2019 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST … · This drug list was updated in December...

Plan coveredCigna-HealthSpring Rx Secure (PDP)

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

2019 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, 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-HealthSpring Rx is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring Rx depends on contract renewal.HPMS Approved Formulary File Submission ID 19142, Version Number 17 INT_19_65288_C_Final_6n Populated Template 07312018

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What is the Cigna-HealthSpring Rx Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx 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-

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-HealthSpring Rx. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Rx Secure (PDP).

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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HealthSpring Rx, please contact us. Our contact information appears on the front and 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 17. 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 17. 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 60. 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-HealthSpring Rx 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-HealthSpring Rx requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna-HealthSpring Rx before you fill these prescriptions. If you don’t get approval, Cigna-HealthSpring Rx may not cover the drug.

• Quantity Limits: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will cover. For example, Cigna-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring Rx will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx 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 17. 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-HealthSpring Rx 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-HealthSpring Rx 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.

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

• 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-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx. 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-HealthSpring Rx.

• You can ask Cigna-HealthSpring Rx 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-HealthSpring Rx Drug List?You can ask Cigna-HealthSpring Rx 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-HealthSpring Rx 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-HealthSpring Rx 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

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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 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-HealthSpring Rx will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring Rx’s Drug ListThe comprehensive drug list that begins on page 17, provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 60. 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-HealthSpring Rx has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 17 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-HealthSpring Rx prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring Rx, 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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Cigna-HealthSpring Rx Secure (PDP)

Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing

Preferred Mail Order

Cost-Sharing

Standard Mail Order

Cost-Sharing

Long-term Care 31 days

Out-of-network 30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

ALABAMATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6

Tier 2: Generic Drugs $3 / $6 / $9 $7 / $14 / $21 $3 / $6 / $9 $7 / $14 / $21 $7

Tier 3: Preferred Brand Drugs $30 / $60 / $90 $30 / $60 / $90 $30 / $60 / $90 $30 / $60 / $90 $30

Tier 4: Non-Preferred Drugs 35% 35% 35% 35% 35%

Tier 5: Specialty Tier 25% (30 days) 25% (30 days) 25% (30 days) 25% (30 days) 25%

ALASKATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billed charge and our typical Standard Retail pharmacy billed costs.

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-HealthSpring Rx 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 Prescription Drug plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring Rx 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.

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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



ARIZONATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





ARKANSASTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





CALIFORNIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





COLORADOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





CONNECTICUTTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



DELAWARETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





DISTRICT OF COLUMBIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





FLORIDATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





GEORGIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





HAWAIITier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



IDAHOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





ILLINOISTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





INDIANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





IOWATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





KANSASTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



KENTUCKYTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





LOUISIANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MAINETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MARYLANDTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MASSACHUSETTSTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



MICHIGANTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MINNESOTATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MISSISSIPPITier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MISSOURITier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MONTANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NEBRASKATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEVADATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEW HAMPSHIRETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEW JERSEYTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEW MEXICOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NEW YORKTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NORTH CAROLINATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NORTH DAKOTATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





OHIOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





OKLAHOMATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



OREGONTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





PENNSYLVANIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





RHODE ISLANDTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





SOUTH CAROLINATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





SOUTH DAKOTA Tier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



TENNESSEETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





TEXASTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





UTAHTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





VERMONTTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





VIRGINIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



WASHINGTONTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WEST VIRGINIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WISCONSINTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WYOMINGTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





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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 1-800-222-6700, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – Sept. 30. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring Rx

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.

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 drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 16.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsacetaminophen/codeine oral soln

2 NDS QL

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MORPHINE SULFATE INJ 8MG/ML

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


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


4 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)oxycodone hydrochloride oral soln

4 NDS QL(1200/30)

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

4 NDS QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

4 NDS QL(240/30)

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

4 NDS QL(360/30)

oxycodone/aspirin 4 NDS QL(180/30)oxycodone/ibuprofen 4 NDS QL(28/30)tramadol hcl 2 NDS QL(240/30)tramadol hydrochloride/acetaminophen

4 NDS QL(240/30)

Anesthetics

Local Anestheticsglydo 3 PAlidocaine hcl external soln 2 PAlidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

4

lidocaine hcl jelly gel 3 PAlidocaine hcl mouth/throat soln 2lidocaine hcl prsy 3 PAlidocaine hcl viscous 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

endocet tabs 325mg; 2.5mg, 325mg; 5mg

4 NDS QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

4 B/D PA NDS

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

4 PA NDS QL(120/30)

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

5 PA NDS QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln 325mg/15ml; 7.5mg/15ml

4 NDS QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg

4 NDS QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg

4 NDS QL(360/30)

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

4 NDS QL(180/30)

lorcet 4 NDS QL(360/30)lorcet hd 4 NDS QL(180/30)lorcet plus tabs 325mg; 7.5mg 4 NDS QL(180/30)MORPHINE SULFATE INJ 5MG/ML

4 B/D PA NDS

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

4 B/D PA NDS

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

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


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

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 4gentamicin sulfate inj 4gentamicin sulfate oint 3gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

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

4

clindacin etz pledgets 4clindacin-p 4clindamycin hcl caps 2clindamycin phosphate crea 4clindamycin phosphate external soln

4

clindamycin phosphate gel 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine oint 4 PA QL(50/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 2lidocaine/prilocaine crea 4 PA

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 4disulfiram 4naltrexone hcl 3Opioid Dependence Treatmentsbuprenorphine hcl subl 4 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)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 inj 0.4mg/ml, 4mg/10ml

2

naloxone hcl inj 2mg/2ml 3NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hydrochloride er (sr) 3 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)

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

polymyxin b sulfate/trimethoprim sulfate

2

rosadan 3silver sulfadiazine 4SIVEXTRO TABS 5 NDS QL(6/30)SSD 4SYNERCID 5 NDStigecycline 5 NDStrimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

vancomycin 4vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg

4

vancomycin hydrochloride caps 125mg

4 QL(40/10)

vancomycin hydrochloride caps 250mg

4 QL(80/10)

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

4

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

4

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

4

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

4

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

4

cefazolin sodium/dextrose inj 2gm; 3%

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4

clindamycin phosphate lotn 4clindamycin phosphate swab 4clindamycin/sodium chloride 4colistimethate sodium 4DAPTOMYCIN INJ 350MG 5 B/D PA NDSdaptomycin inj 500mg 5 B/D PA NDSFIRVANQ 4 QL(300/10)lincomycin hcl 4linezolid inj 4linezolid susr 5 NDS QL(1800/30)linezolid tabs 5 NDS QL(60/30)methenamine hippurate 4metronidazole crea 4metronidazole gel 4metronidazole in nacl 0.79% 4metronidazole inj 500mg/100ml; 0.79%

4

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

4

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

4

nitrofurantoin 4nitrofurantoin macrocrystals 4nitrofurantoin monohydrate 3nitrofurantoin monohydrate/macrocrystals

3

polycin 2polymyxin b sulfate 4

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

4

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium 4oxacillin sodium 4penicillin g potassium 4penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

pfizerpen inj 20000000unit, 5000000unit

4

piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm

4

piperacillin/tazobactam 4MacrolidesAZASITE 3azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 4 QL(90/30)azithromycin susr 100mg/5ml 4 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefdinir 4cefepime 4cefepime/dextrose 4cefixime caps 4 QL(30/30)cefixime susr 4cefotaxime sodium inj 1gm, 500mg

4

cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 4cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

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

4

cefuroxime axetil 3cefuroxime sodium 4cephalexin caps 250mg, 500mg 2cephalexin susr 2tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5 NDSBeta-lactam, OtherAZACTAM 4aztreonam inj 1gm 4aztreonam inj 2gm 5 NDScefotetan 4ertapenem 4ertapenem sodium 4imipenem/cilastatin inj 500mg; 500mg

4

imipenem/cilastatin inj 250mg; 250mg

3

INVANZ 4meropenem 4

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

2

sulfacetamide sodium lotn 4sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 4sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

4

sulfamethoxazole/trimethoprim tabs

1

Tetracyclinesdoxy 100 4doxycycline hyclate caps 4doxycycline hyclate tabs 100mg, 20mg

4

doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 4minocycline hcl caps 2minocycline hcl tabs 4minocycline hydrochloride caps 100mg, 50mg

2

mondoxyne nl caps 100mg 2 QL(60/30)mondoxyne nl caps 75mg 3 QL(60/30)morgidox 1x100mg caps 4morgidox 1x50mg 4morgidox 2x100mg caps 4NUZYRA INJ 4 QL(15/14)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

azithromycin tabs 600mg 2 QL(60/30)clarithromycin 4clarithromycin er 4ery 4ERY-TAB 4ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 4erythromycin base 4ERYTHROMYCIN DR 4erythromycin ethylsuccinate susr 200mg/5ml

4

erythromycin ethylsuccinate tabs

4

erythromycin external soln 2erythromycin gel 4erythromycin oint 2QuinolonesAVELOX 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin hcl tabs 750mg 2ciprofloxacin hcl tabs 100mg 4ciprofloxacin hydrochloride 2ciprofloxacin i.v.-in d5w 4ciprofloxacin susr 4levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 3levofloxacin tabs 500mg 2levofloxacin tabs 250mg, 750mg

2 QL(30/30)

moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl 4moxifloxacin hydrochloride ophthalmic soln

3

moxifloxacin hydrochloride tabs 4

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 4 QL(480/30)clobazam tabs 4 QL(60/30)clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

4 QL(90/30)

clonazepam odt tbdp 1mg 4 QL(120/30)clonazepam odt tbdp 2mg 4 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)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)diazepam rectal gel gel 20mg 3 QL(40/30)divalproex sodium 3divalproex sodium dr 2divalproex sodium er 4gabapentin caps 100mg 2 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUZYRA TABS 4 QL(30/14)tetracycline hydrochloride 4

Anticonvulsants

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

5 NDS QL(30/30) ST

APTIOM TABS 600MG 5 NDS QL(60/30) STBRIVIACT 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 PA QL(720/30)FYCOMPA TABS 4 PA QL(30/30)levetiracetam er tb24 750mg 4 QL(120/30)levetiracetam er tb24 500mg 4 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2levetiracetam/sodium chloride 4magnesium sulfate in d5w 4 B/D PANAYZILAM 4 PA QL(10/30)roweepra 2roweepra xr tb24 750mg 4 QL(120/30)roweepra xr tb24 500mg 4 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 4LYRICA CAPS 225MG, 300MG 3 QL(60/30)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fosphenytoin sodium 4oxcarbazepine susp 4oxcarbazepine tabs 3PEGANONE 4phenytoin chew 3phenytoin infatabs 3phenytoin sodium 4phenytoin sodium extended 2phenytoin susp 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 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 4 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

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

4 PA QL(360/30)

Antidepressants

Antidepressants, Otherbupropion hcl tabs 100mg 3 QL(120/30)bupropion hydrochloride er (sr) 3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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)GABITRIL TABS 12MG, 16MG 4 STGRALISE 3GRALISE STARTER 3 QL(156/365)ONFI SUSP 4 QL(480/30)ONFI TABS 10MG, 20MG 4 QL(60/30)phenobarbital elix 4 QL(1500/30)phenobarbital tabs 4 QL(120/30)primidone 2SABRIL TABS 5 PA NDS QL(180/30)tiagabine hydrochloride 4 STvalproate 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 4lamotrigine odt 4topiramate 2Sodium Channel AgentsBANZEL SUSP 5 PA NDS

QL(2400/30)BANZEL TABS 200MG 5 PA NDS QL(60/30)BANZEL TABS 400MG 5 PA NDS QL(240/30)carbamazepine chew 2carbamazepine er 4carbamazepine susp 4carbamazepine tabs 3DILANTIN 4DILANTIN INFATABS 4epitol 3

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine dr 2 QL(4/28)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

3 QL(30/30)

fluvoxamine maleate tabs 100mg

3 QL(90/30)

paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hydrochloride tabs 20mg

1 QL(90/30)

PAXIL SUSP 4 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 3 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)

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)VIIBRYD 4 QL(30/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bupropion hydrochloride er (xl) tb24 150mg, 300mg

3 QL(30/30)

bupropion hydrochloride tabs 75mg

3 QL(180/30)

maprotiline hcl 4 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 4 QL(30/30)nefazodone hcl 4 QL(60/30)nefazodone hydrochloride 4 QL(60/30)SPRAVATO 56MG DOSE 5 PA NDSSPRAVATO 84MG DOSE 5 PA NDStrazodone hydrochloride 2TRINTELLIX 4 QL(30/30) STMonoamine 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

4 QL(600/30)

citalopram hydrobromide tabs 10mg

1


1 QL(30/30)


1 QL(60/30)

desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 4 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

granisetron hydrochloride 4 B/D PAondansetron hcl oral soln 4 B/D PA QL(450/30)ondansetron hcl tabs 2 B/D PA QL(15/30)ondansetron hydrochloride inj 4ondansetron 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 PA NDSciclodan 4ciclopirox nail lacquer 4ciclopirox olamine 4ciclopirox sham 4ciclopirox susp 4clotrimazole external crea 2clotrimazole external soln 3clotrimazole lozg 2clotrimazole/betamethasone dipropionate crea

2

clotrimazole/betamethasone dipropionate lotn

4

econazole nitrate 4fluconazole in nacl 4fluconazole susr 4fluconazole tabs 2flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PA NDSketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 4naftifine hydrochloride crea 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

2 PA

amoxapine 4clomipramine hcl 4 PAdesipramine hcl 4imipramine 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 4meclizine hcl tabs 2phenadoz 4prochlorperazine 4promethazine hcl supp 4promethazine hcl syrp 4 PApromethazine hcl tabs 12.5mg 2 PApromethazine hydrochloride tabs 25mg, 50mg

2 PA

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)dronabinol 4 PA QL(60/30)EMEND SUSR 4 B/D PA QL(6/28)granisetron hcl inj 1mg/ml 4 B/D PAgranisetron hcl tabs 4 B/D PA QL(30/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dihydroergotamine mesylate nasal soln

4 PA QL(8/30)

ergotamine tartrate/caffeine 3 QL(40/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 4 QL(9/30)rizatriptan benzoate 4 QL(12/30)rizatriptan benzoate odt 4 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)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide er 3pyridostigmine bromide tabs 60mg

3

REGONOL 4

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 4AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 4ethambutol hydrochloride 4isoniazid inj 4isoniazid syrp 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NATACYN 4NOXAFIL SUSP 5 PA NDS QL(600/30)NOXAFIL TBEC 5 PA NDS QL(96/30)nyamyc 4nystatin crea 2nystatin oint 2nystatin powd 3nystatin susp 2nystatin tabs 2nystatin/triamcinolone 4nystop 4POSACONAZOLE DR 5 PA NDS QL(96/30)SPORANOX ORAL SOLN 5 PA NDSterbinafine hcl tabs 2 QL(90/365)terconazole 4voriconazole inj 5 PA NDSvoriconazole susr 5 PA NDS QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4colchicine caps 3 QL(60/30)colchicine tabs 3 QL(120/30)febuxostat 3 QL(30/30) STMITIGARE 3 QL(60/30)probenecid 4probenecid/colchicine 4ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bicalutamide 3 QL(30/30)ERLEADA 5 PA NDS QL(120/30)flutamide 4nilutamide 5 NDS QL(60/30)NUBEQA 5 PA NDS QL(120/30)XTANDI 5 PA NDS QL(120/30)YONSA 5 PA NDS QL(120/30)ZYTIGA TABS 500MG 5 PA NDS QL(60/30)ZYTIGA TABS 250MG 5 PA NDS QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA NDS QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA NDS QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA NDS QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA NDS QL(28/28)

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

QL(30/30)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 4cladribine 4 B/D PAclofarabine 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 4ELITEK 5 B/D PA NDSfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PA NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isoniazid tabs 2PASER 4PRIFTIN 4pyrazinamide 4rifampin 4RIFATER 4SIRTURO 4 PA 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 450mg/45ml, 50mg/5ml

3 B/D PA

carmustine 4 B/D PAcyclophosphamide caps 4 B/D PAcyclophosphamide inj 5 B/D PA NDSdacarbazine 4 B/D PAEVOMELA 5 PA NDSGLEOSTINE 4ifosfamide inj 1gm, 3gm 4 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 4 PATREANDA INJ 100MG 5 B/D PA NDSTREANDA INJ 25MG 5 B/D PA NDS

QL(8/21)VALCHLOR 5 PA NDS QL(60/30)YONDELIS 5 PA NDSZANOSAR 4 B/D PAAntiandrogensabiraterone acetate 5 PA NDS QL(120/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BORTEZOMIB 5 PA NDS QL(14/21)BRAFTOVI 5 PA NDS QL(180/30)carboplatin inj 150mg/15ml 3 B/D PAcisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

4 B/D PA

COPIKTRA 5 PA NDS QL(60/30)dactinomycin 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)decitabine 5 NDSdexrazoxane 4 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 4 B/D PAERWINAZE 5 B/D PA NDS

QL(60/28)ETHYOL 5 B/D PA NDSfludarabine phosphate inj 50mg 4 B/D PAFUSILEV 5 NDSHALAVEN 5 PA NDSidarubicin hcl inj 10mg/10ml 5 B/D PA NDSidarubicin hydrochloride inj 10mg/10ml

5 B/D PA NDS

INREBIC 5 PA NDS QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gemcitabine 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 PA NDS QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA NDS QL(100/28)

mercaptopurine 4NIPENT 5 B/D PA NDSPURIXAN 5 PA NDS QL(300/30)TABLOID 4VYXEOS 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 PA NDSbleomycin 4 B/D PAbleomycin sulfate 4 B/D PA

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4 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)ZOLINZA 5 NDS QL(120/30)ZYKADIA 5 PA NDS QL(140/28)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 4 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 3 B/D PAirinotecan hydrochloride 4 B/D PAKYPROLIS 5 B/D PA NDStoposar 3 B/D PAtopotecan hcl inj 4mg 5 NDSMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA NDS QL(56/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

irinotecan hcl 4 B/D PAirinotecan hydrochloride 4 B/D PAirinotecan inj 100mg/5ml, 500mg/25ml

4 B/D PA

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

4

leucovorin calcium tabs 10mg, 15mg, 25mg

4

leucovorin calcium tabs 5mg 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 PA NDS QL(120/30)MEKTOVI 5 PA NDS QL(180/30)mesna 4 B/D PAMESNEX TABS 5 NDSmitomycin 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 PA NDS QL(3/28)ODOMZO 5 PA NDS QL(30/30)ONCASPAR 5 B/D PA NDSoxaliplatin inj 100mg 5 B/D PA NDSoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml

4 B/D PA

PIQRAY 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 PA NDS QL(100/21)PROLEUKIN 5 B/D PA NDSromidepsin 5 PA NDSROZLYTREK CAPS 200MG 5 PA NDS QL(90/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 PA NDS QL(120/30)IRESSA 5 PA NDS QL(30/30)JAKAFI 5 PA NDS QL(60/30)LENVIMA 10 MG DAILY DOSE 5 PA NDS QL(30/30)LENVIMA 12MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 14 MG DAILY DOSE 5 PA NDS QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA NDS QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA NDS QL(90/30)LENVIMA 4 MG DAILY DOSE 5 PA NDS QL(30/30)LENVIMA 8 MG DAILY DOSE 5 PA NDS QL(60/30)MEKINIST TABS 2MG 5 PA NDS QL(30/30)MEKINIST TABS 0.5MG 5 PA NDS QL(90/30)NEXAVAR 5 PA NDS QL(120/30)SPRYCEL 5 PA NDS QL(30/30)STIVARGA 5 PA NDSSUTENT 5 PA NDS QL(28/28)TAFINLAR 5 PA NDS QL(120/30)TAGRISSO 5 PA NDS QL(30/30)TARCEVA TABS 100MG, 150MG

5 PA NDS QL(30/30)

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

5 PA NDS QL(112/28)

TASIGNA CAPS 50MG 5 PA 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 PA NDS QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AFINITOR DISPERZ TBSO 5MG

5 PA NDS QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA NDS QL(28/28)

AFINITOR TABS 10MG 5 PA 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 PA NDS QL(30/30)

BOSULIF TABS 100MG 5 PA NDS QL(120/30)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 PA NDS QL(30/30)CAPRELSA TABS 100MG 5 PA 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 PA NDS QL(63/28)ERIVEDGE 5 PA NDS QL(28/28)erlotinib hydrochloride tabs 100mg, 150mg

5 PA NDS QL(30/30)

erlotinib hydrochloride tabs 25mg

5 PA NDS QL(60/30)

FARYDAK 5 PA NDS QL(6/21)GILOTRIF 5 PA NDS QL(30/30)IBRANCE 5 PA NDS QL(21/28)ICLUSIG TABS 45MG 5 PA NDS QL(30/30)ICLUSIG TABS 15MG 5 PA NDS QL(60/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 4chloroquine phosphate 2COARTEM 4 QL(24/30)DARAPRIM 5 NDS QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3pentamidine isethionate 3PRIMAQUINE PHOSPHATE 4quinine sulfate 4 QL(42/7)Pediculicides/Scabicideslindane 4malathion 4permethrin 3

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAtrihexyphenidyl hydrochloride 2 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIZIMPRO 5 PA NDS QL(30/30)VOTRIENT 5 PA NDS QL(120/30)XALKORI 5 PA NDS QL(60/30)XOSPATA 5 PA NDS QL(90/30)ZALTRAP 5 PA NDS QL(40/28)ZELBORAF 5 PA NDS QL(240/30)ZYDELIG 5 PA NDS QL(60/30)ZYKADIA 5 PA NDS QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateHERCEPTIN HYLECTA 5 PA NDSKANJINTI INJ 420MG 5 PA NDSLIBTAYO 5 PA NDS QL(7/21)LUMOXITI 5 PA NDSMVASI 5 PA NDSPOTELIGEO 5 PA NDSTECENTRIQ INJ 840MG/14ML 5 PA NDS QL(28/28)Monoclonal Antibody/AntibodyDrug ConjugateAVASTIN 5 PA NDSBAVENCIO 5 PA NDSBESPONSA 5 PA NDSCYRAMZA 5 PA NDSDARZALEX 5 PA NDSEMPLICITI 5 PA NDSERBITUX 5 PA NDSGAZYVA 5 PA NDSIMFINZI 5 PA NDSKADCYLA 5 PA NDSKEYTRUDA 5 PA NDSMYLOTARG 5 PA NDSOPDIVO 5 PA NDS QL(80/28)PERJETA 5 PA NDSRITUXAN 5 PA NDSRITUXAN HYCELA 5 PA NDSTECENTRIQ INJ 1200MG/20ML

5 PA NDS QL(20/21)

UNITUXIN 5 PA NDSVECTIBIX 5 PA NDSYERVOY INJ 50MG/10ML 5 PA NDSYERVOY INJ 200MG/40ML 5 PA NDS QL(80/21)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

loxapine succinate 4molindone hydrochloride 2perphenazine 4pimozide 4prochlorperazine edisylate inj 10mg/2ml

4

prochlorperazine maleate 2thioridazine hcl 4thiothixene 4trifluoperazine hcl 42nd Generation/AtypicalABILIFY MAINTENA 5 NDS QL(1/28)aripiprazole odt 5 NDS QL(60/30)aripiprazole oral soln 4 QL(900/30)aripiprazole tabs 4 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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiparkinson Agents, Otheramantadine hcl 3entacapone 4 QL(240/30)Dopamine AgonistsAPOKYN 5 PA NDS QL(60/30)bromocriptine mesylate 4NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)ropinirole hcl 2ropinirole hydrochloride tabs 0.25mg, 3mg

2

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

4

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

Antipsychotics

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

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 3clozapine tabs 200mg 4 QL(120/30)clozapine tabs 100mg 4 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

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

2

Antivirals

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

3 B/D PA

valganciclovir 5 NDSvalganciclovir hydrochlorde 5 NDSZIRGAN 3Anti-hepatitis B (HBV) Agentsentecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 6000000UNIT/ML

4

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

5 NDS

lamivudine tabs 100mg 3Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA NDS QL(28/28)HARVONI 5 NDS 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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

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

4 QL(30/30)

LATUDA TABS 80MG 4 QL(60/30)NUPLAZID 5 PA NDS QL(30/30)olanzapine inj 4 QL(30/30)olanzapine odt 4 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg, 9mg

4 QL(30/30) ST

paliperidone er tb24 6mg 4 QL(60/30) STPERSERIS 5 NDS QL(1/30)quetiapine fumarate 2 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

4 QL(60/30)

risperidone odt tbdp 4mg 4 QL(120/30)risperidone oral soln 4 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 4 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 NDS QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 NDS QL(2/28)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 4 QL(60/30)CIMDUO 5 NDS QL(30/30)DESCOVY 5 NDS QL(30/30)didanosine 4 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)lamivudine oral soln 3 QL(900/30)lamivudine tabs 300mg 3 QL(30/30)lamivudine tabs 150mg 3 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine 4 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)

zidovudine caps 4 QL(180/30)zidovudine syrp 4 QL(1680/28)zidovudine tabs 4 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 NDS QL(30/30)FUZEON 5 NDS QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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)INTELENCE TABS 100MG, 200MG

5 NDS QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 4 QL(30/30)nevirapine er tb24 100mg 4 QL(90/30)nevirapine susp 4 QL(1200/30)nevirapine tabs 4 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)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

rimantadine hcl 2Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 4 B/D PAacyclovir susp 4acyclovir tabs 2famciclovir 4 QL(60/30)trifluridine 4valacyclovir hcl 3 QL(30/30)valacyclovir hydrochloride 3 QL(30/30)

Anxiolytics

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

2

doxepin hcl 4 PAdoxepin hydrochloride caps 25mg

4 PA

Benzodiazepinesalprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam inj 5mg/ml 2diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 4 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 4 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 carbonate caps 300mg 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 3 QL(480/30)NORVIR PACK 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 4 QL(210/30)REYATAZ PACK 5 NDS QL(180/30)ritonavir 3 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 caps 3oseltamivir phosphate susr 4

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 hcl er tb24 1000mg, 500mg (generic for Fortamet)

4 QL(60/30)

metformin hydrochloride oral soln

4 QL(750/30)

metformin hydrochloride tabs 1000mg

1 QL(60/30)


1 QL(90/30)


1 QL(150/30)

nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/28)pioglitazone hcl 1 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 4 QL(120/30)repaglinide tabs 2mg 4 QL(240/30)RIOMET 4 QL(750/30)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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)BYDUREON 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 2 QL(60/30)glipizide er tb24 5mg 2 QL(120/30)glipizide er tb24 2.5mg 2 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 2 QL(60/30)glipizide xl tb24 5mg 2 QL(120/30)glipizide xl tb24 2.5mg 2 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)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 4 QL(74/30)ELIQUIS TABS 2.5MG 4 QL(60/30)ELIQUIS TABS 5MG 4 QL(74/30)enoxaparin sodium 4fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux 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)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

3

heparin sodium inj 5000unit/0.5ml

4

heparin sodium/d5w 4heparin sodium/dextrose 4heparin 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

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 1PRADAXA 4 QL(60/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 10MG, 20MG 3 QL(30/30)XARELTO TABS 15MG, 2.5MG 3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3SOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA 3

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tranexamic acid tabs 3 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 4 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)dipyridamole tabs 2 PAprasugrel 4 QL(30/30)

Cardiovascular Agents

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

4 QL(4/28)

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

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)prazosin hcl 4prazosin hydrochloride caps 2mg

4

terazosin hcl caps 1mg, 5mg 1terazosin hcl caps 10mg 1 QL(60/30)terazosin hydrochloride 1Angiotensin II Receptor Antagonistscandesartan cilexetil tabs 32mg 2 QL(30/30)candesartan cilexetil tabs 16mg, 4mg, 8mg

2 QL(60/30)

candesartan cilexetil/hydrochlorothiazide

2

EDARBI 4 QL(30/30) STEDARBYCLOR 4 ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BloodFormationModifiersanagrelide hydrochloride 3ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

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

4 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4 PA QL(1.68/28)

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

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA NDS QL(1/21)


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)

MOZOBIL 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

4 PA QL(12/28)

PROMACTA PACK 5 PA NDS QL(360/30)PROMACTA TABS 5 PA NDS QL(30/30)ZARXIO 5 PA NDSHemostasis AgentsRETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

RETACRIT INJ 40000UNIT/ML 5 PA NDS QL(6/28)tranexamic acid inj 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

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 2perindopril erbumine 2 QL(60/30)quinapril hcl 1 QL(60/30)quinapril hydrochloride tabs 10mg

1 QL(60/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

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

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 2 QL(30/30)trandolapril tabs 2mg, 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 50mg/ml, 900mg/18ml

4

amiodarone hcl tabs 400mg 4amiodarone hcl tabs 100mg, 200mg

2

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

4

mexiletine hcl 4MULTAQ 3 QL(60/30)pacerone 4propafenone hcl 4propafenone hydrochloride er 4quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2sotalol hcl af 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENTRESTO 3 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 2olmesartan medoxomil/hydrochlorothiazide

4

telmisartan tabs 20mg, 40mg 2 QL(30/30)telmisartan tabs 80mg 2 QL(60/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg

2 QL(30/30)

telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg

2 QL(60/30)

valsartan tabs 320mg 2 QL(30/30)valsartan tabs 160mg, 40mg, 80mg

2 QL(60/30)

valsartan/hydrochlorothiazide 2 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

2 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

2 QL(60/30)

benazepril hydrochloride 1 QL(60/30)captopril 4captopril/hydrochlorothiazide 4enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide

1

fosinopril sodium 2 QL(60/30)

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propranolol hydrochloride tabs 10mg, 20mg, 60mg

2

propranolol/hydrochlorothiazide 3timolol 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

2 QL(60/30)

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

2 QL(30/30)

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

2 QL(60/30)

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

2

cartia xt 3dilt-xr 3diltiazem cd cp24 180mg 3diltiazem hcl er cp12 3diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg

3

diltiazem hcl er tb24 3diltiazem hcl inj 4diltiazem hcl tabs 2diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg

3

felodipine er 2 QL(60/30)isradipine 4matzim la 3nicardipine hcl 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 1betaxolol hcl tabs 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

4 QL(30/30)

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

4

labetalol hydrochloride tabs 4metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 4nadolol/bendroflumethiazide 4pindolol 3propranolol hcl er 4propranolol hcl inj 4propranolol hcl oral soln 4propranolol hcl tabs 40mg, 80mg

2

propranolol hydrochloride er 4

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 2spironolactone 2spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 2hydrochlorothiazide 1indapamide 2metolazone 3Dyslipidemics, 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 4 QL(30/30)fenofibrate tabs 48mg 4 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)LIVALO 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 2 QL(30/30)simvastatin 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nifedipine er tb24 90mg 3 QL(30/30)nifedipine er tb24 30mg, 60mg 3 QL(60/30)nimodipine 4taztia xt cp24 120mg, 180mg, 240mg, 300mg

3

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 360MG

3 QL(30/30)

verapamil hydrochloride inj 4verapamil hydrochloride tabs 1Cardiovascular Agents, Otheratropine sulfate inj 0.5mg/5ml 4CORLANOR TABS 4 PA QL(60/30)DEMSER 5 NDSdigitek tabs 0.25mg 4 PAdigitek tabs 0.125mg 3 QL(30/30)digox tabs 125mcg 3 QL(30/30)digox tabs 250mcg 4 PAdigoxin inj 4 PAdigoxin tabs 250mcg 4 PAdigoxin tabs 125mcg 3 QL(30/30)NORTHERA CAPS 100MG 5 PA NDS QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA NDS QL(180/30)

pentoxifylline er 2RANEXA 3 QL(60/30)ranolazine er 3 QL(60/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 3acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide inj 4bumetanide tabs 2mg 3bumetanide tabs 0.5mg, 1mg 2ethacrynate sodium 4

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitroglycerin transdermal 2 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

4 QL(30/30)

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

4 QL(60/30)

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

3 QL(60/30)

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

3 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

4 QL(60/30)


4 QL(90/30)


4 QL(120/30)

dextroamphetamine sulfate oral soln

4 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

4 QL(60/30)

dextroamphetamine sulfate tabs 10mg

4 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dyslipidemics, Othercholestyramine 4cholestyramine light 4colestipol hcl 4ezetimibe 4 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 4 QL(30/30)niacin er tbcr 1000mg, 750mg 4 QL(60/30)niacin tabs 500mg 2niacor 2omega-3-acid ethyl esters 4 QL(120/30)PRALUENT 5 PA NDSprevalite 4REPATHA 5 PA NDSREPATHA PUSHTRONEX SYSTEM

5 PA NDS

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 3 QL(180/30)isosorbide dinitrate er 3isosorbide dinitrate tabs 4isosorbide mononitrate 2isosorbide mononitrate er 2minitran 4 QL(30/30)nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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)GILENYA 5 PA NDS QL(30/30)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 Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 4paroex 1pilocarpine hcl 4pilocarpine hydrochloride tabs 5mg

4

triamcinolone acetonide dental paste

4

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 4avita crea 4 PA QL(45/30)avita gel 4 PAcalcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)calcipotriene oint 4 QL(120/30)calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)claravis 4CURITY GAUZE PADS 2”X2” 3diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium transdermal soln

4 QL(1050/30)

erythromycin/benzoyl peroxide 4fluorouracil crea 5% 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 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 tabs

4 QL(90/30)

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

3 QL(90/30)

NAMZARIC C4PK 4 PA QL(56/365)NAMZARIC CP24 4 PA QL(30/30)NUEDEXTA 4 PA QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA NDS QL(90/30)tetrabenazine tabs 25mg 5 PA NDS QL(120/30)Multiple Sclerosis AgentsAMPYRA 5 PA NDS QL(60/30)AVONEX 5 PA NDS QL(4/28)AVONEX PEN 5 PA NDS QL(4/28)BETASERON 5 PA NDS QL(14/28)

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

CLINISOL SF 15% 4 B/D PAdextrose 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PAdextrose 10%/nacl 0.2% 4 B/D PAdextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4dextrose 5%/lactated ringers 4 B/D PAdextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluorouracil crea 0.5% 5 NDSfluorouracil external soln 4imiquimod 4 QL(12/30)isotretinoin 4methoxsalen 4myorisan 4PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)podofilox 4RECTIV 4 QL(30/30)REGRANEX 5 PA NDS QL(15/30)SANTYL 3selenium sulfide lotn 2tacrolimus oint 4 QL(100/90)tazarotene 4TAZORAC CREA 0.05% 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 PAtretinoin microsphere pump gel 0.1%

4 PA

zenatane 4

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN II 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PACARBAGLU 5 PA NDSCLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PApotassium chloride cr 2potassium chloride er 2potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 4potassium chloride pack 2potassium chloride sr 2potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

4 B/D PA

potassium chloride/dextrose/lactated ringers

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 4PREMASOL 4 B/D PAPROCALAMINE 4 B/D PAPROSOL 4 B/D PAringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l

4 B/D PA

sodium bicarbonate inj 4sodium chloride 0.45% 4sodium chloride inj 0.45%, 0.9%, 3%, 5%

4

sodium fluoride chew 0.25mg, 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAElectrolyte/Mineral/MetalModifiersCHEMET 5 NDSCUPRIMINE 5 NDSDEPEN TITRATABS 5 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4 B/D PA

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAKCL 0.075%/D5W/NACL 0.45% 4 B/D PAKCL 0.15%/D5W/NACL 0.2% 4 B/D PAKCL 0.15%/D5W/NACL 0.225% 4 B/D PAKCL 0.15%/D5W/NACL 0.45% 4 B/D PAKCL 0.15%/D5W/NACL 0.9% 4 B/D PAKCL 0.3%/D5W/NACL 0.45% 4 B/D PAKCL 0.3%/D5W/NACL 0.9% 4 B/D PAklor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 2klor-con m20 2klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML

4 B/D PA

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

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PA

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dicyclomine hydrochloride tabs 2ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 1mg, 2mg 4hyoscyamine sulfate elix 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 4nulev 2oscimin 2propantheline bromide 4Gastrointestinal Agents, Othercromolyn sodium conc 4diphenoxylate/atropine 4GATTEX 5 PA NDSloperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 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 caps 3ursodiol tabs 4Histamine2 (H2) Receptor Antagonistsfamotidine inj 4famotidine premixed 4famotidine tabs 20mg, 40mg 2ranitidine hcl inj 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JADENU 5 NDSJADENU SPRINKLE 5 NDSkionex 3penicillamine 5 NDSSAMSCA TABS 15MG 5 PA NDS QL(30/30)SAMSCA TABS 30MG 5 PA NDS QL(60/30)sodium polystyrene sulfonate powd

3

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

3

sps 3SYPRINE 5 NDStrientine hydrochloride 5 NDSVELTASSA 3Phosphate BindersAURYXIA 4 PA QL(360/30)calcium acetate caps 3calcium acetate tabs 667mg 3PHOSLYRA 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)Vitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl oral soln 4dicyclomine hydrochloride caps 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GeneticorEnzymeDisorder:Replacement,Modifiers,Treatment

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

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 4 QL(30/30)MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 5mg

3 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

3 QL(60/30)

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

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ranitidine hcl syrp 4ranitidine hcl tabs 150mg, 300mg

1

ranitidine hydrochloride caps 4ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml

4

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 2lactulose oral soln 2MOVIPREP 4peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3sucralfate 2Proton Pump Inhibitorsomeprazole cpdr 2 QL(60/30)pantoprazole sodium inj 4pantoprazole sodium tbec 2 QL(60/30)

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

fludrocortisone acetate 2fluocinolone acetonide 4fluocinolone acetonide body 4fluocinolone acetonide scalp 4fluocinonide crea 0.05% 3fluocinonide external soln 4fluocinonide gel 4fluocinonide oint 4fluticasone propionate crea 2fluticasone propionate oint 4halobetasol propionate crea 4halobetasol propionate oint 4hydrocortisone butyrate (lipid) 4hydrocortisone butyrate (lipophilic)

4

hydrocortisone butyrate crea 4hydrocortisone butyrate external soln

4

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

4

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

4

methylprednisolone tabs 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Genitourinary Agents, Otherbethanechol chloride 3ELMIRON 4phenazopyridine hydrochloride 2phenazopyridine hydrocholride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ala-cort crea 1% 1alclometasone dipropionate 2augmented betamethasone dipropionate crea

2

augmented betamethasone dipropionate gel

3

augmented betamethasone dipropionate lotn

4

augmented betamethasone dipropionate oint

4

betamethasone dipropionate 3betamethasone valerate crea 3betamethasone valerate foam 4betamethasone valerate lotn 3betamethasone valerate oint 3cortisone acetate 4DEPO-MEDROL INJ 20MG/ML 4desonide lotn 4desonide oint 4desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone 2dexamethasone intensol 4

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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 caps 50mg 3danazol caps 100mg, 200mg 4testosterone cypionate 4testosterone enanthate 4 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump gel 1% 4 PA QL(300/30)Estrogensaltavera 3alyacen 1/35 2alyacen 7/7/7 3amethia 3 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 4ashlyna 4 QL(91/91)aubra 3aviane 2azurette 3balziva 4blisovi fe 1.5/30 2briellyn 2camrese 3 QL(91/91)camrese lo 4 QL(91/91)caziant 2cesia 3chateal 3cryselle-28 2cyclafem 1/35 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone 4prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

4

prednisone intensol 4prednisone oral soln 2prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 5mg 1prednisone tbpk 10mg 2procto-med hc 4procto-pak 2proctosol hc 4proctozone-hc 4SOLU-CORTEF 4TEXACORT 3triamcinolone acetonide crea 2triamcinolone acetonide inj 40mg/ml

4

triamcinolone acetonide lotn 3triamcinolone acetonide oint 2triderm crea 0.1% 2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)desmopressin acetate inj 4desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2GENOTROPIN 5 PA NDSGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA NDS

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

juleber 2junel 1.5/30 4junel 1/20 2junel fe 1.5/30 4junel fe 1/20 2kariva 4kelnor 1/35 4kelnor 1/50 2kurvelo 3larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

3 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg

3

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

4

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

4 QL(91/91)

levora 0.15/30-28 2low-ogestrel 2lutera 3marlissa 2melodetta 24 fe 2MENEST 4 PAmibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cyclafem 7/7/7 4cyred 3cyred eq 3dasetta 1/35 3dasetta 7/7/7 3daysee 3 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 3DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol tabs 0; 0

4

desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg

3

dotti 2 PA QL(8/28)elinest 3emoquette 2enpresse-28 2enskyce 3estarylla 2estradiol crea 4estradiol pttw 4 PA QL(8/28)estradiol ptwk 4 PA QL(4/28)estradiol tabs 10mcg 4 QL(18/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol valerate 4ESTRING 4 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

4

falmina 2femynor 2fyavolv tabs 2.5mcg; 0.5mg 4 PAhailey 24 fe 3introvale 4 QL(91/91)isibloom 3jolessa 3 QL(91/91)

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tydemy 2velivet 4vienva 4viorele 3vyfemla 2vylibra 2wera 3yuvafem 4 QL(18/28)zovia 1/35e 2Progesterone Agonists/AntagonistsELLA 3MAKENA INJ 275MG/1.1ML 5 PA NDSProgestinscamila 2deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 3hydroxyprogesterone caproate 5 PA NDSincassia 2jencycla 3lyza 3medroxyprogesterone acetate inj

4 QL(1/90)

medroxyprogesterone acetate tabs

2

megestrol acetate susp 40mg/ml

4 PA

megestrol acetate tabs 4 PAnora-be 2norethindrone 2norethindrone acetate 4norlyroc 3progesterone caps 2sharobel 2Selective Estrogen Receptor Modifying AgentsDUAVEE 4 PA QL(30/30)raloxifene hydrochloride 3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mili 2mono-linyah 3necon 0.5/35-28 3norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

4 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

3

norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg

3

norgestimate/ethinyl estradiol tabs 0; 0

2

nortrel 0.5/35 (28) 4nortrel 1/35 2nortrel 7/7/7 4ogestrel 3orsythia 2philith 3pimtrea 3pirmella 1/35 2pirmella 7/7/7 3portia-28 2PREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)previfem 2reclipsen 2setlakin 4 QL(91/91)sprintec 28 2sronyx 4tarina fe 1/20 3tri-estarylla 3tri-legest fe 3tri-linyah 3tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2trivora-28 2

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate 4 PASIGNIFOR 5 PA 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 PA 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 4

Immunological Agents

Angioedema AgentsCINRYZE 5 PA NDS QL(20/30)FIRAZYR 5 PA NDS QL(18/30)icatibant acetate 5 PA NDS QL(18/30)RUCONEST 5 PA NDS QL(8/30)Immune SuppressantsASTAGRAF XL 4 PAAZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PAcyclosporine 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG

4

levoxyl tabs 100mcg, 112mcg, 175mcg

4

liothyronine sodium inj 4liothyronine sodium tabs 2SYNTHROID 4UNITHROID 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5 NDS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 4 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)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)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SANDIMMUNE ORAL SOLN 4 PAsirolimus oral soln 5 PA NDSsirolimus tabs 4 PASKYRIZI 5 PA NDS QL(2/28)tacrolimus caps 4 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 4 PAGAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML

5 B/D PA NDS

GAMMAKED INJ 1GM/10ML 3 B/D PAGAMUNEX-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)RINVOQ 5 PA NDS QL(30/30)SIMULECT 5 B/D PA NDSSYNAGIS 5 PA NDSVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BCG VACCINE 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cyclosporine modified 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 4 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)

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 4methotrexate tabs 2mycophenolate mofetil caps 4 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PA NDSmycophenolate mofetil tabs 4 PAmycophenolic acid dr 4 PANULOJIX 5 PA NDS QL(150/30)PROGRAF PACK 4 PARAPAMUNE ORAL SOLN 5 PA NDSRENFLEXIS 5 PA NDS

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 4mesalamine dr tbec 1.2gm 4 QL(120/30)mesalamine enem 4mesalamine kit 4Glucocorticoidsbudesonide cpep 4hydrocortisone enem 3Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

BINOSTO 4calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol 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)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)GARDASIL 9 4 QL(1.5/365)HAVRIX 4HEPLISAV-B 4 B/D PA QL(3/365)HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4 B/D PAINFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4 B/D PARECOMBIVAX HB 4 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 4 QL(2/999)STAMARIL 4 QL(1/999)TDVAX 4TENIVAC 4 QL(0.5/28)TRUMENBA 4TWINRIX 4TYPHIM VI 4

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NOVOFINE 32GX6MM 3 QL(200/30)NOVOFINE AUTOCOVER 30GX8MM

3 QL(200/30)

NOVOTWIST 32GX5MM 3 QL(200/30)NUTRILIPID 4 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 4physiosol irrigation 4RINGERS IRRIGATION 4sodium chloride irrigation 0.9% 4sterile water irrigation 4sterile water irrigation plastic bottle

4

sterile water irrigation w/hanger 4TECHLITE 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 4V-GO 20 3V-GO 30 3V-GO 40 3

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide AnalogsCOMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 3CYSTARAN 5 PA NDS QL(60/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5 NDSpamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 4 QL(90/30)PROLIA 4 QL(1/180)SENSIPAR TABS 30MG, 60MG 5 NDS QL(60/30)SENSIPAR TABS 90MG 5 NDS QL(120/30)TYMLOS 5 PA NDS

QL(1.56/30)XGEVA 5 PA NDS QL(1.7/28)zoledronic acid inj 5mg/100ml 4 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)

FIRDAPSE 5 PA NDSINTRALIPID 4 B/D PAKORLYM 5 PA NDS QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA NDS QL(2/28)NOVOFINE 31 3 QL(200/30)

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4

apraclonidine 4AZOPT 3betaxolol hcl ophthalmic soln 4brimonidine 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)levobunolol hcl 1PHOSPHOLINE IODIDE 4pilocarpine hcl 4ROCKLATAN 4 STSIMBRINZA 4timolol maleate ophthalmic gel forming

4

timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetic acid 2flac 4fluocinolone acetonide 4fluocinolone acetonide ear drops

4

hydrocortisone/acetic acid 4neomycin/polymyxin/hc 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

2

epinastine hcl 4olopatadine hcl ophthalmic soln 4 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

4

PAZEO 3 QL(2.5/30)OphthalmicAnti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3fluorometholone 3flurbiprofen sodium 2ILEVRO 3INVELTYS 4ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4LOTEMAX SM 4neomycin/polymyxin/dexamethasone

2

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

2

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Bronchodilators, AnticholinergicATROVENT HFA 4 QL(25.8/30)COMBIVENT RESPIMAT 4 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, Sympathomimeticalbuterol sulfate er 4albuterol 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 2albuterol sulfate tabs 4ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml 4epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

3 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)levalbuterol tartrate hfa 4 QL(30/30)metaproterenol sulfate 4PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 4VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 PA 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 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

neomycin/polymyxin/hydrocortisone

4

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 4 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)Antihistaminesazelastine hcl nasal soln 4 QL(30/25)azelastine hydrochloride nasal soln

4 QL(30/25)

desloratadine 4 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)

Antileukotrienesmontelukast sodium chew 2 QL(30/30)montelukast sodium pack 4 QL(30/30)montelukast sodium tabs 2 QL(30/30)zafirlukast 4 QL(60/30)

59



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hydrochloride tabs 10mg, 5mg

2 PA QL(90/30)

methocarbamol tabs 2 PAorphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam caps 22.5mg, 7.5mg

4 QL(60/365)

temazepam caps 15mg, 30mg 2 QL(60/365)zaleplon 2 QL(30/30)zolpidem tartrate tabs 2 QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)ramelteon 3 QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA NDS QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 4 PA QL(30/30)DALIRESP TABS 250MCG 4 PA QL(60/365)theophylline er tb12 300mg 2theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA NDS QL(90/30)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)TRACLEER TABS 5 PA NDS QL(60/30)TRACLEER TBSO 5 PA NDStreprostinil 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 4 B/D PAARALAST NP 5 B/D PA NDSPROLASTIN-C 5 B/D PA NDSribavirin inhalation soln 5 B/D PA NDSTRELEGY 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)

60

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir oral soln . . . . . . . . . . . . . . . . . 35abacavir sulfate/lamivudine . . . . . . . . 35abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 35abacavir tabs . . . . . . . . . . . . . . . . . . . . . 35ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 26ABILIFY MAINTENA . . . . . . . . . . . . . . . 33abiraterone acetate . . . . . . . . . . . . . . . . 28ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 29acamprosate calcium dr . . . . . . . . . . . . 19acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 37acebutolol hcl caps 200mg . . . . . . . . . 41acebutolol hydrochloride caps 400mg . . . . . . . . . . . . . . . . . . . . . . . 41acetaminophen/codeine oral soln . . 17acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 17acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 17acetazolamide . . . . . . . . . . . . . . . . . . . . . 42acetazolamide er . . . . . . . . . . . . . . . . . . 57acetazolamide sodium . . . . . . . . . . . . . 42acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 57acetylcysteine inhalation soln . . . . . . 59acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ACTEMRA ACTPEN . . . . . . . . . . . . . . . 54ACTEMRA INJ 162MG/0.9ML . . . . . . 54ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 54ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 54acyclovir caps . . . . . . . . . . . . . . . . . . . . 36acyclovir oint . . . . . . . . . . . . . . . . . . . . . 36acyclovir sodium . . . . . . . . . . . . . . . . . . . 36acyclovir susp . . . . . . . . . . . . . . . . . . . . 36acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 36ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 54ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 59adriamycin inj 2mg/ml . . . . . . . . . . . . . . 29

ADRIAMYCIN INJ 50MG . . . . . . . . . . . 29adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 58ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 58AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 30AFINITOR DISPERZ TBSO 5MG . . . 31AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 31AFINITOR TABS 10MG . . . . . . . . . . . . 31ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 49albendazole . . . . . . . . . . . . . . . . . . . . . . . 32ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 32albuterol sulfate er . . . . . . . . . . . . . . . . . 58albuterol sulfate nebu 0.5% . . . . . . . . 58albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 58albuterol sulfate syrp . . . . . . . . . . . . . . 58albuterol sulfate tabs . . . . . . . . . . . . . . 58alclometasone dipropionate . . . . . . . . 49ALCOHOL PREP PADS . . . . . . . . . . . . 19ALDURAZYME . . . . . . . . . . . . . . . . . . . . 48ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 31alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 55alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 55alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 48ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 32ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 32ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 31allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 27allopurinol sodium . . . . . . . . . . . . . . . . . 27alosetron hydrochloride tabs 0.5mg . . 48alosetron hydrochloride tabs 1mg . . . 48ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 57alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 36alprazolam tabs 2mg . . . . . . . . . . . . . . 36

altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ALUNBRIG TABS 30MG . . . . . . . . . . . 31ALUNBRIG TABS 180MG, 90MG . . . 31ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 31alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 50alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 50amantadine hcl . . . . . . . . . . . . . . . . . . . . 33AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 26ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 59a-methapred . . . . . . . . . . . . . . . . . . . . . . 49amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 50amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 50amikacin sulfate . . . . . . . . . . . . . . . . . . . 19amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 42amiloride/hydrochlorothiazide . . . . . . 42AMINO ACID . . . . . . . . . . . . . . . . . . . . . . 56aminophylline . . . . . . . . . . . . . . . . . . . . . 59AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 45AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 45AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 45amiodarone hcl inj 50mg/ml, 900mg/18ml . . . . . . . . . . . . . 40amiodarone hcl tabs 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 40amiodarone hcl tabs 400mg . . . . . . . . 40amiodarone hydrochloride inj . . . . . . 40AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 48amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 26amitriptyline hydrochloride tabs 10mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 26amlodipine besylate/benazepril hcl caps 5mg; 40mg . . . . . . . . . . . . . . . 41amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 41amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 41amlodipine besylate tabs 2.5mg . . . . 41amlodipine besylate tabs 5mg . . . . . . 41amlodipine besylate tabs 10mg . . . . . 41

61


Covered Drugs Index

ARISTADA INJ 662MG/2.4ML . . . . . . 33ARISTADA INJ 882MG/3.2ML . . . . . . 33ARISTADA INJ 1064MG/3.9ML . . . . . 33armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 59ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 58ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 28arsenic trioxide . . . . . . . . . . . . . . . . . . . . 29ascomp/codeine . . . . . . . . . . . . . . . . . . . 17ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 50aspirin/dipyridamole . . . . . . . . . . . . . . . 39ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 53atazanavir sulfate caps 150mg . . . . . 36atazanavir sulfate caps 200mg . . . . . 36atazanavir sulfate caps 300mg . . . . . 36atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 41atenolol/chlorthalidone . . . . . . . . . . . . . 41ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 54atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 44atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 44atorvastatin calcium . . . . . . . . . . . . . . . 42atovaquone . . . . . . . . . . . . . . . . . . . . . . . 32atovaquone/proguanil hcl . . . . . . . . . . 32ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 35atropine sulfate inj 0.5mg/5ml . . . . . . 42atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . . . . . . . . . . . . . . 47atropine sulfate ophthalmic soln . . . . 56ATROVENT HFA . . . . . . . . . . . . . . . . . . 58aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50augmented betamethasone dipropionate crea . . . . . . . . . . . . . . . . . 49augmented betamethasone dipropionate gel . . . . . . . . . . . . . . . . . . . 49augmented betamethasone dipropionate lotn . . . . . . . . . . . . . . . . . . 49augmented betamethasone dipropionate oint . . . . . . . . . . . . . . . . . . 49AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 47AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 32

APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 33apraclonidine . . . . . . . . . . . . . . . . . . . . . . 57aprepitant caps 40mg . . . . . . . . . . . . . . 26aprepitant caps 80mg . . . . . . . . . . . . . . 26aprepitant caps 125mg . . . . . . . . . . . . . 26aprepitant caps pack . . . . . . . . . . . . . . . 26apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 55APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 23APTIOM TABS 600MG . . . . . . . . . . . . . 23APTIVUS CAPS . . . . . . . . . . . . . . . . . . 36APTIVUS ORAL SOLN . . . . . . . . . . . . 36ARALAST NP . . . . . . . . . . . . . . . . . . . . . 59aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 39ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 39ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 39ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 54aripiprazole odt . . . . . . . . . . . . . . . . . . . . 33aripiprazole oral soln . . . . . . . . . . . . . . 33aripiprazole tabs . . . . . . . . . . . . . . . . . . 33ARISTADA INITIO . . . . . . . . . . . . . . . . . 33ARISTADA INJ 441MG/1.6ML . . . . . . 33

amlodipine besylate/valsartan . . . . . . 41amlodipine/valsartan/hctz . . . . . . . . . . 41amlodipine/valsartan/ hydrochlorothiazide tabs 5mg; 12.5mg; 160mg . . . . . . . . . . . . . . 41ammonium lactate . . . . . . . . . . . . . . . . . 44amnesteem . . . . . . . . . . . . . . . . . . . . . . . 44amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 26amoxicillin caps . . . . . . . . . . . . . . . . . . . 21amoxicillin chew . . . . . . . . . . . . . . . . . . 21amoxicillin/clavulanate potassium . . . 21amoxicillin/clavulanate potassium er . 21amoxicillin susr . . . . . . . . . . . . . . . . . . . 21amoxicillin tabs . . . . . . . . . . . . . . . . . . . 21amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 43amphetamine/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 . . . . . . . . . . . . . . 43amphetamine/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 . . . . . . . 43amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 43amphotericin b . . . . . . . . . . . . . . . . . . . . 26ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 21ampicillin sodium . . . . . . . . . . . . . . . . . . 21ampicillin-sulbactam . . . . . . . . . . . . . . . 21AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 44ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 50anagrelide hydrochloride . . . . . . . . . . . 39anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 47anastrozole . . . . . . . . . . . . . . . . . . . . . . . 30ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 58

62


Covered Drugs Index

bethanechol chloride . . . . . . . . . . . . . . . 49bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 32BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 55bicalutamide . . . . . . . . . . . . . . . . . . . . . . 28BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 21BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 35BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 32BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 55bisoprolol fumarate . . . . . . . . . . . . . . . . 41bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 41bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 29bleomycin sulfate . . . . . . . . . . . . . . . . . . 29BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 22BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 22blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 50BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 55BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 29bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 59BOSULIF TABS 100MG . . . . . . . . . . . . 31BOSULIF TABS 400MG, 500MG . . . 31BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 29BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 58briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 39brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 57brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 57BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 23BRIVIACT ORAL SOLN . . . . . . . . . . . 23BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 23BRIVIACT TABS 100MG . . . . . . . . . . . 23bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 57bromocriptine mesylate . . . . . . . . . . . . 33budesonide cpep . . . . . . . . . . . . . . . . . 55budesonide susp . . . . . . . . . . . . . . . . . . 58

BAQSIMI ONE PACK . . . . . . . . . . . . . . 38BAQSIMI TWO PACK . . . . . . . . . . . . . . 38BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 32BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 22BCG VACCINE . . . . . . . . . . . . . . . . . . . . 54BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” . . . . 56BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” . . . . 56BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM . . . . . . . . 56BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM . . . . . . . . . . . . . 56BD PEN NEEDLE/MINI/ ULTRA-FINE/31G X 5MM . . . . . . . . . . 56BD PEN NEEDLE/NANO/ ULTRA -FINE/32G X 4MM . . . . . . . . . 56BD PEN NEEDLE/ORIGINAL/ ULTRA-FINE/29G X 12.7MM . . . . . . . 56BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 29benazepril hcl . . . . . . . . . . . . . . . . . . . . . 40benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 40benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 40benazepril hydrochloride . . . . . . . . . . . 40BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 28BENLYSTA INJ 120MG . . . . . . . . . . . . 54BENLYSTA INJ 400MG . . . . . . . . . . . . 54benztropine mesylate inj . . . . . . . . . . . 32benztropine mesylate tabs . . . . . . . . . 32BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 22BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 32betamethasone dipropionate . . . . . . . 49betamethasone valerate crea . . . . . . 49betamethasone valerate foam . . . . . 49betamethasone valerate lotn . . . . . . . 49betamethasone valerate oint . . . . . . . 49BETASERON . . . . . . . . . . . . . . . . . . . . . 44betaxolol hcl ophthalmic soln . . . . . . 57betaxolol hcl tabs . . . . . . . . . . . . . . . . . 41

AVELOX . . . . . . . . . . . . . . . . . . . . . . . . . . 22aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50avita crea . . . . . . . . . . . . . . . . . . . . . . . . . 44avita gel . . . . . . . . . . . . . . . . . . . . . . . . . . 44AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 44AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 44azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 29AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 21AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 53AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 21azathioprine inj . . . . . . . . . . . . . . . . . . . 53azathioprine tabs . . . . . . . . . . . . . . . . . 53azelastine hcl nasal soln . . . . . . . . . . . 58azelastine hcl ophthalmic soln . . . . . 57azelastine hydrochloride nasal soln . . 58azithromycin inj . . . . . . . . . . . . . . . . . . . 21azithromycin pack . . . . . . . . . . . . . . . . . 21azithromycin susr 100mg/5ml . . . . . . 21azithromycin susr 200mg/5ml . . . . . . 21azithromycin tabs 250mg, 500mg . . . 21azithromycin tabs 600mg . . . . . . . . . . . 22AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 57aztreonam inj 1gm . . . . . . . . . . . . . . . . . 21aztreonam inj 2gm . . . . . . . . . . . . . . . . . 21azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Bbacitracin inj . . . . . . . . . . . . . . . . . . . . . . 19bacitracin ophthalmic oint . . . . . . . . . . 19bacitracin/polymyxin b . . . . . . . . . . . . . 19baclofen tabs . . . . . . . . . . . . . . . . . . . . . 34balsalazide disodium . . . . . . . . . . . . . . 55BALVERSA TABS 3MG . . . . . . . . . . . . 30BALVERSA TABS 4MG . . . . . . . . . . . . 30BALVERSA TABS 5MG . . . . . . . . . . . . 30balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50BANZEL SUSP . . . . . . . . . . . . . . . . . . . 24BANZEL TABS 200MG . . . . . . . . . . . . 24BANZEL TABS 400MG . . . . . . . . . . . . 24

63


Covered Drugs Index

caspofungin acetate . . . . . . . . . . . . . . . 26CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 58caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 20cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 20CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 20cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 20cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 20cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 21cefepime/dextrose . . . . . . . . . . . . . . . . . 21cefixime caps . . . . . . . . . . . . . . . . . . . . . 21cefixime susr . . . . . . . . . . . . . . . . . . . . . 21cefotaxime sodium inj 1gm, 500mg . . 21cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 21cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 21cefpodoxime proxetil . . . . . . . . . . . . . . . 21cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 21ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 21ceftazidime/dextrose . . . . . . . . . . . . . . . 21ceftriaxone in iso-osmotic dextrose . 21ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 21cefuroxime axetil . . . . . . . . . . . . . . . . . . 21cefuroxime sodium . . . . . . . . . . . . . . . . 21celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 17celecoxib caps 400mg . . . . . . . . . . . . . 17CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 23cephalexin caps 250mg, 500mg . . . . 21cephalexin susr . . . . . . . . . . . . . . . . . . . 21CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 48cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 19CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 19CHANTIX STARTING MONTH PAK . . 19

calcitonin-salmon . . . . . . . . . . . . . . . . . . 55calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 44calcitriol caps . . . . . . . . . . . . . . . . . . . . . 55calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 55calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 44calcitriol oral soln . . . . . . . . . . . . . . . . . 55calcium acetate caps . . . . . . . . . . . . . . 47calcium acetate tabs 667mg . . . . . . . . 47CALQUENCE . . . . . . . . . . . . . . . . . . . . . 31camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 50camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 50candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 39candesartan cilexetil tabs 16mg, 4mg, 8mg . . . . . . . . . . . . . . . . . . 39candesartan cilexetil tabs 32mg . . . . 39CAPASTAT SULFATE . . . . . . . . . . . . . . 27CAPRELSA TABS 100MG . . . . . . . . . 31CAPRELSA TABS 300MG . . . . . . . . . 31captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 40captopril/hydrochlorothiazide . . . . . . . 40CARAFATE SUSP . . . . . . . . . . . . . . . . 48CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 45carbamazepine chew . . . . . . . . . . . . . . 24carbamazepine er . . . . . . . . . . . . . . . . . 24carbamazepine susp . . . . . . . . . . . . . . 24carbamazepine tabs . . . . . . . . . . . . . . 24carbidopa/levodopa . . . . . . . . . . . . . . . . 33carbidopa/levodopa/entacapone . . . . 33carbidopa/levodopa er . . . . . . . . . . . . . 33carbidopa/levodopa odt . . . . . . . . . . . . 33carboplatin inj 150mg/15ml . . . . . . . . . 29carboplatin inj 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 28carmustine . . . . . . . . . . . . . . . . . . . . . . . . 28carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 57cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 41carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 41carvedilol phosphate . . . . . . . . . . . . . . . 41

bumetanide inj . . . . . . . . . . . . . . . . . . . . 42bumetanide tabs 0.5mg, 1mg . . . . . . . 42bumetanide tabs 2mg . . . . . . . . . . . . . . 42buprenorphine hcl inj . . . . . . . . . . . . . . 17buprenorphine hcl/naloxone hcl . . . . . 19buprenorphine hcl subl . . . . . . . . . . . . 19buprenorphine hydrochloride/ naloxone hydrochloride film . . . . . . . . 19bupropion hcl tabs 100mg . . . . . . . . . . 24bupropion hydrochloride er (sr) . . . . . 19bupropion hydrochloride er (sr) . . . . . 24bupropion hydrochloride er (xl) tb24 150mg, 300mg . . . . . . . . . . . . . . . 25bupropion hydrochloride tabs 75mg . . 25buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 36buspirone hydrochloride tabs 10mg, 5mg, 7.5mg . . . . . . . . . . . . 36busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 28BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 28butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 17butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 17butalbital/aspirin/caffeine caps . . . . . 17butalbital/aspirin/caffeine/codeine . . . 17butorphanol tartrate inj 1mg/ml . . . . . 17butorphanol tartrate inj 2mg/ml . . . . . 17butorphanol tartrate nasal soln . . . . . 17BYDUREON BCISE . . . . . . . . . . . . . . . 37BYDUREON PEN . . . . . . . . . . . . . . . . . 37BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 41BYSTOLIC TABS 20MG . . . . . . . . . . . 41

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 53CABOMETYX TABS 20MG, 60MG . 31CABOMETYX TABS 40MG . . . . . . . . 31calcipotriene crea . . . . . . . . . . . . . . . . . 44calcipotriene external soln . . . . . . . . . 44calcipotriene oint . . . . . . . . . . . . . . . . . . 44

64


Covered Drugs Index

clopidogrel tabs 75mg . . . . . . . . . . . . . 39clopidogrel tabs 300mg . . . . . . . . . . . . 39clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 36clorazepate dipotassium tabs 15mg . 36clotrimazole/betamethasone dipropionate crea . . . . . . . . . . . . . . . . . 26clotrimazole/betamethasone dipropionate lotn . . . . . . . . . . . . . . . . . . 26clotrimazole external crea . . . . . . . . . 26clotrimazole external soln . . . . . . . . . . 26clotrimazole lozg . . . . . . . . . . . . . . . . . . 26clozapine odt tbdp 12.5mg, 25mg . . . 34clozapine odt tbdp 100mg . . . . . . . . . . 34clozapine odt tbdp 150mg . . . . . . . . . . 34clozapine odt tbdp 200mg . . . . . . . . . . 34clozapine tabs 25mg, 50mg . . . . . . . . 34clozapine tabs 100mg . . . . . . . . . . . . . . 34clozapine tabs 200mg . . . . . . . . . . . . . . 34COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 32colchicine caps . . . . . . . . . . . . . . . . . . . 27colchicine tabs . . . . . . . . . . . . . . . . . . . . 27colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 43colistimethate sodium . . . . . . . . . . . . . . 20COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 56COMBIVENT RESPIMAT . . . . . . . . . . 58COMETRIQ 60MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 31COMETRIQ 100MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 31COMETRIQ 140MG DAILY DOSE KIT . . . . . . . . . . . . . . . . . . 31COMPLERA . . . . . . . . . . . . . . . . . . . . . . 35compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 26constulose . . . . . . . . . . . . . . . . . . . . . . . . 48COPAXONE INJ 20MG/ML . . . . . . . . . 44COPAXONE INJ 40MG/ML . . . . . . . . . 44COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 29CORLANOR TABS . . . . . . . . . . . . . . . . 42cortisone acetate . . . . . . . . . . . . . . . . . . 49COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 31

clarithromycin er . . . . . . . . . . . . . . . . . . . 22clindacin etz pledgets . . . . . . . . . . . . . . 19clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 19clindamycin hcl caps . . . . . . . . . . . . . . . 19clindamycin phosphate crea . . . . . . . 19clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 19clindamycin phosphate gel . . . . . . . . 19clindamycin phosphate in d5w . . . . . . 20clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml, 9gm/60ml . . . . . . . . . . . . . 20clindamycin phosphate lotn . . . . . . . . 20clindamycin phosphate swab . . . . . . 20clindamycin/sodium chloride . . . . . . . . 20CLINIMIX 4.25%/DEXTROSE 5% . . 45CLINIMIX 4.25%/DEXTROSE 10% . . 45CLINIMIX 4.25%/DEXTROSE 25% . . 45CLINIMIX 5%/DEXTROSE 15% . . . . 45CLINIMIX 5%/DEXTROSE 20% . . . . 45CLINIMIX 5%/DEXTROSE 25% . . . . 45CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 45CLINISOL SF 15% . . . . . . . . . . . . . . . . 45clobazam susp . . . . . . . . . . . . . . . . . . . . 23clobazam tabs . . . . . . . . . . . . . . . . . . . . 23clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 28clomipramine hcl . . . . . . . . . . . . . . . . . . 26clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 23clonazepam odt tbdp 1mg . . . . . . . . . . 23clonazepam odt tbdp 2mg . . . . . . . . . . 23clonazepam tabs 0.5mg . . . . . . . . . . . . 23clonazepam tabs 1mg . . . . . . . . . . . . . 23clonazepam tabs 2mg . . . . . . . . . . . . . 23clonidine hcl er . . . . . . . . . . . . . . . . . . . . 44clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 39clonidine hcl ptwk 0.3mg/24hr . . . . . . 39clonidine hcl tabs . . . . . . . . . . . . . . . . . 39clonidine hydrochloride tabs . . . . . . . 39

chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 46chloramphenicol sodium succinate . . 19chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 44chloroquine phosphate . . . . . . . . . . . . . 32chlorothiazide . . . . . . . . . . . . . . . . . . . . . 42chlorothiazide sodium . . . . . . . . . . . . . . 42chlorpromazine hcl . . . . . . . . . . . . . . . . 33chlorthalidone . . . . . . . . . . . . . . . . . . . . . 42cholestyramine . . . . . . . . . . . . . . . . . . . . 43cholestyramine light . . . . . . . . . . . . . . . 43ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ciclopirox nail lacquer . . . . . . . . . . . . . . 26ciclopirox olamine . . . . . . . . . . . . . . . . . 26ciclopirox sham . . . . . . . . . . . . . . . . . . . 26ciclopirox susp . . . . . . . . . . . . . . . . . . . . 26cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 34cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 39CILOXAN OINT . . . . . . . . . . . . . . . . . . . 22CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 35CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 53CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 22ciprofloxacin hcl tabs 100mg . . . . . . . 22ciprofloxacin hcl tabs 750mg . . . . . . . 22ciprofloxacin hydrochloride . . . . . . . . . 22ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 22ciprofloxacin susr . . . . . . . . . . . . . . . . . 22CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 22cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml . . . . . . . . . . 29citalopram hydrobromide oral soln . . 25citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 25citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 25citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 25cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 28claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 44clarithromycin . . . . . . . . . . . . . . . . . . . . . 22

65


Covered Drugs Index

desvenlafaxine er . . . . . . . . . . . . . . . . . . 25dexamethasone . . . . . . . . . . . . . . . . . . . 49dexamethasone intensol . . . . . . . . . . . 49dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 49dexamethasone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 57dexmethylphenidate hcl tabs 10mg . 44dexmethylphenidate hydrochloride tabs 2.5mg, 5mg . . . . . . . . . . . . . . . . . . 44dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 29dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 43dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 43dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 43dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 43dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 43dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 43dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 45dextrose 2.5%/nacl 0.45% . . . . . . . . . 45DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 45dextrose5% /electrolyte #48 viaflex . . 45dextrose 5%/lactated ringers . . . . . . . 45dextrose 5%/nacl 0.2% . . . . . . . . . . . . 45DEXTROSE 5%/NACL 0.3% . . . . . . . 45dextrose 5%/nacl 0.9% . . . . . . . . . . . . 45dextrose 5%/nacl 0.33% . . . . . . . . . . . 45dextrose 5%/nacl 0.45% . . . . . . . . . . . 45dextrose 5%/nacl 0.225% . . . . . . . . . . 45DEXTROSE 10% . . . . . . . . . . . . . . . . . . 45dextrose 10%/nacl 0.2% . . . . . . . . . . . 45dextrose10%/nacl 0.45% . . . . . . . . . . . 45DEXTROSE 20% . . . . . . . . . . . . . . . . . . 45DEXTROSE 25% . . . . . . . . . . . . . . . . . . 45DEXTROSE 30% . . . . . . . . . . . . . . . . . . 45DEXTROSE 40% . . . . . . . . . . . . . . . . . . 45

DAPTOMYCIN INJ 350MG . . . . . . . . . 20daptomycin inj 500mg . . . . . . . . . . . . . . 20DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 32darifenacin hydrobromide er . . . . . . . . 48DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 32dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 51dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 51daunorubicin hcl . . . . . . . . . . . . . . . . . . . 29daunorubicin hydrochloride inj 20mg/4ml . . . . . . . . . . . . . . . . . . . . . . 29DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML . . . . . . . . . . . . . . . . . . . 29DAURISMO TABS 25MG . . . . . . . . . . 29DAURISMO TABS 100MG . . . . . . . . . 29daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 52decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 29DELESTROGEN INJ 10MG/ML . . . . 51DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 35delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 42DEPEN TITRATABS . . . . . . . . . . . . . . . 46DEPO-ESTRADIOL . . . . . . . . . . . . . . . 51DEPO-MEDROL INJ 20MG/ML . . . . . 49DEPO-PROVERA . . . . . . . . . . . . . . . . . 52DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 35desipramine hcl . . . . . . . . . . . . . . . . . . . 26desloratadine . . . . . . . . . . . . . . . . . . . . . . 58desmopressin acetate inj . . . . . . . . . . 50desmopressin acetate nasal soln . . 50desmopressin acetate tabs . . . . . . . . 50desogestrel/ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 51desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg . . . . . . . . . . . . . . . 51desonide lotn . . . . . . . . . . . . . . . . . . . . . 49desonide oint . . . . . . . . . . . . . . . . . . . . . 49desoximetasone crea . . . . . . . . . . . . . 49desoximetasone gel . . . . . . . . . . . . . . . 49desoximetasone oint . . . . . . . . . . . . . . 49

COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 38CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 48CRIXIVAN CAPS 200MG . . . . . . . . . . 36CRIXIVAN CAPS 400MG . . . . . . . . . . 36cromolyn sodium conc . . . . . . . . . . . . 47cromolyn sodium nebu . . . . . . . . . . . . 59cromolyn sodium ophthalmic soln . . . 57cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 50CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 46CURITY GAUZE PADS 2”X2” . . . . . . 44cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 50cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 51cyclobenzaprine hydrochloride tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 59cyclophosphamide caps . . . . . . . . . . . 28cyclophosphamide inj . . . . . . . . . . . . . 28cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 27cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 53cyclosporine modified . . . . . . . . . . . . . . 54CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 32cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 51CYSTADANE . . . . . . . . . . . . . . . . . . . . . 48CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 48CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 56cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 28cytarabine aqueous . . . . . . . . . . . . . . . . 28

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 28dactinomycin . . . . . . . . . . . . . . . . . . . . . . 29dalfampridine er . . . . . . . . . . . . . . . . . . . 44DALIRESP TABS 250MCG . . . . . . . . . 59DALIRESP TABS 500MCG . . . . . . . . . 59danazol caps 50mg . . . . . . . . . . . . . . . . 50danazol caps 100mg, 200mg . . . . . . . 50dantrolene sodium caps . . . . . . . . . . . 34dapsone tabs . . . . . . . . . . . . . . . . . . . . . 27DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 55

66


Covered Drugs Index

doxorubicin hydrochloride liposomal . . . . . . . . . . . . . . . . . . . . . . . . . 29doxorubicin hydrochloride liposome . . . . . . . . . . . . . . . . . . . . . . . . . . 29doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 22doxycycline hyclate caps . . . . . . . . . . 22doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 22doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 22doxycycline monohydrate tabs . . . . . 22doxycycline susr . . . . . . . . . . . . . . . . . . 22dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 26DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 28DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 52duloxetine hcl cpep 20mg . . . . . . . . . . 25duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 25duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 25DURAMORPH . . . . . . . . . . . . . . . . . . . . 17DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 57dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 48dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 48

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 26EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 39EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 39ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 47EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 35efavirenz caps 50mg . . . . . . . . . . . . . . . 35efavirenz caps 200mg . . . . . . . . . . . . . 35efavirenz tabs . . . . . . . . . . . . . . . . . . . . 35ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 48ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 53ELIGARD INJ 22.5MG . . . . . . . . . . . . . 53ELIGARD INJ 30MG . . . . . . . . . . . . . . . 53ELIGARD INJ 45MG . . . . . . . . . . . . . . . 53elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

diltiazem hcl er cp12 . . . . . . . . . . . . . . 41diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg . . . . . 41diltiazem hcl er tb24 . . . . . . . . . . . . . . . 41diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 41diltiazem hcl tabs . . . . . . . . . . . . . . . . . 41diltiazem hydrochloride er cp24 120mg, 180mg, 240mg, 300mg . . . . . 41dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41diphenhydramine hcl inj . . . . . . . . . . . 58diphenhydramine hydrochloride inj . . . 58diphenoxylate/atropine . . . . . . . . . . . . . 47DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 55dipyridamole tabs . . . . . . . . . . . . . . . . . 39disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 19divalproex sodium . . . . . . . . . . . . . . . . . 23divalproex sodium dr . . . . . . . . . . . . . . . 23divalproex sodium er . . . . . . . . . . . . . . . 23docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 29DOCETAXEL INJ 200MG/10ML . . . . 29dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 40donepezil hcl tabs 10mg . . . . . . . . . . . 24donepezil hcl tbdp 5mg . . . . . . . . . . . . 24donepezil hcl tbdp 10mg . . . . . . . . . . . 24donepezil hydrochloride tabs 5mg . . 24donepezil hydrochloride tabs 10mg . . 24dorzolamide hcl . . . . . . . . . . . . . . . . . . . 57dorzolamide hcl/timolol maleate . . . . 57dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 35doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 39doxazosin mesylate tabs 8mg . . . . . . 39doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 36doxepin hydrochloride caps 25mg . . 36doxercalciferol caps 0.5mcg . . . . . . . . 55doxercalciferol caps 1mcg . . . . . . . . . . 55doxercalciferol caps 2.5mcg . . . . . . . . 55

DEXTROSE 50% . . . . . . . . . . . . . . . . . . 45DEXTROSE 70% . . . . . . . . . . . . . . . . . . 45DIACOMIT CAPS 250MG . . . . . . . . . . 23DIACOMIT CAPS 500MG . . . . . . . . . . 23DIACOMIT PACK 250MG . . . . . . . . . . 23DIACOMIT PACK 500MG . . . . . . . . . . 23DIASTAT ACUDIAL GEL 10MG . . . . . 23DIASTAT ACUDIAL GEL 20MG . . . . . 23DIASTAT PEDIATRIC . . . . . . . . . . . . . . 23diazepam inj 5mg/ml . . . . . . . . . . . . . . . 36diazepam oral soln . . . . . . . . . . . . . . . . 36diazepam rectal gel gel 2.5mg . . . . . . 23diazepam rectal gel gel 10mg . . . . . . 23diazepam rectal gel gel 20mg . . . . . . 23diazepam tabs . . . . . . . . . . . . . . . . . . . . 36diclofenac potassium . . . . . . . . . . . . . . 17diclofenac sodium dr . . . . . . . . . . . . . . . 17diclofenac sodium er . . . . . . . . . . . . . . . 17diclofenac sodium gel 1% . . . . . . . . . . 44diclofenac sodium ophthalmic soln . . 57diclofenac sodium transdermal soln . . 44dicloxacillin sodium . . . . . . . . . . . . . . . . 21dicyclomine hcl oral soln . . . . . . . . . . . 47dicyclomine hydrochloride caps . . . . 47dicyclomine hydrochloride tabs . . . . 47didanosine . . . . . . . . . . . . . . . . . . . . . . . . 35diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 17digitek tabs 0.25mg . . . . . . . . . . . . . . . . 42digitek tabs 0.125mg . . . . . . . . . . . . . . . 42digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 42digoxin tabs 125mcg . . . . . . . . . . . . . . . 42digoxin tabs 250mcg . . . . . . . . . . . . . . . 42digox tabs 125mcg . . . . . . . . . . . . . . . . 42digox tabs 250mcg . . . . . . . . . . . . . . . . 42dihydroergotamine mesylate inj . . . . 27dihydroergotamine mesylate nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 27DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 24DILANTIN INFATABS . . . . . . . . . . . . . . 24diltiazem cd cp24 180mg . . . . . . . . . . . 41

67


Covered Drugs Index

esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 17estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 51estradiol crea . . . . . . . . . . . . . . . . . . . . . 51estradiol pttw . . . . . . . . . . . . . . . . . . . . . 51estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 51estradiol tabs 0.5mg, 1mg, 2mg . . . . 51estradiol tabs 10mcg . . . . . . . . . . . . . . . 51estradiol valerate . . . . . . . . . . . . . . . . . . 51ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 51ethacrynate sodium . . . . . . . . . . . . . . . . 42ethambutol hcl . . . . . . . . . . . . . . . . . . . . 27ethambutol hydrochloride . . . . . . . . . . 27ethosuximide . . . . . . . . . . . . . . . . . . . . . . 23ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 51ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 29etidronate disodium . . . . . . . . . . . . . . . . 55etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 17etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 17etoposide inj . . . . . . . . . . . . . . . . . . . . . . 30EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 28EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 36exemestane . . . . . . . . . . . . . . . . . . . . . . . 30ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 43ezetimibe/simvastatin . . . . . . . . . . . . . . 43

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 48falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 36famotidine inj . . . . . . . . . . . . . . . . . . . . . 47famotidine premixed . . . . . . . . . . . . . . . 47famotidine tabs 20mg, 40mg . . . . . . . 47FANAPT TABS 1MG, 2MG, 4MG . . . 33FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 33FANAPT TITRATION PACK . . . . . . . . 33FARESTON . . . . . . . . . . . . . . . . . . . . . . . 28FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 37FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 31

epinephrine auto-injector 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . . . . . . . . . . . . . . . . 58epinephrine hcl inj 1mg/10ml . . . . . . . 58EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 58EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 58epirubicin hcl inj 200mg/100ml . . . . . 29epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EPIVIR HBV ORAL SOLN . . . . . . . . . 34ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 32ergotamine tartrate/caffeine . . . . . . . . 27ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 31ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 28erlotinib hydrochloride tabs 25mg . . . 31erlotinib hydrochloride tabs 100mg, 150mg . . . . . . . . . . . . . . . . . . . . 31errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 21ertapenem sodium . . . . . . . . . . . . . . . . . 21ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 29ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 22ERYTHROCIN LACTOBIONATE . . . 22erythrocin stearate . . . . . . . . . . . . . . . . . 22erythromycin base . . . . . . . . . . . . . . . . . 22erythromycin/benzoyl peroxide . . . . . 44ERYTHROMYCIN DR . . . . . . . . . . . . . 22erythromycin ethylsuccinate susr 200mg/5ml . . . . . . . . . . . . . . . . . . . 22erythromycin ethylsuccinate tabs . . . 22erythromycin external soln . . . . . . . . . 22erythromycin gel . . . . . . . . . . . . . . . . . . 22erythromycin oint . . . . . . . . . . . . . . . . . 22ESBRIET CAPS . . . . . . . . . . . . . . . . . . 59ESBRIET TABS 267MG . . . . . . . . . . . . 59ESBRIET TABS 801MG . . . . . . . . . . . . 59escitalopram oxalate oral soln . . . . . 25escitalopram oxalate tabs 5mg . . . . . 25escitalopram oxalate tabs 10mg . . . . 25escitalopram oxalate tabs 20mg . . . . 25

ELIQUIS STARTER PACK . . . . . . . . . 38ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 38ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 38ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 49ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 29EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 28EMEND SUSR . . . . . . . . . . . . . . . . . . . . 26emoquette . . . . . . . . . . . . . . . . . . . . . . . . 51EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 32EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 25EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 35EMTRIVA ORAL SOLN . . . . . . . . . . . . 35enalapril maleate . . . . . . . . . . . . . . . . . . 40enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 40ENBREL INJ 25MG/0.5ML . . . . . . . . . 54ENBREL INJ 25MG, 50MG/ML . . . . . 54ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 54ENBREL SURECLICK . . . . . . . . . . . . . 54endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 18endocet tabs 325mg; 7.5mg . . . . . . . . 17endocet tabs 325mg; 10mg . . . . . . . . 17ENGERIX-B INJ 10MCG/0.5ML . . . . 55ENGERIX-B INJ 20MCG/ML . . . . . . . 55enoxaparin sodium . . . . . . . . . . . . . . . . 38enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 51enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 51entacapone . . . . . . . . . . . . . . . . . . . . . . . 33entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 34ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 40enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 54ENVARSUS XR TB24 4MG . . . . . . . . 54EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 34EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 23epinastine hcl . . . . . . . . . . . . . . . . . . . . . 57

68


Covered Drugs Index

flurbiprofen sodium . . . . . . . . . . . . . . . . 57flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 28fluticasone propionate crea . . . . . . . . 49fluticasone propionate oint . . . . . . . . . 49fluticasone propionate susp . . . . . . . . 58fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 25fluvoxamine maleate tabs 100mg . . . 25FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 38fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 38fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 38fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 38FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 55fosamprenavir calcium . . . . . . . . . . . . . 36fosinopril sodium . . . . . . . . . . . . . . . . . . 40fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 40fosphenytoin sodium . . . . . . . . . . . . . . . 24FREAMINE HBC 6.9% . . . . . . . . . . . . . 45FREAMINE 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 . . . . . 46fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 28furosemide inj . . . . . . . . . . . . . . . . . . . . 42furosemide oral soln . . . . . . . . . . . . . . 42furosemide tabs . . . . . . . . . . . . . . . . . . . 42FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 29FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 35fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 51FYCOMPA SUSP . . . . . . . . . . . . . . . . . 23

FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 58FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 58fluconazole in nacl . . . . . . . . . . . . . . . . . 26fluconazole susr . . . . . . . . . . . . . . . . . . 26fluconazole tabs . . . . . . . . . . . . . . . . . . 26flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 26fludarabine phosphate inj 50mg . . . . 29fludrocortisone acetate . . . . . . . . . . . . . 49flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 58fluocinolone acetonide . . . . . . . . . . . . . 49fluocinolone acetonide . . . . . . . . . . . . . 57fluocinolone acetonide body . . . . . . . . 49fluocinolone acetonide ear drops . . . 57fluocinolone acetonide scalp . . . . . . . 49fluocinonide crea 0.05% . . . . . . . . . . . 49fluocinonide external soln . . . . . . . . . . 49fluocinonide gel . . . . . . . . . . . . . . . . . . . 49fluocinonide oint . . . . . . . . . . . . . . . . . . 49fluoride chew 0.25mg . . . . . . . . . . . . . . 45fluoritab chew 0.5mg, 1mg . . . . . . . . . 45fluorometholone . . . . . . . . . . . . . . . . . . . 57fluorouracil crea 0.5% . . . . . . . . . . . . . . 45fluorouracil crea 5% . . . . . . . . . . . . . . . 44fluorouracil external soln . . . . . . . . . . . 45fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 28fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 25fluoxetine hcl caps 20mg . . . . . . . . . . . 25fluoxetine hcl caps 40mg . . . . . . . . . . . 25fluoxetine hydrochloride caps 10mg . 25fluoxetine hydrochloride oral soln . . 25fluoxetine hydrochloride tabs 10mg . 25fluoxetine hydrochloride tabs 20mg . 25fluphenazine decanoate . . . . . . . . . . . . 33fluphenazine hcl conc . . . . . . . . . . . . . 33fluphenazine hcl inj . . . . . . . . . . . . . . . . 33fluphenazine hcl tabs . . . . . . . . . . . . . . 33fluphenazine hydrochloride . . . . . . . . . 33flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 17

FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 28febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 27felbamate susp . . . . . . . . . . . . . . . . . . . 24felbamate tabs . . . . . . . . . . . . . . . . . . . . 24felodipine er . . . . . . . . . . . . . . . . . . . . . . . 41femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 51fenofibrate caps 43mg, 50mg . . . . . . . 42fenofibrate caps 67mg . . . . . . . . . . . . . 42fenofibrate caps 130mg, 150mg . . . . 42fenofibrate caps 134mg, 200mg . . . . 42fenofibrate micronized caps 67mg . . 42fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 42fenofibrate tabs 48mg . . . . . . . . . . . . . . 42fenofibrate tabs 145mg, 160mg . . . . . 42fenofibric acid dr cpdr 45mg . . . . . . . . 42fenofibric acid dr cpdr 135mg . . . . . . . 42fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 17fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 18fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 18fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 18FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 25FETZIMA TITRATION PACK . . . . . . . 25finasteride tabs 5mg . . . . . . . . . . . . . . . 48FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 53FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 56FIRMAGON INJ 80MG . . . . . . . . . . . . . 53FIRMAGON INJ 120MG . . . . . . . . . . . 53FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 20flac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57flecainide acetate . . . . . . . . . . . . . . . . . . 40FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 58FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 58FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 58

69


Covered Drugs Index

granisetron hcl tabs . . . . . . . . . . . . . . . 26granisetron hydrochloride . . . . . . . . . . 26griseofulvin microsize . . . . . . . . . . . . . . 26griseofulvin ultramicrosize . . . . . . . . . . 26GUANIDINE HCL . . . . . . . . . . . . . . . . . . 27

Hhailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 51HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 29halobetasol propionate crea . . . . . . . 49halobetasol propionate oint . . . . . . . . 49haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 33haloperidol decanoate . . . . . . . . . . . . . 33haloperidol lactate . . . . . . . . . . . . . . . . . 33HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 34HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 55heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 52heparin sodium/d5w . . . . . . . . . . . . . . . 38heparin sodium/dextrose . . . . . . . . . . . 38heparin sodium inj 5000unit/0.5ml . . 38heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml . . . . . . . . . . 38heparin sodium/nacl 0.9% . . . . . . . . . . 38heparin sodium/nacl 0.45% inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 38heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 38heparin sodium/sodium chloride 0.9% premix inj 1000unit/500ml; 0.9% . . . . . . . . . . . . . . 38heparin sodium/sodium chloride inj 25000unit/250ml; 0.45%, 25000unit/500ml; 0.45% . . . . . . . . . . . 38HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 46HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 55HERCEPTIN HYLECTA . . . . . . . . . . . . 32HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 44HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 55HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 38

GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 50gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 19gentamicin sulfate crea . . . . . . . . . . . . 19gentamicin sulfate inj . . . . . . . . . . . . . . 19gentamicin sulfate oint . . . . . . . . . . . . 19gentamicin sulfate ophthalmic soln . . 19gentamicin sulfate pediatric . . . . . . . . 19GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 35GEODON INJ . . . . . . . . . . . . . . . . . . . . 33GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 44GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 31GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 28glimepiride tabs 1mg . . . . . . . . . . . . . . . 37glimepiride tabs 2mg . . . . . . . . . . . . . . . 37glimepiride tabs 4mg . . . . . . . . . . . . . . . 37glipizide er tb24 2.5mg . . . . . . . . . . . . . 37glipizide er tb24 5mg . . . . . . . . . . . . . . . 37glipizide er tb24 10mg . . . . . . . . . . . . . 37glipizide/metformin hydrochloride tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . 37glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg . . . 37glipizide tabs 5mg . . . . . . . . . . . . . . . . . 37glipizide tabs 10mg . . . . . . . . . . . . . . . . 37glipizide xl tb24 2.5mg . . . . . . . . . . . . . 37glipizide xl tb24 5mg . . . . . . . . . . . . . . . 37glipizide xl tb24 10mg . . . . . . . . . . . . . . 37GLUCAGEN HYPOKIT . . . . . . . . . . . . 38GLUCAGON EMERGENCY KIT . . . . 38glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 47glycopyrrolate tabs 1mg, 2mg . . . . . . 47glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 37GRALISE . . . . . . . . . . . . . . . . . . . . . . . . . 24GRALISE STARTER . . . . . . . . . . . . . . . 24granisetron hcl inj 1mg/ml . . . . . . . . . . 26

FYCOMPA TABS . . . . . . . . . . . . . . . . . 23

Ggabapentin caps 100mg . . . . . . . . . . . 23gabapentin caps 300mg, 400mg . . . . 24gabapentin oral soln . . . . . . . . . . . . . . 24gabapentin tabs 600mg . . . . . . . . . . . . 24gabapentin tabs 800mg . . . . . . . . . . . . 24GABITRIL TABS 12MG, 16MG . . . . . 24galantamine hydrobromide er . . . . . . 24galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 24galantamine hydrobromide tabs . . . . 24GAMMAKED INJ 1GM/10ML . . . . . . . 54GAMMAKED INJ 10GM/100ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 54GAMUNEX-C INJ 1GM/10ML . . . . . . 54GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 54ganciclovir inj 500mg, 500mg/10ml . . 34GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 55GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 47gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 48gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 48gavilyte-n/flavor pack . . . . . . . . . . . . . . 48GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 32gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 29gemcitabine hcl . . . . . . . . . . . . . . . . . . . . 29gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 29gemcitabine hydrochloride inj 1gm, 1gm/26.3ml, 200mg/5.26ml, 2gm/52.6ml . . . . . . . . . . . . . . . . . . . . . . . 29gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 42generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 48gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 54GENOTROPIN . . . . . . . . . . . . . . . . . . . . 50GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 50

70


Covered Drugs Index

ibuprofen susp . . . . . . . . . . . . . . . . . . . . 17ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 17ibu tabs 600mg, 800mg . . . . . . . . . . . . 17icatibant acetate . . . . . . . . . . . . . . . . . . . 53ICLUSIG TABS 15MG . . . . . . . . . . . . . 31ICLUSIG TABS 45MG . . . . . . . . . . . . . 31idarubicin hcl inj 10mg/10ml . . . . . . . . 29idarubicin hydrochloride inj 10mg/10ml . . . . . . . . . . . . . . . . . . . . . 29IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 28ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 57imatinib mesylate . . . . . . . . . . . . . . . . . . 31IMBRUVICA CAPS 70MG . . . . . . . . . . 31IMBRUVICA CAPS 140MG. . . . . . . . . 31IMBRUVICA TABS . . . . . . . . . . . . . . . . 31IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 32imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 21imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 21imipramine hcl tabs 25mg, 50mg . . . 26imipramine hydrochloride . . . . . . . . . . 26imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 45IMOVAX RABIES (H.D.C.V.) . . . . . . . 55incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 52INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 50INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 58indapamide . . . . . . . . . . . . . . . . . . . . . . . 42INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 55INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 29INFUMORPH 200 . . . . . . . . . . . . . . . . . 17INFUMORPH 500 . . . . . . . . . . . . . . . . . 17INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 31INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 29INTELENCE TABS 25MG . . . . . . . . . . 35INTELENCE TABS 100MG, 200MG . 35INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 56INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 34

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . 18hydrocodone bitartrate/ acetaminophen oral soln 325mg/15ml; 7.5mg/15ml . . . . . . . . . . 18hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg . . 18hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . 18hydrocodone/ibuprofen . . . . . . . . . . . . 18hydrocortisone/acetic acid . . . . . . . . . . 57hydrocortisone butyrate crea . . . . . . . 49hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 49hydrocortisone butyrate (lipid) . . . . . . 49hydrocortisone butyrate (lipophilic) . . 49hydrocortisone butyrate oint . . . . . . . 49hydrocortisone enem . . . . . . . . . . . . . . 55hydrocortisone external crea . . . . . . . 49hydrocortisone lotn 2.5% . . . . . . . . . . . 49hydrocortisone oint 1%, 2.5% . . . . . . 49hydrocortisone rectal crea . . . . . . . . . 49hydrocortisone tabs . . . . . . . . . . . . . . . 49hydrocortisone valerate . . . . . . . . . . . . 49hydromorphone hcl dosette . . . . . . . . 18hydromorphone hcl inj . . . . . . . . . . . . . 18hydromorphone hcl liqd . . . . . . . . . . . 18hydromorphone hcl tabs 2mg, 4mg . . 18hydromorphone hcl tabs 8mg . . . . . . . 18hydroxychloroquine sulfate . . . . . . . . . 32hydroxyprogesterone caproate . . . . . 52hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 29hyoscyamine sulfate elix . . . . . . . . . . . 47hyoscyamine sulfate subl . . . . . . . . . . 47hyoscyamine sulfate tabs . . . . . . . . . . 47hyoscyamine sulfate tbdp . . . . . . . . . . 47

Iibandronate sodium tabs . . . . . . . . . . 56IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 31

HUMALOG JUNIOR KWIKPEN . . . . 38HUMALOG KWIKPEN . . . . . . . . . . . . . 38HUMALOG MIX 50/50 . . . . . . . . . . . . . 38HUMALOG MIX 50/50 KWIKPEN . . . 38HUMALOG MIX 75/25 . . . . . . . . . . . . . 38HUMALOG MIX 75/25 KWIKPEN . . . 38HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 54HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 54HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML (3 AND 6 PACK), 80MG/0.8ML (3 PACK) . . . . . . . . . . . . . 54HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML AND 80MG/0.8ML (1 PEN OF EACH) . . . . . . . . . . . . . . . . . 54HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 54HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 54HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 54HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 54HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 54HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 38HUMULIN 70/30 KWIKPEN . . . . . . . . 38HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 38HUMULIN N KWIKPEN . . . . . . . . . . . . 38HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 38HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 38HUMULIN R U-500 KWIKPEN. . . . . . 38hydralazine hcl inj . . . . . . . . . . . . . . . . . 43hydralazine hcl tabs . . . . . . . . . . . . . . . 43hydralazine hydrochloride tabs 100mg, 25mg, 50mg . . . . . . . . . . 43hydrochlorothiazide . . . . . . . . . . . . . . . . 42hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . 18

71


Covered Drugs Index

juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 35junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 51junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 51junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 51junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 51

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 46KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 32KALETRA TABS 100MG; 25MG . . . . 36KALETRA TABS 200MG; 50MG . . . . 36KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 58KANJINTI INJ 420MG . . . . . . . . . . . . . 32kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 46KCL 0.3%/D5W/NACL 0.45% . . . . . . 46KCL 0.15%/D5W/NACL 0.2% . . . . . . 46KCL 0.15%/D5W/NACL 0.9% . . . . . . 46KCL 0.15%/D5W/NACL 0.45% . . . . . 46KCL 0.15%/D5W/NACL 0.225% . . . . 46KCL 0.075%/D5W/NACL 0.45% . . . . 46kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 51kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 51ketoconazole crea . . . . . . . . . . . . . . . . 26ketoconazole sham . . . . . . . . . . . . . . . 26ketoconazole tabs . . . . . . . . . . . . . . . . . 26ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 57KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 32KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 55kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 30KISQALI FEMARA 200 DOSE . . . . . . 28KISQALI FEMARA 400 DOSE . . . . . . 28KISQALI FEMARA 600 DOSE . . . . . . 28klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 46KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 46KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 46

ISENTRESS HD . . . . . . . . . . . . . . . . . . . 35ISENTRESS PACK . . . . . . . . . . . . . . . 35ISENTRESS TABS . . . . . . . . . . . . . . . . 35isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 51isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 27isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 27isoniazid tabs . . . . . . . . . . . . . . . . . . . . . 28isosorbide dinitrate er . . . . . . . . . . . . . . 43isosorbide dinitrate tabs . . . . . . . . . . . 43isosorbide mononitrate . . . . . . . . . . . . . 43isosorbide mononitrate er . . . . . . . . . . 43isotonic gentamicin . . . . . . . . . . . . . . . . 19isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 45isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 41ISTODAX (OVERFILL) . . . . . . . . . . . . . 30itraconazole caps . . . . . . . . . . . . . . . . . 26itraconazole oral soln . . . . . . . . . . . . . . 26ivermectin tabs . . . . . . . . . . . . . . . . . . . 32IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 47JADENU SPRINKLE . . . . . . . . . . . . . . . 47JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 31jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 38JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 37JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 37JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 37JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 37JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 37jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 52JENTADUETO . . . . . . . . . . . . . . . . . . . . 37JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 37JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 37JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 30jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

INTRON A INJ 6000000UNIT/ML . . . 34introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 51INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 21INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 33INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 33INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 33INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 33INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 33INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 34INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 34INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 34INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 34INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 57INVIRASE . . . . . . . . . . . . . . . . . . . . . . . . 36INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 37INVOKAMET XR . . . . . . . . . . . . . . . . . . 37INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 37IPOL INACTIVATED IPV . . . . . . . . . . . 55ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 58ipratropium bromide inhalation soln . . 58ipratropium bromide nasal soln . . . . 58irbesartan/hydrochlorothiazide . . . . . . 40irbesartan tabs 150mg, 75mg . . . . . . 40irbesartan tabs 300mg . . . . . . . . . . . . . 40IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 31irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 30irinotecan hydrochloride . . . . . . . . . . . . 30irinotecan hydrochloride . . . . . . . . . . . . 30irinotecan inj 100mg/5ml, 500mg/25ml . . . . . . . . . . . 30ISENTRESS CHEW 25MG . . . . . . . . . 35ISENTRESS CHEW 100MG . . . . . . . 35

72


Covered Drugs Index

levonorgestrel/ethinyl estradiol tabs 0; 0, 20mcg; 0.1mg . . . . . . . . . . . 51levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg . . . . . . . . . . . . . . 51levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 51levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 51levothyroxine sodium tabs . . . . . . . . . 53levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 53LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . . 53LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 36LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 32lidocaine hcl external soln . . . . . . . . . 18lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% . . . . . . . . . . . 18lidocaine hcl inj 100mg/5ml, 50mg/5ml . . . . . . . . . . . . . 40lidocaine hcl jelly gel . . . . . . . . . . . . . . 18lidocaine hcl mouth/throat soln . . . . . 18lidocaine hcl prsy . . . . . . . . . . . . . . . . . 18lidocaine hcl viscous . . . . . . . . . . . . . . . 18lidocaine oint . . . . . . . . . . . . . . . . . . . . . 19lidocaine/prilocaine crea . . . . . . . . . . . 19lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 19lidocaine viscous . . . . . . . . . . . . . . . . . . 19lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 20lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 20linezolid susr . . . . . . . . . . . . . . . . . . . . . 20linezolid tabs . . . . . . . . . . . . . . . . . . . . . 20LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 48liothyronine sodium inj . . . . . . . . . . . . . 53liothyronine sodium tabs . . . . . . . . . . . 53LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 56lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 40lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 40lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 40

LENVIMA 10 MG DAILY DOSE . . . . . 31LENVIMA 12MG DAILY DOSE . . . . . 31LENVIMA 14 MG DAILY DOSE . . . . . 31LENVIMA 18 MG DAILY DOSE . . . . . 31LENVIMA 20 MG DAILY DOSE . . . . . 31LENVIMA 24 MG DAILY DOSE . . . . . 31lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 59letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 30leucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 500mg/50ml, 50mg . . . . . . . . 30leucovorin calcium tabs 5mg . . . . . . . 30leucovorin calcium tabs 10mg, 15mg, 25mg . . . . . . . . . . . . . . . . 30LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 28leuprolide acetate . . . . . . . . . . . . . . . . . 53levalbuterol tartrate hfa . . . . . . . . . . . . 58LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 38LEVEMIR FLEXTOUCH . . . . . . . . . . . 38levetiracetam er tb24 500mg . . . . . . . 23levetiracetam er tb24 750mg . . . . . . . 23levetiracetam inj . . . . . . . . . . . . . . . . . . 23levetiracetam oral soln . . . . . . . . . . . . 23levetiracetam/sodium chloride . . . . . . 23levetiracetam tabs . . . . . . . . . . . . . . . . 23levobunolol hcl . . . . . . . . . . . . . . . . . . . . 57levocarnitine . . . . . . . . . . . . . . . . . . . . . . 56levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 58levocetirizine dihydrochloride tabs . . 58levofloxacin in d5w . . . . . . . . . . . . . . . . 22levofloxacin inj . . . . . . . . . . . . . . . . . . . . 22levofloxacin oral soln . . . . . . . . . . . . . . 22levofloxacin tabs 250mg, 750mg . . . . 22levofloxacin tabs 500mg . . . . . . . . . . . 22levoleucovorin . . . . . . . . . . . . . . . . . . . . . 30levoleucovorin calcium . . . . . . . . . . . . . 30levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 51levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 51

klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 46klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 46klor-con sprinkle . . . . . . . . . . . . . . . . . . . 46KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 56kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 30

Llabetalol hydrochloride inj 5mg/ml . . 41labetalol hydrochloride tabs . . . . . . . . 41LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . 46LACTATED RINGERS IRRIGATION . . 56LACTATED RINGERS VIAFLEX . . . . 46lactulose oral soln . . . . . . . . . . . . . . . . . 48lamivudine oral soln . . . . . . . . . . . . . . . 35lamivudine tabs 100mg . . . . . . . . . . . . 34lamivudine tabs 150mg . . . . . . . . . . . . 35lamivudine tabs 300mg . . . . . . . . . . . . 35lamivudine/zidovudine . . . . . . . . . . . . . 35lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 24lamotrigine er . . . . . . . . . . . . . . . . . . . . . 24lamotrigine odt . . . . . . . . . . . . . . . . . . . . 24LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 38LANTUS SOLOSTAR . . . . . . . . . . . . . . 38larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 51larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 51larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 51larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 51larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 30latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 56LATUDA TABS 80MG . . . . . . . . . . . . . . 34LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 34leflunomide . . . . . . . . . . . . . . . . . . . . . . . 54LENVIMA 4 MG DAILY DOSE . . . . . . 31LENVIMA 8 MG DAILY DOSE . . . . . . 31

73


Covered Drugs Index

melphalan hydrochloride . . . . . . . . . . . 28memantine hcl tabs 5mg . . . . . . . . . . . 24memantine hcl tabs 10mg . . . . . . . . . . 24memantine hcl titration pak . . . . . . . . . 24memantine hydrochloride er . . . . . . . . 24memantine hydrochloride oral soln . . 24MENACTRA . . . . . . . . . . . . . . . . . . . . . . 55MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 51MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 55mercaptopurine . . . . . . . . . . . . . . . . . . . . 29meropenem . . . . . . . . . . . . . . . . . . . . . . . 21meropenem/sodium chloride . . . . . . . 21mesalamine dr tbec 1.2gm . . . . . . . . . 55mesalamine enem . . . . . . . . . . . . . . . . 55mesalamine kit . . . . . . . . . . . . . . . . . . . . 55mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30MESNEX TABS . . . . . . . . . . . . . . . . . . . 30metadate er . . . . . . . . . . . . . . . . . . . . . . . 44metaproterenol sulfate . . . . . . . . . . . . . 58metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 37metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 37metformin hcl er tb24 1000mg, 500mg (generic for Fortamet) . . . . . . 37metformin hydrochloride oral soln . . . 37metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 37metformin hydrochloride tabs 850mg . . . . . . . . . . . . . . . . . . . . . . . 37metformin hydrochloride tabs 1000mg . . . . . . . . . . . . . . . . . . . . . . 37methadone hcl conc . . . . . . . . . . . . . . . 17methadone hcl inj . . . . . . . . . . . . . . . . . 17methadone hcl intensol . . . . . . . . . . . . 17methadone hcl oral soln 5mg/5ml . . . 17methadone hcl oral soln 10mg/5ml . . 17methadone hcl tabs 5mg . . . . . . . . . . . 17methadone hcl tabs 10mg . . . . . . . . . . 17methazolamide . . . . . . . . . . . . . . . . . . . . 42methenamine hippurate . . . . . . . . . . . . 20

LUPRON DEPOT (6-MONTH) . . . . . . 53LUPRON DEPOT-PED (1-MONTH) . . 53LUPRON DEPOT-PED (3-MONTH) . . 53lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 30LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 23LYRICA CAPS 225MG, 300MG . . . . . 23LYRICA CR TB24 165MG, 82.5MG . . 44LYRICA CR TB24 330MG . . . . . . . . . . 44LYRICA ORAL SOLN . . . . . . . . . . . . . . 23LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 53lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Mmagnesium sulfate in d5w . . . . . . . . . . 23MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML . . . . . . . . . . . . . . . . . . . . 46magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 46MAKENA INJ 275MG/1.1ML . . . . . . . 52malathion . . . . . . . . . . . . . . . . . . . . . . . . . 32maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 25marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 51MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 25MATULANE . . . . . . . . . . . . . . . . . . . . . . . 28matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 41meclizine hcl tabs . . . . . . . . . . . . . . . . . 26medroxyprogesterone acetate inj . . 52medroxyprogesterone acetate tabs . . 52mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 32megestrol acetate susp 40mg/ml . . . 52megestrol acetate tabs . . . . . . . . . . . . 52MEKINIST TABS 0.5MG . . . . . . . . . . . 31MEKINIST TABS 2MG . . . . . . . . . . . . . 31MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 30melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 51meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 17

lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 37lithium carbonate caps 300mg . . . . . . 36lithium carbonate er . . . . . . . . . . . . . . . . 37lithium carbonate tabs . . . . . . . . . . . . . 37LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 42LONSURF TABS 6.14MG; 15MG . . . 29LONSURF TABS 8.19MG; 20MG . . . 29loperamide hcl caps . . . . . . . . . . . . . . . 47lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 36lorazepam conc . . . . . . . . . . . . . . . . . . . 36lorazepam inj 2mg/ml, 4mg/ml . . . . . . 36lorazepam intensol . . . . . . . . . . . . . . . . 36lorazepam tabs 0.5mg, 1mg . . . . . . . . 36lorazepam tabs 2mg . . . . . . . . . . . . . . . 36LORBRENA TABS 25MG . . . . . . . . . . 30LORBRENA TABS 100MG . . . . . . . . . 30lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 18lorcet plus tabs 325mg; 7.5mg . . . . . . 18losartan potassium . . . . . . . . . . . . . . . . 40losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 40losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 40LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 57LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 57lovastatin tabs 10mg, 20mg . . . . . . . . 42lovastatin tabs 40mg . . . . . . . . . . . . . . . 42low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 51loxapine . . . . . . . . . . . . . . . . . . . . . . . . . . 33loxapine succinate . . . . . . . . . . . . . . . . . 33ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 56LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 48LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 32LUPRON DEPOT (1-MONTH) . . . . . . 53LUPRON DEPOT (3-MONTH) . . . . . . 53LUPRON DEPOT (4-MONTH) . . . . . . 53

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Covered Drugs Index

morphine sulfate er tbcr . . . . . . . . . . . 17morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 18morphine sulfate inj 1mg/ml, 50mg/ml . . . . . . . . . . . . . . . . . . 18MORPHINE SULFATE INJ 2MG/ML . . 18MORPHINE SULFATE INJ 4MG/ML . . 18MORPHINE SULFATE INJ 5MG/ML . . 18MORPHINE SULFATE INJ 8MG/ML . . 18MORPHINE SULFATE INJ 10MG/ML . 18morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 18morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 18morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 18MORPHINE SULFATE TABS . . . . . . 18MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 48moxifloxacin hcl . . . . . . . . . . . . . . . . . . . 22moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 22moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 22moxifloxacin hydrochloride tabs . . . . 22MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 39MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 40multivitamin with fluoride chew . . . . . 47mupirocin crea . . . . . . . . . . . . . . . . . . . . 20mupirocin oint . . . . . . . . . . . . . . . . . . . . 20MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32mycophenolate mofetil caps . . . . . . . 54mycophenolate mofetil inj . . . . . . . . . . 54mycophenolate mofetil susr . . . . . . . . 54mycophenolate mofetil tabs . . . . . . . . 54mycophenolic acid dr . . . . . . . . . . . . . . 54MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 32myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 45MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 48

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 17

metronidazole vaginal . . . . . . . . . . . . . . 20mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 40MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 56mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 51microgestin 1.5/30 . . . . . . . . . . . . . . . . . 51microgestin 1/20 . . . . . . . . . . . . . . . . . . . 51microgestin fe . . . . . . . . . . . . . . . . . . . . . 51microgestin fe 1.5/30 . . . . . . . . . . . . . . 51midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 39miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 48mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 43minocycline hcl caps . . . . . . . . . . . . . . 22minocycline hcl tabs . . . . . . . . . . . . . . . 22minocycline hydrochloride caps 100mg, 50mg . . . . . . . . . . . . . . . . 22minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 43mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 25mirtazapine odt . . . . . . . . . . . . . . . . . . . . 25misoprostol . . . . . . . . . . . . . . . . . . . . . . . 48MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 27mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17mitomycin inj 20mg, 5mg . . . . . . . . . . . 30mitomycin inj 40mg . . . . . . . . . . . . . . . . 30mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 30M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 55moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 40molindone hydrochloride . . . . . . . . . . . 33mometasone furoate crea . . . . . . . . . 50mometasone furoate external soln . . 50mometasone furoate oint . . . . . . . . . . 50mondoxyne nl caps 75mg . . . . . . . . . . 22mondoxyne nl caps 100mg . . . . . . . . . 22mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 52montelukast sodium chew . . . . . . . . . 58montelukast sodium pack . . . . . . . . . . 58montelukast sodium tabs . . . . . . . . . . 58morgidox 1x50mg . . . . . . . . . . . . . . . . . 22morgidox 1x100mg caps . . . . . . . . . . 22morgidox 2x100mg caps . . . . . . . . . . 22

methimazole . . . . . . . . . . . . . . . . . . . . . . 53methocarbamol tabs . . . . . . . . . . . . . . 59methotrexate sodium . . . . . . . . . . . . . . 54methotrexate tabs . . . . . . . . . . . . . . . . . 54methoxsalen . . . . . . . . . . . . . . . . . . . . . . 45methscopolamine bromide . . . . . . . . . 47methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 44methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hydrochloride er tbcr 10mg . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 44methylprednisolone acetate inj 80mg/ml . . . . . . . . . . . . . . . . . . . . . . . 49methylprednisolone dose pack . . . . . 49methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 49methylprednisolone tabs . . . . . . . . . . . 49metoclopramide hcl inj . . . . . . . . . . . . 47metoclopramide hcl oral soln . . . . . . 47metoclopramide hcl tabs . . . . . . . . . . . 47metoclopramide hydrochloride . . . . . . 47metolazone . . . . . . . . . . . . . . . . . . . . . . . 42metoprolol/hydrochlorothiazide . . . . . 41metoprolol succinate er . . . . . . . . . . . . 41metoprolol tartrate inj . . . . . . . . . . . . . . 41metoprolol tartrate tabs . . . . . . . . . . . . 41metronidazole crea . . . . . . . . . . . . . . . . 20metronidazole gel . . . . . . . . . . . . . . . . . 20metronidazole inj 500mg/100ml; 0.79% . . . . . . . . . . . . . . 20metronidazole in nacl 0.79% . . . . . . . 20metronidazole lotn . . . . . . . . . . . . . . . . 20metronidazole tabs . . . . . . . . . . . . . . . . 20

75


Covered Drugs Index

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 52norgestimate/ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 52norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg . . . . . . . . . . . . . . . 52norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 52NORMOSOL-M IN D5W . . . . . . . . . . . 46NORMOSOL -R . . . . . . . . . . . . . . . . . . . 46NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 46NORMOSOL-R IN D5W. . . . . . . . . . . . 46NORTHERA CAPS 100MG . . . . . . . . 42NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 42nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 52nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 52nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 52nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 26nortriptyline hydrochloride . . . . . . . . . . 26NORVIR ORAL SOLN . . . . . . . . . . . . . 36NORVIR PACK . . . . . . . . . . . . . . . . . . . 36NOVOFINE 31 . . . . . . . . . . . . . . . . . . . . 56NOVOFINE 32GX6MM . . . . . . . . . . . . 56NOVOFINE AUTOCOVER 30GX8MM . . . . . . . . . . . . . . . . . . . . . . . . 56NOVOTWIST 32GX5MM . . . . . . . . . . . 56NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 27NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 27NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 28NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 44nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 54NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 34NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 56NUZYRA INJ . . . . . . . . . . . . . . . . . . . . . 22NUZYRA TABS . . . . . . . . . . . . . . . . . . . 23nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 27nystatin crea . . . . . . . . . . . . . . . . . . . . . . 27nystatin oint . . . . . . . . . . . . . . . . . . . . . . 27nystatin powd . . . . . . . . . . . . . . . . . . . . . 27nystatin susp . . . . . . . . . . . . . . . . . . . . . 27

neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 20neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 20NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 46NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 30NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 33nevirapine er tb24 100mg . . . . . . . . . . 35nevirapine er tb24 400mg . . . . . . . . . . 35nevirapine susp . . . . . . . . . . . . . . . . . . . 35nevirapine tabs . . . . . . . . . . . . . . . . . . . 35NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 31niacin er tbcr 500mg . . . . . . . . . . . . . . . 43niacin er tbcr 1000mg, 750mg . . . . . . 43niacin tabs 500mg . . . . . . . . . . . . . . . . . 43niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 41NICOTROL INHALER. . . . . . . . . . . . . . 19nifedipine er tb24 30mg, 60mg . . . . . 42nifedipine er tb24 90mg . . . . . . . . . . . . 42nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 28nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 42NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 30NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 29NITISINONE CAPS 2MG . . . . . . . . . . 48nitisinone caps 10mg, 5mg . . . . . . . . . 48nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 20nitrofurantoin macrocrystals . . . . . . . . 20nitrofurantoin monohydrate . . . . . . . . . 20nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 20nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 43nitroglycerin lingual . . . . . . . . . . . . . . . . 43nitroglycerin subl . . . . . . . . . . . . . . . . . . 43nitroglycerin transdermal . . . . . . . . . . . 43nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 52norethindrone . . . . . . . . . . . . . . . . . . . . . 52norethindrone acetate . . . . . . . . . . . . . . 52norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 52norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 52

nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41nadolol/bendroflumethiazide . . . . . . . . 41nafcillin sodium . . . . . . . . . . . . . . . . . . . . 21naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 26naftifine hydrochloride crea . . . . . . . . 26NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 48nalbuphine hcl inj 10mg/ml . . . . . . . . . 18nalbuphine hcl inj 20mg/ml . . . . . . . . . 18naloxone hcl inj 0.4mg/ml, 4mg/10ml . . . . . . . . . . . . . . . 19naloxone hcl inj 2mg/2ml . . . . . . . . . . . 19naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 19NAMZARIC C4PK . . . . . . . . . . . . . . . . 44NAMZARIC CP24 . . . . . . . . . . . . . . . . . 44naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 17naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 17naproxen susp . . . . . . . . . . . . . . . . . . . . 17naproxen tabs 250mg . . . . . . . . . . . . . . 17naproxen tabs 375mg, 500mg . . . . . . 17naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 27NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 19NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 27nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 37NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 56NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 23NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 32necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 52nefazodone hcl . . . . . . . . . . . . . . . . . . . . 25nefazodone hydrochloride . . . . . . . . . . 25neomycin/bacitracin/polymyxin . . . . . 20neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 20neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 57neomycin/polymyxin/gramicidin . . . . . 20neomycin/polymyxin/hc . . . . . . . . . . . . 57neomycin/polymyxin/hydrocortisone . 20neomycin/polymyxin/hydrocortisone . 58neomycin sulfate . . . . . . . . . . . . . . . . . . 19

76


Covered Drugs Index

paliperidone er tb24 1.5mg, 3mg, 9mg . . . . . . . . . . . . . . . . . . 34paliperidone er tb24 6mg . . . . . . . . . . . 34pamidronate disodium . . . . . . . . . . . . . 56PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 32pantoprazole sodium inj . . . . . . . . . . . 48pantoprazole sodium tbec . . . . . . . . . 48paricalcitol caps 1mcg, 2mcg . . . . . . . 56paricalcitol caps 4mcg . . . . . . . . . . . . . 56paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44paromomycin sulfate . . . . . . . . . . . . . . . 19paroxetine hcl tabs 10mg . . . . . . . . . . 25paroxetine hcl tabs 30mg, 40mg . . . . 25paroxetine hydrochloride tabs 20mg . 25PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 28PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 25PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 57PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 55PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 55peg 3350/electrolytes . . . . . . . . . . . . . . 48peg-3350/electrolytes . . . . . . . . . . . . . . 48peg-3350/nacl/na bicarbonate/kcl . . . 48PEGANONE . . . . . . . . . . . . . . . . . . . . . . 24PEGASYS INJ 180MCG/0.5ML . . . . . 34PEGASYS INJ 180MCG/ML . . . . . . . . 35PEGASYS PROCLICK . . . . . . . . . . . . . 35penicillamine . . . . . . . . . . . . . . . . . . . . . . 47penicillin g potassium . . . . . . . . . . . . . . 21penicillin v potassium oral soln . . . . . 21penicillin v potassium tabs 250mg . . 21penicillin v potassium tabs 500mg . . 21PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 32pentamidine isethionate . . . . . . . . . . . . 32pentoxifylline er . . . . . . . . . . . . . . . . . . . . 42PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 46perindopril erbumine . . . . . . . . . . . . . . . 40PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 32permethrin . . . . . . . . . . . . . . . . . . . . . . . . 32perphenazine . . . . . . . . . . . . . . . . . . . . . 33perphenazine/amitriptyline . . . . . . . . . 26

ORKAMBI TABS . . . . . . . . . . . . . . . . . . 58orphenadrine citrate er . . . . . . . . . . . . . 59orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 52oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 47oseltamivir phosphate caps . . . . . . . . 36oseltamivir phosphate susr . . . . . . . . 36OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 47oxacillin sodium . . . . . . . . . . . . . . . . . . . 21oxaliplatin inj 100mg . . . . . . . . . . . . . . . 30oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 30oxandrolone tabs 2.5mg . . . . . . . . . . . 50oxandrolone tabs 10mg . . . . . . . . . . . . 50oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 17oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 36oxcarbazepine susp . . . . . . . . . . . . . . . 24oxcarbazepine tabs . . . . . . . . . . . . . . . 24oxybutynin chloride er tb24 5mg . . . . 48oxybutynin chloride er tb24 10mg, 15mg . . . . . . . . . . . . . . . . . . . . . . . 48oxybutynin chloride syrp . . . . . . . . . . . 48oxybutynin chloride tabs . . . . . . . . . . . 48oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 18oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 18oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 18oxycodone/aspirin . . . . . . . . . . . . . . . . . 18oxycodone hcl conc . . . . . . . . . . . . . . . 18oxycodone hcl tabs . . . . . . . . . . . . . . . 18oxycodone hydrochloride oral soln . 18oxycodone hydrochloride tabs . . . . . 18oxycodone/ibuprofen . . . . . . . . . . . . . . 18OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 37

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 40paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 30

nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 27nystatin/triamcinolone . . . . . . . . . . . . . . 27nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Ooctreotide acetate . . . . . . . . . . . . . . . . . 53ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 35ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 30OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59ofloxacin ophthalmic soln . . . . . . . . . . 22ofloxacin otic soln . . . . . . . . . . . . . . . . . 22ofloxacin tabs . . . . . . . . . . . . . . . . . . . . . 22ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 52olanzapine inj . . . . . . . . . . . . . . . . . . . . . 34olanzapine odt . . . . . . . . . . . . . . . . . . . . 34olanzapine tabs . . . . . . . . . . . . . . . . . . . 34olmesartan medoxomil . . . . . . . . . . . . . 40olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 40olopatadine hcl ophthalmic soln . . . . 57olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 57omega-3-acid ethyl esters . . . . . . . . . . 43omeprazole cpdr . . . . . . . . . . . . . . . . . . 48OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 56OMNIPOD DASH 5 PACK. . . . . . . . . . 56OMNIPOD STARTER KIT . . . . . . . . . . 56ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 30ondansetron hcl oral soln . . . . . . . . . . 26ondansetron hcl tabs . . . . . . . . . . . . . . 26ondansetron hydrochloride inj . . . . . . 26ondansetron hydrochloride tabs . . . . 26ondansetron odt . . . . . . . . . . . . . . . . . . . 26ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 24ONFI TABS 10MG, 20MG . . . . . . . . . . 24OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 32OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 59oralone dental paste . . . . . . . . . . . . . . . 44ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 48ORKAMBI PACK . . . . . . . . . . . . . . . . . . 58

77


Covered Drugs Index

prednisolone . . . . . . . . . . . . . . . . . . . . . . 50prednisolone acetate . . . . . . . . . . . . . . 57prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 57prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 50prednisone intensol . . . . . . . . . . . . . . . . 50prednisone oral soln . . . . . . . . . . . . . . 50prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 50prednisone tabs 50mg . . . . . . . . . . . . . 50prednisone tbpk 5mg . . . . . . . . . . . . . . 50prednisone tbpk 10mg . . . . . . . . . . . . . 50pregabalin caps 100mg, 150mg, 200mg, 25mg, 50mg, 75mg . . . . . . . . 23pregabalin caps 225mg, 300mg . . . . 23pregabalin oral soln . . . . . . . . . . . . . . . 23PREMARIN CREA . . . . . . . . . . . . . . . . 52PREMARIN INJ . . . . . . . . . . . . . . . . . . . 52PREMARIN TABS . . . . . . . . . . . . . . . . 52PREMASOL . . . . . . . . . . . . . . . . . . . . . . . 46prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 43previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 52PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 36PREZISTA SUSP . . . . . . . . . . . . . . . . . 36PREZISTA TABS 75MG . . . . . . . . . . . . 36PREZISTA TABS 150MG . . . . . . . . . . . 36PREZISTA TABS 600MG . . . . . . . . . . . 36PREZISTA TABS 800MG . . . . . . . . . . . 36PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 28PRIMAQUINE PHOSPHATE . . . . . . . 32primidone . . . . . . . . . . . . . . . . . . . . . . . . . 24PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 25PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 58PROAIR RESPICLICK . . . . . . . . . . . . . 58probenecid . . . . . . . . . . . . . . . . . . . . . . . . 27probenecid/colchicine . . . . . . . . . . . . . . 27PROCALAMINE . . . . . . . . . . . . . . . . . . . 46prochlorperazine . . . . . . . . . . . . . . . . . . 26

PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 46podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 45polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20polymyxin b sulfate . . . . . . . . . . . . . . . . 20polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 20POMALYST . . . . . . . . . . . . . . . . . . . . . . . 28portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 52PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 30POSACONAZOLE DR . . . . . . . . . . . . . 27potassium chloride cr . . . . . . . . . . . . . . 46potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . 46potassium chloride/ dextrose/lactated ringers . . . . . . . . . . . 46potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 46potassium chloride er . . . . . . . . . . . . . . 46potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 46potassium chloride oral soln . . . . . . . 46potassium chloride pack . . . . . . . . . . . 46potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 46potassium chloride sr . . . . . . . . . . . . . . 46potassium citrate er . . . . . . . . . . . . . . . . 46POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 32PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 38PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 43pramipexole dihydrochloride . . . . . . . . 33prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 39pravastatin sodium . . . . . . . . . . . . . . . . 42praziquantel . . . . . . . . . . . . . . . . . . . . . . . 32prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 39prazosin hydrochloride caps 2mg . . . 39PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 57PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 57PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 57prednicarbate oint . . . . . . . . . . . . . . . . . 50

PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 34pfizerpen inj 20000000unit, 5000000unit . . . . . . . . 21phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 26phenazopyridine hydrochloride . . . . . 49phenazopyridine hydrocholride . . . . . 49phenelzine sulfate . . . . . . . . . . . . . . . . . 25phenobarbital elix . . . . . . . . . . . . . . . . . 24phenobarbital tabs . . . . . . . . . . . . . . . . 24phenytoin chew . . . . . . . . . . . . . . . . . . . 24phenytoin infatabs . . . . . . . . . . . . . . . . . 24phenytoin sodium . . . . . . . . . . . . . . . . . . 24phenytoin sodium extended . . . . . . . . 24phenytoin susp . . . . . . . . . . . . . . . . . . . 24philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 47PHOSPHOLINE IODIDE . . . . . . . . . . . 57PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 56physiosol irrigation . . . . . . . . . . . . . . . . . 56PICATO GEL 0.05% . . . . . . . . . . . . . . . 45PICATO GEL 0.015% . . . . . . . . . . . . . . 45PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 35pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 44pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 57pilocarpine hydrochloride tabs 5mg . . 44pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 33pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 52pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 41pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 37pioglitazone hcl/metformin hcl . . . . . . 37pioglitazone hydrochloride tabs 15mg, 30mg . . . . . . . . . . . . . . . . . . 37piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm . . . . . . . . . . 21piperacillin/tazobactam . . . . . . . . . . . . . 21PIQRAY 200MG DAILY DOSE . . . . . . 30PIQRAY 250MG DAILY DOSE . . . . . . 30PIQRAY 300MG DAILY DOSE . . . . . . 30pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 52pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 52

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Covered Drugs Index

RELISTOR INJ 8MG/0.4ML . . . . . . . . 47RELISTOR INJ 12MG/0.6ML . . . . . . . 47REMODULIN . . . . . . . . . . . . . . . . . . . . . . 59RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 54RENVELA PACK . . . . . . . . . . . . . . . . . . 47RENVELA TABS . . . . . . . . . . . . . . . . . . 47repaglinide tabs 0.5mg, 1mg . . . . . . . 37repaglinide tabs 2mg . . . . . . . . . . . . . . 37REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 43REPATHA PUSHTRONEX SYSTEM . 43REPATHA SURECLICK . . . . . . . . . . . . 43RESCRIPTOR . . . . . . . . . . . . . . . . . . . . 35RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 57RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 39RETACRIT INJ 40000UNIT/ML . . . . . 39RETROVIR IV INFUSION . . . . . . . . . . 35REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 28REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 28REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 34REYATAZ PACK . . . . . . . . . . . . . . . . . . 36RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 57ribavirin caps . . . . . . . . . . . . . . . . . . . . . 35ribavirin inhalation soln . . . . . . . . . . . . 59ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 35rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 27rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 28RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 28riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44rimantadine hcl . . . . . . . . . . . . . . . . . . . . 36ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l . . . . . . . . 46RINGERS IRRIGATION . . . . . . . . . . . . 56RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 54RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 37RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 34RISPERDAL CONSTA INJ 50MG . . . 34

PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 46protriptyline hcl . . . . . . . . . . . . . . . . . . . . 26PULMOZYME . . . . . . . . . . . . . . . . . . . . . 58PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 29pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 28pyridostigmine bromide er . . . . . . . . . . 27pyridostigmine bromide tabs 60mg . . 27

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 55quetiapine fumarate . . . . . . . . . . . . . . . 34quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 40quinapril hydrochloride tabs 10mg . . 40quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 40quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 40quinidine sulfate . . . . . . . . . . . . . . . . . . . 40quinine sulfate . . . . . . . . . . . . . . . . . . . . . 32

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 55raloxifene hydrochloride . . . . . . . . . . . . 52ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 59ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 40RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 42ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 47ranitidine hcl syrp . . . . . . . . . . . . . . . . . 48ranitidine hcl tabs 150mg, 300mg . . . 48ranitidine hydrochloride caps . . . . . . 48ranitidine hydrochloride inj 150mg/6ml, 50mg/2ml . . . . . . . . . . . . . 48ranolazine er . . . . . . . . . . . . . . . . . . . . . . 42RAPAMUNE ORAL SOLN . . . . . . . . . 54rasagiline mesylate . . . . . . . . . . . . . . . . 33reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 52RECOMBIVAX HB . . . . . . . . . . . . . . . . . 55RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 45REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 27REGRANEX . . . . . . . . . . . . . . . . . . . . . . 45

prochlorperazine edisylate inj 10mg/2ml . . . . . . . . . . . . . . . . . . . . . . 33prochlorperazine maleate . . . . . . . . . . 33PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 39PROCRIT INJ 20000UNIT/ML . . . . . . 39PROCRIT INJ 40000UNIT/ML . . . . . . 39procto-med hc . . . . . . . . . . . . . . . . . . . . . 50procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 50proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 50proctozone-hc . . . . . . . . . . . . . . . . . . . . . 50progesterone caps . . . . . . . . . . . . . . . . 52PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 38PROGRAF PACK . . . . . . . . . . . . . . . . . 54PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 59PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 57PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 30PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 56PROMACTA PACK . . . . . . . . . . . . . . . . 39PROMACTA TABS . . . . . . . . . . . . . . . . 39promethazine hcl supp . . . . . . . . . . . . 26promethazine hcl syrp . . . . . . . . . . . . . 26promethazine hcl tabs 12.5mg . . . . . . 26promethazine hydrochloride tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . 26promethegan . . . . . . . . . . . . . . . . . . . . . . 26propafenone hcl . . . . . . . . . . . . . . . . . . . 40propafenone hydrochloride er . . . . . . 40propantheline bromide . . . . . . . . . . . . . 47proparacaine hcl . . . . . . . . . . . . . . . . . . . 57propranolol hcl er . . . . . . . . . . . . . . . . . . 41propranolol hcl inj . . . . . . . . . . . . . . . . . 41propranolol hcl oral soln . . . . . . . . . . . 41propranolol hcl tabs 40mg, 80mg . . . 41propranolol hydrochloride er . . . . . . . . 41propranolol hydrochloride tabs 10mg, 20mg, 60mg . . . . . . . . . . . 41propranolol/hydrochlorothiazide . . . . 41propylthiouracil . . . . . . . . . . . . . . . . . . . . 53PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 55

79


Covered Drugs Index

sodium fluoride chew 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 46SODIUM LACTATE INJ 5MEQ/ML . . 46sodium phenylbutyrate . . . . . . . . . . . . . 48sodium polystyrene sulfonate powd . . 47sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 47sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 22solifenacin succinate . . . . . . . . . . . . . . . 48SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 38SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 28SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 50SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 53SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 53SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 53SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 53sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 40sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 40sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 40sotalol hydrochloride af . . . . . . . . . . . . 41sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 41sotalol hydrochloride tabs 120mg, 80mg . . . . . . . . . . . . . . . . . . . . . 41spironolactone . . . . . . . . . . . . . . . . . . . . 42spironolactone/hydrochlorothiazide . 42SPORANOX ORAL SOLN . . . . . . . . . 27SPRAVATO 56MG DOSE . . . . . . . . . . 25SPRAVATO 84MG DOSE . . . . . . . . . . 25sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 52SPRITAM TB3D 750MG . . . . . . . . . . . 23SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 23SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 31sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

SANDIMMUNE ORAL SOLN . . . . . . 54SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 45SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 34scopolamine . . . . . . . . . . . . . . . . . . . . . . 26selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 33selenium sulfide lotn . . . . . . . . . . . . . . 45SELZENTRY ORAL SOLN . . . . . . . . 36SELZENTRY TABS 25MG . . . . . . . . . 36SELZENTRY TABS 150MG, 75MG . 36SELZENTRY TABS 300MG . . . . . . . . 36SENSIPAR TABS 30MG, 60MG . . . . 56SENSIPAR TABS 90MG . . . . . . . . . . . 56SEREVENT DISKUS . . . . . . . . . . . . . . 58sertraline hcl conc . . . . . . . . . . . . . . . . . 25sertraline hcl tabs 25mg . . . . . . . . . . . . 25sertraline hcl tabs 50mg . . . . . . . . . . . . 25sertraline hydrochloride tabs 100mg . . . . . . . . . . . . . . . . . . . . . . . 25setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 52sevelamer carbonate pack . . . . . . . . . 47sevelamer carbonate tabs . . . . . . . . . 47sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 52SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 55SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 53sildenafil citrate tabs 20mg . . . . . . . . . 59SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 59silver sulfadiazine . . . . . . . . . . . . . . . . . 20SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 57SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 54simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 42sirolimus oral soln . . . . . . . . . . . . . . . . . 54sirolimus tabs . . . . . . . . . . . . . . . . . . . . . 54SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 28SIVEXTRO TABS . . . . . . . . . . . . . . . . . 20SKYRIZI . . . . . . . . . . . . . . . . . . . . . . . . . . 54sodium bicarbonate inj . . . . . . . . . . . . 46sodium chloride 0.45% . . . . . . . . . . . . . 46sodium chloride inj 0.45%, 0.9%, 3%, 5% . . . . . . . . . . . . . . 46sodium chloride irrigation 0.9% . . . . . 56

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 34risperidone odt tbdp 4mg . . . . . . . . . . . 34risperidone oral soln . . . . . . . . . . . . . . 34risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 34risperidone tabs 4mg . . . . . . . . . . . . . . 34ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 36RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 32RITUXAN HYCELA . . . . . . . . . . . . . . . . 32rivastigmine tartrate . . . . . . . . . . . . . . . . 24rivastigmine transdermal system . . . . 24rizatriptan benzoate . . . . . . . . . . . . . . . . 27rizatriptan benzoate odt . . . . . . . . . . . . 27ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 57romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 30ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 33ropinirole hydrochloride tabs 0.25mg, 3mg . . . . . . . . . . . . . . . . . 33rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 20rosuvastatin calcium . . . . . . . . . . . . . . . 42ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 55ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 55roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 23roweepra xr tb24 500mg . . . . . . . . . . . 23roweepra xr tb24 750mg . . . . . . . . . . . 23ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 59ROZLYTREK CAPS 100MG . . . . . . . . 30ROZLYTREK CAPS 200MG . . . . . . . . 30RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 30RUCONEST . . . . . . . . . . . . . . . . . . . . . . 53RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 30RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 33

SSABRIL TABS . . . . . . . . . . . . . . . . . . . . 24salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 17SAMSCA TABS 15MG . . . . . . . . . . . . . 47SAMSCA TABS 30MG . . . . . . . . . . . . . 47SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 26

80


Covered Drugs Index

TECHLITE PEN NEEDLES/ 31G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 56TECHLITE PEN NEEDLES/ 32G X 4MM . . . . . . . . . . . . . . . . . . . . . . . 56TECHLITE PEN NEEDLES/ 32G X 6MM . . . . . . . . . . . . . . . . . . . . . . . 56TECHLITE PEN NEEDLES/ 32G X 8MM . . . . . . . . . . . . . . . . . . . . . . . 56TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 21telmisartan/amlodipine . . . . . . . . . . . . . 40telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg . . . 40telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg . . . . . . . . . . . . . . . . 40telmisartan tabs 20mg, 40mg . . . . . . . 40telmisartan tabs 80mg . . . . . . . . . . . . . 40temazepam caps 15mg, 30mg . . . . . 59temazepam caps 22.5mg, 7.5mg . . . 59temsirolimus . . . . . . . . . . . . . . . . . . . . . . 31TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 55tenofovir disoproxil fumarate . . . . . . . 35terazosin hcl caps 1mg, 5mg . . . . . . . 39terazosin hcl caps 10mg . . . . . . . . . . . 39terazosin hydrochloride . . . . . . . . . . . . 39terbinafine hcl tabs . . . . . . . . . . . . . . . . 27terbutaline sulfate . . . . . . . . . . . . . . . . . 58terconazole . . . . . . . . . . . . . . . . . . . . . . . 27testosterone cypionate . . . . . . . . . . . . . 50testosterone enanthate . . . . . . . . . . . . 50testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 50testosterone pump gel 1% . . . . . . . . . 50tetrabenazine tabs 12.5mg . . . . . . . . . 44tetrabenazine tabs 25mg . . . . . . . . . . . 44tetracycline hydrochloride . . . . . . . . . . 23TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 50THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 28THALOMID CAPS 200MG . . . . . . . . . 28theophylline er tb12 300mg . . . . . . . . 59theophylline er tb24 . . . . . . . . . . . . . . . 59

SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 53SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 20SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 37SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 37SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 37SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 30SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 53SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 47

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 29tacrolimus caps . . . . . . . . . . . . . . . . . . . 54tacrolimus oint . . . . . . . . . . . . . . . . . . . . 45TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 31TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 31TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 30tamoxifen citrate . . . . . . . . . . . . . . . . . . . 28tamsulosin hydrochloride . . . . . . . . . . . 48TARCEVA TABS 25MG . . . . . . . . . . . . 31TARCEVA TABS 100MG, 150MG . . . 31TARGRETIN GEL . . . . . . . . . . . . . . . . . 32tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 52TASIGNA CAPS 50MG . . . . . . . . . . . . 31TASIGNA CAPS 150MG, 200MG . . . 31tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 45tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 21TAZORAC CREA 0.05% . . . . . . . . . . . 45TAZORAC GEL . . . . . . . . . . . . . . . . . . . 45taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 42TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 55TECENTRIQ INJ 840MG/14ML . . . . . 32TECENTRIQ INJ 1200MG/20ML . . . 32TECFIDERA CPDR 120MG . . . . . . . . 44TECFIDERA CPDR 240MG . . . . . . . . 44TECFIDERA STARTER PACK . . . . . . 44TECHLITE PEN NEEDLES/ 31G X 6 MM . . . . . . . . . . . . . . . . . . . . . . 56

STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 55stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 35sterile water irrigation . . . . . . . . . . . . . . 56sterile water irrigation plastic bottle . . . . . . . . . . . . . . . . . . . . . . . 56sterile water irrigation w/hanger . . . . . 56STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 31streptomycin sulfate . . . . . . . . . . . . . . . 19STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 35SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 19sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 48sulfacetamide sodium lotn . . . . . . . . . 22sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 22sulfacetamide sodium/ prednisolone sodium phosphate . . . . 22sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 22sulfamethoxazole/trimethoprim ds . . 22sulfamethoxazole/trimethoprim inj . . 22sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 22sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 22sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 55sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 27sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 27sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 27sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 27sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 27sumatriptan succinate tabs . . . . . . . . 27SUPREP BOWEL PREP KIT . . . . . . . 48SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 31SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 30SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 35SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 36SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 54

81


Covered Drugs Index

trifluoperazine hcl . . . . . . . . . . . . . . . . . . 33trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 36trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 32trihexyphenidyl hydrochloride . . . . . . . 32tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 52tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 52trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 20trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 20tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52trimipramine maleate . . . . . . . . . . . . . . 26TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 25tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 52TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 53TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 30tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 52TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 35trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 52tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 52TROGARZO . . . . . . . . . . . . . . . . . . . . . . 36TROPHAMINE . . . . . . . . . . . . . . . . . . . . 46tropicamide . . . . . . . . . . . . . . . . . . . . . . . 57TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 47TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 38TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 55TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 35TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 31TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 55TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 36tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 31TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 56TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 55TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 44

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 27UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 53

tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 18trandolapril tabs 1mg . . . . . . . . . . . . . . 40trandolapril tabs 2mg, 4mg . . . . . . . . . 40tranexamic acid inj . . . . . . . . . . . . . . . . 39tranexamic acid tabs . . . . . . . . . . . . . . 39TRANSDERM-SCOP . . . . . . . . . . . . . . 26tranylcypromine sulfate . . . . . . . . . . . . 25TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 46TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 56trazodone hydrochloride . . . . . . . . . . . 25TREANDA INJ 25MG . . . . . . . . . . . . . . 28TREANDA INJ 100MG . . . . . . . . . . . . . 28TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 28TRELEGY ELLIPTA . . . . . . . . . . . . . . . 59TRELSTAR MIXJECT INJ 3.75MG. . 53TRELSTAR MIXJECT INJ 11.25MG . . 53TRELSTAR MIXJECT INJ 22.5MG. . 53treprostinil . . . . . . . . . . . . . . . . . . . . . . . . . 59TRESIBA . . . . . . . . . . . . . . . . . . . . . . . . . 38TRESIBA FLEXTOUCH . . . . . . . . . . . . 38tretinoin caps . . . . . . . . . . . . . . . . . . . . . 32tretinoin crea . . . . . . . . . . . . . . . . . . . . . 45tretinoin gel 0.01% . . . . . . . . . . . . . . . . . 45tretinoin gel 0.05% . . . . . . . . . . . . . . . . . 45tretinoin gel 0.025% . . . . . . . . . . . . . . . 45tretinoin microsphere . . . . . . . . . . . . . . 45tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 45triamcinolone acetonide crea . . . . . . 50triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 44triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 50triamcinolone acetonide lotn . . . . . . . 50triamcinolone acetonide oint . . . . . . . 50triamterene/hydrochlorothiazide . . . . 42triderm crea 0.1% . . . . . . . . . . . . . . . . . 50trientine hydrochloride . . . . . . . . . . . . . 47tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 52

thioridazine hcl . . . . . . . . . . . . . . . . . . . . 33thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 28thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 33THYMOGLOBULIN . . . . . . . . . . . . . . . . 54tiagabine hydrochloride . . . . . . . . . . . . 24TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 31tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 20timolol maleate ophthalmic gel forming . . . . . . . . . . . . . 57timolol maleate ophthalmic soln . . . . 57timolol maleate tabs . . . . . . . . . . . . . . . 41TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 56TIVICAY TABS 10MG . . . . . . . . . . . . . . 35TIVICAY TABS 25MG, 50MG . . . . . . . 35tizanidine hcl tabs . . . . . . . . . . . . . . . . . 34tizanidine hydrochloride tabs 4mg . . 34TOBI PODHALER . . . . . . . . . . . . . . . . . 58TOBRADEX OINT . . . . . . . . . . . . . . . . 57tobramycin/dexamethasone . . . . . . . . 57tobramycin nebu . . . . . . . . . . . . . . . . . . 58tobramycin ophthalmic soln . . . . . . . . 19tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 19tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . 19TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 45tolterodine tartrate . . . . . . . . . . . . . . . . . 48topiramate . . . . . . . . . . . . . . . . . . . . . . . . 24toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 30topotecan hcl inj 4mg . . . . . . . . . . . . . . 30toremifene citrate . . . . . . . . . . . . . . . . . . 28TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 54torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 42TOUJEO MAX SOLOSTAR . . . . . . . . 38TOUJEO SOLOSTAR . . . . . . . . . . . . . . 38TPN ELECTROLYTES . . . . . . . . . . . . . 46TRACLEER TABS . . . . . . . . . . . . . . . . 59TRACLEER TBSO . . . . . . . . . . . . . . . . 59TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 38tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 18

82


Covered Drugs Index

VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 24vinblastine sulfate . . . . . . . . . . . . . . . . . 30vincristine sulfate . . . . . . . . . . . . . . . . . . 30vinorelbine tartrate inj 50mg/5ml . . . . 30viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52VIRACEPT TABS 250MG . . . . . . . . . . 36VIRACEPT TABS 625MG . . . . . . . . . . 36VIRAMUNE SUSP . . . . . . . . . . . . . . . . 35VIREAD POWD . . . . . . . . . . . . . . . . . . . 35VIREAD TABS 150MG, 200MG, 250MG . . . . . . . . . . . 35VITRAKVI CAPS 25MG . . . . . . . . . . . . 30VITRAKVI CAPS 100MG . . . . . . . . . . . 30VITRAKVI ORAL SOLN . . . . . . . . . . . 30VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 32voriconazole inj . . . . . . . . . . . . . . . . . . . 27voriconazole susr . . . . . . . . . . . . . . . . . 27voriconazole tabs . . . . . . . . . . . . . . . . . 27VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 34VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 32VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 47VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 34VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 34vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 52vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 38wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 32XARELTO STARTER PACK . . . . . . . . 38XARELTO TABS 10MG, 20MG . . . . . 38XARELTO TABS 15MG, 2.5MG . . . . 38XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 54XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 56XIFAXAN TABS 550MG . . . . . . . . . . . . 20

VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 30velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 47VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 47VENCLEXTA STARTING PACK . . . . 30VENCLEXTA TABS 10MG . . . . . . . . . 30VENCLEXTA TABS 50MG . . . . . . . . . 30VENCLEXTA TABS 100MG . . . . . . . . 30venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 25venlafaxine hcl er cp24 37.5mg . . . . . 25venlafaxine hcl er cp24 75mg . . . . . . 25venlafaxine hcl er cp24 150mg . . . . . 25VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 59VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 58verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 42verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 42verapamil hcl er cp24 200mg . . . . . . . 42verapamil hcl er tbcr . . . . . . . . . . . . . . 42VERAPAMIL HCL SR CP24 360MG . . . . . . . . . . . . . . . . . . 42verapamil hydrochloride inj . . . . . . . . 42verapamil hydrochloride tabs . . . . . . 42VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 34VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 30V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 56V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 56V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 56VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 48VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 38VIDEX EC CPDR 125MG . . . . . . . . . . 35VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 35vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52vigabatrin pack . . . . . . . . . . . . . . . . . . . 24vigabatrin tabs . . . . . . . . . . . . . . . . . . . . 24vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 24VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 25VIIBRYD STARTER PACK . . . . . . . . . 26VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 24VIMPAT ORAL SOLN . . . . . . . . . . . . . 24

UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 32ursodiol caps . . . . . . . . . . . . . . . . . . . . . 47ursodiol tabs . . . . . . . . . . . . . . . . . . . . . . 47

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 36valacyclovir hydrochloride . . . . . . . . . . 36VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 28valganciclovir . . . . . . . . . . . . . . . . . . . . . . 34valganciclovir hydrochlorde . . . . . . . . 34valproate sodium inj 100mg/ml . . . . . 24valproic acid . . . . . . . . . . . . . . . . . . . . . . . 24valsartan/hydrochlorothiazide . . . . . . 40valsartan tabs 160mg, 40mg, 80mg . . . . . . . . . . . . . . . 40valsartan tabs 320mg . . . . . . . . . . . . . . 40vancomycin . . . . . . . . . . . . . . . . . . . . . . . 20vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 5gm, 750mg . . . . 20vancomycin hydrochloride caps 125mg . . . . . . . . . . . . . . . . . . . . . . . 20vancomycin hydrochloride caps 250mg . . . . . . . . . . . . . . . . . . . . . . . 20vancomycin hydrochloride/ dextrose inj 5%; 1gm/200ml, 5%; 500mg/100ml, 5%; 750mg/150ml . . . 20VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 1000MG/200ML, 1500MG/300ML . . . . . . . . . . . . . . . . . . . 20vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg . . . . . . . 20vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 20vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 20VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 55VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 55VASCEPA CAPS 0.5GM . . . . . . . . . . . 43VASCEPA CAPS 1GM . . . . . . . . . . . . . 43VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 55VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 32

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Covered Drugs Index

ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 56ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 34ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 34zoledronic acid inj 5mg/100ml . . . . . . 56ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 30zolpidem tartrate tabs . . . . . . . . . . . . . 59zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 23ZORTRESS TABS 0.5MG . . . . . . . . . . 54ZORTRESS TABS 0.25MG . . . . . . . . 54ZORTRESS TABS 0.75MG, 1MG . . . 54ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 55zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 52ZUBSOLV SUBL 0.7MG; 0.18MG . . 19ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 19ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . 34ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . 34ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . 34ZYTIGA TABS 250MG . . . . . . . . . . . . . 28ZYTIGA TABS 500MG . . . . . . . . . . . . . 28

XIGDUO XR TB24 5MG; 1000MG . . 38XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 38XOLAIR INJ 75MG/0.5ML . . . . . . . . . . 59XOLAIR INJ 150MG/ML . . . . . . . . . . . 59XOLAIR VIAL INJ 150MG . . . . . . . . . . 59XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 32XPOVIO 60 MG ONCE WEEKLY . . . 29XPOVIO 80 MG ONCE WEEKLY . . . 29XPOVIO 80 MG TWICE WEEKLY . . 29XPOVIO 100 MG ONCE WEEKLY . . 29XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 17XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 38XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

YYERVOY INJ 50MG/10ML . . . . . . . . . 32YERVOY INJ 200MG/40ML . . . . . . . . 32YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 55YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 28YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 28yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 58zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 59ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 32ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 28ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 39zebutal caps 325mg; 50mg; 40mg . . 17ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 32zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 45ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 48zidovudine caps . . . . . . . . . . . . . . . . . . 35zidovudine syrp . . . . . . . . . . . . . . . . . . . 35zidovudine tabs . . . . . . . . . . . . . . . . . . . 35

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Notes

This drug list was updated in December 2019. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, 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. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.© 2018 Cigna 926064 j

1-800-222-6700 (TTY 711) 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30.

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2019 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST … · This drug list was updated in December...

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