . . . . . . . 11Ritonavir . . . . . . . . . . . . . . . . . . . . 6, 19Rizatriptan Benzoate . . . . . . . . . . . . . 12Robaxin-750. . . . . . . . . . . . . . . . . . . . 20Rocaltrol . . . . . . . . . . . . . . . . . . . . . . . 21Rocklatan . . . . . . . . . . . . . . . . . . . . . . 18

Ropinirole HCL. . . . . . . . . . . . . . . 12, 22Rosadan External Cream . . . . . . . . . 14Rosadan External Gel . . . . . . . . . . . . 14Rosuvastatin . . . . . . . . . . . . . . . . . . . . 10Rosuvastatin Calcium . . . . . . . . . . . . 9Roweepra . . . . . . . . . . . . . . . . . . . . . . 13Roweepra XR . . . . . . . . . . . . . . . . . . . 13Roxicodone Oral Tablet . . . . . . . . . . 22Ruconest. . . . . . . . . . . . . . . . . . . . . . . 20Rybelsus . . . . . . . . . . . . . . . . . . . . . . . 16

SSaphris . . . . . . . . . . . . . . . . . . . . . . . . 11Savaysa . . . . . . . . . . . . . . . . . . . . . . . . 7Scopolamine . . . . . . . . . . . . . . . . . . . 18Seasonique. . . . . . . . . . . . . . . . . . . . . 26Seebri Neohaler . . . . . . . . . . . . . . . . . 23Selzentry . . . . . . . . . . . . . . . . . . . . . . . 19Serevent Diskus . . . . . . . . . . . . . . . . . 23Sertraline. . . . . . . . . . . . . . . . . . . . . . . 11Sertraline HCL Oral . . . . . . . . . . . . . . 11Setlakin . . . . . . . . . . . . . . . . . . . . . . . . 26SF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13SF 5000 Plus . . . . . . . . . . . . . . . . . . . 13Sfrowasa . . . . . . . . . . . . . . . . . . . . . . . 19Sharobel . . . . . . . . . . . . . . . . . . . . . . . 26Sildenafil Citrate Oral Tablet . . . . . . . 20Simliya . . . . . . . . . . . . . . . . . . . . . . . . . 26Simpesse . . . . . . . . . . . . . . . . . . . . . . 26Simponi . . . . . . . . . . . . . . . . . . . . . . . . 20Simvastatin . . . . . . . . . . . . . . . . . . . . . 10Simvastatin/Ezetimibe. . . . . . . . . . . . 10Simvastatin Oral Tablet . . . . . . . . . . . 9Sinemet . . . . . . . . . . . . . . . . . . . . . 12, 22Sinemet Cr . . . . . . . . . . . . . . . . . . . . . 12Sinemet CR . . . . . . . . . . . . . . . . . . . . 22Singulair Oral Packet. . . . . . . . . . . . . 23Sirolimus . . . . . . . . . . . . . . . . . . . . . . . 23Sirolimus Oral Solution . . . . . . . . . . . 20Sirolimus Oral Tablet . . . . . . . . . . . . . 20Skyrizi (150 mg Dose). . . . . . . . . . . . 20Smoking Cessation . . . . . . . . . . . . . . 24Sodium Fluoride 5000 Plus . . . . . . . 13Sodium Fluoride Dental . . . . . . . . . . 13Sofosbuvir-Velpatasvir . . . . . . . . . . . . 6Softclix. . . . . . . . . . . . . . . . . . . . . . . . . 15Soft Touch. . . . . . . . . . . . . . . . . . . . . . 15Soliqua . . . . . . . . . . . . . . . . . . . . . 15, 16Soma Oral Tablet 350 mg . . . . . . . . 20Sotalol HCL Oral . . . . . . . . . . . . . . . . 9Sotylize . . . . . . . . . . . . . . . . . . . . . . . . 9Spiriva Handihaler . . . . . . . . . . . . . . . 23Spiriva Respimat . . . . . . . . . . . . . . . . 23Spironolactone. . . . . . . . . . . . . . . . . . 9Spironolactone-Hydrochlorothiazide. . 10

Spironolactone Oral. . . . . . . . . . . . . . 9Sprintec 28 . . . . . . . . . . . . . . . . . . . . . 26Sprix. . . . . . . . . . . . . . . . . . . . . . . . . . . 22Sronyx . . . . . . . . . . . . . . . . . . . . . . . . . 26SSS 10-5. . . . . . . . . . . . . . . . . . . . . . . 14Starlix. . . . . . . . . . . . . . . . . . . . . . . . . . 16Stavudine . . . . . . . . . . . . . . . . . . . . . . 19Stelara Subcutaneous Solution . . . . 20Stelara Subcutaneous Solution Prefilled Syringe . . . . . . . . . . . . . . . . . 20Stendra . . . . . . . . . . . . . . . . . . . . . . . . 20Stimate . . . . . . . . . . . . . . . . . . . . . . . . 16Strensiq . . . . . . . . . . . . . . . . . . . . . . . . 18Striant . . . . . . . . . . . . . . . . . . . . . . . . . 17Stribild . . . . . . . . . . . . . . . . . . . . . . 6, 19Striverdi Respimat . . . . . . . . . . . . . . . 23Sucralfate Oral Tablet . . . . . . . . . . . . 18Sular. . . . . . . . . . . . . . . . . . . . . . . . . . . 10Sulfacetamide Sodium-Sulfur External Cream. . . . . . . . . . . . . . . . . . 14Sulfacetamide Sodium-Sulfur External Emulsion . . . . . . . . . . . . . . . 14Sulfacetamide Sodium-Sulfur External Liquid . . . . . . . . . . . . . . . . . . 14Sulfacetamide Sodium-Sulfur External Lotion . . . . . . . . . . . . . . . . . . 14Sulfacetamide Sodium-Sulfur External Pad . . . . . . . . . . . . . . . . . . . . 14Sulfacetamide Sodium-Sulfur External Suspension . . . . . . . . . . . . . 14Sulfamethoxazole-Trimethoprim Oral . 5Sulfamez Wash. . . . . . . . . . . . . . . . . . 14Sulfasalazine Oral . . . . . . . . . . . . . . . 19Sulfatrim Pediatric . . . . . . . . . . . . . . . 5Sumatriptan Succinate Oral . . . . . . . 12Sumatriptan Succinate Subcutaneous . . . . . . . . . . . . . . . . . . 12Sumaxin . . . . . . . . . . . . . . . . . . . . . . . 14Sumaxin Wash . . . . . . . . . . . . . . . . . . 14Sunosi . . . . . . . . . . . . . . . . . . . . . . . . . 12Suprep Bowel Prep Kit . . . . . . . . . . . 19Sustiva . . . . . . . . . . . . . . . . . . . . . . . . . 19Syeda. . . . . . . . . . . . . . . . . . . . . . . . . . 26Symax Duotab . . . . . . . . . . . . . . . . . . 19Symax-SL . . . . . . . . . . . . . . . . . . . . . . 19Symax-SR . . . . . . . . . . . . . . . . . . . . . . 19Symbicort . . . . . . . . . . . . . . . . . . . . . . 23Symfi . . . . . . . . . . . . . . . . . . . . . . . 6, 19Symfi Lo . . . . . . . . . . . . . . . . . . . . 6, 19Symjepi . . . . . . . . . . . . . . . . . . . . . . . . 22Symlinpen . . . . . . . . . . . . . . . . . . . . . . 16Symproic . . . . . . . . . . . . . . . . . . . . . . . 19Synjardy. . . . . . . . . . . . . . . . . . . . . . . . 16Synjardy XR . . . . . . . . . . . . . . . . . . . . 16Synthroid. . . . . . . . . . . . . . . . . . . . . . . 17Syprine . . . . . . . . . . . . . . . . . . . . . . . . 24

36

Page 39: Your 2020-2021 Prescription Drug List

TTaclonex External Suspension . . . . . 14Tacrolimus. . . . . . . . . . . . . . . . . . . . . . 23Tacrolimus Oral . . . . . . . . . . . . . . . . . 20Tadalafil Oral Tablet . . . . . . . . . . . . . . 20Takhzyro . . . . . . . . . . . . . . . . . . . . . . . 20Tamoxifen . . . . . . . . . . . . . . . . . . . . . . 6Tamoxifen Citrate Oral Tablet . . . . . . 7Tamsulosin HCL. . . . . . . . . . . . . . . . . 19Tapazole . . . . . . . . . . . . . . . . . . . . . . . 17Targretin External . . . . . . . . . . . . . . . . 7Targretin Oral . . . . . . . . . . . . . . . . . . . 7Tarina 24 FE . . . . . . . . . . . . . . . . . . . . 26Tarina FE 1/20 . . . . . . . . . . . . . . . . . . 26Tarina FE 1/20 EQ. . . . . . . . . . . . . . . 26Tarka . . . . . . . . . . . . . . . . . . . . . . . . . . 10Tasigna . . . . . . . . . . . . . . . . . . . . . . . . 7Tazorac . . . . . . . . . . . . . . . . . . . . . . . . 14Taztia Xt . . . . . . . . . . . . . . . . . . . . . . . . 10Tecfidera . . . . . . . . . . . . . . . . . . . . . . . 12Tegretol . . . . . . . . . . . . . . . . . . . . . . . . 13Tegretol-XR . . . . . . . . . . . . . . . . . . . . . 13Tegsedi . . . . . . . . . . . . . . . . . . . . . . . . 18Tekturna . . . . . . . . . . . . . . . . . . . . . . . 10Tekturna Hct . . . . . . . . . . . . . . . . . . . . 10Tekturna Oral Tablet . . . . . . . . . . . . . 10Telmisartan . . . . . . . . . . . . . . . . . . . . . 10Telmisartan-Hydrochlorothiazide . . . 10Temazepam . . . . . . . . . . . . . . . . . . . . 12Temovate. . . . . . . . . . . . . . . . . . . . . . . 14Tenofovir . . . . . . . . . . . . . . . . . . . . . . . 19Tenofovir Disoproxil Fumarate . . . . . 6Terazosin. . . . . . . . . . . . . . . . . . . . . . . 10Terazosin HCL . . . . . . . . . . . . . . . . . . 19Terbinafine HCL Oral. . . . . . . . . . . . . 6Terbutaline . . . . . . . . . . . . . . . . . . . . . 23Terconazole . . . . . . . . . . . . . . . . . . . . 6Tessalon Perles . . . . . . . . . . . . . . . . . 22Testim . . . . . . . . . . . . . . . . . . . . . . . . . 17Testosterone Cypionate Injection . . 17Testosterone Cypionate Intramuscular . . . . . . . . . . . . . . . . . . . 17Testosterone Enanthate Intramuscular . . . . . . . . . . . . . . . . . . . 17Texacort. . . . . . . . . . . . . . . . . . . . . . . . 14Theo-24. . . . . . . . . . . . . . . . . . . . . . . . 23Theophylline . . . . . . . . . . . . . . . . . . . . 23Theophylline/Guaifenesin. . . . . . . . . 23Thioridazine . . . . . . . . . . . . . . . . . . . . 11Thiothixene . . . . . . . . . . . . . . . . . . . . . 12Thrive Gum. . . . . . . . . . . . . . . . . . . . . 24Thyroid Oral Tablet . . . . . . . . . . . . . . 17Tiazac . . . . . . . . . . . . . . . . . . . . . . . . . 10Tiglutik. . . . . . . . . . . . . . . . . . . . . . . . . 12Timolol. . . . . . . . . . . . . . . . . . . . . . . . . 10

Timolol Maleate Ophthalmic Gel Forming Solution . . . . . . . . . . . . 18Timolol Maleate Ophthalmic Solution . . . . . . . . . . . . . . . . . . . . . . . . 18Timoptic . . . . . . . . . . . . . . . . . . . . . . . 18Timoptic Ocudose . . . . . . . . . . . . . . . 18Timoptic-XE . . . . . . . . . . . . . . . . . . . . 18Tirosint-Sol . . . . . . . . . . . . . . . . . . . . . 17Tivicay . . . . . . . . . . . . . . . . . . . . . . 6, 19Tizanidine HCL Oral Capsule. . . . . . 20Tizanidine HCL Oral Tablet . . . . . . . 20Tobi Podhaler . . . . . . . . . . . . . . . . . . . 22Tobradex Ophthalmic Ointment . . . 17Tobradex Ophthalmic Suspension . 17Tobramycin-Dexamethasone . . . . . . 17Tobramycin Ophthalmic . . . . . . . . . . 17Tobrex Ophthalmic Ointment . . . . . . 17Tobrex Ophthalmic Solution. . . . . . . 17Tolbutamide . . . . . . . . . . . . . . . . . . . . 16Topamax . . . . . . . . . . . . . . . . . . . . . . . 13Topiramate Oral . . . . . . . . . . . . . . . . . 13Toprol Xl . . . . . . . . . . . . . . . . . . . . . . . 10Toremifene . . . . . . . . . . . . . . . . . . . . . 6Torsemide . . . . . . . . . . . . . . . . . . . . . . 10Toujeo . . . . . . . . . . . . . . . . . . . . . . . . . 15Toujeo Max Solostar . . . . . . . . . . . . . 15Toujeo Solostar . . . . . . . . . . . . . . . . . 15Toviaz. . . . . . . . . . . . . . . . . . . . . . . . . . 22Tracleer . . . . . . . . . . . . . . . . . . . . . . . . 23Tradjenta . . . . . . . . . . . . . . . . . . . . . . . 16Tramadol HCL ER Oral Capsule Extended Release 24 Hour . . . . . . . 22Tramadol HCL ER Oral Tablet Extended Release 24 Hour . . . . . . . 22Tramadol HCL LR . . . . . . . . . . . . . . . 22Trandolapril . . . . . . . . . . . . . . . . . . . . . 10Trandolapril-Verapamil . . . . . . . . . . . 10Transderm Scop (1.5 mg). . . . . . . . . 18Transplant . . . . . . . . . . . . . . . . . . . . . . 24Travatan Z . . . . . . . . . . . . . . . . . . . . . . 18Travoprost (Bak Free) . . . . . . . . . . . . 18Trazodone HCL Oral . . . . . . . . . . . . . 11Trelegy Ellipta . . . . . . . . . . . . . . . . . . . 23Tremfya . . . . . . . . . . . . . . . . . . . . . . . . 20Tretinoin Cream 0.025% External . . 14Tretinoin External Cream 0.05% . . . 14Trexall. . . . . . . . . . . . . . . . . . . . . . . . . . 20Trezix . . . . . . . . . . . . . . . . . . . . . . . . . . 22Triamcinolone Acetonide External Aerosol Solution . . . . . . . . . 14Triamcinolone Acetonide External Cream. . . . . . . . . . . . . . . . . . 14Triamcinolone Acetonide External Lotion . . . . . . . . . . . . . . . . . . 14Triamcinolone Acetonide External Ointment . . . . . . . . . . . . . . . 14

Triamterene. . . . . . . . . . . . . . . . . . . . . 10Triamterene-Hctz . . . . . . . . . . . . . . . . 10Triamterene-Hydrochlorothiazide . . 10Triazolam. . . . . . . . . . . . . . . . . . . . . . . 6Triderm External Cream . . . . . . . . . . 14Tridesilon. . . . . . . . . . . . . . . . . . . . . . . 14Tri-Estarylla . . . . . . . . . . . . . . . . . . . . . 26Tri Femynor. . . . . . . . . . . . . . . . . . . . . 26Trifluoperazine . . . . . . . . . . . . . . . . . . 12Trileptal . . . . . . . . . . . . . . . . . . . . . . . . 13Tri-Linyah. . . . . . . . . . . . . . . . . . . . . . . 26Tri-Lo-Estarylla . . . . . . . . . . . . . . . . . . 26Tri-Lo-Marzia . . . . . . . . . . . . . . . . . . . . 26Tri-Lo-Mili . . . . . . . . . . . . . . . . . . . . . . . 26Tri-Lo-Sprintec . . . . . . . . . . . . . . . . . . 26Tri-Mili . . . . . . . . . . . . . . . . . . . . . . . . . 26Trintellix . . . . . . . . . . . . . . . . . . . . . . . . 11Tri-Previfem . . . . . . . . . . . . . . . . . . . . . 26Tri-Sprintec . . . . . . . . . . . . . . . . . . . . . 26Triumeq . . . . . . . . . . . . . . . . . . . . . 6, 19Tri-Vylibra. . . . . . . . . . . . . . . . . . . . . . . 26Tri-Vylibra Lo . . . . . . . . . . . . . . . . . . . . 26Trizivir. . . . . . . . . . . . . . . . . . . . . . . . . . 19Trulicity . . . . . . . . . . . . . . . . . . . . . . . . 16Truvada . . . . . . . . . . . . . . . . . . . . . 6, 19Tulana . . . . . . . . . . . . . . . . . . . . . . . . . 26Tussicaps . . . . . . . . . . . . . . . . . . . . . . 22Tylenol With Codeine . . . . . . . . . . . . 22Tymlos . . . . . . . . . . . . . . . . . . . . . . . . . 21Tyvaso . . . . . . . . . . . . . . . . . . . . . . . . . 24

UUceris Oral . . . . . . . . . . . . . . . . . . . . . 19Uceris Rectal . . . . . . . . . . . . . . . . . . . 19Ulcerative Colitis. . . . . . . . . . . . . . . . . 20Ultram . . . . . . . . . . . . . . . . . . . . . . . . . 22Unithroid . . . . . . . . . . . . . . . . . . . . . . . 17Urocit-K 5 . . . . . . . . . . . . . . . . . . . . . . 24Urocit-K 10 . . . . . . . . . . . . . . . . . . . . . 24Urocit-K 15 . . . . . . . . . . . . . . . . . . . . . 24Uroxatral . . . . . . . . . . . . . . . . . . . . . . . 19Urso 250 . . . . . . . . . . . . . . . . . . . . . . . 19Ursodiol Oral. . . . . . . . . . . . . . . . . . . . 19Urso Forte . . . . . . . . . . . . . . . . . . . . . . 19

VValacyclovir HCL Oral . . . . . . . . . . . . 6Valsartan . . . . . . . . . . . . . . . . . . . . . . . 10Valsartan-Hydrochlorothiazide . . . . . 10Vanatol LQ . . . . . . . . . . . . . . . . . . . . . 22Vanatol S . . . . . . . . . . . . . . . . . . . . . . . 22Vandazole . . . . . . . . . . . . . . . . . . . . . . 5Varubi . . . . . . . . . . . . . . . . . . . . . . . . . 18Vascepa Oral Capsule. . . . . . . . . . . . 10Velphoro . . . . . . . . . . . . . . . . . . . . . . . 22

37

Maricopa CountyPrescription Drug List

Page 40: Your 2020-2021 Prescription Drug List

Veltassa . . . . . . . . . . . . . . . . . . . . . . . . 24Vemlidy . . . . . . . . . . . . . . . . . . . . . . . . 6Venlafaxine HCL . . . . . . . . . . . . . . . . 11Venlafaxine HCL ER Oral Capsule Extended Release 24 Hour . . . . . . . 11Ventolin HFA. . . . . . . . . . . . . . . . . . . . 23Verapamil . . . . . . . . . . . . . . . . . . . . . . 10Verapamil ER . . . . . . . . . . . . . . . . . . . 10Verapamil HCL ER Oral Capsule Extended Release 24 Hour . . . . . . . 10Verapamil HCL ER Oral Tablet Extended Release . . . . . . . . . . . . . . . 10Verapamil HCL Oral. . . . . . . . . . . . . . 10Verelan . . . . . . . . . . . . . . . . . . . . . . . . 10Verelan Pm . . . . . . . . . . . . . . . . . . . . . 10Verzenio . . . . . . . . . . . . . . . . . . . . . . . 7Viberzi . . . . . . . . . . . . . . . . . . . . . . . . . 19Vibramycin Oral Capsule . . . . . . . . . 5Vibramycin Oral Suspension Reconstituted . . . . . . . . . . . . . . . . . . . 5Victoza. . . . . . . . . . . . . . . . . . . . . . . . . 16Victoza Solution Pen-Injector . . . . . . 16Videx . . . . . . . . . . . . . . . . . . . . . . . . . . 19Videx EC . . . . . . . . . . . . . . . . . . . . . . . 19Vienva . . . . . . . . . . . . . . . . . . . . . . . . . 26Viibryd . . . . . . . . . . . . . . . . . . . . . . . . . 11Vimpat Oral. . . . . . . . . . . . . . . . . . . . . 13Viokace . . . . . . . . . . . . . . . . . . . . . . . . 18Viorele . . . . . . . . . . . . . . . . . . . . . . . . . 26Viracept . . . . . . . . . . . . . . . . . . . . . . . . 19Viread Oral Powder . . . . . . . . . . . . . . 6Viread Oral Tablet . . . . . . . . . . . . . . . 6Vistaril . . . . . . . . . . . . . . . . . . . . . . . . . 6Vitamin D (ERgocalciferol) Oral Capsule. . . . . . . . . . . . . . . . . . . . 24Vitamins / Electrolytes. . . . . . . . . . . . 24Vitapearl Cap . . . . . . . . . . . . . . . . . . . 24Vivelle-Dot . . . . . . . . . . . . . . . . . . . . . . 26Voltaren 1% Gel . . . . . . . . . . . . . . . . . 22Vosevi . . . . . . . . . . . . . . . . . . . . . . . . . 6Vraylar . . . . . . . . . . . . . . . . . . . . . . . . . 12Vyfemla . . . . . . . . . . . . . . . . . . . . . . . . 26Vylibra . . . . . . . . . . . . . . . . . . . . . . . . . 26Vyvanse . . . . . . . . . . . . . . . . . . . . . . . . 11

WWakix . . . . . . . . . . . . . . . . . . . . . . . . . . 12Warfarin. . . . . . . . . . . . . . . . . . . . . . . . 7Warfarin Sodium Oral . . . . . . . . . . . . 7Welchol . . . . . . . . . . . . . . . . . . . . . . . . 10Wera . . . . . . . . . . . . . . . . . . . . . . . . . . 26Westhroid . . . . . . . . . . . . . . . . . . . . . . 17Women’s Health: Hormone Replacement and Birth Control. . . . 24WP Thyroid . . . . . . . . . . . . . . . . . . . . . 17

XXarelto . . . . . . . . . . . . . . . . . . . . . . . . . 7Xeljanz . . . . . . . . . . . . . . . . . . . . . . . . . 20Xeljanz XR. . . . . . . . . . . . . . . . . . . . . . 20Xeloda . . . . . . . . . . . . . . . . . . . . . . . . . 7Xelpros . . . . . . . . . . . . . . . . . . . . . . . . 18Xepi . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Xiidra . . . . . . . . . . . . . . . . . . . . . . . . . . 17Xofluza. . . . . . . . . . . . . . . . . . . . . . . . . 6Xolegel. . . . . . . . . . . . . . . . . . . . . . . . . 6Xopenex HFA . . . . . . . . . . . . . . . . . . . 23Xtampza ER . . . . . . . . . . . . . . . . . . . . 22Xulane . . . . . . . . . . . . . . . . . . . . . . . . . 26Xyrem. . . . . . . . . . . . . . . . . . . . . . . . . . 12

YYasmin 28 . . . . . . . . . . . . . . . . . . . . . . 26Yaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Yupelri . . . . . . . . . . . . . . . . . . . . . . . . . 23Yuvafem. . . . . . . . . . . . . . . . . . . . . . . . 26

ZZafirlukast . . . . . . . . . . . . . . . . . . . . . . 23Zarah . . . . . . . . . . . . . . . . . . . . . . . . . . 26Zarxio. . . . . . . . . . . . . . . . . . . . . . . . . . 6Zebutal . . . . . . . . . . . . . . . . . . . . . . . . 22Zejula . . . . . . . . . . . . . . . . . . . . . . . . . . 7Zelnorm. . . . . . . . . . . . . . . . . . . . . . . . 19Zenatane . . . . . . . . . . . . . . . . . . . . . . . 14Zenpep . . . . . . . . . . . . . . . . . . . . . . . . 18Zepatier . . . . . . . . . . . . . . . . . . . . . . . . 6

Zerit . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Zetonna . . . . . . . . . . . . . . . . . . . . . . . . 22Ziac . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Ziac Oral Tablet . . . . . . . . . . . . . . . . . 10Ziagen . . . . . . . . . . . . . . . . . . . . . . . . . 20Zidovudine . . . . . . . . . . . . . . . . . . . . . 20Ziprasidone. . . . . . . . . . . . . . . . . . . . . 12Ziprasidone HCL . . . . . . . . . . . . . . . . 12Zithromax Oral Packet . . . . . . . . . . . 5Zithromax Oral Suspension Reconstituted . . . . . . . . . . . . . . . . . . . 5Zithromax Oral Tablet . . . . . . . . . . . . 5Zithromax Tri-Pak. . . . . . . . . . . . . . . . 5Zithromax Z-Pak . . . . . . . . . . . . . . . . . 5Zocor . . . . . . . . . . . . . . . . . . . . . . . . . . 10Zocor Oral Tablet . . . . . . . . . . . . . . . . 10Zofran . . . . . . . . . . . . . . . . . . . . . . . . . 18Zohydro ER. . . . . . . . . . . . . . . . . . . . . 22Zoloft . . . . . . . . . . . . . . . . . . . . . . . . . . 11Zolpidem Tartrate Oral . . . . . . . . . . . 12Zonegran. . . . . . . . . . . . . . . . . . . . . . . 13Zonisamide Oral. . . . . . . . . . . . . . . . . 13Zontivity . . . . . . . . . . . . . . . . . . . . . . . . 7Zortress . . . . . . . . . . . . . . . . . . . . . . . . 24Zovirax Oral . . . . . . . . . . . . . . . . . . . . 6Zubsolv . . . . . . . . . . . . . . . . . . . . . . . . 12Zumandimine . . . . . . . . . . . . . . . . . . . 26Zyflo . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Zyflo CR. . . . . . . . . . . . . . . . . . . . . . . . 23Zyloprim . . . . . . . . . . . . . . . . . . . . . . . 19Zytiga . . . . . . . . . . . . . . . . . . . . . . . . . . 7

38

Page 41: Your 2020-2021 Prescription Drug List

Notes

39

Maricopa CountyPrescription Drug List

Page 42: Your 2020-2021 Prescription Drug List

Notes

40

Page 43: Your 2020-2021 Prescription Drug List

Notice

41

Maricopa CountyPrescription Drug List

Page 44: Your 2020-2021 Prescription Drug List

All branded medications are trademarks or registered trademarks of their respective owners.©

The content provided is for informational purposes only, and does not constitute medical advice. Always consult your doctor before making any decisions about medical care. The services outlined here do not necessarily reflect the services, vaccine, screenings or tests that will be covered under your benefit plan. Always refer to your plan documents for specific benefit coverage and limitations or call the toll-free member phone number on the back of your ID card. Certain procedures may not be fully covered under some benefit plans.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

Prescription Drug List – Maricopa County Advantage Three-Tier 7/20 Consumer 3/20 © 2020 United HealthCare Services, Inc.