2019 Cigna COMPREHENSIVE DRUG LIST (Formulary) · 1 What is the Cigna Comprehensive Drug List? A...

Plans coveredCigna-HealthSpring Alliance (HMO)Cigna-HealthSpring Preferred (HMO)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT ALL OF THE DRUGS WE COVER IN THIS PLAN.

2019 Cigna COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal.HPMS Approved Formulary File Submission ID 19149, Version Number 19 INT_19_65288_C_Final_4n Populated Template 07312018

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What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2019 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic equivalent of the drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect customers currently taking the drug.) Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect customers currently taking the drug:• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you

are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the following section entitled “How do I request an exception to the Cigna Drug List?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug.

The enclosed drug list is current as of December 2019. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Alliance (HMO) and Cigna-HealthSpring Preferred (HMO).

This document includes a list of the drugs (formulary) for our plans, which is current as of December 2019. For an updated drug list, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

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back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 55. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill these prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for simvastatin 10mg. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not “opioid naïve”) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

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• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Check the Drug Tier and Cost-Share Tables to see if your plan offers copay savings with mail order.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered in the Cigna drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna.

• You can ask Cigna to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Cigna Drug List?You can ask Cigna to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not in our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you

can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna will only approve your request for an exception if the alternative drugs included in our drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not in our drug list or if your ability to get your drugs

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is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list that begins on page 7, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 55. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug.

This plan offers additional prescription drug coverage in the coverage gap. Please refer to your Evidence of Coverage to see this coverage and for more information.We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 7 along with the amount dispensed per the days supplied. (For example: simvastatin 10mg QL 30/30; this means the drug simvastatin 10mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4 or Tier 5. Keep in mind that

the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.CignaHealthSpring.com to search for a preferred retail or mail-order pharmacy near you.

Service Area: Arizona H0354-001 – Cigna-HealthSpring Preferred (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona

Drug Tier

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Preferred Mail Order Cost-Sharing

Standard Mail Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15Tier 2: Generic Drugs $8 / $16 / $16 $13 / $26 / $39 $8 / $16 / $16 $13 / $26 / $39Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300Tier 5: Specialty Tier 29% (30 days) 29% (30 days) 29% (30 days) 29% (30 days)

Service Area: Arizona H0354-028 – Cigna-HealthSpring Alliance (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona

Drug Tier






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Service Area: Arizona H0354-024 – Cigna-HealthSpring Preferred (HMO): Pima, Arizona

Drug Tier






My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna

Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

HI (Home Infusion) – This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. - 8 p.m. local time. TTY users should call 711.

NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugB/D = Drugs covered under Medicare Part B or Part D NDS = Non-extended day supply medicationHI = Home Infusion drug QL = Quantity Limits listed as (qty/days)PA = Prior Authorization may be required ST = Step Therapy rules applyYou can find more information on the symbols by going to page 6.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsacetaminophen/codeine oral soln

2 NDS QL(2700/30)

butalbital/acetaminophen tabs 325mg; 50mg

2 PA QL(180/30)

butalbital/acetaminophen/caffeine caps

2 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

2 PA QL(180/30)

butalbital/aspirin/caffeine caps 2 PA QL(180/30)esgic caps 2 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

2 PA QL(180/30)

NonsteroidalAnti-inflammatoryDrugscelecoxib caps 400mg 3 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

3 QL(60/30)

diclofenac potassium 3diclofenac sodium dr 3diclofenac sodium er 2diclofenac sodium/misoprostol 4diflunisal 3etodolac 3etodolac er 4ibu tabs 600mg, 800mg 2ibuprofen susp 2ibuprofen tabs 400mg, 600mg, 800mg

2

ketorolac tromethamine inj 30mg/ml

4 PA QL(20/30)

ketorolac tromethamine inj 15mg/ml

4 PA QL(40/30)

ketorolac tromethamine tabs 4 PA QL(20/30)meloxicam 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nabumetone 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

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naproxen susp 3naproxen tabs 2salsalate 2sulindac 2Opioid Analgesics, Long-actingbuprenorphine 4 NDS QL(4/28)buprenorphine hcl inj 4 QL(150/30)DURAMORPH 4 B/D PA NDS

QL(180/30)fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr

4 NDS QL(10/30)

morphine sulfate er cp24 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg

4 NDS QL(60/30)

morphine sulfate er tbcr 3 NDS QL(90/30)XTAMPZA ER 3 NDS QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine tabs 300mg; 60mg

2 NDS QL(180/30)

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

2 NDS QL(360/30)

butorphanol tartrate inj 2mg/ml 4 NDS QL(240/30)butorphanol tartrate inj 1mg/ml 4 NDS QL(480/30)butorphanol tartrate nasal soln 4 NDS QL(5/30)codeine sulfate 3 NDS QL(180/30)endocet tabs 325mg; 10mg 3 NDS QL(180/30)endocet tabs 325mg; 7.5mg 3 NDS QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

3 NDS QL(360/30)

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA NDS QL(120/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxycodone hydrochloride oral soln

3 NDS QL(1200/30)

oxycodone hydrochloride tabs 3 NDS QL(180/30)oxycodone/acetaminophen tabs 325mg; 10mg

3 NDS QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

3 NDS QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

3 NDS QL(360/30)

oxycodone/aspirin 3 NDS QL(180/30)tramadol hcl 2 NDS QL(240/30)tramadol hydrochloride/acetaminophen

2 NDS QL(240/30)

Anesthetics

Local Anestheticsglydo 2 PAlidocaine hcl external soln 2 PAlidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

2

lidocaine hcl jelly gel 2 PAlidocaine hcl mouth/throat soln 2lidocaine hcl prsy 2 PAlidocaine hcl viscous 2lidocaine oint 4 PA QL(50/30)lidocaine ptch 3 PA QL(90/30)lidocaine viscous 2lidocaine/prilocaine crea 4 PAAnti-Addiction/Substance Abuse Treatment AgentsAlcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2naltrexone hcl 2VIVITROL 5 PA NDSOpioid Dependence Treatmentsbuprenorphine hcl subl 3 PA QL(90/30)buprenorphine hcl/naloxone hcl 4 QL(90/30)buprenorphine hydrochloride/naloxone hydrochloride film

4 QL(90/30)

SUBOXONE 3 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA NDS QL(120/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

3 NDS QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

3 NDS QL(360/30)

hydrocodone/ibuprofen 3 NDS QL(150/30)hydromorphone hcl dosette 4 NDShydromorphone hcl inj 4 NDShydromorphone hcl liqd 4 NDS QL(1200/30)hydromorphone hcl tabs 8mg 3 NDS QL(120/30)hydromorphone hcl tabs 2mg, 4mg

3 NDS QL(180/30)

lorcet 3 NDS QL(360/30)lorcet hd 3 NDS QL(180/30)lorcet plus tabs 325mg; 7.5mg 3 NDS QL(180/30)MORPHINE SULFATE INJ 5MG/ML

3 B/D PA NDS

morphine sulfate inj 1mg/ml, 50mg/ml

3 B/D PA NDS

morphine sulfate inj 0.5mg/ml, 1mg/ml

3 B/D PA NDS QL(180/30)

MORPHINE SULFATE INJ 10MG/ML

3 B/D PA NDS QL(240/30)


3 B/D PA NDS QL(250/30)


3 B/D PA NDS QL(480/30)


3 B/D PA NDS QL(1200/30)

morphine sulfate oral soln 100mg/5ml

3 NDS QL(240/30)


3 NDS QL(700/30)


3 NDS QL(900/30)

morphine sulfate tabs 3 NDS QL(120/30)nalbuphine hcl inj 20mg/ml 4 NDS QL(90/30)nalbuphine hcl inj 10mg/ml 4 NDS QL(180/30)oxycodone hcl conc 4 NDS QL(120/30)oxycodone hcl tabs 3 NDS QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tobramycin sulfate inj 1.2gm, 1.2gm/30ml, 10mg/ml, 80mg/2ml

2

tobramycin sulfate ophthalmic soln

2

tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml

2

TOBREX OINT 4ZYLET 4Antibacterials, OtherALCOHOL PREP PADS 3bacitracin inj 2bacitracin ophthalmic oint 2bacitracin/polymyxin b 2chloramphenicol sodium succinate

4

CLEOCIN SUPP 4clindacin-p 2clindamycin hcl 2clindamycin phosphate crea 3clindamycin phosphate external soln

3

clindamycin phosphate gel 3clindamycin phosphate in d5w 2 HIclindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml

4 HI

clindamycin phosphate lotn 3clindamycin phosphate swab 2clindamycin/sodium chloride 3 HIcolistimethate sodium 4DAPTOMYCIN INJ 350MG 5 HIdaptomycin inj 500mg 5 HIFEM PH 4FIRVANQ 4 QL(300/10)lincomycin hcl 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZUBSOLV SUBL 0.7MG; 0.18MG

3 QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hydrochloride er (sr) 2 QL(60/30)CHANTIX 3 QL(56/28)CHANTIX CONTINUING MONTH PAK

3 QL(56/28)

CHANTIX STARTING MONTH PAK

3 QL(56/28)

NICOTROL INHALER 4 QL(1008/90)NICOTROL NS 4 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 2 HIgentak 2gentamicin sulfate crea 3gentamicin sulfate inj 2gentamicin sulfate oint 3gentamicin sulfate ophthalmic soln

2

gentamicin sulfate pediatric 2gentamicin sulfate/0.9% sodium chloride

2

isotonic gentamicin 2neomycin sulfate 2paromomycin sulfate 2streptomycin sulfate 2tobramycin ophthalmic soln 2

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tigecycline 5 HItrimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

vancomycin 3 HIvancomycin hcl inj 0.9%; 1gm/200ml

3 HI

vancomycin hcl inj 5gm 2vancomycin hcl inj 10gm, 750mg

2 HI

vancomycin hydrochloride caps 125mg

4 QL(40/10)

vancomycin hydrochloride caps 250mg

4 QL(80/10)

vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg

2 HI

VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML

3 HI

vancomycin hydrochloride/dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml

3 HI

vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

3 HI

XIFAXAN TABS 550MG 5 PA NDS QL(90/30)Beta-lactam, Cephalosporinscefaclor caps 2cefaclor er 3cefaclor susr 3cefadroxil 2cefazolin 3 HIcefazolin sodium inj 100gm, 10gm, 1gm, 1gm/50ml; 4%, 300gm, 500mg

2 HI

cefazolin sodium/dextrose inj 1gm; 4%

2 HI

cefazolin sodium/dextrose inj 2gm; 3%

3 HI

cefdinir caps 2cefdinir susr 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

linezolid inj 4 HIlinezolid susr 5 NDS QL(1800/30)linezolid tabs 5 NDS QL(60/30)methenamine hippurate 2methenamine mandelate tabs 1gm

2

metronidazole caps 2metronidazole crea 3metronidazole gel 3metronidazole in nacl 0.79% 4 HImetronidazole inj 500mg/100ml; 0.79%

4 HI

METRONIDAZOLE INJ 500MG/100ML; 0.74%

3 HI

metronidazole lotn 3metronidazole tabs 2metronidazole vaginal 3MONUROL 4mupirocin crea 4mupirocin oint 2neo-polycin 2neo-polycin hc 3neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

3

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone ophthalmic susp

2

nitrofurantoin 4nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

silver sulfadiazine 2SIVEXTRO TABS 5 NDS QL(6/30)SSD 3SYNERCID 5 HI

11



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, Penicillinsamoxicillin 2amoxicillin/clavulanate potassium

2

ampicillin 2ampicillin sodium inj 125mg, 250mg, 500mg

2

ampicillin sodium inj 10gm, 1gm, 2gm

2 HI

ampicillin-sulbactam 2 HIBICILLIN C-R 4BICILLIN L-A 4dicloxacillin sodium 2NAFCILLIN 3 HInafcillin sodium 2 HIOXACILLIN INJ 1.5GM/50ML; 1GM/50ML, 300MG/50ML; 2GM/50ML

4 HI

oxacillin sodium 4 HIpenicillin g potassium 4 HIpenicillin g potassium in iso-osmotic dextrose

4 HI

penicillin g procaine 4penicillin g sodium 4penicillin v potassium 2pfizerpen inj 20mu, 5000000unit

4 HI

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm

4 HI

piperacillin/tazobactam 4 HIMacrolidesAZASITE 3azithromycin inj 2 HIAZITHROMYCIN PACK 3azithromycin susr 200mg/5ml 2 QL(90/30)azithromycin susr 100mg/5ml 2 QL(150/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefepime 2 HIcefepime/dextrose 2 HIcefixime caps 4cefixime susr 3cefotaxime sodium inj 1gm, 500mg

2

cefotetan/dextrose 2cefoxitin sodium 2 HIcefpodoxime proxetil 2cefprozil 2ceftazidime 4 HIceftazidime/dextrose 4 HIceftriaxone in iso-osmotic dextrose

2

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

2

ceftriaxone/dextrose 2cefuroxime axetil 2cefuroxime sodium 2cephalexin 2SUPRAX CAPS 4SUPRAX CHEW 4SUPRAX SUSR 500MG/5ML 4tazicef inj 1gm, 2gm, 6gm 4 HITEFLARO 5 HIBeta-lactam, OtherAZACTAM 4 HIaztreonam 4 HIcefotetan 2ertapenem 4 HIertapenem sodium 4 HIimipenem/cilastatin 4 HIINVANZ 4 HImeropenem 4 HImeropenem/sodium chloride 4 HI

12


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levofloxacin in d5w 2 HIlevofloxacin inj 2 HIlevofloxacin ophthalmic soln 2levofloxacin oral soln 2levofloxacin tabs 500mg 2levofloxacin tabs 250mg, 750mg

2 QL(30/30)

moxifloxacinhydrochloride/sodium hydrochloride

2

moxifloxacin hcl 2moxifloxacin hydrochloride ophthalmic soln

2

moxifloxacin hydrochloride tabs 2ofloxacin 2SulfonamidesBLEPHAMIDE 4BLEPHAMIDE S.O.P. 4sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 3sulfacetamide sodium oint 2sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 3sulfamethoxazole/trimethoprim ds

2

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

3

sulfamethoxazole/trimethoprim tabs

2

Tetracyclinesdemeclocycline hcl 3doxy 100 2doxycycline hyclate caps 2doxycycline hyclate dr tbec 100mg, 150mg, 75mg

4

doxycycline hyclate tabs 100mg, 20mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2clarithromycin susr 3clarithromycin tabs 2DIFICID 5 PA NDS QL(20/10)e.e.s. 400 3ery 3ERY-TAB 3ERYPED 400 5 NDSERYTHROCIN LACTOBIONATE

3

erythrocin stearate 3erythromycin base 4erythromycin cpep 2erythromycin dr 3erythromycin ethylsuccinate susr 200mg/5ml

3

ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML

5 NDS

erythromycin ethylsuccinate tabs

3

erythromycin external soln 2erythromycin gel 3erythromycin oint 2QuinolonesAVELOX 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin hcl tabs 100mg 3ciprofloxacin hcl tabs 750mg 2ciprofloxacin hydrochloride 2ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

2 HI

ciprofloxacin susr 2gatifloxacin 2 QL(2.5/25)

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

roweepra 2roweepra xr tb24 750mg 2 QL(120/30)roweepra xr tb24 500mg 2 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 4ethosuximide 3LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)pregabalin caps 225mg, 300mg 3 QL(60/30)pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg

3 QL(90/30)

pregabalin oral soln 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam susp 5 NDS QL(480/30)clobazam tabs 20mg 5 NDS QL(60/30)clobazam tabs 10mg 4 QL(60/30)clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

2 QL(90/30)

clonazepam odt tbdp 1mg 2 QL(120/30)clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIACOMIT CAPS 500MG 5 PA NDS QL(180/30)DIACOMIT CAPS 250MG 5 PA NDS QL(360/30)DIACOMIT PACK 500MG 5 PA NDS QL(180/30)DIACOMIT PACK 250MG 5 PA NDS QL(360/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxycycline monohydrate caps 150mg

2

doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2minocycline hydrochloride caps 100mg, 50mg

2

mondoxyne nl caps 100mg 3 QL(60/30)morgidox 1x50mg 2NUZYRA INJ 4 QL(15/14)NUZYRA TABS 4 QL(30/14)tetracycline hydrochloride 2

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 NDS QL(30/30)

APTIOM TABS 600MG 5 NDS QL(60/30)BRIVIACT INJ 5 NDS QL(600/30)BRIVIACT ORAL SOLN 5 NDS QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 NDS QL(60/30)

BRIVIACT TABS 100MG 5 NDS QL(120/30)EPIDIOLEX 5 PA NDSFYCOMPA SUSP 4 QL(720/30)FYCOMPA TABS 4 QL(30/30)levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2levetiracetam/sodium chloride 4magnesium sulfate in d5w 4 B/D PANAYZILAM 5 PA NDS QL(10/30)

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BANZEL TABS 400MG 5 NDS QL(240/30)carbamazepine 2carbamazepine er 2DILANTIN CAPS 30MG 4epitol 2fosphenytoin sodium 4oxcarbazepine 2PEGANONE 4phenytoin 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Cholinesterase Inhibitorsdonepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tabs 23mg 3 QL(30/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

galantamine hydrobromide er 4 QL(30/30)galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 3 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 PA QL(60/30)memantine hcl tabs 5mg 2 PA QL(90/30)memantine hcl titration pak 3 PA QL(49/28)memantine hydrochloride er 4 PA QL(30/30)memantine hydrochloride oral soln

2 PA QL(360/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 4 QL(5/30)diazepam rectal gel gel 10mg 4 QL(20/30)diazepam rectal gel gel 20mg 4 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)GRALISE 3GRALISE STARTER 3 QL(156/365)ONFI SUSP 5 NDS QL(480/30)ONFI TABS 20MG 5 NDS QL(60/30)ONFI TABS 10MG 4 QL(60/30)PHENOBARBITAL ELIX 3 QL(1500/30)PHENOBARBITAL TABS 3 QL(120/30)primidone 2SABRIL TABS 5 PA NDS QL(180/30)tiagabine hydrochloride 4valproate sodium inj 100mg/ml 4valproic acid 2vigabatrin pack 5 PA NDS QL(200/30)vigabatrin tabs 5 PA NDS QL(180/30)vigadrone 5 PA NDS QL(200/30)Glutamate Reducing Agentsfelbamate susp 5 NDSfelbamate tabs 4lamotrigine 2lamotrigine er 2lamotrigine odt 2topiramate 2Sodium Channel AgentsBANZEL SUSP 5 NDS QL(2400/30)BANZEL TABS 200MG 5 NDS QL(60/30)

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 3 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30)FETZIMA TITRATION PACK 4 QL(56/365)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hydrochloride caps 10mg

2 QL(30/30)

fluoxetine hydrochloride oral soln

2 QL(600/30)

fluoxetine hydrochloride tabs 10mg

2 QL(30/30)

fluoxetine hydrochloride tabs 20mg

2 QL(120/30)

fluvoxamine maleate tabs 25mg, 50mg

2 QL(30/30)

fluvoxamine maleate tabs 100mg

2 QL(90/30)

olanzapine/fluoxetine 4 QL(30/30)paroxetine hcl tabs 10mg 2 QL(30/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hydrochloride tabs 20mg

2 QL(90/30)

PAXIL SUSP 4 QL(900/30)PRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 50mg 2 QL(120/30)sertraline hydrochloride tabs 100mg

2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antidepressants

Antidepressants, OtherAPLENZIN 5 NDS QL(30/30)bupropion hcl tabs 100mg 3 QL(120/30)bupropion hydrochloride er (sr) 2 QL(60/30)bupropion hydrochloride er (xl) tb24 150mg, 300mg

3 QL(30/30)

bupropion hydrochloride tabs 75mg

3 QL(180/30)

maprotiline hcl 3 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 3 QL(60/30)nefazodone hydrochloride 3 QL(60/30)SPRAVATO 56MG DOSE 5 PA NDSSPRAVATO 84MG DOSE 5 PA NDStrazodone hydrochloride 2TRINTELLIX 4 QL(30/30)Monoamine Oxidase InhibitorsEMSAM 5 NDS QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 3tranylcypromine sulfate 4SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

3 QL(600/30)

citalopram hydrobromide tabs 10mg

2


2 QL(30/30)


2 QL(60/30)

desvenlafaxine er 3 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethegan 4scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy Adjunctsaprepitant caps 40mg 4 B/D PA QL(1/30)aprepitant caps 125mg 4 B/D PA QL(2/28)aprepitant caps 80mg 4 B/D PA QL(4/28)aprepitant caps pack 4 B/D PA QL(6/28)CESAMET 5 B/D PA NDS

QL(60/30)dronabinol 3 B/D PA QL(60/30)EMEND SUSR 4 B/D PA QL(6/28)granisetron hcl inj 1mg/ml 2 HIgranisetron hcl tabs 3 B/D PA QL(30/30)granisetron hydrochloride 2 HIondansetron hcl oral soln 3 B/D PA QL(450/30)ondansetron hcl tabs 2 B/D PA QL(15/30)ondansetron hydrochloride inj 2 B/D PAondansetron hydrochloride tabs 2 B/D PA QL(90/30)ondansetron odt 2 B/D PA QL(90/30)SANCUSO 5 NDS QL(4/28)

Antifungals

AntifungalsABELCET 5 PA NDSAMBISOME 5 PA NDSamphotericin b 4 PAcaspofungin acetate 5 HIciclodan 3ciclopirox 3ciclopirox nail lacquer 3ciclopirox olamine 3clotrimazole external crea 2clotrimazole external soln 2clotrimazole lozg 2clotrimazole/betamethasone dipropionate crea

2

clotrimazole/betamethasone dipropionate lotn

3

econazole nitrate 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er cp24 75mg 2 QL(90/30)venlafaxine hcl er tb24 225mg, 37.5mg, 75mg

4 QL(30/30)

venlafaxine hcl er tb24 150mg 4 QL(60/30)venlafaxine hydrochloride er tb24 37.5mg, 75mg

4 QL(30/30)

VIIBRYD 4 QL(30/30)VIIBRYD STARTER PACK 4 QL(30/30)Tricyclicsamitriptyline hcl 2 PAamitriptyline hydrochloride tabs 10mg, 50mg

2 PA

amoxapine 3clomipramine hcl 4 PAdesipramine hcl 3imipramine hcl tabs 25mg, 50mg

2 PA

imipramine hydrochloride 2 PAnortriptyline hcl 2nortriptyline hydrochloride 2perphenazine/amitriptyline 4 PAprotriptyline hcl 4trimipramine maleate 4 PA

Antiemetics

Antiemetics, Othercompro 2dimenhydrinate inj 2droperidol 2meclizine hcl tabs 2phenadoz 4prochlorperazine 2promethazine hcl supp 4promethazine hcl syrp 2 PApromethazine hcl tabs 12.5mg 2 PApromethazine hydrochloride inj 2 PApromethazine hydrochloride tabs 25mg, 50mg

2 PA

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

colchicine caps 3 QL(60/30)colchicine tabs 2 QL(120/30)febuxostat 3 QL(30/30) STMITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)dihydroergotamine mesylate nasal soln

4 PA QL(8/30)

ergotamine tartrate/caffeine 3 QL(40/28)migergot 5 NDS QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 3 QL(9/30) STrizatriptan benzoate 3 QL(12/30)rizatriptan benzoate odt 3 QL(12/30)sumatriptan 4 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)zolmitriptan 4 QL(6/30)zolmitriptan odt 4 QL(6/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3MESTINON ORAL SOLN 5 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluconazole 2fluconazole in nacl 2 HIflucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4GYNAZOLE-1 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PA NDSketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2miconazole 3 2MYCAMINE 5 HInaftifine hcl 3naftifine hydrochloride 3NAFTIN GEL 3NATACYN 4NOXAFIL SUSP 5 PA NDS QL(600/30)NOXAFIL TBEC 5 PA NDS QL(96/30)nyamyc 2nystatin 2nystatin/triamcinolone 3nystop 2POSACONAZOLE DR 5 PA NDS QL(96/30)SPORANOX ORAL SOLN 5 PA NDSterbinafine hcl tabs 2 QL(90/365)terconazole 3voriconazole inj 5 HIvoriconazole susr 5 PA NDS QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 2allopurinol sodium 4

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GLEOSTINE CAPS 100MG, 40MG

4

ifosfamide inj 1gm, 3gm 2 B/D PAKISQALI FEMARA 200 DOSE 5 PA NDS QL(49/28)KISQALI FEMARA 400 DOSE 5 PA NDS QL(70/28)KISQALI FEMARA 600 DOSE 5 PA NDS QL(91/28)LEUKERAN 4MATULANE 5 NDSmelphalan hydrochloride 5 B/D PA NDSthiotepa 2 B/D PATREANDA INJ 100MG 5 B/D PA NDSTREANDA INJ 25MG 5 B/D PA NDS

QL(8/21)VALCHLOR 5 NDS QL(60/30)YONDELIS 5 B/D PA NDSZANOSAR 4 B/D PAAntiandrogensabiraterone acetate 5 PA NDS QL(120/30)bicalutamide 2 QL(30/30)ERLEADA 5 NDS QL(120/30)flutamide 2nilutamide 5 NDS QL(60/30)NUBEQA 5 PA NDS QL(120/30)XTANDI 5 NDS QL(120/30)YONSA 5 PA NDS QL(120/30)ZYTIGA TABS 500MG 5 NDS QL(60/30)ZYTIGA TABS 250MG 5 NDS QL(120/30)Antiangiogenic AgentsPOMALYST 5 NDS QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 NDS QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 NDS QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 NDS QL(28/28)

THALOMID CAPS 200MG 5 NDS QL(56/28)Antiestrogens/ModifiersEMCYT 4FARESTON 5 NDS QL(30/30)FASLODEX 5 B/D PA NDS

QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pyridostigmine bromide er 4pyridostigmine bromide oral soln

5 NDS

pyridostigmine bromide tabs 60mg

3

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 3AntitubercularsCAPASTAT SULFATE 3cycloserine 2ethambutol hcl 3ethambutol hydrochloride 3isoniazid inj 2isoniazid syrp 3isoniazid tabs 2PASER 4PRIFTIN 4pyrazinamide 3rifampin 2RIFATER 4SIRTURO 4 QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA NDS

QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PA NDSBUSULFEX 5 B/D PA NDScarboplatin inj 50mg/5ml 4 B/D PAcarmustine 4 B/D PAcyclophosphamide caps 3 B/D PAcyclophosphamide inj 5 B/D PA NDSdacarbazine 2 B/D PAEVOMELA 5 B/D PA NDSGLEOSTINE CAPS 10MG 3

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VYXEOS 5 B/D PA NDSAntineoplasticsXPOVIO 100 MG ONCE WEEKLY

5 PA NDS QL(20/28)

XPOVIO 60 MG ONCE WEEKLY

5 PA NDS QL(12/28)

XPOVIO 80 MG ONCE WEEKLY

5 PA NDS QL(16/28)

XPOVIO 80 MG TWICE WEEKLY

5 PA NDS QL(32/28)

Antineoplastics, OtherABRAXANE 5 PA NDSADRIAMYCIN INJ 50MG 4 B/D PAadriamycin inj 2mg/ml 4 B/D PAarsenic trioxide 4 B/D PAazacitidine 5 B/D PA NDSBELEODAQ 5 B/D PA NDSbleomycin 4 B/D PAbleomycin sulfate 4 B/D PABORTEZOMIB 5 PA NDS QL(14/21)BRAFTOVI 5 PA NDS QL(180/30)carboplatin inj 150mg/15ml, 450mg/45ml

4 B/D PA

cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

2 B/D PA

COPIKTRA 5 PA NDS QL(60/30)COSMEGEN 5 B/D PA NDSdactinomycin 5 B/D PA NDSdaunorubicin hcl 4 B/D PADAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

4 B/D PA

daunorubicin hydrochloride inj 20mg/4ml

4 B/D PA

DAURISMO TABS 100MG 5 PA NDS QL(30/30)DAURISMO TABS 25MG 5 PA NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fulvestrant 5 B/D PA NDS QL(30/30)

SOLTAMOX 5 NDStamoxifen citrate 2toremifene citrate 5 NDS QL(30/30)Antimetabolitesadrucil 4 B/D PAALIMTA 5 PA NDSARRANON 5 B/D PA NDScladribine 5 B/D PA NDSclofarabine 5 B/D PA NDScytarabine 2 B/D PAcytarabine aqueous 2 B/D PADROXIA 3ELITEK 5 B/D PA NDSfloxuridine 3 B/D PAfluorouracil inj 2 B/D PAFOLOTYN 5 B/D PA NDSgemcitabine 4 B/D PAgemcitabine hcl 4 B/D PAgemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml

4 B/D PA

gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA NDS

hydroxyurea 2INFUGEM 5 B/D PA NDSLONSURF TABS 8.19MG; 20MG

5 NDS QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 NDS QL(100/28)

mercaptopurine 2NIPENT 5 B/D PA NDSPURIXAN 5 NDS QL(300/30)TABLOID 4

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mitomycin inj 40mg 5 B/D PA NDSmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 3 B/D PANERLYNX 5 PA NDS QL(180/30)NINLARO 5 NDS QL(3/28)ODOMZO 5 NDS QL(30/30)ONCASPAR 5 B/D PA NDSoxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel 2 B/D PAPIQRAY 200MG DAILY DOSE 5 PA NDS QL(28/28)PIQRAY 250MG DAILY DOSE 5 PA NDS QL(56/28)PIQRAY 300MG DAILY DOSE 5 PA NDS QL(56/28)PORTRAZZA 5 B/D PA NDSPROLEUKIN 5 B/D PA NDSromidepsin 5 B/D PA NDSROZLYTREK CAPS 200MG 5 PA NDS QL(90/30)ROZLYTREK CAPS 100MG 5 PA NDS QL(150/30)RUBRACA 5 PA NDS QL(120/30)RYDAPT 5 PA NDS QL(224/28)SYLATRON 5 PA NDS QL(4/28)SYNRIBO 5 B/D PA NDS

QL(28/28)TALZENNA 5 PA NDS QL(90/30)TICE BCG 3TRISENOX 4 B/D PAVELCADE 5 PA NDS QL(14/21)VENCLEXTA STARTING PACK 5 NDS QL(84/365)VENCLEXTA TABS 50MG 4 QL(30/30)VENCLEXTA TABS 10MG 4 QL(60/30)VENCLEXTA TABS 100MG 5 NDS QL(120/30)VERZENIO 5 PA NDS QL(60/30)vinblastine sulfate 2 B/D PAvincristine sulfate 2 B/D PAvinorelbine tartrate inj 50mg/5ml

2 B/D PA

VITRAKVI CAPS 100MG 5 PA NDS QL(60/30)VITRAKVI CAPS 25MG 5 PA NDS QL(180/30)VITRAKVI ORAL SOLN 5 PA NDS QL(300/30)ZEJULA 5 PA NDS QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

decitabine 5 B/D PA NDSdexrazoxane 2 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PA NDSdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA NDS

doxorubicin hydrochloride liposomal

5 B/D PA NDS

doxorubicin hydrochloride liposome

5 B/D PA NDS

ELZONRIS 5 PA NDSepirubicin hcl inj 200mg/100ml 2 B/D PAERWINAZE 5 B/D PA NDS

QL(60/28)ETHYOL 5 B/D PA NDSfludarabine phosphate inj 50mg 2 B/D PAHALAVEN 5 NDSidarubicin hcl 5 B/D PA NDSidarubicin hydrochloride 5 B/D PA NDSINREBIC 5 PA NDS QL(120/30)irinotecan hcl 4 B/D PAirinotecan hydrochloride 4 B/D PAirinotecan inj 100mg/5ml, 500mg/25ml

4 B/D PA

ISTODAX (OVERFILL) 5 B/D PA NDSJEVTANA 5 PA NDSKISQALI 5 PA NDS QL(63/28)LARTRUVO 5 PA NDSleucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg

3

leucovorin calcium tabs 3levoleucovorin 5 NDSlevoleucovorin calcium 5 NDSLORBRENA TABS 100MG 5 PA NDS QL(30/30)LORBRENA TABS 25MG 5 PA NDS QL(90/30)LYNPARZA 5 NDS QL(120/30)MARQIBO 5 B/D PA NDSMEKTOVI 5 PA NDS QL(180/30)mesna 4 B/D PAMESNEX TABS 5 NDS

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CABOMETYX TABS 20MG, 60MG

5 PA NDS QL(30/30)

CABOMETYX TABS 40MG 5 PA NDS QL(60/30)CALQUENCE 5 PA NDS QL(60/30)CAPRELSA TABS 300MG 5 NDS QL(30/30)CAPRELSA TABS 100MG 5 NDS QL(60/30)COMETRIQ 100MG DAILY DOSE KIT

5 PA NDS QL(56/28)

COMETRIQ 60MG DAILY DOSE KIT

5 PA NDS QL(84/28)

COMETRIQ 140MG DAILY DOSE KIT

5 PA NDS QL(112/28)

COTELLIC 5 NDS QL(63/28)ERIVEDGE 5 NDS QL(28/28)erlotinib hydrochloride tabs 100mg, 150mg

5 NDS QL(30/30)

erlotinib hydrochloride tabs 25mg

5 NDS QL(60/30)

FARYDAK 5 NDS QL(6/21)GILOTRIF 5 NDS QL(30/30)IBRANCE 5 NDS QL(21/28)ICLUSIG TABS 45MG 5 NDS QL(30/30)ICLUSIG TABS 15MG 5 NDS QL(60/30)IDHIFA 5 PA NDS QL(30/30)imatinib mesylate 5 PA NDS QL(60/30)IMBRUVICA CAPS 70MG 5 PA NDS QL(30/30)IMBRUVICA CAPS 140MG 5 PA NDS QL(120/30)IMBRUVICA TABS 5 PA NDS QL(30/30)INLYTA 5 NDS QL(120/30)IRESSA 5 NDSJAKAFI 5 NDS QL(60/30)LENVIMA 10 MG DAILY DOSE 5 NDS QL(30/30)LENVIMA 12MG DAILY DOSE 5 NDS QL(90/30)LENVIMA 14 MG DAILY DOSE 5 NDS QL(60/30)LENVIMA 18 MG DAILY DOSE 5 NDS QL(90/30)LENVIMA 20 MG DAILY DOSE 5 NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZOLINZA 5 NDS QL(120/30)ZYKADIA 5 NDS QL(140/28)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 2 QL(60/30)letrozole 2 QL(30/30)Enzyme InhibitorsBALVERSA TABS 5MG 5 PA NDS QL(30/30)BALVERSA TABS 4MG 5 PA NDS QL(60/30)BALVERSA TABS 3MG 5 PA NDS QL(90/30)etoposide inj 2 B/D PAirinotecan hydrochloride 4 B/D PAKYPROLIS 5 B/D PA NDStoposar 2 B/D PAtopotecan hcl inj lyophilized 4mg

5 B/D PA NDS

topotecan hcl inj 4mg/4ml 4 B/D PAtopotecan hydrochloride 4 B/D PAMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 NDS QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 NDS QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 NDS QL(28/28)

AFINITOR TABS 10MG 5 NDS QL(56/28)ALECENSA 5 PA NDS QL(240/30)ALIQOPA 5 PA NDS QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA NDS QL(30/30)

ALUNBRIG TABS 30MG 5 PA NDS QL(180/30)ALUNBRIG TBPK 5 PA NDS QL(60/365)BOSULIF TABS 400MG, 500MG

5 NDS QL(30/30)

BOSULIF TABS 100MG 5 NDS QL(120/30)

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HERCEPTIN HYLECTA 5 PA NDSIMFINZI 5 PA NDSKADCYLA 5 B/D PA NDSKANJINTI INJ 420MG 5 PA NDSKEYTRUDA 5 B/D PA NDSLIBTAYO 5 PA NDS QL(7/21)LUMOXITI 5 PA NDSMVASI 5 PA NDSMYLOTARG 5 PA NDSOPDIVO 5 B/D PA NDS

QL(80/28)PERJETA 5 B/D PA NDSPOTELIGEO 5 PA NDSRITUXAN 5 PA NDSRITUXAN HYCELA 5 PA NDSTECENTRIQ INJ 1200MG/20ML

5 PA NDS QL(20/21)

TECENTRIQ INJ 840MG/14ML 5 PA NDS QL(28/28)UNITUXIN 5 B/D PA NDSVECTIBIX 5 PA NDSYERVOY INJ 50MG/10ML 5 PA NDSYERVOY INJ 200MG/40ML 5 PA NDS QL(80/21)Retinoidsbexarotene 5 NDSPANRETIN 5 NDSTARGRETIN GEL 5 NDS QL(60/30)tretinoin caps 5 NDS

Antiparasitics

Anthelminticsalbendazole 5 NDSALBENZA 5 NDSBILTRICIDE 4ivermectin tabs 3praziquantel 4AntiprotozoalsALINIA SUSR 5 NDS QL(150/30)ALINIA TABS 5 NDS QL(20/30)atovaquone 4atovaquone/proguanil hcl 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LENVIMA 24 MG DAILY DOSE 5 NDS QL(90/30)LENVIMA 4 MG DAILY DOSE 5 NDS QL(30/30)LENVIMA 8 MG DAILY DOSE 5 NDS QL(60/30)MEKINIST TABS 2MG 5 NDS QL(30/30)MEKINIST TABS 0.5MG 5 NDS QL(90/30)NEXAVAR 5 NDS QL(120/30)SPRYCEL 5 NDS QL(30/30)STIVARGA 5 NDSSUTENT 5 NDS QL(28/28)TAFINLAR 5 NDS QL(120/30)TAGRISSO 5 NDS QL(30/30)TARCEVA TABS 100MG, 150MG

5 NDS QL(30/30)

TARCEVA TABS 25MG 5 NDS QL(60/30)TASIGNA CAPS 150MG, 200MG

5 NDS QL(112/28)

TASIGNA CAPS 50MG 5 NDS QL(420/30)temsirolimus 5 B/D PA NDS

QL(4/28)TIBSOVO 5 PA NDS QL(60/30)TURALIO 5 PA NDS QL(120/30)TYKERB 5 NDS QL(180/30)VIZIMPRO 5 PA NDS QL(30/30)VOTRIENT 5 NDS QL(120/30)XALKORI 5 NDS QL(60/30)XOSPATA 5 PA NDS QL(90/30)ZALTRAP 5 B/D PA NDS

QL(40/28)ZELBORAF 5 NDS QL(240/30)ZYDELIG 5 NDS QL(60/30)ZYKADIA 5 NDS QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PA NDSBAVENCIO 5 B/D PA NDSBESPONSA 5 PA NDSCYRAMZA 5 B/D PA NDSDARZALEX 5 B/D PA NDSEMPLICITI 5 B/D PA NDSERBITUX 5 PA NDSGAZYVA 5 B/D PA NDS

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole er tb24 2mg, 4mg, 6mg, 8mg

4 QL(30/30)

ropinirole er tb24 12mg 4 QL(60/30)ropinirole hcl 2ropinirole hydrochloride tabs 0.25mg, 3mg

2

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 4carbidopa/levodopa 2carbidopa/levodopa er 3carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

3

RYTARY 4 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 3 QL(30/30)selegiline hcl 3ZELAPAR 5 NDS

Antipsychotics

1st Generation/Typicalchlorpromazine hcl 4fluphenazine decanoate 4fluphenazine hcl conc 4fluphenazine hcl inj 4fluphenazine hcl tabs 2fluphenazine hydrochloride 4haloperidol 2haloperidol decanoate 2haloperidol lactate 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

chloroquine phosphate 2COARTEM 4 QL(24/30)DARAPRIM 5 NDS QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 4 B/D PA QL(6/28)PENTAM 300 4pentamidine isethionate 4PRIMAQUINE PHOSPHATE 4quinine sulfate 4 PA QL(42/7)Pediculicides/Scabicidescrotan 4EURAX 4lindane 4malathion 4permethrin 2SKLICE 4

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAtrihexyphenidyl hydrochloride 2 PAAntiparkinson Agents, Otheramantadine hcl 3entacapone 4 QL(240/30)tolcapone 5 NDSDopamine AgonistsAPOKYN 5 PA NDS QL(60/30)bromocriptine mesylate 4NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA TRINZA INJ 546MG/1.75ML

5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 NDS QL(30/30)

LATUDA TABS 80MG 5 NDS QL(60/30)NUPLAZID 5 PA NDS QL(30/30)olanzapine 2 QL(30/30)olanzapine 2 QL(30/30)olanzapine odt 3 QL(30/30)paliperidone er tb24 1.5mg, 3mg

2 QL(30/30)

paliperidone er tb24 6mg 2 QL(60/30)paliperidone er tb24 9mg 5 NDS QL(30/30)PERSERIS 5 NDS QL(1/30)quetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

3 QL(60/30)

REXULTI 5 NDS QL(30/30)RISPERDAL CONSTA INJ 50MG

5 NDS QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

3 QL(60/30)

risperidone odt tbdp 4mg 3 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 NDS QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 3 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 NDS QL(1/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

loxapine caps 10mg, 5mg 2loxapine succinate 2molindone hydrochloride 2perphenazine 4pimozide 3prochlorperazine edisylate inj 10mg/2ml

4

prochlorperazine maleate 2thioridazine hcl 3thiothixene 4trifluoperazine hcl 32nd Generation/AtypicalABILIFY MAINTENA 5 NDS QL(1/28)aripiprazole odt 5 NDS QL(60/30)aripiprazole oral soln 3 QL(900/30)aripiprazole tabs 3 QL(30/30)ARISTADA INITIO 5 NDS QL(4.8/365)ARISTADA INJ 441MG/1.6ML 5 NDS QL(1.6/28)ARISTADA INJ 662MG/2.4ML 5 NDS QL(2.4/28)ARISTADA INJ 882MG/3.2ML 5 NDS QL(3.2/28)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/56)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 NDS QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 78MG/0.5ML

5 NDS QL(0.5/28)

INVEGA SUSTENNA INJ 117MG/0.75ML

5 NDS QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 NDS QL(1/28)


5 NDS QL(1.5/28)


4 QL(0.25/28)


5 QL(0.88/90)


5 QL(1.32/90)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU

5 NDS

INTRON A INJ 6000000UNIT/ML

4

lamivudine tabs 100mg 2Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 3 PA QL(28/28)HARVONI 3 QL(28/28)VOSEVI 5 PA NDS QL(30/30)Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA NDS QL(2/28)PEGASYS INJ 180MCG/ML 5 PA NDS QL(4/28)PEGASYS PROCLICK 5 PA NDS QL(2/28)ribavirin caps 3 QL(168/28)ribavirin tabs 3 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 NDS QL(30/30)DELSTRIGO 5 NDS QL(30/30)DOVATO 5 NDS QL(30/30)GENVOYA 5 NDS QL(30/30)ISENTRESS CHEW 100MG 5 NDS QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS HD 5 NDS QL(60/30)ISENTRESS PACK 5 NDS QL(180/30)ISENTRESS TABS 5 NDS QL(60/30)JULUCA 5 NDS QL(30/30)TIVICAY TABS 25MG, 50MG 5 NDS QL(60/30)TIVICAY TABS 10MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 NDS QL(30/30)EDURANT 5 NDS QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 NDS QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZYPREXA RELPREVV INJ 300MG

5 NDS QL(2/28)

Treatment-Resistantclozapine odt tbdp 200mg 5 NDS QL(120/30)clozapine odt tbdp 12.5mg, 25mg

4

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine tabs 25mg, 50mg 2clozapine tabs 200mg 2 QL(120/30)clozapine tabs 100mg 2 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 2dantrolene sodium caps 3tizanidine hcl caps 4tizanidine hcl tabs 2tizanidine hydrochloride tabs 4mg

2

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5 NDSganciclovir inj 500mg, 500mg/10ml

2 B/D PA

valganciclovir 5 NDSvalganciclovir hydrochlorde 5 NDSZIRGAN 3Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 4 QL(30/30)BARACLUDE ORAL SOLN 4 QL(630/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 4

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 NDS QL(30/30)FUZEON 5 NDS QL(60/30)SELZENTRY ORAL SOLN 5 NDS QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 NDS QL(60/30)

SELZENTRY TABS 300MG 5 NDS QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TROGARZO 5 B/D PA NDSTYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 NDS QL(120/30)APTIVUS ORAL SOLN 5 NDS QL(285/28)atazanavir sulfate caps 300mg 5 NDS QL(30/30)atazanavir sulfate caps 200mg 5 NDS QL(60/30)atazanavir sulfate caps 150mg 4 QL(30/30)CRIXIVAN CAPS 400MG 4 QL(180/30)CRIXIVAN CAPS 200MG 4 QL(270/30)EVOTAZ 5 NDS QL(30/30)fosamprenavir calcium 5 NDS QL(120/30)INVIRASE 5 NDS QL(120/30)KALETRA TABS 200MG; 50MG

5 NDS QL(120/30)

KALETRA TABS 100MG; 25MG

4 QL(300/30)

LEXIVA SUSP 4 QL(1575/28)lopinavir/ritonavir 4 QL(480/30)NORVIR ORAL SOLN 4 QL(480/30)NORVIR PACK 4 QL(360/30)NORVIR TABS 4 QL(360/30)PREZCOBIX 5 NDS QL(30/30)PREZISTA SUSP 5 NDS QL(400/30)PREZISTA TABS 800MG 5 NDS QL(30/30)PREZISTA TABS 600MG 5 NDS QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 3 QL(210/30)REYATAZ PACK 5 NDS QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTELENCE TABS 100MG, 200MG

5 NDS QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 3 QL(30/30)nevirapine er tb24 100mg 3 QL(90/30)nevirapine susp 2 QL(1200/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 NDS QL(30/30)PIFELTRO 5 NDS QL(30/30)RESCRIPTOR 4 QL(180/30)STRIBILD 5 NDS QL(30/30)SYMFI 5 NDS QL(30/30)SYMFI LO 5 NDS QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine 5 NDS QL(30/30)abacavir sulfate/lamivudine/zidovudine

5 NDS QL(60/30)

abacavir tabs 2 QL(60/30)CIMDUO 5 NDS QL(30/30)DESCOVY 5 NDS QL(30/30)didanosine 3 QL(30/30)EMTRIVA CAPS 4 QL(30/30)EMTRIVA ORAL SOLN 4 QL(680/28)lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 2 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)tenofovir disoproxil fumarate 5 NDS QL(30/30)TRIUMEQ 5 NDS QL(30/30)TRUVADA 5 NDS QL(30/30)VIDEX EC CPDR 125MG 4VIDEX PEDIATRIC 4 QL(1200/30)VIREAD POWD 5 NDS QL(240/30)VIREAD TABS 150MG, 200MG, 250MG

5 NDS QL(30/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam conc 2 QL(240/30)diazepam inj 5mg/ml 2diazepam intensol 2 QL(240/30)diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood StabilizersLITHIUM 3lithium carbonate 2lithium carbonate er 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 1 QL(90/30)AVANDIA 4 QL(60/30) STBYDUREON BCISE 4 QL(4/28)BYDUREON PEN 4 QL(4/28)FARXIGA 3 QL(30/30)glimepiride tabs 4mg 1 QL(60/30)glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 1 QL(60/30)glipizide er tb24 5mg 1 QL(120/30)glipizide er tb24 2.5mg 1 QL(240/30)glipizide tabs 5mg 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ritonavir 4 QL(360/30)SYMTUZA 5 NDS QL(30/30)VIRACEPT TABS 625MG 5 NDS QL(120/30)VIRACEPT TABS 250MG 5 NDS QL(270/30)Anti-influenzaAgentsoseltamivir phosphate 3rimantadine hcl 2XOFLUZA 4Antiherpetic Agentsacyclovir caps 2acyclovir crea 5 NDS QL(5/30)acyclovir oint 4 QL(30/30)acyclovir sodium 2 B/D PAacyclovir susp 4acyclovir tabs 2famciclovir 3 QL(60/30)trifluridine 3valacyclovir hcl 2 QL(30/30)valacyclovir hydrochloride 2 QL(30/30)ZOVIRAX CREA 5 NDS QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl 2buspirone hydrochloride tabs 10mg, 5mg, 7.5mg

2

doxepin hcl 3 PAdoxepin hydrochloride caps 25mg

3 PA

Benzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

3 QL(90/30)

alprazolam odt tbdp 2mg 3 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pioglitazone hcl-glimepiride 3 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)pioglitazone hydrochloride tabs 15mg, 30mg

1 QL(30/30)

repaglinide tabs 0.5mg, 1mg 2 QL(120/30)repaglinide tabs 2mg 2 QL(240/30)RIOMET 3 QL(750/30)SYMLINPEN 120 4 QL(10.8/28)SYMLINPEN 60 4 QL(6/30)SYNJARDY 3 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

3 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

3 QL(60/30)

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsBAQSIMI ONE PACK 3 QL(2/30)BAQSIMI TWO PACK 3 QL(2/30)GLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG JUNIOR KWIKPEN 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide xl tb24 5mg 1 QL(120/30)glipizide xl tb24 2.5mg 1 QL(240/30)glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hydrochloride tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 3 QL(30/30)INVOKAMET 4 QL(60/30)INVOKAMET XR 4 QL(60/30)INVOKANA 4 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 3 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hydrochloride oral soln

3 QL(750/30)

metformin hydrochloride tabs 1000mg

1 QL(60/30)


1 QL(90/30)


1 QL(150/30)

miglitol 4 QL(90/30)nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/28)pioglitazone hcl 1 QL(30/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELIQUIS TABS 5MG 3 QL(74/30)enoxaparin sodium 3fondaparinux sodium inj 5mg/0.4ml

5 NDS QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 NDS QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 NDS QL(24/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML

4 QL(6/30) ST

FRAGMIN INJ 7500UNIT/0.3ML

5 NDS QL(9/30) ST


5 NDS QL(15/30) ST


5 NDS QL(18/30) ST

FRAGMIN INJ 18000UNT/0.72ML

5 NDS QL(21.6/30) ST


5 NDS QL(22.8/30) ST

FRAGMIN INJ 10000UNIT/ML 5 NDS QL(30/30) STheparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

2

heparin sodium inj 5000unit/ml 3HEPARIN SODIUM/D5W 4HEPARIN SODIUM/DEXTROSE

4

heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3NOVOLIN 70/30 4 STNOVOLIN 70/30 RELION 4 STNOVOLIN N 4 STNOVOLIN N RELION 4 STNOVOLIN R 4 STNOVOLIN R INNOLET 4 STNOVOLIN R RELION 4 STNOVOLOG 4 STNOVOLOG FLEXPEN 4 STNOVOLOG MIX 70/30 4 STNOVOLOG MIX 70/30 PREFILLED FLEXPEN

4 ST

NOVOLOG PENFILL 4 STSOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA 3TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 3 QL(74/30)ELIQUIS TABS 2.5MG 3 QL(60/30)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROMACTA TABS 5 PA NDS QL(30/30)ZARXIO 5 NDSHemostasis Agentsaminocaproic acid inj 2RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA QL(12/28)

RETACRIT INJ 40000UNIT/ML 5 PA NDS QL(6/28)tranexamic acid inj 2tranexamic acid tabs 3 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 3 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)prasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 1clonidine hydrochloride tabs 1midodrine hcl 2Alpha-adrenergic Blocking Agentsdoxazosin mesylate tabs 1mg, 2mg, 4mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)phenoxybenzamine hydrochloride

5 NDS

prazosin hcl 2prazosin hydrochloride caps 2mg

2

terazosin hcl caps 1mg, 5mg 2terazosin hcl caps 10mg 2 QL(60/30)terazosin hydrochloride 2Angiotensin II Receptor AntagonistsEDARBI 4 QL(30/30) STEDARBYCLOR 4 ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9%

4

heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45%

4

jantoven 2PRADAXA 4 QL(60/30)warfarin sodium 2XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 10MG, 20MG 3 QL(30/30)XARELTO TABS 15MG, 2.5MG 3 QL(60/30)BloodFormationModifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA NDS QL(1/21)

ARANESP ALBUMIN FREE INJ 150MCG/0.3ML

5 PA NDS QL(1.2/28)


5 PA NDS QL(1.6/28)


5 PA NDS QL(2/28)


5 PA NDS QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA NDS QL(4/28)


4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)


4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

LEUKINE INJ 250MCG 5 PA NDSMOZOBIL 5 NDS QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA NDS QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA NDS QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA QL(12/28)

PROMACTA PACK 5 PA NDS QL(360/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 1perindopril erbumine 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril hydrochloride tabs 10mg

1 QL(60/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

1 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 1 QL(30/30)trandolapril tabs 2mg, 4mg 1 QL(60/30)trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg

2 QL(30/30)

trandolapril/verapamil hcl er tbcr 4mg; 240mg

2 QL(60/30)

Antiarrhythmicsamiodarone hcl inj 50mg/ml, 900mg/18ml

2

amiodarone hcl tabs 2amiodarone hydrochloride inj 2dofetilide 4 QL(60/30)flecainide acetate 2lidocaine hcl inj 100mg/5ml, 50mg/5ml

2

mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2procainamide hcl 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENTRESTO 3 PA QL(60/30)irbesartan tabs 300mg 1 QL(30/30)irbesartan tabs 150mg, 75mg 1 QL(60/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium 1 QL(60/30)losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 4olmesartan medoxomil/hydrochlorothiazide

4

telmisartan tabs 20mg, 40mg 1 QL(30/30)telmisartan tabs 80mg 1 QL(60/30)valsartan tabs 320mg 1 QL(30/30)valsartan tabs 160mg, 40mg, 80mg

1 QL(60/30)

valsartan/hydrochlorothiazide 1 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

1 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

1 QL(60/30)

benazepril hydrochloride 1 QL(60/30)enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide

1

enalaprilat 2fosinopril sodium 1 QL(60/30)fosinopril sodium/hydrochlorothiazide

1 QL(120/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propranolol hcl er cp24 120mg, 60mg

2

propranolol hcl inj 2propranolol hcl oral soln 2propranolol hcl tabs 40mg, 80mg

1

propranolol hydrochloride er 2propranolol hydrochloride tabs 10mg, 20mg, 60mg

1

propranolol/hydrochlorothiazide 2timolol maleate tabs 4Calcium Channel Blocking Agentsamlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hcl caps 5mg; 40mg

1 QL(60/30)

amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

1 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

1 QL(60/30)

amlodipine besylate/valsartan 1amlodipine/valsartan/hctz 2amlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg

2

CARDENE IV 4cartia xt 2dilt-cd cp24 180mg, 240mg 2dilt-xr 2diltiazem cd cp24 180mg 2diltiazem hcl 2diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg

2

diltiazem hcl er tb24 2diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg

2

felodipine er 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

procainamide hydrochloride inj 500mg/ml

2

propafenone hcl 2propafenone hydrochloride er 4quinidine sulfate 2sorine 2sotalol hcl (af) 2sotalol hcl af 2sotalol hcl tabs 160mg, 240mg, 80mg

2

sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride af 2sotalol hydrochloride tabs 120mg, 80mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl caps 200mg 2acebutolol hydrochloride caps 400mg

2

atenolol 1atenolol/chlorthalidone 2betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

2

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)carvedilol 1carvedilol phosphate 4 QL(30/30)labetalol hydrochloride inj 5mg/ml

2

labetalol hydrochloride tabs 2metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 2metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 3nadolol/bendroflumethiazide 3pindolol 2propranolol hcl er cp24 160mg 3

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RANEXA 3 QL(60/30)ranolazine er 3 QL(60/30)TEKTURNA 4 QL(30/30)TEKTURNA HCT 4 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 3acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide 2ethacrynate sodium 2ethacrynic acid 3furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 2DYRENIUM 4eplerenone 2spironolactone 1spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide caps

2

triamterene/hydrochlorothiazide tabs

1

Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 1hydrochlorothiazide 1indapamide 2metolazone 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isradipine 3matzim la 2nicardipine hcl 2nifedipine er tb24 90mg 2 QL(30/30)nifedipine er tb24 30mg, 60mg 2 QL(60/30)taztia xt cp24 120mg, 180mg, 240mg, 300mg

2

verapamil hcl 1verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl sr cp24 120mg, 180mg, 240mg

2 QL(30/30)

VERAPAMIL HCL SR CP24 360MG

3 QL(30/30)

verapamil hydrochloride inj 2verapamil hydrochloride tabs 1Cardiovascular Agents, Otheraliskiren 4 QL(30/30)atropine sulfate inj 0.5mg/5ml 4CORLANOR TABS 4 PA QL(60/30)DEMSER 3digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 2 PADIGOXIN ORAL SOLN 3 PA QL(150/30)digoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PALANOXIN TABS 62.5MCG 4 QL(30/30)NORTHERA CAPS 100MG 5 PA NDS QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA NDS QL(180/30)

pentoxifylline er 2

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REPATHA SURECLICK 5 PA NDSVASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)Vasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2hydralazine hydrochloride tabs 100mg, 25mg, 50mg

2

minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 4 QL(180/30)isosorbide dinitrate er 2isosorbide dinitrate tabs 3isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)NITRO-BID 4NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR

4

nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2nitroglycerin transdermal 2 QL(30/30)RECTIV 4 QL(30/30)

Central Nervous System Agents

AttentionDeficitHyperactivityDisorderAgents,Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

3 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 134mg, 200mg 3 QL(30/30)fenofibrate caps 67mg 3 QL(60/30)fenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

3 QL(30/30)

fenofibrate micronized caps 67mg

3 QL(60/30)

fenofibrate tabs 145mg, 160mg 3 QL(30/30)fenofibrate tabs 48mg, 54mg 3 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 4 QL(30/30) STLIVALO 3 QL(30/30) STlovastatin tabs 10mg, 20mg 1 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 1 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 3ezetimibe 2 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacin tabs 500mg 2niacor 2omega-3-acid ethyl esters 4 QL(120/30)PRALUENT 5 PA NDSprevalite 2REPATHA 5 PA NDSREPATHA PUSHTRONEX SYSTEM

5 PA NDS

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methylphenidate hydrochloride chew 2.5mg, 5mg

3 QL(90/30)

methylphenidate hydrochloride chew 10mg

3 QL(180/30)

methylphenidate hydrochloride er cp24 20mg, 30mg, 40mg

4 QL(30/30)

methylphenidate hydrochloride er cpcr 30mg, 40mg

4 QL(30/30)

methylphenidate hydrochloride er tb24 27mg, 54mg

4 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

4 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

4 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg

4 QL(30/30)


4 QL(60/30)


4 QL(90/30)

methylphenidate hydrochloride oral soln

3 QL(900/30)

methylphenidate hydrochloride tabs

3 QL(90/30)

Central Nervous System, OtherHETLIOZ 5 PA NDS QL(30/30)HORIZANT 4LYRICA CR TB24 330MG 3 QL(60/30)LYRICA CR TB24 165MG, 82.5MG

3 QL(90/30)

NUEDEXTA 4 PA QL(60/30)riluzole 2tetrabenazine tabs 12.5mg 5 NDS QL(90/30)tetrabenazine tabs 25mg 5 NDS QL(120/30)Fibromyalgia AgentsSAVELLA 4 QL(60/30)SAVELLA TITRATION PACK 4 QL(110/365)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

3 QL(60/30)


3 QL(90/30)


3 QL(120/30)

dextroamphetamine sulfate oral soln

3 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

3 QL(60/30)

dextroamphetamine sulfate tabs 10mg

3 QL(180/30)

AttentionDeficitHyperactivityDisorderAgents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl tabs 10mg

2 QL(60/30)

dexmethylphenidate hydrochloride tabs 2.5mg, 5mg

2 QL(60/30)

metadate er 4 QL(90/30)methylphenidate hydrochloride cd

4 QL(30/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

calcipotriene oint 3 QL(120/30)calcitrene 4 QL(120/30)claravis 4clindamycin phosphate/tretinoin 4CONDYLOX 4CURITY GAUZE PADS 2”X2” 3diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium gel 3% 5 NDS QL(100/30)DRITHO-CREME HP 3ELIDEL 4 QL(100/90)erythromycin/benzoyl peroxide 4FINACEA 4fluorouracil crea 5% 3fluorouracil crea 0.5% 5 NDSfluorouracil external soln 2imiquimod 3 QL(12/30)isotretinoin 4LEVULAN KERASTICK 3methoxsalen 4myorisan 4ORACEA 4PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)pimecrolimus 4 QL(100/90)podocon 25 in benzoin tincture 2podofilox 2REGRANEX 5 PA NDS QL(15/30)SANTYL 3selenium sulfide lotn 2tazarotene 4TAZORAC CREA 4TAZORAC GEL 4 QL(100/30)TOLAK 4tretinoin crea 4 PA QL(45/30)tretinoin gel 0.025% 4 PAtretinoin gel 0.05% 4 PA QL(45/30)tretinoin gel 0.01% 3 PA QL(45/30)tretinoin microsphere 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Multiple Sclerosis AgentsAMPYRA 5 PA NDS QL(60/30)AVONEX 5 PA NDS QL(4/28)AVONEX PEN 5 PA NDS QL(4/28)COPAXONE INJ 40MG/ML 5 PA NDS QL(12/28)COPAXONE INJ 20MG/ML 5 PA NDS QL(30/30)dalfampridine er 4 PA QL(60/30)EXTAVIA 5 PA NDS QL(15/30)TECFIDERA CPDR 120MG 5 PA NDS QL(14/30)TECFIDERA CPDR 240MG 5 PA NDS QL(60/30)TECFIDERA STARTER PACK 5 PA NDS

QL(120/365)TYSABRI 5 PA NDS QL(15/28)

Dental and Oral Agents

Dental and Oral Agentscevimeline hcl 2chlorhexidine gluconate mouth/throat soln

2

dentagel 2KEPIVANCE 5 NDSoralone dental paste 3paroex 2pilocarpine hcl tabs 3pilocarpine hydrochloride tabs 5mg

3

sf 2triamcinolone acetonide dental paste

3

Dermatological Agents

Dermatological Agentsacitretin 4adapalene crea 3adapalene gel 3ammonium lactate 2amnesteem 4azelaic acid 4AZELEX 3calcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX 4.25%/DEXTROSE 5%

3 B/D PA

CLINIMIX 5%/DEXTROSE 15% 3 B/D PACLINIMIX 5%/DEXTROSE 20% 3 B/D PACLINIMIX 5%/DEXTROSE 25% 3 B/D PACLINIMIX E 2.75%/DEXTROSE 5%

3 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

3 B/D PA

CLINIMIX E 4.25%/DEXTROSE 5%

3 B/D PA

CLINIMIX E 5%/DEXTROSE 15%

3 B/D PA

CLINIMIX E 5%/DEXTROSE 20%

3 B/D PA

CLINISOL SF 15% 3 B/D PAclinpro 5000 2cytra k crystals 2denta 5000 plus 2dextrose 4 B/D PADEXTROSE10%/NACL 0.45% 3 B/D PADEXTROSE5% /ELECTROLYTE #48 VIAFLEX

3 B/D PA

dextrose 10% 4 B/D PADEXTROSE 10%/NACL 0.2% 3 B/D PAdextrose 2.5%/nacl 0.45% 3 B/D PAdextrose 20% 4 B/D PAdextrose 25% 4 B/D PAdextrose 30% 4 B/D PAdextrose 40% 4 B/D PAdextrose 5% 2DEXTROSE 5%/LACTATED RINGERS

3 B/D PA

DEXTROSE 5%/NACL 0.2% 3DEXTROSE 5%/NACL 0.225% 3 B/D PADEXTROSE 5%/NACL 0.3% 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tretinoin microsphere pump gel 0.1%

4 PA

zenatane 4

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML

3 B/D PA

AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

4 B/D PA

AMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 3 B/D PAcalcium gluconate inj 10% 2CARBAGLU 5 PA NDSCLINIMIX 4.25%/DEXTROSE 10%

3 B/D PA

CLINIMIX 4.25%/DEXTROSE 25%

3 B/D PA

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

klor-con 10 3klor-con 8 3klor-con m10 2klor-con m15 2klor-con m20 2klor-con sprinkle 2klor-con/ef 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

3

LACTATED RINGERS VIAFLEX

3

ludent 2magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%

4 B/D PA

NEPHRAMINE 3 B/D PANORMOSOL -R 3 B/D PANORMOSOL-M IN D5W 3 B/D PANORMOSOL-R 3 B/D PANORMOSOL-R IN D5W 3 B/D PAPERIKABIVEN 4 B/D PAPLASMA-LYTE A 3 B/D PAPLASMA-LYTE-148 3 B/D PAPLENAMINE 3 B/D PApotassium chloride cr 2potassium chloride er 2POTASSIUM CHLORIDE INJ 10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML, 2MEQ/ML, 40MEQ/100ML

4 B/D PA

potassium chloride inj 2meq/ml 4 B/D PApotassium chloride oral soln 3potassium chloride pack 2potassium chloride sr 2POTASSIUM CHLORIDE/DEXTROSE INJ 5%; 20MEQ/L, 5%; 40MEQ/L

3 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS

3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DEXTROSE 5%/NACL 0.33% 3DEXTROSE 5%/NACL 0.45% 3dextrose 5%/nacl 0.9% 3dextrose 50% 4 B/D PAdextrose 70% 4effer-k tbef 25meq 2effervescent potassium 2fluoride chew 0.25mg 2fluoritab chew 0.5mg, 1mg 2fluoritab oral soln 2flura-drops 2FREAMINE HBC 6.9% 3 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 3 B/D PAhyperlyte-cr 2 B/D PAIONOSOL-MB/DEXTROSE 5% 3ISOLYTE-P/DEXTROSE 5% 3ISOLYTE-S 3 B/D PAISOLYTE-S PH 7.4 3 B/D PAK-PHOS 3K-PHOS NO 2 3K-TAB 3KABIVEN 4 B/D PAKCL 0.075%/D5W/NACL 0.45% 3 B/D PAKCL 0.15%/D5W/NACL 0.2% 3 B/D PAKCL 0.15%/D5W/NACL 0.225% 3 B/D PAKCL 0.15%/D5W/NACL 0.45% 3 B/D PAKCL 0.15%/D5W/NACL 0.9% 3 B/D PAKCL 0.3%/D5W/NACL 0.45% 3 B/D PAKCL 0.3%/D5W/NACL 0.9% 3 B/D PAklor-con 2

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium fluoride chew 0.25mg, 0.5mg, 1mg

2

sodium fluoride oral soln 2SODIUM LACTATE INJ 5MEQ/ML

3 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

4 B/D PA

TROPHAMINE INJ 54.4MEQ/L; 0.32GM/100ML; 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML

3 B/D PA

Electrolyte/Mineral/MetalModifiersCUPRIMINE 5 NDSFERRIPROX 5 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE

3 B/D PA

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 20MEQ/L; 0.45%, 20MEQ/L; 0.9%, 40MEQ/L; 0.9%

3 B/D PA

potassium citrate er 3potassium citrate/citric acid 2PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML

3 B/D PA

PROCALAMINE 3 B/D PAPROSOL 4 B/D PAringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l

3

sf 5000 plus 2sodium bicarbonate inj 2 B/D PASODIUM CHLORIDE 0.45% 4SODIUM CHLORIDE INJ 0.45%, 0.9%, 3%, 5%

4

sodium citrate/citric acid 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.5mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1mg; 1.05mg; 15unit; 2500unit

2

multivitamin/fluoride oral soln 2multivitamin/fluoride/iron 2multivitamins/fluoride 2mvc-fluoride 2quflora pediatric chew 2quflora pediatric oral soln 45mg/ml; 400unit/ml; 1mg/ml; 3mcg/ml; 81mcg/ml; 150mcg/ml; 12mg/ml; 2mg/ml; 1mg/ml; 1mg/ml; 0.5mg/ml; 1mg/ml; 1100unit/ml; 12unit/ml

2

tri-vitamin/fluoride 2tri-vite/fluoride 2vitamins a/c/d/fluoride 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.4mg/ml, 1mg/ml

2

atropine sulfate inj 0.25mg/5ml 4dicyclomine hcl oral soln 3dicyclomine hydrochloride caps 2dicyclomine hydrochloride tabs 2ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 1mg, 2mg 2hyoscyamine sulfate elix 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JADENU 5 NDSJADENU SPRINKLE 5 NDSkionex 2penicillamine 5 NDSSAMSCA TABS 15MG 5 NDS QL(30/30)SAMSCA TABS 30MG 5 NDS QL(60/30)sodium polystyrene sulfonate powd

2

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

2

sps 2SYPRINE 5 NDStrientine hydrochloride 5 NDSVELTASSA 3Phosphate Binderscalcium acetate caps 2calcium acetate tabs 667mg 2PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)sevelamer carbonate pack 4 QL(180/30)sevelamer carbonate tabs 4 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsadc/fluoride 2multi-vitamin/fluoride drops 2multivitamin with fluoride chew 2multivitamin with fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml; 5unit/ml

2

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml

2

Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 1mg

5 PA NDS QL(60/30)

alosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2GOLYTELY 3lactulose oral soln 2MOVIPREP 3NULYTELY/FLAVOR PACKS 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 2sucralfate 2Proton Pump InhibitorsDEXILANT 4 QL(60/30) STesomeprazole magnesium 3 QL(60/30)lansoprazole cpdr 3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hyoscyamine sulfate tbdp 2methscopolamine bromide 3nulev 2oscimin 2propantheline bromide 4Gastrointestinal Agents, OtherCHENODAL 5 NDScromolyn sodium conc 4diphenoxylate/atropine liqd 3diphenoxylate/atropine tabs 2GATTEX 5 PA NDSloperamide hcl caps 2metoclopramide hcl 2metoclopramide hydrochloride 2OSMOPREP 4RELISTOR INJ 8MG/0.4ML 5 PA NDS

QL(11.2/28)RELISTOR INJ 12MG/0.6ML 5 PA NDS

QL(16.8/28)TRULANCE 4 QL(30/30)ursodiol 3Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 2famotidine premixed 2famotidine susr 2famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl inj 2ranitidine hcl syrp 2ranitidine hcl tabs 150mg, 300mg

2

ranitidine hydrochloride caps 2

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trospium chloride 2 QL(60/30)trospium chloride er 3 QL(30/30)VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

finasteride tabs 5mg 2 QL(30/30)tamsulosin hydrochloride 2 QL(60/30)Genitourinary Agents, Otheracetic acid 0.25% 3bethanechol chloride 2ELMIRON 4LITHOSTAT 4

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ala-cort crea 1% 2alclometasone dipropionate 2augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone sodium phosphate/betamethasone acetate

2

betamethasone valerate crea 2betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate emollient crea

2

clobetasol propionate emollient foam

4

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate liqd 4clobetasol propionate lotn 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 2 QL(60/30)

GeneticorEnzymeDisorder:Replacement,Modifiers,Treatment

GeneticorEnzymeDisorder:Replacement,Modifiers,TreatmentALDURAZYME 5 NDSCEREZYME 5 B/D PA NDSCREON 3CYSTADANE 5 NDSCYSTAGON 4ELAPRASE 5 NDSELELYSO 5 NDSFABRAZYME 5 B/D PA NDSKUVAN 5 PA NDSLUMIZYME 5 NDSmiglustat 5 NDS QL(90/30)NAGLAZYME 5 NDSNITISINONE CAPS 2MG 5 NDSnitisinone caps 10mg, 5mg 5 NDSORFADIN 5 NDSRAVICTI 5 PA NDS QL(525/30)sodium phenylbutyrate 5 PA NDSXIAFLEX 5 PA NDSZENPEP 3

Genitourinary Agents

Antispasmodics, Urinaryflavoxate hcl 2GELNIQUE PUMP 4 QL(30/30)MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 5mg

2 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

2 QL(60/30)

oxybutynin chloride syrp 2 QL(600/30)oxybutynin chloride tabs 2 QL(120/30)solifenacin succinate 2 QL(30/30)tolterodine tartrate 3 QL(60/30)tolterodine tartrate er 4 QL(30/30)

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocortisone butyrate external soln

3

hydrocortisone butyrate oint 3hydrocortisone external crea 2hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 2hydrocortisone tabs 2hydrocortisone valerate 3MEDROL TABS 2MG 4methylprednisolone acetate inj 80mg/ml

2

methylprednisolone dose pack 2methylprednisolone sodiumsuccinate inj 125mg, 40mg

2

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2PANDEL 3prednicarbate 2prednisolone 3prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

3

prednisone 2prednisone intensol 4procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2SOLU-CORTEF 3SOLU-MEDROL INJ 500MG 3SOLU-MEDROL INJ 2GM 3 HI

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clobetasol propionate oint 2clobetasol propionate sham 4clocortolone pivalate 2clodan 4CLODERM 4CORDRAN TAPE 4CORTIFOAM 5 NDScortisone acetate 3DEPO-MEDROL INJ 20MG/ML 4DESONATE 4desonide 3desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone 2dexamethasone intensol 4dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

2

fludrocortisone acetate 2fluocinolone acetonide 2fluocinolone acetonide body 4fluocinolone acetonide scalp 4fluocinonide crea 0.1% 4fluocinonide crea 0.05% 2fluocinonide external soln 3fluocinonide gel 2fluocinonide oint 3fluticasone propionate crea 2fluticasone propionate lotn 2fluticasone propionate oint 2halobetasol propionate crea 3halobetasol propionate oint 3hydrocortisone butyrate crea 4

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EstrogensALORA 4 PA QL(8/28)altavera 2alyacen 1/35 2amabelz 2 PAamethia 2 QL(91/91)amethia lo 2 QL(91/91)ANGELIQ 4 PAapri 2aranelle 2ashlyna 2 QL(91/91)aubra 2aviane 2azurette 2balziva 2blisovi 24 fe 2blisovi fe 1.5/30 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2chateal 2CLIMARA PRO 4 PA QL(4/28)COMBIPATCH 4 PA QL(8/28)cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2cyred eq 2daysee 2 QL(91/91)delyla 2DEPO-ESTRADIOL 3desogestrel/ethinyl estradiol 2DIVIGEL 4 QL(30/30)dotti 2 PA QL(8/28)drospirenone/ethinyl estradiol 2emoquette 2enpresse-28 2enskyce 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TEXACORT 3triamcinolone acetonide aers 4triamcinolone acetonide crea 2triamcinolone acetonide inj 40mg/ml

2

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2triderm crea 0.1% 2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)ACTHAR 5 PA NDS QL(5/5)desmopressin acetate inj 2desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2EGRIFTA 5 PA NDS QL(60/30)GENOTROPIN 5 PA NDSGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA NDS

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

INCRELEX 4 PA

Hormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PA NDSoxandrolone tabs 2.5mg 3 PA QL(120/30)oxandrolone tabs 10mg 4 PA QL(60/30)Androgensdanazol 4testosterone cypionate 2testosterone enanthate 2 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

3 QL(300/30)

testosterone pump gel 1% 3 QL(300/30)

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

larin fe 1/20 2larissia 2layolis fe 4leena 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg

2

levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

levora 0.15/30-28 2lopreeza 2 PAloryna 2low-ogestrel 2lutera 2marlissa 2melodetta 24 fe 2MENEST 4 PAMENOSTAR 4 PA QL(4/28)mibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mili 2mimvey 2 PAmimvey lo 2 PAmono-linyah 2necon 0.5/35-28 2nikki 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

estarylla 2estradiol crea 3estradiol pttw 2 PA QL(8/28)estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol/norethindrone acetate 2 PAESTRING 4 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2femynor 2fyavolv 2 PAgianvi 2hailey 24 fe 2introvale 2 QL(91/91)isibloom 2jasmiel 2jinteli 2 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2junel fe 24 2kaitlib fe 4kariva 2kelnor 1/35 2kelnor 1/50 2kurvelo 2larin 1.5/30 2larin 1/20 2larin 24 fe 2larin fe 1.5/30 2

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-lo-marzia 2tri-lo-sprintec 2tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2tri-vylibra lo 2trivora-28 2tydemy 2velivet 2vienva 2viorele 2vyfemla 2vylibra 2wymzya fe 2xulane 4 QL(3/28)yuvafem 4 QL(18/28)zarah 2zovia 1/35e 2Progesterone Agonists/AntagonistsMAKENA 5 PA NDSProgestinscamila 2deblitane 2DEPO-PROVERA 3 QL(10/28)DEPO-SUBQ PROVERA 104 3 QL(0.65/90)errin 2heather 2hydroxyprogesterone caproate 5 PA NDSincassia 2jencycla 2lyza 2MAKENA 5 PA NDSmedroxyprogesterone acetate inj

2 QL(1/90)

medroxyprogesterone acetate tabs

2

megestrol acetate susp 40mg/ml

2 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone & ethinyl estradiol ferrous fumarate

4

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

2 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norethindrone/ethinyl estradiol/ferrous fumarate

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2NUVARING 4 QL(1/28)ocella 2ogestrel 3orsythia 2ORTHO TRI-CYCLEN LO 4pimtrea 2pirmella 1/35 2portia-28 2PREFEST 4 PAPREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)PREMPHASE 4 PAPREMPRO 4 PAprevifem 2reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina 24 fe 2tarina fe 1/20 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA NDS

QL(4/365)leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA NDS QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA NDS QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate 4 PASANDOSTATIN LAR DEPOT 5 PA NDSSIGNIFOR 5 NDS QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA NDS QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA NDS QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA NDS QL(0.5/28)

SOMAVERT 5 NDS QL(30/30)SYNAREL 5 PA NDSTRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA NDS QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

TRIPTODUR 5 PA NDS QL(1/168)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

megestrol acetate susp 625mg/5ml

4 PA

megestrol acetate tabs 2 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone 2sharobel 2Selective Estrogen Receptor Modifying AgentsDUAVEE 4 PA QL(30/30)raloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium inj 100mcg/5ml, 200mcg/5ml, 500mcg/5ml

5

levothyroxine sodium inj 100mcg, 200mcg, 500mcg

5 NDS

levothyroxine sodium tabs 2LEVOXYL 3liothyronine sodium 2SYNTHROID 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5 NDS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 3 QL(16/28)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML

5 PA NDS QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

5 PA NDS QL(6/365)

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML

5 PA NDS QL(8/365)

methotrexate sodium 2methotrexate tabs 2mycophenolate mofetil caps 2 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PA NDSmycophenolate mofetil tabs 2 PAmycophenolic acid dr 3 PANEORAL 4 PANULOJIX 5 PA NDS QL(150/30)ORENCIA INJ 250MG 5 PA NDSPROGRAF INJ 4 PAPROGRAF PACK 4 PARAPAMUNE ORAL SOLN 5 PA NDSRENFLEXIS 5 PA NDSSANDIMMUNE CAPS 100MG 5 PA NDSSANDIMMUNE CAPS 25MG 4 PASANDIMMUNE INJ 4 PASANDIMMUNE ORAL SOLN 4 PAsirolimus oral soln 5 PA NDSsirolimus tabs 4 PASKYRIZI 5 PA NDS QL(2/28)tacrolimus caps 2 PATORISEL 5 B/D PA NDS

QL(4/28)XATMEP 4 PAZORTRESS TABS 0.25MG 4 PA QL(60/30)ZORTRESS TABS 0.75MG, 1MG

5 PA NDS QL(60/30)

ZORTRESS TABS 0.5MG 5 PA NDS QL(120/30)Immunizing Agents, PassiveATGAM 5 PA NDSGAMMAKED INJ 1GM/10ML 3 B/D PAGAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML

5 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Immunological Agents

Angioedema AgentsBERINERT 5 PA NDSCINRYZE 5 PA NDS QL(20/30)FIRAZYR 5 PA NDS QL(18/30)icatibant acetate 5 PA NDS QL(18/30)KALBITOR 5 PA NDSRUCONEST 5 PA NDS QL(8/30)Immune SuppressantsASTAGRAF XL 4 PAazathioprine 2 PACELLCEPT TABS 5 PA NDScyclosporine caps 4 PAcyclosporine inj 2 PAcyclosporine modified caps 3 PAcyclosporine modified oral soln 4 PAENBREL INJ 25MG/0.5ML 5 PA NDS

QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA NDS QL(8/28)ENBREL MINI 5 PA NDS QL(8/28)ENBREL SURECLICK 5 PA NDS QL(8/28)ENVARSUS XR TB24 4MG 5 PA NDSENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 3 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

5 PA NDS QL(2/28)

HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML

5 PA NDS QL(4/28)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH)

5 PA NDS QL(4/365)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK)

5 PA NDS QL(6/365)

HUMIRA PEN 5 PA NDS QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

5 PA NDS QL(6/365)

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

IMOVAX RABIES (H.D.C.V.) 3 B/D PAINFANRIX 3IPOL INACTIVATED IPV 3IXIARO 3KINRIX 3M-M-R II 3 QL(2/365)MENACTRA 3MENVEO 3PEDIARIX 3PEDVAX HIB 3PENTACEL 3PROQUAD 3 QL(2/365)QUADRACEL 3RABAVERT 3 B/D PARECOMBIVAX HB 3 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 3 QL(2/999)STAMARIL 3 QL(1/999)TDVAX 3TENIVAC 3 QL(0.5/28)TRUMENBA 3TWINRIX 3TYPHIM VI 3VAQTA 3VARIVAX 3 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 3YF-VAX 3ZOSTAVAX 3 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA NDS

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA ACTPEN 5 PA NDS QL(3.6/28)ACTEMRA INJ 162MG/0.9ML 5 PA NDS QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA NDS QL(40/28)

ACTIMMUNE 5 PA NDSARCALYST 5 PA NDSBENLYSTA INJ 400MG 5 PA NDS QL(9/28)BENLYSTA INJ 120MG 5 PA NDS QL(30/28)leflunomide 3 QL(30/30)RIDAURA 4RINVOQ 5 PA NDS QL(30/30)SIMULECT 5 B/D PA NDSSYNAGIS 5 PA NDSVaccinesACTHIB 3ADACEL 3 QL(0.5/365)BCG VACCINE 3BEXSERO 3BOOSTRIX 3 QL(0.5/365)DAPTACEL 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

3

ENGERIX-B INJ 10MCG/0.5ML 3 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 3 B/D PA QL(8/365)GARDASIL 9 3 QL(1.5/365)HAVRIX 3HEPLISAV-B 3 B/D PA QL(3/365)HIBERIX 3

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TYMLOS 5 PA NDS QL(1.56/30)

XGEVA 5 PA NDS QL(1.7/28)zoledronic acid inj 5mg/100ml 2 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAMINO ACID 4 B/D PABD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2”

3 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM

3 QL(200/30)

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM

3 QL(200/30)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”

3 QL(200/30)

BD PEN NEEDLE/MINI/ULTRA-FINE/31G X 5MM

3 QL(200/30)

BD PEN NEEDLE/NANO/ULTRA -FINE/32G X 4MM

3 QL(200/30)

BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM

3 QL(200/30)

BOTOX INJ 200UNIT 4 PA QL(1/90)BOTOX INJ 100UNIT 4 PA QL(4/90)CARNITOR INJ 4 B/D PADYSPORT 4 PAFERRIPROX 5 NDSFIRDAPSE 5 PA NDSINTRALIPID 3 B/D PAKORLYM 5 PA NDS QL(120/30)LACTATED RINGERS IRRIGATION

3

levocarnitine 2LIPOSYN III 3 B/D PAmethylergonovine maleate inj 2NATPARA 5 PA NDS QL(2/28)NOVOFINE 31 3 QL(200/30)NOVOFINE 32GX6MM 3 QL(200/30)NOVOFINE AUTOCOVER 30GX8MM

3 QL(200/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CANASA 5 NDS QL(30/30)mesalamine dr tbec 1.2gm 4 QL(120/30)mesalamine enem 4mesalamine kit 4mesalamine supp 5 NDS QL(30/30)Glucocorticoidsbudesonide cpep 4colocort 3hydrocortisone enem 3Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium oral soln 2 QL(300/28)alendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 2calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 2.5mcg 4 QL(120/30)doxercalciferol caps 1mcg 4 QL(240/30)etidronate disodium 2FORTEO 5 PA NDS QL(2.4/28)ibandronate sodium inj 3 QL(3/90)ibandronate sodium tabs 1 QL(1/28)pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml

4 B/D PA

paricalcitol caps 4mcg 3 QL(60/30)paricalcitol caps 1mcg, 2mcg 3 QL(90/30)paricalcitol inj 4PROLIA 4 QL(1/180)risedronate sodium tabs 150mg 3 QL(1/30)risedronate sodium tabs 35mg 3 QL(4/28)SENSIPAR TABS 30MG, 60MG 5 NDS QL(60/30)SENSIPAR TABS 90MG 5 NDS QL(120/30)

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate oint 2atropine sulfate ophthalmic soln 3CYCLOMYDRIL 3cyclopentolate hcl 2cyclopentolate hydrochloride 2CYSTARAN 5 NDS QL(60/28)homatropaire 2homatropine hbr 2LACRISERT 4phenylephrine hcl ophthalmic soln 10%, 2.5%

3

proparacaine hcl 2RESTASIS 3 QL(60/30)RHOPRESSA 4 STtropicamide 2Ophthalmic Anti-allergy Agentsazelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

olopatadine hcl ophthalmic soln 2 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

3

PAZEO 3 QL(2.5/30)OphthalmicAnti-inflammatoriesdexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3FLAREX 4fluorometholone 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NOVOTWIST 32GX5MM 3 QL(200/30)NUTRILIPID 3 B/D PAOMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)PHYSIOLYTE 3PHYSIOSOL IRRIGATION 3RINGERS IRRIGATION 3SODIUM CHLORIDE IRRIGATION 0.9%

3

STERILE WATER IRRIGATION 3STERILE WATER IRRIGATION PLASTIC BOTTLE

3

STERILE WATER IRRIGATION W/HANGER

3

TECHLITE PEN NEEDLES/31G X 6 MM

3 QL(200/30)

TECHLITE PEN NEEDLES/31G X 8MM

3 QL(200/30)


3 QL(200/30)


3 QL(200/30)


3 QL(200/30)

TIS-U-SOL 3V-GO 20 3V-GO 30 3V-GO 40 3XEOMIN INJ 200UNIT 5 PA NDSXEOMIN INJ 100UNIT, 50UNIT 4 PA

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 4latanoprost 2 QL(5/30)

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ROCKLATAN 4 STSIMBRINZA 3timolol maleate ophthalmic gel forming

4

timolol maleate ophthalmic soln 2

Otic Agents

Otic Agentsacetic acid 2aurodex 2COLY-MYCIN S 4CORTISPORIN-TC 4flac 2fluocinolone acetonide 2fluocinolone acetonide ear drops

2

hydrocortisone/acetic acid 2neomycin/polymyxin/hc 3neomycin/polymyxin/hydrocortisone otic soln

3

neomycin/polymyxin/hydrocortisone otic susp

3

Respiratory Tract/Pulmonary Agents

Anti-inflammatories,InhaledCorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide susp 2 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 3 QL(50/30)fluticasone propionate susp 2 QL(16/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

flurbiprofen sodium 2FML 4FML FORTE 4INVELTYS 4ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4LOTEMAX SM 4neomycin/polymyxin/dexamethasone

2

NEVANAC 4 STPRED MILD 4PRED-G 3PRED-G S.O.P. 3prednisolone acetate 2prednisolone sodium phosphate ophthalmic soln

2

PROLENSA 3TOBRADEX OINT 4tobramycin/dexamethasone 2Ophthalmic Antiglaucoma Agentsacetazolamide er 4ALPHAGAN P OPHTHALMIC SOLN 0.1%

4

apraclonidine 3AZOPT 3betaxolol hcl 2BETIMOL 4BETOPTIC-S 3brimonidine tartrate ophthalmic soln 0.15%

3

brimonidine tartrate ophthalmic soln 0.2%

2

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)IOPIDINE 4levobunolol hcl 2PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic soln 2

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

albuterol sulfate tabs 2ANORO ELLIPTA 3 QL(60/30)BROVANA 4 B/D PA QL(120/30)epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)isoproterenol hydrochloride 3ISUPREL 3levalbuterol 2 B/D PA QL(90/30)levalbuterol hcl nebu 1.25mg/3ml

2 B/D PA QL(90/30)

levalbuterol hcl nebu 0.63mg/3ml

2 B/D PA QL(540/30)

levalbuterol hydrochloride nebu 0.31mg/3ml

2 B/D PA QL(270/30)

levalbuterol tartrate hfa 3 QL(30/30)metaproterenol sulfate 3PERFOROMIST 4 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 3VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 NDS QL(84/56)KALYDECO 5 PA NDS QL(60/30)ORKAMBI PACK 5 PA NDS QL(56/28)ORKAMBI TABS 5 PA NDS QL(120/30)PULMOZYME 5 B/D PA NDS

QL(150/30)TOBI PODHALER 5 NDS QL(1568/365)tobramycin nebu 5 B/D PA NDSMast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XHANCE 4 QL(16/30) STAntihistaminesazelastine hcl nasal soln 3 QL(30/25)azelastine hydrochloride nasal soln

3 QL(30/25)

desloratadine 2 QL(30/30)diphenhydramine hcl inj 4diphenhydramine hydrochloride inj

4

levocetirizine dihydrochloride oral soln

4 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

promethazine hcl inj 2 PAAntileukotrienesmontelukast sodium 2 QL(30/30)zafirlukast 3 QL(60/30)Bronchodilators, AnticholinergicCOMBIVENT RESPIMAT 3 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, SympathomimeticADRENALIN INJ 3albuterol sulfate er 2albuterol sulfate hfa aers 108mcg/act (generic for ProAir)

4 QL(17/30)

albuterol sulfate hfa aers 108mcg/act (generic for Ventolin)

4 QL(36/30)

albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 2

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRELEGY ELLIPTA 3 QL(60/30)XOLAIR INJ 75MG/0.5ML 5 PA NDS QL(2/28)XOLAIR INJ 150MG/ML 5 PA NDS QL(4/28)XOLAIR VIAL INJ 150MG 5 PA NDS QL(6/28)ZEMAIRA 5 B/D PA NDS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hydrochloride tabs 10mg, 5mg

2 PA QL(90/30)

orphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam caps 15mg, 30mg 2 QL(60/365)temazepam caps 22.5mg, 7.5mg

4 QL(60/365)

zaleplon 2 QL(30/30)zolpidem tartrate tabs 3 QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 4 PA QL(30/30)ramelteon 4 QL(30/30)ROZEREM 4 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA NDS QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 3 PA QL(30/30)DALIRESP TABS 250MCG 3 PA QL(60/365)THEO-24 4theophylline 4theophylline er tb12 300mg 3theophylline er tb24 2Pulmonary AntihypertensivesADCIRCA 5 PA NDS QL(60/30)ADEMPAS 5 PA NDS QL(90/30)alyq 5 PA NDS QL(60/30)ambrisentan 5 PA NDS QL(30/30)bosentan 5 PA NDS QL(60/30)LETAIRIS 5 PA NDS QL(30/30)OPSUMIT 5 PA NDS QL(30/30)REMODULIN 5 B/D PA NDSsildenafil citrate tabs 20mg 3 PA QL(90/30)tadalafil tabs 20mg 5 PA NDS QL(60/30)TRACLEER TABS 5 PA NDS QL(60/30)TRACLEER TBSO 5 PA NDStreprostinil 5 B/D PA NDSTYVASO 5 B/D PA NDSTYVASO REFILL 5 B/D PA NDSTYVASO STARTER 5 B/D PA NDSVENTAVIS 5 PA NDS QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA NDS QL(270/30)ESBRIET TABS 801MG 5 PA NDS QL(90/30)ESBRIET TABS 267MG 5 PA NDS QL(270/30)OFEV 5 PA NDS QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP 5 B/D PA NDSGLASSIA 5 B/D PA NDSPROLASTIN-C 5 B/D PA NDSpromethazine/phenylephrine 2 PAribavirin inhalation soln 5 B/D PA NDS

55

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir oral soln . . . . . . . . . . . . . . . . . 26abacavir sulfate/lamivudine . . . . . . . . 26abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 26abacavir tabs . . . . . . . . . . . . . . . . . . . . . 26ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 16ABILIFY MAINTENA . . . . . . . . . . . . . . . 24abiraterone acetate . . . . . . . . . . . . . . . . 18ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 19acamprosate calcium dr . . . . . . . . . . . . . 8acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 27acebutolol hcl caps 200mg . . . . . . . . . 32acebutolol hydrochloride caps 400mg . . . . . . . . . . . . . . . . . . . . . . . 32acetaminophen/codeine oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . . 7acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . . 7acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . . 7acetazolamide . . . . . . . . . . . . . . . . . . . . . 33acetazolamide er . . . . . . . . . . . . . . . . . . 52acetazolamide sodium . . . . . . . . . . . . . 33acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 52acetic acid 0.25% . . . . . . . . . . . . . . . . . . 42acetylcysteine inhalation soln . . . . . . 54acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 36ACTEMRA ACTPEN . . . . . . . . . . . . . . . 49ACTEMRA INJ 162MG/0.9ML . . . . . . 49ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 49ACTHAR . . . . . . . . . . . . . . . . . . . . . . . . . . 44ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 49acyclovir caps . . . . . . . . . . . . . . . . . . . . 27acyclovir crea . . . . . . . . . . . . . . . . . . . . . 27acyclovir oint . . . . . . . . . . . . . . . . . . . . . 27acyclovir sodium . . . . . . . . . . . . . . . . . . . 27acyclovir susp . . . . . . . . . . . . . . . . . . . . 27

acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 27ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 49adapalene crea . . . . . . . . . . . . . . . . . . . 36adapalene gel . . . . . . . . . . . . . . . . . . . . 36adc/fluoride . . . . . . . . . . . . . . . . . . . . . . . 40ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . . 54adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 25ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 54ADRENALIN INJ . . . . . . . . . . . . . . . . . . 53adriamycin inj 2mg/ml . . . . . . . . . . . . . . 19ADRIAMYCIN INJ 50MG . . . . . . . . . . . 19adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 52ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 52AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . 21AFINITOR DISPERZ TBSO 5MG . . . 21AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 21AFINITOR TABS 10MG . . . . . . . . . . . . 21ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 42albendazole . . . . . . . . . . . . . . . . . . . . . . . 22ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 22albuterol sulfate er . . . . . . . . . . . . . . . . . 53albuterol sulfate hfa aers 108mcg/act (generic for ProAir) . . . . . 53albuterol sulfate hfa aers 108mcg/act (generic for Ventolin) . . 53albuterol sulfate nebu 0.5% . . . . . . . . 53albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 53albuterol sulfate syrp . . . . . . . . . . . . . . 53albuterol sulfate tabs . . . . . . . . . . . . . . 53alclometasone dipropionate . . . . . . . . 42ALCOHOL PREP PADS . . . . . . . . . . . . . 9ALDURAZYME . . . . . . . . . . . . . . . . . . . . 42ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 21alendronate sodium oral soln . . . . . . 50alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 50

alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 50alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 42ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 22ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 22ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 21aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 33allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 17allopurinol sodium . . . . . . . . . . . . . . . . . 17ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 44alosetron hydrochloride tabs 0.5mg . . . . . . . . . . . . . . . . . . . . . . . . 41alosetron hydrochloride tabs 1mg . . . . . . . . . . . . . . . . . . . . . . . . . . 41ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 52alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 27alprazolam odt tbdp 2mg . . . . . . . . . . . 27alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 27alprazolam tabs 2mg . . . . . . . . . . . . . . 27altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ALUNBRIG TABS 30MG . . . . . . . . . . . 21ALUNBRIG TABS 180MG, 90MG . . . 21ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 21alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 44alyq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54amabelz . . . . . . . . . . . . . . . . . . . . . . . . . . 44amantadine hcl . . . . . . . . . . . . . . . . . . . . 23AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 16ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 54amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 44amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 44amikacin sulfate . . . . . . . . . . . . . . . . . . . . 9amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 33amiloride/hydrochlorothiazide . . . . . . 33AMINO ACID . . . . . . . . . . . . . . . . . . . . . . 50aminocaproic acid inj . . . . . . . . . . . . . . 30aminophylline . . . . . . . . . . . . . . . . . . . . . 54

56


Covered Drugs Index

aprepitant caps 40mg . . . . . . . . . . . . . . 16aprepitant caps 80mg . . . . . . . . . . . . . . 16aprepitant caps 125mg . . . . . . . . . . . . . 16aprepitant caps pack . . . . . . . . . . . . . . . 16apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 49APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 13APTIOM TABS 600MG . . . . . . . . . . . . . 13APTIVUS CAPS . . . . . . . . . . . . . . . . . . 26APTIVUS ORAL SOLN . . . . . . . . . . . . 26ARALAST NP . . . . . . . . . . . . . . . . . . . . . 54aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 30ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 30ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 30ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 49aripiprazole odt . . . . . . . . . . . . . . . . . . . . 24aripiprazole oral soln . . . . . . . . . . . . . . 24aripiprazole tabs . . . . . . . . . . . . . . . . . . 24ARISTADA INITIO . . . . . . . . . . . . . . . . . 24ARISTADA INJ 441MG/1.6ML . . . . . . 24ARISTADA INJ 662MG/2.4ML . . . . . . 24ARISTADA INJ 882MG/3.2ML . . . . . . 24

amlodipine/valsartan/ hydrochlorothiazide tabs 5mg; 12.5mg; 160mg . . . . . . . . . . . . . . 32ammonium lactate . . . . . . . . . . . . . . . . . 36amnesteem . . . . . . . . . . . . . . . . . . . . . . . 36amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 16amoxicillin . . . . . . . . . . . . . . . . . . . . . . . . . 11amoxicillin/clavulanate potassium . . . 11amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 34amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . . . . . . . . 34amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 35amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 35amphotericin b . . . . . . . . . . . . . . . . . . . . 16ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 11ampicillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 11ampicillin sodium inj 125mg, 250mg, 500mg . . . . . . . . . . . . 11ampicillin-sulbactam . . . . . . . . . . . . . . . 11AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 36ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 44anagrelide hydrochloride . . . . . . . . . . . 30anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 40anastrozole . . . . . . . . . . . . . . . . . . . . . . . 21ANGELIQ . . . . . . . . . . . . . . . . . . . . . . . . . 44ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 53APLENZIN . . . . . . . . . . . . . . . . . . . . . . . . 15APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 23apraclonidine . . . . . . . . . . . . . . . . . . . . . . 52

AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML . . . . . 37AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML . . . . . 37AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 37AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 37amiodarone hcl inj 50mg/ml, 900mg/18ml . . . . . . . . . . . . . 31amiodarone hcl tabs . . . . . . . . . . . . . . 31amiodarone hydrochloride inj . . . . . . 31AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 41amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 16amitriptyline hydrochloride tabs 10mg, 50mg . . . . . . . . . . . . . . . . . . 16amlodipine besylate/benazepril hcl caps 5mg; 40mg . . . . . . . . . . . . . . . 32amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 32amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 32amlodipine besylate tabs 2.5mg . . . . 32amlodipine besylate tabs 5mg . . . . . . 32amlodipine besylate tabs 10mg . . . . . 32amlodipine besylate/valsartan . . . . . . 32amlodipine/valsartan/hctz . . . . . . . . . . 32

57


Covered Drugs Index

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM . . . . . . . . 50BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM . . . . . . . . . . . . . 50BD PEN NEEDLE/MINI/ ULTRA-FINE/31G X 5MM . . . . . . . . . . 50BD PEN NEEDLE/NANO/ ULTRA -FINE/32G X 4MM . . . . . . . . . 50BD PEN NEEDLE/ORIGINAL/ ULTRA-FINE/29G X 12.7MM . . . . . . . 50BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 19benazepril hcl . . . . . . . . . . . . . . . . . . . . . 31benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 31benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 31benazepril hydrochloride . . . . . . . . . . . 31BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 18BENLYSTA INJ 120MG . . . . . . . . . . . . 49BENLYSTA INJ 400MG . . . . . . . . . . . . 49benztropine mesylate inj . . . . . . . . . . . 23benztropine mesylate tabs . . . . . . . . . 23BERINERT . . . . . . . . . . . . . . . . . . . . . . . . 48BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 12BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 22betamethasone dipropionate . . . . . . . 42betamethasone sodium phosphate/betamethasone acetate . . . . . . . . . . . . 42betamethasone valerate crea . . . . . . 42betamethasone valerate lotn . . . . . . . 42betamethasone valerate oint . . . . . . . 42betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 32betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 52bethanechol chloride . . . . . . . . . . . . . . . 42BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . . 52BETOPTIC-S . . . . . . . . . . . . . . . . . . . . . . 52bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 22BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 49bicalutamide . . . . . . . . . . . . . . . . . . . . . . 18BICILLIN C-R . . . . . . . . . . . . . . . . . . . . . 11BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 11

AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 11azathioprine . . . . . . . . . . . . . . . . . . . . . . . 48azelaic acid . . . . . . . . . . . . . . . . . . . . . . . 36azelastine hcl nasal soln . . . . . . . . . . . 53azelastine hcl ophthalmic soln . . . . . 51azelastine hydrochloride nasal soln . . 53AZELEX . . . . . . . . . . . . . . . . . . . . . . . . . . 36azithromycin inj . . . . . . . . . . . . . . . . . . . 11AZITHROMYCIN PACK . . . . . . . . . . . 11azithromycin susr 100mg/5ml . . . . . . 11azithromycin susr 200mg/5ml . . . . . . 11azithromycin tabs 250mg, 500mg . . . 12azithromycin tabs 600mg . . . . . . . . . . . 12AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 52aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 11azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Bbacitracin inj . . . . . . . . . . . . . . . . . . . . . . . 9bacitracin ophthalmic oint . . . . . . . . . . . 9bacitracin/polymyxin b . . . . . . . . . . . . . . 9baclofen tabs . . . . . . . . . . . . . . . . . . . . . 25balsalazide disodium . . . . . . . . . . . . . . 49BALVERSA TABS 3MG . . . . . . . . . . . . 21BALVERSA TABS 4MG . . . . . . . . . . . . 21BALVERSA TABS 5MG . . . . . . . . . . . . 21balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44BANZEL SUSP . . . . . . . . . . . . . . . . . . . 14BANZEL TABS 200MG . . . . . . . . . . . . 14BANZEL TABS 400MG . . . . . . . . . . . . 14BAQSIMI ONE PACK . . . . . . . . . . . . . . 28BAQSIMI TWO PACK . . . . . . . . . . . . . . 28BARACLUDE ORAL SOLN . . . . . . . . 25BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 22BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 12BCG VACCINE . . . . . . . . . . . . . . . . . . . . 49BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” . . . . 50BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” . . . . 50

ARISTADA INJ 1064MG/3.9ML . . . . . 24armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 54ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 52ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 19arsenic trioxide . . . . . . . . . . . . . . . . . . . . 19ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 44aspirin/dipyridamole . . . . . . . . . . . . . . . 30ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 48atazanavir sulfate caps 150mg . . . . . 26atazanavir sulfate caps 200mg . . . . . 26atazanavir sulfate caps 300mg . . . . . 26atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 32atenolol/chlorthalidone . . . . . . . . . . . . . 32ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 48atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 35atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 35atorvastatin calcium . . . . . . . . . . . . . . . 34atovaquone . . . . . . . . . . . . . . . . . . . . . . . 22atovaquone/proguanil hcl . . . . . . . . . . 22ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 26atropine sulfate inj 0.4mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 40atropine sulfate inj 0.5mg/5ml . . . . . . 33atropine sulfate inj 0.25mg/5ml . . . . . 40atropine sulfate oint . . . . . . . . . . . . . . . 51atropine sulfate ophthalmic soln . . . . 51aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 42aurodex . . . . . . . . . . . . . . . . . . . . . . . . . . . 52AVANDIA . . . . . . . . . . . . . . . . . . . . . . . . . 27AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 22AVELOX . . . . . . . . . . . . . . . . . . . . . . . . . . 12aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 36AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 36azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 19AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 11

58


Covered Drugs Index

calcitriol caps . . . . . . . . . . . . . . . . . . . . . 50calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 50calcitriol oral soln . . . . . . . . . . . . . . . . . 50calcium acetate caps . . . . . . . . . . . . . . 40calcium acetate tabs 667mg . . . . . . . . 40calcium gluconate inj 10% . . . . . . . . . . 37CALQUENCE . . . . . . . . . . . . . . . . . . . . . 21camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 44camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 44CANASA . . . . . . . . . . . . . . . . . . . . . . . . . . 50CAPASTAT SULFATE . . . . . . . . . . . . . . 18CAPRELSA TABS 100MG . . . . . . . . . 21CAPRELSA TABS 300MG . . . . . . . . . 21CARAFATE SUSP . . . . . . . . . . . . . . . . 41CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 37carbamazepine . . . . . . . . . . . . . . . . . . . . 14carbamazepine er . . . . . . . . . . . . . . . . . 14carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 23carbidopa/levodopa . . . . . . . . . . . . . . . . 23carbidopa/levodopa/entacapone . . . . 23carbidopa/levodopa er . . . . . . . . . . . . . 23carbidopa/levodopa odt . . . . . . . . . . . . 23carboplatin inj 50mg/5ml . . . . . . . . . . . 18carboplatin inj 150mg/15ml, 450mg/45ml . . . . . . . . . . 19CARDENE IV . . . . . . . . . . . . . . . . . . . . . 32carmustine . . . . . . . . . . . . . . . . . . . . . . . . 18CARNITOR INJ . . . . . . . . . . . . . . . . . . . 50carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 52cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 32carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 32carvedilol phosphate . . . . . . . . . . . . . . . 32caspofungin acetate . . . . . . . . . . . . . . . 16CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 53caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44cefaclor caps . . . . . . . . . . . . . . . . . . . . . 10cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 10cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 10cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 10

buprenorphine hcl inj . . . . . . . . . . . . . . . 7buprenorphine hcl/naloxone hcl . . . . . . 8buprenorphine hcl subl . . . . . . . . . . . . . 8buprenorphine hydrochloride/ naloxone hydrochloride film . . . . . . . . . 8bupropion hcl tabs 100mg . . . . . . . . . . 15bupropion hydrochloride er (sr) . . . . . . 9bupropion hydrochloride er (sr) . . . . . 15bupropion hydrochloride er (xl) tb24 150mg, 300mg . . . . . . . . . . . . . . . 15bupropion hydrochloride tabs 75mg . . 15buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 27buspirone hydrochloride tabs 10mg, 5mg, 7.5mg . . . . . . . . . . . . 27busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 18BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 18butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . . 7butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . . 7butalbital/acetaminophen tabs 325mg; 50mg . . . . . . . . . . . . . . . . . . 7butalbital/aspirin/caffeine caps . . . . . . 7butorphanol tartrate inj 1mg/ml . . . . . . 7butorphanol tartrate inj 2mg/ml . . . . . . 7butorphanol tartrate nasal soln . . . . . . 7BYDUREON BCISE . . . . . . . . . . . . . . . 27BYDUREON PEN . . . . . . . . . . . . . . . . . 27BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 32BYSTOLIC TABS 20MG . . . . . . . . . . . 32

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 47CABOMETYX TABS 20MG, 60MG . 21CABOMETYX TABS 40MG . . . . . . . . 21calcipotriene crea . . . . . . . . . . . . . . . . . 36calcipotriene external soln . . . . . . . . . 36calcipotriene oint . . . . . . . . . . . . . . . . . . 36calcitonin-salmon . . . . . . . . . . . . . . . . . . 50calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 36

BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 25BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 22bimatoprost ophthalmic soln . . . . . . . 51bisoprolol fumarate . . . . . . . . . . . . . . . . 32bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 32bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 19bleomycin sulfate . . . . . . . . . . . . . . . . . . 19BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 12BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 12blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 44blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 44BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 49BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 19bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 54BOSULIF TABS 100MG . . . . . . . . . . . . 21BOSULIF TABS 400MG, 500MG . . . 21BOTOX INJ 100UNIT . . . . . . . . . . . . . . 50BOTOX INJ 200UNIT . . . . . . . . . . . . . . 50BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 19BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 52briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 30brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 52brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 52BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 13BRIVIACT ORAL SOLN . . . . . . . . . . . 13BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 13BRIVIACT TABS 100MG . . . . . . . . . . . 13bromocriptine mesylate . . . . . . . . . . . . 23BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 53budesonide cpep . . . . . . . . . . . . . . . . . 50budesonide susp . . . . . . . . . . . . . . . . . . 52bumetanide . . . . . . . . . . . . . . . . . . . . . . . 33buprenorphine . . . . . . . . . . . . . . . . . . . . . . 7

59


Covered Drugs Index

claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 36clarithromycin er . . . . . . . . . . . . . . . . . . . 12clarithromycin susr . . . . . . . . . . . . . . . . 12clarithromycin tabs . . . . . . . . . . . . . . . . 12CLEOCIN SUPP . . . . . . . . . . . . . . . . . . . 9CLIMARA PRO . . . . . . . . . . . . . . . . . . . . 44clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . . 9clindamycin hcl . . . . . . . . . . . . . . . . . . . . . 9clindamycin phosphate crea . . . . . . . . 9clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . . 9clindamycin phosphate gel . . . . . . . . . 9clindamycin phosphate in d5w . . . . . . . 9clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml . . . . . . . . . . . . . . 9clindamycin phosphate lotn . . . . . . . . . 9clindamycin phosphate swab . . . . . . . 9clindamycin phosphate/tretinoin . . . . 36clindamycin/sodium chloride . . . . . . . . . 9CLINIMIX 4.25%/DEXTROSE 5% . . 37CLINIMIX 4.25%/DEXTROSE 10% . . 37CLINIMIX 4.25%/DEXTROSE 25% . . 37CLINIMIX 5%/DEXTROSE 15% . . . . 37CLINIMIX 5%/DEXTROSE 20% . . . . 37CLINIMIX 5%/DEXTROSE 25% . . . . 37CLINIMIX E 2.75%/DEXTROSE 5% . . 37CLINIMIX E 4.25%/DEXTROSE 5% . . 37CLINIMIX E 4.25%/DEXTROSE 10% . 37CLINIMIX E 5%/DEXTROSE 15% . . 37CLINIMIX E 5%/DEXTROSE 20% . . 37CLINISOL SF 15% . . . . . . . . . . . . . . . . 37clinpro 5000 . . . . . . . . . . . . . . . . . . . . . . . 37clobazam susp . . . . . . . . . . . . . . . . . . . . 13clobazam tabs 10mg . . . . . . . . . . . . . . . 13clobazam tabs 20mg . . . . . . . . . . . . . . . 13clobetasol propionate crea . . . . . . . . . 42clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 42clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 42

chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44CHENODAL . . . . . . . . . . . . . . . . . . . . . . . 41chloramphenicol sodium succinate . . . 9chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 36chloroquine phosphate . . . . . . . . . . . . . 23chlorothiazide . . . . . . . . . . . . . . . . . . . . . 33chlorothiazide sodium . . . . . . . . . . . . . . 33chlorpromazine hcl . . . . . . . . . . . . . . . . 23chlorthalidone . . . . . . . . . . . . . . . . . . . . . 33cholestyramine . . . . . . . . . . . . . . . . . . . . 34cholestyramine light . . . . . . . . . . . . . . . 34ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox nail lacquer . . . . . . . . . . . . . . 16ciclopirox olamine . . . . . . . . . . . . . . . . . 16cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 25cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 30CILOXAN OINT . . . . . . . . . . . . . . . . . . . 12CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 26cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 41cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 41CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 48CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 12ciprofloxacin hcl tabs 100mg . . . . . . . 12ciprofloxacin hcl tabs 750mg . . . . . . . 12ciprofloxacin hydrochloride . . . . . . . . . 12ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% . . . . . . . . . . . . . . . . . 12ciprofloxacin susr . . . . . . . . . . . . . . . . . 12CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 12cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml . . . . . . . . . . 19citalopram hydrobromide oral soln . . . 15citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 15cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 19

cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 10cefazolin sodium/ dextrose inj 1gm; 4% . . . . . . . . . . . . . . 10cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 10cefazolin sodium inj 100gm, 10gm, 1gm, 1gm/50ml; 4%, 300gm, 500mg . . . . . 10cefdinir caps . . . . . . . . . . . . . . . . . . . . . . 10cefdinir susr . . . . . . . . . . . . . . . . . . . . . . 10cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime/dextrose . . . . . . . . . . . . . . . . . 11cefixime caps . . . . . . . . . . . . . . . . . . . . . 11cefixime susr . . . . . . . . . . . . . . . . . . . . . 11cefotaxime sodium inj 1gm, 500mg . . 11cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefotetan/dextrose . . . . . . . . . . . . . . . . . 11cefoxitin sodium . . . . . . . . . . . . . . . . . . . 11cefpodoxime proxetil . . . . . . . . . . . . . . . 11cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime/dextrose . . . . . . . . . . . . . . . 11ceftriaxone/dextrose . . . . . . . . . . . . . . . 11ceftriaxone in iso-osmotic dextrose . . 11ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 11cefuroxime axetil . . . . . . . . . . . . . . . . . . 11cefuroxime sodium . . . . . . . . . . . . . . . . 11celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . . 7celecoxib caps 400mg . . . . . . . . . . . . . . 7CELLCEPT TABS . . . . . . . . . . . . . . . . . 48CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 13cephalexin . . . . . . . . . . . . . . . . . . . . . . . . 11CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 42CESAMET . . . . . . . . . . . . . . . . . . . . . . . . 16cevimeline hcl . . . . . . . . . . . . . . . . . . . . . 36CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX STARTING MONTH PAK . . 9

60


Covered Drugs Index

CRIXIVAN CAPS 400MG . . . . . . . . . . 26cromolyn sodium conc . . . . . . . . . . . . 41cromolyn sodium nebu . . . . . . . . . . . . 53cromolyn sodium ophthalmic soln . . . 51crotan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 44CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 39CURITY GAUZE PADS 2”X2” . . . . . . 36cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 44cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 44cyclobenzaprine hydrochloride tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 54CYCLOMYDRIL . . . . . . . . . . . . . . . . . . . 51cyclopentolate hcl . . . . . . . . . . . . . . . . . 51cyclopentolate hydrochloride . . . . . . . 51cyclophosphamide caps . . . . . . . . . . . 18cyclophosphamide inj . . . . . . . . . . . . . 18cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 18cyclosporine caps . . . . . . . . . . . . . . . . . 48cyclosporine inj . . . . . . . . . . . . . . . . . . . 48cyclosporine modified caps . . . . . . . . 48cyclosporine modified oral soln . . . . 48CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 22cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 44CYSTADANE . . . . . . . . . . . . . . . . . . . . . 42CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 42CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 51cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 19cytarabine aqueous . . . . . . . . . . . . . . . . 19cytra k crystals . . . . . . . . . . . . . . . . . . . . 37

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 18dactinomycin . . . . . . . . . . . . . . . . . . . . . . 19dalfampridine er . . . . . . . . . . . . . . . . . . . 36DALIRESP TABS 250MCG . . . . . . . . . 54DALIRESP TABS 500MCG . . . . . . . . . 54danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

clozapine odt tbdp 150mg . . . . . . . . . . 25clozapine odt tbdp 200mg . . . . . . . . . . 25clozapine tabs 25mg, 50mg . . . . . . . . 25clozapine tabs 100mg . . . . . . . . . . . . . . 25clozapine tabs 200mg . . . . . . . . . . . . . . 25COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 23codeine sulfate . . . . . . . . . . . . . . . . . . . . . 7colchicine caps . . . . . . . . . . . . . . . . . . . 17colchicine tabs . . . . . . . . . . . . . . . . . . . . 17colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 34colistimethate sodium . . . . . . . . . . . . . . . 9colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 50COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 52COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 51COMBIPATCH . . . . . . . . . . . . . . . . . . . . 44COMBIVENT RESPIMAT . . . . . . . . . . 53COMETRIQ 60MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 21COMETRIQ 100MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 21COMETRIQ 140MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 21COMPLERA . . . . . . . . . . . . . . . . . . . . . . 25compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 16CONDYLOX . . . . . . . . . . . . . . . . . . . . . . 36constulose . . . . . . . . . . . . . . . . . . . . . . . . 41COPAXONE INJ 20MG/ML . . . . . . . . . 36COPAXONE INJ 40MG/ML . . . . . . . . . 36COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 19CORDRAN TAPE . . . . . . . . . . . . . . . . . 43CORLANOR TABS . . . . . . . . . . . . . . . . 33CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . 43cortisone acetate . . . . . . . . . . . . . . . . . . 43CORTISPORIN-TC . . . . . . . . . . . . . . . . 52COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 19COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 21COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 29CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 34CRIXIVAN CAPS 200MG . . . . . . . . . . 26

clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 42clobetasol propionate foam . . . . . . . . 42clobetasol propionate gel . . . . . . . . . . 42clobetasol propionate liqd . . . . . . . . . 42clobetasol propionate lotn . . . . . . . . . 42clobetasol propionate oint . . . . . . . . . 43clobetasol propionate sham . . . . . . . . 43clocortolone pivalate . . . . . . . . . . . . . . . 43clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CLODERM . . . . . . . . . . . . . . . . . . . . . . . . 43clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 19clomipramine hcl . . . . . . . . . . . . . . . . . . 16clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 13clonazepam odt tbdp 1mg . . . . . . . . . . 13clonazepam odt tbdp 2mg . . . . . . . . . . 13clonazepam tabs 0.5mg . . . . . . . . . . . . 13clonazepam tabs 1mg . . . . . . . . . . . . . 13clonazepam tabs 2mg . . . . . . . . . . . . . 13clonidine hcl er . . . . . . . . . . . . . . . . . . . . 35clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 30clonidine hcl ptwk 0.3mg/24hr . . . . . . 30clonidine hcl tabs . . . . . . . . . . . . . . . . . 30clonidine hydrochloride tabs . . . . . . . 30clopidogrel tabs 75mg . . . . . . . . . . . . . 30clopidogrel tabs 300mg . . . . . . . . . . . . 30clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 27clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 27clotrimazole/betamethasone dipropionate crea . . . . . . . . . . . . . . . . . 16clotrimazole/betamethasone dipropionate lotn . . . . . . . . . . . . . . . . . . 16clotrimazole external crea . . . . . . . . . 16clotrimazole external soln . . . . . . . . . . 16clotrimazole lozg . . . . . . . . . . . . . . . . . . 16clozapine odt tbdp 12.5mg, 25mg . . . 25clozapine odt tbdp 100mg . . . . . . . . . . 25

61


Covered Drugs Index

dextrose 25% . . . . . . . . . . . . . . . . . . . . . 37dextrose 30% . . . . . . . . . . . . . . . . . . . . . 37dextrose 40% . . . . . . . . . . . . . . . . . . . . . 37dextrose 50% . . . . . . . . . . . . . . . . . . . . . 38dextrose 70% . . . . . . . . . . . . . . . . . . . . . 38DIACOMIT CAPS 250MG . . . . . . . . . . 13DIACOMIT CAPS 500MG . . . . . . . . . . 13DIACOMIT PACK 250MG . . . . . . . . . . 13DIACOMIT PACK 500MG . . . . . . . . . . 13DIASTAT ACUDIAL GEL 10MG . . . . . 13DIASTAT ACUDIAL GEL 20MG . . . . . 14DIASTAT PEDIATRIC . . . . . . . . . . . . . . 14diazepam conc . . . . . . . . . . . . . . . . . . . 27diazepam inj 5mg/ml . . . . . . . . . . . . . . . 27diazepam intensol . . . . . . . . . . . . . . . . . 27diazepam oral soln . . . . . . . . . . . . . . . . 27diazepam rectal gel gel 2.5mg . . . . . . 14diazepam rectal gel gel 10mg . . . . . . 14diazepam rectal gel gel 20mg . . . . . . 14diazepam tabs . . . . . . . . . . . . . . . . . . . . 27diclofenac potassium . . . . . . . . . . . . . . . 7diclofenac sodium dr . . . . . . . . . . . . . . . . 7diclofenac sodium er . . . . . . . . . . . . . . . . 7diclofenac sodium gel 1% . . . . . . . . . . 36diclofenac sodium gel 3% . . . . . . . . . . 36diclofenac sodium/misoprostol . . . . . . . 7diclofenac sodium ophthalmic soln . . . 51dicloxacillin sodium . . . . . . . . . . . . . . . . 11dicyclomine hcl oral soln . . . . . . . . . . . 40dicyclomine hydrochloride caps . . . . 40dicyclomine hydrochloride tabs . . . . 40didanosine . . . . . . . . . . . . . . . . . . . . . . . . 26DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 12diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . 7digitek tabs 0.25mg . . . . . . . . . . . . . . . . 33digitek tabs 0.125mg . . . . . . . . . . . . . . . 33digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 33DIGOXIN ORAL SOLN . . . . . . . . . . . . 33digoxin tabs 125mcg . . . . . . . . . . . . . . . 33digoxin tabs 250mcg . . . . . . . . . . . . . . . 33

desvenlafaxine er . . . . . . . . . . . . . . . . . . 15dexamethasone . . . . . . . . . . . . . . . . . . . 43dexamethasone intensol . . . . . . . . . . . 43dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 43dexamethasone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 51DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 41dexmethylphenidate hcl tabs 10mg . . 35dexmethylphenidate hydrochloride tabs 2.5mg, 5mg . . . . . 35dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 20dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 35dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 35dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 37dextrose 2.5%/nacl 0.45% . . . . . . . . . 37dextrose 5% . . . . . . . . . . . . . . . . . . . . . . . 37DEXTROSE5% / ELECTROLYTE #48 VIAFLEX . . . . . 37DEXTROSE 5%/ LACTATED RINGERS . . . . . . . . . . . . . 37DEXTROSE 5%/NACL 0.2% . . . . . . . 37DEXTROSE 5%/NACL 0.3% . . . . . . . 37dextrose 5%/nacl 0.9% . . . . . . . . . . . . 38DEXTROSE 5%/NACL 0.33% . . . . . . 38DEXTROSE 5%/NACL 0.45% . . . . . . 38DEXTROSE 5%/NACL 0.225% . . . . . 37dextrose 10% . . . . . . . . . . . . . . . . . . . . . 37DEXTROSE 10%/NACL 0.2% . . . . . . 37DEXTROSE10%/NACL 0.45% . . . . . 37dextrose 20% . . . . . . . . . . . . . . . . . . . . . 37

dantrolene sodium caps . . . . . . . . . . . 25dapsone tabs . . . . . . . . . . . . . . . . . . . . . 18DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 49DAPTOMYCIN INJ 350MG . . . . . . . . . . 9daptomycin inj 500mg . . . . . . . . . . . . . . . 9DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 23DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 22daunorubicin hcl . . . . . . . . . . . . . . . . . . . 19daunorubicin hydrochloride inj 20mg/4ml . . . . . . . . . . . . . . . . . . . . . . 19DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML . . . . . . . . . . . . . . . . . . . 19DAURISMO TABS 25MG . . . . . . . . . . 19DAURISMO TABS 100MG . . . . . . . . . 19daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 46decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 20DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 25delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44demeclocycline hcl . . . . . . . . . . . . . . . . 12DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 33denta 5000 plus . . . . . . . . . . . . . . . . . . . 37dentagel . . . . . . . . . . . . . . . . . . . . . . . . . . 36DEPO-ESTRADIOL . . . . . . . . . . . . . . . 44DEPO-MEDROL INJ 20MG/ML . . . . . 43DEPO-PROVERA . . . . . . . . . . . . . . . . . 46DEPO-SUBQ PROVERA 104 . . . . . . 46DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 26desipramine hcl . . . . . . . . . . . . . . . . . . . 16desloratadine . . . . . . . . . . . . . . . . . . . . . . 53desmopressin acetate inj . . . . . . . . . . 44desmopressin acetate nasal soln . . . 44desmopressin acetate tabs . . . . . . . . 44desogestrel/ethinyl estradiol . . . . . . . . 44DESONATE . . . . . . . . . . . . . . . . . . . . . . . 43desonide . . . . . . . . . . . . . . . . . . . . . . . . . . 43desoximetasone crea . . . . . . . . . . . . . 43desoximetasone gel . . . . . . . . . . . . . . . 43desoximetasone oint . . . . . . . . . . . . . . 43

62


Covered Drugs Index

DYRENIUM . . . . . . . . . . . . . . . . . . . . . . . 33DYSPORT . . . . . . . . . . . . . . . . . . . . . . . . 50

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 16EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 30EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 30ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 40EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 25e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 12efavirenz caps 50mg . . . . . . . . . . . . . . . 25efavirenz caps 200mg . . . . . . . . . . . . . 25efavirenz tabs . . . . . . . . . . . . . . . . . . . . 25effer-k tbef 25meq . . . . . . . . . . . . . . . . . 38effervescent potassium . . . . . . . . . . . . 38EGRIFTA . . . . . . . . . . . . . . . . . . . . . . . . . 44ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 42ELELYSO . . . . . . . . . . . . . . . . . . . . . . . . . 42ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 36ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 47ELIGARD INJ 22.5MG . . . . . . . . . . . . . 47ELIGARD INJ 30MG . . . . . . . . . . . . . . . 47ELIGARD INJ 45MG . . . . . . . . . . . . . . . 47ELIQUIS STARTER PACK . . . . . . . . . 29ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 29ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 29ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 42ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 20EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EMEND SUSR . . . . . . . . . . . . . . . . . . . . 16emoquette . . . . . . . . . . . . . . . . . . . . . . . . 44EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 22EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 15EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 26EMTRIVA ORAL SOLN . . . . . . . . . . . . 26enalaprilat . . . . . . . . . . . . . . . . . . . . . . . . . 31enalapril maleate . . . . . . . . . . . . . . . . . . 31

dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 25doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 30doxazosin mesylate tabs 8mg . . . . . . 30doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 27doxepin hydrochloride caps 25mg . . 27doxercalciferol caps 0.5mcg . . . . . . . . 50doxercalciferol caps 1mcg . . . . . . . . . . 50doxercalciferol caps 2.5mcg . . . . . . . . 50doxorubicin hydrochloride liposomal . . . . . . . . . . . . . . . . . . . . . . . . . 20doxorubicin hydrochloride liposome . . . . . . . . . . . . . . . . . . . . . . . . . . 20doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 12doxycycline hyclate caps . . . . . . . . . . 12doxycycline hyclate dr tbec 100mg, 150mg, 75mg . . . . . . . . . . . . . . 12doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 12doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 13doxycycline monohydrate caps 150mg . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate tabs . . . . . 13doxycycline susr . . . . . . . . . . . . . . . . . . 13DRITHO-CREME HP . . . . . . . . . . . . . . 36dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 16droperidol . . . . . . . . . . . . . . . . . . . . . . . . . 16drospirenone/ethinyl estradiol . . . . . . 44DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 19DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 47duloxetine hcl cpep 20mg . . . . . . . . . . 15duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 15duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 15DURAMORPH . . . . . . . . . . . . . . . . . . . . . 7DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 51dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 42dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 42

digox tabs 125mcg . . . . . . . . . . . . . . . . 33digox tabs 250mcg . . . . . . . . . . . . . . . . 33dihydroergotamine mesylate inj . . . . . 17dihydroergotamine mesylate nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 17DILANTIN CAPS 30MG . . . . . . . . . . . . 14dilt-cd cp24 180mg, 240mg . . . . . . . . 32diltiazem cd cp24 180mg . . . . . . . . . . . 32diltiazem hcl . . . . . . . . . . . . . . . . . . . . . . . 32diltiazem hcl er cp12 . . . . . . . . . . . . . . 32diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg . . . . . 32diltiazem hcl er tb24 . . . . . . . . . . . . . . . 32diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg . . . . . 32dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32dimenhydrinate inj . . . . . . . . . . . . . . . . 16diphenhydramine hcl inj . . . . . . . . . . . 53diphenhydramine hydrochloride inj . . . 53diphenoxylate/atropine liqd . . . . . . . . 41diphenoxylate/atropine tabs . . . . . . . . 41DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 49disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . 8divalproex sodium . . . . . . . . . . . . . . . . . 14divalproex sodium dr . . . . . . . . . . . . . . . 14divalproex sodium er . . . . . . . . . . . . . . . 14DIVIGEL . . . . . . . . . . . . . . . . . . . . . . . . . . 44docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 20DOCETAXEL INJ 200MG/10ML . . . . 20dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 31donepezil hcl tabs 10mg . . . . . . . . . . . 14donepezil hcl tabs 23mg . . . . . . . . . . . 14donepezil hcl tbdp 5mg . . . . . . . . . . . . 14donepezil hcl tbdp 10mg . . . . . . . . . . . 14donepezil hydrochloride tabs 5mg . . 14donepezil hydrochloride tabs 10mg . . 14dorzolamide hcl . . . . . . . . . . . . . . . . . . . 52dorzolamide hcl/timolol maleate . . . . 52

63


Covered Drugs Index

ethambutol hcl . . . . . . . . . . . . . . . . . . . . 18ethambutol hydrochloride . . . . . . . . . . 18ethosuximide . . . . . . . . . . . . . . . . . . . . . . 13ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 45ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 20etidronate disodium . . . . . . . . . . . . . . . . 50etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . 7etoposide inj . . . . . . . . . . . . . . . . . . . . . . 21EURAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 23EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 18EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 26exemestane . . . . . . . . . . . . . . . . . . . . . . . 21EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . . . 36ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 34ezetimibe/simvastatin . . . . . . . . . . . . . . 34

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 42falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 27famotidine inj . . . . . . . . . . . . . . . . . . . . . 41famotidine premixed . . . . . . . . . . . . . . . 41famotidine susr . . . . . . . . . . . . . . . . . . . 41famotidine tabs 20mg, 40mg . . . . . . . 41FANAPT TABS 1MG, 2MG, 4MG . . . 24FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 24FANAPT TITRATION PACK . . . . . . . . 24FARESTON . . . . . . . . . . . . . . . . . . . . . . . 18FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 27FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 21FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 18febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 17felbamate susp . . . . . . . . . . . . . . . . . . . 14felbamate tabs . . . . . . . . . . . . . . . . . . . . 14felodipine er . . . . . . . . . . . . . . . . . . . . . . . 32FEM PH . . . . . . . . . . . . . . . . . . . . . . . . . . . 9femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 11ertapenem sodium . . . . . . . . . . . . . . . . . 11ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 20ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 12ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYTHROCIN LACTOBIONATE . . . 12erythrocin stearate . . . . . . . . . . . . . . . . . 12erythromycin base . . . . . . . . . . . . . . . . . 12erythromycin/benzoyl peroxide . . . . . 36erythromycin cpep . . . . . . . . . . . . . . . . 12erythromycin dr . . . . . . . . . . . . . . . . . . . . 12erythromycin ethylsuccinate susr 200mg/5ml . . . . . . . . . . . . . . . . . . . 12ERYTHROMYCIN ETHYLSUCCINATE SUSR 400MG/5ML . . . . . . . . . . . . . . . . 12erythromycin ethylsuccinate tabs . . . 12erythromycin external soln . . . . . . . . . 12erythromycin gel . . . . . . . . . . . . . . . . . . 12erythromycin oint . . . . . . . . . . . . . . . . . 12ESBRIET CAPS . . . . . . . . . . . . . . . . . . 54ESBRIET TABS 267MG . . . . . . . . . . . . 54ESBRIET TABS 801MG . . . . . . . . . . . . 54escitalopram oxalate oral soln . . . . . 15escitalopram oxalate tabs 5mg . . . . . 15escitalopram oxalate tabs 10mg . . . . 15escitalopram oxalate tabs 20mg . . . . 15esgic caps . . . . . . . . . . . . . . . . . . . . . . . . . 7esomeprazole magnesium . . . . . . . . . 41estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 45estradiol crea . . . . . . . . . . . . . . . . . . . . . 45estradiol/norethindrone acetate . . . . . 45estradiol pttw . . . . . . . . . . . . . . . . . . . . . 45estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 45estradiol tabs 0.5mg, 1mg, 2mg . . . . 45estradiol tabs 10mcg . . . . . . . . . . . . . . . 45ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 45ethacrynate sodium . . . . . . . . . . . . . . . . 33ethacrynic acid . . . . . . . . . . . . . . . . . . . . 33

enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 31ENBREL INJ 25MG/0.5ML . . . . . . . . . 48ENBREL INJ 25MG, 50MG/ML . . . . . 48ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 48ENBREL SURECLICK . . . . . . . . . . . . . 48endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . . 7endocet tabs 325mg; 7.5mg . . . . . . . . . 7endocet tabs 325mg; 10mg . . . . . . . . . 7ENGERIX-B INJ 10MCG/0.5ML . . . . 49ENGERIX-B INJ 20MCG/ML . . . . . . . 49enoxaparin sodium . . . . . . . . . . . . . . . . 29enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 44enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 44entacapone . . . . . . . . . . . . . . . . . . . . . . . 23entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 25ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 31enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 48ENVARSUS XR TB24 4MG . . . . . . . . 48EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 25EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 13epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . . . . . . . . . . . . . . . . 53EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 53EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 53epirubicin hcl inj 200mg/100ml . . . . . 20epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14EPIVIR HBV ORAL SOLN . . . . . . . . . 25eplerenone . . . . . . . . . . . . . . . . . . . . . . . . 33ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 22ergotamine tartrate/caffeine . . . . . . . . 17ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 21ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 18erlotinib hydrochloride tabs 25mg . . . 21erlotinib hydrochloride tabs 100mg, 150mg . . . . . . . . . . . . . . . . . . . . 21errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

64


Covered Drugs Index

fluphenazine hydrochloride . . . . . . . . . 23flura-drops . . . . . . . . . . . . . . . . . . . . . . . . 38flurbiprofen sodium . . . . . . . . . . . . . . . . 52flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 18fluticasone propionate crea . . . . . . . . 43fluticasone propionate lotn . . . . . . . . . 43fluticasone propionate oint . . . . . . . . . 43fluticasone propionate susp . . . . . . . . 52fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 15fluvoxamine maleate tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 15FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52FML FORTE . . . . . . . . . . . . . . . . . . . . . . 52FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 19fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 29fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 29fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 29fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 29FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 50fosamprenavir calcium . . . . . . . . . . . . . 26fosinopril sodium . . . . . . . . . . . . . . . . . . 31fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 31fosphenytoin sodium . . . . . . . . . . . . . . . 14FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML . . . . . . . . . . . . . . . . . . 29FRAGMIN INJ 7500UNIT/0.3ML . . . . 29FRAGMIN INJ 10000UNIT/ML. . . . . . 29FRAGMIN INJ 12500UNIT/0.5ML. . . 29FRAGMIN INJ 15000UNIT/0.6ML. . . 29FRAGMIN INJ 18000UNT/0.72ML . . 29FRAGMIN INJ 95000UNIT/3.8ML. . . 29FREAMINE HBC 6.9% . . . . . . . . . . . . . 38

FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 52floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . 19fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 17fluconazole in nacl . . . . . . . . . . . . . . . . . 17flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 17fludarabine phosphate inj 50mg . . . . 20fludrocortisone acetate . . . . . . . . . . . . . 43flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 52fluocinolone acetonide . . . . . . . . . . . . . 43fluocinolone acetonide . . . . . . . . . . . . . 52fluocinolone acetonide body . . . . . . . . 43fluocinolone acetonide ear drops . . . 52fluocinolone acetonide scalp . . . . . . . 43fluocinonide crea 0.1% . . . . . . . . . . . . . 43fluocinonide crea 0.05% . . . . . . . . . . . 43fluocinonide external soln . . . . . . . . . . 43fluocinonide gel . . . . . . . . . . . . . . . . . . . 43fluocinonide oint . . . . . . . . . . . . . . . . . . 43fluoride chew 0.25mg . . . . . . . . . . . . . . 38fluoritab chew 0.5mg, 1mg . . . . . . . . . 38fluoritab oral soln . . . . . . . . . . . . . . . . . 38fluorometholone . . . . . . . . . . . . . . . . . . . 51fluorouracil crea 0.5% . . . . . . . . . . . . . . 36fluorouracil crea 5% . . . . . . . . . . . . . . . 36fluorouracil external soln . . . . . . . . . . . 36fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 19fluoxetine hcl caps 20mg . . . . . . . . . . . 15fluoxetine hcl caps 40mg . . . . . . . . . . . 15fluoxetine hydrochloride caps 10mg . . . . . . . . . . . . . . . . . . . . . . . . 15fluoxetine hydrochloride oral soln . . . 15fluoxetine hydrochloride tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 15fluoxetine hydrochloride tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 15fluphenazine decanoate . . . . . . . . . . . . 23fluphenazine hcl conc . . . . . . . . . . . . . 23fluphenazine hcl inj . . . . . . . . . . . . . . . . 23fluphenazine hcl tabs . . . . . . . . . . . . . . 23

fenofibrate caps 43mg, 50mg . . . . . . . 34fenofibrate caps 67mg . . . . . . . . . . . . . 34fenofibrate caps 130mg, 150mg . . . . 34fenofibrate caps 134mg, 200mg . . . . 34fenofibrate micronized caps 67mg . . 34fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 34fenofibrate tabs 48mg, 54mg . . . . . . . 34fenofibrate tabs 145mg, 160mg . . . . . 34fenofibric acid dr cpdr 45mg . . . . . . . . 34fenofibric acid dr cpdr 135mg . . . . . . . 34fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . . 7fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . . 8fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr . . . . . . 7FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 39FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 50FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 15FETZIMA TITRATION PACK . . . . . . . 15FINACEA . . . . . . . . . . . . . . . . . . . . . . . . . 36finasteride tabs 5mg . . . . . . . . . . . . . . . 42FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 48FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 50FIRMAGON INJ 80MG . . . . . . . . . . . . . 47FIRMAGON INJ 120MG . . . . . . . . . . . 47FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . . 9flac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52FLAREX . . . . . . . . . . . . . . . . . . . . . . . . . . 51flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 42flecainide acetate . . . . . . . . . . . . . . . . . . 31FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 52FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 52FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 52FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 52

65


Covered Drugs Index

glipizide er tb24 10mg . . . . . . . . . . . . . 27glipizide/metformin hydrochloride tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . 28glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg . . . 28glipizide tabs 5mg . . . . . . . . . . . . . . . . . 27glipizide tabs 10mg . . . . . . . . . . . . . . . . 28glipizide xl tb24 2.5mg . . . . . . . . . . . . . 28glipizide xl tb24 5mg . . . . . . . . . . . . . . . 28glipizide xl tb24 10mg . . . . . . . . . . . . . . 28GLUCAGEN HYPOKIT . . . . . . . . . . . . 28GLUCAGON EMERGENCY KIT . . . . 28glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 40glycopyrrolate tabs 1mg, 2mg . . . . . . 40glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 28GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . 41GRALISE . . . . . . . . . . . . . . . . . . . . . . . . . 14GRALISE STARTER . . . . . . . . . . . . . . . 14granisetron hcl inj 1mg/ml . . . . . . . . . . 16granisetron hcl tabs . . . . . . . . . . . . . . . 16granisetron hydrochloride . . . . . . . . . . 16griseofulvin microsize . . . . . . . . . . . . . . 17griseofulvin ultramicrosize . . . . . . . . . . 17GUANIDINE HCL . . . . . . . . . . . . . . . . . . 17GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . . 17

Hhailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 45HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 20halobetasol propionate crea . . . . . . . 43halobetasol propionate oint . . . . . . . . 43haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 23haloperidol decanoate . . . . . . . . . . . . . 23haloperidol lactate . . . . . . . . . . . . . . . . . 23HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 25HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 49heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 46HEPARIN SODIUM/D5W . . . . . . . . . . 29

gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 41gavilyte-n/flavor pack . . . . . . . . . . . . . . 41GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 22GELNIQUE PUMP . . . . . . . . . . . . . . . . . 42gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 19gemcitabine hcl . . . . . . . . . . . . . . . . . . . . 19gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 19gemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml . . . . . . . . . . . . . . . . . . . . . . . 19gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 34generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 41gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 48GENOTROPIN . . . . . . . . . . . . . . . . . . . . 44GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 44GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 44gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . . 9gentamicin sulfate crea . . . . . . . . . . . . . 9gentamicin sulfate inj . . . . . . . . . . . . . . . 9gentamicin sulfate oint . . . . . . . . . . . . . 9gentamicin sulfate ophthalmic soln . . . 9gentamicin sulfate pediatric . . . . . . . . . 9GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 25GEODON INJ . . . . . . . . . . . . . . . . . . . . 24gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 21GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . . 54GLEOSTINE CAPS 10MG . . . . . . . . . 18GLEOSTINE CAPS 100MG, 40MG . . 18glimepiride tabs 1mg . . . . . . . . . . . . . . . 27glimepiride tabs 2mg . . . . . . . . . . . . . . . 27glimepiride tabs 4mg . . . . . . . . . . . . . . . 27glipizide er tb24 2.5mg . . . . . . . . . . . . . 27glipizide er tb24 5mg . . . . . . . . . . . . . . . 27

FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 38fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 19furosemide inj . . . . . . . . . . . . . . . . . . . . 33furosemide oral soln . . . . . . . . . . . . . . 33furosemide tabs . . . . . . . . . . . . . . . . . . . 33FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 26fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45FYCOMPA SUSP . . . . . . . . . . . . . . . . . 13FYCOMPA TABS . . . . . . . . . . . . . . . . . 13

Ggabapentin caps 100mg . . . . . . . . . . . 14gabapentin caps 300mg, 400mg . . . . 14gabapentin oral soln . . . . . . . . . . . . . . 14gabapentin tabs 600mg . . . . . . . . . . . . 14gabapentin tabs 800mg . . . . . . . . . . . . 14galantamine hydrobromide er . . . . . . 14galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 14galantamine hydrobromide tabs . . . . 14GAMMAKED INJ 1GM/10ML . . . . . . . 48GAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 48GAMUNEX-C INJ 1GM/10ML . . . . . . 49GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 49ganciclovir inj 500mg, 500mg/10ml . . 25GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 49gatifloxacin . . . . . . . . . . . . . . . . . . . . . . . . 12GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 41gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 41

66


Covered Drugs Index

hydrocortisone valerate . . . . . . . . . . . . 43hydromorphone hcl dosette . . . . . . . . . 8hydromorphone hcl inj . . . . . . . . . . . . . . 8hydromorphone hcl liqd . . . . . . . . . . . . 8hydromorphone hcl tabs 2mg, 4mg . . 8hydromorphone hcl tabs 8mg . . . . . . . . 8hydroxychloroquine sulfate . . . . . . . . . 23hydroxyprogesterone caproate . . . . . 46hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 19hyoscyamine sulfate elix . . . . . . . . . . . 40hyoscyamine sulfate subl . . . . . . . . . . 40hyoscyamine sulfate tabs . . . . . . . . . . 40hyoscyamine sulfate tbdp . . . . . . . . . . 41hyperlyte-cr . . . . . . . . . . . . . . . . . . . . . . . 38

Iibandronate sodium inj . . . . . . . . . . . . 50ibandronate sodium tabs . . . . . . . . . . 50IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 21ibuprofen susp . . . . . . . . . . . . . . . . . . . . . 7ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . . 7ibu tabs 600mg, 800mg . . . . . . . . . . . . . 7icatibant acetate . . . . . . . . . . . . . . . . . . . 48ICLUSIG TABS 15MG . . . . . . . . . . . . . 21ICLUSIG TABS 45MG . . . . . . . . . . . . . 21idarubicin hcl . . . . . . . . . . . . . . . . . . . . . . 20idarubicin hydrochloride . . . . . . . . . . . . 20IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 18imatinib mesylate . . . . . . . . . . . . . . . . . . 21IMBRUVICA CAPS 70MG . . . . . . . . . . 21IMBRUVICA CAPS 140MG. . . . . . . . . 21IMBRUVICA TABS . . . . . . . . . . . . . . . . 21IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 22imipenem/cilastatin . . . . . . . . . . . . . . . . 11imipramine hcl tabs 25mg, 50mg . . . 16imipramine hydrochloride . . . . . . . . . . 16imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 36

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH) . . . . . . . . . . . . . . . . . 48HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 48HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 48HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 48HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 48HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 48HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 28HUMULIN 70/30 KWIKPEN . . . . . . . . 28HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 29HUMULIN N KWIKPEN . . . . . . . . . . . . 29HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 29HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 29HUMULIN R U-500 KWIKPEN. . . . . . 29hydralazine hcl inj . . . . . . . . . . . . . . . . . 34hydralazine hcl tabs . . . . . . . . . . . . . . . 34hydralazine hydrochloride tabs 100mg, 25mg, 50mg . . . . . . . . . . . . . . . 34hydrochlorothiazide . . . . . . . . . . . . . . . . 33hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . . 8hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . . 8hydrocodone/ibuprofen . . . . . . . . . . . . . 8hydrocortisone/acetic acid . . . . . . . . . . 52hydrocortisone butyrate crea . . . . . . . 43hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 43hydrocortisone butyrate oint . . . . . . . 43hydrocortisone enem . . . . . . . . . . . . . . 50hydrocortisone external crea . . . . . . . 43hydrocortisone lotn 2.5% . . . . . . . . . . . 43hydrocortisone oint 1%, 2.5% . . . . . . 43hydrocortisone rectal crea . . . . . . . . . 43hydrocortisone tabs . . . . . . . . . . . . . . . 43

HEPARIN SODIUM/DEXTROSE . . . 29heparin sodium inj 5000unit/ml . . . . . 29heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 29heparin sodium/nacl 0.9% . . . . . . . . . . 29heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 29heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 29heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9% . . . . . . . . . . . . . . 30heparin sodium/ sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 30HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 38HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 49HERCEPTIN HYLECTA . . . . . . . . . . . . 22HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 35HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 49homatropaire . . . . . . . . . . . . . . . . . . . . . . 51homatropine hbr . . . . . . . . . . . . . . . . . . . 51HORIZANT . . . . . . . . . . . . . . . . . . . . . . . 35HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 28HUMALOG JUNIOR KWIKPEN . . . . 28HUMALOG KWIKPEN . . . . . . . . . . . . . 28HUMALOG MIX 50/50 . . . . . . . . . . . . . 28HUMALOG MIX 50/50 KWIKPEN . . . 28HUMALOG MIX 75/25 . . . . . . . . . . . . . 28HUMALOG MIX 75/25 KWIKPEN . . . 28HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 48HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 48HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK) . . . . . . . . . . . . . 48

67


Covered Drugs Index

ivermectin tabs . . . . . . . . . . . . . . . . . . . 22IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 40JADENU SPRINKLE . . . . . . . . . . . . . . . 40JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 21jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 30JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 28JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 28JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 28JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 28JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 28jasmiel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 46JENTADUETO . . . . . . . . . . . . . . . . . . . . 28JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 28JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 28JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 20jinteli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 25junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 45junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 45junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 45junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 45junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 45

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 38KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 22kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 45KALBITOR . . . . . . . . . . . . . . . . . . . . . . . . 48KALETRA TABS 100MG; 25MG . . . . 26KALETRA TABS 200MG; 50MG . . . . 26

IOPIDINE . . . . . . . . . . . . . . . . . . . . . . . . . 52IPOL INACTIVATED IPV . . . . . . . . . . . 49ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 53ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 53ipratropium bromide nasal soln . . . . 53irbesartan/hydrochlorothiazide . . . . . . 31irbesartan tabs 150mg, 75mg . . . . . . 31irbesartan tabs 300mg . . . . . . . . . . . . . 31IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 21irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 20irinotecan hydrochloride . . . . . . . . . . . . 20irinotecan hydrochloride . . . . . . . . . . . . 21irinotecan inj 100mg/5ml, 500mg/25ml . . . . . . . . . . . 20ISENTRESS CHEW 25MG . . . . . . . . . 25ISENTRESS CHEW 100MG . . . . . . . 25ISENTRESS HD . . . . . . . . . . . . . . . . . . . 25ISENTRESS PACK . . . . . . . . . . . . . . . 25ISENTRESS TABS . . . . . . . . . . . . . . . . 25isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ISOLYTE-P/DEXTROSE 5% . . . . . . . 38ISOLYTE-S . . . . . . . . . . . . . . . . . . . . . . . 38ISOLYTE-S PH 7.4 . . . . . . . . . . . . . . . . 38isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 18isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 18isoniazid tabs . . . . . . . . . . . . . . . . . . . . . 18isoproterenol hydrochloride . . . . . . . . 53isosorbide dinitrate er . . . . . . . . . . . . . . 34isosorbide dinitrate tabs . . . . . . . . . . . 34isosorbide mononitrate . . . . . . . . . . . . . 34isosorbide mononitrate er . . . . . . . . . . 34isotonic gentamicin . . . . . . . . . . . . . . . . . 9isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 36isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 33ISTODAX (OVERFILL) . . . . . . . . . . . . . 20ISUPREL . . . . . . . . . . . . . . . . . . . . . . . . . 53itraconazole caps . . . . . . . . . . . . . . . . . 17itraconazole oral soln . . . . . . . . . . . . . . 17

IMOVAX RABIES (H.D.C.V.) . . . . . . . 49incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 46INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 44INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 53indapamide . . . . . . . . . . . . . . . . . . . . . . . 33INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 49INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 19INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 21INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 20INTELENCE TABS 25MG . . . . . . . . . . 26INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 26INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 50INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 25INTRON A INJ 6000000UNIT/ML . . . 25introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 45INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 11INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 24INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 24INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 24INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 24INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 24INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 24INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 24INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 24INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 24INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 52INVIRASE . . . . . . . . . . . . . . . . . . . . . . . . 26INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 28INVOKAMET XR . . . . . . . . . . . . . . . . . . 28INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 28IONOSOL-MB/DEXTROSE 5% . . . . . 38

68


Covered Drugs Index

leflunomide . . . . . . . . . . . . . . . . . . . . . . . 49LENVIMA 4 MG DAILY DOSE . . . . . . 22LENVIMA 8 MG DAILY DOSE . . . . . . 22LENVIMA 10 MG DAILY DOSE . . . . . 21LENVIMA 12MG DAILY DOSE . . . . . 21LENVIMA 14 MG DAILY DOSE . . . . . 21LENVIMA 18 MG DAILY DOSE . . . . . 21LENVIMA 20 MG DAILY DOSE . . . . . 21LENVIMA 24 MG DAILY DOSE . . . . . 22lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 54letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 21leucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg . . . . . . . . 20leucovorin calcium tabs . . . . . . . . . . . 20LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 18LEUKINE INJ 250MCG . . . . . . . . . . . . 30leuprolide acetate . . . . . . . . . . . . . . . . . 47levalbuterol . . . . . . . . . . . . . . . . . . . . . . . 53levalbuterol hcl nebu 0.63mg/3ml . . . 53levalbuterol hcl nebu 1.25mg/3ml . . . 53levalbuterol hydrochloride nebu 0.31mg/3ml . . . . . . . . . . . . . . . . . . 53levalbuterol tartrate hfa . . . . . . . . . . . . 53LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 29LEVEMIR FLEXTOUCH . . . . . . . . . . . 29levetiracetam er tb24 500mg . . . . . . . 13levetiracetam er tb24 750mg . . . . . . . 13levetiracetam inj . . . . . . . . . . . . . . . . . . 13levetiracetam oral soln . . . . . . . . . . . . 13levetiracetam/sodium chloride . . . . . . 13levetiracetam tabs . . . . . . . . . . . . . . . . 13levobunolol hcl . . . . . . . . . . . . . . . . . . . . 52levocarnitine . . . . . . . . . . . . . . . . . . . . . . 50levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 53levocetirizine dihydrochloride tabs . . 53levofloxacin in d5w . . . . . . . . . . . . . . . . 12levofloxacin inj . . . . . . . . . . . . . . . . . . . . 12

kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 42KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 21

Llabetalol hydrochloride inj 5mg/ml . . 32labetalol hydrochloride tabs . . . . . . . . 32LACRISERT . . . . . . . . . . . . . . . . . . . . . . 51LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 38LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 50LACTATED RINGERS VIAFLEX . . . . 38lactulose oral soln . . . . . . . . . . . . . . . . . 41lamivudine oral soln . . . . . . . . . . . . . . . 26lamivudine tabs 100mg . . . . . . . . . . . . 25lamivudine tabs 150mg . . . . . . . . . . . . 26lamivudine tabs 300mg . . . . . . . . . . . . 26lamivudine/zidovudine . . . . . . . . . . . . . 26lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 14lamotrigine er . . . . . . . . . . . . . . . . . . . . . 14lamotrigine odt . . . . . . . . . . . . . . . . . . . . 14LANOXIN TABS 62.5MCG . . . . . . . . . 33lansoprazole cpdr . . . . . . . . . . . . . . . . . 41LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 29LANTUS SOLOSTAR . . . . . . . . . . . . . . 29larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 45larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 45larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 45larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 45larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 45larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 20latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 51LATUDA TABS 80MG . . . . . . . . . . . . . . 24LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 24layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 45leena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 53KANJINTI INJ 420MG . . . . . . . . . . . . . 22kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 38KCL 0.3%/D5W/NACL 0.45% . . . . . . 38KCL 0.15%/D5W/NACL 0.2% . . . . . . 38KCL 0.15%/D5W/NACL 0.9% . . . . . . 38KCL 0.15%/D5W/NACL 0.45% . . . . . 38KCL 0.15%/D5W/NACL 0.225% . . . . 38KCL 0.075%/D5W/NACL 0.45% . . . . 38kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 45kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 45KEPIVANCE . . . . . . . . . . . . . . . . . . . . . . 36ketoconazole crea . . . . . . . . . . . . . . . . 17ketoconazole sham . . . . . . . . . . . . . . . 17ketoconazole tabs . . . . . . . . . . . . . . . . . 17ketorolac tromethamine inj 15mg/ml . . 7ketorolac tromethamine inj 30mg/ml . . 7ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 52ketorolac tromethamine tabs . . . . . . . . 7KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 22KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 49kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 20KISQALI FEMARA 200 DOSE . . . . . . 18KISQALI FEMARA 400 DOSE . . . . . . 18KISQALI FEMARA 600 DOSE . . . . . . 18klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 38klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 38klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 38klor-con/ef . . . . . . . . . . . . . . . . . . . . . . . . 38klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 38klor-con m15 . . . . . . . . . . . . . . . . . . . . . . 38klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 38klor-con sprinkle . . . . . . . . . . . . . . . . . . . 38KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 50K-PHOS . . . . . . . . . . . . . . . . . . . . . . . . . . 38K-PHOS NO 2 . . . . . . . . . . . . . . . . . . . . . 38K-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

69


Covered Drugs Index

lovastatin tabs 10mg, 20mg . . . . . . . . 34lovastatin tabs 40mg . . . . . . . . . . . . . . . 34low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 45loxapine caps 10mg, 5mg . . . . . . . . . . 24loxapine succinate . . . . . . . . . . . . . . . . . 24ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 51LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 42LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 22LUPRON DEPOT (1-MONTH) . . . . . . 47LUPRON DEPOT (3-MONTH) . . . . . . 47LUPRON DEPOT (4-MONTH) . . . . . . 47LUPRON DEPOT (6-MONTH) . . . . . . 47LUPRON DEPOT-PED (1-MONTH) . . 47LUPRON DEPOT-PED (3-MONTH) . . 47lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 20LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 13LYRICA CAPS 225MG, 300MG . . . . . 13LYRICA CR TB24 165MG, 82.5MG . . 35LYRICA CR TB24 330MG . . . . . . . . . . 35LYRICA ORAL SOLN . . . . . . . . . . . . . . 13LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 47lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Mmagnesium sulfate in d5w . . . . . . . . . . 13magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 38MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 46MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 46malathion . . . . . . . . . . . . . . . . . . . . . . . . . 23maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 15marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 45MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 15MARQIBO . . . . . . . . . . . . . . . . . . . . . . . . 20MATULANE . . . . . . . . . . . . . . . . . . . . . . . 18

linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 10linezolid susr . . . . . . . . . . . . . . . . . . . . . 10linezolid tabs . . . . . . . . . . . . . . . . . . . . . 10LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 41liothyronine sodium . . . . . . . . . . . . . . . . 47LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 50lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 31lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 31lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 31LITHIUM . . . . . . . . . . . . . . . . . . . . . . . . . . 27lithium carbonate . . . . . . . . . . . . . . . . . . 27lithium carbonate er . . . . . . . . . . . . . . . . 27LITHOSTAT . . . . . . . . . . . . . . . . . . . . . . . 42LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 34LONSURF TABS 6.14MG; 15MG . . . 19LONSURF TABS 8.19MG; 20MG . . . 19loperamide hcl caps . . . . . . . . . . . . . . . 41lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 26lopreeza . . . . . . . . . . . . . . . . . . . . . . . . . . 45lorazepam conc . . . . . . . . . . . . . . . . . . . 27lorazepam inj . . . . . . . . . . . . . . . . . . . . . 27lorazepam intensol . . . . . . . . . . . . . . . . 27lorazepam tabs 0.5mg, 1mg . . . . . . . . 27lorazepam tabs 2mg . . . . . . . . . . . . . . . 27LORBRENA TABS 25MG . . . . . . . . . . 20LORBRENA TABS 100MG . . . . . . . . . 20lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet plus tabs 325mg; 7.5mg . . . . . . . 8loryna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45losartan potassium . . . . . . . . . . . . . . . . 31losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 31losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 31LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 52LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 52

levofloxacin ophthalmic soln . . . . . . . 12levofloxacin oral soln . . . . . . . . . . . . . . 12levofloxacin tabs 250mg, 750mg . . . . 12levofloxacin tabs 500mg . . . . . . . . . . . 12levoleucovorin . . . . . . . . . . . . . . . . . . . . . 20levoleucovorin calcium . . . . . . . . . . . . . 20levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 45levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 45levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg . . . . . . . 45levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 45levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 45levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 45levothyroxine sodium inj 100mcg/5ml, 200mcg/5ml, 500mcg/5ml . . . . . . . . . . . . . . . . . . . . . . . 47levothyroxine sodium inj 100mcg, 200mcg, 500mcg . . . . . . . . . 47levothyroxine sodium tabs . . . . . . . . . 47LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . 47LEVULAN KERASTICK . . . . . . . . . . . . 36LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 26LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 22lidocaine hcl external soln . . . . . . . . . . 8lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% . . . . . . . . . . . . 8lidocaine hcl inj 100mg/5ml, 50mg/5ml . . . . . . . . . . . . . 31lidocaine hcl jelly gel . . . . . . . . . . . . . . . 8lidocaine hcl mouth/throat soln . . . . . . 8lidocaine hcl prsy . . . . . . . . . . . . . . . . . . 8lidocaine hcl viscous . . . . . . . . . . . . . . . . 8lidocaine oint . . . . . . . . . . . . . . . . . . . . . . 8lidocaine/prilocaine crea . . . . . . . . . . . . 8lidocaine ptch . . . . . . . . . . . . . . . . . . . . . . 8lidocaine viscous . . . . . . . . . . . . . . . . . . . 8lincomycin hcl . . . . . . . . . . . . . . . . . . . . . . 9lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

70


Covered Drugs Index

methylprednisolone dose pack . . . . . 43methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 43methylprednisolone tabs . . . . . . . . . . . 43metoclopramide hcl . . . . . . . . . . . . . . . . 41metoclopramide hydrochloride . . . . . . 41metolazone . . . . . . . . . . . . . . . . . . . . . . . 33metoprolol/hydrochlorothiazide . . . . . 32metoprolol succinate er . . . . . . . . . . . . 32metoprolol tartrate inj . . . . . . . . . . . . . . 32metoprolol tartrate tabs . . . . . . . . . . . . 32metronidazole caps . . . . . . . . . . . . . . . 10metronidazole crea . . . . . . . . . . . . . . . . 10metronidazole gel . . . . . . . . . . . . . . . . . 10METRONIDAZOLE INJ 500MG/100ML; 0.74% . . . . . . . . . . . . . 10metronidazole inj 500mg/100ml; 0.79% . . . . . . . . . . . . . . 10metronidazole in nacl 0.79% . . . . . . . 10metronidazole lotn . . . . . . . . . . . . . . . . 10metronidazole tabs . . . . . . . . . . . . . . . . 10metronidazole vaginal . . . . . . . . . . . . . . 10mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 31mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 45miconazole 3 . . . . . . . . . . . . . . . . . . . . . . 17microgestin 1.5/30 . . . . . . . . . . . . . . . . . 45microgestin 1/20 . . . . . . . . . . . . . . . . . . . 45microgestin fe . . . . . . . . . . . . . . . . . . . . . 45microgestin fe 1.5/30 . . . . . . . . . . . . . . 45midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 30migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 17miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 42mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . . 45mimvey lo . . . . . . . . . . . . . . . . . . . . . . . . . 45minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 34minocycline hcl . . . . . . . . . . . . . . . . . . . . 13minocycline hydrochloride caps 100mg, 50mg . . . . . . . . . . . . . . . . 13

metformin hydrochloride oral soln . . . 28metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 28metformin hydrochloride tabs 850mg . . . . . . . . . . . . . . . . . . . . . . . 28metformin hydrochloride tabs 1000mg . . . . . . . . . . . . . . . . . . . . . . 28methazolamide . . . . . . . . . . . . . . . . . . . . 33methenamine hippurate . . . . . . . . . . . . 10methenamine mandelate tabs 1gm . . 10methimazole . . . . . . . . . . . . . . . . . . . . . . 47methotrexate sodium . . . . . . . . . . . . . . 48methotrexate tabs . . . . . . . . . . . . . . . . . 48methoxsalen . . . . . . . . . . . . . . . . . . . . . . 36methscopolamine bromide . . . . . . . . . 41methylergonovine maleate inj . . . . . . 50methylphenidate hydrochloride cd . . 35methylphenidate hydrochloride chew 2.5mg, 5mg . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride chew 10mg . . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er cp24 20mg, 30mg, 40mg . . . . . . . . 35methylphenidate hydrochloride er cpcr 30mg, 40mg . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tbcr 10mg . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 35methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 35methylprednisolone acetate inj 80mg/ml . . . . . . . . . . . . . . . . . . . . . . . 43

matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 33meclizine hcl tabs . . . . . . . . . . . . . . . . . 16MEDROL TABS 2MG . . . . . . . . . . . . . . 43medroxyprogesterone acetate inj . . . 46medroxyprogesterone acetate tabs . . 46mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 23megestrol acetate susp 40mg/ml . . . 46megestrol acetate susp 625mg/5ml . . 47megestrol acetate tabs . . . . . . . . . . . . 47MEKINIST TABS 0.5MG . . . . . . . . . . . 22MEKINIST TABS 2MG . . . . . . . . . . . . . 22MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 20melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 45meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . 7melphalan hydrochloride . . . . . . . . . . . 18memantine hcl tabs 5mg . . . . . . . . . . . 14memantine hcl tabs 10mg . . . . . . . . . . 14memantine hcl titration pak . . . . . . . . . 14memantine hydrochloride er . . . . . . . . 14memantine hydrochloride oral soln . . 14MENACTRA . . . . . . . . . . . . . . . . . . . . . . 49MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 45MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 45MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 49mercaptopurine . . . . . . . . . . . . . . . . . . . . 19meropenem . . . . . . . . . . . . . . . . . . . . . . . 11meropenem/sodium chloride . . . . . . . 11mesalamine dr tbec 1.2gm . . . . . . . . . 50mesalamine enem . . . . . . . . . . . . . . . . 50mesalamine kit . . . . . . . . . . . . . . . . . . . . 50mesalamine supp . . . . . . . . . . . . . . . . . 50mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20MESNEX TABS . . . . . . . . . . . . . . . . . . . 20MESTINON ORAL SOLN . . . . . . . . . . 17metadate er . . . . . . . . . . . . . . . . . . . . . . . 35metaproterenol sulfate . . . . . . . . . . . . . 53metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 28metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 28

71


Covered Drugs Index

MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 42

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . . 7nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32nadolol/bendroflumethiazide . . . . . . . . 32NAFCILLIN . . . . . . . . . . . . . . . . . . . . . . . 11nafcillin sodium . . . . . . . . . . . . . . . . . . . . 11naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 17naftifine hydrochloride . . . . . . . . . . . . . 17NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 17NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 42nalbuphine hcl inj 10mg/ml . . . . . . . . . . 8nalbuphine hcl inj 20mg/ml . . . . . . . . . . 8naloxone hcl . . . . . . . . . . . . . . . . . . . . . . . 9naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . 8naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . . 7naproxen susp . . . . . . . . . . . . . . . . . . . . . 7naproxen tabs . . . . . . . . . . . . . . . . . . . . . 7naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 17NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . . 9NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 17nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 28NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 50NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 13NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 23necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 45nefazodone hcl . . . . . . . . . . . . . . . . . . . . 15nefazodone hydrochloride . . . . . . . . . . 15neomycin/bacitracin/polymyxin . . . . . 10neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 10neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 52neomycin/polymyxin/gramicidin . . . . . 10neomycin/polymyxin/hc . . . . . . . . . . . . 52neomycin/polymyxin/ hydrocortisone ophthalmic susp . . . . 10

moxifloxacin hcl . . . . . . . . . . . . . . . . . . . 12moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 12moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 12moxifloxacin hydrochloride tabs . . . . 12MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 30MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 31multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.5mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1mg; 1.05mg; 15unit; 2500unit . . . . . . . . . . . 40multi-vitamin/fluoride drops . . . . . . . . . 40multivitamin/fluoride/iron . . . . . . . . . . . 40multivitamin/fluoride oral soln . . . . . . 40multivitamins/fluoride . . . . . . . . . . . . . . 40multivitamin with fluoride chew . . . . . 40multivitamin with fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml; 5unit/ml . . . . . . . . . . . . . . . 40mupirocin crea . . . . . . . . . . . . . . . . . . . . 10mupirocin oint . . . . . . . . . . . . . . . . . . . . 10MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22mvc-fluoride . . . . . . . . . . . . . . . . . . . . . . . 40MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . 17mycophenolate mofetil caps . . . . . . . 48mycophenolate mofetil inj . . . . . . . . . . 48mycophenolate mofetil susr . . . . . . . . 48mycophenolate mofetil tabs . . . . . . . . 48mycophenolic acid dr . . . . . . . . . . . . . . 48MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 22myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 36

minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 34mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 15mirtazapine odt . . . . . . . . . . . . . . . . . . . . 15misoprostol . . . . . . . . . . . . . . . . . . . . . . . 41MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 17mitomycin inj 20mg, 5mg . . . . . . . . . . . 20mitomycin inj 40mg . . . . . . . . . . . . . . . . 20mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 20M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 49modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 54moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 31molindone hydrochloride . . . . . . . . . . . 24mometasone furoate crea . . . . . . . . . 43mometasone furoate external soln . . 43mometasone furoate oint . . . . . . . . . . 43mondoxyne nl caps 100mg . . . . . . . . . 13mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 45montelukast sodium . . . . . . . . . . . . . . . 53MONUROL . . . . . . . . . . . . . . . . . . . . . . . 10morgidox 1x50mg . . . . . . . . . . . . . . . . . 13morphine sulfate er cp24 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg . . . . . . . . . . 7morphine sulfate er tbcr . . . . . . . . . . . . 7morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . . 8morphine sulfate inj 1mg/ml, 50mg/ml . . . . . . . . . . . . . . . . . . . 8MORPHINE SULFATE INJ 2MG/ML . . . 8MORPHINE SULFATE INJ 4MG/ML . . . 8MORPHINE SULFATE INJ 5MG/ML . . . 8MORPHINE SULFATE INJ 8MG/ML . . . 8MORPHINE SULFATE INJ 10MG/ML . . 8morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . . 8morphine sulfate tabs . . . . . . . . . . . . . . 8MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 41

72


Covered Drugs Index

NOVOLIN N . . . . . . . . . . . . . . . . . . . . . . . 29NOVOLIN N RELION . . . . . . . . . . . . . . 29NOVOLIN R . . . . . . . . . . . . . . . . . . . . . . . 29NOVOLIN R INNOLET . . . . . . . . . . . . . 29NOVOLIN R RELION . . . . . . . . . . . . . . 29NOVOLOG . . . . . . . . . . . . . . . . . . . . . . . . 29NOVOLOG FLEXPEN . . . . . . . . . . . . . 29NOVOLOG MIX 70/30 . . . . . . . . . . . . . 29NOVOLOG MIX 70/30 PREFILLED FLEXPEN . . . . . . . . . . . . 29NOVOLOG PENFILL . . . . . . . . . . . . . . 29NOVOTWIST 32GX5MM . . . . . . . . . . . 51NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 17NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 17NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 18NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 35nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 48NULYTELY/FLAVOR PACKS . . . . . . . 41NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 24NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 51NUVARING . . . . . . . . . . . . . . . . . . . . . . . 46NUZYRA INJ . . . . . . . . . . . . . . . . . . . . . 13NUZYRA TABS . . . . . . . . . . . . . . . . . . . 13nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 17nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 17nystatin/triamcinolone . . . . . . . . . . . . . . 17nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Oocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46octreotide acetate . . . . . . . . . . . . . . . . . 47ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 26ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 20OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 12ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 46olanzapine . . . . . . . . . . . . . . . . . . . . . . . . 24olanzapine . . . . . . . . . . . . . . . . . . . . . . . . 24

nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 34nitroglycerin lingual . . . . . . . . . . . . . . . . 34nitroglycerin subl . . . . . . . . . . . . . . . . . . 34nitroglycerin transdermal . . . . . . . . . . . 34nizatidine caps . . . . . . . . . . . . . . . . . . . . 41nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 47norethindrone . . . . . . . . . . . . . . . . . . . . . 47norethindrone acetate . . . . . . . . . . . . . . 47norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 46norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg . . . . . . . . . . . . . . . . . 46norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 46norethindrone & ethinyl estradiol ferrous fumarate . . . . . . . . . . 46norethindrone/ethinyl estradiol/ferrous fumarate . . . . . . . . . . 46norgestimate/ethinyl estradiol . . . . . . 46norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 47NORMOSOL-M IN D5W . . . . . . . . . . . 38NORMOSOL -R . . . . . . . . . . . . . . . . . . . 38NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 38NORMOSOL-R IN D5W. . . . . . . . . . . . 38NORTHERA CAPS 100MG . . . . . . . . 33NORTHERA CAPS 200MG, 300MG . . 33nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 46nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 46nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 46nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 16nortriptyline hydrochloride . . . . . . . . . . 16NORVIR ORAL SOLN . . . . . . . . . . . . . 26NORVIR PACK . . . . . . . . . . . . . . . . . . . 26NORVIR TABS . . . . . . . . . . . . . . . . . . . . 26NOVOFINE 31 . . . . . . . . . . . . . . . . . . . . 50NOVOFINE 32GX6MM . . . . . . . . . . . . 50NOVOFINE AUTOCOVER 30GX8MM . . . . . . . . . . . . . . . . . . . . . . . . 50NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . . 29NOVOLIN 70/30 RELION . . . . . . . . . . 29

neomycin/polymyxin/ hydrocortisone otic soln . . . . . . . . . . . 52neomycin/polymyxin/ hydrocortisone otic susp . . . . . . . . . . . 52neomycin sulfate . . . . . . . . . . . . . . . . . . . 9neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 10neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 10NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . . 48NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 38NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 20NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 23NEVANAC . . . . . . . . . . . . . . . . . . . . . . . . 52nevirapine er tb24 100mg . . . . . . . . . . 26nevirapine er tb24 400mg . . . . . . . . . . 26nevirapine susp . . . . . . . . . . . . . . . . . . . 26nevirapine tabs . . . . . . . . . . . . . . . . . . . 26NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 22niacin er tbcr 500mg . . . . . . . . . . . . . . . 34niacin er tbcr 1000mg, 750mg . . . . . . 34niacin tabs 500mg . . . . . . . . . . . . . . . . . 34niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 33NICOTROL INHALER. . . . . . . . . . . . . . . 9NICOTROL NS . . . . . . . . . . . . . . . . . . . . . 9nifedipine er tb24 30mg, 60mg . . . . . 33nifedipine er tb24 90mg . . . . . . . . . . . . 33nikki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 18NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 20NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 19NITISINONE CAPS 2MG . . . . . . . . . . 42nitisinone caps 10mg, 5mg . . . . . . . . . 42NITRO-BID . . . . . . . . . . . . . . . . . . . . . . . 34NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR . . . . . . . . . . . . . 34nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 10nitrofurantoin macrocrystals . . . . . . . . 10nitrofurantoin monohydrate . . . . . . . . . 10nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 10

73


Covered Drugs Index

paroxetine hcl tabs 30mg, 40mg . . . . 15paroxetine hydrochloride tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 15PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 15PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 51PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 49PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 49peg 3350/electrolytes . . . . . . . . . . . . . . 41peg-3350/electrolytes . . . . . . . . . . . . . . 41peg-3350/nacl/na bicarbonate/kcl . . . 41PEGANONE . . . . . . . . . . . . . . . . . . . . . . 14PEGASYS INJ 180MCG/0.5ML . . . . . 25PEGASYS INJ 180MCG/ML . . . . . . . . 25PEGASYS PROCLICK . . . . . . . . . . . . . 25penicillamine . . . . . . . . . . . . . . . . . . . . . . 40penicillin g potassium . . . . . . . . . . . . . . 11penicillin g potassium in iso-osmotic dextrose . . . . . . . . . . . . 11penicillin g procaine . . . . . . . . . . . . . . . . 11penicillin g sodium . . . . . . . . . . . . . . . . . 11penicillin v potassium . . . . . . . . . . . . . . 11PENTACEL . . . . . . . . . . . . . . . . . . . . . . . 49PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 23pentamidine isethionate . . . . . . . . . . . . 23pentoxifylline er . . . . . . . . . . . . . . . . . . . . 33PERFOROMIST . . . . . . . . . . . . . . . . . . . 53PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 38perindopril erbumine . . . . . . . . . . . . . . . 31PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 22permethrin . . . . . . . . . . . . . . . . . . . . . . . . 23perphenazine . . . . . . . . . . . . . . . . . . . . . 24perphenazine/amitriptyline . . . . . . . . . 16PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 24pfizerpen inj 20mu, 5000000unit . . . . 11phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 16phenelzine sulfate . . . . . . . . . . . . . . . . . 15PHENOBARBITAL ELIX . . . . . . . . . . . 14PHENOBARBITAL TABS . . . . . . . . . . 14phenoxybenzamine hydrochloride . . 30

oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml . . . . . . . . . . . 20oxandrolone tabs 2.5mg . . . . . . . . . . . 44oxandrolone tabs 10mg . . . . . . . . . . . . 44oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 27oxcarbazepine . . . . . . . . . . . . . . . . . . . . 14oxybutynin chloride er tb24 5mg . . . . 42oxybutynin chloride er tb24 10mg, 15mg . . . . . . . . . . . . . . . . . . . . . . . 42oxybutynin chloride syrp . . . . . . . . . . . 42oxybutynin chloride tabs . . . . . . . . . . . 42oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . . 8oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . . 8oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . . 8oxycodone/aspirin . . . . . . . . . . . . . . . . . . 8oxycodone hcl conc . . . . . . . . . . . . . . . . 8oxycodone hcl tabs . . . . . . . . . . . . . . . . 8oxycodone hydrochloride oral soln . . . 8oxycodone hydrochloride tabs . . . . . . 8OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 28

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 31paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 20paliperidone er tb24 1.5mg, 3mg . . . 24paliperidone er tb24 6mg . . . . . . . . . . . 24paliperidone er tb24 9mg . . . . . . . . . . . 24pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml . . . . 50PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . . 43PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 22pantoprazole sodium tbec . . . . . . . . . 42paricalcitol caps 1mcg, 2mcg . . . . . . . 50paricalcitol caps 4mcg . . . . . . . . . . . . . 50paricalcitol inj . . . . . . . . . . . . . . . . . . . . . 50paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36paromomycin sulfate . . . . . . . . . . . . . . . . 9paroxetine hcl tabs 10mg . . . . . . . . . . 15

olanzapine/fluoxetine . . . . . . . . . . . . . . 15olanzapine odt . . . . . . . . . . . . . . . . . . . . 24olmesartan medoxomil . . . . . . . . . . . . . 31olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 31olopatadine hcl ophthalmic soln . . . . 51olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 51omega-3-acid ethyl esters . . . . . . . . . . 34omeprazole cpdr . . . . . . . . . . . . . . . . . . 42OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 51OMNIPOD DASH 5 PACK. . . . . . . . . . 51OMNIPOD STARTER KIT . . . . . . . . . . 51ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 20ondansetron hcl oral soln . . . . . . . . . . 16ondansetron hcl tabs . . . . . . . . . . . . . . 16ondansetron hydrochloride inj . . . . . . 16ondansetron hydrochloride tabs . . . . 16ondansetron odt . . . . . . . . . . . . . . . . . . . 16ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 14ONFI TABS 10MG . . . . . . . . . . . . . . . . . 14ONFI TABS 20MG . . . . . . . . . . . . . . . . . 14OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 22OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 54ORACEA . . . . . . . . . . . . . . . . . . . . . . . . . 36oralone dental paste . . . . . . . . . . . . . . . 36ORENCIA INJ 250MG . . . . . . . . . . . . . 48ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 42ORKAMBI PACK . . . . . . . . . . . . . . . . . . 53ORKAMBI TABS . . . . . . . . . . . . . . . . . . 53orphenadrine citrate er . . . . . . . . . . . . . 54orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ORTHO TRI-CYCLEN LO . . . . . . . . . . 46oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 41oseltamivir phosphate . . . . . . . . . . . . . . 27OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 41OXACILLIN INJ 1.5GM/50ML; 1GM/50ML, 300MG/50ML; 2GM/50ML . . . . . . . . . . 11oxacillin sodium . . . . . . . . . . . . . . . . . . . 11

74


Covered Drugs Index

prednicarbate . . . . . . . . . . . . . . . . . . . . . 43prednisolone . . . . . . . . . . . . . . . . . . . . . . 43prednisolone acetate . . . . . . . . . . . . . . 52prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 52prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 43prednisone . . . . . . . . . . . . . . . . . . . . . . . . 43prednisone intensol . . . . . . . . . . . . . . . . 43PREFEST . . . . . . . . . . . . . . . . . . . . . . . . . 46pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg . . . . . . . . 13pregabalin caps 225mg, 300mg . . . . 13pregabalin oral soln . . . . . . . . . . . . . . . 13PREMARIN CREA . . . . . . . . . . . . . . . . 46PREMARIN INJ . . . . . . . . . . . . . . . . . . . 46PREMARIN TABS . . . . . . . . . . . . . . . . 46PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . 39PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML . . . . . 39PREMPHASE . . . . . . . . . . . . . . . . . . . . . 46PREMPRO . . . . . . . . . . . . . . . . . . . . . . . . 46prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 34previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 46PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 26PREZISTA SUSP . . . . . . . . . . . . . . . . . 26

POMALYST . . . . . . . . . . . . . . . . . . . . . . . 18portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 46PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 20POSACONAZOLE DR . . . . . . . . . . . . . 17potassium chloride cr . . . . . . . . . . . . . . 38POTASSIUM CHLORIDE/ DEXTROSE INJ 5%; 20MEQ/L, 5%; 40MEQ/L . . . . . . . . . . . 38POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS . . 38POTASSIUM CHLORIDE/ DEXTROSE/SODIUM CHLORIDE . . 39potassium chloride er . . . . . . . . . . . . . . 38potassium chloride inj 2meq/ml . . . . . 38POTASSIUM CHLORIDE INJ 10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML, 2MEQ/ML, 40MEQ/100ML . . . . . . . . . . . . . . . . . . . . 38potassium chloride oral soln . . . . . . . 38potassium chloride pack . . . . . . . . . . . 38POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 20MEQ/L; 0.45%, 20MEQ/L; 0.9%, 40MEQ/L; 0.9% . . . 39potassium chloride sr . . . . . . . . . . . . . . 38potassium citrate/citric acid . . . . . . . . . 39potassium citrate er . . . . . . . . . . . . . . . . 39POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 22PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 30PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 34pramipexole dihydrochloride . . . . . . . . 23pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 23pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 23prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 30pravastatin sodium . . . . . . . . . . . . . . . . 34praziquantel . . . . . . . . . . . . . . . . . . . . . . . 22prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 30prazosin hydrochloride caps 2mg . . . 30PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 52PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 52PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 52

phenylephrine hcl ophthalmic soln 10%, 2.5% . . . . . . . . 51phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 14phenytoin sodium . . . . . . . . . . . . . . . . . . 14phenytoin sodium extended . . . . . . . . 14PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 40PHOSPHOLINE IODIDE . . . . . . . . . . . 52PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 51PHYSIOSOL IRRIGATION . . . . . . . . . 51PICATO GEL 0.05% . . . . . . . . . . . . . . . 36PICATO GEL 0.015% . . . . . . . . . . . . . . 36PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 26pilocarpine hcl ophthalmic soln . . . . . 52pilocarpine hcl tabs . . . . . . . . . . . . . . . 36pilocarpine hydrochloride tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 36pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 36pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 24pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 46pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 32pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 28pioglitazone hcl-glimepiride . . . . . . . . 28pioglitazone hcl/metformin hcl . . . . . . 28pioglitazone hydrochloride tabs 15mg, 30mg . . . . . . . . . . . . . . . . . . 28piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm . . . . . . . . . . 11piperacillin/tazobactam . . . . . . . . . . . . . 11PIQRAY 200MG DAILY DOSE . . . . . . 20PIQRAY 250MG DAILY DOSE . . . . . . 20PIQRAY 300MG DAILY DOSE . . . . . . 20pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 46PLASMA-LYTE-148 . . . . . . . . . . . . . . . 38PLASMA-LYTE A . . . . . . . . . . . . . . . . . . 38PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 38podocon 25 in benzoin tincture . . . . . 36podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 36polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10polymyxin b sulfate . . . . . . . . . . . . . . . . 10polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 10

75


Covered Drugs Index

quflora pediatric chew . . . . . . . . . . . . . 40quflora pediatric oral soln 45mg/ml; 400unit/ml; 1mg/ml; 3mcg/ml; 81mcg/ml; 150mcg/ml; 12mg/ml; 2mg/ml; 1mg/ml; 1mg/ml; 0.5mg/ml; 1mg/ml; 1100unit/ml; 12unit/ml . . . . . . . . . . . . . . 40quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 31quinapril hydrochloride tabs 10mg . . 31quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 31quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 31quinidine sulfate . . . . . . . . . . . . . . . . . . . 32quinine sulfate . . . . . . . . . . . . . . . . . . . . . 23

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 49raloxifene hydrochloride . . . . . . . . . . . . 47ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 54ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 31RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 33ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 41ranitidine hcl syrp . . . . . . . . . . . . . . . . . 41ranitidine hcl tabs 150mg, 300mg . . . 41ranitidine hydrochloride caps . . . . . . 41ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml . . . . . . . . . . . . . 41ranolazine er . . . . . . . . . . . . . . . . . . . . . . 33RAPAMUNE ORAL SOLN . . . . . . . . . 48rasagiline mesylate . . . . . . . . . . . . . . . . 23RAVICTI . . . . . . . . . . . . . . . . . . . . . . . . . . 42reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 46RECOMBIVAX HB . . . . . . . . . . . . . . . . . 49RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REGRANEX . . . . . . . . . . . . . . . . . . . . . . 36RELISTOR INJ 8MG/0.4ML . . . . . . . . 41RELISTOR INJ 12MG/0.6ML . . . . . . . 41REMODULIN . . . . . . . . . . . . . . . . . . . . . . 54RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 48RENVELA PACK . . . . . . . . . . . . . . . . . . 40

promethazine hcl supp . . . . . . . . . . . . 16promethazine hcl syrp . . . . . . . . . . . . . 16promethazine hcl tabs 12.5mg . . . . . . 16promethazine hydrochloride inj . . . . . 16promethazine hydrochloride tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 16promethazine/phenylephrine . . . . . . . 54promethegan . . . . . . . . . . . . . . . . . . . . . . 16propafenone hcl . . . . . . . . . . . . . . . . . . . 32propafenone hydrochloride er . . . . . . 32propantheline bromide . . . . . . . . . . . . . 41proparacaine hcl . . . . . . . . . . . . . . . . . . . 51propranolol hcl er cp24 120mg, 60mg . . . . . . . . . . . . . . . . . . . . . 32propranolol hcl er cp24 160mg . . . . . 32propranolol hcl inj . . . . . . . . . . . . . . . . . 32propranolol hcl oral soln . . . . . . . . . . . 32propranolol hcl tabs 40mg, 80mg . . . 32propranolol hydrochloride er . . . . . . . . 32propranolol hydrochloride tabs 10mg, 20mg, 60mg . . . . . . . . . . . . . . . . 32propranolol/hydrochlorothiazide . . . . 32propylthiouracil . . . . . . . . . . . . . . . . . . . . 47PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 49PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 39protriptyline hcl . . . . . . . . . . . . . . . . . . . . 16PULMOZYME . . . . . . . . . . . . . . . . . . . . . 53PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 19pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 18pyridostigmine bromide er . . . . . . . . . . 18pyridostigmine bromide oral soln . . . 18pyridostigmine bromide tabs 60mg . . 18

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 49quetiapine fumarate . . . . . . . . . . . . . . . 24quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 24quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 24

PREZISTA TABS 75MG . . . . . . . . . . . . 26PREZISTA TABS 150MG . . . . . . . . . . . 26PREZISTA TABS 600MG . . . . . . . . . . . 26PREZISTA TABS 800MG . . . . . . . . . . . 26PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 18PRIMAQUINE PHOSPHATE . . . . . . . 23primidone . . . . . . . . . . . . . . . . . . . . . . . . . 14PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 15PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 53PROAIR RESPICLICK . . . . . . . . . . . . . 53probenecid . . . . . . . . . . . . . . . . . . . . . . . . 17probenecid/colchicine . . . . . . . . . . . . . . 17procainamide hcl . . . . . . . . . . . . . . . . . . 31procainamide hydrochloride inj 500mg/ml . . . . . . . . . . . . . . . . . . . . . . 32PROCALAMINE . . . . . . . . . . . . . . . . . . . 39prochlorperazine . . . . . . . . . . . . . . . . . . 16prochlorperazine edisylate inj 10mg/2ml . . . . . . . . . . . . . . . . . . . . . . 24prochlorperazine maleate . . . . . . . . . . 24PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 30PROCRIT INJ 20000UNIT/ML . . . . . . 30PROCRIT INJ 40000UNIT/ML . . . . . . 30procto-med hc . . . . . . . . . . . . . . . . . . . . . 43procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 43proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 43proctozone-hc . . . . . . . . . . . . . . . . . . . . . 43progesterone . . . . . . . . . . . . . . . . . . . . . . 47PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 28PROGRAF INJ . . . . . . . . . . . . . . . . . . . 48PROGRAF PACK . . . . . . . . . . . . . . . . . 48PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 54PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 52PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 20PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PROMACTA PACK . . . . . . . . . . . . . . . . 30PROMACTA TABS . . . . . . . . . . . . . . . . 30promethazine hcl inj . . . . . . . . . . . . . . . 53

76


Covered Drugs Index

SANDIMMUNE CAPS 25MG . . . . . . . 48SANDIMMUNE CAPS 100MG . . . . . . 48SANDIMMUNE INJ . . . . . . . . . . . . . . . 48SANDIMMUNE ORAL SOLN . . . . . . 48SANDOSTATIN LAR DEPOT . . . . . . . 47SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 36SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 24SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . . 35SAVELLA TITRATION PACK . . . . . . . 35scopolamine . . . . . . . . . . . . . . . . . . . . . . 16selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 23selenium sulfide lotn . . . . . . . . . . . . . . 36SELZENTRY ORAL SOLN . . . . . . . . 26SELZENTRY TABS 25MG . . . . . . . . . 26SELZENTRY TABS 150MG, 75MG . . 26SELZENTRY TABS 300MG . . . . . . . . 26SENSIPAR TABS 30MG, 60MG . . . . 50SENSIPAR TABS 90MG . . . . . . . . . . . 50SEREVENT DISKUS . . . . . . . . . . . . . . 53sertraline hcl conc . . . . . . . . . . . . . . . . . 15sertraline hcl tabs 25mg . . . . . . . . . . . . 15sertraline hcl tabs 50mg . . . . . . . . . . . . 15sertraline hydrochloride tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 15setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 46sevelamer carbonate pack . . . . . . . . . 40sevelamer carbonate tabs . . . . . . . . . 40sf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36sf 5000 plus . . . . . . . . . . . . . . . . . . . . . . . 39sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 47SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 49SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 47sildenafil citrate tabs 20mg . . . . . . . . . 54SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 54silver sulfadiazine . . . . . . . . . . . . . . . . . 10SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 52SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 49simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 34sirolimus oral soln . . . . . . . . . . . . . . . . . 48sirolimus tabs . . . . . . . . . . . . . . . . . . . . . 48

risperidone odt tbdp 4mg . . . . . . . . . . . 24risperidone oral soln . . . . . . . . . . . . . . 24risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 24risperidone tabs 4mg . . . . . . . . . . . . . . 24ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 27RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 22RITUXAN HYCELA . . . . . . . . . . . . . . . . 22rivastigmine tartrate . . . . . . . . . . . . . . . . 14rivastigmine transdermal system . . . . 14rizatriptan benzoate . . . . . . . . . . . . . . . . 17rizatriptan benzoate odt . . . . . . . . . . . . 17ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 52romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 20ropinirole er tb24 2mg, 4mg, 6mg, 8mg . . . . . . . . . . . . . . 23ropinirole er tb24 12mg . . . . . . . . . . . . 23ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 23ropinirole hydrochloride tabs 0.25mg, 3mg . . . . . . . . . . . . . . . . . 23rosuvastatin calcium . . . . . . . . . . . . . . . 34ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 49ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 49roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 13roweepra xr tb24 500mg . . . . . . . . . . . 13roweepra xr tb24 750mg . . . . . . . . . . . 13ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 54ROZLYTREK CAPS 100MG . . . . . . . . 20ROZLYTREK CAPS 200MG . . . . . . . . 20RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 20RUCONEST . . . . . . . . . . . . . . . . . . . . . . 48RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 20RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 23

SSABRIL TABS . . . . . . . . . . . . . . . . . . . . 14salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . 7SAMSCA TABS 15MG . . . . . . . . . . . . . 40SAMSCA TABS 30MG . . . . . . . . . . . . . 40SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 16

RENVELA TABS . . . . . . . . . . . . . . . . . . 40repaglinide tabs 0.5mg, 1mg . . . . . . . 28repaglinide tabs 2mg . . . . . . . . . . . . . . 28REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 34REPATHA PUSHTRONEX SYSTEM . 34REPATHA SURECLICK . . . . . . . . . . . . 34RESCRIPTOR . . . . . . . . . . . . . . . . . . . . 26RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 51RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 30RETACRIT INJ 40000UNIT/ML . . . . . 30RETROVIR IV INFUSION . . . . . . . . . . 26REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 18REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 18REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 24REYATAZ PACK . . . . . . . . . . . . . . . . . . 26RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 51ribavirin caps . . . . . . . . . . . . . . . . . . . . . 25ribavirin inhalation soln . . . . . . . . . . . . 54ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 25RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 49rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 18rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 18RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 18riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35rimantadine hcl . . . . . . . . . . . . . . . . . . . . 27ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l . . . . . . . . 39RINGERS IRRIGATION . . . . . . . . . . . . 51RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 49RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 28risedronate sodium tabs 35mg . . . . . 50risedronate sodium tabs 150mg . . . . 50RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 24RISPERDAL CONSTA INJ 50MG . . . 24risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 24

77


Covered Drugs Index

sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 17sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 17sumatriptan succinate tabs . . . . . . . . 17SUPRAX CAPS . . . . . . . . . . . . . . . . . . . 11SUPRAX CHEW . . . . . . . . . . . . . . . . . . 11SUPRAX SUSR 500MG/5ML . . . . . . . 11SUPREP BOWEL PREP KIT . . . . . . . 41SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 22SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 20SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 26SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 28SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 28SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 27SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 49SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 47SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 10SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 28SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 28SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 28SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 20SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 47SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 40

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 19tacrolimus caps . . . . . . . . . . . . . . . . . . . 48tadalafil tabs 20mg . . . . . . . . . . . . . . . . 54TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 22TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 22TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 20

sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 32sotalol hydrochloride tabs 120mg, 80mg . . . . . . . . . . . . . . . . . . . . . 32spironolactone . . . . . . . . . . . . . . . . . . . . 33spironolactone/hydrochlorothiazide . . 33SPORANOX ORAL SOLN . . . . . . . . . 17SPRAVATO 56MG DOSE . . . . . . . . . . 15SPRAVATO 84MG DOSE . . . . . . . . . . 15sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 46SPRITAM TB3D 750MG . . . . . . . . . . . 13SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 13SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 22sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 49stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 26STERILE WATER IRRIGATION . . . . 51STERILE WATER IRRIGATION PLASTIC BOTTLE . . . . . . . . . . . . . . . . . 51STERILE WATER IRRIGATION W/HANGER . . . . . . . . . . . . . . . . . . . . . . . 51STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 22streptomycin sulfate . . . . . . . . . . . . . . . . 9STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 26SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . 8sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 41sulfacetamide sodium lotn . . . . . . . . . 12sulfacetamide sodium oint . . . . . . . . . 12sulfacetamide sodium/ prednisolone sodium phosphate . . . . 12sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 12sulfamethoxazole/trimethoprim ds . . . 12sulfamethoxazole/trimethoprim inj . . . 12sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 12sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 12sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 50

SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 18SIVEXTRO TABS . . . . . . . . . . . . . . . . . 10SKLICE . . . . . . . . . . . . . . . . . . . . . . . . . . . 23SKYRIZI . . . . . . . . . . . . . . . . . . . . . . . . . . 48sodium bicarbonate inj . . . . . . . . . . . . 39SODIUM CHLORIDE 0.45% . . . . . . . 39SODIUM CHLORIDE INJ 0.45%, 0.9%, 3%, 5% . . . . . . . . . . 39SODIUM CHLORIDE IRRIGATION 0.9% . . . . . . . . . . . . . . . . . 51sodium citrate/citric acid . . . . . . . . . . . 39sodium fluoride chew 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 39sodium fluoride oral soln . . . . . . . . . . . 39SODIUM LACTATE INJ 5MEQ/ML . . . . . . . . . . . . . . . . . . . . . 39sodium phenylbutyrate . . . . . . . . . . . . . 42sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 40sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 40sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 12solifenacin succinate . . . . . . . . . . . . . . . 42SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 29SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 19SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 43SOLU-MEDROL INJ 2GM . . . . . . . . . . 43SOLU-MEDROL INJ 500MG . . . . . . . 43SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 47SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 47SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 47SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 47sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 32sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 32sotalol hcl tabs 160mg, 240mg, 80mg . . . . . . . . . . . . . . 32sotalol hydrochloride af . . . . . . . . . . . . 32

78


Covered Drugs Index

tizanidine hydrochloride tabs 4mg . . . . . . . . . . . . . . . . . . . . . . . . . . 25TOBI PODHALER . . . . . . . . . . . . . . . . . 53TOBRADEX OINT . . . . . . . . . . . . . . . . 52tobramycin/dexamethasone . . . . . . . . 52tobramycin nebu . . . . . . . . . . . . . . . . . . 53tobramycin ophthalmic soln . . . . . . . . . 9tobramycin sulfate inj 1.2gm, 1.2gm/30ml, 10mg/ml, 80mg/2ml . . . . . . . . . . . . . . . . . 9tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . . . 9tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml . . . . . . . . . . 9TOBREX OINT . . . . . . . . . . . . . . . . . . . . 9TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 36tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 23tolterodine tartrate . . . . . . . . . . . . . . . . . 42tolterodine tartrate er . . . . . . . . . . . . . . 42topiramate . . . . . . . . . . . . . . . . . . . . . . . . 14toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 21topotecan hcl inj 4mg/4ml . . . . . . . . . . 21topotecan hcl inj lyophilized 4mg . . . 21topotecan hydrochloride . . . . . . . . . . . 21toremifene citrate . . . . . . . . . . . . . . . . . . 19TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 48torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 33TOUJEO MAX SOLOSTAR . . . . . . . . 29TOUJEO SOLOSTAR . . . . . . . . . . . . . . 29TPN ELECTROLYTES . . . . . . . . . . . . . 39TRACLEER TABS . . . . . . . . . . . . . . . . 54TRACLEER TBSO . . . . . . . . . . . . . . . . 54TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 28tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . . 8tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . . 8trandolapril tabs 1mg . . . . . . . . . . . . . . 31trandolapril tabs 2mg, 4mg . . . . . . . . . 31trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg . . . . . . . . . . . . . . . 31

terazosin hcl caps 1mg, 5mg . . . . . . . 30terazosin hcl caps 10mg . . . . . . . . . . . 30terazosin hydrochloride . . . . . . . . . . . . 30terbinafine hcl tabs . . . . . . . . . . . . . . . . 17terbutaline sulfate . . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . . . . . . . . . 17testosterone cypionate . . . . . . . . . . . . . 44testosterone enanthate . . . . . . . . . . . . 44testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 44testosterone pump gel 1% . . . . . . . . . 44tetrabenazine tabs 12.5mg . . . . . . . . . 35tetrabenazine tabs 25mg . . . . . . . . . . . 35tetracycline hydrochloride . . . . . . . . . . 13TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 44THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 18THALOMID CAPS 200MG . . . . . . . . . 18THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 54theophylline . . . . . . . . . . . . . . . . . . . . . . . 54theophylline er tb12 300mg . . . . . . . . 54theophylline er tb24 . . . . . . . . . . . . . . . 54thioridazine hcl . . . . . . . . . . . . . . . . . . . . 24thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 18thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 24THYMOGLOBULIN . . . . . . . . . . . . . . . . 49tiagabine hydrochloride . . . . . . . . . . . . 14TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 22TICE BCG . . . . . . . . . . . . . . . . . . . . . . . . 20tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 10timolol maleate ophthalmic gel forming . . . . . . . . . . . . . . . . . . . . . . . . 52timolol maleate ophthalmic soln . . . . 52timolol maleate tabs . . . . . . . . . . . . . . . 32TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 51TIVICAY TABS 10MG . . . . . . . . . . . . . . 25TIVICAY TABS 25MG, 50MG . . . . . . . 25tizanidine hcl caps . . . . . . . . . . . . . . . . 25tizanidine hcl tabs . . . . . . . . . . . . . . . . . 25

tamoxifen citrate . . . . . . . . . . . . . . . . . . . 19tamsulosin hydrochloride . . . . . . . . . . . 42TARCEVA TABS 25MG . . . . . . . . . . . . 22TARCEVA TABS 100MG, 150MG . . . 22TARGRETIN GEL . . . . . . . . . . . . . . . . . 22tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 46tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 46TASIGNA CAPS 50MG . . . . . . . . . . . . 22TASIGNA CAPS 150MG, 200MG . . . 22tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 36tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 11TAZORAC CREA . . . . . . . . . . . . . . . . . 36TAZORAC GEL . . . . . . . . . . . . . . . . . . . 36taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 33TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 49TECENTRIQ INJ 840MG/14ML . . . . . 22TECENTRIQ INJ 1200MG/20ML . . . 22TECFIDERA CPDR 120MG . . . . . . . . 36TECFIDERA CPDR 240MG . . . . . . . . 36TECFIDERA STARTER PACK . . . . . . 36TECHLITE PEN NEEDLES/ 31G X 6 MM . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 31G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 4MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 6MM . . . . . . . . . . . . . . . . . . . . . . . 51TECHLITE PEN NEEDLES/ 32G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 51TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 11TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 33TEKTURNA HCT . . . . . . . . . . . . . . . . . . 33telmisartan tabs 20mg, 40mg . . . . . . . 31telmisartan tabs 80mg . . . . . . . . . . . . . 31temazepam caps 15mg, 30mg . . . . . 54temazepam caps 22.5mg, 7.5mg . . . 54temsirolimus . . . . . . . . . . . . . . . . . . . . . . 22TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 49tenofovir disoproxil fumarate . . . . . . . 26

79


Covered Drugs Index

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML . . . . 39tropicamide . . . . . . . . . . . . . . . . . . . . . . . 51trospium chloride . . . . . . . . . . . . . . . . . . 42trospium chloride er . . . . . . . . . . . . . . . . 42TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 41TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 28TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 49TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 26TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 22TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 49TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 26tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 22TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 50TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 49TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 36TYVASO . . . . . . . . . . . . . . . . . . . . . . . . . . 54TYVASO REFILL . . . . . . . . . . . . . . . . . . 54TYVASO STARTER . . . . . . . . . . . . . . . 54

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 17UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 22ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 27valacyclovir hydrochloride . . . . . . . . . . 27VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 18valganciclovir . . . . . . . . . . . . . . . . . . . . . . 25valganciclovir hydrochlorde . . . . . . . . 25

tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 46trifluoperazine hcl . . . . . . . . . . . . . . . . . . 24trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 27trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 23trihexyphenidyl hydrochloride . . . . . . . 23tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 46tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 46tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 46tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 46tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 46trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 10trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 10tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46trimipramine maleate . . . . . . . . . . . . . . 16TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 15tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 46TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 47TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 20tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 46TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 26tri-vitamin/fluoride . . . . . . . . . . . . . . . . . 40tri-vite/fluoride . . . . . . . . . . . . . . . . . . . . . 40trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 46tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 46tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 46TROGARZO . . . . . . . . . . . . . . . . . . . . . . 26TROPHAMINE INJ 54.4MEQ/L; 0.32GM/100ML; 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML . . . . 39

trandolapril/verapamil hcl er tbcr 4mg; 240mg . . . . . . . . . . . . . . . . 31tranexamic acid inj . . . . . . . . . . . . . . . . 30tranexamic acid tabs . . . . . . . . . . . . . . 30TRANSDERM-SCOP . . . . . . . . . . . . . . 16tranylcypromine sulfate . . . . . . . . . . . . 15TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 39TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 51trazodone hydrochloride . . . . . . . . . . . 15TREANDA INJ 25MG . . . . . . . . . . . . . . 18TREANDA INJ 100MG . . . . . . . . . . . . . 18TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 18TRELEGY ELLIPTA . . . . . . . . . . . . . . . 54TRELSTAR MIXJECT INJ 3.75MG . . 47TRELSTAR MIXJECT INJ 11.25MG . . 47TRELSTAR MIXJECT INJ 22.5MG . . 47treprostinil . . . . . . . . . . . . . . . . . . . . . . . . . 54TRESIBA . . . . . . . . . . . . . . . . . . . . . . . . . 29TRESIBA FLEXTOUCH . . . . . . . . . . . . 29tretinoin caps . . . . . . . . . . . . . . . . . . . . . 22tretinoin crea . . . . . . . . . . . . . . . . . . . . . 36tretinoin gel 0.01% . . . . . . . . . . . . . . . . . 36tretinoin gel 0.05% . . . . . . . . . . . . . . . . . 36tretinoin gel 0.025% . . . . . . . . . . . . . . . 36tretinoin microsphere . . . . . . . . . . . . . . 36tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 37triamcinolone acetonide aers . . . . . . 44triamcinolone acetonide crea . . . . . . 44triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 36triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 44triamcinolone acetonide lotn . . . . . . . 44triamcinolone acetonide oint . . . . . . . 44triamterene/ hydrochlorothiazide caps . . . . . . . . . . 33triamterene/ hydrochlorothiazide tabs . . . . . . . . . . . 33triderm crea 0.1% . . . . . . . . . . . . . . . . . 44trientine hydrochloride . . . . . . . . . . . . . 40

80


Covered Drugs Index

vinorelbine tartrate inj 50mg/5ml . . . . 20viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46VIRACEPT TABS 250MG . . . . . . . . . . 27VIRACEPT TABS 625MG . . . . . . . . . . 27VIRAMUNE SUSP . . . . . . . . . . . . . . . . 26VIREAD POWD . . . . . . . . . . . . . . . . . . . 26VIREAD TABS 150MG, 200MG, 250MG . . . . . . . . . . . 26vitamins a/c/d/fluoride . . . . . . . . . . . . . . 40VITRAKVI CAPS 25MG . . . . . . . . . . . . 20VITRAKVI CAPS 100MG . . . . . . . . . . . 20VITRAKVI ORAL SOLN . . . . . . . . . . . 20VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . 8VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 22voriconazole inj . . . . . . . . . . . . . . . . . . . 17voriconazole susr . . . . . . . . . . . . . . . . . 17voriconazole tabs . . . . . . . . . . . . . . . . . 17VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 25VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 22VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 40VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 24VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 24vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 46vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 30wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 46

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 22XARELTO STARTER PACK . . . . . . . . 30XARELTO TABS 10MG, 20MG . . . . . 30XARELTO TABS 15MG, 2.5MG . . . . 30XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 48XEOMIN INJ 100UNIT, 50UNIT . . . . . 51XEOMIN INJ 200UNIT . . . . . . . . . . . . . 51XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

venlafaxine hcl er cp24 75mg . . . . . . 16venlafaxine hcl er cp24 150mg . . . . . 16venlafaxine hcl er tb24 150mg . . . . . . 16venlafaxine hcl er tb24 225mg, 37.5mg, 75mg . . . . . . . . . . . . . 16venlafaxine hydrochloride er tb24 37.5mg, 75mg . . . . . . . . . . . . . 16VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 54VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 53verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 33verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 33verapamil hcl er cp24 200mg . . . . . . . 33verapamil hcl er tbcr . . . . . . . . . . . . . . 33verapamil hcl sr cp24 120mg, 180mg, 240mg . . . . . . . . . . . . 33VERAPAMIL HCL SR CP24 360MG . . . . . . . . . . . . . . . . . . 33verapamil hydrochloride inj . . . . . . . . 33verapamil hydrochloride tabs . . . . . . 33VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 25VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 20VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 42V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 51VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 41VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 28VIDEX EC CPDR 125MG . . . . . . . . . . 26VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 26vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46vigabatrin pack . . . . . . . . . . . . . . . . . . . 14vigabatrin tabs . . . . . . . . . . . . . . . . . . . . 14vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 14VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 16VIIBRYD STARTER PACK . . . . . . . . . 16VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 14VIMPAT ORAL SOLN . . . . . . . . . . . . . 14VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 14vinblastine sulfate . . . . . . . . . . . . . . . . . 20vincristine sulfate . . . . . . . . . . . . . . . . . . 20

valproate sodium inj 100mg/ml . . . . . 14valproic acid . . . . . . . . . . . . . . . . . . . . . . . 14valsartan/hydrochlorothiazide . . . . . . 31valsartan tabs 160mg, 40mg, 80mg . . . . . . . . . . . . . . . 31valsartan tabs 320mg . . . . . . . . . . . . . . 31vancomycin . . . . . . . . . . . . . . . . . . . . . . . 10vancomycin hcl inj 0.9%; 1gm/200ml . . . . . . . . . . . . . . . . . . 10vancomycin hcl inj 5gm . . . . . . . . . . . . 10vancomycin hcl inj 10gm, 750mg . . . 10vancomycin hydrochloride caps 125mg . . . . . . . . . . . . . . . . . . . . . . . 10vancomycin hydrochloride caps 250mg . . . . . . . . . . . . . . . . . . . . . . . 10vancomycin hydrochloride/ dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml . . . 10VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML . . . . . . . . . . . . . . . . . . . 10vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg . . . . . . . 10vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 10VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 49VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 49VASCEPA CAPS 0.5GM . . . . . . . . . . . 34VASCEPA CAPS 1GM . . . . . . . . . . . . . 34VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 49VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 22VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 20velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 40VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 40VENCLEXTA STARTING PACK . . . . 20VENCLEXTA TABS 10MG . . . . . . . . . 20VENCLEXTA TABS 50MG . . . . . . . . . 20VENCLEXTA TABS 100MG . . . . . . . . 20venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 16venlafaxine hcl er cp24 37.5mg . . . . . 16

81


Covered Drugs Index

ZELAPAR . . . . . . . . . . . . . . . . . . . . . . . . . 23ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 22ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 54zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 37ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 42zidovudine caps . . . . . . . . . . . . . . . . . . 26zidovudine syrp . . . . . . . . . . . . . . . . . . . 26zidovudine tabs . . . . . . . . . . . . . . . . . . . 26ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 51ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 24ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 25zoledronic acid inj 5mg/100ml . . . . . . 50ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 21zolmitriptan . . . . . . . . . . . . . . . . . . . . . . . 17zolmitriptan odt . . . . . . . . . . . . . . . . . . . . 17zolpidem tartrate tabs . . . . . . . . . . . . . 54zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 13ZORTRESS TABS 0.5MG . . . . . . . . . . 48ZORTRESS TABS 0.25MG . . . . . . . . 48ZORTRESS TABS 0.75MG, 1MG . . . 48ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 49zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 46ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 27ZUBSOLV SUBL 0.7MG; 0.18MG . . . 9ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . . 9ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 22ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 21ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 22ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . 24ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . 25ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . 24ZYTIGA TABS 250MG . . . . . . . . . . . . . 18ZYTIGA TABS 500MG . . . . . . . . . . . . . 18

XHANCE . . . . . . . . . . . . . . . . . . . . . . . . . . 53XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 42XIFAXAN TABS 550MG . . . . . . . . . . . . 10XIGDUO XR TB24 5MG; 1000MG . . 28XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 28XOFLUZA . . . . . . . . . . . . . . . . . . . . . . . . . 27XOLAIR INJ 75MG/0.5ML . . . . . . . . . . 54XOLAIR INJ 150MG/ML . . . . . . . . . . . 54XOLAIR VIAL INJ 150MG . . . . . . . . . . 54XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 22XPOVIO 60 MG ONCE WEEKLY . . . 19XPOVIO 80 MG ONCE WEEKLY . . . 19XPOVIO 80 MG TWICE WEEKLY . . 19XPOVIO 100 MG ONCE WEEKLY . . 19XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . . 7XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 18xulane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 29XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

YYERVOY INJ 50MG/10ML . . . . . . . . . 22YERVOY INJ 200MG/40ML . . . . . . . . 22YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 49YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 18YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 18yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 53zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 54ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 22ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 18zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 30zebutal caps 325mg; 50mg; 40mg . . . 7ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 20

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Notes

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaHealthSpring.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc.© 2018 Cigna 926061 j

1-800-627-7534 (TTY 711) October 1 – March 31, 7 days a week, 8 a.m. – 8 p.m. local time. From April 1 – September 30, Monday – Friday, 8 a.m. – 8 p.m. local time (a voicemail system is available on weekends and holidays).

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