Four-Tier Drug List - mmeht.org

Four-Tier Drug List Maine Municipal Employees Health Trust Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food and Drug Administration (FDA). Here are things to remember about the drug list:

• You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that are not on this list may not be covered by your plan and may cost you more out of pocket.

• There are rules that affect which drugs are covered by your plan. These limitations and exclusions are included in your Evidence of Coverage (EOC) and Summary Plan Description (SPD). To access them, log in to anthem.com and go to My Plans > Medical > Plan Documents.

• We update this booklet quarterly. To access the most up-to-date drug list for your plan, log in to anthem.com and choose My Plans > Pharmacy.

If you have questions about your pharmacy benefits, we’re here to help. Just call us at the Pharmacy Member Services number on your ID card.

Frequently asked questions What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes brand-name and generic drugs approved by the FDA. What is the difference between brand-name and generic drugs? A brand-name drug is FDA approved and usually available from only one company. It may be protected by a patent, which means it can only be made or sold by the company that has the patent. Brand-name drugs are in UPPER CASE, bold type on the drug list. A generic drug is also FDA approved. It has the same active ingredients and works the same as the brand-name drug. A generic drug is usually available only after the patent on the brand-name drug ends. Generic drugs are in lower case, plain type on the drug list.

Is this a complete list of all covered drugs? Yes, this list includes all the drugs covered by your plan.

Why are certain drugs not included? There are rules that affect which drugs your plan covers and which ones it does not. These limitations and exclusions are listed in your Evidence of Coverage (EOC) and Summary Plan Description (SPD). To access them, log in to anthem.com and go to My Plans > Medical > Plan Documents.

How can I find a drug on the list? Drugs are organized by their drug class, also called therapeutic class. I see a tier next to each drug. What do the tiers mean? The drug list is set up in five tiers or levels. We place drugs in different tiers based on:

• How well they work to improve health.

• If there are over-the-counter (OTC) options available.

• Their costs compared to other drugs used for the same type of treatment. How do the tiers affect how much a drug costs? The lower the tier, the lower your share of the cost. Here is a breakdown of the tiers in your plan:

• Tier 1 select generic drugs have the lowest copay. These drugs offer the greatest value within a drug class. Select generics are the most commonly prescribed generic drugs. They’re known for their effectiveness and value in treating many conditions. All of these drugs are generic versions of brandname drugs.

• Tier 1 standard drugs have the second lowest copay. These drugs offer a good value. Some of these drugs are generic versions of brand-name drugs.

• Tier 2 drugs have a medium copay. They may be preferred brand-name drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.

• Tier 3 drugs have a higher copay. They may be higher-cost, brand-name drugs or generic drugs that cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

• Tier 4 specialty and lifestyle drugs have the highest copay. They may be the highest-cost, brand-name drugs or generic drugs that cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA. Specialty drugs are used to treat complex, chronic conditions and may need special handling. Lifestyle drugs are most commonly used to treat impotency.

How can I tell what my cost share may be? You can log in to anthem.com and enter the drug name in our Price a Medication tool. Search results will show how much the drug costs at pharmacies near you. If a drug I take isn’t on the list, what are my options? Here are things to think about:

• If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

• Your plan may cover another brand-name or generic drug that works just as well. You can search for recent updates about generic drugs at anthem.com.

• Talk to a doctor or pharmacist to see if over-the-counter (OTC) drugs are an option. OTC drugs are not included on the drug list.

• If a drug you take isn’t covered, your doctor can ask us to review your coverage. This process is called preapproval or prior authorization. The doctor can start the process by calling the Pharmacy Member Services number on your member ID card or by downloading a prior authorization form from our website. If we approve the request, the amount you pay for the drug will depend on your plan’s benefit.

• Only you and your doctor can decide which medications are best for you. What do I need to look for in the Notes column? If a drug needs preapproval or prior authorization, you will see “PA” next to it. If you need to try another drug first, which is called step therapy, you will see “ST” next to it. Who decides which drugs to include on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists, and healthcare professionals decides which drugs we include. The group meets regularly to review new and existing drugs. They recommend drugs based on their safety, how well they work to improve health, and the value they offer our members. Does the drug list change? How will I know if it does? Drugs on our list are reviewed regularly. They are sometimes added, removed, or moved to a different tier. We will send you a letter if a drug you take is removed from the list, and in some cases, if a drug you take is moved to a higher tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier. You can always check the drug list to make sure medicines you take are still on it. To access the most up-to-date drug list, log in to anthem.com. Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA) when specific criteria are met. How can I find a pharmacy in my plan? Go to anthem.com to find a pharmacy near you.

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication

T1S = Tier 1 Select Effective 10/1/21

1

Anthem National Drug List

Four Tier

CURRENT AS OF 10/1/2021

Drug Name Tier Notes

1ST TIER UNIFINE

PENTIPS Tier 3 ST; QL

1ST TIER UNIFINE

PENTIPS PLUS Tier 3 ST; QL

1ST TIER UNILET

COMFORTOUCH Tier 2 QL

abacavir sulfate oral solution Tier 1 QL

abacavir sulfate oral tablet Tier 1 QL

abacavir sulfate-lamivudine

oral tablet Tier 1 QL

abacavir-lamivudine-

zidovudine oral tablet Tier 1 QL

ABELCET

INTRAVENOUS

SUSPENSION Tier 3

ABILIFY MAINTENA

INTRAMUSCULAR

PREFILLED SYRINGE Tier 3

ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED ER

Tier 3

ABILIFY MYCITE

MAINTENANCE KIT

ORAL TABLET 10 MG,

15 MG, 2 MG, 5 MG

Tier 3 ST; DO; QL

ABILIFY MYCITE

MAINTENANCE KIT

ORAL TABLET 20 MG,

30 MG

Tier 3 ST; QL

ABILIFY MYCITE ORAL

TABLET 10 MG, 15 MG, 2

MG, 5 MG Tier 3 ST; DO; QL

ABILIFY MYCITE ORAL

TABLET 20 MG, 30 MG Tier 3 ST; QL


ABILIFY MYCITE

STARTER KIT ORAL


MG, 5 MG

Tier 3 ST; DO; QL

ABILIFY MYCITE

STARTER KIT ORAL


abiraterone acetate oral tablet Tier 1 PA; QL; SP

ABLYSINOL INTRA-

ARTERIAL SOLUTION Tier 3

ABOUTTIME PEN

NEEDLE Tier 3 ST; QL

ABRAXANE

INTRAVENOUS

SUSPENSION

RECONSTITUTED

Tier 3 PA; QL; SP

ABSORICA LD ORAL

CAPSULE Tier 3 PA; QL

ABSORICA ORAL


ACACIA

SUBCUTANEOUS

SOLUTION Tier 3

acamprosate calcium oral

tablet delayed release Tier 1

acarbose oral tablet Tier 1

ACCOLATE ORAL

TABLET Tier 3

ACCRUFER ORAL

CAPSULE Tier 3

ACCU-CHEK AVIVA

PLUS IN VITRO STRIP Tier 2 ST; QL

ACCU-CHEK COMPACT

PLUS IN VITRO STRIP Tier 2 ST; QL

ACCU-CHEK FASTCLIX

LANCET KIT Tier 2

ACCU-CHEK FASTCLIX

LANCETS Tier 2 QL

ACCU-CHEK GUIDE IN

VITRO STRIP Tier 2 ST; QL



2


ACCU-CHEK

MULTICLIX LANCETS Tier 2 QL

ACCU-CHEK SAFE-T

PRO LANCETS Tier 2 QL

ACCU-CHEK

SMARTVIEW IN VITRO

STRIP Tier 2 ST; QL

ACCU-CHEK SOFTCLIX

LANCET DEV KIT Tier 2

ACCU-CHEK SOFTCLIX

LANCETS Tier 2 QL

ACCURETIC ORAL

TABLET Tier 3

accutane oral capsule Tier 2 PA; QL

ACCUTREND GLUCOSE

IN VITRO STRIP Tier 2 ST; QL

acebutolol hcl oral capsule Tier 1

ACETADOTE

INTRAVENOUS

SOLUTION Tier 3

acetaminophen intravenous

solution Tier 1

acetaminophen-codeine #2






acetaminophen-codeine oral

solution Tier 1 QL

acetaminophen-codeine oral

tablet Tier 1 QL

acetazolamide er oral capsule

extended release 12 hour Tier 1 T1S

acetazolamide oral tablet Tier 1 T1S

acetazolamide sodium

injection solution

reconstituted Tier 1

acetic acid irrigation solution Tier 1

acetic acid otic solution Tier 1


acetylcysteine inhalation

solution Tier 1

acetylcysteine intravenous

solution Tier 1

acitretin oral capsule Tier 1

ACNESIC EXTERNAL

GEL Tier 3

ACREMONIUM

SUBCUTANEOUS

SOLUTION Tier 3

ACTHAR INJECTION

GEL Tier 4 PA; QL; LD; SP

ACTHIB

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 3 $0

ACTIFLOVIT EAR

HEALTH ORAL TABLET Tier 2 $0

ACTIFOAM COLLAGEN

SPONGE EXTERNAL Tier 3

ACTI-LANCE 28G Tier 2 QL

ACTI-LANCE LITE

LANCETS 28G Tier 2 QL

ACTI-LANCE SPECIAL


ACTI-LANCE

UNIVERSAL 23G Tier 2 QL

ACTIMMUNE

SUBCUTANEOUS

SOLUTION Tier 4 PA; QL; LD; SP

ACTIVASE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ACTIVELLA ORAL

TABLET Tier 3

ACTONEL ORAL

TABLET Tier 3

ACTOPLUS MET ORAL

TABLET Tier 3 ST; QL



3


ACULAR LS

OPHTHALMIC

SOLUTION Tier 3

ACULAR OPHTHALMIC

SOLUTION Tier 3

ACUVAIL

OPHTHALMIC

SOLUTION Tier 3

acyclovir external cream Tier 1 PA; QL

acyclovir external ointment Tier 1

acyclovir oral capsule Tier 1

acyclovir oral suspension Tier 1

acyclovir oral tablet Tier 1

acyclovir sodium intravenous

solution Tier 1

ADACEL

INTRAMUSCULAR

SUSPENSION Tier 3 $0

ADAKVEO

INTRAVENOUS


adapalene external cream Tier 1 PA; QL

adapalene external gel Tier 1 PA; QL

adapalene external pad Tier 1 PA; QL

adapalene-benzoyl peroxide

external gel Tier 1 PA; QL

ADASUVE INHALATION

AEROSOL POWDER

BREATH ACTIVATED Tier 3

adc/f (0.5mg/ml) oral

solution Tier 1 $0

ADCETRIS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD; SP

ADDYI ORAL TABLET Tier 3 PA; QL

adefovir dipivoxil oral tablet Tier 4 SP

ADEMPAS ORAL

TABLET Tier 4 PA; QL; LD; SP


adenosine intravenous

solution Tier 1

ADHANSIA XR ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR Tier 3 ST; QL

ADIPEX-P ORAL


ADIPEX-P ORAL

TABLET Tier 3 PA; QL

ADJUSTABLE LANCING

DEVICE Tier 2

ADRENAL C FORMULA

ORAL TABLET Tier 3

ADRENALIN INJECTION

SOLUTION Tier 3

adriamycin intravenous

solution Tier 1 SP

adriamycin intravenous

solution reconstituted Tier 1 SP

adult aspirin regimen oral

tablet delayed release Tier 1 $0

ADVAIR HFA

INHALATION AEROSOL Tier 2

ADVANCED MOBILE

LANCET Tier 2 QL

ADVATE INTRAVENOUS

SOLUTION

RECONSTITUTED Tier 4 PA; QL; SP

ADVOCATE INSULIN

PEN NEEDLES Tier 3 ST; QL

ADVOCATE INSULIN

SYRINGE Tier 3 ST; QL

ADVOCATE LANCETS Tier 2 QL

ADVOCATE LANCETS

30G Tier 2 QL

ADVOCATE LANCING

DEVICE Tier 2

ADVOCATE RAPID-

SAFE LANCING Tier 2

ADVOCATE SAFETY

LANCETS Tier 2 QL



4


ADVOCATE SAFETY


ADYNOVATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

ADZENYS ER ORAL

SUSPENSION

EXTENDED RELEASE Tier 3 PA; QL

ADZENYS XR-ODT

ORAL TABLET

EXTENDED RELEASE

DISPERSIBLE

Tier 3 ST; QL

AEMCOLO ORAL

TABLET DELAYED

RELEASE Tier 3 PA; QL

AFFINITY EXTERNAL

SHEET Tier 3

AFINITOR DISPERZ

ORAL TABLET

SOLUBLE Tier 3 PA; QL; SP

AFINITOR ORAL

TABLET 10 MG Tier 2 PA; QL; SP

AFINITOR ORAL

TABLET 2.5 MG, 5 MG,

7.5 MG Tier 3 PA; QL; SP

afirmelle oral tablet Tier 1 $0

AFLURIA

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

Tier 2 QL; $0

AFLURIA

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 QL; $0

AFSTYLA

INTRAVENOUS KIT Tier 4 PA; QL; SP

aftera oral tablet Tier 1 $0

afterpill oral tablet Tier 1 $0

AGAMATRIX ULTRA-

THIN LANCETS Tier 2 QL


AGGRASTAT

INTRAVENOUS

CONCENTRATE Tier 3

AGGRASTAT

INTRAVENOUS

SOLUTION Tier 3

AGRYLIN ORAL

CAPSULE Tier 3

AIMOVIG

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

AIMSCO TWIST


AIMSCO TWIST


ak-fluor intravenous solution

10 % Tier 1

AK-FLUOR

INTRAVENOUS

SOLUTION 25 % Tier 3

AKLIEF EXTERNAL

CREAM Tier 3 ST; QL

AKOVAZ

INTRAVENOUS

SOLUTION Tier 3

ak-poly-bac ophthalmic

ointment Tier 1

AKTEN OPHTHALMIC

GEL Tier 3

AKYNZEO

INTRAVENOUS

SOLUTION Tier 3 PA; QL

AKYNZEO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL

AKYNZEO ORAL

CAPSULE Tier 3

ala-cort external cream Tier 1

albendazole oral tablet Tier 1 PA; QL



5


ALBENZA ORAL


ALBUKED 25

INTRAVENOUS

SOLUTION Tier 3

ALBUKED 5

INTRAVENOUS

SOLUTION Tier 3

ALBUMIN HUMAN

INTRAVENOUS

SOLUTION Tier 3

ALBUMINEX

INTRAVENOUS

SOLUTION Tier 3

ALBUMIN-ZLB

INTRAVENOUS

SOLUTION Tier 3

ALBURX INTRAVENOUS

SOLUTION Tier 3

ALBUTEIN

INTRAVENOUS

SOLUTION Tier 3

albuterol sulfate hfa

inhalation aerosol solution Tier 1

albuterol sulfate inhalation

nebulization solution Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

ALCAINE

OPHTHALMIC

SOLUTION Tier 3

alclometasone dipropionate

external cream Tier 1

alclometasone dipropionate

external ointment Tier 1

ALDACTAZIDE ORAL

TABLET 25-25 MG Tier 3 DO

ALDACTAZIDE ORAL

TABLET 50-50 MG Tier 3

ALDACTONE ORAL

TABLET 100 MG Tier 3


ALDACTONE ORAL

TABLET 25 MG, 50 MG Tier 3 DO

ALDARA EXTERNAL

CREAM Tier 3 ST; QL

ALDER

SUBCUTANEOUS

SOLUTION Tier 3

ALDURAZYME

INTRAVENOUS


ALECENSA ORAL

CAPSULE Tier 3 PA; QL; LD; SP

alendronate sodium oral

solution Tier 1

alendronate sodium oral

tablet Tier 1

ALFENTANIL HCL

INTRAVENOUS

SOLUTION Tier 3

ALFERON N INJECTION

SOLUTION Tier 4 SP

alfuzosin hcl er oral tablet

extended release 24 hour Tier 1

ALIMTA INTRAVENOUS

SOLUTION


ALINIA ORAL

SUSPENSION

RECONSTITUTED Tier 3

ALINIA ORAL TABLET Tier 3

ALIQOPA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD

aliskiren fumarate oral tablet

150 mg Tier 1 DO

aliskiren fumarate oral tablet

300 mg Tier 1

ALKERAN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP



6


ALKERAN ORAL

TABLET Tier 3 SP

ALKINDI SPRINKLE

ORAL CAPSULE

SPRINKLE Tier 3 PA; QL

allbee/c oral tablet Tier 1 $0

allopurinol oral tablet Tier 1 T1S

allopurinol sodium

intravenous solution


almotriptan malate oral tablet Tier 1 QL

alogliptin benzoate oral

tablet Tier 1 ST; QL

alogliptin-metformin hcl oral


alogliptin-pioglitazone oral


alophen oral tablet delayed

release Tier 1 $0

ALOPRIM

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ALORA TRANSDERMAL

PATCH TWICE

WEEKLY Tier 3

alosetron hcl oral tablet Tier 1 PA; QL

ALOXI INTRAVENOUS


ALPHAGAN P

OPHTHALMIC

SOLUTION 0.1 % Tier 2

ALPHAGAN P

OPHTHALMIC

SOLUTION 0.15 % Tier 3

ALPHANATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP


ALPHANINE SD

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

alprazolam er oral tablet


ALPRAZOLAM

INTENSOL ORAL

CONCENTRATE Tier 3

alprazolam oral tablet Tier 1

alprazolam oral tablet

dispersible Tier 1

alprazolam xr oral tablet


ALPROLIX

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

alprostadil injection solution Tier 1

ALREX OPHTHALMIC

SUSPENSION Tier 3

ALTABAX EXTERNAL

OINTMENT Tier 2

altafluor benox ophthalmic

solution Tier 1

altafrin ophthalmic solution Tier 1

altavera oral tablet Tier 1 $0

ALTERNARIA

SUBCUTANEOUS

SOLUTION Tier 3

ALUNBRIG ORAL

TABLET Tier 3 PA; QL; SP

ALUNBRIG ORAL

TABLET THERAPY

PACK Tier 3 PA; QL; SP

alvimopan oral capsule Tier 1

alyacen 1/35 oral tablet Tier 1 $0

alyacen 7/7/7 oral tablet Tier 1 $0

alyq oral tablet Tier 4 PA; QL; SP



7


amabelz oral tablet Tier 1

amantadine hcl oral capsule Tier 1

amantadine hcl oral syrup Tier 1

amantadine hcl oral tablet Tier 1

AMARYL ORAL


AMBISOME

INTRAVENOUS

SUSPENSION

RECONSTITUTED

Tier 3

ambrisentan oral tablet Tier 4 PA; QL; LD; SP

amcinonide external cream Tier 3 ST; QL

amcinonide external lotion Tier 3 ST; QL

AMELUZ EXTERNAL

GEL Tier 3

AMERICAN BEECH

SUBCUTANEOUS

SOLUTION Tier 3

AMERICAN

COCKROACH

SUBCUTANEOUS

SOLUTION

Tier 3

AMERICAN ELM

SUBCUTANEOUS

SOLUTION Tier 3

amethia oral tablet Tier 1 $0

amethyst oral tablet Tier 1 $0

AMICAR ORAL

SOLUTION Tier 3

AMICAR ORAL TABLET Tier 3

AMIDATE

INTRAVENOUS

SOLUTION Tier 3

amikacin sulfate injection

solution Tier 1

amiloride hcl oral tablet Tier 1

amiloride-

hydrochlorothiazide oral

tablet Tier 1


aminocaproic acid

intravenous solution Tier 1

aminocaproic acid oral

solution Tier 1

aminocaproic acid oral tablet Tier 1

aminophylline intravenous

solution Tier 1

AMINOPROTECT

INTRAVENOUS

SOLUTION Tier 3

AMINOSYN II

INTRAVENOUS

SOLUTION Tier 3

AMINOSYN-PF

INTRAVENOUS

SOLUTION Tier 3

AMIODARONE HCL IN

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

amiodarone hcl intravenous

solution Tier 1

amiodarone hcl oral tablet Tier 1

amitriptyline hcl oral tablet Tier 1

amlodipine besy-benazepril

hcl oral capsule 10-20 mg,

10-40 mg, 5-40 mg Tier 1

amlodipine besy-benazepril

hcl oral capsule 2.5-10 mg,

5-10 mg, 5-20 mg Tier 1 DO

amlodipine besylate oral

tablet 10 mg Tier 1 T1S

amlodipine besylate oral

tablet 2.5 mg, 5 mg Tier 1 DO; T1S

amlodipine besylate-

valsartan oral tablet 10-160

mg, 10-320 mg, 5-320 mg Tier 1

amlodipine besylate-

valsartan oral tablet 5-160

mg Tier 1 DO



8


amlodipine-atorvastatin oral

tablet 10-10 mg, 10-20 mg,

10-40 mg, 10-80 mg, 5-80

mg

Tier 1

amlodipine-atorvastatin oral

tablet 2.5-10 mg, 2.5-20 mg,

2.5-40 mg, 5-10 mg, 5-20

mg, 5-40 mg

Tier 1 DO

amlodipine-olmesartan oral

tablet 10-20 mg, 10-40 mg,

5-40 mg Tier 1

amlodipine-olmesartan oral

tablet 5-20 mg Tier 1 DO

amlodipine-valsartan-hctz

oral tablet 10-160-12.5 mg,

10-160-25 mg, 10-320-25

mg, 5-160-25 mg

Tier 1

amlodipine-valsartan-hctz

oral tablet 5-160-12.5 mg Tier 1 DO

ammonium lactate external

cream Tier 1

ammonium lactate external

lotion Tier 1

AMMONUL

INTRAVENOUS

SOLUTION Tier 3

amnesteem oral capsule Tier 2 PA; QL

AMNIOFIX INJECTION

SUSPENSION


AMNIOTEXT

EXTERNAL SHEET Tier 3

AMONDYS 45

INTRAVENOUS

SOLUTION Tier 4 PA; QL; LD

amoxapine oral tablet 100

mg, 150 mg Tier 1

amoxapine oral tablet 25 mg,

50 mg Tier 1 DO

amoxicill-clarithro-lansopraz

oral Tier 1 ST; QL

amoxicillin oral capsule Tier 1


amoxicillin oral suspension


amoxicillin oral tablet Tier 1

amoxicillin oral tablet

chewable Tier 1

amoxicillin-pot clavulanate

er oral tablet extended

release 12 hour Tier 1


oral suspension reconstituted Tier 1


oral tablet Tier 1


oral tablet chewable Tier 1

AMPHADASE

INJECTION SOLUTION Tier 3

AMPHENOL-40

INJECTION

SUSPENSION

RECONSTITUTED

Tier 3

amphetamine er oral

suspension extended release Tier 1

amphetamine sulfate oral

tablet 10 mg Tier 1

amphetamine sulfate oral

tablet 5 mg Tier 1 DO

amphetamine-dextroamphet

er oral capsule extended

release 24 hour 10 mg, 15

mg, 5 mg

Tier 1 PA; DO; QL

amphetamine-dextroamphet

er oral capsule extended


mg, 30 mg

Tier 1 PA; QL

amphetamine-

dextroamphetamine oral

tablet 10 mg, 12.5 mg, 15

mg, 5 mg, 7.5 mg

Tier 1 PA; DO; QL

amphetamine-

dextroamphetamine oral

tablet 20 mg, 30 mg Tier 1 PA; QL



9


amphotericin b intravenous

solution reconstituted Tier 1

ampicillin oral capsule Tier 1

ampicillin sodium injection


ampicillin sodium



ampicillin-sulbactam sodium

injection solution


ampicillin-sulbactam sodium



AMPYRA ORAL TABLET

EXTENDED RELEASE 12

HOUR Tier 4 PA; QL; LD; SP

AMVISC INTRAOCULAR

SOLUTION Tier 4

AMVISC PLUS

INTRAOCULAR

SOLUTION Tier 4

anagrelide hcl oral capsule Tier 1

ANALPRAM-HC

EXTERNAL CREAM Tier 3

ANALPRAM-HC

EXTERNAL LOTION Tier 3

ANASCORP

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

anastrozole oral tablet Tier 1 $0

ANAVIP INTRAVENOUS

SOLUTION


ANCOBON ORAL


ANDEXXA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3


ANDRODERM

TRANSDERMAL PATCH

24 HOUR Tier 3 PA; QL

ANECTINE INJECTION

SOLUTION Tier 3

ANESTHESIA S/I-40A

INTRAVENOUS KIT Tier 3

ANESTHESIA S/I-40H


ANESTHESIA S/I-40S


ANGELIQ ORAL

TABLET Tier 3

ANGIOMAX

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ANJESO INTRAVENOUS

INJECTABLE Tier 3

ANNOVERA VAGINAL

RING Tier 3

ANORO ELLIPTA

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

anti-oxidant oral tablet Tier 1 $0

ANTIVENIN

LATRODECTUS

MACTANS INJECTION

KIT

Tier 3

ANTIVENIN MICRURUS

FULVIUS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ANTIVERT ORAL

TABLET Tier 3

ANUSOL-HC EXTERNAL

CREAM Tier 3

APADAZ ORAL TABLET Tier 3 QL

apap-caff-dihydrocodeine

oral capsule Tier 1 QL



10


apap-caff-dihydrocodeine


APLENZIN ORAL

TABLET EXTENDED

RELEASE 24 HOUR 174

MG

Tier 3 ST; DO; QL

APLENZIN ORAL

TABLET EXTENDED

RELEASE 24 HOUR 348

MG, 522 MG

Tier 3 ST; QL

APLIGRAF EXTERNAL

DISK Tier 3

APOKYN

SUBCUTANEOUS

SOLUTION CARTRIDGE Tier 4 PA; QL; LD; SP

APO-VARENICLINE

ORAL TABLET Tier 3 PA; QL; $0

apraclonidine hcl ophthalmic

solution Tier 1

aprepitant oral Tier 1

aprepitant oral capsule Tier 1

apri oral tablet Tier 1 $0

APRISO ORAL CAPSULE

EXTENDED RELEASE 24

HOUR Tier 3 ST; QL

APTIOM ORAL TABLET

200 MG, 400 MG Tier 3 DO

APTIOM ORAL TABLET

600 MG, 800 MG Tier 3

APTIVUS ORAL


AQUALANCE LANCETS

30G Tier 2 QL

AQUASOL A

INTRAMUSCULAR

SOLUTION Tier 3

ARAKODA ORAL

TABLET Tier 3


ARALAST NP

INTRAVENOUS

SOLUTION

RECONSTITUTED


aranelle oral tablet Tier 1 $0

ARANESP (ALBUMIN

FREE) INJECTION

SOLUTION Tier 4 PA; QL; SP

ARANESP (ALBUMIN

FREE) INJECTION

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

ARAVA ORAL TABLET Tier 3

ARAZLO EXTERNAL

LOTION Tier 3 ST; QL

ARCALYST

SUBCUTANEOUS

SOLUTION

RECONSTITUTED


arformoterol tartrate

inhalation nebulization

solution Tier 1

ARGATROBAN IN

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

ARGATROBAN

INTRAVENOUS

SOLUTION Tier 3

ARGININE HCL


argyle sterile saline irrigation

solution Tier 1

argyle sterile water irrigation

solution Tier 1

ARICEPT ORAL

TABLET 10 MG, 23 MG Tier 3

ARICEPT ORAL

TABLET 5 MG Tier 3 DO

ARIKAYCE

INHALATION

SUSPENSION Tier 4 PA; QL; LD



11


aripiprazole oral solution Tier 1

aripiprazole oral tablet 10

mg, 15 mg, 2 mg, 5 mg Tier 1 DO

aripiprazole oral tablet 20

mg, 30 mg Tier 1

aripiprazole oral tablet

dispersible Tier 1

ARISTADA INITIO

INTRAMUSCULAR


ARISTADA

INTRAMUSCULAR

PREFILLED SYRINGE

1064 MG/3.9ML

Tier 3 PA; QL

ARISTADA

INTRAMUSCULAR

PREFILLED SYRINGE

441 MG/1.6ML, 662

MG/2.4ML, 882

MG/3.2ML

Tier 3

ARIXTRA

SUBCUTANEOUS

SOLUTION Tier 4

ARIZONA CYPRESS

SUBCUTANEOUS

SOLUTION Tier 3

armodafinil oral tablet Tier 1 PA; QL

ARMOUR THYROID

ORAL TABLET Tier 3

ARNUITY ELLIPTA

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

AROMASIN ORAL

TABLET Tier 3

ARRANON

INTRAVENOUS

SOLUTION Tier 3 SP

arsenic trioxide intravenous

solution Tier 1 SP


ARTESUNATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

articadent dental injection

solution cartridge Tier 3

ARTISS EXTERNAL

SOLUTION Tier 3

ARZERRA

INTRAVENOUS

CONCENTRATE Tier 3 PA; QL; LD; SP

ASCENIV

INTRAVENOUS


ASCLERA

INTRAVENOUS

SOLUTION Tier 3

ascomp-codeine oral capsule Tier 1 QL

ASCOR INTRAVENOUS

SOLUTION Tier 3

asenapine maleate sublingual

tablet sublingual 10 mg Tier 1

asenapine maleate sublingual

tablet sublingual 2.5 mg, 5

mg Tier 1 DO

ashlyna oral tablet Tier 1 $0

ASPARLAS

INTRAVENOUS


ASPERGILLUS

FUMIGATUS


aspirin 81 oral tablet

chewable Tier 1 $0

aspirin adult low dose oral


aspirin adult low strength

oral tablet delayed release Tier 1 $0

aspirin childrens oral tablet

chewable Tier 1 $0

aspirin ec adult low strength




12


aspirin ec low dose oral


aspirin ec low strength oral


aspirin ec oral tablet delayed

release Tier 1 $0

aspirin low dose oral tablet

chewable Tier 1 $0

aspirin low dose oral tablet

delayed release Tier 1 $0

aspirin low strength oral

tablet chewable Tier 1 $0

aspirin oral tablet Tier 1 $0

aspirin oral tablet chewable Tier 1 $0

aspirin oral tablet delayed

release Tier 1 $0

aspirin-dipyridamole er oral

capsule extended release 12

hour Tier 1

ASPIRIN-OMEPRAZOLE

ORAL TABLET

DELAYED RELEASE Tier 3 PA; QL

ASSURE COMFORT


ASSURE HAEMOLANCE

PLUS HIGH Tier 2 QL

ASSURE HAEMOLANCE

PLUS LOW Tier 2 QL

ASSURE HAEMOLANCE

PLUS MICRO Tier 2 QL

ASSURE HAEMOLANCE

PLUS NORMAL Tier 2 QL

ASSURE HAEMOLANCE

PLUS PED Tier 2 QL

ASSURE ID SAFETY PEN

NEEDLES Tier 3 ST; QL

ASSURE LANCE

LANCETS Tier 2 QL

ASSURE LANCE



ASSURE LANCE PLUS

SAFETY 25G Tier 2 QL

ASSURE LANCE PLUS

SAFETY 30G Tier 2 QL

ASSURE LANCE SAFETY

LANCET 28G Tier 2 QL

ASTAGRAF XL ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR Tier 3

ATABEX EC ORAL

TABLET DELAYED

RELEASE Tier 3

ATABEX OB ORAL

TABLET Tier 3

atazanavir sulfate oral

capsule Tier 1 QL

ATELVIA ORAL

TABLET DELAYED

RELEASE Tier 3

atenolol oral tablet Tier 1 T1S

atenolol-chlorthalidone oral

tablet Tier 1

ATGAM INTRAVENOUS

INJECTABLE Tier 3 SP

atomoxetine hcl oral capsule

10 mg, 18 mg, 25 mg, 40 mg Tier 1 PA; DO; QL

atomoxetine hcl oral capsule

100 mg, 60 mg, 80 mg Tier 1 PA; QL

atorvastatin calcium oral

tablet 10 mg, 20 mg Tier 1 DO; $0




tablet 80 mg Tier 1

atovaquone oral suspension Tier 1

atovaquone-proguanil hcl

oral tablet Tier 1

atracurium besylate




13


ATROPEN

INTRAMUSCULAR

SOLUTION AUTO-

INJECTOR

Tier 3

atropine sulfate injection

solution prefilled syringe Tier 1

ATROPINE SULFATE

INTRAVENOUS

SOLUTION Tier 3

ATROPINE SULFATE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

atropine sulfate ophthalmic

ointment Tier 1

ATROPINE SULFATE

OPHTHALMIC

SOLUTION Tier 3

ATROVENT HFA

INHALATION AEROSOL

SOLUTION Tier 2

AUBAGIO ORAL


aubra eq oral tablet Tier 1 $0

aubra oral tablet Tier 1 $0

AUGMENTIN ES-600

ORAL SUSPENSION


AUGMENTIN ORAL

SUSPENSION


AUGMENTIN ORAL

TABLET Tier 3

AUREOBASIDIUM

PULLULANS INJECTION

SOLUTION Tier 3

AUREOBASIDIUM

SUBCUTANEOUS

SOLUTION Tier 3

AURORA LANCET

SUPER THIN 30G Tier 2 QL


AURORA LANCET THIN

23G Tier 2 QL

AURORA PEN NEEDLES Tier 3 ST; QL

AURORA UNIFINE


aurovela 1.5/30 oral tablet Tier 1 $0

aurovela 1/20 oral tablet Tier 1 $0

aurovela 24 fe oral tablet Tier 1 $0

aurovela fe 1.5/30 oral tablet Tier 1 $0

aurovela fe 1/20 oral tablet Tier 1 $0

AURYXIA ORAL


AUSTEDO ORAL


AUSTRALIAN PINE

SUBCUTANEOUS

SOLUTION Tier 3

AUTO-LANCET Tier 2

AUTO-LANCET MINI Tier 2

AUTOLET II CLINISAFE

KIT Tier 2

AUTOLET LANCING

DEVICE Tier 2

AUTOLET LITE

CLINISAFE KIT Tier 2

AUTOLET LITE

STARTER PACK KIT Tier 2

AUTOLET MINI Tier 2

AUTOLET PLATFORMS Tier 2

AUTOLET PLUS Tier 2

AVASTIN

INTRAVENOUS


aviane oral tablet Tier 1 $0

avita external cream Tier 1 ST; QL

avita external gel Tier 1 ST; QL

AVITENE EXTERNAL

PAD Tier 3



14


AVITENE FLOUR

EXTERNAL POWDER Tier 3

AVONEX PEN

INTRAMUSCULAR

AUTO-INJECTOR KIT Tier 4 PA; QL; SP

AVONEX PREFILLED

INTRAMUSCULAR

PREFILLED SYRINGE

KIT

Tier 4 PA; QL; SP

AVYCAZ

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

AYGESTIN ORAL

TABLET Tier 3

ayuna oral tablet Tier 1 $0

AYVAKIT ORAL

TABLET Tier 3 PA; QL; LD

azacitidine injection

suspension reconstituted Tier 1 PA; QL; SP

AZACTAM INJECTION

SOLUTION


AZASAN ORAL TABLET Tier 3

AZASITE OPHTHALMIC

SOLUTION Tier 3

azathioprine oral tablet Tier 1

AZATHIOPRINE

SODIUM INJECTION

SOLUTION

RECONSTITUTED

Tier 3

AZEDRA DOSIMETRIC

INTRAVENOUS


AZEDRA THERAPEUTIC

INTRAVENOUS


azelaic acid external gel Tier 1

azelastine hcl nasal solution Tier 1

azelastine hcl ophthalmic

solution Tier 1


azelastine-fluticasone nasal

suspension Tier 3

AZESCO ORAL TABLET Tier 3 ST; QL

AZILECT ORAL

TABLET Tier 3

azithromycin intravenous


azithromycin oral packet Tier 1 QL

azithromycin oral suspension

reconstituted Tier 1 QL

azithromycin oral tablet Tier 1 QL

AZOPT OPHTHALMIC

SUSPENSION Tier 3

AZSTARYS ORAL

CAPSULE Tier 3 ST; QL

aztreonam injection solution


AZULFIDINE EN-TABS

ORAL TABLET

DELAYED RELEASE Tier 3

AZULFIDINE ORAL

TABLET Tier 3

azurette oral tablet Tier 1 $0

b complex (folic acid) oral

tablet Tier 1 $0

b complex (lipotropics) oral

tablet Tier 1 $0

b complex 100 tr oral tablet

extended release Tier 1 $0

b complex formula 1

(lipotrop) oral tablet Tier 1 $0

b complex formula 1 (w/ fa)

oral tablet Tier 1 $0

b complex plus oral tablet Tier 1 $0

b complex-b12 oral tablet Tier 1 $0

b complex-biotin-fa oral

tablet Tier 1 $0

b complex-c oral tablet Tier 1 $0

B COMPLEX-C-BIOTIN-

E-FA ORAL TABLET Tier 2 $0



15


b complex-c-folic acid oral

tablet Tier 1 $0

b-100 b-complex oral tablet Tier 1 $0

b-100 complex cr oral tablet


b-100 complex oral tablet Tier 1 $0

b-100 cr oral tablet extended

release Tier 1 $0

b-100 oral tablet Tier 1 $0

b-100 tr oral tablet extended

release Tier 1 $0

b-50 complex oral tablet


b-50 oral tablet Tier 1 $0

bac oral tablet Tier 1

bacitracin intramuscular


bacitracin ophthalmic

ointment Tier 1

bacitracin-polymyxin b

ophthalmic ointment Tier 1

bacitra-neomycin-

polymyxin-hc ophthalmic

ointment Tier 1

baclofen intrathecal solution Tier 4

BACLOFEN

INTRATHECAL

SOLUTION PREFILLED

SYRINGE

Tier 4

baclofen oral tablet Tier 1

BACTRIM DS ORAL

TABLET Tier 3

BACTRIM ORAL

TABLET Tier 3

BAHIA SUBCUTANEOUS

SOLUTION Tier 3

BAL IN OIL

INTRAMUSCULAR

SOLUTION Tier 3


balance b-100 oral tablet Tier 1 $0

balance b-50 oral tablet Tier 1 $0

balanced b complex oral

tablet Tier 1 $0

balanced b-100 complex cr

oral tablet extended release Tier 1 $0

balanced b-100 oral tablet Tier 1 $0

balanced b-100 oral tablet


balanced b-50 complex oral

tablet Tier 1 $0

balanced b-50/fa oral tablet Tier 1 $0

balanced salt intraocular

solution Tier 1

BALCOLTRA ORAL

TABLET Tier 3

BALD CYPRESS

SUBCUTANEOUS

SOLUTION Tier 3

balsalazide disodium oral

capsule Tier 1

BALVERSA ORAL


balziva oral tablet Tier 1 $0

BANZEL ORAL

SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

BAQSIMI ONE PACK

NASAL POWDER Tier 3

BAQSIMI TWO PACK

NASAL POWDER Tier 3

BARACLUDE ORAL

SOLUTION Tier 4

BARHEMSYS

INTRAVENOUS

SOLUTION Tier 3

BAVENCIO

INTRAVENOUS




16


BAXDELA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

BAXDELA ORAL


BAYBERRY (WAX

MYRTLE)

SUBCUTANEOUS

SOLUTION

Tier 3

bayer advanced aspirin reg st


bayer aspirin ec low dose


bayer aspirin oral tablet Tier 1 $0

bayer aspirin oral tablet


bayer low dose oral tablet

chewable Tier 1 $0

bayer low dose oral tablet


BCG VACCINE

INJECTION

INJECTABLE Tier 3 $0

b-compleet-100 oral tablet Tier 1 $0

b-compleet-50 oral tablet Tier 1 $0

b-complex (folic acid) oral

tablet Tier 1 $0

b-complex balanced oral

tablet Tier 1 $0

B-COMPLEX

INJECTION

INJECTABLE Tier 3

b-complex oral tablet Tier 1 $0

b-complex plus b-12 oral

tablet Tier 1 $0

b-complex/b-12 oral tablet Tier 1 $0

b-complex/vitamin c oral

tablet Tier 1 $0

b-complex-c (w/folic acid)



b-complex-c oral tablet Tier 1 $0

BD AUTOSHIELD Tier 2 ST; QL

BD AUTOSHIELD DUO Tier 2 ST; QL

BD INSULIN SYR

ULTRAFINE II Tier 2 ST; QL

BD INSULIN SYRINGE

25G X 1" 1 ML, 25G X

5/8" 1 ML, 26G X 1/2" 1

ML, 27.5G X 5/8" 2 ML

Tier 2

BD INSULIN SYRINGE

27G X 1/2" 1 ML, 29G X

1/2" 0.3 ML, 29G X 1/2"

0.5 ML, 29G X 1/2" 1 ML,

U-100 1 ML

Tier 2 ST; QL

BD INSULIN SYRINGE

HALF-UNIT Tier 2

BD INSULIN SYRINGE

MICROFINE 27G X 5/8" 1

ML Tier 2

BD INSULIN SYRINGE

MICROFINE 28G X 1/2"

0.5 ML, 28G X 1/2" 1 ML Tier 2 ST; QL

BD INSULIN SYRINGE

U/F Tier 2 ST; QL

BD INSULIN SYRINGE

U/F 1/2UNIT Tier 2 ST; QL

BD INSULIN SYRINGE

U-500 Tier 2

BD INSULIN SYRINGE

ULTRAFINE 29G X 1/2"

0.3 ML, 29G X 1/2" 0.5

ML, 29G X 1/2" 1 ML, 30G

X 1/2" 0.5 ML, 31G X

5/16" 0.5 ML

Tier 2 ST; QL

BD INSULIN SYRINGE

ULTRAFINE 30G X 1/2"

0.3 ML Tier 2

BD LANCET

ULTRAFINE 30G Tier 2 QL

BD LANCET

ULTRAFINE 33G Tier 2 QL



17


BD MICROTAINER

LANCETS Tier 2 QL

BD PEN NEEDLE MICRO

U/F Tier 2 ST; QL

BD PEN NEEDLE MINI

U/F Tier 2 ST; QL

BD PEN NEEDLE NANO

2ND GEN Tier 2 ST; QL

BD PEN NEEDLE NANO

U/F Tier 2 ST; QL

BD PEN NEEDLE

ORIGINAL U/F Tier 2 ST; QL

BD PEN NEEDLE SHORT

U/F Tier 2 ST; QL

BD SAFETYGLIDE

INSULIN SYRINGE 29G

X 1/2" 0.3 ML, 29G X 1/2"

0.5 ML, 30G X 5/16" 0.5

ML, 31G X 15/64" 0.3 ML,

31G X 15/64" 0.5 ML, 31G

X 5/16" 0.3 ML

Tier 2 ST; QL

BD SAFETYGLIDE

INSULIN SYRINGE 31G

X 15/64" 1 ML Tier 2

BD SAFETY-LOK

INSULIN SYRINGE Tier 2 ST; QL

BD VEO INSULIN SYR

U/F 1/2UNIT Tier 2 ST; QL

BD VEO INSULIN

SYRINGE U/F 31G X

15/64" 0.3 ML, 31G X

15/64" 0.5 ML

Tier 2 ST; QL

BD VEO INSULIN

SYRINGE U/F 31G X

15/64" 1 ML Tier 2

BELBUCA BUCCAL

FILM Tier 3 PA; QL

BELEODAQ

INTRAVENOUS

SOLUTION

RECONSTITUTED



BELRAPZO

INTRAVENOUS


BELSOMRA ORAL


benazepril hcl oral tablet Tier 1 T1S

benazepril-


tablet 10-12.5 mg Tier 1 DO

benazepril-


tablet 20-12.5 mg, 20-25 mg Tier 1

BENAZEPRIL-

HYDROCHLOROTHIAZI

DE ORAL TABLET 5-6.25

MG

Tier 1 DO

BENDEKA

INTRAVENOUS


BENEFIX


BENLYSTA

INTRAVENOUS

SOLUTION

RECONSTITUTED


BENLYSTA

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


BENLYSTA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


BENTYL

INTRAMUSCULAR

SOLUTION Tier 3

BENZALKONIUM

CHLORIDE EXTERNAL

SOLUTION Tier 3

BENZAMYCIN

EXTERNAL GEL Tier 3 ST; QL



18


BENZHYDROCODONE-

ACETAMINOPHEN

ORAL TABLET Tier 3 QL

BENZNIDAZOLE ORAL

TABLET Tier 3

benzonatate oral capsule Tier 1

benzoyl peroxide-

erythromycin external gel Tier 1

benzphetamine hcl oral tablet

25 mg Tier 1

benzphetamine hcl oral tablet

50 mg Tier 1 PA; QL

benztropine mesylate

injection solution Tier 1

benztropine mesylate oral

tablet Tier 1

BEOVU INTRAVITREAL


BERINERT

INTRAVENOUS KIT Tier 4 PA; QL; LD; SP

BERMUDA GRASS


BERMUDA GRASS

SUBCUTANEOUS

SOLUTION Tier 3

beser external lotion Tier 1

BESIVANCE

OPHTHALMIC

SUSPENSION Tier 3

BESPONSA

INTRAVENOUS

SOLUTION

RECONSTITUTED


BETADINE

OPHTHALMIC PREP

OPHTHALMIC

SOLUTION

Tier 3

betamethasone dipropionate

aug external cream Tier 1


aug external gel Tier 1



aug external lotion Tier 1


aug external ointment Tier 1




external lotion Tier 1



betamethasone valerate



external foam Tier 3 ST; QL


external lotion Tier 1 ST; QL



BETASERON

SUBCUTANEOUS KIT Tier 4 PA; QL; SP

betaxolol hcl ophthalmic

solution Tier 1

betaxolol hcl oral tablet Tier 1

bethanechol chloride oral

tablet Tier 1

BETHKIS INHALATION

NEBULIZATION

SOLUTION Tier 4 LD; SP

BETIMOL

OPHTHALMIC

SOLUTION Tier 3

BETOPTIC-S

OPHTHALMIC

SUSPENSION Tier 2

better b complex oral tablet Tier 1 $0

BEVACIZUMAB

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3 PA; QL

bexarotene oral capsule Tier 1 PA; QL; SP



19


BEXSERO

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3 $0

BEYAZ ORAL TABLET Tier 3

bicalutamide oral tablet Tier 1

BICILLIN C-R 900/300

INTRAMUSCULAR

SUSPENSION Tier 3

BICILLIN C-R

INTRAMUSCULAR

SUSPENSION Tier 3

BICILLIN L-A

INTRAMUSCULAR

SUSPENSION Tier 3

BICNU INTRAVENOUS

SOLUTION

RECONSTITUTED Tier 3 SP

BIDIL ORAL TABLET Tier 2

big 100 (biotin) oral tablet Tier 1 $0

big 100 oral tablet Tier 1 $0

BIJUVA ORAL CAPSULE Tier 2

BIKTARVY ORAL

TABLET Tier 2 QL

BILTRICIDE ORAL

TABLET Tier 3

bimatoprost external solution Tier 1

bimatoprost ophthalmic

solution Tier 1

BINOSTO ORAL

TABLET

EFFERVESCENT Tier 3

BIORPHEN

INTRAVENOUS

SOLUTION Tier 3

BIOTHRAX

INTRAMUSCULAR

SUSPENSION Tier 3

BIOVANCE EXTERNAL

SHEET Tier 3


bisacodyl ec oral tablet


bisoprolol fumarate oral

tablet Tier 1

bisoprolol-


tablet Tier 1

BIVALIRUDIN RTU

INTRAVENOUS

SOLUTION Tier 3

BIVALIRUDIN-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

BIVIGAM

INTRAVENOUS


BLACK WILLOW

SUBCUTANEOUS

SOLUTION Tier 3

blanche external cream Tier 1

BLENREP

INTRAVENOUS

SOLUTION

RECONSTITUTED


bleomycin sulfate injection


BLEPH-10

OPHTHALMIC

SOLUTION Tier 3

BLEPHAMIDE

OPHTHALMIC

SUSPENSION Tier 3

BLEPHAMIDE S.O.P.

OPHTHALMIC

OINTMENT Tier 3

BLINCYTO

INTRAVENOUS

SOLUTION

RECONSTITUTED


blisovi 24 fe oral tablet Tier 1 $0

blisovi fe 1.5/30 oral tablet Tier 1 $0



20


blisovi fe 1/20 oral tablet Tier 1 $0

BLOXIVERZ

INTRAVENOUS

SOLUTION Tier 3

BONIVA ORAL TABLET Tier 3 ST; QL

BONJESTA ORAL

TABLET EXTENDED


BOOSTRIX

INTRAMUSCULAR


BORIC ACID EXTERNAL

GRANULES Tier 3

BORTEZOMIB

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL

bosentan oral tablet Tier 4 PA; QL; LD; SP

BOSULIF ORAL TABLET Tier 2 PA; QL; SP

BOTOX COSMETIC

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 4 PA; QL

BOTOX INJECTION

SOLUTION

RECONSTITUTED Tier 4 PA; QL

BOTRYTIS INJECTION

SOLUTION Tier 3

BOTRYTIS

SUBCUTANEOUS

SOLUTION Tier 3

bp wash external liquid Tier 1

BRAFTOVI ORAL


BREO ELLIPTA

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

BRETYLIUM TOSYLATE



BREVIBLOC IN NACL

INTRAVENOUS

SOLUTION Tier 3

BREVIBLOC

INTRAVENOUS

SOLUTION Tier 3

BREVIBLOC PREMIXED

DS INTRAVENOUS

SOLUTION Tier 3

BREVIBLOC PREMIXED

INTRAVENOUS

SOLUTION Tier 3

BREVITAL SODIUM

INJECTION SOLUTION


BREXAFEMME ORAL

TABLET Tier 3

BREZTRI AEROSPHERE


BRIDION

INTRAVENOUS

SOLUTION Tier 3

briellyn oral tablet Tier 1 $0

BRILINTA ORAL

TABLET Tier 2

brimonidine tartrate

ophthalmic solution Tier 1

brinzolamide ophthalmic

suspension Tier 1

BRIVIACT

INTRAVENOUS

SOLUTION Tier 3

BRIVIACT ORAL

SOLUTION Tier 3

BRIVIACT ORAL

TABLET Tier 3

BROME

SUBCUTANEOUS

SOLUTION Tier 3

bromfenac sodium (once-

daily) ophthalmic solution Tier 1



21


bromocriptine mesylate oral

capsule Tier 1

bromocriptine mesylate oral

tablet Tier 1

BROMSITE

OPHTHALMIC

SOLUTION Tier 3

BRONCHITOL

INHALATION CAPSULE Tier 4 PA; QL; LD; SP

BRONCHITOL

TOLERANCE TEST

INHALATION CAPSULE Tier 4 PA; QL; LD; SP

BROVANA INHALATION

NEBULIZATION

SOLUTION Tier 3

BRUKINSA ORAL

CAPSULE Tier 3 PA; QL; LD

BSP 0820 INJECTION

KIT Tier 3

BSS INTRAOCULAR

SOLUTION Tier 3

BSS PLUS

INTRAOCULAR

SOLUTION Tier 3

budesonide er oral tablet


budesonide inhalation

suspension Tier 1

budesonide oral capsule

delayed release particles Tier 1

budesonide-formoterol

fumarate inhalation aerosol Tier 1

bumetanide injection solution Tier 1

bumetanide oral tablet Tier 1 T1S

BUMEX ORAL TABLET Tier 3

BUNAVAIL BUCCAL

FILM Tier 3 QL

BUPHENYL ORAL

POWDER Tier 3 PA; QL; LD


BUPHENYL ORAL


BUPIVACAINE

FISIOPHARMA


bupivacaine hcl (pf) injection

solution Tier 1

bupivacaine hcl injection

solution Tier 1

BUPIVACAINE HCL-

NACL EPIDURAL

SOLUTION Tier 3

BUPIVACAINE HCL-

NACL EPIDURAL

SOLUTION PREFILLED

SYRINGE

Tier 3

bupivacaine in dextrose

intrathecal solution Tier 1

bupivacaine spinal

intrathecal solution Tier 1

bupivacaine-epinephrine (pf)


bupivacaine-epinephrine


BUPRENEX INJECTION

SOLUTION Tier 3 QL

buprenorphine hcl injection

solution Tier 1 QL

buprenorphine hcl sublingual

tablet sublingual Tier 1 QL

buprenorphine hcl-naloxone

hcl sublingual film Tier 1 QL

buprenorphine hcl-naloxone

hcl sublingual tablet

sublingual Tier 1 QL

buprenorphine transdermal

patch weekly Tier 1 PA; QL

bupropion hcl er (smoking

det) oral tablet extended

release 12 hour Tier 1 PA; QL; $0



22


bupropion hcl er (sr) oral

tablet extended release 12

hour 100 mg Tier 1 DO

bupropion hcl er (sr) oral


hour 150 mg, 200 mg Tier 1

bupropion hcl er (xl) oral


hour 150 mg Tier 1 DO

bupropion hcl er (xl) oral



bupropion hcl oral tablet 100

mg Tier 1

bupropion hcl oral tablet 75

mg Tier 1 DO

buspirone hcl oral tablet Tier 1

busulfan intravenous solution Tier 1 SP

BUSULFEX

INTRAVENOUS

SOLUTION Tier 3 SP

butalbital-acetaminophen

oral capsule Tier 1

butalbital-acetaminophen

oral tablet Tier 1

butalbital-apap-caff-cod oral

capsule Tier 1 QL

butalbital-apap-caffeine oral

capsule Tier 1

butalbital-apap-caffeine oral

tablet Tier 1

butalbital-asa-caff-codeine

oral capsule Tier 1 QL

butalbital-aspirin-caffeine

oral capsule Tier 1

butorphanol tartrate injection

solution Tier 1 QL

butorphanol tartrate nasal

solution Tier 1 QL


BUTRANS

TRANSDERMAL PATCH

WEEKLY Tier 3 PA; QL

BYFAVO INTRAVENOUS

SOLUTION


BYLVAY (PELLETS)

ORAL CAPSULE

SPRINKLE Tier 4 PA; QL; LD

BYLVAY ORAL


BYSTOLIC ORAL

TABLET Tier 2

CABENUVA

INTRAMUSCULAR

SUSPENSION

EXTENDED RELEASE

Tier 3 PA; QL; LD

cabergoline oral tablet Tier 1

CABLIVI INJECTION

KIT Tier 4 PA; QL; LD

CABOMETYX ORAL


CADUET ORAL TABLET

10-10 MG, 10-20 MG, 10-

40 MG, 10-80 MG, 5-80

MG

Tier 3

CADUET ORAL TABLET

5-10 MG, 5-20 MG, 5-40

MG Tier 3 DO

CAFCIT INTRAVENOUS

SOLUTION Tier 3

caffeine citrate intravenous

solution Tier 1

caffeine citrate oral solution Tier 1

CALAN SR ORAL

TABLET EXTENDED

RELEASE Tier 3

calcipotriene external cream Tier 1

calcipotriene external foam Tier 1

calcipotriene external

ointment Tier 1



23


calcipotriene external

solution Tier 1

calcipotriene-betameth

diprop external ointment Tier 2 ST; QL

calcipotriene-betameth

diprop external suspension Tier 2 ST; QL

calcitonin (salmon) injection

solution Tier 4

calcitonin (salmon) nasal

solution Tier 1

calcitrene external ointment Tier 1

calcitriol external ointment Tier 1

calcitriol intravenous

solution Tier 1 PA; QL

calcitriol oral capsule Tier 1 PA; QL

calcitriol oral solution Tier 1 PA; QL

calcium acetate (phos binder)

oral capsule Tier 1

calcium acetate (phos binder)

oral tablet Tier 1

calcium acetate oral tablet Tier 1

CALCIUM DISODIUM

VERSENATE


CALCIUM GLUCONATE

INTRAVENOUS

SOLUTION Tier 3

CALCIUM

GLUCONATE-NACL

INTRAVENOUS

SOLUTION

Tier 3

CALDOLOR

INTRAVENOUS

SOLUTION Tier 3

CALIFORNIA PEPPER

TREE SUBCUTANEOUS

SOLUTION Tier 3

CALQUENCE ORAL


camila oral tablet Tier 1 $0


CAMPTOSAR

INTRAVENOUS

SOLUTION Tier 3 SP

camrese lo oral tablet Tier 1 $0

camrese oral tablet Tier 1 $0

CANASA RECTAL

SUPPOSITORY Tier 3

CANCIDAS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

candesartan cilexetil oral

tablet Tier 1

candesartan cilexetil-hctz

oral tablet Tier 1

CANDIDA ALBICANS

EXTRACT INJECTION

SOLUTION Tier 3

CANDIDA ALBICANS

EXTRACT

SUBCUTANEOUS

SOLUTION

Tier 3

CAPASTAT SULFATE

INJECTION SOLUTION


CAPCOF ORAL SYRUP Tier 3

capecitabine oral tablet Tier 1 PA; QL; SP

CAPLYTA ORAL


CAPRELSA ORAL


captopril oral tablet Tier 1

CARAC EXTERNAL

CREAM Tier 3 ST; QL

CARAFATE ORAL

SUSPENSION Tier 3

CARAFATE ORAL

TABLET Tier 3

CARBAGLU ORAL




24


carbamazepine er oral


hour Tier 1

carbamazepine er oral tablet


carbamazepine oral

suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet

chewable Tier 1

carbidopa oral tablet Tier 1

carbidopa-levodopa er oral

tablet extended release Tier 1

carbidopa-levodopa oral

tablet Tier 1

CARBIDOPA-

LEVODOPA ORAL

TABLET DISPERSIBLE Tier 1

carbidopa-levodopa-

entacapone oral tablet Tier 1

carbinoxamine maleate oral

solution Tier 1

carbinoxamine maleate oral

tablet Tier 1

CARBOCAINE


CARBOCAINE

PRESERVATIVE-FREE


carboplatin intravenous

solution Tier 1 SP

carboprost tromethamine

intramuscular solution Tier 1

CARDENE IV

INTRAVENOUS

SOLUTION Tier 3

CARDIOCOM LANCING

DEVICE Tier 2

CARDIZEM LA ORAL

TABLET EXTENDED

RELEASE 24 HOUR Tier 3 DO


CARDIZEM ORAL


CARDIZEM ORAL


CARDURA ORAL

TABLET Tier 3

CARDURA XL ORAL

TABLET EXTENDED


CAREFINE PEN


CAREONE ADVANCED

LANCING DEV Tier 2

CAREONE INSULIN


CAREONE LANCET


CAREONE LANCET

THIN 23G Tier 2 QL

CAREONE UNIFINE


CAREONE UNIFINE


CARESENS LANCETS Tier 2 QL

CARETOUCH INSULIN


CARETOUCH

LANCING/EJECTOR Tier 2

CARETOUCH PEN


CARETOUCH SAFETY

LANCETS Tier 2 QL

CARETOUCH SAFETY


CARETOUCH TWIST


CARETOUCH TWIST


CARETOUCH TWIST




25


carisoprodol oral tablet Tier 1

carisoprodol-aspirin-codeine

oral tablet Tier 1

carmustine intravenous


CARNITOR

INTRAVENOUS

SOLUTION Tier 3

CARNITOR ORAL

SOLUTION Tier 3

CARNITOR ORAL

TABLET Tier 3

CARNITOR SF ORAL

SOLUTION Tier 3

CAROSPIR ORAL

SUSPENSION Tier 3

carteolol hcl ophthalmic

solution Tier 1

cartia xt oral capsule

extended release 24 hour 120

mg, 180 mg Tier 1 DO

cartia xt oral capsule


mg, 300 mg Tier 1

carvedilol oral tablet Tier 1

carvedilol phosphate er oral


hour Tier 1

CASCARA SAGRADA

ORAL FLUID EXTRACT Tier 3

CASODEX ORAL

TABLET Tier 3

CASPOFUNGIN

ACETATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

CAT HAIR EXTRACT



CAT HAIR EXTRACT

SUBCUTANEOUS

SOLUTION Tier 3

cataflam oral tablet Tier 1

CATAPRES-TTS-1

TRANSDERMAL PATCH

WEEKLY Tier 3

CATAPRES-TTS-2

TRANSDERMAL PATCH

WEEKLY Tier 3

CATAPRES-TTS-3

TRANSDERMAL PATCH

WEEKLY Tier 3

CATHFLO ACTIVASE

INJECTION SOLUTION


CATTLE EPITHELIUM

SUBCUTANEOUS

SOLUTION Tier 3

cavarest dental gel Tier 1

CAVERJECT IMPULSE

INTRACAVERNOSAL

KIT Tier 3 PA; QL

CAVERJECT

INTRACAVERNOSAL

SOLUTION

RECONSTITUTED

Tier 3 PA; QL

CAYA VAGINAL

DIAPHRAGM Tier 2 $0

CAYSTON INHALATION

SOLUTION

RECONSTITUTED Tier 4 LD; SP

caziant oral tablet Tier 1 $0

CEDAR ELM

SUBCUTANEOUS

SOLUTION Tier 3

CEFACLOR ER ORAL

TABLET EXTENDED


cefaclor oral capsule Tier 1



26


cefaclor oral suspension


cefadroxil oral capsule Tier 1

cefadroxil oral suspension


cefadroxil oral tablet Tier 1

CEFAZOLIN IN SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

cefazolin sodium injection

solution reconstituted 1 gm,

10 gm, 500 mg Tier 1

CEFAZOLIN SODIUM

INJECTION SOLUTION

RECONSTITUTED 100

GM, 300 GM

Tier 3

CEFAZOLIN SODIUM

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

cefazolin sodium intravenous


CEFAZOLIN SODIUM-

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

CEFAZOLIN SODIUM-

DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cefdinir oral capsule Tier 1

cefdinir oral suspension


cefepime hcl injection


CEFEPIME HCL

INTRAVENOUS

SOLUTION Tier 3


CEFEPIME HCL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

CEFEPIME-DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cefixime oral capsule Tier 1

cefixime oral suspension


CEFOTAN INJECTION

SOLUTION


cefotaxime sodium injection


cefotetan disodium injection


CEFOTETAN

DISODIUM-DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cefoxitin sodium injection


cefoxitin sodium intravenous


CEFOXITIN SODIUM-

DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cefpodoxime proxetil oral

suspension reconstituted Tier 1

cefpodoxime proxetil oral

tablet Tier 1

cefprozil oral suspension


cefprozil oral tablet Tier 1



27


CEFTAZIDIME AND

DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ceftazidime injection solution


ceftriaxone sodium in

dextrose intravenous solution Tier 1

ceftriaxone sodium injection


2 gm, 250 mg, 500 mg Tier 1

CEFTRIAXONE SODIUM

INJECTION SOLUTION

RECONSTITUTED 100

GM

Tier 3

ceftriaxone sodium



CEFTRIAXONE

SODIUM-DEXTROSE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cefuroxime axetil oral tablet Tier 1

cefuroxime sodium injection


cefuroxime sodium



celecoxib oral capsule Tier 1 ST; QL

CELESTONE SOLUSPAN

INJECTION

SUSPENSION Tier 3

CELLCEPT

INTRAVENOUS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

CELLCEPT ORAL

CAPSULE Tier 3


CELLCEPT ORAL

SUSPENSION


CELLCEPT ORAL

TABLET Tier 3

CELLUGEL

INTRAOCULAR

SOLUTION Tier 3

CELONTIN ORAL

CAPSULE Tier 3

CENTANY EXTERNAL

OINTMENT Tier 3 ST; QL

cephalexin oral capsule Tier 1

cephalexin oral suspension


cephalexin oral tablet Tier 1

CEPROTIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 LD; SP

CERDELGA ORAL


CEREBYX INJECTION

SOLUTION Tier 3

CEREZYME

INTRAVENOUS

SOLUTION

RECONSTITUTED


CEROVEL EXTERNAL

LOTION Tier 3

CERVIDIL VAGINAL

INSERT Tier 3

CETACAINE EXTERNAL

GEL Tier 3

cetirizine hcl oral solution Tier 1

CETRAXAL OTIC

SOLUTION Tier 3

CETROTIDE


cevimeline hcl oral capsule Tier 1



28


charlotte 24 fe oral tablet

chewable Tier 1 $0

chateal eq oral tablet Tier 1 $0

chateal oral tablet Tier 1 $0

CHEMET ORAL

CAPSULE Tier 3

childrens aspirin oral tablet

chewable Tier 1 $0

chloramphenicol sod

succinate intravenous


chlordiazepoxide hcl oral

capsule Tier 1

chlordiazepoxide-

amitriptyline oral tablet Tier 1

chlordiazepoxide-clidinium

oral capsule Tier 1

chlorhexidine gluconate

mouth/throat solution Tier 1

chloroprocaine hcl (pf)


chloroquine phosphate oral

tablet Tier 1

chlorothiazide sodium



chlorpromazine hcl injection

solution Tier 1

CHLORPROMAZINE

HCL ORAL

CONCENTRATE Tier 3

chlorpromazine hcl oral

tablet Tier 1

chlorthalidone oral tablet Tier 1 T1S

chlorzoxazone oral tablet 375

mg, 750 mg Tier 1 ST; QL

chlorzoxazone oral tablet 500

mg Tier 1

CHOLBAM ORAL



cholestyramine light oral

packet Tier 1

cholestyramine light oral

powder Tier 1

cholestyramine oral packet Tier 1

cholestyramine oral powder Tier 1

CHORIONIC

GONADOTROPIN

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

chromic chloride intravenous

solution Tier 1

ciclopirox external gel Tier 1

ciclopirox external shampoo Tier 1

ciclopirox external solution Tier 1

ciclopirox olamine external

cream Tier 1

ciclopirox olamine external

suspension Tier 1

cidofovir intravenous

solution Tier 1

cilostazol oral tablet Tier 1

CILOXAN

OPHTHALMIC

OINTMENT Tier 3

CILOXAN

OPHTHALMIC

SOLUTION Tier 3

CIMDUO ORAL TABLET Tier 3 QL

cimetidine hcl oral solution Tier 1

cimetidine oral tablet Tier 1

cinacalcet hcl oral tablet Tier 4 PA; QL

CINQAIR

INTRAVENOUS




29


CINRYZE

INTRAVENOUS

SOLUTION

RECONSTITUTED


CINVANTI

INTRAVENOUS

EMULSION Tier 3 PA; QL

CIPRO HC OTIC

SUSPENSION Tier 3

CIPRO ORAL

SUSPENSION

RECONSTITUTED Tier 3 QL

CIPRO ORAL TABLET Tier 3 QL

CIPRODEX OTIC

SUSPENSION Tier 3

ciprofloxacin hcl ophthalmic

solution Tier 1

ciprofloxacin hcl oral tablet Tier 1 QL

ciprofloxacin hcl otic

solution Tier 1

ciprofloxacin in d5w


ciprofloxacin-dexamethasone

otic suspension Tier 1

ciprofloxacin-fluocinolone pf

otic solution Tier 1

cisatracurium besylate (pf)


cisatracurium besylate


cisplatin intravenous solution Tier 1 SP

CISPLATIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

citalopram hydrobromide

oral solution Tier 1


oral tablet 10 mg, 20 mg Tier 1 DO


oral tablet 40 mg Tier 1


CITRANATAL 90 DHA

ORAL Tier 3 ST; QL

CITRANATAL ASSURE

ORAL Tier 3 ST; QL

CITRANATAL B-CALM

ORAL Tier 3

CITRANATAL BLOOM

DHA ORAL Tier 3 ST; QL

CITRANATAL BLOOM

ORAL TABLET Tier 3 ST; QL

CITRANATAL DHA

ORAL Tier 3 ST; QL

CITRANATAL ESSENCE

ORAL THERAPY PACK Tier 3 ST; QL

CITRANATAL

HARMONY ORAL


CITRANATAL MEDLEY

ORAL CAPSULE Tier 3 ST; QL

CITRANATAL RX ORAL


citrate of magnesia oral

solution Tier 1 $0

citroma oral solution Tier 1 $0

CITRULLINE EASY

ORAL TABLET

EXTENDED RELEASE Tier 3

CLADOSPORIUM

CLADOSPORIOIDES


CLADOSPORIUM

CLADOSPORIOIDES

INTRADERMAL

SOLUTION

Tier 3

CLADOSPORIUM

CLADOSPORIOIDES

SUBCUTANEOUS

SOLUTION

Tier 3

CLADOSPORIUM

SPHAEROSPERMUM

SUBCUTANEOUS

SOLUTION

Tier 3



30


cladribine intravenous

solution Tier 1 SP

claravis oral capsule Tier 2 PA; QL

CLARINEX ORAL


CLARINEX-D 12 HOUR

ORAL TABLET

EXTENDED RELEASE 12

HOUR

Tier 3 ST; QL

clarithromycin er oral tablet


clarithromycin oral

suspension reconstituted Tier 1 QL

clarithromycin oral tablet Tier 1 QL

CLASSIC PRENATAL

ORAL TABLET Tier 2 $0

CLEANLET LANCETS

28G Tier 2 QL

clearlax oral powder Tier 1 $0

CLEMASTINE

FUMARATE ORAL

SYRUP Tier 3

clemastine fumarate oral

tablet Tier 1

CLENPIQ ORAL

SOLUTION Tier 3

CLEOCIN ORAL

CAPSULE Tier 3

CLEOCIN ORAL

SOLUTION


CLEOCIN PHOSPHATE


CLEOCIN VAGINAL

CREAM Tier 3

CLEOCIN VAGINAL

SUPPOSITORY Tier 2

CLEOCIN-T EXTERNAL


CLEVER CHEK

LANCETS Tier 2 QL


CLEVER CHOICE

COMFORT EZ Tier 3 ST; QL

CLEVER CHOICE


CLEVER CHOICE


CLEVER CHOICE


CLEVIPREX

INTRAVENOUS

EMULSION Tier 3

CLICKFINE PEN


CLIMARA PRO

TRANSDERMAL PATCH

WEEKLY Tier 2

CLIMARA

TRANSDERMAL PATCH

WEEKLY Tier 3

clindacin etz external swab Tier 1

clindacin-p external swab Tier 1

clindamycin hcl oral capsule Tier 1

clindamycin palmitate hcl

oral solution reconstituted Tier 1

clindamycin phos-benzoyl

perox external gel Tier 1

clindamycin phosphate

external foam Tier 1


external gel Tier 1




external solution Tier 1


external swab Tier 1

clindamycin phosphate in

d5w intravenous solution Tier 1



31


CLINDAMYCIN

PHOSPHATE IN NACL

INTRAVENOUS

SOLUTION

Tier 3




vaginal cream Tier 1

clindamycin-tretinoin

external gel Tier 3 ST; QL

CLINDESSE VAGINAL

CREAM Tier 3

CLINIMIX E/DEXTROSE

(2.75/5) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX E/DEXTROSE


SOLUTION Tier 3

CLINIMIX E/DEXTROSE


SOLUTION Tier 3

CLINIMIX E/DEXTROSE

(5/15) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX E/DEXTROSE

(5/20) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX E/DEXTROSE

(8/10) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX E/DEXTROSE

(8/14) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX/DEXTROSE


SOLUTION Tier 3

CLINIMIX/DEXTROSE


SOLUTION Tier 3

CLINIMIX/DEXTROSE

(5/15) INTRAVENOUS

SOLUTION Tier 3


CLINIMIX/DEXTROSE

(5/20) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX/DEXTROSE

(6/5) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX/DEXTROSE

(8/10) INTRAVENOUS

SOLUTION Tier 3

CLINIMIX/DEXTROSE

(8/14) INTRAVENOUS

SOLUTION Tier 3

clinisol sf intravenous

solution Tier 1

CLINOLIPID

INTRAVENOUS

EMULSION Tier 3

clinpro 5000 dental paste Tier 1

clobazam oral suspension Tier 1

clobazam oral tablet Tier 1

clobetasol prop emollient

base external cream Tier 1

clobetasol propionate e


clobetasol propionate

emulsion external foam Tier 1




external foam Tier 1


external gel Tier 1


external liquid Tier 1






external shampoo Tier 1



32




clocortolone pivalate external

cream Tier 3 ST; QL

clodan external shampoo Tier 1

clofarabine intravenous

solution Tier 1 SP

CLOLAR

INTRAVENOUS

SOLUTION Tier 3 SP

clomiphene citrate oral tablet Tier 1 PA; QL

clomipramine hcl oral

capsule Tier 1

clonazepam oral tablet Tier 1

clonazepam oral tablet

dispersible Tier 1

clonidine hcl (analgesia)

epidural solution Tier 1

clonidine hcl er oral tablet

extended release 12 hour Tier 1 PA; QL

clonidine hcl oral tablet Tier 1

clonidine transdermal patch

weekly Tier 1

clopidogrel bisulfate oral

tablet Tier 1

clorazepate dipotassium oral

tablet Tier 1

CLOROTEKAL

INTRATHECAL

SOLUTION Tier 3

clotrimazole external cream Tier 1

clotrimazole external

solution Tier 1

clotrimazole mouth/throat

troche Tier 1

clotrimazole-betamethasone


clotrimazole-betamethasone



clovique oral capsule Tier 1 PA; QL; SP

clozapine oral tablet 100 mg,

200 mg Tier 1

clozapine oral tablet 25 mg,

50 mg Tier 1 DO

clozapine oral tablet

dispersible 100 mg, 150 mg,

200 mg Tier 1

clozapine oral tablet

dispersible 12.5 mg, 25 mg Tier 1 DO

C-NATE DHA ORAL

CAPSULE Tier 3

COAGADEX

INTRAVENOUS

SOLUTION

RECONSTITUTED


COAGUCHEK LANCETS Tier 2 QL

coal tar external solution Tier 1

COARTEM ORAL

TABLET Tier 3

COCKLEBUR

SUBCUTANEOUS

SOLUTION Tier 3

COD LIVER OIL ORAL

OIL Tier 3

CODEINE SULFATE

ORAL TABLET 15 MG,

60 MG Tier 3 QL

codeine sulfate oral tablet 30

mg Tier 1 QL

CODITUSSIN AC ORAL

LIQUID Tier 3

CODITUSSIN DAC ORAL

LIQUID Tier 3

COGENTIN INJECTION

SOLUTION Tier 3

colchicine oral tablet Tier 2

colchicine-probenecid oral

tablet Tier 1

colesevelam hcl oral packet Tier 3



33


colesevelam hcl oral tablet Tier 1

COLESTID FLAVORED

ORAL GRANULES Tier 3

COLESTID FLAVORED

ORAL PACKET Tier 3

COLESTID ORAL

GRANULES Tier 3

COLESTID ORAL

PACKET Tier 3

COLESTID ORAL

TABLET Tier 3

colestipol hcl oral granules Tier 1

colestipol hcl oral packet Tier 1

colestipol hcl oral tablet Tier 1

colistimethate sodium (cba)

injection solution


COLY-MYCIN M

INJECTION SOLUTION


COMBIGAN

OPHTHALMIC

SOLUTION Tier 2

COMBIPATCH

TRANSDERMAL PATCH

TWICE WEEKLY Tier 2

COMBIVENT RESPIMAT

INHALATION AEROSOL

SOLUTION Tier 2

COMBIVIR ORAL

TABLET Tier 3 QL

COMETRIQ (100 MG

DAILY DOSE) ORAL KIT Tier 3 PA; QL; LD; SP

COMETRIQ (140 MG


COMETRIQ (60 MG


COMFORT ASSIST



COMFORT ASSURED


COMFORT ASSURED


COMFORT EZ INSULIN


COMFORT EZ MICRO


COMFORT EZ PEN


COMFORT EZ SHORT


COMFORT LANCETS Tier 2 QL

COMFORT TOUCH

INSULIN PEN NEED Tier 3 ST; QL

COMFORT TOUCH


COMFORT TOUCH

PLUS LANCETS 30G Tier 2 QL

COMPLERA ORAL


COMPLETE NATAL

DHA ORAL Tier 3

COMPLETENATE ORAL

TABLET CHEWABLE Tier 2

complex b-100 oral tablet


complex b-100-inositol oral

tablet extended release Tier 1 $0

complex b-50 prolonged

release oral tablet extended

release Tier 1 $0

compro rectal suppository Tier 1

COMTAN ORAL

TABLET Tier 3

CO-NATAL FA ORAL

TABLET Tier 3

CONCEPT DHA ORAL

CAPSULE Tier 3



34


CONCEPT OB ORAL

CAPSULE Tier 3

CONDYLOX EXTERNAL

GEL Tier 3

CONJUPRI ORAL

TABLET 2.5 MG Tier 3 ST; DO; QL

CONJUPRI ORAL

TABLET 5 MG Tier 3 ST; QL

constulose oral solution Tier 1

CONTRAVE ORAL

TABLET EXTENDED

RELEASE 12 HOUR Tier 3 PA; QL

CONZIP ORAL

CAPSULE EXTENDED


COPAXONE

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

COPIKTRA ORAL


coremino oral tablet

extended release 24 hour Tier 1 ST; QL

CORIFACT

INTRAVENOUS KIT Tier 4 PA; QL; LD; SP

CORLANOR ORAL


CORLANOR ORAL


CORLOPAM

INTRAVENOUS

SOLUTION Tier 3

CORN POLLEN

SUBCUTANEOUS

SOLUTION Tier 3

correctol oral tablet delayed

release Tier 1 $0

CORTEF ORAL TABLET Tier 3

CORTENEMA RECTAL

ENEMA Tier 3


CORTIFOAM

EXTERNAL FOAM Tier 3

corti-sav external cream Tier 1

CORTISPORIN-TC OTIC

SUSPENSION Tier 3

CORVERT

INTRAVENOUS

SOLUTION Tier 3

COSELA INTRAVENOUS

SOLUTION

RECONSTITUTED Tier 3 PA; QL; LD

COSENTYX (300 MG

DOSE) SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


COSENTYX

SENSOREADY (300 MG)

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


COSENTYX

SENSOREADY PEN

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


COSENTYX

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


COSMEGEN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

COTELLIC ORAL


COTEMPLA XR-ODT

ORAL TABLET

EXTENDED RELEASE

DISPERSIBLE

Tier 3 ST; QL

CREON ORAL CAPSULE

DELAYED RELEASE

PARTICLES Tier 2



35


CRESEMBA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL

CRESEMBA ORAL


CRINONE VAGINAL

GEL 4 % Tier 4 SP

CRINONE VAGINAL

GEL 8 % Tier 4 PA; QL; SP

CRIXIVAN ORAL

CAPSULE Tier 2 QL

CROFAB INTRAVENOUS

SOLUTION


cromolyn sodium inhalation


cromolyn sodium ophthalmic

solution Tier 1

cromolyn sodium oral

concentrate Tier 1

crotan external lotion Tier 1

CRYODOSE TA

EXTERNAL AEROSOL Tier 3

cryselle-28 oral tablet Tier 1 $0

CRYSVITA

SUBCUTANEOUS


CUBICIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

CUBICIN RF

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cupric chloride intravenous

solution Tier 1

curity sterile saline irrigation

solution Tier 1


CUROSURF

INTRATRACHEAL

SUSPENSION Tier 3

CURVULARIA

SUBCUTANEOUS

SOLUTION Tier 3

CUTAQUIG

SUBCUTANEOUS


CUVITRU

SUBCUTANEOUS


CUVPOSA ORAL

SOLUTION Tier 3

cvs aspirin adult low dose

oral tablet chewable Tier 1 $0

cvs aspirin adult low strength


cvs aspirin ec oral tablet


cvs aspirin low dose oral


cvs aspirin low strength oral


cvs aspirin oral tablet Tier 1 $0

cvs b complex plus c oral

tablet Tier 1 $0

cvs balanced b50 oral tablet Tier 1 $0

cvs bisacodyl oral tablet


cvs citrate of magnesia oral

solution Tier 1 $0

cvs c-lax laxative oral tablet


cvs folic acid oral tablet Tier 1 $0

cvs gentle laxative oral tablet


cvs gentle laxative womens


cvs inner ear plus oral tablet Tier 1 $0



36


CVS LANCETS 21G Tier 2 QL

CVS LANCETS MICRO

THIN 33G Tier 2 QL

CVS LANCETS

ORIGINAL Tier 2 QL

CVS LANCETS THIN 26G Tier 2 QL

CVS LANCETS ULTRA

THIN 30G Tier 2 QL

CVS LANCETS ULTRA-

THIN 30G Tier 2 QL

CVS LANCING DEVICE Tier 2

cvs magnesium citrate oral

solution Tier 1 $0

cvs milk of magnesia oral

suspension Tier 1 $0

cvs nicotine mouth/throat

gum Tier 1 $0

cvs nicotine mouth/throat

lozenge Tier 1 $0

cvs nicotine polacrilex

mouth/throat gum Tier 1 $0

cvs nicotine polacrilex

mouth/throat lozenge Tier 1 $0

cvs nicotine transdermal

patch 24 hour Tier 1 $0

CVS PRENATAL ORAL

TABLET Tier 2 $0

cvs purelax oral packet Tier 1 $0

cvs purelax oral powder Tier 1 $0

cvs super b complex/c oral

tablet Tier 1 $0

CVS ULTRA THIN

LANCETS Tier 2 QL

cyanocobalamin injection

solution 1000 mcg/ml Tier 1

CYANOCOBALAMIN

INJECTION SOLUTION

2000 MCG/ML Tier 3


CYANOKIT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

cyclafem 1/35 oral tablet Tier 1 $0

cyclafem 7/7/7 oral tablet Tier 1 $0

cyclobenzaprine hcl oral

tablet Tier 1

CYCLOGYL

OPHTHALMIC

SOLUTION Tier 3

CYCLOMYDRIL

OPHTHALMIC

SOLUTION Tier 3

CYCLOPAK

COMBINATION

THERAPY PACK Tier 3

cyclopentolate hcl


cyclophosphamide injection


CYCLOPHOSPHAMIDE

INTRAVENOUS

SOLUTION Tier 3 SP

cyclophosphamide oral

capsule Tier 1 SP

CYCLOPHOSPHAMIDE

ORAL TABLET Tier 3

cycloserine oral capsule Tier 1

CYCLOSET ORAL

TABLET Tier 3

cyclosporine intravenous

solution Tier 1 SP

cyclosporine modified oral

capsule Tier 1

cyclosporine modified oral

solution Tier 1

cyclosporine oral capsule Tier 1

CYKLOKAPRON

INTRAVENOUS

SOLUTION Tier 3



37


cyproheptadine hcl oral

syrup Tier 1

cyproheptadine hcl oral

tablet Tier 1

CYRAMZA

INTRAVENOUS


cyred eq oral tablet Tier 1 $0

cyred oral tablet Tier 1 $0

CYSTADANE ORAL

POWDER Tier 3 LD

CYSTADROPS

OPHTHALMIC


CYSTAGON ORAL

CAPSULE Tier 4 LD; SP

CYSTARAN

OPHTHALMIC


cytarabine (pf) injection

solution Tier 1 SP

cytarabine injection solution Tier 1 SP

CYTOGAM

INTRAVENOUS

INJECTABLE Tier 4 SP

CYTOMEL ORAL

TABLET Tier 3

CYTOTEC ORAL

TABLET Tier 3

dacarbazine intravenous


DACOGEN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

dactinomycin intravenous


daily multiple vitamins oral

tablet Tier 1 $0

daily multiple vitamins/iron



daily value multivitamin oral

tablet Tier 1 $0

daily vitamin formula+iron


daily vitamin oral tablet Tier 1 $0

daily vitamins oral tablet Tier 1 $0

daily vite multivitamin/iron


daily vite oral tablet Tier 1 $0

daily vites oral tablet Tier 1 $0

daily-vitamin oral tablet Tier 1 $0

daily-vitamin/iron oral tablet Tier 1 $0

daily-vite multivitamin oral

tablet Tier 1 $0

daily-vite oral tablet Tier 1 $0

dalfampridine er oral tablet

extended release 12 hour Tier 4 PA; QL; SP

DALIRESP ORAL


DALVANCE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

danazol oral capsule Tier 1

DANDELION

SUBCUTANEOUS

SOLUTION Tier 3

DANTRIUM

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

DANTRIUM ORAL

CAPSULE Tier 3

dantrolene sodium



dantrolene sodium oral

capsule Tier 1



38


DANYELZA

INTRAVENOUS


dapsone external gel 5 % Tier 1 ST; QL

dapsone external gel 7.5 % Tier 3 ST; QL

dapsone oral tablet Tier 1

DAPTACEL

INTRAMUSCULAR


DAPTOMYCIN

INTRAVENOUS

SOLUTION

RECONSTITUTED 350

MG

Tier 3

daptomycin intravenous

solution reconstituted 500

mg Tier 1

DARAPRIM ORAL


darifenacin hydrobromide er

oral tablet extended release

24 hour Tier 1

DARZALEX FASPRO

SUBCUTANEOUS


DARZALEX

INTRAVENOUS


dasetta 1/35 oral tablet Tier 1 $0

dasetta 7/7/7 oral tablet Tier 1 $0

DAUNORUBICIN HCL

INTRAVENOUS

SOLUTION Tier 3 SP

DAURISMO ORAL


DAYPRO ORAL TABLET Tier 3

daysee oral tablet Tier 1 $0

DAYTRANA

TRANSDERMAL PATCH

10 MG/9HR, 15 MG/9HR Tier 3 ST; DO; QL


DAYTRANA

TRANSDERMAL PATCH

20 MG/9HR, 30 MG/9HR Tier 3 ST; QL

DAYVIGO ORAL


DDAVP INJECTION

SOLUTION Tier 3

DDAVP ORAL TABLET

0.1 MG Tier 3 DO

DDAVP ORAL TABLET

0.2 MG Tier 3

DDAVP PF INJECTION

SOLUTION Tier 3

deblitane oral tablet Tier 1 $0

decadron oral tablet Tier 1 T1S

decitabine intravenous


deferasirox granules oral

packet Tier 4 PA; QL; SP

deferasirox oral packet Tier 4 PA; QL; SP

deferasirox oral tablet Tier 4 PA; QL; SP

deferasirox oral tablet

soluble Tier 4 PA; QL; SP

deferiprone oral tablet Tier 4 PA; QL

deferoxamine mesylate

injection solution

reconstituted Tier 4 SP

DEFITELIO

INTRAVENOUS

SOLUTION Tier 4

DEFLUX INJECTION


DELESTROGEN

INTRAMUSCULAR OIL Tier 3

DELFLEX-LC/1.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3



39


DELFLEX-LC/2.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DELFLEX-LC/4.25%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DELFLEX-SM/1.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 2

DELFLEX-SM/2.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DELSTRIGO ORAL

TABLET Tier 3 QL

delyla oral tablet Tier 1 $0

DELZICOL ORAL

CAPSULE DELAYED

RELEASE Tier 3 ST; QL

demeclocycline hcl oral

tablet Tier 1

DEMEROL INJECTION

SOLUTION Tier 3 QL

DEMSER ORAL


DENAVIR EXTERNAL

CREAM Tier 3 PA; QL

denta 5000 plus dental cream Tier 1

dentagel dental gel Tier 1

DEPEN TITRATABS

ORAL TABLET Tier 3 PA; QL; LD

DEPO-ESTRADIOL

INTRAMUSCULAR OIL Tier 3

DEPO-MEDROL

INJECTION

SUSPENSION Tier 3

DEPO-PROVERA

INTRAMUSCULAR

SUSPENSION Tier 3


DEPO-PROVERA

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3

DEPO-SUBQ PROVERA

104 SUBCUTANEOUS

SUSPENSION

PREFILLED SYRINGE

Tier 3 $0

DEPO-TESTOSTERONE

INTRAMUSCULAR


DERMOTIC OTIC OIL Tier 3

DESCOVY ORAL

TABLET Tier 3 QL; $0

DESFERAL INJECTION

SOLUTION


desflurane inhalation solution Tier 1

desipramine hcl oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet

dispersible Tier 1

desmopressin ace spray

refrig nasal solution Tier 1

desmopressin acetate


desmopressin acetate oral

tablet 0.1 mg Tier 1 DO

desmopressin acetate oral

tablet 0.2 mg Tier 1

desmopressin acetate pf


desmopressin acetate spray

nasal solution Tier 1

desogestrel-ethinyl estradiol

oral tablet 0.15-0.02/0.01 mg

(21/5) Tier 1 $0

desogestrel-ethinyl estradiol

oral tablet 0.15-30 mg-mcg Tier 1 $0

desonide external cream Tier 1



40


desonide external gel Tier 1

desonide external lotion Tier 1

desonide external ointment Tier 1

desoximetasone external

cream Tier 3 ST; QL

desoximetasone external gel Tier 3 ST; QL


liquid Tier 3 ST; QL


ointment Tier 3 ST; QL

desrx external gel Tier 1

DESVENLAFAXINE ER

ORAL TABLET

EXTENDED RELEASE 24

HOUR

Tier 3 ST; QL

desvenlafaxine succinate er


24 hour 100 mg Tier 1

desvenlafaxine succinate er


24 hour 25 mg, 50 mg Tier 1 DO

DEXABLISS ORAL

TABLET THERAPY

PACK Tier 3

DEXAMETHASONE

INTENSOL ORAL

CONCENTRATE Tier 2

dexamethasone oral elixir Tier 1 T1S

dexamethasone oral solution Tier 1 T1S

dexamethasone oral tablet Tier 1 T1S

dexamethasone oral tablet

therapy pack Tier 1

DEXAMETHASONE SOD

PHOS-NACL

INTRAVENOUS

SOLUTION

Tier 3

dexamethasone sod

phosphate pf injection

solution Tier 1


DEXAMETHASONE SOD

PHOSPHATE PF

INJECTION SOLUTION

PREFILLED SYRINGE

Tier 3

DEXAMETHASONE

SODIUM PHOSPHATE

INJECTION SOLUTION

10 MG/ML, 4 MG/ML

Tier 3

dexamethasone sodium

phosphate injection solution

100 mg/10ml, 120 mg/30ml,

20 mg/5ml

Tier 1

dexamethasone sodium

phosphate ophthalmic

solution Tier 1

DEXAMETHASONE-

MOXIFLOXACIN

INTRAOCULAR

SOLUTION

Tier 3

DEXAMETH-

MOXIFLOX-

KETOROLAC

INTRAOCULAR

SOLUTION

Tier 3

DEXCOM G4 PLAT PED

RCV/SHARE DEVICE Tier 2 PA; QL

DEXCOM G4 PLAT PED

RECEIVER DEVICE Tier 2 PA; QL

DEXCOM G4 PLATINUM

RCV/SHARE DEVICE Tier 2 PA; QL

DEXCOM G4 PLATINUM


DEXCOM G4 PLATINUM

TRANSMITTER Tier 2 PA; QL

DEXCOM G4 SENSOR Tier 2 PA; QL

DEXCOM G5 MOB/G4

PLAT SENSOR Tier 2 PA; QL

DEXCOM G5 MOBILE


DEXCOM G5 MOBILE




41


DEXCOM G5 RECEIVER

KIT DEVICE Tier 2 PA; QL

DEXCOM G6 RECEIVER

DEVICE Tier 2 PA; QL

DEXCOM G6 SENSOR Tier 2 PA; QL

DEXCOM G6


DEXILANT ORAL

CAPSULE DELAYED


dexmedetomidine hcl in nacl


DEXMEDETOMIDINE

HCL IN NACL

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

DEXMEDETOMIDINE

HCL INTRAVENOUS

SOLUTION 1000

MCG/10ML, 400

MCG/4ML

Tier 3

dexmedetomidine hcl

intravenous solution 200

mcg/2ml Tier 1

DEXMEDETOMIDINE

HCL-DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

dexmethylphenidate hcl er

oral capsule extended release

24 hour 10 mg, 15 mg, 20

mg, 5 mg

Tier 1 PA; DO; QL

dexmethylphenidate hcl er


24 hour 25 mg, 30 mg, 35

mg, 40 mg

Tier 1 PA; QL

dexmethylphenidate hcl oral

tablet 10 mg Tier 1 PA; QL

dexmethylphenidate hcl oral

tablet 2.5 mg, 5 mg Tier 1 PA; DO; QL

DEXPANTHENOL



dexrazoxane hcl intravenous


DEXTENZA

OPHTHALMIC INSERT Tier 3

dextroamphetamine sulfate er


24 hour 10 mg, 15 mg Tier 1 PA; QL

dextroamphetamine sulfate er


24 hour 5 mg Tier 1 PA; DO; QL

dextroamphetamine sulfate

oral solution Tier 1 PA; QL


oral tablet 10 mg, 15 mg, 20

mg, 30 mg Tier 1 PA; QL


oral tablet 5 mg Tier 1 PA; DO; QL

DEXTROSE

5%/ELECTROLYTE #48

INTRAVENOUS

SOLUTION

Tier 3

dextrose in lactated ringers


dextrose intravenous solution

10 %, 250 mg/ml, 5 %, 70 % Tier 1

DEXTROSE

INTRAVENOUS

SOLUTION 20 %, 40 % Tier 3

DEXTROSE-NACL

INTRAVENOUS

SOLUTION 10-0.2 %, 2.5-

0.45 %

Tier 3

dextrose-nacl intravenous

solution 10-0.45 %, 5-0.2 %,

5-0.33 %, 5-0.45 %, 5-0.9 % Tier 1

dextrose-sodium chloride

intravenous solution 2.5-0.45

%, 5-0.45 %, 5-0.9 % Tier 1

DEXTROSE-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION 5-0.225 %, 5-

0.3 %

Tier 3



42


DEXYCU

INTRAOCULAR

SUSPENSION Tier 3

DIACOMIT ORAL


DIACOMIT ORAL

PACKET Tier 4 PA; QL; LD

dialyvite 800 oral tablet Tier 1 $0

DIANEAL LOW

CALCIUM/1.5% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

DIANEAL LOW

CALCIUM/2.5% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

DIANEAL LOW

CALCIUM/4.25% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

DIANEAL PD-2/1.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DIANEAL PD-2/2.5%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DIANEAL PD-2/4.25%

DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

DIASTAT ACUDIAL

RECTAL GEL Tier 3

DIASTAT PEDIATRIC

RECTAL GEL Tier 3

DIATHRIVE LANCET

ULTRA THIN 30 Tier 2 QL

DIATHRIVE LANCETS Tier 2 QL

DIATHRIVE LANCING

DEVICE Tier 2


DIATHRIVE PEN


diazepam injection solution Tier 1

diazepam intensol oral

concentrate Tier 1

DIAZEPAM

INTRAMUSCULAR

SOLUTION AUTO-

INJECTOR

Tier 3

diazepam oral concentrate Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1

diazepam rectal gel Tier 1

diazoxide oral suspension Tier 1

DIBENZYLINE ORAL


diclofenac potassium oral

tablet Tier 1

diclofenac sodium er oral


hour Tier 1

diclofenac sodium external

gel Tier 1

diclofenac sodium


diclofenac sodium oral tablet

delayed release Tier 1

diclofenac-misoprostol oral

tablet delayed release Tier 1 ST; QL

dicloxacillin sodium oral

capsule Tier 1

dicyclomine hcl


dicyclomine hcl oral capsule Tier 1

dicyclomine hcl oral solution Tier 1

dicyclomine hcl oral tablet Tier 1



43


diethylpropion hcl er oral


hour Tier 1 PA; QL

diethylpropion hcl oral tablet Tier 1 PA; QL

DIFICID ORAL

SUSPENSION


DIFICID ORAL TABLET Tier 3

diflorasone diacetate external

cream Tier 3 ST; QL

diflorasone diacetate external


DIFLUCAN ORAL

SUSPENSION


DIFLUCAN ORAL

TABLET Tier 3

diflunisal oral tablet Tier 1

DIGIFAB

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

digitek oral tablet Tier 1

digox oral tablet Tier 1

digoxin injection solution Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

dihydroergotamine mesylate

injection solution Tier 1 PA; QL

DILANTIN INFATABS

ORAL TABLET

CHEWABLE Tier 3

DILANTIN ORAL

CAPSULE 100 MG Tier 3

DILANTIN ORAL

CAPSULE 30 MG Tier 2

DILANTIN ORAL

SUSPENSION Tier 3


DILAUDID INJECTION

SOLUTION Tier 3 QL

DILAUDID ORAL

LIQUID Tier 3 QL

DILAUDID ORAL

TABLET Tier 3 QL

diltiazem hcl er beads oral


hour 120 mg, 180 mg Tier 1 DO

diltiazem hcl er beads oral


hour 240 mg, 300 mg, 360

mg, 420 mg

Tier 1

diltiazem hcl er coated beads


24 hour 120 mg, 180 mg Tier 1 DO



24 hour 240 mg, 300 mg, 360

mg

Tier 1



24 hour 180 mg Tier 1 DO



24 hour 240 mg, 300 mg, 360

mg, 420 mg

Tier 1

diltiazem hcl er oral capsule







mg Tier 1

diltiazem hcl intravenous

solution Tier 1

DILTIAZEM HCL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

diltiazem hcl oral tablet 120

mg, 90 mg Tier 1



44


diltiazem hcl oral tablet 30

mg, 60 mg Tier 1 DO

DILTIAZEM HCL-

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

DILTIAZEM HCL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

dilt-xr oral capsule extended


mg Tier 1 DO

dilt-xr oral capsule extended

release 24 hour 240 mg Tier 1

DIMENHYDRINATE


dimethyl fumarate oral

capsule delayed release Tier 4 PA; QL; SP

dimethyl fumarate starter

pack oral Tier 4 PA; QL; SP

DIPENTUM ORAL


diphen oral elixir Tier 1

di-phen oral elixir Tier 1

diphenhydramine hcl


diphenhydramine hcl oral

elixir Tier 1

diphenoxylate-atropine oral

liquid Tier 1

diphenoxylate-atropine oral

tablet Tier 1

DIPHTHERIA-TETANUS

TOXOIDS DT

INTRAMUSCULAR

SUSPENSION

Tier 3 $0

DIPRIVAN

INTRAVENOUS

EMULSION Tier 3

dipyridamole oral tablet Tier 1


DISCOVISC

INTRAOCULAR

SOLUTION Tier 3

disopyramide phosphate oral

capsule Tier 1

disulfiram oral tablet Tier 1

DIURIL ORAL

SUSPENSION Tier 3

divalproex sodium er oral


hour Tier 1

divalproex sodium oral

capsule delayed release

sprinkle Tier 1

divalproex sodium oral tablet


DIVIGEL

TRANSDERMAL GEL Tier 2

dobutamine hcl intravenous

solution Tier 1

DOBUTAMINE IN D5W

INTRAVENOUS

SOLUTION Tier 3

DOCETAXEL

INTRAVENOUS

CONCENTRATE Tier 3 PA; QL; SP

DOCETAXEL

INTRAVENOUS


dofetilide oral capsule Tier 1

DOG EPITHELIUM

SUBCUTANEOUS

SOLUTION Tier 3

DOG FENNEL

SUBCUTANEOUS

SOLUTION Tier 3

DOJOLVI ORAL LIQUID Tier 4 PA; QL; LD; SP

dolishale oral tablet Tier 1 $0

donepezil hcl oral tablet 10

mg, 23 mg Tier 1



45


donepezil hcl oral tablet 5

mg Tier 1 DO

donepezil hcl oral tablet

dispersible Tier 1

dopamine hcl intravenous

solution Tier 1

DOPAMINE IN D5W

INTRAVENOUS

SOLUTION Tier 3

DOPRAM

INTRAVENOUS

SOLUTION Tier 3

DOPTELET ORAL


DORAL ORAL TABLET Tier 3 ST; QL

dorzolamide hcl ophthalmic

solution Tier 1

dorzolamide hcl-timolol mal


dorzolamide hcl-timolol mal

pf ophthalmic solution Tier 1

dotti transdermal patch twice

weekly Tier 1

DOVATO ORAL TABLET Tier 2

DOVONEX EXTERNAL

CREAM Tier 3

doxazosin mesylate oral

tablet Tier 1 T1S

doxepin hcl external cream Tier 1 PA; QL

doxepin hcl oral capsule Tier 1 T1S

doxepin hcl oral concentrate Tier 1 T1S

doxepin hcl oral tablet Tier 1 ST; QL

doxercalciferol intravenous


doxercalciferol oral capsule Tier 1 PA; QL

DOXIL INTRAVENOUS

INJECTABLE Tier 3 PA; QL; SP

doxorubicin hcl intravenous

solution Tier 1 SP


doxorubicin hcl intravenous


doxorubicin hcl liposomal

intravenous injectable Tier 1 PA; QL; SP

doxy 100 intravenous


doxycycline hyclate



doxycycline hyclate oral

capsule Tier 1

doxycycline hyclate oral

tablet Tier 1

doxycycline monohydrate

oral capsule 100 mg, 50 mg,

75 mg Tier 1


oral capsule 150 mg Tier 3




oral tablet Tier 1

doxylamine-pyridoxine oral

tablet delayed release Tier 1 PA; QL

DRECHSLERA

SUBCUTANEOUS

SOLUTION Tier 3

DRISDOL ORAL

CAPSULE Tier 3

dronabinol oral capsule Tier 1

droperidol injection solution Tier 1

DROPLET GENTEEL

LANCING DEVICE Tier 2



46


DROPLET INSULIN

SYRINGE 29G X 1/2" 0.3

ML, 29G X 1/2" 0.5 ML,

29G X 1/2" 1 ML, 30G X

1/2" 0.3 ML, 30G X 1/2"

0.5 ML, 30G X 1/2" 1 ML,

30G X 15/64" 0.3 ML, 30G

X 15/64" 1 ML, 30G X

5/16" 0.3 ML, 30G X 5/16"

0.5 ML, 30G X 5/16" 1 ML,

31G X 15/64" 0.3 ML, 31G

X 15/64" 0.5 ML, 31G X

15/64" 1 ML, 31G X 5/16"

0.3 ML, 31G X 5/16" 0.5

ML, 31G X 5/16" 1 ML

Tier 3 ST; QL

DROPLET INSULIN

SYRINGE 30G X 15/64"

0.5 ML Tier 3

DROPLET LANCETS

ULTRA THIN 30G Tier 2 QL

DROPLET LANCING

DEVICE Tier 2

DROPLET MICRON Tier 3

DROPLET PEN


DROPLET PERSONAL


DROPSAFE SAFETY PEN


drospiren-eth estrad-

levomefol oral tablet Tier 1 $0

drospirenone-ethinyl

estradiol oral tablet Tier 1 $0

DROXIA ORAL

CAPSULE Tier 2

droxidopa oral capsule Tier 1 PA; QL; LD; SP

DRUG MART LANCETS

THIN 26G Tier 2 QL

DRUG MART LANCING

DEVICE Tier 2

DRUG MART ON-THE-

GO LANCET 30G Tier 2 QL


DRUG MART UNIFINE


DRUG MART UNIFINE


DRUG MART UNILET


DRUG MART UNILET


DRUG MART UNILET


DSUVIA SUBLINGUAL

TABLET SUBLINGUAL Tier 3

DUAVEE ORAL TABLET Tier 3 PA; QL

DUET DHA 400 ORAL Tier 3 ST; QL

DUET DHA BALANCED

ORAL Tier 3 ST; QL

DUETACT ORAL


dulcolax milk of magnesia

oral suspension Tier 1 $0

dulcolax oral suspension Tier 1 $0

duloxetine hcl oral capsule

delayed release particles 20

mg, 40 mg, 60 mg Tier 1

duloxetine hcl oral capsule

delayed release particles 30

mg Tier 1 DO

DUOBRII EXTERNAL

LOTION Tier 3 PA; QL

DUODOTE

INTRAMUSCULAR

SOLUTION AUTO-

INJECTOR

Tier 3

DUOPA ENTERAL

SUSPENSION Tier 3 PA; QL; LD; SP

DUOVISC

INTRAOCULAR KIT Tier 3

DUPIXENT

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP



47


DUPIXENT

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

DURACLON EPIDURAL

SOLUTION Tier 3

duramorph injection solution Tier 1 QL

DUREZOL

OPHTHALMIC

EMULSION Tier 2

DURLAZA ORAL

CAPSULE EXTENDED


DUROLANE INTRA-

ARTICULAR

PREFILLED SYRINGE Tier 4 PA; QL

DURYSTA

INTRAOCULAR

IMPLANT Tier 4 PA; QL; LD; SP

DUST MITE MIXED

ALLERGEN EXT


DUST MITE MIXED

ALLERGEN EXT

SUBCUTANEOUS

SOLUTION

Tier 3

dutasteride oral capsule Tier 1

dutasteride-tamsulosin hcl

oral capsule Tier 1

DUTOPROL ORAL

TABLET EXTENDED


DXEVO 11-DAY ORAL

TABLET THERAPY

PACK Tier 3

DYANAVEL XR ORAL

SUSPENSION

EXTENDED RELEASE Tier 3 ST; QL

DYMISTA NASAL

SUSPENSION Tier 3


DYSPORT

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

e.e.s. 400 oral tablet Tier 1

ear health formula oral tablet Tier 1 $0

ear health plus oral tablet Tier 1 $0

EASTERN

COTTONWOOD

SUBCUTANEOUS

SOLUTION

Tier 3

EASY COMFORT


EASY COMFORT

LANCETS Tier 2 QL

EASY COMFORT

LANCETS TWIST TOP Tier 2 QL

EASY COMFORT PEN


EASY GLIDE PEN


EASY MINI EJECT


EASY MINI LANCING

DEVICE Tier 2

EASY TOUCH

FLIPLOCK INSULIN SY Tier 3 ST; QL

EASY TOUCH INSULIN

SAFETY SYR Tier 3 ST; QL

EASY TOUCH INSULIN


EASY TOUCH LANCETS

21G Tier 2 QL

EASY TOUCH LANCETS

23G Tier 2 QL

EASY TOUCH LANCETS

26G Tier 2 QL

EASY TOUCH LANCETS

28G Tier 2 QL

EASY TOUCH LANCETS

28G/TWIST Tier 2 QL



48


EASY TOUCH LANCETS

30G Tier 2 QL

EASY TOUCH LANCETS

30G/TWIST Tier 2 QL

EASY TOUCH LANCETS

32G Tier 2 QL

EASY TOUCH LANCETS

32G/TWIST Tier 2 QL

EASY TOUCH LANCETS

33G/TWIST Tier 2 QL

EASY TOUCH LANCING

DEVICE Tier 2

EASY TOUCH PEN


EASY TOUCH SAFETY


EASY TOUCH SAFETY


EASY TOUCH SAFETY


EASY TOUCH SAFETY


EASY TOUCH SAFETY


EASY TOUCH

SHEATHLOCK


easygel dental gel Tier 1

ec-naproxen oral tablet


econazole nitrate external

cream Tier 1

econtra ez oral tablet Tier 1 $0

econtra one-step oral tablet Tier 1 $0

ecotrin low strength oral


ECOZA EXTERNAL

FOAM Tier 3 ST; QL

EDARBI ORAL TABLET

40 MG Tier 3 DO


EDARBI ORAL TABLET

80 MG Tier 3

EDARBYCLOR ORAL

TABLET Tier 3

EDECRIN ORAL

TABLET Tier 3

EDETATE DISODIUM

INTRAVENOUS

SOLUTION Tier 3

EDEX

INTRACAVERNOSAL

KIT Tier 3 PA; QL

EDLUAR SUBLINGUAL

TABLET SUBLINGUAL Tier 3 ST; QL

EDURANT ORAL


efavirenz oral capsule Tier 1 QL

efavirenz oral tablet Tier 1 QL

efavirenz-emtricitab-

tenofovir oral tablet Tier 1

efavirenz-lamivudine-

tenofovir oral tablet Tier 1 QL

EFUDEX EXTERNAL

CREAM Tier 3 ST; QL

EGRIFTA SV

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD

ELAPRASE

INTRAVENOUS


ELCYS INTRAVENOUS

SOLUTION Tier 3

ELELYSO

INTRAVENOUS

SOLUTION

RECONSTITUTED


ELEPSIA XR ORAL

TABLET EXTENDED


ELESTRIN




49


eletriptan hydrobromide oral

tablet Tier 1 QL

ELIGARD


elinest oral tablet Tier 1 $0

ELIQUIS DVT/PE

STARTER PACK ORAL

TABLET THERAPY

PACK

Tier 2

ELIQUIS ORAL TABLET Tier 2

ELITEK INTRAVENOUS

SOLUTION


elite-ob oral tablet Tier 1

ELIXOPHYLLIN ORAL

ELIXIR Tier 2

ELLA ORAL TABLET Tier 3 $0

ELLENCE

INTRAVENOUS


ELLIOTTS B

INTRATHECAL

SOLUTION Tier 3

ELMIRON ORAL

CAPSULE Tier 3

ELOCTATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

eluryng vaginal ring Tier 1 $0

ELZONRIS

INTRAVENOUS


EMBRACE LANCETS


EMBRACE LANCING

DEVICE/EJECTOR Tier 2

EMBRACE PRESSURE

ACTIVATED 21G Tier 2 QL

EMBRACE PRESSURE

ACTIVATED 28G Tier 2 QL


EMCYT ORAL CAPSULE Tier 2 PA; QL

EMEND ORAL

SUSPENSION


EMERPHED

INTRAVENOUS

SOLUTION Tier 3

EMGALITY (300 MG

DOSE) SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3 PA; QL

EMGALITY

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

EMGALITY

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3 PA; QL

emoquette oral tablet Tier 1 $0

EMPAVELI

SUBCUTANEOUS


EMPLICITI

INTRAVENOUS

SOLUTION

RECONSTITUTED


EMSAM

TRANSDERMAL PATCH

24 HOUR Tier 3

emtricitabine oral capsule Tier 1 $0

emtricitabine-tenofovir df

oral tablet 100-150 mg, 133-

200 mg, 167-250 mg Tier 1

emtricitabine-tenofovir df

oral tablet 200-300 mg Tier 1 QL; $0

EMTRIVA ORAL

CAPSULE Tier 3 QL

EMTRIVA ORAL

SOLUTION Tier 2 QL

EMVERM ORAL




50


enalapril maleate oral

solution Tier 1

enalapril maleate oral tablet Tier 1

enalaprilat intravenous

injectable Tier 1

enalapril-hydrochlorothiazide

oral tablet Tier 1

ENBRACE HR ORAL


ENBREL MINI

SUBCUTANEOUS

SOLUTION CARTRIDGE Tier 4 PA; QL; SP

ENBREL

SUBCUTANEOUS


ENBREL

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

ENBREL

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

ENBREL SURECLICK

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

ENCARE VAGINAL

SUPPOSITORY Tier 2 $0

ENDARI ORAL PACKET Tier 4 PA; QL; LD

ENDO AVITENE

EXTERNAL Tier 3

endocet oral tablet Tier 1 QL

ENDOMETRIN

VAGINAL INSERT Tier 3 PA; QL

endur-b oral tablet extended

release Tier 1 $0

ENFAMIL EXPECTA

ORAL Tier 2 $0

ENGERIX-B INJECTION



ENHERTU

INTRAVENOUS

SOLUTION

RECONSTITUTED


ENLITE GLUCOSE

SENSOR Tier 3 PA; QL

enoxaparin sodium injection

solution Tier 4

enoxaparin sodium

subcutaneous solution Tier 4

enpresse-28 oral tablet Tier 1 $0

enskyce oral tablet Tier 1 $0

ENSPRYNG

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


ENSTILAR EXTERNAL

FOAM Tier 3

entacapone oral tablet Tier 1

entecavir oral tablet Tier 4

ENTEREG ORAL

CAPSULE Tier 3

ENTOCORT EC ORAL

CAPSULE DELAYED

RELEASE PARTICLES Tier 3

ENTRESTO ORAL

TABLET Tier 3

ENTYVIO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

enulose oral solution Tier 1

ENVARSUS XR ORAL

TABLET EXTENDED


EPANED ORAL

SOLUTION Tier 3

EPCLUSA ORAL




51


EPHEDRINE SULFATE

(PRESSORS) INJECTION

SOLUTION PREFILLED

SYRINGE

Tier 3

EPHEDRINE SULFATE

INTRAVENOUS

SOLUTION Tier 3

EPHEDRINE SULFATE-

NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

EPICOCCUM NIGRUM


EPICOCCUM

SUBCUTANEOUS

SOLUTION Tier 3

EPICORD EXTERNAL

SHEET Tier 3

EPIDIOLEX ORAL


EPIFIX EXTERNAL DISK Tier 3

EPIFIX EXTERNAL

SHEET Tier 3

EPIFIX MICRONIZED

INJECTION

SUSPENSION

RECONSTITUTED

Tier 3

EPIFOAM EXTERNAL

FOAM Tier 3

epinastine hcl ophthalmic

solution Tier 1

epinephrine (anaphylaxis)


EPINEPHRINE HCL

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

EPINEPHRINE HCL-

NACL INTRAVENOUS

SOLUTION Tier 3

epinephrine injection

solution auto-injector Tier 1


EPINEPHRINE

INJECTION SOLUTION


EPINEPHRINE

INTRAVENOUS

SOLUTION Tier 3

EPINEPHRINE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

EPINEPHRINE PF


EPINEPHRINE-

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

EPINEPHRINE-NACL

INTRAVENOUS

SOLUTION Tier 3

epirubicin hcl intravenous

solution Tier 1 PA; QL; SP

epitol oral tablet Tier 1

EPIVIR HBV ORAL

SOLUTION Tier 4

EPIVIR HBV ORAL

TABLET Tier 4

EPIVIR ORAL

SOLUTION Tier 3 QL

EPIVIR ORAL TABLET Tier 3 QL

eplerenone oral tablet Tier 1

EPOGEN INJECTION


epoprostenol sodium


reconstituted Tier 4 PA; QL; LD; SP

eptifibatide intravenous

solution Tier 1

EPZICOM ORAL

TABLET Tier 3 QL

eq aspirin adult low dose oral




52


eq aspirin low dose oral


eq aspirin oral tablet Tier 1 $0

eq clearlax oral powder Tier 1 $0

eq gentle laxative oral tablet


eq magnesium citrate oral

solution Tier 1 $0

eq nicotine mouth/throat

lozenge Tier 1 $0

eq nicotine polacrilex


eq nicotine polacrilex


eq nicotine step 3

transdermal patch 24 hour Tier 1 $0

eq nicotine transdermal patch

24 hour Tier 1 $0

eql aspirin ec oral tablet


eql aspirin low dose oral


eql aspirin low dose oral


eql b complex 50 oral tablet Tier 1 $0

eql b-100 complex oral tablet


eql clearlax oral powder Tier 1 $0

EQL COLOR LANCETS

21G Tier 2 QL

EQL COLOR LANCETS

MICRO 33G Tier 2 QL

eql gentle laxative oral tablet


EQL INSULIN SYRINGE Tier 3 ST; QL

eql laxative oral tablet


eql magnesium citrate oral

solution Tier 1 $0


eql milk of magnesia oral


eql nicotine polacrilex


EQL PRENATAL

FORMULA ORAL

TABLET Tier 2 $0

eql super b complex/vitamin

c oral tablet Tier 1 $0

EQL SUPER THIN


EQL THIN LANCETS

26G Tier 2 QL

EQUETRO ORAL

CAPSULE EXTENDED


ERAXIS INTRAVENOUS

SOLUTION


ERBITUX

INTRAVENOUS


ergocalciferol oral capsule Tier 1

ergoloid mesylates oral tablet Tier 1

ergotamine-caffeine oral

tablet Tier 1

ERIVEDGE ORAL


ERLEADA ORAL


erlotinib hcl oral tablet Tier 1 PA; QL; SP

errin oral tablet Tier 1 $0

ERTACZO EXTERNAL

CREAM Tier 3 ST; QL

ertapenem sodium injection


ERWINASE INJECTION

SOLUTION


ery external pad Tier 1



53


ERYGEL EXTERNAL

GEL Tier 3

ery-tab oral tablet delayed

release Tier 1

ERYTHROCIN

LACTOBIONATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

erythrocin stearate oral tablet Tier 1

erythromycin base oral

capsule delayed release

particles Tier 1

erythromycin base oral tablet Tier 1

erythromycin base oral tablet


erythromycin ethylsuccinate


erythromycin ethylsuccinate

oral tablet Tier 1

erythromycin external gel Tier 1

erythromycin external

solution Tier 1

erythromycin ophthalmic

ointment Tier 1

erythromycin oral tablet


ESBRIET ORAL


ESBRIET ORAL TABLET Tier 4 PA; QL; LD; SP

escitalopram oxalate oral

solution Tier 1


tablet 10 mg, 5 mg Tier 1 DO


tablet 20 mg Tier 1

esgic oral capsule Tier 1

ESKATA EXTERNAL

SOLUTION Tier 3


esmolol hcl intravenous

solution 100 mg/10ml Tier 1

ESMOLOL HCL

INTRAVENOUS

SOLUTION 2000

MG/100ML, 2500

MG/250ML

Tier 3

ESMOLOL HCL

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

esmolol hcl-sodium chloride


esomeprazole sodium



ESPEROCT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

est estrogens-methyltest oral

tablet Tier 1

estarylla oral tablet Tier 1 $0

estazolam oral tablet Tier 1

ESTRADIOL IMPLANT

PELLET Tier 3

estradiol oral tablet Tier 1 T1S

estradiol transdermal patch

twice weekly Tier 1

estradiol transdermal patch

weekly Tier 1 T1S

estradiol vaginal cream Tier 1

estradiol vaginal tablet Tier 1

estradiol valerate

intramuscular oil Tier 1

estradiol-norethindrone acet

oral tablet Tier 1

ESTRING VAGINAL

RING Tier 3

ESTROFACTORS ORAL

TABLET Tier 2 $0



54


ESTROGEL


ESTROSTEP FE ORAL

TABLET Tier 3

eszopiclone oral tablet Tier 1

ethacrynate sodium



ethacrynic acid oral tablet Tier 1

ethambutol hcl oral tablet Tier 1

ETHAMOLIN

INTRAVENOUS

SOLUTION Tier 3

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

ethynodiol diac-eth estradiol


ETHYOL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

etodolac er oral tablet


etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etomidate intravenous

solution Tier 1

etonogestrel-ethinyl estradiol

vaginal ring Tier 1 $0

ETOPOPHOS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

etoposide intravenous

solution Tier 1 SP

etoposide oral capsule Tier 1 SP

etravirine oral tablet Tier 1 PA; QL

EUCRISA EXTERNAL



EUFLEXXA INTRA-

ARTICULAR SOLUTION


euthyrox oral tablet Tier 1 T1S

EVAMIST

TRANSDERMAL

SOLUTION Tier 2

EVEKEO ODT ORAL

TABLET DISPERSIBLE Tier 3 ST; QL

EVENITY

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

everolimus oral tablet 0.25

mg, 0.5 mg, 0.75 mg Tier 1

everolimus oral tablet 2.5

mg, 5 mg, 7.5 mg Tier 1 PA; QL; SP

EVERSENSE

SENSOR/HOLDER Tier 3 PA; QL

EVERSENSE SMART


EVISTA ORAL TABLET Tier 3 $0

EVKEEZA

INTRAVENOUS


EVOCLIN EXTERNAL

FOAM Tier 3 ST; QL

EVOMELA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 LD; SP

EVOTAZ ORAL TABLET Tier 3 QL

EVOXAC ORAL

CAPSULE Tier 3

EVRYSDI ORAL

SOLUTION


EXEL COMFORT POINT

INSULIN SYR Tier 3 ST; QL

EXEL COMFORT POINT

PEN NEEDLE Tier 3 ST; QL



55


EXELDERM EXTERNAL

CREAM Tier 3 ST; QL

EXELDERM EXTERNAL

SOLUTION Tier 3 ST; QL

EXELON

TRANSDERMAL PATCH

24 HOUR Tier 3 ST; QL

exemestane oral tablet Tier 1 $0

ex-lax ultra oral tablet


EXONDYS 51

INTRAVENOUS


EXSERVAN ORAL FILM Tier 4

EXTAVIA


EXTINA EXTERNAL

FOAM Tier 3

EXTRANEAL

INTRAPERITONEAL

SOLUTION Tier 3

EYLEA INTRAVITREAL


EYLEA INTRAVITREAL

SOLUTION PREFILLED

SYRINGE Tier 4 PA; QL; LD

E-Z JECT LANCET

MICRO-THIN 33G Tier 2 QL

E-Z JECT LANCET


E-Z JECT LANCETS Tier 2 QL

E-Z JECT LANCETS 21G Tier 2 QL

E-Z JECT LANCETS

THIN 26G Tier 2 QL

ezetimibe oral tablet Tier 1 ST; QL

ezetimibe-simvastatin oral


EZ-LETS LANCETS 21G Tier 2 QL





fa-8 oral capsule Tier 1 $0

FABRAZYME

INTRAVENOUS

SOLUTION

RECONSTITUTED


falmina oral tablet Tier 1 $0

famciclovir oral tablet Tier 1

famotidine intravenous

solution Tier 1

famotidine oral suspension


famotidine oral tablet Tier 1

famotidine premixed


FANAPT ORAL TABLET

1 MG, 2 MG, 4 MG, 6 MG Tier 3 ST; DO; QL

FANAPT ORAL TABLET

10 MG, 12 MG, 8 MG Tier 3 ST; QL

FANAPT TITRATION

PACK ORAL TABLET Tier 3 ST; QL

FARESTON ORAL

TABLET Tier 3

FARXIGA ORAL


FARYDAK ORAL


FASENRA PEN

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; LD

FASENRA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


FASLODEX

INTRAMUSCULAR


fa-vitamin b-6-vitamin b-12

oral tablet Tier 1



56


fayosim oral tablet Tier 1 $0

FC FEMALE CONDOM Tier 2 $0

FC2 FEMALE CONDOM Tier 2 $0

febuxostat oral tablet Tier 1 ST; QL

feenamint oral tablet delayed

release Tier 1 $0

FEIBA INTRAVENOUS

SOLUTION


felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

FELDENE ORAL

CAPSULE Tier 3

felodipine er oral tablet


mg Tier 1

felodipine er oral tablet

extended release 24 hour 2.5

mg, 5 mg Tier 1 DO

FEMARA ORAL TABLET Tier 3

FEMCAP VAGINAL

DEVICE Tier 2 $0

FEMHRT ORAL TABLET Tier 3

FEMRING VAGINAL

RING Tier 3

femynor oral tablet Tier 1 $0

fenofibrate micronized oral

capsule Tier 1

fenofibrate oral capsule Tier 1

fenofibrate oral tablet 120

mg, 40 mg Tier 3

fenofibrate oral tablet 145

mg, 160 mg, 48 mg, 54 mg Tier 1

fenofibric acid oral capsule


fenofibric acid oral tablet Tier 1

FENOGLIDE ORAL



FENSOLVI (6 MONTH)

SUBCUTANEOUS KIT Tier 3 PA; QL; LD; SP

FENTANYL CITRATE

(PF) INJECTION

SOLUTION 100

MCG/2ML, 250

MCG/5ML, 50 MCG/ML

Tier 3

fentanyl citrate (pf) injection

solution 1000 mcg/20ml,

2500 mcg/50ml, 500

mcg/10ml

Tier 1

fentanyl citrate (pf) injection


fentanyl citrate buccal

lozenge on a handle Tier 1 PA; QL

fentanyl citrate buccal tablet Tier 1 PA; QL

FENTANYL CITRATE

INTRAVENOUS

SOLUTION Tier 3

FENTANYL CITRATE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

FENTANYL CITRATE PF

INJECTION SOLUTION


FENTANYL CITRATE-

NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

FENTANYL CIT-

ROPIVACAINE-NACL

EPIDURAL SOLUTION Tier 3

fentanyl transdermal patch

72 hour Tier 1 PA; QL

FENTANYL-

BUPIVACAINE-NACL

EPIDURAL SOLUTION Tier 3

FENTORA BUCCAL


FERAHEME

INTRAVENOUS




57


FERRIPROX ORAL


FERRIPROX TWICE-A-

DAY ORAL TABLET Tier 4 PA; QL; LD

FERRLECIT

INTRAVENOUS


ferumoxytol intravenous


FETROJA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

FETZIMA ORAL

CAPSULE EXTENDED


FETZIMA TITRATION

ORAL CAPSULE ER 24

HOUR THERAPY PACK Tier 3 ST; QL

fexmid oral tablet Tier 1 ST; QL

FIBRICOR ORAL


FIBRYGA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL

FIFTY50 PEN NEEDLES Tier 3 ST; QL

FIFTY50 SAFETY SEAL

LANCETS Tier 2 QL

FIFTY50 SUPERIOR

COMFORT SYR Tier 3 ST; QL

FIFTY50 UNILET


FINACEA EXTERNAL

FOAM Tier 2

finasteride oral tablet Tier 1

FINE 30 Tier 2 QL

FINGERSTIX LANCETS Tier 2 QL

FINTEPLA ORAL



FIRDAPSE ORAL


FIRE ANT

SUBCUTANEOUS

SOLUTION Tier 3

FIRMAGON (240 MG

DOSE) SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

FIRMAGON

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

FIRVANQ ORAL

SOLUTION


flac otic oil Tier 1

FLAGYL ORAL

CAPSULE Tier 3

FLAREX OPHTHALMIC

SUSPENSION Tier 3

flavoxate hcl oral tablet Tier 1

FLEBOGAMMA DIF

INTRAVENOUS


flecainide acetate oral tablet Tier 1

FLEXBUMIN

INTRAVENOUS

SOLUTION Tier 3

FLEXIN EXTERNAL

PATCH Tier 3

FLOLAN INTRAVENOUS

SOLUTION

RECONSTITUTED Tier 4 PA; QL; LD; SP

FLORIVA ORAL LIQUID Tier 3

FLORIVA ORAL


FLORIVA PLUS ORAL

SOLUTION Tier 3



58


FLOVENT DISKUS

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

FLOVENT HFA


floxuridine injection solution


FLUAD

QUADRIVALENT

INTRAMUSCULAR

PREFILLED SYRINGE

Tier 2 $0

FLUARIX

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 QL; $0

FLUBLOK

QUADRIVALENT

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE

Tier 2 QL; $0

FLUCELVAX

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

Tier 2 QL; $0

FLUCELVAX

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 QL; $0

fluconazole in sodium

chloride intravenous solution Tier 1

fluconazole oral suspension


fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1 PA; QL

fludarabine phosphate

intravenous solution Tier 1 SP

fludarabine phosphate




fludrocortisone acetate oral

tablet Tier 1

FLULAVAL

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 QL; $0

flumazenil intravenous

solution Tier 1

FLUMIST

QUADRIVALENT NASAL


flunisolide nasal solution Tier 3 ST; QL

fluocinolone acetonide body

external oil Tier 1 ST; QL

fluocinolone acetonide






fluocinolone acetonide otic

oil Tier 1

fluocinolone acetonide scalp

external oil Tier 1

fluocinonide emulsified base


fluocinonide external cream Tier 1

fluocinonide external gel Tier 1

fluocinonide external

ointment Tier 1

fluocinonide external

solution Tier 1

FLUORESCEIN

SODIUM/BENOXINATE

OPHTHALMIC

SOLUTION

Tier 3

fluorescein-benoxinate




59


FLUORESCITE

INTRAVENOUS

SOLUTION Tier 3

fluoridex daily renewal

mouth/throat concentrate Tier 1

fluoridex dental paste Tier 1

fluoridex enhanced

whitening dental paste Tier 1

fluoridex sensitivity relief

dental paste Tier 1

fluor-i-strips a.t. ophthalmic

strip Tier 1

fluoritab oral solution Tier 1 $0

fluorometholone ophthalmic

suspension Tier 1

FLUOROPLEX

EXTERNAL CREAM Tier 3 ST; QL

fluorouracil external cream

0.5 % Tier 1 ST; QL

fluorouracil external cream 5

% Tier 1

fluorouracil external solution Tier 1

fluorouracil intravenous

solution Tier 1 SP

fluoxetine hcl (pmdd) oral


fluoxetine hcl (pmdd) oral

tablet 20 mg Tier 1

fluoxetine hcl oral capsule 10

mg Tier 1 DO

fluoxetine hcl oral capsule 20

mg, 40 mg Tier 1

fluoxetine hcl oral capsule


fluoxetine hcl oral solution Tier 1

fluoxetine hcl oral tablet 10

mg Tier 1 DO

fluoxetine hcl oral tablet 20

mg Tier 1


FLUOXETINE HCL

ORAL TABLET 60 MG Tier 3

fluphenazine decanoate


fluphenazine hcl injection

solution Tier 1

fluphenazine hcl oral

concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

flurandrenolide external

cream Tier 3 ST; QL


lotion Tier 3 ST; QL



FLURA-SAFE

OPHTHALMIC

SOLUTION Tier 3

flurazepam hcl oral capsule Tier 1

flurbiprofen oral tablet Tier 1

flurbiprofen sodium


flutamide oral capsule Tier 1

fluticasone propionate






fluticasone propionate nasal

suspension Tier 1

fluticasone-salmeterol

inhalation aerosol powder

breath activated Tier 1

fluvastatin sodium oral

capsule Tier 1 DO; $0



60


fluvoxamine maleate er oral


hour Tier 1

fluvoxamine maleate oral

tablet 100 mg Tier 1

fluvoxamine maleate oral

tablet 25 mg, 50 mg Tier 1 DO

FLUZONE HIGH-DOSE

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 $0

FLUZONE

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

Tier 2 QL; $0

FLUZONE

QUADRIVALENT

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 QL; $0

FML FORTE

OPHTHALMIC

SUSPENSION Tier 3

FML LIQUIFILM

OPHTHALMIC

SUSPENSION Tier 3

FML OPHTHALMIC

OINTMENT Tier 3

FOCALIN ORAL

TABLET 10 MG Tier 3 PA; QL

FOCALIN ORAL

TABLET 2.5 MG, 5 MG Tier 3 PA; DO; QL

folate oral tablet Tier 1 $0

FOLGARD OS ORAL

TABLET Tier 3

FOLGARD RX ORAL

TABLET Tier 3

folic acid injection solution Tier 1

folic acid oral capsule Tier 1 $0

folic acid oral tablet 1 mg Tier 1


folic acid oral tablet 400

mcg, 800 mcg Tier 1 $0

FOLIVANE-OB ORAL

CAPSULE Tier 2

FOLOTYN

INTRAVENOUS

SOLUTION Tier 3 SP

foltabs 800 oral tablet Tier 1 $0

foltrin oral capsule Tier 1

fomepizole intravenous

solution Tier 1

fondaparinux sodium

subcutaneous solution Tier 4

FORA LANCETS Tier 2 QL

FORA LANCING

DEVICE Tier 2

FORANE INHALATION

SOLUTION Tier 3

FORMALDEHYDE

EXTERNAL SOLUTION Tier 3

formoterol fumarate

inhalation nebulization

solution Tier 1

FORTAZ INJECTION

SOLUTION


FORTAZ INTRAVENOUS

SOLUTION


FORTEO

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

FOSAMAX ORAL

TABLET Tier 3

FOSAMAX PLUS D

ORAL TABLET Tier 2

fosamprenavir calcium oral

tablet Tier 1 QL



61


fosaprepitant dimeglumine


reconstituted Tier 1 PA; QL

foscarnet sodium intravenous

solution Tier 1

FOSCAVIR

INTRAVENOUS

SOLUTION Tier 3

fosfomycin tromethamine

oral packet Tier 1

fosinopril sodium oral tablet Tier 1 T1S

fosinopril sodium-hctz oral

tablet Tier 1

fosphenytoin sodium


FOSRENOL ORAL

PACKET Tier 3 ST; QL

FOSRENOL ORAL

TABLET CHEWABLE Tier 3 ST; QL

FOTIVDA ORAL


FRAGMIN

SUBCUTANEOUS

SOLUTION Tier 4 QL

FREAMINE III

INTRAVENOUS

SOLUTION Tier 3

FREDS PHARMACY

AUTOLET LANCING Tier 2

FREDS PHARMACY

UNIFINE PENTIP+ Tier 3 ST; QL

FREDS PHARMACY

UNIFINE PENTIPS Tier 3 ST; QL

FREDS PHARMACY

UNILET LANC 28G Tier 2 QL

FREDS PHARMACY

UNILET LANC 30G Tier 2 QL

FREESTYLE LANCETS Tier 2 QL

FREESTYLE LIBRE 14

DAY READER DEVICE Tier 2 PA; QL


FREESTYLE LIBRE 14

DAY SENSOR Tier 2 PA; QL

FREESTYLE LIBRE 2

READER DEVICE Tier 2 PA; QL

FREESTYLE LIBRE 2

SENSOR Tier 2 PA; QL

FREESTYLE LIBRE

READER DEVICE Tier 2 PA; QL

FREESTYLE PRECISION

INS SYR Tier 3 ST; QL

FREESTYLE UNISTICK

II LANCETS Tier 2 QL

fresenius propoven

intravenous emulsion Tier 1

frovatriptan succinate oral


FULL SPECTRUM

B/VITAMIN C ORAL

TABLET Tier 2 $0

FULPHILA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

fulvestrant intramuscular


FUROSEMIDE IN

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

furosemide injection solution Tier 1

furosemide oral solution Tier 1 T1S

furosemide oral tablet Tier 1 T1S

FUSARIUM

SUBCUTANEOUS

SOLUTION Tier 3

FUZEON

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 2 PA; QL

fyavolv oral tablet Tier 1



62


FYCOMPA ORAL

SUSPENSION Tier 3

FYCOMPA ORAL

TABLET Tier 3

g tussin ac oral solution Tier 1

gabapentin oral capsule Tier 1

gabapentin oral solution Tier 1

gabapentin oral tablet Tier 1

GABLOFEN

INTRATHECAL

SOLUTION Tier 4

GABLOFEN

INTRATHECAL

SOLUTION PREFILLED

SYRINGE

Tier 4

GALAFOLD ORAL


galantamine hydrobromide er


24 hour 16 mg, 24 mg Tier 1

galantamine hydrobromide er



galantamine hydrobromide



oral tablet 12 mg, 8 mg Tier 1


oral tablet 4 mg Tier 1 DO

GALZIN ORAL

CAPSULE Tier 3

GAMASTAN

INTRAMUSCULAR


GAMIFANT

INTRAVENOUS


GAMMAGARD

INJECTION SOLUTION Tier 4 PA; QL; SP


GAMMAGARD S/D LESS

IGA INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

GAMMAKED


GAMMAPLEX

INTRAVENOUS


GAMUNEX-C


GANCICLOVIR

INTRAVENOUS

SOLUTION Tier 4 SP

GANCICLOVIR SODIUM

INTRAVENOUS

SOLUTION Tier 4 SP

ganciclovir sodium



GANIRELIX ACETATE

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

GARDASIL 9

INTRAMUSCULAR


GARDASIL 9

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2 $0

GASTROCROM ORAL

CONCENTRATE Tier 3

gatifloxacin ophthalmic

solution Tier 1

GATTEX


gavilax oral powder Tier 1 $0

gavilyte-c oral solution

reconstituted Tier 1 $0

gavilyte-g oral solution

reconstituted Tier 1 $0



63


gavilyte-n with flavor pack

oral solution reconstituted Tier 1 $0

GAVRETO ORAL


GAZYVA

INTRAVENOUS


GEL-FLOW NT

EXTERNAL PREFILLED

SYRINGE Tier 3

GELFOAM

COMPRESSED SIZE 100

EXTERNAL Tier 3

GELFOAM DENTAL

PACK SIZE 4

EXTERNAL Tier 3

GELFOAM

MOUTH/THROAT

POWDER Tier 3

GELFOAM SPONGE

EXTERNAL Tier 3

GELFOAM SPONGE

SIZE 100 EXTERNAL Tier 3

GELFOAM SPONGE


GELFOAM SPONGE


GEL-ONE INTRA-

ARTICULAR

PREFILLED SYRINGE Tier 4 PA; QL; SP

GELSYN-3 INTRA-

ARTICULAR SOLUTION


GEMCITABINE HCL

INTRAVENOUS

SOLUTION Tier 3 SP

gemcitabine hcl intravenous


gemfibrozil oral tablet Tier 1

gemmily oral capsule Tier 1 $0


GENERESS FE ORAL


generlac oral solution Tier 1

gengraf oral capsule Tier 1

gengraf oral solution Tier 1

gentak ophthalmic ointment Tier 1

gentamicin in saline


gentamicin sulfate external

cream Tier 1

gentamicin sulfate external

ointment Tier 1

gentamicin sulfate injection

solution Tier 1

gentamicin sulfate


GENTEEL BUTTERFLY

TOUCH LANCET Tier 2 QL

GENTEEL CONTACT

TIPS (BLUE) Tier 2

GENTEEL CONTACT

TIPS (CLEAR) Tier 2

GENTEEL CONTACT

TIPS (GREEN) Tier 2

GENTEEL CONTACT

TIPS (ORANGE) Tier 2

GENTEEL CONTACT

TIPS (RAINBOW) Tier 2

GENTEEL CONTACT

TIPS (VIOLET) Tier 2

GENTEEL CONTACT

TIPS (YELLOW) Tier 2

GENTEEL LANCING KIT

(BLUE) KIT Tier 2

GENTEEL NOZZLES Tier 2

GENTEEL PLUS

LANCING (BLACK) Tier 2

GENTEEL PLUS

LANCING (PURPLE) Tier 2



64


GENTEEL PLUS

LANCING (WHITE) Tier 2

GENTEEL PLUS

LANCING DEV(BLUE) Tier 2

GENTEEL PLUS

LANCING DEV(PINK) Tier 2

gentle laxative oral tablet


gentlelax oral powder Tier 1 $0

GENTLE-LET GP

LANCETS Tier 2 QL

GENTLE-LET LANCETS Tier 2 QL

GENTLE-LET

PLATFORMS Tier 2

GENVOYA ORAL

TABLET Tier 2 QL

GEODON

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 3

GERMAN COCKROACH

SUBCUTANEOUS

SOLUTION Tier 3

GIAPREZA

INTRAVENOUS

SOLUTION Tier 3

GILENYA ORAL

CAPSULE Tier 4 PA; QL; SP

GILOTRIF ORAL


GILPHEX TR ORAL

TABLET Tier 3

GIMOTI NASAL


GIVLAARI

SUBCUTANEOUS


GLASSIA

INTRAVENOUS



glatiramer acetate

subcutaneous solution

prefilled syringe Tier 4 PA; QL; SP

glatopa subcutaneous

solution prefilled syringe Tier 4 PA; QL; SP

GLEOSTINE ORAL


GLIADEL WAFER

IMPLANT WAFER Tier 3

glimepiride oral tablet Tier 1 ST; QL; T1S

glipizide er oral tablet

extended release 24 hour Tier 1 ST; QL; T1S

glipizide oral tablet Tier 1 ST; QL; T1S

glipizide xl oral tablet

extended release 24 hour Tier 1 ST; QL; T1S

glipizide-metformin hcl oral


GLOBAL EASE INJECT


GLOBAL EASY GLIDE


GLOBAL EASY GLIDE


GLOBAL INJECT EASE


GLOBAL INJECT EASE


GLOBAL INJECT EASE


GLOBAL INSULIN

SYRINGES Tier 3 ST; QL

GLOBAL LANCING

DEVICE Tier 2

GLOPERBA ORAL


GLUCAGEN HYPOKIT

INJECTION SOLUTION


GLUCAGON

EMERGENCY

INJECTION KIT Tier 1



65


GLUCAGON

EMERGENCY

INJECTION SOLUTION

RECONSTITUTED

Tier 3

GLUCOCOM LANCETS

28G Tier 2 QL

GLUCOCOM LANCETS

30G Tier 2 QL

GLUCOCOM LANCETS

33G Tier 2 QL

GLUCOPRO INSULIN


GLUCOTROL XL ORAL

TABLET EXTENDED


GLUTARALDEHYDE


GLUTATHIONE


GLUTATHIONE

INTRAVENOUS

SOLUTION Tier 3

glyburide micronized oral

tablet Tier 1 ST; QL; T1S

glyburide oral tablet Tier 1 ST; QL; T1S

glyburide-metformin oral


GLYCINE INJECTION

SOLUTION Tier 3

glycine irrigation solution Tier 1

glycine urologic irrigation

solution Tier 1

glycolax oral powder Tier 1 $0

glycopyrrolate injection

solution Tier 1

glycopyrrolate oral tablet Tier 1

GLYCOPYRROLATE PF

INJECTION SOLUTION



glydo external prefilled

syringe Tier 1

GLYNASE ORAL


GLYRX-PF INJECTION

SOLUTION Tier 3

GLYRX-PF INJECTION

SOLUTION PREFILLED

SYRINGE Tier 3

gnp adult aspirin low

strength oral tablet chewable Tier 1 $0

gnp aspirin low dose oral


gnp aspirin oral tablet Tier 1 $0

gnp aspirin oral tablet


gnp b-100 complex oral


gnp b-50 complex oral tablet


gnp b-complex plus vitamin

c oral tablet Tier 1 $0

gnp clearlax oral packet Tier 1 $0

gnp clearlax oral powder Tier 1 $0

GNP CLICKFINE PEN


gnp essential one daily oral

tablet Tier 1 $0

gnp folic acid oral tablet Tier 1 $0

gnp gentle laxative oral tablet


GNP INSULIN SYRINGE Tier 3 ST; QL

GNP INSULIN SYRINGES

28GX1/2" Tier 3 ST; QL









66


GNP LANCETS 21G Tier 2 QL

GNP LANCETS MICRO

THIN 33G Tier 2 QL

GNP LANCETS SUPER

THIN 30G Tier 2 QL

GNP LANCETS THIN Tier 2 QL

GNP LANCETS THIN

26G Tier 2 QL

gnp milk of magnesia oral


gnp nicotine mini


gnp nicotine mouth/throat

gum Tier 1 $0

gnp nicotine polacrilex


gnp nicotine polacrilex


gnp nicotine transdermal


GNP PRENATAL ORAL

TABLET Tier 2 $0

GNP STERILE LANCETS

28G Tier 2 QL

GNP STERILE LANCETS

30G Tier 2 QL

GNP STERILE LANCETS

33G Tier 2 QL

GNP ULTICARE PEN


GNP ULTRA COM


gnp womens gentle laxative


GOCOVRI ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 137

MG

Tier 3 PA; QL


GOCOVRI ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 68.5

MG

Tier 3 PA; DO; QL

GOJJI LANCING

DEVICE/CLEAR CAP Tier 2

GOJJI STERILE

LANCETS Tier 2 QL

GOLDENROD

SUBCUTANEOUS

SOLUTION Tier 3

GOLYTELY ORAL

SOLUTION


GONAL-F INJECTION

SOLUTION


GONAL-F RFF

REDIJECT

SUBCUTANEOUS

SOLUTION

Tier 4 PA; QL; SP

GONAL-F RFF

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

GONITRO SUBLINGUAL

PACKET Tier 3

goodsense aspirin adult low

st oral tablet chewable Tier 1 $0

goodsense aspirin adults oral

tablet Tier 1 $0

goodsense aspirin low dose


goodsense aspirin oral tablet Tier 1 $0

goodsense aspirin oral tablet

chewable Tier 1 $0

goodsense aspirin oral tablet


goodsense bisacodyl ec oral


goodsense clearlax oral

powder Tier 1 $0



67


GOODSENSE

CLICKFINE PEN


GOODSENSE COLOR


GOODSENSE LANCETS

26G UNIV Tier 2 QL

GOODSENSE LANCETS

30G Tier 2 QL

GOODSENSE LANCETS

30G UNIV Tier 2 QL

GOODSENSE LANCETS

33G Tier 2 QL

GOODSENSE LANCETS

33G UNIV Tier 2 QL

GOODSENSE LANCING

DEVICE Tier 2

goodsense magnesium citrate

oral solution Tier 1 $0

goodsense nicotine


goodsense nicotine


GOODSENSE PEN

NEEDLE PENFINE Tier 3 ST; QL

goodsense womens laxative


GOPRELTO NASAL

SOLUTION Tier 3

GRALISE ORAL

TABLET 300 MG Tier 2 PA; DO; QL

GRALISE ORAL

TABLET 600 MG Tier 2 PA; QL

granisetron hcl intravenous

solution Tier 1

granisetron hcl oral tablet Tier 1 QL

GRANIX

SUBCUTANEOUS



GRANIX

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

GRASS POLLEN(K-O-R-

T-SWT VERN)


GRASTEK SUBLINGUAL

TABLET SUBLINGUAL Tier 3 PA; QL

griseofulvin microsize oral

suspension Tier 1

griseofulvin microsize oral

tablet Tier 1

griseofulvin ultramicrosize

oral tablet Tier 1

guaiatussin ac oral syrup Tier 1

guaifenesin ac oral syrup Tier 1

guaifenesin-codeine oral

solution Tier 1

guanfacine hcl er oral tablet


mg, 2 mg Tier 1 PA; DO; QL

guanfacine hcl er oral tablet


mg, 4 mg Tier 1 PA; QL

guanfacine hcl oral tablet Tier 1

GUARDIAN CONNECT


GUARDIAN LINK 3


GUARDIAN REAL-TIME

REPLACE PED DEVICE Tier 3 PA; QL

GUARDIAN SENSOR (3) Tier 3 PA; QL

GUARDIAN SENSOR 3 Tier 3 PA; QL

GVOKE HYPOPEN 1-

PACK SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3



68


GVOKE HYPOPEN 2-

PACK SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3

GVOKE PFS

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

GYNAZOLE-1 VAGINAL

CREAM Tier 3

habitrol transdermal patch 24

hour Tier 1 $0

HACKBERRY

SUBCUTANEOUS

SOLUTION Tier 3

HAEGARDA

SUBCUTANEOUS

SOLUTION

RECONSTITUTED


HAEMOLANCE Tier 2 QL

HAEMOLANCE LOW

FLOW LANCETS Tier 2 QL

HAEMOLANCE PLUS Tier 2 QL

HAEMOLANCE PLUS

HIGH FLOW Tier 2 QL

HAEMOLANCE PLUS

LOW FLOW Tier 2 QL

HAEMOLANCE PLUS

MAX FLOW Tier 2 QL

HAEMOLANCE PLUS

PEDIATRIC FLOW Tier 2 QL

hailey 1.5/30 oral tablet Tier 1 $0

hailey 24 fe oral tablet Tier 1 $0

hailey fe 1.5/30 oral tablet Tier 1 $0

hailey fe 1/20 oral tablet Tier 1 $0

HALAVEN

INTRAVENOUS


halcinonide external cream Tier 3 ST; QL

HALCION ORAL

TABLET Tier 3


HALDOL DECANOATE

INTRAMUSCULAR

SOLUTION Tier 3

halobetasol propionate


halobetasol propionate


haloperidol decanoate


haloperidol lactate injection

solution Tier 1

haloperidol lactate oral

concentrate Tier 1

haloperidol oral tablet Tier 1

HARVONI ORAL

PACKET Tier 4 PA; QL

HARVONI ORAL

TABLET 45-200 MG Tier 4 PA; QL

HARVONI ORAL

TABLET 90-400 MG Tier 4 PA; QL; SP

HAVRIX

INTRAMUSCULAR


HEALON DUET PRO

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 4

HEALON GV

INTRAOCULAR

SOLUTION Tier 4

HEALON GV PRO

INTRAOCULAR

SOLUTION Tier 4

HEALON

INTRAOCULAR

SOLUTION Tier 4

HEALON PRO

INTRAOCULAR

SOLUTION Tier 4

HEALON5

INTRAOCULAR

SOLUTION Tier 4



69


HEALON5 PRO

INTRAOCULAR

SOLUTION Tier 4

HEALTH CARE


HEALTHWISE INSULIN

SYR/NEEDLE Tier 3 ST; QL

HEALTHWISE MICRON


HEALTHWISE MINI PEN


HEALTHWISE PEN


HEALTHWISE SHORT


HEALTHWISE UNIFINE


HEALTHY ACCENTS


HEALTHY ACCENTS

UNIFINE PENTIP Tier 3 ST; QL

HEALTHY ACCENTS

UNILET LANCETS Tier 2 QL

healthy hair/skin/nails oral

tablet Tier 1 $0

healthylax oral packet Tier 1 $0

heather oral tablet Tier 1 $0

h-e-b aspirin oral tablet


H-E-B INCONTROL ADV

LANCING Tier 2

H-E-B INCONTROL


H-E-B INCONTROL


H-E-B INCONTROL


H-E-B INCONTROL PEN



H-E-B INCONTROL

UNIFINE PENTIP Tier 3 ST; QL

HECTOROL

INTRAVENOUS


HELIDAC THERAPY

ORAL Tier 3 ST; QL

HEMABATE

INTRAMUSCULAR

SOLUTION Tier 3

HEMADY ORAL


HEMANGEOL ORAL

SOLUTION Tier 3

HEMLIBRA

SUBCUTANEOUS


HEMOFIL M

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

HEPAGAM B

INJECTION SOLUTION Tier 4 SP

heparin (porcine) in nacl

intravenous solution 1000-

0.9 ut/500ml-%, 2000-0.9

unit/l-%

Tier 1

HEPARIN (PORCINE) IN

NACL INTRAVENOUS

SOLUTION 12500-0.45

UT/250ML-%, 25000-0.45

UT/250ML-%, 25000-0.45

UT/500ML-%

Tier 3


NACL INTRAVENOUS

SOLUTION 2500-0.9

UT/500ML-%, 30000-0.9

UNIT/L-%, 4000-0.9

UNIT/L-%, 500-0.9

UT/500ML-%, 5000-0.9

UNIT/L-%, 5000-0.9

UT/500ML-%

Tier 3



70



NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

heparin lock flush


HEPARIN SOD

(PORCINE) IN D5W

INTRAVENOUS

SOLUTION 100

UNIT/ML, 25000-5

UT/500ML-%

Tier 3

heparin sod (porcine) in d5w

intravenous solution 40-5

unit/ml-% Tier 1

heparin sodium (porcine)


HEPARIN SODIUM

(PORCINE) INJECTION

SOLUTION PREFILLED

SYRINGE

Tier 3

heparin sodium (porcine) pf

injection solution 5000

unit/0.5ml Tier 1

HEPARIN SODIUM

(PORCINE) PF

INJECTION SOLUTION

5000 UNIT/ML

Tier 3

heparin sodium lock flush


HEPLISAV-B

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3 $0

HEPSERA ORAL

TABLET Tier 4 SP

HERCEPTIN HYLECTA

SUBCUTANEOUS

SOLUTION Tier 3 SP

HERCEPTIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP


HERZUMA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

HESPAN INTRAVENOUS

SOLUTION Tier 3

hetastarch-nacl intravenous

solution Tier 1

HETLIOZ LQ ORAL


HETLIOZ ORAL


HEXTEND

INTRAVENOUS

SOLUTION Tier 3

HIBERIX INJECTION

SOLUTION

RECONSTITUTED Tier 3 $0

HIGH POTENCY

MULTIVITAMIN ORAL

TABLET Tier 2 $0

HIPREX ORAL TABLET Tier 3

HISTEX-AC ORAL

SYRUP Tier 3

HIZENTRA

SUBCUTANEOUS


HIZENTRA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


hm adult aspirin oral tablet Tier 1 $0

hm aspirin ec low dose oral


hm aspirin ec oral tablet


hm aspirin oral tablet Tier 1 $0

hm aspirin oral tablet

chewable Tier 1 $0

hm aspirin oral tablet delayed

release Tier 1 $0



71


hm b complex/c oral tablet Tier 1 $0

hm clearlax oral packet Tier 1 $0

hm clearlax oral powder Tier 1 $0

hm folic acid oral tablet Tier 1 $0

hm laxative oral tablet


hm magnesium citrate oral

solution Tier 1 $0

hm milk of magnesia oral


hm nicotine polacrilex


hm nicotine polacrilex


hm nicotine transdermal


HM ONE DAILY

PRENATAL ORAL Tier 2 $0

hm one daily/iron oral tablet Tier 1 $0

HM PRENATAL ORAL

TABLET Tier 2 $0

HM ULTICARE INSULIN


HM ULTICARE MINI


HM ULTICARE SHORT


hm vitamin b

complex/vitamin c oral tablet Tier 1 $0

hm vitamin b100 complex


hm vitamin b50 complex oral

tablet Tier 1 $0

HONEY BEE VENOM

PROTEIN INJECTION

SOLUTION

RECONSTITUTED

Tier 3


HONEY BEE VENOM

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3

HORIZANT ORAL

TABLET EXTENDED


HORSE EPITHELIUM

SUBCUTANEOUS

SOLUTION Tier 3

HUMALOG JUNIOR

KWIKPEN

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

HUMALOG KWIKPEN

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

HUMALOG MIX 50/50

KWIKPEN

SUBCUTANEOUS

SUSPENSION PEN-

INJECTOR

Tier 2

HUMALOG MIX 50/50

SUBCUTANEOUS

SUSPENSION Tier 2

HUMALOG MIX 75/25

KWIKPEN

SUBCUTANEOUS

SUSPENSION PEN-

INJECTOR

Tier 2

HUMALOG MIX 75/25

SUBCUTANEOUS

SUSPENSION Tier 2

HUMALOG

SUBCUTANEOUS

SOLUTION Tier 2

HUMALOG

SUBCUTANEOUS

SOLUTION CARTRIDGE Tier 2



72


HUMAN ALBUMIN

GRIFOLS

INTRAVENOUS

SOLUTION

Tier 3

HUMATE-P

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

HUMATIN ORAL

CAPSULE Tier 3

HUMATROPE

INJECTION SOLUTION


HUMIRA PEDIATRIC

CROHNS START

SUBCUTANEOUS

PREFILLED SYRINGE

KIT

Tier 4 PA; QL; SP

HUMIRA PEN

SUBCUTANEOUS PEN-

INJECTOR KIT Tier 4 PA; QL; SP

HUMIRA PEN-CD/UC/HS

STARTER

SUBCUTANEOUS PEN-

INJECTOR KIT

Tier 4 PA; QL; SP

HUMIRA PEN-

PEDIATRIC UC START

SUBCUTANEOUS PEN-

INJECTOR KIT

Tier 4 PA; QL; SP

HUMIRA PEN-

PS/UV/ADOL HS START

SUBCUTANEOUS PEN-

INJECTOR KIT

Tier 4 PA; QL; SP

HUMIRA PEN-

PSOR/UVEIT STARTER

SUBCUTANEOUS PEN-

INJECTOR KIT

Tier 4 PA; QL; SP

HUMIRA

SUBCUTANEOUS

PREFILLED SYRINGE

KIT

Tier 4 PA; QL; SP


HUMULIN 70/30

KWIKPEN

SUBCUTANEOUS

SUSPENSION PEN-

INJECTOR

Tier 2

HUMULIN 70/30

SUBCUTANEOUS

SUSPENSION Tier 2

HUMULIN N KWIKPEN

SUBCUTANEOUS

SUSPENSION PEN-

INJECTOR

Tier 2

HUMULIN N

SUBCUTANEOUS

SUSPENSION Tier 2

HUMULIN R INJECTION

SOLUTION Tier 2

HUMULIN R U-500

(CONCENTRATED)

SUBCUTANEOUS

SOLUTION

Tier 2 PA; QL

HUMULIN R U-500

KWIKPEN

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2 PA; QL

HYALGAN INTRA-

ARTICULAR SOLUTION Tier 4 PA; QL

HYALGAN INTRA-

ARTICULAR SOLUTION


HYCAMTIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

HYCAMTIN ORAL


HYCODAN ORAL SYRUP Tier 3

hydralazine hcl injection

solution Tier 1

hydralazine hcl oral tablet Tier 1



73


HYDREA ORAL

CAPSULE Tier 3


capsule Tier 1 T1S


tablet Tier 1 T1S

hydrocod polst-cpm polst er

oral suspension extended

release Tier 1

hydrocodone bitartrate er

oral tablet er 24 hour abuse-

deterrent Tier 1 PA; QL

hydrocodone-acetaminophen

oral solution Tier 1 QL

hydrocodone-acetaminophen


hydrocodone-homatropine

oral syrup Tier 1

hydrocodone-homatropine

oral tablet Tier 1 PA; QL

hydrocodone-ibuprofen oral

tablet Tier 1 QL

hydrocortisone (perianal)


hydrocortisone ace-

pramoxine external cream Tier 1

hydrocortisone butyr lipo

base external cream Tier 3 ST; QL

hydrocortisone butyrate

external cream Tier 3 ST; QL


external lotion Tier 3 ST; QL


external ointment Tier 3 ST; QL


external solution Tier 3 ST; QL

hydrocortisone external

cream Tier 1


lotion Tier 1



ointment Tier 1

hydrocortisone oral tablet Tier 1

hydrocortisone rectal enema Tier 1

hydrocortisone valerate

external cream Tier 3 ST; QL

hydrocortisone valerate


hydrocortisone-acetic acid

otic solution Tier 1

hydromet oral syrup Tier 1

hydromorphone hcl er oral


hour Tier 1 PA; QL

hydromorphone hcl injection

solution Tier 1 QL

hydromorphone hcl oral

liquid Tier 1 QL

hydromorphone hcl oral

tablet Tier 1 QL

HYDROMORPHONE

HCL PF INJECTION

SOLUTION 1 MG/ML, 10

MG/ML, 2 MG/ML, 4

MG/ML

Tier 3 QL

hydromorphone hcl pf

injection solution 50 mg/5ml,

500 mg/50ml Tier 1 QL

HYDROMORPHONE

HCL-NACL

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

hydroxocobalamin acetate


hydroxychloroquine sulfate


hydroxyprogesterone

caproate intramuscular oil Tier 4 PA; QL; SP



74


hydroxyprogesterone

caproate intramuscular


hydroxyurea oral capsule Tier 1

hydroxyzine hcl


hydroxyzine hcl oral syrup Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral

capsule Tier 1

HYLENEX INJECTION

SOLUTION Tier 3

HYMOVIS INTRA-

ARTICULAR SOLUTION

PREFILLED SYRINGE Tier 4 PA; QL; LD; SP

hyoscyamine sulfate er oral


hour Tier 1

hyoscyamine sulfate sl

sublingual tablet sublingual Tier 1

hyoscyamine sulfate

sublingual tablet sublingual Tier 1

HYPERHEP B

INTRAMUSCULAR

SOLUTION Tier 4 SP

HYPERRAB INJECTION

SOLUTION Tier 4 SP

HYPERRHO S/D

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE

Tier 4 SP

HYPERSAL

INHALATION

NEBULIZATION

SOLUTION

Tier 3

HYPERTET S/D

INTRAMUSCULAR

INJECTABLE Tier 3

HYPOLANCE AST

LANCING KIT Tier 2


HYQVIA


HY-VEE LANCETS Tier 2 QL

HY-VEE THIN LANCETS Tier 2 QL

ibandronate sodium


ibandronate sodium oral

tablet Tier 1

IBRANCE ORAL


IBRANCE ORAL


ibu oral tablet Tier 1 T1S

ibuprofen lysine intravenous

solution Tier 1

ibuprofen oral suspension Tier 1 T1S

ibuprofen oral tablet Tier 1 T1S

ibutilide fumarate


icatibant acetate

subcutaneous solution Tier 4 PA; QL; LD; SP

iclevia oral tablet Tier 1 $0

ICLUSIG ORAL TABLET Tier 2 PA; QL; LD

icosapent ethyl oral capsule Tier 1 PA; QL

IDAMYCIN PFS

INTRAVENOUS

SOLUTION Tier 3 SP

idarubicin hcl intravenous

solution Tier 1 SP

IDELVION

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

IDHIFA ORAL TABLET Tier 3 PA; QL; LD; SP

IFEX INTRAVENOUS

SOLUTION


ifosfamide intravenous

solution Tier 1 SP



75


ifosfamide intravenous

solution reconstituted 1 gm Tier 1 SP

IFOSFAMIDE

INTRAVENOUS

SOLUTION

RECONSTITUTED 3 GM

Tier 3 SP

ILARIS

SUBCUTANEOUS


ILEVRO OPHTHALMIC

SUSPENSION Tier 2

ILIDERM EXTERNAL

EMULSION Tier 3

ILUVIEN

INTRAVITREAL


imatinib mesylate oral tablet Tier 1 PA; QL; SP

IMBRUVICA ORAL


IMBRUVICA ORAL


IMCIVREE

SUBCUTANEOUS


IMFINZI INTRAVENOUS


imipenem-cilastatin



imipramine hcl oral tablet Tier 1

imipramine pamoate oral

capsule Tier 1

imiquimod external cream

3.75 % Tier 1 ST; QL

imiquimod external cream 5

% Tier 1

imiquimod pump external

cream Tier 1 ST; QL

IMLYGIC

INTRALESIONAL

SUSPENSION Tier 3 LD


IMOGAM RABIES-HT


IMOVAX RABIES

INTRAMUSCULAR

INJECTABLE Tier 3

IMPAVIDO ORAL


IMURAN ORAL TABLET Tier 3

IMVEXXY

MAINTENANCE PACK

VAGINAL INSERT Tier 3

IMVEXXY STARTER

PACK VAGINAL INSERT Tier 3

IN TOUCH LANCING

DEVICE Tier 2

IN TOUCH STERILE


inatal gt oral tablet Tier 1

INBRIJA INHALATION


incassia oral tablet Tier 1 $0

INCRELEX

SUBCUTANEOUS


indapamide oral tablet Tier 1 T1S

INDERAL XL ORAL

CAPSULE EXTENDED


indomethacin er oral capsule

extended release Tier 1

indomethacin oral capsule Tier 1

indomethacin sodium



INFANRIX

INTRAMUSCULAR


INFASURF

INTRATRACHEAL

SUSPENSION Tier 3



76


INFED INJECTION


INFLECTRA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

INFUGEM

INTRAVENOUS

SOLUTION Tier 3 SP

INFUMORPH 200


INFUMORPH 500


INFUVITE ADULT

INTRAVENOUS

INJECTABLE Tier 3

INFUVITE PEDIATRIC

INTRAVENOUS

SOLUTION Tier 3

INGREZZA ORAL

CAPSULE 40 MG Tier 4 PA; DO; QL; LD

INGREZZA ORAL

CAPSULE 60 MG, 80 MG Tier 4 PA; QL; LD

INGREZZA ORAL

CAPSULE THERAPY

PACK Tier 4 PA; QL; LD

INJECTAFER

INTRAVENOUS


INLYTA ORAL TABLET Tier 2 PA; QL; LD; SP

inner ear plus oral tablet Tier 1 $0

INNOPRAN XL ORAL

CAPSULE EXTENDED


INQOVI ORAL TABLET Tier 3 PA; QL; LD; SP

INREBIC ORAL


INSPRA ORAL TABLET Tier 3

INSTAT EXTERNAL PAD Tier 3


INSULIN LISPRO (1

UNIT DIAL)

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

INSULIN LISPRO

JUNIOR KWIKPEN

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

INSULIN LISPRO PROT

& LISPRO

SUBCUTANEOUS

SUSPENSION PEN-

INJECTOR

Tier 2

INSULIN LISPRO

SUBCUTANEOUS

SOLUTION Tier 2


INSULIN

SYRINGE/NEEDLE Tier 3 ST; QL

INSULIN SYRINGE-

NEEDLE U-100 Tier 3 ST; QL

INSUPEN PEN NEEDLES Tier 3 ST; QL

INSUPEN SENSITIVE Tier 3 ST; QL

INSUPEN ULTRAFIN Tier 3 ST; QL

INTELENCE ORAL


INTERCEED (TC7)

EXTERNAL PAD Tier 3

INTERCEED EXTERNAL

PAD Tier 3

INTRALIPID

INTRAVENOUS

EMULSION Tier 3

INTRAROSA VAGINAL

INSERT Tier 3 ST; QL

INTRON A INJECTION


INTRON A INJECTION

SOLUTION




77


introvale oral tablet Tier 1 $0

INVANZ INJECTION

SOLUTION


INVEGA SUSTENNA

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3

INVEGA TRINZA

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3

INVELTYS

OPHTHALMIC

SUSPENSION Tier 3

INVIRASE ORAL

TABLET Tier 2 QL

IODINE TINCTURE

EXTERNAL TINCTURE Tier 3

IODOFLEX EXTERNAL

PAD Tier 3

IODOSORB EXTERNAL

GEL Tier 3

IONOSOL-MB IN D5W

INTRAVENOUS

SOLUTION Tier 3

IOPIDINE

OPHTHALMIC

SOLUTION Tier 3

IPOL INJECTION


ipratropium bromide

inhalation solution Tier 1

ipratropium bromide nasal

solution Tier 1

ipratropium-albuterol

inhalation solution Tier 1

irbesartan oral tablet 150 mg,

75 mg Tier 1 DO

irbesartan oral tablet 300 mg Tier 1


irbesartan-


tablet Tier 1

IRESSA ORAL TABLET Tier 2 PA; QL; LD; SP

irinotecan hcl intravenous

solution Tier 1 SP

ISENTRESS HD ORAL

TABLET Tier 3 QL

ISENTRESS ORAL

PACKET Tier 3 QL

ISENTRESS ORAL

TABLET Tier 2 QL

ISENTRESS ORAL

TABLET CHEWABLE Tier 2 QL

isibloom oral tablet Tier 1 $0

isoflurane inhalation solution Tier 1

ISOLYTE-P IN D5W

INTRAVENOUS

SOLUTION Tier 3

ISOLYTE-S

INTRAVENOUS

SOLUTION Tier 3

ISOLYTE-S PH 7.4

INTRAVENOUS

SOLUTION Tier 3

isoniazid injection solution Tier 1

isoniazid oral syrup Tier 1 T1S

isoniazid oral tablet Tier 1 T1S

isoproterenol hcl injection

solution Tier 1

ISOPROTERENOL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

ISOPTO ATROPINE

OPHTHALMIC

SOLUTION Tier 3

ISOPTO CARPINE

OPHTHALMIC

SOLUTION Tier 3



78


ISORDIL TITRADOSE

ORAL TABLET Tier 3

isosorbide dinitrate oral

tablet 10 mg, 20 mg, 30 mg,

5 mg Tier 1 T1S

isosorbide dinitrate oral

tablet 40 mg Tier 1

isosorbide mononitrate er


24 hour Tier 1 T1S

isosorbide mononitrate oral

tablet Tier 1 T1S

isotretinoin oral capsule Tier 2 PA; QL

isradipine oral capsule Tier 1

ISTODAX (OVERFILL)

INTRAVENOUS

SOLUTION

RECONSTITUTED


ISTURISA ORAL


ISUPREL INJECTION

SOLUTION Tier 3

itraconazole oral capsule Tier 1 PA; QL

itraconazole oral solution Tier 1 PA; QL

ivermectin external cream Tier 1

ivermectin external lotion Tier 1

ivermectin oral tablet Tier 1 PA; QL

IXEMPRA KIT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

IXIARO

INTRAMUSCULAR

SUSPENSION Tier 3

IXINITY INTRAVENOUS

SOLUTION


jaimiess oral tablet Tier 1 $0

JAKAFI ORAL TABLET Tier 2 PA; QL; LD; SP

JALYN ORAL CAPSULE Tier 3


jantoven oral tablet Tier 1 T1S

JANUMET ORAL


JANUMET XR ORAL

TABLET EXTENDED


JANUVIA ORAL


JARDIANCE ORAL


jasmiel oral tablet Tier 1 $0

JATENZO ORAL


JELMYTO SOLUTION


JEMPERLI

INTRAVENOUS


jencycla oral tablet Tier 1 $0

JENLIVA

PRENATAL/POSTNATAL


JEVTANA

INTRAVENOUS


jinteli oral tablet Tier 1

JIVI INTRAVENOUS

SOLUTION


JOHNSON GRASS

SUBCUTANEOUS

SOLUTION Tier 3

jolessa oral tablet Tier 1 $0

JORNAY PM ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 100

MG, 60 MG, 80 MG

Tier 3 ST; QL

JORNAY PM ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 20

MG, 40 MG

Tier 3 ST; DO; QL



79


JUBLIA EXTERNAL

SOLUTION Tier 3

juleber oral tablet Tier 1 $0

JULUCA ORAL TABLET Tier 3 PA; QL

JUNE GRASS POLLEN

STANDARDIZED

SUBCUTANEOUS

SOLUTION

Tier 3

junel 1.5/30 oral tablet Tier 1 $0

junel 1/20 oral tablet Tier 1 $0

junel fe 1.5/30 oral tablet Tier 1 $0

junel fe 1/20 oral tablet Tier 1 $0

junel fe 24 oral tablet Tier 1 $0

JUXTAPID ORAL

CAPSULE Tier 3 PA; DO; QL; LD

JYNARQUE ORAL


JYNARQUE ORAL

TABLET THERAPY


KABIVEN

INTRAVENOUS

EMULSION Tier 3

KADCYLA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

kaitlib fe oral tablet chewable Tier 1 $0

KALBITOR

SUBCUTANEOUS


KALETRA ORAL

SOLUTION Tier 3 QL

KALETRA ORAL

TABLET Tier 2 QL

kalliga oral tablet Tier 1 $0

KALYDECO ORAL


KALYDECO ORAL



KANJINTI

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

KANUMA

INTRAVENOUS


KAPOK

SUBCUTANEOUS

SOLUTION Tier 3

KAPSPARGO SPRINKLE

ORAL CAPSULE ER 24

HOUR SPRINKLE Tier 3

KAPVAY ORAL TABLET

EXTENDED RELEASE 12

HOUR Tier 3 PA; QL

KARBINAL ER ORAL

SUSPENSION


KARDIAMEMBRANE


kariva oral tablet Tier 1 $0

KATERZIA ORAL

SUSPENSION Tier 3

KCENTRA


KCL (IN NACL 0.9%)

INTRAVENOUS

SOLUTION Tier 3

kcl in dextrose-nacl

intravenous solution 10-5-

0.45 meq/l-%-%, 20-5-0.2

meq/l-%-%, 20-5-0.45 meq/l-

%-%, 20-5-0.9 meq/l-%-%,

30-5-0.45 meq/l-%-%, 40-5-

0.45 meq/l-%-%

Tier 1

KCL IN DEXTROSE-

NACL INTRAVENOUS

SOLUTION 20-5-0.225

MEQ/L-%-%, 40-5-0.9

MEQ/L-%-%

Tier 3



80


KCL-LACTATED

RINGERS-D5W

INTRAVENOUS

SOLUTION

Tier 3

KEDBUMIN

INTRAVENOUS

SOLUTION Tier 3

KEDRAB INJECTION

SOLUTION Tier 4 SP

KEFLEX ORAL

CAPSULE Tier 3

kelnor 1/35 oral tablet Tier 1 $0

kelnor 1/50 oral tablet Tier 1 $0

KENALOG INJECTION

SUSPENSION Tier 3

KENALOG-80

INJECTION

SUSPENSION Tier 3

KENDALL HYDROGEL

WOUND DRESS

EXTERNAL Tier 3

KENGREAL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

KEPIVANCE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4

KERENDIA ORAL


KESIMPTA

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


KETALAR INJECTION

SOLUTION Tier 3

ketamine hcl injection

solution Tier 1


KETAMINE HCL

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

KETAMINE HCL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

ketoconazole external cream Tier 1

ketoconazole external foam Tier 3

ketoconazole external

shampoo Tier 1

ketoconazole oral tablet Tier 1

ketoprofen er oral capsule


ketoprofen oral capsule Tier 1

ketorolac tromethamine

injection solution Tier 1 QL


intramuscular solution Tier 1 QL



ketorolac tromethamine oral

tablet Tier 1 QL

KEVEYIS ORAL


KEYTRUDA

INTRAVENOUS


KHAPZORY

INTRAVENOUS

SOLUTION

RECONSTITUTED


KIMYRSA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

KINNEY LANCETS Tier 2 QL

KINNEY THIN LANCETS Tier 2 QL



81


KINRAY INSULIN


KINRIX

INTRAMUSCULAR


KISQALI (200 MG DOSE)

ORAL TABLET

THERAPY PACK Tier 2 PA; QL; SP


ORAL TABLET



ORAL TABLET


KISQALI FEMARA (400

MG DOSE) ORAL

TABLET THERAPY

PACK

Tier 2 PA; QL; SP

KISQALI FEMARA (600

MG DOSE) ORAL

TABLET THERAPY

PACK

Tier 2 PA; QL; SP

KISQALI FEMARA(200

MG DOSE) ORAL

TABLET THERAPY

PACK

Tier 2 PA; QL; SP

KLARON EXTERNAL

LOTION Tier 3

KLISYRI EXTERNAL


klor-con 10 oral tablet

extended release Tier 1 T1S

klor-con m10 oral tablet






klor-con oral packet Tier 1 T1S

klor-con oral tablet extended

release Tier 1 T1S


kls aspirin low dose oral


kls laxaclear oral powder Tier 1 $0

kls quit2 mouth/throat gum Tier 1 $0

kls quit2 mouth/throat

lozenge Tier 1 $0

kls quit4 mouth/throat gum Tier 1 $0

kls quit4 mouth/throat

lozenge Tier 1 $0

KMART VALU INSULIN

SYRINGE 29G Tier 3 ST; QL

KMART VALU INSULIN

SYRINGE 30G Tier 3 ST; QL

KOATE INTRAVENOUS

SOLUTION


KOATE-DVI

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

kobee oral tablet Tier 1 $0

KOCHIA

SUBCUTANEOUS

SOLUTION Tier 3

KOGENATE FS


KORLYM ORAL


KOSELUGO ORAL


KOSHER PRENATAL

PLUS IRON ORAL


KOVALTRY

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

kp aspirin oral tablet delayed

release Tier 1 $0

kp b complex-c oral tablet Tier 1 $0



82


kp bisacodyl oral tablet


kp folic acid oral tablet Tier 1 $0

KP PRENATAL

MULTIVITAMINS ORAL

TABLET Tier 2 $0

K-PHOS NO 2 ORAL

TABLET Tier 3

K-PHOS ORAL TABLET Tier 2

K-PHOS-NEUTRAL

ORAL TABLET Tier 3

KPN PRENATAL ORAL

TABLET Tier 2 $0

KRINTAFEL ORAL

TABLET Tier 3

KRISTALOSE ORAL

PACKET Tier 3

KROGER AUTOLET


KROGER HEALTHPRO

LANCET 26G Tier 2 QL

KROGER INSULIN


KROGER LANCETS Tier 2 QL

KROGER LANCETS 21G Tier 2 QL

KROGER LANCETS

MICRO THIN 33G Tier 2 QL

KROGER LANCETS

SUPER THIN Tier 2 QL

KROGER LANCETS

THIN Tier 2 QL

KROGER LANCETS

THIN 26G Tier 2 QL

KROGER LANCETS

ULTRATHIN 30G Tier 2 QL

KROGER LANCING

DEVICE Tier 2

KROGER PEN NEEDLES Tier 3 ST; QL


KRYSTEXXA

INTRAVENOUS


K-TAB ORAL TABLET


kurvelo oral tablet Tier 1 $0

KUVAN ORAL PACKET Tier 4 PA; QL; LD; SP

KUVAN ORAL TABLET Tier 4 PA; QL; LD; SP

KYLEENA

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 4 LD; SP

KYNMOBI SUBLINGUAL

FILM Tier 3 PA; QL; LD

KYPROLIS

INTRAVENOUS

SOLUTION

RECONSTITUTED


labetalol hcl oral tablet Tier 1

LABETALOL HCL-

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

LABETALOL HCL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

lactated ringers intravenous

solution Tier 1

lactated ringers irrigation

solution Tier 1

LACTIC ACID E


LACTIC ACID


lactulose encephalopathy oral

solution Tier 1

LACTULOSE ORAL

PACKET Tier 3

lactulose oral solution Tier 1

lamivudine oral solution Tier 1 QL



83


lamivudine oral tablet 100

mg Tier 1

lamivudine oral tablet 150

mg, 300 mg Tier 1 QL

lamivudine-zidovudine oral

tablet Tier 1 QL

lamotrigine er oral tablet


lamotrigine oral kit Tier 1

lamotrigine oral tablet Tier 1

lamotrigine oral tablet

chewable Tier 1

lamotrigine oral tablet

dispersible Tier 1

lamotrigine starter kit-blue

oral kit Tier 1

lamotrigine starter kit-green

oral kit Tier 1

lamotrigine starter kit-orange

oral kit Tier 1

LAMPIT ORAL TABLET Tier 3

LANCET DEVICE Tier 2

LANCET DEVICE WITH

EJECTOR Tier 2

LANCET

TRANSPORTER CASE Tier 2

LANCETS Tier 2 QL



LANCETS MICRO THIN

33G Tier 2 QL

LANCETS SUPER THIN

28G Tier 2 QL

LANCETS THIN Tier 2 QL

LANCETS ULTRA THIN Tier 2 QL

LANCETS ULTRA THIN

30G Tier 2 QL



LANOXIN INJECTION

SOLUTION Tier 3

LANOXIN ORAL

TABLET Tier 2

LANOXIN PEDIATRIC


lanthanum carbonate oral

tablet chewable Tier 1

LANTUS SOLOSTAR

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

LANTUS

SUBCUTANEOUS

SOLUTION Tier 2

LANZO Tier 2

lapatinib ditosylate oral

tablet Tier 1 PA; QL; SP

larin 1.5/30 oral tablet Tier 1 $0

larin 1/20 oral tablet Tier 1 $0

larin 24 fe oral tablet Tier 1 $0

larin fe 1.5/30 oral tablet Tier 1 $0

larin fe 1/20 oral tablet Tier 1 $0

larissia oral tablet Tier 1 $0

LASIX ORAL TABLET Tier 3

latanoprost ophthalmic

solution Tier 1

LATISSE EXTERNAL

SOLUTION Tier 3

LATUDA ORAL TABLET

120 MG, 80 MG Tier 3

LATUDA ORAL TABLET

20 MG, 40 MG, 60 MG Tier 3 DO

laxative oral tablet delayed

release Tier 1 $0

layolis fe oral tablet

chewable Tier 1 $0

LEADER ADVANCED




84


LEADER INSULIN


LEADER UNIFINE


LEADER UNIFINE


leena oral tablet Tier 1 $0

leflunomide oral tablet Tier 1

LEMTRADA

INTRAVENOUS


LENSCALE

SUBCUTANEOUS

SOLUTION Tier 3

LENVIMA (10 MG DAILY

DOSE) ORAL CAPSULE

THERAPY PACK Tier 3 PA; QL; LD; SP


DOSE) ORAL CAPSULE



DOSE) ORAL CAPSULE



DOSE) ORAL CAPSULE



DOSE) ORAL CAPSULE



DOSE) ORAL CAPSULE


LENVIMA (4 MG DAILY

DOSE) ORAL CAPSULE


LENVIMA (8 MG DAILY

DOSE) ORAL CAPSULE


lessina oral tablet Tier 1 $0

letrozole oral tablet Tier 1 $0


leucovorin calcium injection

solution Tier 1

leucovorin calcium injection


leucovorin calcium oral

tablet Tier 1

LEUKERAN ORAL

TABLET Tier 2

LEUKINE INJECTION

SOLUTION


leuprolide acetate injection

kit Tier 1 PA; QL; SP

LEUPROLIDE

ACETATE-

BUPIVACAINE

INTRAMUSCULAR

SOLUTION

Tier 3

levalbuterol hcl inhalation


levalbuterol tartrate

inhalation aerosol Tier 1

LEVEMIR FLEXTOUCH

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

LEVEMIR

SUBCUTANEOUS

SOLUTION Tier 2

levetiracetam er oral tablet


LEVETIRACETAM IN

NACL INTRAVENOUS

SOLUTION Tier 3

levetiracetam intravenous

solution Tier 1

levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1

levobunolol hcl ophthalmic

solution Tier 1

levocarnitine oral solution Tier 1



85


levocarnitine oral tablet Tier 1

levocarnitine sf oral solution Tier 1

levocetirizine

dihydrochloride oral solution Tier 1

levocetirizine

dihydrochloride oral tablet Tier 1

levofloxacin in d5w


levofloxacin intravenous

solution Tier 1

levofloxacin ophthalmic

solution Tier 1

levofloxacin oral solution Tier 1 QL

levofloxacin oral tablet Tier 1 QL

levoleucovorin calcium



levoleucovorin calcium pf


levonest oral tablet Tier 1 $0

levonorgest-eth est & eth est


levonorgest-eth estrad 91-day


levonorgestrel oral tablet Tier 1 $0

levonorgestrel-ethinyl estrad

oral tablet 0.1-20 mg-mcg,

0.15-30 mg-mcg Tier 1 $0

levonorgestrel-ethinyl estrad

oral tablet 90-20 mcg Tier 1 $0

levonorg-eth estrad triphasic


LEVOPHED

INTRAVENOUS

SOLUTION Tier 3

levora 0.15/30 (28) oral

tablet Tier 1 $0

levorphanol tartrate oral

tablet Tier 1 PA; QL

levo-t oral tablet Tier 1 T1S


LEVOTHYROXINE

SODIUM INTRAVENOUS

SOLUTION Tier 3

LEVOTHYROXINE

SODIUM INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

levothyroxine sodium oral

capsule Tier 1

levothyroxine sodium oral

tablet Tier 1 T1S

levoxyl oral tablet Tier 1 T1S

LEVULAN KERASTICK

EXTERNAL SOLUTION


LEXIVA ORAL

SUSPENSION Tier 2 QL

LEXIVA ORAL TABLET Tier 3 QL

LIBERTY MEDICAL

LANCETS Tier 2 QL

LIBERTY MINI


LIBRAX ORAL

CAPSULE Tier 3

LIBTAYO

INTRAVENOUS


LIDOCAINE

(ANORECTAL) RECTAL

SUPPOSITORY Tier 3

lidocaine external ointment Tier 1

lidocaine external patch Tier 1 PA; QL

LIDOCAINE HCL

(CARDIAC)

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE 100 MG/10ML

Tier 3

LIDOCAINE HCL

(CARDIAC)

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE 100 MG/5ML

Tier 3



86


lidocaine hcl (cardiac)

intravenous solution prefilled

syringe 50 mg/5ml Tier 1

LIDOCAINE HCL

(CARDIAC) PF

INTRAVENOUS

SOLUTION

Tier 3

lidocaine hcl (cardiac) pf

intravenous solution prefilled

syringe Tier 1

lidocaine hcl (pf) injection

solution Tier 1

lidocaine hcl external

solution Tier 1

lidocaine hcl injection

solution Tier 1

LIDOCAINE HCL

INJECTION SOLUTION


lidocaine hcl intradermal jet-

injector Tier 1

lidocaine hcl mouth/throat

solution Tier 1

lidocaine hcl

urethral/mucosal external gel Tier 1

lidocaine hcl

urethral/mucosal external

prefilled syringe Tier 1

LIDOCAINE HCL-

TETRACAINE HCL


lidocaine in d5w intravenous

solution Tier 1

LIDOCAINE IN

DEXTROSE SOLUTION Tier 3

lidocaine viscous hcl

mouth/throat solution Tier 1

lidocaine-epinephrine



LIDOCAINE-

EPINEPHRINE

INTRAOCULAR

SOLUTION

Tier 3

LIDOCAINE-

PHENYLEPHRINE

INTRAOCULAR

SOLUTION

Tier 3

LIDOCAINE-

PHENYLEPHRINE-BSS

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

lidocaine-prilocaine external

kit Tier 1

LIDOCAINE-SODIUM

BICARBONATE

INJECTION SOLUTION

PREFILLED SYRINGE

Tier 3

LIFESCAN UNISTIK 2 Tier 2 QL

LIFESCAN UNISTIK II

LANCETS Tier 2 QL

LILETTA (52 MG)

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 3 LD; SP

lillow oral tablet Tier 1 $0

LINCOCIN INJECTION

SOLUTION Tier 3

lincomycin hcl injection

solution Tier 1

lindane external shampoo Tier 1

linezolid in sodium chloride


linezolid intravenous solution Tier 1

linezolid oral suspension


linezolid oral tablet Tier 1 PA; QL

LINZESS ORAL

CAPSULE Tier 2



87


LIORESAL

INTRATHECAL

SOLUTION Tier 3

liothyronine sodium


liothyronine sodium oral

tablet Tier 1 T1S

lipo flavonoid plus oral tablet Tier 1 $0

LIPO INTRAMUSCULAR

SOLUTION Tier 3

LIPO-B

INTRAMUSCULAR

SOLUTION Tier 3

LIPO-C

INTRAMUSCULAR

SOLUTION Tier 3

LIPOFEN ORAL


lipoflavovit oral tablet Tier 1 $0

LIPOTRIAD ORAL

TABLET Tier 2 $0

lisinopril oral tablet 10 mg,

2.5 mg, 20 mg, 5 mg Tier 1 DO; T1S

lisinopril oral tablet 30 mg,

40 mg Tier 1 T1S

lisinopril-



lisinopril-


tablet 20-12.5 mg, 20-25 mg Tier 1

LITE TOUCH LANCETS Tier 2 QL

LITE TOUCH LANCING

PEN Tier 2

LITETOUCH INSULIN


LITETOUCH LANCETS Tier 2 QL

LITETOUCH PEN


lithium carbonate er oral

tablet extended release Tier 1 T1S


lithium carbonate oral

capsule Tier 1 T1S

lithium carbonate oral tablet Tier 1 T1S

LITHOSTAT ORAL

TABLET Tier 3

LIVE BETTER ADV


LIVE BETTER LANCET


LIVE BETTER LANCET

ULTRA THIN Tier 2 QL

lmd in d5w intravenous

solution Tier 1

lmd in nacl intravenous

solution Tier 1

LO LOESTRIN FE ORAL

TABLET Tier 2

LODINE ORAL TABLET Tier 3

LODOSYN ORAL

TABLET Tier 3

loestrin 1.5/30 (21) oral

tablet Tier 1 $0

loestrin 1/20 (21) oral tablet Tier 1 $0

loestrin fe 1.5/30 oral tablet Tier 1 $0

loestrin fe 1/20 oral tablet Tier 1 $0

lojaimiess oral tablet Tier 1 $0

LOKELMA ORAL

PACKET Tier 3

LOMAIRA ORAL


LOMOTIL ORAL

TABLET Tier 3

LONGS INSULIN


LONGS LANCETS

STANDARD Tier 2 QL

LONGS LANCETS THIN Tier 2 QL

LONGS LANCETS




88


LONHALA MAGNAIR

REFILL KIT

INHALATION

SOLUTION

Tier 3 ST; QL

LONHALA MAGNAIR

STARTER KIT

INHALATION

SOLUTION

Tier 3 ST; QL

LONSURF ORAL


loperamide hcl oral capsule Tier 1

LOPID ORAL TABLET Tier 3 ST; QL

lopinavir-ritonavir oral

solution Tier 1 QL

lopinavir-ritonavir oral tablet Tier 1 QL

LOPROX EXTERNAL

CREAM Tier 3 ST; QL

LOPROX EXTERNAL

SHAMPOO Tier 3

LOPROX EXTERNAL

SUSPENSION Tier 3 ST; QL

lorazepam injection solution Tier 1

lorazepam intensol oral

concentrate Tier 1

lorazepam oral concentrate Tier 1

lorazepam oral tablet Tier 1

LORBRENA ORAL


loryna oral tablet Tier 1 $0

lorzone oral tablet Tier 1 ST; QL

losartan potassium oral tablet Tier 1

losartan potassium-hctz oral

tablet 100-12.5 mg, 100-25

mg Tier 1

losartan potassium-hctz oral


LOSEASONIQUE ORAL

TABLET Tier 3


LOTEMAX

OPHTHALMIC GEL Tier 3

LOTEMAX

OPHTHALMIC

OINTMENT Tier 3

LOTEMAX

OPHTHALMIC

SUSPENSION Tier 3

LOTEMAX SM

OPHTHALMIC GEL Tier 3

LOTENSIN HCT ORAL

TABLET 10-12.5 MG Tier 3 DO

LOTENSIN HCT ORAL

TABLET 20-12.5 MG, 20-

25 MG Tier 3

LOTENSIN ORAL

TABLET Tier 3

loteprednol etabonate

ophthalmic gel Tier 1

loteprednol etabonate

ophthalmic suspension Tier 1

LOTRONEX ORAL


lovastatin oral tablet 10 mg,

20 mg Tier 1 DO; $0

lovastatin oral tablet 40 mg Tier 1 $0

low-ogestrel oral tablet Tier 1 $0

loxapine succinate oral

capsule Tier 1

lo-zumandimine oral tablet Tier 1 $0

lubiprostone oral capsule Tier 1

LUCEMYRA ORAL

TABLET Tier 3

LUCENTIS

INTRAVITREAL


LUCENTIS

INTRAVITREAL

SOLUTION PREFILLED

SYRINGE


luliconazole external cream Tier 1 ST; QL



89


LUMAKRAS ORAL


LUMIGAN

OPHTHALMIC

SOLUTION Tier 2

LUMIZYME

INTRAVENOUS

SOLUTION

RECONSTITUTED


LUMOXITI

INTRAVENOUS

SOLUTION

RECONSTITUTED


LUPANETA PACK

COMBINATION KIT Tier 4 PA; QL; SP

LUPKYNIS ORAL


LUPRON DEPOT (1-

MONTH)

INTRAMUSCULAR KIT

3.75 MG

Tier 4 PA; QL; SP

LUPRON DEPOT (1-

MONTH)

INTRAMUSCULAR KIT

7.5 MG

Tier 3 PA; QL; SP

LUPRON DEPOT (3-

MONTH)

INTRAMUSCULAR KIT

11.25 MG

Tier 4 PA; QL; SP

LUPRON DEPOT (3-

MONTH)

INTRAMUSCULAR KIT

22.5 MG

Tier 3 PA; QL; SP

LUPRON DEPOT (4-

MONTH)

INTRAMUSCULAR KIT Tier 3 PA; QL; SP

LUPRON DEPOT (6-

MONTH)


LUPRON DEPOT-PED (1-

MONTH)



LUPRON DEPOT-PED (3-

MONTH)


LUTATHERA

INTRAVENOUS


lutera oral tablet Tier 1 $0

LUZU EXTERNAL

CREAM Tier 3 ST; QL

lyleq oral tablet Tier 1 $0

lyllana transdermal patch

twice weekly Tier 1

LYNPARZA ORAL


LYRICA CR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 165

MG, 82.5 MG

Tier 3 PA; DO; QL

LYRICA CR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 330

MG

Tier 3 PA; QL

LYSINE HCL


LYSODREN ORAL

TABLET Tier 2

LYSTEDA ORAL

TABLET Tier 3

lyza oral tablet Tier 1 $0

M.V.I. ADULT

INTRAVENOUS

INJECTABLE Tier 3

M.V.I. PEDIATRIC

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

MACROBID ORAL

CAPSULE Tier 3

MACRODANTIN ORAL

CAPSULE Tier 3

mafenide acetate external

packet Tier 1



90


MAGELLAN INSULIN


magnesium citrate oral

solution Tier 1 $0

MAGNESIUM SULFATE

IN D5W INTRAVENOUS

SOLUTION Tier 3

MAGNESIUM SULFATE

INTRAVENOUS

SOLUTION Tier 3

MAKENA

INTRAMUSCULAR OIL Tier 4 PA; QL; LD; SP

MAKENA

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


MALARONE ORAL

TABLET Tier 3

malathion external lotion Tier 1

manganese chloride


mannitol intravenous

solution Tier 1

MARATHON MEDICAL


MARCAINE INJECTION

SOLUTION Tier 3

MARCAINE

PRESERVATIVE FREE


MARCAINE SPINAL

INTRATHECAL

SOLUTION Tier 3

MARCAINE/EPINEPHRI

NE INJECTION

SOLUTION Tier 3

MARCAINE/EPINEPHRI

NE PF INJECTION

SOLUTION Tier 3

MAR-COF BP ORAL

LIQUID Tier 3


MAR-COF CG

EXPECTORANT ORAL

LIQUID Tier 2

MARGENZA

INTRAVENOUS


MARINOL ORAL

CAPSULE Tier 3

marlissa oral tablet Tier 1 $0

MARPLAN ORAL

TABLET Tier 3

MARQIBO

INTRAVENOUS

SUSPENSION Tier 3 LD

MATULANE ORAL

CAPSULE Tier 2 LD

matzim la oral tablet


mg Tier 1 DO

matzim la oral tablet


mg, 300 mg, 360 mg, 420 mg Tier 1

MAVENCLAD (10 TABS)

ORAL TABLET


MAVENCLAD (4 TABS)

ORAL TABLET


MAVENCLAD (5 TABS)

ORAL TABLET


MAVENCLAD (6 TABS)

ORAL TABLET


MAVENCLAD (7 TABS)

ORAL TABLET


MAVENCLAD (8 TABS)

ORAL TABLET




91


MAVENCLAD (9 TABS)

ORAL TABLET


MAXICOMFORT II PEN


MAXI-COMFORT


MAXI-COMFORT

SAFETY PEN NEEDLE Tier 3 ST; QL

MAXICOMFORT SYR

27G X 1/2" Tier 3 ST; QL

MAXIDEX

OPHTHALMIC

SUSPENSION Tier 3

MAXITROL

OPHTHALMIC

OINTMENT Tier 3

MAXITROL

OPHTHALMIC

SUSPENSION Tier 3

maxi-tuss ac oral solution Tier 1

MAXI-TUSS CD ORAL

LIQUID Tier 2

MAXZIDE ORAL

TABLET Tier 3

MAXZIDE-25 ORAL

TABLET Tier 3

MAYZENT ORAL


MAYZENT STARTER

PACK ORAL TABLET


M-CLEAR WC ORAL

SOLUTION Tier 2

MEADOW FESCUE

GRASS POLLEN

SUBCUTANEOUS

SOLUTION

Tier 3

meclizine hcl oral tablet Tier 1

meclofenamate sodium oral

capsule Tier 1


MEDIC INSULIN


MEDICHOICE SAFETY

LANCET Tier 2 QL

MEDICHOICE SAFETY

LANCET EXTRA Tier 2 QL

MEDICHOICE SAFETY

LANCET NORM Tier 2 QL

MEDICINE SHOPPE PEN


MEDISENSE THIN

LANCETS Tier 2 QL

MEDLANCE EXTRA 21G Tier 2 QL

MEDLANCE LITE 25G Tier 2 QL

MEDLANCE PLUS

EXTRA 21G Tier 2 QL

MEDLANCE PLUS

LANCETS Tier 2 QL

MEDLANCE PLUS LITE

25G Tier 2 QL

MEDLANCE PLUS

SPECIAL 0.8MM Tier 2 QL

MEDLANCE PLUS

SUPERLITE 30G Tier 2 QL

MEDLANCE PLUS


MEDLANCE


MEDROL ORAL


MG, 8 MG Tier 3

MEDROL ORAL

TABLET 2 MG Tier 2

MEDROL ORAL

TABLET THERAPY

PACK Tier 3

medroxyprogesterone acetate

intramuscular suspension Tier 1 $0


intramuscular suspension

prefilled syringe Tier 1 $0



92



oral tablet Tier 1

mefenamic acid oral capsule Tier 1

mefloquine hcl oral tablet Tier 1

mega multiple/chelated

mineral oral tablet Tier 1 $0

megestrol acetate oral

suspension Tier 1

megestrol acetate oral tablet Tier 1

meijer aspirin ec oral tablet


MEIJER LANCETS Tier 2 QL

MEIJER LANCETS THIN Tier 2 QL

MEIJER LANCETS


MEIJER LANCETS


MEIJER LANCETS


MEIJER PEN NEEDLES Tier 3 ST; QL

MEIJER SUPER THIN

LANCETS Tier 2 QL

MEKINIST ORAL


MEKTOVI ORAL


MELALEUCA

SUBCUTANEOUS

SOLUTION Tier 3

meloxicam oral tablet Tier 1

melphalan hcl intravenous


melphalan oral tablet Tier 1 SP

memantine hcl er oral



memantine hcl er oral




memantine hcl oral solution Tier 1

memantine hcl oral tablet 10

mg, 28 x 5 mg & 21 x 10 mg Tier 1

memantine hcl oral tablet 5

mg Tier 1 DO

MEMBRANEBLUE

OPHTHALMIC

SOLUTION Tier 3

MENACTRA

INTRAMUSCULAR


M-END PE ORAL

LIQUID Tier 3

MENEST ORAL TABLET Tier 2

MENOPUR

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

MENOSTAR

TRANSDERMAL PATCH

WEEKLY Tier 3

MENQUADFI

INTRAMUSCULAR


MENTAX EXTERNAL

CREAM Tier 3 ST; QL

MENVEO

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 3 $0

meperidine hcl injection

solution Tier 1 QL

meperidine hcl oral solution Tier 1 QL

meperidine hcl oral tablet Tier 1 QL

MEPHYTON ORAL

TABLET Tier 3

meprobamate oral tablet Tier 3

MEPRON ORAL

SUSPENSION Tier 3



93


MEPSEVII

INTRAVENOUS


mercaptopurine oral tablet Tier 1

meropenem intravenous


MEROPENEM-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

merzee oral capsule Tier 1 $0

mesalamine er oral capsule


mesalamine oral capsule


mesalamine oral tablet


mesalamine rectal enema Tier 1

mesalamine rectal

suppository Tier 1

mesalamine-cleanser rectal

kit Tier 1

mesna intravenous solution Tier 1 PA; QL

MESNEX

INTRAVENOUS


MESNEX ORAL TABLET Tier 2 PA; QL

MESQUITE

SUBCUTANEOUS

SOLUTION Tier 3

MESTINON ORAL

SOLUTION Tier 3

MESTINON ORAL

TABLET Tier 3

MESTINON ORAL

TABLET EXTENDED

RELEASE Tier 3

metaxalone oral tablet Tier 1 ST; QL


metformin hcl er oral tablet


metformin hcl oral solution Tier 3 PA; QL

metformin hcl oral tablet Tier 1 T1S

METHADONE HCL

INJECTION SOLUTION Tier 3 PA; QL

methadone hcl intensol oral

concentrate Tier 1 PA; QL

methadone hcl oral

concentrate Tier 1 PA; QL

methadone hcl oral solution Tier 1 PA; QL

methadone hcl oral tablet Tier 1 PA; QL

methadone hcl oral tablet

soluble Tier 1 PA; QL

METHADOSE ORAL

CONCENTRATE Tier 3 PA; QL

methadose oral tablet soluble Tier 1 PA; QL

METHADOSE SUGAR-

FREE ORAL

CONCENTRATE Tier 3 PA; QL

methazolamide oral tablet Tier 1

methenamine hippurate oral

tablet Tier 1

methergine oral tablet Tier 1

methimazole oral tablet Tier 1 T1S

methocarbamol injection

solution Tier 1

methocarbamol oral tablet Tier 1

METHOHEXITAL

SODIUM INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

methotrexate oral tablet Tier 1

methotrexate sodium (pf)


methotrexate sodium




94


methotrexate sodium

injection solution


methotrexate sodium oral

tablet Tier 1

methoxsalen rapid oral

capsule Tier 1 SP

methscopolamine bromide

oral tablet Tier 1

METHYLCOBALAMIN

INJECTION SOLUTION


METHYLDOPA ORAL

TABLET 250 MG Tier 1 DO

METHYLDOPA ORAL


methylergonovine maleate


methylergonovine maleate

oral tablet Tier 1

METHYLIN ORAL


methylphenidate hcl er (cd)


10 mg, 20 mg, 30 mg Tier 1 PA; DO; QL

methylphenidate hcl er (cd)


40 mg, 50 mg, 60 mg Tier 1 PA; QL

methylphenidate hcl er (la)


24 hour 10 mg, 20 mg Tier 1 PA; DO; QL

methylphenidate hcl er (la)


24 hour 30 mg, 40 mg, 60

mg

Tier 1 PA; QL

methylphenidate hcl er (xr)


24 hour 10 mg, 15 mg, 20

mg, 30 mg

Tier 1 PA; DO; QL


methylphenidate hcl er (xr)


24 hour 40 mg, 50 mg, 60

mg

Tier 1 PA; QL

methylphenidate hcl er oral


mg, 18 mg, 27 mg Tier 1 PA; DO; QL



mg, 36 mg, 54 mg Tier 1 PA; QL



hour Tier 1 PA; DO; QL

METHYLPHENIDATE

HCL ER ORAL TABLET

EXTENDED RELEASE 72

MG

Tier 3 ST; QL

methylphenidate hcl oral



tablet 10 mg, 5 mg Tier 1 PA; DO; QL


tablet 20 mg Tier 1 PA; QL


tablet chewable 10 mg Tier 1 PA; QL


tablet chewable 2.5 mg Tier 1 ST; DO; QL


tablet chewable 5 mg Tier 1 PA; DO; QL

methylprednisolone oral

tablet Tier 1

methylprednisolone oral

tablet therapy pack Tier 1

methylprednisolone sodium

succ injection solution


metoclopramide hcl injection

solution Tier 1

metoclopramide hcl oral

solution Tier 1 T1S


tablet Tier 1 T1S



95


METOCLOPRAMIDE

HCL ORAL TABLET

DISPERSIBLE 10 MG Tier 3 ST; QL


tablet dispersible 5 mg Tier 1 ST; QL

metolazone oral tablet Tier 1

metoprolol succinate er oral


hour Tier 1

metoprolol tartrate


metoprolol tartrate oral tablet Tier 1 T1S

metoprolol-


tablet Tier 1

METROCREAM


metronidazole external cream Tier 1

metronidazole external gel Tier 1

metronidazole external lotion Tier 1

metronidazole in nacl

intravenous solution 5-0.79

mg/ml-%, 500-0.79

mg/100ml-%

Tier 1

METRONIDAZOLE IN

NACL INTRAVENOUS

SOLUTION 500-0.74

MG/100ML-%

Tier 3

metronidazole oral capsule Tier 1

metronidazole oral tablet Tier 1

metronidazole vaginal gel Tier 1

metyrosine oral capsule Tier 1 PA; QL

mexiletine hcl oral capsule Tier 1

MI PASTE DENTAL

PASTE Tier 3

MI PASTE PLUS

DENTAL PASTE Tier 3

MIACALCIN INJECTION

SOLUTION Tier 4


mibelas 24 fe oral tablet

chewable Tier 1 $0

micafungin sodium



miconazole 3 vaginal

suppository Tier 1

miconazole-zinc oxide-

petrolat external ointment Tier 1

MICRHOGAM ULTRA-

FILTERED PLUS

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE

Tier 4 SP

MICRODOT PEN


microgestin 1.5/30 oral tablet Tier 1 $0

microgestin 1/20 oral tablet Tier 1 $0

microgestin 24 fe oral tablet Tier 1 $0

microgestin fe 1.5/30 oral

tablet Tier 1 $0

microgestin fe 1/20 oral

tablet Tier 1 $0

MICROLET LANCETS Tier 2 QL

MICROLET NEXT


midazolam hcl (pf) injection

solution Tier 1

midazolam hcl injection

solution Tier 1

midazolam hcl oral syrup Tier 1

MIDAZOLAM HCL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

MIDAZOLAM HCL-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3



96


MIDAZOLAM

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

MIDAZOLAM-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

MIDAZOLAM-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

midodrine hcl oral tablet Tier 1

MIFEPREX ORAL

TABLET Tier 3

mifepristone oral tablet Tier 1

migergot rectal suppository Tier 1

miglitol oral tablet Tier 1

miglustat oral capsule Tier 4 PA; QL; SP

mili oral tablet Tier 1 $0

milk of magnesia concentrate


milk of magnesia oral


millguard oral tablet Tier 1 $0

MILLIPRED ORAL

TABLET Tier 3

milrinone lactate in dextrose


milrinone lactate intravenous

solution Tier 1

mimvey oral tablet Tier 1

MINASTRIN 24 FE ORAL


mineral oil heavy oral oil Tier 1

MINI LANCING DEVICE Tier 2

MINILINK REAL-TIME



MINIMED 630G

GUARDIAN PRESS Tier 3 PA; QL

MINIMED GUARDIAN

LINK 3 Tier 3 PA; QL

MINIPRESS ORAL

CAPSULE Tier 3

minitran transdermal patch

24 hour Tier 1

MINOCIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

minocycline hcl oral capsule Tier 1

minocycline hcl oral tablet Tier 1

minoxidil oral tablet Tier 1

MIOCHOL-E

INTRAOCULAR

SOLUTION

RECONSTITUTED

Tier 3

MIOSTAT

INTRAOCULAR

SOLUTION Tier 3

MIRAPEX ER ORAL

TABLET EXTENDED


MIRCERA INJECTION

SOLUTION PREFILLED

SYRINGE Tier 4 PA; QL; LD

MIRCETTE ORAL

TABLET Tier 3

MIRENA (52 MG)

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 3 LD; SP

mirtazapine oral tablet Tier 1

mirtazapine oral tablet

dispersible Tier 1

MIRVASO EXTERNAL

GEL Tier 3

misoprostol oral tablet Tier 1



97


MITE (D. FARINAE)


MITE (D. FARINAE)

SUBCUTANEOUS

SOLUTION Tier 3

MITE (D.

PTERONYSSINUS)


MITE (D.

PTERONYSSINUS)

SUBCUTANEOUS

SOLUTION

Tier 3

mitigo injection solution Tier 1 QL

MITOMYCIN

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

mitomycin intravenous


MITOMYCIN

INTRAVESICAL

SOLUTION PREFILLED

SYRINGE

Tier 3

MITOSOL

OPHTHALMIC KIT Tier 3

mitoxantrone hcl intravenous

concentrate Tier 1 SP

MIXED ASPERGILLUS

SUBCUTANEOUS

SOLUTION Tier 3

MIXED FEATHERS

SUBCUTANEOUS

SOLUTION Tier 3

MIXED RAGWEED

SUBCUTANEOUS

SOLUTION Tier 3

MIXED VESPID VENOM

PROTEIN INJECTION

SOLUTION

RECONSTITUTED

Tier 3


MIXED VESPID VENOM

PROTEIN

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3

mm clearlax oral powder Tier 1 $0

MM INSULIN

SYRINGE/NEEDLE Tier 3 ST; QL

MM LANCING DEVICE Tier 2

MM PEN NEEDLES Tier 3 ST; QL

MM TWIST LANCETS Tier 2 QL

M-M-R II INJECTION

SOLUTION


M-NATAL PLUS ORAL

TABLET Tier 3

modafinil oral tablet 100 mg Tier 1 PA; DO; QL

modafinil oral tablet 200 mg Tier 1 PA; QL

moexipril hcl oral tablet Tier 1

molindone hcl oral tablet Tier 1

mometasone furoate external

cream Tier 1


ointment Tier 1


solution Tier 1

mometasone furoate nasal

suspension Tier 3 ST; QL

mondoxyne nl oral capsule Tier 1

MONJUVI

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD

MONOFERRIC

INTRAVENOUS


MONOJECT BONE

MARROW BIOPSY




98


monoject flush syringe


MONOJECT INSULIN


monoject sodium chloride

flush intravenous solution Tier 1

MONOJECT ULTRA

COMFORT SYRINGE Tier 3 ST; QL

MONOLET LANCETS Tier 2 QL

MONOLET OPD

LANCETS Tier 2 QL

MONOLETTOR SAFETY

LANCETS Tier 2 QL

mono-linyah oral tablet Tier 1 $0

MONONINE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

MONOVISC INTRA-

ARTICULAR SOLUTION


montelukast sodium oral

packet Tier 1


tablet Tier 1


tablet chewable Tier 1

MONUROL ORAL

PACKET Tier 3

morgidox oral capsule Tier 1

morphine sulfate

(concentrate) oral solution Tier 1 QL

morphine sulfate (pf)

injection solution 0.5 mg/ml,

1 mg/ml Tier 1 QL

MORPHINE SULFATE

(PF) INJECTION

SOLUTION 10 MG/ML, 2

MG/ML, 4 MG/ML, 5

MG/ML, 8 MG/ML

Tier 3 QL


MORPHINE SULFATE

(PF) INTRAVENOUS

SOLUTION Tier 3 QL

morphine sulfate er beads



morphine sulfate er oral


hour Tier 1 PA; QL

morphine sulfate er oral

tablet extended release Tier 1 PA; QL

MORPHINE SULFATE


morphine sulfate oral

solution Tier 1 QL

morphine sulfate oral tablet Tier 1 QL

MORPHINE SULFATE-

NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

MOTOFEN ORAL

TABLET Tier 3

MOUNTAIN CEDAR

SUBCUTANEOUS

SOLUTION Tier 3

MOUSE EPITHELIUM

SUBCUTANEOUS

SOLUTION Tier 3

MOVANTIK ORAL

TABLET Tier 2

MOVIPREP ORAL

SOLUTION


MOXEZA OPHTHALMIC

SOLUTION Tier 3

moxifloxacin hcl (2x day)


moxifloxacin hcl in nacl


MOXIFLOXACIN HCL

INTRAOCULAR

SOLUTION Tier 3



99


MOXIFLOXACIN HCL

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

MOXIFLOXACIN HCL

INTRAVENOUS

SOLUTION Tier 3

moxifloxacin hcl ophthalmic

solution Tier 1

moxifloxacin hcl oral tablet Tier 1

MOZOBIL

SUBCUTANEOUS


MPD SAFETY LANCET

21G Tier 2 QL

MPD SAFETY LANCET

23G Tier 2 QL

MPD SAFETY LANCET

28G Tier 2 QL

MPD SAFETY LANCET

30G Tier 2 QL

MS INSULIN SYRINGE Tier 3 ST; QL

MUCOR INJECTION

SOLUTION Tier 3

MUCOR INTRADERMAL

SOLUTION Tier 3

MUCOR

SUBCUTANEOUS

SOLUTION Tier 3

MUGWORT

SUBCUTANEOUS

SOLUTION Tier 3

MULPLETA ORAL


MULTAQ ORAL

TABLET Tier 3

MULTI PRENATAL


multi vitamin daily oral

tablet Tier 1 $0


MULTI VITAMIN ORAL

TABLET Tier 2 $0

MULTI VITAMIN W/D-3


multi-day oral tablet Tier 1 $0

multi-day plus iron oral

tablet Tier 1 $0

MULTI-LANCET

DEVICE Tier 2

MULTI-LANCET

DEVICE 2 KIT Tier 2

multiple vitamin-folic acid


multiple vitamins essential


multiple vitamins oral tablet Tier 1 $0

multiple vitamins/iron oral

tablet Tier 1 $0

multivitamin adult oral tablet Tier 1 $0

multi-vitamin daily oral

tablet Tier 1 $0

multivitamin iron-free oral

tablet Tier 1 $0

MULTIVITAMIN ORAL

TABLET Tier 2 $0

multi-vitamin oral tablet Tier 1 $0

multivitamin plus iron adult


multivitamin select/fluoride

oral solution Tier 1 $0

multivitamin/fluoride oral

solution Tier 1 $0

multi-vitamin/fluoride oral

solution Tier 1 $0

multivitamin/fluoride oral

tablet chewable 0.25 mg, 0.5

mg, 1 mg Tier 1 $0



100


MULTIVITAMIN/FLUOR

IDE ORAL TABLET

CHEWABLE 0.25-0.3 MG,

0.5-0.3 MG, 1-0.3 MG

Tier 3

multi-vitamin/fluoride/iron


multi-vitamin/iron oral tablet Tier 1 $0

MULTRYS

INTRAVENOUS

SOLUTION Tier 3

mupirocin external ointment Tier 1

MUSE URETHRAL

PELLET Tier 3 PA; QL

mutamycin intravenous


MVASI INTRAVENOUS


my choice oral tablet Tier 1 $0

my way oral tablet Tier 1 $0

MYALEPT

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD

MYAMBUTOL ORAL

TABLET Tier 3

MYCAMINE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

MYCAPSSA ORAL

CAPSULE DELAYED

RELEASE Tier 4 PA; QL; LD

MYCOBUTIN ORAL

CAPSULE Tier 3

mycophenolate mofetil hcl



mycophenolate mofetil




mycophenolate mofetil oral

capsule Tier 1


suspension reconstituted Tier 1


tablet Tier 1

mycophenolate sodium oral


MYDAYIS ORAL

CAPSULE EXTENDED


MYDRIACYL

OPHTHALMIC

SOLUTION Tier 3

MYFEMBREE ORAL


MYFORTIC ORAL

TABLET DELAYED

RELEASE Tier 3

MYGLUCOHEALTH


MYLERAN ORAL

TABLET Tier 2

MYLOTARG

INTRAVENOUS

SOLUTION

RECONSTITUTED


MYNATAL ORAL


MYNATAL PLUS ORAL

TABLET Tier 2

MYNATAL-Z ORAL

TABLET Tier 2

MYOBLOC

INTRAMUSCULAR


myorisan oral capsule Tier 2 PA; QL

MYRBETRIQ ORAL

SUSPENSION

RECONSTITUTED ER Tier 3



101


MYRBETRIQ ORAL

TABLET EXTENDED


MYTESI ORAL TABLET

DELAYED RELEASE Tier 3 PA; QL; LD

MYXREDLIN

INTRAVENOUS

SOLUTION Tier 3

na ferric gluc cplx in sucrose


NABI-HB

INTRAMUSCULAR

SOLUTION Tier 4 SP

nabumetone oral tablet Tier 1

nadolol oral tablet Tier 1

NAFCILLIN SODIUM IN

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

nafcillin sodium injection


nafcillin sodium intravenous


NAFRINSE DAILY

ACIDULATED

MOUTH/THROAT

SOLUTION

RECONSTITUTED

Tier 3

NAFRINSE

DAILY/NEUTRAL

MOUTH/THROAT

SOLUTION

RECONSTITUTED

Tier 3

nafrinse drops oral solution Tier 1 $0

nafrinse oral tablet chewable Tier 1 $0

NAFRINSE WEEKLY

MOUTH/THROAT

SOLUTION

RECONSTITUTED

Tier 3

naftifine hcl external cream Tier 1 ST; QL

naftifine hcl external gel Tier 1 ST; QL


NAFTIN EXTERNAL

GEL Tier 3 ST; QL

NAGLAZYME

INTRAVENOUS


nalbuphine hcl injection

solution Tier 1

naloxone hcl injection

solution Tier 1




solution prefilled syringe Tier 1

naltrexone hcl oral tablet Tier 1

NAMENDA TITRATION

PAK ORAL TABLET Tier 3

NAMZARIC ORAL

CAPSULE ER 24 HOUR

THERAPY PACK Tier 2

NAMZARIC ORAL

CAPSULE EXTENDED


naproxen oral tablet Tier 1

naproxen oral tablet delayed

release Tier 1

naproxen sodium oral tablet Tier 1

naratriptan hcl oral tablet Tier 1 QL

NARCAN NASAL LIQUID Tier 2

NARDIL ORAL TABLET Tier 3

NAROPIN INJECTION

SOLUTION Tier 3

NATACHEW ORAL


NATACYN

OPHTHALMIC

SUSPENSION Tier 3

NATALVIT ORAL

TABLET Tier 3



102


NATAZIA ORAL

TABLET Tier 3

nateglinide oral tablet Tier 1

NATPARA

SUBCUTANEOUS

CARTRIDGE Tier 3 PA; QL; LD; SP

NATROBA EXTERNAL

SUSPENSION Tier 3

nat-rul b-50 oral tablet Tier 1 $0

nat-rul daily-vite+iron oral

tablet Tier 1 $0

NATURE-THROID ORAL

TABLET Tier 3

NAVELBINE

INTRAVENOUS

SOLUTION Tier 3 SP

NAYZILAM NASAL


NEBUPENT

INHALATION

SOLUTION

RECONSTITUTED

Tier 3

necon 0.5/35 (28) oral tablet Tier 1 $0

NEEVO DHA ORAL


nefazodone hcl oral tablet Tier 1

NEMBUTAL INJECTION

SOLUTION Tier 3

NEOMULTIVITE ORAL

TABLET Tier 2 $0

neomycin sulfate oral tablet Tier 1

neomycin-bacitracin zn-

polymyx ophthalmic

ointment Tier 1

neomycin-polymyxin b gu

irrigation solution Tier 1

neomycin-polymyxin-

dexameth ophthalmic

ointment Tier 1


neomycin-polymyxin-

dexameth ophthalmic

suspension Tier 1

neomycin-polymyxin-

gramicidin ophthalmic

solution Tier 1

neomycin-polymyxin-hc


neomycin-polymyxin-hc otic

solution Tier 1

neomycin-polymyxin-hc otic

suspension Tier 1

NEONATAL + DHA

ORAL Tier 3 ST; QL

NEONATAL 19 ORAL


NEONATAL COMPLETE


NEONATAL FE ORAL


NEONATAL PLUS ORAL


NEONATAL VITAMIN


neo-polycin hc ophthalmic

ointment Tier 1

neo-polycin ophthalmic

ointment Tier 1

NEOPROFEN

INTRAVENOUS

SOLUTION Tier 3

NEORAL ORAL

CAPSULE Tier 3

NEORAL ORAL

SOLUTION Tier 3

NEOSTIGMINE

METHYLSULFATE

INTRAVENOUS

SOLUTION

Tier 3

NEO-SYNALAR




103


NEOX 100 EXTERNAL

SHEET Tier 3

NEOX CORD 1K


nephro vitamins oral tablet Tier 1 $0

NEPHRO-VITE ORAL

TABLET Tier 2 $0

NERLYNX ORAL


NESACAINE INJECTION

SOLUTION Tier 3

NESACAINE-MPF


NESTABS DHA ORAL Tier 3 ST; QL

NESTABS ONE ORAL


NESTABS ORAL


neuac external gel Tier 1

NEULASTA ONPRO

SUBCUTANEOUS

PREFILLED SYRINGE

KIT

Tier 4 PA; QL; SP

NEULASTA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

NEUPOGEN INJECTION


NEUPOGEN INJECTION

SOLUTION PREFILLED

SYRINGE Tier 4 PA; QL; SP

NEUPRO

TRANSDERMAL PATCH

24 HOUR Tier 3

NEURIN-SL

SUBLINGUAL TABLET

SUBLINGUAL Tier 3

NEVANAC

OPHTHALMIC

SUSPENSION Tier 3


nevirapine er oral tablet


mg Tier 1

nevirapine er oral tablet


mg Tier 1 QL

nevirapine oral suspension Tier 1 QL

nevirapine oral tablet Tier 1 QL

new day oral tablet Tier 1 $0

NEXAVAR ORAL


NEXAVIR INJECTION

SOLUTION Tier 3

NEXIUM I.V.

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

NEXLETOL ORAL


NEXLIZET ORAL


NEXPLANON

SUBCUTANEOUS

IMPLANT Tier 4 LD; SP

NEXTERONE

INTRAVENOUS

SOLUTION Tier 3

NEXTSTELLIS ORAL

TABLET Tier 3

NEXVIAZYME

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 SP

niacin (antihyperlipidemic)

oral tablet Tier 1 ST; QL

niacin er

(antihyperlipidemic) oral

tablet extended release Tier 1 ST; QL

niacor oral tablet Tier 1 ST; QL

NIASPAN ORAL TABLET

EXTENDED RELEASE Tier 3 ST; QL



104


NICARDIPINE HCL IN

NACL INTRAVENOUS

SOLUTION Tier 3

NICARDIPINE HCL IN

NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

nicardipine hcl intravenous

solution Tier 1

nicardipine hcl oral capsule Tier 1 T1S

NICODERM CQ

TRANSDERMAL PATCH

24 HOUR Tier 2 $0

NICORETTE MINI

MOUTH/THROAT

LOZENGE Tier 2 $0

NICORETTE

MOUTH/THROAT GUM Tier 2 $0

NICORETTE

MOUTH/THROAT

LOZENGE Tier 2 $0

NICORETTE STARTER

KIT MOUTH/THROAT

GUM Tier 2 $0

nicotine mini mouth/throat

lozenge Tier 1 $0

nicotine polacrilex mini


nicotine polacrilex


nicotine polacrilex


nicotine step 1 transdermal






NICOTINE

TRANSDERMAL KIT Tier 2 $0

nicotine transdermal patch 24

hour Tier 1 $0


NICOTROL

INHALATION INHALER Tier 3 PA; QL; $0

NICOTROL NS NASAL

SOLUTION Tier 3 PA; QL; $0

nifedipine er oral tablet


mg Tier 1 DO

nifedipine er oral tablet


mg, 90 mg Tier 1

nifedipine er osmotic release



nifedipine er osmotic release


24 hour 60 mg, 90 mg Tier 1

nifedipine oral capsule Tier 1

nikki oral tablet Tier 1 $0

NILANDRON ORAL

TABLET Tier 3 QL

nilutamide oral tablet Tier 1 QL

NIMBEX INTRAVENOUS

SOLUTION Tier 3

nimodipine oral capsule Tier 1

NINJACOF-XG ORAL

LIQUID Tier 3

NINLARO ORAL


NIPENT INTRAVENOUS

SOLUTION


NIPRIDE RTU

INTRAVENOUS

SOLUTION Tier 3

nisoldipine er oral tablet


mg, 20 mg, 8.5 mg Tier 1 DO

nisoldipine er oral tablet

extended release 24 hour

25.5 mg, 30 mg, 34 mg, 40

mg

Tier 1



105


nitazoxanide oral tablet Tier 1

NITHIODOTE


nitisinone oral capsule Tier 4 PA; QL; SP

NITRO-BID

TRANSDERMAL

OINTMENT Tier 3

NITRO-DUR

TRANSDERMAL PATCH

24 HOUR 0.1 MG/HR, 0.2

MG/HR, 0.4 MG/HR, 0.6

MG/HR

Tier 3

NITRO-DUR

TRANSDERMAL PATCH

24 HOUR 0.3 MG/HR, 0.8

MG/HR

Tier 2

nitrofurantoin macrocrystal

oral capsule Tier 1

nitrofurantoin monohyd

macro oral capsule Tier 1

nitrofurantoin oral

suspension Tier 1

nitroglycerin in d5w


NITROGLYCERIN

INTRAVENOUS

SOLUTION Tier 3

nitroglycerin sublingual

tablet sublingual Tier 1

nitroglycerin transdermal

patch 24 hour Tier 1

nitroglycerin translingual

solution Tier 1

NITROLINGUAL

TRANSLINGUAL

SOLUTION Tier 3

NITROMIST

TRANSLINGUAL

AEROSOL SOLUTION Tier 3

nitroprusside sodium



NITROSTAT

SUBLINGUAL TABLET

SUBLINGUAL Tier 3

NITYR ORAL TABLET Tier 4 PA; QL; LD

NIVA-PLUS ORAL

TABLET Tier 3

NIVESTYM INJECTION


NIVESTYM INJECTION

SOLUTION PREFILLED


nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

NOCDURNA

SUBLINGUAL TABLET

SUBLINGUAL Tier 4 PA; QL

nolix external lotion Tier 3 ST; QL

nora-be oral tablet Tier 1 $0

NOREPINEPHRINE

(BASE)-DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

norepinephrine bitartrate


NOREPINEPHRINE-

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

NOREPINEPHRINE-

SODIUM CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

norethin ace-eth estrad-fe

oral capsule Tier 1 $0





norethindrone acetate oral

tablet Tier 1



106


norethindrone acet-ethinyl

est oral tablet Tier 1 $0

norethindrone oral tablet Tier 1 $0

norethindrone-eth estradiol

oral tablet Tier 1

norethin-eth estradiol-fe oral


norgestimate-eth estradiol


norgestim-eth estrad triphasic


NORITATE EXTERNAL

CREAM Tier 3 ST; QL

norlyda oral tablet Tier 1 $0

norlyroc oral tablet Tier 1 $0

normal saline flush


NORMOSOL-M IN D5W

INTRAVENOUS

SOLUTION Tier 3

NORMOSOL-R IN D5W

INTRAVENOUS

SOLUTION Tier 3

NORMOSOL-R

INTRAVENOUS

SOLUTION Tier 3

NORMOSOL-R PH 7.4

INTRAVENOUS

SOLUTION Tier 3

NORPACE CR ORAL

CAPSULE EXTENDED


NORPACE ORAL

CAPSULE Tier 3

NORPRAMIN ORAL

TABLET Tier 3

NORTHERA ORAL


nortrel 0.5/35 (28) oral tablet Tier 1 $0

nortrel 1/35 (21) oral tablet Tier 1 $0


nortrel 1/35 (28) oral tablet Tier 1 $0

nortrel 7/7/7 oral tablet Tier 1 $0

nortriptyline hcl oral capsule Tier 1

nortriptyline hcl oral solution Tier 1

NORVIR ORAL PACKET Tier 3 QL

NORVIR ORAL

SOLUTION Tier 2 QL

NORVIR ORAL TABLET Tier 3 QL

NOURIANZ ORAL


NOVA SAFETY


NOVA SAFETY


NOVA SUREFLEX

LANCETS Tier 2 QL

NOVA SUREFLEX


NOVACHOR EXTERNAL

SHEET Tier 3

NOVAREL

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

NOVOEIGHT

INTRAVENOUS

SOLUTION

RECONSTITUTED


NOVOFINE

AUTOCOVER PEN


NOVOFINE PEN


NOVOFINE PLUS PEN


NOVOSEVEN RT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP



107


NOVOTWIST PEN


NOXAFIL

INTRAVENOUS

SOLUTION Tier 3

NOXAFIL ORAL

SUSPENSION Tier 3 PA; QL

NOXAFIL ORAL

TABLET DELAYED


np thyroid oral tablet Tier 1

NPLATE

SUBCUTANEOUS

SOLUTION

RECONSTITUTED 125

MCG

Tier 4 PA; QL

NPLATE

SUBCUTANEOUS

SOLUTION

RECONSTITUTED 250

MCG, 500 MCG

Tier 4 PA; QL; SP

NUBEQA ORAL TABLET Tier 3 PA; QL; LD; SP

NUCALA

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR


NUCALA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


NUCALA

SUBCUTANEOUS

SOLUTION

RECONSTITUTED


NUCYNTA ORAL

TABLET Tier 3 QL

NUEDEXTA ORAL


NULIBRY

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD


NULOJIX

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

NULYTELY LEMON-

LIME ORAL SOLUTION


NUMBRINO NASAL

SOLUTION Tier 3

NUPLAZID ORAL


NUPLAZID ORAL


NURTEC ORAL TABLET

DISPERSIBLE Tier 2 PA; QL

NUSHIELD EXTERNAL

DISK Tier 3

NUSHIELD EXTERNAL

SHEET Tier 3

NUTRILIPID

INTRAVENOUS

EMULSION Tier 3

NUTROPIN AQ NUSPIN

10 SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

NUTROPIN AQ NUSPIN

20 SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

NUTROPIN AQ NUSPIN 5

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

NUVARING VAGINAL

RING Tier 3

NUVESSA VAGINAL

GEL Tier 3

NUWIQ INTRAVENOUS

KIT Tier 4 PA; QL; SP



108


NUWIQ INTRAVENOUS

SOLUTION


NUZYRA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 LD

NUZYRA ORAL TABLET Tier 3 PA; QL; LD

nyamyc external powder Tier 1

nylia 7/7/7 oral tablet Tier 1 $0

NYMALIZE ORAL

SOLUTION Tier 3

nymyo oral tablet Tier 1 $0

nystatin external cream Tier 1

nystatin external ointment Tier 1

nystatin external powder Tier 1

nystatin mouth/throat

suspension Tier 1

nystatin oral tablet Tier 1

nystatin-triamcinolone


nystatin-triamcinolone


nystop external powder Tier 1

NYVEPRIA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


OB COMPLETE ONE


OB COMPLETE ORAL


OB COMPLETE PETITE


OB COMPLETE

PREMIER ORAL


OB COMPLETE/DHA



OBIZUR INTRAVENOUS

SOLUTION


OBSTETRIX DHA ORAL Tier 3

OBSTETRIX EC ORAL

TABLET Tier 3

OBSTETRIX ONE ORAL

CAPSULE Tier 3

OCALIVA ORAL


ocella oral tablet Tier 1 $0

OCTAGAM

INTRAVENOUS

SOLUTION 1 GM/20ML,

10 GM/100ML, 10

GM/200ML, 2 GM/20ML,

2.5 GM/50ML, 20

GM/200ML, 25

GM/500ML, 5 GM/100ML,

5 GM/50ML

Tier 4 PA; QL; SP

OCTAGAM

INTRAVENOUS

SOLUTION 30 GM/300ML Tier 4 PA; QL

OCTAPLAS BLOOD

GROUP A

INTRAVENOUS

SOLUTION

Tier 3

OCTAPLAS BLOOD

GROUP AB

INTRAVENOUS

SOLUTION

Tier 3

OCTAPLAS BLOOD

GROUP B

INTRAVENOUS

SOLUTION

Tier 3

OCTAPLAS BLOOD

GROUP O

INTRAVENOUS

SOLUTION

Tier 3

octreotide acetate injection


ocucoat viscoadherent

intraocular solution Tier 1



109


OCUFLOX

OPHTHALMIC

SOLUTION Tier 3

ODACTRA

SUBLINGUAL TABLET


ODEFSEY ORAL


ODOMZO ORAL


OFEV ORAL CAPSULE Tier 4 PA; QL; LD; SP

OFIRMEV

INTRAVENOUS

SOLUTION Tier 3

ofloxacin ophthalmic

solution Tier 1

ofloxacin oral tablet 300 mg Tier 1 QL

ofloxacin oral tablet 400 mg Tier 1

ofloxacin otic solution Tier 1

OGIVRI INTRAVENOUS

SOLUTION


olanzapine intramuscular

solution reconstituted Tier 1 PA; QL

olanzapine oral tablet 10 mg,

2.5 mg, 5 mg, 7.5 mg Tier 1 DO

olanzapine oral tablet 15 mg,

20 mg Tier 1

olanzapine oral tablet

dispersible 10 mg, 5 mg Tier 1 DO

olanzapine oral tablet

dispersible 15 mg, 20 mg Tier 1

olanzapine-fluoxetine hcl

oral capsule 12-25 mg, 12-50

mg, 6-50 mg Tier 1

olanzapine-fluoxetine hcl

oral capsule 3-25 mg, 6-25

mg Tier 1 DO

OLINVYK

INTRAVENOUS

SOLUTION Tier 3


OLIVE TREE

SUBCUTANEOUS

SOLUTION Tier 3

olmesartan medoxomil oral


olmesartan medoxomil oral

tablet 40 mg, 5 mg Tier 1

olmesartan medoxomil-hctz

oral tablet 20-12.5 mg Tier 1 DO

olmesartan medoxomil-hctz

oral tablet 40-12.5 mg, 40-25

mg Tier 1

olmesartan-amlodipine-hctz

oral tablet 20-5-12.5 mg Tier 1 DO

olmesartan-amlodipine-hctz

oral tablet 40-10-12.5 mg,

40-10-25 mg, 40-5-12.5 mg,

40-5-25 mg

Tier 1

olopatadine hcl nasal

solution Tier 1

OMECLAMOX-PAK

ORAL Tier 3 ST; QL

omega-3-acid ethyl esters

oral capsule Tier 1 PA; QL

OMEGAVEN

INTRAVENOUS

EMULSION Tier 3

omeprazole oral capsule

delayed release Tier 1 QL

OMIDRIA

INTRAOCULAR

SOLUTION Tier 3

OMNICAP ORAL

TABLET Tier 2 $0

OMNIFLEX

DIAPHRAGM VAGINAL

DIAPHRAGM Tier 3

OMNIPOD 5 PACK Tier 2 PA; QL

OMNIPOD DASH 5 PACK

PODS Tier 2 PA; QL

OMNIPOD STARTER

KIT Tier 2 PA; QL



110


ONCASPAR INJECTION


once daily oral tablet Tier 1 $0

ondansetron hcl injection

solution Tier 1

ondansetron hcl oral solution Tier 1 QL

ondansetron hcl oral tablet Tier 1 QL

ondansetron oral tablet

dispersible Tier 1 QL

one daily essential oral tablet Tier 1 $0

one daily multivitamin adult


one daily multivitamin/iron


one daily oral tablet Tier 1 $0

ONE VITE WOMENS


ONE VITE WOMENS

PLUS ORAL TABLET Tier 3

ONE-A-DAY ESSENTIAL


ONE-A-DAY MENS


ONE-A-DAY WOMENS


one-daily multi vitamins oral

tablet Tier 1 $0

one-daily multi-vitamin oral

tablet Tier 1 $0

one-daily multi-vitamin/iron


one-daily/iron oral tablet Tier 1 $0

ONETOUCH CLUB

LANCETS FINE PT Tier 2 QL

ONETOUCH DELICA


ONETOUCH DELICA


ONETOUCH DELICA

LANCING DEV Tier 2


ONETOUCH DELICA

PLUS LANCET30G Tier 2 QL

ONETOUCH DELICA

PLUS LANCET33G Tier 2 QL

ONETOUCH DELICA

PLUS LANCING Tier 2

ONETOUCH DELICA

SAFETY LANCING Tier 2

ONETOUCH FINEPOINT

LANCETS Tier 2 QL

ONETOUCH SURESOFT

LANCING DEV Tier 2

ONETOUCH ULTRA IN

VITRO STRIP Tier 2

ONETOUCH

ULTRASOFT LANCETS Tier 2 QL

ONETOUCH VERIO IN

VITRO STRIP Tier 2 ST; QL

ONEXTON EXTERNAL

GEL Tier 2

ONGENTYS ORAL


ONIVYDE

INTRAVENOUS

INJECTABLE Tier 3 LD

ONPATTRO

INTRAVENOUS


ONTRUZANT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

ONUREG ORAL TABLET Tier 3 PA; QL; LD; SP

opcicon one-step oral tablet Tier 1 $0

OPDIVO INTRAVENOUS


OPSUMIT ORAL


option 2 oral tablet Tier 1 $0



111


OPTIONS GYNOL II

CONTRACEPTIVE

VAGINAL GEL Tier 2 $0

ORABLOC INJECTION

SOLUTION CARTRIDGE Tier 3

ORALAIR SUBLINGUAL

TABLET SUBLINGUAL Tier 3 PA; QL; LD

oralone mouth/throat paste Tier 1

ORAPRED ODT ORAL

TABLET DISPERSIBLE

10 MG, 30 MG Tier 3

ORAPRED ODT ORAL

TABLET DISPERSIBLE

15 MG Tier 3 DO

ORAVIG BUCCAL

TABLET Tier 3

ORBACTIV

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ORCHARD GRASS

POLLEN

SUBCUTANEOUS

SOLUTION

Tier 3

ORENITRAM ORAL

TABLET EXTENDED

RELEASE Tier 4 PA; QL; LD; SP

ORFADIN ORAL


ORFADIN ORAL


ORGOVYX ORAL


ORIAHNN ORAL

CAPSULE THERAPY

PACK Tier 3 PA; QL

ORILISSA ORAL


ORKAMBI ORAL


ORKAMBI ORAL



ORLADEYO ORAL


orphenadrine citrate er oral


hour Tier 1

orphenadrine citrate injection

solution Tier 1

orphenadrine-asa-caffeine


orphengesic forte oral tablet Tier 1 ST; QL

orsythia oral tablet Tier 1 $0

ORTHOVISC INTRA-

ARTICULAR SOLUTION


ORTIKOS ORAL

CAPSULE EXTENDED


oseltamivir phosphate oral

capsule Tier 1 QL

oseltamivir phosphate oral

suspension reconstituted Tier 1 QL

osmitrol intravenous solution Tier 1

OSMOLEX ER ORAL

TABLET ER 24 HOUR

THERAPY PACK Tier 3 PA; QL

OSMOLEX ER ORAL

TABLET EXTENDED

RELEASE 24 HOUR 129

MG

Tier 3 PA; DO; QL

OSMOLEX ER ORAL

TABLET EXTENDED

RELEASE 24 HOUR 193

MG, 258 MG

Tier 3 PA; QL

OSMOPREP ORAL

TABLET Tier 3

OSPHENA ORAL


OTEZLA ORAL TABLET Tier 4 PA; QL; SP

OTEZLA ORAL TABLET




112


OTIPRIO

INTRATYMPANIC

SUSPENSION Tier 3

OTOVEL OTIC

SOLUTION Tier 3

OTREXUP

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

OVIDE EXTERNAL

LOTION Tier 3

OVIDREL

SUBCUTANEOUS


OXACILLIN SODIUM IN

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

oxacillin sodium injection


oxacillin sodium intravenous


oxaliplatin intravenous

solution Tier 1 SP

oxaliplatin intravenous


oxandrolone oral tablet Tier 1 PA; QL

oxaprozin oral tablet Tier 1

OXAYDO ORAL TABLET Tier 3 QL

oxazepam oral capsule Tier 1

OXBRYTA ORAL


oxcarbazepine oral

suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXERVATE

OPHTHALMIC


oxiconazole nitrate external

cream Tier 3


OXISTAT EXTERNAL

CREAM Tier 3 ST; QL

OXISTAT EXTERNAL


OXLUMO

SUBCUTANEOUS


OXTELLAR XR ORAL

TABLET EXTENDED


oxybutynin chloride er oral


hour Tier 1

oxybutynin chloride oral

syrup Tier 1

oxybutynin chloride oral

tablet Tier 1

oxycodone hcl er oral tablet

er 12 hour abuse-deterrent Tier 3 PA; QL

oxycodone hcl oral capsule Tier 1 QL

oxycodone hcl oral

concentrate Tier 1 QL

oxycodone hcl oral solution Tier 1 QL

oxycodone hcl oral tablet Tier 1 QL

oxycodone-acetaminophen


OXYCONTIN ORAL

TABLET ER 12 HOUR

ABUSE-DETERRENT Tier 3 PA; QL

oxymorphone hcl er oral


hour Tier 1 PA; QL

oxymorphone hcl oral tablet Tier 1 QL

oxytocin injection solution Tier 1

OXYTOCIN-LACTATED

RINGERS

INTRAVENOUS

SOLUTION

Tier 3



113


OXYTOCIN-SODIUM

CHLORIDE

INTRAVENOUS

SOLUTION

Tier 3

OZEMPIC (0.25 OR 0.5

MG/DOSE)

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2 ST; QL

OZEMPIC (1 MG/DOSE)

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2 ST; QL

OZURDEX

INTRAVITREAL


pacerone oral tablet Tier 1

paclitaxel intravenous

concentrate Tier 1 SP

PADCEV INTRAVENOUS

SOLUTION


PALFORZIA (12 MG

DAILY DOSE) ORAL Tier 4 PA; QL; LD; SP

PALFORZIA (120 MG


PALFORZIA (160 MG


PALFORZIA (20 MG


PALFORZIA (200 MG


PALFORZIA (240 MG


PALFORZIA (3 MG


PALFORZIA (300 MG

MAINTENANCE) ORAL

PACKET Tier 4 PA; QL; LD; SP

PALFORZIA (300 MG

TITRATION) ORAL

PACKET Tier 4 PA; QL; LD; SP


PALFORZIA (40 MG


PALFORZIA (6 MG


PALFORZIA (80 MG


PALFORZIA INITIAL

ESCALATION ORAL Tier 4 PA; QL; LD; SP

PALINGEN FLOW

INJECTION

INJECTABLE Tier 3

PALINGEN

HYDROMEMBRANE


PALINGEN INOVOFLO

INJECTION

INJECTABLE Tier 3

PALINGEN MEMBRANE


PALINGEN XPLUS

HYDROMEMBRANE


PALINGEN XPLUS

MEMBRANE EXTERNAL

SHEET Tier 3

paliperidone er oral tablet

extended release 24 hour 1.5

mg, 3 mg Tier 1 DO

paliperidone er oral tablet


mg, 9 mg Tier 1

PALONOSETRON HCL

INTRAVENOUS

SOLUTION 0.25 MG/2ML Tier 3 PA; QL

palonosetron hcl intravenous

solution 0.25 mg/5ml Tier 1 PA; QL

palonosetron hcl intravenous

solution prefilled syringe Tier 1 PA; QL

PALYNZIQ

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE




114


PAMELOR ORAL

CAPSULE Tier 3

pamidronate disodium


mg/10ml, 90 mg/10ml Tier 4 SP

PAMIDRONATE

DISODIUM

INTRAVENOUS

SOLUTION 6 MG/ML

Tier 4 SP

PANCREAZE ORAL

CAPSULE DELAYED

RELEASE PARTICLES Tier 3 ST; QL

pancuronium bromide


PANHEMATIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

PANRETIN EXTERNAL

GEL Tier 3 SP

pantoprazole sodium



pantoprazole sodium oral

tablet delayed release Tier 1 QL

PANZYGA

INTRAVENOUS


PARADIGM REAL-TIME


PARAGARD

INTRAUTERINE

COPPER

INTRAUTERINE

INTRAUTERINE

DEVICE

Tier 3

paraplatin intravenous

solution Tier 1 SP

PAREMYD

OPHTHALMIC

SOLUTION Tier 3

paricalcitol intravenous



paricalcitol oral capsule Tier 1 PA; QL

PARLODEL ORAL

CAPSULE Tier 3

PARLODEL ORAL

TABLET Tier 3

PARNATE ORAL

TABLET Tier 3

paromomycin sulfate oral

capsule Tier 1

paroxetine hcl er oral tablet


12.5 mg Tier 1 DO

paroxetine hcl er oral tablet


mg, 37.5 mg Tier 1

paroxetine hcl oral tablet 10

mg, 20 mg Tier 1 DO

paroxetine hcl oral tablet 30

mg, 40 mg Tier 1

paroxetine mesylate oral

capsule Tier 1

PARSABIV

INTRAVENOUS


PASER ORAL PACKET Tier 3

PATANASE NASAL

SOLUTION Tier 3

PAXIL ORAL


PC LANCETS SUPER

THIN 30G Tier 2 QL

PC UNIFINE PENTIPS Tier 3 ST; QL

PEDIAPRED ORAL

SOLUTION Tier 3

PEDIARIX

INTRAMUSCULAR


PEDVAX HIB

INTRAMUSCULAR


peg 3350 oral packet Tier 1 $0



115


peg 3350 oral powder Tier 1 $0

peg 3350-kcl-na bicarb-nacl


peg-3350/electrolytes oral

solution reconstituted Tier 1 $0

peg-

3350/electrolytes/ascorbat


PEGASYS

SUBCUTANEOUS

SOLUTION Tier 4 SP

peg-kcl-nacl-nasulf-na asc-c


peg-prep oral kit Tier 1 $0

PEMAZYRE ORAL



PEN NEEDLES 1/2" Tier 3 ST; QL

PEN NEEDLES 5/16" Tier 3 ST; QL

penicillamine oral capsule Tier 1 PA; QL

penicillamine oral tablet Tier 1 PA; QL

PENICILLIN G POT IN

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

penicillin g potassium

injection solution


PENICILLIN G

PROCAINE

INTRAMUSCULAR

SUSPENSION

Tier 3

penicillin g sodium injection


penicillin v potassium oral


penicillin v potassium oral

tablet Tier 1

PENICILLIUM

NOTATUM INJECTION

SOLUTION Tier 3


PENICILLIUM

NOTATUM

SUBCUTANEOUS

SOLUTION

Tier 3

PENLET II BLOOD

SAMPLER KIT Tier 2

PENLET II

REPLACEMENT CAP Tier 2

PENTACEL

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 3 $0

PENTAM INJECTION

SOLUTION


pentamidine isethionate

inhalation solution


pentamidine isethionate

injection solution


PENTASA ORAL

CAPSULE EXTENDED

RELEASE Tier 2

pentazocine-naloxone hcl


PENTETATE CALCIUM

TRISODIUM

COMBINATION

SOLUTION

Tier 3

PENTETATE ZINC

TRISODIUM

COMBINATION

SOLUTION

Tier 3


pentobarbital sodium


pentoxifylline er oral tablet


PEPAXTO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD



116


PEPCID ORAL TABLET Tier 3

PERENNIAL RYE GRASS

POLLEN INJECTION

SOLUTION Tier 3

PERFECT LANCETS 28G Tier 2 QL

PERFECT LANCETS 30G Tier 2 QL

PERFOROMIST

INHALATION

NEBULIZATION

SOLUTION

Tier 3

PERIDEX

MOUTH/THROAT

SOLUTION Tier 3

PERIKABIVEN

INTRAVENOUS

EMULSION Tier 3

perindopril erbumine oral

tablet Tier 1

periogard mouth/throat

solution Tier 1

PERJETA

INTRAVENOUS


permethrin external cream Tier 1

perphenazine oral tablet Tier 1

perphenazine-amitriptyline

oral tablet Tier 1

PERRY PRENATAL

ORAL CAPSULE Tier 2 $0

PERSERIS

SUBCUTANEOUS


PERTZYE ORAL

CAPSULE DELAYED

RELEASE PARTICLES Tier 3 ST; QL

PEXEVA ORAL TABLET

10 MG, 20 MG Tier 3 ST; DO; QL

PEXEVA ORAL TABLET

30 MG, 40 MG Tier 3 ST; QL

pfizerpen injection solution



PHARMACIST CHOICE

LANCETS Tier 2 QL

PHARMACY COUNTER

LANCETS Tier 2 QL

phendimetrazine tartrate er



phendimetrazine tartrate oral


phenelzine sulfate oral tablet Tier 1

PHENERGAN


phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

phenobarbital sodium


phenohytro oral elixir Tier 1

phenohytro oral tablet Tier 1

phenoxybenzamine hcl oral

capsule Tier 1 PA; QL

phentermine hcl oral capsule Tier 1 PA; QL

phentermine hcl oral tablet Tier 1 PA; QL

phentolamine mesylate

injection solution


PHENYLEPHRINE HCL

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

PHENYLEPHRINE HCL

INTRAVENOUS

SOLUTION Tier 3

phenylephrine hcl


PHENYLEPHRINE HCL-

NACL INTRAVENOUS

SOLUTION Tier 3



117


PHENYLEPHRINE HCL-

NACL INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

PHENYTEK ORAL

CAPSULE Tier 3

phenytoin infatabs oral tablet

chewable Tier 1

phenytoin oral suspension Tier 1

phenytoin oral tablet

chewable Tier 1

phenytoin sodium extended

oral capsule 100 mg Tier 1 T1S

phenytoin sodium extended

oral capsule 200 mg, 300 mg Tier 1

phenytoin sodium injection

solution Tier 1

PHESGO

SUBCUTANEOUS


PHEXXI VAGINAL GEL Tier 3

philith oral tablet Tier 1 $0

phillips milk of magnesia


PHOMA EXIGUA

SUBCUTANEOUS

SOLUTION Tier 3

PHOSLYRA ORAL


phosphorous oral tablet Tier 1

phospho-trin 250 neutral oral

tablet Tier 1

PHOTOFRIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

PHOTREXA VISCOUS

OPHTHALMIC

SOLUTION PREFILLED

SYRINGE

Tier 3


PHOTREXA-PHOTREXA

VISCOUS KIT

OPHTHALMIC

SOLUTION PREFILLED

SYRINGE

Tier 3

PHOXILLUM B22K4/0

INTRAVENOUS

SOLUTION Tier 3

PHOXILLUM BK4/2.5

INTRAVENOUS

SOLUTION Tier 3

physiolyte irrigation solution Tier 1

physiosol irrigation irrigation

solution Tier 1

phytonadione injection

solution Tier 1

phytonadione oral tablet Tier 1

PIFELTRO ORAL

TABLET Tier 3 QL

pilocarpine hcl ophthalmic

solution Tier 1

pilocarpine hcl oral tablet Tier 1

pimecrolimus external cream Tier 1 ST; QL

pimozide oral tablet Tier 1

pimtrea oral tablet Tier 1 $0

pindolol oral tablet Tier 1

pioglitazone hcl oral tablet Tier 1 ST; QL

pioglitazone hcl-glimepiride


pioglitazone hcl-metformin

hcl oral tablet Tier 1 ST; QL

PIP LANCETS 28G Tier 2 QL

PIP LANCETS 30G Tier 2 QL

piperacillin sod-tazobactam

so intravenous solution


PIQRAY (200 MG DAILY

DOSE) ORAL TABLET




118



DOSE) ORAL TABLET



DOSE) ORAL TABLET


pirmella 1/35 oral tablet Tier 1 $0

pirmella 7/7/7 oral tablet Tier 1 $0

piroxicam oral capsule Tier 1

PITOCIN INJECTION

SOLUTION Tier 3

PLASBUMIN-25

INTRAVENOUS

SOLUTION Tier 3

PLASBUMIN-5

INTRAVENOUS

SOLUTION Tier 3

PLASMA-LYTE 148

INTRAVENOUS

SOLUTION Tier 3

PLASMA-LYTE A

INTRAVENOUS

SOLUTION Tier 3

PLASMANATE

INTRAVENOUS

SOLUTION Tier 3

PLEGRIDY

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE


PLEGRIDY STARTER

PACK SUBCUTANEOUS

SOLUTION PEN-

INJECTOR


PLEGRIDY STARTER

PACK SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


PLEGRIDY

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR



PLEGRIDY

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


plenamine intravenous

solution Tier 1

PLENVU ORAL

SOLUTION


PNEUMOVAX 23

INJECTION


PNV TABS 20-1 ORAL


PNV TABS 29-1 ORAL


pnv-dha oral capsule Tier 1

PNV-DHA+DOCUSATE


PNV-OMEGA ORAL

CAPSULE Tier 3

pnv-select oral tablet Tier 1 ST; QL

podofilox external solution Tier 1

POINT OF CARE LM-2.5


POLIVY INTRAVENOUS

SOLUTION


polocaine injection solution Tier 1

polocaine-mpf injection

solution Tier 1

polycin ophthalmic ointment Tier 1

polyethylene glycol 3350

oral packet Tier 1 $0

polyethylene glycol 3350

oral powder Tier 1 $0

polymyxin b sulfate injection


polymyxin b-trimethoprim




119


POLYTRIM

OPHTHALMIC

SOLUTION Tier 3

POLY-TUSSIN AC ORAL

LIQUID Tier 2

POLY-VI-FLOR ORAL

SUSPENSION Tier 3

POLY-VI-FLOR ORAL


POLY-VI-FLOR/IRON

ORAL SUSPENSION Tier 3

POLY-VI-FLOR/IRON

ORAL TABLET

CHEWABLE Tier 3

POMALYST ORAL


PONVORY ORAL


PONVORY STARTER

PACK ORAL TABLET


portia-28 oral tablet Tier 1 $0

PORTRAZZA

INTRAVENOUS


posaconazole oral tablet

delayed release Tier 1 PA; QL

pot & sod cit-cit ac oral

solution Tier 1

potassium acetate


potassium chloride crys er

oral tablet extended release Tier 1 T1S

potassium chloride er oral

capsule extended release Tier 1 T1S

potassium chloride er oral

tablet extended release Tier 1 T1S

potassium chloride in

dextrose intravenous solution Tier 1


POTASSIUM CHLORIDE

IN NACL INTRAVENOUS

SOLUTION 20-0.45

MEQ/L-%, 40-0.9 MEQ/L-

%

Tier 3

potassium chloride in nacl

intravenous solution 20-0.9

meq/l-% Tier 1

POTASSIUM CHLORIDE

INTRAVENOUS

SOLUTION 10

MEQ/100ML, 10

MEQ/50ML, 20

MEQ/100ML, 20

MEQ/50ML, 40

MEQ/100ML

Tier 3

potassium chloride


meq/ml Tier 1

potassium chloride oral

packet Tier 1 T1S

potassium chloride oral

solution Tier 1 T1S

potassium citrate er oral


POTASSIUM

PHOSPHATES

INTRAVENOUS

SOLUTION 15

MMOLE/5ML, 150

MMOLE/50ML

Tier 3

potassium phosphates


mmole/15ml Tier 1

potassium phosphates(66

meq k) intravenous solution Tier 1

POTASSIUM

PHOSPHATES(71 MEQ

K) INTRAVENOUS

SOLUTION

Tier 3

POTELIGEO

INTRAVENOUS




120


PRALUENT

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

pramipexole dihydrochloride

er oral tablet extended

release 24 hour Tier 1

pramipexole dihydrochloride

oral tablet Tier 1

PRAMOSONE


PRAMOSONE


PRAMOTIC OTIC

LIQUID Tier 3

prasugrel hcl oral tablet 10

mg Tier 1

prasugrel hcl oral tablet 5 mg Tier 1 DO

pravastatin sodium oral tablet

10 mg, 20 mg, 40 mg Tier 1 DO; $0

pravastatin sodium oral tablet

80 mg Tier 1 $0

PRAXBIND

INTRAVENOUS

SOLUTION Tier 3

praziquantel oral tablet Tier 1

prazosin hcl oral capsule Tier 1 T1S

PRECEDEX

INTRAVENOUS

SOLUTION Tier 3

PRECISION SUREDOSE

PLUS SYR Tier 3 ST; QL

PRECISION SURE-DOSE


PRECISION THINS GP

LANCETS Tier 2 QL

PRECOSE ORAL

TABLET Tier 3

PRED MILD

OPHTHALMIC

SUSPENSION Tier 3


PRED-G OPHTHALMIC

SUSPENSION Tier 3

PRED-G S.O.P.

OPHTHALMIC

OINTMENT Tier 3

prednicarbate external

ointment Tier 1

prednisolone acetate


prednisolone oral solution Tier 1

PREDNISOLONE

SODIUM PHOSPHATE

OPHTHALMIC

SOLUTION

Tier 3

prednisolone sodium

phosphate oral solution Tier 1

prednisolone sodium

phosphate oral tablet


prednisolone sodium

phosphate oral tablet

dispersible 15 mg Tier 1 DO

PREDNISONE

INTENSOL ORAL

CONCENTRATE Tier 3

prednisone oral solution Tier 1 T1S

prednisone oral tablet Tier 1 T1S

prednisone oral tablet

therapy pack Tier 1 T1S

PREFERRED PLUS


PREFERRED PLUS

LANCETS COLORED Tier 2 QL

PREFERRED PLUS

LANCETS THIN Tier 2 QL

PREFERRED PLUS


PREFEST ORAL

TABLET Tier 3



121


pregabalin er oral tablet


mg, 82.5 mg Tier 1 PA; DO; QL

pregabalin er oral tablet


mg Tier 1 PA; QL

pregabalin oral capsule Tier 1

pregabalin oral solution Tier 1

PREGEN DHA ORAL


PREGENNA ORAL


PREGNYL

INTRAMUSCULAR

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

PREMARIN INJECTION

SOLUTION


PREMARIN ORAL

TABLET Tier 2

PREMARIN VAGINAL

CREAM Tier 2

PREMASOL

INTRAVENOUS

SOLUTION Tier 3

PREMESISRX ORAL


PREMPHASE ORAL

TABLET Tier 2

PREMPRO ORAL

TABLET Tier 2

PRENA 1 TRUE ORAL Tier 3

PRENA1 ORAL TABLET

CHEWABLE Tier 2 ST; QL

PRENA1 PEARL ORAL

CAPSULE EXTENDED


PRENAISSANCE ORAL



PRENAISSANCE PLUS


PRENARA ORAL


prenatabs rx oral tablet Tier 1 ST; QL

PRENATAL (W/IRON &

FA) ORAL TABLET Tier 2 $0

PRENATAL 19 ORAL

TABLET Tier 3

prenatal 19 oral tablet

chewable Tier 1

PRENATAL 19 ORAL

TABLET CHEWABLE 29-

1 MG Tier 3

PRENATAL COMPLETE


PRE-NATAL FORMULA


PRENATAL FORTE


PRENATAL

MULTIVITAMIN + DHA

ORAL Tier 2 $0

PRENATAL ONE DAILY


PRENATAL ORAL

TABLET 27-0.8 MG, 28-

0.8 MG Tier 2 $0

PRENATAL ORAL


PRENATAL PLUS IRON


PRENATAL VITAMIN

AND MINERAL ORAL

TABLET Tier 2 $0

PRENATAL VITAMIN


PRENATAL VITAMIN

PLUS LOW IRON ORAL

TABLET Tier 2



122


PRENATAL VITAMINS


PRENATAL/IRON ORAL

TABLET Tier 2 $0

PRENATAL-U ORAL

CAPSULE Tier 2

PRENATE AM ORAL


PRENATE DHA ORAL


PRENATE ELITE ORAL


PRENATE ENHANCE


PRENATE ESSENTIAL


PRENATE MINI ORAL


PRENATE ORAL


PRENATE PIXIE ORAL


PRENATE RESTORE


PRENATRIX ORAL


PRENATRYL ORAL


PRENATVITE

COMPLETE ORAL


PRENATVITE PLUS


PRENATVITE RX ORAL


PREPIDIL VAGINAL

GEL Tier 3

PREPLUS ORAL

TABLET Tier 2

PRESTALIA ORAL



PRESTALIA ORAL

TABLET 3.5-2.5 MG, 7-5

MG Tier 3 DO

PRETAB ORAL TABLET Tier 2

PRETOMANID ORAL

TABLET Tier 3

prevalite oral packet Tier 1

prevalite oral powder Tier 1

PREVENT SAFETY PEN


preventeza oral tablet Tier 1 $0

PREVIDENT 5000

BOOSTER PLUS

DENTAL PASTE Tier 3

PREVIDENT 5000 DRY

MOUTH DENTAL GEL Tier 3

PREVIDENT 5000

ENAMEL PROTECT

DENTAL PASTE Tier 3

PREVIDENT 5000

ORTHO DEFENSE

DENTAL PASTE Tier 3

PREVIDENT 5000 PLUS

DENTAL CREAM Tier 3

PREVIDENT 5000

SENSITIVE DENTAL

PASTE Tier 3

PREVIDENT DENTAL

GEL Tier 3

PREVIDENT

MOUTH/THROAT

SOLUTION Tier 3

previfem oral tablet Tier 1 $0

PREVNAR 13

INTRAMUSCULAR


PREVNAR 20

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 2



123


PREVYMIS

INTRAVENOUS


PREVYMIS ORAL


PREZCOBIX ORAL

TABLET Tier 3 QL

PREZISTA ORAL


PREZISTA ORAL

TABLET Tier 2 QL

PRIALT INTRATHECAL


PRIFTIN ORAL TABLET Tier 2

PRILO PATCH II

EXTERNAL KIT Tier 3

PRIMACARE ORAL


PRIMAQUINE

PHOSPHATE ORAL

TABLET Tier 3

PRIMAXIN IV

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

primidone oral tablet Tier 1 T1S

PRIMSOL ORAL

SOLUTION Tier 3

PRISMASOL B22GK 4/0

INTRAVENOUS

SOLUTION Tier 3

PRISMASOL BGK 0/2.5

INTRAVENOUS

SOLUTION Tier 3

PRISMASOL BGK 2/0

INTRAVENOUS

SOLUTION Tier 3

PRISMASOL BGK 2/3.5

INTRAVENOUS

SOLUTION Tier 3


PRISMASOL BGK 4/0/1.2

INTRAVENOUS

SOLUTION Tier 3

PRISMASOL BGK 4/2.5

INTRAVENOUS

SOLUTION Tier 3

PRISMASOL BK 0/0/1.2

INTRAVENOUS

SOLUTION Tier 3

PRIVET

SUBCUTANEOUS

SOLUTION Tier 3

PRIVIGEN

INTRAVENOUS


PRO COMFORT


PRO COMFORT


PRO COMFORT


PRO COMFORT PEN


PROAIR DIGIHALER

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 3 ST; QL

PROAIR HFA

INHALATION AEROSOL


PROAIR RESPICLICK

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

probenecid oral tablet Tier 1

procainamide hcl injection

solution Tier 1

PROCALAMINE

INTRAVENOUS

SOLUTION Tier 3



124


PROCARDIA XL ORAL

TABLET EXTENDED

RELEASE 24 HOUR 30

MG

Tier 3 DO

PROCARDIA XL ORAL

TABLET EXTENDED

RELEASE 24 HOUR 60

MG, 90 MG

Tier 3

procentra oral solution Tier 1 PA; QL

prochlorperazine edisylate


prochlorperazine maleate

oral tablet Tier 1

prochlorperazine rectal

suppository Tier 1

PROCRIT INJECTION


PROCTOCORT


PROCTOFOAM HC

EXTERNAL FOAM Tier 3

procto-med hc external

cream Tier 1

procto-pak external cream Tier 1

proctozone-hc external cream Tier 1

PROCYSBI ORAL

CAPSULE DELAYED

RELEASE Tier 4 ST; QL; LD

PROCYSBI ORAL

PACKET Tier 4 ST; QL; LD

PRODIGY INSULIN


PRODIGY LANCETS 28G Tier 2 QL

PRODIGY LANCING

DEVICE Tier 2

PRODIGY SAFETY


PRODIGY TWIST TOP



PROFILNINE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

progesterone intramuscular

oil Tier 1

progesterone oral capsule Tier 1

PROGLYCEM ORAL

SUSPENSION Tier 3

PROGRAF

INTRAVENOUS

SOLUTION Tier 2 SP

PROGRAF ORAL

CAPSULE Tier 3

PROGRAF ORAL

PACKET Tier 3

PROLASTIN-C

INTRAVENOUS


PROLASTIN-C

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD

PROLENSA

OPHTHALMIC

SOLUTION Tier 3

PROLEUKIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

PROLIA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3 PA; QL; SP

PROMACTA ORAL

PACKET 12.5 MG Tier 4

PA; DO; QL; LD;

SP

PROMACTA ORAL

PACKET 25 MG Tier 4 PA; QL; LD; SP

PROMACTA ORAL

TABLET 12.5 MG, 25 MG Tier 4

PA; DO; QL; LD;

SP

PROMACTA ORAL

TABLET 50 MG, 75 MG Tier 4 PA; QL; LD; SP



125


promethazine hcl injection

solution Tier 1

promethazine hcl oral

solution Tier 1

promethazine hcl oral syrup Tier 1

promethazine hcl oral tablet Tier 1

promethazine hcl rectal

suppository Tier 1

promethazine vc oral syrup Tier 1

promethazine vc/codeine oral

syrup Tier 1

promethazine-codeine oral

solution Tier 1

promethazine-codeine oral

syrup Tier 1

promethazine-dm oral syrup Tier 1

promethazine-phenyleph-

codeine oral syrup Tier 1

promethazine-phenylephrine

oral syrup Tier 1

promethegan rectal

suppository Tier 1

PROMISEB EXTERNAL

CREAM Tier 3

propafenone hcl er oral


hour Tier 1

propafenone hcl oral tablet Tier 1

proparacaine hcl ophthalmic

solution Tier 1

proparacaine-fluorescein


PROPECIA ORAL

TABLET Tier 3

PROPEL MINI NASAL

IMPLANT Tier 3

PROPEL NASAL

IMPLANT Tier 3


propofol intravenous

emulsion Tier 1

propofol-lipuro intravenous

emulsion Tier 1

propranolol hcl er oral


hour Tier 1 T1S

propranolol hcl intravenous

solution Tier 1

propranolol hcl oral solution Tier 1 T1S

propranolol hcl oral tablet Tier 1 T1S

propylthiouracil oral tablet Tier 1 T1S

PROQUAD

SUBCUTANEOUS

SUSPENSION

RECONSTITUTED

Tier 3 $0

PRO-RED AC ORAL

SYRUP Tier 3 PA; QL

PROSCAR ORAL

TABLET Tier 3

PROSOL INTRAVENOUS

SOLUTION Tier 3

PROSTIN VR


protamine sulfate intravenous

solution Tier 1

PROTONIX

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

PROTOPAM CHLORIDE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

protriptyline hcl oral tablet Tier 1

PROVAYBLUE

INTRAVENOUS

SOLUTION Tier 3

PROVENGE

INTRAVENOUS

SUSPENSION Tier 4 PA; QL



126


PROVENTIL HFA

INHALATION AEROSOL


PROVERA ORAL

TABLET Tier 3

PROVIDA OB ORAL

CAPSULE Tier 3

PROVISC

INTRAOCULAR

SOLUTION Tier 4

pseudoeph-bromphen-dm

oral syrup Tier 1

PSS SELECT GP

LANCETS Tier 2 QL

PSS SELECT

PLATFORMS Tier 2

PSS SELECT SAFETY

LANCETS Tier 2 QL

PULMOZYME

INHALATION

SOLUTION Tier 4 SP

PURE COMFORT


PURE COMFORT PEN


PURIXAN ORAL


PX ADVANCED


px aspirin oral tablet Tier 1 $0

px aspirin oral tablet

chewable Tier 1 $0

px b complex/vitamin c oral

tablet Tier 1 $0

px b-50 oral tablet Tier 1 $0

px enteric aspirin oral tablet


PX EXTRA SHORT PEN


px folic acid oral tablet Tier 1 $0


PX INSULIN SYRINGE Tier 3 ST; QL

PX LANCET AUTO

INJECTOR Tier 2

PX LANCETS

MICROTHIN 33G Tier 2 QL

PX LANCETS ULTRA

THIN Tier 2 QL

PX LANCETS ULTRA

THIN 28G Tier 2 QL

px laxative oral tablet


px milk of magnesia oral


PX MINI PEN NEEDLES Tier 3 ST; QL

PX PEN NEEDLE Tier 3 ST; QL

PX PRENATAL

MULTIVITAMINS ORAL

TABLET Tier 2 $0

PX SHORTLENGTH PEN


px stop smoking aid


px stop smoking aid


PYLERA ORAL


pyrazinamide oral tablet Tier 1

pyridostigmine bromide er

oral tablet extended release Tier 1

pyridostigmine bromide oral

solution Tier 1

pyridostigmine bromide oral

tablet Tier 1

pyridoxine hcl injection

solution Tier 1

pyrimethamine oral tablet Tier 1 PA; QL

QBRELIS ORAL

SOLUTION Tier 3

QBREXZA EXTERNAL

PAD Tier 3 PA; QL



127


QC ADVANCED


qc aspirin low dose oral


qc aspirin low dose oral


qc aspirin oral tablet Tier 1 $0

qc aspirin oral tablet delayed

release Tier 1 $0

qc b50 prolonged release oral


qc b-complex/vitamin c oral

tablet Tier 1 $0

qc childrens aspirin oral


qc daily multivitamins/iron


qc enteric aspirin oral tablet


qc essentials oral tablet Tier 1 $0

qc folic acid oral tablet Tier 1 $0

qc gentle laxative oral tablet


QC LANCETS SUPER

THIN 30G Tier 2 QL

QC LANCETS ULTRA

THIN Tier 2 QL

qc magnesium citrate oral

solution Tier 1 $0

qc milk of magnesia oral


qc natura-lax oral powder Tier 1 $0

qc nicotine transdermal

system transdermal patch 24

hour Tier 1 $0

QC PEN NEEDLES Tier 3 ST; QL

QC PRENATAL ORAL

TABLET Tier 2 $0

QC UNIFINE PENTIPS Tier 3 ST; QL


QC UNILET LANCETS

28G Tier 2 QL

QC UNILET LANCETS

MICRO THIN Tier 2 QL

QDOLO ORAL

SOLUTION Tier 3 QL

QINLOCK ORAL


QSYMIA ORAL

CAPSULE EXTENDED


QUADRACEL

INTRAMUSCULAR


QUADRAMET

INTRAVENOUS

SOLUTION Tier 3

QUALAQUIN ORAL


QUARTETTE ORAL

TABLET Tier 3

quazepam oral tablet Tier 1

QUDEXY XR ORAL

CAPSULE ER 24 HOUR

SPRINKLE Tier 3 ST; QL

QUEEN PALM

SUBCUTANEOUS

SOLUTION Tier 3

QUELICIN INJECTION

SOLUTION Tier 3

QUESTRAN LIGHT

ORAL POWDER Tier 3

QUESTRAN ORAL

PACKET Tier 3

QUESTRAN ORAL

POWDER Tier 3

quetiapine fumarate er oral





128


quetiapine fumarate er oral


hour 300 mg, 400 mg, 50 mg Tier 1

quetiapine fumarate oral

tablet 100 mg, 25 mg, 50 mg Tier 1 DO

quetiapine fumarate oral

tablet 200 mg, 300 mg, 400

mg Tier 1

QUFLORA FE ORAL


QUFLORA FE

PEDIATRIC ORAL

LIQUID Tier 3

QUFLORA GUMMIES

ORAL TABLET

CHEWABLE Tier 2

QUFLORA PEDIATRIC

ORAL SOLUTION Tier 3

QUFLORA PEDIATRIC

ORAL TABLET

CHEWABLE Tier 3

QUILLICHEW ER ORAL

TABLET CHEWABLE

EXTENDED RELEASE 20

MG

Tier 3 ST; DO; QL

QUILLICHEW ER ORAL

TABLET CHEWABLE

EXTENDED RELEASE 30

MG, 40 MG

Tier 3 ST; QL

QUILLIVANT XR ORAL

SUSPENSION

RECONSTITUTED ER Tier 3 ST; QL

quin b strong b-25 oral tablet Tier 1 $0

quinapril hcl oral tablet Tier 1 T1S

quinapril-


tablet Tier 1

quinidine gluconate er oral


quinidine sulfate oral tablet Tier 1 T1S

quinine sulfate oral capsule Tier 1 PA; QL


QUINTABS ORAL

TABLET Tier 2 $0

QUTENZA (4 PATCH)

EXTERNAL KIT Tier 3 LD

QUZYTTIR

INTRAVENOUS

SOLUTION Tier 3

QVAR REDIHALER

INHALATION AEROSOL

BREATH ACTIVATED Tier 2

ra aspirin adult low dose oral


ra aspirin adult low strength


ra aspirin childrens oral


ra aspirin ec adult low st oral


ra aspirin ec oral tablet


ra aspirin oral tablet Tier 1 $0

ra balanced b-100 cr oral


ra balanced b-100 oral tablet Tier 1 $0

ra balanced b-50 oral tablet Tier 1 $0

ra balanced b-50 tr oral tablet


ra b-complex oral tablet Tier 1 $0

ra b-complex with b-12 oral

tablet Tier 1 $0

RA E-ZJECT LANCETS

28G Tier 2 QL

RA E-ZJECT LANCETS

THIN 26G Tier 2 QL

RA E-ZJECT LANCETS

THIN 28G Tier 2 QL

RA E-ZJECT LANCETS


ra folic acid oral tablet Tier 1 $0

RA INSULIN SYRINGE Tier 3 ST; QL



129


ra laxative oral powder Tier 1 $0

ra laxative oral tablet delayed

release Tier 1 $0

ra milk of magnesia oral


ra mini nicotine mouth/throat

lozenge Tier 1 $0

ra nicotine gum mouth/throat

gum Tier 1 $0

ra nicotine mouth/throat gum Tier 1 $0

ra nicotine polacrilex


ra nicotine transdermal patch

24 hour Tier 1 $0

ra pain relief aspirin oral

tablet Tier 1 $0

RA PEN NEEDLES Tier 3 ST; QL

RA PRENATAL

FORMULA ORAL

TABLET Tier 2 $0

RA PRENATAL ORAL

TABLET Tier 2 $0

ra womens laxative oral


RABAVERT

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 3

RABBIT EPITHELIUM

SUBCUTANEOUS

SOLUTION Tier 3

RADIOGARDASE ORAL

CAPSULE Tier 3

RAGWITEK

SUBLINGUAL TABLET


raloxifene hcl oral tablet Tier 1 $0

ramelteon oral tablet Tier 1 ST; QL

ramipril oral capsule Tier 1


RANEXA ORAL TABLET

EXTENDED RELEASE 12

HOUR Tier 3

ranolazine er oral tablet


RAPAMUNE ORAL

SOLUTION Tier 3

RAPAMUNE ORAL

TABLET Tier 3

RAPIVAB

INTRAVENOUS

SOLUTION Tier 3

rasagiline mesylate oral

tablet Tier 1

RASUVO

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

RAVICTI ORAL LIQUID Tier 3 PA; QL; LD; SP

RAYALDEE ORAL

CAPSULE EXTENDED


RAZADYNE ER ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 16

MG, 24 MG

Tier 3

RAZADYNE ER ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 8 MG Tier 3 DO

react oral tablet Tier 1 $0

READYLANCE SAFETY

LANCETS Tier 2 QL

REAL HEAL-I

EXTERNAL KIT Tier 3

REALITY INSULIN


REALITY LANCETS Tier 2 QL

REALITY TRIGGER

LANCETS Tier 2 QL



130


REBIF REBIDOSE

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

REBIF REBIDOSE

TITRATION PACK

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

REBIF SUBCUTANEOUS

SOLUTION PREFILLED


REBIF TITRATION

PACK SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

REBINYN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

REBLOZYL

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

RECARBRIO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

RECLAST

INTRAVENOUS


reclipsen oral tablet Tier 1 $0

RECOMBINATE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

RECOMBIVAX HB

INJECTION


RECOTHROM

EXTERNAL SOLUTION



RECOTHROM SPRAY

KIT EXTERNAL

SOLUTION

RECONSTITUTED

Tier 3

RECTIV RECTAL

OINTMENT Tier 3

RED MAPLE

SUBCUTANEOUS

SOLUTION Tier 3

RED MULBERRY

SUBCUTANEOUS

SOLUTION Tier 3

RED TOP GRASS

POLLEN

SUBCUTANEOUS

SOLUTION

Tier 3

REDITREX

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; LD

refissa external cream Tier 1 PA; QL

REGLAN ORAL TABLET Tier 3

REGONOL

INTRAVENOUS

SOLUTION Tier 3

REGRANEX EXTERNAL

GEL Tier 3

relafen oral tablet Tier 1

RELENZA DISKHALER

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2 QL

RELEXXII ORAL

TABLET EXTENDED


RELION INSULIN


RELION LANCET

DEVICES 30G Tier 2

RELION LANCETS




131


RELION LANCETS THIN

26G Tier 2 QL

RELION LANCETS

ULTRA-THIN 30G Tier 2 QL

RELION LANCING

DEVICE Tier 2

RELION LANCING

DEVICE KIT Tier 2

RELION MINI PEN


RELION PEN NEEDLES Tier 3 ST; QL

RELION SHORT PEN


RELION ULTRA THIN


RELION ULTRA THIN

PLUS LANCETS Tier 2 QL

RELISTOR ORAL


RELISTOR

SUBCUTANEOUS


RELNATE DHA ORAL


REMERON ORAL

TABLET Tier 3

REMERON SOLTAB

ORAL TABLET

DISPERSIBLE Tier 3

REMESENSE DENTAL Tier 3

REMICADE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP

remifentanil hcl intravenous


REMODULIN

INJECTION SOLUTION Tier 4 PA; QL; LD; SP

RENACIDIN

IRRIGATION SOLUTION Tier 3


renal multivitamin formula


renal vitamin oral tablet Tier 1 $0

renal-vite oral tablet Tier 1 $0

rena-vite oral tablet Tier 1 $0

RENOVA EXTERNAL

CREAM Tier 3 PA; QL

RENOVA PUMP

EXTERNAL CREAM Tier 3 PA; QL

RENVELA ORAL


RENVELA ORAL


repaglinide oral tablet Tier 1

REPATHA

PUSHTRONEX SYSTEM

SUBCUTANEOUS

SOLUTION CARTRIDGE

Tier 3 PA; QL

REPATHA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3 PA; QL

REPATHA SURECLICK

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

RESTASIS MULTIDOSE

OPHTHALMIC


RESTASIS

OPHTHALMIC


RESTORA RX ORAL

CAPSULE Tier 3

RESTORIL ORAL

CAPSULE Tier 3

RETACRIT INJECTION


RETAVASE HALF-KIT




132


RETAVASE


RETEVMO ORAL


RETISERT

INTRAVITREAL


RETROVIR

INTRAVENOUS

SOLUTION Tier 2

RETROVIR ORAL

CAPSULE Tier 3 QL

RETROVIR ORAL

SYRUP Tier 3 QL

REVCOVI

INTRAMUSCULAR


REVLIMID ORAL


revonto intravenous solution


REXALL LANCETS


REXULTI ORAL

TABLET 0.25 MG, 0.5

MG, 1 MG, 2 MG Tier 3 ST; DO; QL

REXULTI ORAL


REYATAZ ORAL

CAPSULE Tier 3 QL

REYATAZ ORAL

PACKET Tier 2 QL

REZUROCK ORAL


RHIZOPUS

SUBCUTANEOUS

SOLUTION Tier 3

RHOFADE EXTERNAL

CREAM Tier 3


RHOGAM ULTRA-

FILTERED PLUS

INTRAMUSCULAR

SOLUTION PREFILLED

SYRINGE

Tier 4 SP

RHOPHYLAC

INJECTION SOLUTION

PREFILLED SYRINGE Tier 4 SP

RHOPRESSA

OPHTHALMIC

SOLUTION Tier 3

RIABNI INTRAVENOUS


RIASTAP

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL

ribavirin inhalation solution


ribavirin oral capsule Tier 4 SP

ribavirin oral tablet Tier 4 SP

RIDAURA ORAL

CAPSULE Tier 2

rifabutin oral capsule Tier 1

RIFADIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

rifampin intravenous solution


rifampin oral capsule Tier 1

RIGHTEST ALTERNATE

SITE ADAPT Tier 2

RIGHTEST GD500


RIGHTEST GL300

LANCETS Tier 2 QL

RILUTEK ORAL

TABLET Tier 4 SP

riluzole oral tablet Tier 4 SP

rimantadine hcl oral tablet Tier 1



133


RIMSO-50

INTRAVESICAL

SOLUTION Tier 3

ringers intravenous solution Tier 1

ringers irrigation irrigation

solution Tier 1

RINVOQ ORAL TABLET

EXTENDED RELEASE 24

HOUR Tier 4 PA; QL; LD; SP

RIOMET ORAL


risanoid plus oral tablet Tier 1 $0

risedronate sodium oral

tablet Tier 1

risedronate sodium oral


RISPERDAL CONSTA

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED ER

Tier 2

risperidone oral solution Tier 1 ST; QL

risperidone oral tablet 0.25

mg, 0.5 mg, 1 mg, 2 mg Tier 1 DO

risperidone oral tablet 3 mg,

4 mg Tier 1

risperidone oral tablet

dispersible 0.25 mg Tier 1 PA; DO; QL


dispersible 0.5 mg, 1 mg, 2

mg Tier 1 DO



RITALIN LA ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 10

MG, 20 MG

Tier 3 PA; DO; QL

RITALIN LA ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 30

MG, 40 MG

Tier 3 PA; QL


RITALIN ORAL TABLET

10 MG, 5 MG Tier 3 PA; DO; QL

RITALIN ORAL TABLET

20 MG Tier 3 PA; QL

ritonavir oral tablet Tier 1 QL

RITUXAN HYCELA

SUBCUTANEOUS


RITUXAN

INTRAVENOUS


rivastigmine tartrate oral

capsule 1.5 mg, 3 mg Tier 1 DO

rivastigmine tartrate oral

capsule 4.5 mg, 6 mg Tier 1

rivastigmine transdermal


rivelsa oral tablet Tier 1 $0

RIXUBIS INTRAVENOUS

SOLUTION


rizatriptan benzoate oral

tablet Tier 1 QL

rizatriptan benzoate oral

tablet dispersible Tier 1 QL

ROBAXIN INJECTION


ROCALTROL ORAL


ROCALTROL ORAL


ROCKLATAN

OPHTHALMIC

SOLUTION Tier 3

rocuronium bromide


ROCURONIUM

BROMIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3



134


ROMIDEPSIN

INTRAVENOUS


ropinirole hcl er oral tablet


ropinirole hcl oral tablet Tier 1

ropivacaine hcl injection

solution Tier 1

ROPIVACAINE HCL-

NACL EPIDURAL

SOLUTION Tier 3

rosadan external cream Tier 1

rosadan external gel Tier 1

rosuvastatin calcium oral

tablet 10 mg, 5 mg Tier 1 DO; $0




tablet 40 mg Tier 1

ROTARIX ORAL

SUSPENSION


ROTATEQ ORAL

SOLUTION Tier 3 $0

ROUGH MARSH ELDER

SUBCUTANEOUS

SOLUTION Tier 3

ROWASA RECTAL KIT Tier 3

roweepra oral tablet Tier 1

ROXICODONE ORAL

TABLET Tier 3 QL

ROZLYTREK ORAL


RUBRACA ORAL


RUCONEST

INTRAVENOUS

SOLUTION

RECONSTITUTED


rufinamide oral suspension Tier 1


rufinamide oral tablet Tier 1

RUKOBIA ORAL

TABLET EXTENDED

RELEASE 12 HOUR Tier 3 PA; QL; LD

RUSSIAN THISTLE

SUBCUTANEOUS

SOLUTION Tier 3

RUXIENCE

INTRAVENOUS


RUZURGI ORAL


RYANODEX

INTRAVENOUS

SUSPENSION

RECONSTITUTED

Tier 3

RYBELSUS ORAL


RYBREVANT

INTRAVENOUS


ryclora oral solution Tier 1

RYDAPT ORAL


RYDEX ORAL LIQUID Tier 2

RYLAZE

INTRAMUSCULAR


RYTARY ORAL

CAPSULE EXTENDED

RELEASE Tier 3

RYTHMOL SR ORAL

CAPSULE EXTENDED


RYVENT ORAL TABLET Tier 1

SACCHAROMYCES

CEREVISIAE




135


SACCHAROMYCES

CEREVISIAE

SUBCUTANEOUS

SOLUTION

Tier 3

SAFE-T-LANCE Tier 2 QL

SAFE-T-LANCE PLUS Tier 2 QL

SAFETY INSULIN

SYRINGES Tier 3 ST; QL

SAFETY LANCET

30G/PRESSURE ACT Tier 2 QL

SAFETY LANCETS Tier 2 QL

SAFETY LANCETS 21G Tier 2 QL

SAFETY LANCETS 28G Tier 2 QL

SAFYRAL ORAL

TABLET Tier 3

sajazir subcutaneous solution Tier 4 PA; QL; SP

SALAGEN ORAL

TABLET Tier 3

SAMSCA ORAL TABLET Tier 3 PA; QL; LD; SP

SANCUSO

TRANSDERMAL PATCH Tier 3 QL

SANDIMMUNE

INTRAVENOUS

SOLUTION Tier 3 SP

SANDIMMUNE ORAL

CAPSULE Tier 3

SANDIMMUNE ORAL

SOLUTION Tier 3

SANDOSTATIN


SANDOSTATIN LAR

DEPOT


SANTYL EXTERNAL

OINTMENT Tier 3

SAPHNELO

INTRAVENOUS

SOLUTION Tier 4 LD

sapropterin dihydrochloride

oral packet Tier 4 PA; QL; SP


sapropterin dihydrochloride

oral tablet Tier 4 PA; QL; SP

SAPS HEALTH TWIST

TOP LANCETS Tier 2 QL

SAPS TWIST TOP

LANCETS Tier 2 QL

SAPSCARE TWIST TOP

LANCETS Tier 2 QL

SARCLISA

INTRAVENOUS


SAVELLA ORAL

TABLET Tier 2

SAVELLA TITRATION

PACK ORAL Tier 2

SAXENDA

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 3 PA; QL

sb aspirin ec oral tablet


sb aspirin oral tablet Tier 1 $0

sb bisacodyl laxative ec oral


sb childrens aspirin oral


sb gentle lax-women oral


SB INSULIN SYRINGE Tier 3 ST; QL

SB LANCETS THIN Tier 2 QL

SB LANCETS ULTRA

THIN Tier 2 QL

sb low dose asa ec oral tablet


sb magnesium citrate oral

solution Tier 1 $0

sb milk of magnesia oral


sb polyethylene glycol 3350

oral powder Tier 1 $0



136


SCENESSE

SUBCUTANEOUS

IMPLANT Tier 3 PA; QL; LD

SCLEROSOL

INTRAPLEURAL

INTRAPLEURAL

AEROSOL POWDER

Tier 3

scopolamine transdermal


SEASONIQUE ORAL

TABLET Tier 3

SECUADO

TRANSDERMAL PATCH

24 HOUR Tier 3 ST; QL

SECURESAFE INSULIN


SECURESAFE SAFETY


SELECT-LITE

DEVICE/LANCETS KIT Tier 2

SELECT-LITE LANCING

DEVICE Tier 2

SELECT-OB ORAL

TABLET CHEWABLE 29-

0.6-0.4 MG Tier 3 ST; QL

SELECT-OB ORAL

TABLET CHEWABLE 29-

1 MG Tier 3

SELECT-OB+DHA ORAL Tier 3 ST; QL

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

SELENIOUS ACID

INTRAVENOUS

SOLUTION Tier 3

selenium sulfide external

lotion Tier 1

SELZENTRY ORAL

SOLUTION Tier 3 QL

SELZENTRY ORAL

TABLET Tier 2 QL


SEMGLEE

SUBCUTANEOUS

SOLUTION Tier 3

SEMGLEE

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 3

SE-NATAL 19 ORAL

TABLET Tier 2

SE-NATAL 19 ORAL


sensorcaine injection solution Tier 1

sensorcaine/epinephrine


sensorcaine-mpf injection

solution Tier 1

sensorcaine-mpf/epinephrine

injection solution 0.25% -

1:200000, 0.5% -1:200000 Tier 1

SENSORCAINE-

MPF/EPINEPHRINE

INJECTION SOLUTION

0.75-1:200000 %

Tier 3

SEREVENT DISKUS

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

SEROSTIM

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD

sertraline hcl oral concentrate Tier 1

sertraline hcl oral tablet 100

mg Tier 1

sertraline hcl oral tablet 25

mg, 50 mg Tier 1 DO

setlakin oral tablet Tier 1 $0

sevelamer carbonate oral

packet Tier 1

sevelamer carbonate oral

tablet Tier 1



137


sevelamer hcl oral tablet Tier 1

SEVENFACT

INTRAVENOUS

SOLUTION

RECONSTITUTED


sevoflurane inhalation

solution Tier 1

sf 5000 plus dental cream Tier 1

sf dental gel Tier 1

SFROWASA RECTAL

ENEMA Tier 3

SHAGBARK HICKORY

SUBCUTANEOUS

SOLUTION Tier 3

sharobel oral tablet Tier 1 $0

SHEEP SORREL

SUBCUTANEOUS

SOLUTION Tier 3

SHINGRIX

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 3 $0

SHOPKO AUTOLET


SHOPKO ON-THE-GO


SHOPKO UNIFINE


SHOPKO UNIFINE


SHOPKO UNILET


SHOPKO UNILET


SHORT RAGWEED

POLLEN EXT

SUBCUTANEOUS

SOLUTION

Tier 3

SHUR-SEAL

CONTRACEPTIVE



SIGNIFOR LAR

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED ER

Tier 4 PA; QL; LD

SIGNIFOR

SUBCUTANEOUS


SIKLOS ORAL TABLET Tier 3 PA; QL; SP

sildenafil citrate intravenous


sildenafil citrate oral

suspension reconstituted Tier 4 PA; QL; SP

sildenafil citrate oral tablet

100 mg, 25 mg, 50 mg Tier 4

PA; QL

sildenafil citrate oral tablet

20 mg Tier 4 PA; QL; SP

SILENOR ORAL


silodosin oral capsule Tier 1

SILVADENE EXTERNAL

CREAM Tier 3

silver sulfadiazine external

cream Tier 1

SIMBRINZA

OPHTHALMIC

SUSPENSION Tier 2

simliya oral tablet Tier 1 $0

simpesse oral tablet Tier 1 $0

SIMPLE DIAGNOSTICS

LANCING DEV Tier 2

SIMPONI ARIA

INTRAVENOUS


SIMPONI

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

SIMPONI

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP



138


SIMULECT

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

simvastatin oral tablet 10 mg,

20 mg, 40 mg, 5 mg Tier 1 DO; T1S; $0

simvastatin oral tablet 80 mg Tier 1 PA; QL; T1S

SINEMET ORAL

TABLET Tier 3

SINGLE-LET Tier 2 QL

sirolimus oral solution Tier 1

sirolimus oral tablet Tier 1

SIRTURO ORAL

TABLET Tier 3

SIVEXTRO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

SIVEXTRO ORAL


SKELAXIN ORAL


SKYLA INTRAUTERINE

INTRAUTERINE

DEVICE Tier 3 LD; SP

SKYRIZI (150 MG DOSE)

SUBCUTANEOUS

PREFILLED SYRINGE

KIT

Tier 4 PA; QL; SP

SKYRIZI PEN

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 4 PA; QL; SP

SKYRIZI

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

SLYND ORAL TABLET Tier 3

sm aspirin adult low strength



sm aspirin adult low strength


sm aspirin ec low strength


sm aspirin ec oral tablet


sm aspirin low dose oral


sm aspirin oral tablet Tier 1 $0

sm aspirin tri-buffered oral

tablet Tier 1 $0

sm b super vitamin complex


sm b100 complex oral tablet Tier 1 $0

sm balanced b-100 oral tablet Tier 1 $0

sm balanced b-50 oral tablet Tier 1 $0

sm b-complex oral tablet Tier 1 $0

SM B-

COMPLEX/VITAMIN C


sm childrens aspirin oral


sm clearlax oral powder Tier 1 $0

sm folic acid oral tablet Tier 1 $0

sm gentle laxative oral tablet


SM LANCETS 33G Tier 2 QL

sm magnesium citrate oral

solution Tier 1 $0

sm milk of magnesia oral


sm multiple vitamins

essential oral tablet Tier 1 $0

sm multiple vitamins/iron


sm nicotine mouth/throat

gum Tier 1 $0

sm nicotine mouth/throat

lozenge Tier 1 $0



139


sm nicotine polacrilex


sm nicotine polacrilex


sm nicotine transdermal


SM ONE DAILY


SM PRENATAL

VITAMINS ORAL

TABLET Tier 2 $0

sm super b complex/c oral

tablet Tier 1 $0

SM TRUEDRAW


sm vitamin b

complex/vitamin c oral tablet Tier 1 $0

SMART DIABETES

VANTAGE LANCING Tier 2

SMART SENSE COLOR


SMART SENSE

STANDARD LANCETS Tier 2 QL

SMART SENSE SUPER


SMART SENSE THIN


SMARTEST LANCETS

28G Tier 2 QL

SMOFLIPID

INTRAVENOUS

EMULSION Tier 3

smooth lax oral packet Tier 1 $0

smooth lax oral powder Tier 1 $0

sod benz-sod phenylacet


SODIUM ACETATE

INTRAVENOUS

SOLUTION Tier 3

sodium bicarbonate



SODIUM BICARBONATE

ORAL POWDER Tier 3

sodium chloride flush


sodium chloride inhalation


sodium chloride injection

solution Tier 1

sodium chloride intravenous

solution Tier 1

sodium chloride irrigation

solution Tier 1

SODIUM CITRATE

LOCK FLUSH

INTRAVENOUS

SOLUTION

Tier 3

SODIUM CITRATE

LOCK FLUSH

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

SODIUM DIURIL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

SODIUM EDECRIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

sodium fluoride 5000 enamel

dental paste Tier 1

sodium fluoride 5000 plus

dental cream Tier 1

sodium fluoride 5000 ppm

dental cream Tier 1

sodium fluoride 5000 ppm

dental paste Tier 1

sodium fluoride 5000

sensitive dental paste Tier 1

sodium fluoride dental cream Tier 1

sodium fluoride dental gel Tier 1



140


sodium fluoride mouth/throat

solution Tier 1

sodium fluoride oral solution

0.5 mg/ml Tier 1 $0

sodium fluoride oral solution

1.1 (0.5 f) mg/ml Tier 1 $0

sodium fluoride oral tablet Tier 1 $0

sodium fluoride oral tablet

chewable Tier 1 $0

SODIUM IODIDE I-131

ORAL SOLUTION Tier 3

SODIUM NITRITE

INTRAVENOUS

SOLUTION Tier 3

sodium nitroprusside


sodium phenylbutyrate oral

powder Tier 1 PA; QL

sodium phenylbutyrate oral


sodium phosphates


sodium polystyrene sulfonate

oral powder Tier 1

SODIUM

SULFACETAMIDE-

BAKUCHIOL

EXTERNAL LIQUID

Tier 3

sodium tetradecyl sulfate


SOLESTA INJECTION

GEL Tier 4 LD; SP

solifenacin succinate oral

tablet Tier 1

SOLIQUA

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 3 ST; QL

SOLIRIS INTRAVENOUS



SOLOSEC ORAL


SOLTAMOX ORAL

SOLUTION Tier 2 $0

SOLU-CORTEF

INJECTION SOLUTION


SOLU-MEDROL

INJECTION SOLUTION


SOLUS V2 LANCETS 28G Tier 2 QL

SOLUS V2 LANCING

DEVICE Tier 2

SOLUS V2 TWIST


SOMA ORAL TABLET Tier 3 ST; QL

SOMATULINE DEPOT

SUBCUTANEOUS


SOMAVERT

SUBCUTANEOUS

SOLUTION

RECONSTITUTED


SOOLANTRA


SORBITOL IRRIGATION

SOLUTION Tier 3

SORBITOL-MANNITOL

IRRIGATION SOLUTION Tier 3

SORIATANE ORAL

CAPSULE Tier 3

SORILUX EXTERNAL

FOAM Tier 3

sorine oral tablet Tier 1

SORREL/DOCK MIX

SUBCUTANEOUS

SOLUTION Tier 3

sotalol hcl (af) oral tablet Tier 1

SOTALOL HCL

INTRAVENOUS

SOLUTION Tier 3



141


sotalol hcl oral tablet Tier 1

SOTRADECOL

INTRAVENOUS

SOLUTION 1 % Tier 3

sotradecol intravenous

solution 3 % Tier 1

SOTYLIZE ORAL

SOLUTION Tier 3

spinosad external suspension Tier 1

SPINY PIGWEED

SUBCUTANEOUS

SOLUTION Tier 3

SPIRIVA HANDIHALER

INHALATION CAPSULE Tier 2

SPIRIVA RESPIMAT

INHALATION AEROSOL

SOLUTION Tier 2

spironolactone oral tablet

100 mg Tier 1 T1S

spironolactone oral tablet 25

mg, 50 mg Tier 1 DO; T1S

spironolactone-hctz oral

tablet Tier 1 DO

SPORANOX ORAL


SPORANOX ORAL


SPORANOX PULSEPAK

ORAL CAPSULE Tier 3 PA; QL

SPRAVATO (56 MG

DOSE) NASAL

SOLUTION THERAPY

PACK

Tier 4 PA; QL; LD

SPRAVATO (84 MG

DOSE) NASAL

SOLUTION THERAPY

PACK

Tier 4 PA; QL; LD

sprintec 28 oral tablet Tier 1 $0


SPRITAM ORAL

TABLET

DISINTEGRATING

SOLUBLE

Tier 3

SPRYCEL ORAL


sps oral suspension Tier 1

sronyx oral tablet Tier 1 $0

ssd external cream Tier 1

SSKI ORAL SOLUTION Tier 3

st joseph aspirin oral tablet


st joseph low dose oral tablet

chewable Tier 1 $0

st joseph low dose oral tablet


STALEVO 100 ORAL

TABLET Tier 3

STALEVO 125 ORAL

TABLET Tier 3

STALEVO 150 ORAL

TABLET Tier 3

STALEVO 200 ORAL

TABLET Tier 3

STALEVO 50 ORAL

TABLET Tier 3

STALEVO 75 ORAL

TABLET Tier 3

STAMARIL INJECTION

SUSPENSION


stavudine oral capsule Tier 1 QL

STELARA

INTRAVENOUS


STELARA

SUBCUTANEOUS




142


STELARA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

STEMPHYLIUM

SUBCUTANEOUS

SOLUTION Tier 3

STERILANCE PA Tier 2

STERILANCE TL Tier 2 QL

STERILE TALC

POWDER

INTRAPLEURAL

SUSPENSION

RECONSTITUTED

Tier 3

sterile water for irrigation


STERITALC

INTRAPLEURAL

POWDER Tier 3

STIMATE NASAL


STIOLTO RESPIMAT

INHALATION AEROSOL

SOLUTION Tier 2

STIVARGA ORAL


STRAVIX EXTERNAL

SHEET Tier 3

STRENSIQ

SUBCUTANEOUS


streptomycin sulfate

intramuscular solution


stress b complex/iron oral

tablet Tier 1 $0

stress formula (folic acid)


stress formula oral tablet Tier 1 $0

stress formula/iron oral tablet Tier 1 $0

stresstabs energy oral tablet Tier 1 $0


STRIBILD ORAL

TABLET Tier 2 QL

STRIVERDI RESPIMAT

INHALATION AEROSOL

SOLUTION Tier 3

STROMECTOL ORAL


STRONTIUM CHLORIDE

SR-89 INTRAVENOUS

SOLUTION Tier 3

SUBLOCADE

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 LD

subvenite oral tablet Tier 1

subvenite starter kit-blue oral

kit Tier 1

subvenite starter kit-green

oral kit Tier 1

subvenite starter kit-orange

oral kit Tier 1

SUCCINYLCHOLINE

CHLORIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

SUCRAID ORAL


sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1

SUFENTANIL CITRATE

INTRAVENOUS

SOLUTION Tier 3

SULAR ORAL TABLET

EXTENDED RELEASE 24

HOUR 17 MG, 8.5 MG Tier 3 DO

SULAR ORAL TABLET

EXTENDED RELEASE 24

HOUR 34 MG Tier 3

sulconazole nitrate external

cream Tier 1 ST; QL



143


sulconazole nitrate external

solution Tier 1 ST; QL

sulfacetamide sodium (acne)


sulfacetamide sodium

ophthalmic ointment Tier 1

sulfacetamide sodium


sulfacetamide sod-sulfur

wash external liquid Tier 1 PA; QL

sulfacetamide-prednisolone


SULFADIAZINE ORAL

TABLET Tier 3

sulfamethoxazole-

trimethoprim intravenous

solution Tier 1

sulfamethoxazole-

trimethoprim oral suspension Tier 1

sulfamethoxazole-

trimethoprim oral tablet Tier 1

SULFAMYLON


SULFAMYLON

EXTERNAL PACKET Tier 3

sulfasalazine oral tablet Tier 1 T1S

sulfasalazine oral tablet


sulfatrim pediatric oral

suspension Tier 1

SULFURATED LIME


sulindac oral tablet Tier 1

sumatriptan nasal solution Tier 1 QL

sumatriptan succinate oral

tablet Tier 1 QL

sumatriptan succinate refill

subcutaneous solution

cartridge Tier 1 QL


sumatriptan succinate

subcutaneous solution Tier 1 QL

sumatriptan succinate

subcutaneous solution auto-

injector Tier 1 QL

sunitinib malate oral capsule Tier 1 PA; QL; SP

SUNOSI ORAL TABLET

150 MG Tier 3 PA; QL

SUNOSI ORAL TABLET

75 MG Tier 3 PA; DO; QL

SUPARTZ FX INTRA-

ARTICULAR SOLUTION


super b complex maxi oral

tablet Tier 1 $0

super b complex/fa/vit c oral

tablet Tier 1 $0

super b complex/vitamin c


super b-100 oral tablet Tier 1 $0

super b-50 oral tablet Tier 1 $0

super b-complex + vitamin c


super b-complex oral tablet Tier 1 $0

super b-complex/vit c/fa oral

tablet Tier 1 $0

super dec b-100 oral tablet Tier 1 $0

super quints b-50 oral tablet Tier 1 $0

super stress b-complex cr

oral tablet extended release Tier 1 $0

SUPER THIN LANCETS Tier 2 QL

SUPPRELIN LA


SUPRANE INHALATION

SOLUTION Tier 3

SUPRAX ORAL

CAPSULE Tier 3

SUPRAX ORAL

SUSPENSION




144


SUPRAX ORAL TABLET

CHEWABLE Tier 3

SUPREP BOWEL PREP

KIT ORAL SOLUTION Tier 2

SURE COMFORT


SURE COMFORT


SURE COMFORT


SURE COMFORT


SURE COMFORT


SURE COMFORT


SURE COMFORT

LANCING PEN Tier 2

SURE COMFORT PEN


SURE-FINE PEN


SURE-JECT INSULIN


SURE-LANCE FLAT

LANCETS Tier 2 QL

SURE-LANCE LANCETS

26G Tier 2 QL

SURE-LANCE THIN


SURE-LANCE ULTRA


SURELITE LANCETS Tier 2 QL

SURE-PEN Tier 2

SURE-TOUCH LANCETS

UNIVERSAL Tier 2 QL

SURGICEL FIBRILLAR

EXTERNAL PAD Tier 3

SURGICEL NU-KNIT

EXTERNAL PAD Tier 3


SURVANTA

INTRATRACHEAL

SUSPENSION Tier 3

SUSTIVA ORAL

CAPSULE Tier 3 QL

SUSTIVA ORAL TABLET Tier 3 QL

SUSTOL

SUBCUTANEOUS


SUTENT ORAL


SWEET GUM

SUBCUTANEOUS

SOLUTION Tier 3

SWEET VERNAL GRASS

POLLEN

SUBCUTANEOUS

SOLUTION

Tier 3

syeda oral tablet Tier 1 $0

SYLVANT

INTRAVENOUS

SOLUTION

RECONSTITUTED


SYMBICORT


SYMBYAX ORAL

CAPSULE Tier 3 DO

SYMDEKO ORAL

TABLET THERAPY


SYMJEPI INJECTION

SOLUTION PREFILLED

SYRINGE Tier 2 QL

SYMLINPEN 120

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

SYMLINPEN 60

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

SYMPAZAN ORAL FILM Tier 3



145


SYMPROIC ORAL


SYMTUZA ORAL

TABLET Tier 3 QL

SYNAGIS

INTRAMUSCULAR


SYNAREL NASAL


SYNDROS ORAL

SOLUTION Tier 3

SYNERCID

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

SYNJARDY ORAL


SYNJARDY XR ORAL

TABLET EXTENDED


SYNRIBO

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD

SYNTHROID ORAL

TABLET Tier 3

SYNVISC INTRA-

ARTICULAR SOLUTION


SYNVISC ONE INTRA-

ARTICULAR SOLUTION


SYRINGE AVITENE

EXTERNAL Tier 3

tab-a-vite oral tablet Tier 1 $0

tab-a-vite/beta carotene oral

tablet Tier 1 $0

tab-a-vite/iron oral tablet Tier 1 $0

TAB-A-VITE/IRON/BETA

CAROTENE ORAL

TABLET Tier 2 $0


TABLOID ORAL

TABLET Tier 2

TABRECTA ORAL


TACHOSIL EXTERNAL

PATCH Tier 3

TACLONEX EXTERNAL


TACLONEX EXTERNAL


tacrolimus external ointment Tier 1 ST; QL

tacrolimus oral capsule Tier 1

tadalafil (pah) oral tablet Tier 4 PA; QL; SP

tadalafil oral tablet Tier 4 PA; QL

TAFINLAR ORAL


TAGRISSO ORAL


take action oral tablet Tier 1 $0

TAKHZYRO

SUBCUTANEOUS


TALICIA ORAL

CAPSULE DELAYED


TALL RAGWEED

SUBCUTANEOUS

SOLUTION Tier 3

TALTZ SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR Tier 4 PA; QL; LD; SP

TALTZ SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE Tier 4 PA; QL; LD; SP

TALZENNA ORAL


TAMIFLU ORAL

CAPSULE Tier 3 QL

TAMIFLU ORAL

SUSPENSION




146


tamoxifen citrate oral tablet Tier 1 $0

tamsulosin hcl oral capsule Tier 1

TAPAZOLE ORAL

TABLET Tier 3

taperdex 12-day oral tablet

therapy pack Tier 1


therapy pack Tier 1


therapy pack Tier 1

TARCEVA ORAL


TARGRETIN EXTERNAL

GEL Tier 2 PA; QL; SP

tarina 24 fe oral tablet Tier 1 $0

tarina fe 1/20 eq oral tablet Tier 1 $0

tarina fe 1/20 oral tablet Tier 1 $0

TARON-C DHA ORAL

CAPSULE Tier 3

TARON-PREX ORAL

CAPSULE Tier 3

TAROXIA EXTERNAL

GEL Tier 3

TASIGNA ORAL


TASMAR ORAL TABLET Tier 3 PA; QL

TAURINE INJECTION

SOLUTION Tier 3

tavaborole external solution Tier 1 ST; QL

TAVALISSE ORAL


taysofy oral capsule Tier 1 $0

TAYTULLA ORAL

CAPSULE Tier 3

tazarotene external cream Tier 1

tazicef injection solution



TAZICEF

INTRAVENOUS

SOLUTION Tier 3

tazicef intravenous solution


TAZORAC EXTERNAL

CREAM Tier 2

TAZORAC EXTERNAL

GEL Tier 2

taztia xt oral capsule



taztia xt oral capsule


mg, 300 mg, 360 mg Tier 1

TAZVERIK ORAL


TDVAX

INTRAMUSCULAR


TECENTRIQ

INTRAVENOUS


TECHLITE AST

LANCETS Tier 2 QL

TECHLITE INSULIN


TECHLITE LANCETS Tier 2 QL

TECHLITE LANCETS

30G Tier 2 QL

TECHLITE PEN


TEFLARO

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

TEGADERM AG MESH

EXTERNAL PAD Tier 2

TEGSEDI

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; LD



147


TEKTURNA HCT ORAL


TEKTURNA HCT ORAL

TABLET 150-25 MG, 300-

12.5 MG, 300-25 MG Tier 3

telmisartan oral tablet 20 mg,

40 mg Tier 1 DO

telmisartan oral tablet 80 mg Tier 1

telmisartan-amlodipine oral

tablet 40-10 mg, 80-10 mg,

80-5 mg Tier 1

telmisartan-amlodipine oral

tablet 40-5 mg Tier 1 DO

telmisartan-hctz oral tablet

40-12.5 mg Tier 1 DO

telmisartan-hctz oral tablet

80-12.5 mg, 80-25 mg Tier 1

temazepam oral capsule Tier 1

TEMIXYS ORAL

TABLET Tier 3 QL

TEMODAR

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 2 PA; QL; SP

TEMODAR ORAL


temozolomide oral capsule Tier 1 PA; QL; SP

temsirolimus intravenous


tencon oral tablet Tier 1

TENIVAC

INTRAMUSCULAR


tenofovir disoproxil fumarate


TENORETIC 100 ORAL

TABLET Tier 3

TENORETIC 50 ORAL

TABLET Tier 3


TEPADINA INJECTION

SOLUTION


TEPEZZA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL

TEPMETKO ORAL


terazosin hcl oral capsule Tier 1

terbinafine hcl oral tablet Tier 1

terbutaline sulfate injection

solution Tier 1

terbutaline sulfate oral tablet Tier 1 T1S

terconazole vaginal cream Tier 1

terconazole vaginal

suppository Tier 1

TERIPARATIDE

(RECOMBINANT)

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

terrell inhalation solution Tier 1

TESSALON PERLES

ORAL CAPSULE Tier 3

TESTOPEL IMPLANT

PELLET Tier 3 PA; QL

testosterone cypionate

intramuscular solution Tier 1 PA; QL

testosterone enanthate

intramuscular solution Tier 1 PA; QL

testosterone transdermal gel Tier 1 PA; QL

testosterone transdermal


TETANUS-DIPHTHERIA

TOXOIDS TD

INTRAMUSCULAR

SUSPENSION

Tier 3 $0

tetrabenazine oral tablet Tier 1 PA; QL; SP



148


tetracaine hcl ophthalmic

solution Tier 1

tetracycline hcl oral capsule Tier 1

TGT LANCET MICRO

THIN 33G Tier 2 QL

TGT LANCET THIN 26G Tier 2 QL

TGT LANCET ULTRA

THIN 30G Tier 2 QL

TGT LANCING DEVICE Tier 2

THALOMID ORAL


THAM INTRAVENOUS

SOLUTION Tier 3

THE LIQUILIFT TRACE


THEO-24 ORAL

CAPSULE EXTENDED


theophylline er oral tablet


theophylline er oral tablet


theophylline oral solution Tier 1

THERA ORAL TABLET Tier 2 $0

thera-mill oral tablet Tier 1 $0

thera-tabs oral tablet Tier 1 $0

THEREMS ORAL

TABLET Tier 2 $0

thiamine hcl injection

solution Tier 1

THINLETS GP LANCETS Tier 2 QL

THIOLA EC ORAL

TABLET DELAYED

RELEASE Tier 3 PA; QL; LD

THIOLA ORAL TABLET Tier 3 PA; QL; LD

thioridazine hcl oral tablet Tier 1

thiotepa injection solution



thiothixene oral capsule Tier 1 PA; QL

thrive mouth/throat gum Tier 1 $0

THRIVITE RX ORAL


THROMBATE III

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

THROMBI-GEL 10

EXTERNAL PAD Tier 3

THROMBI-GEL 100

EXTERNAL PAD Tier 3

THROMBI-GEL 40

EXTERNAL PAD Tier 3

THROMBIN-JMI

EPISTAXIS EXTERNAL

KIT Tier 3

THROMBIN-JMI

EXTERNAL KIT Tier 3

THROMBIN-JMI

EXTERNAL SOLUTION


THROMBI-PAD

EXTERNAL PAD Tier 3

THROMBOGEN

EXTERNAL KIT Tier 3

THROMBOGEN

EXTERNAL SOLUTION


THYMOGLOBULIN

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

THYQUIDITY ORAL

SOLUTION Tier 3

tiadylt er oral capsule



tiadylt er oral capsule


mg, 300 mg, 360 mg, 420 mg Tier 1



149


tiagabine hcl oral tablet Tier 1

TIAZAC ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 120

MG, 180 MG

Tier 3 DO

TIAZAC ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 240

MG, 300 MG, 360 MG, 420

MG

Tier 3

TIBSOVO ORAL


TICE BCG

INTRAVESICAL

SUSPENSION

RECONSTITUTED

Tier 4 SP

TIGAN

INTRAMUSCULAR

SOLUTION Tier 3

TIGECYCLINE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

TIGLUTIK ORAL

SUSPENSION Tier 4

tilia fe oral tablet Tier 1 $0

timolol maleate ocudose


timolol maleate ophthalmic

gel forming solution Tier 1

timolol maleate ophthalmic

solution Tier 1

timolol maleate oral tablet Tier 1

timolol maleate pf


TIMOPTIC OCUDOSE

OPHTHALMIC

SOLUTION Tier 3

TIMOPTIC

OPHTHALMIC

SOLUTION Tier 3


TIMOPTIC-XE

OPHTHALMIC GEL

FORMING SOLUTION Tier 3

TIMOTHY GRASS

POLLEN ALLERGEN


TIMOTHY GRASS

POLLEN ALLERGEN

SUBCUTANEOUS

SOLUTION

Tier 3

tinidazole oral tablet Tier 1

tiopronin oral tablet Tier 1 PA; QL

TIROSINT ORAL

CAPSULE Tier 3

TIROSINT-SOL ORAL

SOLUTION Tier 3

TISSEEL EXTERNAL

KIT Tier 3

TISSEEL EXTERNAL

SOLUTION Tier 3

TISSUEBLUE

INTRAOCULAR

SOLUTION PREFILLED

SYRINGE

Tier 3

tis-u-sol irrigation solution Tier 1

TIVICAY ORAL TABLET Tier 3 QL; LD

TIVICAY PD ORAL

TABLET SOLUBLE Tier 3 QL; LD

tizanidine hcl oral capsule Tier 1

tizanidine hcl oral tablet Tier 1

TNKASE INTRAVENOUS

KIT Tier 3

TOBI PODHALER

INHALATION CAPSULE Tier 4 LD; SP

TOBRADEX

OPHTHALMIC

OINTMENT Tier 2

TOBRADEX

OPHTHALMIC

SUSPENSION Tier 3



150


TOBRADEX ST

OPHTHALMIC

SUSPENSION Tier 3

tobramycin inhalation

nebulization solution Tier 4 SP

tobramycin ophthalmic

solution Tier 1

tobramycin sulfate injection

solution Tier 1

tobramycin sulfate injection


tobramycin-dexamethasone


TOBREX OPHTHALMIC

OINTMENT Tier 3

TOBREX OPHTHALMIC

SOLUTION Tier 3

TODAY SPONGE

VAGINAL Tier 2 $0

TODAYS HEALTH


TODAYS HEALTH MINI


TODAYS HEALTH PEN


TODAYS HEALTH

SHORT PEN NEEDLE Tier 3 ST; QL

TODAYS HEALTH THIN


TODAYS HEALTH THIN


tolbutamide oral tablet Tier 1 ST; QL

tolcapone oral tablet Tier 1 PA; QL

TOLSURA ORAL


tolterodine tartrate er oral


hour Tier 1

tolterodine tartrate oral tablet Tier 1

tolvaptan oral tablet Tier 1 PA; QL


TOPCARE CLICKFINE


TOPCARE LANCETS


TOPCARE ULTRA

COMFORT INS SYR Tier 3 ST; QL

topiramate er oral capsule er

24 hour sprinkle Tier 1

topiramate oral capsule

sprinkle Tier 1

topiramate oral tablet Tier 1

toposar intravenous solution Tier 1 SP

TOPOTECAN HCL

INTRAVENOUS

SOLUTION Tier 3 SP

topotecan hcl intravenous


toremifene citrate oral tablet Tier 1

TORISEL

INTRAVENOUS


torsemide oral tablet Tier 1

TOTECT INTRAVENOUS

SOLUTION


TOUJEO MAX

SOLOSTAR

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

TOUJEO SOLOSTAR

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

tovet external foam Tier 1

TOVIAZ ORAL TABLET

EXTENDED RELEASE 24

HOUR Tier 3

TPN ELECTROLYTES

INTRAVENOUS

CONCENTRATE Tier 3



151


TRACLEER ORAL

TABLET SOLUBLE Tier 4 PA; QL; LD; SP

TRALEMENT

INTRAVENOUS

SOLUTION Tier 3

tramadol hcl er (biphasic)



tramadol hcl er oral capsule


tramadol hcl er oral tablet


tramadol hcl oral tablet Tier 1 QL

tramadol-acetaminophen oral

tablet Tier 1 QL

trandolapril oral tablet Tier 1 T1S

trandolapril-verapamil hcl er

oral tablet extended release Tier 1

tranexamic acid intravenous

solution Tier 1

tranexamic acid oral tablet Tier 1

TRANEXAMIC ACID-

NACL INTRAVENOUS

SOLUTION Tier 3

tranylcypromine sulfate oral

tablet Tier 1

TRAVASOL

INTRAVENOUS

SOLUTION Tier 3

TRAVEL LANCETS Tier 2 QL

TRAVEL LANCETS

ADVANCED 28G Tier 2 QL

travoprost (bak free)


TRAZIMERA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

trazodone hcl oral tablet Tier 1


TREANDA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; SP

TRECATOR ORAL

TABLET Tier 3

TRELEGY ELLIPTA

INHALATION AEROSOL

POWDER BREATH

ACTIVATED

Tier 2

TRELSTAR MIXJECT

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 3 PA; QL; SP

TREMFYA

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

TREMFYA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

treprostinil injection solution Tier 4 PA; QL; SP

TRESIBA FLEXTOUCH

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2

TRESIBA

SUBCUTANEOUS

SOLUTION Tier 2

tretinoin (emollient) external

cream Tier 1 PA; QL

tretinoin external cream Tier 1 PA; QL

tretinoin external gel Tier 1 PA; QL

tretinoin microsphere


tretinoin microsphere pump


tretinoin oral capsule Tier 1



152


TRETTEN

INTRAVENOUS

SOLUTION

RECONSTITUTED


TREXALL ORAL

TABLET Tier 2

trezix oral capsule Tier 1 QL

tri femynor oral tablet Tier 1 $0

triamcinolone acetonide

external aerosol solution Tier 3 ST; QL






external ointment 0.025 %,

0.1 %, 0.5 % Tier 1


external ointment 0.05 % Tier 3 ST; QL


mouth/throat paste Tier 1

triamcinolone in absorbase


TRIAMCINOLONE-

MOXIFLOXACIN

INTRAOCULAR

SUSPENSION

Tier 3

TRI-AMINO INJECTION

SOLUTION Tier 3

triamterene oral capsule Tier 1

triamterene-hctz oral capsule Tier 1

triamterene-hctz oral tablet Tier 1

triazolam oral tablet Tier 1

tri-buffered aspirin oral tablet Tier 1 $0

TRICARE ORAL

TABLET Tier 3

TRICARE PRENATAL

DHA ONE ORAL

CAPSULE Tier 3


TRICHOPHYTON

MENTAGROPHYTES

SUBCUTANEOUS

SOLUTION

Tier 3

TRICHOPHYTON

SUBCUTANEOUS

SOLUTION Tier 3

TRICOR ORAL TABLET Tier 3 ST; QL

triderm external cream Tier 1

trientine hcl oral capsule Tier 1 PA; QL; SP

TRIESENCE

INTRAOCULAR

SUSPENSION Tier 3

tri-estarylla oral tablet Tier 1 $0

TRIFERIC

HEMODIALYSIS

PACKET Tier 4 PA; QL

TRIFERIC

HEMODIALYSIS


trifluoperazine hcl oral tablet Tier 1

trifluridine ophthalmic

solution Tier 1

trihexyphenidyl hcl oral

solution Tier 1

trihexyphenidyl hcl oral

tablet Tier 1

TRIKAFTA ORAL

TABLET THERAPY


tri-legest fe oral tablet Tier 1 $0

tri-linyah oral tablet Tier 1 $0

TRILIPIX ORAL

CAPSULE DELAYED


tri-lo-estarylla oral tablet Tier 1 $0

tri-lo-marzia oral tablet Tier 1 $0

tri-lo-mili oral tablet Tier 1 $0

tri-lo-sprintec oral tablet Tier 1 $0



153


TRI-LUMA EXTERNAL

CREAM Tier 3

TRILURON INTRA-

ARTICULAR SOLUTION


trimethobenzamide hcl oral

capsule Tier 1

trimethoprim oral tablet Tier 1

tri-mili oral tablet Tier 1 $0

trimipramine maleate oral

capsule Tier 1

TRINATAL RX 1 ORAL

TABLET Tier 2

trinate oral tablet Tier 1

TRINAZ ORAL TABLET Tier 3 ST; QL

TRINTELLIX ORAL


TRINTELLIX ORAL

TABLET 20 MG Tier 3

tri-nymyo oral tablet Tier 1 $0

TRIOSTAT

INTRAVENOUS

SOLUTION Tier 3

tri-previfem oral tablet Tier 1 $0

TRIPTODUR

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED ER

Tier 4 PA; QL; LD

TRISENOX

INTRAVENOUS

SOLUTION Tier 3 SP

tri-sprintec oral tablet Tier 1 $0

TRISTART DHA ORAL


TRISTART FREE ORAL


TRISTART ONE ORAL


tritocin external ointment Tier 3


TRIUMEQ ORAL

TABLET Tier 2 QL

TRI-VI-FLOR ORAL

SUSPENSION Tier 3

TRI-VI-FLORO ORAL

SUSPENSION Tier 3

tri-vite/fluoride oral solution Tier 1 $0

trivora (28) oral tablet Tier 1 $0

tri-vylibra lo oral tablet Tier 1 $0

tri-vylibra oral tablet Tier 1 $0

TRIZIVIR ORAL

TABLET Tier 3 QL

TRODELVY

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD

TROGARZO

INTRAVENOUS


TROKENDI XR ORAL

CAPSULE EXTENDED


TROPHAMINE

INTRAVENOUS

SOLUTION Tier 3

tropicamide ophthalmic

solution Tier 1

trospium chloride er oral


hour Tier 1

trospium chloride oral tablet Tier 1

TRUE COMFORT


TRUE COMFORT PEN


TRUE COMFORT PRO


TRUE COMFORT PRO


TRUE COMFORT TWIST

TOP LANCETS Tier 2 QL



154


TRUEDRAW LANCING

DEVICE Tier 2

TRUEPLUS 5-BEVEL


TRUEPLUS INSULIN


TRUEPLUS LANCETS

26G Tier 2 QL

TRUEPLUS LANCETS

28G Tier 2 QL

TRUEPLUS LANCETS

30G Tier 2 QL

TRUEPLUS LANCETS

33G Tier 2 QL

TRUEPLUS PEN


TRUEPLUS SAFETY


TRULICITY

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2 ST; QL

TRUMENBA

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3 $0

TRUSELTIQ (100MG

DAILY DOSE) ORAL

CAPSULE THERAPY

PACK

Tier 3 PA; QL; LD

TRUSELTIQ (125MG

DAILY DOSE) ORAL

CAPSULE THERAPY

PACK

Tier 3 PA; QL; LD

TRUSELTIQ (50MG

DAILY DOSE) ORAL

CAPSULE THERAPY

PACK

Tier 3 PA; QL; LD

TRUSELTIQ (75MG

DAILY DOSE) ORAL

CAPSULE THERAPY

PACK

Tier 3 PA; QL; LD


TRUSKIN EXTERNAL

SHEET Tier 3

TRUSOPT

OPHTHALMIC

SOLUTION Tier 3

TRUVADA ORAL


TRUXIMA

INTRAVENOUS


trymine cg oral liquid Tier 1

TUKYSA ORAL TABLET Tier 3 PA; QL; LD

tulana oral tablet Tier 1 $0

TURALIO ORAL


TUSNEL C ORAL SYRUP Tier 2 PA; QL

TUSSICAPS ORAL

CAPSULE EXTENDED


TUXARIN ER ORAL

TABLET EXTENDED


TUZISTRA XR ORAL

SUSPENSION


TWINRIX

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3 $0

TWIRLA

TRANSDERMAL PATCH

WEEKLY Tier 3

TWYNSTA ORAL

TABLET 40-10 MG, 80-10

MG, 80-5 MG Tier 3

TWYNSTA ORAL

TABLET 40-5 MG Tier 3 DO

TYBLUME ORAL


TYBOST ORAL TABLET Tier 3 QL

tydemy oral tablet Tier 1 $0



155


TYGACIL

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

TYKERB ORAL TABLET Tier 3 PA; QL; LD; SP

TYMLOS

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 4 PA; QL; SP

TYPHIM VI

INTRAMUSCULAR

SOLUTION Tier 3

TYSABRI

INTRAVENOUS

CONCENTRATE Tier 4 PA; QL; LD; SP

TYVASO INHALATION


TYVASO REFILL

INHALATION


TYVASO STARTER

INHALATION


UCERIS ORAL TABLET

EXTENDED RELEASE 24

HOUR Tier 3

UCERIS RECTAL FOAM Tier 3

UDENYCA

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 4 PA; QL; SP

UKONIQ ORAL TABLET Tier 3 PA; QL; LD

ULTANE INHALATION

SOLUTION Tier 3

ULTICARE INSULIN


ULTICARE INSULIN


ULTICARE MICRO PEN


ULTICARE MINI PEN



ULTICARE PEN


ULTICARE SHORT PEN


ULTIGUARD SAFEPACK


ULTIGUARD SAFEPACK

SYR/NEEDLE Tier 3 ST; QL

ULTI-LANCE

AUTOMATIC Tier 2

ULTILET CLASSIC

LANCETS Tier 2 QL

ULTILET LANCETS Tier 2 QL

ULTILET PEN NEEDLE Tier 3 ST; QL

ULTILET SAFETY

LANCETS Tier 2 QL

ULTILET SAFETY


ULTIVA INTRAVENOUS

SOLUTION


ULTOMIRIS

INTRAVENOUS


ultra b-100 complex oral

tablet Tier 1 $0

ULTRA COMFORT


ULTRA FLO INSULIN


ULTRA FLO INSULIN

SYR 1/2 UNIT Tier 3 ST; QL

ULTRA FLO INSULIN


ULTRA THIN LANCETS

31G Tier 2 QL

ULTRA THIN PEN




156


ULTRABAG/DIANEAL

PD-2/1.5% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRABAG/DIANEAL

PD-2/2.5% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRABAG/DIANEAL

PD-2/4.25%DEX

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRABAG/DIANEAL/1.

5% DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRABAG/DIANEAL/2.

5% DEXTROSE

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRABAG/DIANEAL/4.

25% DEX

INTRAPERITONEAL

SOLUTION

Tier 3

ULTRACARE INSULIN


ULTRA-CARE LANCETS

30G Tier 2 QL

ULTRACARE PEN


ULTRAFOAM SPONGE

2X6.25X7CM EXTERNAL Tier 3

ULTRAFOAM SPONGE


ULTRAFOAM SPONGE


ULTRAFOAM SPONGE

8X25X1CM EXTERNAL Tier 3

ULTRAFOAM SPONGE


ULTRA-THIN II AUTO

LANCET Tier 2 QL


ULTRA-THIN II INS SYR

SHORT Tier 3 ST; QL

ULTRA-THIN II INSULIN


ULTRA-THIN II

LANCETS Tier 2 QL

ULTRA-THIN II MINI


ULTRA-THIN II PEN

NEEDLE SHORT Tier 3 ST; QL

ULTRA-THIN II PEN


UNASYN INJECTION

SOLUTION


UNASYN INTRAVENOUS

SOLUTION


UNIFINE PEN NEEDLES Tier 3 ST; QL


UNIFINE PENTIPS PLUS Tier 3 ST; QL

UNIFINE

SAFECONTROL PEN


UNILET

COMFORTOUCH

LANCET Tier 2 QL

UNILET EXCELITE Tier 2 QL

UNILET EXCELITE II Tier 2 QL

UNILET G.P. LANCET Tier 2 QL

UNILET G.P. SUPERLITE

LANCET Tier 2 QL

UNILET GP 28 ULTRA

THIN Tier 2 QL

UNILET LANCET Tier 2 QL

UNILET MICRO-THIN

33G Tier 2 QL

UNILET SUPERLITE

LANCET Tier 2 QL



157


UNILET SUPER-THIN

30G Tier 2 QL

UNILET ULTRA-THIN

28G Tier 2 QL

UNISTIK 1 Tier 2

UNISTIK 2 Tier 2

UNISTIK 2 COMFORT Tier 2

UNISTIK 2 EXTRA Tier 2

UNISTIK 2 NEONATAL Tier 2

UNISTIK 2 NORMAL Tier 2

UNISTIK 2 SUPER Tier 2

UNISTIK 3 Tier 2

UNISTIK 3 COMFORT Tier 2

UNISTIK 3 EXTRA Tier 2

UNISTIK 3 GENTLE Tier 2 QL

UNISTIK 3 NEONATAL Tier 2

UNISTIK 3 NORMAL Tier 2

UNISTIK CZT

COMFORT Tier 2

UNISTIK CZT NORMAL Tier 2

UNISTIK NORMAL Tier 2

UNISTIK PRO SAFETY

LANCET Tier 2 QL

UNISTIK SAFETY


UNISTIK SAFETY


UNISTIK TOUCH

SAFETY LANC 21G Tier 2 QL

UNISTIK TOUCH


UNISTIK TOUCH


UNISTIK TOUCH


unithroid oral tablet Tier 1 T1S


UNITUXIN

INTRAVENOUS

SOLUTION Tier 3 LD

UNIVERSAL 1 LANCETS

THIN 26G Tier 2 QL

UNIVERSAL 1 LANCETS

THIN 33G Tier 2 QL

UNIVERSAL 1 LANCETS


UPLIZNA

INTRAVENOUS


UPNEEQ OPHTHALMIC


UPTRAVI

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; LD

UPTRAVI ORAL


UPTRAVI ORAL

TABLET THERAPY

PACK Tier 4 PA; QL; LD; SP

UROCIT-K 10 ORAL

TABLET EXTENDED

RELEASE Tier 3

UROCIT-K 15 ORAL

TABLET EXTENDED

RELEASE Tier 3

UROCIT-K 5 ORAL

TABLET EXTENDED

RELEASE Tier 3

URSO 250 ORAL

TABLET Tier 3

URSO FORTE ORAL

TABLET Tier 3

URSODIOL ORAL

CAPSULE 200 MG, 400

MG Tier 3

ursodiol oral capsule 300 mg Tier 1

ursodiol oral tablet Tier 1



158


UVADEX INJECTION

SOLUTION Tier 3

VABOMERE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

valacyclovir hcl oral tablet Tier 1

VALCHLOR EXTERNAL

GEL Tier 3 PA; QL; LD

VALCYTE ORAL

SOLUTION


VALCYTE ORAL

TABLET Tier 3

valganciclovir hcl oral


valganciclovir hcl oral tablet Tier 1

valproate sodium intravenous

solution Tier 1

valproic acid oral capsule Tier 1

valproic acid oral solution Tier 1

valrubicin intravesical

solution Tier 1 SP

valsartan oral tablet Tier 1

valsartan-


tablet 160-12.5 mg, 80-12.5

mg

Tier 1 DO

valsartan-


tablet 160-25 mg, 320-12.5

mg, 320-25 mg

Tier 1

VALSTAR

INTRAVESICAL

SOLUTION Tier 3 SP

VALTOCO 10 MG DOSE

NASAL LIQUID Tier 3 PA; QL

VALTOCO 15 MG DOSE

NASAL LIQUID



VALTOCO 20 MG DOSE

NASAL LIQUID


VALTOCO 5 MG DOSE

NASAL LIQUID Tier 3 PA; QL

VALUE HEALTH


VALUE PLUS LANCET

STANDARD 21G Tier 2 QL

VALUE PLUS LANCETS


VALUE PLUS LANCETS

THIN 26G Tier 2 QL

VALUE PLUS LANCING

DEVICE Tier 2

VALUMARK LANCET


VALUMARK LANCET


VALUMARK PEN


VANCOCIN HCL ORAL


VANCOCIN ORAL


VANCOMYCIN HCL IN

DEXTROSE

INTRAVENOUS

SOLUTION

Tier 3

VANCOMYCIN HCL IN

NACL INTRAVENOUS

SOLUTION Tier 3

VANCOMYCIN HCL

INTRAVENOUS

SOLUTION Tier 3

vancomycin hcl intravenous


10 gm, 100 gm, 1000 mg, 5

gm, 500 mg, 750 mg

Tier 1



159


VANCOMYCIN HCL

INTRAVENOUS

SOLUTION

RECONSTITUTED 1.25

GM, 1.5 GM, 250 MG

Tier 3

vancomycin hcl oral capsule Tier 1 PA; QL

VANCOMYCIN HCL

ORAL SOLUTION


vandazole vaginal gel Tier 1

VANIQA EXTERNAL

CREAM Tier 3

VANISHPOINT INSULIN

SYRINGE 29G X 1/2" 1

ML, 29G X 5/16" 1 ML,

30G X 1/2" 0.5 ML, 30G X

5/16" 0.5 ML, 30G X 5/16"

1 ML

Tier 3 ST; QL

VANISHPOINT INSULIN

SYRINGE 30G X 3/16" 0.5

ML, 30G X 3/16" 1 ML Tier 3

VANTAS


VAPRISOL

INTRAVENOUS

SOLUTION Tier 3

VAQTA

INTRAMUSCULAR


vardenafil hcl oral tablet

dispersible Tier 4 PA; QL

VARITHENA

INTRAVENOUS FOAM Tier 3 LD

VARIVAX

SUBCUTANEOUS


VARIZIG

INTRAMUSCULAR

SOLUTION Tier 3

VARUBI (180 MG DOSE)

ORAL TABLET

THERAPY PACK Tier 3


VASCEPA ORAL


VASERETIC ORAL

TABLET Tier 3

VASOSTRICT

INTRAVENOUS

SOLUTION Tier 3

VAXCHORA ORAL

SUSPENSION


VAXELIS

INTRAMUSCULAR

SUSPENSION Tier 3

VAXELIS

INTRAMUSCULAR

SUSPENSION

PREFILLED SYRINGE

Tier 3

VAZCULEP

INTRAVENOUS

SOLUTION Tier 3

VCF VAGINAL

CONTRACEPTIVE

VAGINAL FILM Tier 2 $0

VCF VAGINAL

CONTRACEPTIVE

VAGINAL FOAM Tier 2 $0

VCF VAGINAL

CONTRACEPTIVE


VECAMYL ORAL

TABLET Tier 3

VECTIBIX

INTRAVENOUS


VECURONIUM

BROMIDE

INTRAVENOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

vecuronium bromide





160


VELCADE INJECTION

SOLUTION


VELETRI

INTRAVENOUS

SOLUTION

RECONSTITUTED


velivet oral tablet Tier 1 $0

VELPHORO ORAL


VELTASSA ORAL

PACKET Tier 3

VEMLIDY ORAL

TABLET Tier 4 SP

VENCLEXTA ORAL


VENCLEXTA STARTING

PACK ORAL TABLET

THERAPY PACK Tier 3 PA; QL; LD

VENEXA ORAL TABLET Tier 3

VENIPUNCTURE PX1

PHLEBOTOMY

EXTERNAL KIT Tier 3

venlafaxine hcl er oral


hour 150 mg Tier 1

venlafaxine hcl er oral


hour 37.5 mg, 75 mg Tier 1 DO

venlafaxine hcl er oral tablet


mg, 225 mg Tier 1

venlafaxine hcl er oral tablet


37.5 mg, 75 mg Tier 1 DO

venlafaxine hcl oral tablet Tier 1

VENOFER

INTRAVENOUS


VENOMIL HONEY BEE

VENOM INJECTION KIT Tier 3


VENOMIL MIXED

VESPID VENOM

INJECTION SOLUTION

RECONSTITUTED

Tier 3

VENOMIL WASP

VENOM INJECTION KIT Tier 3

VENOMIL WHITE

FACED HORNET


VENOMIL YELLOW

HORNET VENOM


VENOMIL YELLOW

JACKET VENOM


VENTAVIS

INHALATION


VENTOLIN HFA

INHALATION AEROSOL


verapamil hcl er oral capsule


mg, 120 mg, 180 mg Tier 1 DO

verapamil hcl er oral capsule


mg, 240 mg, 300 mg, 360 mg Tier 1

verapamil hcl er oral tablet


verapamil hcl intravenous

solution Tier 1

verapamil hcl oral tablet Tier 1

VEREGEN EXTERNAL

OINTMENT Tier 3

VERELAN ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 120

MG, 180 MG

Tier 3 DO

VERELAN ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 240

MG, 360 MG

Tier 3



161


VERELAN PM ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 100

MG

Tier 3 DO

VERELAN PM ORAL

CAPSULE EXTENDED

RELEASE 24 HOUR 200

MG, 300 MG

Tier 3

VERQUVO ORAL


VERSACLOZ ORAL

SUSPENSION Tier 3

VERZENIO ORAL


vestura oral tablet Tier 1 $0

VFEND ORAL

SUSPENSION


VFEND ORAL TABLET Tier 3 PA; QL

VIBATIV

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

VIBERZI ORAL TABLET Tier 3 PA; QL

VICTOZA

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 2 ST; QL

VIDA MIA AUTOLET

LANCING DEV Tier 2

VIDA MIA UNIFINE


VIDA MIA UNILET


VIDA MIA UNILET


VIDAZA INJECTION

SUSPENSION


vienva oral tablet Tier 1 $0

vigabatrin oral packet Tier 1 LD; SP


vigabatrin oral tablet Tier 1 LD; SP

vigadrone oral packet Tier 1 LD

VIGAMOX

OPHTHALMIC

SOLUTION Tier 3

VILTEPSO

INTRAVENOUS


VIMIZIM

INTRAVENOUS


VIMPAT INTRAVENOUS

SOLUTION Tier 3

VIMPAT ORAL

SOLUTION Tier 3

VIMPAT ORAL TABLET Tier 3

VINATE DHA RF ORAL


VINATE II ORAL

TABLET Tier 2

VINATE ONE ORAL

TABLET Tier 2

vinblastine sulfate


vincristine sulfate


vinorelbine tartrate


VIOKACE ORAL

TABLET Tier 3

viorele oral tablet Tier 1 $0

VIRACEPT ORAL

TABLET Tier 2 QL

VIRAMUNE ORAL


VIRAMUNE XR ORAL

TABLET EXTENDED

RELEASE 24 HOUR Tier 3 QL



162


VIRAZOLE

INHALATION

SOLUTION

RECONSTITUTED

Tier 3

VIREAD ORAL POWDER Tier 2

VIREAD ORAL TABLET Tier 2

VIRT-C DHA ORAL

CAPSULE Tier 3

VIRT-NATE DHA ORAL


virt-phos 250 neutral oral

tablet Tier 1

VIRT-PN DHA ORAL

CAPSULE Tier 3

VIRT-PN PLUS ORAL


virtussin a/c oral solution Tier 1

virtussin ac w/alc oral liquid Tier 1

VIRTUSSIN DAC ORAL

SOLUTION Tier 2

VISCO-3 INTRA-

ARTICULAR SOLUTION


VISCOAT

INTRAOCULAR

SOLUTION Tier 3

VISIONBLUE

OPHTHALMIC

SOLUTION Tier 3

VISTARIL ORAL

CAPSULE Tier 3

VISTOGARD ORAL


VISUDYNE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 4 LD; SP

vit e-vit c-beta carotene oral

tablet Tier 1 $0


VITAFOL FE+ ORAL


VITAFOL GUMMIES

ORAL TABLET

CHEWABLE Tier 3 ST; QL

VITAFOL STRIPS ORAL

FILM Tier 3 ST; QL

VITAFOL ULTRA ORAL


VITAFOL-NANO ORAL


VITAFOL-OB ORAL


VITAFOL-OB+DHA

ORAL Tier 3 ST; QL

VITAFOL-ONE ORAL


vitalee oral tablet Tier 1 $0

VITALINE BIOTIN

FORTE ORAL TABLET Tier 2 $0

VITAMEDMD ONE

RX/QUATREFOLIC


VITAMEDMD

REDICHEW RX ORAL


vitamin b + c complex oral

tablet Tier 1 $0

vitamin b complex oral tablet Tier 1 $0

vitamin b-complex oral tablet Tier 1 $0

vitamin d (ergocalciferol)

oral capsule Tier 1

vitamin k1 injection solution Tier 1

vitamin-b complex oral tablet Tier 1 $0

vitamins acd-fluoride oral

solution Tier 1 $0

VITAPEARL ORAL

CAPSULE EXTENDED




163


VITATHELY WITH

GINGER ORAL TABLET Tier 3 ST; QL

VITATRUE ORAL Tier 3 ST; QL

VITRAKVI ORAL


VITRAKVI ORAL


VITRAMYN ORAL

TABLET Tier 3

VITRANOL FE ORAL

TABLET Tier 3

VITRASE INJECTION

SOLUTION Tier 3

VIVA DHA ORAL


VIVAGUARD LANCETS Tier 2 QL

VIVAGUARD LANCING

DEVICE Tier 2

VIVITROL

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 4 LD; SP

VIZIMPRO ORAL


volnea oral tablet Tier 1 $0

VONVENDI

INTRAVENOUS

SOLUTION

RECONSTITUTED


VORAXAZE

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 LD

voriconazole intravenous


voriconazole oral suspension


voriconazole oral tablet Tier 1 PA; QL

VOSEVI ORAL TABLET Tier 4 PA; QL; SP

VOTRIENT ORAL



VP INSULIN SYRINGE Tier 3 ST; QL

VP-PNV-DHA ORAL


VPRIV INTRAVENOUS

SOLUTION


VRAYLAR ORAL

CAPSULE 1.5 MG, 3 MG Tier 3 ST; DO; QL

VRAYLAR ORAL

CAPSULE 4.5 MG, 6 MG Tier 3 ST; QL

VRAYLAR ORAL

CAPSULE THERAPY

PACK Tier 3 ST; QL

VUSION EXTERNAL

OINTMENT Tier 3

vyfemla oral tablet Tier 1 $0

VYLEESI

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

vylibra oral tablet Tier 1 $0

VYNDAMAX ORAL


VYNDAQEL ORAL


VYONDYS 53

INTRAVENOUS


VYVANSE ORAL

CAPSULE 10 MG, 20 MG,

30 MG Tier 2 PA; DO; QL

VYVANSE ORAL

CAPSULE 40 MG, 50 MG,

60 MG, 70 MG Tier 2 PA; QL

VYVANSE ORAL

TABLET CHEWABLE 10

MG, 20 MG, 30 MG Tier 2 PA; DO; QL

VYVANSE ORAL

TABLET CHEWABLE 40

MG, 50 MG, 60 MG Tier 2 PA; QL



164


VYXEOS INTRAVENOUS

SUSPENSION


VYZULTA

OPHTHALMIC

SOLUTION Tier 3

WAKIX ORAL TABLET

17.8 MG Tier 4 PA; QL; LD; SP

WAKIX ORAL TABLET

4.45 MG Tier 4

PA; DO; QL; LD;

SP

WALGREENS ADV

TRAVEL LANCETS Tier 2 QL

WALGREENS LANCETS Tier 2 QL

WALGREENS LANCETS

MICRO THIN Tier 2 QL

WALGREENS LANCETS


WALGREENS THIN

LANCETS Tier 2 QL

WALGREENS ULTRA


warfarin sodium oral tablet Tier 1 T1S

WASP VENOM PROTEIN

INJECTION SOLUTION


WASP VENOM PROTEIN

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3

water for irrigation, sterile


WEGMANS UNIFINE


WEGOVY

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3 PA; QL

WELIREG ORAL

TABLET Tier 3 LD

wera oral tablet Tier 1 $0


WESTAB PLUS ORAL

TABLET Tier 3 ST

WESTERN JUNIPER

SUBCUTANEOUS

SOLUTION Tier 3

WESTGEL DHA ORAL


WESTHROID ORAL

TABLET Tier 3

WEST-VITE W/FOLIC

ACID ORAL TABLET Tier 2 $0

WHITE BIRCH

SUBCUTANEOUS

SOLUTION Tier 3

WHITE FACED HORNET

VENOM

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3

WHITE MULBERRY

SUBCUTANEOUS

SOLUTION Tier 3

WHITE OAK

SUBCUTANEOUS

SOLUTION Tier 3

WHITE PINE

SUBCUTANEOUS

SOLUTION Tier 3

WHITE-FACED HORNET

VENOM INJECTION

SOLUTION

RECONSTITUTED

Tier 3

WIDE-SEAL

DIAPHRAGM 60

VAGINAL DIAPHRAGM Tier 2 $0

WIDE-SEAL

DIAPHRAGM 65


WIDE-SEAL

DIAPHRAGM 70




165


WIDE-SEAL

DIAPHRAGM 75


WIDE-SEAL

DIAPHRAGM 80


WIDE-SEAL

DIAPHRAGM 85


WIDE-SEAL

DIAPHRAGM 90


WIDE-SEAL

DIAPHRAGM 95


WILATE INTRAVENOUS

KIT Tier 4 PA; QL; SP

WILZIN ORAL CAPSULE Tier 3

WINRHO SDF


wixela inhub inhalation

aerosol powder breath

activated Tier 1

womans laxative oral tablet


womens laxative oral tablet


WOUNDGELHA

MATRIX EXTERNAL

GEL Tier 3

WP THYROID ORAL

TABLET Tier 3

wymzya fe oral tablet

chewable Tier 1 $0

XADAGO ORAL TABLET Tier 3 PA; QL

XALKORI ORAL


XARACOLL IMPLANT

IMPLANT Tier 3

XARELTO ORAL

TABLET Tier 2


XARELTO STARTER

PACK ORAL TABLET

THERAPY PACK Tier 2

XATMEP ORAL


XCOPRI (250 MG DAILY

DOSE) ORAL TABLET

THERAPY PACK Tier 3

XCOPRI (350 MG DAILY

DOSE) ORAL TABLET

THERAPY PACK Tier 3

XCOPRI ORAL TABLET Tier 3

XCOPRI ORAL TABLET

THERAPY PACK Tier 3

XELJANZ ORAL


XELJANZ ORAL


XELJANZ XR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 11

MG

Tier 4 PA; QL; SP

XELJANZ XR ORAL

TABLET EXTENDED

RELEASE 24 HOUR 22

MG

Tier 4 PA; QL

XELODA ORAL TABLET Tier 3 PA; QL; SP

XELPROS

OPHTHALMIC

EMULSION Tier 3

XEMBIFY

SUBCUTANEOUS


XENICAL ORAL


XENLETA

INTRAVENOUS

SOLUTION Tier 3

XENLETA ORAL




166


XEOMIN

INTRAMUSCULAR

SOLUTION

RECONSTITUTED


XEPI EXTERNAL

CREAM Tier 3

XERAVA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

XERESE EXTERNAL

CREAM Tier 3 PA; QL

XERMELO ORAL


XGEVA

SUBCUTANEOUS


XIAFLEX INJECTION

SOLUTION


XIFAXAN ORAL


XIGDUO XR ORAL

TABLET EXTENDED


XIIDRA OPHTHALMIC


XOFIGO INTRAVENOUS


XOFLUZA (40 MG DOSE)

ORAL TABLET

THERAPY PACK Tier 3

XOFLUZA (80 MG DOSE)

ORAL TABLET

THERAPY PACK Tier 3

XOLAIR

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


XOLAIR

SUBCUTANEOUS

SOLUTION

RECONSTITUTED



XOLEGEL EXTERNAL

GEL Tier 3

XOPENEX HFA


XOSPATA ORAL


XPOVIO (100 MG ONCE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (40 MG ONCE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (40 MG TWICE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (60 MG ONCE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (60 MG TWICE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (80 MG ONCE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XPOVIO (80 MG TWICE

WEEKLY) ORAL

TABLET THERAPY

PACK

Tier 3 PA; QL; LD

XTANDI ORAL


XTANDI ORAL TABLET Tier 2 PA; QL; LD; SP

xulane transdermal patch

weekly Tier 1 $0

XULTOPHY

SUBCUTANEOUS

SOLUTION PEN-

INJECTOR

Tier 3 ST; QL



167


XURIDEN ORAL


XYLOCAINE


XYLOCAINE/EPINEPHR

INE INJECTION

SOLUTION Tier 3

XYLOCAINE-MPF


XYLOCAINE-

MPF/EPINEPHRINE


XYNTHA


XYNTHA SOLOFUSE


XYREM ORAL


YASMIN 28 ORAL

TABLET Tier 3

YAZ ORAL TABLET Tier 3

YELLOW DOCK

SUBCUTANEOUS

SOLUTION Tier 3

YELLOW HORNET

VENOM PROTEIN

INJECTION SOLUTION

RECONSTITUTED

Tier 3

YELLOW HORNET

VENOM PROTEIN

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3

YELLOW JACKET

VENOM PROTEIN

INJECTION SOLUTION

RECONSTITUTED

Tier 3

YELLOW JACKET

VENOM PROTEIN

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 3


YERVOY

INTRAVENOUS


YF-VAX

SUBCUTANEOUS

INJECTABLE Tier 3

yl balanced b-100 oral tablet Tier 1 $0

yl folic acid oral tablet Tier 1 $0

YONDELIS

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 LD; SP

YONSA ORAL TABLET Tier 3 PA; QL; LD; SP

YOSPRALA ORAL

TABLET DELAYED


YUPELRI INHALATION


YUTIQ INTRAVITREAL

IMPLANT Tier 3 PA; QL; LD

yuvafem vaginal tablet Tier 1

zafemy transdermal patch

weekly Tier 1 $0

zafirlukast oral tablet Tier 1

zaleplon oral capsule Tier 1

ZALTRAP

INTRAVENOUS


ZALVIT ORAL TABLET Tier 3 ST; QL

ZANAFLEX ORAL


ZANAFLEX ORAL


ZANOSAR

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 SP

zarah oral tablet Tier 1 $0



168


ZARXIO INJECTION

SOLUTION PREFILLED


ZATEAN-PN DHA ORAL


ZATEAN-PN PLUS ORAL


ZCORT 7-DAY ORAL

TABLET THERAPY

PACK Tier 3

zebutal oral capsule Tier 1

ZEGALOGUE

SUBCUTANEOUS

SOLUTION AUTO-

INJECTOR

Tier 3

ZEGALOGUE

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE

Tier 3

ZEJULA ORAL


ZELAPAR ORAL

TABLET DISPERSIBLE Tier 3 PA; QL

ZELBORAF ORAL


ZEMAIRA

INTRAVENOUS

SOLUTION

RECONSTITUTED


ZEMDRI INTRAVENOUS

SOLUTION Tier 3

ZEMPLAR

INTRAVENOUS


ZEMPLAR ORAL


zenatane oral capsule Tier 2 PA; QL

ZENPEP ORAL

CAPSULE DELAYED

RELEASE PARTICLES Tier 2

zenzedi oral tablet 10 mg, 15

mg, 20 mg, 30 mg, 7.5 mg Tier 1 PA; QL


zenzedi oral tablet 2.5 mg, 5

mg Tier 1 PA; DO; QL

ZEPOSIA 7-DAY

STARTER PACK ORAL

CAPSULE THERAPY

PACK


ZEPOSIA ORAL


ZEPOSIA STARTER KIT

ORAL CAPSULE


ZEPZELCA

INTRAVENOUS

SOLUTION

RECONSTITUTED


ZERBAXA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ZESTORETIC ORAL


ZESTORETIC ORAL

TABLET 20-12.5 MG, 20-

25 MG Tier 3

ZEVALIN Y-90

INTRAVENOUS KIT Tier 3 PA; QL

ZEVRX INSULIN


ZEVRX PEN NEEDLES Tier 3 ST; QL

ZEVRX TWIST TOP


ZIAC ORAL TABLET Tier 3

ZIAGEN ORAL

SOLUTION Tier 3 QL

ZIAGEN ORAL TABLET Tier 3 QL

zidovudine oral capsule Tier 1 QL

zidovudine oral syrup Tier 1 QL

zidovudine oral tablet Tier 1 QL



169


ZIEXTENZO

SUBCUTANEOUS

SOLUTION PREFILLED

SYRINGE


ZILRETTA INTRA-

ARTICULAR

SUSPENSION

RECONSTITUTED ER

Tier 4 PA; QL

ZILXI EXTERNAL

FOAM Tier 3 ST; QL

zinc chloride intravenous

solution Tier 1

zinc sulfate intravenous

solution Tier 1

ZINGO INTRADERMAL

JET-INJECTOR Tier 3

ZINPLAVA

INTRAVENOUS


ZIOPTAN OPHTHALMIC

SOLUTION Tier 3

ziprasidone hcl oral capsule

20 mg, 40 mg Tier 1 DO

ziprasidone hcl oral capsule

60 mg, 80 mg Tier 1

ziprasidone mesylate

intramuscular solution


ZIRABEV

INTRAVENOUS


ZIRGAN OPHTHALMIC

GEL Tier 3

ZITHROMAX

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3

ZITHROMAX ORAL

PACKET Tier 3 QL

ZITHROMAX ORAL

SUSPENSION



ZITHROMAX ORAL

TABLET Tier 3 QL

ZITHROMAX TRI-PAK


ZITHROMAX Z-PAK


ZOFRAN ORAL TABLET Tier 3 QL

ZOKINVY ORAL


ZOLADEX

SUBCUTANEOUS

IMPLANT Tier 3 PA; QL; SP

zoledronic acid intravenous

concentrate Tier 1 PA; QL; SP

ZOLEDRONIC ACID

INTRAVENOUS

SOLUTION 4 MG/100ML Tier 4 PA; QL; SP

zoledronic acid intravenous

solution 5 mg/100ml Tier 4 PA; QL; SP

ZOLINZA ORAL


zolmitriptan nasal solution Tier 1 ST; QL

zolmitriptan oral tablet Tier 1 QL

zolmitriptan oral tablet

dispersible Tier 1 QL

zolpidem tartrate er oral

tablet extended release Tier 1 ST; QL

zolpidem tartrate oral tablet Tier 1

zolpidem tartrate sublingual

tablet sublingual Tier 1 ST; QL

ZOLPIMIST ORAL


zonisamide oral capsule Tier 1

ZONTIVITY ORAL


ZORBTIVE

SUBCUTANEOUS

SOLUTION

RECONSTITUTED

Tier 4 PA; QL; SP



170


ZORTRESS ORAL

TABLET Tier 3

ZOSYN INTRAVENOUS

SOLUTION Tier 3

zovia 1/35 (28) oral tablet Tier 1 $0

zovia 1/35e (28) oral tablet Tier 1 $0

ZOVIRAX EXTERNAL

OINTMENT Tier 3

ZOVIRAX ORAL

SUSPENSION Tier 3

ZUBSOLV SUBLINGUAL

TABLET SUBLINGUAL Tier 3 QL

ZULRESSO

INTRAVENOUS


zumandimine oral tablet Tier 1 $0

ZUPLENZ ORAL FILM Tier 3 QL

ZYCLARA EXTERNAL

CREAM Tier 3 ST; QL

ZYCLARA PUMP


ZYDELIG ORAL


ZYKADIA ORAL


ZYLET OPHTHALMIC

SUSPENSION Tier 2

ZYLOPRIM ORAL

TABLET Tier 3

ZYMAXID

OPHTHALMIC

SOLUTION Tier 3

ZYNLONTA

INTRAVENOUS

SOLUTION

RECONSTITUTED

Tier 3 PA; QL; LD

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION

RECONSTITUTED

Tier 3

ZYTIGA ORAL TABLET Tier 3 PA; QL; LD; SP


ZYVANA ORAL

CAPSULE Tier 3

ZYVOX INTRAVENOUS

SOLUTION Tier 3

ZYVOX ORAL

SUSPENSION


ZYVOX ORAL TABLET Tier 3 PA; QL

Key terms

Here are some terms and notes you’ll find on the drug list.

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met. DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength. LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides. PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled. QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time. SP = specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered. Online pharmacy resources

Log in to anthem.com to find your closest network pharmacy and the most up-to-date drug list information, including pricing, brands and generics, and dosage options. Most plans include our convenient home delivery program at no extra cost to you. Find out more at anthem.com or call 833-236-6196.

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If you have questions about the drug list or your pharmacy benefits, call the Pharmacy Member Services number on your ID card.

A note about opioid analgesics: In response to the opioid epidemic, the U.S. Food and Drug Administration (FDA) encouraged the development of painkillers that prevent misuse. You may pay less for these types of opioids in certain states.

Drug(s) may be excluded from the list based on your plan's benefit design.

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Four-Tier Drug List - mmeht.org

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Transcript of Four-Tier Drug List - mmeht.org