1
Fidelis Care
2023 List of Covered Drugs
PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN.
Members must use network pharmacies to fill their prescription drugs. Your benefits, drug
list, pharmacy network, premium and/or copayments/coinsurance may sometimes change.
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What is the Fidelis Care Drug List?
A drug list is a list of covered drugs. Fidelis Care works with a team of health care providers
to choose drugs that provide quality treatment. Fidelis Care covers drugs on our drug list,
as long as:
• The drug is medically necessary
• The prescription is filled at a Fidelis Care network pharmacy
• Other plan rules are followed
For more information on how to fill your prescriptions, please review your plan document
or other plan materials.
Can the Drug List change?
The drug list may change from time to time as described in the plan document or other
plan materials. The enclosed drug list is the most current drug list covered by Fidelis
Care. To get updated information about the drugs covered by Fidelis Care, please
visit www.fideliscare.org or call Member Services at 1-888-343-3547, 7 days a week,
and 24 hours a day.
How do I use the Drug List?
There are two ways to find your drug on the drug list:
1. Medical Condition
The drug list starts on page (5). The drugs on this drug list are grouped by the type of
medical conditions they are used to treat. For example, drugs used to treat a heart
condition are listed under “Cardiovascular”
• If you know what your drug is used for, look for the category name in the list that starts
on page (5)
• Then look under the category name for your drug
2. Alphabetical Listing
If you are not sure what category to look under, look for your drug in the Index that starts
on page 123. The Index is an alphabetical list of all the drugs in this document. Both
brand name drugs and generic drugs are in the Index.
• Look in the Index and find your drug
• Next to your drug, see the page number where you can find coverage
information
• Turn to the page listed in the Index and find the name of your drug in the
first column of the list
For more information about your Fidelis Care prescription drug coverage, please look at
your plan document and other plan materials. If you have questions about Fidelis Care,
or this drug list please visit www.fideliscare.org or call Member Services at 1-888-343-
3547, 7 days a week, 24 hours a day.
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Fidelis Care Drug List
The drug list gives information about the drugs covered by Fidelis Care. A generic drug is
approved by the FDA as having the same active ingredient as the brand-name drug.
Generic drugs usually cost less than brand-name drugs, but provide the same quality of
treatment. Upon release of a generic drug to the market, the generic drug will generally
be added to the formulary and the associated brand drug will be removed. However,
some generic drugs do not cost less than brand-name drugs and may not be added to
your formulary.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin).
The information in the Requirements/Limits column tells you if Fidelis Care has any special
requirements for coverage of your drug. These requirements and limits may include:
• Prior Authorization: Fidelis Care needs you (or your doctor) to get prior approval
or authorization for certain drugs. This means that you need to get approval from
Fidelis Care before you fill your prescriptions. If you don’t get approval, Fidelis
Care may not cover the drug
• Quantity Limits: For certain drugs, Fidelis Care limits the amount of the drug that
it will cover. For example, Fidelis Care provides 2 inhalers per 25 days per
prescription for albuterol sulfate inhaler. Fidelis Care also limits the amount of
drugs you can receive within a class of drugs. These classes have an “§” next to
them on the drug list. For these classes, only one drug should be taken at a time
for safety reasons. This may be in addition to a standard one-month or three-
month supply
• Step Therapy: Fidelis Care needs you to try certain drugs as the first step to treat
your medical condition before covering another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, Fidelis Care may
not cover Drug B unless you try Drug A first. If Drug A does not work for you,
Fidelis Care will then cover Drug B
Why do my diabetes drugs have a different copayment*?
Some diabetes supplies, insulin, and oral medications are provided as a part of a
separate benefit setup. This means that the amount you pay may differ from the other
drugs listed on this formulary. These drugs have a ‘^’ next to them on the drug list. See
your Summary of Benefits to find out how much you will pay for these drugs.
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What if my drug is not on the Drug List?
If your drug is not on this drug list, call Member Services and make sure that your drug is
not covered. If you learn that Fidelis Care does not cover your drug, you have two
choices:
• Ask Member Services for a list of similar drugs that are covered by Fidelis Care.
When you get the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by Fidelis Care. Similar drugs that are preferred and covered
by your plan’s formulary may be easier to obtain and lower cost to you than non-
preferred drugs.
• Ask Fidelis Care to make an exception and cover your drug. You can ask us to cover
your drug even if it is not on our drug list.
How likely is it that I will get an exception?
Generally, Fidelis Care will only approve your request for an exception if the preferred
drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization
restrictions would:
• Not be as effective in treating your condition
• Cause you to have adverse medical effects
How do I find out if my exception is granted?
When you ask for a drug list formulary exception, please send a statement from
your prescriber that supports your request. Then:
• We will make our decision within 24 hours of receipt of the information necessary to make
a decision.
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
5
Effective 04/01/2023
Drug Name
Drug Tier
Requirements/Limits
ANALGESICS
COX-2 INHIBITORS
celecoxib caps 50mg, 100mg, 200mg
1
GOUT
allopurinol tabs 100mg, 300mg
1
colchicine tabs .6mg
1
colchicine w/ probenecid tab 0.5-500 mg
1
febuxostat tabs 40mg, 80mg
1
ST; PA**
probenecid tabs 500mg
1
NSAIDS, COMBINATIONS§
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg
1
diclofenac w/ misoprostol tab delayed
release 75-0.2 mg
1
NSAIDS§
diclofenac potassium tabs 50mg
1
diclofenac sodium tb24 100mg; tbec
25mg, 50mg, 75mg
1
etodolac caps 200mg, 300mg; tabs
400mg, 500mg; tb24 400mg, 500mg,
600mg
1
fenoprofen calcium tabs 600mg
3
flurbiprofen tabs 50mg, 100mg
1
ibuprofen susp 100mg/5ml; tabs 400mg,
600mg, 800mg
1
ketorolac tromethamine soln 15mg/ml,
30mg/ml
1
ketorolac tromethamine tabs 10mg
1
QL (20 tabs every 30
days)
meclofenamate sodium caps 50mg,
100mg
1
mefenamic acid caps 250mg
1
meloxicam tabs 7.5mg, 15mg
1
nabumetone tabs 500mg, 750mg
1
naproxen tabs 250mg, 375mg, 500mg
1
oxaprozin tabs 600mg
1
piroxicam caps 10mg, 20mg
1
sulindac tabs 150mg, 200mg
1
OPIOID ANALGESICS§
acetaminophen w/ codeine soln 120-12
mg/5ml
1
ST, QL (2700 mL every
30 days); Subject to
initial 7-day limit
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
6
Drug Name
Drug Tier
Requirements/Limits
acetaminophen w/ codeine tab 300-15 mg
1
ST, QL (400 tabs every
30 days); Subject to
initial 7-day limit
acetaminophen w/ codeine tab 300-30 mg
1
ST, QL (360 tabs every
30 days); Subject to
initial 7-day limit
acetaminophen w/ codeine tab 300-60 mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
acetaminophen-caffeine-dihydrocodeine
cap 320.5-30-16 mg
1
ST, QL (300 caps every
30 days); Subject to
initial 7-day limit
butorphanol tartrate soln 10mg/ml
1
QL (2 bottles every 30
days)
codeine sulfate tabs 30mg
1
ST, QL (42 tabs every
30 days); Subject to
initial 7-day limit
CODEINE SULFATE TABS 60mg
3
ST, QL (42 tabs every
30 days); Subject to
initial 7-day limit
endocet tab 2.5-325
1
ST, QL (360 tabs every
30 days); Subject to
initial 7-day limit
endocet tab 5-325mg
1
ST, QL (360 tabs every
30 days); Subject to
initial 7-day limit
endocet tab 7.5-325
1
ST, QL (240 tabs every
30 days); Subject to
initial 7-day limit
endocet tab 10-325mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
fentanyl pt72 12mcg/hr, 25mcg/hr
1
ST, QL (10 patches
every 30 days)
fentanyl pt72 50mcg/hr, 75mcg/hr,
100mcg/hr
1
ST, PA; High Strength
Requires PA
fentanyl citrate lpop 200mcg, 400mcg,
600mcg, 800mcg, 1200mcg, 1600mcg
1
PA, QL (120 lozenges
every 30 days)
hydrocodone bitartrate t24a 20mg, 30mg,
40mg, 60mg, 80mg
1
ST, QL (30 tabs every
30 days)
hydrocodone bitartrate t24a 100mg,
120mg
1
ST, PA; High Strength
Requires PA
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
1
ST, QL (2700 mL every
30 days); Subject to
initial 7-day limit
hydrocodone-acetaminophen tab 5-325 mg
1
ST, QL (240 tabs every
30 days); Subject to
initial 7-day limit
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
7
Drug Name
Drug Tier
Requirements/Limits
hydrocodone-acetaminophen tab 7.5-325
mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
hydrocodone-acetaminophen tab 10-325
mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
hydrocodone-ibuprofen tab 10-200 mg
1
ST, QL (50 tabs every
30 days); Subject to
initial 7-day limit
hydromorphone hcl tabs 2mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
hydromorphone hcl tabs 4mg
1
ST, QL (150 tabs every
30 days); Subject to
initial 7-day limit
hydromorphone hcl tabs 8mg
1
ST, QL (60 tabs every
30 days); Subject to
initial 7-day limit
hydromorphone hcl tb24 8mg, 12mg,
16mg
1
ST, QL (30 tabs every
30 days)
hydromorphone hcl tb24 32mg
1
ST, PA; High Strength
Requires PA
methadone hcl conc 10mg/ml
1
QL (30 mL every 30
days); (indicated for
opioid addiction)
methadone hcl soln 5mg/5ml
1
ST, QL (450 mL every
30 days)
methadone hcl soln 10mg/5ml
1
ST, QL (300 mL every
30 days)
methadone hcl tabs 5mg
1
ST, QL (90 tabs every
30 days)
methadone hcl tabs 10mg
1
ST, QL (60 tabs every
30 days)
methadone hcl tbso 40mg
1
QL (9 tabs every 30
days)
methadone hydrochloride i conc 10mg/ml
1
ST, QL (60 mL every 30
days); (generic of
Methadone Intensol,
indicated for pain)
methadose tbso 40mg
1
QL (9 tabs every 30
days)
morphine sulfate cp24 10mg, 20mg,
30mg
1
ST, QL (60 caps every
30 days)
morphine sulfate cp24 50mg, 60mg,
80mg
1
ST, QL (30 caps every
30 days)
morphine sulfate cp24 100mg; tbcr 60mg,
100mg, 200mg
1
ST, PA; High Strength
Requires PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
8
Drug Name
Drug Tier
Requirements/Limits
morphine sulfate soln 10mg/5ml
1
ST, QL (900 mL every
30 days); Subject to
initial 7-day limit
morphine sulfate soln 20mg/5ml
1
ST, QL (675 mL every
30 days); Subject to
initial 7-day limit
morphine sulfate soln 20mg/ml
1
ST, QL (135 mL every
30 days); Subject to
initial 7-day limit
morphine sulfate tabs 15mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
morphine sulfate tabs 30mg
1
ST, QL (90 tabs every
30 days); Subject to
initial 7-day limit
morphine sulfate tbcr 15mg, 30mg
1
ST, QL (90 tabs every
30 days)
morphine sulfate beads cp24 30mg,
45mg, 60mg, 75mg, 90mg
1
ST, QL (30 caps every
30 days)
morphine sulfate beads cp24 120mg
1
ST, PA; High Strength
Requires PA
nalbuphine hcl soln 10mg/ml, 20mg/ml
1
NUCYNTA TABS 50mg
2
ST, QL (120 tabs every
30 days); Subject to
initial 7-day limit
NUCYNTA TABS 75mg
2
ST, QL (90 tabs every
30 days); Subject to
initial 7-day limit
NUCYNTA TABS 100mg
2
ST, QL (60 tabs every
30 days); Subject to
initial 7-day limit
NUCYNTA ER TB12 50mg, 100mg
3
ST, QL (60 tabs every
30 days)
NUCYNTA ER TB12 150mg, 200mg,
250mg
3
ST, PA; High Strength
Requires PA
oxycodone hcl caps 5mg
1
ST, QL (180 caps every
30 days); Subject to
initial 7-day limit
oxycodone hcl conc 100mg/5ml
1
ST, QL (90 mL every 30
days); Subject to initial
7-day limit
oxycodone hcl soln 5mg/5ml
1
ST, QL (900 mL every
30 days); Subject to
initial 7-day limit
oxycodone hcl t12a 10mg, 20mg
1
ST, QL (60 tabs every
30 days)
oxycodone hcl t12a 40mg, 80mg
1
ST, PA; High Strength
Requires PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
9
Drug Name
Drug Tier
Requirements/Limits
oxycodone hcl tabs 5mg, 10mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
oxycodone hcl tabs 15mg
1
ST, QL (120 tabs every
30 days); Subject to
initial 7-day limit
oxycodone hcl tabs 20mg
1
ST, QL (90 tabs every
30 days); Subject to
initial 7-day limit
oxycodone hcl tabs 30mg
1
ST, QL (60 tabs every
30 days); Subject to
initial 7-day limit
oxycodone w/ acetaminophen tab 2.5-325
mg
1
ST, QL (360 tabs every
30 days); Subject to
initial 7-day limit
oxycodone w/ acetaminophen tab 5-325
mg
1
ST, QL (360 tabs every
30 days); Subject to
initial 7-day limit
oxycodone w/ acetaminophen tab 7.5-325
mg
1
ST, QL (240 tabs every
30 days); Subject to
initial 7-day limit
oxycodone w/ acetaminophen tab 10-325
mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
oxymorphone hcl tabs 5mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
oxymorphone hcl tabs 10mg
1
ST, QL (90 tabs every
30 days); Subject to
initial 7-day limit
oxymorphone hcl tb12 5mg, 7.5mg,
10mg, 15mg
1
ST, QL (60 tabs every
30 days)
oxymorphone hcl tb12 20mg, 30mg,
40mg
1
ST, PA; High Strength
Requires PA
tramadol hcl tabs 50mg
1
ST, QL (180 tabs every
30 days); Subject to
initial 7-day limit
tramadol hcl tb24 100mg
1
ST, QL (30 tabs every
30 days)
tramadol hcl tb24 200mg, 300mg
1
ST, PA; High Strength
Requires PA
tramadol-acetaminophen tab 37.5-325 mg
1
ST, QL (40 tabs every
30 days); Subject to
initial 7-day limit
XTAMPZA ER C12A 9mg, 13.5mg, 18mg,
27mg
2
ST, QL (60 caps every
30 days)
XTAMPZA ER C12A 36mg
2
ST, PA; High Strength
Requires Prior Auth
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
10
Drug Name
Drug Tier
Requirements/Limits
OPIOID PARTIAL AGONISTS§
BELBUCA FILM 75mcg, 150mcg, 300mcg,
450mcg
2
ST, QL (60 films every
30 days)
BELBUCA FILM 600mcg, 750mcg, 900mcg
2
ST, PA; High Strength
Requires Prior Auth
buprenorphine ptwk 5mcg/hr, 7.5mcg/hr,
10mcg/hr
1
ST, QL (4 patches every
30 days)
buprenorphine ptwk 15mcg/hr, 20mcg/hr
1
ST, PA; High Strength
Requires Prior Auth
SUBLOCADE SOSY 100mg/0.5ml,
300mg/1.5ml
3
SALICYLATES
aspirin enteric coated ad tbec 81mg
0
QL (100 tabs every 30
days), OTC; $0 copay
for members at risk for
preeclampsia, otherwise
not covered
diflunisal tabs 500mg
1
goodsense aspirin chew 81mg
0
QL (100 tabs every 30
days), OTC; $0 copay
for members at risk for
preeclampsia, otherwise
not covered
ANTI-INFECTIVES
ANTHELMINTICS
EMVERM CHEW 100mg
3
QL (12 tabs every 365
days)
ivermectin tabs 3mg
1
praziquantel tabs 600mg
1
QL (24 tabs every 365
days)
ANTI-BACTERIALS - MISCELLANEOUS
fosfomycin tromethamine pack 3gm
1
neomycin sulfate tabs 500mg
1
paromomycin sulfate caps 250mg
1
sulfadiazine tabs 500mg
1
sulfamethoxazole-trimethoprim susp 200-
40 mg/5ml
1
sulfamethoxazole-trimethoprim tab 400-80
mg
1
sulfamethoxazole-trimethoprim tab 800-
160 mg
1
tinidazole tabs 250mg, 500mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
11
Drug Name
Drug Tier
Requirements/Limits
ANTIFUNGALS
amphotericin b solr 50mg
1
QL (3 vials every day);
Initial limit allows up to
a 14 day course every
365 days
CRESEMBA CAPS 186mg
3
fluconazole susr 10mg/ml, 40mg/ml; tabs
50mg, 100mg, 150mg, 200mg
1
griseofulvin microsize susp 125mg/5ml;
tabs 500mg
1
griseofulvin ultramicrosize tabs 125mg,
250mg
1
itraconazole caps 100mg; soln 10mg/ml
1
PA
NOXAFIL SUSP 40mg/ml
2
PA
nystatin tabs 500000unit
1
posaconazole tbec 100mg
3
PA
terbinafine hcl tabs 250mg
1
voriconazole susr 40mg/ml; tabs 50mg,
200mg
3
PA
ANTIMALARIALS
atovaquone-proguanil hcl tab 62.5-25 mg
1
atovaquone-proguanil hcl tab 250-100 mg
1
chloroquine phosphate tabs 250mg,
500mg
1
COARTEM TAB 20-120MG
3
mefloquine hcl tabs 250mg
1
primaquine phosphate tabs 26.3mg
1
quinine sulfate caps 324mg
1
ANTIRETROVIRAL AGENTS
abacavir sulfate soln 20mg/ml
1
QL (900 mL every 30
days)
abacavir sulfate tabs 300mg
1
QL (60 tabs every 30
days)
APTIVUS CAPS 250mg
2
QL (120 caps every 30
days)
atazanavir sulfate caps 150mg, 300mg
1
QL (30 caps every 30
days)
atazanavir sulfate caps 200mg
1
QL (60 caps every 30
days)
EDURANT TABS 25mg
2
QL (60 tabs every 30
days)
efavirenz caps 50mg, 200mg
1
QL (90 caps every 30
days)
efavirenz tabs 600mg
1
QL (30 tabs every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
12
Drug Name
Drug Tier
Requirements/Limits
emtricitabine caps 200mg
1
QL (30 caps every 30
days)
EMTRIVA SOLN 10mg/ml
2
QL (680 ml every 28
days)
etravirine tabs 100mg
1
QL (120 tabs every 30
days)
etravirine tabs 200mg
1
QL (60 tabs every 30
days)
fosamprenavir calcium tabs 700mg
1
QL (120 tabs every 30
days)
FUZEON SOLR 90mg
3
PA, QL (60 vials every
30 days)
INTELENCE TABS 25mg
2
QL (120 tabs every 30
days)
ISENTRESS CHEW 25mg, 100mg
2
QL (180 tabs every 30
days)
ISENTRESS PACK 100mg
2
QL (60 packets every 30
days)
ISENTRESS TABS 400mg
2
QL (120 tabs every 30
days)
ISENTRESS HD TABS 600mg
2
QL (60 tabs every 30
days)
lamivudine soln 10mg/ml
1
QL (960 ml every 30
days)
lamivudine tabs 150mg
1
QL (60 tabs every 30
days)
lamivudine tabs 300mg
1
QL (30 tabs every 30
days)
LEXIVA SUSP 50mg/ml
2
QL (1575 mL every 28
days)
maraviroc tabs 150mg
1
QL (60 tabs every 30
days)
maraviroc tabs 300mg
1
QL (120 tabs every 30
days)
nevirapine susp 50mg/5ml
1
QL (1200 mL every 30
days)
nevirapine tabs 200mg
1
QL (60 tabs every 30
days)
nevirapine tb24 100mg
1
QL (90 tabs every 30
days)
nevirapine tb24 400mg
1
QL (30 tabs every 30
days)
NORVIR PACK 100mg
2
QL (360 packets every
30 days)
NORVIR SOLN 80mg/ml
2
QL (480 mL every 30
days)
PREZISTA SUSP 100mg/ml
2
QL (400 ml every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
13
Drug Name
Drug Tier
Requirements/Limits
PREZISTA TABS 75mg
2
QL (300 tabs every 30
days)
PREZISTA TABS 150mg
2
QL (180 tabs every 30
days)
PREZISTA TABS 600mg
2
QL (60 tabs every 30
days)
PREZISTA TABS 800mg
2
QL (30 tabs every 30
days)
REYATAZ PACK 50mg
2
QL (180 packets every
30 days)
ritonavir tabs 100mg
1
QL (360 tabs every 30
days)
SELZENTRY SOLN 20mg/ml
2
QL (1840 mL every 30
days)
SELZENTRY TABS 25mg
2
QL (240 tabs every 30
days)
SELZENTRY TABS 75mg
2
QL (60 tabs every 30
days)
stavudine caps 15mg, 20mg, 30mg, 40mg
1
QL (60 caps every 30
days)
tenofovir disoproxil fumarate tabs 300mg
1
QL (30 tabs every 30
days)
TIVICAY TABS 10mg
2
QL (240 tabs every 30
days)
TIVICAY TABS 25mg, 50mg
2
QL (60 tabs every 30
days)
TIVICAY PD TBSO 5mg
2
QL (360 tabs every 30
days)
TROGARZO SOLN 200mg/1.33ml
3
TYBOST TABS 150mg
2
QL (30 tabs every 30
days)
VIRACEPT TABS 250mg
2
QL (300 tabs every 30
days)
VIRACEPT TABS 625mg
2
QL (120 tabs every 30
days)
VIREAD POWD 40mg/gm
2
QL (240 gm every 30
days)
VIREAD TABS 150mg, 200mg, 250mg
2
QL (30 tabs every 30
days)
zidovudine caps 100mg
1
QL (180 caps every 30
days)
zidovudine syrp 50mg/5ml
1
QL (1920 ml every 30
days)
zidovudine tabs 300mg
1
QL (60 tabs every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
14
Drug Name
Drug Tier
Requirements/Limits
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine tab 600-300
mg
1
QL (30 tabs every 30
days)
BIKTARVY TAB
2
QL (30 tabs every 30
days)
CIMDUO TAB 300-300
2
QL (30 tabs every 30
days)
DESCOVY TAB 120-15MG
2
QL (30 tabs every 30
days)
DESCOVY TAB 200/25MG
2
QL (30 tabs every 30
days); Exception
process available for $0
copay when medically
necessary for pre-
exposure prophylaxis
DOVATO TAB 50-300MG
2
QL (30 tabs every 30
days)
efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg
1
QL (30 tabs every 30
days)
efavirenz-lamivudine-tenofovir df tab 400-
300-300 mg
1
QL (30 tabs every 30
days)
efavirenz-lamivudine-tenofovir df tab 600-
300-300 mg
1
QL (30 tabs every 30
days)
emtricitabine-tenofovir disoproxil fumarate
tab 100-150 mg
1
QL (30 tabs every 30
days)
emtricitabine-tenofovir disoproxil fumarate
tab 133-200 mg
1
QL (30 tabs every 30
days)
emtricitabine-tenofovir disoproxil fumarate
tab 167-250 mg
1
QL (30 tabs every 30
days)
emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg
1
QL (30 tabs every 30
days); $0 copay for pre-
exposure prophylaxis
EVOTAZ TAB 300-150
2
QL (30 tabs every 30
days)
GENVOYA TAB
2
QL (30 tabs every 30
days)
lamivudine-zidovudine tab 150-300 mg
1
QL (60 tabs every 30
days)
lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)
1
QL (480 ml every 30
days)
lopinavir-ritonavir tab 100-25 mg
1
QL (240 tabs every 30
days)
lopinavir-ritonavir tab 200-50 mg
1
QL (120 tabs every 30
days)
ODEFSEY TAB
2
QL (30 tabs every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
15
Drug Name
Drug Tier
Requirements/Limits
PREZCOBIX TAB 800-150
2
QL (30 tabs every 30
days)
TRIUMEQ PD TAB
3
QL (180 tabs every 30
days)
TRIUMEQ TAB
3
QL (30 tabs every 30
days)
ANTITUBERCULAR AGENTS
cycloserine caps 250mg
1
ethambutol hcl tabs 100mg, 400mg
1
isoniazid syrp 50mg/5ml; tabs 100mg,
300mg
1
PASER PACK 4gm
3
PRIFTIN TABS 150mg
2
pyrazinamide tabs 500mg
1
rifabutin caps 150mg
1
rifampin caps 150mg, 300mg
1
SIRTURO TABS 20mg, 100mg
3
PA
TRECATOR TABS 250mg
2
ANTIVIRALS§
acyclovir caps 200mg; susp 200mg/5ml;
tabs 400mg, 800mg
1
adefovir dipivoxil tabs 10mg
3
BARACLUDE SOLN .05mg/ml
3
PA, QL (630 mL every
30 days)
entecavir tabs .5mg, 1mg
3
PA, QL (30 tabs every
30 days)
EPIVIR HBV SOLN 5mg/ml
2
famciclovir tabs 125mg, 250mg, 500mg
1
lamivudine (hbv) tabs 100mg
1
oseltamivir phosphate caps 30mg
1
QL (40 caps every 90
days)
oseltamivir phosphate caps 45mg, 75mg
1
QL (20 caps every 90
days)
oseltamivir phosphate susr 6mg/ml
1
QL (360 mL every 90
days)
RELENZA DISKHALER AEPB 5mg/blister
2
QL (2 inhalers every 90
days)
rimantadine hydrochloride tabs 100mg
1
valacyclovir hcl tabs 500mg, 1000mg
1
valganciclovir hcl solr 50mg/ml
3
PA, QL (1000 mL every
30 days)
valganciclovir hcl tabs 450mg
3
PA, QL (120 tabs every
30 days)
VEMLIDY TABS 25mg
3
PA, QL (30 tabs every
30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
16
Drug Name
Drug Tier
Requirements/Limits
CEPHALOSPORINS
cefaclor caps 250mg, 500mg; susr
125mg/5ml, 250mg/5ml, 375mg/5ml
1
cefadroxil caps 500mg; susr 250mg/5ml,
500mg/5ml; tabs 1gm
1
cefdinir caps 300mg; susr 125mg/5ml,
250mg/5ml
1
cefepime hcl solr 1gm, 2gm
1
cefixime caps 400mg; susr 100mg/5ml,
200mg/5ml
1
cefpodoxime proxetil susr 50mg/5ml,
100mg/5ml; tabs 100mg, 200mg
1
cefprozil susr 125mg/5ml, 250mg/5ml;
tabs 250mg, 500mg
1
ceftazidime solr 2gm
1
ceftriaxone sodium solr 1gm, 2gm,
250mg, 500mg
1
QL (2 vials every day);
Initial limit allows up to
a 14 day course every
365 days
ceftriaxone sodium solr 10gm
1
QL (0.5 vials every
day); Initial limit allows
up to a 14 day course
every 365 days
cefuroxime axetil tabs 250mg, 500mg
1
cephalexin caps 250mg, 500mg, 750mg;
susr 125mg/5ml, 250mg/5ml; tabs
250mg, 500mg
1
SUPRAX CHEW 100mg, 200mg; SUSR
500mg/5ml
2
tazicef solr 1gm
1
ERYTHROMYCINS/MACROLIDES
azithromycin pack 1gm; susr 100mg/5ml,
200mg/5ml; tabs 250mg, 500mg, 600mg
1
clarithromycin susr 125mg/5ml,
250mg/5ml; tabs 250mg, 500mg; tb24
500mg
1
DIFICID SUSR 40mg/ml; TABS 200mg
2
PA
ery-tab tbec 250mg, 333mg, 500mg
1
erythrocin stearate tabs 250mg
1
erythromycin base cpep 250mg; tabs
250mg, 500mg
1
erythromycin ethylsuccinate susr
200mg/5ml, 400mg/5ml; tabs 400mg
1
FLUOROQUINOLONES
BAXDELA TABS 450mg
3
CIPRO SUSR 500mg/5ml
3
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
17
Drug Name
Drug Tier
Requirements/Limits
ciprofloxacin hcl tabs 100mg, 250mg,
500mg, 750mg
1
levofloxacin soln 25mg/ml; tabs 250mg,
500mg, 750mg
1
moxifloxacin hcl tabs 400mg
1
ofloxacin tabs 300mg, 400mg
1
HEPATITIS C
EPCLUSA PAK 150-37.5
3
PA, QL (28 pellets every
28 days)
EPCLUSA PAK 200-50MG
3
PA, QL (28 pellets every
28 days)
EPCLUSA TAB 200-50MG
3
PA, QL (28 tabs every
28 days)
EPCLUSA TAB 400-100
3
PA, QL (28 tabs every
28 days)
HARVONI PAK
3
PA, QL (28 pellets every
28 days)
HARVONI PAK 45-200MG
3
PA, QL (28 pellets every
28 days)
HARVONI TAB 45-200MG
3
PA, QL (28 tabs every
28 days)
HARVONI TAB 90-400MG
3
PA, QL (28 tabs every
28 days)
PEGASYS SOLN 180mcg/ml; SOSY
180mcg/0.5ml
3
PA
ribavirin (hepatitis c) caps 200mg; tabs
200mg
1
PA
SOVALDI PACK 150mg, 200mg
3
ST, PA, QL (28 pellets
every 28 days)
SOVALDI TABS 200mg, 400mg
3
ST, PA, QL (28 tabs
every 28 days)
VOSEVI TAB
3
PA, QL (28 tabs every
28 days)
ZEPATIER TAB 50-100MG
3
ST, PA, QL (28 tabs
every 28 days)
MISCELLANEOUS
ALINIA SUSR 100mg/5ml
3
QL (540 mL every 30
days)
atovaquone susp 750mg/5ml
1
aztreonam solr 1gm, 2gm
1
clindamycin hcl caps 75mg, 150mg,
300mg
1
clindamycin palmitate hydrochloride solr
75mg/5ml
1
dapsone tabs 25mg, 100mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
18
Drug Name
Drug Tier
Requirements/Limits
ertapenem sodium solr 1gm
1
QL (2 vials every day);
Initial limit allows up to
a 14 day course every
365 days
linezolid susr 100mg/5ml; tabs 600mg
1
methenamine hippurate tabs 1gm
1
metronidazole caps 375mg; tabs 250mg,
500mg
1
nitazoxanide tabs 500mg
1
QL (20 tabs every 30
days)
nitrofurantoin macrocrystal caps 25mg,
50mg, 100mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
nitrofurantoin monohyd macro caps
100mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
pentamidine isethionate solr 300mg
1
pyrimethamine tabs 25mg
3
PA
trimethoprim tabs 100mg
1
TRIMETHOPRIM TABS 100mg
3
vancomycin hcl caps 125mg, 250mg
1
QL (80 caps every 10
days)
XIFAXAN TABS 200mg
2
QL (9 tabs every 30
days)
XIFAXAN TABS 550mg
2
PA
PENICILLINS
amoxicillin caps 250mg, 500mg; chew
125mg, 250mg; susr 125mg/5ml,
200mg/5ml, 250mg/5ml, 400mg/5ml; tabs
500mg, 875mg
1
amoxicillin & k clavulanate chew tab 200-
28.5 mg
1
amoxicillin & k clavulanate chew tab 400-
57 mg
1
amoxicillin & k clavulanate for susp 200-
28.5 mg/5ml
1
amoxicillin & k clavulanate for susp 250-
62.5 mg/5ml
1
amoxicillin & k clavulanate for susp 400-57
mg/5ml
1
amoxicillin & k clavulanate for susp 600-
42.9 mg/5ml
1
amoxicillin & k clavulanate tab 250-125 mg
1
amoxicillin & k clavulanate tab 500-125 mg
1
amoxicillin & k clavulanate tab 875-125 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
19
Drug Name
Drug Tier
Requirements/Limits
amoxicillin & k clavulanate tab er 12hr
1000-62.5 mg
1
ampicillin caps 500mg
1
dicloxacillin sodium caps 250mg, 500mg
1
penicillin g potassium solr 5000000unit,
20000000unit
1
penicillin g sodium solr 5000000unit
1
penicillin v potassium solr 125mg/5ml,
250mg/5ml; tabs 250mg, 500mg
1
pfizerpen solr 20000000unit
1
TETRACYCLINES
avidoxy tabs 100mg
1
demeclocycline hcl tabs 150mg, 300mg
1
doxycycline (monohydrate) caps 50mg,
100mg; susr 25mg/5ml; tabs 50mg,
75mg, 150mg
1
doxycycline hyclate caps 50mg, 100mg;
tabs 20mg, 100mg
1
minocycline hcl caps 50mg, 75mg,
100mg; tabs 50mg, 75mg, 100mg
1
tetracycline hcl caps 250mg, 500mg
1
QL (120 caps every 30
days)
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
busulfan soln 6mg/ml
1
carmustine solr 100mg
1
cyclophosphamide caps 25mg, 50mg
1
cyclophosphamide solr 1gm, 2gm, 500mg
3
dacarbazine solr 100mg, 200mg
1
EMCYT CAPS 140mg
3
GLEOSTINE CAPS 10mg, 40mg, 100mg
3
GLIADEL WAF 7.7MG
2
ifosfamide soln 1gm/20ml, 3gm/60ml;
solr 1gm
1
LEUKERAN TABS 2mg
2
MATULANE CAPS 50mg
2
melphalan tabs 2mg
1
TEMODAR SOLR 100mg
3
PA
temozolomide caps 5mg, 20mg, 100mg,
140mg, 180mg, 250mg
3
PA
ANTIBIOTICS
adriamycin solr 50mg
1
bleomycin sulfate solr 15unit, 30unit
1
daunorubicin hcl soln 20mg/4ml
1
doxorubicin hcl soln 2mg/ml; solr 10mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
20
Drug Name
Drug Tier
Requirements/Limits
doxorubicin hcl liposomal inj 2mg/ml
1
idarubicin hcl soln 5mg/5ml, 10mg/10ml,
20mg/20ml
1
mitomycin solr 5mg, 20mg, 40mg
1
mitoxantrone hcl conc 2mg/ml
3
ANTIMETABOLITES
azacitidine susr 100mg
3
PA
capecitabine tabs 150mg, 500mg
3
PA
cladribine soln 10mg/10ml
1
clofarabine soln 1mg/ml
1
cytarabine soln 20mg/ml, 100mg/ml
1
decitabine solr 50mg
3
PA
floxuridine solr .5gm
1
fludarabine phosphate soln 50mg/2ml;
solr 50mg
1
fluorouracil soln 1gm/20ml, 2.5gm/50ml,
5gm/100ml, 500mg/10ml
1
gemcitabine hcl soln 1gm/26.3ml,
2gm/52.6ml, 200mg/5.26ml; solr 1gm,
2gm, 200mg
3
mercaptopurine tabs 50mg
1
methotrexate sodium soln 1gm/40ml,
50mg/2ml, 250mg/10ml; solr 1gm
1
pemetrexed disodium solr 100mg, 500mg
3
TABLOID TABS 40mg
2
ANTIMITOTIC, TAXOIDS
docetaxel conc 20mg/ml, 80mg/4ml,
160mg/8ml; soln 20mg/2ml, 80mg/8ml,
160mg/16ml
1
paclitaxel conc 30mg/5ml, 100mg/16.7ml,
150mg/25ml, 300mg/50ml
1
paclitaxel protein-bound particles for iv
susp 100 mg
1
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate soln 1mg/ml
1
vincristine sulfate soln 1mg/ml
1
vinorelbine tartrate soln 10mg/ml,
50mg/5ml
1
ANTINEOPLASTIC, BCL-2 INHIBITORS
VENCLEXTA TABS 10mg, 50mg
3
PA, QL (120 tabs every
30 days)
VENCLEXTA TABS 100mg
3
PA, QL (180 tabs every
30 days)
VENCLEXTA TAB START PK
3
PA, QL (1 pack every 28
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
21
Drug Name
Drug Tier
Requirements/Limits
BIOLOGIC RESPONSE MODIFIERS
ERBITUX SOLN 100mg/50ml,
200mg/100ml
3
PA
ERIVEDGE CAPS 150mg
3
PA, QL (30 caps every
30 days)
GAZYVA SOLN 1000mg/40ml
3
PA
KADCYLA SOLR 100mg, 160mg
3
PA
KEYTRUDA SOLN 100mg/4ml
3
PA
POMALYST CAPS 1mg, 2mg, 3mg, 4mg
3
PA, QL (21 caps every
28 days)
REVLIMID CAPS 2.5mg, 5mg, 10mg,
15mg
3
PA, QL (28 caps every
28 days)
REVLIMID CAPS 20mg, 25mg
3
PA, QL (21 caps every
28 days)
THALOMID CAPS 50mg, 100mg
3
PA, QL (28 caps every
28 days)
THALOMID CAPS 150mg, 200mg
3
PA, QL (56 caps every
28 days)
TICE BCG SUSR 50mg
2
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone acetate tabs 250mg
3
PA, QL (120 tabs every
30 days)
abiraterone acetate tabs 500mg
3
PA, QL (60 tabs every
30 days)
anastrozole tabs 1mg
1
$0 copay for women
ages 35 and older for
the primary prevention
of breast cancer
bicalutamide tabs 50mg
1
ELIGARD KIT 7.5mg, 22.5mg, 30mg,
45mg
3
PA
ERLEADA TABS 60mg
3
PA, QL (120 tabs every
30 days)
exemestane tabs 25mg
1
$0 copay for women
ages 35 and older for
the primary prevention
of breast cancer
flutamide caps 125mg
1
fulvestrant sosy 250mg/5ml
3
PA
letrozole tabs 2.5mg
1
leuprolide acetate kit 1mg/0.2ml
3
PA
LYSODREN TABS 500mg
2
megestrol acetate susp 40mg/ml; tabs
20mg, 40mg
1
nilutamide tabs 150mg
1
NUBEQA TABS 300mg
3
PA, QL (120 tabs every
30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
22
Drug Name
Drug Tier
Requirements/Limits
tamoxifen citrate tabs 10mg, 20mg
1
$0 copay for women
ages 35 and older for
the primary prevention
of breast cancer
toremifene citrate tabs 60mg
1
XTANDI CAPS 40mg
3
PA, QL (120 caps every
30 days)
XTANDI TABS 40mg
3
PA, QL (120 tabs every
30 days)
XTANDI TABS 80mg
3
PA, QL (60 tabs every
30 days)
YONSA TABS 125mg
3
PA, QL (120 tabs every
30 days)
KINASE INHIBITORS
ALECENSA CAPS 150mg
3
PA, QL (240 caps every
30 days)
CABOMETYX TABS 20mg, 40mg, 60mg
3
PA, QL (30 tabs every
30 days)
CALQUENCE CAPS 100mg
3
PA, QL (60 caps every
30 days)
CALQUENCE TABS 100mg
3
PA, QL (60 tabs every
30 days)
CAPRELSA TABS 100mg
3
PA, QL (60 tabs every
30 days)
CAPRELSA TABS 300mg
3
PA, QL (30 tabs every
30 days)
COMETRIQ KIT 20mg
3
PA, QL (1 kit every 28
days)
COMETRIQ KIT 100MG
3
PA, QL (1 kit every 28
days)
COMETRIQ KIT 140MG
3
PA, QL (1 kit every 28
days)
erlotinib hcl tabs 25mg
3
PA, QL (60 tabs every
30 days)
erlotinib hcl tabs 100mg, 150mg
3
PA, QL (30 tabs every
30 days)
everolimus tabs 2.5mg, 5mg, 7.5mg,
10mg
3
PA, QL (30 tabs every
30 days)
everolimus tbso 2mg, 5mg
3
PA, QL (60 tabs every
30 days)
everolimus tbso 3mg
3
PA, QL (90 tabs every
30 days)
IBRANCE CAPS 75mg, 100mg, 125mg
3
PA, QL (21 caps every
28 days)
IBRANCE TABS 75mg, 100mg, 125mg
3
PA, QL (21 tabs every
28 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
23
Drug Name
Drug Tier
Requirements/Limits
ICLUSIG TABS 10mg, 15mg, 30mg, 45mg
3
PA, QL (30 tabs every
30 days)
imatinib mesylate tabs 100mg
3
PA, QL (120 tabs every
30 days)
imatinib mesylate tabs 400mg
3
PA, QL (60 tabs every
30 days)
IMBRUVICA CAPS 70mg
3
PA, QL (30 caps every
30 days)
IMBRUVICA CAPS 140mg
3
PA, QL (90 caps every
30 days)
IMBRUVICA SUSP 70mg/ml
3
PA, QL (216 ml every 36
days)
IMBRUVICA TABS 140mg, 280mg, 420mg,
560mg
3
PA, QL (30 tabs every
30 days)
INLYTA TABS 1mg
3
PA, QL (240 tabs every
30 days)
INLYTA TABS 5mg
3
PA, QL (120 tabs every
30 days)
JAKAFI TABS 5mg, 10mg, 15mg, 20mg,
25mg
3
PA, QL (60 tabs every
30 days)
KISQALI TBPK 200mg
3
PA, QL (21 tabs every
28 days); 200 mg dose
KISQALI TBPK 200mg
3
PA, QL (42 tabs every
28 days); 400 mg dose
KISQALI TBPK 200mg
3
PA, QL (63 tabs every
28 days); 600 mg dose
lapatinib ditosylate tabs 250mg
3
PA, QL (180 tabs every
30 days)
LENVIMA 4 MG DAILY DOSE CPPK 4mg
3
PA, QL (30 caps every
30 days)
LENVIMA 8 MG DAILY DOSE CPPK 4mg
3
PA, QL (60 caps every
30 days)
LENVIMA 10 MG DAILY DOSE CPPK 10mg
3
PA, QL (30 caps every
30 days)
LENVIMA 12MG DAILY DOSE CPPK 4mg
3
PA, QL (90 caps every
30 days)
LENVIMA 20 MG DAILY DOSE CPPK 10mg
3
PA, QL (60 caps every
30 days)
LENVIMA CAP 14 MG
3
PA, QL (60 caps every
30 days)
LENVIMA CAP 18 MG
3
PA, QL (90 caps every
30 days)
LENVIMA CAP 24 MG
3
PA, QL (90 caps every
30 days)
LORBRENA TABS 25mg
3
PA, QL (90 tabs every
30 days)
LORBRENA TABS 100mg
3
PA, QL (30 tabs every
30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
24
Drug Name
Drug Tier
Requirements/Limits
MEKINIST TABS 2mg
3
PA, QL (30 tabs every
30 days)
MEKINIST TABS .5mg
3
PA, QL (90 tabs every
30 days)
RYDAPT CAPS 25mg
3
PA, QL (224 caps every
28 days)
sorafenib tosylate tabs 200mg
3
PA, QL (120 tabs every
30 days)
SPRYCEL TABS 20mg
3
PA, QL (90 tabs every
30 days)
SPRYCEL TABS 50mg, 70mg, 80mg,
100mg, 140mg
3
PA, QL (30 tabs every
30 days)
STIVARGA TABS 40mg
3
PA, QL (84 tabs every
28 days)
sunitinib malate caps 12.5mg, 25mg,
37.5mg, 50mg
3
PA, QL (30 caps every
30 days)
TAFINLAR CAPS 50mg, 75mg
3
PA, QL (120 caps every
30 days)
TUKYSA TABS 50mg, 150mg
3
PA, QL (120 tabs every
30 days)
VITRAKVI CAPS 25mg
3
PA, QL (180 caps every
30 days)
VITRAKVI CAPS 100mg
3
PA, QL (60 caps every
30 days)
VITRAKVI SOLN 20mg/ml
3
PA, QL (300 mL every
30 days)
VOTRIENT TABS 200mg
3
PA, QL (120 tabs every
30 days)
XALKORI CAPS 200mg, 250mg
3
PA, QL (120 caps every
30 days)
ZELBORAF TABS 240mg
3
PA, QL (240 tabs every
30 days)
ZYDELIG TABS 100mg, 150mg
3
PA, QL (60 tabs every
30 days)
ZYKADIA TABS 150mg
3
PA, QL (90 tabs every
30 days)
MISCELLANEOUS
arsenic trioxide soln 10mg/10ml,
12mg/6ml
1
bexarotene caps 75mg
3
PA
hydroxyurea caps 500mg
1
IDHIFA TABS 50mg, 100mg
3
PA, QL (30 tabs every
30 days)
LYNPARZA TABS 100mg, 150mg
3
PA, QL (120 tabs every
30 days)
NIPENT SOLR 10mg
2
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
25
Drug Name
Drug Tier
Requirements/Limits
ODOMZO CAPS 200mg
3
PA, QL (30 caps every
30 days)
ONCASPAR SOLN 750unit/ml
3
PA
PHOTOFRIN SOLR 75mg
2
tretinoin (chemotherapy) caps 10mg
1
VISTOGARD PACK 10gm
3
QL (20 packets every 5
days)
ZEJULA CAPS 100mg
3
PA, QL (90 caps every
30 days)
ZOLINZA CAPS 100mg
3
PA, QL (120 caps every
30 days)
PLATINUM-BASED AGENTS
carboplatin soln 50mg/5ml, 150mg/15ml,
450mg/45ml, 600mg/60ml
1
cisplatin soln 50mg/50ml, 100mg/100ml,
200mg/200ml
1
oxaliplatin soln 50mg/10ml, 100mg/20ml;
solr 50mg, 100mg
3
paraplatin soln 1000mg/100ml
1
PROTECTIVE AGENTS
dexrazoxane hcl solr 250mg, 500mg
1
leucovorin calcium solr 50mg, 100mg,
200mg, 350mg, 500mg; tabs 5mg, 10mg,
15mg, 25mg
1
mesna soln 100mg/ml
1
MESNEX TABS 400mg
3
TOPOISOMERASE INHIBITORS
etoposide caps 50mg; soln 100mg/5ml
1
irinotecan hcl soln 40mg/2ml, 100mg/5ml,
500mg/25ml
3
irinotecan hcl soln 300mg/15ml
1
toposar soln 1gm/50ml, 100mg/5ml,
500mg/25ml
1
topotecan hcl solr 4mg
1
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl cap 2.5-
10 mg
1
amlodipine besylate-benazepril hcl cap 5-
10 mg
1
amlodipine besylate-benazepril hcl cap 5-
20 mg
1
amlodipine besylate-benazepril hcl cap 5-
40 mg
1
amlodipine besylate-benazepril hcl cap 10-
20 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
26
Drug Name
Drug Tier
Requirements/Limits
amlodipine besylate-benazepril hcl cap 10-
40 mg
1
benazepril & hydrochlorothiazide tab 5-
6.25 mg
1
benazepril & hydrochlorothiazide tab 10-
12.5 mg
1
benazepril & hydrochlorothiazide tab 20-
12.5 mg
1
benazepril & hydrochlorothiazide tab 20-25
mg
1
enalapril maleate & hydrochlorothiazide tab
5-12.5 mg
1
enalapril maleate & hydrochlorothiazide tab
10-25 mg
1
fosinopril sodium & hydrochlorothiazide tab
10-12.5 mg
1
fosinopril sodium & hydrochlorothiazide tab
20-12.5 mg
1
lisinopril & hydrochlorothiazide tab 10-12.5
mg
1
lisinopril & hydrochlorothiazide tab 20-12.5
mg
1
lisinopril & hydrochlorothiazide tab 20-25
mg
1
quinapril-hydrochlorothiazide tab 10-12.5
mg
1
quinapril-hydrochlorothiazide tab 20-12.5
mg
1
quinapril-hydrochlorothiazide tab 20-25 mg
1
trandolapril-verapamil hcl tab er 1-240 mg
1
trandolapril-verapamil hcl tab er 2-180 mg
1
trandolapril-verapamil hcl tab er 2-240 mg
1
trandolapril-verapamil hcl tab er 4-240 mg
1
ACE INHIBITORS
benazepril hcl tabs 5mg, 10mg, 20mg,
40mg
1
captopril tabs 12.5mg, 25mg, 50mg,
100mg
1
enalapril maleate tabs 2.5mg, 5mg,
10mg, 20mg
1
fosinopril sodium tabs 10mg, 20mg, 40mg
1
lisinopril tabs 2.5mg, 5mg, 10mg, 20mg,
30mg, 40mg
1
moexipril hcl tabs 7.5mg, 15mg
1
perindopril erbumine tabs 2mg, 4mg, 8mg
1
quinapril hcl tabs 5mg, 10mg, 20mg,
40mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
27
Drug Name
Drug Tier
Requirements/Limits
ramipril caps 1.25mg, 2.5mg, 5mg, 10mg
1
trandolapril tabs 1mg, 2mg, 4mg
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone tabs 25mg, 50mg
1
ALPHA BLOCKERS
doxazosin mesylate tabs 1mg, 2mg, 4mg,
8mg
1
prazosin hcl caps 1mg, 2mg, 5mg
1
terazosin hcl caps 1mg, 2mg, 5mg, 10mg
1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-olmesartan medoxomil
tab 5-20 mg
1
amlodipine besylate-olmesartan medoxomil
tab 5-40 mg
1
amlodipine besylate-olmesartan medoxomil
tab 10-20 mg
1
amlodipine besylate-olmesartan medoxomil
tab 10-40 mg
1
amlodipine besylate-valsartan tab 5-160
mg
1
amlodipine besylate-valsartan tab 5-320
mg
1
amlodipine besylate-valsartan tab 10-160
mg
1
amlodipine besylate-valsartan tab 10-320
mg
1
amlodipine-valsartan-hydrochlorothiazide
tab 5-160-12.5 mg
1
amlodipine-valsartan-hydrochlorothiazide
tab 5-160-25 mg
1
amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg
1
amlodipine-valsartan-hydrochlorothiazide
tab 10-160-25 mg
1
amlodipine-valsartan-hydrochlorothiazide
tab 10-320-25 mg
1
candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg
1
candesartan cilexetil-hydrochlorothiazide
tab 32-12.5 mg
1
candesartan cilexetil-hydrochlorothiazide
tab 32-25 mg
1
irbesartan-hydrochlorothiazide tab 150-
12.5 mg
1
irbesartan-hydrochlorothiazide tab 300-
12.5 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
28
Drug Name
Drug Tier
Requirements/Limits
losartan potassium & hydrochlorothiazide
tab 50-12.5 mg
1
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg
1
losartan potassium & hydrochlorothiazide
tab 100-25 mg
1
olmesartan medoxomil-hydrochlorothiazide
tab 20-12.5 mg
1
olmesartan medoxomil-hydrochlorothiazide
tab 40-12.5 mg
1
olmesartan medoxomil-hydrochlorothiazide
tab 40-25 mg
1
olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
1
olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-12.5 mg
1
olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-25 mg
1
olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-12.5 mg
1
olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-25 mg
1
telmisartan-amlodipine tab 40-5 mg
1
telmisartan-amlodipine tab 40-10 mg
1
telmisartan-amlodipine tab 80-5 mg
1
telmisartan-amlodipine tab 80-10 mg
1
telmisartan-hydrochlorothiazide tab 40-
12.5 mg
1
telmisartan-hydrochlorothiazide tab 80-
12.5 mg
1
telmisartan-hydrochlorothiazide tab 80-25
mg
1
valsartan-hydrochlorothiazide tab 80-12.5
mg
1
valsartan-hydrochlorothiazide tab 160-12.5
mg
1
valsartan-hydrochlorothiazide tab 160-25
mg
1
valsartan-hydrochlorothiazide tab 320-12.5
mg
1
valsartan-hydrochlorothiazide tab 320-25
mg
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil tabs 4mg, 8mg,
16mg, 32mg
1
irbesartan tabs 75mg, 150mg, 300mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
29
Drug Name
Drug Tier
Requirements/Limits
losartan potassium tabs 25mg, 50mg,
100mg
1
olmesartan medoxomil tabs 5mg, 20mg,
40mg
1
telmisartan tabs 20mg, 40mg, 80mg
1
valsartan tabs 40mg, 80mg, 160mg,
320mg
1
ANTIARRHYTHMICS
amiodarone hcl tabs 200mg, 400mg
1
disopyramide phosphate caps 100mg,
150mg
1
dofetilide caps 125mcg, 250mcg, 500mcg
1
PA
flecainide acetate tabs 50mg, 100mg,
150mg
1
MULTAQ TABS 400mg
3
PA
NORPACE CR CP12 100mg, 150mg
2
pacerone tabs 100mg, 200mg
1
procainamide hcl soln 100mg/ml
1
propafenone hcl cp12 225mg, 325mg,
425mg; tabs 150mg, 225mg, 300mg
1
sorine tabs 80mg, 120mg, 160mg, 240mg
1
sotalol hcl tabs 80mg, 120mg, 160mg,
240mg
1
sotalol hcl (afib/afl) tabs 80mg, 120mg,
160mg
1
ANTILIPEMICS, BILE ACID RESINS
cholestyramine pack 4gm; powd
4gm/dose
1
cholestyramine light pack 4gm; powd
4gm/dose
1
colestipol hcl gran 5gm; pack 5gm; tabs
1gm
1
prevalite powd 4gm/dose
1
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe tabs 10mg
1
ANTILIPEMICS, FIBRATES
fenofibrate caps 150mg; tabs 48mg,
54mg, 145mg, 160mg
1
fenofibrate micronized caps 43mg, 67mg,
134mg, 200mg
1
gemfibrozil tabs 600mg
1
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS
ezetimibe-simvastatin tab 10-10 mg
1
ezetimibe-simvastatin tab 10-20 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
30
Drug Name
Drug Tier
Requirements/Limits
ezetimibe-simvastatin tab 10-40 mg
1
ezetimibe-simvastatin tab 10-80 mg
1
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium tabs 10mg, 20mg
1
$0 copay for members
age 40 through 75
atorvastatin calcium tabs 40mg, 80mg
1
fluvastatin sodium caps 20mg, 40mg;
tb24 80mg
1
$0 copay for members
age 40 through 75
lovastatin tabs 10mg, 20mg, 40mg
1
$0 copay for members
age 40 through 75
pravastatin sodium tabs 10mg, 20mg,
40mg, 80mg
1
$0 copay for members
age 40 through 75
rosuvastatin calcium tabs 5mg, 10mg
1
$0 copay for members
age 40 through 75
rosuvastatin calcium tabs 20mg, 40mg
1
simvastatin tabs 5mg, 10mg, 20mg, 40mg
1
$0 copay for members
age 40 through 75
simvastatin tabs 80mg
1
ST; PA**
ANTILIPEMICS, MISCELLANEOUS
niacin (antihyperlipidemic) tbcr 500mg,
750mg, 1000mg
1
ANTILIPEMICS, OMEGA-3 FATTY ACIDS
icosapent ethyl caps 1gm
1
Only indicated as an
adjunct to diet to reduce
TG levels in adult
patients with severe
(greater than or equal to
500 mg/dL)
hypertriglyceridemia
icosapent ethyl caps .5gm
1
omega-3-acid ethyl esters cap 1 gm
1
ANTILIPEMICS, PCSK9 INHIBITORS
PRALUENT SOAJ 75mg/ml, 150mg/ml
3
PA, QL (2 pens every 28
days)
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone tab 50-25 mg
1
atenolol & chlorthalidone tab 100-25 mg
1
bisoprolol & hydrochlorothiazide tab 2.5-
6.25 mg
1
bisoprolol & hydrochlorothiazide tab 5-6.25
mg
1
bisoprolol & hydrochlorothiazide tab 10-
6.25 mg
1
metoprolol & hydrochlorothiazide tab 50-
25 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
31
Drug Name
Drug Tier
Requirements/Limits
metoprolol & hydrochlorothiazide tab 100-
25 mg
1
metoprolol & hydrochlorothiazide tab 100-
50 mg
1
BETA-BLOCKERS
acebutolol hcl caps 200mg, 400mg
1
atenolol tabs 25mg, 50mg, 100mg
1
betaxolol hcl tabs 10mg, 20mg
1
bisoprolol fumarate tabs 5mg, 10mg
1
carvedilol tabs 3.125mg, 6.25mg,
12.5mg, 25mg
1
labetalol hcl tabs 100mg, 200mg, 300mg
1
metoprolol succinate tb24 25mg, 50mg,
100mg, 200mg
1
metoprolol tartrate tabs 25mg, 50mg,
100mg
1
nadolol tabs 20mg, 40mg, 80mg
1
nebivolol hcl tabs 2.5mg, 5mg, 10mg,
20mg
1
pindolol tabs 5mg, 10mg
1
propranolol hcl cp24 60mg, 80mg, 120mg,
160mg; soln 20mg/5ml, 40mg/5ml; tabs
10mg, 20mg, 40mg, 60mg, 80mg
1
timolol maleate tabs 5mg, 10mg, 20mg
1
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine besylate-atorvastatin calcium
tab 2.5-10 mg
1
amlodipine besylate-atorvastatin calcium
tab 2.5-20 mg
1
amlodipine besylate-atorvastatin calcium
tab 2.5-40 mg
1
amlodipine besylate-atorvastatin calcium
tab 5-10 mg
1
amlodipine besylate-atorvastatin calcium
tab 5-20 mg
1
amlodipine besylate-atorvastatin calcium
tab 5-40 mg
1
amlodipine besylate-atorvastatin calcium
tab 5-80 mg
1
amlodipine besylate-atorvastatin calcium
tab 10-10 mg
1
amlodipine besylate-atorvastatin calcium
tab 10-20 mg
1
amlodipine besylate-atorvastatin calcium
tab 10-40 mg
1
amlodipine besylate-atorvastatin calcium
tab 10-80 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
32
Drug Name
Drug Tier
Requirements/Limits
CALCIUM CHANNEL BLOCKERS
amlodipine besylate tabs 2.5mg, 5mg,
10mg
1
CARDIZEM LA TB24 120mg
3
cartia xt cp24 120mg, 180mg, 240mg,
300mg
1
dilt-xr cp24 120mg, 180mg, 240mg
1
diltiazem hcl cp12 60mg, 90mg, 120mg;
tabs 30mg, 60mg, 90mg, 120mg
1
diltiazem hcl coated beads cp24 120mg,
180mg, 240mg, 300mg, 360mg
1
diltiazem hcl extended release beads cp24
120mg, 180mg, 240mg, 300mg, 360mg,
420mg
1
felodipine tb24 2.5mg, 5mg, 10mg
1
isradipine caps 2.5mg, 5mg
1
matzim la tb24 180mg, 240mg, 300mg,
360mg, 420mg
1
nicardipine hcl caps 20mg, 30mg
1
nifedipine tb24 30mg, 60mg, 90mg
1
nimodipine caps 30mg
1
nisoldipine tb24 8.5mg, 17mg, 20mg,
25.5mg, 30mg, 34mg, 40mg
1
taztia xt cp24 120mg, 180mg, 240mg,
300mg, 360mg
1
verapamil hcl cp24 100mg, 120mg,
180mg, 200mg, 240mg, 300mg, 360mg;
tabs 40mg, 80mg, 120mg; tbcr 120mg,
180mg, 240mg
1
DIGITALIS GLYCOSIDES
digoxin soln .05mg/ml; tabs 62.5mcg,
125mcg, 250mcg
1
DIRECT RENIN INHIBITORS/COMBINATIONS
aliskiren fumarate tabs 150mg, 300mg
1
DIURETICS
acetazolamide cp12 500mg; tabs 125mg,
250mg
1
ALDACTAZIDE TAB 50/50
2
amiloride & hydrochlorothiazide tab 5-50
mg
1
amiloride hcl tabs 5mg
1
bumetanide tabs .5mg, 1mg, 2mg
1
chlorthalidone tabs 25mg, 50mg
1
DIURIL SUSP 250mg/5ml
3
ethacrynic acid tabs 25mg
3
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
33
Drug Name
Drug Tier
Requirements/Limits
furosemide soln 10mg/ml, 40mg/5ml;
tabs 20mg, 40mg, 80mg
1
hydrochlorothiazide caps 12.5mg; tabs
12.5mg, 25mg, 50mg
1
indapamide tabs 1.25mg, 2.5mg
1
mannitol soln 20%, 25%
1
methazolamide tabs 25mg, 50mg
1
metolazone tabs 2.5mg, 5mg, 10mg
1
osmitrol viaflex soln 10%, 15%
1
spironolactone tabs 25mg, 50mg, 100mg
1
spironolactone & hydrochlorothiazide tab
25-25 mg
1
torsemide tabs 5mg, 10mg, 20mg, 100mg
1
triamterene caps 50mg, 100mg
1
triamterene & hydrochlorothiazide cap
37.5-25 mg
1
triamterene & hydrochlorothiazide tab
37.5-25 mg
1
triamterene & hydrochlorothiazide tab 75-
50 mg
1
HEART FAILURE
ENTRESTO TAB 24-26MG
2
ENTRESTO TAB 49-51MG
2
ENTRESTO TAB 97-103MG
2
MISCELLANEOUS
clonidine ptwk .1mg/24hr, .2mg/24hr,
.3mg/24hr
1
clonidine hcl tabs .1mg, .2mg, .3mg
1
guanfacine hcl tabs 1mg, 2mg
1
hydralazine hcl tabs 10mg, 25mg, 50mg,
100mg
1
methyldopa tabs 250mg, 500mg
1
midodrine hcl tabs 2.5mg, 5mg, 10mg
1
minoxidil tabs 2.5mg, 10mg
1
phenoxybenzamine hcl caps 10mg
3
PA, QL (360 caps every
30 days)
ranolazine tb12 500mg, 1000mg
1
ST; PA**
NITRATES
isosorbide dinitrate tabs 5mg, 10mg,
20mg, 30mg
1
isosorbide mononitrate tabs 10mg, 20mg;
tb24 30mg, 60mg, 120mg
1
NITRO-DUR PT24 .3mg/hr, .8mg/hr
2
nitroglycerin pt24 .1mg/hr, .2mg/hr,
.4mg/hr, .6mg/hr; soln .4mg/spray; subl
.3mg, .4mg, .6mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
34
Drug Name
Drug Tier
Requirements/Limits
PULMONARY ARTERIAL HYPERTENSION
ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg,
2.5mg
3
PA, QL (90 tabs every
30 days)
ambrisentan tabs 5mg, 10mg
3
PA, QL (30 tabs every
30 days)
bosentan tabs 62.5mg, 125mg
3
PA, QL (60 tabs every
30 days)
OPSUMIT TABS 10mg
3
PA, QL (30 tabs every
30 days)
ORENITRAM TBCR .125mg, .25mg, 1mg,
2.5mg, 5mg
3
PA
REMODULIN SOLN 20mg/20ml,
50mg/20ml, 100mg/20ml, 200mg/20ml
3
PA
sildenafil citrate (pulmonary hypertension)
soln 10mg/12.5ml
3
PA
sildenafil citrate (pulmonary hypertension)
tabs 20mg
3
PA, QL (90 tabs every
30 days)
tadalafil (pulmonary hypertension) tabs
20mg
3
PA, QL (60 tabs every
30 days)
TYVASO SOLN .6mg/ml
3
PA, QL (28 ampules
every 28 days)
TYVASO REFILL SOLN .6mg/ml
3
PA, QL (28 ampules
every 28 days)
TYVASO STARTER SOLN .6mg/ml
3
PA, QL (28 ampules
every 28 days)
UPTRAVI SOLR 1800mcg
3
PA
UPTRAVI TABS 200mcg
3
PA, QL (140 tabs every
28 days)
UPTRAVI TABS 400mcg, 600mcg,
800mcg, 1000mcg, 1200mcg, 1400mcg,
1600mcg
3
PA, QL (60 tabs every
30 days)
UPTRAVI PACK TAB 200/800
3
PA, QL (1 pack every 28
days)
VENTAVIS SOLN 10mcg/ml, 20mcg/ml
3
PA, QL (270 ampules
every 30 days)
CENTRAL NERVOUS SYSTEM
ALCOHOL DETERRENTS
acamprosate calcium tbec 333mg
1
disulfiram tabs 250mg, 500mg
1
ANTIANXIETY§
alprazolam tabs .25mg, .5mg, 1mg, 2mg;
tbdp .25mg, .5mg, 1mg, 2mg
1
QL (150 tabs every 30
days)
ALPRAZOLAM INTENSOL CONC 1mg/ml
2
QL (300 mL every 30
days)
buspirone hcl tabs 5mg, 7.5mg, 10mg,
15mg, 30mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
35
Drug Name
Drug Tier
Requirements/Limits
chlordiazepoxide hcl caps 5mg, 10mg,
25mg
1
QL (360 caps every 30
days)
clomipramine hcl caps 25mg, 50mg
1
QL (150 caps every 30
days); QL applies to
members age 65 and
older
clomipramine hcl caps 75mg
1
QL (90 caps every 30
days); QL applies to
members age 65 and
older
fluvoxamine maleate cp24 100mg,
150mg; tabs 25mg, 50mg, 100mg
1
lorazepam conc 2mg/ml
1
QL (150 mL every 30
days)
lorazepam tabs .5mg, 1mg, 2mg
1
QL (150 tabs every 30
days)
meprobamate tabs 200mg, 400mg
1
oxazepam caps 10mg, 15mg, 30mg
1
QL (120 caps every 30
days)
ANTIDEMENTIA
donepezil hydrochloride tabs 5mg, 10mg,
23mg; tbdp 5mg, 10mg
1
galantamine hydrobromide cp24 8mg,
16mg, 24mg; soln 4mg/ml; tabs 4mg,
8mg, 12mg
1
memantine hcl cp24 7mg, 14mg, 21mg,
28mg; soln 2mg/ml; tabs 5mg, 10mg
1
PA; PA applies for
members less than 30
years of age
memantine hcl tab 28 x 5 mg & 21 x 10
mg titration pack
1
PA; PA applies for
members less than 30
years of age
rivastigmine tartrate caps 1.5mg, 3mg,
4.5mg, 6mg
1
PA
ANTIDEPRESSANTS§
amitriptyline hcl tabs 10mg
1
QL (150 tabs every 30
days); QL applies to
members age 65 and
older
amitriptyline hcl tabs 25mg
1
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
amitriptyline hcl tabs 50mg
1
QL (30 tabs every 30
days); QL applies to
members age 65 and
older
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
36
Drug Name
Drug Tier
Requirements/Limits
amitriptyline hcl tabs 75mg, 100mg,
150mg
1
PA; High strength
requires PA for members
age 65 and older
amoxapine tabs 25mg, 50mg, 100mg
1
QL (90 tabs every 30
days); QL applies to
members age 65 and
older
amoxapine tabs 150mg
1
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
bupropion hcl tabs 75mg, 100mg; tb12
100mg, 150mg, 200mg; tb24 150mg,
300mg
1
citalopram hydrobromide soln 10mg/5ml;
tabs 10mg, 20mg, 40mg
1
desipramine hcl tabs 10mg, 25mg, 50mg
1
QL (90 tabs every 30
days); QL applies to
members age 65 and
older
desipramine hcl tabs 75mg
1
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
desipramine hcl tabs 100mg, 150mg
1
QL (30 tabs every 30
days); QL applies to
members age 65 and
older
desvenlafaxine succinate tb24 25mg,
50mg, 100mg
1
ST, QL (30 tabs every
30 days); (generic of
Pristiq) PA**
doxepin hcl caps 10mg, 25mg, 50mg
1
QL (90 caps every 30
days); QL applies to
members age 65 and
older
doxepin hcl caps 75mg
1
QL (60 caps every 30
days); QL applies to
members age 65 and
older
doxepin hcl caps 100mg, 150mg
1
QL (30 caps every 30
days); QL applies to
members age 65 and
older
doxepin hcl conc 10mg/ml
1
QL (450 mL every 30
days); QL applies to
members age 65 and
older
duloxetine hcl cpep 20mg, 30mg, 60mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
37
Drug Name
Drug Tier
Requirements/Limits
EMSAM PT24 6mg/24hr, 9mg/24hr,
12mg/24hr
3
PA
escitalopram oxalate soln 5mg/5ml; tabs
5mg, 10mg, 20mg
1
FETZIMA CP24 20mg, 40mg, 80mg,
120mg
3
ST, QL (30 caps every
30 days); PA**
FETZIMA CAP TITRATIO
3
ST, QL (30 caps every
30 days); PA**
fluoxetine hcl caps 10mg, 20mg, 40mg;
soln 20mg/5ml
1
fluoxetine hcl tabs 10mg, 20mg
1
(generic Sarafem not
covered)
imipramine hcl tabs 10mg, 25mg
1
QL (120 tabs every 30
days); QL applies to
members age 65 and
older
imipramine hcl tabs 50mg
1
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
imipramine pamoate caps 75mg, 100mg
1
QL (30 caps every 30
days); QL applies to
members age 65 and
older
imipramine pamoate caps 125mg, 150mg
1
PA; High strength
requires PA for members
age 65 and older
MARPLAN TABS 10mg
3
mirtazapine tabs 7.5mg, 15mg, 30mg,
45mg; tbdp 15mg, 30mg, 45mg
1
nefazodone hcl tabs 50mg, 100mg,
150mg, 200mg, 250mg
1
nortriptyline hcl caps 10mg
1
QL (150 caps every 30
days); QL applies to
members age 65 and
older
nortriptyline hcl caps 25mg
1
QL (60 caps every 30
days); QL applies to
members age 65 and
older
nortriptyline hcl caps 50mg
1
QL (30 caps every 30
days); QL applies to
members age 65 and
older
nortriptyline hcl caps 75mg
1
PA; High strength
requires PA for members
age 65 and older
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
38
Drug Name
Drug Tier
Requirements/Limits
nortriptyline hcl soln 10mg/5ml
1
QL (750 mL every 30
days); QL applies to
members age 65 and
older
paroxetine hcl tabs 10mg, 20mg, 30mg,
40mg; tb24 12.5mg, 25mg, 37.5mg
1
phenelzine sulfate tabs 15mg
1
protriptyline hcl tabs 5mg
1
QL (90 tabs every 30
days); QL applies to
members age 65 and
older
protriptyline hcl tabs 10mg
1
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
sertraline hcl conc 20mg/ml; tabs 25mg,
50mg, 100mg
1
tranylcypromine sulfate tabs 10mg
1
trazodone hcl tabs 50mg, 100mg, 150mg,
300mg
1
trimipramine maleate caps 25mg, 50mg
1
QL (60 caps every 30
days); QL applies to
members age 65 and
older
trimipramine maleate caps 100mg
1
QL (30 caps every 30
days); QL applies to
members age 65 and
older
TRINTELLIX TABS 5mg, 10mg, 20mg
3
ST; PA**
venlafaxine hcl cp24 37.5mg, 75mg,
150mg; tabs 25mg, 37.5mg, 50mg, 75mg,
100mg; tb24 37.5mg, 75mg, 150mg
1
VIIBRYD KIT STARTER
3
vilazodone hcl tabs 10mg, 20mg, 40mg
1
ANTIPARKINSONIAN AGENTS
amantadine hcl caps 100mg; soln
50mg/5ml; tabs 100mg
1
APOKYN SOCT 30mg/3ml
3
PA, QL (20 cartridges
every 30 days)
benztropine mesylate tabs .5mg, 1mg,
2mg
1
bromocriptine mesylate caps 5mg; tabs
2.5mg
1
carbidopa tabs 25mg
1
carbidopa & levodopa orally disintegrating
tab 10-100 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
39
Drug Name
Drug Tier
Requirements/Limits
carbidopa & levodopa orally disintegrating
tab 25-100 mg
1
carbidopa & levodopa orally disintegrating
tab 25-250 mg
1
carbidopa & levodopa tab 10-100 mg
1
carbidopa & levodopa tab 25-100 mg
1
carbidopa & levodopa tab 25-250 mg
1
carbidopa & levodopa tab er 25-100 mg
1
carbidopa & levodopa tab er 50-200 mg
1
carbidopa-levodopa-entacapone tabs 12.5-
50-200 mg
1
carbidopa-levodopa-entacapone tabs
18.75-75-200 mg
1
carbidopa-levodopa-entacapone tabs 25-
100-200 mg
1
carbidopa-levodopa-entacapone tabs
31.25-125-200 mg
1
carbidopa-levodopa-entacapone tabs 37.5-
150-200 mg
1
carbidopa-levodopa-entacapone tabs 50-
200-200 mg
1
entacapone tabs 200mg
1
INBRIJA CAPS 42mg
3
PA, QL (300 caps every
30 days)
NEUPRO PT24 1mg/24hr, 2mg/24hr,
3mg/24hr, 4mg/24hr, 6mg/24hr,
8mg/24hr
2
ONGENTYS CAPS 25mg, 50mg
3
PA
pramipexole dihydrochloride tabs .125mg,
.25mg, .5mg, .75mg, 1mg, 1.5mg; tb24
.375mg, .75mg, 1.5mg, 2.25mg, 3mg,
3.75mg, 4.5mg
1
rasagiline mesylate tabs .5mg, 1mg
1
ropinirole hydrochloride tabs .25mg,
.5mg, 1mg, 2mg, 3mg, 4mg, 5mg
1
selegiline hcl caps 5mg; tabs 5mg
1
trihexyphenidyl hcl soln .4mg/ml; tabs
2mg, 5mg
1
ANTIPSYCHOTICS
aripiprazole soln 1mg/ml; tabs 2mg, 5mg,
10mg, 15mg, 20mg, 30mg; tbdp 10mg,
15mg
1
ARISTADA PRSY 441mg/1.6ml,
662mg/2.4ml, 882mg/3.2ml,
1064mg/3.9ml
2
ARISTADA INITIO PRSY 675mg/2.4ml
2
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
40
Drug Name
Drug Tier
Requirements/Limits
asenapine maleate subl 2.5mg, 5mg,
10mg
1
chlorpromazine hcl tabs 10mg, 25mg,
50mg, 100mg, 200mg
1
clozapine tabs 25mg, 50mg, 100mg,
200mg; tbdp 12.5mg, 25mg, 100mg,
150mg, 200mg
1
fluphenazine hcl conc 5mg/ml; elix
2.5mg/5ml; tabs 1mg, 2.5mg, 5mg, 10mg
1
haloperidol tabs .5mg, 1mg, 2mg, 5mg,
10mg, 20mg
1
haloperidol decanoate soln 50mg/ml,
100mg/ml
1
haloperidol lactate conc 2mg/ml
1
LATUDA TABS 20mg, 40mg, 60mg, 80mg,
120mg
2
ST; PA**
loxapine succinate caps 5mg, 10mg,
25mg, 50mg
1
olanzapine tabs 2.5mg, 5mg, 7.5mg,
10mg, 15mg, 20mg; tbdp 5mg, 10mg,
15mg, 20mg
1
paliperidone tb24 1.5mg, 3mg, 6mg, 9mg
1
perphenazine tabs 2mg, 4mg, 8mg, 16mg
1
quetiapine fumarate tabs 25mg, 50mg,
100mg, 200mg, 300mg, 400mg; tb24
50mg, 150mg, 200mg, 300mg, 400mg
1
risperidone soln 1mg/ml; tabs .25mg,
.5mg, 1mg, 2mg, 3mg, 4mg; tbdp .25mg,
.5mg, 1mg, 2mg, 3mg, 4mg
1
thioridazine hcl tabs 10mg, 25mg, 50mg,
100mg
1
thiothixene caps 1mg, 2mg, 5mg, 10mg
1
trifluoperazine hcl tabs 1mg, 2mg, 5mg,
10mg
1
VRAYLAR CAPS 1.5mg, 3mg, 4.5mg, 6mg
2
ST; PA**
VRAYLAR CAP 1.5-3MG
2
ST; PA**
ziprasidone hcl caps 20mg, 40mg, 60mg,
80mg
1
ANTISEIZURE AGENTS§
carbamazepine chew 100mg; cp12
100mg, 200mg, 300mg; susp 100mg/5ml;
tabs 200mg; tb12 100mg, 200mg, 400mg
1
CELONTIN CAPS 300mg
3
clobazam susp 2.5mg/ml; tabs 10mg,
20mg
1
clonazepam tabs .5mg, 1mg, 2mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
41
Drug Name
Drug Tier
Requirements/Limits
clorazepate dipotassium tabs 3.75mg,
7.5mg, 15mg
1
QL (180 tabs every 30
days)
diazepam soln 5mg/5ml
1
QL (1200 mL every 30
days)
diazepam soln 5mg/ml
1
diazepam tabs 2mg, 5mg, 10mg
1
QL (120 tabs every 30
days)
diazepam intensol conc 5mg/ml
1
QL (240 mL every 30
days)
divalproex sodium csdr 125mg; tb24
250mg, 500mg; tbec 125mg, 250mg,
500mg
1
epitol tabs 200mg
1
ethosuximide caps 250mg; soln
250mg/5ml
1
felbamate susp 600mg/5ml; tabs 400mg,
600mg
1
fosphenytoin sodium soln 100mgpe/2ml,
500mgpe/10ml
1
FYCOMPA SUSP .5mg/ml; TABS 2mg,
4mg, 6mg, 8mg, 10mg, 12mg
3
gabapentin caps 100mg, 300mg, 400mg
1
QL (6 caps every day)
gabapentin soln 250mg/5ml
1
QL (72 mL every day)
gabapentin tabs 600mg
1
QL (6 tabs every day)
gabapentin tabs 800mg
1
QL (4 tabs every day)
lacosamide soln 10mg/ml; tabs 50mg,
100mg, 150mg, 200mg
1
lamotrigine chew 5mg, 25mg; kit 25mg;
tabs 25mg, 100mg, 150mg, 200mg; tb24
25mg, 50mg, 100mg, 200mg, 250mg,
300mg; tbdp 25mg, 50mg, 100mg, 200mg
1
lamotrigine tab 25 mg (42) & 100 mg (7)
starter kit
1
lamotrigine tab 84 x 25 mg & 14 x 100 mg
starter kit
1
levetiracetam soln 100mg/ml; tabs
250mg, 500mg, 750mg, 1000mg; tb24
500mg, 750mg
1
NAYZILAM SOLN 5mg/0.1ml
2
QL (10 units every 30
days)
oxcarbazepine susp 60mg/ml; tabs
150mg, 300mg, 600mg
1
phenobarbital elix 20mg/5ml; tabs 15mg,
16.2mg, 30mg, 32.4mg, 60mg, 64.8mg,
97.2mg, 100mg
1
phenytoin susp 125mg/5ml
1
phenytoin infatabs chew 50mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
42
Drug Name
Drug Tier
Requirements/Limits
phenytoin sodium extended caps 100mg,
200mg, 300mg
1
pregabalin caps 25mg, 50mg, 75mg,
100mg, 150mg, 200mg, 225mg, 300mg;
soln 20mg/ml
1
ST; PA**
primidone tabs 50mg, 250mg
1
rufinamide susp 40mg/ml; tabs 200mg,
400mg
1
tiagabine hcl tabs 2mg, 4mg, 12mg, 16mg
1
topiramate cpsp 15mg, 25mg; tabs 25mg,
50mg, 100mg, 200mg
1
valproate sodium soln 250mg/5ml
1
valproic acid caps 250mg
1
vigabatrin pack 500mg
3
PA, QL (180 packets
every 30 days)
vigabatrin tabs 500mg
3
PA, QL (180 tabs every
30 days)
XCOPRI TABS 50mg, 100mg, 150mg,
200mg
2
XCOPRI PAK 12.5-25
2
XCOPRI PAK 50-100MG
2
XCOPRI PAK 100-150
2
XCOPRI PAK 150-200
2
zonisamide caps 25mg, 50mg, 100mg
1
ATTENTION DEFICIT HYPERACTIVITY DISORDER§
amphetamine-dextroamphetamine cap er
24hr 5 mg
1
PA; QL (90 caps every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine cap er
24hr 10 mg
1
PA; QL (90 caps every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine cap er
24hr 15 mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine cap er
24hr 20 mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine cap er
24hr 25 mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
43
Drug Name
Drug Tier
Requirements/Limits
amphetamine-dextroamphetamine cap er
24hr 30 mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 5
mg
1
PA; QL (90 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 7.5
mg
1
PA; QL (90 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 10
mg
1
PA; QL (90 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab
12.5 mg
1
PA; QL (90 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 15
mg
1
PA; QL (60 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 20
mg
1
PA; QL (60 tabs every
30 days); PA applies to
members ≥19 years of
age
amphetamine-dextroamphetamine tab 30
mg
1
PA; QL (30 tabs every
30 days); PA applies to
members ≥19 years of
age
atomoxetine hcl caps 10mg, 18mg, 25mg,
40mg, 60mg, 80mg, 100mg
1
AZSTARYS CAP 26.1-5.2
3
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
AZSTARYS CAP 39.2-7.8
3
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
AZSTARYS CAP 52.3-10.
3
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
44
Drug Name
Drug Tier
Requirements/Limits
dexmethylphenidate hcl cp24 5mg, 10mg,
15mg, 20mg
1
PA; QL (60 caps every
30 days); PA applies to
members ≥19 years of
age
dexmethylphenidate hcl cp24 25mg,
30mg, 35mg, 40mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
dexmethylphenidate hcl tabs 2.5mg, 5mg
1
PA; QL (120 tabs every
30 days); PA applies to
members ≥19 years of
age
dexmethylphenidate hcl tabs 10mg
1
PA; QL (60 tabs every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate cp24 5mg,
10mg
1
PA; QL (120 caps every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate cp24 15mg
1
PA; QL (60 caps every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate soln 5mg/5ml
1
PA; QL (1,200 mL every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate tabs 5mg,
10mg
1
PA; QL (120 tabs every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate tabs 15mg,
20mg
1
PA; QL (60 tabs every
30 days); PA applies to
members ≥19 years of
age
dextroamphetamine sulfate tabs 30mg
1
PA; QL (30 tabs every
30 days); PA applies to
members ≥19 years of
age
guanfacine hcl (adhd) tb24 1mg, 2mg,
3mg, 4mg
1
methamphetamine hcl tabs 5mg
1
PA; QL (150 tabs every
30 days); PA applies to
members ≥19 years of
age
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
45
Drug Name
Drug Tier
Requirements/Limits
methylphenidate hcl chew 2.5mg, 5mg,
10mg
1
PA; QL (180 chew tabs
every 30 days); PA
applies to members ≥19
years of age
methylphenidate hcl cp24 20mg, 30mg;
cpcr 10mg, 20mg, 30mg
1
PA; QL (60 caps every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl cp24 40mg, 60mg;
cpcr 40mg, 50mg, 60mg
1
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl soln 5mg/5ml
1
PA; QL (1800 mL every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl soln 10mg/5ml
1
PA; QL (900 mL every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl tabs 5mg, 10mg
1
PA; QL (180 tabs every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl tabs 20mg; tbcr
10mg, 20mg
1
PA; QL (90 tabs every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl tbcr 18mg, 27mg,
36mg
1
PA; QL (60 tabs every
30 days); PA applies to
members ≥19 years of
age
methylphenidate hcl tbcr 54mg
1
PA; QL (30 tabs every
30 days); PA applies to
members ≥19 years of
age
VYVANSE CAPS 10mg, 20mg, 30mg
2
PA; QL (60 caps every
30 days); PA applies to
members ≥19 years of
age
VYVANSE CAPS 40mg, 50mg, 60mg,
70mg
2
PA; QL (30 caps every
30 days); PA applies to
members ≥19 years of
age
VYVANSE CHEW 10mg, 20mg, 30mg
2
PA; QL (60 chew tabs
every 30 days); PA
applies to members ≥19
years of age
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
46
Drug Name
Drug Tier
Requirements/Limits
VYVANSE CHEW 40mg, 50mg, 60mg
2
PA; QL (30 chew tabs
every 30 days); PA
applies to members ≥19
years of age
zenzedi tabs 2.5mg, 7.5mg
1
PA; QL (120 tabs every
30 days); PA applies to
members ≥19 years of
age
FIBROMYALGIA
SAVELLA TABS 12.5mg, 25mg, 50mg,
100mg
3
ST; PA**
SAVELLA MIS TITR PAK
3
ST; PA**
HYPNOTICS§
BELSOMRA TABS 5mg, 10mg, 15mg,
20mg
2
ST; PA**
cvs sleep-aid nighttime tabs 25mg
1
OTC
DAYVIGO TABS 5mg, 10mg
2
PA, QL (30 tabs every
30 days)
doxepin hcl (sleep) tabs 3mg, 6mg
1
QL (30 tabs every 30
days); QL applies to
members age 65 and
older
estazolam tabs 1mg, 2mg
3
QL (15 tabs every 30
days)
eszopiclone tabs 1mg, 2mg, 3mg
1
QL (15 tabs every 30
days)
HETLIOZ CAPS 20mg
3
PA, QL (30 caps every
30 days)
ramelteon tabs 8mg
1
QL (15 tabs every 30
days)
tasimelteon caps 20mg
3
PA, QL (30 caps every
30 days)
temazepam caps 7.5mg, 15mg, 22.5mg,
30mg
1
QL (15 caps every 30
days)
triazolam tabs .125mg, .25mg
3
QL (10 tabs every 30
days)
zaleplon caps 5mg, 10mg
1
QL (15 caps every 30
days)
zolpidem tartrate tabs 5mg, 10mg; tbcr
6.25mg, 12.5mg
1
QL (15 tabs every 30
days)
MIGRAINE§
AJOVY SOAJ 225mg/1.5ml; SOSY
225mg/1.5ml
2
ST, QL (3 injections
every 90 days); PA**
almotriptan malate tabs 6.25mg, 12.5mg
1
QL (12 tabs every 30
days)
dihydroergotamine mesylate soln 1mg/ml
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
47
Drug Name
Drug Tier
Requirements/Limits
eletriptan hydrobromide tabs 20mg, 40mg
1
QL (12 tabs every 30
days)
EMGALITY SOAJ 120mg/ml; SOSY
120mg/ml
2
ST, QL (2 injections
every 30 days); PA**
EMGALITY SOSY 100mg/ml
2
ST, QL (3 injections
every 30 days); PA**
ergotamine w/ caffeine tab 1-100 mg
3
frovatriptan succinate tabs 2.5mg
1
QL (18 tabs every 30
days)
naratriptan hcl tabs 1mg, 2.5mg
1
QL (12 tabs every 30
days)
rizatriptan benzoate tabs 5mg, 10mg;
tbdp 5mg, 10mg
1
QL (18 tabs every 30
days)
sumatriptan soln 5mg/act
1
QL (24 sprays every 30
days)
sumatriptan soln 20mg/act
1
QL (12 sprays every 30
days)
sumatriptan succinate soaj 4mg/0.5ml;
soct 4mg/0.5ml
1
QL (18 syringes every
30 days)
sumatriptan succinate soaj 6mg/0.5ml;
soct 6mg/0.5ml
1
QL (12 units every 30
days)
sumatriptan succinate soln 6mg/0.5ml
1
QL (12 vials every 30
days)
sumatriptan succinate tabs 25mg, 50mg,
100mg
1
QL (12 tabs every 30
days)
sumatriptan-naproxen sodium tab 85-500
mg
3
ST, QL (9 tabs every 30
days); PA**
UBRELVY TABS 50mg, 100mg
2
ST, QL (16 tabs every
30 days); PA**
zolmitriptan soln 2.5mg, 5mg
1
QL (12 sprays every 30
days)
zolmitriptan tabs 2.5mg, 5mg; tbdp
2.5mg, 5mg
1
QL (12 tabs every 30
days)
MISCELLANEOUS
EVRYSDI SOLR .75mg/ml
3
PA, QL (2 bottles every
24 days)
lithium carbonate caps 150mg, 300mg,
600mg; tabs 300mg; tbcr 300mg, 450mg
1
pyridostigmine bromide soln 60mg/5ml;
tabs 60mg; tbcr 180mg
1
riluzole tabs 50mg
1
MOVEMENT DISORDERS
tetrabenazine tabs 12.5mg
3
PA, QL (120 tabs every
30 days)
tetrabenazine tabs 25mg
3
PA, QL (60 tabs every
30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
48
Drug Name
Drug Tier
Requirements/Limits
MULTIPLE SCLEROSIS AGENTS
AUBAGIO TABS 7mg, 14mg
3
PA, QL (30 tabs every
30 days)
BETASERON KIT .3mg
3
PA, QL (14 injections
every 28 days)
COPAXONE SOSY 20mg/ml
3
PA, QL (30 injections
every 30 days)
COPAXONE SOSY 40mg/ml
3
PA, QL (12 syringes
every 28 days)
dalfampridine tb12 10mg
3
PA, QL (60 tabs every
30 days)
dimethyl fumarate cpdr 120mg
3
PA, QL (14 caps every
28 days)
dimethyl fumarate cpdr 240mg
3
PA, QL (60 caps every
30 days)
dimethyl fumarate capsule dr starter pack
120 mg & 240 mg
3
PA, QL (1 kit every 30
days)
fingolimod hcl caps .5mg
3
PA, QL (30 caps every
30 days)
GILENYA CAPS .5mg
3
PA, QL (30 caps every
30 days)
glatiramer acetate sosy 40mg/ml
2
PA, QL (12 syringes
every 28 days)
glatopa sosy 20mg/ml
2
PA, QL (30 injections
every 30 days)
TYSABRI CONC 300mg/15ml
3
PA, QL (1 vial every 28
days)
MUSCULOSKELETAL THERAPY AGENTS
baclofen tabs 5mg, 10mg, 20mg
1
carisoprodol tabs 350mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
carisoprodol w/ aspirin & codeine tab 200-
325-16 mg
3
PA, QL (168 tabs every
30 days); High Risk
Medications require PA
for members age 70 and
older
chlorzoxazone tabs 500mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
cyclobenzaprine hcl tabs 5mg, 10mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
49
Drug Name
Drug Tier
Requirements/Limits
dantrolene sodium caps 25mg, 50mg,
100mg
1
metaxalone tabs 800mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
methocarbamol tabs 500mg, 750mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
orphenadrine citrate soln 30mg/ml
1
orphenadrine citrate tb12 100mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
tizanidine hcl tabs 2mg, 4mg
1
NARCOLEPSY/CATAPLEXY
armodafinil tabs 50mg
1
PA, QL (60 tabs every
30 days)
armodafinil tabs 150mg, 200mg, 250mg
1
PA, QL (30 tabs every
30 days)
modafinil tabs 100mg, 200mg
1
PA, QL (60 tabs every
30 days)
SUNOSI TABS 75mg, 150mg
2
PA, QL (30 tabs every
30 days)
OPIOID AGONIST/ANTAGONIST
buprenorphine hcl-naloxone hcl sl film 2-
0.5 mg (base equiv)
1
QL (3 units every day)
buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)
1
QL (3 units every day)
buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)
1
QL (3 units every day)
buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)
1
QL (2 units every day)
buprenorphine hcl-naloxone hcl sl tab 2-
0.5 mg (base equiv)
0
QL (3 tabs every day);
$0 copay
buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv)
0
QL (3 tabs every day);
$0 copay
ZUBSOLV SUB 0.7-0.18
2
QL (3 units every day)
ZUBSOLV SUB 1.4-0.36
2
QL (3 units every day)
ZUBSOLV SUB 2.9-0.71
2
QL (3 units every day)
ZUBSOLV SUB 5.7-1.4
2
QL (3 units every day)
ZUBSOLV SUB 8.6-2.1
2
QL (2 units every day)
ZUBSOLV SUB 11.4-2.9
2
QL (1 unit every day)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
50
Drug Name
Drug Tier
Requirements/Limits
OPIOID ANTAGONIST
naloxone hcl liqd 4mg/0.1ml; soct
.4mg/ml; soln .4mg/ml, 4mg/10ml; sosy
2mg/2ml
1
naltrexone hcl tabs 50mg
0
$0 copay
VIVITROL SUSR 380mg
3
QL (1 vial every 28
days)
OPIOID PARTIAL AGONISTS§
buprenorphine hcl subl 2mg, 8mg
0
QL (90 tabs every 30
days); $0 copay; Must
obtain approval after the
first 30 day supply
PSYCHOTHERAPEUTIC-MISC
chlordiazepoxide-amitriptyline tab 5-12.5
mg
3
QL (120 tabs every 30
days); QL applies to
members age 65 and
older
chlordiazepoxide-amitriptyline tab 10-25
mg
3
QL (60 tabs every 30
days); QL applies to
members age 65 and
older
NUEDEXTA CAP 20-10MG
2
PA
perphenazine-amitriptyline tab 2-10 mg
3
QL (150 units every 30
days); QL applies to
members age 65 and
older
perphenazine-amitriptyline tab 2-25 mg
3
QL (60 units every 30
days); QL applies to
members age 65 and
older
perphenazine-amitriptyline tab 4-10 mg
3
QL (120 units every 30
days); QL applies to
members age 65 and
older
perphenazine-amitriptyline tab 4-25 mg
3
QL (60 units every 30
days); QL applies to
members age 65 and
older
perphenazine-amitriptyline tab 4-50 mg
3
QL (30 units every 30
days); QL applies to
members age 65 and
older
pimozide tabs 1mg, 2mg
1
SMOKING DETERRENTS
bupropion hcl (smoking deterrent) tb12
150mg
0
$0 limited to 2
treatment cycles/year
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
51
Drug Name
Drug Tier
Requirements/Limits
goodsense nicotine polacr gum 4mg; lozg
4mg
0
OTC; $0 limited to 2
treatment cycles/year
nicotine pt24 7mg/24hr, 14mg/24hr,
21mg/24hr
0
OTC; $0 limited to 2
treatment cycles/year
nicotine polacrilex gum 2mg, 4mg; lozg
2mg
0
OTC; $0 limited to 2
treatment cycles/year
nicotine step 3 pt24 7mg/24hr
0
OTC; $0 limited to 2
treatment cycles/year
NICOTROL INHALER INHA 10mg
0
QL (max 168 days every
year); $0 limited to 2
treatment cycles/year
NICOTROL NS SOLN 10mg/ml
0
QL (max 168 days every
year); $0 limited to 2
treatment cycles/year
sm nicotine transdermal s pt24 7mg/24hr,
14mg/24hr, 21mg/24hr
0
OTC; $0 limited to 2
treatment cycles/year
varenicline tartrate tabs .5mg, 1mg
0
$0 limited to 2
treatment cycles/year
varenicline tartrate tab 11 x 0.5 mg & 42 x
1 mg start pack
0
$0 limited to 2
treatment cycles/year
ENDOCRINE AND METABOLIC
ACROMEGALY
octreotide acetate soln 50mcg/ml,
100mcg/ml, 500mcg/ml; sosy 50mcg/ml,
100mcg/ml, 500mcg/ml
3
PA, QL (90 ml every 30
days)
octreotide acetate soln 200mcg/ml
3
PA, QL (225 ml every 30
days)
octreotide acetate soln 1000mcg/ml
3
PA, QL (45 ml every 30
days)
SOMATULINE DEPOT SOLN 60mg/0.2ml,
90mg/0.3ml, 120mg/0.5ml
3
PA, QL (1 injection every
28 days)
SOMAVERT SOLR 10mg, 15mg, 20mg,
25mg, 30mg
3
PA, QL (30 vials every
30 days)
ANDROGENS
testosterone gel 10mg/act, 25mg/2.5gm
1
PA
testosterone cypionate soln 100mg/ml,
200mg/ml
1
PA
testosterone enanthate soln 200mg/ml
1
PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS^
acarbose tabs 25mg, 50mg, 100mg
1
miglitol tabs 25mg, 50mg, 100mg
1
ANTIDIABETICS, AMYLIN ANALOGS^
SYMLINPEN 60 SOPN 1500mcg/1.5ml
3
ST; PA**
SYMLINPEN 120 SOPN 2700mcg/2.7ml
3
ST; PA**
ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS^
glipizide-metformin hcl tab 2.5-250 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
52
Drug Name
Drug Tier
Requirements/Limits
glipizide-metformin hcl tab 2.5-500 mg
1
glipizide-metformin hcl tab 5-500 mg
1
ANTIDIABETICS, BIGUANIDE^
metformin hcl tabs 500mg, 1000mg; tb24
500mg, 750mg
1
metformin hcl tabs 850mg
1
$0 copay for members
age 35-70 for
prevention of diabetes
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS^
alogliptin benzoate tabs 6.25mg, 12.5mg,
25mg
1
ST; PA**
JANUVIA TABS 25mg, 50mg, 100mg
2
ST; PA**
ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS^
alogliptin-metformin hcl tab 12.5-500 mg
1
ST; PA**
alogliptin-metformin hcl tab 12.5-1000 mg
1
ST; PA**
JANUMET TAB 50-500MG
2
ST; PA**
JANUMET TAB 50-1000
2
ST; PA**
JANUMET XR TAB 50-500MG
2
ST; PA**
JANUMET XR TAB 50-1000
2
ST; PA**
JANUMET XR TAB 100-1000
2
ST; PA**
JENTADUETO TAB XR
3
ST; PA**
ANTIDIABETICS, INCRETIN MIMETIC AGENTS^
OZEMPIC SOPN 2mg/1.5ml
2
ST, QL (1.5 mL every 28
days); PA**
OZEMPIC SOPN 2mg/3ml, 4mg/3ml
2
ST, QL (3 mL every 28
days); PA**
OZEMPIC INJ 8MG/3ML
2
ST, QL (3 mL every 28
days); PA**
TRULICITY SOPN .75mg/0.5ml,
1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml
2
ST, QL (4 pens every 28
days); PA**
VICTOZA SOPN 18mg/3ml
2
ST, QL (3 pens every 30
days); PA**
ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS^
SOLIQUA INJ 100/33
2
ST; PA**
XULTOPHY INJ 100/3.6
2
ST; PA**
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE
COMBINATION^
pioglitazone hcl-metformin hcl tab 15-500
mg
1
pioglitazone hcl-metformin hcl tab 15-850
mg
1
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA
COMBINATION^
pioglitazone hcl-glimepiride tab 30-2 mg
1
pioglitazone hcl-glimepiride tab 30-4 mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
53
Drug Name
Drug Tier
Requirements/Limits
ANTIDIABETICS, INSULIN SENSITIZER^
pioglitazone hcl tabs 15mg, 30mg, 45mg
1
ANTIDIABETICS, INSULIN^
BASAGLAR KWIKPEN SOPN 100unit/ml
2
BASAGLAR TEMPO PEN SOPN 100unit/ml
2
FIASP FLEX INJ TOUCH
2
FIASP INJ 100/ML
2
FIASP PENFIL INJ U-100
2
HUMULIN INJ 70/30
3
OTC
HUMULIN INJ 70/30KWP
3
OTC
HUMULIN N SUSP 100unit/ml
3
OTC
HUMULIN N KWIKPEN SUPN 100unit/ml
3
OTC
HUMULIN R SOLN 100unit/ml
3
OTC
HUMULIN R U-500 (CONCENTR SOLN
500unit/ml
2
HUMULIN R U-500 KWIKPEN SOPN
500unit/ml
2
LEVEMIR SOLN 100unit/ml
2
LEVEMIR FLEXTOUCH SOPN 100unit/ml
2
NOVOLIN INJ 70/30
2
OTC; RELION not
covered
NOVOLIN INJ 70/30 FP
2
OTC; RELION not
covered
NOVOLIN N SUSP 100unit/ml
2
OTC; RELION not
covered
NOVOLIN N FLEXPEN SUPN 100unit/ml
2
OTC; RELION not
covered
NOVOLIN R SOLN 100unit/ml
2
OTC; RELION not
covered
NOVOLIN R FLEXPEN SOPN 100unit/ml
2
OTC; RELION not
covered
NOVOLOG SOLN 100unit/ml
2
NOVOLOG FLEXPEN SOPN 100unit/ml
2
NOVOLOG MIX INJ 70/30
2
NOVOLOG MIX INJ FLEXPEN
2
NOVOLOG PENFILL SOCT 100unit/ml
2
TRESIBA SOLN 100unit/ml
2
TRESIBA FLEXTOUCH SOPN 100unit/ml,
200unit/ml
2
ANTIDIABETICS, MEGLITINIDE^
nateglinide tabs 60mg, 120mg
1
repaglinide tabs .5mg, 1mg, 2mg
1
ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER-2 (SGLT2)
INHIBITOR COMBINATIONS^
SYNJARDY TAB
2
ST; PA**
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
54
Drug Name
Drug Tier
Requirements/Limits
SYNJARDY TAB 5-500MG
2
ST; PA**
SYNJARDY TAB 5-1000MG
2
ST; PA**
SYNJARDY TAB 12.5-500
2
ST; PA**
SYNJARDY XR TAB
2
ST; PA**
SYNJARDY XR TAB 5-1000MG
2
ST; PA**
SYNJARDY XR TAB 10-1000
2
ST; PA**
SYNJARDY XR TAB 25-1000
2
ST; PA**
ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER-2 (SGLT2)
INHIBITOR/DPP-4 INHIBITOR COMBINATIONS^
GLYXAMBI TAB 10-5 MG
2
ST; PA**
GLYXAMBI TAB 25-5 MG
2
ST; PA**
ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER-2 (SGLT2)
INHIBITORS^
JARDIANCE TABS 10mg, 25mg
2
ST; PA**
ANTIDIABETICS, SULFONYLUREA^
glimepiride tabs 1mg, 2mg, 4mg
1
glipizide tabs 5mg, 10mg; tb24 2.5mg,
5mg, 10mg
1
BISPHOSPHONATES
alendronate sodium soln 70mg/75ml; tabs
5mg, 10mg, 35mg, 70mg
1
FOSAMAX + D TAB 70-2800
3
ST; PA**
FOSAMAX + D TAB 70-5600
3
ST; PA**
ibandronate sodium tabs 150mg
1
pamidronate disodium soln 30mg/10ml
1
risedronate sodium tabs 5mg, 30mg,
35mg, 150mg; tbec 35mg
1
zoledronic acid conc 4mg/5ml; soln
5mg/100ml
3
PA
CALCIUM RECEPTOR AGONISTS
cinacalcet hcl tabs 30mg, 60mg
3
PA, QL (60 tabs every
30 days)
cinacalcet hcl tabs 90mg
3
PA, QL (120 tabs every
30 days)
CHELATING AGENTS
CHEMET CAPS 100mg
3
deferiprone tabs 500mg, 1000mg
3
PA
FERRIPROX SOLN 100mg/ml
3
PA
FERRIPROX TWICE-A-DAY TABS 1000mg
3
PA
penicillamine tabs 250mg
3
PA
sps susp 15gm/60ml
1
CONTRACEPTIVES
altavera
0
alyacen 1/35
0
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
55
Drug Name
Drug Tier
Requirements/Limits
alyacen 7/7/7
0
amethia
0
amethyst
0
ANNOVERA MIS
0
QL (1 every 300 days)
apri
0
aranelle
0
ashlyna
0
aviane
0
azurette
0
camila tabs .35mg
0
CAYA DPR
0
QL (1 every 300 days)
chateal
0
CONDOMS MIS
0
QL (12 condoms every
30 days), OTC
cryselle-28
0
dasetta 1/35
0
dasetta 7/7/7
0
delyla
0
DEPO-SUBQ PROVERA 104 SUSY
104mg/0.65ml
0
QL (4 inj every 300
days)
drospirenone-ethinyl estrad-levomefolate
tab 3-0.02-0.451 mg
0
drospirenone-ethinyl estrad-levomefolate
tab 3-0.03-0.451 mg
0
drospirenone-ethinyl estradiol tab 3-0.02
mg
0
drospirenone-ethinyl estradiol tab 3-0.03
mg
0
DUREX MIS REALFEEL
0
QL (12 condoms every
30 days), OTC
elinest
0
ELLA TABS 30mg
0
enpresse-28
0
enskyce
0
errin tabs .35mg
0
ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg
0
etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr
0
QL (13 every 300 days)
falmina
0
fayosim
0
FC2 FEMALE MIS CONDOM
0
QL (12 condoms every
30 days), OTC
FEMCAP MIS 22MM
0
QL (1 every 300 days)
FEMCAP MIS 26MM
0
QL (1 every 300 days)
FEMCAP MIS 30MM
0
QL (1 every 300 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
56
Drug Name
Drug Tier
Requirements/Limits
gemmily
0
heather tabs .35mg
0
introvale
0
jolessa
0
junel 1.5/30
0
junel 1/20
0
junel fe 1.5/30
0
junel fe 1/20
0
junel fe 24
0
kariva
0
kelnor 1/35
0
kurvelo
0
KYLEENA IUD 19.5mg
0
QL (1 every 300 days)
larin 1.5/30
0
leena
0
lessina
0
levonest
0
levonorg-eth est tab 0.1-0.02mg(84) & eth
est tab 0.01mg(7)
0
levonorgestrel & ethinyl estradiol (91-day)
tab 0.15-0.03 mg
0
levonorgestrel & ethinyl estradiol tab 0.1
mg-20 mcg
0
levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg
0
levora 0.15/30-28
0
LILETTA IUD 20.1mcg/day
0
QL (1 every 300 days)
LO LOESTRIN TAB 1-10-10
0
loryna
0
low-ogestrel
0
lutera
0
marlissa
0
medroxyprogesterone acetate
(contraceptive) susp 150mg/ml; susy
150mg/ml
0
QL (4 inj every 300
days)
microgestin 1.5/30
0
MIRENA IUD 20mcg/day
0
QL (1 every 300 days)
mono-linyah
0
NATAZIA TAB
0
necon 0.5/35-28
0
NEXPLANON IMPL 68mg
0
QL (1 every 300 days)
NEXTSTELLIS TAB 3-14.2MG
0
nikki
0
nora-be tabs .35mg
0
norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg
0
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
57
Drug Name
Drug Tier
Requirements/Limits
norethindrone & ethinyl estradiol-fe chew
tab 0.8 mg-25 mcg
0
norethindrone (contraceptive) tabs .35mg
0
norethindrone ace & ethinyl estradiol tab 1
mg-20 mcg
0
norethindrone ace-eth estradiol-fe chew
tab 1 mg-20 mcg (24)
0
norethindrone ace-ethinyl estradiol-fe cap
1 mg-20 mcg (24)
0
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg
0
norgestimate-eth estrad tab 0.18-
25/0.215-25/0.25-25 mg-mcg
0
norgestimate-eth estrad tab 0.18-
35/0.215-35/0.25-35 mg-mcg
0
nortrel 0.5/35 (28)
0
nortrel 1/35
0
nortrel 7/7/7
0
nylia 1/35
0
ocella
0
OMNIFLEX DPR
0
QL (1 every 300 days)
PARAGARD IUD T380A
0
QL (1 unit every 300
days)
pirmella 1/35
0
pirmella 7/7/7
0
portia-28
0
reclipsen
0
rivelsa
0
SKYLA IUD 13.5mg
0
QL (1 every 300 days)
SLYND TABS 4mg
0
sprintec 28
0
sronyx
0
syeda
0
take action tabs 1.5mg
0
OTC
tilia fe
0
tri-linyah
0
tri-sprintec
0
trivora-28
0
TRUSTEX/RIA MIS NON-LUB
0
QL (12 condoms every
30 days), OTC
TRUSTX NON-9 MIS RIB/STUD
0
QL (12 condoms every
30 days), OTC
TWIRLA DIS 120-30
0
TYBLUME CHW 0.1-0.02
0
velivet
0
viorele
0
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
58
Drug Name
Drug Tier
Requirements/Limits
vyfemla
0
wera
0
WIDE-SEAL SILICONE DIAPHR DPRH 2%
0
QL (1 every 300 days)
xulane
0
zovia 1/35
0
DIABETIC SUPPLIES^
ALCOHOL PREP PAD
2
OTC
AUTOLET PLAT MIS 1.8MM
2
OTC
BLOOD GLUCOSE CALIBRATION SOLUTION
2
OTC
DEXCOM G5 MIS RECEIVER
2
DEXCOM G5 MIS TRANSMIT
2
DEXCOM G6 MIS RECEIVER
2
DEXCOM G6 MIS SENSOR
2
DEXCOM G6 MIS TRANSMIT
2
FREESTY LIBR KIT 2 SENSOR
2
FREESTY LIBR MIS 2 READER
2
FREESTYLE BLOOD GLUCOSE TEST STRIPS
2
QL (204 Test Strips
every 30 days), OTC
FREESTYLE KIT FREEDOM
2
OTC
FREESTYLE KIT INSULINX
2
OTC
FREESTYLE KIT LITE
2
OTC
FREESTYLE KIT SENSOR
2
FREESTYLE MIS READER
2
G4 PLAT PED MIS RVC/SHAR
2
G4 PLATINUM MIS PEDIATRC
2
G4 PLATINUM MIS RCV/SHAR
2
G4 PLATINUM MIS RECEIVER
2
G4 PLATINUM MIS TRANSMIT
2
G4 SENSOR MIS
2
G5/G4 MIS SENSOR
2
GLUCOSE URINE TEST STRIPS
2
OTC
INSULIN PEN NEEDLES
2
OTC
INSULIN PEN NEEDLES/SYRINGES
2
OTC
KETONE URINE TEST STRIPS
2
OTC
LANCETS
2
OTC
LANCING DEVICE
2
OTC
NOVOFINE PEN NEEDLES
2
OTC
OMNIPOD 5 G6 KIT INTRO
2
OMNIPOD 5 G6 MIS PODS
2
OMNIPOD DASH KIT INTRO
2
OMNIPOD DASH MIS PODS
2
OMNIPOD MIS CLASSIC
2
OMNIPOD PDM KIT CLASSIC
2
PREC NEO SYS KIT FREESTYL
2
OTC
PRECISION MIS XTRA
2
OTC
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
59
Drug Name
Drug Tier
Requirements/Limits
PRECISION TES XTRA
2
QL (204 Test Strips
every 30 days), OTC
PRECISN XTRA TES KETONE
2
OTC
SHARPS CONTAINER
2
OTC
URINE GLUCOSE MONITORING SUPPLIES
2
OTC
URINE TEST STRIPS
2
OTC
V-GO 20 KIT
2
V-GO 30 KIT
2
V-GO 40 KIT
2
ENDOMETRIOSIS
danazol caps 50mg, 100mg, 200mg
1
ORILISSA TABS 150mg, 200mg
2
ENZYME REPLACEMENTS
betaine anhy pow
3
PA
CERDELGA CAPS 84mg
3
PA, QL (56 caps every
28 days)
CYSTAGON CAPS 50mg, 150mg
3
PA
sapropterin dihydrochloride pack 100mg,
500mg; tabs 100mg
3
PA
ESTROGENS
CLIMARA PRO DIS WEEKLY
2
DUAVEE TAB 0.45-20
2
estradiol pttw .025mg/24hr,
.037mg/24hr, .05mg/24hr, .075mg/24hr,
.1mg/24hr; ptwk .025mg/24hr,
.05mg/24hr, .06mg/24hr, .075mg/24hr,
.1mg/24hr, 37.5mcg/24hr; tabs .5mg,
1mg, 2mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
estradiol & norethindrone acetate tab 0.5-
0.1 mg
1
estradiol & norethindrone acetate tab 1-0.5
mg
1
estradiol vaginal crea .1mg/gm
1
IMVEXXY MAINTENANCE PACK INST
4mcg, 10mcg
2
IMVEXXY STARTER PACK INST 4mcg,
10mcg
2
jinteli
1
MENEST TABS .3mg, .625mg, 1.25mg,
2.5mg
3
PA; High Risk
Medications require PA
for members age 70 and
older
mimvey
1
norethindrone acetate-ethinyl estradiol tab
0.5 mg-2.5 mcg
1
PREMARIN CREA .625mg/gm
3
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
60
Drug Name
Drug Tier
Requirements/Limits
PREMARIN TABS .3mg, .45mg, .625mg,
.9mg, 1.25mg
3
PA; High Risk
Medications require PA
for members age 70 and
older
yuvafem tabs 10mcg
1
GLUCOCORTICOIDS
dexamethasone elix .5mg/5ml; soln
.5mg/5ml; tabs .5mg, .75mg, 1mg,
1.5mg, 2mg, 4mg, 6mg
1
DEXAMETHASONE INTENSOL CONC
1mg/ml
2
EMFLAZA SUSP 22.75mg/ml
3
PA, QL (52 mL every 30
days)
EMFLAZA TABS 6mg
3
PA, QL (60 tabs every
30 days)
EMFLAZA TABS 18mg, 30mg, 36mg
3
PA, QL (30 tabs every
30 days)
fludrocortisone acetate tabs .1mg
1
hydrocortisone tabs 5mg, 10mg, 20mg
1
MEDROL TABS 2mg
2
methylprednisolone tabs 4mg, 8mg,
16mg, 32mg; tbpk 4mg
1
prednisolone soln 15mg/5ml
1
prednisolone sodium phosphate soln
6.7mg/5ml, 15mg/5ml, 25mg/5ml
1
prednisone soln 5mg/5ml; tabs 1mg,
2.5mg, 5mg, 10mg, 20mg, 50mg; tbpk
5mg, 10mg
1
PREDNISONE INTENSOL CONC 5mg/ml
2
GLUCOSE ELEVATING AGENTS^
glucagon (rdna) kit 1mg
1
INSTA-GLUCOSE GEL 77.4%
2
OTC
HEREDITARY TYROSINEMIA TYPE 1 AGENTS
nitisinone caps 2mg, 5mg, 10mg
3
PA
ORFADIN CAPS 20mg; SUSP 4mg/ml
3
PA
HUMAN GROWTH HORMONES
GENOTROPIN CART 5mg, 12mg
3
PA
GENOTROPIN MINIQUICK PRSY .2mg,
.4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg,
1.6mg, 1.8mg, 2mg
3
PA
NORDIPEN 5 MIS DEVICE
2
NORDIPEN DEL MIS SYSTEM
2
OTC
NORDITROPIN FLEXPRO SOPN
5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml,
30mg/3ml
3
PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
61
Drug Name
Drug Tier
Requirements/Limits
LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS
SYNAREL SOLN 2mg/ml
3
PA
TRIPTODUR SRER 22.5mg
3
PA
MINERALOCORTICOID RECEPTOR ANTAGONISTS
KERENDIA TABS 10mg, 20mg
3
PA
MISCELLANEOUS
cabergoline tabs .5mg
1
calcitonin (salmon) soln 200unit/act
1
INCRELEX SOLN 40mg/4ml
3
PA
INTRAROSA INST 6.5mg
3
mifepristone tabs 200mg
1
OSPHENA TABS 60mg
3
PA
PROLIA SOSY 60mg/ml
3
PA, QL (60mg every 24
weeks)
raloxifene hcl tabs 60mg
1
$0 copay for women
ages 35 and older for
the primary prevention
of breast cancer
SUPPRELIN LA KIT 50mg
3
PA
tolvaptan tabs 15mg, 30mg
3
PA
TYMLOS SOPN 3120mcg/1.56ml
3
PA, QL (1 pen every 30
days)
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate binder) caps
667mg; tabs 667mg
1
FOSRENOL PACK 750mg, 1000mg
3
sevelamer carbonate pack .8gm, 2.4gm;
tabs 800mg
1
VELPHORO CHEW 500mg
3
PROGESTINS
CRINONE GEL 4%, 8%
2
medroxyprogesterone acetate tabs 2.5mg,
5mg, 10mg
1
norethindrone acetate tabs 5mg
1
progesterone caps 100mg, 200mg
1
THYROID AGENTS
levothyroxine sodium tabs 25mcg, 50mcg,
75mcg, 88mcg, 100mcg, 112mcg,
125mcg, 137mcg, 150mcg, 175mcg,
200mcg, 300mcg
1
levoxyl tabs 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg, 200mcg
1
liothyronine sodium tabs 5mcg, 25mcg,
50mcg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
62
Drug Name
Drug Tier
Requirements/Limits
methimazole tabs 5mg, 10mg
1
propylthiouracil tabs 50mg
1
SYNTHROID TABS 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg, 200mcg,
300mcg
2
unithroid tabs 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg,
200mcg, 300mcg
1
VASOPRESSINS
desmopressin acetate tabs .1mg, .2mg
1
desmopressin acetate spray soln .01%
1
desmopressin acetate spray refrigerated
soln .01%
1
GASTROINTESTINAL
ANTICHOLINERGICS
dicyclomine hcl caps 10mg; soln
10mg/5ml; tabs 20mg
1
glycopyrrolate soln 1mg/5ml; tabs 1mg,
2mg
1
methscopolamine bromide tabs 2.5mg,
5mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
ANTIDIARRHEALS
cvs anti-diarrheal tabs 2mg
1
OTC
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
1
diphenoxylate w/ atropine tab 2.5-0.025
mg
1
loperamide hcl caps 2mg
1
MOTOFEN TAB 1-0.025
3
ANTIEMETICS§
AKYNZEO CAP 300-0.5
3
QL (2 caps every 28
days)
aprepitant caps 40mg
1
QL (3 caps every 180
days)
aprepitant caps 80mg
1
QL (4 caps every 28
days)
aprepitant caps 125mg
1
QL (2 caps every 28
days)
aprepitant capsule therapy pack 80 & 125
mg
1
QL (2 packs every 28
days)
compro supp 25mg
1
dronabinol caps 2.5mg, 5mg, 10mg
1
QL (60 caps every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
63
Drug Name
Drug Tier
Requirements/Limits
granisetron hcl tabs 1mg
1
QL (12 tabs every 28
days)
meclizine hcl tabs 12.5mg, 25mg
1
metoclopramide hcl soln 10mg/10ml; tabs
5mg, 10mg
1
ondansetron tbdp 4mg, 8mg
1
QL (18 tabs every 28
days)
ondansetron hcl soln 4mg/5ml
1
QL (200 mL every 28
days)
ondansetron hcl tabs 4mg, 8mg
1
QL (18 tabs every 28
days)
ondansetron hcl tabs 24mg
1
QL (2 tabs every 28
days)
prochlorperazine supp 25mg
1
prochlorperazine maleate tabs 5mg, 10mg
1
promethazine hcl supp 12.5mg, 25mg
1
promethazine hcl syrp 6.25mg/5ml; tabs
12.5mg, 25mg, 50mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
promethegan supp 12.5mg, 25mg, 50mg
1
SANCUSO PTCH 3.1mg/24hr
2
QL (2 patches every 28
days)
scopolamine pt72 1mg/3days
1
trimethobenzamide hcl caps 300mg
1
VARUBI TBPK 90mg
2
H2-RECEPTOR ANTAGONISTS
cimetidine tabs 200mg, 300mg, 400mg,
800mg
1
cimetidine hcl soln 300mg/5ml
1
famotidine susr 40mg/5ml; tabs 20mg,
40mg
1
nizatidine caps 150mg, 300mg
1
INFLAMMATORY BOWEL DISEASE
balsalazide disodium caps 750mg
1
budesonide cpep 3mg; tb24 9mg
1
DIPENTUM CAPS 250mg
3
PA
hydrocortisone (intrarectal) enem
100mg/60ml
1
mesalamine cp24 .375gm; cpdr 400mg;
enem 4gm; supp 1000mg; tbec 1.2gm,
800mg
1
mesalamine w/ cleanser kit 4gm
1
sulfasalazine tabs 500mg; tbec 500mg
1
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION
LINZESS CAPS 72mcg, 145mcg, 290mcg
2
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
64
Drug Name
Drug Tier
Requirements/Limits
lubiprostone caps 8mcg, 24mcg
1
IRRITABLE BOWEL SYNDROME WITH DIARRHEA
alosetron hcl tabs .5mg, 1mg
1
PA
LAXATIVES
CLENPIQ SOL
0
$0 copay for members
age 45 through 75, Tier
2 for all others
enulose soln 10gm/15ml
1
gavilyte-c
1
gavilyte-g
1
generlac soln 10gm/15ml
1
lactulose soln 10gm/15ml
1
OSMOPREP TAB 1.5GM
3
peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm
1
peg 3350-kcl-nacl-na sulfate-na ascorbate-
c for soln 100 gm
0
$0 copay for members
age 45 through 75,
otherwise not covered
peg 3350-kcl-sod bicarb-nacl for soln 420
gm
1
PEG-PREP KIT
0
$0 copay for members
age 45 through 75,
otherwise not covered
PLENVU SOL
0
$0 copay for members
age 45 through 75,
otherwise not covered
polyethylene glycol 3350 powd
17gm/scoop
1
OTC
sod sulfate-pot sulf-mg sulf oral sol 17.5-
3.13-1.6 gm/177ml
0
$0 copay for members
age 45 through 75,
otherwise not covered
SUPREP BOWEL SOL PREP KIT
0
$0 copay for members
age 45 through 75,
otherwise not covered
SUTAB TAB
0
$0 copay for members
age 45 through 75,
otherwise not covered
MISCELLANEOUS
misoprostol tabs 100mcg, 200mcg
1
MOVANTIK TABS 12.5mg, 25mg
2
SUCRAID SOLN 8500unit/ml
3
PA, QL (354 mL every
30 days)
sucralfate tabs 1gm
1
ursodiol caps 300mg; tabs 250mg, 500mg
1
PANCREATIC ENZYMES
CREON CAP 3000UNIT
2
PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
65
Drug Name
Drug Tier
Requirements/Limits
CREON CAP 6000UNIT
2
PA
CREON CAP 12000UNT
2
PA
CREON CAP 24000UNT
2
PA
CREON CAP 36000UNT
2
PA
VIOKACE TAB 10440
2
PA
VIOKACE TAB 20880
2
PA
ZENPEP CAP 3000UNIT
2
PA
ZENPEP CAP 5000UNIT
2
PA
ZENPEP CAP 10000UNT
2
PA
ZENPEP CAP 15000UNT
2
PA
ZENPEP CAP 20000UNT
2
PA
ZENPEP CAP 25000UNT
2
PA
ZENPEP CAP 40000UNT
2
PA
PROTON PUMP INHIBITORS§
cvs omeprazole/sodium bic
1
QL (90 caps every 365
days), OTC
dexlansoprazole cpdr 30mg, 60mg
1
QL (90 caps every 365
days)
esomeprazole magnesium cpdr 20mg,
40mg
1
QL (90 caps every 365
days)
esomeprazole magnesium pack 10mg
1
QL (90 packets every
365 days); Covered for
age less than 1 year
only
esomeprazole magnesium tbec 20mg
1
QL (90 tabs every 365
days), OTC
goodsense lansoprazole cpdr 15mg
1
QL (90 caps every 365
days), OTC
kls esomeprazole magnesiu cpdr 20mg
1
QL (90 caps every 365
days), OTC
lansoprazole cpdr 15mg, 30mg
1
QL (90 caps every 365
days)
NEXIUM PACK 2.5mg, 5mg
3
QL (90 packets every
365 days); Covered for
age less than 1 year
only
NEXIUM 24HR CPDR 20mg
1
QL (90 caps every 365
days), OTC
omeprazole cpdr 10mg, 20mg, 40mg
1
QL (90 caps every 365
days)
omeprazole tbec 20mg
1
QL (90 tabs every 365
days), OTC
omeprazole magnesium cpdr 20.6mg
1
QL (90 caps every 365
days), OTC
pantoprazole sodium tbec 20mg, 40mg
1
QL (90 tabs every 365
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
66
Drug Name
Drug Tier
Requirements/Limits
rabeprazole sodium tbec 20mg
1
QL (90 tabs every 365
days)
RECTAL, CORTICOSTEROIDS
hydrocortisone (rectal) crea 2.5%
1
procto-pak crea 1%
1
ULCER THERAPY COMBINATIONS
amoxicillin cap-clarithro tab-lansopraz cap
dr therapy pack
1
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl tb24 10mg
1
CARDURA XL TB24 4mg, 8mg
3
ST; PA**
dutasteride caps .5mg
1
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
1
finasteride tabs 5mg
1
silodosin caps 4mg, 8mg
1
tadalafil tabs 2.5mg, 5mg
1
PA, QL (30 tabs every
30 days)
tamsulosin hcl caps .4mg
1
CONTRACEPTIVES
ENCARE SUPP 100mg
0
OTC
OPTIONS GYNOL II VAGINAL GEL 3%
0
OTC
PHEXXI GEL
0
SHUR-SEAL GEL 2%
0
OTC
TODAY SPONGE MISC 1000mg
0
OTC
VCF VAGINAL CONTRACEPTIVE FILM 28%;
FOAM 12.5%; GEL 4%
0
OTC
MISCELLANEOUS
bethanechol chloride tabs 5mg, 10mg,
25mg, 50mg
1
ELMIRON CAPS 100mg
3
phenazopyridine tab 95mg tabs 95mg
1
OTC
potassium citrate (alkalinizer) tbcr 15meq,
540mg, 1080mg
1
URINARY ANTISPASMODICS
darifenacin hydrobromide tb24 7.5mg,
15mg
1
fesoterodine fumarate tb24 4mg, 8mg
1
GEMTESA TABS 75mg
3
MYRBETRIQ SRER 8mg/ml; TB24 25mg,
50mg
2
oxybutynin chloride syrp 5mg/5ml; tabs
5mg; tb24 5mg, 10mg, 15mg
1
solifenacin succinate tabs 5mg, 10mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
67
Drug Name
Drug Tier
Requirements/Limits
tolterodine tartrate cp24 2mg, 4mg; tabs
1mg, 2mg
1
trospium chloride cp24 60mg; tabs 20mg
1
VAGINAL ANTI-INFECTIVES
CLEOCIN SUPP 100mg
2
clindamycin phosphate vaginal crea 2%
1
cvs miconazole 1 combinat
1
OTC
GYNAZOLE-1 CREA 2%
3
metronidazole vaginal gel .75%
1
miconazole 3 supp 200mg
1
miconazole 3 combination
1
OTC
miconazole 7 crea 2%
1
OTC
sm miconazole 3
1
OTC
terconazole vaginal crea .4%, .8%; supp
80mg
1
HEMATOLOGIC
ANTICOAGULANTS
dabigatran etexilate mesylate caps 150mg
1
ELIQUIS TABS 2.5mg, 5mg
2
ELIQUIS STARTER PACK TBPK 5mg
2
enoxaparin sodium soln 300mg/3ml; sosy
30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml, 100mg/ml, 120mg/0.8ml,
150mg/ml
1
fondaparinux sodium soln 2.5mg/0.5ml,
5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
1
FRAGMIN SOLN 95000unit/3.8ml; SOSY
2500unit/0.2ml, 5000unit/0.2ml,
7500unit/0.3ml, 10000unit/ml,
12500unit/0.5ml, 15000unit/0.6ml,
18000unt/0.72ml
3
heparin sodium (porcine) soln
1000unit/ml, 5000unit/0.5ml, 5000unit/ml,
10000unit/ml, 20000unit/ml
1
jantoven tabs 1mg, 2mg, 2.5mg, 3mg,
4mg, 5mg, 6mg, 7.5mg, 10mg
1
PRADAXA CAPS 75mg, 110mg, 150mg
3
warfarin sodium tabs 1mg, 2mg, 2.5mg,
3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg
1
XARELTO SUSR 1mg/ml; TABS 2.5mg,
10mg, 15mg, 20mg
2
XARELTO STAR TAB 15/20MG
2
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
68
Drug Name
Drug Tier
Requirements/Limits
HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE SOLN 25mcg/ml,
40mcg/ml, 60mcg/ml, 100mcg/ml,
200mcg/ml; SOSY 10mcg/0.4ml,
25mcg/0.42ml, 40mcg/0.4ml,
60mcg/0.3ml, 100mcg/0.5ml,
150mcg/0.3ml, 200mcg/0.4ml,
300mcg/0.6ml, 500mcg/ml
3
PA
DOPTELET TAB 20MG (10 TABLETS) TABS
20mg
3
PA, QL (1 carton every 5
days)
DOPTELET TAB 20MG (15 TABLETS) TABS
20mg
3
PA, QL (1 carton every 5
days)
DOPTELET TAB 20MG (30 TABLETS) TABS
20mg
3
PA, QL (2 cartons every
30 days)
MIRCERA SOSY 30mcg/0.3ml,
50mcg/0.3ml, 75mcg/0.3ml,
100mcg/0.3ml, 150mcg/0.3ml,
200mcg/0.3ml
3
PA
NIVESTYM SOLN 300mcg/ml,
480mcg/1.6ml; SOSY 300mcg/0.5ml,
480mcg/0.8ml
3
PA
RETACRIT SOLN 2000unit/ml,
3000unit/ml, 4000unit/ml, 10000unit/ml,
20000unit/ml, 40000unit/ml
3
PA
ZIEXTENZO SOSY 6mg/0.6ml
3
PA, QL (2 injections
every 28 days)
HEMOPHILIA A AGENTS
HEMLIBRA SOLN 30mg/ml, 60mg/0.4ml,
105mg/0.7ml, 150mg/ml
3
PA
MISCELLANEOUS
anagrelide hcl caps .5mg, 1mg
1
cilostazol tabs 50mg, 100mg
1
DROXIA CAPS 200mg, 300mg, 400mg
2
pentoxifylline tbcr 400mg
1
tranexamic acid soln 1000mg/10ml; tabs
650mg
1
PLATELET AGGREGATION INHIBITORS
aspirin-dipyridamole cap er 12hr 25-200
mg
1
BRILINTA TABS 60mg, 90mg
2
clopidogrel bisulfate tabs 75mg, 300mg
1
dipyridamole tabs 25mg, 50mg, 75mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
prasugrel hcl tabs 5mg, 10mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
69
Drug Name
Drug Tier
Requirements/Limits
ZONTIVITY TABS 2.08mg
2
IMMUNOLOGIC AGENTS
AUTOIMMUNE AGENTS (PHYSICIAN-ADMINISTERED)
ACTEMRA SOLN 80mg/4ml
3
ST, PA, QL (10 vials
every 14 days)
ACTEMRA SOLN 200mg/10ml
3
ST, PA, QL (4 vials every
14 days)
ACTEMRA SOLN 400mg/20ml
3
ST, PA, QL (2 vials every
14 days)
INFLIXIMAB SOLR 100mg
3
PA, QL (5 vials every 42
days)
SIMPONI ARIA SOLN 50mg/4ml
3
PA, QL (200 mg every 8
weeks)
SKYRIZI SOLN 600mg/10ml
3
PA, QL (3 vials every 56
days); Preferred Agent
for Crohn's Disease
AUTOIMMUNE AGENTS (SELF-ADMINISTERED)
ACTEMRA SOSY 162mg/0.9ml
3
ST, PA, QL (4 syringes
every 28 days)
COSENTYX SOSY 75mg/0.5ml, 150mg/ml
3
PA, QL (1 syringe every
28 days); Preferred
agent for Ankylosing
Spondylitis and Psoriatic
Arthritis
COSENTYX SOSY 150mg/ml
3
PA, QL (300 mg every
28 days); Preferred
agent for Ankylosing
Spondylitis and Psoriatic
Arthritis
COSENTYX SENSOREADY PEN SOAJ
150mg/ml
3
PA, QL (1 pen every 28
days); Preferred agent
for Ankylosing
Spondylitis and Psoriatic
Arthritis
COSENTYX SENSOREADY PEN SOAJ
150mg/ml
3
PA, QL (300 mg every
28 days); Preferred
agent for Ankylosing
Spondylitis and Psoriatic
Arthritis
ENBREL SOLN 25mg/0.5ml
3
PA, QL (8 vials every 28
days); Preferred agent
for Ankylosing
Spondylitis, Psoriatic
Arthritis, and
Rheumatoid Arthritis
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
70
Drug Name
Drug Tier
Requirements/Limits
ENBREL SOSY 25mg/0.5ml
3
PA, QL (8 syringes every
28 days); Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis, and
Rheumatoid Arthritis
ENBREL SOSY 50mg/ml
3
PA, QL (4 syringes every
28 days); Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis, and
Rheumatoid Arthritis
ENBREL MINI SOCT 50mg/ml
3
PA, QL (4 cartridges
every 28 days);
Preferred agent for
Ankylosing Spondylitis,
Psoriatic Arthritis, and
Rheumatoid Arthritis
ENBREL SURECLICK SOAJ 50mg/ml
3
PA, QL (4 syringes every
28 days); Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis, and
Rheumatoid Arthritis
HUMIRA PSKT 10mg/0.1ml
3
PA, QL (2 injections
every 28 days)
HUMIRA PSKT 20mg/0.2ml, 40mg/0.4ml,
40mg/0.8ml
3
PA, QL (4 injections
every 28 days)
HUMIRA PEDIA INJ CROHNS
3
PA, QL (2 injections
every 28 days); (80mg
and 40mg dual strength
kit)
HUMIRA PEDIATRIC CROHNS D PSKT
80mg/0.8ml
3
PA, QL (3 injections
every 28 days); (80mg
single strength kit)
HUMIRA PEN PNKT 40mg/0.4ml
3
PA, QL (4 injections
every 28 days)
HUMIRA PEN KIT PS/UV
3
PA, QL (1 kit every 28
days)
HUMIRA PEN-CD/UC/HS START PNKT
40mg/0.8ml
3
PA, QL (6 pens every 28
days)
HUMIRA PEN-CD/UC/HS START PNKT
80mg/0.8ml
3
PA, QL (1 kit every 28
days)
HUMIRA PEN-PS/UV STARTER PNKT
40mg/0.8ml
3
PA, QL (4 pens every 28
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
71
Drug Name
Drug Tier
Requirements/Limits
KEVZARA SOAJ 150mg/1.14ml,
200mg/1.14ml
3
PA, QL (2 pens every 28
days); Preferred agent
for Rheumatoid Arthritis
(after failure of 2 other
preferred agents)
KEVZARA SOSY 150mg/1.14ml,
200mg/1.14ml
3
PA, QL (2 syringes every
4 weeks); Preferred
agent for Rheumatoid
Arthritis (after failure of
2 other preferred
agents)
OTEZLA TABS 30mg
3
PA, QL (60 tabs every
30 days); Preferred
agent for Psoriasis and
Psoriatic Arthritis
OTEZLA TAB 10/20/30
3
PA, QL (55 tabs every
28 days); Preferred
agent for Psoriasis and
Psoriatic Arthritis
RINVOQ TB24 15mg
3
PA, QL (30 tabs every
30 days); Preferred
agent for Ankylosing
Spondylitis, Atopic
Dermatitis, Psoriatic
Arthritis, Rheumatoid
Arthritis, and Ulcerative
Colitis.
RINVOQ TB24 30mg
3
PA, QL (30 tabs every
30 days); Preferred
agent for Atopic
Dermatitis and
Ulcerative Colitis.
RINVOQ TB24 45mg
3
PA, QL (56 tabs every
56 days); Preferred
agent for Ulcerative
Colitis. Dose is one time
induction dose for UC
diagnosis only
SIMPONI SOAJ 50mg/0.5ml, 100mg/ml;
SOSY 50mg/0.5ml, 100mg/ml
3
ST, PA, QL (1 injection
every 28 days)
SKYRIZI PSKT 75mg/0.83ml
3
PA, QL (2 syringes every
12 weeks); Preferred
agent for Psoriasis and
Psoriatic Arthritis
SKYRIZI SOCT 180mg/1.2ml,
360mg/2.4ml
3
PA, QL (1 cartridge
every 56 days);
Preferred Agent for
Crohn's Disease
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
72
Drug Name
Drug Tier
Requirements/Limits
SKYRIZI SOSY 150mg/ml
3
PA, QL (1 syringe every
12 weeks); Preferred
agent for Psoriasis and
Psoriatic Arthritis
SKYRIZI PEN SOAJ 150mg/ml
3
PA, QL (1 syringe every
12 weeks); Preferred
agent for Psoriasis and
Psoriatic Arthritis
STELARA SOLN 45mg/0.5ml
3
PA, QL (1 vial every 84
days); Preferred agent
for Crohn's Disease,
Psoriasis, and Ulcerative
Colitis
STELARA SOSY 45mg/0.5ml
3
PA, QL (1 syringe every
84 days); Preferred
agent for Crohn's
Disease, Psoriasis, and
Ulcerative Colitis
STELARA SOSY 90mg/ml
3
PA, QL (1 syringe every
56 days); Preferred
agent for Crohn's
Disease, Psoriasis, and
Ulcerative Colitis
TALTZ SOAJ 80mg/ml; SOSY 80mg/ml
3
PA, QL (1 injection every
28 days); Preferred
agent for Psoriasis
TREMFYA SOPN 100mg/ml; SOSY
100mg/ml
3
PA, QL (1 injection every
56 days); Preferred
agent for Psoriasis
XELJANZ SOLN 1mg/ml
3
PA, QL (240 mL every
24 days)
XELJANZ TABS 5mg
3
PA, QL (60 tabs every
30 days); Preferred
agent for Rheumatoid
Arthritis and Ulcerative
Colitis.
XELJANZ TABS 10mg
3
PA, QL (60 tabs every
30 days); Preferred
agent for Ulcerative
Colitis.
XELJANZ XR TB24 11mg
3
PA, QL (30 tabs every
30 days); Preferred
agent for Rheumatoid
Arthritis and Ulcerative
Colitis.
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
73
Drug Name
Drug Tier
Requirements/Limits
XELJANZ XR TB24 22mg
3
PA, QL (30 tabs every
30 days); Preferred
agent for Ulcerative
Colitis.
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
hydroxychloroquine sulfate tabs 200mg
1
leflunomide tabs 10mg, 20mg
1
methotrexate sodium tabs 2.5mg
1
HEREDITARY ANGIOEDEMA
HAEGARDA SOLR 2000unit, 3000unit
3
PA, QL (20 vials every
30 days)
icatibant acetate soln 30mg/3ml
3
PA, QL (45 syringes
every 90 days)
IMMUNOGLOBULIN
HYQVIA INJ 2.5-200
3
PA
HYQVIA INJ 5-400
3
PA
HYQVIA INJ 10-800
3
PA
HYQVIA INJ 20-1600
3
PA
HYQVIA INJ 30-2400
3
PA
IMMUNOMODULATORS
ACTIMMUNE SOLN 2000000unit/0.5ml
3
PA
INTRON A SOLR 10000000unit,
18000000unit, 50000000unit
3
PA
IMMUNOSUPPRESSANTS
azathioprine tabs 50mg
1
cyclosporine modified (for microemulsion)
caps 25mg, 50mg, 100mg; soln 100mg/ml
1
everolimus (immunosuppressant) tabs
.25mg, .5mg, .75mg, 1mg
1
gengraf caps 25mg, 100mg; soln
100mg/ml
1
mycophenolate mofetil caps 250mg; susr
200mg/ml; tabs 500mg
1
mycophenolate sodium tbec 180mg,
360mg
1
sirolimus soln 1mg/ml; tabs .5mg, 1mg,
2mg
1
tacrolimus caps .5mg, 1mg, 5mg
1
VACCINES
ACTHIB INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
ADACEL INJ
0
BEXSERO INJ
0
BOOSTRIX INJ
0
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
74
Drug Name
Drug Tier
Requirements/Limits
DAPTACEL INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
DENGVAXIA SUS
0
$0 copay for members
age 18 and younger,
otherwise not covered
DIP/TET PED INJ 25-5LFU
0
$0 copay for members
age 18 and younger,
otherwise not covered
ENGERIX-B SUSP 20mcg/ml; SUSY
10mcg/0.5ml, 20mcg/ml
0
FLUMIST
0
GARDASIL 9 INJ
0
HAVRIX SUSP 720elu/0.5ml, 1440elu/ml
0
HEPLISAV-B SOSY 20mcg/0.5ml
0
HIBERIX SOLR 10mcg
0
$0 copay for members
age 18 and younger,
otherwise not covered
INFANRIX INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
INFLUENZA VACCINE
0
IPOL INJ INACTIVE
0
$0 copay for members
age 18 and younger,
otherwise not covered
KINRIX INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
M-M-R II INJ
0
MENACTRA INJ
0
MENQUADFI INJ
0
MENVEO INJ
0
MENVEO SOL
0
PEDIARIX INJ 0.5ML
0
$0 copay for members
age 18 and younger,
otherwise not covered
PEDVAX HIB SUSP 7.5mcg/0.5ml
0
$0 copay for members
age 18 and younger,
otherwise not covered
PENTACEL INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
PNEUMOVAX 23/1 DOSE INJ 25mcg/0.5ml
0
PREHEVBRIO SUSP 10mcg/ml
0
PREVNAR 13 INJ
0
PREVNAR 20 INJ
0
PRIORIX INJ
0
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
75
Drug Name
Drug Tier
Requirements/Limits
PROQUAD INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
QUADRACEL INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
QUADRACEL INJ 0.5ML
0
$0 copay for members
age 18 and younger,
otherwise not covered
RECOMBIVAX HB SUSP 5mcg/0.5ml,
10mcg/ml, 40mcg/ml; SUSY 5mcg/0.5ml,
10mcg/ml
0
ROTARIX SUS
0
$0 copay for members
age 18 and younger,
otherwise not covered
ROTATEQ SOL
0
$0 copay for members
age 18 and younger,
otherwise not covered
SHINGRIX SUSR 50mcg/0.5ml
0
$0 copay for members
age 19 and older,
otherwise not covered
TDVAX INJ 2-2 LF
0
$0 copay for members
age 19 and older,
otherwise not covered
TENIVAC INJ 5-2LF
0
$0 copay for members
age 19 and older,
otherwise not covered
TRUMENBA INJ
0
TWINRIX INJ
0
$0 copay for members
age 19 and older,
otherwise not covered
VAQTA SUSP 25unit/0.5ml, 50unit/ml
0
VARIVAX INJ 1350pfu/0.5ml
0
VAXELIS INJ
0
$0 copay for members
age 18 and younger,
otherwise not covered
VAXNEUVANCE INJ
0
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
effer-k tbef 25meq
1
fluoritab soln .125mg/drop
0
$0 applies for ages 5
and under, otherwise
not covered
klor-con 8 tbcr 8meq
1
klor-con 10 tbcr 10meq
1
klor-con m15 tbcr 15meq
1
monoject sodium chloride soln .9%
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
76
Drug Name
Drug Tier
Requirements/Limits
nafrinse chew 2.2mg
1
nafrinse drops soln .125mg/drop
0
$0 applies for ages 5
and under, otherwise
not covered
potassium chloride cpcr 8meq, 10meq;
soln 10%, 20%; tbcr 8meq, 10meq,
20meq
1
potassium chloride microencapsulated
crystals er tbcr 10meq, 20meq
1
sodium chloride soln 2.5meq/ml
1
sodium fluoride chew .25mg, .5mg; soln
.5mg/ml; tabs .5mg
0
$0 applies for ages 5
and under, otherwise
not covered
sodium fluoride tabs 1mg
1
IV REPLACEMENT SOLUTIONS
sodium chloride soln .45%, .9%, 3%, 5%
1
PRENATAL VITAMINS
CITRANATAL CAP HARMONY
2
CITRANATAL CAP MEDLEY
2
CITRANATAL MIS 90 DHA
2
CITRANATAL MIS B-CALM
2
CITRANATAL PAK ASSURE
2
CITRANATAL PAK DHA
2
CITRANATAL TAB BLOOM
2
elite-ob
1
prenatabs rx
1
VITAMINS
calcitriol caps .25mcg, .5mcg; soln
1mcg/ml
1
cholecalciferol caps 50000unit
1
OTC
cyanocobalamin soln 1000mcg/ml
1
doxercalciferol caps .5mcg, 1mcg, 2.5mcg
1
ergocalciferol caps 50000unit
1
folic acid caps 800mcg
0
QL (100 caps every 30
days), OTC; $0 copay
for members 55 and
younger capable of
pregnancy, otherwise
not covered
folic acid tabs 1mg
1
folic acid tabs 400mcg, 800mcg
0
QL (100 tabs every 30
days), OTC; $0 copay
for members 55 and
younger capable of
pregnancy, otherwise
not covered
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
77
Drug Name
Drug Tier
Requirements/Limits
multi-vitamin/fluoride dr
1
multi-vitamin/fluoride/ir
1
multivitamin/fluoride
1
paricalcitol caps 1mcg, 2mcg, 4mcg
1
phytonadione tabs 5mg
1
pyridoxine hcl tabs 25mg, 50mg
1
OTC
tri-vite/fluoride
1
vitamins a/c/d/fluoride
1
westab max
1
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
1
BLEPHAMIDE OIN S.O.P.
2
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
1
neomycin-polymyxin-dexamethasone
ophth susp 0.1%
1
neomycin-polymyxin-hc ophth susp
1
PRED-G SUS OP
3
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
1
TOBRADEX OIN 0.3-0.1%
2
TOBRADEX ST SUS 0.3-0.05
2
tobramycin-dexamethasone ophth susp
0.3-0.1%
1
ZYLET SUS 0.5-0.3%
3
ANTI-INFECTIVES
AZASITE SOLN 1%
2
bacitracin (ophthalmic) oint 500unit/gm
1
bacitracin-polymyxin b ophth oint
1
BESIVANCE SUSP .6%
3
ciprofloxacin hcl (ophth) soln .3%
1
erythromycin (ophth) oint 5mg/gm
1
gatifloxacin (ophth) soln .5%
1
gentak oint .3%
1
gentamicin sulfate (ophth) soln .3%
1
QL (20 mL every 30
days)
levofloxacin (ophth) soln .5%
1
moxifloxacin hcl (ophth) soln .5%
1
NATACYN SUSP 5%
2
neomycin-bacitrac zn-polymyx 5(3.5)mg-
400unt-10000unt op oin
1
neomycin-polymy-gramicid op sol 1.75-
10000-0.025mg-unt-mg/ml
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
78
Drug Name
Drug Tier
Requirements/Limits
ofloxacin (ophth) soln .3%
1
polycin
1
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1%
1
sulfacetamide sodium (ophth) oint 10%;
soln 10%
1
tobramycin (ophth) soln .3%
1
trifluridine soln 1%
1
ZIRGAN GEL .15%
3
ANTI-INFLAMMATORIES
ACUVAIL SOLN .45%
2
bromfenac sodium (ophth) soln .09%
1
dexamethasone sodium phosphate (ophth)
soln .1%
1
diclofenac sodium (ophth) soln .1%
1
difluprednate emul .05%
1
flurbiprofen sodium soln .03%
1
FML OINT .1%
2
ILEVRO SUSP .3%
2
ketorolac tromethamine (ophth) soln .4%,
.5%
1
loteprednol etabonate susp .5%
1
NEVANAC SUSP .1%
2
prednisolone acetate (ophth) susp 1%
1
PREDNISOLONE SODIUM PHOSP SOLN 1%
2
ANTIALLERGICS
ALOCRIL SOLN 2%
3
ALOMIDE SOLN .1%
3
azelastine hcl (ophth) soln .05%
1
ST
bepotastine besilate soln 1.5%
1
ST
cromolyn sodium (ophth) soln 4%
1
epinastine hcl (ophth) soln .05%
1
ST
ketotifen fumarate (ophth) soln .025%
1
OTC
olopatadine hcl soln .1%, .2%
1
ST
ZERVIATE SOLN .24%
3
ST
ANTIGLAUCOMA
apraclonidine hcl soln .5%
1
betaxolol hcl (ophth) soln .5%
1
BETIMOL SOLN .25%, .5%
3
BETOPTIC-S SUSP .25%
2
brimonidine tartrate soln .15%, .2%
1
brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%
1
brinzolamide susp 1%
1
carteolol hcl (ophth) soln 1%
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
79
Drug Name
Drug Tier
Requirements/Limits
dorzolamide hcl soln 2%
1
dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml
1
latanoprost soln .005%
1
levobunolol hcl soln .5%
1
LUMIGAN SOLN .01%
2
ST; PA**
PHOSPHOLINE IODIDE SOLR .125%
3
pilocarpine hcl soln 1%
1
SIMBRINZA SUS 1-0.2%
2
tafluprost soln .015mg/ml
1
timolol maleate (ophth) solg .25%, .5%;
soln .25%, .5%
1
travoprost soln .004%
1
ZIOPTAN SOLN .015mg/ml
3
DRY EYE DISEASE
RESTASIS EMUL .05%
1
RESTASIS MULTIDOSE EMUL .05%
2
Multi-dose vial remains
on preferred brand tier
MISCELLANEOUS
atropine sulfate (ophthalmic) soln 1%
1
CYSTARAN SOLN .44%
3
PA, QL (4 bottles every
28 days)
LACRISERT INST 5mg
3
phenylephrine hcl (mydriatic) soln 2.5%,
10%
1
tropicamide soln .5%, 1%
1
OTHER
IRRIGATION SOLUTIONS
physiolyte
1
RESPIRATORY
ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS
PROLASTIN-C SOLN 1000mg/20ml; SOLR
1000mg
3
PA
ANAPHYLAXIS TREATMENT AGENTS
epinephrine (anaphylaxis) soaj
.15mg/0.3ml, .3mg/0.3ml
1
QL (4 auto-injectors
every 30 days)
epinephrine (anaphylaxis) soaj
.15mg/0.15ml
1
QL (4 auto-injectors
every 30 days); (generic
of Adrenaclick)
EPIPEN 2-PAK SOAJ .3mg/0.3ml
2
QL (4 auto-injectors
every 30 days)
EPIPEN-JR 2-PAK SOAJ .15mg/0.3ml
2
QL (4 auto-injectors
every 30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
80
Drug Name
Drug Tier
Requirements/Limits
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§
ANORO ELLIPT AER 62.5-25
2
QL (1 package every 30
days)
BEVESPI AER 9-4.8MCG
2
QL (1 package every 30
days)
BREZTRI AERO AER SPHERE
2
QL (1 package every 30
days)
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
1
QL (6 boxes every 30
days)
ANTICHOLINERGIC/BETA AGONIST/STEROID COMBINATIONS§
TRELEGY AER 100MCG
2
QL (1 package every 30
days)
TRELEGY AER 200MCG
2
QL (1 package every 30
days)
ANTICHOLINERGICS§
ipratropium bromide soln .02%
1
QL (5 boxes every 30
days)
ipratropium bromide (nasal) soln .03%,
.06%
1
SPIRIVA HANDIHALER CAPS 18mcg
2
QL (1 package every 30
days)
SPIRIVA RESPIMAT AERS 1.25mcg/act,
2.5mcg/act
2
QL (1 package every 30
days)
ANTIHISTAMINE COMBINATIONS
azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act
1
QL (1 package every 30
days)
ANTIHISTAMINES§
allergy relief caps 10mg
1
OTC
azelastine hcl soln .1%, .15%
1
QL (2 bottles every 30
days)
carbinoxamine maleate tabs 4mg
1
cetirizine hcl chew 5mg, 10mg; tabs 5mg,
10mg
1
OTC
cetirizine hcl childrens soln 1mg/ml
1
OTC
clemastine fumarate tabs 2.68mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
cvs allergy relief childr susp 30mg/5ml
1
OTC
cyproheptadine hcl syrp 2mg/5ml; tabs
4mg
1
desloratadine tabs 5mg; tbdp 2.5mg, 5mg
1
ST
diphenhydramine hcl elix 12.5mg/5ml
1
PA; High Risk
Medications require PA
for members age 70 and
older
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
81
Drug Name
Drug Tier
Requirements/Limits
diphenhydramine hcl soln 50mg/ml
1
fexofenadine hcl tabs 180mg
1
OTC
gnp loratadine syrp 5mg/5ml
1
OTC
hydroxyzine hcl syrp 10mg/5ml; tabs
10mg, 25mg, 50mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
hydroxyzine pamoate caps 25mg, 50mg,
100mg
1
PA; High Risk
Medications require PA
for members age 70 and
older
levocetirizine dihydrochloride soln
2.5mg/5ml; tabs 5mg
1
loratadine caps 10mg; tabs 10mg
1
OTC
olopatadine hcl (nasal) soln .6%
1
QL (1 container every
30 days)
px allergy relief tbdp 10mg
1
OTC
sm fexofenadine hydrochlo tabs 60mg
1
OTC
ZYRTEC ALLERGY CAPS 10mg
1
OTC
BETA AGONISTS§
albuterol sulfate aers 108mcg/act
1
QL (2 inhalers every 30
days)
albuterol sulfate nebu .5%
1
QL (60 mL every 30
days)
albuterol sulfate nebu .083%, .63mg/3ml,
1.25mg/3ml
1
QL (5 boxes every 30
days)
albuterol sulfate syrp 2mg/5ml; tabs 2mg,
4mg
1
formoterol fumarate nebu 20mcg/2ml
1
QL (60 vials every 30
days)
levalbuterol hcl nebu 1.25mg/0.5ml
1
QL (45 mL every 30
days)
levalbuterol hcl nebu .31mg/3ml,
.63mg/3ml, 1.25mg/3ml
1
QL (300 mL every 30
days)
SEREVENT DISKUS AEPB 50mcg/dose
2
QL (1 package every 30
days)
STRIVERDI RESPIMAT AERS 2.5mcg/act
2
QL (1 package every 30
days)
terbutaline sulfate tabs 2.5mg, 5mg
1
COLD/COUGH
benzonatate caps 100mg, 200mg
1
guaifenesin-codeine soln 100-10 mg/5ml
1
QL (60 mL every day),
OTC; Subject to initial 7-
day limit
hydrocod polst-chlorphen polst er susp 10-
8 mg/5ml
1
QL (10 mL every day);
Subject to initial 7-day
limit
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
82
Drug Name
Drug Tier
Requirements/Limits
hydrocodone bitart-homatropine
methylbrom soln 5-1.5 mg/5ml
1
QL (30 mL every day);
Subject to initial 7-day
limit
hydrocodone bitart-homatropine
methylbromide tab 5-1.5 mg
1
QL (6 tabs every day);
Subject to initial 7-day
limit
promethazine & phenylephrine syrup 6.25-
5 mg/5ml
1
promethazine w/ codeine syrup 6.25-10
mg/5ml
1
QL (30 mL every day);
Subject to initial 7-day
limit
promethazine-dm syrup 6.25-15 mg/5ml
1
promethazine-phenylephrine-codeine syrup
6.25-5-10 mg/5ml
1
QL (30 mL every day);
Subject to initial 7-day
limit
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml
1
TUZISTRA XR SUS
3
QL (20 mL every day);
Subject to initial 7-day
limit
CYSTIC FIBROSIS
CAYSTON SOLR 75mg
3
PA, QL (84 vials every
28 days)
KALYDECO PACK 25mg, 50mg, 75mg
3
PA, QL (56 packets
every 28 days)
KALYDECO TABS 150mg
3
PA, QL (56 tabs every
28 days); carton
consists of 56 tablets
ORKAMBI GRA 75-94MG
3
PA, QL (56 packets
every 28 days)
ORKAMBI GRA 100-125
3
PA, QL (56 packets
every 28 days)
ORKAMBI GRA 150-188
3
PA, QL (56 packets
every 28 days)
ORKAMBI TAB 100-125
3
PA, QL (112 tabs every
28 days)
ORKAMBI TAB 200-125
3
PA, QL (112 tabs every
28 days)
SYMDEKO TAB 50-75MG
3
PA, QL (56 tabs every
28 days)
SYMDEKO TAB 100-150
3
PA, QL (56 tabs every
28 days)
tobramycin nebu 300mg/4ml
3
PA, QL (224 mL every
28 days)
tobramycin nebu 300mg/5ml
3
PA, QL (280 mL every
28 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
83
Drug Name
Drug Tier
Requirements/Limits
TRIKAFTA TAB
3
PA, QL (84 tabs every
28 days)
LEUKOTRIENE MODIFIERS
zileuton tb12 600mg
3
PA
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium chew 4mg, 5mg;
pack 4mg; tabs 10mg
1
zafirlukast tabs 10mg, 20mg
1
MAST CELL STABILIZERS§
cromolyn sodium nebu 20mg/2ml
1
QL (2 boxes every 30
days)
MISCELLANEOUS
acetylcysteine soln 10%, 20%
1
DALIRESP TABS 250mcg, 500mcg
3
PA
roflumilast tabs 250mcg, 500mcg
1
PA
sodium chloride (inhalant) nebu .9%, 3%,
7%, 10%
1
NASAL STEROIDS§
budesonide (nasal) susp 32mcg/act
1
QL (1 bottle every 30
days), OTC
flunisolide (nasal) soln .025%
1
QL (3 containers every
30 days)
fluticasone propionate (nasal) susp
50mcg/act
1
QL (1 container every
30 days)
fluticasone propionate (nasal) susp
50mcg/act
1
QL (1 container every
30 days), OTC
mometasone furoate (nasal) susp
50mcg/act
1
QL (2 packages every
30 days)
triamcinolone acetonide (nasal) aero
55mcg/act
1
QL (1 package every 30
days), OTC
PULMONARY FIBROSIS AGENTS
ESBRIET CAPS 267mg
3
PA, QL (270 caps every
30 days)
pirfenidone caps 267mg
3
PA, QL (270 caps every
30 days)
pirfenidone tabs 267mg
3
PA, QL (270 tabs every
30 days)
pirfenidone tabs 801mg
3
PA, QL (90 tabs every
30 days)
RESPIRATORY THERAPY SUPPLIES
ADULT RESPIRATORY MASK
2
HOLD CHAMBER MIS MEDIUM
2
OTC
PEDIATRIC RESPIRATORY MASK
2
PEDIATRIC RESPIRATORY MASK
2
OTC
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
84
Drug Name
Drug Tier
Requirements/Limits
SEVERE ASTHMA AGENTS
FASENRA SOSY 30mg/ml
3
PA, QL (1 syringe every
56 days)
FASENRA PEN SOAJ 30mg/ml
3
PA, QL (1 syringe every
56 days)
XOLAIR SOLR 150mg
3
PA, QL (8 vials every 28
days)
XOLAIR SOSY 75mg/0.5ml
3
PA, QL (2 syringes every
28 days)
XOLAIR SOSY 150mg/ml
3
PA, QL (8 syringes every
28 days)
STEROID INHALANTS§
ALVESCO AERS 80mcg/act
3
QL (3 packages every
30 days)
ALVESCO AERS 160mcg/act
3
QL (2 packages every
30 days)
ARNUITY ELLIPTA AEPB 50mcg/act,
100mcg/act, 200mcg/act
3
QL (1 package every 30
days)
budesonide (inhalation) susp 1mg/2ml
1
QL (1 box every 30
days)
budesonide (inhalation) susp .5mg/2ml
1
QL (2 boxes every 30
days)
budesonide (inhalation) susp .25mg/2ml
1
QL (3 boxes every 30
days)
PULMICORT FLEXHALER AEPB 90mcg/act
2
QL (3 packages every
30 days)
PULMICORT FLEXHALER AEPB 180mcg/act
2
QL (2 packages every
30 days)
QVAR REDIHALER AERB 40mcg/act,
80mcg/act
2
QL (2 packages every
30 days)
STEROID/BETA-AGONIST COMBINATIONS§
ADVAIR DISKU AER 100/50
1
QL (1 package every 30
days)
ADVAIR DISKU AER 250/50
1
QL (1 package every 30
days)
ADVAIR DISKU AER 500/50
1
QL (1 package every 30
days)
ADVAIR HFA AER 45/21
2
QL (1 package every 30
days)
ADVAIR HFA AER 115/21
2
QL (1 package every 30
days)
ADVAIR HFA AER 230/21
2
QL (1 package every 30
days)
BREO ELLIPTA INH 100-25
2
QL (1 package every 30
days)
BREO ELLIPTA INH 200-25
2
QL (1 package every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
85
Drug Name
Drug Tier
Requirements/Limits
SYMBICORT AER 80-4.5
2
QL (3 packages every
30 days)
SYMBICORT AER 160-4.5
2
QL (3 packages every
30 days)
XANTHINES
theophylline elix 80mg/15ml; soln
80mg/15ml; tb12 300mg, 450mg; tb24
400mg, 600mg
1
TOPICAL
DERMATOLOGY, ACNE
acne medication 5 gel 5%
1
OTC
ACNE MEDICATION 5 LOTN 5%
1
OTC
ACNE MEDICATION 10 LOTN 10%
1
OTC
adapalene crea .1%; gel .1%, .3%
1
PA, QL (45g every 28
days); PA applies for
members age 35 and
older
adapalene-benzoyl peroxide gel 0.1-2.5%
1
ST
adapalene-benzoyl peroxide gel 0.3-2.5%
1
ST
avita crea .025%; gel .025%
1
PA; PA applies for
members age 35 and
older
benzoyl peroxide gel 2.5%, 5%, 10%
1
OTC
benzoyl peroxide wash liqd 5%, 10%
1
OTC
benzoyl peroxide-erythromycin gel 5-3%
1
ST, QL (47g every 30
days)
bp wash liqd 2.5%, 5%
1
OTC
clearskin crea 10%
1
OTC
clindacin etz pledgets swab 1%
1
CLINDACIN KIT PAC 1%
3
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5%
1
QL (45g every 30 days)
clindamycin phosphate (topical) foam 1%
1
clindamycin phosphate (topical) gel 1%
1
QL (75g every 30 days)
clindamycin phosphate (topical) lotn 1%;
soln 1%
1
QL (60 mL every 30
days)
clindamycin phosphate-benzoyl peroxide
gel 1-5%
1
QL (50g every 30 days)
clindamycin phosphate-benzoyl peroxide
gel 1.2-2.5%
1
QL (50g every 30 days)
cvs acne cleansing bar bar 10%
1
OTC
cvs creamy acne face wash liqd 4%
1
OTC
cvs targeted acne spot tr crea 2.5%
1
OTC
ery pads 2%
1
erythromycin (acne aid) gel 2%
1
QL (60g every 30 days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
86
Drug Name
Drug Tier
Requirements/Limits
erythromycin (acne aid) soln 2%
1
QL (60 mL every 30
days)
isotretinoin caps 10mg, 20mg, 30mg,
40mg
1
PA
NEUTROGENA CLEAR PORE CLE LIQD
3.5%
1
OTC
sulfacetamide sodium (acne) lotn 10%
1
tretinoin crea .025%, .05%, .1%; gel
.01%, .025%, .05%
1
PA; PA applies for
members age 35 and
older
DERMATOLOGY, ACTINIC KERATOSIS
fluorouracil (topical) crea 5%; soln 2%,
5%
1
imiquimod crea 5%
1
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical) crea .1%; oint
.1%
1
QL (120g every 30
days)
IV PREP WIPE PAD
2
OTC
mupirocin oint 2%
1
QL (30g every 30 days)
qc bacitracin oint 500unit/gm
1
OTC
silver sulfadiazine crea 1%
1
ssd crea 1%
1
SULFAMYLON CREA 85mg/gm
3
triple antibiotic
1
OTC
DERMATOLOGY, ANTIFUNGALS
antifungal crea 1%, 2%
1
OTC
athletes foot spray aero 1%
1
OTC
butenafine hcl crea 1%
1
OTC
ciclopirox gel .77%
1
ST, QL (120g every 30
days)
ciclopirox sham 1%
1
QL (120 mL every 30
days)
ciclopirox soln 8%
1
ciclopirox olamine crea .77%
1
ST, QL (120g every 30
days)
ciclopirox olamine susp .77%
1
ST, QL (120 mL every
30 days)
clotrimazole (topical) crea 1%
1
ST, QL (120g every 30
days)
clotrimazole (topical) crea 1%; soln 1%
1
OTC
clotrimazole (topical) soln 1%
1
QL (120 mL every 30
days)
clotrimazole w/ betamethasone cream 1-
0.05%
1
QL (60g every 30 days)
clotrimazole w/ betamethasone lotion 1-
0.05%
1
QL (60 mL every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
87
Drug Name
Drug Tier
Requirements/Limits
cruex prescription streng aerp 2%
1
OTC
cvs athletes foot liquid aero 2%
1
OTC
econazole nitrate crea 1%
1
ST, QL (60g every 30
days)
ERTACZO CREA 2%
3
QL (60g every 30 days)
gnp miconazorb af powd 2%
1
OTC
gnp terbinafine hydrochlo crea 1%
1
OTC
JUBLIA SOLN 10%
3
PA, QL (4 mL every 28
days)
ketoconazole (topical) crea 2%
1
ST, QL (120g every 30
days)
LOTRIMIN ANTIFUNGAL AERO 2%
1
OTC
LOTRIMIN ULTRA CREA 1%
1
OTC
medicated anti-fungal soln 1%
1
OTC
MENTAX CREA 1%
3
QL (60g every 30 days)
naftifine hcl crea 1%, 2%
1
ST, QL (60g every 30
days)
nyamyc powd 100000unit/gm
1
ST, QL (120g every 30
days)
nystatin (topical) crea 100000unit/gm;
oint 100000unit/gm
1
ST, QL (120g every 30
days)
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
1
QL (60g every 30 days)
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
1
QL (60g every 30 days)
nystop powd 100000unit/gm
1
ST, QL (120g every 30
days)
oxiconazole nitrate crea 1%
1
ST, QL (60g every 30
days)
sulconazole nitrate crea 1%
1
QL (60g every 30 days)
sulconazole nitrate soln 1%
1
QL (60 mL every 30
days)
TINACTIN AERO 1%
1
OTC
tolnaftate aerp 1%; powd 1%
1
OTC
triple paste af oint 2%
1
OTC
DERMATOLOGY, ANTIPRURITIC
doxepin hcl (antipruritic) crea 5%
3
QL (45g every 30 days)
DERMATOLOGY, ANTIPSORIATICS
acitretin caps 10mg, 17.5mg, 25mg
1
calcipotriene soln .005%
1
ST, QL (60 mL every 30
days); PA**
calcitriol (topical) oint 3mcg/gm
3
ST, QL (100g every 30
days); PA**
methoxsalen rapid caps 10mg
1
tazarotene crea .1%; gel .05%, .1%
1
PA
TAZORAC CREA .05%; GEL .05%, .1%
2
PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
88
Drug Name
Drug Tier
Requirements/Limits
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole (topical) sham 2%
1
QL (120 mL every 30
days)
selenium sulfide lotn 2.5%
1
DERMATOLOGY, CORTICOSTEROIDS
alclometasone dipropionate crea .05%;
oint .05%
1
QL (120g every 30
days)
amcinonide crea .1%
1
QL (120g every 30
days)
amcinonide lotn .1%
1
QL (120 mL every 30
days)
AMCINONIDE OINT .1%
2
QL (120g every 30
days)
betamethasone dipropionate (topical) crea
.05%
1
QL (120g every 30
days)
betamethasone dipropionate (topical) lotn
.05%
1
QL (120 mL every 30
days)
betamethasone dipropionate augmented
crea .05%; gel .05%; oint .05%
1
QL (120g every 30
days)
betamethasone dipropionate augmented
lotn .05%
1
QL (120 mL every 30
days)
betamethasone valerate crea .1%; foam
.12%; oint .1%
1
QL (120g every 30
days)
betamethasone valerate lotn .1%
1
QL (120 mL every 30
days)
calcipotriene-betamethasone dipropionate
oint 0.005-0.064%
3
ST, QL (60g every 30
days); PA**
clobetasol propionate crea .05%; foam
.05%; gel .05%; oint .05%
1
QL (120g every 30
days)
clobetasol propionate liqd .05%; lotn
.05%; sham .05%; soln .05%
1
QL (120 mL every 30
days)
clobetasol propionate emollient base crea
.05%
1
QL (120g every 30
days)
clocortolone pivalate crea .1%
3
QL (120g every 30
days)
desonide crea .05%; oint .05%
1
QL (120g every 30
days)
desonide lotn .05%
1
QL (120 mL every 30
days)
desoximetasone crea .05%, .25%; gel
.05%; oint .25%
1
QL (120g every 30
days)
desoximetasone liqd .25%
3
QL (120 mL every 30
days)
diflorasone diacetate crea .05%; oint
.05%
3
QL (120g every 30
days); PA
fluocinolone acetonide crea .01%, .025%;
oint .025%
1
QL (120g every 30
days)
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
89
Drug Name
Drug Tier
Requirements/Limits
fluocinolone acetonide oil .01%; soln
.01%
1
QL (120 mL every 30
days)
fluocinonide crea .05%; gel .05%; oint
.05%
1
QL (120g every 30
days)
fluocinonide soln .05%
1
QL (120 mL every 30
days)
fluticasone propionate crea .05%; oint
.005%
1
QL (120g every 30
days)
fluticasone propionate lotn .05%
1
QL (120 mL every 30
days)
halobetasol propionate crea .05%; oint
.05%
1
QL (120g every 30
days)
hydrocortisone (topical) crea 1%, 2.5%;
oint 2.5%
1
QL (120g every 30
days)
hydrocortisone (topical) lotn 2.5%
1
QL (120 mL every 30
days)
hydrocortisone butyrate crea .1%; oint
.1%
1
QL (120g every 30
days)
hydrocortisone butyrate soln .1%
1
QL (120 mL every 30
days)
hydrocortisone valerate crea .2%; oint
.2%
1
QL (120g every 30
days)
mometasone furoate crea .1%; oint .1%
1
QL (120g every 30
days)
mometasone furoate soln .1%
1
QL (120 mL every 30
days)
prednicarbate oint .1%
1
QL (120g every 30
days)
triamcinolone acetonide (topical) crea
.025%, .1%, .5%; oint .025%, .1%, .5%
1
QL (120g every 30
days)
triamcinolone acetonide (topical) lotn
.025%, .1%
1
QL (120 mL every 30
days)
triderm crea .1%
1
QL (120g every 30
days)
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl gel 2%; prsy 2%
1
QL (60 mL every 30
days)
lidocaine hcl soln 4%
1
QL (50 mL every 30
days)
lidocaine pain relief pat ptch 4%
1
QL (30 patches every 30
days), OTC
lidocaine-prilocaine cream 2.5-2.5%
1
QL (30g every 30 days)
SYNERA DIS 70-70MG
3
QL (2 patches every 30
days)
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir topical crea 5%
3
bexarotene (topical) gel 1%
3
PA
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
90
Drug Name
Drug Tier
Requirements/Limits
CONDYLOX GEL .5%
3
DENAVIR CREA 1%
3
ST
diclofenac sodium (topical) gel 1%
1
QL (300g every 30
days)
diclofenac sodium (topical) gel 1%
1
QL (300g every 30
days), OTC
docosanol crea 10%
1
OTC
EUCRISA OINT 2%
2
ST, QL (60g every 30
days); PA**
lactic acid (ammonium lactate) crea 12%;
lotn 12%
1
penciclovir crea 1%
1
ST
pimecrolimus crea 1%
3
ST; PA**
podofilox soln .5%
1
RECTIV OINT .4%
3
tacrolimus (topical) oint .03%, .1%
3
ST; PA**
VOLTAREN GEL 1%
1
QL (300g every 30
days), OTC
DERMATOLOGY, ROSACEA
azelaic acid gel 15%
1
brimonidine tartrate (topical) gel .33%
1
PA
FINACEA FOAM 15%
2
ivermectin (rosacea) crea 1%
1
PA
metronidazole (topical) crea .75%; gel
.75%, 1%
1
QL (60g every 30 days)
metronidazole (topical) lotn .75%
1
QL (60 mL every 30
days)
MIRVASO GEL .33%
3
PA
rosadan crea .75%
1
QL (60g every 30 days)
DERMATOLOGY, SCABICIDES AND PEDICULICIDES
crotan lotn 10%
1
cvs ivermectin lice treat lotn .5%
1
OTC
cvs lice treatment liqd 1%
1
OTC
ivermectin (pediculicide) lotn .5%
1
lice treatment lotn 1%
1
OTC
malathion lotn .5%
1
ST; PA**
permethrin crea 5%
1
spinosad susp .9%
1
ST; PA**
DERMATOLOGY, WOUND CARE AGENTS
REGRANEX GEL .01%
3
PA, QL (30g every 30
days)
sodium chloride (gu irrigant) soln .9%
1
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl caps 30mg
1
OTC - Over the counter PA - Prior Authorization PA** - PA Applies if Step is Not Met
QL - Quantity Limits ST - Step Therapy
91
Drug Name
Drug Tier
Requirements/Limits
chlorhexidine gluconate (mouth-throat)
soln .12%
1
clotrimazole troc 10mg
1
QL (90 lozenges every
30 days)
lidocaine hcl (mouth-throat) soln 2%, 4%
1
nystatin (mouth-throat) susp
100000unit/ml
1
oralone dental paste pste .1%
1
ORAVIG TABS 50mg
3
QL (14 tabs every 30
days)
periogard soln .12%
1
pilocarpine hcl (oral) tabs 5mg, 7.5mg
1
triamcinolone acetonide (mouth) pste .1%
1
OTIC
acetic acid (otic) soln 2%
1
ciprofloxacin hcl (otic) soln .2%
1
ciprofloxacin-dexamethasone otic susp 0.3-
0.1%
1
ciprofloxacin-fluocinolone aceton (pf) otic
soln 0.3-0.025%
3
CORTISPORIN SUS -TC OTIC
3
fluocinolone acetonide (otic) oil .01%
1
hydrocortisone w/ acetic acid otic soln 1-
2%
1
neomycin-polymyxin-hc otic soln 1%
1
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
1
ofloxacin (otic) soln .3%
1
92
Index
A
abacavir sulfate ..................................................................... 11
abacavir sulfate-lamivudine tab 600-300 mg ............ 13
abiraterone acetate .............................................................. 21
acamprosate calcium ........................................................... 34
acarbose ................................................................................... 51
acebutolol hcl .......................................................................... 30
acetaminophen w/ codeine soln 120-12 mg/5ml........ 5
acetaminophen w/ codeine tab 300-15 mg .................. 6
acetaminophen w/ codeine tab 300-30 mg .................. 6
acetaminophen w/ codeine tab 300-60 mg .................. 6
acetaminophen-caffeine-dihydrocodeine cap 320.5-
30-16 mg .............................................................................. 6
acetazolamide......................................................................... 32
acetic acid (otic) .................................................................... 89
acetylcysteine ......................................................................... 82
acitretin ..................................................................................... 86
ACNE MEDICATION 10 ........................................................ 84
acne medication 5 ................................................................. 83
ACNE MEDICATION 5 ........................................................... 84
ACTEMRA .................................................................................. 68
ACTHIB INJ .............................................................................. 72
ACTIMMUNE ............................................................................ 72
ACUVAIL ................................................................................... 77
acyclovir ................................................................................... 15
acyclovir topical ..................................................................... 88
ADACEL INJ ............................................................................. 72
adapalene ................................................................................. 84
adapalene-benzoyl peroxide gel 0.1-2.5% ................. 84
adapalene-benzoyl peroxide gel 0.3-2.5% ................. 84
adefovir dipivoxil ................................................................... 15
ADEMPAS .................................................................................. 33
adriamycin ............................................................................... 19
ADULT RESPIRATORY MASK ............................................. 82
ADVAIR DISKU AER 100/50 .............................................. 83
ADVAIR DISKU AER 250/50 .............................................. 83
ADVAIR DISKU AER 500/50 .............................................. 83
ADVAIR HFA AER 115/21 ................................................... 83
ADVAIR HFA AER 230/21 ................................................... 83
ADVAIR HFA AER 45/21 ..................................................... 83
AJOVY ........................................................................................ 46
AKYNZEO CAP 300-0.5 ....................................................... 61
albuterol sulfate ..................................................................... 80
alclometasone dipropionate .............................................. 86
ALCOHOL PREP PAD ............................................................. 57
ALDACTAZIDE TAB 50/50 .................................................. 32
ALECENSA ................................................................................ 22
alendronate sodium.............................................................. 53
alfuzosin hcl ............................................................................ 65
ALINIA ....................................................................................... 17
aliskiren fumarate ................................................................. 32
allergy relief ............................................................................ 79
allopurinol .................................................................................. 5
almotriptan malate ............................................................... 46
ALOCRIL.................................................................................... 77
alogliptin benzoate ............................................................... 51
alogliptin-metformin hcl tab 12.5-1000 mg ............... 51
alogliptin-metformin hcl tab 12.5-500 mg .................. 51
ALOMIDE .................................................................................. 77
alosetron hcl ........................................................................... 63
alprazolam ............................................................................... 34
ALPRAZOLAM INTENSOL .................................................... 34
altavera .................................................................................... 54
ALVESCO .................................................................................. 83
alyacen 1/35 ........................................................................... 54
alyacen 7/7/7 ......................................................................... 54
amantadine hcl ...................................................................... 38
ambrisentan ............................................................................ 33
amcinonide .............................................................................. 86
AMCINONIDE .......................................................................... 86
amethia .................................................................................... 54
amethyst .................................................................................. 54
amiloride & hydrochlorothiazide tab 5-50 mg ........... 32
amiloride hcl ........................................................................... 32
amiodarone hcl ...................................................................... 28
amitriptyline hcl .................................................................... 35
amlodipine besylate ............................................................. 31
amlodipine besylate-atorvastatin calcium tab 10-10
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 10-20
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 10-40
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 10-80
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 5-10
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 5-20
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 5-40
mg ......................................................................................... 31
amlodipine besylate-atorvastatin calcium tab 5-80
mg ......................................................................................... 31
amlodipine besylate-benazepril hcl cap 10-20 mg .. 25
amlodipine besylate-benazepril hcl cap 10-40 mg .. 25
amlodipine besylate-benazepril hcl cap 2.5-10 mg . 25
amlodipine besylate-benazepril hcl cap 5-10 mg ..... 25
amlodipine besylate-benazepril hcl cap 5-20 mg ..... 25
amlodipine besylate-benazepril hcl cap 5-40 mg ..... 25
amlodipine besylate-olmesartan medoxomil tab 10-
20 mg .................................................................................. 27
amlodipine besylate-olmesartan medoxomil tab 10-
40 mg .................................................................................. 27
amlodipine besylate-olmesartan medoxomil tab 5-20
mg ......................................................................................... 26
amlodipine besylate-olmesartan medoxomil tab 5-40
mg ......................................................................................... 26
93
amlodipine besylate-valsartan tab 10-160 mg .......... 27
amlodipine besylate-valsartan tab 10-320 mg .......... 27
amlodipine besylate-valsartan tab 5-160 mg............. 27
amlodipine besylate-valsartan tab 5-320 mg............. 27
amlodipine-valsartan-hydrochlorothiazide tab 10-
160-12.5 mg ...................................................................... 27
amlodipine-valsartan-hydrochlorothiazide tab 10-
160-25 mg .......................................................................... 27
amlodipine-valsartan-hydrochlorothiazide tab 10-
320-25 mg .......................................................................... 27
amlodipine-valsartan-hydrochlorothiazide tab 5-160-
12.5 mg ............................................................................... 27
amlodipine-valsartan-hydrochlorothiazide tab 5-160-
25 mg ................................................................................... 27
amoxapine ............................................................................... 35
amoxicillin ................................................................................ 18
amoxicillin & k clavulanate chew tab 200-28.5 mg . 18
amoxicillin & k clavulanate chew tab 400-57 mg ..... 18
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml ................................................................................ 18
amoxicillin & k clavulanate for susp 250-62.5
mg/5ml ................................................................................ 18
amoxicillin & k clavulanate for susp 400-57 mg/5ml
................................................................................................ 18
amoxicillin & k clavulanate for susp 600-42.9
mg/5ml ................................................................................ 18
amoxicillin & k clavulanate tab 250-125 mg .............. 18
amoxicillin & k clavulanate tab 500-125 mg .............. 18
amoxicillin & k clavulanate tab 875-125 mg .............. 18
amoxicillin & k clavulanate tab er 12hr 1000-62.5
mg ......................................................................................... 18
amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack ...................................................................... 65
amphetamine-dextroamphetamine cap er 24hr 10
mg ......................................................................................... 42
amphetamine-dextroamphetamine cap er 24hr 15
mg ......................................................................................... 42
amphetamine-dextroamphetamine cap er 24hr 20
mg ......................................................................................... 42
amphetamine-dextroamphetamine cap er 24hr 25
mg ......................................................................................... 42
amphetamine-dextroamphetamine cap er 24hr 30
mg ......................................................................................... 42
amphetamine-dextroamphetamine cap er 24hr 5 mg
................................................................................................ 42
amphetamine-dextroamphetamine tab 10 mg .......... 42
amphetamine-dextroamphetamine tab 12.5 mg ...... 42
amphetamine-dextroamphetamine tab 15 mg .......... 42
amphetamine-dextroamphetamine tab 20 mg .......... 42
amphetamine-dextroamphetamine tab 30 mg .......... 43
amphetamine-dextroamphetamine tab 5 mg............. 42
amphetamine-dextroamphetamine tab 7.5 mg ......... 42
amphotericin b ....................................................................... 10
ampicillin .................................................................................. 18
anagrelide hcl ......................................................................... 67
anastrozole .............................................................................. 21
ANNOVERA MIS ..................................................................... 54
ANORO ELLIPT AER 62.5-25 ............................................. 78
antifungal ................................................................................. 85
APOKYN ..................................................................................... 38
apraclonidine hcl ................................................................... 77
aprepitant .......................................................................... 61, 62
aprepitant capsule therapy pack 80 & 125 mg ......... 62
apri ............................................................................................. 54
APTIVUS ................................................................................... 11
aranelle ..................................................................................... 54
ARANESP ALBUMIN FREE................................................... 67
aripiprazole ............................................................................. 39
ARISTADA ................................................................................ 39
ARISTADA INITIO ................................................................. 39
armodafinil .............................................................................. 48
ARNUITY ELLIPTA ................................................................. 83
arsenic trioxide ...................................................................... 24
asenapine maleate ............................................................... 39
ashlyna ..................................................................................... 54
aspirin enteric coated ad ................................................... 10
aspirin-dipyridamole cap er 12hr 25-200 mg ............ 67
atazanavir sulfate ................................................................. 11
atenolol ..................................................................................... 30
atenolol & chlorthalidone tab 100-25 mg .................... 30
atenolol & chlorthalidone tab 50-25 mg ...................... 30
athletes foot spray ............................................................... 85
atomoxetine hcl ..................................................................... 43
atorvastatin calcium ............................................................ 29
atovaquone ............................................................................. 17
atovaquone-proguanil hcl tab 250-100 mg ................ 11
atovaquone-proguanil hcl tab 62.5-25 mg ................. 11
atropine sulfate (ophthalmic) .......................................... 78
AUBAGIO .................................................................................. 47
AUTOLET PLAT MIS 1.8MM ............................................... 57
aviane ....................................................................................... 54
avidoxy ..................................................................................... 18
avita ........................................................................................... 84
azacitidine ............................................................................... 19
AZASITE ................................................................................... 76
azathioprine ............................................................................ 72
azelaic acid .............................................................................. 89
azelastine hcl .......................................................................... 79
azelastine hcl (ophth) ......................................................... 77
azelastine hcl-fluticasone prop nasal spray 137-50
mcg/act ............................................................................... 79
azithromycin ........................................................................... 16
AZSTARYS CAP 26.1-5.2 ................................................... 43
AZSTARYS CAP 39.2-7.8 ................................................... 43
AZSTARYS CAP 52.3-10. ................................................... 43
aztreonam ............................................................................... 17
azurette .................................................................................... 54
B
bacitracin (ophthalmic) ...................................................... 76
bacitracin-polymyxin b ophth oint ................................. 76
bacitracin-polymyxin-neomycin-hc ophth oint 1% .. 76
baclofen .................................................................................... 47
balsalazide disodium ........................................................... 62
BARACLUDE ............................................................................ 15
BASAGLAR KWIKPEN ........................................................... 52
BASAGLAR TEMPO PEN ....................................................... 52
BAXDELA .................................................................................. 16
BELBUCA .................................................................................. 10
94
BELSOMRA ............................................................................... 45
benazepril & hydrochlorothiazide tab 10-12.5 mg ... 25
benazepril & hydrochlorothiazide tab 20-12.5 mg ... 25
benazepril & hydrochlorothiazide tab 20-25 mg ....... 25
benazepril & hydrochlorothiazide tab 5-6.25 mg ...... 25
benazepril hcl ......................................................................... 26
benzonatate ............................................................................ 80
benzoyl peroxide ................................................................... 84
benzoyl peroxide wash ........................................................ 84
benzoyl peroxide-erythromycin gel 5-3% ................... 84
benztropine mesylate .......................................................... 38
bepotastine besilate ............................................................. 77
BESIVANCE .............................................................................. 76
betaine anhy pow .................................................................. 58
betamethasone dipropionate (topical) .................... 86, 87
betamethasone dipropionate augmented .................... 87
betamethasone valerate ..................................................... 87
BETASERON ............................................................................. 47
betaxolol hcl ............................................................................ 30
betaxolol hcl (ophth) ........................................................... 77
bethanechol chloride ............................................................ 65
BETIMOL ................................................................................... 77
BETOPTIC-S ............................................................................ 77
BEVESPI AER 9-4.8MCG ..................................................... 78
bexarotene............................................................................... 24
bexarotene (topical) ............................................................. 88
BEXSERO INJ .......................................................................... 72
bicalutamide ............................................................................ 21
BIKTARVY TAB ........................................................................ 13
bisoprolol & hydrochlorothiazide tab 10-6.25 mg ..... 30
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ... 30
bisoprolol & hydrochlorothiazide tab 5-6.25 mg ....... 30
bisoprolol fumarate .............................................................. 30
bleomycin sulfate .................................................................. 19
BLEPHAMIDE OIN S.O.P. .................................................... 76
BLOOD GLUCOSE CALIBRATION SOLUTION ............... 57
BOOSTRIX INJ ........................................................................ 72
bosentan ................................................................................... 33
bp wash .................................................................................... 84
BREO ELLIPTA INH 100-25 ................................................ 83
BREO ELLIPTA INH 200-25 ................................................ 83
BREZTRI AERO AER SPHERE ............................................ 78
BRILINTA .................................................................................. 67
brimonidine tartrate ............................................................. 77
brimonidine tartrate (topical) ........................................... 89
brimonidine tartrate-timolol maleate ophth soln 0.2-
0.5% ..................................................................................... 77
brinzolamide............................................................................ 77
bromfenac sodium (ophth) ................................................ 77
bromocriptine mesylate ...................................................... 38
budesonide .............................................................................. 62
budesonide (inhalation) ...................................................... 83
budesonide (nasal) ............................................................... 82
bumetanide ............................................................................. 32
buprenorphine ........................................................................ 10
buprenorphine hcl ................................................................. 49
buprenorphine hcl-naloxone hcl sl film 12-3 mg
(base equiv) ....................................................................... 49
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg
(base equiv) ....................................................................... 48
buprenorphine hcl-naloxone hcl sl film 4-1 mg (base
equiv) ................................................................................... 48
buprenorphine hcl-naloxone hcl sl film 8-2 mg (base
equiv) ................................................................................... 49
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
(base equiv) ...................................................................... 49
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv) ................................................................................... 49
bupropion hcl ......................................................................... 35
bupropion hcl (smoking deterrent) ................................ 50
buspirone hcl .......................................................................... 34
busulfan .................................................................................... 19
butenafine hcl ........................................................................ 85
butorphanol tartrate .............................................................. 6
C
cabergoline .............................................................................. 60
CABOMETYX ............................................................................ 22
calcipotriene ........................................................................... 86
calcipotriene-betamethasone dipropionate oint
0.005-0.064% .................................................................. 87
calcitonin (salmon)............................................................... 60
calcitriol .................................................................................... 75
calcitriol (topical) .................................................................. 86
calcium acetate (phosphate binder) .............................. 60
CALQUENCE ............................................................................ 22
camila ........................................................................................ 54
candesartan cilexetil ............................................................ 28
candesartan cilexetil-hydrochlorothiazide tab 16-
12.5 mg............................................................................... 27
candesartan cilexetil-hydrochlorothiazide tab 32-
12.5 mg............................................................................... 27
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg ......................................................................................... 27
capecitabine ............................................................................ 19
CAPRELSA ................................................................................ 22
captopril ................................................................................... 26
carbamazepine ...................................................................... 40
carbidopa ................................................................................. 38
carbidopa & levodopa orally disintegrating tab 10-
100 mg ................................................................................ 38
carbidopa & levodopa orally disintegrating tab 25-
100 mg ................................................................................ 38
carbidopa & levodopa orally disintegrating tab 25-
250 mg ................................................................................ 38
carbidopa & levodopa tab 10-100 mg .......................... 38
carbidopa & levodopa tab 25-100 mg .......................... 38
carbidopa & levodopa tab 25-250 mg .......................... 38
carbidopa & levodopa tab er 25-100 mg ..................... 38
carbidopa & levodopa tab er 50-200 mg ..................... 38
carbidopa-levodopa-entacapone tabs 12.5-50-200
mg ......................................................................................... 38
carbidopa-levodopa-entacapone tabs 18.75-75-200
mg ......................................................................................... 38
carbidopa-levodopa-entacapone tabs 25-100-200
mg ......................................................................................... 38
carbidopa-levodopa-entacapone tabs 31.25-125-200
mg ......................................................................................... 38
95
carbidopa-levodopa-entacapone tabs 37.5-150-200
mg ......................................................................................... 38
carbidopa-levodopa-entacapone tabs 50-200-200
mg ......................................................................................... 38
carbinoxamine maleate....................................................... 79
carboplatin ............................................................................... 24
CARDIZEM LA ......................................................................... 31
CARDURA XL ........................................................................... 65
carisoprodol ............................................................................. 48
carisoprodol w/ aspirin & codeine tab 200-325-16
mg ......................................................................................... 48
carmustine ............................................................................... 19
carteolol hcl (ophth)............................................................. 77
cartia xt .................................................................................... 31
carvedilol .................................................................................. 30
CAYA DPR ................................................................................. 54
CAYSTON .................................................................................. 81
cefaclor...................................................................................... 15
cefadroxil .................................................................................. 15
cefdinir ...................................................................................... 15
cefepime hcl ............................................................................ 15
cefixime .................................................................................... 15
cefpodoxime proxetil ........................................................... 15
cefprozil .................................................................................... 16
ceftazidime .............................................................................. 16
ceftriaxone sodium ............................................................... 16
cefuroxime axetil ................................................................... 16
celecoxib ..................................................................................... 5
CELONTIN ................................................................................ 40
cephalexin ................................................................................ 16
CERDELGA ............................................................................... 58
cetirizine hcl ............................................................................ 79
cetirizine hcl childrens ......................................................... 79
cevimeline hcl ......................................................................... 89
chateal ....................................................................................... 54
CHEMET .................................................................................... 54
chlordiazepoxide hcl ............................................................. 34
chlordiazepoxide-amitriptyline tab 10-25 mg ............ 49
chlordiazepoxide-amitriptyline tab 5-12.5 mg ........... 49
chlorhexidine gluconate (mouth-throat) ...................... 89
chloroquine phosphate ........................................................ 11
chlorpromazine hcl ............................................................... 39
chlorthalidone ......................................................................... 32
chlorzoxazone ......................................................................... 48
cholecalciferol ......................................................................... 75
cholestyramine ....................................................................... 29
cholestyramine light ............................................................. 29
ciclopirox .................................................................................. 85
ciclopirox olamine ................................................................. 85
cilostazol ................................................................................... 67
CIMDUO TAB 300-300 ......................................................... 13
cimetidine................................................................................. 62
cimetidine hcl.......................................................................... 62
cinacalcet hcl .......................................................................... 54
CIPRO ........................................................................................ 16
ciprofloxacin hcl ..................................................................... 16
ciprofloxacin hcl (ophth) ..................................................... 76
ciprofloxacin hcl (otic) ......................................................... 89
ciprofloxacin-dexamethasone otic susp 0.3-0.1%.... 89
ciprofloxacin-fluocinolone aceton (pf) otic soln 0.3-
0.025% ............................................................................... 90
cisplatin .................................................................................... 25
citalopram hydrobromide .................................................. 35
CITRANATAL CAP HARMONY ............................................ 75
CITRANATAL CAP MEDLEY................................................. 75
CITRANATAL MIS 90 DHA .................................................. 75
CITRANATAL MIS B-CALM ................................................. 75
CITRANATAL PAK ASSURE ................................................ 75
CITRANATAL PAK DHA ........................................................ 75
CITRANATAL TAB BLOOM .................................................. 75
cladribine ................................................................................. 19
clarithromycin ........................................................................ 16
clearskin ................................................................................... 84
clemastine fumarate ............................................................ 79
CLENPIQ SOL ......................................................................... 63
CLEOCIN .................................................................................. 66
CLIMARA PRO DIS WEEKLY .............................................. 58
clindacin etz pledgets .......................................................... 84
CLINDACIN KIT PAC 1% .................................................... 84
clindamycin hcl ...................................................................... 17
clindamycin palmitate hydrochloride ............................. 17
clindamycin phosphate (topical) ..................................... 84
clindamycin phosphate vaginal ....................................... 66
clindamycin phosphate-benzoyl peroxide gel 1.2-
2.5% .................................................................................... 84
clindamycin phosphate-benzoyl peroxide gel 1-5% 84
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5%................................................................................. 84
clobazam .................................................................................. 40
clobetasol propionate .......................................................... 87
clobetasol propionate emollient base ............................ 87
clocortolone pivalate ........................................................... 87
clofarabine ............................................................................... 19
clomipramine hcl ................................................................... 34
clonazepam ............................................................................. 40
clonidine ................................................................................... 33
clonidine hcl ............................................................................ 33
clopidogrel bisulfate ............................................................. 67
clorazepate dipotassium .................................................... 40
clotrimazole ............................................................................ 89
clotrimazole (topical) .......................................................... 85
clotrimazole w/ betamethasone cream 1-0.05% ..... 85
clotrimazole w/ betamethasone lotion 1-0.05% ....... 85
clozapine .................................................................................. 39
COARTEM TAB 20-120MG.................................................. 11
codeine sulfate......................................................................... 6
CODEINE SULFATE ................................................................. 6
colchicine ................................................................................... 5
colchicine w/ probenecid tab 0.5-500 mg ..................... 5
colestipol hcl ........................................................................... 29
COMETRIQ ............................................................................... 22
COMETRIQ KIT 100MG ....................................................... 22
COMETRIQ KIT 140MG ....................................................... 22
compro ...................................................................................... 62
CONDOMS MIS ...................................................................... 54
CONDYLOX .............................................................................. 88
COPAXONE .............................................................................. 47
CORTISPORIN SUS -TC OTIC ........................................... 90
COSENTYX ............................................................................... 68
96
COSENTYX SENSOREADY PEN ......................................... 68
CREON CAP 12000UNT ....................................................... 64
CREON CAP 24000UNT ....................................................... 64
CREON CAP 3000UNIT ........................................................ 64
CREON CAP 36000UNT ....................................................... 64
CREON CAP 6000UNIT ........................................................ 64
CRESEMBA ............................................................................... 11
CRINONE .................................................................................. 60
cromolyn sodium ................................................................... 82
cromolyn sodium (ophth)................................................... 77
crotan ........................................................................................ 89
cruex prescription streng ................................................... 85
cryselle-28 ............................................................................... 54
cvs acne cleansing bar ........................................................ 84
cvs allergy relief childr ........................................................ 79
cvs anti-diarrheal .................................................................. 61
cvs athletes foot liquid ........................................................ 85
cvs creamy acne face wash ............................................... 84
cvs ivermectin lice treat ..................................................... 89
cvs lice treatment ................................................................. 89
cvs miconazole 1 combinat ............................................... 66
cvs omeprazole/sodium bic ............................................... 64
cvs sleep-aid nighttime ....................................................... 45
cvs targeted acne spot tr ................................................... 84
cyanocobalamin ..................................................................... 75
cyclobenzaprine hcl .............................................................. 48
cyclophosphamide ................................................................ 19
cycloserine ............................................................................... 14
cyclosporine modified (for microemulsion) ................. 72
cyproheptadine hcl ............................................................... 79
CYSTAGON ............................................................................... 58
CYSTARAN ............................................................................... 78
cytarabine ................................................................................ 19
D
dabigatran etexilate mesylate .......................................... 66
dacarbazine ............................................................................. 19
dalfampridine .......................................................................... 47
DALIRESP ................................................................................. 82
danazol ...................................................................................... 58
dantrolene sodium ................................................................ 48
dapsone .................................................................................... 17
DAPTACEL INJ ........................................................................ 72
darifenacin hydrobromide .................................................. 65
dasetta 1/35 ........................................................................... 54
dasetta 7/7/7 .......................................................................... 54
daunorubicin hcl .................................................................... 19
DAYVIGO .................................................................................. 45
decitabine ................................................................................. 19
deferiprone .............................................................................. 54
delyla ......................................................................................... 54
demeclocycline hcl ................................................................ 18
DENAVIR ................................................................................... 88
DENGVAXIA SUS ................................................................... 73
DEPO-SUBQ PROVERA 104 ............................................... 54
DESCOVY TAB 120-15MG .................................................. 13
DESCOVY TAB 200/25MG .................................................. 14
desipramine hcl ................................................................ 35, 36
desloratadine .......................................................................... 79
desmopressin acetate ......................................................... 61
desmopressin acetate spray ............................................. 61
desmopressin acetate spray refrigerated .................... 61
desonide ................................................................................... 87
desoximetasone .................................................................... 87
desvenlafaxine succinate ................................................... 36
dexamethasone ..................................................................... 59
DEXAMETHASONE INTENSOL .......................................... 59
dexamethasone sodium phosphate (ophth) ............... 77
DEXCOM G5 MIS RECEIVER ............................................. 57
DEXCOM G5 MIS TRANSMIT ............................................. 57
DEXCOM G6 MIS RECEIVER ............................................. 57
DEXCOM G6 MIS SENSOR ................................................. 57
DEXCOM G6 MIS TRANSMIT ............................................. 57
dexlansoprazole .................................................................... 64
dexmethylphenidate hcl ..................................................... 43
dexrazoxane hcl .................................................................... 25
dextroamphetamine sulfate ........................................ 43, 44
diazepam ................................................................................. 40
diazepam intensol ................................................................ 40
diclofenac potassium ............................................................. 5
diclofenac sodium ................................................................... 5
diclofenac sodium (ophth) ................................................. 77
diclofenac sodium (topical) ............................................... 88
diclofenac w/ misoprostol tab delayed release 50-0.2
mg ........................................................................................... 5
diclofenac w/ misoprostol tab delayed release 75-0.2
mg ........................................................................................... 5
dicloxacillin sodium .............................................................. 18
dicyclomine hcl ...................................................................... 61
DIFICID .................................................................................... 16
diflorasone diacetate ........................................................... 87
diflunisal ................................................................................... 10
difluprednate .......................................................................... 77
digoxin ...................................................................................... 32
dihydroergotamine mesylate ............................................ 46
diltiazem hcl ........................................................................... 31
diltiazem hcl coated beads ................................................ 31
diltiazem hcl extended release beads ........................... 31
dilt-xr ........................................................................................ 31
dimethyl fumarate ................................................................ 47
dimethyl fumarate capsule dr starter pack 120 mg &
240 mg ................................................................................ 47
DIP/TET PED INJ 25-5LFU ................................................. 73
DIPENTUM ............................................................................... 62
diphenhydramine hcl ........................................................... 79
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml .... 61
diphenoxylate w/ atropine tab 2.5-0.025 mg ............ 61
dipyridamole ........................................................................... 67
disopyramide phosphate .................................................... 28
disulfiram ................................................................................. 34
DIURIL ...................................................................................... 32
divalproex sodium ................................................................ 40
docetaxel ................................................................................. 20
docosanol ................................................................................. 88
dofetilide .................................................................................. 28
donepezil hydrochloride ..................................................... 34
DOPTELET TAB 20MG (10 TABLETS) ............................. 67
DOPTELET TAB 20MG (15 TABLETS) ............................. 67
DOPTELET TAB 20MG (30 TABLETS) ............................. 67
97
dorzolamide hcl ...................................................................... 77
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml ................................................................................... 77
DOVATO TAB 50-300MG .................................................... 14
doxazosin mesylate .............................................................. 26
doxepin hcl .............................................................................. 36
doxepin hcl (antipruritic) .................................................... 86
doxepin hcl (sleep) ............................................................... 45
doxercalciferol ........................................................................ 75
doxorubicin hcl ....................................................................... 19
doxorubicin hcl liposomal ................................................... 19
doxycycline (monohydrate) ............................................... 19
doxycycline hyclate .............................................................. 19
dronabinol ................................................................................ 62
drospirenone-ethinyl estradiol tab 3-0.02 mg ........... 54
drospirenone-ethinyl estradiol tab 3-0.03 mg ........... 54
drospirenone-ethinyl estrad-levomefolate tab 3-
0.02-0.451 mg .................................................................. 54
drospirenone-ethinyl estrad-levomefolate tab 3-
0.03-0.451 mg .................................................................. 54
DROXIA ..................................................................................... 67
DUAVEE TAB 0.45-20 .......................................................... 58
duloxetine hcl ......................................................................... 36
DUREX MIS REALFEEL ......................................................... 54
dutasteride .............................................................................. 65
dutasteride-tamsulosin hcl cap 0.5-0.4 mg ................ 65
E
econazole nitrate ................................................................... 85
EDURANT .................................................................................. 11
efavirenz ................................................................................... 11
efavirenz-emtricitabine-tenofovir df tab 600-200-
300 mg ................................................................................ 14
efavirenz-lamivudine-tenofovir df tab 400-300-300
mg ......................................................................................... 14
efavirenz-lamivudine-tenofovir df tab 600-300-300
mg ......................................................................................... 14
effer-k ........................................................................................ 74
eletriptan hydrobromide ..................................................... 46
ELIGARD ................................................................................... 21
elinest ........................................................................................ 54
ELIQUIS .................................................................................... 66
ELIQUIS STARTER PACK ..................................................... 66
elite-ob ...................................................................................... 75
ELLA ........................................................................................... 55
ELMIRON .................................................................................. 65
EMCYT ....................................................................................... 19
EMFLAZA................................................................................... 59
EMGALITY ................................................................................. 46
EMSAM ...................................................................................... 36
emtricitabine ........................................................................... 11
emtricitabine-tenofovir disoproxil fumarate tab 100-
150 mg ................................................................................ 14
emtricitabine-tenofovir disoproxil fumarate tab 133-
200 mg ................................................................................ 14
emtricitabine-tenofovir disoproxil fumarate tab 167-
250 mg ................................................................................ 14
emtricitabine-tenofovir disoproxil fumarate tab 200-
300 mg ................................................................................ 14
EMTRIVA .................................................................................. 11
EMVERM ................................................................................... 10
enalapril maleate .................................................................. 26
enalapril maleate & hydrochlorothiazide tab 10-25
mg ......................................................................................... 25
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg ......................................................................................... 25
ENBREL ............................................................................... 68, 69
ENBREL MINI .......................................................................... 69
ENBREL SURECLICK............................................................. 69
ENCARE .................................................................................... 65
endocet tab 10-325mg ......................................................... 6
endocet tab 2.5-325 .............................................................. 6
endocet tab 5-325mg ........................................................... 6
endocet tab 7.5-325 .............................................................. 6
ENGERIX-B .............................................................................. 73
enoxaparin sodium ............................................................... 66
enpresse-28 ............................................................................ 55
enskyce .................................................................................... 55
entacapone.............................................................................. 38
entecavir .................................................................................. 15
ENTRESTO TAB 24-26MG .................................................. 33
ENTRESTO TAB 49-51MG .................................................. 33
ENTRESTO TAB 97-103MG ................................................ 33
enulose ..................................................................................... 63
EPCLUSA PAK 150-37.5 ..................................................... 16
EPCLUSA PAK 200-50MG ................................................... 16
EPCLUSA TAB 200-50MG ................................................... 16
EPCLUSA TAB 400-100 ....................................................... 17
epinastine hcl (ophth) ......................................................... 77
epinephrine (anaphylaxis) ................................................. 78
EPIPEN 2-PAK......................................................................... 78
EPIPEN-JR 2-PAK .................................................................. 78
epitol ......................................................................................... 40
EPIVIR HBV ............................................................................. 15
eplerenone .............................................................................. 26
ERBITUX ................................................................................... 20
ergocalciferol .......................................................................... 75
ergotamine w/ caffeine tab 1-100 mg .......................... 46
ERIVEDGE ................................................................................ 20
ERLEADA .................................................................................. 21
erlotinib hcl ............................................................................. 22
errin ........................................................................................... 55
ERTACZO ................................................................................. 85
ertapenem sodium ............................................................... 17
ery .............................................................................................. 84
ery-tab ...................................................................................... 16
erythrocin stearate ............................................................... 16
erythromycin (acne aid) ..................................................... 84
erythromycin (ophth) .......................................................... 76
erythromycin base ............................................................... 16
erythromycin ethylsuccinate ............................................ 16
ESBRIET ................................................................................... 82
escitalopram oxalate ........................................................... 36
esomeprazole magnesium ................................................. 64
estazolam ................................................................................ 45
estradiol ................................................................................... 58
estradiol & norethindrone acetate tab 0.5-0.1 mg .. 58
estradiol & norethindrone acetate tab 1-0.5 mg ...... 58
estradiol vaginal .................................................................... 58
98
eszopiclone .............................................................................. 45
ethacrynic acid ....................................................................... 32
ethambutol hcl ....................................................................... 14
ethosuximide .......................................................................... 40
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
mcg ....................................................................................... 55
etodolac ...................................................................................... 5
etonogestrel-ethinyl estradiol va ring 0.120-0.015
mg/24hr .............................................................................. 55
etoposide .................................................................................. 25
etravirine ............................................................................ 11, 12
EUCRISA ................................................................................... 88
everolimus ............................................................................... 22
everolimus (immunosuppressant) .................................. 72
EVOTAZ TAB 300-150 ......................................................... 14
EVRYSDI ................................................................................... 47
exemestane ............................................................................. 21
ezetimibe .................................................................................. 29
ezetimibe-simvastatin tab 10-10 mg ............................ 29
ezetimibe-simvastatin tab 10-20 mg ............................ 29
ezetimibe-simvastatin tab 10-40 mg ............................ 29
ezetimibe-simvastatin tab 10-80 mg ............................ 29
F
falmina ...................................................................................... 55
famciclovir................................................................................ 15
famotidine ................................................................................ 62
FASENRA .................................................................................. 82
FASENRA PEN ......................................................................... 82
fayosim ..................................................................................... 55
FC2 FEMALE MIS CONDOM ................................................ 55
febuxostat .................................................................................. 5
felbamate ................................................................................. 40
felodipine .................................................................................. 31
FEMCAP MIS 22MM ............................................................... 55
FEMCAP MIS 26MM ............................................................... 55
FEMCAP MIS 30MM ............................................................... 55
fenofibrate ............................................................................... 29
fenofibrate micronized ........................................................ 29
fenoprofen calcium ................................................................. 5
fentanyl ....................................................................................... 6
fentanyl citrate ......................................................................... 6
FERRIPROX .............................................................................. 54
FERRIPROX TWICE-A-DAY ................................................. 54
fesoterodine fumarate ......................................................... 65
FETZIMA ................................................................................... 36
FETZIMA CAP TITRATIO...................................................... 36
fexofenadine hcl .................................................................... 79
FIASP FLEX INJ TOUCH ....................................................... 52
FIASP INJ 100/ML ................................................................. 52
FIASP PENFIL INJ U-100 .................................................... 52
FINACEA ................................................................................... 89
finasteride ................................................................................ 65
fingolimod hcl ......................................................................... 47
flecainide acetate .................................................................. 28
floxuridine ................................................................................ 19
fluconazole ............................................................................... 11
fludarabine phosphate ......................................................... 20
fludrocortisone acetate ....................................................... 59
FLUMIST ................................................................................... 73
flunisolide (nasal) ................................................................. 82
fluocinolone acetonide ........................................................ 87
fluocinolone acetonide (otic) ............................................ 90
fluocinonide ............................................................................. 87
fluoritab .................................................................................... 74
fluorouracil .............................................................................. 20
fluorouracil (topical) ............................................................ 84
fluoxetine hcl .......................................................................... 36
fluphenazine hcl .................................................................... 39
flurbiprofen ............................................................................... 5
flurbiprofen sodium .............................................................. 77
flutamide .................................................................................. 21
fluticasone propionate ........................................................ 87
fluticasone propionate (nasal) ......................................... 82
fluvastatin sodium ................................................................ 29
fluvoxamine maleate ........................................................... 34
FML ............................................................................................. 77
folic acid ................................................................................... 75
fondaparinux sodium ........................................................... 66
formoterol fumarate ............................................................ 80
FOSAMAX + D TAB 70-2800 ............................................ 53
FOSAMAX + D TAB 70-5600 ............................................ 53
fosamprenavir calcium........................................................ 12
fosfomycin tromethamine .................................................. 10
fosinopril sodium ................................................................... 26
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg ......................................................................................... 26
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg ......................................................................................... 26
fosphenytoin sodium ........................................................... 40
FOSRENOL ............................................................................... 60
FRAGMIN .................................................................................. 66
FREESTY LIBR KIT 2 SENSOR .......................................... 57
FREESTY LIBR MIS 2 READER.......................................... 57
FREESTYLE BLOOD GLUCOSE TEST STRIPS ............... 57
FREESTYLE KIT FREEDOM ................................................. 57
FREESTYLE KIT INSULINX ................................................. 57
FREESTYLE KIT LITE ............................................................ 57
FREESTYLE KIT SENSOR .................................................... 57
FREESTYLE MIS READER ................................................... 57
frovatriptan succinate ......................................................... 46
fulvestrant ............................................................................... 21
furosemide .............................................................................. 32
FUZEON .................................................................................... 12
FYCOMPA ................................................................................. 40
G
G4 PLAT PED MIS RVC/SHAR ........................................... 57
G4 PLATINUM MIS PEDIATRC .......................................... 57
G4 PLATINUM MIS RCV/SHAR ......................................... 57
G4 PLATINUM MIS RECEIVER .......................................... 57
G4 PLATINUM MIS TRANSMIT.......................................... 57
G4 SENSOR MIS .................................................................... 57
G5/G4 MIS SENSOR ............................................................ 57
gabapentin .............................................................................. 40
galantamine hydrobromide ............................................... 35
GARDASIL 9 INJ .................................................................... 73
gatifloxacin (ophth) ............................................................. 76
99
gavilyte-c ................................................................................. 63
gavilyte-g ................................................................................. 63
GAZYVA ..................................................................................... 20
gemcitabine hcl ...................................................................... 20
gemfibrozil ............................................................................... 29
gemmily .................................................................................... 55
GEMTESA .................................................................................. 66
generlac .................................................................................... 63
gengraf ...................................................................................... 72
GENOTROPIN .......................................................................... 60
GENOTROPIN MINIQUICK .................................................. 60
gentak ....................................................................................... 76
gentamicin sulfate (ophth) ................................................ 76
gentamicin sulfate (topical) .............................................. 85
GENVOYA TAB ........................................................................ 14
GILENYA ................................................................................... 47
glatiramer acetate ................................................................ 47
glatopa ...................................................................................... 47
GLEOSTINE .............................................................................. 19
GLIADEL WAF 7.7MG ........................................................... 19
glimepiride ............................................................................... 53
glipizide ..................................................................................... 53
glipizide-metformin hcl tab 2.5-250 mg ....................... 51
glipizide-metformin hcl tab 2.5-500 mg ....................... 51
glipizide-metformin hcl tab 5-500 mg ........................... 51
glucagon (rdna) ..................................................................... 59
GLUCOSE URINE TEST STRIPS ........................................ 57
glycopyrrolate ......................................................................... 61
GLYXAMBI TAB 10-5 MG .................................................... 53
GLYXAMBI TAB 25-5 MG .................................................... 53
gnp loratadine ........................................................................ 79
gnp miconazorb af ................................................................ 85
gnp terbinafine hydrochlo .................................................. 85
goodsense aspirin ................................................................. 10
goodsense lansoprazole ...................................................... 64
goodsense nicotine polacr.................................................. 50
granisetron hcl ....................................................................... 62
griseofulvin microsize .......................................................... 11
griseofulvin ultramicrosize ................................................. 11
guaifenesin-codeine soln 100-10 mg/5ml ................... 80
guanfacine hcl ........................................................................ 33
guanfacine hcl (adhd).......................................................... 44
GYNAZOLE-1 ........................................................................... 66
H
HAEGARDA .............................................................................. 72
halobetasol propionate ........................................................ 87
haloperidol ............................................................................... 39
haloperidol decanoate ......................................................... 39
haloperidol lactate ................................................................ 39
HARVONI PAK ......................................................................... 17
HARVONI PAK 45-200MG ................................................... 17
HARVONI TAB 45-200MG ................................................... 17
HARVONI TAB 90-400MG ................................................... 17
HAVRIX ..................................................................................... 73
heather ...................................................................................... 55
HEMLIBRA ................................................................................ 67
heparin sodium (porcine) ................................................... 66
HEPLISAV-B ............................................................................. 73
HETLIOZ ................................................................................... 45
HIBERIX ................................................................................... 73
HOLD CHAMBER MIS MEDIUM ......................................... 82
HUMIRA .................................................................................... 69
HUMIRA PEDIA INJ CROHNS ............................................ 69
HUMIRA PEDIATRIC CROHNS D ...................................... 69
HUMIRA PEN ........................................................................... 69
HUMIRA PEN KIT PS/UV ..................................................... 69
HUMIRA PEN-CD/UC/HS START ...................................... 69
HUMIRA PEN-PS/UV STARTER ......................................... 69
HUMULIN INJ 70/30............................................................. 52
HUMULIN INJ 70/30KWP.................................................... 52
HUMULIN N ............................................................................. 52
HUMULIN N KWIKPEN ......................................................... 52
HUMULIN R ............................................................................. 52
HUMULIN R U-500 (CONCENTR ...................................... 52
HUMULIN R U-500 KWIKPEN............................................ 52
hydralazine hcl ....................................................................... 33
hydrochlorothiazide ............................................................. 32
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
............................................................................................... 80
hydrocodone bitart-homatropine methylbrom soln 5-
1.5 mg/5ml ........................................................................ 80
hydrocodone bitart-homatropine methylbromide tab
5-1.5 mg ............................................................................. 80
hydrocodone bitartrate ......................................................... 6
hydrocodone-acetaminophen soln 7.5-325 mg/15ml6
hydrocodone-acetaminophen tab 10-325 mg .............. 7
hydrocodone-acetaminophen tab 5-325 mg ................ 6
hydrocodone-acetaminophen tab 7.5-325 mg ............ 7
hydrocodone-ibuprofen tab 10-200 mg ......................... 7
hydrocortisone ....................................................................... 59
hydrocortisone (intrarectal) .............................................. 63
hydrocortisone (rectal) ....................................................... 65
hydrocortisone (topical) ..................................................... 87
hydrocortisone butyrate ..................................................... 88
hydrocortisone valerate ..................................................... 88
hydrocortisone w/ acetic acid otic soln 1-2% ............ 90
hydromorphone hcl ................................................................ 7
hydroxychloroquine sulfate ............................................... 72
hydroxyurea ........................................................................... 24
hydroxyzine hcl ..................................................................... 79
hydroxyzine pamoate .......................................................... 80
HYQVIA INJ 10-800 ............................................................. 72
HYQVIA INJ 2.5-200 ............................................................ 72
HYQVIA INJ 20-1600 ........................................................... 72
HYQVIA INJ 30-2400 ........................................................... 72
HYQVIA INJ 5-400 ................................................................ 72
I
ibandronate sodium ............................................................. 53
IBRANCE .................................................................................. 22
ibuprofen .................................................................................... 5
icatibant acetate ................................................................... 72
ICLUSIG ................................................................................... 22
icosapent ethyl ...................................................................... 30
idarubicin hcl .......................................................................... 19
IDHIFA ...................................................................................... 24
ifosfamide ................................................................................ 19
100
ILEVRO ...................................................................................... 77
imatinib mesylate .................................................................. 22
IMBRUVICA .............................................................................. 22
imipramine hcl ........................................................................ 36
imipramine pamoate ...................................................... 36, 37
imiquimod ................................................................................ 85
IMVEXXY MAINTENANCE PACK ........................................ 59
IMVEXXY STARTER PACK ................................................... 59
INBRIJA ..................................................................................... 38
INCRELEX ................................................................................. 60
indapamide .............................................................................. 32
INFANRIX INJ ......................................................................... 73
INFLIXIMAB ............................................................................. 68
INFLUENZA VACCINE ........................................................... 73
INLYTA....................................................................................... 23
INSTA-GLUCOSE ................................................................... 59
INSULIN PEN NEEDLES ....................................................... 57
INSULIN PEN NEEDLES/SYRINGES ................................ 58
INTELENCE .............................................................................. 12
INTRAROSA ............................................................................. 60
INTRON A ................................................................................. 72
introvale.................................................................................... 55
IPOL INJ INACTIVE ............................................................... 73
ipratropium bromide ............................................................ 79
ipratropium bromide (nasal) ............................................. 79
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
................................................................................................ 78
irbesartan ................................................................................. 28
irbesartan-hydrochlorothiazide tab 150-12.5 mg ..... 27
irbesartan-hydrochlorothiazide tab 300-12.5 mg ..... 27
irinotecan hcl .......................................................................... 25
ISENTRESS .............................................................................. 12
ISENTRESS HD ....................................................................... 12
isoniazid .................................................................................... 14
isosorbide dinitrate ............................................................... 33
isosorbide mononitrate ....................................................... 33
isotretinoin ............................................................................... 84
isradipine .................................................................................. 31
itraconazole ............................................................................. 11
IV PREP WIPE PAD ................................................................ 85
ivermectin ................................................................................ 10
ivermectin (pediculicide) .................................................... 89
ivermectin (rosacea) ............................................................ 89
J
JAKAFI ....................................................................................... 23
jantoven.................................................................................... 66
JANUMET TAB 50-1000 ....................................................... 51
JANUMET TAB 50-500MG ................................................... 51
JANUMET XR TAB 100-1000 ............................................. 51
JANUMET XR TAB 50-1000 ................................................ 51
JANUMET XR TAB 50-500MG ............................................ 51
JANUVIA.................................................................................... 51
JARDIANCE .............................................................................. 53
JENTADUETO TAB XR .......................................................... 51
jinteli .......................................................................................... 59
jolessa ....................................................................................... 55
JUBLIA ....................................................................................... 85
junel 1.5/30 ............................................................................ 55
junel 1/20 ................................................................................ 55
junel fe 1.5/30 ....................................................................... 55
junel fe 1/20 ........................................................................... 55
junel fe 24 ............................................................................... 55
K
KADCYLA .................................................................................. 20
KALYDECO ............................................................................... 81
kariva ........................................................................................ 55
kelnor 1/35 ............................................................................. 55
KERENDIA ................................................................................ 60
ketoconazole (topical) ................................................... 85, 86
KETONE URINE TEST STRIPS ........................................... 58
ketorolac tromethamine ....................................................... 5
ketorolac tromethamine (ophth) .................................... 77
ketotifen fumarate (ophth) ............................................... 77
KEVZARA .................................................................................. 70
KEYTRUDA ............................................................................... 20
KINRIX INJ .............................................................................. 73
KISQALI .................................................................................... 23
klor-con 10 .............................................................................. 74
klor-con 8 ................................................................................ 74
klor-con m15 .......................................................................... 74
kls esomeprazole magnesiu .............................................. 64
kurvelo ...................................................................................... 55
KYLEENA .................................................................................. 55
L
labetalol hcl ............................................................................. 30
lacosamide .............................................................................. 40
LACRISERT .............................................................................. 78
lactic acid (ammonium lactate) ....................................... 88
lactulose ................................................................................... 63
lamivudine ............................................................................... 12
lamivudine (hbv) ................................................................... 15
lamivudine-zidovudine tab 150-300 mg ...................... 14
lamotrigine .............................................................................. 41
lamotrigine tab 25 mg (42) & 100 mg (7) starter kit
............................................................................................... 41
lamotrigine tab 84 x 25 mg & 14 x 100 mg starter
kit .......................................................................................... 41
LANCETS .................................................................................. 58
LANCING DEVICE .................................................................. 58
lansoprazole ............................................................................ 64
lapatinib ditosylate ............................................................... 23
larin 1.5/30 ............................................................................. 55
latanoprost .............................................................................. 77
LATUDA .................................................................................... 39
leena .......................................................................................... 55
leflunomide ............................................................................. 72
LENVIMA 10 MG DAILY DOSE .......................................... 23
LENVIMA 12MG DAILY DOSE ........................................... 23
LENVIMA 20 MG DAILY DOSE .......................................... 23
LENVIMA 4 MG DAILY DOSE ............................................. 23
LENVIMA 8 MG DAILY DOSE ............................................. 23
LENVIMA CAP 14 MG ........................................................... 23
LENVIMA CAP 18 MG ........................................................... 23
LENVIMA CAP 24 MG ........................................................... 23
101
lessina ....................................................................................... 55
letrozole .................................................................................... 21
leucovorin calcium ................................................................ 25
LEUKERAN ................................................................................ 19
leuprolide acetate ................................................................. 21
levalbuterol hcl ....................................................................... 80
LEVEMIR ................................................................................... 52
LEVEMIR FLEXTOUCH .......................................................... 52
levetiracetam .......................................................................... 41
levobunolol hcl ....................................................................... 77
levocetirizine dihydrochloride ........................................... 80
levofloxacin.............................................................................. 16
levofloxacin (ophth) ............................................................. 76
levonest .................................................................................... 55
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-
0.03 mg ............................................................................... 55
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
................................................................................................ 55
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg ....................................................................................... 55
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) .......................................................................... 55
levora 0.15/30-28 ................................................................. 55
levothyroxine sodium .......................................................... 61
levoxyl ....................................................................................... 61
LEXIVA ...................................................................................... 12
lice treatment ......................................................................... 89
lidocaine hcl ............................................................................ 88
lidocaine hcl (mouth-throat) ............................................. 89
lidocaine pain relief pat ....................................................... 88
lidocaine-prilocaine cream 2.5-2.5% ............................. 88
LILETTA ..................................................................................... 55
linezolid ..................................................................................... 17
LINZESS ................................................................................... 63
liothyronine sodium .............................................................. 61
lisinopril .................................................................................... 26
lisinopril & hydrochlorothiazide tab 10-12.5 mg ....... 26
lisinopril & hydrochlorothiazide tab 20-12.5 mg ....... 26
lisinopril & hydrochlorothiazide tab 20-25 mg ........... 26
lithium carbonate .................................................................. 47
LO LOESTRIN TAB 1-10-10 ............................................... 55
loperamide hcl ........................................................................ 61
lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml) ................................................................................. 14
lopinavir-ritonavir tab 100-25 mg .................................. 14
lopinavir-ritonavir tab 200-50 mg .................................. 14
loratadine ................................................................................. 80
lorazepam ................................................................................ 34
LORBRENA ............................................................................... 23
loryna......................................................................................... 55
losartan potassium ............................................................... 28
losartan potassium & hydrochlorothiazide tab 100-
12.5 mg ............................................................................... 27
losartan potassium & hydrochlorothiazide tab 100-
25 mg ................................................................................... 27
losartan potassium & hydrochlorothiazide tab 50-
12.5 mg ............................................................................... 27
loteprednol etabonate ......................................................... 77
LOTRIMIN ANTIFUNGAL ...................................................... 85
LOTRIMIN ULTRA .................................................................. 85
lovastatin ................................................................................. 29
low-ogestrel ............................................................................ 55
loxapine succinate ................................................................ 39
lubiprostone ............................................................................ 63
LUMIGAN .................................................................................. 77
lutera ......................................................................................... 55
LYNPARZA ................................................................................ 24
LYSODREN ............................................................................... 21
M
malathion ................................................................................. 89
mannitol ................................................................................... 32
maraviroc ................................................................................. 12
marlissa .................................................................................... 56
MARPLAN ................................................................................. 37
MATULANE ............................................................................... 19
matzim la ................................................................................. 31
meclizine hcl ........................................................................... 62
meclofenamate sodium ........................................................ 5
medicated anti-fungal ......................................................... 85
MEDROL.................................................................................... 59
medroxyprogesterone acetate ......................................... 60
medroxyprogesterone acetate (contraceptive) ......... 56
mefenamic acid ....................................................................... 5
mefloquine hcl ....................................................................... 11
megestrol acetate ................................................................. 21
MEKINIST ................................................................................ 23
meloxicam ................................................................................. 5
melphalan ................................................................................ 19
memantine hcl ....................................................................... 35
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration
pack ...................................................................................... 35
MENACTRA INJ....................................................................... 73
MENEST .................................................................................... 59
MENQUADFI INJ .................................................................... 73
MENTAX .................................................................................... 86
MENVEO INJ............................................................................ 73
MENVEO SOL .......................................................................... 73
meprobamate ......................................................................... 34
mercaptopurine ..................................................................... 20
mesalamine ............................................................................. 63
mesalamine w/ cleanser .................................................... 63
mesna ....................................................................................... 25
MESNEX .................................................................................... 25
metaxalone ............................................................................. 48
metformin hcl ......................................................................... 51
methadone hcl ......................................................................... 7
methadone hydrochloride i ................................................. 7
methadose................................................................................. 7
methamphetamine hcl ........................................................ 44
methazolamide ...................................................................... 32
methenamine hippurate ..................................................... 17
methimazole ........................................................................... 61
methocarbamol...................................................................... 48
methotrexate sodium .................................................... 20, 72
methoxsalen rapid ................................................................ 86
methscopolamine bromide ................................................ 61
methyldopa ............................................................................. 33
methylphenidate hcl ...................................................... 44, 45
102
methylprednisolone .............................................................. 59
metoclopramide hcl .............................................................. 62
metolazone .............................................................................. 32
metoprolol & hydrochlorothiazide tab 100-25 mg .... 30
metoprolol & hydrochlorothiazide tab 100-50 mg .... 30
metoprolol & hydrochlorothiazide tab 50-25 mg ...... 30
metoprolol succinate ............................................................ 30
metoprolol tartrate ............................................................... 30
metronidazole ......................................................................... 17
metronidazole (topical) ....................................................... 89
metronidazole vaginal ......................................................... 66
miconazole 3 ........................................................................... 66
miconazole 3 combination ................................................. 66
miconazole 7 ........................................................................... 66
microgestin 1.5/30 ............................................................... 56
midodrine hcl .......................................................................... 33
mifepristone ............................................................................ 60
miglitol ...................................................................................... 51
mimvey ..................................................................................... 59
minocycline hcl ....................................................................... 19
minoxidil ................................................................................... 33
MIRCERA .................................................................................. 67
MIRENA ..................................................................................... 56
mirtazapine.............................................................................. 37
MIRVASO .................................................................................. 89
misoprostol .............................................................................. 64
mitomycin ................................................................................ 19
mitoxantrone hcl ................................................................... 19
M-M-R II INJ ........................................................................... 73
modafinil ................................................................................... 48
moexipril hcl............................................................................ 26
mometasone furoate ............................................................ 88
mometasone furoate (nasal) ............................................ 82
monoject sodium chloride .................................................. 74
mono-linyah ............................................................................ 56
montelukast sodium ............................................................. 81
morphine sulfate ................................................................. 7, 8
morphine sulfate beads ........................................................ 8
MOTOFEN TAB 1-0.025 ....................................................... 61
MOVANTIK ............................................................................... 64
moxifloxacin hcl ..................................................................... 16
moxifloxacin hcl (ophth) ..................................................... 76
MULTAQ .................................................................................... 28
multivitamin/fluoride ........................................................... 75
multi-vitamin/fluoride dr .................................................... 75
multi-vitamin/fluoride/ir ..................................................... 75
mupirocin ................................................................................. 85
mycophenolate mofetil ........................................................ 72
mycophenolate sodium ....................................................... 72
MYRBETRIQ ............................................................................. 66
N
nabumetone .............................................................................. 5
nadolol ....................................................................................... 30
nafrinse ..................................................................................... 74
nafrinse drops......................................................................... 74
naftifine hcl .............................................................................. 86
nalbuphine hcl .......................................................................... 8
naloxone hcl ............................................................................ 49
naltrexone hcl ........................................................................ 49
naproxen .................................................................................... 5
naratriptan hcl ....................................................................... 46
NATACYN ................................................................................. 76
NATAZIA TAB ......................................................................... 56
nateglinide ............................................................................... 53
NAYZILAM ................................................................................ 41
nebivolol hcl ............................................................................ 30
necon 0.5/35-28 ................................................................... 56
nefazodone hcl ....................................................................... 37
neomycin sulfate ................................................................... 10
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-
10000unt op oin .............................................................. 76
neomycin-polymy-gramicid op sol 1.75-10000-
0.025mg-unt-mg/ml ...................................................... 76
neomycin-polymyxin-dexamethasone ophth oint
0.1% .................................................................................... 76
neomycin-polymyxin-dexamethasone ophth susp
0.1% .................................................................................... 76
neomycin-polymyxin-hc ophth susp .............................. 76
neomycin-polymyxin-hc otic soln 1% ........................... 90
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1% ........................................................................ 90
NEUPRO .................................................................................... 39
NEUTROGENA CLEAR PORE CLE ..................................... 84
NEVANAC ................................................................................. 77
nevirapine ................................................................................ 12
NEXIUM .................................................................................... 64
NEXIUM 24HR ........................................................................ 64
NEXPLANON ............................................................................ 56
NEXTSTELLIS TAB 3-14.2MG ........................................... 56
niacin (antihyperlipidemic)................................................ 30
nicardipine hcl ........................................................................ 31
nicotine ..................................................................................... 50
nicotine polacrilex ................................................................. 50
nicotine step 3 ....................................................................... 50
NICOTROL INHALER ............................................................ 50
NICOTROL NS ........................................................................ 50
nifedipine ................................................................................. 31
nikki ........................................................................................... 56
nilutamide ................................................................................ 21
nimodipine ............................................................................... 32
NIPENT...................................................................................... 24
nisoldipine ............................................................................... 32
nitazoxanide ........................................................................... 17
nitisinone ................................................................................. 59
NITRO-DUR ............................................................................. 33
nitrofurantoin macrocrystal .............................................. 17
nitrofurantoin monohyd macro ........................................ 18
nitroglycerin ............................................................................ 33
NIVESTYM ................................................................................ 67
nizatidine ................................................................................. 62
nora-be ..................................................................................... 56
NORDIPEN 5 MIS DEVICE .................................................. 60
NORDIPEN DEL MIS SYSTEM ........................................... 60
NORDITROPIN FLEXPRO .................................................... 60
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg ........................................................................ 56
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg ........................................................................ 56
103
norethindrone (contraceptive) ......................................... 56
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg ....................................................................................... 56
norethindrone ace-eth estradiol-fe chew tab 1 mg-
20 mcg (24) ....................................................................... 56
norethindrone ace-ethinyl estradiol-fe cap 1 mg-20
mcg (24) ............................................................................. 56
norethindrone acetate ......................................................... 60
norethindrone acetate-ethinyl estradiol tab 0.5 mg-
2.5 mcg ............................................................................... 59
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg ....................................................................................... 56
norgestimate-eth estrad tab 0.18-25/0.215-
25/0.25-25 mg-mcg ....................................................... 56
norgestimate-eth estrad tab 0.18-35/0.215-
35/0.25-35 mg-mcg ....................................................... 56
NORPACE CR ........................................................................... 28
nortrel 0.5/35 (28) ............................................................... 56
nortrel 1/35 ............................................................................. 56
nortrel 7/7/7 ........................................................................... 56
nortriptyline hcl ...................................................................... 37
NORVIR ..................................................................................... 12
NOVOFINE PEN NEEDLES ................................................... 58
NOVOLIN INJ 70/30 ............................................................. 52
NOVOLIN INJ 70/30 FP ....................................................... 52
NOVOLIN N .............................................................................. 52
NOVOLIN N FLEXPEN ........................................................... 52
NOVOLIN R .............................................................................. 52
NOVOLIN R FLEXPEN ........................................................... 52
NOVOLOG ................................................................................. 53
NOVOLOG FLEXPEN .............................................................. 53
NOVOLOG MIX INJ 70/30 ................................................... 53
NOVOLOG MIX INJ FLEXPEN ............................................. 53
NOVOLOG PENFILL ............................................................... 53
NOXAFIL ................................................................................... 11
NUBEQA .................................................................................... 21
NUCYNTA .................................................................................... 8
NUCYNTA ER ............................................................................. 8
NUEDEXTA CAP 20-10MG .................................................. 49
nyamyc ..................................................................................... 86
nylia 1/35 ................................................................................. 56
nystatin ..................................................................................... 11
nystatin (mouth-throat) ..................................................... 89
nystatin (topical) ................................................................... 86
nystatin-triamcinolone cream 100000-0.1 unit/gm-
% ........................................................................................... 86
nystatin-triamcinolone oint 100000-0.1 unit/gm-% 86
nystop ........................................................................................ 86
O
ocella .......................................................................................... 56
octreotide acetate ................................................................. 50
ODEFSEY TAB ......................................................................... 14
ODOMZO .................................................................................. 24
ofloxacin ................................................................................... 16
ofloxacin (ophth) ................................................................... 76
ofloxacin (otic) ....................................................................... 90
olanzapine ................................................................................ 39
olmesartan medoxomil........................................................ 28
olmesartan medoxomil-hydrochlorothiazide tab 20-
12.5 mg............................................................................... 27
olmesartan medoxomil-hydrochlorothiazide tab 40-
12.5 mg............................................................................... 27
olmesartan medoxomil-hydrochlorothiazide tab 40-
25 mg .................................................................................. 27
olmesartan-amlodipine-hydrochlorothiazide tab 20-
5-12.5 mg .......................................................................... 27
olmesartan-amlodipine-hydrochlorothiazide tab 40-
10-12.5 mg ........................................................................ 28
olmesartan-amlodipine-hydrochlorothiazide tab 40-
10-25 mg ............................................................................ 28
olmesartan-amlodipine-hydrochlorothiazide tab 40-
5-12.5 mg .......................................................................... 27
olmesartan-amlodipine-hydrochlorothiazide tab 40-
5-25 mg .............................................................................. 28
olopatadine hcl ...................................................................... 77
olopatadine hcl (nasal) ....................................................... 80
omega-3-acid ethyl esters cap 1 gm ............................ 30
omeprazole ............................................................................. 65
omeprazole magnesium ..................................................... 65
OMNIFLEX DPR ...................................................................... 56
OMNIPOD 5 G6 KIT INTRO ............................................... 58
OMNIPOD 5 G6 MIS PODS ................................................ 58
OMNIPOD DASH KIT INTRO.............................................. 58
OMNIPOD DASH MIS PODS .............................................. 58
OMNIPOD MIS CLASSIC ..................................................... 58
OMNIPOD PDM KIT CLASSIC ............................................ 58
ONCASPAR .............................................................................. 24
ondansetron ............................................................................ 62
ondansetron hcl ..................................................................... 62
ONGENTYS .............................................................................. 39
OPSUMIT .................................................................................. 33
OPTIONS GYNOL II VAGINAL ........................................... 65
oralone dental paste ............................................................ 89
ORAVIG .................................................................................... 89
ORENITRAM ............................................................................ 33
ORFADIN .................................................................................. 60
ORILISSA ................................................................................. 58
ORKAMBI GRA 100-125 ..................................................... 81
ORKAMBI GRA 150-188 ..................................................... 81
ORKAMBI GRA 75-94MG .................................................... 81
ORKAMBI TAB 100-125 ...................................................... 81
ORKAMBI TAB 200-125 ...................................................... 81
orphenadrine citrate ............................................................ 48
oseltamivir phosphate......................................................... 15
osmitrol viaflex ...................................................................... 32
OSMOPREP TAB 1.5GM ....................................................... 63
OSPHENA ................................................................................. 60
OTEZLA ..................................................................................... 70
OTEZLA TAB 10/20/30........................................................ 70
oxaliplatin ................................................................................ 25
oxaprozin ................................................................................... 5
oxazepam ................................................................................ 34
oxcarbazepine ........................................................................ 41
oxiconazole nitrate ............................................................... 86
oxybutynin chloride ............................................................. 66
oxycodone hcl ...................................................................... 8, 9
oxycodone w/ acetaminophen tab 10-325 mg ............ 9
oxycodone w/ acetaminophen tab 2.5-325 mg .......... 9
104
oxycodone w/ acetaminophen tab 5-325 mg ............... 9
oxycodone w/ acetaminophen tab 7.5-325 mg ........... 9
oxymorphone hcl ..................................................................... 9
OZEMPIC .................................................................................. 51
OZEMPIC INJ 8MG/3ML....................................................... 51
P
pacerone ................................................................................... 28
paclitaxel .................................................................................. 20
paclitaxel protein-bound particles for iv susp 100 mg
................................................................................................ 20
paliperidone ............................................................................. 39
pamidronate disodium ......................................................... 53
pantoprazole sodium ........................................................... 65
PARAGARD IUD T380A ........................................................ 56
paraplatin ................................................................................. 25
paricalcitol ................................................................................ 75
paromomycin sulfate ........................................................... 10
paroxetine hcl ......................................................................... 37
PASER ........................................................................................ 15
PEDIARIX INJ 0.5ML ............................................................ 73
PEDIATRIC RESPIRATORY MASK ..................................... 82
PEDVAX HIB ............................................................................ 73
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm ......................................................................................... 63
peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln
100 gm ................................................................................ 63
peg 3350-kcl-sod bicarb-nacl for soln 420 gm .......... 63
PEGASYS .................................................................................. 17
PEG-PREP KIT ......................................................................... 63
pemetrexed disodium .......................................................... 20
penciclovir ................................................................................ 88
penicillamine ........................................................................... 54
penicillin g potassium .......................................................... 18
penicillin g sodium ................................................................ 18
penicillin v potassium .......................................................... 18
PENTACEL INJ ......................................................................... 73
pentamidine isethionate ..................................................... 18
pentoxifylline .......................................................................... 67
perindopril erbumine ........................................................... 26
periogard .................................................................................. 89
permethrin ............................................................................... 89
perphenazine .......................................................................... 39
perphenazine-amitriptyline tab 2-10 mg ..................... 49
perphenazine-amitriptyline tab 2-25 mg ..................... 49
perphenazine-amitriptyline tab 4-10 mg ..................... 50
perphenazine-amitriptyline tab 4-25 mg ..................... 50
perphenazine-amitriptyline tab 4-50 mg ..................... 50
pfizerpen................................................................................... 18
phenazopyridine tab 95mg ................................................ 65
phenelzine sulfate ................................................................. 37
phenobarbital .......................................................................... 41
phenoxybenzamine hcl ....................................................... 33
phenylephrine hcl (mydriatic) .......................................... 78
phenytoin ................................................................................. 41
phenytoin infatabs ................................................................ 41
phenytoin sodium extended .............................................. 41
PHEXXI GEL ............................................................................. 65
PHOSPHOLINE IODIDE ........................................................ 77
PHOTOFRIN ............................................................................. 24
physiolyte ................................................................................ 78
phytonadione.......................................................................... 75
pilocarpine hcl ........................................................................ 78
pilocarpine hcl (oral) ........................................................... 89
pimecrolimus .......................................................................... 88
pimozide ................................................................................... 50
pindolol ..................................................................................... 30
pioglitazone hcl ...................................................................... 52
pioglitazone hcl-glimepiride tab 30-2 mg .................... 52
pioglitazone hcl-glimepiride tab 30-4 mg .................... 52
pioglitazone hcl-metformin hcl tab 15-500 mg ......... 52
pioglitazone hcl-metformin hcl tab 15-850 mg ......... 52
pirfenidone .............................................................................. 82
pirmella 1/35 .......................................................................... 56
pirmella 7/7/7 ........................................................................ 56
piroxicam ................................................................................... 5
PLENVU SOL ........................................................................... 63
PNEUMOVAX 23/1 DOSE .................................................... 73
podofilox .................................................................................. 88
polycin....................................................................................... 76
polyethylene glycol 3350 ................................................... 63
polymyxin b-trimethoprim ophth soln 10000 unit/ml-
0.1% .................................................................................... 76
POMALYST ............................................................................... 20
portia-28 .................................................................................. 56
posaconazole .......................................................................... 11
potassium chloride ............................................................... 75
potassium chloride microencapsulated crystals er... 75
potassium citrate (alkalinizer) ......................................... 65
PRADAXA ................................................................................. 66
PRALUENT ................................................................................ 30
pramipexole dihydrochloride ............................................ 39
prasugrel hcl ........................................................................... 67
pravastatin sodium .............................................................. 29
praziquantel ............................................................................ 10
prazosin hcl ............................................................................. 26
PREC NEO SYS KIT FREESTYL.......................................... 58
PRECISION MIS XTRA ......................................................... 58
PRECISION TES XTRA ......................................................... 58
PRECISN XTRA TES KETONE ............................................ 58
PRED-G SUS OP .................................................................... 76
prednicarbate ......................................................................... 88
prednisolone ........................................................................... 59
prednisolone acetate (ophth) ........................................... 77
PREDNISOLONE SODIUM PHOSP.................................... 77
prednisolone sodium phosphate ..................................... 59
prednisone ............................................................................... 59
PREDNISONE INTENSOL .................................................... 59
pregabalin ................................................................................ 41
PREHEVBRIO .......................................................................... 73
PREMARIN ............................................................................... 59
prenatabs rx ........................................................................... 75
prevalite ................................................................................... 29
PREVNAR 13 INJ ................................................................... 73
PREVNAR 20 INJ ................................................................... 73
PREZCOBIX TAB 800-150 .................................................. 14
PREZISTA ........................................................................... 12, 13
PRIFTIN .................................................................................... 15
primaquine phosphate ........................................................ 11
105
primidone ................................................................................. 41
PRIORIX INJ ............................................................................ 73
probenecid ................................................................................. 5
procainamide hcl ................................................................... 29
prochlorperazine .................................................................... 62
prochlorperazine maleate .................................................. 62
procto-pak ............................................................................... 65
progesterone ........................................................................... 60
PROLASTIN-C ......................................................................... 78
PROLIA ...................................................................................... 60
promethazine & phenylephrine syrup 6.25-5 mg/5ml
................................................................................................ 80
promethazine hcl ................................................................... 62
promethazine w/ codeine syrup 6.25-10 mg/5ml .... 81
promethazine-dm syrup 6.25-15 mg/5ml ................... 81
promethazine-phenylephrine-codeine syrup 6.25-5-
10 mg/5ml .......................................................................... 81
promethegan .......................................................................... 62
propafenone hcl ..................................................................... 29
propranolol hcl ....................................................................... 31
propylthiouracil ...................................................................... 61
PROQUAD INJ ......................................................................... 73
protriptyline hcl ...................................................................... 37
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml
................................................................................................ 81
PULMICORT FLEXHALER ..................................................... 83
px allergy relief ...................................................................... 80
pyrazinamide .......................................................................... 15
pyridostigmine bromide ...................................................... 47
pyridoxine hcl ......................................................................... 76
pyrimethamine ....................................................................... 18
Q
qc bacitracin ............................................................................ 85
QUADRACEL INJ .................................................................... 74
QUADRACEL INJ 0.5ML ....................................................... 74
quetiapine fumarate ............................................................. 39
quinapril hcl ............................................................................. 26
quinapril-hydrochlorothiazide tab 10-12.5 mg .......... 26
quinapril-hydrochlorothiazide tab 20-12.5 mg .......... 26
quinapril-hydrochlorothiazide tab 20-25 mg .............. 26
quinine sulfate ........................................................................ 11
QVAR REDIHALER ................................................................. 83
R
rabeprazole sodium .............................................................. 65
raloxifene hcl .......................................................................... 60
ramelteon ................................................................................. 46
ramipril ...................................................................................... 26
ranolazine ................................................................................ 33
rasagiline mesylate............................................................... 39
reclipsen ................................................................................... 56
RECOMBIVAX HB ................................................................... 74
RECTIV ...................................................................................... 88
REGRANEX ............................................................................... 89
RELENZA DISKHALER .......................................................... 15
REMODULIN ............................................................................ 33
repaglinide ............................................................................... 53
RESTASIS ................................................................................ 78
RESTASIS MULTIDOSE ....................................................... 78
RETACRIT ................................................................................ 67
REVLIMID ................................................................................. 20
REYATAZ .................................................................................. 13
ribavirin (hepatitis c) ........................................................... 17
rifabutin .................................................................................... 15
rifampin .................................................................................... 15
riluzole ...................................................................................... 47
rimantadine hydrochloride ................................................ 15
RINVOQ .................................................................................... 70
risedronate sodium .............................................................. 53
risperidone .............................................................................. 40
ritonavir .................................................................................... 13
rivastigmine tartrate............................................................ 35
rivelsa ....................................................................................... 56
rizatriptan benzoate ............................................................. 46
roflumilast ............................................................................... 82
ropinirole hydrochloride ..................................................... 39
rosadan ..................................................................................... 89
rosuvastatin calcium ............................................................ 29
ROTARIX SUS ......................................................................... 74
ROTATEQ SOL ........................................................................ 74
rufinamide ............................................................................... 41
RYDAPT ..................................................................................... 23
S
SANCUSO ................................................................................. 62
sapropterin dihydrochloride .............................................. 58
SAVELLA ................................................................................... 45
SAVELLA MIS TITR PAK ...................................................... 45
scopolamine ............................................................................ 62
selegiline hcl ........................................................................... 39
selenium sulfide .................................................................... 86
SELZENTRY ............................................................................. 13
SEREVENT DISKUS .............................................................. 80
sertraline hcl ........................................................................... 37
sevelamer carbonate ........................................................... 60
SHARPS CONTAINER ........................................................... 58
SHINGRIX ................................................................................ 74
SHUR-SEAL ............................................................................. 65
sildenafil citrate (pulmonary hypertension) ................ 33
silodosin ................................................................................... 65
silver sulfadiazine ................................................................. 85
SIMBRINZA SUS 1-0.2% ................................................... 78
SIMPONI ................................................................................... 70
SIMPONI ARIA ....................................................................... 68
simvastatin .............................................................................. 29
sirolimus ................................................................................... 72
SIRTURO .................................................................................. 15
SKYLA ........................................................................................ 56
SKYRIZI ........................................................................ 68, 70, 71
SKYRIZI PEN ........................................................................... 71
SLYND ....................................................................................... 56
sm fexofenadine hydrochlo ............................................... 80
sm miconazole 3 ................................................................... 66
sm nicotine transdermal s ................................................. 50
sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6
gm/177ml ........................................................................... 63
106
sodium chloride ...................................................................... 75
sodium chloride (gu irrigant) ............................................ 89
sodium chloride (inhalant) ................................................. 82
sodium fluoride ...................................................................... 75
solifenacin succinate ............................................................ 66
SOLIQUA INJ 100/33 ........................................................... 52
SOMATULINE DEPOT ............................................................ 50
SOMAVERT ............................................................................... 51
sorafenib tosylate.................................................................. 23
sorine ......................................................................................... 29
sotalol hcl ................................................................................. 29
sotalol hcl (afib/afl) .............................................................. 29
SOVALDI ................................................................................... 17
spinosad.................................................................................... 89
SPIRIVA HANDIHALER......................................................... 79
SPIRIVA RESPIMAT............................................................... 79
spironolactone ........................................................................ 32
spironolactone & hydrochlorothiazide tab 25-25 mg
................................................................................................ 32
sprintec 28 ............................................................................... 56
SPRYCEL ................................................................................... 23
sps .............................................................................................. 54
sronyx ........................................................................................ 56
ssd .............................................................................................. 85
stavudine .................................................................................. 13
STELARA ................................................................................... 71
STIVARGA ................................................................................ 23
STRIVERDI RESPIMAT ......................................................... 80
SUBLOCADE ............................................................................ 10
SUCRAID .................................................................................. 64
sucralfate ................................................................................. 64
sulconazole nitrate................................................................ 86
sulfacetamide sodium (acne) ........................................... 84
sulfacetamide sodium (ophth) ......................................... 76
sulfacetamide sodium-prednisolone ophth soln 10-
0.23(0.25)% ...................................................................... 76
sulfadiazine .............................................................................. 10
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
................................................................................................ 10
sulfamethoxazole-trimethoprim tab 400-80 mg ....... 10
sulfamethoxazole-trimethoprim tab 800-160 mg ..... 10
SULFAMYLON .......................................................................... 85
sulfasalazine ............................................................................ 63
sulindac ....................................................................................... 5
sumatriptan ............................................................................. 46
sumatriptan succinate ......................................................... 46
sumatriptan-naproxen sodium tab 85-500 mg .......... 46
sunitinib malate ..................................................................... 24
SUNOSI ..................................................................................... 48
SUPPRELIN LA ........................................................................ 60
SUPRAX ..................................................................................... 16
SUPREP BOWEL SOL PREP KIT ........................................ 63
SUTAB TAB .............................................................................. 63
syeda ......................................................................................... 57
SYMBICORT AER 160-4.5................................................... 83
SYMBICORT AER 80-4.5 ..................................................... 83
SYMDEKO TAB 100-150 ...................................................... 81
SYMDEKO TAB 50-75MG .................................................... 81
SYMLINPEN 120 ..................................................................... 51
SYMLINPEN 60 ....................................................................... 51
SYNAREL .................................................................................. 60
SYNERA DIS 70-70MG ........................................................ 88
SYNJARDY TAB ...................................................................... 53
SYNJARDY TAB 12.5-500 ................................................... 53
SYNJARDY TAB 5-1000MG ................................................ 53
SYNJARDY TAB 5-500MG ................................................... 53
SYNJARDY XR TAB ................................................................ 53
SYNJARDY XR TAB 10-1000 ............................................. 53
SYNJARDY XR TAB 25-1000 ............................................. 53
SYNJARDY XR TAB 5-1000MG ......................................... 53
SYNTHROID ............................................................................ 61
T
TABLOID ................................................................................... 20
tacrolimus ................................................................................ 72
tacrolimus (topical) .............................................................. 88
tadalafil ..................................................................................... 65
tadalafil (pulmonary hypertension) ............................... 33
TAFINLAR ................................................................................. 24
tafluprost ................................................................................. 78
take action .............................................................................. 57
TALTZ ........................................................................................ 71
tamoxifen citrate ................................................................... 21
tamsulosin hcl ........................................................................ 65
tasimelteon ............................................................................. 46
tazarotene ............................................................................... 86
tazicef........................................................................................ 16
TAZORAC ................................................................................. 86
taztia xt .................................................................................... 32
TDVAX INJ 2-2 LF ................................................................. 74
telmisartan .............................................................................. 28
telmisartan-amlodipine tab 40-10 mg .......................... 28
telmisartan-amlodipine tab 40-5 mg ............................ 28
telmisartan-amlodipine tab 80-10 mg .......................... 28
telmisartan-amlodipine tab 80-5 mg ............................ 28
telmisartan-hydrochlorothiazide tab 40-12.5 mg ..... 28
telmisartan-hydrochlorothiazide tab 80-12.5 mg ..... 28
telmisartan-hydrochlorothiazide tab 80-25 mg ......... 28
temazepam ............................................................................. 46
TEMODAR ................................................................................. 19
temozolomide ......................................................................... 19
TENIVAC INJ 5-2LF .............................................................. 74
tenofovir disoproxil fumarate ........................................... 13
terazosin hcl ........................................................................... 26
terbinafine hcl ........................................................................ 11
terbutaline sulfate ................................................................ 80
terconazole vaginal .............................................................. 66
testosterone ............................................................................ 51
testosterone cypionate ....................................................... 51
testosterone enanthate ...................................................... 51
tetrabenazine ......................................................................... 47
tetracycline hcl ...................................................................... 19
THALOMID ............................................................................... 21
theophylline ............................................................................ 83
thioridazine hcl ...................................................................... 40
thiothixene .............................................................................. 40
tiagabine hcl ........................................................................... 41
TICE BCG ................................................................................. 21
tilia fe ........................................................................................ 57
107
timolol maleate ...................................................................... 31
timolol maleate (ophth) ...................................................... 78
TINACTIN ................................................................................. 86
tinidazole .................................................................................. 10
TIVICAY ..................................................................................... 13
TIVICAY PD .............................................................................. 13
tizanidine hcl ........................................................................... 48
TOBRADEX OIN 0.3-0.1%.................................................. 76
TOBRADEX ST SUS 0.3-0.05 ............................................ 76
tobramycin ............................................................................... 81
tobramycin (ophth) .............................................................. 77
tobramycin-dexamethasone ophth susp 0.3-0.1% .. 76
TODAY SPONGE ..................................................................... 65
tolnaftate .................................................................................. 86
tolterodine tartrate ............................................................... 66
tolvaptan .................................................................................. 60
topiramate ............................................................................... 41
toposar ...................................................................................... 25
topotecan hcl .......................................................................... 25
toremifene citrate ................................................................. 21
torsemide ................................................................................. 32
tramadol hcl .............................................................................. 9
tramadol-acetaminophen tab 37.5-325 mg .................. 9
trandolapril .............................................................................. 26
trandolapril-verapamil hcl tab er 1-240 mg ................ 26
trandolapril-verapamil hcl tab er 2-180 mg ................ 26
trandolapril-verapamil hcl tab er 2-240 mg ................ 26
trandolapril-verapamil hcl tab er 4-240 mg ................ 26
tranexamic acid ..................................................................... 67
tranylcypromine sulfate ...................................................... 37
travoprost ................................................................................ 78
trazodone hcl .......................................................................... 37
TRECATOR ............................................................................... 15
TRELEGY AER 100MCG ........................................................ 79
TRELEGY AER 200MCG ........................................................ 79
TREMFYA .................................................................................. 71
TRESIBA ................................................................................... 53
TRESIBA FLEXTOUCH .......................................................... 53
tretinoin .................................................................................... 84
tretinoin (chemotherapy) ................................................... 24
triamcinolone acetonide (mouth) .................................... 89
triamcinolone acetonide (nasal) ...................................... 82
triamcinolone acetonide (topical) ................................... 88
triamterene .............................................................................. 32
triamterene & hydrochlorothiazide cap 37.5-25 mg 32
triamterene & hydrochlorothiazide tab 37.5-25 mg 32
triamterene & hydrochlorothiazide tab 75-50 mg .... 32
triazolam .................................................................................. 46
triderm ...................................................................................... 88
trifluoperazine hcl ................................................................. 40
trifluridine ................................................................................ 77
trihexyphenidyl hcl ............................................................... 39
TRIKAFTA TAB ........................................................................ 81
tri-linyah ................................................................................... 57
trimethobenzamide hcl ....................................................... 62
trimethoprim ........................................................................... 18
TRIMETHOPRIM ...................................................................... 18
trimipramine maleate .................................................... 37, 38
TRINTELLIX ............................................................................. 38
triple antibiotic ....................................................................... 85
triple paste af ......................................................................... 86
TRIPTODUR ............................................................................. 60
tri-sprintec ............................................................................... 57
TRIUMEQ PD TAB .................................................................. 14
TRIUMEQ TAB......................................................................... 14
tri-vite/fluoride ...................................................................... 76
trivora-28................................................................................. 57
TROGARZO .............................................................................. 13
tropicamide ............................................................................. 78
trospium chloride .................................................................. 66
TRULICITY ............................................................................... 51
TRUMENBA INJ ...................................................................... 74
TRUSTEX/RIA MIS NON-LUB ............................................ 57
TRUSTX NON-9 MIS RIB/STUD ....................................... 57
TUKYSA..................................................................................... 24
TUZISTRA XR SUS ................................................................ 81
TWINRIX INJ ........................................................................... 74
TWIRLA DIS 120-30 ............................................................ 57
TYBLUME CHW 0.1-0.02 .................................................... 57
TYBOST ..................................................................................... 13
TYMLOS .................................................................................... 60
TYSABRI ................................................................................... 47
TYVASO .................................................................................... 33
TYVASO REFILL ..................................................................... 34
TYVASO STARTER ................................................................. 34
U
UBRELVY .................................................................................. 46
unithroid ................................................................................... 61
UPTRAVI ................................................................................... 34
UPTRAVI PACK TAB 200/800............................................ 34
URINE GLUCOSE MONITORING SUPPLIES .................. 58
URINE TEST STRIPS ............................................................ 58
ursodiol ..................................................................................... 64
V
valacyclovir hcl ...................................................................... 15
valganciclovir hcl................................................................... 15
valproate sodium .................................................................. 41
valproic acid ............................................................................ 41
valsartan .................................................................................. 28
valsartan-hydrochlorothiazide tab 160-12.5 mg ...... 28
valsartan-hydrochlorothiazide tab 160-25 mg .......... 28
valsartan-hydrochlorothiazide tab 320-12.5 mg ...... 28
valsartan-hydrochlorothiazide tab 320-25 mg .......... 28
valsartan-hydrochlorothiazide tab 80-12.5 mg ......... 28
vancomycin hcl ...................................................................... 18
VAQTA ....................................................................................... 74
varenicline tartrate............................................................... 50
varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg
start pack ........................................................................... 50
VARIVAX................................................................................... 74
VARUBI ..................................................................................... 62
VAXELIS INJ ........................................................................... 74
VAXNEUVANCE INJ ............................................................... 74
VCF VAGINAL CONTRACEPTIVE ...................................... 65
velivet ....................................................................................... 57
VELPHORO ............................................................................... 60
108
VEMLIDY ................................................................................... 15
VENCLEXTA ............................................................................. 20
VENCLEXTA TAB START PK ............................................... 20
venlafaxine hcl ....................................................................... 38
VENTAVIS ................................................................................. 34
verapamil hcl .......................................................................... 32
V-GO 20 KIT ............................................................................ 58
V-GO 30 KIT ............................................................................ 58
V-GO 40 KIT ............................................................................ 58
VICTOZA ................................................................................... 52
vigabatrin ................................................................................. 41
VIIBRYD KIT STARTER ........................................................ 38
vilazodone hcl ......................................................................... 38
vinblastine sulfate ................................................................. 20
vincristine sulfate .................................................................. 20
vinorelbine tartrate ............................................................... 20
VIOKACE TAB 10440 ............................................................ 64
VIOKACE TAB 20880 ............................................................ 64
viorele ........................................................................................ 57
VIRACEPT ................................................................................. 13
VIREAD ...................................................................................... 13
VISTOGARD ............................................................................. 24
vitamins a/c/d/fluoride ....................................................... 76
VITRAKVI .................................................................................. 24
VIVITROL .................................................................................. 49
VOLTAREN ................................................................................ 89
voriconazole ............................................................................ 11
VOSEVI TAB ............................................................................ 17
VOTRIENT ................................................................................ 24
VRAYLAR ................................................................................... 40
VRAYLAR CAP 1.5-3MG ....................................................... 40
vyfemla ..................................................................................... 57
VYVANSE .................................................................................. 45
W
warfarin sodium ..................................................................... 66
wera ........................................................................................... 57
westab max ............................................................................. 76
WIDE-SEAL SILICONE DIAPHR ........................................ 57
X
XALKORI ................................................................................... 24
XARELTO................................................................................... 66
XARELTO STAR TAB 15/20MG .......................................... 67
XCOPRI...................................................................................... 41
XCOPRI PAK 100-150 .......................................................... 41
XCOPRI PAK 12.5-25 ........................................................... 41
XCOPRI PAK 150-200 .......................................................... 41
XCOPRI PAK 50-100MG ...................................................... 41
XELJANZ ................................................................................... 71
XELJANZ XR ............................................................................ 71
XIFAXAN ................................................................................... 18
XOLAIR ..................................................................................... 82
XTAMPZA ER ............................................................................. 9
XTANDI ..................................................................................... 21
xulane ....................................................................................... 57
XULTOPHY INJ 100/3.6 ...................................................... 52
Y
YONSA....................................................................................... 21
yuvafem ................................................................................... 59
Z
zafirlukast ................................................................................ 81
zaleplon .................................................................................... 46
ZEJULA ...................................................................................... 24
ZELBORAF ............................................................................... 24
ZENPEP CAP 10000UNT ...................................................... 64
ZENPEP CAP 15000UNT ...................................................... 64
ZENPEP CAP 20000UNT ...................................................... 64
ZENPEP CAP 25000UNT ...................................................... 64
ZENPEP CAP 3000UNIT ...................................................... 64
ZENPEP CAP 40000UNT ...................................................... 64
ZENPEP CAP 5000UNIT ...................................................... 64
zenzedi...................................................................................... 45
ZEPATIER TAB 50-100MG ................................................. 17
ZERVIATE ................................................................................ 77
zidovudine ............................................................................... 13
ZIEXTENZO ............................................................................. 67
zileuton ..................................................................................... 81
ZIOPTAN .................................................................................. 78
ziprasidone hcl ....................................................................... 40
ZIRGAN ..................................................................................... 77
zoledronic acid ....................................................................... 53
ZOLINZA .................................................................................. 24
zolmitriptan ............................................................................. 47
zolpidem tartrate .................................................................. 46
zonisamide .............................................................................. 41
ZONTIVITY .............................................................................. 68
zovia 1/35 ............................................................................... 57
ZUBSOLV SUB 0.7-0.18 ..................................................... 49
ZUBSOLV SUB 1.4-0.36 ..................................................... 49
ZUBSOLV SUB 11.4-2.9 ..................................................... 49
ZUBSOLV SUB 2.9-0.71 ..................................................... 49
ZUBSOLV SUB 5.7-1.4 ........................................................ 49
ZUBSOLV SUB 8.6-2.1 ........................................................ 49
ZYDELIG ................................................................................... 24
ZYKADIA .................................................................................. 24
ZYLET SUS 0.5-0.3% .......................................................... 76
ZYRTEC ALLERGY .................................................................. 80
