2 Tier 2018 Formulary (List of covered drugs)hp/...Some medicines are on the drug list, but you need...

2 Tier

2018 Formulary

(List of covered drugs)

For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.

Effective: October 1, 2018

©2018 HealthPartners

What’s the GenericsAdvantageRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3.

Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier Status can be used to determine how much a medicine will cost you. For exact cost information, • Find the tier status for your medicine. • Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or, • Log on to your myHealthPartners account to check your pharmacy benefits.

• Tier 1 – Formulary Generics & Brands • Tier 2 – Specialty Generics & Brands

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines.

What do the abbreviations in the More details column mean?

This column gives special information about the medicine you’re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list:

• Prior Authorization Required PA • Step Therapy Required ST • Age Edit AE • Gender Edit Female GE Female • Gender Edit Male GE Male

• Quantity Limit QL • Smoking Cessation Benefit SC • Trial Drug Program TD • Weight Loss Benefit WL • Oncology Benefit ONC

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (10/18) ©2018 HealthPartners

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance.

What’s an Age Edit (AE)? An age edit means some medicines are only covered if you’re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.

What’s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to:

• Side effects • High cost • High potential for waste

Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you’ll get the rest of your month supply. If a copay applies to the medicine, you’ll pay no more than one copay for each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

List of Covered Drugs

Table of Contents

Alcohol Dependency .................................................................................................................................................6Allergy .......................................................................................................................................................................6Alpha-1 Antitrypsin Deficiency ................................................................................................................................ 7Anti-Addiction/Substance Abuse Treatment Agents .............................................................................................. 7Anti-Infective ............................................................................................................................................................7Arthritis ...................................................................................................................................................................15Asthma & Copd .......................................................................................................................................................16Behavioral Health ...................................................................................................................................................18Birth Control ........................................................................................................................................................... 22Bleeding Disorders ................................................................................................................................................. 27Blood Modifier ........................................................................................................................................................27Blood Thinner ......................................................................................................................................................... 30Bone Health ............................................................................................................................................................ 31Cancer ..................................................................................................................................................................... 32Corticosteroids ....................................................................................................................................................... 35Cough & Cold .......................................................................................................................................................... 36Cystic Fibrosis ......................................................................................................................................................... 36Dementia ................................................................................................................................................................ 37Diabetes ..................................................................................................................................................................37Ear Conditions ........................................................................................................................................................ 40Enzyme Replacement ............................................................................................................................................. 41Eye Conditions ........................................................................................................................................................ 41Gout ........................................................................................................................................................................ 44Heart Health ........................................................................................................................................................... 44Hereditary Angioedema ......................................................................................................................................... 50Idiopathic Pulmonary Fibrosis ............................................................................................................................... 51Immune Deficiency .................................................................................................................................................51Immune Suppressant ............................................................................................................................................. 52Kidney Failure .........................................................................................................................................................52Men's Health .......................................................................................................................................................... 53Migraine ..................................................................................................................................................................53Mouth & Throat ......................................................................................................................................................54Multiple Sclerosis ................................................................................................................................................... 54Muscle Relaxant ..................................................................................................................................................... 55Other Conditions .................................................................................................................................................... 55Pain ......................................................................................................................................................................... 57Parkinson's ..............................................................................................................................................................60Pulmonary Hypertension ....................................................................................................................................... 61Seizures / Epilepsy ..................................................................................................................................................61Skin Conditions .......................................................................................................................................................64Sleep Disorders .......................................................................................................................................................68Smoking Cessation ................................................................................................................................................. 68Stomach / Gastrointestinal .................................................................................................................................... 68Thyroid ....................................................................................................................................................................72Urinary & Bladder Health .......................................................................................................................................72Vaccines .................................................................................................................................................................. 72

4

Vitamins And Minerals ...........................................................................................................................................76Weight Loss .............................................................................................................................................................78Women's Health .....................................................................................................................................................78

5

List of Covered Drugs

Drug Tier Status More Details

Alcohol Dependency

Alcohol Dependency

acamprosate oral tablet,delayed release (dr/ec)333 mg

Tier 1

disulfiram oral tablet 250 mg, 500 mg Tier 1

naltrexone oral tablet 50 mg Tier 1

Allergy

Allergy, Eye

azelastine ophthalmic (eye) drops 0.05 % Tier 1

cromolyn ophthalmic (eye) drops 4 % Tier 1

epinastine ophthalmic (eye) drops 0.05 % Tier 1

olopatadine ophthalmic (eye) drops 0.1 % Tier 1

Allergy, Injection

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml

Tier 1

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR0.15 MG/0.3 ML

Tier 1

Allergy, Other Nasal

azelastine nasal aerosol,spray 137 mcg (0.1 %) Tier 1

ipratropium bromide nasal spray,non-aerosol0.03 %, 42 mcg (0.06 %)

Tier 1

Allergy, Other Oral

GRASTEK SUBLINGUAL TABLET 2,800 BAU Tier 1 PA

ODACTRA SUBLINGUAL TABLET 12 SQ-HDM Tier 1 PA

RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT

Tier 1 PA

Antihistamines, Oral

cyproheptadine oral syrup 2 mg/5 ml Tier 1

cyproheptadine oral tablet 4 mg Tier 1

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 QL; AE

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 QL; AE

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

Tier 1 QL; AE

promethazine oral syrup 6.25 mg/5 ml Tier 1 QL; AE

promethazine oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 QL; AE

GenericsAdvantageRx: October 1, 20186


Corticosteroids, Nasal

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Tier 1

fluticasone nasal spray,suspension 50 mcg/actuation

Tier 1

Alpha-1 Antitrypsin Deficiency

Alpha-1 Antitrypsin Deficiency

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG

Tier 2 PA; Specialty

GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)


PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG


PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML


ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Tier 2 PA; Specialty

Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents

naloxone injection syringe 1 mg/ml Tier 1

NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION

Tier 1

Anti-Infective

Antibiotics, Cephalosporins

cefadroxil oral capsule 500 mg Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet 1 gram Tier 1

cefdinir oral capsule 300 mg Tier 1

cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

cefprozil oral tablet 250 mg, 500 mg Tier 1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML

Tier 1

cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1



cephalexin oral capsule 250 mg, 500 mg Tier 1

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

SUPRAX ORAL CAPSULE 400 MG Tier 1 QL

Antibiotics, Macrolides

azithromycin oral suspension for reconstitution100 mg/5 ml, 200 mg/5 ml

Tier 1

azithromycin oral tablet 250 mg, 500 mg Tier 1

azithromycin oral tablet 600 mg Tier 1

clarithromycin oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml

Tier 1

clarithromycin oral tablet 250 mg, 500 mg Tier 1

DIFICID ORAL TABLET 200 MG Tier 1 PA

Antibiotics, Other

clindamycin hcl oral capsule 150 mg, 300 mg Tier 1

clindamycin hcl oral capsule 75 mg Tier 1

clindamycin palmitate hcl oral recon soln 75 mg/5 ml

Tier 1

FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML

Tier 1

linezolid oral suspension for reconstitution 100 mg/5 ml

Tier 1 PA

linezolid oral tablet 600 mg Tier 1 PA

neomycin oral tablet 500 mg Tier 1

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5 ml

Tier 1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

Tier 1

trimethoprim oral tablet 100 mg Tier 1

vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg

Tier 1

vancomycin oral capsule 125 mg, 250 mg Tier 1

XIFAXAN ORAL TABLET 200 MG, 550 MG Tier 1 PA

Antibiotics, Penicillins

amoxicillin oral capsule 250 mg, 500 mg Tier 1

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

Tier 1



amoxicillin oral tablet 500 mg, 875 mg Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

Tier 1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable200-28.5 mg, 400-57 mg

Tier 1

ampicillin oral capsule 250 mg, 500 mg Tier 1

ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

dicloxacillin oral capsule 250 mg, 500 mg Tier 1

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml

Tier 1

penicillin v potassium oral tablet 250 mg, 500 mg Tier 1

Antibiotics, Quinolones

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML

Tier 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

Tier 1

ciprofloxacin oral suspension,microcapsule recon250 mg/5 ml, 500 mg/5 ml

Tier 1

levofloxacin oral solution 250 mg/10 ml Tier 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1

moxifloxacin oral tablet 400 mg Tier 1

Antibiotics, Tetracyclines

demeclocycline oral tablet 150 mg, 300 mg Tier 1

doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1

doxycycline monohydrate oral capsule 100 mg, 50 mg

Tier 1

doxycycline monohydrate oral tablet 100 mg, 50 mg

Tier 1

minocycline oral capsule 100 mg, 50 mg, 75 mg Tier 1

tetracycline oral capsule 250 mg, 500 mg Tier 1

Antifungals

clotrimazole mucous membrane troche 10 mg Tier 1



CRESEMBA ORAL CAPSULE 186 MG Tier 1 PA

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

Tier 1

fluconazole oral tablet 100 mg, 200 mg Tier 1

fluconazole oral tablet 150 mg, 50 mg Tier 1

griseofulvin microsize oral suspension 125 mg/5 ml

Tier 1

griseofulvin microsize oral tablet 500 mg Tier 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 1

itraconazole oral capsule 100 mg Tier 1 PA

ketoconazole oral tablet 200 mg Tier 1

NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)

Tier 1 PA

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG

Tier 1 PA

nystatin oral suspension 100,000 unit/ml Tier 1

nystatin oral tablet 500,000 unit Tier 1

terbinafine hcl oral tablet 250 mg Tier 1

voriconazole oral suspension for reconstitution200 mg/5 ml (40 mg/ml)

Tier 1 PA

voriconazole oral tablet 200 mg, 50 mg Tier 1 PA

Anti-Infective, Other

ALBENZA ORAL TABLET 200 MG Tier 1 PA

atovaquone oral suspension 750 mg/5 ml Tier 1

dapsone oral tablet 100 mg, 25 mg Tier 1

ivermectin oral tablet 3 mg Tier 1

praziquantel oral tablet 600 mg Tier 1

rifabutin oral capsule 150 mg Tier 1

SIVEXTRO ORAL TABLET 200 MG Tier 1 PA

Antiprotozoals

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

Tier 1 PA

ALINIA ORAL TABLET 500 MG Tier 1 PA

atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg

Tier 1

chloroquine phosphate oral tablet 250 mg, 500 mg

Tier 1



hydroxychloroquine oral tablet 200 mg Tier 1

mefloquine oral tablet 250 mg Tier 1

metronidazole oral tablet 250 mg, 500 mg Tier 1

Antiviral, Hepatitis B

adefovir oral tablet 10 mg Tier 1

BARACLUDE ORAL SOLUTION 0.05 MG/ML Tier 1

entecavir oral tablet 0.5 mg, 1 mg Tier 1

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)

Tier 1

lamivudine oral tablet 100 mg Tier 1

VEMLIDY ORAL TABLET 25 MG Tier 1

Antiviral, Hepatitis C

EPCLUSA ORAL TABLET 400-100 MG Tier 2 PA; Specialty

HARVONI ORAL TABLET 90-400 MG Tier 2 PA; Specialty

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

Tier 2 Specialty

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML

Tier 2 Specialty

MAVYRET ORAL TABLET 100-40 MG Tier 2 PA; Specialty

OLYSIO ORAL CAPSULE 150 MG Tier 2 PA; Specialty

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML


PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML


PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML


PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML


PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML


REBETOL ORAL SOLUTION 40 MG/ML Tier 2 Specialty

ribavirin oral capsule 200 mg Tier 2 Specialty

ribavirin oral tablet 200 mg Tier 2 Specialty

VOSEVI ORAL TABLET 400-100-100 MG Tier 2 PA; Specialty

Antiviral, Hiv

abacavir oral solution 20 mg/ml Tier 1



abacavir oral tablet 300 mg Tier 1

abacavir-lamivudine oral tablet 600-300 mg Tier 1

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

Tier 1

APTIVUS ORAL CAPSULE 250 MG Tier 1

APTIVUS ORAL SOLUTION 100 MG/ML Tier 1

atazanavir oral capsule 150 mg, 200 mg, 300 mg Tier 1

ATRIPLA ORAL TABLET 600-200-300 MG Tier 1

BIKTARVY ORAL TABLET 50-200-25 MG Tier 1

COMPLERA ORAL TABLET 200-25-300 MG Tier 1

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 1

DESCOVY ORAL TABLET 200-25 MG Tier 1

didanosine oral capsule,delayed release(dr/ec)125 mg, 200 mg, 250 mg, 400 mg

Tier 1

EDURANT ORAL TABLET 25 MG Tier 1

efavirenz oral capsule 200 mg, 50 mg Tier 1

efavirenz oral tablet 600 mg Tier 1

EMTRIVA ORAL CAPSULE 200 MG Tier 1

EMTRIVA ORAL SOLUTION 10 MG/ML Tier 1

EVOTAZ ORAL TABLET 300-150 MG Tier 1

fosamprenavir oral tablet 700 mg Tier 1

FUZEON SUBCUTANEOUS RECON SOLN 90 MG Tier 2 Specialty

GENVOYA ORAL TABLET 150-150-200-10 MG Tier 1

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

Tier 1

INVIRASE ORAL CAPSULE 200 MG Tier 1

INVIRASE ORAL TABLET 500 MG Tier 1

ISENTRESS HD ORAL TABLET 600 MG Tier 1

ISENTRESS ORAL POWDER IN PACKET 100 MG Tier 1

ISENTRESS ORAL TABLET 400 MG Tier 1

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG

Tier 1

JULUCA ORAL TABLET 50-25 MG Tier 1

KALETRA ORAL TABLET 100-25 MG, 200-50 MG Tier 1

lamivudine oral solution 10 mg/ml Tier 1

lamivudine oral tablet 150 mg, 300 mg Tier 1

lamivudine-zidovudine oral tablet 150-300 mg Tier 1



LEXIVA ORAL SUSPENSION 50 MG/ML Tier 1

lopinavir-ritonavir oral solution 400-100 mg/5 ml Tier 1

nevirapine oral suspension 50 mg/5 ml Tier 1

nevirapine oral tablet 200 mg Tier 1

nevirapine oral tablet extended release 24 hr 100 mg, 400 mg

Tier 1

NORVIR ORAL SOLUTION 80 MG/ML Tier 1

ODEFSEY ORAL TABLET 200-25-25 MG Tier 1

PREZCOBIX ORAL TABLET 800-150 MG-MG Tier 1

PREZISTA ORAL SUSPENSION 100 MG/ML Tier 1

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 1

RESCRIPTOR ORAL TABLET 200 MG Tier 1

RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG Tier 1

REYATAZ ORAL POWDER IN PACKET 50 MG Tier 1

ritonavir oral tablet 100 mg Tier 1

SELZENTRY ORAL SOLUTION 20 MG/ML Tier 1

SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

Tier 1

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

Tier 1

STRIBILD ORAL TABLET 150-150-200-300 MG Tier 1

SYMTUZA ORAL TABLET 800-150-200-10 MG Tier 1

tenofovir disoproxil fumarate oral tablet 300 mg Tier 1

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 1

TRIUMEQ ORAL TABLET 600-50-300 MG Tier 1

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

Tier 1

TYBOST ORAL TABLET 150 MG Tier 1

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)

Tier 1

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)

Tier 1

VIRACEPT ORAL TABLET 250 MG, 625 MG Tier 1

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)

Tier 1

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 1

VITEKTA ORAL TABLET 150 MG, 85 MG Tier 1



ZERIT ORAL RECON SOLN 1 MG/ML Tier 1

zidovudine oral capsule 100 mg Tier 1

zidovudine oral syrup 10 mg/ml Tier 1

zidovudine oral tablet 300 mg Tier 1

Antiviral, Other

acyclovir oral capsule 200 mg Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet 400 mg, 800 mg Tier 1

amantadine hcl oral capsule 100 mg Tier 1

amantadine hcl oral solution 50 mg/5 ml Tier 1

amantadine hcl oral tablet 100 mg Tier 1

famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1

oseltamivir oral capsule 30 mg, 45 mg, 75 mg Tier 1 QL

oseltamivir oral suspension for reconstitution 6 mg/ml

Tier 1 QL

PREVYMIS ORAL TABLET 240 MG, 480 MG Tier 1

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION

Tier 1 QL

rimantadine oral tablet 100 mg Tier 1

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG Tier 1 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML

Tier 1 QL

valacyclovir oral tablet 1 gram, 500 mg Tier 1

valganciclovir oral recon soln 50 mg/ml Tier 1

valganciclovir oral tablet 450 mg Tier 1

Tuberculosis

cycloserine oral capsule 250 mg Tier 1 PA

ethambutol oral tablet 100 mg, 400 mg Tier 1

isoniazid oral solution 50 mg/5 ml Tier 1

isoniazid oral tablet 100 mg, 300 mg Tier 1

PRIFTIN ORAL TABLET 150 MG Tier 1

pyrazinamide oral tablet 500 mg Tier 1

rifampin oral capsule 150 mg, 300 mg Tier 1

SIRTURO ORAL TABLET 100 MG Tier 1 PA

TRECATOR ORAL TABLET 250 MG Tier 1 PA



Urinary Anti-Infectives

MONUROL ORAL PACKET 3 GRAM Tier 1

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

Tier 1 QL; AE

nitrofurantoin monohyd/m-cryst oral capsule 100 mg

Tier 1 QL; AE

nitrofurantoin oral suspension 25 mg/5 ml Tier 1 QL; AE

Arthritis

Arthritis, Other

DEPEN TITRATABS ORAL TABLET 250 MG Tier 2 PA; Specialty

Disease Modifying Agents

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML


ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)


ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)


ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)


KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML


leflunomide oral tablet 10 mg, 20 mg Tier 1

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML


OTEZLA ORAL TABLET 30 MG Tier 2 PA; Specialty

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML

Tier 1 PA

RIDAURA ORAL CAPSULE 3 MG Tier 1



Asthma & Copd

Asthma & Copd, Other

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

Tier 1

cromolyn inhalation solution for nebulization 20 mg/2 ml

Tier 1

DALIRESP ORAL TABLET 250 MCG Tier 1 PA

DALIRESP ORAL TABLET 500 MCG Tier 1 PA

ipratropium bromide inhalation solution 0.02 % Tier 1

montelukast oral granules in packet 4 mg Tier 1

montelukast oral tablet 10 mg Tier 1

montelukast oral tablet,chewable 4 mg, 5 mg Tier 1

Bronchodilators, Inhaled

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

Tier 1

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION

Tier 1

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE

Tier 1

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

Tier 1

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

Tier 1

Bronchodilators, Oral

albuterol sulfate oral syrup 2 mg/5 ml Tier 1

albuterol sulfate oral tablet 2 mg, 4 mg Tier 1

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

Tier 1

theophylline oral tablet extended release 12 hr100 mg, 200 mg, 300 mg, 450 mg

Tier 1

theophylline oral tablet extended release 24 hr400 mg

Tier 1

theophylline oral tablet extended release 600 mg Tier 1

Combination Agents, Inhaled

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

Tier 1



ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

Tier 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION

Tier 1

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

Tier 1

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

Tier 1

DULERA INHALATION HFA AEROSOL INHALER100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION

Tier 1 PA

fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

Tier 1

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

Tier 1

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG

Tier 1

Corticosteroids, Inhaled

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION

Tier 1

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION

Tier 1

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

Tier 1

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

Tier 1

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

Tier 1

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

Tier 1

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION

Tier 1



QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

Tier 1

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION

Tier 1

Behavioral Health

Antipsychotic

aripiprazole oral solution 1 mg/ml Tier 1 AE

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

Tier 1 AE

aripiprazole oral tablet,disintegrating 10 mg, 15 mg

Tier 1 PA; AE

chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 PA

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 AE

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

Tier 1 PA; AE

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

Tier 1 PA

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

Tier 1 PA

fluphenazine hcl oral concentrate 5 mg/ml Tier 1 AE

fluphenazine hcl oral elixir 2.5 mg/5 ml Tier 1 AE

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

Tier 1 AE

haloperidol lactate oral concentrate 2 mg/ml Tier 1 AE

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

Tier 1 AE

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

Tier 1 PA; QL

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

Tier 1 AE

NUPLAZID ORAL CAPSULE 34 MG Tier 2 PA; Specialty

NUPLAZID ORAL TABLET 10 MG, 17 MG Tier 2 PA; Specialty

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

Tier 1 AE

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

Tier 1 PA; AE



paliperidone oral tablet extended release 24hr1.5 mg, 3 mg, 6 mg, 9 mg

Tier 1 PA

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

Tier 1 AE

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

Tier 1 AE

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

Tier 1 PA; AE

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

Tier 1 PA

risperidone oral solution 1 mg/ml Tier 1 AE

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 1 AE

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 1 PA; AE

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET10 MG, 5 MG

Tier 1 PA

SAPHRIS SUBLINGUAL TABLET 2.5 MG Tier 1 PA

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 1 AE

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 AE

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg

Tier 1 AE

VERSACLOZ ORAL SUSPENSION 50 MG/ML Tier 1 PA; AE

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

Tier 1 PA

VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)

Tier 1 PA

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

Tier 1 AE

Anxiety

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1 QL

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

Tier 1 QL

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

Tier 1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg Tier 1 QL

chlordiazepoxide hcl oral capsule 5 mg Tier 1 QL



lorazepam oral concentrate 2 mg/ml Tier 1 QL

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL

Attention Deficit/Hyperactivity Disorder (Adhd)

adderall xr oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Tier 1 QL

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

Tier 1 QL

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

Tier 1 QL

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1 QL

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg

Tier 1 QL

dextroamphetamine oral tablet 10 mg, 5 mg Tier 1 QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

Tier 1 QL

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

Tier 1 QL

metadate er oral tablet extended release 20 mg Tier 1 QL

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Tier 1 QL

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

Tier 1 QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

Tier 1 QL

methylphenidate hcl oral tablet extended release10 mg, 20 mg

Tier 1 QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Tier 1 QL

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG

Tier 1 QL

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)

Tier 1 QL

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

Tier 1 QL

VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

Tier 1 QL



Bipolar Disorder

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

Tier 1

lithium carbonate oral tablet 300 mg Tier 1

lithium carbonate oral tablet extended release300 mg, 450 mg

Tier 1

lithium citrate oral solution 8 meq/5 ml Tier 1

Depression, Atypical Antidepressants

bupropion hcl oral tablet 100 mg, 75 mg Tier 1

bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg

Tier 1

bupropion hcl oral tablet sustained-release 12 hr100 mg, 150 mg, 200 mg

Tier 1

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

Tier 1

Depression, Maois

phenelzine oral tablet 15 mg Tier 1

tranylcypromine oral tablet 10 mg Tier 1

Depression, Serotonin Modulators

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

Tier 1

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg

Tier 1

Depression, Snris

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

Tier 1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

Tier 1

venlafaxine oral capsule,extended release 24hr150 mg, 37.5 mg, 75 mg

Tier 1

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Tier 1

Depression, Ssris

citalopram oral solution 10 mg/5 ml Tier 1

citalopram oral tablet 10 mg, 20 mg, 40 mg Tier 1

escitalopram oxalate oral solution 5 mg/5 ml Tier 1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

Tier 1



fluoxetine oral capsule 10 mg, 20 mg, 40 mg Tier 1

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) Tier 1

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg Tier 1

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

Tier 1

PAXIL ORAL SUSPENSION 10 MG/5 ML Tier 1

sertraline oral concentrate 20 mg/ml Tier 1

sertraline oral tablet 100 mg, 25 mg, 50 mg Tier 1

Depression, Tricyclic & Tetracyclic Antidepressants

amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1 AE

clomipramine oral capsule 25 mg, 50 mg, 75 mg Tier 1 AE

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1 AE

doxepin oral concentrate 10 mg/ml Tier 1 AE

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 AE

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg

Tier 1

nortriptyline oral solution 10 mg/5 ml Tier 1

Birth Control

Contraceptives, Other

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR

Tier 1

xulane transdermal patch weekly 150-35 mcg/24 hr

Tier 1

Emergency Contraception

ELLA ORAL TABLET 30 MG Tier 1

levonorgestrel oral tablet 1.5 mg Tier 1

my way oral tablet 1.5 mg Tier 1

next choice one dose oral tablet 1.5 mg Tier 1

Oral Contraceptives

altavera (28) oral tablet 0.15-0.03 mg Tier 1

alyacen 1/35 (28) oral tablet 1-35 mg-mcg Tier 1



alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

Tier 1

apri oral tablet 0.15-0.03 mg Tier 1

aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg Tier 1

aubra oral tablet 0.1-20 mg-mcg Tier 1

aviane oral tablet 0.1-20 mg-mcg Tier 1

azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

Tier 1

balziva (28) oral tablet 0.4-35 mg-mcg Tier 1

blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

Tier 1

blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

Tier 1

brevicon (28) oral tablet 0.5-35 mg-mcg Tier 1

briellyn oral tablet 0.4-35 mg-mcg Tier 1

camila oral tablet 0.35 mg Tier 1

caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg Tier 1

chateal oral tablet 0.15-0.03 mg Tier 1

cryselle (28) oral tablet 0.3-30 mg-mcg Tier 1

cyclafem 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

Tier 1

dasetta 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

Tier 1

desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg

Tier 1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

Tier 1

elinest oral tablet 0.3-30 mg-mcg Tier 1

emoquette oral tablet 0.15-0.03 mg Tier 1

enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10)

Tier 1

enskyce oral tablet 0.15-0.03 mg Tier 1

errin oral tablet 0.35 mg Tier 1

estarylla oral tablet 0.25-35 mg-mcg Tier 1

falmina (28) oral tablet 0.1-20 mg-mcg Tier 1

gianvi (28) oral tablet 3-0.02 mg Tier 1



gildagia oral tablet 0.4-35 mg-mcg Tier 1

heather oral tablet 0.35 mg Tier 1

introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg

Tier 1

jencycla oral tablet 0.35 mg Tier 1

jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg

Tier 1

jolivette oral tablet 0.35 mg Tier 1

junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg Tier 1

junel 1/20 (21) oral tablet 1-20 mg-mcg Tier 1

junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

Tier 1

junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

Tier 1

kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

Tier 1

kelnor 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

kurvelo oral tablet 0.15-0.03 mg Tier 1

larin 1/20 (21) oral tablet 1-20 mg-mcg Tier 1

larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

Tier 1

larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

Tier 1

leena 28 oral tablet 0.5/1/0.5-35 mg-mcg Tier 1

lessina oral tablet 0.1-20 mg-mcg Tier 1

levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)

Tier 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

Tier 1

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg

Tier 1

levora-28 oral tablet 0.15-0.03 mg Tier 1

loryna (28) oral tablet 3-0.02 mg Tier 1

low-ogestrel (28) oral tablet 0.3-30 mg-mcg Tier 1

lutera (28) oral tablet 0.1-20 mg-mcg Tier 1

lyza oral tablet 0.35 mg Tier 1

marlissa oral tablet 0.15-0.03 mg Tier 1



microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg

Tier 1

microgestin 1/20 (21) oral tablet 1-20 mg-mcg Tier 1

microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

Tier 1

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

Tier 1

mono-linyah oral tablet 0.25-35 mg-mcg Tier 1

mononessa (28) oral tablet 0.25-35 mg-mcg Tier 1

myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10)

Tier 1

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg Tier 1

necon 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

necon 1/50 (28) oral tablet 1-50 mg-mcg Tier 1

necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg

Tier 1

necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

Tier 1

nora-be oral tablet 0.35 mg Tier 1

norethindrone (contraceptive) oral tablet 0.35 mg Tier 1

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Tier 1

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

Tier 1

norinyl 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg Tier 1

nortrel 1/35 (21) oral tablet 1-35 mg-mcg Tier 1

nortrel 1/35 (28) oral tablet 1-35 mg-mcg Tier 1

nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg

Tier 1

ocella oral tablet 3-0.03 mg Tier 1

ogestrel (28) oral tablet 0.5-50 mg-mcg Tier 1

orsythia oral tablet 0.1-20 mg-mcg Tier 1

philith oral tablet 0.4-35 mg-mcg Tier 1

pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

Tier 1



pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg

Tier 1

portia oral tablet 0.15-0.03 mg Tier 1

previfem oral tablet 0.25-35 mg-mcg Tier 1

quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg

Tier 1

reclipsen (28) oral tablet 0.15-0.03 mg Tier 1

sprintec (28) oral tablet 0.25-35 mg-mcg Tier 1

sronyx oral tablet 0.1-20 mg-mcg Tier 1

syeda oral tablet 3-0.03 mg Tier 1

tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)

Tier 1

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1

tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)

Tier 1

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

Tier 1

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

Tier 1

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

Tier 1

tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1

tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1

trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)

Tier 1

velivet triphasic regimen (28) oral tablet0.1/.125/.15-25 mg-mcg

Tier 1

vestura (28) oral tablet 3-0.02 mg Tier 1

viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

Tier 1

vyfemla (28) oral tablet 0.4-35 mg-mcg Tier 1

wera (28) oral tablet 0.5-35 mg-mcg Tier 1



zarah oral tablet 3-0.03 mg Tier 1

zenchent (28) oral tablet 0.4-35 mg-mcg Tier 1

zovia 1/35e (28) oral tablet 1-35 mg-mcg Tier 1

zovia 1/50e (28) oral tablet 1-50 mg-mcg Tier 1

Bleeding Disorders

Bleeding Disorders, Hemophilia

STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)

Tier 1 PA

Bleeding Disorders, Other

AMICAR ORAL SOLUTION 250 MG/ML (25 %) Tier 1

AMICAR ORAL TABLET 500 MG Tier 1

Blood Modifier

Blood Modifiers

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 2 Specialty

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

Tier 2 Specialty

FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML

Tier 2 Specialty

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 1 Specialty; ONC

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML


LEUKINE INJECTION RECON SOLN 250 MCG Tier 2 Specialty

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML

Tier 2 Specialty

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML

Tier 2 Specialty

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

Tier 2 Specialty

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 2 Specialty



PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 2 Specialty

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG


REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

Tier 2 Specialty

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 2 Specialty

Clotting Disorders

ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT

Tier 2 Specialty

AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

Tier 2 Specialty

ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML

Tier 2 Specialty

ALPHANINE SD INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT

Tier 2 Specialty

BEBULIN INTRAVENOUS RECON SOLN 700 (+/-) UNIT

Tier 2 Specialty

BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

Tier 2 Specialty



COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

Tier 2 Specialty

CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT

Tier 2 Specialty

ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT

Tier 2 Specialty

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT

Tier 2 Specialty

HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

HEMOFIL M HIGH INTRAVENOUS RECON SOLN801-1,500 UNIT

Tier 2 Specialty

HEMOFIL M LOW INTRAVENOUS RECON SOLN220-400 UNIT

Tier 2 Specialty

HEMOFIL M MID INTRAVENOUS RECON SOLN401-800 UNIT

Tier 2 Specialty

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT

Tier 2 Specialty

HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT

Tier 2 Specialty

IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

Tier 2 Specialty

JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

KOGENATE FS INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

MONOCLATE-P INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT

Tier 2 Specialty



NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG)

Tier 2 Specialty

NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT

Tier 2 Specialty

OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE

Tier 2 Specialty

PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 %

Tier 2 Specialty

PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

RECOMBINATE INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

Tier 2 Specialty

THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT

Tier 2 Specialty

TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT

Tier 2 Specialty

VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE

Tier 2 Specialty

WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 450-450 UNIT, 500-500 UNIT, 900-900 UNIT

Tier 2 Specialty

XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

Tier 2 Specialty

Blood Thinner

Anticoagulants

ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 1

ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS)

Tier 1



enoxaparin subcutaneous solution 300 mg/3 ml Tier 1 QL

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

Tier 1 QL

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

Tier 1 PA

heparin (porcine) injection cartridge 5,000 unit/ml (1 ml)

Tier 1

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

Tier 1

heparin (porcine) injection syringe 5,000 unit/ml Tier 1

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

Tier 1

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

Tier 1

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

Tier 1 PA

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

Tier 1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Tier 1

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)

Tier 1

Platelet Inhibitors

anagrelide oral capsule 0.5 mg, 1 mg Tier 1

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

Tier 1

BRILINTA ORAL TABLET 60 MG, 90 MG Tier 1

cilostazol oral tablet 100 mg, 50 mg Tier 1

clopidogrel oral tablet 75 mg Tier 1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 1

pentoxifylline oral tablet extended release 400 mg

Tier 1

prasugrel oral tablet 10 mg, 5 mg Tier 1

ZONTIVITY ORAL TABLET 2.08 MG Tier 1 PA

Bone Health

Bone Health, Other

etidronate disodium oral tablet 200 mg, 400 mg Tier 1



Osteoporosis

alendronate oral solution 70 mg/75 ml Tier 1

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

Tier 1

alendronate oral tablet 40 mg Tier 1

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

Tier 1

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML


ibandronate oral tablet 150 mg Tier 1

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)


Cancer

Cancer, Alkylating Agents

EMCYT ORAL CAPSULE 140 MG Tier 1

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG

Tier 1

HEXALEN ORAL CAPSULE 50 MG Tier 1 Specialty; ONC

LEUKERAN ORAL TABLET 2 MG Tier 1

MATULANE ORAL CAPSULE 50 MG Tier 1 PA; Specialty; ONC

melphalan oral tablet 2 mg Tier 1

MYLERAN ORAL TABLET 2 MG Tier 1

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg


VALCHLOR TOPICAL GEL 0.016 % Tier 1 PA; Specialty; ONC; QL

Cancer, Antiandrogens

bicalutamide oral tablet 50 mg Tier 1

ERLEADA ORAL TABLET 60 MG Tier 1 PA; Specialty; ONC

flutamide oral capsule 125 mg Tier 1

XTANDI ORAL CAPSULE 40 MG Tier 1 PA; Specialty; TD; ONC

ZYTIGA ORAL TABLET 250 MG, 500 MG Tier 1 PA; Specialty; TD; ONC

Cancer, Antimetabolites

capecitabine oral tablet 150 mg, 500 mg Tier 1 Specialty; ONC

hydroxyurea oral capsule 500 mg Tier 1

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 1 PA; Specialty; ONC

mercaptopurine oral tablet 50 mg Tier 1



TABLOID ORAL TABLET 40 MG Tier 1

Cancer, Aromatase Inhibitors

anastrozole oral tablet 1 mg Tier 1

exemestane oral tablet 25 mg Tier 1

letrozole oral tablet 2.5 mg Tier 1

Cancer, Hdac Inhibitors

ZOLINZA ORAL CAPSULE 100 MG Tier 1 PA; Specialty; TD; ONC

Cancer, Immunosuppressives

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

Tier 1 Specialty; TD; ONC

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG


cyclophosphamide oral capsule 25 mg, 50 mg Tier 1

methotrexate sodium (pf) injection solution 25 mg/ml

Tier 1

methotrexate sodium injection solution 25 mg/ml Tier 1

methotrexate sodium oral tablet 2.5 mg Tier 1

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

Tier 1 PA; Specialty; ONC

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG


THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG


Cancer, Interferons

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


Cancer, Natural And Semi-Synthetic

etoposide oral capsule 50 mg Tier 1

HYCAMTIN INTRAVENOUS RECON SOLN 4 MG Tier 1 Specialty; ONC

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG Tier 1 Specialty; ONC

Cancer, Other Agents

LYSODREN ORAL TABLET 500 MG Tier 1 PA; Specialty; ONC

megestrol oral tablet 20 mg, 40 mg Tier 1

ODOMZO ORAL CAPSULE 200 MG Tier 1 PA; Specialty; ONC

ZEJULA ORAL CAPSULE 100 MG Tier 1 PA; Specialty; ONC



Cancer, Retinoids

tretinoin (chemotherapy) oral capsule 10 mg Tier 1 Specialty; ONC

Cancer, Serms

SOLTAMOX ORAL SOLUTION 10 MG/5 ML Tier 1

tamoxifen oral tablet 10 mg, 20 mg Tier 1

Cancer, Signal Transduction Inhibitors

ALECENSA ORAL CAPSULE 150 MG Tier 1 PA; Specialty; ONC

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG

Tier 1 PA; Specialty; TD; ONC

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG


CAPRELSA ORAL TABLET 100 MG, 300 MG Tier 1 Specialty; ONC

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


COTELLIC ORAL TABLET 20 MG Tier 1 PA; Specialty; ONC

ERIVEDGE ORAL CAPSULE 150 MG Tier 1 PA; Specialty; TD; ONC

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG Tier 1 PA; Specialty; ONC

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


ICLUSIG ORAL TABLET 15 MG, 45 MG Tier 1 PA; Specialty; ONC

IDHIFA ORAL TABLET 100 MG, 50 MG Tier 1 PA; Specialty; ONC

imatinib oral tablet 100 mg, 400 mg Tier 1 Specialty; TD; ONC

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG Tier 1 PA; Specialty; ONC

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG


INLYTA ORAL TABLET 1 MG, 5 MG Tier 1 PA; Specialty; TD; ONC

IRESSA ORAL TABLET 250 MG Tier 1 PA; Specialty; TD; ONC

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG


KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)


MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 1 PA; Specialty; ONC



NERLYNX ORAL TABLET 40 MG Tier 1 PA; Specialty; ONC

NEXAVAR ORAL TABLET 200 MG Tier 1 Specialty; TD; ONC

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 1 PA; Specialty; ONC

RYDAPT ORAL CAPSULE 25 MG Tier 1 PA; Specialty; ONC

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG


STIVARGA ORAL TABLET 40 MG Tier 1 PA; Specialty; ONC

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


TAFINLAR ORAL CAPSULE 50 MG, 75 MG Tier 1 PA; Specialty; ONC

TAGRISSO ORAL TABLET 40 MG, 80 MG Tier 1 PA; Specialty; TD; ONC

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG Tier 1 Specialty; TD; ONC

TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG


TYKERB ORAL TABLET 250 MG Tier 1 Specialty; ONC

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


VOTRIENT ORAL TABLET 200 MG Tier 1 Specialty; TD; ONC

XALKORI ORAL CAPSULE 200 MG, 250 MG Tier 1 PA; Specialty; TD; ONC

ZELBORAF ORAL TABLET 240 MG Tier 1 PA; Specialty; ONC

ZYKADIA ORAL CAPSULE 150 MG Tier 1 PA; Specialty; TD; ONC

Corticosteroids

Corticosteroids, Injectable

dexamethasone sodium phosphate injection solution 4 mg/ml

Tier 1

Corticosteroids, Oral

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

Tier 1

dexamethasone oral elixir 0.5 mg/5 ml Tier 1

dexamethasone oral solution 0.5 mg/5 ml Tier 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg

Tier 1

dexamethasone oral tablet 2 mg Tier 1

fludrocortisone oral tablet 0.1 mg Tier 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1

MEDROL ORAL TABLET 2 MG Tier 1



methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 1

methylprednisolone oral tablets,dose pack 4 mg Tier 1

MILLIPRED ORAL TABLET 5 MG Tier 1

prednisolone oral solution 15 mg/5 ml Tier 1

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

Tier 1

prednisone oral solution 5 mg/5 ml Tier 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

Tier 1

prednisone oral tablets,dose pack 10 mg, 5 mg Tier 1

Cough & Cold

Cough & Cold

benzonatate oral capsule 100 mg, 200 mg Tier 1

codeine-guaifenesin oral liquid 10-100 mg/5 ml Tier 1 QL; AE

promethazine vc oral syrup 6.25-5 mg/5 ml Tier 1

promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1

Cystic Fibrosis

Cystic Fibrosis

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

Tier 1

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML


KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG


KALYDECO ORAL TABLET 150 MG Tier 2 PA; Specialty

ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG


PULMOZYME INHALATION SOLUTION 1 MG/ML Tier 2 PA; Specialty; QL

SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N)


tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml




Dementia

Dementia

donepezil oral tablet 10 mg, 5 mg Tier 1

donepezil oral tablet,disintegrating 10 mg, 5 mg Tier 1

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg

Tier 1

galantamine oral solution 4 mg/ml Tier 1

galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 1

memantine oral solution 2 mg/ml Tier 1

memantine oral tablet 10 mg, 5 mg Tier 1

memantine oral tablets,dose pack 5-10 mg Tier 1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

Tier 1

Diabetes

Diabetes, Alpha-Glucosidase Inhibitors

acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1

miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1

Diabetes, Biguanides

metformin oral tablet 1,000 mg, 500 mg, 850 mg Tier 1

metformin oral tablet extended release 24 hr 500 mg, 750 mg

Tier 1

Diabetes, Dpp-4 Inhibitor / Biguanide Combinations

JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG

Tier 1

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG

Tier 1

Diabetes, Dpp-4 Inhibitors

TRADJENTA ORAL TABLET 5 MG Tier 1

Diabetes, Glp-1 Agonists

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML

Tier 1 QL

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML

Tier 1 QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG

Tier 1 QL



BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML

Tier 1 QL

OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML)

Tier 1 QL

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML

Tier 1 QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML)

Tier 1 QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML)

Tier 1 QL

Diabetes, Intermediate-Acting Insulins

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

Tier 1

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

Tier 1

Diabetes, Long-Acting Insulins

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

Tier 1

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

Tier 1 PA

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 1 PA

Diabetes, Meglitinides

nateglinide oral tablet 120 mg, 60 mg Tier 1

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

Diabetes, Other Oral Agents

CYCLOSET ORAL TABLET 0.8 MG Tier 1 PA

Diabetes, Pre-Mixed Insulins

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)

Tier 1

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)

Tier 1



HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

Tier 1

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

Tier 1

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

Tier 1

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

Tier 1

Diabetes, Rapid-Acting Insulins

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML

Tier 1

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)

Tier 1

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

Tier 1

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML

Tier 1

Diabetes, Rescue Agents

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

Tier 1

GLUCAGEN INJECTION RECON SOLN 1 MG Tier 1

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG

Tier 1

Diabetes, Sglt2 Inhibitor / Biguanide Combinations

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

Tier 1

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

Tier 1

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG

Tier 1

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG

Tier 1



Diabetes, Sglt2 Inhibitors

INVOKANA ORAL TABLET 100 MG, 300 MG Tier 1

JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 1

Diabetes, Short-Acting Insulins

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML

Tier 1

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML

Tier 1

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

Tier 1

Diabetes, Sulfonylurea / Biguanide Combination

glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

Tier 1

Diabetes, Sulfonylureas

glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1

glipizide oral tablet 10 mg, 5 mg Tier 1

glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg

Tier 1

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

Tier 1 PA

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 PA

Diabetes, Thiazolidinedione / Biguanide Combinations

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg

Tier 1

Diabetes, Thiazolidinedione / Sulfonylurea Combinations

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg

Tier 1

Diabetes, Thiazolidinediones

pioglitazone oral tablet 15 mg, 30 mg, 45 mg Tier 1

Ear Conditions

Anti-Infectives, Ear

acetic acid otic (ear) solution 2 % Tier 1



CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %

Tier 1

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

Tier 1

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

Tier 1

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

Tier 1

ofloxacin otic (ear) drops 0.3 % Tier 1

Ear Conditions, Other

fluocinolone acetonide oil otic (ear) drops 0.01 % Tier 1

Enzyme Replacement

Enzyme Replacement

CERDELGA ORAL CAPSULE 84 MG Tier 2 PA; Specialty

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

Tier 1

miglustat oral capsule 100 mg Tier 2 PA; Specialty

STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML


SUCRAID ORAL SOLUTION 8,500 UNIT/ML Tier 2 PA; Specialty

Eye Conditions

Anti-Infectives, Eye

bacitracin ophthalmic (eye) ointment 500 unit/gram

Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment500-10,000 unit/gram

Tier 1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 %

Tier 1 PA

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %

Tier 1

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 1

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % Tier 1

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)

Tier 1

gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram)

Tier 1



moxifloxacin ophthalmic (eye) drops 0.5 % Tier 1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

Tier 1

ofloxacin ophthalmic (eye) drops 0.3 % Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

Tier 1

sulfacetamide sodium ophthalmic (eye) drops 10 %

Tier 1

sulfacetamide sodium ophthalmic (eye) ointment10 %

Tier 1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)

Tier 1

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %

Tier 1

tobramycin ophthalmic (eye) drops 0.3 % Tier 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

Tier 1

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 1

trifluridine ophthalmic (eye) drops 1 % Tier 1

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % Tier 1

Anti-Inflammatories, Eye

bromfenac ophthalmic (eye) drops 0.09 % Tier 1

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %

Tier 1

diclofenac sodium ophthalmic (eye) drops 0.1 % Tier 1

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

Tier 1

flurbiprofen sodium ophthalmic (eye) drops 0.03 %

Tier 1

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % Tier 1

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % Tier 1

PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %

Tier 1

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

Tier 1



prednisolone acetate ophthalmic (eye) drops,suspension 1 %

Tier 1

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

Tier 1

Eye Conditions, Other

atropine ophthalmic (eye) drops 1 % Tier 1

atropine ophthalmic (eye) ointment 1 % Tier 1

cyclopentolate ophthalmic (eye) drops 1 % Tier 1

CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % Tier 2 PA; Specialty

homatropaire ophthalmic (eye) drops 5 % Tier 1

phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 %

Tier 1

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 %

Tier 1

RESTASIS OPHTHALMIC (EYE) DROPPERETTE0.05 %

Tier 1

Glaucoma

betaxolol ophthalmic (eye) drops 0.5 % Tier 1

bimatoprost ophthalmic (eye) drops 0.03 % Tier 1

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % Tier 1

carteolol ophthalmic (eye) drops 1 % Tier 1

dorzolamide ophthalmic (eye) drops 2 % Tier 1

dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 %

Tier 1 PA

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

Tier 1

latanoprost ophthalmic (eye) drops 0.005 % Tier 1

levobunolol ophthalmic (eye) drops 0.5 % Tier 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % Tier 1

methazolamide oral tablet 25 mg, 50 mg Tier 1

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Tier 1

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 %

Tier 1

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

Tier 1

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % Tier 1



ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE0.0015 %

Tier 1 PA

Gout

Gout

allopurinol oral tablet 100 mg, 300 mg Tier 1

colchicine oral capsule 0.6 mg Tier 1

colchicine oral tablet 0.6 mg Tier 1

probenecid oral tablet 500 mg Tier 1

probenecid-colchicine oral tablet 500-0.5 mg Tier 1

ULORIC ORAL TABLET 40 MG, 80 MG Tier 1 ST

Heart Health

Angina

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

Tier 1

isosorbide dinitrate oral tablet extended release40 mg

Tier 1

isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

Tier 1

NITRO-BID TRANSDERMAL OINTMENT 2 % Tier 1

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

Tier 1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

Tier 1

Antiarrhythmics

amiodarone oral tablet 100 mg, 200 mg, 400 mg Tier 1

disopyramide phosphate oral capsule 100 mg, 150 mg

Tier 1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

Tier 1

flecainide oral tablet 100 mg, 150 mg, 50 mg Tier 1

mexiletine oral capsule 150 mg, 200 mg, 250 mg Tier 1

MULTAQ ORAL TABLET 400 MG Tier 1 PA

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG

Tier 1

propafenone oral tablet 150 mg, 225 mg, 300 mg Tier 1



quinidine gluconate oral tablet extended release324 mg

Tier 1

quinidine sulfate oral tablet 200 mg, 300 mg Tier 1

sotalol af oral tablet 120 mg, 160 mg, 80 mg Tier 1

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

Tier 1

Blood Pressure, Acei & Arb

amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

Tier 1

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

Tier 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

Tier 1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

Tier 1

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

Tier 1

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

Tier 1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

Tier 1

fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1

fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg

Tier 1

irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

Tier 1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

Tier 1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1

losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

Tier 1

moexipril oral tablet 15 mg, 7.5 mg Tier 1



moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

Tier 1

olmesartan oral tablet 20 mg, 40 mg, 5 mg Tier 1

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

Tier 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

Tier 1

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

Tier 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Tier 1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Tier 1

Blood Pressure, Beta Blockers

atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

Tier 1

bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

Tier 1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

Tier 1

labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg

Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1

nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1

propranolol oral capsule,extended release 24 hr120 mg, 160 mg, 60 mg, 80 mg

Tier 1

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

Tier 1



propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Tier 1

propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg

Tier 1

Blood Pressure, Calcium Channel Blockers

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

Tier 1

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Tier 1

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

Tier 1

diltiazem hcl oral capsule,ext.rel 24h degradable120 mg, 180 mg, 240 mg

Tier 1

diltiazem hcl oral capsule,extended release 24 hr120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Tier 1

diltiazem hcl oral capsule,extended release 24hr120 mg, 180 mg, 240 mg, 300 mg

Tier 1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

Tier 1

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Tier 1

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

Tier 1

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg

Tier 1

nimodipine oral capsule 30 mg Tier 1

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tier 1

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg

Tier 1

verapamil oral tablet 120 mg, 40 mg, 80 mg Tier 1

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg

Tier 1

Blood Pressure, Other

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1



clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr

Tier 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg Tier 1

guanfacine oral tablet 1 mg, 2 mg Tier 1

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 1

methyldopa oral tablet 250 mg, 500 mg Tier 1

midodrine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1

minoxidil oral tablet 10 mg, 2.5 mg Tier 1

phenoxybenzamine oral capsule 10 mg Tier 1 PA

prazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1

Cholesterol Lowering, Bile Acid Resins

cholestyramine (with sugar) oral powder 4 gram Tier 1

cholestyramine (with sugar) oral powder in packet 4 gram

Tier 1

cholestyramine light oral powder 4 gram Tier 1

cholestyramine light oral powder in packet 4 gram

Tier 1

colestipol oral tablet 1 gram Tier 1

prevalite oral powder 4 gram Tier 1

prevalite oral powder in packet 4 gram Tier 1

Cholesterol Lowering, Other

ezetimibe oral tablet 10 mg Tier 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG


KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML


REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE140 MG/ML


Cholesterol Lowering, Statins

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1

lovastatin oral tablet 10 mg, 20 mg, 40 mg Tier 1



pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1

simvastatin oral tablet 10 mg, 20 mg, 5 mg Tier 1

simvastatin oral tablet 40 mg Tier 1 QL

simvastatin oral tablet 80 mg Tier 1 PA

Diuretics

acetazolamide oral capsule, extended release 500 mg

Tier 1

acetazolamide oral tablet 125 mg, 250 mg Tier 1

amiloride oral tablet 5 mg Tier 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

Tier 1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

chlorothiazide oral tablet 250 mg, 500 mg Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

eplerenone oral tablet 25 mg, 50 mg Tier 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

Tier 1

furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1

hydrochlorothiazide oral capsule 12.5 mg Tier 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1

indapamide oral tablet 1.25 mg, 2.5 mg Tier 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1

spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

Tier 1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

Tier 1

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg

Tier 1

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg

Tier 1

Heart Health, Other

DIGOXIN ORAL SOLUTION 50 MCG/ML Tier 1

digoxin oral tablet 125 mcg Tier 1



digoxin oral tablet 250 mcg Tier 1 AE

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

Tier 1

klor-con m10 oral tablet,er particles/crystals 10 meq

Tier 1

klor-con m15 oral tablet,er particles/crystals 15 meq

Tier 1

KLOR-CON/25 ORAL PACKET 25 MEQ Tier 1

potassium chloride oral capsule, extended release10 meq, 8 meq

Tier 1

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

Tier 1

potassium chloride oral packet 20 meq Tier 1

potassium chloride oral tablet extended release10 meq, 20 meq, 8 meq

Tier 1

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq

Tier 1

Triglyceride Lowering

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

Tier 1

fenofibrate oral tablet 160 mg, 54 mg Tier 1

gemfibrozil oral tablet 600 mg Tier 1

omega-3 acid ethyl esters oral capsule 1 gram Tier 1

Hereditary Angioedema

Hereditary Angioedema

BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) Tier 2 PA; Specialty

BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 ML)


CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)


FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML Tier 2 PA; Specialty; QL

HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT


KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML)


RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT




Idiopathic Pulmonary Fibrosis

Idiopathic Pulmonary Fibrosis

ESBRIET ORAL CAPSULE 267 MG Tier 2 PA; Specialty

ESBRIET ORAL TABLET 267 MG, 801 MG Tier 2 PA; Specialty

OFEV ORAL CAPSULE 100 MG, 150 MG Tier 2 PA; Specialty

Immune Deficiency

Immune Deficiency

BIVIGAM INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM


CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %)


FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 %


GAMASTAN S/D INTRAMUSCULAR SOLUTION15-18 % RANGE


GAMMAGARD LIQUID INJECTION SOLUTION 10 %


GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM


GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)


GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 %


GAMMAPLEX INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %)


HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)


HYQVIA HY COMPONENT SUBCUTANEOUS SOLUTION 1,600 UNIT/10 ML, 2,400 UNIT/15 ML, 200 UNIT/1.25 ML, 400 UNIT/2.5 ML, 800 UNIT/5 ML




HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %)


HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)


OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % Tier 2 PA; Specialty

PRIVIGEN INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty

Immune Suppressant

Immune Suppressant

azathioprine oral tablet 50 mg Tier 1

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

Tier 1

cyclosporine modified oral solution 100 mg/ml Tier 1

cyclosporine oral capsule 100 mg, 25 mg Tier 1

gengraf oral capsule 100 mg, 25 mg Tier 1

gengraf oral solution 100 mg/ml Tier 1

mycophenolate mofetil oral capsule 250 mg Tier 1

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

Tier 1

mycophenolate mofetil oral tablet 500 mg Tier 1

RAPAMUNE ORAL SOLUTION 1 MG/ML Tier 1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Tier 1

Kidney Failure

Kidney Failure

calcium acetate oral capsule 667 mg Tier 1

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML

Tier 1

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG Tier 1

sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram

Tier 1

sevelamer carbonate oral tablet 800 mg Tier 1



Men's Health

Benign Prostatic Hypertrophy

alfuzosin oral tablet extended release 24 hr 10 mg

Tier 1

dutasteride oral capsule 0.5 mg Tier 1

finasteride oral tablet 5 mg Tier 1

tamsulosin oral capsule 0.4 mg Tier 1

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1

Testosterone Deficiency

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 1 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Tier 1 PA

androxy oral tablet 10 mg Tier 1 QL

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

Tier 1 PA

testosterone enanthate intramuscular oil 200 mg/ml

Tier 1 PA

testosterone transdermal gel 50 mg/5 gram (1 %) Tier 1 PA

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %)

Tier 1 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

Tier 1 PA

Migraine

Migraine, Other

isometh-dichloral-acetaminophn oral capsule 65-100-325 mg

Tier 1 QL

Migraine, Preventives

AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML

Tier 2 PA; Specialty; QL

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML

Tier 2 PA; Specialty; QL

Migraine, Triptans

eletriptan oral tablet 20 mg, 40 mg Tier 1 PA; QL

naratriptan oral tablet 1 mg, 2.5 mg Tier 1 QL

rizatriptan oral tablet 10 mg, 5 mg Tier 1 QL



rizatriptan oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

Tier 1 QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

Tier 1 QL

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

Tier 1 QL

sumatriptan succinate subcutaneous pen injector4 mg/0.5 ml, 6 mg/0.5 ml

Tier 1 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml

Tier 1 QL

Mouth & Throat

Dental Health

chlorhexidine gluconate mucous membrane mouthwash 0.12 %

Tier 1

periogard mucous membrane mouthwash 0.12 % Tier 1

triamcinolone acetonide dental paste 0.1 % Tier 1

Dry Mouth

cevimeline oral capsule 30 mg Tier 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 1

Pain

lidocaine hcl mucous membrane jelly 2 % Tier 1

lidocaine hcl mucous membrane jelly in applicator 2 %

Tier 1

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

Tier 1

lidocaine viscous mucous membrane solution 2 % Tier 1

Multiple Sclerosis

Multiple Sclerosis, Injection

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT30 MCG

Tier 2 Specialty; QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML


EXTAVIA SUBCUTANEOUS KIT 0.3 MG Tier 2 Specialty; QL

glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml




glatopa subcutaneous syringe 20 mg/ml Tier 2 Specialty; QL

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)


Multiple Sclerosis, Oral

AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 2 Specialty; QL

dalfampridine oral tablet extended release 12 hr10 mg


GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG Tier 2 Specialty; QL

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG


Muscle Relaxant

Muscle Relaxants

baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1

chlorzoxazone oral tablet 500 mg Tier 1 AE

cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1 AE

dantrolene oral capsule 100 mg, 25 mg, 50 mg Tier 1

methocarbamol oral tablet 500 mg, 750 mg Tier 1 AE

tizanidine oral tablet 2 mg, 4 mg Tier 1

Other Conditions

Other Agents

ACTHAR H.P. INJECTION GEL 80 UNIT/ML Tier 2 PA; Specialty

ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML

Tier 2 Specialty

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG


AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 2 PA; Specialty

CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML

Tier 1



CHEMET ORAL CAPSULE 100 MG Tier 1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 1

desmopressin nasal spray with pump 10 mcg/spray (0.1 ml)

Tier 1 PA

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

Tier 1 PA

desmopressin oral tablet 0.1 mg, 0.2 mg Tier 1 AE

ergoloid oral tablet 1 mg Tier 1 PA

EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG

Tier 2 PA; Specialty; TD

FERRIPROX ORAL SOLUTION 100 MG/ML Tier 2 PA; Specialty

FERRIPROX ORAL TABLET 500 MG Tier 2 PA; Specialty

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML


INGREZZA ORAL CAPSULE 40 MG, 80 MG Tier 2 PA; Specialty

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG Tier 2 PA; Specialty; TD

JADENU SPRINKLE ORAL GRANULES IN PACKET180 MG, 360 MG, 90 MG

Tier 2 PA; Specialty; TD

kionex oral powder Tier 1

KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG


KUVAN ORAL TABLET,SOLUBLE 100 MG Tier 2 PA; Specialty

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

Tier 1

levocarnitine (with sugar) oral solution 100 mg/ml

Tier 1

levocarnitine oral tablet 330 mg Tier 1

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

Tier 1

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

Tier 2 Specialty

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

Tier 2 Specialty

oxandrolone oral tablet 10 mg, 2.5 mg Tier 1 PA; QL

pyridostigmine bromide oral tablet 60 mg Tier 1

pyridostigmine bromide oral tablet extended release 180 mg

Tier 1

riluzole oral tablet 50 mg Tier 1



SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG

Tier 2 Specialty

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)


sodium phenylbutyrate oral powder 0.94 gram/gram

Tier 1 PA

sodium polystyrene (sorb free) oral suspension 15 gram/60 ml

Tier 1

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension 15 gram/60 ml

Tier 1

tetrabenazine oral tablet 12.5 mg, 25 mg Tier 2 PA; Specialty

THIOLA ORAL TABLET 100 MG Tier 2 PA; Specialty

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


Pain

Fibromyalgia / Neuropathic Pain

gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 QL

gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)

Tier 1 QL

gabapentin oral tablet 600 mg, 800 mg Tier 1 QL

Non-Steroidal Anti-Inflammatories

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

Tier 1

diclofenac potassium oral tablet 50 mg Tier 1

diclofenac sodium oral tablet extended release 24 hr 100 mg

Tier 1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

Tier 1

etodolac oral capsule 200 mg, 300 mg Tier 1

etodolac oral tablet 400 mg, 500 mg Tier 1

etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

Tier 1

flurbiprofen oral tablet 100 mg, 50 mg Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

indomethacin oral capsule 25 mg, 50 mg Tier 1 QL; AE



ketorolac oral tablet 10 mg Tier 1 QL

meloxicam oral suspension 7.5 mg/5 ml Tier 1

meloxicam oral tablet 15 mg, 7.5 mg Tier 1

nabumetone oral tablet 500 mg, 750 mg Tier 1

naproxen oral suspension 125 mg/5 ml Tier 1

naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg

Tier 1

piroxicam oral capsule 10 mg, 20 mg Tier 1

salsalate oral tablet 500 mg, 750 mg Tier 1

sulindac oral tablet 150 mg, 200 mg Tier 1

tolmetin oral capsule 400 mg Tier 1 PA

tolmetin oral tablet 200 mg, 600 mg Tier 1 PA

Pain, Opioids

acetaminophen-codeine oral solution 120-12 mg/5 ml

Tier 1 QL; AE

acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml

Tier 1 QL; AE

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

Tier 1 QL; AE

buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour

Tier 1 PA; QL

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg

Tier 1 QL

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Tier 1 QL; AE

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 75 mcg/hr

Tier 1 PA

fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr

Tier 1 PA; QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

Tier 1 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 QL

hydrocodone-ibuprofen oral tablet 7.5-200 mg Tier 1 QL

hydromorphone oral liquid 1 mg/ml Tier 1 QL



hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 QL

hydromorphone rectal suppository 3 mg Tier 1 QL

methadone oral concentrate 10 mg/ml Tier 1 PA; QL

methadone oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 PA; QL

methadone oral tablet 10 mg, 5 mg Tier 1 PA; QL

methadone oral tablet,soluble 40 mg Tier 1 PA

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)

Tier 1 QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)

Tier 1 QL

MORPHINE ORAL TABLET 15 MG, 30 MG Tier 1 QL

morphine oral tablet extended release 100 mg, 200 mg, 60 mg

Tier 1 PA

morphine oral tablet extended release 15 mg, 30 mg

Tier 1 PA; QL

morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

Tier 1 QL

oxycodone oral capsule 5 mg Tier 1 QL

oxycodone oral concentrate 20 mg/ml Tier 1 QL

oxycodone oral solution 5 mg/5 ml Tier 1 QL

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg Tier 1 QL

oxycodone oral tablet 30 mg Tier 1 PA

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg

Tier 1 PA; QL

oxycodone oral tablet,oral only,ext.rel.12 hr 30 mg, 40 mg, 60 mg, 80 mg

Tier 1 PA

oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 QL

oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG

Tier 1 PA; QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG, 40 MG, 60 MG, 80 MG

Tier 1 PA

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

Tier 1 QL

Pain, Other

butalbital-acetaminophen oral tablet 50-325 mg Tier 1 QL



butalbital-acetaminophen-caff oral capsule 50-325-40 mg

Tier 1 QL

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

Tier 1 QL

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

Tier 1 QL

tramadol oral tablet 50 mg Tier 1 QL; AE

Pain, Topical

diclofenac sodium topical gel 1 % Tier 1

lidocaine-prilocaine topical cream 2.5-2.5 % Tier 1 QL

Parkinson's

Parkinson's

benztropine oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

bromocriptine oral capsule 5 mg Tier 1

bromocriptine oral tablet 2.5 mg Tier 1

carbidopa oral tablet 25 mg Tier 1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

Tier 1

carbidopa-levodopa oral tablet extended release25-100 mg, 50-200 mg

Tier 1

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

Tier 1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

Tier 1

entacapone oral tablet 200 mg Tier 1

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

Tier 1 PA

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

Tier 1

rasagiline oral tablet 0.5 mg, 1 mg Tier 1 PA

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

Tier 1

RYTARY ORAL CAPSULE, EXTENDED RELEASE23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

Tier 1 PA



selegiline hcl oral capsule 5 mg Tier 1

selegiline hcl oral tablet 5 mg Tier 1

trihexyphenidyl oral elixir 0.4 mg/ml Tier 1

trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1

Pulmonary Hypertension

Pulmonary Hypertension

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


epoprostenol (glycine) intravenous recon soln 1.5 mg


FLOLAN INTRAVENOUS RECON SOLN 1.5 MG Tier 2 PA; Specialty

LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 2 PA; Specialty

OPSUMIT ORAL TABLET 10 MG Tier 2 PA; Specialty

REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML


sildenafil (antihypertensive) oral tablet 20 mg Tier 1 PA; QL

TRACLEER ORAL TABLET 125 MG, 62.5 MG Tier 2 PA; Specialty

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)


TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)


TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML


UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)


VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG


VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML


Seizures / Epilepsy

Seizures / Epilepsy

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

Tier 1 PA



BANZEL ORAL SUSPENSION 40 MG/ML Tier 1 PA; QL

BANZEL ORAL TABLET 200 MG, 400 MG Tier 1 PA; QL

BRIVIACT ORAL SOLUTION 10 MG/ML Tier 1 PA

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

Tier 1 PA

carbamazepine oral capsule, er multiphase 12 hr100 mg, 200 mg, 300 mg

Tier 1

carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml)

Tier 1

carbamazepine oral tablet 200 mg Tier 1

carbamazepine oral tablet extended release 12 hr100 mg, 200 mg, 400 mg

Tier 1

carbamazepine oral tablet,chewable 100 mg Tier 1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1 QL

diazepam intensol oral concentrate 5 mg/ml Tier 1 QL

diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 QL

diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 QL

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg

Tier 1 QL

DILANTIN KAPSEAL ORAL CAPSULE 30 MG Tier 1

DILANTIN ORAL CAPSULE 30 MG Tier 1

divalproex oral capsule, delayed rel sprinkle 125 mg

Tier 1

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

Tier 1

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

Tier 1

ethosuximide oral capsule 250 mg Tier 1

ethosuximide oral solution 250 mg/5 ml Tier 1

felbamate oral suspension 600 mg/5 ml Tier 1

felbamate oral tablet 400 mg, 600 mg Tier 1

FYCOMPA ORAL SUSPENSION 0.5 MG/ML Tier 1 PA

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

Tier 1 PA

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

Tier 1



lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7)

Tier 1 PA

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

Tier 1

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 PA

levetiracetam oral solution 100 mg/ml Tier 1

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

Tier 1

levetiracetam oral tablet extended release 24 hr500 mg, 750 mg

Tier 1

ONFI ORAL SUSPENSION 2.5 MG/ML Tier 1 QL

ONFI ORAL TABLET 10 MG, 20 MG Tier 1 QL

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

Tier 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

Tier 1

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) Tier 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60 mg

Tier 1

phenytoin oral suspension 125 mg/5 ml Tier 1

phenytoin oral tablet,chewable 50 mg Tier 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

Tier 1

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG

Tier 1 QL

primidone oral tablet 250 mg, 50 mg Tier 1

SABRIL ORAL TABLET 500 MG Tier 2 PA; Specialty

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg Tier 1

topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)

Tier 1

valproic acid oral capsule 250 mg Tier 1

VIGABATRIN ORAL POWDER IN PACKET 500 MG Tier 2 PA; Specialty

VIMPAT ORAL SOLUTION 10 MG/ML Tier 1 QL

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

Tier 1 QL



zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 1

Skin Conditions

Acne, Oral

amnesteem oral capsule 10 mg, 20 mg, 40 mg Tier 1

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg Tier 1

myorisan oral capsule 10 mg, 20 mg, 40 mg Tier 1

zenatane oral capsule 10 mg, 20 mg, 40 mg Tier 1

Acne, Topical

adapalene topical cream 0.1 % Tier 1

adapalene topical gel 0.3 % Tier 1

adapalene topical gel with pump 0.3 % Tier 1

avita topical cream 0.025 % Tier 1

avita topical gel 0.025 % Tier 1

clindamycin phosphate topical gel 1 % Tier 1

clindamycin phosphate topical lotion 1 % Tier 1

clindamycin phosphate topical solution 1 % Tier 1

clindamycin phosphate topical swab 1 % Tier 1

DIFFERIN TOPICAL GEL 0.1 % Tier 1 PA

erythromycin with ethanol topical gel 2 % Tier 1

erythromycin with ethanol topical solution 2 % Tier 1

sulfacetamide sodium (acne) topical suspension10 %

Tier 1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

Tier 1

sulfacetamide sod-sulfur-urea topical cleanser10-5-10 %

Tier 1

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % Tier 1

tretinoin topical gel 0.01 %, 0.025 % Tier 1

Antifungals, Topical

ciclopirox topical cream 0.77 % Tier 1

ciclopirox topical gel 0.77 % Tier 1

ciclopirox topical solution 8 % Tier 1



ciclopirox topical suspension 0.77 % Tier 1

ketoconazole topical cream 2 % Tier 1

ketoconazole topical shampoo 2 % Tier 1

nystatin topical cream 100,000 unit/gram Tier 1

nystatin topical ointment 100,000 unit/gram Tier 1

nystatin topical powder 100,000 unit/gram Tier 1

Anti-Infectives, Topical

gentamicin topical cream 0.1 % Tier 1

gentamicin topical ointment 0.1 % Tier 1

mupirocin topical ointment 2 % Tier 1

silver sulfadiazine topical cream 1 % Tier 1

Corticosteroids, Topical

alclometasone topical cream 0.05 % Tier 1

alclometasone topical ointment 0.05 % Tier 1

betamethasone dipropionate topical cream 0.05 %

Tier 1

betamethasone dipropionate topical lotion 0.05 %

Tier 1

betamethasone dipropionate topical ointment0.05 %

Tier 1

betamethasone valerate topical cream 0.1 % Tier 1

betamethasone valerate topical lotion 0.1 % Tier 1

betamethasone valerate topical ointment 0.1 % Tier 1

betamethasone, augmented topical cream 0.05 %

Tier 1

betamethasone, augmented topical gel 0.05 % Tier 1

betamethasone, augmented topical lotion 0.05 % Tier 1

betamethasone, augmented topical ointment0.05 %

Tier 1

clobetasol scalp solution 0.05 % Tier 1

clobetasol topical cream 0.05 % Tier 1

clobetasol topical gel 0.05 % Tier 1

clobetasol topical ointment 0.05 % Tier 1

clobetasol-emollient topical cream 0.05 % Tier 1

desonide topical cream 0.05 % Tier 1

desonide topical lotion 0.05 % Tier 1

desonide topical ointment 0.05 % Tier 1



desoximetasone topical cream 0.05 %, 0.25 % Tier 1

desoximetasone topical gel 0.05 % Tier 1

desoximetasone topical ointment 0.25 % Tier 1

fluocinolone and shower cap scalp oil 0.01 % Tier 1

fluocinolone topical cream 0.01 %, 0.025 % Tier 1

fluocinolone topical oil 0.01 % Tier 1

fluocinolone topical ointment 0.025 % Tier 1

fluocinonide topical cream 0.05 % Tier 1

fluocinonide topical gel 0.05 % Tier 1

fluocinonide topical ointment 0.05 % Tier 1

fluocinonide topical solution 0.05 % Tier 1

fluocinonide-e topical cream 0.05 % Tier 1

fluticasone topical cream 0.05 % Tier 1

fluticasone topical ointment 0.005 % Tier 1

hydrocortisone topical cream 2.5 % Tier 1

hydrocortisone topical lotion 2.5 % Tier 1

hydrocortisone topical ointment 2.5 % Tier 1

hydrocortisone valerate topical cream 0.2 % Tier 1

hydrocortisone valerate topical ointment 0.2 % Tier 1

hydrocortisone-pramoxine topical cream 2.5-1 % Tier 1

iodoquinol-hc topical cream 1-1 % Tier 1

mometasone topical cream 0.1 % Tier 1

mometasone topical ointment 0.1 % Tier 1

mometasone topical solution 0.1 % Tier 1

triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 %

Tier 1

triamcinolone acetonide topical lotion 0.025 %, 0.1 %

Tier 1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 1

trianex topical ointment 0.05 % Tier 1

triderm topical cream 0.1 %, 0.5 % Tier 1

Lice / Scabies, Topical

malathion topical lotion 0.5 % Tier 1

permethrin topical cream 5 % Tier 1



Psoriasis, Other

acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 1

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR150 MG/ML


COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML


ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML)


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML


Psoriasis, Topical

calcipotriene scalp solution 0.005 % Tier 1

calcipotriene topical cream 0.005 % Tier 1

calcipotriene topical ointment 0.005 % Tier 1

Rosacea

metronidazole topical cream 0.75 % Tier 1

metronidazole topical gel 0.75 % Tier 1

metronidazole topical lotion 0.75 % Tier 1

Skin Conditions, Other

ammonium lactate topical cream 12 % Tier 1

ammonium lactate topical lotion 12 % Tier 1

DRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 % Tier 1

DRYSOL TOPICAL SOLUTION 20 % Tier 1

DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML


ELIDEL TOPICAL CREAM 1 % Tier 1

EUCRISA TOPICAL OINTMENT 2 % Tier 1 PA; QL

fluorouracil topical cream 5 % Tier 1

fluorouracil topical solution 2 %, 5 % Tier 1

imiquimod topical cream in packet 5 % Tier 1

PICATO TOPICAL GEL 0.015 %, 0.05 % Tier 1 PA

podofilox topical solution 0.5 % Tier 1

selenium sulfide topical lotion 2.5 % Tier 1

tacrolimus topical ointment 0.03 %, 0.1 % Tier 1

urea topical cream 40 % Tier 1

urea topical gel 40 % Tier 1



urea topical lotion 40 % Tier 1

Sleep Disorders

Insomnia

eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 1 QL; AE

temazepam oral capsule 15 mg, 30 mg Tier 1 QL

zaleplon oral capsule 10 mg, 5 mg Tier 1 QL; AE

zolpidem oral tablet 10 mg, 5 mg Tier 1 QL; AE

Narcolepsy / Excessive Sleepiness

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

Tier 1 QL

modafinil oral tablet 100 mg, 200 mg Tier 1 QL

XYREM ORAL SOLUTION 500 MG/ML Tier 2 PA; Specialty; QL

Smoking Cessation

Nicotine Replacement

nicotine (polacrilex) buccal gum 2 mg, 4 mg Tier 1 SC

nicotine (polacrilex) buccal lozenge 2 mg, 4 mg Tier 1 SC

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 22 mg/24 hr, 7 mg/24 hr

Tier 1 SC

NICOTROL INHALATION CARTRIDGE 10 MG Tier 1 SC

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML

Tier 1 SC

Smoking Cessation, Other

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

Tier 1

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

Tier 1 SC; QL

CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 1 SC; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

Tier 1 SC; QL

Stomach / Gastrointestinal

Bowel Prep

gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram

Tier 1

gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram

Tier 1

gavilyte-n oral recon soln 420 gram Tier 1



Constipation

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG Tier 1 QL

enulose oral solution 10 gram/15 ml Tier 1

lactulose oral solution 10 gram/15 ml Tier 1

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

Tier 1 QL

polyethylene glycol 3350 oral powder 17 gram/dose

Tier 1

SYMPROIC ORAL TABLET 0.2 MG Tier 1 PA

Crohn's Disease / Ulcerative Colitis

balsalazide oral capsule 750 mg Tier 1

budesonide oral capsule,delayed,extend.release 3 mg

Tier 1

CANASA RECTAL SUPPOSITORY 1,000 MG Tier 1

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG

Tier 1

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML


lialda oral tablet,delayed release (dr/ec) 1.2 gram Tier 1

mesalamine oral tablet,delayed release (dr/ec)800 mg

Tier 1

mesalamine rectal enema 4 gram/60 ml Tier 1

PENTASA ORAL CAPSULE, EXTENDED RELEASE250 MG, 500 MG

Tier 1

sulfasalazine oral tablet 500 mg Tier 1

sulfasalazine oral tablet,delayed release (dr/ec)500 mg

Tier 1

Nausea / Vomiting

aprepitant oral capsule 125 mg, 40 mg, 80 mg Tier 1



aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)

Tier 1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 QL

EMEND ORAL CAPSULE 125 MG, 40 MG Tier 1

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)

Tier 1

metoclopramide hcl oral solution 5 mg/5 ml Tier 1

metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1

ondansetron hcl oral solution 4 mg/5 ml Tier 1

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg Tier 1

ondansetron oral tablet,disintegrating 4 mg, 8 mg

Tier 1

prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1

prochlorperazine rectal suppository 25 mg Tier 1

promethazine rectal suppository 12.5 mg, 25 mg, 50 mg

Tier 1

scopolamine base transdermal patch 3 day 1 mg over 3 days

Tier 1

trimethobenzamide oral capsule 300 mg Tier 1

Stomach / Gastrointestinal Other

L-GLUTAMINE POWDER Tier 1 PA

Stomach / Gastrointestinal, Other

alosetron oral tablet 0.5 mg, 1 mg Tier 1 PA

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG Tier 2 PA; Specialty

CHOLBAM ORAL CAPSULE 250 MG, 50 MG Tier 2 PA; Specialty

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML)

Tier 1 PA

dicyclomine oral capsule 10 mg Tier 1

dicyclomine oral solution 10 mg/5 ml Tier 1

dicyclomine oral tablet 20 mg Tier 1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml

Tier 1 QL

diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 QL

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1

hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1



hyoscyamine sulfate oral tablet 0.125 mg Tier 1

hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg

Tier 1

hyoscyamine sulfate oral tablet,disintegrating0.125 mg

Tier 1

hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1

MOVANTIK ORAL TABLET 12.5 MG, 25 MG Tier 1 PA; QL

paregoric oral liquid 2 mg/5 ml Tier 1 QL

propantheline oral tablet 15 mg Tier 1

ursodiol oral capsule 300 mg Tier 1

ursodiol oral tablet 250 mg, 500 mg Tier 1

XERMELO ORAL TABLET 250 MG Tier 2 PA; Specialty

Stomach / Gastrointestinal, Rectal

hydrocortisone acetate rectal suppository 25 mg Tier 1

hydrocortisone rectal enema 100 mg/60 ml Tier 1

hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 %

Tier 1

proctosol hc rectal cream with applicator 2.5 % Tier 1

proctozone-hc topical cream with perineal applicator 2.5 %

Tier 1

Ulcers / Heartburn / Gerd

CARAFATE ORAL SUSPENSION 100 MG/ML Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

lansoprazole oral capsule,delayed release(dr/ec)15 mg, 30 mg

Tier 1

lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg

Tier 1 AE

misoprostol oral tablet 100 mcg, 200 mcg Tier 1

omeprazole oral capsule,delayed release(dr/ec)10 mg, 20 mg, 40 mg

Tier 1

pantoprazole oral tablet,delayed release (dr/ec)20 mg, 40 mg

Tier 1

rabeprazole oral tablet,delayed release (dr/ec) 20 mg

Tier 1

ranitidine hcl oral syrup 15 mg/ml Tier 1

ranitidine hcl oral tablet 150 mg, 300 mg Tier 1

sucralfate oral suspension 100 mg/ml Tier 1

sucralfate oral tablet 1 gram Tier 1



Thyroid

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet 50 mg Tier 1

Thyroid Agents

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg Tier 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

Urinary & Bladder Health

Overactive Bladder

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG

Tier 1

oxybutynin chloride oral syrup 5 mg/5 ml Tier 1

oxybutynin chloride oral tablet 5 mg Tier 1

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg

Tier 1

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

Tier 1

tolterodine oral tablet 1 mg, 2 mg Tier 1

trospium oral tablet 20 mg Tier 1

Urinary & Bladder Health, Other

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

Tier 1

ELMIRON ORAL CAPSULE 100 MG Tier 1

phenazopyridine oral tablet 100 mg, 200 mg Tier 1

potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)

Tier 1

Vaccines

Vaccines

ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

Tier 1



ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

Tier 1

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

Tier 1

ADENOVIRUS VAC LIVE TYPE-4, 7 ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 1

ADENOVIRUS VACCINE LIVE TYPE-4 ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 1

ADENOVIRUS VACCINE LIVE TYPE-7 ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 1

AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

Tier 1

AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML

Tier 1

AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML

Tier 1

AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML

Tier 1

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML

Tier 1

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION2.5-8-5 LF-MCG-LF/0.5ML

Tier 1

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

Tier 1

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

Tier 1

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION20 MCG/ML

Tier 1

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML

Tier 1

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML

Tier 1

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

Tier 1

FLUAD 2018-2019 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

Tier 1



FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML

Tier 1

FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML

Tier 1

FLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML

Tier 1

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

Tier 1

GARDASIL (PF) INTRAMUSCULAR SUSPENSION20-40-40-20 MCG/0.5 ML

Tier 1

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION0.5 ML

Tier 1

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

Tier 1

HAVRIX (PF) INTRAMUSCULAR SUSPENSION1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

Tier 1

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

Tier 1

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

Tier 1

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

Tier 1



INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML

Tier 1

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

Tier 1

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML

Tier 1

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML

Tier 1

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN5-2.5 MCG/0.5 ML

Tier 1

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG

Tier 1

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

Tier 1

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML

Tier 1

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION7.5 MCG/0.5 ML

Tier 1

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML

Tier 1

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

Tier 1

PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML

Tier 1

PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML

Tier 1

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

Tier 1

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

Tier 1

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 40 MCG/ML

Tier 1

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML

Tier 1

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

Tier 1

SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION

Tier 1



SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG

Tier 1

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML

Tier 1

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML

Tier 1

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML

Tier 1

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML

Tier 1

TWINRIX (PF) INTRAMUSCULAR SUSPENSION720 ELISA UNIT- 20 MCG/ML

Tier 1

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML

Tier 1

VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML

Tier 1

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML

Tier 1

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

Tier 1

VAXCHORA BUFFER COMPONENT ORAL SUSPENSION FOR RECONSTITUTION

Tier 1

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

Tier 1

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 BILLION UNIT

Tier 1

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

Tier 1

Vitamins And Minerals

Vitamins And Minerals

calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1

calcitriol oral solution 1 mcg/ml Tier 1

completenate oral tablet,chewable 29 mg iron- 1 mg

Tier 1

cyanocobalamin (vitamin b-12) injection solution1,000 mcg/ml

Tier 1



denta 5000 plus dental cream 1.1 % Tier 1

dentagel dental gel 1.1 % Tier 1

fluoridex daily defense dental gel 1.1 % Tier 1

folic acid oral tablet 1 mg Tier 1

mynatal advance oral tablet 90-1-50 mg Tier 1

mynatal oral tablet 90-1-50 mg Tier 1

mynatal plus oral tablet 65 mg iron- 1 mg Tier 1

mynatal-z oral tablet 65 mg iron- 1 mg Tier 1

mynate 90 plus oral tablet extended release 90 mg iron-1 mg

Tier 1

o-cal prenatal oral tablet 15 mg iron- 1,000 mcg Tier 1

phytonadione (vitamin k1) oral tablet 5 mg Tier 1 QL

PRENATA ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG

Tier 1

prenatabs fa oral tablet 29-1 mg Tier 1

prenatabs rx oral tablet 29 mg iron- 1 mg Tier 1

prenatal plus (calcium carb) oral tablet 27 mg iron- 1 mg

Tier 1

prenatal plus oral tablet 29 mg iron- 1 mg Tier 1

prenatal rx oral tablet 60 mg iron-1 mg Tier 1

prenatal-u oral capsule 106.5-1 mg Tier 1 PA

PRENATE ELITE ORAL TABLET 26 MG IRON- 1 MG Tier 1

purefe ob plus oral capsule 106 mg iron- 1 mg Tier 1

se-natal 19 (with docusate) oral tablet 29 mg iron- 1 mg-25 mg

Tier 1

se-natal 19 oral tablet,chewable 29 mg iron- 1 mg

Tier 1

sf 5000 plus dental cream 1.1 % Tier 1

sf dental gel 1.1 % Tier 1

triadvance oral tablet 90-1-50 mg Tier 1

trinatal gt oral tablet 90-1-50 mg Tier 1

trinate oral tablet 28 mg iron- 1 mg Tier 1

triveen-prx rnf oral capsule 26-1.2-55-300 mg Tier 1

vinate care oral tablet,chewable 40 mg iron- 1 mg

Tier 1

vinate gt oral tablet 90-1-50 mg Tier 1

vinate m oral tablet 27 mg iron-1 mg Tier 1



vinate one oral tablet 60 mg iron-1 mg Tier 1

vinate ultra oral tablet 90-1-50 mg Tier 1

vitamin b-12 injection solution 1,000 mcg/ml Tier 1

vitamin d2 oral capsule 50,000 unit Tier 1

Weight Loss

Weight Loss

ALLI ORAL CAPSULE 60 MG Tier 1 PA; WL

lomaira oral tablet 8 mg Tier 1 WL; QL

phentermine oral capsule 15 mg, 30 mg, 37.5 mg Tier 1 WL; QL

phentermine oral tablet 37.5 mg Tier 1 WL; QL

XENICAL ORAL CAPSULE 120 MG Tier 1 PA; WL

Women's Health

Anti-Infectives, Vaginal

CLEOCIN VAGINAL SUPPOSITORY 100 MG Tier 1

clindamycin phosphate vaginal cream 2 % Tier 1

metronidazole vaginal gel 0.75 % Tier 1

terconazole vaginal cream 0.4 %, 0.8 % Tier 1

terconazole vaginal suppository 80 mg Tier 1

Estrogens, Vaginal

estradiol vaginal cream 0.01 % (0.1 mg/gram) Tier 1

PREMARIN VAGINAL CREAM 0.625 MG/GRAM Tier 1

yuvafem vaginal tablet 10 mcg Tier 1

Hormone Replacement

estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

Tier 1

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

Tier 1

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg Tier 1

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1

norethindrone acetate oral tablet 5 mg Tier 1

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

Tier 1



progesterone micronized oral capsule 100 mg, 200 mg

Tier 1

Women's Health, Other

cabergoline oral tablet 0.5 mg Tier 1

danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1

methylergonovine oral tablet 0.2 mg Tier 1

nifedipine oral capsule 10 mg, 20 mg Tier 1 GE Female; AE

raloxifene oral tablet 60 mg Tier 1

tranexamic acid oral tablet 650 mg Tier 1 QL


Index abacavir ................................ 11, 12abacavir-lamivudine ................... 12abacavir-lamivudine-zidovudine .12acamprosate .................................6acarbose ..................................... 37acetaminophen-codeine ............. 58acetazolamide ............................ 49acetic acid ...................................40acetylcysteine ............................. 36acitretin ...................................... 67ACTEMRA ................................... 15ACTHAR H.P. ...............................55ACTHIB (PF) ................................ 72acyclovir ......................................14ADACEL(TDAP ADOLESN/ADULT)(PF) ................73adapalene ................................... 64adderall xr ...................................20adefovir .......................................11ADEMPAS ................................... 61ADENOVIRUS VAC LIVE TYPE-4, 7 ..................................................73ADENOVIRUS VACCINE LIVE TYPE-4 .........................................73ADENOVIRUS VACCINE LIVE TYPE-7 .........................................73ADVAIR DISKUS .......................... 16ADVAIR HFA ............................... 17ADVATE ...................................... 28ADYNOVATE ............................... 28AFINITOR .................................... 33AFINITOR DISPERZ ......................33AFLURIA 2018-2019 ....................73AFLURIA 2018-2019 (PF) ............ 73AFLURIA QUAD 2018-2019 ........ 73AFLURIA QUAD 2018-2019 (PF) . 73AFSTYLA ......................................28AIMOVIG AUTOINJECTOR ..........53AIMOVIG AUTOINJECTOR (2 PACK) ..........................................53ALBENZA .....................................10albuterol sulfate ......................... 16alclometasone ............................ 65ALECENSA ................................... 34alendronate ................................ 32ALFERON N ................................. 55alfuzosin ......................................53

ALINIA .........................................10ALLI ............................................. 78allopurinol ...................................44alosetron .....................................70ALPHANATE ................................28ALPHANINE SD ........................... 28alprazolam ..................................19ALPROLIX ....................................28altavera (28) ............................... 22alyacen 1/35 (28) ........................22alyacen 7/7/7 (28) ...................... 23amantadine hcl ...........................14AMICAR ...................................... 27amiloride .....................................49amiloride-hydrochlorothiazide ... 49amiodarone ................................ 44AMITIZA ......................................69amitriptyline ............................... 22amlodipine .................................. 47amlodipine-benazepril ................ 45amlodipine-valsartan ..................47amlodipine-valsartan-hcthiazid ..47ammonium lactate ..................... 67amnesteem ................................. 64amoxicillin .................................8, 9amoxicillin-pot clavulanate ...........9ampicillin ...................................... 9anagrelide ...................................31anastrozole ................................. 33ANDROGEL ................................. 53androxy .......................................53ANORO ELLIPTA ..........................17aprepitant ............................. 69, 70apri ..............................................23APTIOM ...................................... 61APTIVUS ......................................12ARALAST NP ................................. 7aranelle (28) ............................... 23ARANESP (IN POLYSORBATE) .....27ARCALYST ................................... 55aripiprazole .................................18armodafinil ................................. 68ARNUITY ELLIPTA ....................... 17ASMANEX HFA ........................... 17ASMANEX TWISTHALER .............17aspirin-dipyridamole ...................31atazanavir ...................................12

atenolol .......................................46atenolol-chlorthalidone .............. 46atomoxetine ................................20atorvastatin ................................ 48atovaquone .................................10atovaquone-proguanil ................ 10ATRIPLA ...................................... 12atropine ...................................... 43ATROVENT HFA .......................... 16AUBAGIO .................................... 55aubra .......................................... 23AUSTEDO .................................... 55aviane ......................................... 23avita ............................................64AVONEX ......................................54AVONEX (WITH ALBUMIN) ........ 54azathioprine ................................52azelastine ......................................6azithromycin ................................. 8azurette (28) ............................... 23bacitracin ....................................41bacitracin-polymyxin b ............... 41baclofen ...................................... 55balsalazide .................................. 69balziva (28) ................................. 23BANZEL ....................................... 62BARACLUDE ................................11BASAGLAR KWIKPEN U-100 INSULIN ...................................... 38BEBULIN ......................................28benazepril ................................... 45benazepril-hydrochlorothiazide .. 45BENEFIX ...................................... 28benzonatate ................................36benztropine .................................60BERINERT ....................................50BESIVANCE ................................. 41betamethasone dipropionate ..... 65betamethasone valerate ............ 65betamethasone, augmented ...... 65betaxolol ..................................... 43bethanechol chloride .................. 72BEXSERO .....................................73bicalutamide ............................... 32BIKTARVY ................................... 12bimatoprost ................................ 43bisoprolol fumarate .................... 46


bisoprolol-hydrochlorothiazide ...46BIVIGAM .....................................51BLEPHAMIDE S.O.P. ................... 41blisovi fe 1.5/30 (28) ................... 23blisovi fe 1/20 (28) ...................... 23BOOSTRIX TDAP ......................... 73BOSULIF ...................................... 34BREO ELLIPTA ............................. 17brevicon (28) ...............................23briellyn ........................................ 23BRILINTA .....................................31brimonidine .................................43BRIVIACT .....................................62bromfenac .................................. 42bromocriptine ............................. 60budesonide ............................17, 69bumetanide .................................49buprenorphine ............................ 58buprenorphine-naloxone ............ 58bupropion hcl ..............................21bupropion hcl (smoking deter) ....68buspirone .................................... 19butalbital-acetaminophen .......... 59butalbital-acetaminophen-caff ...60butalbital-aspirin-caffeine .......... 60BYDUREON ................................. 37BYDUREON BCISE ....................... 37BYETTA ....................................... 38cabergoline ................................. 79CABOMETYX ...............................34calcipotriene ............................... 67calcitonin (salmon) ..................... 32calcitriol ...................................... 76calcium acetate .......................... 52camila ......................................... 23CANASA ...................................... 69capecitabine ............................... 32CAPRELSA ................................... 34captopril ......................................45captopril-hydrochlorothiazide .... 45CARAFATE ...................................71CARBAGLU ..................................70carbamazepine ........................... 62carbidopa ....................................60carbidopa-levodopa ....................60carbidopa-levodopa-entacapone .................................60CARIMUNE NF NANOFILTERED ..51

CARNITOR (SUGAR-FREE) .......... 55carteolol ......................................43cartia xt .......................................47carvedilol .................................... 46CAYSTON .................................... 36caziant (28) ................................. 23cefadroxil ...................................... 7cefdinir ..........................................7cefprozil ........................................ 7CEFTIN .......................................... 7cefuroxime axetil .......................... 7celecoxib ..................................... 57cephalexin .....................................8CERDELGA ...................................41cevimeline ...................................54CHANTIX ..................................... 68CHANTIX CONTINUING MONTH BOX .............................................68CHANTIX STARTING MONTH BOX .............................................68chateal ........................................ 23CHEMET ...................................... 56chlordiazepoxide hcl ................... 19chlorhexidine gluconate ..............54chloroquine phosphate ............... 10chlorothiazide ............................. 49chlorpromazine ...........................18chlorthalidone .............................49chlorzoxazone ............................. 55CHOLBAM ...................................70cholestyramine (with sugar) ....... 48cholestyramine light ................... 48ciclopirox ...............................64, 65cilostazol ..................................... 31CILOXAN ..................................... 41CINRYZE ...................................... 50CIPRO ............................................9CIPRO HC .................................... 41CIPRODEX ................................... 41ciprofloxacin ................................. 9ciprofloxacin hcl ...................... 9, 41citalopram .................................. 21claravis ........................................64clarithromycin ...............................8CLEOCIN ......................................78clindamycin hcl ............................. 8clindamycin palmitate hcl .............8clindamycin phosphate ......... 64, 78

clobetasol ....................................65clobetasol-emollient ................... 65clomipramine ..............................22clonazepam .................................62clonidine ..................................... 48clonidine hcl ................................ 47clopidogrel .................................. 31clotrimazole .................................. 9clozapine .....................................18COAGADEX ................................. 29codeine sulfate ............................58codeine-guaifenesin ....................36colchicine .................................... 44colestipol .....................................48COMBIVENT RESPIMAT ..............17COMETRIQ ..................................34COMPLERA ................................. 12completenate ..............................76CORIFACT ....................................29COSENTYX .................................. 67COSENTYX PEN ...........................67COTELLIC .....................................34CREON ........................................ 41CRESEMBA ..................................10CRIXIVAN ....................................12cromolyn ................................. 6, 16cryselle (28) .................................23CUVITRU ..................................... 51CUVPOSA ....................................70cyanocobalamin (vitamin b-12) .. 76cyclafem 1/35 (28) ......................23cyclafem 7/7/7 (28) .................... 23cyclobenzaprine .......................... 55cyclopentolate ............................ 43cyclophosphamide ...................... 33cycloserine .................................. 14CYCLOSET ....................................38cyclosporine ................................ 52cyclosporine modified ................. 52cyproheptadine .............................6CYSTAGON ..................................56CYSTARAN .................................. 43dalfampridine ............................. 55DALIRESP .................................... 16danazol ....................................... 79dantrolene .................................. 55dapsone ...................................... 10


DAPTACEL (DTAP PEDIATRIC) (PF) ............................................. 73dasetta 1/35 (28) ........................23dasetta 7/7/7 (28) ...................... 23DELZICOL .................................... 69demeclocycline ..............................9denta 5000 plus .......................... 77dentagel ......................................77DEPEN TITRATABS ......................15DESCOVY .................................... 12desipramine ................................ 22desmopressin ..............................56desogestrel-ethinyl estradiol ...... 23desonide ......................................65desoximetasone ..........................66desvenlafaxine succinate ............ 21dexamethasone .......................... 35DEXAMETHASONE INTENSOL .... 35dexamethasone sodium phosphate ............................. 35, 42dexmethylphenidate ...................20dextroamphetamine ................... 20dextroamphetamine-amphetamine ............................. 20diazepam .................................... 62diazepam intensol .......................62diclofenac potassium .................. 57diclofenac sodium ........... 42, 57, 60dicloxacillin ................................... 9dicyclomine ................................. 70didanosine .................................. 12DIFFERIN .....................................64DIFICID ..........................................8DIGOXIN ..................................... 49digoxin .................................. 49, 50DILANTIN .................................... 62DILANTIN KAPSEAL .....................62diltiazem hcl ................................47dilt-xr .......................................... 47DIOVAN ...................................... 45DIOVAN HCT ...............................45diphenoxylate-atropine .............. 70dipyridamole ...............................31disopyramide phosphate ............ 44disulfiram ......................................6divalproex ................................... 62dofetilide .....................................44donepezil .....................................37

dorzolamide ................................43dorzolamide-timolol ................... 43dorzolamide-timolol (pf) .............43doxazosin .................................... 48doxepin ....................................... 22doxycycline hyclate ....................... 9doxycycline monohydrate .............9dronabinol .................................. 70drospirenone-ethinyl estradiol ....23DRYSOL .......................................67DRYSOL DAB-O-MATIC ...............67DULERA .......................................17duloxetine ................................... 21DUPIXENT ...................................67dutasteride ................................. 53EDURANT ....................................12efavirenz ..................................... 12eletriptan .................................... 53ELIDEL ......................................... 67elinest ......................................... 23ELIQUIS ....................................... 30ELLA ............................................ 22ELMIRON .................................... 72ELOCTATE ................................... 29EMCYT ........................................ 32EMEND ....................................... 70emoquette .................................. 23EMTRIVA .................................... 12enalapril maleate ........................45enalapril-hydrochlorothiazide .....45ENBREL ....................................... 15ENBREL MINI .............................. 67ENBREL SURECLICK .....................15endocet ....................................... 58ENGERIX-B (PF) ...........................73ENGERIX-B PEDIATRIC (PF) ........ 73enoxaparin ..................................31enpresse ......................................23enskyce ....................................... 23entacapone .................................60entecavir ..................................... 11ENTRESTO ...................................50enulose ........................................69EPCLUSA ..................................... 11epinastine ..................................... 6epinephrine ...................................6EPIPEN JR 2-PAK ...........................6EPIVIR HBV ................................. 11

eplerenone ..................................49epoprostenol (glycine) ................ 61ergoloid .......................................56ERIVEDGE ................................... 34ERLEADA .....................................32errin ............................................ 23erythromycin ...............................41erythromycin with ethanol ......... 64ESBRIET .......................................51escitalopram oxalate .................. 21estarylla ...................................... 23estradiol ......................................78estropipate ................................. 78eszopiclone ................................. 68ethambutol ................................. 14ethosuximide .............................. 62etidronate disodium ................... 31etodolac ...................................... 57etoposide .................................... 33EUCRISA ......................................67EVOTAZ .......................................12exemestane .................................33EXJADE ........................................56EXTAVIA ......................................54ezetimibe .................................... 48falmina (28) ................................ 23famciclovir .................................. 14famotidine .................................. 71FANAPT .......................................18FEIBA NF ..................................... 29felbamate ................................... 62fenofibrate ..................................50fenofibrate micronized ............... 50fenofibrate nanocrystallized ....... 50fentanyl .......................................58FERRIPROX ................................. 56finasteride ...................................53FIRAZYR ...................................... 50FIRVANQ .......................................8FLEBOGAMMA DIF ..................... 51flecainide .................................... 44FLOLAN ....................................... 61FLOVENT DISKUS ........................17FLOVENT HFA ............................. 17FLUAD 2018-2019 (65 YR UP)(PF) ........................................73FLUBLOK QUAD 2018-2019 (PF) 74FLUCELVAX QUAD 2018-2019 ....74


FLUCELVAX QUAD 2018-2019 (PF) ............................................. 74fluconazole ..................................10fludrocortisone ............................35FLULAVAL QUAD 2018-2019 ...... 74FLULAVAL QUAD 2018-2019 (PF) ............................................. 74FLUMIST QUAD 2018-2019 ........ 74flunisolide ..................................... 7fluocinolone ................................ 66fluocinolone acetonide oil ...........41fluocinolone and shower cap ......66fluocinonide ................................ 66fluocinonide-e ............................. 66fluoridex daily defense ................77fluorometholone ......................... 42fluorouracil ................................. 67fluoxetine ....................................22fluphenazine hcl ..........................18flurbiprofen .................................57flurbiprofen sodium .................... 42flutamide .................................... 32fluticasone .............................. 7, 66fluticasone-salmeterol ................ 17fluvoxamine ................................ 22FLUZONE HIGH-DOSE 2018-19 (PF) ............................................. 74FLUZONE QUAD 2018-2019 (PF) ............................................. 74FLUZONE QUAD PEDI 2018-19 (PF) ............................................. 74FML S.O.P. .................................. 42folic acid ......................................77fondaparinux .............................. 31FORTEO .......................................32fosamprenavir .............................12fosinopril .....................................45fosinopril-hydrochlorothiazide ....45FULPHILA .................................... 27furosemide ..................................49FUZEON ...................................... 12FYCOMPA ................................... 62gabapentin ................................. 57galantamine ............................... 37GAMASTAN S/D ......................... 51GAMMAGARD LIQUID ............... 51GAMMAGARD S-D (IGA < 1 MCG/ML) ............ 51

GAMMAKED ............................... 51GAMMAPLEX ..............................51GAMMAPLEX (WITH SORBITOL) .................................. 51GAMUNEX-C ...............................51GARDASIL (PF) ............................74GARDASIL 9 (PF) ......................... 74gavilyte-c .................................... 68gavilyte-g .................................... 68gavilyte-n .................................... 68gemfibrozil ..................................50gengraf ....................................... 52gentamicin ............................ 41, 65GENVOYA ................................... 12gianvi (28) ...................................23gildagia ....................................... 24GILENYA ......................................55GILOTRIF .....................................34GLASSIA ........................................ 7glatiramer ...................................54glatopa ....................................... 55GLEOSTINE ..................................32glimepiride ..................................40glipizide .......................................40glipizide-metformin .................... 40GLUCAGEN ..................................39GLUCAGEN HYPOKIT .................. 39GLUCAGON EMERGENCY KIT (HUMAN) ....................................39glyburide .....................................40glyburide micronized .................. 40glycopyrrolate .............................70GRANIX .......................................27GRASTEK .......................................6griseofulvin microsize ................. 10griseofulvin ultramicrosize ..........10guanfacine ............................ 20, 48HAEGARDA ................................. 50haloperidol ..................................18haloperidol lactate ......................18HARVONI .................................... 11HAVRIX (PF) ................................74heather ....................................... 24HELIXATE FS ................................29HEMLIBRA .................................. 27HEMOFIL M HIGH .......................29HEMOFIL M LOW ........................29HEMOFIL M MID ........................ 29

HEMOFIL M SUPER HIGH ........... 29heparin (porcine) ........................ 31heparin, porcine (pf) ................... 31HEXALEN .....................................32HIBERIX (PF) ............................... 74HIZENTRA ................................... 51homatropaire ..............................43HUMALOG JUNIOR KWIKPEN U-100 .......................................... 39HUMALOG KWIKPEN INSULIN ... 39HUMALOG MIX 50-50 INSULN U-100 .......................................... 38HUMALOG MIX 50-50 KWIKPEN .................................... 38HUMALOG MIX 75-25 KWIKPEN .................................... 39HUMALOG MIX 75-25(U-100)INSULN ................................ 39HUMALOG U-100 INSULIN .........39HUMATE-P ..................................29HUMIRA ......................................69HUMIRA PEDIATRIC CROHN'S START ......................................... 69HUMIRA PEN .............................. 69HUMIRA PEN CROHN'S-UC-HS START ......................................... 69HUMIRA PEN PSORIASIS-UVEITIS ....................................... 67HUMULIN 70/30 U-100 INSULIN ...................................... 39HUMULIN 70/30 U-100 KWIKPEN .................................... 39HUMULIN N NPH INSULIN KWIKPEN .................................... 38HUMULIN N NPH U-100 INSULIN ...................................... 38HUMULIN R REGULAR U-100 INSULN ....................................... 40HUMULIN R U-500 (CONC) INSULIN ...................................... 40HUMULIN R U-500 (CONC) KWIKPEN .................................... 40HYCAMTIN ..................................33hydralazine ................................. 48hydrochlorothiazide ....................49hydrocodone-acetaminophen .....58hydrocodone-ibuprofen .............. 58hydrocortisone ................ 35, 66, 71


hydrocortisone acetate ...............71hydrocortisone valerate ..............66hydrocortisone-pramoxine ....66, 71hydromorphone .................... 58, 59hydroxychloroquine .................... 11hydroxyurea ................................32hydroxyzine hcl ............................. 6hydroxyzine pamoate ................... 6hyoscyamine sulfate ............. 70, 71HYQVIA .......................................52HYQVIA HY COMPONENT .......... 51HYQVIA IG COMPONENT ........... 52ibandronate ................................ 32IBRANCE ..................................... 34ibuprofen .................................... 57ICLUSIG ....................................... 34IDELVION .................................... 29IDHIFA .........................................34ILARIS (PF) .................................. 56imatinib .......................................34IMBRUVICA ................................ 34imipramine hcl ............................ 22imiquimod ...................................67INCRUSE ELLIPTA ........................16indapamide .................................49indomethacin ..............................57INFANRIX (DTAP) (PF) .......... 74, 75INGREZZA ................................... 56INLYTA ........................................ 34INTELENCE .................................. 12INTRON A ................................... 11introvale ......................................24INVIRASE .................................... 12INVOKAMET ............................... 39INVOKAMET XR ..........................39INVOKANA ..................................40iodoquinol-hc .............................. 66ipratropium bromide .............. 6, 16ipratropium-albuterol .................17irbesartan ................................... 45irbesartan-hydrochlorothiazide .. 45IRESSA .........................................34ISENTRESS ...................................12ISENTRESS HD .............................12isometh-dichloral-acetaminophn .............................53isoniazid ......................................14isosorbide dinitrate .....................44

isosorbide mononitrate ...............44itraconazole ................................ 10ivermectin ................................... 10IXINITY ........................................29JADENU .......................................56JADENU SPRINKLE ...................... 56JAKAFI .........................................34jantoven ......................................31JARDIANCE ................................. 40jencycla ....................................... 24JENTADUETO .............................. 37JENTADUETO XR .........................37JIVI .............................................. 29jolessa ......................................... 24jolivette .......................................24JULUCA ....................................... 12junel 1.5/30 (21) ......................... 24junel 1/20 (21) ............................ 24junel fe 1.5/30 (28) ..................... 24junel fe 1/20 (28) ........................ 24JUXTAPID ....................................48KALBITOR ................................... 50KALETRA ..................................... 12KALYDECO .................................. 36kariva (28) ...................................24kelnor 1/35 (28) .......................... 24ketoconazole .........................10, 65ketorolac ...............................42, 58KINERET ...................................... 15KINRIX (PF) ................................. 75kionex ......................................... 56KISQALI .......................................34KISQALI FEMARA CO-PACK ........ 34klor-con m10 ...............................50klor-con m15 ...............................50KLOR-CON/25 .............................50KOATE-DVI ..................................29KOGENATE FS ............................. 29KOVALTRY .................................. 29kurvelo ........................................ 24KUVAN ........................................56KYNAMRO .................................. 48labetalol ......................................46lactulose ......................................69lamivudine ............................ 11, 12lamivudine-zidovudine ................12lamotrigine ........................... 62, 63lansoprazole ............................... 71

larin 1/20 (21) .............................24larin fe 1.5/30 (28) ......................24larin fe 1/20 (28) .........................24latanoprost ................................. 43LATUDA ...................................... 18leena 28 ...................................... 24leflunomide .................................15lessina ......................................... 24LETAIRIS ......................................61letrozole ...................................... 33leucovorin calcium ...................... 56LEUKERAN .................................. 32LEUKINE ......................................27LEVEMIR FLEXTOUCH U-100 INSULN ....................................... 38LEVEMIR U-100 INSULIN ............ 38levetiracetam ..............................63levobunolol ................................. 43levocarnitine ............................... 56levocarnitine (with sugar) ...........56levofloxacin ...................................9levonest (28) ............................... 24levonorgestrel .............................22levonorgestrel-ethinyl estrad ......24levora-28 .....................................24levothyroxine .............................. 72LEXIVA ........................................ 13L-GLUTAMINE .............................70lialda ........................................... 69lidocaine hcl ................................ 54lidocaine viscous ......................... 54lidocaine-prilocaine .................... 60linezolid .........................................8LINZESS ....................................... 69liothyronine .................................72lisinopril ...................................... 45lisinopril-hydrochlorothiazide ..... 45lithium carbonate ....................... 21lithium citrate ............................. 21lomaira ....................................... 78LONSURF .................................... 32lopinavir-ritonavir .......................13lorazepam ...................................20loryna (28) .................................. 24losartan .......................................45losartan-hydrochlorothiazide ..... 45lovastatin .................................... 48low-ogestrel (28) .........................24


loxapine succinate ...................... 18LUMIGAN ....................................43lutera (28) ................................... 24LYSODREN .................................. 33lyza ..............................................24malathion ................................... 66marlissa ...................................... 24MATULANE .................................32MAVYRET ................................... 11MEDROL ..................................... 35medroxyprogesterone ................ 78mefloquine ..................................11megestrol ..............................33, 56MEKINIST ....................................34meloxicam .................................. 58melphalan ...................................32memantine ................................. 37MENACTRA (PF) ......................... 75MENHIBRIX (PF) ......................... 75MENOMUNE - A/C/Y/W-135 ..... 75MENVEO A-C-Y-W-135-DIP (PF) .75mercaptopurine .......................... 32mesalamine ................................ 69metadate er ................................ 20metformin ...................................37methadone ................................. 59methazolamide ...........................43methimazole ............................... 72methocarbamol .......................... 55methotrexate sodium ................. 33methotrexate sodium (pf) ...........33methyldopa .................................48methylergonovine .......................79methylphenidate hcl ................... 20methylprednisolone .................... 36metoclopramide hcl .................... 70metolazone ................................. 49metoprolol succinate .................. 46metoprolol ta-hydrochlorothiaz ..46metoprolol tartrate .....................46metronidazole .................11, 67, 78mexiletine ................................... 44microgestin 1.5/30 (21) .............. 25microgestin 1/20 (21) ................. 25microgestin fe 1.5/30 (28) .......... 25microgestin fe 1/20 (28) ............. 25midodrine ....................................48miglitol ........................................37

miglustat .....................................41MILLIPRED .................................. 36minocycline ................................... 9minoxidil ..................................... 48mirtazapine .................................21misoprostol ................................. 71modafinil .....................................68moexipril ..................................... 45moexipril-hydrochlorothiazide ....46mometasone ...............................66MONOCLATE-P ........................... 29mono-linyah ................................25mononessa (28) .......................... 25montelukast ................................16MONUROL .................................. 15morphine .................................... 59MORPHINE ................................. 59morphine concentrate ................ 59MOVANTIK ................................. 71moxifloxacin ............................9, 42MULTAQ ..................................... 44mupirocin ....................................65my way ....................................... 22mycophenolate mofetil ...............52MYLERAN ....................................32mynatal .......................................77mynatal advance ........................ 77mynatal plus ............................... 77mynatal-z ....................................77mynate 90 plus ........................... 77myorisan ..................................... 64MYRBETRIQ ................................ 72myzilra ........................................ 25nabumetone ............................... 58nadolol ........................................46naloxone ....................................... 7naltrexone .....................................6naproxen .....................................58naratriptan ................................. 53NARCAN ........................................7nateglinide ..................................38necon 0.5/35 (28) ....................... 25necon 1/35 (28) .......................... 25necon 1/50 (28) .......................... 25necon 10/11 (28) ........................ 25necon 7/7/7 (28) .........................25nefazodone ................................. 21neomycin ...................................... 8

neomycin-bacitracin-polymyxin ..42neomycin-polymyxin b-dexameth ....................................42neomycin-polymyxin-gramicidin .42neomycin-polymyxin-hc .............. 41NERLYNX .....................................35NEULASTA .................................. 27NEUPOGEN .................................27NEUPRO ......................................60nevirapine ................................... 13NEXAVAR ....................................35next choice one dose ...................22nicotine ....................................... 68nicotine (polacrilex) .................... 68NICOTROL ...................................68NICOTROL NS ............................. 68nifedipine .............................. 47, 79nimodipine ..................................47NINLARO .....................................35NITRO-BID .................................. 44nitrofurantoin ............................. 15nitrofurantoin macrocrystal ....... 15nitrofurantoin monohyd/m-cryst ............................................ 15nitroglycerin ................................44nora-be ....................................... 25norethindrone (contraceptive) ....25norethindrone acetate ................78norethindrone ac-eth estradiol ...25norgestimate-ethinyl estradiol ... 25norinyl 1/35 (28) ......................... 25NORPACE CR ...............................44nortrel 0.5/35 (28) ...................... 25nortrel 1/35 (21) ......................... 25nortrel 1/35 (28) ......................... 25nortrel 7/7/7 (28) ........................25nortriptyline ................................ 22NORVIR .......................................13NOVOEIGHT ................................30NOVOSEVEN RT ..........................30NOXAFIL ..................................... 10NUPLAZID ................................... 18NUVARING ..................................22NUWIQ ....................................... 30nystatin ................................. 10, 65OBIZUR ....................................... 30o-cal prenatal ..............................77ocella .......................................... 25


OCTAGAM .................................. 52octreotide acetate ...................... 56ODACTRA ......................................6ODEFSEY ..................................... 13ODOMZO .................................... 33OFEV ........................................... 51ofloxacin ............................... 41, 42ogestrel (28) ................................25olanzapine .................................. 18olmesartan ..................................46olmesartan-hydrochlorothiazide 46olopatadine ...................................6OLYSIO ........................................11omega-3 acid ethyl esters ...........50omeprazole ................................. 71ondansetron ................................70ondansetron hcl .......................... 70ONFI ............................................63OPSUMIT .................................... 61ORENCIA .....................................15ORENCIA CLICKJECT ....................15ORKAMBI ....................................36orsythia .......................................25oseltamivir .................................. 14OTEZLA ....................................... 15OTEZLA STARTER ........................15oxandrolone ................................56oxcarbazepine .............................63oxybutynin chloride .................... 72oxycodone ...................................59oxycodone-acetaminophen ........ 59oxycodone-aspirin .......................59OXYCONTIN ................................59OZEMPIC .....................................38paliperidone ................................19pantoprazole ...............................71paregoric .....................................71paroxetine hcl ............................. 22PAXIL .......................................... 22PEDIARIX (PF) ............................. 75PEDVAX HIB (PF) ........................ 75PEGASYS ..................................... 11PEGASYS PROCLICK .................... 11PEGINTRON ................................ 11PEGINTRON REDIPEN .................11penicillin v potassium ....................9PENTACEL (PF) ............................75

PENTACEL DTAP-IPV COMPNT (PF) ............................................. 75PENTASA .....................................69pentoxifylline .............................. 31perindopril erbumine .................. 46periogard .................................... 54permethrin ..................................66perphenazine .............................. 19phenazopyridine ......................... 72phenelzine ...................................21phenobarbital ............................. 63phenoxybenzamine .....................48phentermine ............................... 78phenylephrine hcl ........................43phenytoin ....................................63phenytoin sodium extended ....... 63philith ..........................................25PHOSLYRA .................................. 52phytonadione (vitamin k1) ..........77PICATO ........................................67pilocarpine hcl .......................43, 54pimtrea (28) ................................25pioglitazone ................................ 40pioglitazone-glimepiride .............40pioglitazone-metformin ..............40pirmella .......................................26piroxicam .................................... 58PLASMANATE ............................. 30PLEGRIDY ....................................55PNEUMOVAX 23 .........................75podofilox ..................................... 67polyethylene glycol 3350 ............ 69polymyxin b sulf-trimethoprim ... 42POMALYST ..................................33portia .......................................... 26potassium chloride ......................50potassium citrate ........................72POTIGA ....................................... 63PRADAXA ....................................31pramipexole ................................60prasugrel .....................................31pravastatin ................................. 49praziquantel ................................10prazosin ...................................... 48PRED FORTE ................................42PRED MILD ..................................42prednisolone ............................... 36prednisolone acetate .................. 43

prednisolone sodium phosphate.............................................. 36, 43prednisone .................................. 36PREDNISONE INTENSOL ............. 36PREMARIN ..................................78PREMPRO ................................... 78PRENATA .................................... 77prenatabs fa ............................... 77prenatabs rx ................................77prenatal plus ...............................77prenatal plus (calcium carb) ....... 77prenatal rx .................................. 77prenatal-u ................................... 77PRENATE ELITE ........................... 77prevalite ......................................48previfem ......................................26PREVNAR 13 (PF) ........................75PREVYMIS ...................................14PREZCOBIX ................................. 13PREZISTA .................................... 13PRIFTIN ....................................... 14primidone ....................................63PRIVIGEN .................................... 52probenecid .................................. 44probenecid-colchicine ................. 44prochlorperazine .........................70prochlorperazine maleate ...........70PROCRIT ......................................28proctosol hc ................................ 71proctozone-hc ............................. 71PROFILNINE ................................ 30progesterone micronized ............ 79PROLASTIN-C ................................ 7PROMACTA .................................28promethazine ..........................6, 70promethazine vc ......................... 36promethazine-dm ....................... 36propafenone ............................... 44propantheline ............................. 71propranolol ........................... 46, 47propranolol-hydrochlorothiazid ..47propylthiouracil ...........................72PROQUAD (PF) ........................... 75PULMICORT FLEXHALER .............17PULMOZYME .............................. 36purefe ob plus ............................. 77pyrazinamide .............................. 14pyridostigmine bromide ..............56


quasense .....................................26quetiapine ...................................19QUILLICHEW ER ..........................20QUILLIVANT XR .......................... 20quinapril ......................................46quinapril-hydrochlorothiazide .... 46quinidine gluconate .................... 45quinidine sulfate ......................... 45QVAR .......................................... 18QVAR REDIHALER .......................18rabeprazole .................................71RAGWITEK .................................... 6raloxifene ....................................79ramipril ....................................... 46ranitidine hcl ...............................71RAPAMUNE ................................ 52rasagiline .................................... 60RASUVO (PF) .............................. 15REBETOL ..................................... 11REBIF (WITH ALBUMIN) ............. 55REBIF REBIDOSE ......................... 55REBIF TITRATION PACK .............. 55REBINYN ..................................... 28reclipsen (28) .............................. 26RECOMBINATE ........................... 30RECOMBIVAX HB (PF) ................ 75RELENZA DISKHALER ..................14REMODULIN ............................... 61repaglinide ..................................38REPATHA PUSHTRONEX .............48REPATHA SURECLICK ..................48REPATHA SYRINGE ..................... 48RESCRIPTOR ............................... 13RESTASIS .....................................43RESTASIS MULTIDOSE ................ 43RETACRIT .................................... 28REVLIMID ....................................33REXULTI ...................................... 19REYATAZ ..................................... 13ribavirin .......................................11RIDAURA .................................... 15rifabutin ...................................... 10rifampin ...................................... 14riluzole ........................................ 56rimantadine ................................ 14risperidone ..................................19ritonavir ...................................... 13rivastigmine tartrate .................. 37

RIXUBIS .......................................30rizatriptan ............................. 53, 54ropinirole .................................... 60rosuvastatin ................................49RUCONEST ..................................50RYDAPT .......................................35RYTARY .......................................60SABRIL ........................................ 63salsalate ......................................58SANDOSTATIN LAR DEPOT .........57SAPHRIS ......................................19SAPHRIS (BLACK CHERRY) ..........19scopolamine base ....................... 70selegiline hcl ............................... 61selenium sulfide .......................... 67SELZENTRY ..................................13se-natal 19 .................................. 77se-natal 19 (with docusate) ........ 77SENSIPAR ....................................52SEREVENT DISKUS ...................... 16sertraline .....................................22sevelamer carbonate .................. 52sf ................................................. 77sf 5000 plus .................................77SHINGRIX (PF) .............................75SHINGRIX ADJUVANT COMPONENT-PF .........................75SHINGRIX GE ANTIGEN COMPONENT ..............................76SIGNIFOR .................................... 57sildenafil (antihypertensive) ....... 61silver sulfadiazine ....................... 65simvastatin ................................. 49sirolimus ......................................52SIRTURO ..................................... 14SIVEXTRO ....................................10sodium phenylbutyrate ...............57sodium polystyrene (sorb free) ... 57sodium polystyrene sulfonate .....57SOLTAMOX ................................. 34sotalol ......................................... 45sotalol af ..................................... 45spironolactone ............................ 49spironolacton-hydrochlorothiaz ..49sprintec (28) ................................26SPRYCEL ......................................35sronyx ......................................... 26stavudine .................................... 13

STIMATE ..................................... 27STIVARGA ................................... 35STRENSIQ ....................................41STRIBILD ..................................... 13STRIVERDI RESPIMAT .................16SUBOXONE ................................. 59SUCRAID ..................................... 41sucralfate ....................................71sulfacetamide sodium .................42sulfacetamide sodium (acne) ......64sulfacetamide sodium-sulfur ...... 64sulfacetamide sod-sulfur-urea ....64sulfacetamide-prednisolone ....... 42sulfamethoxazole-trimethoprim ...8sulfasalazine ............................... 69sulindac .......................................58sumatriptan ................................ 54sumatriptan succinate ................ 54SUPRAX .........................................8SUTENT ....................................... 35syeda ...........................................26SYLATRON .................................. 33SYMDEKO ................................... 36SYMPROIC .................................. 69SYMTUZA ....................................13SYNJARDY ...................................39SYNJARDY XR ..............................39SYNTHROID ................................ 72TABLOID ..................................... 33tacrolimus ............................. 52, 67TAFINLAR ....................................35TAGRISSO ................................... 35TAMIFLU .....................................14tamoxifen ....................................34tamsulosin .................................. 53TARCEVA .....................................35TASIGNA ..................................... 35taztia xt .......................................47TECFIDERA ..................................55temazepam .................................68temozolomide ............................. 32TENIVAC (PF) .............................. 76tenofovir disoproxil fumarate ..... 13terazosin ..................................... 53terbinafine hcl .............................10terconazole ................................. 78testosterone ................................53testosterone cypionate ............... 53


testosterone enanthate .............. 53TETANUS,DIPHTHERIA TOX PED(PF) .......................................76TETANUS-DIPHTHERIA TOXOIDS-TD ............................... 76tetrabenazine ..............................57tetracycline ................................... 9THALOMID ..................................33theophylline ................................ 16THIOLA ........................................57thioridazine .................................19thiothixene ..................................19THROMBATE III .......................... 30tiagabine .....................................63tilia fe ..........................................26timolol maleate .......................... 43TIVICAY .......................................13tizanidine .................................... 55TOBRADEX ..................................42tobramycin ..................................42tobramycin in 0.225 % nacl .........36tobramycin-dexamethasone .......42TOBREX .......................................42tolmetin ...................................... 58tolterodine .................................. 72topiramate ..................................63torsemide ....................................49TRACLEER ................................... 61TRADJENTA .................................37tramadol ..................................... 60trandolapril .................................46tranexamic acid .......................... 79tranylcypromine ..........................21TRAVATAN Z ...............................43trazodone ....................................21TRECATOR .................................. 14TRELEGY ELLIPTA ........................17tretinoin ...................................... 64tretinoin (chemotherapy) ............34TRETTEN ..................................... 30triadvance ...................................77triamcinolone acetonide ....... 54, 66triamterene-hydrochlorothiazid . 49trianex .........................................66triderm ........................................66tri-estarylla ................................. 26trifluoperazine ............................ 19trifluridine ................................... 42

trihexyphenidyl ........................... 61tri-legest fe ................................. 26tri-linyah ..................................... 26tri-lo-estarylla ............................. 26tri-lo-sprintec .............................. 26trimethobenzamide .................... 70trimethoprim ................................ 8trinatal gt ....................................77trinate ......................................... 77trinessa (28) ................................26trinessa lo ................................... 26tri-previfem (28) ..........................26tri-sprintec (28) ........................... 26TRIUMEQ ....................................13triveen-prx rnf .............................77trivora (28) ..................................26trospium ......................................72TRULICITY ................................... 38TRUMENBA ................................ 76TRUVADA ................................... 13TWINRIX (PF) ..............................76TYBOST ....................................... 13TYKERB ....................................... 35TYMLOS ...................................... 32TYVASO .......................................61TYVASO REFILL KIT ..................... 61TYVASO STARTER KIT ................. 61ULORIC ........................................44UPTRAVI ..................................... 61urea .......................................67, 68ursodiol ....................................... 71valacyclovir ................................. 14VALCHLOR .................................. 32valganciclovir ..............................14valproic acid ................................63valproic acid (as sodium salt) ..... 63valsartan .....................................46valsartan-hydrochlorothiazide ....46vancomycin ...................................8VAQTA (PF) .................................76VARIVAX (PF) ..............................76VAXCHORA BUFFER COMPONENT ..............................76VAXCHORA VACCINE ..................76VELETRI .......................................61velivet triphasic regimen (28) ..... 26VEMLIDY .....................................11venlafaxine ................................. 21

VENTAVIS ................................... 61VENTOLIN HFA ........................... 16verapamil ....................................47VERSACLOZ .................................19VERZENIO ................................... 35vestura (28) .................................26VICTOZA 2-PAK ...........................38VICTOZA 3-PAK ...........................38VIDEX 2 GRAM PEDIATRIC ......... 13VIDEX 4 GRAM PEDIATRIC ......... 13VIGABATRIN ............................... 63VIMPAT .......................................63vinate care .................................. 77vinate gt ......................................77vinate m ......................................77vinate one ................................... 78vinate ultra ................................. 78viorele (28) ..................................26VIRACEPT ....................................13VIREAD ....................................... 13VISTOGARD ................................ 57vitamin b-12 ................................78vitamin d2 ...................................78VITEKTA ...................................... 13VIVOTIF .......................................76VONVENDI ..................................30voriconazole ................................10VOSEVI ........................................11VOTRIENT ................................... 35VRAYLAR .....................................19vyfemla (28) ................................26VYVANSE .................................... 20warfarin ...................................... 31wera (28) .................................... 26WILATE ....................................... 30XALKORI ..................................... 35XARELTO .....................................31XENICAL ......................................78XERMELO ....................................71XIFAXAN ....................................... 8XTANDI ....................................... 32xulane ......................................... 22XYNTHA ...................................... 30XYNTHA SOLOFUSE .................... 30XYREM ........................................ 68yuvafem ...................................... 78zaleplon ...................................... 68zarah ...........................................27


ZARXIO ....................................... 28ZEJULA ........................................ 33ZELBORAF ................................... 35ZEMAIRA .......................................7zenatane ..................................... 64zenchent (28) .............................. 27ZERIT ...........................................14zidovudine ...................................14ZIOPTAN (PF) ..............................44ziprasidone hcl ............................ 19ZIRGAN ....................................... 42ZOLINZA ......................................33zolpidem ..................................... 68zonisamide ..................................64ZONTIVITY .................................. 31ZOSTAVAX (PF) ...........................76zovia 1/35e (28) ..........................27zovia 1/50e (28) ..........................27ZYKADIA ..................................... 35ZYTIGA ........................................ 32


2 Tier 2018 Formulary (List of covered drugs)hp/...Some medicines are on the drug list, but you need...

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Transcript of 2 Tier 2018 Formulary (List of covered drugs)hp/...Some medicines are on the drug list, but you need...