OptumRx 2022 Premium Standard Formulary
Transcript of OptumRx 2022 Premium Standard Formulary
2022 Premium Standard FormularyEffective January 1, 2022
For the most current list of covered medications or if you have questions:
Call the number on your member ID card.
Visit your plan’s website on your member ID card or log on to the OptumRx app to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
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Understanding your formulary
What is a formulary?
A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.
To create the list, OptumRx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.
How do I use my formulary?
You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor.
When does the formulary change?
• Medications may move to a lower tier at any time.• Medications may move to a higher tier when a generic
equal becomes available.• Medications may move to a higher tier or be excluded from
coverage on January 1 or July 1 of each year.
If a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same as or is similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card.
About this formulary
Where differences exist between this list and your benefit plan, the benefit plan documents rule. This is not a complete list of your covered medications. Please review your benefit plan documents for full details. Not all formulary alternatives listed in this document may be appropriate for your specific condition. Please talk to your doctor.
Medication tips
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. In some situations, brand-name medications could be lower in cost.
What if my doctor writes a brand-name prescription?
If your doctor gives you a prescription for a brand-name medication, ask if a lower-cost option could be right for you.
What if I am taking a specialty medication?
Specialty medications are used to treat complex conditions and are generally higher in cost. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask how you can have your prescriptions delivered right to your home or doctor’s office.
Over-the-counter medications (OTC)
Talk to your doctor about OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.
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Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.
Drug tier Includes Helpful tips
Tier 1 $ Lower-cost generics and some brand name
Use tier 1 drugs for the lowest out-of-pocket costs.
Tier 2 $$ Mid-range cost preferred brand name
Use tier 2 drugs instead of tier 3 to help reduce your out-of-pocket costs.
Tier 3 $$$ Higher-cost brand name and some generics
Many tier 3 drugs have lower-cost options in tier 1 or 2. Ask your doctor if they could work for you.
Tier E Excluded May not be covered or need prior authorization. Lower-cost options are available and covered.
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.
M Authorized generic or cobranded product
PA Prior authorization – Your doctor is required to give OptumRx more information to determine coverage.
QL Quantity limit – Medication may be limited to a certain quantity.
SP Specialty medication – Medication is designated as specialty.
ST Step therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered
3P Tier 3 preferred
++ Benefit design options – Coverage is determined by your prescription medication benefit plan.
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Analgesics - drugs for pain .................................................. 5
Analgesics - drugs for pain and inflammation ...................... 5
Anesthetics ......................................................................... 6
Anti-addiction / substance abuse treatment agents ............. 6
Antibacterials ...................................................................... 6
Anticoagulants .................................................................... 8
Anticonvulsants - drugs for seizures .................................... 8
Antidementia agents - drugs for Alzheimer’s disease and dementia ..................................................................... 9
Antidepressants .................................................................. 9
Antiemetics - drugs for nausea and vomiting ...................... 9
Antifungals ....................................................................... 10
Antigout agents ................................................................ 10
Antimigraine agents .......................................................... 10
Antimyasthenic agents ...................................................... 10
Antimycobacterials ............................................................ 10
Antineoplastics - drugs for cancer ..................................... 11
Antiparasitics .................................................................... 12
Antiparkinson agents ........................................................ 12
Antiplatelets ..................................................................... 13
Antipsychotics - drugs for mood disorders ......................... 13
Antivirals ........................................................................... 13
Anxiolytics - drugs for anxiety ........................................... 14
Bipolar agents - drugs for mood disorders ......................... 14
Blood products and modifiers - drugs for blood disorders .. 14
Cardiovascular agents - drugs for heart and circulation conditions ........................................................ 15
Central nervous system agents - drugs for attention deficit disorder .................................................................. 17
Central nervous system agents - drugs for multiple sclerosis 17
Central nervous system agents - miscellaneous ................. 17
Dental and oral agents - drugs for mouth and throat conditions ......................................................................... 17
Dermatological agents - drugs for skin conditions ............. 18
Diabetes - antidiabetic agents ........................................... 19
Diabetes - glucose monitoring ........................................... 19
Diabetes - glycemic agents ................................................ 20
Diabetes - insulins ............................................................. 20
Electrolytes / minerals / metals / vitamins ........................... 20
Gastrointestinal agents - drugs for acid reflux and ulcer .... 21
Gastrointestinal agents - drugs for bowel, intestine and stomach conditions .................................................... 21
Genetic or enzyme disorder - drugs for replacement, modification, treatment .................................................... 22
Genitourinary agents - drugs for bladder, genital and kidney conditions .............................................................. 22
Genitourinary agents - drugs for prostate conditions ......... 22
Hormonal agents - adrenal ................................................ 22
Hormonal agents - men’s health ........................................ 23
Hormonal agents - pituitary .............................................. 23
Hormonal agents - selective estrogen receptor modifying agents .............................................................. 23
Hormonal agents - sex hormones and birth control ........... 23
Hormonal agents - thyroid ................................................ 26
Immunological agents - drugs for immune system stimulation or suppression ................................................ 26
Immunological agents - drugs for vaccination ................... 27
Inflammatory bowel disease agents ................................... 27
Metabolic bone disease agents - drugs for osteoporosis .... 28
Metabolic bone disease agents - other .............................. 28
Miscellaneous therapeutic agents ...................................... 28
Ophthalmic agents - drugs for eye allergy, infection and inflammation ............................................................. 29
Ophthalmic agents - drugs for glaucoma .......................... 29
Ophthalmic agents - drugs for miscellaneous eye conditions ......................................................................... 29
Otic agents - drugs for ear conditions ............................... 30
Respiratory tract / pulmonary agents - drugs for allergies, cough, cold ........................................................ 30
Respiratory tract / pulmonary agents - drugs for asthma and other lung conditions ..................................... 30
Respiratory tract / pulmonary agents - drugs for cystic fibrosis ..................................................................... 31
Respiratory tract / pulmonary agents - drugs for pulmonary hypertension ................................................... 31
Skeletal muscle relaxants - drugs for muscle pain and spasm ............................................................................... 31
Sleep disorder agents ........................................................ 32
Contents
5PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
Analgesics - drugs for pain
acetaminophen intravenous solution Generic
acetaminophen-codeine Generic QL
acetaminophen-codeine #2 Generic QL
acetaminophen-codeine #3 Generic QL
acetaminophen-codeine #4 Generic QL
alfentanil hcl Generic
apap-caff-dihydrocodeine Generic QL
ascomp-codeine Generic
bac Generic
BELBUCA Brand PA; QL
buprenorphine Generic PA; QL
buprenorphine hcl injection Generic
butalbital-acetaminophen Generic
butalbital-apap-caff-cod Generic
butalbital-apap-caffeine Generic
butalbital-asa-caff-codeine Generic
butalbital-aspirin-caffeine Generic
butorphanol tartrate injection Generic
butorphanol tartrate nasal Generic QL
carisoprodol-aspirin-codeine Generic
codeine sulfate Generic QL
duramorph Generic
endocet Generic QL
fentanyl Generic PA; QL
fentanyl citrate buccal lozenge on a handle
Generic PA; QL
fentanyl citrate injection solution prefilled syringe
Generic
hydrocodone bitartrate er oral capsule extended release 12 hour
Generic PA; QL
hydrocodone-acetaminophen Generic QL
hydrocodone-ibuprofen Generic QL
hydromorphone hcl er Generic PA; QL
hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml
Generic
hydromorphone hcl oral Generic QL
hydromorphone hcl pf Generic
hydromorphone hcl solution 1 mg/ml injection
Generic
levorphanol tartrate oral Generic QL
meperidine hcl injection Generic
meperidine hcl oral Generic QL
methadone hcl injection Generic
Drug nameDrug tier Notes
methadone hcl intensol Generic
methadone hcl oral concentrate Generic
methadone hcl oral solution Generic
methadone hcl oral tablet Generic PA
methadone hcl oral tablet soluble Generic
methadose oral concentrate 10 mg/ml
Generic
methadose oral tablet soluble Generic
methadose sugar-free Generic
mitigo Generic
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
Generic QL
morphine sulfate (pf) Generic
morphine sulfate er Generic PA; QL
morphine sulfate er beads Generic PA; QL
morphine sulfate injection solution 2 mg/ml, 4 mg/ml
Generic
morphine sulfate intravenous solution 4 mg/ml, 8 mg/ml
Generic
morphine sulfate oral Generic QL
nalbuphine hcl injection Generic
oxycodone hcl oral capsule Generic QL
oxycodone hcl oral concentrate 100 mg/5ml
Generic QL
oxycodone hcl oral solution Generic QL
oxycodone hcl oral tablet Generic QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic QL
oxymorphone hcl Generic QL
oxymorphone hcl er Generic PA; QL
pentazocine-naloxone hcl Generic QL
remifentanil hcl Generic
tramadol hcl er (biphasic) Generic PA; QL
tramadol hcl er oral tablet extended release 24 hour
Generic PA; QL
tramadol hcl ir Generic QL
tramadol-acetaminophen Generic QL
XTAMPZA ER Brand PA; QL
Analgesics - drugs for pain and inflammation
celecoxib oral Generic QL
diclofenac potassium Generic
diclofenac sodium er Generic
diclofenac sodium external gel 1 % Generic QL
diclofenac sodium external solution Generic PA
6PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
diclofenac sodium oral Generic
diclofenac-misoprostol Generic
diflunisal oral Generic
ec-naproxen Generic
etodolac Generic
etodolac er Generic
fenoprofen calcium oral Generic
fenortho Generic
flurbiprofen oral Generic
ibuprofen lysine Generic
ibuprofen oral suspension 100 mg/5ml
Generic
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Generic
indomethacin er Generic
indomethacin oral capsule 25 mg, 50 mg
Generic
indomethacin sodium Generic
ketoprofen er Generic
ketoprofen oral Generic
ketorolac tromethamine injection Generic
ketorolac tromethamine intramuscular
Generic
ketorolac tromethamine oral Generic QL
meclofenamate sodium oral Generic
mefenamic acid oral Generic
meloxicam oral Generic
nabumetone oral Generic
naproxen oral Generic
naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg
Generic
naproxen sodium oral tablet 275 mg, 550 mg
Generic
naproxen-esomeprazole Generic QL
oxaprozin Generic
piroxicam oral Generic
sulindac oral Generic
Anesthetics
bupivacaine fisiopharma Generic
bupivacaine hcl (pf) Generic
bupivacaine hcl injection solution 0.25 %, 0.5 %
Generic
bupivacaine-epinephrine Generic
bupivacaine-epinephrine (pf) Generic
Drug nameDrug tier Notes
chloroprocaine hcl (pf) Generic
ethyl chloride Generic
glydo Generic
lidocaine external ointment 5 % Generic
lidocaine external patch 5 % Generic
lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml
Generic
lidocaine hcl (cardiac) pf Generic
lidocaine hcl (cardiac) solution prefilled syringe 100 mg/5ml intravenous
Generic
lidocaine hcl (pf) Generic
lidocaine hcl external solution Generic
lidocaine hcl injection solution Generic
lidocaine hcl urethral/mucosal Generic
lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%
Generic
lidocaine-epinephrine injection Generic
lidocaine-prilocaine external cream Generic
polocaine Generic
polocaine-mpf Generic
ropivacaine hcl injection solution Generic
tetracaine hcl injection Generic
Anti-addiction / substance abuse treatment agents
acamprosate calcium Generic
buprenorphine hcl sublingual Generic QL
buprenorphine hcl-naloxone hcl Generic QL
bupropion hcl er (smoking det) Generic QL
disulfiram oral Generic
KLOXXADO Brand
naloxone hcl injection Generic
naltrexone hcl oral Generic
NARCAN Brand
ZUBSOLV Brand QL
Antibacterials
amikacin sulfate injection Generic
amoxicillin Generic
amoxicillin-potassium clavulanate Generic
amoxicillin-potassium clavulanate er Generic
ampicillin Generic
ampicillin sodium Generic
ampicillin-sulbactam sodium Generic
avidoxy Generic
7PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
azithromycin intravenous Generic
azithromycin oral Generic
aztreonam Generic
bacitracin intramuscular Generic
benzalkonium chloride external solution
Generic
cefaclor Generic
cefaclor er Generic
cefadroxil Generic
cefazolin sodium injection Generic
cefazolin sodium intravenous solution reconstituted
Generic
cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-%
Generic
cefazolin sodium-dextrose intravenous solution reconstituted
Generic
cefdinir Generic
cefepime hcl injection Generic
cefepime hcl intravenous solution Generic
cefepime-dextrose Generic
cefixime Generic
cefotaxime sodium Generic
cefotetan disodium Generic
cefotetan disodium-dextrose Generic
cefoxitin sodium Generic
cefpodoxime proxetil Generic
cefprozil Generic
ceftazidime and dextrose Generic
ceftazidime injection Generic
ceftazidime intravenous Generic
ceftriaxone sodium in dextrose Generic
ceftriaxone sodium injection Generic
ceftriaxone sodium intravenous Generic
ceftriaxone sodium-dextrose Generic
cefuroxime axetil Generic
cefuroxime sodium Generic
cephalexin Generic
chloramphenicol sod succinate Generic
ciprofloxacin hcl oral Generic
ciprofloxacin in d5w Generic
clarithromycin er Generic
clarithromycin oral Generic
clindamycin hcl oral Generic
Drug nameDrug tier Notes
clindamycin palmitate hcl Generic
clindamycin phosphate in d5w Generic
clindamycin phosphate injection Generic
clindamycin phosphate vaginal Generic
colistimethate sodium (cba) Generic
coremino Generic
daptomycin Generic
demeclocycline hcl Generic
dicloxacillin sodium Generic
doxy 100 Generic
doxycycline hyclate intravenous Generic
doxycycline hyclate oral capsule Generic
doxycycline hyclate oral tablet Generic
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg
Generic
doxycycline monohydrate oral Generic
ertapenem sodium Generic
erythromycin base Generic
erythromycin ethylsuccinate oral Generic
erythromycin oral Generic
fosfomycin tromethamine Generic
gentamicin in saline Generic
gentamicin sulfate external Generic
gentamicin sulfate injection Generic
hydrogen peroxide Generic
imipenem-cilastatin Generic
levofloxacin in d5w Generic
levofloxacin intravenous Generic
levofloxacin oral Generic
lincomycin hcl injection Generic
linezolid in sodium chloride Generic
linezolid intravenous Generic
linezolid oral Generic QL
mafenide acetate external Generic
meropenem Generic
methenamine hippurate Generic
metronidazole in nacl Generic
metronidazole oral Generic
metronidazole vaginal Generic
minocycline hcl er oral tablet extended release 24 hour
Generic
minocycline hcl oral Generic
mondoxyne nl Generic
8PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
moxifloxacin hcl in nacl Generic
moxifloxacin hcl oral Generic
mupirocin calcium Generic
mupirocin external Generic
nafcillin sodium Generic
neomycin sulfate oral Generic
neomycin-polymyxin b gu Generic
nitrofurantoin Generic
nitrofurantoin macrocrystal Generic
nitrofurantoin monohydrate macrocrystals
Generic
ofloxacin oral Generic
oxacillin sodium Generic
paromomycin sulfate oral Generic
penicillin g potassium Generic
penicillin g procaine Generic
penicillin g sodium Generic
penicillin v potassium Generic
piperacillin sod-tazobactam so Generic
polymyxin b sulfate injection Generic
silver sulfadiazine external Generic
ssd Generic
streptomycin sulfate intramuscular Generic
sulfadiazine oral Generic
sulfamethoxazole-trimethoprim Generic
sulfatrim pediatric Generic
tazicef injection Generic
tazicef intravenous solution reconstituted
Generic
tetracycline hcl oral Generic
tigecycline Generic
tinidazole oral Generic
tobramycin sulfate injection Generic
trimethoprim oral Generic
vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%
Generic
vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%
Generic
vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous
Generic
vancomycin hcl intravenous Generic
vancomycin hcl oral Generic
Drug nameDrug tier Notes
vandazole Generic
Anticoagulants
argatroban Generic
bivalirudin trifluoroacetate Generic
ELIQUIS Brand QL
ELIQUIS DVT/PE STARTER PACK Brand QL
enoxaparin sodium Generic SP; QL
fondaparinux sodium Generic SP; QL
heparin (porcine) in nacl intravenous solution
Generic
heparin sod (porcine) in d5w Generic
heparin sodium (porcine) Generic
heparin sodium (porcine) pf Generic
jantoven Generic
PRADAXA Brand QL
warfarin sodium oral Generic
XARELTO Brand QL
XARELTO STARTER PACK Brand QL
Anticonvulsants - drugs for seizures
carbamazepine er Generic
carbamazepine oral Generic
clobazam Generic PA
diazepam rectal Generic QL
divalproex sodium er Generic
divalproex sodium oral Generic
epitol Generic
ethosuximide oral Generic
felbamate Generic
fosphenytoin sodium Generic
gabapentin oral Generic
lamotrigine er Generic
lamotrigine oral Generic
lamotrigine starter kit-blue Generic
lamotrigine starter kit-green Generic
lamotrigine starter kit-orange Generic
levetiracetam er Generic
levetiracetam in nacl Generic
levetiracetam intravenous Generic
levetiracetam oral Generic
oxcarbazepine Generic
pentobarbital sodium injection Generic
phenobarbital oral Generic
phenobarbital sodium injection Generic
phenytoin infatabs Generic
9PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
phenytoin oral Generic
phenytoin sodium extended Generic
phenytoin sodium injection Generic
primidone oral Generic
roweepra Generic
rufinamide Generic PA
subvenite Generic
subvenite starter kit-blue Generic
subvenite starter kit-green Generic
subvenite starter kit-orange Generic
tiagabine hcl Generic
topiramate er Generic
topiramate oral Generic
valproate sodium intravenous Generic
valproic acid oral Generic
vigabatrin Generic PA; SP
vigadrone Generic PA; SP
zonisamide oral Generic
Antidementia agents - drugs for Alzheimer's disease and dementia
donepezil hcl Generic
galantamine hydrobromide Generic
galantamine hydrobromide er Generic
memantine hcl Generic
memantine hcl er Generic QL
NAMZARIC Brand QL
rivastigmine Generic
rivastigmine tartrate Generic
Antidepressants
amitriptyline hcl oral Generic
amoxapine Generic
bupropion hcl er (sr) Generic QL
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
Generic QL
bupropion hcl oral Generic
chlordiazepoxide-amitriptyline Generic
citalopram hydrobromide Generic
clomipramine hcl oral Generic
desipramine hcl oral Generic
desvenlafaxine succinate er Generic QL
doxepin hcl oral capsule Generic
doxepin hcl oral concentrate Generic
duloxetine hcl oral Generic QL
Drug nameDrug tier Notes
escitalopram oxalate Generic
fluoxetine hcl (pmdd) Generic
fluoxetine hcl oral capsule Generic
fluoxetine hcl oral capsule delayed release
Generic QL
fluoxetine hcl oral solution Generic
fluoxetine hcl oral tablet Generic
fluvoxamine maleate Generic
fluvoxamine maleate er Generic QL
imipramine hcl oral Generic
imipramine pamoate Generic
mirtazapine oral Generic
nefazodone hcl Generic
nortriptyline hcl oral Generic
olanzapine-fluoxetine hcl Generic QL
paroxetine hcl Generic
paroxetine hcl er Generic
paroxetine mesylate Generic QL
perphenazine-amitriptyline Generic
phenelzine sulfate oral Generic
protriptyline hcl Generic
sertraline hcl oral concentrate Generic
sertraline hcl oral tablet Generic
tranylcypromine sulfate Generic
trazodone hcl oral Generic
trimipramine maleate oral Generic
venlafaxine hcl Generic
venlafaxine hcl er Generic
Antiemetics - drugs for nausea and vomiting
aprepitant Generic QL
compro Generic
dimenhydrinate injection Generic
doxylamine-pyridoxine Generic PA; QL
dronabinol Generic PA; QL
droperidol injection Generic
fosaprepitant dimeglumine Generic
granisetron hcl intravenous Generic
granisetron hcl oral Generic QL
meclizine hcl oral tablet Generic
metoclopramide hcl injection Generic
metoclopramide hcl oral Generic
ondansetron hcl injection Generic
ondansetron hcl oral solution Generic QL
ondansetron hcl oral tablet 24 mg Generic QL
10PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
ondansetron hcl oral tablet 4 mg, 8 mg
Generic
ondansetron odt Generic
palonosetron hcl Generic
perphenazine oral Generic
prochlorperazine Generic
prochlorperazine edisylate injection Generic
prochlorperazine maleate oral Generic
scopolamine Generic
trimethobenzamide hcl oral Generic
Antifungals
amphotericin b intravenous Generic
caspofungin acetate Generic
ciclodan Generic
ciclopirox external Generic
ciclopirox olamine external Generic
clotrimazole external Generic
clotrimazole mouth/throat Generic
clotrimazole-betamethasone Generic
econazole nitrate external Generic
fluconazole in sodium chloride Generic
fluconazole oral Generic
flucytosine oral Generic
griseofulvin microsize oral Generic
griseofulvin ultramicrosize Generic
itraconazole oral Generic PA
ketoconazole external Generic
ketoconazole oral Generic
ketodan external foam Generic
micafungin sodium Generic
miconazole 3 Generic
naftifine hcl Generic
nyamyc Generic
nystatin external Generic
nystatin mouth/throat Generic
nystatin oral Generic
nystatin-triamcinolone Generic
nystop Generic
oxiconazole nitrate Generic
posaconazole Generic PA
tavaborole Generic PA
terbinafine hcl oral Generic QL
terconazole Generic
voriconazole intravenous Generic
Drug nameDrug tier Notes
voriconazole oral Generic PA
Antigout agents
allopurinol oral Generic
allopurinol sodium Generic
colchicine oral tablet Generic
colchicine-probenecid Generic
febuxostat Generic
probenecid Generic
Antimigraine agents
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML
Brand PA; QL
almotriptan malate Generic QL
dihydroergotamine mesylate injection
Generic PA; QL
dihydroergotamine mesylate nasal Generic PA; QL
eletriptan hydrobromide Generic QL
EMGALITY Brand PA; QL
EMGALITY (300 MG DOSE) Brand PA; QL
ergotamine-caffeine Generic PA
frovatriptan succinate Generic QL
naratriptan hcl Generic QL
NURTEC Brand PA; QL
rizatriptan benzoate Generic QL
sumatriptan nasal Generic QL
sumatriptan succinate oral Generic QL
sumatriptan succinate refill Generic QL
sumatriptan succinate subcutaneous Generic QL
sumatriptan-naproxen sodium Generic QL
UBRELVY Brand PA; QL
zolmitriptan oral Generic QL
zolmitriptan solution 5 mg nasal Generic QL
Antimyasthenic agents
neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml
Generic
pyridostigmine bromide er Generic
pyridostigmine bromide oral Generic
Antimycobacterials
cycloserine oral Generic
dapsone oral Generic
ethambutol hcl oral Generic
isoniazid injection Generic
isoniazid oral Generic
11PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
pyrazinamide oral Generic
rifabutin Generic
rifampin intravenous Generic
rifampin oral Generic
Antineoplastics - drugs for cancer
abiraterone acetate Generic PA; SP
ABRAXANE Brand SP
ADCETRIS Brand PA; SP
adriamycin Generic SP
ALECENSA Brand PA; SP
ALIMTA Brand SP
ALUNBRIG Brand PA; SP; QL
anastrozole oral Generic
ARRANON Brand SP
arsenic trioxide intravenous Generic SP
ARZERRA Brand PA; SP; QL
azacitidine Generic SP
bexarotene Generic PA; SP
bicalutamide Generic
bleomycin sulfate Generic SP
busulfan Generic SP
CABOMETYX Brand PA; SP
capecitabine Generic PA; SP
CAPRELSA ORAL TABLET 100 MG Brand PA; SP; QL
CAPRELSA ORAL TABLET 300 MG Brand PA; SP
carboplatin Generic SP
carmustine Generic SP
cisplatin intravenous solution Generic SP
cladribine Generic SP
clofarabine Generic SP
cyclophosphamide injection Generic SP
cyclophosphamide oral capsule Generic
CYCLOPHOSPHAMIDE ORAL TABLET Brand
cytarabine Generic SP
cytarabine (pf) Generic SP
dacarbazine Generic SP
dactinomycin Generic SP
daunorubicin hcl Generic SP
decitabine Generic PA; SP
dexrazoxane hcl Generic SP
docetaxel Generic SP
doxorubicin hcl Generic SP
doxorubicin hcl liposomal Generic SP
Drug nameDrug tier Notes
EMCYT Brand
epirubicin hcl Generic SP
ERBITUX Brand PA; SP
ERIVEDGE Brand PA; SP
erlotinib hcl oral tablet 100 mg, 150 mg
Generic PA; SP
erlotinib hcl oral tablet 25 mg Generic PA; SP; QL
etoposide intravenous Generic SP
etoposide oral Generic SP
everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg
Generic PA; SP; QL
everolimus oral tablet soluble Generic PA; SP
exemestane Generic
floxuridine Generic SP
fludarabine phosphate Generic SP
fluorouracil intravenous Generic SP
flutamide Generic
FOLOTYN Brand PA; SP
fulvestrant Generic SP
gemcitabine hcl Generic SP
HALAVEN Brand PA; SP
hydroxyurea oral Generic
idarubicin hcl Generic SP
ifosfamide Generic SP
imatinib mesylate Generic PA; SP
irinotecan hcl Generic SP
IXEMPRA KIT Brand SP
JAKAFI ORAL TABLET 10 MG Brand PA; SP; QL
JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG
Brand PA; SP
JEVTANA Brand PA; SP
KANJINTI Brand PA; SP
KYPROLIS Brand PA; SP
lapatinib ditosylate Generic PA; SP
letrozole oral Generic
leucovorin calcium injection Generic
leucovorin calcium oral Generic
LEUKERAN Brand
levoleucovorin calcium Generic SP
levoleucovorin calcium pf Generic SP
LYNPARZA Brand PA; SP
LYSODREN Brand
MATULANE Brand SP
MEKINIST Brand PA; SP
12PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
melphalan Generic SP
melphalan hcl Generic SP
mercaptopurine oral Generic
mesna Generic SP
mitomycin intravenous Generic SP
mitoxantrone hcl Generic PA; SP
mutamycin Generic SP
MVASI Brand PA; SP
MYLERAN Brand
NEXAVAR Brand PA; SP
nilutamide Generic SP
ONCASPAR Brand SP
oxaliplatin Generic SP
paclitaxel Generic SP
paraplatin Generic SP
PERJETA Brand PA; SP
PHESGO Brand PA; SP
PROLEUKIN Brand SP
REVLIMID Brand PA; SP
RUBRACA Brand PA; SP
RUXIENCE Brand PA; SP
SPRYCEL Brand PA; SP
sunitinib malate Generic PA; SP
TABLOID Brand SP
TAFINLAR Brand PA; SP
tamoxifen citrate oral Generic
TEMODAR INTRAVENOUS Brand SP
temozolomide Generic PA; SP
THALOMID Brand PA; SP
thiotepa injection Generic SP
toposar Generic SP
topotecan hcl Generic SP
toremifene citrate Generic
TRAZIMERA Brand PA; SP
tretinoin oral Generic SP
valrubicin Generic SP
VELCADE Brand PA; SP
vinblastine sulfate Generic SP
vincristine sulfate Generic SP
vinorelbine tartrate Generic SP
XOFIGO Brand
YERVOY Brand PA; SP
ZALTRAP Brand PA; SP
Drug nameDrug tier Notes
ZANOSAR Brand SP
ZEJULA Brand PA; SP
ZIRABEV Brand PA; SP
ZOLINZA Brand PA; SP
Antiparasitics
albendazole oral Generic PA
ALINIA ORAL SUSPENSION RECONSTITUTED
Brand
atovaquone Generic
atovaquone-proguanil hcl Generic
chloroquine phosphate oral Generic
crotan Generic
EMVERM Brand
hydroxychloroquine sulfate oral Generic
ivermectin external lotion Generic
ivermectin oral Generic PA; QL
lindane Generic
malathion Generic
mefloquine hcl Generic
nitazoxanide oral Generic
pentamidine isethionate Generic
permethrin external Generic
praziquantel oral Generic
primaquine phosphate Generic
pyrimethamine oral Generic PA; SP
quinine sulfate oral Generic PA
spinosad Generic
sulfurated lime Generic
Antiparkinson agents
amantadine hcl oral Generic
benztropine mesylate Generic
bromocriptine mesylate oral Generic
carbidopa oral Generic
carbidopa-levodopa Generic
carbidopa-levodopa er Generic
carbidopa-levodopa-entacapone Generic
entacapone Generic
pramipexole dihydrochloride Generic
pramipexole dihydrochloride er Generic
rasagiline mesylate oral Generic
ropinirole hcl Generic
ropinirole hcl er Generic
selegiline hcl oral Generic
tolcapone Generic
13PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
trihexyphenidyl hcl Generic
Antiplatelets
aspirin-dipyridamole er Generic
BRILINTA Brand
cilostazol Generic
clopidogrel bisulfate oral Generic
dipyridamole oral Generic
eptifibatide Generic
prasugrel hcl Generic
Antipsychotics - drugs for mood disorders
aripiprazole Generic QL
asenapine maleate Generic QL
chlorpromazine hcl injection Generic
chlorpromazine hcl oral Generic
clozapine Generic QL
fluphenazine decanoate injection Generic
fluphenazine hcl Generic
haloperidol decanoate intramuscular Generic
haloperidol lactate Generic
haloperidol oral Generic
loxapine succinate Generic
molindone hcl Generic
olanzapine intramuscular Generic
olanzapine oral Generic QL
paliperidone er Generic QL
pimozide Generic
quetiapine fumarate Generic QL
quetiapine fumarate er Generic QL
risperidone Generic QL
thioridazine hcl oral Generic
thiothixene Generic
trifluoperazine hcl Generic
ziprasidone hcl Generic QL
ziprasidone mesylate Generic
Antivirals
abacavir sulfate Generic
abacavir sulfate-lamivudine Generic
abacavir-lamivudine-zidovudine Generic
acyclovir external Generic
acyclovir oral Generic
acyclovir sodium Generic
adefovir dipivoxil Generic
APTIVUS Brand
Drug nameDrug tier Notes
atazanavir sulfate Generic
cidofovir intravenous Generic
CIMDUO Brand
COMPLERA Brand
CRIXIVAN Brand
DOVATO Brand
EDURANT Brand
efavirenz Generic
efavirenz-emtricitab-tenofovir Generic
efavirenz-lamivudine-tenofovir Generic
emtricitabine Generic
emtricitabine-tenofovir df Generic
EMTRIVA ORAL SOLUTION Brand
entecavir Generic QL
EPCLUSA Brand PA; SP; QL
EPIVIR HBV ORAL SOLUTION Brand
etravirine Generic
EVOTAZ Brand
famciclovir oral Generic
fosamprenavir calcium Generic
foscarnet sodium Generic
FUZEON Brand
ganciclovir sodium Generic
HARVONI Brand PA; SP; QL
INTELENCE ORAL TABLET 25 MG Brand
INVIRASE Brand
ISENTRESS Brand
ISENTRESS HD Brand
JULUCA Brand
lamivudine Generic
lamivudine-zidovudine Generic
LEXIVA ORAL SUSPENSION Brand
lopinavir-ritonavir Generic
MAVYRET Brand PA; SP; QL
nevirapine Generic
nevirapine er Generic
NORVIR ORAL PACKET Brand
NORVIR ORAL SOLUTION Brand
oseltamivir phosphate oral Generic QL
PEGASYS Brand PA
PREZCOBIX Brand
PREZISTA Brand
RETROVIR INTRAVENOUS Brand
14PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
REYATAZ ORAL PACKET Brand
ribavirin inhalation Generic
ribavirin oral Generic SP
rimantadine hcl Generic
ritonavir Generic
RUKOBIA Brand
SELZENTRY Brand PA
stavudine Generic
SYMFI Brand
SYMFI LO Brand
tenofovir disoproxil fumarate Generic
TIVICAY Brand
TIVICAY PD Brand
TRIUMEQ Brand
TYBOST Brand
valacyclovir hcl oral Generic QL
valganciclovir hcl Generic
VIRACEPT Brand
VIREAD ORAL POWDER Brand
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
Brand
VOSEVI Brand PA; SP; QL
zidovudine Generic
Anxiolytics - drugs for anxiety
alprazolam er Generic QL
alprazolam intensol Generic QL
alprazolam oral Generic QL
alprazolam xr Generic QL
buspirone hcl oral Generic
chlordiazepoxide hcl Generic QL
clonazepam oral Generic QL
clorazepate dipotassium Generic QL
diazepam injection Generic
diazepam intensol Generic
diazepam intramuscular Generic
diazepam oral Generic
estazolam Generic QL
hydroxyzine hcl intramuscular Generic
hydroxyzine hcl oral Generic
hydroxyzine pamoate oral Generic
lorazepam injection Generic
lorazepam intensol Generic QL
lorazepam oral concentrate 2 mg/ml Generic QL
lorazepam oral tablet Generic QL
Drug nameDrug tier Notes
meprobamate Generic
oxazepam Generic QL
quazepam Generic QL
triazolam Generic QL
Bipolar agents - drugs for mood disorders
lithium carbonate er Generic
lithium carbonate oral Generic
Blood products and modifiers - drugs for blood disorders
ADVATE Brand SP
ALPHANATE Brand SP
ALPHANINE SD Brand SP
aminocaproic acid intravenous Generic
aminocaproic acid oral Generic
anagrelide hcl Generic
ARANESP (ALBUMIN FREE) Brand PA; SP
BENEFIX Brand SP
CORIFACT Brand SP
FEIBA Brand SP
FIBRYGA Brand SP
hetastarch-nacl Generic
HUMATE-P Brand SP
KOATE Brand SP
KOATE-DVI Brand SP
KOGENATE FS Brand SP
KOVALTRY Brand SP
MONONINE Brand SP
MOZOBIL Brand PA; SP; QL
MULPLETA Brand PA; SP
NIVESTYM Brand PA; SP
NOVOEIGHT Brand SP
NOVOSEVEN RT Brand SP
NUWIQ Brand SP
PROFILNINE Brand SP
protamine sulfate intravenous Generic
RECOMBINATE Brand SP
RETACRIT Brand PA; SP
RIASTAP Brand SP
tranexamic acid intravenous Generic
tranexamic acid oral Generic
WILATE Brand SP
XYNTHA Brand SP
XYNTHA SOLOFUSE Brand SP
ZARXIO Brand PA; SP
15PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
Cardiovascular agents - drugs for heart and circulation conditions
acebutolol hcl oral Generic
acetazolamide sodium Generic
adenosine intravenous solution 12 mg/4ml, 6 mg/2ml
Generic
aliskiren fumarate Generic
alprostadil injection Generic
amiloride hcl oral Generic
amiloride-hydrochlorothiazide Generic
amiodarone hcl Generic
amlodipine besylate oral Generic
amlodipine besylate-benazepril hcl Generic
amlodipine besylate-valsartan Generic
amlodipine-atorvastatin Generic
amlodipine-olmesartan Generic
amlodipine-valsartan-hctz Generic
atenolol oral Generic
atenolol-chlorthalidone Generic
atorvastatin calcium oral Generic
benazepril hcl oral Generic
benazepril-hydrochlorothiazide Generic
betaxolol hcl oral Generic
bisoprolol fumarate oral Generic
bisoprolol-hydrochlorothiazide Generic
bumetanide Generic
candesartan cilexetil Generic
candesartan cilexetil-hctz Generic
captopril oral Generic
cartia xt Generic
carvedilol Generic
carvedilol phosphate er Generic
chlorothiazide sodium Generic
chlorthalidone Generic
cholestyramine light Generic
cholestyramine oral Generic
clonidine Generic
clonidine hcl oral Generic
colesevelam hcl Generic
colestipol hcl Generic
digitek Generic
digox Generic
digoxin injection Generic
digoxin oral Generic
Drug nameDrug tier Notes
diltiazem hcl er Generic
diltiazem hcl er beads Generic
diltiazem hcl er coated beads Generic
diltiazem hcl intravenous Generic
diltiazem hcl oral Generic
dilt-xr Generic
disopyramide phosphate Generic
dobutamine hcl Generic
dobutamine in d5w Generic
dofetilide Generic
dopamine hcl intravenous Generic
dopamine in d5w Generic
doxazosin mesylate oral Generic
droxidopa Generic PA; SP
enalapril maleate oral Generic
enalaprilat Generic
enalapril-hydrochlorothiazide Generic
ENTRESTO Brand QL
ephedrine sulfate intravenous solution 50 mg/ml
Generic
epinephrine intravenous solution prefilled syringe 1 mg/10ml
Generic
epinephrine pf Generic
eplerenone Generic
esmolol hcl intravenous solution 100 mg/10ml
Generic
esmolol hcl-sodium chloride Generic
ethacrynate sodium Generic
ethacrynic acid Generic
ezetimibe Generic
ezetimibe-simvastatin Generic
felodipine er Generic
fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg
Generic
fenofibrate oral Generic
fenofibric acid Generic
flecainide acetate Generic
fluvastatin sodium Generic
fluvastatin sodium er Generic
fosinopril sodium Generic
fosinopril sodium-hctz Generic
furosemide injection Generic
furosemide oral Generic
16PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
gemfibrozil oral Generic
guanfacine hcl Generic
hydralazine hcl injection Generic
hydralazine hcl oral Generic
hydrochlorothiazide oral Generic
ibutilide fumarate Generic
icosapent ethyl Generic
indapamide Generic
irbesartan Generic
irbesartan-hydrochlorothiazide Generic
isosorbide dinitrate Generic
isosorbide mononitrate Generic
isosorbide mononitrate er Generic
isradipine Generic
labetalol hcl intravenous solution Generic
labetalol hcl oral Generic
LANOXIN ORAL Brand
lisinopril oral Generic
lisinopril-hydrochlorothiazide Generic
losartan potassium oral Generic
losartan potassium-hctz Generic
lovastatin oral Generic
mannitol intravenous Generic
matzim la Generic
methyldopa Generic
metolazone Generic
metoprolol succinate er Generic
metoprolol tartrate intravenous Generic
metoprolol tartrate oral Generic
metoprolol-hydrochlorothiazide Generic
metyrosine Generic
mexiletine hcl oral Generic
midodrine hcl Generic
milrinone lactate Generic
milrinone lactate in dextrose Generic
minoxidil oral Generic
moexipril hcl Generic
nadolol oral Generic
nebivolol hcl Generic
NEXLETOL Brand QL
NEXLIZET Brand QL
niacin (antihyperlipidemic) Generic
niacin er (antihyperlipidemic) Generic
Drug nameDrug tier Notes
niacor Generic
nicardipine hcl Generic
nifedipine er Generic
nifedipine er osmotic release Generic
nifedipine oral Generic
nimodipine oral Generic
nisoldipine er Generic
nitroglycerin Generic
nitroglycerin in d5w Generic
nitroprusside sodium Generic
norepinephrine bitartrate intravenous
Generic
NORPACE CR Brand
olmesartan medoxomil oral Generic
olmesartan medoxomil-hctz Generic
olmesartan-amlodipine-hctz Generic
omega-3-acid ethyl esters Generic
pentoxifylline er Generic
perindopril erbumine Generic
phenoxybenzamine hcl oral Generic
phentolamine mesylate injection Generic
phenylephrine hcl intravenous solution 10 mg/ml
Generic
pindolol Generic
pravastatin sodium Generic
prazosin hcl oral Generic
prevalite Generic
procainamide hcl injection Generic
propafenone hcl Generic
propafenone hcl er Generic
propranolol hcl er Generic
propranolol hcl intravenous Generic
propranolol hcl oral Generic
quinapril hcl Generic
quinapril-hydrochlorothiazide Generic
quinidine gluconate er Generic
quinidine sulfate Generic
ramipril Generic
ranolazine er Generic
REPATHA Brand QL
REPATHA PUSHTRONEX SYSTEM Brand QL
REPATHA SURECLICK Brand QL
rosuvastatin calcium Generic
simvastatin oral Generic
17PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
sodium nitroprusside Generic
sorine Generic
sotalol hcl (af) Generic
sotalol hcl oral Generic
spironolactone oral Generic
spironolactone-hctz Generic
taztia xt Generic
TEKTURNA Brand
TEKTURNA HCT Brand
telmisartan Generic
telmisartan-amlodipine Generic
telmisartan-hctz Generic
tiadylt er Generic
timolol maleate oral Generic
torsemide Generic
trandolapril Generic
trandolapril-verapamil hcl er Generic
triamterene oral Generic
triamterene-hctz Generic
valsartan Generic
valsartan-hydrochlorothiazide Generic
VASCEPA Brand
verapamil hcl er Generic
verapamil hcl intravenous Generic
verapamil hcl oral Generic
Central nervous system agents - drugs for attention deficit disorder
amphetamine sulfate Generic QL
amphetamine-dextroamphetamine Generic QL
amphetamine-dextroamphetamine er
Generic QL
atomoxetine hcl Generic QL
clonidine hcl er Generic
dexmethylphenidate hcl Generic QL
dexmethylphenidate hcl er Generic QL
dextroamphetamine sulfate Generic QL
dextroamphetamine sulfate er Generic QL
guanfacine hcl er Generic
methamphetamine hcl Generic QL
methylphenidate hcl er Generic QL
methylphenidate hcl er (cd) Generic QL
methylphenidate hcl er (la) Generic QL
methylphenidate hcl er (xr) Generic QL
methylphenidate hcl oral Generic QL
Drug nameDrug tier Notes
relexxii Generic QL
VYVANSE Brand ST; QL
Central nervous system agents - drugs for multiple sclerosis
AVONEX PEN Brand PA; SP; QL
AVONEX PREFILLED Brand PA; SP; QL
BAFIERTAM Brand PA; SP; QL
BETASERON Brand PA; SP; QL
COPAXONE Brand PA; SP; QL
dalfampridine er Generic PA; SP; QL
dimethyl fumarate oral Generic PA; SP; QL
dimethyl fumarate starter pack Generic PA; SP; QL
glatiramer acetate Generic PA; SP; QL
glatopa Generic PA; SP; QL
KESIMPTA Brand PA; SP; QL
VUMERITY Brand PA; SP; QL
Central nervous system agents - miscellaneous
atracurium besylate Generic
caffeine citrate Generic
cisatracurium besylate Generic
cisatracurium besylate (pf) Generic
pancuronium bromide Generic
pregabalin Generic QL
pregabalin er Generic QL
riluzole Generic PA; QL
rocuronium bromide intravenous solution
Generic
succinylcholine chloride injection solution
Generic
tetrabenazine Generic PA; SP
vecuronium bromide intravenous solution reconstituted
Generic
Dental and oral agents - drugs for mouth and throat conditions
cevimeline hcl Generic
chlorhexidine gluconate mouth/throat
Generic
KEPIVANCE Brand SP
lidocaine viscous hcl Generic
oralone Generic
periogard Generic
pilocarpine hcl oral Generic
sodium fluoride 5000 enamel Generic
sodium fluoride 5000 sensitive Generic
18PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
triamcinolone acetonide mouth/throat
Generic
Dermatological agents - drugs for skin conditions
accutane Generic PA
acitretin Generic
ACZONE EXTERNAL GEL 7.5 % Brand
adapalene external cream Generic PA
adapalene external gel Generic PA
adapalene-benzoyl peroxide external gel
Generic
ala-cort Generic
alclometasone dipropionate Generic
amcinonide Generic
ammonium lactate external Generic
amnesteem Generic PA
azelaic acid external Generic
balsam peru-castor oil Generic
benzoyl peroxide-erythromycin Generic
beser external lotion Generic
betamethasone dipropionate aug Generic
betamethasone dipropionate external
Generic
betamethasone valerate external Generic
calcipotriene external cream Generic
calcipotriene external ointment Generic
calcipotriene external solution Generic
calcipotriene-betameth diprop Generic QL
calcitriol external Generic
claravis Generic PA
clindacin etz external swab Generic
clindacin-p Generic
clindamycin phosphate-benzoyl peroxide
Generic
clindamycin phosphate external Generic
clindamycin-tretinoin Generic
clobetasol prop emollient base Generic
clobetasol propionate e Generic
clobetasol propionate emulsion Generic
clobetasol propionate external Generic
clocortolone pivalate Generic
clodan external shampoo Generic
coal tar external Generic
dapsone external gel 5 % Generic
desonide external Generic
Drug nameDrug tier Notes
desoximetasone external Generic
desrx Generic
diclofenac sodium external gel 3 % Generic QL
diflorasone diacetate Generic
doxepin hcl external Generic
doxycycline Generic
DUPIXENT Brand PA; SP; QL
ery Generic
erythromycin external Generic
EUCRISA Brand
fluocinolone acetonide body Generic
fluocinolone acetonide external Generic
fluocinolone acetonide scalp Generic
fluocinonide emulsified base Generic
fluocinonide external Generic
FLUOROURACIL EXTERNAL CREAM 0.5 %
Brand
fluorouracil external cream 5 % Generic
fluorouracil external solution Generic
flurandrenolide Generic
fluticasone propionate external Generic
halcinonide Generic
halobetasol propionate external cream
Generic
halobetasol propionate external ointment
Generic
hydrocortisone butyr lipo base Generic
hydrocortisone butyrate Generic
hydrocortisone external cream 1 %, 2.5 %
Generic
hydrocortisone external lotion 2.5 %
Generic
hydrocortisone external ointment 1 %, 2.5 %
Generic
hydrocortisone valerate Generic
imiquimod external Generic
isotretinoin oral Generic PA
ivermectin external cream Generic
lactic acid e Generic
lactic acid external Generic
methoxsalen rapid Generic
metronidazole external Generic
mometasone furoate external Generic
myorisan Generic PA
neuac external gel Generic
19PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
nolix Generic
pimecrolimus Generic ST
podofilox external Generic
prednicarbate Generic
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
Brand PA
rosadan external cream Generic
rosadan external gel Generic
selenium sulfide external lotion Generic
sulfacetamide sodium (acne) Generic
tacrolimus external Generic
tazarotene external cream Generic PA
tovet external foam Generic
tretinoin external Generic PA
tretinoin microsphere Generic PA
tretinoin microsphere pump Generic PA
triamcinolone acetonide external aerosol solution
Generic
triamcinolone acetonide external cream
Generic
triamcinolone acetonide external lotion
Generic
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %
Generic
triderm Generic
zenatane Generic PA
Diabetes - antidiabetic agents
acarbose oral Generic
BYDUREON BCISE AUTOINJECTOR Brand QL
BYETTA 10 MCG PEN Brand QL
BYETTA 5 MCG PEN Brand QL
FARXIGA Brand
glimepiride Generic
glipizide er Generic
glipizide ir Generic
glipizide xl Generic
glipizide-metformin hcl Generic
glyburide micronized Generic
glyburide oral Generic
glyburide-metformin Generic
GLYXAMBI Brand
JANUMET Brand
JANUMET XR Brand
JANUVIA Brand
Drug nameDrug tier Notes
JARDIANCE Brand
JENTADUETO Brand
JENTADUETO XR Brand
metformin hcl er Generic
metformin hcl ir Generic
miglitol Generic
nateglinide Generic
OZEMPIC Brand QL
pioglitazone hcl Generic
pioglitazone hcl-glimepiride Generic
pioglitazone hcl-metformin hcl Generic
repaglinide Generic
RYBELSUS Brand QL
SOLIQUA Brand QL
STEGLATRO Brand
SYNJARDY Brand
SYNJARDY XR Brand
TRADJENTA Brand
TRIJARDY XR Brand
TRULICITY Brand QL
VICTOZA Brand QL
XIGDUO XR Brand
Diabetes - glucose monitoring
ACCU-CHEK FASTCLIX LANCET KIT Brand
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
Brand
DEXCOM G4 PLAT PED RCV/SHARE Brand
DEXCOM G4 PLAT PED RECEIVER Brand
DEXCOM G4 PLATINUM RCV/SHARE
Brand
DEXCOM G4 PLATINUM RECEIVER Brand
DEXCOM G4 PLATINUM TRANSMITTER
Brand
DEXCOM G4 SENSOR Brand
DEXCOM G5 MOB/G4 PLAT SENSOR Brand
DEXCOM G5 MOBILE RECEIVER Brand
DEXCOM G5 MOBILE TRANSMITTER Brand
DEXCOM G5 RECEIVER KIT Brand
DEXCOM G6 RECEIVER Brand
DEXCOM G6 SENSOR Brand
DEXCOM G6 TRANSMITTER Brand
LANCETS Brand
ONETOUCH ULTRA TEST STRIPS Brand QL
ONETOUCH ULTRA 2 KIT W/DEVICE Brand
20PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
ONETOUCH ULTRA MINI KIT W/DEVICE
Brand
ONETOUCH VERIO KIT W/DEVICE Brand
ONETOUCH VERIO FLEX SYSTEM Brand
ONETOUCH VERIO TEST STRIPS Brand QL
ONETOUCH VERIO IQ SYSTEM Brand
ONETOUCH VERIO REFLECT Brand
ONETOUCH VERIO SYNC SYSTEM Brand
RELION PREMIER CLASSIC Brand
RELION PREMIER TEST Brand QL
TRUE METRIX BLOOD GLUCOSE TEST
Brand QL
V-GO 20 Brand
V-GO 30 Brand
V-GO 40 Brand
Diabetes - glycemic agents
BAQSIMI ONE PACK Brand
BAQSIMI TWO PACK Brand
diazoxide oral Generic
glucagon emergency kit Generic
GLUCAGON EMERGENCY KIT Brand
GVOKE HYPOPEN 1-PACK Brand
GVOKE HYPOPEN 2-PACK Brand
GVOKE PFS Brand
ZEGALOGUE Brand
Diabetes - insulins
BD AUTOSHIELD DUO PEN NEEDLES Brand
BD ULTRA-FINE INSULIN SYRINGES Brand
BD ULTRA-FINE PEN NEEDLES Brand
DROPLET MICRON Brand
HUMALOG Brand
HUMALOG KWIKPEN Brand
HUMALOG MIX 50/50 KWIKPEN Brand
HUMALOG MIX 50/50 VIAL Brand
HUMALOG MIX 75/25 KWIKPEN Brand
HUMALOG MIX 75/25 VIAL Brand
HUMALOG U-100 JUNIOR KWIKPEN Brand
HUMULIN 70/30 KWIKPEN Brand
HUMULIN 70/30 VIAL Brand
HUMULIN N KWIKPEN Brand
HUMULIN N VIAL Brand
HUMULIN R U-500 KWIKPEN Brand
HUMULIN R U-500 VIAL Brand
HUMULIN R VIAL Brand
Drug nameDrug tier Notes
INSULIN PEN NEEDLES Brand
INSULIN SYRINGES Brand
LANTUS SOLOSTAR Brand
LANTUS U-100 VIAL Brand
LYUMJEV KWIKPEN Brand
LYUMJEV VIAL Brand
NOVOFINE AUTOCOVER PEN NEEDLE
Brand
NOVOFINE PEN NEEDLE Brand
NOVOFINE PLUS PEN NEEDLE Brand
NOVOLIN 70/30 FLEXPEN RELION Brand
NOVOLIN 70/30 RELION Brand
NOVOLIN N RELION Brand
NOVOLIN R RELION Brand
NOVOTWIST PEN NEEDLE Brand
TOUJEO MAX SOLOSTAR Brand
TOUJEO SOLOSTAR Brand
ULTIGUARD SAFEPACK SYR/NEEDLE Brand
Electrolytes / minerals / metals / vitamins
argyle sterile saline Generic
argyle sterile water Generic
calcium chloride Generic
calcium gluconate intravenous Generic
CARBAGLU Brand SP
chromic chloride intravenous Generic
curity sterile saline Generic
cyanocobalamin injection solution 1000 mcg/ml
Generic
deferasirox Generic PA
deferasirox granules Generic PA
deferiprone Generic PA
dextrose intravenous Generic
effer-k oral tablet effervescent 25 meq
Generic
ergocalciferol oral capsule Generic
ferumoxytol Generic
folic acid injection Generic
folic acid oral tablet 1 mg Generic
hematinic/folic acid Generic
hemocyte-f Generic
hydroxocobalamin acetate Generic
iodine strong oral Generic
klor-con Generic
klor-con 10 Generic
21PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
klor-con m10 Generic
klor-con m15 Generic
klor-con m20 Generic
klor-con/ef Generic
k-prime Generic
lactated ringers irrigation Generic
levocarnitine oral solution Generic
levocarnitine oral tablet Generic
levocarnitine sf Generic
magnesium chloride injection Generic
magnesium sulfate in d5w Generic
magnesium sulfate injection Generic
magnesium sulfate intravenous Generic
monoject flush syringe Generic
monoject sodium chloride flush Generic
na ferric gluc cplx in sucrose Generic
normal saline flush Generic
phosphorous Generic
phospho-trin 250 neutral Generic
phytonadione injection Generic
phytonadione oral Generic
potassium acetate intravenous Generic
potassium chloride crys er Generic
potassium chloride er Generic
potassium chloride intravenous Generic
potassium chloride oral Generic
potassium citrate er Generic
potassium phosphates(71 meq k) Generic
pyridoxine hcl injection Generic
ringers irrigation Generic
saline bacteriostatic Generic
sod citrate-citric acid Generic
sodium acetate intravenous Generic
sodium bicarbonate intravenous Generic
sodium chloride (pf) Generic
sodium chloride bacteriostatic Generic
sodium chloride flush Generic
sodium chloride injection Generic
sodium chloride intravenous Generic
sodium chloride irrigation Generic
sodium polystyrene sulfonate Generic
sps Generic
sterile water for irrigation Generic
Drug nameDrug tier Notes
thiamine hcl injection Generic
tis-u-sol Generic
tolvaptan oral tablet 30 mg Generic PA; SP; QL
trientine hcl Generic PA; SP
virt-phos 250 neutral Generic
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
Generic
vitamin k1 injection Generic
water for irrigation, sterile Generic
Gastrointestinal agents - drugs for acid reflux and ulcer
cimetidine hcl Generic
cimetidine oral Generic
CYTOTEC Brand
famotidine intravenous Generic
famotidine oral suspension reconstituted
Generic
famotidine oral tablet 20 mg, 40 mg Generic
famotidine premixed Generic
misoprostol oral Generic
nizatidine Generic
sucralfate oral Generic
Gastrointestinal agents - drugs for bowel, intestine and stomach conditions
alosetron hcl Generic PA
alvimopan Generic
amoxicill-clarithro-lansopraz Generic
atropine sulfate injection solution 8 mg/20ml
Generic
atropine sulfate injection solution prefilled syringe
Generic
atropine sulfate intravenous solution Generic
cascara sagrada oral fluid extract Generic
chlordiazepoxide-clidinium Generic
constulose Generic
cromolyn sodium oral Generic
dicyclomine hcl intramuscular Generic
dicyclomine hcl oral Generic
diphenoxylate-atropine Generic
enulose Generic
gavilyte-c Generic
gavilyte-g Generic
gavilyte-n with flavor pack Generic
generlac Generic
glycopyrrolate injection solution Generic
22PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
glycopyrrolate oral Generic
glycopyrrolate pf Generic
hyoscyamine sulfate oral Generic
hyoscyamine sulfate sl Generic
hyoscyamine sulfate sublingual Generic
hyosyne Generic
lactulose Generic
lactulose encephalopathy Generic
LINZESS Brand QL
loperamide hcl oral capsule Generic
methscopolamine bromide oral Generic
mineral oil heavy oral Generic
OMECLAMOX-PAK Brand
peg 3350-kcl-na bicarb-nacl Generic
peg-3350/electrolytes Generic
peg-3350/electrolytes/ascorbat Generic
peg-kcl-nacl-nasulf-na asc-c Generic
peg-prep Generic
PYLERA Brand
sodium bicarbonate oral powder Generic
SYMPROIC Brand QL
ursodiol oral capsule 300 mg Generic
ursodiol oral tablet Generic
Genetic or enzyme disorder - drugs for replacement, modification, treatment
ALDURAZYME Brand PA; SP
CREON Brand
ELAPRASE Brand PA; SP
FABRAZYME Brand PA; SP
LUMIZYME Brand PA; SP
miglustat Generic PA; SP
NAGLAZYME Brand PA; SP
nitisinone Generic PA; SP
sapropterin dihydrochloride Generic PA; SP
sod benz-sod phenylacet Generic
sodium phenylbutyrate oral Generic SP
STRENSIQ Brand PA; SP
ZENPEP Brand
Genitourinary agents - drugs for bladder, genital and kidney conditions
acetic acid irrigation Generic
bethanechol chloride oral Generic
calcium acetate (phos binder) Generic
calcium acetate oral tablet 667 mg Generic
Drug nameDrug tier Notes
darifenacin hydrobromide er Generic
DEPEN TITRATABS Brand SP
flavoxate hcl Generic
glycine irrigation Generic
glycine urologic Generic
lanthanum carbonate Generic
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR
Brand
oxybutynin chloride er Generic
oxybutynin chloride oral Generic
penicillamine oral capsule Generic PA; SP
penicillamine oral tablet Generic SP
phenazo oral tablet 200 mg Generic
phenazopyridine hcl oral tablet 100 mg, 200 mg
Generic
sevelamer carbonate Generic
sevelamer hcl Generic
solifenacin succinate Generic
tiopronin oral Generic SP
tolterodine tartrate Generic
tolterodine tartrate er Generic
trospium chloride Generic
trospium chloride er Generic
Genitourinary agents - drugs for prostate conditions
alfuzosin hcl er Generic
dutasteride oral Generic
dutasteride-tamsulosin hcl Generic
finasteride oral tablet 5 mg Generic
silodosin Generic
tamsulosin hcl Generic
terazosin hcl Generic
Hormonal agents - adrenal
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
Generic
dexamethasone intensol Generic
dexamethasone oral Generic
dexamethasone sod phosphate pf Generic
dexamethasone sodium phosphate injection
Generic
fludrocortisone acetate oral Generic
hydrocortisone oral Generic
MEDROL ORAL TABLET 2 MG Brand
methylprednisolone acetate suspension 40 mg/ml injection
Generic
23PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
methylprednisolone acetate suspension 80 mg/ml injection
Generic
methylprednisolone oral Generic
methylprednisolone sodium succ Generic
prednisolone oral solution Generic
prednisolone sodium phosphate oral Generic
prednisone intensol Generic
prednisone oral Generic
triamcinolone acetonide suspension 40 mg/ml injection
Generic
Hormonal agents - men's health
ANDRODERM Brand PA
danazol oral Generic
testosterone cypionate intramuscular
Generic PA
testosterone enanthate intramuscular
Generic PA
testosterone transdermal Generic PA
Hormonal agents - pituitary
ACTHAR Brand PA; SP
cabergoline Generic
desmopressin ace spray refrig Generic
desmopressin acetate injection Generic
desmopressin acetate oral Generic
desmopressin acetate pf Generic
desmopressin acetate spray Generic
INCRELEX Brand PA; SP
leuprolide acetate injection Generic PA; SP
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG
Brand PA; SP
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG
Brand PA; SP
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
Brand PA; SP
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
Brand PA; SP
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG, 7.5 MG
Brand PA; SP
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED)
Brand PA; SP
octreotide acetate Generic PA; SP
OMNITROPE Brand PA; SP
ORILISSA Brand QL
oxytocin injection Generic
SUPPRELIN LA Brand PA; SP; QL
Drug nameDrug tier Notes
SYNAREL Brand
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG
Brand SP; QL
Hormonal agents - selective estrogen receptor modifying agents
raloxifene hcl Generic
Hormonal agents - sex hormones and birth control
afirmelle Generic
altavera Generic
alyacen 1/35 Generic
alyacen 7/7/7 Generic
amabelz Generic
amethia Generic QL
amethyst Generic
apri Generic
aranelle Generic
ashlyna Generic QL
aubra Generic
aubra eq Generic
aurovela 1.5/30 Generic
aurovela 1/20 Generic
aurovela 24 fe Generic
aurovela fe 1.5/30 Generic
aurovela fe 1/20 Generic
aviane Generic
ayuna Generic
azurette Generic
balziva Generic
blisovi 24 fe Generic
blisovi fe 1.5/30 Generic
blisovi fe 1/20 Generic
briellyn Generic
camila Generic
camrese Generic QL
camrese lo Generic QL
caziant Generic
charlotte 24 fe Generic
chateal Generic
chateal eq Generic
CLIMARA PRO Brand
cryselle-28 Generic
cyclafem 1/35 Generic
cyclafem 7/7/7 Generic
cyred Generic
24PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
cyred eq Generic
dasetta 1/35 Generic
dasetta 7/7/7 Generic
daysee Generic QL
deblitane Generic
delyla Generic
desogestrel-ethinyl estradiol Generic
dolishale Generic
dotti Generic
drospiren-eth estrad-levomefol Generic
drospirenone-ethinyl estradiol Generic
DUAVEE Brand
elinest Generic
eluryng Generic
emoquette Generic
ENDOMETRIN Brand
enpresse-28 Generic
enskyce Generic
errin Generic
estarylla Generic
estradiol oral Generic
estradiol transdermal Generic
estradiol vaginal Generic
estradiol valerate intramuscular Generic
estradiol-norethindrone acet Generic
ethynodiol diac-eth estradiol Generic
etonogestrel-ethinyl estradiol Generic
falmina Generic
fayosim Generic QL
femynor Generic
fyavolv Generic
gemmily Generic
hailey 1.5/30 Generic
hailey 24 fe Generic
hailey fe 1.5/30 Generic
hailey fe 1/20 Generic
heather Generic
hydroxyprogesterone caproate intramuscular
Generic PA; SP
iclevia Generic QL
IMVEXXY MAINTENANCE PACK Brand
IMVEXXY STARTER PACK Brand
incassia Generic
introvale Generic QL
Drug nameDrug tier Notes
isibloom Generic
jaimiess Generic QL
jasmiel Generic
jencycla Generic
jinteli Generic
jolessa Generic QL
juleber Generic
junel 1.5/30 Generic
junel 1/20 Generic
junel fe 1.5/30 Generic
junel fe 1/20 Generic
junel fe 24 Generic
kaitlib fe Generic
kalliga Generic
kariva Generic
kelnor 1/35 Generic
kelnor 1/50 Generic
kurvelo Generic
larin 1.5/30 Generic
larin 1/20 Generic
larin 24 fe Generic
larin fe 1.5/30 Generic
larin fe 1/20 Generic
larissia Generic
layolis fe Generic
leena Generic
lessina Generic
levonest Generic
levonorgest-eth est & eth est Generic QL
levonorgest-eth estrad 91-day Generic QL
levonorgestrel-ethinyl estrad Generic
levonorg-eth estrad triphasic Generic
levora 0.15/30 (28) Generic
lillow Generic
lojaimiess Generic QL
loryna Generic
low-ogestrel Generic
lo-zumandimine Generic
lutera Generic
lyleq Generic
lyllana Generic
lyza Generic
MAKENA Brand PA; SP
25PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
marlissa Generic
medroxyprogesterone acetate intramuscular
Generic QL
medroxyprogesterone acetate oral Generic
megestrol acetate oral Generic
MENEST Brand
merzee Generic
mibelas 24 fe Generic
microgestin 1.5/30 Generic
microgestin 1/20 Generic
microgestin 24 fe Generic
microgestin fe 1.5/30 Generic
microgestin fe 1/20 Generic
mili Generic
mimvey Generic
mono-linyah Generic
MYFEMBREE Brand QL
NATAZIA Brand
necon 0.5/35 (28) Generic
nikki Generic
nora-be Generic
norethin ace-eth estrad-fe Generic
norethindrone acetate oral Generic
norethindrone acet-ethinyl est Generic
norethindrone oral Generic
norethindrone-eth estradiol Generic
norethin-eth estradiol-fe Generic
norgestimate-eth estradiol Generic
norgestimate-ethinyl estradiol triphasic
Generic
norlyda Generic
norlyroc Generic
nortrel 0.5/35 (28) Generic
nortrel 1/35 (21) Generic
nortrel 1/35 (28) Generic
nortrel 7/7/7 Generic
nylia 7/7/7 Generic
nymyo Generic
ocella Generic
ORIAHNN Brand QL
orsythia Generic
philith Generic
pimtrea Generic
pirmella 1/35 Generic
Drug nameDrug tier Notes
pirmella 7/7/7 Generic
portia-28 Generic
PREMARIN ORAL Brand
PREMARIN VAGINAL Brand
PREMPHASE Brand
PREMPRO Brand
previfem Generic
progesterone intramuscular Generic
progesterone oral Generic
reclipsen Generic
rivelsa Generic QL
setlakin Generic QL
sharobel Generic
simliya Generic
simpesse Generic QL
sprintec 28 Generic
sronyx Generic
syeda Generic
tarina 24 fe Generic
tarina fe 1/20 Generic
tarina fe 1/20 eq Generic
taysofy Generic
tilia fe Generic
tri femynor Generic
tri-estarylla Generic
tri-legest fe Generic
tri-linyah Generic
tri-lo-estarylla Generic
tri-lo-marzia Generic
tri-lo-mili Generic
tri-lo-sprintec Generic
tri-mili Generic
tri-nymyo Generic
tri-previfem Generic
tri-sprintec Generic
trivora (28) Generic
tri-vylibra Generic
tri-vylibra lo Generic
tulana Generic
tyblume Generic
tydemy Generic
velivet Generic
vestura Generic
26PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
vienva Generic
viorele Generic
volnea Generic
vyfemla Generic
vylibra Generic
wera Generic
wymzya fe Generic
xulane Generic
yuvafem Generic
zafemy Generic
zarah Generic
zovia 1/35 (28) Generic
zovia 1/35e (28) Generic
zumandimine Generic
Hormonal agents - thyroid
euthyrox Generic
levo-t Generic
levothyroxine sodium intravenous Generic
levothyroxine sodium oral tablet Generic
levoxyl Generic
liothyronine sodium intravenous Generic
liothyronine sodium oral Generic
methimazole oral Generic
np thyroid Generic
propylthiouracil oral Generic
unithroid Generic
Immunological agents - drugs for immune system stimulation or suppression
ACTIMMUNE Brand PA; SP
ALFERON N Brand SP
ATGAM Brand
AVSOLA Brand PA; SP
azathioprine oral Generic
azathioprine sodium Generic
CIMZIA Brand PA; SP
CIMZIA PREFILLED KIT Brand PA; SP
CIMZIA STARTER KIT Brand PA; SP
CUVITRU Brand PA; SP
cyclosporine intravenous Generic
cyclosporine modified Generic
cyclosporine oral Generic
CYTOGAM Brand PA; SP
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg
Generic
Drug nameDrug tier Notes
GAMASTAN Brand PA; SP
GAMMAGARD Brand PA; SP
GAMMAKED Brand PA; SP
GAMUNEX-C Brand PA; SP
gengraf Generic
HIZENTRA SUBCUTANEOUS SOLUTION
Brand PA; SP
HUMIRA Brand PA; SP
HUMIRA PEDIATRIC CROHNS START Brand PA; SP
HUMIRA PEN Brand PA; SP
HUMIRA PEN-CD/UC/HS STARTER Brand PA; SP
HUMIRA PEN-PEDIATRIC UC START Brand PA; SP
HUMIRA PEN-PS/UV/ADOL HS START
Brand PA; SP
HUMIRA PEN-PSOR/UVEIT STARTER Brand PA; SP
HYPERRHO S/D Brand SP
icatibant acetate Generic PA; SP; QL
ILARIS Brand PA; SP; QL
INFLECTRA Brand PA; SP
leflunomide oral Generic
methotrexate oral Generic
methotrexate sodium Generic
methotrexate sodium (pf) Generic
MICRHOGAM ULTRA-FILTERED PLUS Brand SP
mycophenolate mofetil hcl Generic
mycophenolate mofetil intravenous Generic
mycophenolate mofetil oral Generic
mycophenolate sodium Generic
OTEZLA Brand PA; SP
RASUVO Brand PA; QL
RHOGAM ULTRA-FILTERED PLUS Brand SP
RHOPHYLAC Brand
RINVOQ Brand PA; SP
sajazir Generic PA; SP; QL
SANDIMMUNE INTRAVENOUS Brand
SANDIMMUNE ORAL SOLUTION Brand
SIMPONI Brand PA; SP
SIMPONI ARIA Brand PA; SP
sirolimus oral Generic
SKYRIZI Brand PA; SP; QL
SKYRIZI (150 MG DOSE) Brand PA; SP; QL
SKYRIZI PEN Brand PA; SP; QL
STELARA INTRAVENOUS Brand PA; SP
STELARA SUBCUTANEOUS Brand PA; SP; QL
27PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
SYNAGIS Brand PA; SP
tacrolimus oral Generic
temsirolimus Generic SP
TICE BCG Brand SP
TREMFYA Brand PA; SP
WINRHO SDF Brand SP
XELJANZ Brand PA; SP
XELJANZ XR Brand PA; SP
Immunological agents - drugs for vaccination
ACTHIB Brand
ADACEL Brand
AFLURIA QUADRIVALENT Brand
BCG VACCINE Brand
BEXSERO Brand
BIOTHRAX Brand
BOOSTRIX Brand
DAPTACEL Brand
DIPHTHERIA-TETANUS TOXOIDS DT Brand
ENGERIX-B Brand
FLUAD QUADRIVALENT Brand
FLUARIX QUADRIVALENT Brand
FLUBLOK QUADRIVALENT Brand
FLUCELVAX QUADRIVALENT Brand
FLULAVAL QUADRIVALENT Brand
FLUMIST QUADRIVALENT Brand
FLUZONE HIGH-DOSE QUADRIVALENT
Brand
FLUZONE QUADRIVALENT Brand
GARDASIL 9 Brand
HAVRIX Brand
HEPLISAV-B Brand
HIBERIX Brand
IMOVAX RABIES Brand
INFANRIX Brand
IPOL Brand
IXIARO Brand
JANSSEN COVID-19 VACCINE Brand
KINRIX Brand
MENACTRA Brand
MENQUADFI Brand
MENVEO Brand
M-M-R II Brand
MODERNA COVID-19 VACCINE Brand
PEDIARIX Brand
Drug nameDrug tier Notes
PEDVAX HIB Brand
PENTACEL Brand
PFIZER COVID-19 VAC-TRIS 5-11Y Brand
PFIZER-BIONT COVID-19 VAC-TRIS Brand
PFIZER-BIONTECH COVID-19 VACC Brand
PNEUMOVAX 23 Brand
PREVNAR 13 Brand
PREVNAR 20 Brand
PROQUAD Brand
QUADRACEL Brand
RABAVERT Brand
RECOMBIVAX HB Brand
ROTARIX Brand
ROTATEQ Brand
SHINGRIX Brand
STAMARIL Brand
TDVAX Brand
TENIVAC Brand
TETANUS-DIPHTHERIA TOXOIDS TD Brand
TICOVAC Brand
TRUMENBA Brand
TWINRIX Brand
TYPHIM VI Brand
VAQTA Brand
VARIVAX Brand
VAXCHORA Brand
VAXELIS Brand
VAXNEUVANCE Brand
YF-VAX Brand
Inflammatory bowel disease agents
balsalazide disodium Generic
budesonide er Generic
budesonide oral Generic
hydrocortisone (perianal) Generic
hydrocortisone ace-pramoxine external cream 1-1 %
Generic
hydrocortisone rectal Generic
mesalamine er oral capsule 0.375 gm
Generic
mesalamine oral Generic
mesalamine rectal Generic
mesalamine-cleanser Generic
PROCTOFOAM HC Brand
procto-med hc Generic
28PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
procto-pak Generic
proctosol hc Generic
proctozone-hc Generic
SFROWASA Brand
sulfasalazine oral Generic
Metabolic bone disease agents - drugs for osteoporosis
alendronate sodium oral solution Generic
alendronate sodium oral tablet 10 mg, 5 mg
Generic
alendronate sodium oral tablet 35 mg, 70 mg
Generic QL
calcitonin (salmon) injection Generic
calcitonin (salmon) nasal Generic QL
ibandronate sodium Generic QL
pamidronate disodium Generic SP
PROLIA Brand PA; SP; QL
risedronate sodium oral tablet 150 mg, 35 mg
Generic QL
risedronate sodium oral tablet 30 mg, 5 mg
Generic
risedronate sodium oral tablet delayed release
Generic QL
TERIPARATIDE (RECOMBINANT) Brand PA; SP
TYMLOS Brand PA; SP
XGEVA Brand PA; SP
zoledronic acid Generic SP
Metabolic bone disease agents - other
calcitriol intravenous Generic
calcitriol oral Generic
cinacalcet hcl Generic PA
doxercalciferol Generic
paricalcitol Generic
Miscellaneous therapeutic agents
acetylcysteine intravenous Generic
AEROCHAMBER MINI CHAMBER Brand
AEROCHAMBER MV Brand
AEROCHAMBER PLUS FLO-VU Brand
AEROCHAMBER PLUS FLOW VU Brand
AEROCHAMBER W/FLOWSIGNAL Brand
bal in oil Generic
BOTOX Brand PA; SP
BREATHE EASE LARGE Brand
BREATHE EASE MEDIUM Brand
BREATHE EASE SMALL Brand
Drug nameDrug tier Notes
CLEVER CHOICE HOLDING CHAMBER
Brand
COMPACT SPACE CHAMBER Brand
COMPACT SPACE CHAMBER/LG MASK
Brand
COMPACT SPACE CHAMBER/MED MASK
Brand
COMPACT SPACE CHAMBER/SM MASK
Brand
deferoxamine mesylate Generic
dexmedetomidine hcl in nacl intravenous solution
Generic
dexmedetomidine hcl intravenous solution 200 mcg/2ml
Generic
diluent for treprostinil Generic
DUROLANE Brand PA; SP
EASIVENT Brand
ergoloid mesylates oral Generic
EUFLEXXA Brand PA; SP
FLEXICHAMBER Brand
FLEXICHAMBER ADULT MASK/SMALL
Brand
FLEXICHAMBER CHILD MASK/LARGE
Brand
FLEXICHAMBER CHILD MASK/SMALL
Brand
flumazenil intravenous Generic
fomepizole Generic
formaldehyde external solution 37 %
Generic
GELSYN-3 Brand PA; SP
glutaraldehyde external Generic
heparin lock flush Generic
heparin sodium lock flush Generic
INSPIREASE RESERVOIR BAGS Brand
methergine Generic QL
methylergonovine maleate injection Generic
methylergonovine maleate oral Generic QL
MICROCHAMBER Brand
OPTICHAMBER DIAMOND Brand
OPTICHAMBER DIAMOND-LG MASK
Brand
OPTICHAMBER DIAMOND-MD MASK
Brand
OPTICHAMBER DIAMOND-SM MASK
Brand
29PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
PANDA MASK LARGE Brand
PANDA MASK MEDIUM Brand
PANDA MASK SMALL Brand
PEDIATRIC PANDA MASK Brand
POCKET SPACER Brand
PRO COMFORT SPACER ADULT Brand
PRO COMFORT SPACER CHILD Brand
PRO COMFORT SPACER INFANT Brand
PROCARE SPACER/ADULT MASK Brand
PROCARE SPACER/CHILD MASK Brand
sodium nitrite intravenous Generic
sodium saccharin powder Generic
sodium thiosulfate intravenous Generic
sorbitol-mannitol Generic
sterile diluent/epoprostenol Generic
sterile water for injection Generic
VORTEX VALVED HOLDING CHAMBER
Brand
XIAFLEX Brand PA; SP
Ophthalmic agents - drugs for eye allergy, infection and inflammation
azelastine hcl ophthalmic Generic
bacitracin ophthalmic Generic
bepotastine besilate Generic
bromfenac sodium (once-daily) Generic QL
ciprofloxacin hcl ophthalmic Generic
cromolyn sodium ophthalmic Generic
dexamethasone sodium phosphate ophthalmic
Generic
diclofenac sodium ophthalmic Generic
difluprednate Generic
epinastine hcl Generic
erythromycin ophthalmic Generic
fluorometholone Generic
flurbiprofen sodium Generic
FML Brand
gatifloxacin ophthalmic Generic
gentak Generic
gentamicin sulfate ophthalmic Generic
ketorolac tromethamine ophthalmic Generic
levofloxacin ophthalmic Generic
loteprednol etabonate ophthalmic gel
Generic QL
Drug nameDrug tier Notes
loteprednol etabonate ophthalmic suspension
Generic
MOXEZA Brand
moxifloxacin hcl (2x day) Generic
moxifloxacin hcl ophthalmic solution Generic
NATACYN Brand
ofloxacin ophthalmic Generic
olopatadine hcl ophthalmic Generic
prednisolone acetate ophthalmic Generic
prednisolone sodium phosphate ophthalmic
Generic
PROLENSA Brand QL
sulfacetamide sodium ophthalmic Generic
tobramycin ophthalmic Generic
trifluridine Generic
Ophthalmic agents - drugs for glaucoma
acetazolamide er Generic
acetazolamide oral Generic
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
Brand
apraclonidine hcl Generic
betaxolol hcl ophthalmic Generic
bimatoprost ophthalmic Generic QL
brimonidine tartrate ophthalmic Generic
brinzolamide Generic
carteolol hcl Generic
COMBIGAN Brand
dorzolamide hcl ophthalmic Generic
dorzolamide hcl-timolol mal Generic
dorzolamide hcl-timolol mal pf Generic
latanoprost ophthalmic Generic
levobunolol hcl Generic
LUMIGAN Brand QL
methazolamide oral Generic
pilocarpine hcl ophthalmic Generic
SIMBRINZA Brand
timolol maleate (once-daily) Generic
timolol maleate ocudose Generic
timolol maleate ophthalmic Generic
timolol maleate pf Generic
travoprost (bak free) Generic QL
Ophthalmic agents - drugs for miscellaneous eye conditions
ak-poly-bac Generic
30PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
altafrin Generic
atropine sulfate ophthalmic ointment
Generic
atropine sulfate ophthalmic solution 1 %
Generic
bacitracin-polymyxin b ophthalmic Generic
bacitra-neomycin-polymyxin-hc Generic
cyclopentolate hcl ophthalmic Generic
homatropaire Generic
LUCENTIS Brand PA; SP
neomycin-bacitracin zn-polymyx Generic
neomycin-polymyxin-dexameth ophthalmic ointment
Generic
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
Generic
neomycin-polymyxin-gramicidin Generic
neomycin-polymyxin-hc ophthalmic Generic
neo-polycin Generic
neo-polycin hc Generic
phenylephrine hcl ophthalmic Generic
polycin Generic
polymyxin b-trimethoprim Generic
proparacaine hcl ophthalmic Generic
RESTASIS Brand PA
RESTASIS MULTIDOSE Brand PA
sulfacetamide-prednisolone ophthalmic solution
Generic
tetracaine hcl ophthalmic Generic
tobramycin-dexamethasone Generic
XIIDRA Brand PA
Otic agents - drugs for ear conditions
acetic acid otic Generic
ciprofloxacin hcl otic Generic
ciprofloxacin-dexamethasone Generic
cortic-nd Generic
flac Generic
fluocinolone acetonide otic Generic
hydrocortisone-acetic acid Generic
neomycin-polymyxin-hc otic Generic
ofloxacin otic Generic
Respiratory tract / pulmonary agents - drugs for allergies, cough, cold
azelastine hcl nasal Generic QL
azelastine-fluticasone Generic QL
Drug nameDrug tier Notes
benzonatate Generic
carbinoxamine maleate Generic
clemastine fumarate oral syrup Generic
clemastine fumarate oral tablet 2.68 mg
Generic
cyproheptadine hcl oral Generic
dexchlorpheniramine maleate oral Generic
di-phen Generic
diphen oral elixir Generic
diphenhydramine hcl injection Generic
diphenhydramine hcl oral elixir Generic
DYMISTA Brand QL
FASENRA Brand PA; SP
FASENRA PEN Brand PA; SP
flunisolide nasal Generic QL
fluticasone propionate nasal Generic
guaiatussin ac Generic PA; QL
guaifenesin ac Generic PA; QL
hydrocodone polst-chlorphen polst er susp
Generic PA; QL
hydrocodone-homatropine Generic PA; QL
hydromet Generic PA; QL
ipratropium bromide nasal Generic
maxi-tuss ac Generic PA; QL
mometasone furoate nasal Generic QL
NUCALA Brand PA; SP; QL
olopatadine hcl nasal Generic QL
promethazine hcl injection Generic
promethazine hcl oral Generic
promethazine hcl rectal Generic
promethazine vc Generic
promethazine vc/codeine Generic PA; QL
promethazine-codeine Generic PA; QL
promethazine-dm Generic
promethazine-phenyleph-codeine Generic PA; QL
promethazine-phenylephrine Generic
promethegan Generic
pseudoephedrine-bromphen-dm Generic
ryvent Generic
sodium chloride inhalation Generic
virtussin ac w/alc Generic PA; QL
XOLAIR Brand PA; SP
Respiratory tract / pulmonary agents - drugs for asthma and other lung conditions
31PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
acetylcysteine inhalation Generic
ADVAIR HFA Brand QL
albuterol sulfate hfa Generic QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml
Generic QL
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml
Generic
albuterol sulfate oral Generic
aminophylline Generic
ANORO ELLIPTA Brand QL
arformoterol tartrate Generic QL
ARNUITY ELLIPTA Brand QL
BREO ELLIPTA Brand QL
BREZTRI AEROSPHERE Brand QL
budesonide inhalation Generic QL
COMBIVENT RESPIMAT Brand QL
cromolyn sodium inhalation Generic
DULERA Brand QL
ELIXOPHYLLIN Brand
epinephrine (anaphylaxis) Generic
epinephrine injection solution auto-injector
Generic
FLOVENT DISKUS Brand QL
FLOVENT HFA Brand QL
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
Generic QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
Generic QL
formoterol fumarate inhalation Generic QL
ipratropium bromide inhalation Generic QL
ipratropium-albuterol Generic QL
isoproterenol hcl injection Generic
levalbuterol hcl inhalation Generic QL
montelukast sodium oral Generic
PULMICORT FLEXHALER Brand QL
SEREVENT DISKUS Brand QL
SPIRIVA HANDIHALER Brand QL
SPIRIVA RESPIMAT Brand QL
STIOLTO RESPIMAT Brand QL
Drug nameDrug tier Notes
STRIVERDI RESPIMAT Brand QL
SYMBICORT Brand QL
terbutaline sulfate injection Generic
terbutaline sulfate oral Generic
theophylline Generic
theophylline er Generic
TRELEGY ELLIPTA Brand QL
TUDORZA PRESSAIR Brand QL
wixela inhub Generic QL
zafirlukast Generic
zileuton er Generic
Respiratory tract / pulmonary agents - drugs for cystic fibrosis
PULMOZYME Brand PA; SP
tobramycin inhalation Generic SP
Respiratory tract / pulmonary agents - drugs for pulmonary hypertension
ADEMPAS Brand PA; SP; QL
alyq Generic PA; SP; QL
ambrisentan Generic PA; SP; QL
bosentan Generic PA; SP; QL
epoprostenol sodium Generic PA; SP
OPSUMIT Brand PA; SP; QL
sildenafil citrate intravenous Generic PA; SP
sildenafil citrate oral suspension reconstituted
Generic PA; SP; QL
sildenafil citrate oral tablet 20 mg Generic PA; SP; QL
tadalafil (pah) Generic PA; SP; QL
treprostinil Generic PA; SP
Skeletal muscle relaxants - drugs for muscle pain and spasm
baclofen oral Generic
carisoprodol oral Generic
chlorzoxazone Generic
cyclobenzaprine hcl er Generic
cyclobenzaprine hcl oral Generic
dantrolene sodium intravenous Generic
dantrolene sodium oral Generic
metaxalone Generic
methocarbamol injection Generic
methocarbamol oral Generic
orphenadrine citrate er Generic
orphenadrine citrate injection Generic
orphenadrine-asa-caffeine Generic
32PA: Prior Authorization QL: Quantity Limit SP: Specialty Medication ST: Step Therapy
Drug nameDrug tier Notes
revonto Generic
tizanidine hcl oral Generic
Sleep disorder agents
armodafinil Generic PA; QL
doxepin hcl oral tablet Generic QL
eszopiclone Generic QL
flurazepam hcl Generic PA; QL
modafinil Generic PA; QL
ramelteon Generic QL
SUNOSI Brand PA; QL
temazepam Generic QL
zaleplon Generic QL
zolpidem tartrate Generic QL
zolpidem tartrate er Generic QL
33
Index
abacavir sulfate-lamivudine ......................13abacavir sulfate ........................................13abacavir-lamivudine-zidovudine ................13abiraterone acetate ..................................11ABRAXANE ..............................................11acamprosate calcium .................................6acarbose oral ...........................................19ACCU-CHEK FASTCLIX LANCET KIT .........19ACCU-CHEK SOFTCLIX LANCET DEVICE KIT ..............................................19accutane ..................................................18acebutolol hcl oral ...................................15acetaminophen intravenous solution ..........5acetaminophen-codeine #2 ........................5acetaminophen-codeine #3 ........................5acetaminophen-codeine #4 ........................5acetaminophen-codeine .............................5acetazolamide er ......................................29acetazolamide oral ...................................29acetazolamide sodium .............................15acetic acid irrigation .................................22acetic acid otic .........................................30acetylcysteine inhalation ..........................31acetylcysteine intravenous ........................28acitretin ...................................................18ACTHAR ..................................................23ACTHIB ....................................................27ACTIMMUNE ...........................................26acyclovir external .....................................13acyclovir oral ............................................13acyclovir sodium ......................................13ACZONE EXTERNAL GEL 7.5 % ................18ADACEL ...................................................27adapalene external cream ........................18adapalene external gel .............................18adapalene-benzoyl peroxide external gel ..18ADCETRIS ................................................11adefovir dipivoxil ......................................13ADEMPAS ................................................31adenosine intravenous solution 12 mg/4ml, 6 mg/2ml ...................................15adriamycin ...............................................11ADVAIR HFA ............................................31ADVATE ...................................................14AEROCHAMBER MINI CHAMBER .............28AEROCHAMBER MV ................................28AEROCHAMBER PLUS FLO-VU .................28AEROCHAMBER PLUS FLOW VU ..............28AEROCHAMBER W/FLOWSIGNAL ............28afirmelle ..................................................23AFLURIA QUADRIVALENT .........................27AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML 10ak-poly-bac ..............................................29ala-cort ....................................................18albendazole oral ......................................12albuterol sulfate hfa .................................31albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml .......31
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml ...........................................31albuterol sulfate oral ................................31alclometasone dipropionate .....................18ALDURAZYME .........................................22ALECENSA ...............................................11alendronate sodium oral solution .............28alendronate sodium oral tablet 10 mg, 5 mg ........................................................28alendronate sodium oral tablet 35 mg, 70 mg ......................................................28alfentanil hcl ..............................................5ALFERON N ..............................................26alfuzosin hcl er .........................................22ALIMTA ....................................................11ALINIA ORAL SUSPENSION RECONSTITUTED ......................................12aliskiren fumarate ....................................15allopurinol oral .........................................10allopurinol sodium ...................................10almotriptan malate ..................................10alosetron hcl ............................................21ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % .....................................29ALPHANATE .............................................14ALPHANINE SD ........................................14alprazolam er ...........................................14alprazolam intensol ..................................14alprazolam oral ........................................14alprazolam xr ...........................................14alprostadil injection ..................................15altafrin .....................................................30altavera ....................................................23ALUNBRIG ...............................................11alvimopan ................................................21alyacen 1/35 ............................................23alyacen 7/7/7 ...........................................23alyq .........................................................31amabelz ...................................................23amantadine hcl oral .................................12ambrisentan .............................................31amcinonide ..............................................18amethia ...................................................23amethyst ..................................................23amikacin sulfate injection ...........................6amiloride hcl oral .....................................15amiloride-hydrochlorothiazide ..................15aminocaproic acid intravenous .................14aminocaproic acid oral .............................14aminophylline ..........................................31amiodarone hcl ........................................15amitriptyline hcl oral ..................................9amlodipine besylate oral ..........................15amlodipine besylate-benazepril hcl ...........15amlodipine besylate-valsartan ..................15amlodipine-atorvastatin ...........................15amlodipine-olmesartan ............................15amlodipine-valsartan-hctz ........................15ammonium lactate external......................18amnesteem ..............................................18amoxapine .................................................9
amoxicill-clarithro-lansopraz .....................21amoxicillin-potassium clavulanate er ...........6amoxicillin-potassium clavulanate ...............6amoxicillin ..................................................6amphetamine sulfate ...............................17amphetamine-dextroamphetamine er ......17amphetamine-dextroamphetamine ..........17amphotericin b intravenous ......................10ampicillin sodium .......................................6ampicillin-sulbactam sodium ......................6ampicillin ...................................................6anagrelide hcl ..........................................14anastrozole oral .......................................11ANDRODERM ..........................................23ANORO ELLIPTA .......................................31apap-caff-dihydrocodeine ..........................5apraclonidine hcl ......................................29aprepitant ..................................................9apri ..........................................................23APTIVUS ..................................................13aranelle ....................................................23ARANESP (ALBUMIN FREE) .......................14arformoterol tartrate ................................31argatroban .................................................8argyle sterile saline ...................................20argyle sterile water ...................................20aripiprazole ..............................................13armodafinil ..............................................32ARNUITY ELLIPTA .....................................31ARRANON ...............................................11arsenic trioxide intravenous ......................11ARZERRA .................................................11ascomp-codeine .........................................5asenapine maleate ...................................13ashlyna ....................................................23aspirin-dipyridamole er .............................13atazanavir sulfate .....................................13atenolol oral ............................................15atenolol-chlorthalidone ............................15ATGAM ...................................................26atomoxetine hcl .......................................17atorvastatin calcium oral ..........................15atovaquone-proguanil hcl ........................12atovaquone .............................................12atracurium besylate ..................................17atropine sulfate injection solution 8 mg/20ml ..................................................21atropine sulfate injection solution prefilled syringe .......................................21atropine sulfate intravenous solution ........21atropine sulfate ophthalmic ointment.......30atropine sulfate ophthalmic solution 1 % .30aubra eq ..................................................23aubra .......................................................23aurovela 1.5/30 ........................................23aurovela 1/20 ...........................................23aurovela 24 fe ..........................................23aurovela fe 1.5/30 ....................................23aurovela fe 1/20 .......................................23aviane ......................................................23avidoxy ......................................................6AVONEX PEN ...........................................17
34
AVONEX PREFILLED ..................................17AVSOLA ...................................................26ayuna ......................................................23azacitidine ...............................................11azathioprine oral ......................................26azathioprine sodium ................................26azelaic acid external .................................18azelastine hcl nasal ..................................30azelastine hcl ophthalmic .........................29azelastine-fluticasone ...............................30azithromycin intravenous ...........................7azithromycin oral .......................................7aztreonam .................................................7azurette ...................................................23bac ............................................................5bacitra-neomycin-polymyxin-hc ................30bacitracin intramuscular .............................7bacitracin ophthalmic ...............................29bacitracin-polymyxin b ophthalmic ...........30baclofen oral ............................................31BAFIERTAM ..............................................17bal in oil ...................................................28balsalazide disodium ................................27balsam peru-castor oil ..............................18balziva .....................................................23BAQSIMI ONE PACK .................................20BAQSIMI TWO PACK ................................20BCG VACCINE .........................................27BD AUTOSHIELD DUO PEN NEEDLES ........20BD ULTRA-FINE INSULIN SYRINGES ...........20BD ULTRA-FINE PEN NEEDLES ...................20BELBUCA ...................................................5benazepril hcl oral ....................................15benazepril-hydrochlorothiazide ................15BENEFIX ...................................................14benzalkonium chloride external solution ....7benzonatate ............................................30benzoyl peroxide-erythromycin.................18benztropine mesylate ...............................12bepotastine besilate .................................29beser external lotion ................................18betamethasone dipropionate aug ............18betamethasone dipropionate external ......18betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml ...........22betamethasone valerate external..............18BETASERON .............................................17betaxolol hcl ophthalmic ..........................29betaxolol hcl oral .....................................15bethanechol chloride oral .........................22bexarotene ..............................................11BEXSERO .................................................27bicalutamide ............................................11bimatoprost ophthalmic ...........................29BIOTHRAX ...............................................27bisoprolol fumarate oral ...........................15bisoprolol-hydrochlorothiazide .................15bivalirudin trifluoroacetate .........................8bleomycin sulfate .....................................11blisovi 24 fe .............................................23blisovi fe 1.5/30 .......................................23blisovi fe 1/20 ..........................................23BOOSTRIX ................................................27bosentan .................................................31BOTOX ....................................................28
BREATHE EASE LARGE .............................28BREATHE EASE MEDIUM ..........................28BREATHE EASE SMALL .............................28BREO ELLIPTA ...........................................31BREZTRI AEROSPHERE ..............................31briellyn .....................................................23BRILINTA ..................................................13brimonidine tartrate ophthalmic ...............29brinzolamide ............................................29bromfenac sodium (once-daily) ................29bromocriptine mesylate oral .....................12budesonide er ..........................................27budesonide inhalation ..............................31budesonide oral .......................................27bumetanide .............................................15bupivacaine fisiopharma ............................6bupivacaine hcl (pf) ....................................6bupivacaine hcl injection solution 0.25 %, 0.5 % ..................................................6bupivacaine-epinephrine (pf) ......................6bupivacaine-epinephrine ............................6buprenorphine hcl injection .......................5buprenorphine hcl sublingual .....................6buprenorphine hcl-naloxone hcl .................6buprenorphine ...........................................5bupropion hcl er (smoking det) ..................6bupropion hcl er (sr) ...................................9bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg 9bupropion hcl oral .....................................9buspirone hcl oral ....................................14busulfan ..................................................11butalbital-acetaminophen ..........................5butalbital-apap-caff-cod .............................5butalbital-apap-caffeine .............................5butalbital-asa-caff-codeine .........................5butalbital-aspirin-caffeine ...........................5butorphanol tartrate injection ....................5butorphanol tartrate nasal .........................5BYDUREON BCISE AUTOINJECTOR ...........19BYETTA 10 MCG PEN ...............................19BYETTA 5 MCG PEN .................................19cabergoline ..............................................23CABOMETYX ...........................................11caffeine citrate .........................................17calcipotriene external cream .....................18calcipotriene external ointment ................18calcipotriene external solution ..................18calcipotriene-betameth diprop .................18calcitonin (salmon) injection .....................28calcitonin (salmon) nasal ..........................28calcitriol external ......................................18calcitriol intravenous ................................28calcitriol oral ............................................28calcium acetate (phos binder) ...................22calcium acetate oral tablet 667 mg ..........22calcium chloride .......................................20calcium gluconate intravenous .................20camila ......................................................23camrese lo ...............................................23camrese ...................................................23candesartan cilexetil-hctz .........................15candesartan cilexetil .................................15capecitabine ............................................11CAPRELSA ORAL TABLET 100 MG ............11
CAPRELSA ORAL TABLET 300 MG ............11captopril oral ...........................................15CARBAGLU ..............................................20carbamazepine er ......................................8carbamazepine oral ....................................8carbidopa oral ..........................................12carbidopa-levodopa er .............................12carbidopa-levodopa-entacapone ..............12carbidopa-levodopa .................................12carbinoxamine maleate ............................30carboplatin ..............................................11carisoprodol oral ......................................31carisoprodol-aspirin-codeine ......................5carmustine ...............................................11carteolol hcl .............................................29cartia xt ...................................................15carvedilol phosphate er ............................15carvedilol .................................................15cascara sagrada oral fluid extract .............21caspofungin acetate .................................10caziant .....................................................23cefaclor er ..................................................7cefaclor ......................................................7cefadroxil ...................................................7cefazolin sodium injection ..........................7cefazolin sodium intravenous solution reconstituted .............................................7cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-% .............................................7cefazolin sodium-dextrose intravenous solution reconstituted ................................7cefdinir ......................................................7cefepime hcl injection ................................7cefepime hcl intravenous solution ..............7cefepime-dextrose .....................................7cefixime .....................................................7cefotaxime sodium .....................................7cefotetan disodium-dextrose ......................7cefotetan disodium ....................................7cefoxitin sodium ........................................7cefpodoxime proxetil .................................7cefprozil .....................................................7ceftazidime and dextrose ...........................7ceftazidime injection ..................................7ceftazidime intravenous .............................7ceftriaxone sodium in dextrose ...................7ceftriaxone sodium injection ......................7ceftriaxone sodium intravenous ..................7ceftriaxone sodium-dextrose ......................7cefuroxime axetil ........................................7cefuroxime sodium ....................................7celecoxib oral .............................................5cephalexin .................................................7cevimeline hcl ..........................................17charlotte 24 fe .........................................23chateal eq ................................................23chateal .....................................................23chloramphenicol sod succinate ...................7chlordiazepoxide hcl ................................14chlordiazepoxide-amitriptyline ....................9chlordiazepoxide-clidinium .......................21chlorhexidine gluconate mouth/throat .....17chloroprocaine hcl (pf) ...............................6chloroquine phosphate oral .....................12
35
chlorothiazide sodium ..............................15chlorpromazine hcl injection ....................13chlorpromazine hcl oral ............................13chlorthalidone ..........................................15chlorzoxazone ..........................................31cholestyramine light .................................15cholestyramine oral ..................................15chromic chloride intravenous ...................20ciclodan ...................................................10ciclopirox external ....................................10ciclopirox olamine external .......................10cidofovir intravenous ................................13cilostazol ..................................................13CIMDUO ..................................................13cimetidine hcl ..........................................21cimetidine oral .........................................21CIMZIA PREFILLED KIT ..............................26CIMZIA STARTER KIT ................................26CIMZIA ....................................................26cinacalcet hcl ...........................................28ciprofloxacin hcl ophthalmic .....................29ciprofloxacin hcl oral ..................................7ciprofloxacin hcl otic ................................30ciprofloxacin in d5w ...................................7ciprofloxacin-dexamethasone ...................30cisatracurium besylate (pf) ........................17cisatracurium besylate ..............................17cisplatin intravenous solution ...................11citalopram hydrobromide ...........................9cladribine .................................................11claravis .....................................................18clarithromycin er ........................................7clarithromycin oral .....................................7clemastine fumarate oral syrup ................30clemastine fumarate oral tablet 2.68 mg ..30CLEVER CHOICE HOLDING CHAMBER .....28CLIMARA PRO .........................................23clindacin etz external swab ......................18clindacin-p ...............................................18clindamycin hcl oral ...................................7clindamycin palmitate hcl ...........................7clindamycin phosphate external ...............18clindamycin phosphate in d5w ...................7clindamycin phosphate injection ................7clindamycin phosphate vaginal ...................7clindamycin phosphate-benzoyl peroxide .18clindamycin-tretinoin ...............................18clobazam ...................................................8clobetasol prop emollient base .................18clobetasol propionate e ............................18clobetasol propionate emulsion ................18clobetasol propionate external .................18clocortolone pivalate ................................18clodan external shampoo .........................18clofarabine ...............................................11clomipramine hcl oral .................................9clonazepam oral ......................................14clonidine hcl er ........................................17clonidine hcl oral ......................................15clonidine ..................................................15clopidogrel bisulfate oral ..........................13clorazepate dipotassium ...........................14clotrimazole external ................................10clotrimazole mouth/throat .......................10clotrimazole-betamethasone ....................10
clozapine .................................................13coal tar external .......................................18codeine sulfate ..........................................5colchicine oral tablet ................................10colchicine-probenecid ..............................10colesevelam hcl ........................................15colestipol hcl ............................................15colistimethate sodium (cba) ........................7COMBIGAN .............................................29COMBIVENT RESPIMAT ............................31COMPACT SPACE CHAMBER/LG MASK ...28COMPACT SPACE CHAMBER/MED MASK 28COMPACT SPACE CHAMBER/SM MASK...28COMPACT SPACE CHAMBER ...................28COMPLERA ..............................................13compro ......................................................9constulose ...............................................21COPAXONE ..............................................17coremino ...................................................7CORIFACT ................................................14cortic-nd ..................................................30CREON ....................................................22CRIXIVAN .................................................13cromolyn sodium inhalation .....................31cromolyn sodium ophthalmic ...................29cromolyn sodium oral ..............................21crotan ......................................................12cryselle-28 ...............................................23curity sterile saline ....................................20CUVITRU ..................................................26cyanocobalamin injection solution 1000 mcg/ml ...........................................20cyclafem 1/35 ..........................................23cyclafem 7/7/7 .........................................23cyclobenzaprine hcl er ..............................31cyclobenzaprine hcl oral ...........................31cyclopentolate hcl ophthalmic ..................30cyclophosphamide injection .....................11cyclophosphamide oral capsule ................11CYCLOPHOSPHAMIDE ORAL TABLET .......11cycloserine oral ........................................10cyclosporine intravenous ..........................26cyclosporine modified ..............................26cyclosporine oral ......................................26cyproheptadine hcl oral ............................30cyred eq ...................................................24cyred .......................................................23cytarabine (pf) ..........................................11cytarabine ................................................11CYTOGAM ..............................................26CYTOTEC .................................................21dacarbazine .............................................11dactinomycin ...........................................11dalfampridine er ......................................17danazol oral .............................................23dantrolene sodium intravenous ................31dantrolene sodium oral ............................31dapsone external gel 5 % ........................18dapsone oral ............................................10DAPTACEL ...............................................27daptomycin ................................................7darifenacin hydrobromide er ....................22dasetta 1/35 ............................................24dasetta 7/7/7 ...........................................24daunorubicin hcl ......................................11
daysee .....................................................24deblitane .................................................24decitabine ................................................11deferasirox granules .................................20deferasirox ...............................................20deferiprone ..............................................20deferoxamine mesylate ............................28delyla .......................................................24demeclocycline hcl .....................................7DEPEN TITRATABS ....................................22desipramine hcl oral ...................................9desmopressin ace spray refrig...................23desmopressin acetate injection .................23desmopressin acetate oral ........................23desmopressin acetate pf ..........................23desmopressin acetate spray ......................23desogestrel-ethinyl estradiol .....................24desonide external ....................................18desoximetasone external ..........................18desrx ........................................................18desvenlafaxine succinate er ........................9dexamethasone intensol ..........................22dexamethasone oral .................................22dexamethasone sod phosphate pf ............22dexamethasone sodium phosphate injection ...................................................22dexamethasone sodium phosphate ophthalmic ..............................................29dexchlorpheniramine maleate oral ...........30DEXCOM G4 PLAT PED RCV/SHARE .........19DEXCOM G4 PLAT PED RECEIVER ............19DEXCOM G4 PLATINUM RCV/SHARE .......19DEXCOM G4 PLATINUM RECEIVER ..........19DEXCOM G4 PLATINUM TRANSMITTER ...19DEXCOM G4 SENSOR ..............................19DEXCOM G5 MOB/G4 PLAT SENSOR .......19DEXCOM G5 MOBILE RECEIVER ...............19DEXCOM G5 MOBILE TRANSMITTER ........19DEXCOM G5 RECEIVER KIT ......................19DEXCOM G6 RECEIVER ............................19DEXCOM G6 SENSOR ..............................19DEXCOM G6 TRANSMITTER .....................19dexmedetomidine hcl in nacl intravenous solution .................................28dexmedetomidine hcl intravenous solution 200 mcg/2ml ..............................28dexmethylphenidate hcl er .......................17dexmethylphenidate hcl ...........................17dexrazoxane hcl .......................................11dextroamphetamine sulfate er..................17dextroamphetamine sulfate......................17dextrose intravenous ................................20di-phen ....................................................30diazepam injection ...................................14diazepam intensol ....................................14diazepam intramuscular ...........................14diazepam oral ..........................................14diazepam rectal .........................................8diazoxide oral ..........................................20diclofenac potassium .................................5diclofenac sodium er ..................................5diclofenac sodium external gel 1 % ...........5diclofenac sodium external gel 3 % .........18diclofenac sodium external solution ...........5diclofenac sodium ophthalmic ..................29
36
diclofenac sodium oral ...............................6diclofenac-misoprostol ...............................6dicloxacillin sodium ....................................7dicyclomine hcl intramuscular ..................21dicyclomine hcl oral .................................21diflorasone diacetate ................................18diflunisal oral .............................................6difluprednate ...........................................29digitek .....................................................15digox .......................................................15digoxin injection ......................................15digoxin oral ..............................................15dihydroergotamine mesylate injection ......10dihydroergotamine mesylate nasal ...........10dilt-xr .......................................................15diltiazem hcl er beads ..............................15diltiazem hcl er coated beads ...................15diltiazem hcl er ........................................15diltiazem hcl intravenous ..........................15diltiazem hcl oral ......................................15diluent for treprostinil ..............................28dimenhydrinate injection ............................9dimethyl fumarate oral .............................17dimethyl fumarate starter pack ................17diphen oral elixir ......................................30diphenhydramine hcl injection .................30diphenhydramine hcl oral elixir .................30diphenoxylate-atropine ............................21DIPHTHERIA-TETANUS TOXOIDS DT .........27dipyridamole oral .....................................13disopyramide phosphate ..........................15disulfiram oral ............................................6divalproex sodium er ..................................8divalproex sodium oral ...............................8dobutamine hcl ........................................15dobutamine in d5w .................................15docetaxel .................................................11dofetilide .................................................15dolishale ..................................................24donepezil hcl .............................................9dopamine hcl intravenous ........................15dopamine in d5w .....................................15dorzolamide hcl ophthalmic .....................29dorzolamide hcl-timolol mal pf .................29dorzolamide hcl-timolol mal .....................29dotti ........................................................24DOVATO ..................................................13doxazosin mesylate oral ...........................15doxepin hcl external .................................18doxepin hcl oral capsule .............................9doxepin hcl oral concentrate ......................9doxepin hcl oral tablet .............................32doxercalciferol ..........................................28doxorubicin hcl liposomal .........................11doxorubicin hcl ........................................11doxy 100 ...................................................7doxycycline hyclate intravenous ..................7doxycycline hyclate oral capsule .................7doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg .................................................7doxycycline hyclate oral tablet ....................7doxycycline monohydrate oral ....................7doxycycline ..............................................18doxylamine-pyridoxine ...............................9
dronabinol .................................................9droperidol injection ....................................9DROPLET MICRON ...................................20drospiren-eth estrad-levomefol.................24drospirenone-ethinyl estradiol ..................24droxidopa ................................................15DUAVEE ...................................................24DULERA ...................................................31duloxetine hcl oral .....................................9DUPIXENT ................................................18duramorph ................................................5DUROLANE ..............................................28dutasteride oral ........................................22dutasteride-tamsulosin hcl .......................22DYMISTA .................................................30EASIVENT .................................................28ec-naproxen ...............................................6econazole nitrate external ........................10EDURANT ................................................13efavirenz-emtricitab-tenofovir ..................13efavirenz-lamivudine-tenofovir .................13efavirenz ..................................................13effer-k oral tablet effervescent 25 meq .....20ELAPRASE ................................................22eletriptan hydrobromide ..........................10elinest ......................................................24ELIQUIS DVT/PE STARTER PACK ..................8ELIQUIS ......................................................8ELIXOPHYLLIN ..........................................31eluryng ....................................................24EMCYT ....................................................11EMGALITY (300 MG DOSE) ......................10EMGALITY ...............................................10emoquette ...............................................24emtricitabine-tenofovir df ........................13emtricitabine ............................................13EMTRIVA ORAL SOLUTION .......................13EMVERM .................................................12enalapril maleate oral ...............................15enalapril-hydrochlorothiazide ...................15enalaprilat ................................................15endocet .....................................................5ENDOMETRIN ..........................................24ENGERIX-B ...............................................27enoxaparin sodium ....................................8enpresse-28 .............................................24enskyce ....................................................24entacapone ..............................................12entecavir ..................................................13ENTRESTO ................................................15enulose ....................................................21EPCLUSA .................................................13ephedrine sulfate intravenous solution 50 mg/ml .................................................15epinastine hcl ...........................................29epinephrine (anaphylaxis) .........................31epinephrine injection solution auto-injector ....................................................31epinephrine intravenous solution prefilled syringe 1 mg/10ml ......................15epinephrine pf .........................................15epirubicin hcl ...........................................11epitol .........................................................8EPIVIR HBV ORAL SOLUTION ....................13eplerenone ..............................................15
epoprostenol sodium ...............................31eptifibatide ..............................................13ERBITUX ...................................................11ergocalciferol oral capsule ........................20ergoloid mesylates oral ............................28ergotamine-caffeine .................................10ERIVEDGE ................................................11erlotinib hcl oral tablet 100 mg, 150 mg ..11erlotinib hcl oral tablet 25 mg ..................11errin .........................................................24ertapenem sodium .....................................7ery ...........................................................18erythromycin base ......................................7erythromycin ethylsuccinate oral ................7erythromycin external ..............................18erythromycin ophthalmic .........................29erythromycin oral .......................................7escitalopram oxalate ..................................9esmolol hcl intravenous solution 100 mg/10ml ..................................................15esmolol hcl-sodium chloride .....................15estarylla ...................................................24estazolam ................................................14estradiol oral ............................................24estradiol transdermal ...............................24estradiol vaginal .......................................24estradiol valerate intramuscular ................24estradiol-norethindrone acet ....................24eszopiclone ..............................................32ethacrynate sodium .................................15ethacrynic acid .........................................15ethambutol hcl oral ..................................10ethosuximide oral ......................................8ethyl chloride .............................................6ethynodiol diac-eth estradiol ....................24etodolac er ................................................6etodolac ....................................................6etonogestrel-ethinyl estradiol ...................24etoposide intravenous ..............................11etoposide oral ..........................................11etravirine .................................................13EUCRISA ..................................................18EUFLEXXA ................................................28euthyrox ..................................................26everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg ............................................26everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg ...........................................11everolimus oral tablet soluble ...................11EVOTAZ ...................................................13exemestane .............................................11ezetimibe-simvastatin ...............................15ezetimibe .................................................15FABRAZYME ............................................22falmina ....................................................24famciclovir oral ........................................13famotidine intravenous ............................21famotidine oral suspension reconstituted .21famotidine oral tablet 20 mg, 40 mg .......21famotidine premixed ................................21FARXIGA ..................................................19FASENRA PEN ..........................................30FASENRA .................................................30fayosim ....................................................24febuxostat ...............................................10
37
FEIBA .......................................................14felbamate ..................................................8felodipine er ............................................15femynor ...................................................24fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 15fenofibrate oral ........................................15fenofibric acid ..........................................15fenoprofen calcium oral .............................6fenortho ....................................................6fentanyl citrate buccal lozenge on a handle 5fentanyl citrate injection solution prefilled syringe .........................................5fentanyl .....................................................5ferumoxytol .............................................20FIBRYGA ..................................................14finasteride oral tablet 5 mg ......................22flac ..........................................................30flavoxate hcl ............................................22flecainide acetate .....................................15FLEXICHAMBER ADULT MASK/SMALL ......28FLEXICHAMBER CHILD MASK/LARGE .......28FLEXICHAMBER CHILD MASK/SMALL .......28FLEXICHAMBER .......................................28FLOVENT DISKUS .....................................31FLOVENT HFA ..........................................31floxuridine ...............................................11FLUAD QUADRIVALENT ............................27FLUARIX QUADRIVALENT .........................27FLUBLOK QUADRIVALENT ........................27FLUCELVAX QUADRIVALENT ....................27fluconazole in sodium chloride .................10fluconazole oral .......................................10flucytosine oral ........................................10fludarabine phosphate .............................11fludrocortisone acetate oral .....................22FLULAVAL QUADRIVALENT .......................27flumazenil intravenous .............................28FLUMIST QUADRIVALENT .........................27flunisolide nasal .......................................30fluocinolone acetonide body ....................18fluocinolone acetonide external ...............18fluocinolone acetonide otic ......................30fluocinolone acetonide scalp ....................18fluocinonide emulsified base ....................18fluocinonide external ...............................18fluorometholone ......................................29FLUOROURACIL EXTERNAL CREAM 0.5 % ......................................................18fluorouracil external cream 5 % ...............18fluorouracil external solution ....................18fluorouracil intravenous ...........................11fluoxetine hcl (pmdd) .................................9fluoxetine hcl oral capsule delayed release .9fluoxetine hcl oral capsule ..........................9fluoxetine hcl oral solution .........................9fluoxetine hcl oral tablet ............................9fluphenazine decanoate injection .............13fluphenazine hcl ......................................13flurandrenolide ........................................18flurazepam hcl .........................................32flurbiprofen oral .........................................6flurbiprofen sodium .................................29flutamide .................................................11fluticasone propionate external ................18
fluticasone propionate nasal ....................30fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose .....................................31FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT 31fluvastatin sodium er ................................15fluvastatin sodium ....................................15fluvoxamine maleate er ..............................9fluvoxamine maleate ..................................9FLUZONE HIGH-DOSE QUADRIVALENT .....27FLUZONE QUADRIVALENT ........................27FML .........................................................29folic acid injection ....................................20folic acid oral tablet 1 mg ........................20FOLOTYN .................................................11fomepizole ...............................................28fondaparinux sodium .................................8formaldehyde external solution 37 % ......28formoterol fumarate inhalation ................31fosamprenavir calcium .............................13fosaprepitant dimeglumine ........................9foscarnet sodium .....................................13fosfomycin tromethamine ..........................7fosinopril sodium-hctz ..............................15fosinopril sodium .....................................15fosphenytoin sodium .................................8frovatriptan succinate ..............................10fulvestrant ...............................................11furosemide injection ................................15furosemide oral ........................................15FUZEON ...................................................13fyavolv .....................................................24gabapentin oral .........................................8galantamine hydrobromide er ....................9galantamine hydrobromide ........................9GAMASTAN .............................................26GAMMAGARD ........................................26GAMMAKED ...........................................26GAMUNEX-C ...........................................26ganciclovir sodium ...................................13GARDASIL 9 .............................................27gatifloxacin ophthalmic ............................29gavilyte-c .................................................21gavilyte-g .................................................21gavilyte-n with flavor pack .......................21GELSYN-3 ................................................28gemcitabine hcl .......................................11gemfibrozil oral ........................................16gemmily ...................................................24generlac ...................................................21gengraf ....................................................26gentak .....................................................29gentamicin in saline ...................................7gentamicin sulfate external ........................7gentamicin sulfate injection .......................7gentamicin sulfate ophthalmic .................29glatiramer acetate ....................................17glatopa ....................................................17glimepiride ...............................................19glipizide er ...............................................19glipizide ir ................................................19
glipizide xl ................................................19glipizide-metformin hcl ............................19glucagon emergency kit ...........................20GLUCAGON EMERGENCY KIT ..................20glutaraldehyde external............................28glyburide micronized ................................19glyburide oral ...........................................19glyburide-metformin ................................19glycine irrigation ......................................22glycine urologic ........................................22glycopyrrolate injection solution ...............21glycopyrrolate oral ...................................22glycopyrrolate pf ......................................22glydo .........................................................6GLYXAMBI ...............................................19granisetron hcl intravenous ........................9granisetron hcl oral ....................................9griseofulvin microsize oral ........................10griseofulvin ultramicrosize ........................10guaiatussin ac ..........................................30guaifenesin ac ..........................................30guanfacine hcl er .....................................17guanfacine hcl .........................................16GVOKE HYPOPEN 1-PACK .......................20GVOKE HYPOPEN 2-PACK .......................20GVOKE PFS ..............................................20hailey 1.5/30 ............................................24hailey 24 fe ..............................................24hailey fe 1.5/30 ........................................24hailey fe 1/20 ...........................................24HALAVEN.................................................11halcinonide ..............................................18halobetasol propionate external cream .....18halobetasol propionate external ointment 18haloperidol decanoate intramuscular ........13haloperidol lactate ...................................13haloperidol oral ........................................13HARVONI .................................................13HAVRIX ....................................................27heather ....................................................24hematinic/folic acid ..................................20hemocyte-f ..............................................20heparin (porcine) in nacl intravenous solution .....................................................8heparin lock flush ....................................28heparin sod (porcine) in d5w ......................8heparin sodium (porcine) pf .......................8heparin sodium (porcine) ...........................8heparin sodium lock flush ........................28HEPLISAV-B ..............................................27hetastarch-nacl ........................................14HIBERIX ....................................................27HIZENTRA SUBCUTANEOUS SOLUTION ....26homatropaire ...........................................30HUMALOG KWIKPEN ...............................20HUMALOG MIX 50/50 KWIKPEN ..............20HUMALOG MIX 50/50 VIAL .....................20HUMALOG MIX 75/25 KWIKPEN ..............20HUMALOG MIX 75/25 VIAL .....................20HUMALOG U-100 JUNIOR KWIKPEN ........20HUMALOG ..............................................20HUMATE-P ...............................................14HUMIRA PEDIATRIC CROHNS START ........26HUMIRA PEN-CD/UC/HS STARTER ............26HUMIRA PEN-PEDIATRIC UC START ..........26
38
HUMIRA PEN-PS/UV/ADOL HS START .......26HUMIRA PEN-PSOR/UVEIT STARTER ..........26HUMIRA PEN ...........................................26HUMIRA ..................................................26HUMULIN 70/30 KWIKPEN .......................20HUMULIN 70/30 VIAL ..............................20HUMULIN N KWIKPEN .............................20HUMULIN N VIAL .....................................20HUMULIN R U-500 KWIKPEN ...................20HUMULIN R U-500 VIAL ...........................20HUMULIN R VIAL .....................................20hydralazine hcl injection ...........................16hydralazine hcl oral ..................................16hydrochlorothiazide oral ..........................16hydrocodone bitartrate er oral capsule extended release 12 hour ...........................5hydrocodone polst-chlorphen polst er susp .........................................................30hydrocodone-acetaminophen ....................5hydrocodone-homatropine ......................30hydrocodone-ibuprofen .............................5hydrocortisone (perianal) ..........................27hydrocortisone ace-pramoxine external cream 1-1 % ..............................27hydrocortisone butyr lipo base .................18hydrocortisone butyrate ...........................18hydrocortisone external cream 1 %, 2.5 % ......................................................18hydrocortisone external lotion 2.5 % .......18hydrocortisone external ointment 1 %, 2.5 % ................................................18hydrocortisone oral ..................................22hydrocortisone rectal ...............................27hydrocortisone valerate ............................18hydrocortisone-acetic acid ........................30hydrogen peroxide .....................................7hydromet .................................................30hydromorphone hcl er ...............................5hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml ......................................5hydromorphone hcl oral .............................5hydromorphone hcl pf ...............................5hydromorphone hcl solution 1 mg/ml injection .....................................................5hydroxocobalamin acetate .......................20hydroxychloroquine sulfate oral ................12hydroxyprogesterone caproate intramuscular ...........................................24hydroxyurea oral ......................................11hydroxyzine hcl intramuscular ..................14hydroxyzine hcl oral .................................14hydroxyzine pamoate oral ........................14hyoscyamine sulfate oral ..........................22hyoscyamine sulfate sl ..............................22hyoscyamine sulfate sublingual ................22hyosyne ...................................................22HYPERRHO S/D ........................................26ibandronate sodium .................................28ibuprofen lysine .........................................6ibuprofen oral suspension 100 mg/5ml ......6ibuprofen oral tablet 400 mg, 600 mg, 800 mg ...............................................6ibutilide fumarate ....................................16icatibant acetate ......................................26iclevia ......................................................24
icosapent ethyl .........................................16idarubicin hcl ...........................................11ifosfamide ................................................11ILARIS ......................................................26imatinib mesylate .....................................11imipenem-cilastatin ....................................7imipramine hcl oral ....................................9imipramine pamoate ..................................9imiquimod external ..................................18IMOVAX RABIES .......................................27IMVEXXY MAINTENANCE PACK ...............24IMVEXXY STARTER PACK .........................24incassia ....................................................24INCRELEX .................................................23indapamide ..............................................16indomethacin er .........................................6indomethacin oral capsule 25 mg, 50 mg ..6indomethacin sodium ................................6INFANRIX .................................................27INFLECTRA ...............................................26INSPIREASE RESERVOIR BAGS ..................28INSULIN PEN NEEDLES ..............................20INSULIN SYRINGES ...................................20INTELENCE ORAL TABLET 25 MG .............13introvale ..................................................24INVIRASE .................................................13iodine strong oral .....................................20IPOL .........................................................27ipratropium bromide inhalation ................31ipratropium bromide nasal .......................30ipratropium-albuterol ...............................31irbesartan-hydrochlorothiazide .................16irbesartan ................................................16irinotecan hcl ...........................................11ISENTRESS HD ..........................................13ISENTRESS ................................................13isibloom ...................................................24isoniazid injection ....................................10isoniazid oral ............................................10isoproterenol hcl injection ........................31isosorbide dinitrate ..................................16isosorbide mononitrate er ........................16isosorbide mononitrate ............................16isotretinoin oral ........................................18isradipine .................................................16itraconazole oral ......................................10ivermectin external cream ........................18ivermectin external lotion .........................12ivermectin oral .........................................12IXEMPRA KIT ............................................11IXIARO .....................................................27jaimiess ....................................................24JAKAFI ORAL TABLET 10 MG ...................11JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG ..........................................11JANSSEN COVID-19 VACCINE ..................27jantoven ....................................................8JANUMET XR ...........................................19JANUMET ................................................19JANUVIA ..................................................19JARDIANCE ..............................................19jasmiel .....................................................24jencycla ....................................................24JENTADUETO XR ......................................19JENTADUETO ...........................................19
JEVTANA ..................................................11jinteli .......................................................24jolessa ......................................................24juleber .....................................................24JULUCA ...................................................13junel 1.5/30 .............................................24junel 1/20 ................................................24junel fe 1.5/30 .........................................24junel fe 1/20 ............................................24junel fe 24 ...............................................24k-prime ....................................................21kaitlib fe ..................................................24kalliga ......................................................24KANJINTI ..................................................11kariva .......................................................24kelnor 1/35 ..............................................24kelnor 1/50 ..............................................24KEPIVANCE ..............................................17KESIMPTA ................................................17ketoconazole external ..............................10ketoconazole oral ....................................10ketodan external foam .............................10ketoprofen er .............................................6ketoprofen oral ..........................................6ketorolac tromethamine injection ...............6ketorolac tromethamine intramuscular .......6ketorolac tromethamine ophthalmic.........29ketorolac tromethamine oral ......................6KINRIX .....................................................27klor-con 10 ..............................................20klor-con m10 ...........................................21klor-con m15 ...........................................21klor-con m20 ...........................................21klor-con/ef ...............................................21klor-con ...................................................20KLOXXADO ...............................................6KOATE-DVI ..............................................14KOATE .....................................................14KOGENATE FS ..........................................14KOVALTRY ...............................................14kurvelo ....................................................24KYPROLIS .................................................11labetalol hcl intravenous solution .............16labetalol hcl oral ......................................16lactated ringers irrigation .........................21lactic acid e ..............................................18lactic acid external ...................................18lactulose encephalopathy .........................22lactulose ..................................................22lamivudine-zidovudine .............................13lamivudine ...............................................13lamotrigine er ............................................8lamotrigine oral .........................................8lamotrigine starter kit-blue .........................8lamotrigine starter kit-green .......................8lamotrigine starter kit-orange .....................8LANCETS .................................................19LANOXIN ORAL ........................................16lanthanum carbonate ...............................22LANTUS SOLOSTAR ..................................20LANTUS U-100 VIAL .................................20lapatinib ditosylate ...................................11larin 1.5/30 ..............................................24larin 1/20 .................................................24larin 24 fe ................................................24
39
larin fe 1.5/30 ..........................................24larin fe 1/20 .............................................24larissia ......................................................24latanoprost ophthalmic ............................29layolis fe ..................................................24leena .......................................................24leflunomide oral .......................................26lessina ......................................................24letrozole oral ............................................11leucovorin calcium injection .....................11leucovorin calcium oral ............................11LEUKERAN ...............................................11leuprolide acetate injection ......................23levalbuterol hcl inhalation ........................31levetiracetam er .........................................8levetiracetam in nacl ..................................8levetiracetam intravenous ..........................8levetiracetam oral ......................................8levo-t .......................................................26levobunolol hcl ........................................29levocarnitine oral solution ........................21levocarnitine oral tablet............................21levocarnitine sf ........................................21levofloxacin in d5w ....................................7levofloxacin intravenous .............................7levofloxacin ophthalmic ...........................29levofloxacin oral .........................................7levoleucovorin calcium pf .........................11levoleucovorin calcium .............................11levonest ...................................................24levonorg-eth estrad triphasic ....................24levonorgest-eth est & eth est ...................24levonorgest-eth estrad 91-day ..................24levonorgestrel-ethinyl estrad ....................24levora 0.15/30 (28) ..................................24levorphanol tartrate oral ............................5levothyroxine sodium intravenous ............26levothyroxine sodium oral tablet ..............26levoxyl .....................................................26LEXIVA ORAL SUSPENSION .......................13lidocaine external ointment 5 % ................6lidocaine external patch 5 %......................6lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml ..........6lidocaine hcl (cardiac) pf .............................6lidocaine hcl (cardiac) solution prefilled syringe 100 mg/5ml intravenous ................6lidocaine hcl (pf) ........................................6lidocaine hcl external solution ....................6lidocaine hcl injection solution ...................6lidocaine hcl urethral/mucosal ....................6lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-% ......................6lidocaine viscous hcl .................................17lidocaine-epinephrine injection ...................6lidocaine-prilocaine external cream ............6lillow ........................................................24lincomycin hcl injection ..............................7lindane ....................................................12linezolid in sodium chloride ........................7linezolid intravenous ..................................7linezolid oral ..............................................7LINZESS ....................................................22liothyronine sodium intravenous ..............26liothyronine sodium oral ..........................26
lisinopril oral ............................................16lisinopril-hydrochlorothiazide....................16lithium carbonate er .................................14lithium carbonate oral ..............................14lo-zumandimine .......................................24lojaimiess .................................................24loperamide hcl oral capsule ......................22lopinavir-ritonavir .....................................13lorazepam injection ..................................14lorazepam intensol ...................................14lorazepam oral concentrate 2 mg/ml ........14lorazepam oral tablet ...............................14loryna ......................................................24losartan potassium oral ............................16losartan potassium-hctz ...........................16loteprednol etabonate ophthalmic gel ......29loteprednol etabonate ophthalmic suspension ...............................................29lovastatin oral ..........................................16low-ogestrel .............................................24loxapine succinate ....................................13LUCENTIS .................................................30LUMIGAN ................................................29LUMIZYME ...............................................22LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG .................23LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG ...............23LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG ...................23LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG ...................23LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG, 7.5 MG .....23LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED) .........23lutera .......................................................24lyleq .........................................................24lyllana ......................................................24LYNPARZA ................................................11LYSODREN ...............................................11LYUMJEV KWIKPEN ..................................20LYUMJEV VIAL .........................................20lyza ..........................................................24M-M-R II ..................................................27mafenide acetate external ..........................7magnesium chloride injection ...................21magnesium sulfate in d5w .......................21magnesium sulfate injection .....................21magnesium sulfate intravenous ................21MAKENA .................................................24malathion ................................................12mannitol intravenous ...............................16marlissa ...................................................25MATULANE ..............................................11matzim la .................................................16MAVYRET ................................................13maxi-tuss ac .............................................30meclizine hcl oral tablet .............................9meclofenamate sodium oral .......................6MEDROL ORAL TABLET 2 MG ..................22medroxyprogesterone acetate intramuscular ...........................................25medroxyprogesterone acetate oral ...........25mefenamic acid oral ...................................6
mefloquine hcl .........................................12megestrol acetate oral .............................25MEKINIST .................................................11meloxicam oral ..........................................6melphalan hcl ..........................................12melphalan ................................................12memantine hcl er .......................................9memantine hcl ...........................................9MENACTRA .............................................27MENEST ...................................................25MENQUADFI ............................................27MENVEO ..................................................27meperidine hcl injection .............................5meperidine hcl oral ....................................5meprobamate ..........................................14mercaptopurine oral ................................12meropenem ...............................................7merzee ....................................................25mesalamine er oral capsule 0.375 gm ......27mesalamine oral .......................................27mesalamine rectal ....................................27mesalamine-cleanser ................................27mesna ......................................................12metaxalone ..............................................31metformin hcl er ......................................19metformin hcl ir .......................................19methadone hcl injection .............................5methadone hcl intensol ..............................5methadone hcl oral concentrate .................5methadone hcl oral solution .......................5methadone hcl oral tablet soluble ..............5methadone hcl oral tablet ..........................5methadose oral concentrate 10 mg/ml .......5methadose oral tablet soluble ....................5methadose sugar-free ................................5methamphetamine hcl .............................17methazolamide oral .................................29methenamine hippurate .............................7methergine ..............................................28methimazole oral .....................................26methocarbamol injection .........................31methocarbamol oral .................................31methotrexate oral ....................................26methotrexate sodium (pf) .........................26methotrexate sodium ...............................26methoxsalen rapid ...................................18methscopolamine bromide oral ................22methyldopa .............................................16methylergonovine maleate injection .........28methylergonovine maleate oral ................28methylphenidate hcl er (cd) ......................17methylphenidate hcl er (la) .......................17methylphenidate hcl er (xr) .......................17methylphenidate hcl er ............................17methylphenidate hcl oral ..........................17methylprednisolone acetate suspension 40 mg/ml injection .................22methylprednisolone acetate suspension 80 mg/ml injection .................23methylprednisolone oral ...........................23methylprednisolone sodium succ ..............23metoclopramide hcl injection .....................9metoclopramide hcl oral ............................9metolazone ..............................................16metoprolol succinate er ............................16
40
metoprolol tartrate intravenous ................16metoprolol tartrate oral ............................16metoprolol-hydrochlorothiazide ...............16metronidazole external ............................18metronidazole in nacl .................................7metronidazole oral .....................................7metronidazole vaginal ................................7metyrosine ...............................................16mexiletine hcl oral ....................................16mibelas 24 fe ...........................................25micafungin sodium ..................................10miconazole 3 ...........................................10MICRHOGAM ULTRA-FILTERED PLUS ........26MICROCHAMBER ....................................28microgestin 1.5/30 ...................................25microgestin 1/20 ......................................25microgestin 24 fe .....................................25microgestin fe 1.5/30 ...............................25microgestin fe 1/20 ..................................25midodrine hcl ...........................................16miglitol ....................................................19miglustat .................................................22mili ..........................................................25milrinone lactate in dextrose ....................16milrinone lactate ......................................16mimvey ....................................................25mineral oil heavy oral ...............................22minocycline hcl er oral tablet extended release 24 hour ..........................................7minocycline hcl oral ...................................7minoxidil oral ...........................................16mirtazapine oral .........................................9misoprostol oral .......................................21mitigo ........................................................5mitomycin intravenous .............................12mitoxantrone hcl ......................................12modafinil .................................................32MODERNA COVID-19 VACCINE ...............27moexipril hcl ............................................16molindone hcl ..........................................13mometasone furoate external ..................18mometasone furoate nasal .......................30mondoxyne nl ............................................7mono-linyah ............................................25monoject flush syringe .............................21monoject sodium chloride flush ...............21MONONINE .............................................14montelukast sodium oral ..........................31morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml .................5morphine sulfate (pf) .................................5morphine sulfate er beads ..........................5morphine sulfate er ....................................5morphine sulfate injection solution 2 mg/ml, 4 mg/ml .........................................5morphine sulfate intravenous solution 4 mg/ml, 8 mg/ml ......................................5morphine sulfate oral .................................5MOXEZA ..................................................29moxifloxacin hcl (2x day) ..........................29moxifloxacin hcl in nacl ..............................8moxifloxacin hcl ophthalmic solution ........29moxifloxacin hcl oral ..................................8MOZOBIL .................................................14MULPLETA ...............................................14
mupirocin calcium ......................................8mupirocin external .....................................8mutamycin ...............................................12MVASI .....................................................12mycophenolate mofetil hcl .......................26mycophenolate mofetil intravenous .........26mycophenolate mofetil oral .....................26mycophenolate sodium ............................26MYFEMBREE ............................................25MYLERAN ................................................12myorisan ..................................................18MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR ...................................22na ferric gluc cplx in sucrose ....................21nabumetone oral .......................................6nadolol oral .............................................16nafcillin sodium ..........................................8naftifine hcl .............................................10NAGLAZYME ...........................................22nalbuphine hcl injection .............................5naloxone hcl injection ................................6naltrexone hcl oral .....................................6NAMZARIC ................................................9naproxen oral ............................................6naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 6naproxen sodium oral tablet 275 mg, 550 mg ......................................................6naproxen-esomeprazole .............................6naratriptan hcl .........................................10NARCAN ....................................................6NATACYN ................................................29NATAZIA ..................................................25nateglinide ...............................................19nebivolol hcl ............................................16necon 0.5/35 (28) ....................................25nefazodone hcl ..........................................9neo-polycin hc .........................................30neo-polycin ..............................................30neomycin sulfate oral .................................8neomycin-bacitracin zn-polymyx ..............30neomycin-polymyxin b gu ..........................8neomycin-polymyxin-dexameth ophthalmic ointment ...............................30neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 .....30neomycin-polymyxin-gramicidin ...............30neomycin-polymyxin-hc ophthalmic .........30neomycin-polymyxin-hc otic .....................30neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml .............10neuac external gel ...................................18nevirapine er ............................................13nevirapine ................................................13NEXAVAR.................................................12NEXLETOL ................................................16NEXLIZET .................................................16niacin (antihyperlipidemic) ........................16niacin er (antihyperlipidemic) ....................16niacor ......................................................16nicardipine hcl .........................................16nifedipine er osmotic release ....................16nifedipine er ............................................16nifedipine oral ..........................................16nikki ........................................................25
nilutamide ...............................................12nimodipine oral ........................................16nisoldipine er ...........................................16nitazoxanide oral .....................................12nitisinone .................................................22nitrofurantoin macrocrystal ........................8nitrofurantoin monohydrate macrocrystals .8nitrofurantoin ............................................8nitroglycerin in d5w .................................16nitroglycerin .............................................16nitroprusside sodium ................................16NIVESTYM ...............................................14nizatidine .................................................21nolix ........................................................19nora-be ....................................................25norepinephrine bitartrate intravenous ......16norethin ace-eth estrad-fe ........................25norethin-eth estradiol-fe ..........................25norethindrone acet-ethinyl est..................25norethindrone acetate oral .......................25norethindrone oral ...................................25norethindrone-eth estradiol .....................25norgestimate-eth estradiol .......................25norgestimate-ethinyl estradiol triphasic ....25norlyda ....................................................25norlyroc ...................................................25normal saline flush ...................................21NORPACE CR ...........................................16nortrel 0.5/35 (28) ...................................25nortrel 1/35 (21) ......................................25nortrel 1/35 (28) ......................................25nortrel 7/7/7 ............................................25nortriptyline hcl oral ...................................9NORVIR ORAL PACKET .............................13NORVIR ORAL SOLUTION .........................13NOVOEIGHT ............................................14NOVOFINE AUTOCOVER PEN NEEDLE ......20NOVOFINE PEN NEEDLE ...........................20NOVOFINE PLUS PEN NEEDLE ...................20NOVOLIN 70/30 FLEXPEN RELION .............20NOVOLIN 70/30 RELION ...........................20NOVOLIN N RELION .................................20NOVOLIN R RELION ..................................20NOVOSEVEN RT .......................................14NOVOTWIST PEN NEEDLE ........................20np thyroid ................................................26NUCALA ..................................................30NURTEC ...................................................10NUWIQ ....................................................14nyamyc ....................................................10nylia 7/7/7 ................................................25nymyo .....................................................25nystatin external ......................................10nystatin mouth/throat ..............................10nystatin oral .............................................10nystatin-triamcinolone .............................10nystop .....................................................10ocella .......................................................25octreotide acetate ....................................23ofloxacin ophthalmic ................................29ofloxacin oral .............................................8ofloxacin otic ...........................................30olanzapine intramuscular .........................13olanzapine oral ........................................13olanzapine-fluoxetine hcl ...........................9
41
olmesartan medoxomil oral ......................16olmesartan medoxomil-hctz .....................16olmesartan-amlodipine-hctz .....................16olopatadine hcl nasal ...............................30olopatadine hcl ophthalmic ......................29OMECLAMOX-PAK ..................................22omega-3-acid ethyl esters ........................16OMNITROPE .............................................23ONCASPAR ..............................................12ondansetron hcl injection ...........................9ondansetron hcl oral solution .....................9ondansetron hcl oral tablet 24 mg .............9ondansetron hcl oral tablet 4 mg, 8 mg ...10ondansetron odt ......................................10ONETOUCH ULTRA 2 KIT W/DEVICE .........19ONETOUCH ULTRA MINI KIT W/DEVICE....20ONETOUCH ULTRA TEST STRIPS ...............19ONETOUCH VERIO FLEX SYSTEM .............20ONETOUCH VERIO IQ SYSTEM .................20ONETOUCH VERIO KIT W/DEVICE ............20ONETOUCH VERIO REFLECT .....................20ONETOUCH VERIO SYNC SYSTEM ...........20ONETOUCH VERIO TEST STRIPS ................20OPSUMIT .................................................31OPTICHAMBER DIAMOND-LG MASK .......28OPTICHAMBER DIAMOND-MD MASK ......28OPTICHAMBER DIAMOND-SM MASK ......28OPTICHAMBER DIAMOND .......................28oralone ....................................................17ORIAHNN .................................................25ORILISSA ..................................................23orphenadrine citrate er ............................31orphenadrine citrate injection ..................31orphenadrine-asa-caffeine .......................31orsythia ....................................................25oseltamivir phosphate oral .......................13OTEZLA ....................................................26oxacillin sodium .........................................8oxaliplatin ................................................12oxaprozin ...................................................6oxazepam ................................................14oxcarbazepine ............................................8oxiconazole nitrate ...................................10oxybutynin chloride er ..............................22oxybutynin chloride oral ...........................22oxycodone hcl oral capsule ........................5oxycodone hcl oral concentrate 100 mg/5ml ......................................................5oxycodone hcl oral solution ........................5oxycodone hcl oral tablet ...........................5oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg ...............................................5oxymorphone hcl er ...................................5oxymorphone hcl .......................................5oxytocin injection .....................................23OZEMPIC .................................................19paclitaxel .................................................12paliperidone er .........................................13palonosetron hcl ......................................10pamidronate disodium .............................28pancuronium bromide .............................17PANDA MASK LARGE ..............................29PANDA MASK MEDIUM ...........................29PANDA MASK SMALL ..............................29
paraplatin ................................................12paricalcitol ...............................................28paromomycin sulfate oral ...........................8paroxetine hcl er ........................................9paroxetine hcl ............................................9paroxetine mesylate ...................................9PEDIARIX .................................................27PEDIATRIC PANDA MASK .........................29PEDVAX HIB .............................................27peg 3350-kcl-na bicarb-nacl .....................22peg-3350/electrolytes/ascorbat ................22peg-3350/electrolytes ..............................22peg-kcl-nacl-nasulf-na asc-c .....................22peg-prep ..................................................22PEGASYS .................................................13penicillamine oral capsule ........................22penicillamine oral tablet ...........................22penicillin g potassium .................................8penicillin g procaine ...................................8penicillin g sodium .....................................8penicillin v potassium .................................8PENTACEL ................................................27pentamidine isethionate ...........................12pentazocine-naloxone hcl ..........................5pentobarbital sodium injection ...................8pentoxifylline er .......................................16perindopril erbumine ...............................16periogard .................................................17PERJETA ...................................................12permethrin external .................................12perphenazine oral ....................................10perphenazine-amitriptyline .........................9PFIZER COVID-19 VAC-TRIS 5-11Y ...........27PFIZER-BIONT COVID-19 VAC-TRIS ...........27PFIZER-BIONTECH COVID-19 VACC ..........27phenazo oral tablet 200 mg .....................22phenazopyridine hcl oral tablet 100 mg, 200 mg .............................................22phenelzine sulfate oral ...............................9phenobarbital oral .....................................8phenobarbital sodium injection ..................8phenoxybenzamine hcl oral ......................16phentolamine mesylate injection ..............16phenylephrine hcl intravenous solution 10 mg/ml .................................................16phenylephrine hcl ophthalmic ..................30phenytoin infatabs .....................................8phenytoin oral ...........................................9phenytoin sodium extended .......................9phenytoin sodium injection ........................9PHESGO ...................................................12philith ......................................................25phospho-trin 250 neutral .........................21phosphorous ............................................21phytonadione injection ............................21phytonadione oral ....................................21pilocarpine hcl ophthalmic .......................29pilocarpine hcl oral ...................................17pimecrolimus ...........................................19pimozide ..................................................13pimtrea ....................................................25pindolol ...................................................16pioglitazone hcl-glimepiride .....................19pioglitazone hcl-metformin hcl .................19pioglitazone hcl .......................................19
piperacillin sod-tazobactam so ...................8pirmella 1/35 ...........................................25pirmella 7/7/7 ..........................................25piroxicam oral ............................................6PNEUMOVAX 23 ......................................27POCKET SPACER ......................................29podofilox external ....................................19polocaine-mpf ...........................................6polocaine ...................................................6polycin .....................................................30polymyxin b sulfate injection ......................8polymyxin b-trimethoprim ........................30portia-28 .................................................25posaconazole ...........................................10potassium acetate intravenous .................21potassium chloride crys er ........................21potassium chloride er ...............................21potassium chloride intravenous ................21potassium chloride oral ............................21potassium citrate er .................................21potassium phosphates(71 meq k) .............21PRADAXA ..................................................8pramipexole dihydrochloride er ................12pramipexole dihydrochloride ....................12prasugrel hcl ............................................13pravastatin sodium ...................................16praziquantel oral ......................................12prazosin hcl oral .......................................16prednicarbate ..........................................19prednisolone acetate ophthalmic .............29prednisolone oral solution ........................23prednisolone sodium phosphate ophthalmic ..............................................29prednisolone sodium phosphate oral ........23prednisone intensol ..................................23prednisone oral ........................................23pregabalin er ...........................................17pregabalin ...............................................17PREMARIN ORAL ......................................25PREMARIN VAGINAL ................................25PREMPHASE .............................................25PREMPRO ................................................25prevalite ...................................................16previfem ..................................................25PREVNAR 13 ............................................27PREVNAR 20 ............................................27PREZCOBIX ..............................................13PREZISTA ..................................................13primaquine phosphate .............................12primidone oral ...........................................9PRO COMFORT SPACER ADULT ................29PRO COMFORT SPACER CHILD ................29PRO COMFORT SPACER INFANT ...............29probenecid ..............................................10procainamide hcl injection .......................16PROCARE SPACER/ADULT MASK ..............29PROCARE SPACER/CHILD MASK ..............29prochlorperazine edisylate injection ..........10prochlorperazine maleate oral ..................10prochlorperazine ......................................10procto-med hc .........................................27procto-pak ...............................................28PROCTOFOAM HC ...................................27proctosol hc .............................................28proctozone-hc .........................................28
42
PROFILNINE ..............................................14progesterone intramuscular......................25progesterone oral ....................................25PROLENSA ...............................................29PROLEUKIN ..............................................12PROLIA ....................................................28promethazine hcl injection .......................30promethazine hcl oral ..............................30promethazine hcl rectal ............................30promethazine vc/codeine .........................30promethazine vc ......................................30promethazine-codeine .............................30promethazine-dm ....................................30promethazine-phenyleph-codeine ............30promethazine-phenylephrine ...................30promethegan ...........................................30propafenone hcl er ..................................16propafenone hcl ......................................16proparacaine hcl ophthalmic ....................30propranolol hcl er ....................................16propranolol hcl intravenous ......................16propranolol hcl oral ..................................16propylthiouracil oral .................................26PROQUAD ...............................................27protamine sulfate intravenous ..................14protriptyline hcl ..........................................9pseudoephedrine-bromphen-dm ..............30PULMICORT FLEXHALER ...........................31PULMOZYME ...........................................31PYLERA ....................................................22pyrazinamide oral ....................................11pyridostigmine bromide er .......................10pyridostigmine bromide oral ....................10pyridoxine hcl injection ............................21pyrimethamine oral ..................................12QUADRACEL ............................................27quazepam ................................................14quetiapine fumarate er ............................13quetiapine fumarate ................................13quinapril hcl .............................................16quinapril-hydrochlorothiazide ...................16quinidine gluconate er .............................16quinidine sulfate ......................................16quinine sulfate oral ..................................12RABAVERT ...............................................27raloxifene hcl ...........................................23ramelteon ................................................32ramipril ....................................................16ranolazine er ............................................16rasagiline mesylate oral ............................12RASUVO ..................................................26reclipsen ..................................................25RECOMBINATE .........................................14RECOMBIVAX HB .....................................27relexxii .....................................................17RELION PREMIER CLASSIC ........................20RELION PREMIER TEST ..............................20remifentanil hcl ..........................................5repaglinide ...............................................19REPATHA PUSHTRONEX SYSTEM ..............16REPATHA SURECLICK ...............................16REPATHA .................................................16RESTASIS MULTIDOSE ...............................30RESTASIS ..................................................30RETACRIT .................................................14
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 % ......................................19RETROVIR INTRAVENOUS .........................13REVLIMID .................................................12revonto ....................................................32REYATAZ ORAL PACKET ...........................14RHOGAM ULTRA-FILTERED PLUS ..............26RHOPHYLAC ............................................26RIASTAP ...................................................14ribavirin inhalation ...................................14ribavirin oral .............................................14rifabutin ...................................................11rifampin intravenous ................................11rifampin oral ............................................11riluzole .....................................................17rimantadine hcl ........................................14ringers irrigation ......................................21RINVOQ ...................................................26risedronate sodium oral tablet 150 mg, 35 mg ...............................................28risedronate sodium oral tablet 30 mg, 5 mg ........................................................28risedronate sodium oral tablet delayed release .....................................................28risperidone ...............................................13ritonavir ...................................................14rivastigmine tartrate ...................................9rivastigmine ...............................................9rivelsa ......................................................25rizatriptan benzoate .................................10rocuronium bromide intravenous solution 17ropinirole hcl er ........................................12ropinirole hcl ............................................12ropivacaine hcl injection solution ................6rosadan external cream ............................19rosadan external gel .................................19rosuvastatin calcium .................................16ROTARIX ..................................................27ROTATEQ .................................................27roweepra ...................................................9RUBRACA ................................................12rufinamide .................................................9RUKOBIA .................................................14RUXIENCE ................................................12RYBELSUS ................................................19ryvent ......................................................30sajazir ......................................................26saline bacteriostatic ..................................21SANDIMMUNE INTRAVENOUS .................26SANDIMMUNE ORAL SOLUTION ..............26sapropterin dihydrochloride .....................22scopolamine ............................................10selegiline hcl oral .....................................12selenium sulfide external lotion ................19SELZENTRY ..............................................14SEREVENT DISKUS ....................................31sertraline hcl oral concentrate ....................9sertraline hcl oral tablet ..............................9setlakin ....................................................25sevelamer carbonate ................................22sevelamer hcl ...........................................22SFROWASA ..............................................28sharobel ...................................................25SHINGRIX .................................................27sildenafil citrate intravenous .....................31
sildenafil citrate oral suspension reconstituted ...........................................31sildenafil citrate oral tablet 20 mg ............31silodosin ..................................................22silver sulfadiazine external ..........................8SIMBRINZA ..............................................29simliya .....................................................25simpesse ..................................................25SIMPONI ARIA ..........................................26SIMPONI ..................................................26simvastatin oral ........................................16sirolimus oral ...........................................26SKYRIZI (150 MG DOSE) ...........................26SKYRIZI PEN .............................................26SKYRIZI ....................................................26sod benz-sod phenylacet ..........................22sod citrate-citric acid ................................21sodium acetate intravenous .....................21sodium bicarbonate intravenous ..............21sodium bicarbonate oral powder ..............22sodium chloride (pf) .................................21sodium chloride bacteriostatic ..................21sodium chloride flush ...............................21sodium chloride inhalation .......................30sodium chloride injection .........................21sodium chloride intravenous ....................21sodium chloride irrigation ........................21sodium fluoride 5000 enamel ..................17sodium fluoride 5000 sensitive .................17sodium nitrite intravenous ........................29sodium nitroprusside ................................17sodium phenylbutyrate oral ......................22sodium polystyrene sulfonate ...................21sodium saccharin powder ........................29sodium thiosulfate intravenous ................29solifenacin succinate ................................22SOLIQUA .................................................19sorbitol-mannitol .....................................29sorine ......................................................17sotalol hcl (af) ..........................................17sotalol hcl oral .........................................17spinosad ..................................................12SPIRIVA HANDIHALER ..............................31SPIRIVA RESPIMAT ....................................31spironolactone oral ..................................17spironolactone-hctz .................................17sprintec 28 ...............................................25SPRYCEL ..................................................12sps ...........................................................21sronyx ......................................................25ssd .............................................................8STAMARIL ................................................27stavudine .................................................14STEGLATRO .............................................19STELARA INTRAVENOUS ..........................26STELARA SUBCUTANEOUS .......................26sterile diluent/epoprostenol ......................29sterile water for injection .........................29sterile water for irrigation .........................21STIOLTO RESPIMAT ...................................31STRENSIQ .................................................22streptomycin sulfate intramuscular .............8STRIVERDI RESPIMAT ................................31subvenite starter kit-blue ............................9subvenite starter kit-green .........................9
43
subvenite starter kit-orange .......................9subvenite ...................................................9succinylcholine chloride injection solution 17sucralfate oral ..........................................21sulfacetamide sodium (acne) ....................19sulfacetamide sodium ophthalmic ............29sulfacetamide-prednisolone ophthalmic solution .................................30sulfadiazine oral .........................................8sulfamethoxazole-trimethoprim .................8sulfasalazine oral ......................................28sulfatrim pediatric ......................................8sulfurated lime .........................................12sulindac oral ..............................................6sumatriptan nasal ....................................10sumatriptan succinate oral .......................10sumatriptan succinate refill ......................10sumatriptan succinate subcutaneous ........10sumatriptan-naproxen sodium .................10sunitinib malate .......................................12SUNOSI ....................................................32SUPPRELIN LA ..........................................23syeda .......................................................25SYMBICORT .............................................31SYMFI LO .................................................14SYMFI ......................................................14SYMPROIC ...............................................22SYNAGIS ..................................................27SYNAREL .................................................23SYNJARDY XR ..........................................19SYNJARDY ...............................................19TABLOID ..................................................12tacrolimus external ...................................19tacrolimus oral .........................................27tadalafil (pah) ...........................................31TAFINLAR .................................................12tamoxifen citrate oral ...............................12tamsulosin hcl ..........................................22tarina 24 fe ..............................................25tarina fe 1/20 eq ......................................25tarina fe 1/20 ...........................................25tavaborole ...............................................10taysofy .....................................................25tazarotene external cream ........................19tazicef injection ..........................................8tazicef intravenous solution reconstituted ..8taztia xt ...................................................17TDVAX .....................................................27TEKTURNA HCT .......................................17TEKTURNA ...............................................17telmisartan-amlodipine ............................17telmisartan-hctz .......................................17telmisartan ...............................................17temazepam ..............................................32TEMODAR INTRAVENOUS ........................12temozolomide ..........................................12temsirolimus ............................................27TENIVAC ..................................................27tenofovir disoproxil fumarate ...................14terazosin hcl ............................................22terbinafine hcl oral ...................................10terbutaline sulfate injection ......................31terbutaline sulfate oral .............................31terconazole ..............................................10TERIPARATIDE (RECOMBINANT) ...............28
testosterone cypionate intramuscular .......23testosterone enanthate intramuscular ......23testosterone transdermal .........................23TETANUS-DIPHTHERIA TOXOIDS TD .........27tetrabenazine ...........................................17tetracaine hcl injection ...............................6tetracaine hcl ophthalmic .........................30tetracycline hcl oral ....................................8THALOMID ..............................................12theophylline er .........................................31theophylline .............................................31thiamine hcl injection ...............................21thioridazine hcl oral .................................13thiotepa injection .....................................12thiothixene ..............................................13tiadylt er ..................................................17tiagabine hcl ..............................................9TICE BCG .................................................27TICOVAC .................................................27tigecycline ..................................................8tilia fe ......................................................25timolol maleate (once-daily) .....................29timolol maleate ocudose ..........................29timolol maleate ophthalmic ......................29timolol maleate oral .................................17timolol maleate pf ....................................29tinidazole oral ............................................8tiopronin oral ...........................................22tis-u-sol ....................................................21TIVICAY PD ..............................................14TIVICAY ...................................................14tizanidine hcl oral .....................................32tobramycin inhalation ..............................31tobramycin ophthalmic ............................29tobramycin sulfate injection .......................8tobramycin-dexamethasone .....................30tolcapone ................................................12tolterodine tartrate er ..............................22tolterodine tartrate ..................................22tolvaptan oral tablet 30 mg ......................21topiramate er .............................................9topiramate oral ..........................................9toposar ....................................................12topotecan hcl ...........................................12toremifene citrate ....................................12torsemide ................................................17TOUJEO MAX SOLOSTAR .........................20TOUJEO SOLOSTAR ..................................20tovet external foam..................................19TRADJENTA ..............................................19tramadol hcl er (biphasic) ...........................5tramadol hcl er oral tablet extended release 24 hour ..........................................5tramadol hcl ir ...........................................5tramadol-acetaminophen ...........................5trandolapril-verapamil hcl er .....................17trandolapril ..............................................17tranexamic acid intravenous .....................14tranexamic acid oral .................................14tranylcypromine sulfate ..............................9travoprost (bak free) ................................29TRAZIMERA .............................................12trazodone hcl oral ......................................9TRELEGY ELLIPTA .....................................31TREMFYA .................................................27
treprostinil ...............................................31tretinoin external .....................................19tretinoin microsphere pump .....................19tretinoin microsphere ...............................19tretinoin oral ............................................12tri femynor ...............................................25tri-estarylla ...............................................25tri-legest fe ..............................................25tri-linyah ..................................................25tri-lo-estarylla ...........................................25tri-lo-marzia .............................................25tri-lo-mili ..................................................25tri-lo-sprintec ...........................................25tri-mili ......................................................25tri-nymyo .................................................25tri-previfem ..............................................25tri-sprintec ...............................................25tri-vylibra lo ..............................................25tri-vylibra .................................................25triamcinolone acetonide external aerosol solution .......................................19triamcinolone acetonide external cream ...19triamcinolone acetonide external lotion....19triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % ............19triamcinolone acetonide mouth/throat .....18triamcinolone acetonide suspension 40 mg/ml injection ...................................23triamterene oral .......................................17triamterene-hctz ......................................17triazolam .................................................14triderm ....................................................19trientine hcl .............................................21trifluoperazine hcl ....................................13trifluridine ................................................29trihexyphenidyl hcl ...................................13TRIJARDY XR ............................................19trimethobenzamide hcl oral .....................10trimethoprim oral .......................................8trimipramine maleate oral ..........................9TRIUMEQ .................................................14trivora (28) ...............................................25trospium chloride er .................................22trospium chloride .....................................22TRUE METRIX BLOOD GLUCOSE TEST ......20TRULICITY ................................................19TRUMENBA ..............................................27TUDORZA PRESSAIR .................................31tulana ......................................................25TWINRIX ..................................................27tyblume ...................................................25TYBOST ...................................................14tydemy ....................................................25TYMLOS ..................................................28TYPHIM VI ...............................................27UBRELVY ..................................................10ULTIGUARD SAFEPACK SYR/NEEDLE .........20unithroid ..................................................26ursodiol oral capsule 300 mg ...................22ursodiol oral tablet ...................................22V-GO 20 ..................................................20V-GO 30 ..................................................20V-GO 40 ..................................................20valacyclovir hcl oral ..................................14valganciclovir hcl ......................................14
44
valproate sodium intravenous ....................9valproic acid oral ........................................9valrubicin .................................................12valsartan-hydrochlorothiazide...................17valsartan ..................................................17vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-% ...................................8vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-% .............................................8vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous ....................8vancomycin hcl intravenous .......................8vancomycin hcl oral ...................................8vandazole ..................................................8VAQTA .....................................................27VARIVAX ..................................................27VASCEPA .................................................17VAXCHORA .............................................27VAXELIS ...................................................27VAXNEUVANCE .......................................27vecuronium bromide intravenous solution reconstituted ..............................17VELCADE .................................................12velivet ......................................................25venlafaxine hcl er .......................................9venlafaxine hcl ...........................................9verapamil hcl er .......................................17verapamil hcl intravenous .........................17verapamil hcl oral .....................................17vestura .....................................................25VICTOZA ..................................................19vienva ......................................................26vigabatrin ..................................................9vigadrone ..................................................9vinblastine sulfate ....................................12vincristine sulfate .....................................12vinorelbine tartrate ..................................12viorele ......................................................26VIRACEPT ................................................14VIREAD ORAL POWDER ...........................14VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ...........................................14virt-phos 250 neutral ...............................21virtussin ac w/alc ......................................30vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) .................................21vitamin k1 injection ..................................21volnea ......................................................26voriconazole intravenous ..........................10voriconazole oral ......................................10VORTEX VALVED HOLDING CHAMBER .....29VOSEVI ....................................................14VUMERITY ...............................................17vyfemla ....................................................26vylibra ......................................................26VYVANSE .................................................17warfarin sodium oral ..................................8water for irrigation, sterile ........................21wera ........................................................26WILATE ....................................................14WINRHO SDF ...........................................27wixela inhub ............................................31
wymzya fe ...............................................26XARELTO STARTER PACK ............................8XARELTO ...................................................8XELJANZ XR .............................................27XELJANZ ..................................................27XGEVA .....................................................28XIAFLEX ...................................................29XIGDUO XR .............................................19XIIDRA .....................................................30XOFIGO ...................................................12XOLAIR ....................................................30XTAMPZA ER .............................................5xulane ......................................................26XYNTHA SOLOFUSE .................................14XYNTHA ..................................................14YERVOY...................................................12YF-VAX ....................................................27yuvafem ...................................................26zafemy .....................................................26zafirlukast ................................................31zaleplon ...................................................32ZALTRAP ..................................................12ZANOSAR ................................................12zarah .......................................................26ZARXIO ....................................................14ZEGALOGUE ............................................20ZEJULA ....................................................12zenatane ..................................................19ZENPEP ....................................................22zidovudine ...............................................14zileuton er ...............................................31ziprasidone hcl .........................................13ziprasidone mesylate ................................13ZIRABEV ...................................................12ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ....................................................23zoledronic acid .........................................28ZOLINZA ..................................................12zolmitriptan oral ......................................10zolmitriptan solution 5 mg nasal ..............10zolpidem tartrate er .................................32zolpidem tartrate .....................................32zonisamide oral ..........................................9zovia 1/35 (28) .........................................26zovia 1/35e (28) .......................................26ZUBSOLV ...................................................6zumandimine ...........................................26
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