2020 Group Formulary - Blue Cross Blue Shield …2019/10/16 · formulary, appears on the front and back cover pages. You can ask Blue Cross Group MedicareRx to make an exception

Blue Cross Group MedicareRx (PDP)SM

2020 Group Formulary (List of Covered Drugs)

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

HPMS Approved Formulary File ID: 00020119, Version 8

This formulary was updated on 10/16/2019. For more recent information or other questions, please contact Blue Cross Group MedicareRxSM Customer Service at 1-877-838-3833 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.myprime.com.

Y0096_BEN_OK_GRP_PDPSTFRM20NR_C 90319.1019

http://www.myprime.com

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Blue Cross Group MedicareRx (PDP)

2020 Formulary (List of Covered Drugs)

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

When this drug list (formulary) refers to “we”, “us”, or “our”, it means HCSC Insurance Services Company (HISC) . When it refers to “plan” or “our plan,” it means Blue Cross Group MedicareRx.

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

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

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

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but “we” or Blue Cross Group MedicareRx may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specificchange(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Blue Cross Group MedicareRx’s Formulary?”

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

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

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Blue Cross Group MedicareRx Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of 10/16/2019. To get updated information about the drugs covered by Blue Cross Group MedicareRx, please contact us. Our contact information appears on the front and back cover pages. Formulary publications are updated and posted online on a monthly basis with applicable changes, including negative changes. The web address is located on the front and back cover of this formulary.

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How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 109. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

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

• Quantity Limits: For certain drugs, Blue Cross Group MedicareRx limits the amount of the drug that Blue Cross Group MedicareRx will cover. For example, Blue Cross Group MedicareRx provides 60 tablets per 30-day prescription for Losartan 25 mg. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions.You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.You can ask Blue Cross Group MedicareRx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue Cross Group MedicareRx’s formulary?” on page iv for information about how to request an exception.

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What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.If you learn that Blue Cross Group MedicareRx does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Blue Cross Group MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Cross Group MedicareRx.

• You can ask Blue Cross Group MedicareRx to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Blue Cross Group MedicareRx’s Formulary? You can ask Blue Cross Group MedicareRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

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

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

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You may have changes that take you from one treatment setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s exception and appeals processes. However, when you are admitted to, or discharged from, a long-term care setting, you may not have access to the drugs you were previously given. You may get a refill upon admission or discharge to prevent a gap in care.

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

http://www.medicare.gov

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Blue Cross Group MedicareRx’s Formulary The formulary below provides coverage information about the drugs covered by Blue Cross Group MedicareRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 109. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if Blue Cross Group MedicareRx has any special requirements for coverage of your drug.

Most drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contact information appears on the front and back cover pages.

KEY Tier 1 = Preferred Generic Drugs

Tier 2 = Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be providedthat describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more informationconsult your Pharmacy Directory or call Customer Service at 1-877-838-3833, 8:00 a.m. – 8:00 p.m., local time, 7days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail)will be used on weekends and holidays. TTY users should call 711.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers.Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

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Copayment and Coinsurance Amounts: For more information on Copayment and Coinsurance, please review your Evidence of Coverage.

Below is the key for abbreviations used within the drug list.

KEY

act actuation

ad adsorbed

aepb aerosol powder blister

aer, aero aerosol

app applicator

ba, breath act, breath activ breath activated

cal calcium

cap, caps capsules

cart cartridge

cd continuous delivery

chew tab chewable tablets

conc concentrate

conj conjugate, conjugated

crys crystals

deter deterrent

disint, disintegr disintegrating

dr delayed-release

ec enteric coated

el, elu enzyme-linked immunosorbent assay

mcg microgram

meq milliequivalent

misc miscellaneous

mg milligram

ml milliliter

mu million units

nebu nebules

orally disintegr tab

orally disintegrating tablets

oin, oint ointment

op, ophth ophthalmic

osm osmotic

pah pulmonary arterial hypertension

pak pack

pf preservative-free

pfu plaque forming units

pmdd premenstrual dysphoric disorder

pow, powd powder

pref, prefill prefilled

pttw patch twice weekly

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KEY Continued

er, extend- release, extended, extended rel, xr

extended-release

ext extract

gm gram

gu genitourinary

hr hour

im intramuscular

inh, inhal inhalation

inj injection

ir index of reactivity

iv intravenous

l liter

la long acting

lf, Ifu flocculation units

liq, liqd liquid

ptwk patch weekly

recomb recombinant

refrig refrigerate

sl sublingual

sol, soln solution

sqcm square centimeter

supp, suppos suppositories

sus, susp suspension

syr syringe

tab, tabs tablets

td transdermal

tl translingual

unt unit

va vaginal

vac vaccine

2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

1

Drug Name Drug Tier Requirements/LimitsAnalgesicsacetaminophen w/ codeine soln 120-12 mg/5ml 4 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 4 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg# 3 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 3butorphanol tartrate nasal soln 10 mg/ml 4 QL (87.5 mls/30 days)celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 60 mg 4 QL (180 tablets/30 days)codeine sulfate tab 30 mg 4 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2 QL (120 tablets/30 days)diclofenac sodium gel 1% 3 PAdiclofenac sodium soln 1.5% 3 PAdiclofenac sodium tab delayed release 25 mg 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 QL (90 tablets/30 days)diflunisal tab 500 mg 3 QL (90 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg 2 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg 2 QL (90 tablets/30 days)etodolac cap 200 mg 2 QL (150 capsules/30 days)etodolac cap 300 mg 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg 2 QL (30 tablets/30 days)etodolac tab 400 mg 2 QL (60 tablets/30 days)

2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsetodolac tab 500 mg 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg 2 QL (90 tablets/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydromorphone hcl inj 2 mg/ml 4 BDhydromorphone hcl preservative free inj 2 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 2 QL (240 tablets/30 days)ibuprofen tab 600 mg 2 QL (150 tablets/30 days)ibuprofen tab 800 mg 2 QL (120 tablets/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 3 mg 5 QL (120 tablets/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg 2 QL (60 tablets/30 days)meloxicam tab 15 mg 2 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)morphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab er 15 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 4 PA, QL (90 tablets/30 days)

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Drug Name Drug Tier Requirements/Limitsmorphine sulfate tab er 100 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab er 24hr 375 mg 3 QL (120 tablets/30 days)naproxen sodium tab er 24hr 500 mg 3 QL (90 tablets/30 days)naproxen sodium tab 275 mg 3 QL (150 tablets/30 days)naproxen sodium tab 550 mg 3 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 3 QL (1800 mls/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 2 QL (180 tablets/30 days)naproxen tab 375 mg 2 QL (120 tablets/30 days)naproxen tab 500 mg 2 QL (90 tablets/30 days)oxaprozin tab 600 mg 3 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg 3 QL (60 capsules/30 days)piroxicam cap 20 mg 3 QL (30 capsules/30 days)sulindac tab 150 mg 2 QL (60 tablets/30 days)sulindac tab 200 mg 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsAnestheticslidocaine hcl soln 4% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2% 2 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 2lidocaine oint 5% 2 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg 2 QL (30 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

3

disulfiram tab 250 mg 2disulfiram tab 500 mg 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 2naloxone hcl inj 0.4 mg/ml 2naloxone hcl inj 4 mg/10ml 2naltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3

2020


5

Drug Name Drug Tier Requirements/LimitsAMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 3AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 3amoxicillin (trihydrate) cap 250 mg 2amoxicillin (trihydrate) cap 500 mg 2amoxicillin (trihydrate) for susp 125 mg/5ml 2amoxicillin (trihydrate) for susp 200 mg/5ml 2amoxicillin (trihydrate) for susp 250 mg/5ml 2amoxicillin (trihydrate) for susp 400 mg/5ml 2amoxicillin (trihydrate) tab 500 mg 2amoxicillin (trihydrate) tab 875 mg 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 3amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 3amoxicillin & k clavulanate for susp 400-57 mg/5ml 3amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 3amoxicillin & k clavulanate tab 250-125 mg 3amoxicillin & k clavulanate tab 500-125 mg 3amoxicillin & k clavulanate tab 875-125 mg 3AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

3

AMOXICILLIN/CLAVULANATE POTASSIUM ER - amoxicillin & kclavulanate tab er 12hr 1000-62.5 mg

3

AMPICILLIN - ampicillin cap 500 mg 2ampicillin & sulbactam sodium for inj 3 (2-1) gm 3AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg 3ampicillin sodium for inj 500 mg 3ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm 3ampicillin sodium for iv soln 2 gm 3ampicillin sodium for iv soln 10 gm 3AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm3

AUGMENTIN - amoxicillin & k clavulanate for susp125-31.25 mg/5ml

4

AZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZITHROMYCIN - azithromycin powd pack for susp 1 gm 3azithromycin for susp 100 mg/5ml 3

2020


Drug Name Drug Tier Requirements/Limitsazithromycin for susp 200 mg/5ml 3azithromycin iv for soln 500 mg 3azithromycin tab 250 mg 2azithromycin tab 500 mg 2azithromycin tab 600 mg 2aztreonam for inj 1 gm 3aztreonam for inj 2 gm 3BACTOCILL IN DEXTROSE - oxacillin sodium in dextrose inj

1 gm/50ml4

BACTOCILL IN DEXTROSE - oxacillin sodium in dextrose inj2 gm/50ml

4

BICILLIN C-R - penicillin g benzathine & procaine inj susp 1200000unit/2ml

4

BICILLIN C-R - penicillin g benzathine & procaine inj900000-300000 unt/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 600000unit/ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 2cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 3cefdinir for susp 250 mg/5ml 3cefepime hcl for inj 1 gm 3cefepime hcl for inj 2 gm 3cefixime cap 400 mg 3cefixime for susp 100 mg/5ml 3cefixime for susp 200 mg/5ml 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3

2020


7

Drug Name Drug Tier Requirements/Limitscefoxitin sodium for inj 10 gm 3cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml 3cefpodoxime proxetil for susp 100 mg/5ml 3cefpodoxime proxetil tab 100 mg 3cefpodoxime proxetil tab 200 mg 3cefprozil for susp 125 mg/5ml 3cefprozil for susp 250 mg/5ml 3cefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 3ceftazidime for inj 2 gm 3ceftazidime for inj 6 gm 3CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

3

ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74% 50 ml3

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22% 50 ml

3

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 3cefuroxime sodium for inj 7.5 gm 3cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg 2cephalexin cap 500 mg 2cephalexin cap 750 mg 2cephalexin for susp 125 mg/5ml 3cephalexin for susp 250 mg/5ml 3

2020


Drug Name Drug Tier Requirements/LimitsCHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 3ciprofloxacin hcl tab 250 mg 2ciprofloxacin hcl tab 500 mg 2ciprofloxacin hcl tab 750 mg 2ciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml 3CLARITHROMYCIN - clarithromycin for susp 250 mg/5ml 3clarithromycin tab er 24hr 500 mg 3clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2CLEOCIN - clindamycin phosphate vaginal cream 2% 4clindamycin hcl cap 75 mg 2clindamycin hcl cap 150 mg 2clindamycin hcl cap 300 mg 2clindamycin palmitate hcl for soln 75 mg/5ml 3clindamycin phosphate gel 1% 2clindamycin phosphate in d5w iv soln 300 mg/50ml 3clindamycin phosphate in d5w iv soln 600 mg/50ml 3clindamycin phosphate in d5w iv soln 900 mg/50ml 3clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 3colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 3demeclocycline hcl tab 300 mg 3

2020


9

Drug Name Drug Tier Requirements/Limitsdicloxacillin sodium cap 250 mg 3dicloxacillin sodium cap 500 mg 3DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 3doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 3doxycycline monohydrate cap 75 mg 3doxycycline monohydrate cap 100 mg 3doxycycline monohydrate cap 150 mg 3doxycycline monohydrate tab 50 mg 3doxycycline monohydrate tab 75 mg 3doxycycline monohydrate tab 100 mg 3doxycycline monohydrate tab 150 mg 3ertapenem sodium for inj 1 gm 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 3erythromycin ethylsuccinate for susp 400 mg/5ml 3erythromycin pads 2% 2erythromycin soln 2% 2erythromycin tab delayed release 250 mg 4erythromycin tab delayed release 333 mg 4erythromycin tab delayed release 500 mg 4erythromycin tab 250 mg 3erythromycin tab 500 mg 3erythromycin w/ delayed release particles cap 250 mg 3gentamicin in saline inj 1.2 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 1 mg/ml3

GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin insaline inj 1.6 mg/ml

3

imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3

2020


Drug Name Drug Tier Requirements/LimitsIMPAVIDO - miltefosine cap 50 mg 5ISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 3levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 3levofloxacin oral soln 25 mg/ml 3levofloxacin tab 250 mg 2levofloxacin tab 500 mg 2levofloxacin tab 750 mg 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%4

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 3meropenem iv for soln 1 gm 3methenamine hippurate tab 1 gm 2METROGEL-VAGINAL - metronidazole vaginal gel 0.75% 4METRONIDAZOLE - metronidazole in nacl 0.74% iv soln

500 mg/100ml3

METRONIDAZOLE - metronidazole iv soln 5 mg/ml 3metronidazole cap 375 mg 3metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 3minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 3minocycline hcl tab 50 mg 3minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg 3MOXIFLOXACIN HCL - moxifloxacin hcl iv solution 400 mg/250ml 3moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 3

2020


11

Drug Name Drug Tier Requirements/Limitsnafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 3nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg 2NEOMYCIN/POLYMYXIN B SULFATES - neomycin-polymyxin b gu

irrigation soln3

nitrofurantoin macrocrystalline cap 50 mg# 3nitrofurantoin macrocrystalline cap 100 mg# 3nitrofurantoin monohydrate macrocrystalline cap 100 mg# 3nitrofurantoin susp 25 mg/5ml# 4ofloxacin tab 400 mg 2paromomycin sulfate cap 250 mg 3penicillin g potassium for inj 5000000 unit 3penicillin g potassium for inj 20000000 unit 3PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

3

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 3PENICILLIN V POTASSIUM - penicillin v potassium for soln

125 mg/5ml2

PENICILLIN V POTASSIUM - penicillin v potassium for soln250 mg/5ml

2

penicillin v potassium tab 250 mg 2penicillin v potassium tab 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 3sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 3sulfamethoxazole-trimethoprim tab 400-80 mg 2sulfamethoxazole-trimethoprim tab 800-160 mg 2SUPRAX - cefixime chew tab 100 mg 4

2020


Drug Name Drug Tier Requirements/LimitsSUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm 3TAZICEF - ceftazidime for iv soln 2 gm 3TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5tinidazole tab 250 mg 3tinidazole tab 500 mg 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3trimethoprim tab 100 mg 2VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm 3vancomycin hcl cap 125 mg 3 QL (120 capsules/30 days)vancomycin hcl cap 250 mg 3 QL (240 capsules/30 days)vancomycin hcl for iv soln 500 mg 3vancomycin hcl for iv soln 750 mg 3vancomycin hcl for iv soln 1 gm 3vancomycin hcl for iv soln 5 gm 3vancomycin hcl for iv soln 10 gm 3VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose iv

soln 500 mg/100ml-5%4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 750 mg/150ml-5%

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 1 gm/200ml-5%

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln250 mg

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

3

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln2-0.25gm/50ml

4

2020


13

Drug Name Drug Tier Requirements/LimitsZOSYN - piperacillin sod-tazobactam sod in dex iv soln

4-0.5gm/100ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg 2carbamazepine cap er 12hr 200 mg 2carbamazepine cap er 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab er 12hr 100 mg 2carbamazepine tab er 12hr 200 mg 2carbamazepine tab er 12hr 400 mg 2carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

2020


Drug Name Drug Tier Requirements/LimitsDIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

20 mg4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 3divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab er 24 hr 250 mg 2divalproex sodium tab er 24 hr 500 mg 2EPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PAethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 3felbamate tab 600 mg 3fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg 2 QL (1080 capsules/30 days)gabapentin cap 300 mg 2 QL (360 capsules/30 days)gabapentin cap 400 mg 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 2 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 2lamotrigine tab 150 mg 2lamotrigine tab 200 mg 2levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3

2020


15

Drug Name Drug Tier Requirements/Limitslevetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3oxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 15 mg# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 30 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 60 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenobarbital tab 100 mg# 4 PAphenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2pregabalin cap 25 mg 3 QL (90 capsules/30 days)pregabalin cap 50 mg 3 QL (90 capsules/30 days)pregabalin cap 75 mg 3 QL (90 capsules/30 days)pregabalin cap 100 mg 3 QL (90 capsules/30 days)pregabalin cap 150 mg 3 QL (90 capsules/30 days)pregabalin cap 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg 3 QL (60 capsules/30 days)pregabalin cap 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)primidone tab 50 mg 2primidone tab 250 mg 2

2020


Drug Name Drug Tier Requirements/LimitsSPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 3tiagabine hcl tab 12 mg 3tiagabine hcl tab 16 mg 3topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 2topiramate tab 50 mg 2topiramate tab 100 mg 2topiramate tab 200 mg 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml 2valproic acid cap 250 mg 2vigabatrin powd pack 500 mg* 5 QL (180 packets/30 days)vigabatrin tab 500 mg* 5 QL (180 tablets/30 days)VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg 2zonisamide cap 50 mg 2zonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 2donepezil hydrochloride tab 10 mg 2donepezil hydrochloride tab 23 mg 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3

2020


17

Drug Name Drug Tier Requirements/LimitsGALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml3

galantamine hydrobromide cap er 24hr 8 mg 2galantamine hydrobromide cap er 24hr 16 mg 2galantamine hydrobromide cap er 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2galantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 3 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PArivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2rivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 3rivastigmine td patch 24hr 9.5 mg/24hr 3rivastigmine td patch 24hr 13.3 mg/24hr 3Antidepressantsamitriptyline hcl tab 10 mg# 3amitriptyline hcl tab 25 mg# 3amitriptyline hcl tab 50 mg# 3amitriptyline hcl tab 75 mg# 3amitriptyline hcl tab 100 mg# 3amitriptyline hcl tab 150 mg# 3AMOXAPINE - amoxapine tab 25 mg# 3AMOXAPINE - amoxapine tab 50 mg# 3AMOXAPINE - amoxapine tab 100 mg# 3AMOXAPINE - amoxapine tab 150 mg# 3bupropion hcl tab er 12hr 100 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)CELEXA - citalopram hydrobromide tab 10 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 20 mg 4 QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsCELEXA - citalopram hydrobromide tab 40 mg 4 QL (30 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4clomipramine hcl cap 50 mg# 4clomipramine hcl cap 75 mg# 4desipramine hcl tab 10 mg# 4desipramine hcl tab 25 mg# 4desipramine hcl tab 50 mg# 4desipramine hcl tab 75 mg# 4desipramine hcl tab 100 mg# 4desipramine hcl tab 150 mg# 4desvenlafaxine succinate tab er 24hr 25 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 3 QL (30 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 150 mg# 3doxepin hcl cap 10 mg# 3doxepin hcl cap 25 mg# 3doxepin hcl cap 50 mg# 3doxepin hcl cap 75 mg# 3doxepin hcl cap 100 mg# 3doxepin hcl conc 10 mg/ml# 3duloxetine hcl enteric coated pellets cap 20 mg 3 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 3 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 3 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 3 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)

2020


19

Drug Name Drug Tier Requirements/LimitsFETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 3imipramine hcl tab 25 mg# 3imipramine hcl tab 50 mg# 3LEXAPRO - escitalopram oxalate tab 5 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 10 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 20 mg 4 QL (30 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 1 QL (30 tablets/30 days)mirtazapine tab 15 mg 1 QL (45 tablets/30 days)mirtazapine tab 30 mg 1 QL (30 tablets/30 days)mirtazapine tab 45 mg 1 QL (30 tablets/30 days)NARDIL - phenelzine sulfate tab 15 mg 4NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 250 mg 2nefazodone hcl tab 50 mg 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 3nortriptyline hcl cap 10 mg# 3nortriptyline hcl cap 25 mg# 3nortriptyline hcl cap 50 mg# 3

2020


Drug Name Drug Tier Requirements/Limitsnortriptyline hcl cap 75 mg# 3PARNATE - tranylcypromine sulfate tab 10 mg 4paroxetine hcl tab 10 mg# 3 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 3 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 3 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 3 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)PAXIL - paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)PAXIL - paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)PAXIL - paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)phenelzine sulfate tab 15 mg 2protriptyline hcl tab 5 mg# 3protriptyline hcl tab 10 mg# 3PROZAC - fluoxetine hcl cap 10 mg 4 QL (90 capsules/30 days)PROZAC - fluoxetine hcl cap 20 mg 4 QL (120 capsules/30 days)PROZAC - fluoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)REMERON - mirtazapine tab 15 mg 4 QL (45 tablets/30 days)REMERON - mirtazapine tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 4 QL (30 tablets/30 days)sertraline hcl oral concentrate for solution 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

x 2 (56 mg dose pack)5 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln 28 mg/devicex 3 (84 mg dose pack)

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg 2trazodone hcl tab 100 mg 2trazodone hcl tab 150 mg 2trazodone hcl tab 300 mg 2trimipramine maleate cap 25 mg# 3trimipramine maleate cap 50 mg# 3trimipramine maleate cap 100 mg# 3TRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)

2020


21

Drug Name Drug Tier Requirements/LimitsTRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

ZOLOFT - sertraline hcl tab 25 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 50 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 100 mg 4 QL (60 tablets/30 days)Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 3 BDaprepitant capsule 40 mg 3 BDaprepitant capsule 80 mg 3 BDaprepitant capsule 125 mg 3 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 3 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 3 PAchlorpromazine hcl tab 100 mg 3 PAchlorpromazine hcl tab 200 mg 3 PAdronabinol cap 2.5 mg 4 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3granisetron hcl tab 1 mg 2 BDmeclizine hcl tab 12.5 mg# 3

2020


Drug Name Drug Tier Requirements/Limitsondansetron hcl inj 4 mg/2ml (2 mg/ml) 3ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml 3 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

perphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PAPROCHLORPERAZINE EDISYLATE - prochlorperazine edisylate

inj 50 mg/10ml4

prochlorperazine edisylate inj 10 mg/2ml 4prochlorperazine maleate tab 5 mg 2prochlorperazine maleate tab 10 mg 2prochlorperazine suppos 25 mg 3promethazine hcl suppos 12.5 mg# 3 PApromethazine hcl suppos 25 mg# 3 PApromethazine hcl syrup 6.25 mg/5ml# 3 PApromethazine hcl tab 12.5 mg# 3 PApromethazine hcl tab 25 mg# 3 PApromethazine hcl tab 50 mg# 3 PAscopolamine td patch 72hr 1 mg/3days# 3 PAtrimethobenzamide hcl cap 300 mg 3AntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 3 BDcaspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2ciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2

2020


23

Drug Name Drug Tier Requirements/Limitsciclopirox solution 8% 2clotrimazole cream 1% 2clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1% 3fluconazole for susp 10 mg/ml 3fluconazole for susp 40 mg/ml 3fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 3griseofulvin microsize tab 500 mg 3griseofulvin ultramicrosize tab 125 mg 3griseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 3ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 2posaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg 2

2020


Drug Name Drug Tier Requirements/LimitsTERCONAZOLE - terconazole vaginal cream 0.8% 3terconazole vaginal cream 0.4% 3terconazole vaginal suppos 80 mg 3voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg 2allopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine w/ probenecid tab 0.5-500 mg 2MITIGARE - colchicine cap 0.6 mg 3probenecid tab 500 mg 2ZYLOPRIM - allopurinol tab 100 mg 4ZYLOPRIM - allopurinol tab 300 mg 4Antimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/

ml3 PA, QL (2 pens/30 days)

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector140 mg/ml

3 PA, QL (1 pen/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector120 mg/ml

3 PA, QL (2 pens/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr100 mg/ml

3 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr120 mg/ml


ergotamine w/ caffeine tab 1-100 mg 3frovatriptan succinate tab 2.5 mg 3 QL (18 tablets/30 days)MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg 3 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 3 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 3 QL (12 units (2

packages)/30 days)

2020


25

Drug Name Drug Tier Requirements/LimitsSUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml4

sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 4sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 3pyridostigmine bromide oral soln 60 mg/5ml 5pyridostigmine bromide tab er 180 mg 3pyridostigmine bromide tab 60 mg 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4cycloserine cap 250 mg 5dapsone tab 25 mg 3dapsone tab 100 mg 3ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2ISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg 2isoniazid tab 300 mg 2PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 3rifabutin cap 150 mg 4rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg* 5TRECATOR - ethionamide tab 250 mg 4Antineoplasticsabiraterone acetate tab 250 mg 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAADRIAMYCIN - doxorubicin hcl for inj 10 mg 4 BDADRIAMYCIN - doxorubicin hcl for inj 50 mg 4 BD

2020


Drug Name Drug Tier Requirements/LimitsAFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5 PAALIMTA - pemetrexed disodium for iv soln 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg* 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 2ARRANON - nelarabine iv soln 5 mg/ml 5 PAarsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 4arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5 PAARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5 PAAVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5 PAAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5 PABALVERSA - erdafitinib tab 3 mg 5 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg 5 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg 5 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5 PABELEODAQ - belinostat for iv inj 500 mg 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg 5 PAbicalutamide tab 50 mg 2bleomycin sulfate for inj 15 unit 3 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)

2020


27

Drug Name Drug Tier Requirements/LimitsBRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg* 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 PA, QL (112 capsules/28 days)

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*


COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 3 BDcyclophosphamide cap 50 mg 3 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5 PACYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5 PACYTARABINE - cytarabine inj 20 mg/ml 3 BDcytarabine inj pf 20 mg/ml 3 BDcytarabine inj pf 100 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3

2020


Drug Name Drug Tier Requirements/Limitsdactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5 PADARZALEX - daratumumab iv soln 400 mg/20ml* 5 PAdaunorubicin hcl iv soln 20 mg/4ml 3DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml3

DAURISMO - glasdegib maleate tab 25 mg 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane hcl for inj 250 mg 5dexrazoxane hcl for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5docetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg 4 BDdoxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 3 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PAELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg 5 PAEMPLICITI - elotuzumab for iv soln 400 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 4epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 4ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5 PAERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4

2020


29

Drug Name Drug Tier Requirements/Limitsetoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3EVOMELA - melphalan hcl for inj 50 mg (propylene glycol (pg) free) 5exemestane tab 25 mg 3FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5 PAfludarabine phosphate for inj 50 mg 3fludarabine phosphate inj 25 mg/ml 3fluorouracil iv soln 500 mg/10ml (50 mg/ml) 3 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml) 3 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 3 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 3 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAfulvestrant inj 250 mg/5ml 5 PAGAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 3gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 3gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 3GILOTRIF - afatinib dimaleate tab 20 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg* 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 5HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk inj

600-10000 mg-unit/5ml*5 PA

hydroxyurea cap 500 mg 3IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)

2020


Drug Name Drug Tier Requirements/LimitsIBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg* 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg* 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg* 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg* 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 4ifosfamide iv inj 3 gm/60ml (50 mg/ml) 4imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg* 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg* 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg* 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)

2020


31

Drug Name Drug Tier Requirements/LimitsJAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml) 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (42 tablets/28 days)

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mgtab)

5 PA, QL (63 tablets/28 days)

KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk






KYPROLIS - carfilzomib for inj 10 mg 5 PAKYPROLIS - carfilzomib for inj 30 mg 5 PAKYPROLIS - carfilzomib for inj 60 mg 5 PALARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

2020


Drug Name Drug Tier Requirements/Limitsletrozole tab 2.5 mg 2LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)3

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium inj 500 mg/50ml (10 mg/ml) 3leucovorin calcium tab 5 mg 3leucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 5LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml)* 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PALYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 5mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MVASI - bevacizumab-awwb iv soln 100 mg/4ml (for infusion) 5 PA

2020


33

Drug Name Drug Tier Requirements/LimitsMVASI - bevacizumab-awwb iv soln 400 mg/16ml (for infusion) 5 PAMYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg* 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5NUBEQA - darolutamide tab 300 mg 5 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml 5 PAOPDIVO - nivolumab iv soln 100 mg/10ml 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml 5 PAoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mgdaily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg dailydose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 140 mg 5 PAPOMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PA

2020


Drug Name Drug Tier Requirements/LimitsPROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml*5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml*

5 PA

RUBRACA - rucaparib camsylate tab 200 mg* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg* 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg* 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg* 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg 2

2020


35

Drug Name Drug Tier Requirements/Limitstamoxifen citrate tab 20 mg 2TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 840 mg/14ml* 5 PATECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 4topotecan hcl inj 4 mg/4ml (for infusion) 4toremifene citrate tab 60 mg 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg* 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BD

2020


Drug Name Drug Tier Requirements/Limitsvincristine sulfate iv soln 1 mg/ml 3 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VITRAKVI - larotrectinib sulfate cap 25 mg 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg* 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack

20 mg (100 mg once weekly)5 PA, QL (1 box/28 days)

XPOVIO 60 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (60 mg once weekly)

5 PA, QL (1 box/28 days)

XPOVIO 80 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (80 mg once weekly)


XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapy pack20 mg (80 mg twice weekly)


XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5 PAYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5 PAYONDELIS - trabectedin for inj 1 mg 5 PAYONSA - abiraterone acetate tab 125 mg* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5 PAZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg* 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (90 capsules/30 days)ZYKADIA - ceritinib tab 150 mg* 5 PA, QL (90 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 5

2020


37

Drug Name Drug Tier Requirements/LimitsALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg 3COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2LINDANE - lindane shampoo 1% 3malathion lotion 0.5% 3MEFLOQUINE HCL - mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4pentamidine isethionate for soln 300 mg 3permethrin cream 5% 3praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg 3Antiparkinson Agentsamantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2amantadine hcl tab 100 mg 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 3bromocriptine mesylate tab 2.5 mg 3carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab er 25-100 mg 2carbidopa & levodopa tab er 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2

2020


Drug Name Drug Tier Requirements/Limitscarbidopa & levodopa tab 25-100 mg 2carbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 4CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

3


3


3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

3

entacapone tab 200 mg 3INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg 2pramipexole dihydrochloride tab 0.25 mg 2pramipexole dihydrochloride tab 0.5 mg 2pramipexole dihydrochloride tab 0.75 mg 2pramipexole dihydrochloride tab 1 mg 2pramipexole dihydrochloride tab 1.5 mg 2rasagiline mesylate tab 0.5 mg 3rasagiline mesylate tab 1 mg 3ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2RYTARY - carbidopa & levodopa cap er 23.75-95 mg 4RYTARY - carbidopa & levodopa cap er 36.25-145 mg 4RYTARY - carbidopa & levodopa cap er 48.75-195 mg 4RYTARY - carbidopa & levodopa cap er 61.25-245 mg 4selegiline hcl cap 5 mg 3selegiline hcl tab 5 mg 3tolcapone tab 100 mg 5

2020


39

Drug Name Drug Tier Requirements/LimitsAntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 3 QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 QL (60 tablets/30 days)aripiprazole tab 2 mg 3 QL (45 tablets/30 days)aripiprazole tab 5 mg 3 QL (45 tablets/30 days)aripiprazole tab 10 mg 3 QL (30 tablets/30 days)aripiprazole tab 15 mg 3 QL (30 tablets/30 days)aripiprazole tab 20 mg 3 QL (30 tablets/30 days)aripiprazole tab 30 mg 3 QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 QL (1 syringe/28 days)





ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml


clozapine orally disintegrating tab 12.5 mg 3 QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 3 QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 3 QL (270 tablets/30 days)clozapine tab 25 mg 2 QL (90 tablets/30 days)clozapine tab 50 mg 2 QL (90 tablets/30 days)clozapine tab 100 mg 2 QL (270 tablets/30 days)clozapine tab 200 mg 2 QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 QL (7 packs (56 tablets)/28 days)

fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PA

2020


Drug Name Drug Tier Requirements/Limitsfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PAfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml3 PA

GEODON - ziprasidone mesylate for inj 20 mg 4 QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PAhaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref syr

39 mg/0.25ml4 QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate er susp pref syr78 mg/0.5ml

5 QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate er susp pref syr156 mg/ml




INVEGA TRINZA - paliperidone palmitate er susp pref syr273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PA

2020


41

Drug Name Drug Tier Requirements/Limitsloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)olanzapine for im inj 10 mg 3 QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 QL (45 tablets/30 days)olanzapine tab 5 mg 2 QL (45 tablets/30 days)olanzapine tab 7.5 mg 2 QL (45 tablets/30 days)olanzapine tab 10 mg 2 QL (45 tablets/30 days)olanzapine tab 15 mg 2 QL (30 tablets/30 days)olanzapine tab 20 mg 2 QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


PIMOZIDE - pimozide tab 1 mg 3PIMOZIDE - pimozide tab 2 mg 3quetiapine fumarate tab er 24hr 50 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 3 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 3 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab 25 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 2 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsquetiapine fumarate tab 400 mg 2 QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for im extended

rel susp 12.5 mg4 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 25 mg

5 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 50 mg


RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 QL (480 mls/30 days)risperidone tab 0.25 mg 2 QL (60 tablets/30 days)risperidone tab 0.5 mg 2 QL (60 tablets/30 days)risperidone tab 1 mg 2 QL (60 tablets/30 days)risperidone tab 2 mg 2 QL (60 tablets/30 days)risperidone tab 3 mg 2 QL (60 tablets/30 days)risperidone tab 4 mg 2 QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 QL (60 tablets/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PA

2020


43

Drug Name Drug Tier Requirements/Limitstrifluoperazine hcl tab 1 mg 2 PAtrifluoperazine hcl tab 2 mg 2 PAtrifluoperazine hcl tab 5 mg 2 PAtrifluoperazine hcl tab 10 mg 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 4 QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 2 QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg


ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 1baclofen tab 20 mg 1dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 2tizanidine hcl tab 2 mg 1tizanidine hcl tab 4 mg 1Antiviralsabacavir sulfate soln 20 mg/ml 3 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 3 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir oint 5% 4 PAacyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg 2

2020


Drug Name Drug Tier Requirements/Limitsacyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg5 QL (30 tablets/30 days)

DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 3 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (120 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 3entecavir tab 1 mg 3EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2

2020


45

Drug Name Drug Tier Requirements/Limitsfosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 3 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 3 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 3 QL (60 tablets/30 days)LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab 90-400 mg 5 PALEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)nevirapine susp 50 mg/5ml 3 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg 2

2020


Drug Name Drug Tier Requirements/Limitsoseltamivir phosphate cap 45 mg 2oseltamivir phosphate cap 75 mg 2oseltamivir phosphate for susp 6 mg/ml 3PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 480 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 5RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab therapy pack 400 mg

(800 mg daily dose)5

RIBASPHERE RIBAPAK - ribavirin tab therapy pack 600 mg(1200 mg daily dose)

5

ribavirin cap 200 mg 3ribavirin tab 200 mg 3ritonavir tab 100 mg 3 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOFOSBUVIR/VELPATASVIR - sofosbuvir-velpatasvir tab

400-100 mg5 PA

stavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)

2020


47

Drug Name Drug Tier Requirements/Limitsstavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


tenofovir disoproxil fumarate tab 300 mg 4 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)





TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg 2valacyclovir hcl tab 1 gm 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 400 mg 4 QL (30 capsules/30 days)VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsVIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)XOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg (80 mgdose)

4

zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 3 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsalprazolam tab 0.25 mg 4 QL (120 tablets/30 days)alprazolam tab 0.5 mg 4 QL (120 tablets/30 days)alprazolam tab 1 mg 4 QL (120 tablets/30 days)alprazolam tab 2 mg 4 QL (150 tablets/30 days)buspirone hcl tab 5 mg 2buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 2buspirone hcl tab 15 mg 2buspirone hcl tab 30 mg 2chlordiazepoxide hcl cap 5 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 10 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 25 mg 3 PA, QL (360 capsules/30 days)clonazepam orally disintegrating tab 0.125 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 QL (300 tablets/30 days)clonazepam tab 0.5 mg 2 QL (120 tablets/30 days)clonazepam tab 1 mg 2 QL (120 tablets/30 days)clonazepam tab 2 mg 2 QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg 2 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 3 PA

2020


49

Drug Name Drug Tier Requirements/Limitshydroxyzine hcl tab 10 mg# 3 PAhydroxyzine hcl tab 25 mg# 3 PAhydroxyzine hcl tab 50 mg# 3 PAlorazepam tab 0.5 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 2 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg 2lithium carbonate cap 300 mg 2lithium carbonate cap 600 mg 2lithium carbonate tab er 300 mg 2lithium carbonate tab er 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 15 mg 4 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 30 mg 4 QL (30 tablets/30 days)ACTOS - pioglitazone hcl tab 45 mg 4 QL (30 tablets/30 days)ALCOHOL SWABS 3AMARYL - glimepiride tab 1 mg 4 QL (240 tablets/30 days)AMARYL - glimepiride tab 2 mg 4 QL (120 tablets/30 days)AMARYL - glimepiride tab 4 mg 4 QL (60 tablets/30 days)ASSURE ID INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X 1/2" 3ASSURE ID INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" 3ASSURE ID SAFETY PEN NEEDLES 31G X 5MM (1/5" OR 3/16") 3BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X 15/64" 3BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30G

X 1/2"3

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X1/2"

3

2020


Drug Name Drug Tier Requirements/LimitsEASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X

1/2"3

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE1ML/29G X 1/2"

3

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30G X 1/2" 3GAUZE PADS 2" X 2" 3glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 1 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3 QL (4 kits/30 days)GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 4 QL (4 kits/30 days)GLUCOPHAGE - metformin hcl tab 500 mg 4 QL (150 tablets/30 days)GLUCOPHAGE - metformin hcl tab 850 mg 4 QL (90 tablets/30 days)GLUCOPHAGE - metformin hcl tab 1000 mg 4 QL (75 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 500 mg 4 QL (120 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 750 mg 4 QL (60 tablets/30 days)GLUCOTROL - glipizide tab 5 mg 4 QL (240 tablets/30 days)GLUCOTROL - glipizide tab 10 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 2.5 mg 4 QL (240 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 5 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 10 mg 4 QL (60 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 2 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 2 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)2 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml(1 unit dial)

2 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 2 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (6 vials/30 days)

2020


51

Drug Name Drug Tier Requirements/LimitsHUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus

pen-inj 100 unit/ml (50-50)2 QL (20 pens/30 days)

HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)


HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml2 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml2 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

2 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN PEN NEEDLE 29G X 12.7MM (1/2") 3INSULIN PEN NEEDLE 29G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 29G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 30G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 30G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 31G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 32G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 33G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 6MM (1/4" OR 15/64") 3INSULIN PEN NEEDLE 33G X 8MM (1/3" OR 5/16") 3INSULIN SYRINGE (DISP) U-100/0.3ML 3INSULIN SYRINGE (DISP) U-100/0.5ML 3INSULIN SYRINGE (DISP) U-100/1ML 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X 1" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/30G 3

2020


Drug Name Drug Tier Requirements/LimitsINSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/8" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 1" 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/26G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X 5/8" 3INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X 6MM (15/64") 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)

2020


53

Drug Name Drug Tier Requirements/LimitsJANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 2 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 2 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml2 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)miglitol tab 25 mg 3 QL (360 tablets/30 days)miglitol tab 50 mg 3 QL (180 tablets/30 days)miglitol tab 100 mg 3 QL (90 tablets/30 days)MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2"3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"

3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"

3

nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsOZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PRECOSE - acarbose tab 25 mg 4 QL (360 tablets/30 days)PRECOSE - acarbose tab 50 mg 4 QL (180 tablets/30 days)PRECOSE - acarbose tab 100 mg 4 QL (90 tablets/30 days)PREVENT SAFETY PEN NEEDLES 31G X 1/4" 3PREVENT SAFETY PEN NEEDLES 31G X 5/16" 3PROGLYCEM - diazoxide susp 50 mg/ml 3repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SAFETY INSULIN SYRINGES 1ML/30G X 1/2" 3STARLIX - nateglinide tab 60 mg 4 QL (180 tablets/30 days)STARLIX - nateglinide tab 120 mg 4 QL (90 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 3

2020


55

Drug Name Drug Tier Requirements/LimitsTECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 5/16" 3TECHLITE PEN NEEDLES 29G X 10MM 3TECHLITE PEN NEEDLES 29G X 12MM 3TECHLITE PEN NEEDLES 31G X 5MM 3TECHLITE PEN NEEDLES/31G X 6MM 3TECHLITE PEN NEEDLES/31G X 8MM 3TECHLITE PEN NEEDLES/32G X 4MM 3TECHLITE PEN NEEDLES/32G X 6MM 3TECHLITE PEN NEEDLES/32G X 8MM 3TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300

unit/ml (2 unit dial)2 QL (60 mls/30 days)

TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit dial)

2 QL (60 mls/30 days)

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 2 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml2 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 3

2020


Drug Name Drug Tier Requirements/LimitsTRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 3TRUEPLUS PEN NEEDLES 29G X 12MM 3TRUEPLUS PEN NEEDLES 31G X 5MM 3TRUEPLUS PEN NEEDLES 31G X 6MM 3TRUEPLUS PEN NEEDLES 31G X 8MM 3TRUEPLUS PEN NEEDLES 32G X 4MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 3TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 QL (4 pens/28 days), STULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" 3ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 3VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 3VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 3anagrelide hcl cap 1 mg 3ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA


4 PA


5 PA


5 PA


5 PA


5 PA

2020


57

Drug Name Drug Tier Requirements/LimitsARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

300 mcg/0.6ml5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 3azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg 1cilostazol tab 100 mg 1clopidogrel bisulfate tab 75 mg 2clopidogrel bisulfate tab 300 mg 3COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 3dipyridamole tab 50 mg# 3dipyridamole tab 75 mg# 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PA

2020


Drug Name Drug Tier Requirements/LimitsEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5 PA

HEPARIN SODIUM - heparin sodium (porcine) inj soln pref syr5000 unit/0.5ml

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3HEPARIN SODIUM/D5W - heparin sodium (porcine)-dextrose iv sol

20000 unit/500ml-5%3

LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PAMOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NIVESTYM - filgrastim-aafi inj 300 mcg/ml 5 PANIVESTYM - filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 5 PAPRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PA

2020


59

Drug Name Drug Tier Requirements/LimitsPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 3tranexamic acid tab 650 mg 3UDENYCA - pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml 5 PAwarfarin sodium tab 1 mg 2warfarin sodium tab 2 mg 2warfarin sodium tab 2.5 mg 2warfarin sodium tab 3 mg 2warfarin sodium tab 4 mg 2warfarin sodium tab 5 mg 2warfarin sodium tab 6 mg 2warfarin sodium tab 7.5 mg 2warfarin sodium tab 10 mg 2XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml 5 PAZARXIO - filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml 5 PAZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular AgentsACCUPRIL - quinapril hcl tab 5 mg 4ACCUPRIL - quinapril hcl tab 10 mg 4ACCUPRIL - quinapril hcl tab 20 mg 4ACCUPRIL - quinapril hcl tab 40 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5 mg 4

2020


Drug Name Drug Tier Requirements/LimitsACCURETIC - quinapril-hydrochlorothiazide tab 20-25 mg 4acebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2acetazolamide cap er 12hr 500 mg 3acetazolamide tab 125 mg 3acetazolamide tab 250 mg 3ADALAT CC - nifedipine tab er 24hr 30 mg 4ADALAT CC - nifedipine tab er 24hr 60 mg 4ADALAT CC - nifedipine tab er 24hr 90 mg 4ALDACTONE - spironolactone tab 25 mg 4ALDACTONE - spironolactone tab 50 mg 4ALDACTONE - spironolactone tab 100 mg 4aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)ALTACE - ramipril cap 1.25 mg 4ALTACE - ramipril cap 2.5 mg 4ALTACE - ramipril cap 5 mg 4ALTACE - ramipril cap 10 mg 4amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 100 mg 3amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 3amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-10 mg 3amlodipine besylate-atorvastatin calcium tab 5-20 mg 3amlodipine besylate-atorvastatin calcium tab 5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-80 mg 3amlodipine besylate-atorvastatin calcium tab 10-10 mg 3amlodipine besylate-atorvastatin calcium tab 10-20 mg 3amlodipine besylate-atorvastatin calcium tab 10-40 mg 3amlodipine besylate-atorvastatin calcium tab 10-80 mg 3amlodipine besylate-benazepril hcl cap 2.5-10 mg 2

2020


61

Drug Name Drug Tier Requirements/Limitsamlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2amlodipine besylate-benazepril hcl cap 10-20 mg 2amlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-olmesartan medoxomil tab 5-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 5-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 3 QL (30 tablets/30 days)ATACAND - candesartan cilexetil tab 4 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 8 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 16 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 32 mg 4 QL (30 tablets/30 days)ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab

16-12.5 mg4 QL (30 tablets/30 days)

ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg


ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-25 mg


atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2atenolol tab 25 mg 1atenolol tab 50 mg 1atenolol tab 100 mg 1atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5 mg 4 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5 mg 4 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsAVAPRO - irbesartan tab 75 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 150 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 300 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 4 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1BENICAR - olmesartan medoxomil tab 5 mg 4 QL (60 tablets/30 days)BENICAR - olmesartan medoxomil tab 20 mg 4 QL (30 tablets/30 days)BENICAR - olmesartan medoxomil tab 40 mg 4 QL (30 tablets/30 days)BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-25 mg


betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg 2bisoprolol fumarate tab 5 mg 2bisoprolol fumarate tab 10 mg 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2bumetanide tab 2 mg 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4

2020


63

Drug Name Drug Tier Requirements/LimitsCALAN - verapamil hcl tab 120 mg 4CALAN SR - verapamil hcl tab er 120 mg 4CALAN SR - verapamil hcl tab er 240 mg 4candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2captopril tab 50 mg 2captopril tab 100 mg 2CARDIZEM - diltiazem hcl tab 30 mg 4CARDIZEM - diltiazem hcl tab 60 mg 4CARDIZEM - diltiazem hcl tab 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 180 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 240 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 300 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 360 mg 4carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg 2chlorthalidone tab 25 mg 2chlorthalidone tab 50 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg 1clonidine hcl tab 0.2 mg 1

2020


Drug Name Drug Tier Requirements/Limitsclonidine hcl tab 0.3 mg 1clonidine td patch weekly 0.1 mg/24hr 2clonidine td patch weekly 0.2 mg/24hr 2clonidine td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2colestipol hcl granules 5 gm 2colestipol hcl tab 1 gm 2COREG - carvedilol tab 3.125 mg 4COREG - carvedilol tab 6.25 mg 4COREG - carvedilol tab 12.5 mg 4COREG - carvedilol tab 25 mg 4CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)COZAAR - losartan potassium tab 25 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 50 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 100 mg 4 QL (30 tablets/30 days)DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 3 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 3 PA, QL (30 tablets/30 days)diltiazem hcl cap er 24hr 120 mg 3diltiazem hcl cap er 12hr 60 mg 3diltiazem hcl cap er 12hr 90 mg 3diltiazem hcl cap er 12hr 120 mg 3diltiazem hcl cap er 24hr 180 mg 3diltiazem hcl cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 120 mg 3diltiazem hcl coated beads cap er 24hr 180 mg 3diltiazem hcl coated beads cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 300 mg 3diltiazem hcl coated beads cap er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 180 mg 3diltiazem hcl coated beads tab er 24hr 240 mg 3diltiazem hcl coated beads tab er 24hr 300 mg 3diltiazem hcl coated beads tab er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 420 mg 3diltiazem hcl extended release beads cap er 24hr 120 mg 3

2020


65

Drug Name Drug Tier Requirements/Limitsdiltiazem hcl extended release beads cap er 24hr 180 mg 3diltiazem hcl extended release beads cap er 24hr 240 mg 3diltiazem hcl extended release beads cap er 24hr 300 mg 3diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg 3diltiazem hcl tab 30 mg 3diltiazem hcl tab 60 mg 3diltiazem hcl tab 90 mg 3diltiazem hcl tab 120 mg 3DIOVAN - valsartan tab 40 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 80 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 160 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 320 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25 mg 4 QL (30 tablets/30 days)dofetilide cap 125 mcg (0.125 mg) 3dofetilide cap 250 mcg (0.25 mg) 3dofetilide cap 500 mcg (0.5 mg) 3doxazosin mesylate tab 1 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1enalapril maleate & hydrochlorothiazide tab 10-25 mg 1enalapril maleate tab 2.5 mg 1enalapril maleate tab 5 mg 1enalapril maleate tab 10 mg 1enalapril maleate tab 20 mg 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg 2eplerenone tab 50 mg 2EXFORGE - amlodipine besylate-valsartan tab 5-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 5-320 mg 4 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsEXFORGE - amlodipine besylate-valsartan tab 10-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-320 mg 4 QL (30 tablets/30 days)EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg4 QL (30 tablets/30 days)

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg


EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg






ezetimibe tab 10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fluvastatin sodium cap 20 mg 3 QL (60 capsules/30 days)fluvastatin sodium cap 40 mg 3 QL (60 capsules/30 days)fluvastatin sodium tab er 24 hr 80 mg 3 QL (30 tablets/30 days)fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 3furosemide oral soln 10 mg/ml 2

2020


67

Drug Name Drug Tier Requirements/Limitsfurosemide tab 20 mg 1furosemide tab 40 mg 1furosemide tab 80 mg 1gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 2hydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg 1hydrochlorothiazide tab 25 mg 1hydrochlorothiazide tab 50 mg 1HYZAAR - losartan potassium & hydrochlorothiazide tab


HYZAAR - losartan potassium & hydrochlorothiazide tab100-12.5 mg


HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg 4 QL (30 tablets/30 days)indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg 1 QL (30 tablets/30 days)irbesartan tab 150 mg 1 QL (30 tablets/30 days)irbesartan tab 300 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 1 QL (30 tablets/30 days)ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30 mg 3isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide mononitrate tab er 24hr 30 mg 2isosorbide mononitrate tab er 24hr 60 mg 2isosorbide mononitrate tab er 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2labetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2labetalol hcl tab 300 mg 2LASIX - furosemide tab 20 mg 4

2020


Drug Name Drug Tier Requirements/LimitsLASIX - furosemide tab 40 mg 4LASIX - furosemide tab 80 mg 4LIDOCAINE HCL - lidocaine hcl (cardiac) iv pf soln pref syr

50 mg/5ml(1%)4

LIDOCAINE HCL - lidocaine hcl (cardiac) iv soln pref syr 50 mg/5ml(1%)

4

lisinopril & hydrochlorothiazide tab 10-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1lisinopril tab 30 mg 1lisinopril tab 40 mg 1LOPRESSOR - metoprolol tartrate tab 50 mg 4LOPRESSOR - metoprolol tartrate tab 100 mg 4losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)losartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)LOTENSIN - benazepril hcl tab 10 mg 4LOTENSIN - benazepril hcl tab 20 mg 4LOTENSIN - benazepril hcl tab 40 mg 4lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 3metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab er 24hr 25 mg 2metoprolol succinate tab er 24hr 50 mg 2metoprolol succinate tab er 24hr 100 mg 2

2020


69

Drug Name Drug Tier Requirements/Limitsmetoprolol succinate tab er 24hr 200 mg 2metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1MEXILETINE HCL - mexiletine hcl cap 150 mg 3MEXILETINE HCL - mexiletine hcl cap 200 mg 3MEXILETINE HCL - mexiletine hcl cap 250 mg 3MICARDIS - telmisartan tab 20 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 40 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 80 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 40-12.5 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (60 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-25 mg 4 QL (30 tablets/30 days)midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2minoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2moexipril hcl tab 15 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2nadolol tab 80 mg 2niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab er 24hr 30 mg 3nifedipine tab er 24hr 60 mg 3nifedipine tab er 24hr 90 mg 3nifedipine tab er 24hr osmotic release 30 mg 3nifedipine tab er 24hr osmotic release 60 mg 3nifedipine tab er 24hr osmotic release 90 mg 3nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg 3

2020


Drug Name Drug Tier Requirements/Limitsnisoldipine tab er 24hr 17 mg 3nisoldipine tab er 24hr 34 mg 3NITRO-BID - nitroglycerin oint 2% 3nitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 3NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PANORVASC - amlodipine besylate tab 2.5 mg 4NORVASC - amlodipine besylate tab 5 mg 4NORVASC - amlodipine besylate tab 10 mg 4olmesartan medoxomil tab 5 mg 1 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg 1 QL (30 tablets/30 days)olmesartan medoxomil tab 40 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg 1 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg 3 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm 3pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 2pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 1 QL (45 tablets/30 days)

2020


71

Drug Name Drug Tier Requirements/Limitspravastatin sodium tab 40 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2PRINIVIL - lisinopril tab 5 mg 4PRINIVIL - lisinopril tab 10 mg 4PRINIVIL - lisinopril tab 20 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 30 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 60 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 90 mg 4propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 3propafenone hcl cap er 12hr 425 mg 3propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl cap er 24hr 60 mg 2propranolol hcl cap er 24hr 80 mg 2propranolol hcl cap er 24hr 120 mg 2propranolol hcl cap er 24hr 160 mg 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg 1propranolol hcl tab 20 mg 1propranolol hcl tab 40 mg 1propranolol hcl tab 60 mg 1propranolol hcl tab 80 mg 1quinapril hcl tab 5 mg 1quinapril hcl tab 10 mg 1quinapril hcl tab 20 mg 1quinapril hcl tab 40 mg 1quinapril-hydrochlorothiazide tab 10-12.5 mg 2quinapril-hydrochlorothiazide tab 20-12.5 mg 2quinapril-hydrochlorothiazide tab 20-25 mg 2quinidine gluconate tab er 324 mg 3QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg 1

2020


Drug Name Drug Tier Requirements/Limitsramipril cap 2.5 mg 1ramipril cap 5 mg 1ramipril cap 10 mg 1ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)RECTIV - nitroglycerin oint 0.4% 4REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml3 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

3 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

3 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)simvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 2spironolactone tab 50 mg 2spironolactone tab 100 mg 2TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)

2020


73

Drug Name Drug Tier Requirements/Limitstelmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg 1 QL (60 capsules/30 days)TIAZAC - diltiazem hcl extended release beads cap er 24hr 120 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 180 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 240 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 300 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 360 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 420 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3timolol maleate tab 5 mg 2torsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 1trandolapril tab 1 mg 1trandolapril tab 2 mg 1trandolapril tab 4 mg 1triamterene & hydrochlorothiazide cap 37.5-25 mg 2triamterene & hydrochlorothiazide tab 37.5-25 mg 2triamterene & hydrochlorothiazide tab 75-50 mg 2TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg4 QL (30 tablets/30 days)

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg


valsartan tab 40 mg 2 QL (60 tablets/30 days)valsartan tab 80 mg 2 QL (60 tablets/30 days)valsartan tab 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsvalsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3VASERETIC - enalapril maleate & hydrochlorothiazide tab

10-25 mg4

VASOTEC - enalapril maleate tab 2.5 mg 4VASOTEC - enalapril maleate tab 5 mg 4VASOTEC - enalapril maleate tab 10 mg 4VASOTEC - enalapril maleate tab 20 mg 4verapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2VERAPAMIL HCL ER- verapamil hcl cap er 24hr 100 mg 2VERAPAMIL HCL SR - verapamil hcl cap er 24hr 360 mg 2verapamil hcl tab er 120 mg 2verapamil hcl tab er 180 mg 2verapamil hcl tab er 240 mg 2verapamil hcl tab 40 mg 1verapamil hcl tab 80 mg 1verapamil hcl tab 120 mg 1VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 4ZESTRIL - lisinopril tab 2.5 mg 4ZESTRIL - lisinopril tab 5 mg 4ZESTRIL - lisinopril tab 10 mg 4ZESTRIL - lisinopril tab 20 mg 4ZESTRIL - lisinopril tab 30 mg 4ZESTRIL - lisinopril tab 40 mg 4Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 4 QL (30 capsules/30 days)

2020


75

Drug Name Drug Tier Requirements/Limitsamphetamine-dextroamphetamine cap er 24hr 10 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)atomoxetine hcl cap 10 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 3 QL (30 capsules/30 days)AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)dalfampridine tab er 12hr 10 mg 5 PAdexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)MAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsmethylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack


PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack


riluzole tab 50 mg 3TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentscevimeline hcl cap 30 mg 3chlorhexidine gluconate soln 0.12% 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2Dermatological Agentsacitretin cap 10 mg 3acitretin cap 17.5 mg 3acitretin cap 25 mg 3alclometasone dipropionate cream 0.05% 2 QL (120 grams/30 days)alclometasone dipropionate oint 0.05% 2 QL (120 grams/30 days)AUGMENTED BETAMETHASONE DIPROPIONATE -

betamethasone dipropionate augmented gel 0.05%3 QL (200 grams/28 days)

azelaic acid gel 15% 3AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 3betamethasone dipropionate augmented cream 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate augmented lotion 0.05% 2 QL (210 mls/30 days)

2020


77

Drug Name Drug Tier Requirements/Limitsbetamethasone dipropionate augmented oint 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate cream 0.05% 2 QL (135 grams/30 days)betamethasone dipropionate lotion 0.05% 2 QL (120 mls/30 days)betamethasone dipropionate oint 0.05% 2 QL (135 grams/30 days)betamethasone valerate cream 0.1% 2 QL (135 grams/30 days)betamethasone valerate lotion 0.1% 2 QL (120 mls/30 days)betamethasone valerate oint 0.1% 2 QL (135 grams/30 days)calcipotriene cream 0.005% 3calcipotriene oint 0.005% 3calcipotriene soln 0.005% (50 mcg/ml) 3clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 3clindamycin phosphate-benzoyl peroxide gel 1-5% 3clobetasol propionate cream 0.05% 3 QL (210 grams/28 days)clobetasol propionate emollient base cream 0.05% 3 QL (210 grams/28 days)clobetasol propionate gel 0.05% 3 QL (210 grams/28 days)clobetasol propionate oint 0.05% 3 QL (210 grams/28 days)clobetasol propionate soln 0.05% 3 QL (200 mls/28 days)clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2desonide cream 0.05% 3 QL (120 grams/30 days)desonide lotion 0.05% 3 QL (118 mls/30 days)desonide oint 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.25% 3 QL (120 grams/30 days)desoximetasone gel 0.05% 3 QL (120 grams/30 days)desoximetasone oint 0.25% 3 QL (120 grams/30 days)diclofenac sodium (actinic keratoses) gel 3% 4diflorasone diacetate oint 0.05% 4 QL (120 grams/30 days)ELIDEL - pimecrolimus cream 1% 4 PAfluocinolone acetonide cream 0.01% 2 QL (120 grams/30 days)fluocinonide cream 0.05% 2 QL (120 grams/30 days)fluocinonide emulsified base cream 0.05% 2 QL (120 grams/30 days)fluocinonide gel 0.05% 2 QL (120 grams/30 days)fluocinonide oint 0.05% 2 QL (120 grams/30 days)fluocinonide soln 0.05% 2 QL (120 mls/30 days)FLUOROURACIL - fluorouracil cream 0.5% 5FLUOROURACIL - fluorouracil soln 2% 2FLUOROURACIL - fluorouracil soln 5% 2

2020


Drug Name Drug Tier Requirements/Limitsfluorouracil cream 5% 3fluticasone propionate cream 0.05% 2 QL (120 grams/30 days)fluticasone propionate oint 0.005% 2 QL (120 grams/30 days)gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2halobetasol propionate cream 0.05% 3 QL (200 grams/28 days)halobetasol propionate oint 0.05% 3 QL (200 grams/28 days)hydrocortisone butyrate cream 0.1% 3 QL (135 grams/30 days)hydrocortisone butyrate hydrophilic lipo base cream 0.1% 3 QL (120 grams/30 days)hydrocortisone butyrate oint 0.1% 3 QL (135 grams/30 days)hydrocortisone butyrate soln 0.1% 3 QL (120 mls/30 days)hydrocortisone cream 1% 2 QL (454 grams/30 days)hydrocortisone cream 2.5% 2 QL (454 grams/30 days)hydrocortisone lotion 2.5% 2 QL (118 mls/30 days)hydrocortisone oint 1% 2 QL (453.6 grams/30 days)hydrocortisone oint 2.5% 2 QL (454 grams/30 days)hydrocortisone valerate cream 0.2% 3 QL (120 grams/30 days)hydrocortisone valerate oint 0.2% 3 QL (120 grams/30 days)imiquimod cream 5% 2 PAisotretinoin cap 10 mg 3isotretinoin cap 20 mg 3isotretinoin cap 30 mg 3isotretinoin cap 40 mg 3lactic acid (ammonium lactate) cream 12% 2lactic acid (ammonium lactate) lotion 12% 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75% 2metronidazole gel 0.75% 2metronidazole gel 1% 2metronidazole lotion 0.75% 2mometasone furoate cream 0.1% 2 QL (135 grams/28 days)mometasone furoate oint 0.1% 2 QL (135 grams/28 days)mometasone furoate solution 0.1% (lotion) 2 QL (120 mls/30 days)mupirocin calcium cream 2% 3mupirocin oint 2% 2nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4

2020


79

Drug Name Drug Tier Requirements/LimitsPICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)pimecrolimus cream 1% 4 PApodofilox soln 0.5% 2PREDNICARBATE - prednicarbate cream 0.1% 2 QL (120 grams/30 days)PREDNICARBATE - prednicarbate oint 0.1% 2 QL (120 grams/30 days)REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 3tacrolimus oint 0.03% 2 PAtacrolimus oint 0.1% 2 PAtazarotene cream 0.1% 3 PATAZORAC - tazarotene cream 0.05% 4 PATAZORAC - tazarotene gel 0.05% 4 PATAZORAC - tazarotene gel 0.1% 4 PAtretinoin cream 0.025% 3 PAtretinoin cream 0.05% 3 PAtretinoin cream 0.1% 3 PAtretinoin gel 0.01% 3 PAtretinoin gel 0.025% 3 PAtriamcinolone acetonide cream 0.025% 2 QL (454 grams/30 days)triamcinolone acetonide cream 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide cream 0.5% 2 QL (454 grams/30 days)triamcinolone acetonide lotion 0.025% 2 QL (120 mls/30 days)triamcinolone acetonide lotion 0.1% 2 QL (120 mls/30 days)triamcinolone acetonide oint 0.025% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.5% 2 QL (120 grams/30 days)Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDAMINOSYN II - amino acid infusion 10% 4 BDAMINOSYN-PF - amino acid infusion 10% 4 BDAMINOSYN-PF 7% - amino acid infusion 7% 4 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PA, QL (360 tablets/30 days)calcium acetate cap 667 mg 2calcium acetate tab 667 mg 2

2020


Drug Name Drug Tier Requirements/LimitsCARBAGLU - carglumic acid tab 200 mg* 5 PACHEMET - succimer cap 100 mg 5CLINIMIX E 2.75%/DEXTROSE 5% - amino acid electrolyte w/cal

infusion 2.75% in d5w4 BD

CLINIMIX E 4.25%/DEXTROSE 10% - amino acid electrolyte w/calinfusion 4.25% in d10w

4 BD

CLINIMIX E 4.25%/DEXTROSE 5% - amino acid electrolyte w/calinfusion 4.25% in d5w

4 BD

CLINIMIX E 5%/DEXTROSE 15% - amino acid electrolyte w/calinfusion 5% in d15w

4 BD

CLINIMIX E 5%/DEXTROSE 20% - amino acid electrolyte w/calinfusion 5% in d20w

4 BD

CLINIMIX 4.25%/DEXTROSE 10% - amino acid infusion 4.25% ind10w

4 BD


4 BD


4 BD

CLINIMIX 5%/DEXTROSE 15% - amino acid infusion 5% in d15w 4 BDCLINIMIX 5%/DEXTROSE 20% - amino acid infusion 5% in d20w 4 BDCLINIMIX 5%/DEXTROSE 25% - amino acid infusion 5% in d25w 4 BDdeferasirox tab for oral susp 125 mg 5 PAdeferasirox tab for oral susp 250 mg 5 PAdeferasirox tab for oral susp 500 mg 5 PAdextrose inj 5% 3dextrose inj 10% 3DEXTROSE 2.5%/NACL 0.45% - dextrose 2.5% w/ sodium chloride

0.45%3

dextrose 5% in lactated ringers 3dextrose 5% w/ sodium chloride 0.2% 3dextrose 5% w/ sodium chloride 0.33% 3dextrose 5% w/ sodium chloride 0.45% 3dextrose 5% w/ sodium chloride 0.9% 3fomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)FREAMINE HBC 6.9% - amino acid infusion 6.9% 4 BDFREAMINE III - amino acid infusion 10% 4 BDHEPATAMINE - amino acid infusion 8% 4 BDINTRALIPID - fat emulsion plant based iv emulsion 20% 4 BDJADENU - deferasirox tab 90 mg* 5 PA

2020


81

Drug Name Drug Tier Requirements/LimitsJADENU - deferasirox tab 180 mg* 5 PAJADENU - deferasirox tab 360 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg* 5 PAK-TAB - potassium chloride tab er 20 meq (1500 mg) 3kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 3kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 3kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 3lactated ringer's solution 4lanthanum carbonate chew tab 500 mg 5 QL (90 tablets/30 days)lanthanum carbonate chew tab 750 mg 5 QL (180 tablets/30 days)lanthanum carbonate chew tab 1000 mg 5 QL (120 tablets/30 days)levocarnitine oral soln 1 gm/10ml (10%) 3levocarnitine tab 330 mg 3magnesium sulfate inj 50% 3NEPHRAMINE - amino acid infusion 5.4% 4 BDNORMOSOL-M IN D5W - electrolyte-m in d5w soln 4NUTRILIPID - fat emulsion plant based iv emulsion 20% 4 BDPHOSLYRA - calcium acetate oral soln 667 mg/5ml 4potassium chloride cap er 8 meq 2potassium chloride cap er 10 meq 2POTASSIUM CHLORIDE ER - potassium chloride tab er 20 meq

(1500 mg)3

potassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq 2potassium chloride microencapsulated crys er tab 20 meq 2potassium chloride oral soln 10% (20 meq/15ml) 3potassium chloride tab er 8 meq (600 mg) 3potassium chloride tab er 10 meq 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 3POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

3

2020


Drug Name Drug Tier Requirements/LimitsPOTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -

potassium chloride 40 meq/l (0.3%) in d5w lactated ringers3

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE - kcl20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj

3

potassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2PREMASOL - amino acid infusion 10% 4 BDPROCALAMINE - amino acid electrolyte infusion 3% 4 BDPROSOL - amino acid infusion 20% 4 BDSAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5 QL (270 packets/30 days)sevelamer carbonate packet 2.4 gm 5 QL (90 packets/30 days)sevelamer carbonate tab 800 mg 3 QL (270 tablets/30 days)sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.45% 3sodium chloride iv soln 0.9% 3sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2TRAVASOL - amino acid infusion 10% 4 BDtrientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)TROPHAMINE - amino acid infusion 10% 4 BDVELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5 QL (180 tablets/30 days)VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 5water for irrigation, sterile irrigation soln 3Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5 PA, QL (60 tablets/30 days)alosetron hcl tab 1 mg 5 PA, QL (60 tablets/30 days)AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACARAFATE - sucralfate susp 1 gm/10ml 4CHENODAL - chenodiol tab 250 mg* 5 PACIMETIDINE HCL - cimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2

2020


83

Drug Name Drug Tier Requirements/Limitscimetidine tab 400 mg 2cimetidine tab 800 mg 2COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 240 gm4

cromolyn sodium oral conc 100 mg/5ml 3dicyclomine hcl tab 20 mg# 3 PAesomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg3

esomeprazole sodium for intravenous soln 40 mg 3famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg 2famotidine tab 40 mg 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for soln

236 gm4

lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 3metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 3metoclopramide hcl tab 5 mg 2metoclopramide hcl tab 10 mg 2misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

2020


Drug Name Drug Tier Requirements/LimitsMYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppack 2.5 mg


nizatidine cap 150 mg 2nizatidine cap 300 mg 2NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for

soln 420 gm4

omeprazole cap delayed release 10 mg 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 2 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 2 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 3peg 3350-kcl-sod bicarb-nacl for soln 420 gm 3peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 3peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg5

ranitidine hcl cap 150 mg 2ranitidine hcl cap 300 mg 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2ranitidine hcl tab 150 mg 2ranitidine hcl tab 300 mg 2RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg 3ursodiol tab 250 mg 3ursodiol tab 500 mg 3XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)

2020


85

Drug Name Drug Tier Requirements/LimitsGenetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

CEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CRYSVITA - burosumab-twza inj 10 mg/ml 5 PACRYSVITA - burosumab-twza inj 20 mg/ml 5 PACRYSVITA - burosumab-twza inj 30 mg/ml 5 PACYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4 PACYSTAGON - cysteamine bitartrate cap 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml) 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg* 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5nitisinone cap 2 mg* 5nitisinone cap 5 mg* 5nitisinone cap 10 mg* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5

2020


Drug Name Drug Tier Requirements/LimitsPALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVPRIV - velaglucerase alfa for inj 400 unit 5 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2D-PENAMINE - penicillamine tab 125 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)

2020


87

Drug Name Drug Tier Requirements/Limitsfinasteride tab 5 mg 2 QL (30 tablets/30 days)FLOMAX - tamsulosin hcl cap 0.4 mg 4 QL (60 capsules/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)PROSCAR - finasteride tab 5 mg 4 QL (30 tablets/30 days)silodosin cap 4 mg 3 QL (30 capsules/30 days)silodosin cap 8 mg 3 QL (30 capsules/30 days)tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone tab 1 mg 2DEXAMETHASONE - dexamethasone tab 2 mg 2dexamethasone elixir 0.5 mg/5ml 3dexamethasone sodium phosphate inj 4 mg/ml 3dexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab 0.5 mg 2dexamethasone tab 0.75 mg 2dexamethasone tab 1.5 mg 2dexamethasone tab 4 mg 2dexamethasone tab 6 mg 2fludrocortisone acetate tab 0.1 mg 2hydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2

2020


Drug Name Drug Tier Requirements/Limitshydrocortisone tab 20 mg 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21) 3methylprednisolone tab 4 mg 3methylprednisolone tab 8 mg 3methylprednisolone tab 16 mg 3methylprednisolone tab 32 mg 3prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 3prednisolone sod phosphate oral soln 15 mg/5ml 3prednisolone sod phosphate oral soln 10 mg/5ml 3prednisolone sod phosphate oral soln 20 mg/5ml 3prednisolone syrup 15 mg/5ml 3PREDNISONE - prednisone oral soln 5 mg/5ml 3PREDNISONE - prednisone tab 50 mg 3prednisone tab therapy pack 5 mg (21) 2prednisone tab therapy pack 5 mg (48) 2prednisone tab therapy pack 10 mg (21) 2prednisone tab therapy pack 10 mg (48) 2prednisone tab 1 mg 2prednisone tab 2.5 mg 2prednisone tab 5 mg 2prednisone tab 10 mg 2prednisone tab 20 mg 2Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit4 PA

desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal spray soln 0.01% 3desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PA

2020


89

Drug Name Drug Tier Requirements/LimitsPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit4 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day#4

COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.25 mg/day#

4

danazol cap 50 mg 3 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 3 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 3desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 3desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg 3drospirenone-ethinyl estradiol tab 3-0.02 mg 3drospirenone-ethinyl estradiol tab 3-0.03 mg 3DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 0.5-0.1 mg# 4estradiol & norethindrone acetate tab 1-0.5 mg# 4estradiol tab 0.5 mg# 3estradiol tab 1 mg# 3estradiol tab 2 mg# 3estradiol td patch twice weekly 0.025 mg/24hr# 4estradiol td patch twice weekly 0.0375 mg/24hr# 4estradiol td patch twice weekly 0.05 mg/24hr# 4estradiol td patch twice weekly 0.075 mg/24hr# 4estradiol td patch twice weekly 0.1 mg/24hr# 4estradiol td patch weekly 0.025 mg/24hr# 4

2020


Drug Name Drug Tier Requirements/Limitsestradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4estradiol td patch weekly 0.05 mg/24hr# 4estradiol td patch weekly 0.06 mg/24hr# 4estradiol td patch weekly 0.075 mg/24hr# 4estradiol td patch weekly 0.1 mg/24hr# 4estradiol vaginal cream 0.1 mg/gm 3estradiol vaginal tab 10 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 3HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 3levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 3levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 3levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 3levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 3medroxyprogesterone acetate im susp 150 mg/ml 3medroxyprogesterone acetate tab 2.5 mg 2medroxyprogesterone acetate tab 5 mg 2medroxyprogesterone acetate tab 10 mg 2megestrol acetate susp 40 mg/ml# 3 PAmegestrol acetate tab 20 mg# 3 PAmegestrol acetate tab 40 mg# 3 PAMETHYLTESTOSTERONE - methyltestosterone cap 10 mg 5 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 3norethindrone acetate tab 5 mg 2

2020


91

Drug Name Drug Tier Requirements/Limitsnorethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg# 4norethindrone tab 0.35 mg 3norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 3norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 3norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 3norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 3norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 3norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 3oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4


4


4

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4

progesterone micronized cap 100 mg 3progesterone micronized cap 200 mg 3raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 12.5 mg/act (1%) 3 PA, QL (4 pump bottles/30 days)testosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 units/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 50 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 75 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 88 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 100 mcg (levo-t, levoxyl, unithroid) 2

2020


Drug Name Drug Tier Requirements/Limitslevothyroxine sodium tab 112 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 125 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 137 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 150 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 175 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 200 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 300 mcg (levo-t, unithroid) 2liothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2liothyronine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 5LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5

2020


93

Drug Name Drug Tier Requirements/LimitsLUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 3 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 3 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 3 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 3 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PA

2020


Drug Name Drug Tier Requirements/LimitsSYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 2methimazole tab 10 mg 2propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

4

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)*5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneousauto-inj 150 mg/ml (300 mg dose)*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

CUVITRU - immune globulin (human) subcutaneous inj 1 gm/5ml 5 BD, PA

2020


95

Drug Name Drug Tier Requirements/LimitsCUVITRU - immune globulin (human) subcutaneous inj 2 gm/10ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 4 gm/20ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 8 gm/40ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 10 gm/50ml 5 BD, PAcyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 3 BDcyclosporine iv soln 50 mg/ml 3 BDcyclosporine modified cap 50 mg 3 BDcyclosporine modified cap 25 mg 3 BDcyclosporine modified cap 100 mg 3 BDcyclosporine modified oral soln 100 mg/ml 3 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDGARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im

susp4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit*

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit*

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PA

2020


Drug Name Drug Tier Requirements/LimitsHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 4 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4INFLECTRA - infliximab-dyyb for iv inj 100 mg 5 PAIPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles-mumps-rubella virus vaccines for inj soln 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)2

methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2

2020


97

Drug Name Drug Tier Requirements/Limitsmethotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 3 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 3 BDmycophenolate sodium tab dr 360 mg 3 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector125 mg/ml

5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg*

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 4PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

4

PRIVIGEN - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 40 gm/400ml 5 BD, PAPROGRAF - tacrolimus inj 5 mg/ml 4 BDPROGRAF - tacrolimus packet for susp 0.2 mg 4 BDPROGRAF - tacrolimus packet for susp 1 mg 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp4

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

4

RABAVERT - rabies vaccine, pcec for inj 4 BD

2020


Drug Name Drug Tier Requirements/LimitsRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5RINVOQ - upadacitinib tab er 24hr 15 mg 5 PAROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus oral soln 1 mg/ml 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 3 BDsirolimus tab 2 mg 5 BDSKYRIZI - risankizumab-rzaa sol prefilled syringe 2 x 75 mg/0.83ml

kit5 PA

STAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 3 BDtacrolimus cap 1 mg 3 BDtacrolimus cap 5 mg 3 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 4 BDTHYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TREMFYA - guselkumab soln pen-injector 100 mg/ml 5 PA

2020


99

Drug Name Drug Tier Requirements/LimitsTREMFYA - guselkumab soln prefilled syringe 100 mg/ml 5 PATRUMENBA - meningococcal group b vac (recomb) im susp

prefilled syr4

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 4TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml4

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

VARIZIG - varicella-zoster immune glob (human) im inj 125unit/1.2ml

4

XATMEP - methotrexate oral soln 2.5 mg/ml 4 BDXELJANZ - tofacitinib citrate tab 5 mg 5 PAXELJANZ - tofacitinib citrate tab 10 mg 5 PAXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe 150 mg/ml*

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 4 QL (90 capsules/30 days)CANASA - mesalamine suppos 1000 mg 5hydrocortisone enema 100 mg/60ml 3hydrocortisone rectal cream 1% 2hydrocortisone rectal cream 2.5% 2mesalamine cap dr 400 mg 3 QL (180 capsules/30 days)mesalamine enema 4 gm 3mesalamine rectal enema 4 gm & cleanser wipe kit 3mesalamine suppos 1000 mg 5mesalamine tab delayed release 800 mg 3 QL (180 tablets/30 days)mesalamine tab delayed release 1.2 gm 3 QL (120 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsPENTASA - mesalamine cap er 250 mg 4 QL (480 capsules/30 days)PENTASA - mesalamine cap er 500 mg 4 QL (240 capsules/30 days)sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2CALCITRIOL - calcitriol inj 1 mcg/ml 4calcitriol cap 0.25 mcg 2calcitriol cap 0.5 mcg 2calcitriol oral soln 1 mcg/ml 3cinacalcet hcl tab 30 mg 5 PAcinacalcet hcl tab 60 mg 5 PAcinacalcet hcl tab 90 mg 5 PAFORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 3ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 3paricalcitol cap 2 mcg 3paricalcitol cap 4 mcg 3paricalcitol iv soln 2 mcg/ml 3paricalcitol iv soln 5 mcg/ml 3PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)

2020


101

Drug Name Drug Tier Requirements/LimitsTYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4Ophthalmic AgentsACULAR - ketorolac tromethamine ophth soln 0.5% 4ACULAR LS - ketorolac tromethamine ophth soln 0.4% 4ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03% 2brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 2BROMFENAC - bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 2CILOXAN - ciprofloxacin hcl ophth soln 0.3% 4ciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 2CYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PADEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 3FLURBIPROFEN SODIUM - flurbiprofen sodium ophth soln 0.03% 3FML LIQUIFILM - fluorometholone ophth susp 0.1% 4

2020


Drug Name Drug Tier Requirements/Limitsgatifloxacin ophth soln 0.5% 3GENTAK - gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 2levofloxacin ophth soln 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MAXITROL - neomycin-polymyxin-dexamethasone ophth oint 0.1% 4MAXITROL - neomycin-polymyxin-dexamethasone ophth susp

0.1%4

MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5% 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml2

OCUFLOX - ofloxacin ophth soln 0.3% 4ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2olopatadine hcl ophth soln 0.2% 2PATANOL - olopatadine hcl ophth soln 0.1% 4PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 3pilocarpine hcl ophth soln 2% 3pilocarpine hcl ophth soln 4% 3polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 2POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%4

PRED FORTE - prednisolone acetate ophth susp 1% 4PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 4

2020


103

Drug Name Drug Tier Requirements/LimitsRESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 STSIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth soln 0.25% 2timolol maleate ophth soln 0.5% 2timolol maleate ophth soln 0.5% (once-daily) 2TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timolol

maleate ophth gel forming soln 0.25%2

TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timololmaleate ophth gel forming soln 0.5%

2

TIMOPTIC - timolol maleate ophth soln 0.25% 4TIMOPTIC - timolol maleate ophth soln 0.5% 4TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25% 4TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4TOBRADEX - tobramycin-dexamethasone ophth susp 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TOBREX - tobramycin ophth soln 0.3% 4TRAVATAN Z - travoprost ophth soln 0.004% 3TRIFLURIDINE - trifluridine ophth soln 1% 3Otic Agentsacetic acid otic soln 2% 2fluocinolone acetonide (otic) oil 0.01% 3hydrocortisone w/ acetic acid otic soln 1-2% 3neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 3Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADEMPAS - riociguat tab 0.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg* 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

2020


Drug Name Drug Tier Requirements/LimitsADVAIR DISKUS - fluticasone-salmeterol aer powder ba

250-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 4 mg 3ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 8 mg 3albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BDalbuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab 2 mg 3albuterol sulfate tab 4 mg 3ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act

3 QL (30 blisters/30 days)





ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh












2020


105

Drug Name Drug Tier Requirements/LimitsATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/

act4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 3 BDbudesonide inhalation susp 0.5 mg/2ml 3 BDbudesonide inhalation susp 1 mg/2ml 3 BDcaffeine citrate oral soln 60 mg/3ml 2CAYSTON - aztreonam lysine for inhal soln 75 mg* 5CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 250 mcg 4 PA, QL (30 tablets/30 days)DALIRESP - roflumilast tab 500 mcg 4 PA, QL (30 tablets/30 days)diphenhydramine hcl inj 50 mg/ml 3DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(generic for

EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


2020


Drug Name Drug Tier Requirements/LimitsFLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act

(250/valve)3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act


INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh


ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 25 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 1mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 2montelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 3montelukast sodium tab 10 mg 2OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer80 mcg/act

3 QL (2 canisters/30 days)

REMODULIN - treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BD

2020


107

Drug Name Drug Tier Requirements/LimitsREMODULIN - treprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tabtbpk


SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 3terbutaline sulfate tab 5 mg 3theophylline tab er 12hr 300 mg 2theophylline tab er 12hr 450 mg 2theophylline tab er 24hr 400 mg 2theophylline tab er 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDtreprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDtreprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDtreprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDUPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg

(60)*5 PA, QL (1 pack (200

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)

2020

108

Drug Name Drug Tier Requirements/LimitsUPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 3zafirlukast tab 20 mg 3Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PASleep Disorder Agentsarmodafinil tab 50 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 3 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 3 PA, QL (30 tablets/30 days)modafinil tab 200 mg 3 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4zaleplon cap 10 mg# 4zolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA


2020

109

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................43abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................43abacavir sulfate soln 20 mg/ml.................................. 43abacavir sulfate tab 300 mg.......................................43abiraterone acetate tab 250 mg.................................25ABRAXANE...................................................................25acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 49acarbose tab 25 mg.................................................... 49acarbose tab 50 mg.................................................... 49ACCUPRIL.................................................................... 59ACCUPRIL.................................................................... 59ACCUPRIL.................................................................... 59ACCUPRIL.................................................................... 59ACCURETIC................................................................. 59ACCURETIC................................................................. 59ACCURETIC................................................................. 60acebutolol hcl cap 200 mg..........................................60acebutolol hcl cap 400 mg..........................................60acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................60acetazolamide tab 125 mg......................................... 60acetazolamide tab 250 mg......................................... 60acetic acid otic soln 2%............................................ 103acetylcysteine inhal soln 10%..................................103acetylcysteine inhal soln 20%..................................103acitretin cap 10 mg......................................................76acitretin cap 17.5 mg...................................................76acitretin cap 25 mg......................................................76ACTHIB..........................................................................94ACTIMMUNE................................................................ 94ACTOS...........................................................................49ACTOS...........................................................................49ACTOS...........................................................................49ACULAR......................................................................101ACULAR LS................................................................101acyclovir cap 200 mg.................................................. 43acyclovir oint 5%..........................................................43

acyclovir sodium iv soln 50 mg/ml.............................43acyclovir susp 200 mg/5ml......................................... 43acyclovir tab 400 mg................................................... 43acyclovir tab 800 mg................................................... 44ADACEL........................................................................ 94ADALAT CC..................................................................60ADALAT CC..................................................................60ADALAT CC..................................................................60ADASUVE..................................................................... 39adefovir dipivoxil tab 10 mg........................................44ADEMPAS...................................................................103ADEMPAS...................................................................103ADEMPAS...................................................................103ADEMPAS...................................................................103ADEMPAS...................................................................103ADRIAMYCIN............................................................... 25ADRIAMYCIN............................................................... 25ADVAIR DISKUS....................................................... 103ADVAIR DISKUS....................................................... 104ADVAIR DISKUS....................................................... 104ADVAIR HFA.............................................................. 104ADVAIR HFA.............................................................. 104ADVAIR HFA.............................................................. 104AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AIMOVIG....................................................................... 24AIMOVIG....................................................................... 24albendazole tab 200 mg............................................. 36ALBUTEROL SULFATE ER..................................... 104ALBUTEROL SULFATE ER..................................... 104albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................104albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................. 104albuterol sulfate soln nebu 0.63

mg/3ml......................................................................104albuterol sulfate soln nebu 1.25

mg/3ml......................................................................104albuterol sulfate syrup 2 mg/5ml..............................104albuterol sulfate tab 2 mg.........................................104albuterol sulfate tab 4 mg.........................................104alclometasone dipropionate cream

0.05%..........................................................................76alclometasone dipropionate oint

0.05%..........................................................................76ALCOHOL SWABS......................................................49ALDACTONE................................................................ 60

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ALDACTONE................................................................ 60ALDACTONE................................................................ 60ALDURAZYME............................................................. 85ALECENSA................................................................... 26alendronate sodium tab 10 mg................................ 100alendronate sodium tab 35 mg................................ 100alendronate sodium tab 5 mg.................................. 100alendronate sodium tab 70 mg................................ 100alfuzosin hcl tab er 24hr 10 mg................................. 86ALIMTA.......................................................................... 26ALIMTA.......................................................................... 26ALINIA............................................................................37ALINIA............................................................................37ALIQOPA....................................................................... 26aliskiren fumarate tab 150 mg....................................60aliskiren fumarate tab 300 mg....................................60allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24alosetron hcl tab 0.5 mg............................................. 82alosetron hcl tab 1 mg................................................ 82ALPHAGAN P............................................................ 101alprazolam tab 0.25 mg.............................................. 48alprazolam tab 0.5 mg................................................ 48alprazolam tab 1 mg....................................................48alprazolam tab 2 mg....................................................48ALTACE......................................................................... 60ALTACE......................................................................... 60ALTACE......................................................................... 60ALTACE......................................................................... 60ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26amantadine hcl cap 100 mg.......................................37amantadine hcl syrup 50 mg/5ml...............................37amantadine hcl tab 100 mg........................................37AMARYL........................................................................ 49AMARYL........................................................................ 49AMARYL........................................................................ 49AMBISOME...................................................................22ambrisentan tab 10 mg.............................................104ambrisentan tab 5 mg............................................... 104amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................4amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................4amiloride & hydrochlorothiazide tab 5-50

mg................................................................................60amiloride hcl tab 5 mg.................................................60amino acid infusion 15%.............................................79amino acid infusion 6%...............................................79

AMINOSYN II............................................................... 79AMINOSYN-PF.............................................................79AMINOSYN-PF 7%......................................................79amiodarone hcl tab 100 mg........................................60amiodarone hcl tab 200 mg........................................60amiodarone hcl tab 400 mg........................................60AMITIZA.........................................................................82AMITIZA.........................................................................82amitriptyline hcl tab 100 mg....................................... 17amitriptyline hcl tab 10 mg..........................................17amitriptyline hcl tab 150 mg....................................... 17amitriptyline hcl tab 25 mg..........................................17amitriptyline hcl tab 50 mg..........................................17amitriptyline hcl tab 75 mg..........................................17amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................60amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................60amlodipine besylate-atorvastatin calcium tab 2.5-10







mg................................................................................60amlodipine besylate-benazepril hcl cap 10-20


mg................................................................................61amlodipine besylate-benazepril hcl cap 2.5-10




mg................................................................................61amlodipine besylate-olmesartan medoxomil tab

10-20 mg....................................................................61amlodipine besylate-olmesartan medoxomil tab

10-40 mg....................................................................61

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amlodipine besylate-olmesartan medoxomil tab 5-20mg................................................................................61

amlodipine besylate-olmesartan medoxomil tab 5-40mg................................................................................61

amlodipine besylate tab 10 mg..................................60amlodipine besylate tab 2.5 mg.................................60amlodipine besylate tab 5 mg.................................... 60amlodipine besylate-valsartan tab 10-160

mg................................................................................61amlodipine besylate-valsartan tab 10-320



mg................................................................................61amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................61amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................61amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................61amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................61amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 61AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXICILLIN................................................................. 5AMOXICILLIN................................................................. 5AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5AMOXICILLIN/CLAVULANATE POTASSIUM

ER..................................................................................5amoxicillin (trihydrate) cap 250 mg..............................5amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 5amoxicillin (trihydrate) tab 500 mg...............................5amoxicillin (trihydrate) tab 875 mg...............................5amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 5

amoxicillin & k clavulanate for susp 250-62.5mg/5ml.......................................................................... 5

amoxicillin & k clavulanate for susp 400-57mg/5ml.......................................................................... 5

amoxicillin & k clavulanate for susp 600-42.9mg/5ml.......................................................................... 5

amoxicillin & k clavulanate tab 250-125mg..................................................................................5



amphetamine-dextroamphetamine cap er 24hr 10mg................................................................................75






amphetamine-dextroamphetamine tab 10mg................................................................................75

amphetamine-dextroamphetamine tab 12.5mg................................................................................75





amphetamine-dextroamphetamine tab 7.5mg................................................................................75

AMPHOTERICIN B......................................................22AMPICILLIN.................................................................... 5ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................5AMPICILLIN SODIUM................................................... 5ampicillin sodium for inj 1 gm.......................................5ampicillin sodium for inj 250 mg...................................5ampicillin sodium for inj 2 gm.......................................5ampicillin sodium for inj 500 mg...................................5ampicillin sodium for iv soln 10 gm..............................5ampicillin sodium for iv soln 2 gm................................5AMPICILLIN-SULBACTAM........................................... 5ANADROL-50............................................................... 89anagrelide hcl cap 0.5 mg.......................................... 56

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anagrelide hcl cap 1 mg............................................. 56anastrozole tab 1 mg...................................................26ANDRODERM.............................................................. 89ANDRODERM.............................................................. 89ANORO ELLIPTA.......................................................104APOKYN........................................................................37aprepitant capsule 125 mg.........................................21aprepitant capsule 40 mg........................................... 21aprepitant capsule 80 mg........................................... 21aprepitant capsule therapy pack 80 & 125

mg................................................................................21APRISO......................................................................... 99APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 44APTIVUS....................................................................... 44ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARCALYST....................................................................94aripiprazole orally disintegrating tab 10

mg................................................................................39aripiprazole orally disintegrating tab 15

mg................................................................................39aripiprazole oral solution 1 mg/ml..............................39aripiprazole tab 10 mg................................................ 39aripiprazole tab 15 mg................................................ 39aripiprazole tab 20 mg................................................ 39aripiprazole tab 2 mg...................................................39aripiprazole tab 30 mg................................................ 39aripiprazole tab 5 mg...................................................39ARISTADA.....................................................................39ARISTADA.....................................................................39ARISTADA.....................................................................39ARISTADA.....................................................................39ARISTADA INITIO........................................................39armodafinil tab 150 mg............................................. 108armodafinil tab 200 mg............................................. 108

armodafinil tab 250 mg............................................. 108armodafinil tab 50 mg............................................... 108ARNUITY ELLIPTA....................................................104ARNUITY ELLIPTA....................................................104ARNUITY ELLIPTA....................................................104ARRANON.................................................................... 26arsenic trioxide iv soln 10 mg/10ml (1 mg/

ml)................................................................................26arsenic trioxide iv soln 12 mg/6ml (2 mg/

ml)................................................................................26ARZERRA..................................................................... 26ARZERRA..................................................................... 26ASMANEX HFA..........................................................104ASMANEX HFA..........................................................104ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................104ASMANEX TWISTHALER 14 METERED





DOSES.....................................................................104aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................57ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"......................................... 49ASSURE ID INSULIN SAFETY SYRINGE/

U-100/1ML/29G X 1/2".............................................49ASSURE ID SAFETY PEN NEEDLES 31G X 5MM

(1/5" OR 3/16")..........................................................49ATACAND......................................................................61ATACAND......................................................................61ATACAND......................................................................61ATACAND......................................................................61ATACAND HCT............................................................ 61ATACAND HCT............................................................ 61ATACAND HCT............................................................ 61atazanavir sulfate cap 150 mg...................................44atazanavir sulfate cap 200 mg...................................44atazanavir sulfate cap 300 mg...................................44atenolol & chlorthalidone tab 100-25

mg................................................................................61atenolol & chlorthalidone tab 50-25 mg.................... 61atenolol tab 100 mg.....................................................61atenolol tab 25 mg.......................................................61atenolol tab 50 mg.......................................................61ATGAM.......................................................................... 94atomoxetine hcl cap 100 mg...................................... 75

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atomoxetine hcl cap 10 mg........................................ 75atomoxetine hcl cap 18 mg........................................ 75atomoxetine hcl cap 25 mg........................................ 75atomoxetine hcl cap 40 mg........................................ 75atomoxetine hcl cap 60 mg........................................ 75atomoxetine hcl cap 80 mg........................................ 75atorvastatin calcium tab 10 mg.................................. 61atorvastatin calcium tab 20 mg.................................. 61atorvastatin calcium tab 40 mg.................................. 61atorvastatin calcium tab 80 mg.................................. 61atovaquone-proguanil hcl tab 250-100

mg................................................................................37atovaquone-proguanil hcl tab 62.5-25

mg................................................................................37atovaquone susp 750 mg/5ml....................................37ATRIPLA........................................................................ 44ATROVENT HFA........................................................105AUGMENTED BETAMETHASONE

DIPROPIONATE....................................................... 76AUGMENTIN...................................................................5AURYXIA.......................................................................79AVALIDE........................................................................ 61AVALIDE........................................................................ 61AVAPRO........................................................................ 62AVAPRO........................................................................ 62AVAPRO........................................................................ 62AVASTIN........................................................................26AVASTIN........................................................................26AVONEX........................................................................ 75AVONEX PEN.............................................................. 75azacitidine for inj 100 mg............................................57AZACTAM........................................................................5AZACTAM........................................................................5AZASAN........................................................................ 94AZASAN........................................................................ 94AZATHIOPRINE........................................................... 94azathioprine tab 50 mg............................................... 94azelaic acid gel 15%................................................... 76azelastine hcl nasal spray 0.1% (137 mcg/

spray)........................................................................105azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)........................................................................105azelastine hcl ophth soln 0.05%..............................101AZELEX......................................................................... 76AZITHROMYCIN............................................................ 5azithromycin for susp 100 mg/5ml...............................5azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT.........................................................................101

AZOR............................................................................. 62AZOR............................................................................. 62AZOR............................................................................. 62AZOR............................................................................. 62aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN.............................................................. 101bacitracin-polymyxin b ophth oint............................ 101bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................. 101baclofen tab 10 mg......................................................43baclofen tab 20 mg......................................................43BACTOCILL IN DEXTROSE........................................ 6BACTOCILL IN DEXTROSE........................................ 6balsalazide disodium cap 750 mg............................. 99BALVERSA....................................................................26BALVERSA....................................................................26BALVERSA....................................................................26BANZEL.........................................................................13BANZEL.........................................................................13BANZEL.........................................................................13BARACLUDE................................................................ 44BAVENCIO.................................................................... 26BCG VACCINE.............................................................94BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G

X 15/64"......................................................................49BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G

X 15/64"......................................................................49BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X

15/64"..........................................................................49BELEODAQ.................................................................. 26BELSOMRA................................................................ 108BELSOMRA................................................................ 108BELSOMRA................................................................ 108BELSOMRA................................................................ 108benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................62benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................62benazepril & hydrochlorothiazide tab 20-25

mg................................................................................62benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................62benazepril hcl tab 10 mg............................................ 62benazepril hcl tab 20 mg............................................ 62benazepril hcl tab 40 mg............................................ 62benazepril hcl tab 5 mg.............................................. 62BENDEKA..................................................................... 26BENICAR.......................................................................62BENICAR.......................................................................62BENICAR.......................................................................62

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BENICAR HCT............................................................. 62BENICAR HCT............................................................. 62BENICAR HCT............................................................. 62BENLYSTA.................................................................... 94BENLYSTA.................................................................... 94BENLYSTA.................................................................... 94BENLYSTA.................................................................... 94BENZNIDAZOLE..........................................................37BENZNIDAZOLE..........................................................37benzoyl peroxide-erythromycin gel

5-3%............................................................................76benztropine mesylate tab 0.5 mg.............................. 37benztropine mesylate tab 1 mg..................................37benztropine mesylate tab 2 mg..................................37BESIVANCE................................................................101BESPONSA.................................................................. 26betamethasone dipropionate augmented cream

0.05%..........................................................................76betamethasone dipropionate augmented lotion

0.05%..........................................................................76betamethasone dipropionate augmented oint

0.05%..........................................................................77betamethasone dipropionate cream

0.05%..........................................................................77betamethasone dipropionate lotion

0.05%..........................................................................77betamethasone dipropionate oint

0.05%..........................................................................77betamethasone valerate cream 0.1%....................... 77betamethasone valerate lotion 0.1%.........................77betamethasone valerate oint 0.1%............................77BETASERON................................................................ 75betaxolol hcl ophth soln 0.5%..................................101betaxolol hcl tab 10 mg...............................................62betaxolol hcl tab 20 mg...............................................62bethanechol chloride tab 10 mg.................................86bethanechol chloride tab 25 mg.................................86bethanechol chloride tab 50 mg.................................86bethanechol chloride tab 5 mg...................................86BETOPTIC-S.............................................................. 101BEVYXXA......................................................................57BEVYXXA......................................................................57bexarotene cap 75 mg................................................ 26BEXSERO..................................................................... 94bicalutamide tab 50 mg...............................................26BICILLIN C-R..................................................................6BICILLIN C-R..................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BIKTARVY..................................................................... 44bimatoprost ophth soln 0.03%................................. 101

bisoprolol & hydrochlorothiazide tab 10-6.25mg................................................................................62

bisoprolol & hydrochlorothiazide tab 2.5-6.25mg................................................................................62

bisoprolol & hydrochlorothiazide tab 5-6.25mg................................................................................62

bisoprolol fumarate tab 10 mg................................... 62bisoprolol fumarate tab 5 mg..................................... 62bleomycin sulfate for inj 15 unit................................. 26bleomycin sulfate for inj 30 unit................................. 26BLINCYTO.....................................................................26BOOSTRIX....................................................................94bosentan tab 125 mg................................................ 105bosentan tab 62.5 mg............................................... 105BOSULIF....................................................................... 26BOSULIF....................................................................... 26BOSULIF....................................................................... 26BRAFTOVI.....................................................................27BREO ELLIPTA..........................................................105BREO ELLIPTA..........................................................105BRILINTA.......................................................................57BRILINTA.......................................................................57brimonidine tartrate ophth soln 0.15%.................... 101brimonidine tartrate ophth soln 0.2%...................... 101BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BROMFENAC.............................................................101bromocriptine mesylate cap 5 mg..............................37bromocriptine mesylate tab 2.5 mg........................... 37budesonide delayed release particles cap 3

mg................................................................................99budesonide inhalation susp 0.25

mg/2ml......................................................................105budesonide inhalation susp 0.5

mg/2ml......................................................................105budesonide inhalation susp 1 mg/2ml.....................105bumetanide inj 0.25 mg/ml......................................... 62bumetanide tab 0.5 mg............................................... 62bumetanide tab 1 mg.................................................. 62bumetanide tab 2 mg.................................................. 62buprenorphine hcl-naloxone hcl sl film 12-3

mg..................................................................................4buprenorphine hcl-naloxone hcl sl film 2-0.5

mg..................................................................................4buprenorphine hcl-naloxone hcl sl film 4-1

mg..................................................................................4

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buprenorphine hcl-naloxone hcl sl film 8-2mg..................................................................................4

buprenorphine hcl-naloxone hcl sl tab 2-0.5mg..................................................................................4

buprenorphine hcl-naloxone hcl sl tab 8-2mg..................................................................................4

buprenorphine hcl sl tab 2 mg......................................4buprenorphine hcl sl tab 8 mg......................................4bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................4bupropion hcl tab 100 mg...........................................17bupropion hcl tab 75 mg.............................................17bupropion hcl tab er 12hr 100 mg............................. 17bupropion hcl tab er 12hr 150 mg............................. 17bupropion hcl tab er 12hr 200 mg............................. 17bupropion hcl tab er 24hr 150 mg............................. 17bupropion hcl tab er 24hr 300 mg............................. 17buspirone hcl tab 10 mg............................................. 48buspirone hcl tab 15 mg............................................. 48buspirone hcl tab 30 mg............................................. 48buspirone hcl tab 5 mg............................................... 48buspirone hcl tab 7.5 mg............................................ 48busulfan inj 6 mg/ml.................................................... 27butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg.........................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON BCISE.....................................................49BYDUREON PEN........................................................ 49BYSTOLIC.....................................................................62BYSTOLIC.....................................................................62BYSTOLIC.....................................................................62BYSTOLIC.....................................................................62Ccabergoline tab 0.5 mg............................................... 92CABLIVI......................................................................... 94CABOMETYX............................................................... 27CABOMETYX............................................................... 27CABOMETYX............................................................... 27

caffeine citrate oral soln 60 mg/3ml........................ 105CALAN........................................................................... 63CALAN SR.................................................................... 63CALAN SR.................................................................... 63calcipotriene cream 0.005%.......................................77calcipotriene oint 0.005%............................................77calcipotriene soln 0.005% (50 mcg/ml).....................77calcitonin (salmon) nasal soln 200 unit/

act..............................................................................100CALCITRIOL...............................................................100calcitriol cap 0.25 mcg.............................................. 100calcitriol cap 0.5 mcg................................................ 100calcitriol oral soln 1 mcg/ml......................................100calcium acetate cap 667 mg...................................... 79calcium acetate tab 667 mg....................................... 79CALQUENCE................................................................27CANASA........................................................................99candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................63candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................63candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................63candesartan cilexetil tab 16 mg................................. 63candesartan cilexetil tab 32 mg................................. 63candesartan cilexetil tab 4 mg................................... 63candesartan cilexetil tab 8 mg................................... 63CAPASTAT SULFATE..................................................25CAPRELSA................................................................... 27CAPRELSA................................................................... 27captopril tab 100 mg....................................................63captopril tab 12.5 mg...................................................63captopril tab 25 mg......................................................63captopril tab 50 mg......................................................63CARAFATE....................................................................82CARBAGLU.................................................................. 80carbamazepine cap er 12hr 100 mg......................... 13carbamazepine cap er 12hr 200 mg......................... 13carbamazepine cap er 12hr 300 mg......................... 13carbamazepine chew tab 100 mg..............................13carbamazepine susp 100 mg/5ml..............................13carbamazepine tab 200 mg........................................13carbamazepine tab er 12hr 100 mg.......................... 13carbamazepine tab er 12hr 200 mg.......................... 13carbamazepine tab er 12hr 400 mg.......................... 13CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38

2020

116

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................38



carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................37



carbidopa & levodopa tab 10-100 mg....................... 37carbidopa & levodopa tab 25-100 mg....................... 38carbidopa & levodopa tab 25-250 mg....................... 38carbidopa & levodopa tab er 25-100

mg................................................................................37carbidopa & levodopa tab er 50-200

mg................................................................................37carbidopa tab 25 mg................................................... 38carboplatin iv soln 150 mg/15ml................................ 27carboplatin iv soln 450 mg/45ml................................ 27carboplatin iv soln 50 mg/5ml.................................... 27carboplatin iv soln 600 mg/60ml................................ 27CARDIZEM....................................................................63CARDIZEM....................................................................63CARDIZEM....................................................................63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63carmustine for inj 100 mg...........................................27carteolol hcl ophth soln 1%...................................... 101carvedilol tab 12.5 mg.................................................63carvedilol tab 25 mg....................................................63carvedilol tab 3.125 mg...............................................63carvedilol tab 6.25 mg.................................................63caspofungin acetate for iv soln 50 mg...................... 22caspofungin acetate for iv soln 70 mg...................... 22CAYSTON................................................................... 105cefaclor cap 250 mg......................................................6cefaclor cap 500 mg......................................................6cefadroxil cap 500 mg...................................................6cefadroxil for susp 250 mg/5ml....................................6cefadroxil for susp 500 mg/5ml....................................6cefadroxil tab 1 gm........................................................ 6cefazolin sodium for inj 10 gm..................................... 6cefazolin sodium for inj 1 gm....................................... 6cefazolin sodium for inj 500 mg................................... 6cefdinir cap 300 mg....................................................... 6cefdinir for susp 125 mg/5ml........................................6

cefdinir for susp 250 mg/5ml........................................6cefepime hcl for inj 1 gm.............................................. 6cefepime hcl for inj 2 gm.............................................. 6cefixime cap 400 mg..................................................... 6cefixime for susp 100 mg/5ml...................................... 6cefixime for susp 200 mg/5ml...................................... 6CEFOTAXIME SODIUM................................................6cefotaxime sodium for inj 1 gm.................................... 6cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................7cefprozil tab 500 mg......................................................7ceftazidime for inj 1 gm.................................................7ceftazidime for inj 2 gm.................................................7ceftazidime for inj 6 gm.................................................7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7ceftriaxone sodium for inj 10 gm..................................7ceftriaxone sodium for inj 1 gm....................................7ceftriaxone sodium for inj 250 mg................................7ceftriaxone sodium for inj 2 gm....................................7ceftriaxone sodium for inj 500 mg................................7ceftriaxone sodium for iv soln 1 gm.............................7ceftriaxone sodium for iv soln 2 gm.............................7cefuroxime axetil tab 250 mg....................................... 7cefuroxime axetil tab 500 mg....................................... 7cefuroxime sodium for inj 7.5 gm.................................7cefuroxime sodium for inj 750 mg................................7cefuroxime sodium for iv soln 1.5 gm..........................7celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELEXA.........................................................................17CELEXA.........................................................................17CELEXA.........................................................................18CELONTIN.................................................................... 13cephalexin cap 250 mg.................................................7cephalexin cap 500 mg.................................................7

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cephalexin cap 750 mg.................................................7cephalexin for susp 125 mg/5ml..................................7cephalexin for susp 250 mg/5ml..................................7CEREZYME.................................................................. 85cevimeline hcl cap 30 mg...........................................76CHANTIX......................................................................... 4CHANTIX......................................................................... 4CHANTIX CONTINUING MONTH

PACK.............................................................................4CHANTIX STARTING MONTH PACK.........................4CHEMET........................................................................80CHENODAL.................................................................. 82CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlordiazepoxide hcl cap 10 mg................................ 48chlordiazepoxide hcl cap 25 mg................................ 48chlordiazepoxide hcl cap 5 mg.................................. 48chlorhexidine gluconate soln 0.12%..........................76CHLOROQUINE PHOSPHATE................................. 37chloroquine phosphate tab 500 mg...........................37CHLOROTHIAZIDE..................................................... 63chlorothiazide tab 500 mg.......................................... 63CHLORPROMAZINE HCL..........................................21CHLORPROMAZINE HCL..........................................21chlorpromazine hcl tab 100 mg..................................21chlorpromazine hcl tab 10 mg....................................21chlorpromazine hcl tab 200 mg..................................21chlorpromazine hcl tab 25 mg....................................21chlorpromazine hcl tab 50 mg....................................21chlorthalidone tab 25 mg............................................ 63chlorthalidone tab 50 mg............................................ 63cholestyramine light powder 4 gm/

dose............................................................................ 63cholestyramine light powder packets 4

gm................................................................................63cholestyramine powder 4 gm/dose............................63cholestyramine powder packets 4 gm.......................63choline fenofibrate cap dr 135 mg............................. 63choline fenofibrate cap dr 45 mg............................... 63CHORIONIC GONADOTROPIN................................88ciclopirox gel 0.77%.................................................... 22ciclopirox olamine cream 0.77%................................22ciclopirox olamine susp 0.77%...................................22ciclopirox shampoo 1%............................................... 22ciclopirox solution 8%..................................................23cidofovir iv inj 75 mg/ml.............................................. 44cilostazol tab 100 mg.................................................. 57cilostazol tab 50 mg.................................................... 57CILOXAN.....................................................................101CIMDUO........................................................................ 44CIMETIDINE HCL........................................................ 82cimetidine tab 200 mg.................................................82

cimetidine tab 300 mg.................................................82cimetidine tab 400 mg.................................................83cimetidine tab 800 mg.................................................83cinacalcet hcl tab 30 mg...........................................100cinacalcet hcl tab 60 mg...........................................100cinacalcet hcl tab 90 mg...........................................100CINRYZE.......................................................................94ciprofloxacin 200 mg/100ml in d5w............................. 8ciprofloxacin 400 mg/200ml in d5w............................. 8ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................8CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%............................ 101ciprofloxacin hcl tab 250 mg.........................................8ciprofloxacin hcl tab 500 mg.........................................8ciprofloxacin hcl tab 750 mg.........................................8CISPLATIN.................................................................... 27cisplatin inj 100 mg/100ml (1 mg/ml).........................27cisplatin inj 50 mg/50ml (1 mg/ml).............................27citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 18citalopram hydrobromide tab 10 mg..........................18citalopram hydrobromide tab 20 mg..........................18citalopram hydrobromide tab 40 mg..........................18cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................27CLARITHROMYCIN.......................................................8CLARITHROMYCIN.......................................................8clarithromycin tab 250 mg............................................ 8clarithromycin tab 500 mg............................................ 8clarithromycin tab er 24hr 500 mg...............................8CLEMASTINE FUMARATE......................................105CLEOCIN.........................................................................8clindamycin hcl cap 150 mg......................................... 8clindamycin hcl cap 300 mg......................................... 8clindamycin hcl cap 75 mg........................................... 8clindamycin palmitate hcl for soln 75

mg/5ml.......................................................................... 8clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................77clindamycin phosphate gel 1%.................................... 8clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 8clindamycin phosphate inj 300 mg/2ml....................... 8clindamycin phosphate inj 600 mg/4ml....................... 8clindamycin phosphate inj 900 mg/6ml....................... 8clindamycin phosphate inj 9 gm/60ml......................... 8

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clindamycin phosphate iv soln 300mg/2ml.......................................................................... 8



clindamycin phosphate lotion 1%................................ 8clindamycin phosphate soln 1%...................................8clindamycin phosphate swab 1%.................................8clindamycin phosphate vaginal cream

2%..................................................................................8clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5%......................................................................... 77CLINIMIX 4.25%/DEXTROSE 10%...........................80CLINIMIX 4.25%/DEXTROSE 25%...........................80CLINIMIX 4.25%/DEXTROSE 5%.............................80CLINIMIX 5%/DEXTROSE 15%................................ 80CLINIMIX 5%/DEXTROSE 20%................................ 80CLINIMIX 5%/DEXTROSE 25%................................ 80CLINIMIX E 2.75%/DEXTROSE 5%......................... 80CLINIMIX E 4.25%/DEXTROSE 10%.......................80CLINIMIX E 4.25%/DEXTROSE 5%......................... 80CLINIMIX E 5%/DEXTROSE 15%............................ 80CLINIMIX E 5%/DEXTROSE 20%............................ 80clobazam suspension 2.5 mg/ml............................... 13clobazam tab 10 mg....................................................13clobazam tab 20 mg....................................................13clobetasol propionate cream 0.05%..........................77clobetasol propionate emollient base cream

0.05%..........................................................................77clobetasol propionate gel 0.05%................................77clobetasol propionate oint 0.05%.............................. 77clobetasol propionate soln 0.05%..............................77clofarabine iv soln 1 mg/ml.........................................27clomipramine hcl cap 25 mg...................................... 18clomipramine hcl cap 50 mg...................................... 18clomipramine hcl cap 75 mg...................................... 18clonazepam orally disintegrating tab 0.125

mg................................................................................48clonazepam orally disintegrating tab 0.25

mg................................................................................48clonazepam orally disintegrating tab 0.5

mg................................................................................48clonazepam orally disintegrating tab 1

mg................................................................................48clonazepam orally disintegrating tab 2

mg................................................................................48clonazepam tab 0.5 mg.............................................. 48clonazepam tab 1 mg..................................................48clonazepam tab 2 mg..................................................48clonidine hcl tab 0.1 mg..............................................63clonidine hcl tab 0.2 mg..............................................63

clonidine hcl tab 0.3 mg..............................................64clonidine hcl tab er 12hr 0.1 mg................................ 75clonidine td patch weekly 0.1 mg/24hr......................64clonidine td patch weekly 0.2 mg/24hr......................64clonidine td patch weekly 0.3 mg/24hr......................64clopidogrel bisulfate tab 300 mg................................57clopidogrel bisulfate tab 75 mg..................................57clorazepate dipotassium tab 15 mg...........................48clorazepate dipotassium tab 3.75 mg....................... 48clorazepate dipotassium tab 7.5 mg......................... 48clotrimazole cream 1%................................................23clotrimazole troche 10 mg.......................................... 23clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 77clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 77clozapine orally disintegrating tab 100

mg................................................................................39clozapine orally disintegrating tab 12.5

mg................................................................................39clozapine orally disintegrating tab 25

mg................................................................................39clozapine tab 100 mg..................................................39clozapine tab 200 mg..................................................39clozapine tab 25 mg....................................................39clozapine tab 50 mg....................................................39COARTEM.....................................................................37codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24colestipol hcl granule packets 5 gm.......................... 64colestipol hcl granules 5 gm.......................................64colestipol hcl tab 1 gm................................................ 64colistimethate sod for inj 150 mg................................. 8COLYTE-FLAVOR PACKS......................................... 83COMBIGAN................................................................ 101COMBIPATCH.............................................................. 89COMBIPATCH.............................................................. 89COMBIVENT RESPIMAT......................................... 105COMETRIQ...................................................................27COMETRIQ...................................................................27COMETRIQ...................................................................27COMPLERA.................................................................. 44COPIKTRA....................................................................27COPIKTRA....................................................................27COREG..........................................................................64COREG..........................................................................64COREG..........................................................................64COREG..........................................................................64CORLANOR..................................................................64CORLANOR..................................................................64

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CORLANOR..................................................................64CORTISONE ACETATE..............................................87COSENTYX.................................................................. 94COSENTYX.................................................................. 94COSENTYX SENSOREADY PEN............................ 94COSENTYX SENSOREADY PEN............................ 94COTELLIC.....................................................................27COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COZAAR........................................................................64COZAAR........................................................................64COZAAR........................................................................64CREON..........................................................................85CREON..........................................................................85CREON..........................................................................85CREON..........................................................................85CREON..........................................................................85CRESEMBA.................................................................. 23CRESEMBA.................................................................. 23CRIXIVAN......................................................................44CRIXIVAN......................................................................44cromolyn sodium ophth soln 4%..............................101cromolyn sodium oral conc 100

mg/5ml........................................................................ 83cromolyn sodium soln nebu 20

mg/2ml......................................................................105CRYSVITA.....................................................................85CRYSVITA.....................................................................85CRYSVITA.....................................................................85CUVITRU.......................................................................94CUVITRU.......................................................................95CUVITRU.......................................................................95CUVITRU.......................................................................95CUVITRU.......................................................................95cyclobenzaprine hcl tab 10 mg................................ 108cyclobenzaprine hcl tab 5 mg.................................. 108cyclophosphamide cap 25 mg................................... 27cyclophosphamide cap 50 mg................................... 27cyclophosphamide for inj 1 gm.................................. 27cyclophosphamide for inj 2 gm.................................. 27cyclophosphamide for inj 500 mg..............................27cycloserine cap 250 mg..............................................25CYCLOSET...................................................................49cyclosporine cap 100 mg............................................95cyclosporine cap 25 mg..............................................95

cyclosporine iv soln 50 mg/ml....................................95cyclosporine modified cap 100 mg............................ 95cyclosporine modified cap 25 mg.............................. 95cyclosporine modified cap 50 mg.............................. 95cyclosporine modified oral soln 100 mg/

ml.................................................................................95CYRAMZA.....................................................................27CYRAMZA.....................................................................27CYSTADANE................................................................ 85CYSTAGON.................................................................. 85CYSTAGON.................................................................. 85CYSTARAN.................................................................101CYTARABINE............................................................... 27cytarabine inj pf 100 mg/ml........................................ 27cytarabine inj pf 20 mg/ml.......................................... 27DDACARBAZINE............................................................ 27dacarbazine for inj 200 mg.........................................27dactinomycin for inj 0.5 mg........................................ 28dalfampridine tab er 12hr 10 mg................................75DALIRESP.................................................................. 105DALIRESP.................................................................. 105DALVANCE......................................................................8danazol cap 100 mg....................................................89danazol cap 200 mg....................................................89danazol cap 50 mg......................................................89dantrolene sodium cap 100 mg................................. 43dantrolene sodium cap 25 mg....................................43dantrolene sodium cap 50 mg....................................43dapsone tab 100 mg................................................... 25dapsone tab 25 mg......................................................25DAPTACEL....................................................................95daptomycin for iv soln 500 mg..................................... 8DARAPRIM................................................................... 37DARZALEX................................................................... 28DARZALEX................................................................... 28daunorubicin hcl iv soln 20 mg/4ml........................... 28DAUNORUBICIN HYDROCHLORIDE......................28DAURISMO...................................................................28DAURISMO...................................................................28decitabine for inj 50 mg.............................................. 28deferasirox tab for oral susp 125 mg.........................80deferasirox tab for oral susp 250 mg.........................80deferasirox tab for oral susp 500 mg.........................80DELSTRIGO................................................................. 44demeclocycline hcl tab 150 mg....................................8demeclocycline hcl tab 300 mg....................................8DEMSER....................................................................... 64DENAVIR.......................................................................44DEPEN TITRATABS.................................................... 86DEPO-PROVERA........................................................ 89

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DESCOVY.....................................................................44desipramine hcl tab 100 mg.......................................18desipramine hcl tab 10 mg......................................... 18desipramine hcl tab 150 mg.......................................18desipramine hcl tab 25 mg......................................... 18desipramine hcl tab 50 mg......................................... 18desipramine hcl tab 75 mg......................................... 18desmopressin acetate inj 4 mcg/ml...........................88desmopressin acetate nasal spray soln

0.01%..........................................................................88desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 88desmopressin acetate tab 0.1 mg............................. 88desmopressin acetate tab 0.2 mg............................. 88desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 89desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................89

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................89

desonide cream 0.05%............................................... 77desonide lotion 0.05%.................................................77desonide oint 0.05%....................................................77desoximetasone cream 0.05%...................................77desoximetasone cream 0.25%...................................77desoximetasone gel 0.05%........................................ 77desoximetasone oint 0.25%....................................... 77desvenlafaxine succinate tab er 24hr 100

mg................................................................................18desvenlafaxine succinate tab er 24hr 25

mg................................................................................18desvenlafaxine succinate tab er 24hr 50

mg................................................................................18DEXAMETHASONE.................................................... 87DEXAMETHASONE.................................................... 87dexamethasone elixir 0.5 mg/5ml..............................87DEXAMETHASONE SODIUM

PHOSPHATE...........................................................101dexamethasone sodium phosphate inj 120

mg/30ml......................................................................87dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 87dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................87dexamethasone tab 0.5 mg........................................87dexamethasone tab 0.75 mg......................................87dexamethasone tab 1.5 mg........................................87dexamethasone tab 4 mg...........................................87dexamethasone tab 6 mg...........................................87dexmethylphenidate hcl tab 10 mg............................75dexmethylphenidate hcl tab 2.5 mg...........................75

dexmethylphenidate hcl tab 5 mg..............................75dexrazoxane hcl for inj 250 mg..................................28dexrazoxane hcl for inj 500 mg..................................28dextroamphetamine sulfate cap er 24hr 10

mg................................................................................75dextroamphetamine sulfate cap er 24hr 15

mg................................................................................75dextroamphetamine sulfate cap er 24hr 5

mg................................................................................75dextroamphetamine sulfate tab 10 mg......................75dextroamphetamine sulfate tab 5 mg........................75DEXTROSE 2.5%/NACL 0.45%................................ 80dextrose 5% in lactated ringers................................. 80dextrose 5% w/ sodium chloride 0.2%...................... 80dextrose 5% w/ sodium chloride

0.33%..........................................................................80dextrose 5% w/ sodium chloride

0.45%..........................................................................80dextrose 5% w/ sodium chloride 0.9%...................... 80dextrose inj 10%.......................................................... 80dextrose inj 5%.............................................................80DIASTAT ACUDIAL......................................................13DIASTAT ACUDIAL......................................................13DIASTAT PEDIATRIC..................................................13DIAZEPAM.................................................................... 48diazepam conc 5 mg/ml..............................................48DIAZEPAM RECTAL GEL.......................................... 13DIAZEPAM RECTAL GEL.......................................... 13DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................48diazepam tab 2 mg......................................................48diazepam tab 5 mg......................................................48diclofenac potassium tab 50 mg.................................. 1diclofenac sodium (actinic keratoses) gel

3%............................................................................... 77diclofenac sodium gel 1%.............................................1diclofenac sodium ophth soln 0.1%.........................101diclofenac sodium soln 1.5%........................................1diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl tab 20 mg..........................................83

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didanosine delayed release capsule 200mg................................................................................44



DIFICID............................................................................ 9diflorasone diacetate oint 0.05%................................77diflunisal tab 500 mg..................................................... 1DIGOXIN........................................................................64digoxin tab 125 mcg (0.125 mg)................................64digoxin tab 250 mcg (0.25 mg).................................. 64DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 64diltiazem hcl cap er 12hr 60 mg.................................64diltiazem hcl cap er 12hr 90 mg.................................64diltiazem hcl cap er 24hr 120 mg.............................. 64diltiazem hcl cap er 24hr 180 mg.............................. 64diltiazem hcl cap er 24hr 240 mg.............................. 64diltiazem hcl coated beads cap er 24hr 120

mg................................................................................64diltiazem hcl coated beads cap er 24hr 180




mg................................................................................64diltiazem hcl coated beads tab er 24hr 180





mg................................................................................64diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 64diltiazem hcl extended release beads cap er 24hr





420 mg....................................................................... 65diltiazem hcl tab 120 mg.............................................65

diltiazem hcl tab 30 mg...............................................65diltiazem hcl tab 60 mg...............................................65diltiazem hcl tab 90 mg...............................................65DIOVAN......................................................................... 65DIOVAN......................................................................... 65DIOVAN......................................................................... 65DIOVAN......................................................................... 65DIOVAN HCT................................................................65DIOVAN HCT................................................................65DIOVAN HCT................................................................65DIOVAN HCT................................................................65DIOVAN HCT................................................................65diphenhydramine hcl inj 50 mg/ml...........................105DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................95dipyridamole tab 25 mg.............................................. 57dipyridamole tab 50 mg.............................................. 57dipyridamole tab 75 mg.............................................. 57disulfiram tab 250 mg....................................................4disulfiram tab 500 mg....................................................4divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium tab delayed release 125



mg................................................................................14divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................14DIVIGEL.........................................................................89DIVIGEL.........................................................................89DIVIGEL.........................................................................89DIVIGEL.........................................................................89DOCETAXEL.................................................................28docetaxel for inj conc 160 mg/8ml (20 mg/

ml)................................................................................28docetaxel for inj conc 20 mg/ml................................. 28docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................28docetaxel soln for iv infusion 160

mg/16ml......................................................................28docetaxel soln for iv infusion 20

mg/2ml........................................................................ 28docetaxel soln for iv infusion 80

mg/8ml........................................................................ 28dofetilide cap 125 mcg (0.125 mg)............................65dofetilide cap 250 mcg (0.25 mg).............................. 65dofetilide cap 500 mcg (0.5 mg)................................ 65donepezil hydrochloride orally disintegrating tab 10

mg................................................................................16

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donepezil hydrochloride orally disintegrating tab 5mg................................................................................16

donepezil hydrochloride tab 10 mg........................... 16donepezil hydrochloride tab 23 mg........................... 16donepezil hydrochloride tab 5 mg..............................16dorzolamide hcl ophth soln 2%................................101dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 101DOVATO........................................................................ 44doxazosin mesylate tab 1 mg.................................... 65doxazosin mesylate tab 2 mg.................................... 65doxazosin mesylate tab 4 mg.................................... 65doxazosin mesylate tab 8 mg.................................... 65DOXEPIN HCL............................................................. 18doxepin hcl cap 100 mg..............................................18doxepin hcl cap 10 mg................................................18doxepin hcl cap 25 mg................................................18doxepin hcl cap 50 mg................................................18doxepin hcl cap 75 mg................................................18doxepin hcl conc 10 mg/ml.........................................18doxorubicin hcl for inj 10 mg...................................... 28doxorubicin hcl for inj 50 mg...................................... 28doxorubicin hcl inj 2 mg/ml.........................................28doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................28doxycycline hyclate cap 100 mg..................................9doxycycline hyclate cap 50 mg.................................... 9doxycycline hyclate for inj 100 mg...............................9doxycycline hyclate tab 100 mg...................................9doxycycline hyclate tab 20 mg.....................................9doxycycline monohydrate cap 100 mg........................9doxycycline monohydrate cap 150 mg........................9doxycycline monohydrate cap 50 mg..........................9doxycycline monohydrate cap 75 mg..........................9doxycycline monohydrate tab 100 mg.........................9doxycycline monohydrate tab 150 mg.........................9doxycycline monohydrate tab 50 mg...........................9doxycycline monohydrate tab 75 mg...........................9D-PENAMINE............................................................... 86dronabinol cap 10 mg................................................. 21dronabinol cap 2.5 mg................................................ 21dronabinol cap 5 mg....................................................21drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................89drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................89drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................89drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................89DUAVEE........................................................................ 89DULERA......................................................................105

DULERA......................................................................105duloxetine hcl enteric coated pellets cap 20

mg................................................................................18duloxetine hcl enteric coated pellets cap 30

mg................................................................................18duloxetine hcl enteric coated pellets cap 60

mg................................................................................18DUPIXENT.................................................................... 95DUPIXENT.................................................................... 95DUREZOL................................................................... 101dutasteride cap 0.5 mg............................................... 86dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................86EEASY TOUCH FLIPLOCK SAFETY INSULIN

SYRINGE 1ML/30G X 1/2"......................................49EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/0.5ML/29G X 1/2"......................................... 49EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/1ML/30G X 1/2".............................................50EASY TOUCH SHEATHLOCK SAFETY INSULIN

SYRINGE 1ML/29G X 1/2"......................................50EASY TOUCH SHEATHLOCK SAFETY SYRINGE

1ML/30G X 1/2"........................................................ 50EC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1econazole nitrate cream 1%.......................................23EDURANT..................................................................... 44efavirenz cap 200 mg..................................................44efavirenz cap 50 mg....................................................44efavirenz tab 600 mg...................................................44EGRIFTA....................................................................... 88EGRIFTA....................................................................... 88ELAPRASE................................................................... 85ELELYSO.......................................................................85ELIDEL...........................................................................77ELIGARD.......................................................................92ELIGARD.......................................................................92ELIGARD.......................................................................92ELIGARD.......................................................................92ELIQUIS.........................................................................57ELIQUIS.........................................................................57ELIQUIS STARTER PACK......................................... 57ELITEK...........................................................................28ELITEK...........................................................................28ELLA...............................................................................89EMCYT.......................................................................... 28EMEND..........................................................................21EMGALITY.................................................................... 24EMGALITY.................................................................... 24EMGALITY.................................................................... 24EMPLICITI.....................................................................28

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EMPLICITI.....................................................................28EMSAM..........................................................................18EMSAM..........................................................................18EMSAM..........................................................................18EMTRIVA.......................................................................44EMTRIVA.......................................................................44enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................65enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................65enalapril maleate tab 10 mg.......................................65enalapril maleate tab 2.5 mg......................................65enalapril maleate tab 20 mg.......................................65enalapril maleate tab 5 mg.........................................65ENBREL........................................................................ 95ENBREL........................................................................ 95ENBREL........................................................................ 95ENBREL MINI...............................................................95ENBREL SURECLICK................................................ 95ENGERIX-B.................................................................. 95ENGERIX-B.................................................................. 95enoxaparin sodium inj 100 mg/ml..............................57enoxaparin sodium inj 120 mg/0.8ml........................ 57enoxaparin sodium inj 150 mg/ml..............................57enoxaparin sodium inj 300 mg/3ml............................57enoxaparin sodium inj 30 mg/0.3ml...........................57enoxaparin sodium inj 40 mg/0.4ml...........................57enoxaparin sodium inj 60 mg/0.6ml...........................57enoxaparin sodium inj 80 mg/0.8ml...........................57entacapone tab 200 mg..............................................38entecavir tab 0.5 mg....................................................44entecavir tab 1 mg.......................................................44ENTRESTO...................................................................65ENTRESTO...................................................................65ENTRESTO...................................................................65EPCLUSA......................................................................44EPIDIOLEX................................................................... 14epinastine hcl ophth soln 0.05%..............................101epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).................................................................... 105epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak).................... 105epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................28epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................28EPIVIR HBV..................................................................44eplerenone tab 25 mg.................................................65eplerenone tab 50 mg.................................................65EPOGEN....................................................................... 57EPOGEN....................................................................... 57EPOGEN....................................................................... 58

EPOGEN....................................................................... 58EPOGEN....................................................................... 58ERBITUX....................................................................... 28ERBITUX....................................................................... 28ERGOLOID MESYLATES...........................................16ergotamine w/ caffeine tab 1-100 mg........................24ERIVEDGE....................................................................28ERLEADA......................................................................28erlotinib hcl tab 100 mg.............................................. 28erlotinib hcl tab 150 mg.............................................. 28erlotinib hcl tab 25 mg.................................................28ertapenem sodium for inj 1 gm.................................... 9ERWINAZE................................................................... 28ERYTHROCIN LACTOBIONATE.................................9ERYTHROCIN STEARATE.......................................... 9erythromycin ethylsuccinate for susp 200

mg/5ml.......................................................................... 9erythromycin ethylsuccinate for susp 400

mg/5ml.......................................................................... 9erythromycin ophth oint 5 mg/gm............................ 101erythromycin pads 2%...................................................9erythromycin soln 2%.................................................... 9erythromycin tab 250 mg.............................................. 9erythromycin tab 500 mg.............................................. 9erythromycin tab delayed release 250

mg..................................................................................9erythromycin tab delayed release 333

mg..................................................................................9erythromycin tab delayed release 500

mg..................................................................................9erythromycin w/ delayed release particles cap 250

mg..................................................................................9ESBRIET..................................................................... 105ESBRIET..................................................................... 105ESBRIET..................................................................... 105escitalopram oxalate soln 5 mg/5ml..........................18escitalopram oxalate tab 10 mg.................................18escitalopram oxalate tab 20 mg.................................18escitalopram oxalate tab 5 mg...................................18esomeprazole magnesium cap delayed release 20

mg................................................................................83esomeprazole magnesium cap delayed release 40

mg................................................................................83ESOMEPRAZOLE SODIUM...................................... 83esomeprazole sodium for intravenous soln 40

mg................................................................................83estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................89estradiol & norethindrone acetate tab 1-0.5

mg................................................................................89estradiol tab 0.5 mg.....................................................89estradiol tab 1 mg........................................................89

2020

124

estradiol tab 2 mg........................................................89estradiol td patch twice weekly 0.025

mg/24hr...................................................................... 89estradiol td patch twice weekly 0.0375




mg/24hr...................................................................... 89estradiol td patch weekly 0.025

mg/24hr...................................................................... 89estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 90estradiol td patch weekly 0.05 mg/24hr.................... 90estradiol td patch weekly 0.06 mg/24hr.................... 90estradiol td patch weekly 0.075

mg/24hr...................................................................... 90estradiol td patch weekly 0.1 mg/24hr...................... 90estradiol vaginal cream 0.1 mg/gm........................... 90estradiol vaginal tab 10 mcg...................................... 90ethambutol hcl tab 100 mg.........................................25ethambutol hcl tab 400 mg.........................................25ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................90ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................90ETHYOL........................................................................ 28etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................1etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 600 mg........................................ 1ETOPOPHOS............................................................... 28etoposide inj 100 mg/5ml (20 mg/ml)........................29etoposide inj 1 gm/50ml (20 mg/ml).......................... 29etoposide inj 500 mg/25ml (20 mg/ml)......................29EVOMELA..................................................................... 29EVOTAZ.........................................................................44exemestane tab 25 mg............................................... 29EXFORGE.....................................................................65EXFORGE.....................................................................65EXFORGE.....................................................................66EXFORGE.....................................................................66EXFORGE HCT........................................................... 66EXFORGE HCT........................................................... 66EXFORGE HCT........................................................... 66

EXFORGE HCT........................................................... 66EXFORGE HCT........................................................... 66ezetimibe-simvastatin tab 10-10 mg..........................66ezetimibe-simvastatin tab 10-20 mg..........................66ezetimibe-simvastatin tab 10-40 mg..........................66ezetimibe-simvastatin tab 10-80 mg..........................66ezetimibe tab 10 mg....................................................66FFABRAZYME................................................................ 85FABRAZYME................................................................ 85famciclovir tab 125 mg................................................44famciclovir tab 250 mg................................................44famciclovir tab 500 mg................................................44famotidine inj 200 mg/20ml........................................ 83famotidine inj 20 mg/2ml.............................................83famotidine inj 40 mg/4ml.............................................83famotidine tab 20 mg...................................................83famotidine tab 40 mg...................................................83FANAPT.........................................................................39FANAPT.........................................................................39FANAPT.........................................................................39FANAPT.........................................................................39FANAPT.........................................................................39FANAPT.........................................................................39FANAPT.........................................................................39FANAPT TITRATION PACK....................................... 39FARYDAK......................................................................29FARYDAK......................................................................29FARYDAK......................................................................29FASLODEX................................................................... 29felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 66felodipine tab er 24hr 2.5 mg..................................... 66felodipine tab er 24hr 5 mg........................................ 66fenofibrate micronized cap 134 mg........................... 66fenofibrate micronized cap 200 mg........................... 66fenofibrate micronized cap 67 mg............................. 66fenofibrate tab 145 mg................................................66fenofibrate tab 160 mg................................................66fenofibrate tab 48 mg.................................................. 66fenofibrate tab 54 mg.................................................. 66fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600



mcg................................................................................2

2020

125

fentanyl citrate lozenge on a handle 600mcg................................................................................2

fentanyl citrate lozenge on a handle 800mcg................................................................................2

fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 18FETZIMA....................................................................... 18FETZIMA....................................................................... 18FETZIMA....................................................................... 18FETZIMA TITRATION PACK......................................19finasteride tab 5 mg.....................................................87FIRMAGON...................................................................92FIRMAGON...................................................................92flecainide acetate tab 100 mg....................................66flecainide acetate tab 150 mg....................................66flecainide acetate tab 50 mg...................................... 66FLOMAX........................................................................87FLOVENT DISKUS....................................................105FLOVENT DISKUS....................................................105FLOVENT DISKUS....................................................105FLOVENT HFA...........................................................105FLOVENT HFA...........................................................105FLOVENT HFA...........................................................106fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................23fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................23fluconazole tab 200 mg...............................................23fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 23flucytosine cap 500 mg............................................... 23fludarabine phosphate for inj 50 mg..........................29fludarabine phosphate inj 25 mg/ml.......................... 29fludrocortisone acetate tab 0.1 mg............................ 87fluocinolone acetonide (otic) oil

0.01%........................................................................103fluocinolone acetonide cream 0.01%........................ 77fluocinonide cream 0.05%.......................................... 77fluocinonide emulsified base cream

0.05%..........................................................................77

fluocinonide gel 0.05%................................................77fluocinonide oint 0.05%...............................................77fluocinonide soln 0.05%..............................................77fluorometholone ophth susp 0.1%...........................101FLUOROURACIL......................................................... 77FLUOROURACIL......................................................... 77FLUOROURACIL......................................................... 77fluorouracil cream 5%................................................. 78fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................29fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................29fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................29fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................29FLUOXETINE DR........................................................ 19fluoxetine hcl cap 10 mg.............................................19fluoxetine hcl cap 20 mg.............................................19fluoxetine hcl cap 40 mg.............................................19fluoxetine hcl solution 20 mg/5ml.............................. 19fluoxetine hcl tab 10 mg..............................................19fluoxetine hcl tab 20 mg..............................................19fluphenazine decanoate inj 25 mg/ml........................39FLUPHENAZINE HCL.................................................39FLUPHENAZINE HCL.................................................39fluphenazine hcl tab 10 mg........................................ 40fluphenazine hcl tab 1 mg.......................................... 40fluphenazine hcl tab 2.5 mg....................................... 40fluphenazine hcl tab 5 mg.......................................... 40FLUPHENAZINE HYDROCHLORIDE...................... 40FLURBIPROFEN SODIUM...................................... 101flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................29FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 106FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 106FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 106fluticasone propionate cream 0.05%.........................78fluticasone propionate nasal susp 50 mcg/

act..............................................................................106fluticasone propionate oint 0.005%........................... 78fluvastatin sodium cap 20 mg.................................... 66fluvastatin sodium cap 40 mg.................................... 66fluvastatin sodium tab er 24 hr 80 mg.......................66fluvoxamine maleate tab 100 mg...............................19fluvoxamine maleate tab 25 mg.................................19fluvoxamine maleate tab 50 mg.................................19FML LIQUIFILM......................................................... 101

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FOLOTYN......................................................................29FOLOTYN......................................................................29fomepizole inj 1 gm/ml (for iv infusion)......................80fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................58fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................58fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................58fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................58FORTEO......................................................................100fosamprenavir calcium tab 700 mg........................... 45fosaprepitant dimeglumine for iv infusion 150

mg................................................................................21fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................66fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................66fosinopril sodium tab 10 mg....................................... 66fosinopril sodium tab 20 mg....................................... 66fosinopril sodium tab 40 mg....................................... 66fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................14FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80FREAMINE HBC 6.9%................................................80FREAMINE III............................................................... 80frovatriptan succinate tab 2.5 mg.............................. 24FULPHILA..................................................................... 58fulvestrant inj 250 mg/5ml...........................................29furosemide inj 10 mg/ml..............................................66furosemide oral soln 10 mg/ml...................................66furosemide tab 20 mg................................................. 67furosemide tab 40 mg................................................. 67furosemide tab 80 mg................................................. 67FUZEON........................................................................45FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14Ggabapentin cap 100 mg.............................................. 14gabapentin cap 300 mg.............................................. 14gabapentin cap 400 mg.............................................. 14gabapentin oral soln 250 mg/5ml.............................. 14gabapentin tab 600 mg............................................... 14gabapentin tab 800 mg............................................... 14

GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

mg................................................................................17galantamine hydrobromide cap er 24hr 24

mg................................................................................17galantamine hydrobromide cap er 24hr 8

mg................................................................................17galantamine hydrobromide tab 12 mg...................... 17galantamine hydrobromide tab 4 mg.........................17galantamine hydrobromide tab 8 mg.........................17ganciclovir sodium for inj 500 mg.............................. 45GARDASIL 9.................................................................95GARDASIL 9.................................................................95gatifloxacin ophth soln 0.5%.................................... 102GATTEX.........................................................................83GAUZE PADS 2" X 2".................................................50GAZYVA.........................................................................29gemcitabine hcl for inj 1 gm....................................... 29gemcitabine hcl for inj 200 mg...................................29gemcitabine hcl for inj 2 gm....................................... 29gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................29gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................29gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................29gemfibrozil tab 600 mg............................................... 67GENTAK...................................................................... 102gentamicin in saline inj 1.2 mg/ml................................9GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE...................................................................9GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE...................................................................9gentamicin sulfate cream 0.1%..................................78gentamicin sulfate inj 10 mg/ml....................................9gentamicin sulfate inj 40 mg/ml....................................9gentamicin sulfate oint 0.1%...................................... 78gentamicin sulfate ophth soln 0.3%........................ 102GENVOYA.....................................................................45GEODON.......................................................................40GILENYA....................................................................... 75GILOTRIF......................................................................29GILOTRIF......................................................................29GILOTRIF......................................................................29glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................75glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................75GLEOSTINE..................................................................29GLEOSTINE..................................................................29GLEOSTINE..................................................................29glimepiride tab 1 mg....................................................50

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glimepiride tab 2 mg....................................................50glimepiride tab 4 mg....................................................50glipizide-metformin hcl tab 2.5-250 mg.....................50glipizide-metformin hcl tab 2.5-500 mg.....................50glipizide-metformin hcl tab 5-500 mg........................ 50glipizide tab 10 mg...................................................... 50glipizide tab 5 mg.........................................................50glipizide tab er 24hr 10 mg.........................................50glipizide tab er 24hr 2.5 mg........................................50glipizide tab er 24hr 5 mg...........................................50GLUCAGEN HYPOKIT............................................... 50GLUCAGON EMERGENCY KIT............................... 50GLUCOPHAGE............................................................ 50GLUCOPHAGE............................................................ 50GLUCOPHAGE............................................................ 50GLUCOPHAGE XR..................................................... 50GLUCOPHAGE XR..................................................... 50GLUCOTROL................................................................50GLUCOTROL................................................................50GLUCOTROL XL......................................................... 50GLUCOTROL XL......................................................... 50GLUCOTROL XL......................................................... 50glycopyrrolate tab 1 mg.............................................. 83glycopyrrolate tab 2 mg.............................................. 83GLYXAMBI.................................................................... 50GLYXAMBI.................................................................... 50GOLYTELY....................................................................83granisetron hcl inj 1 mg/ml......................................... 21granisetron hcl inj 4 mg/4ml (1 mg/ml)......................21granisetron hcl tab 1 mg.............................................21GRANIX......................................................................... 58GRANIX......................................................................... 58GRANIX......................................................................... 58GRANIX......................................................................... 58griseofulvin microsize susp 125

mg/5ml........................................................................ 23griseofulvin microsize tab 500 mg............................. 23griseofulvin ultramicrosize tab 125 mg......................23griseofulvin ultramicrosize tab 250 mg......................23GUANIDINE HCL.........................................................25HHAEGARDA.................................................................. 95HAEGARDA.................................................................. 95HALAVEN...................................................................... 29halobetasol propionate cream 0.05%........................78halobetasol propionate oint 0.05%............................ 78haloperidol decanoate im soln 100 mg/

ml.................................................................................40haloperidol decanoate im soln 50 mg/

ml.................................................................................40haloperidol lactate inj 5 mg/ml................................... 40

haloperidol lactate oral conc 2 mg/ml........................40haloperidol tab 0.5 mg................................................ 40haloperidol tab 10 mg................................................. 40haloperidol tab 1 mg....................................................40haloperidol tab 20 mg................................................. 40haloperidol tab 2 mg....................................................40haloperidol tab 5 mg....................................................40HARVONI...................................................................... 45HAVRIX..........................................................................95HAVRIX..........................................................................95HEPARIN SODIUM......................................................58HEPARIN SODIUM......................................................58HEPARIN SODIUM/D5W............................................58heparin sodium (porcine) inj 10000 unit/

ml.................................................................................58heparin sodium (porcine) inj 1000 unit/



ml.................................................................................58heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................58HEPATAMINE............................................................... 80HERCEPTIN................................................................. 29HERCEPTIN HYLECTA.............................................. 29HETLIOZ..................................................................... 108HIBERIX........................................................................ 95HUMALOG.................................................................... 50HUMALOG.................................................................... 50HUMALOG JUNIOR KWIKPEN.................................50HUMALOG KWIKPEN.................................................50HUMALOG KWIKPEN.................................................50HUMALOG MIX 50/50.................................................50HUMALOG MIX 50/50 KWIKPEN............................. 51HUMALOG MIX 75/25.................................................51HUMALOG MIX 75/25 KWIKPEN............................. 51HUMIRA.........................................................................95HUMIRA.........................................................................96HUMIRA.........................................................................96HUMIRA.........................................................................96HUMIRA.........................................................................96HUMIRA.........................................................................96HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................96HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................96HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................96HUMIRA PEN............................................................... 96HUMIRA PEN............................................................... 96HUMIRA PEN-CD/UC/HS STARTER........................96

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HUMIRA PEN-CD/UC/HS STARTER........................96HUMIRA PEN-PS/UV STARTER...............................96HUMIRA PEN-PS/UV STARTER...............................96HUMULIN 70/30...........................................................51HUMULIN 70/30 KWIKPEN....................................... 51HUMULIN N..................................................................51HUMULIN N KWIKPEN.............................................. 51HUMULIN R..................................................................51HUMULIN R U-500 (CONCENTRATE).....................51HUMULIN R U-500 KWIKPEN...................................51hydralazine hcl tab 100 mg........................................ 67hydralazine hcl tab 10 mg.......................................... 67hydralazine hcl tab 25 mg.......................................... 67hydralazine hcl tab 50 mg.......................................... 67hydrochlorothiazide cap 12.5 mg...............................67hydrochlorothiazide tab 12.5 mg................................67hydrochlorothiazide tab 25 mg...................................67hydrochlorothiazide tab 50 mg...................................67hydrocodone-acetaminophen tab 10-325

mg..................................................................................2hydrocodone-acetaminophen tab 5-325

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocortisone butyrate cream 0.1%........................ 78hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................78hydrocortisone butyrate oint 0.1%.............................78hydrocortisone butyrate soln 0.1%............................ 78hydrocortisone cream 1%...........................................78hydrocortisone cream 2.5%........................................78hydrocortisone enema 100 mg/60ml.........................99hydrocortisone lotion 2.5%......................................... 78hydrocortisone oint 1%............................................... 78hydrocortisone oint 2.5%............................................ 78hydrocortisone rectal cream 1%................................ 99hydrocortisone rectal cream 2.5%.............................99hydrocortisone tab 10 mg...........................................87hydrocortisone tab 20 mg...........................................88hydrocortisone tab 5 mg............................................. 87hydrocortisone valerate cream 0.2%.........................78hydrocortisone valerate oint 0.2%............................. 78hydrocortisone w/ acetic acid otic soln

1-2%..........................................................................103hydromorphone hcl inj 2 mg/ml....................................2hydromorphone hcl preservative free inj 2 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 37

HYDROXYPROGESTERONECAPROATE................................................................90

hydroxyurea cap 500 mg............................................ 29hydroxyzine hcl syrup 10 mg/5ml.............................. 48hydroxyzine hcl tab 10 mg..........................................49hydroxyzine hcl tab 25 mg..........................................49hydroxyzine hcl tab 50 mg..........................................49HYZAAR........................................................................ 67HYZAAR........................................................................ 67HYZAAR........................................................................ 67Iibandronate sodium iv soln 3 mg/3ml..................... 100ibandronate sodium tab 150 mg..............................100IBRANCE.......................................................................29IBRANCE.......................................................................30IBRANCE.......................................................................30ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen tab 400 mg.................................................... 2ibuprofen tab 600 mg.................................................... 2ibuprofen tab 800 mg.................................................... 2icatibant acetate inj 30 mg/3ml.................................. 96ICLUSIG........................................................................ 30ICLUSIG........................................................................ 30idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................30IDHIFA............................................................................30IDHIFA............................................................................30IFEX............................................................................... 30IFOSFAMIDE................................................................ 30ifosfamide for inj 1 gm.................................................30ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 30ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 30ILARIS............................................................................96ILEVRO........................................................................102imatinib mesylate tab 100 mg.................................... 30imatinib mesylate tab 400 mg.................................... 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMFINZI..........................................................................30IMFINZI..........................................................................30imipenem-cilastatin intravenous for soln 250

mg..................................................................................9imipenem-cilastatin intravenous for soln 500

mg..................................................................................9

2020

129

imipramine hcl tab 10 mg........................................... 19imipramine hcl tab 25 mg........................................... 19imipramine hcl tab 50 mg........................................... 19imiquimod cream 5%...................................................78IMLYGIC........................................................................ 30IMLYGIC........................................................................ 30IMOVAX RABIES (H.D.C.V.)...................................... 96IMPAVIDO..................................................................... 10INBRIJA......................................................................... 38INCRELEX.................................................................... 88INCRUSE ELLIPTA................................................... 106indapamide tab 1.25 mg............................................. 67indapamide tab 2.5 mg............................................... 67INFANRIX......................................................................96INFLECTRA.................................................................. 96INLYTA...........................................................................30INLYTA...........................................................................30INREBIC........................................................................ 30INSULIN PEN NEEDLE 29G X 12.7MM

(1/2")........................................................................... 51INSULIN PEN NEEDLE 29G X 5MM (1/5" OR

3/16")...........................................................................51INSULIN PEN NEEDLE 29G X 8MM (1/3" OR








15/64")........................................................................ 51INSULIN PEN NEEDLE 33G X 8MM (1/3" OR

5/16")...........................................................................51INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X

1/2".............................................................................. 51INSULIN SYRINGE/NEEDLE

U-100/0.3ML/29G......................................................51INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X

1"................................................................................. 51INSULIN SYRINGE/NEEDLE

U-100/0.3ML/30G......................................................51INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X

1/4" (6MM)..................................................................52INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X

1/2".............................................................................. 52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X5/16"............................................................................52

INSULIN SYRINGE/NEEDLEU-100/0.5ML/29G......................................................52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X5/16"............................................................................52

INSULIN SYRINGE/NEEDLEU-100/0.5ML/30G......................................................52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X3/16" (5MM)............................................................... 52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X3/8".............................................................................. 52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X1/4" (6MM)..................................................................52

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X1"................................................................................. 52

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X5/8".............................................................................. 52




INSULIN SYRINGE/NEEDLE U-100/1ML/28G X5/16"............................................................................52

INSULIN SYRINGE/NEEDLE U-100/1ML/29G X5/16"............................................................................52

INSULIN SYRINGE/NEEDLEU-100/1ML/30G.........................................................52

INSULIN SYRINGE/NEEDLE U-100/1ML/30G X3/16" (5MM)............................................................... 52

INSULIN SYRINGE/NEEDLE U-100/1ML/31G X1/4" (6MM)..................................................................52

INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X5/8".............................................................................. 52

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X5/16"............................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X5/16"............................................................................51

INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X6MM (15/64").............................................................52

INSULIN SYRINGE (DISP)U-100/0.3ML.............................................................. 51

INSULIN SYRINGE (DISP)U-100/0.5ML.............................................................. 51

2020

130

INSULIN SYRINGE (DISP)U-100/1ML................................................................. 51

INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTRALIPID.................................................................. 80INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INVEGA SUSTENNA.................................................. 40INVEGA SUSTENNA.................................................. 40INVEGA SUSTENNA.................................................. 40INVEGA SUSTENNA.................................................. 40INVEGA SUSTENNA.................................................. 40INVEGA TRINZA..........................................................40INVEGA TRINZA..........................................................40INVEGA TRINZA..........................................................40INVEGA TRINZA..........................................................40INVIRASE......................................................................45INVOKAMET.................................................................52INVOKAMET.................................................................52INVOKAMET.................................................................52INVOKAMET.................................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKANA....................................................................52INVOKANA....................................................................52IPOL INACTIVATED IPV.............................................96ipratropium bromide inhal soln 0.02%.....................106ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................106ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................106irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................67irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................67irbesartan tab 150 mg.................................................67irbesartan tab 300 mg.................................................67irbesartan tab 75 mg................................................... 67IRESSA..........................................................................30IRINOTECAN................................................................30irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................30irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 30ISENTRESS..................................................................45ISENTRESS..................................................................45ISENTRESS..................................................................45

ISENTRESS..................................................................45ISENTRESS HD...........................................................45ISONIAZID.................................................................... 25isoniazid tab 100 mg................................................... 25isoniazid tab 300 mg................................................... 25ISOSORBIDE DINITRATE..........................................67isosorbide dinitrate tab 10 mg....................................67isosorbide dinitrate tab 20 mg....................................67isosorbide dinitrate tab 5 mg......................................67isosorbide mononitrate tab 10 mg............................. 67isosorbide mononitrate tab 20 mg............................. 67isosorbide mononitrate tab er 24hr 120

mg................................................................................67isosorbide mononitrate tab er 24hr 30

mg................................................................................67isosorbide mononitrate tab er 24hr 60

mg................................................................................67ISOTONIC GENTAMICIN........................................... 10isotretinoin cap 10 mg.................................................78isotretinoin cap 20 mg.................................................78isotretinoin cap 30 mg.................................................78isotretinoin cap 40 mg.................................................78isradipine cap 2.5 mg..................................................67isradipine cap 5 mg..................................................... 67ISTODAX (OVERFILL)................................................30itraconazole cap 100 mg............................................ 23ivermectin tab 3 mg.....................................................37IXEMPRA KIT...............................................................30IXEMPRA KIT...............................................................30IXIARO...........................................................................96JJADENU........................................................................ 80JADENU........................................................................ 81JADENU........................................................................ 81JADENU SPRINKLE................................................... 81JADENU SPRINKLE................................................... 81JADENU SPRINKLE................................................... 81JAKAFI...........................................................................30JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JANUMET......................................................................52JANUMET......................................................................52JANUMET XR...............................................................52JANUMET XR...............................................................52JANUMET XR...............................................................53JANUVIA........................................................................53JANUVIA........................................................................53JANUVIA........................................................................53JARDIANCE..................................................................53

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JARDIANCE..................................................................53JENTADUETO.............................................................. 53JENTADUETO.............................................................. 53JENTADUETO.............................................................. 53JENTADUETO XR....................................................... 53JENTADUETO XR....................................................... 53JEVTANA.......................................................................31JULUCA.........................................................................45KKADCYLA......................................................................31KADCYLA......................................................................31KALETRA...................................................................... 45KALETRA...................................................................... 45KALYDECO.................................................................106KALYDECO.................................................................106KALYDECO.................................................................106KALYDECO.................................................................106KANJINTI.......................................................................31kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 81kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%


inj................................................................................. 81kcl 20 meq/l (0.15%) in nacl 0.45% inj......................81kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 81KEPIVANCE..................................................................76ketoconazole cream 2%..............................................23ketoconazole shampoo 2%........................................ 23ketoconazole tab 200 mg........................................... 23ketorolac tromethamine ophth soln

0.4%..........................................................................102ketorolac tromethamine ophth soln

0.5%..........................................................................102KEYTRUDA...................................................................31KINERET....................................................................... 96KINRIX........................................................................... 96KISQALI.........................................................................31KISQALI.........................................................................31KISQALI.........................................................................31KISQALI FEMARA 200 DOSE...................................31KISQALI FEMARA 400 DOSE...................................31KISQALI FEMARA 600 DOSE...................................31KOMBIGLYZE XR........................................................53KOMBIGLYZE XR........................................................53KOMBIGLYZE XR........................................................53KORLYM........................................................................92K-TAB.............................................................................81KUVAN...........................................................................85

KUVAN...........................................................................85KUVAN...........................................................................85KYPROLIS.................................................................... 31KYPROLIS.................................................................... 31KYPROLIS.................................................................... 31Llabetalol hcl tab 100 mg..............................................67labetalol hcl tab 200 mg..............................................67labetalol hcl tab 300 mg..............................................67LACRISERT................................................................102lactated ringer's solution............................................. 81lactic acid (ammonium lactate) cream

12%............................................................................. 78lactic acid (ammonium lactate) lotion

12%............................................................................. 78lactulose (encephalopathy) solution 10

gm/15ml......................................................................83lactulose solution 10 gm/15ml....................................83lamivudine oral soln 10 mg/ml................................... 45lamivudine tab 100 mg (hbv)......................................45lamivudine tab 150 mg................................................45lamivudine tab 300 mg................................................45lamivudine-zidovudine tab 150-300 mg.................... 45lamotrigine tab 100 mg............................................... 14lamotrigine tab 150 mg............................................... 14lamotrigine tab 200 mg............................................... 14lamotrigine tab 25 mg................................................. 14lamotrigine tab chewable dispersible 25

mg................................................................................14lamotrigine tab chewable dispersible 5

mg................................................................................14lansoprazole cap delayed release 15

mg................................................................................83lansoprazole cap delayed release 30

mg................................................................................83lanthanum carbonate chew tab 1000



mg................................................................................81LANTUS.........................................................................53LANTUS SOLOSTAR..................................................53LARTRUVO...................................................................31LARTRUVO...................................................................31LASIX............................................................................. 67LASIX............................................................................. 68LASIX............................................................................. 68latanoprost ophth soln 0.005%................................ 102LATUDA.........................................................................40LATUDA.........................................................................40

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LATUDA.........................................................................40LATUDA.........................................................................40LATUDA.........................................................................40LEDIPASVIR/SOFOSBUVIR...................................... 45leflunomide tab 10 mg.................................................96leflunomide tab 20 mg.................................................96LENVIMA 10 MG DAILY DOSE.................................31LENVIMA 12MG DAILY DOSE..................................31LENVIMA 14 MG DAILY DOSE.................................31LENVIMA 18 MG DAILY DOSE.................................31LENVIMA 20 MG DAILY DOSE.................................31LENVIMA 24 MG DAILY DOSE.................................31LENVIMA 4 MG DAILY DOSE...................................31LENVIMA 8 MG DAILY DOSE...................................31letrozole tab 2.5 mg.....................................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32leucovorin calcium for inj 100 mg.............................. 32leucovorin calcium for inj 200 mg.............................. 32leucovorin calcium for inj 350 mg.............................. 32leucovorin calcium for inj 500 mg.............................. 32leucovorin calcium for inj 50 mg................................ 32leucovorin calcium inj 500 mg/50ml (10 mg/

ml)................................................................................32leucovorin calcium tab 25 mg.................................... 32leucovorin calcium tab 5 mg.......................................32LEUKERAN...................................................................32LEUKINE....................................................................... 58leuprolide acetate inj kit 5 mg/ml............................... 92LEVEMIR.......................................................................53LEVEMIR FLEXTOUCH..............................................53levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................14levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................14levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................14levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levobunolol hcl ophth soln 0.5%..............................102levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 81levocarnitine tab 330 mg............................................ 81levocetirizine dihydrochloride tab 5

mg............................................................................. 106

levofloxacin in d5w iv soln 250mg/50ml......................................................................10

levofloxacin in d5w iv soln 500mg/100ml....................................................................10

levofloxacin in d5w iv soln 750mg/150ml....................................................................10

levofloxacin iv soln 25 mg/ml..................................... 10levofloxacin ophth soln 0.5%................................... 102levofloxacin oral soln 25 mg/ml..................................10levofloxacin tab 250 mg..............................................10levofloxacin tab 500 mg..............................................10levofloxacin tab 750 mg..............................................10levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 90levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................90levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................90levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................90levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................90levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................90levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................90LEVORPHANOL TARTRATE....................................... 2levorphanol tartrate tab 2 mg....................................... 2levothyroxine sodium tab 100 mcg (levo-t, levoxyl,

unithroid).....................................................................91levothyroxine sodium tab 112 mcg (levo-t, levoxyl,







unithroid).....................................................................91levothyroxine sodium tab 300 mcg (levo-t,




unithroid).....................................................................91

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LEXAPRO......................................................................19LEXAPRO......................................................................19LEXAPRO......................................................................19LEXIVA...........................................................................45LIBTAYO........................................................................ 32LIDOCAINE HCL..........................................................68LIDOCAINE HCL..........................................................68lidocaine hcl soln 4%.....................................................4lidocaine hcl urethral/mucosal gel 2%.........................4lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4LINDANE....................................................................... 37LINEZOLID....................................................................10linezolid for susp 100 mg/5ml.................................... 10linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................10linezolid tab 600 mg.................................................... 10LINZESS........................................................................83LINZESS........................................................................83LINZESS........................................................................83liothyronine sodium tab 25 mcg.................................92liothyronine sodium tab 50 mcg.................................92liothyronine sodium tab 5 mcg................................... 92lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................68lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................68lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................68lisinopril tab 10 mg...................................................... 68lisinopril tab 2.5 mg..................................................... 68lisinopril tab 20 mg...................................................... 68lisinopril tab 30 mg...................................................... 68lisinopril tab 40 mg...................................................... 68lisinopril tab 5 mg.........................................................68LITHIUM........................................................................ 49lithium carbonate cap 150 mg....................................49lithium carbonate cap 300 mg....................................49lithium carbonate cap 600 mg....................................49lithium carbonate tab 300 mg.....................................49lithium carbonate tab er 300 mg................................49lithium carbonate tab er 450 mg................................49LONSURF..................................................................... 32LONSURF..................................................................... 32loperamide hcl cap 2 mg............................................ 83lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................45LOPRESSOR................................................................68

LOPRESSOR................................................................68lorazepam tab 0.5 mg................................................. 49lorazepam tab 1 mg.................................................... 49lorazepam tab 2 mg.................................................... 49LORBRENA.................................................................. 32LORBRENA.................................................................. 32losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 68losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................68losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................68losartan potassium tab 100 mg..................................68losartan potassium tab 25 mg....................................68losartan potassium tab 50 mg....................................68LOTENSIN.................................................................... 68LOTENSIN.................................................................... 68LOTENSIN.................................................................... 68lovastatin tab 10 mg....................................................68lovastatin tab 20 mg....................................................68lovastatin tab 40 mg....................................................68loxapine succinate cap 10 mg....................................41loxapine succinate cap 25 mg....................................41loxapine succinate cap 50 mg....................................41loxapine succinate cap 5 mg......................................40LUMIGAN....................................................................102LUMIZYME....................................................................85LUMOXITI......................................................................32LUPRON DEPOT (1-MONTH)...................................92LUPRON DEPOT (1-MONTH)...................................92LUPRON DEPOT (3-MONTH)...................................93LUPRON DEPOT (3-MONTH)...................................93LUPRON DEPOT (4-MONTH)...................................93LUPRON DEPOT (6-MONTH)...................................93LUPRON DEPOT-PED (1-MONTH)..........................93LUPRON DEPOT-PED (1-MONTH)..........................93LUPRON DEPOT-PED (1-MONTH)..........................93LUPRON DEPOT-PED (3-MONTH)..........................93LUPRON DEPOT-PED (3-MONTH)..........................93LYNPARZA....................................................................32LYNPARZA....................................................................32LYSODREN...................................................................92Mmagnesium sulfate inj 50%........................................ 81malathion lotion 0.5%..................................................37MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MARPLAN..................................................................... 19MARQIBO......................................................................32MATULANE...................................................................32

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MAXITROL..................................................................102MAXITROL..................................................................102MAYZENT......................................................................75MAYZENT......................................................................75meclizine hcl tab 12.5 mg...........................................21medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................90medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 90medroxyprogesterone acetate tab 10

mg................................................................................90medroxyprogesterone acetate tab 2.5

mg................................................................................90medroxyprogesterone acetate tab 5

mg................................................................................90MEFLOQUINE HCL.....................................................37megestrol acetate susp 40 mg/ml..............................90megestrol acetate tab 20 mg..................................... 90megestrol acetate tab 40 mg..................................... 90MEKINIST......................................................................32MEKINIST......................................................................32MEKTOVI.......................................................................32meloxicam tab 15 mg....................................................2meloxicam tab 7.5 mg...................................................2melphalan hcl for inj 50 mg........................................ 32memantine hcl oral solution 2 mg/ml.........................17memantine hcl tab 10 mg...........................................17memantine hcl tab 5 mg............................................. 17memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................17MENACTRA.................................................................. 96MENVEO....................................................................... 96mercaptopurine tab 50 mg......................................... 32meropenem iv for soln 1 gm...................................... 10meropenem iv for soln 500 mg.................................. 10mesalamine cap dr 400 mg........................................99mesalamine enema 4 gm........................................... 99mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 99mesalamine suppos 1000 mg.................................... 99mesalamine tab delayed release 1.2

gm................................................................................99mesalamine tab delayed release 800

mg................................................................................99mesna inj 100 mg/ml...................................................32MESNEX........................................................................32metformin hcl tab 1000 mg.........................................53metformin hcl tab 500 mg...........................................53metformin hcl tab 850 mg...........................................53metformin hcl tab er 24hr 500 mg............................. 53metformin hcl tab er 24hr 750 mg............................. 53methadone hcl tab 10 mg.............................................2

methadone hcl tab 5 mg............................................... 2methazolamide tab 25 mg.......................................... 68methazolamide tab 50 mg.......................................... 68methenamine hippurate tab 1 gm..............................10methimazole tab 10 mg.............................................. 94methimazole tab 5 mg.................................................94methocarbamol tab 500 mg..................................... 108methocarbamol tab 750 mg..................................... 108METHOTREXATE SODIUM.......................................96methotrexate sodium for inj 1 gm.............................. 96methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................97methotrexate sodium inj pf 1000 mg/40ml (25 mg/



ml)................................................................................96methotrexate sodium tab 2.5 mg............................... 97methoxsalen rapid cap 10 mg....................................78methscopolamine bromide tab 2.5 mg......................83methscopolamine bromide tab 5 mg......................... 83methylergonovine maleate tab 0.2 mg......................87methylphenidate hcl tab 10 mg..................................76methylphenidate hcl tab 20 mg..................................76methylphenidate hcl tab 5 mg....................................76methylphenidate hcl tab er 20 mg............................. 75methylprednisolone sod succ for inj 1000

mg................................................................................88methylprednisolone sod succ for inj 125

mg................................................................................88methylprednisolone sod succ for inj 40

mg................................................................................88methylprednisolone tab 16 mg...................................88methylprednisolone tab 32 mg...................................88methylprednisolone tab 4 mg.....................................88methylprednisolone tab 8 mg.....................................88methylprednisolone tab therapy pack 4 mg

(21)..............................................................................88METHYLTESTOSTERONE........................................ 90metoclopramide hcl inj 5 mg/ml................................. 83metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................83metoclopramide hcl tab 10 mg...................................83metoclopramide hcl tab 5 mg.....................................83metolazone tab 10 mg................................................ 68metolazone tab 2.5 mg............................................... 68metolazone tab 5 mg...................................................68metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................68metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................68

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135

metoprolol succinate tab er 24hr 100mg................................................................................68




metoprolol tartrate tab 100 mg...................................69metoprolol tartrate tab 25 mg.....................................69metoprolol tartrate tab 50 mg.....................................69METROGEL-VAGINAL................................................10METRONIDAZOLE...................................................... 10METRONIDAZOLE...................................................... 10metronidazole cap 375 mg.........................................10metronidazole cream 0.75%.......................................78metronidazole gel 0.75%............................................ 78metronidazole gel 1%..................................................78metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................10metronidazole lotion 0.75%........................................ 78metronidazole tab 250 mg..........................................10metronidazole tab 500 mg..........................................10metronidazole vaginal gel 0.75%...............................10MEXILETINE HCL....................................................... 69MEXILETINE HCL....................................................... 69MEXILETINE HCL....................................................... 69MIACALCIN................................................................ 100MICARDIS.....................................................................69MICARDIS.....................................................................69MICARDIS.....................................................................69MICARDIS HCT........................................................... 69MICARDIS HCT........................................................... 69MICARDIS HCT........................................................... 69midodrine hcl tab 10 mg............................................. 69midodrine hcl tab 2.5 mg............................................ 69midodrine hcl tab 5 mg............................................... 69MIGERGOT...................................................................24miglitol tab 100 mg...................................................... 53miglitol tab 25 mg........................................................ 53miglitol tab 50 mg........................................................ 53miglustat cap 100 mg..................................................85MIGRANAL....................................................................24minocycline hcl cap 100 mg.......................................10minocycline hcl cap 50 mg......................................... 10minocycline hcl cap 75 mg......................................... 10minocycline hcl tab 100 mg........................................10minocycline hcl tab 50 mg..........................................10minocycline hcl tab 75 mg..........................................10minoxidil tab 10 mg..................................................... 69minoxidil tab 2.5 mg.................................................... 69

mirtazapine orally disintegrating tab 15mg................................................................................19



mirtazapine tab 15 mg................................................ 19mirtazapine tab 30 mg................................................ 19mirtazapine tab 45 mg................................................ 19mirtazapine tab 7.5 mg............................................... 19misoprostol tab 100 mcg............................................ 83misoprostol tab 200 mcg............................................ 83MITIGARE..................................................................... 24mitomycin for iv soln 20 mg....................................... 32mitomycin for iv soln 40 mg....................................... 32mitomycin for iv soln 5 mg..........................................32mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................32mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................32mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................32M-M-R II........................................................................ 96modafinil tab 100 mg.................................................108modafinil tab 200 mg.................................................108moexipril hcl tab 15 mg...............................................69moexipril hcl tab 7.5 mg..............................................69MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41mometasone furoate cream 0.1%............................. 78mometasone furoate nasal susp 50 mcg/

act..............................................................................106mometasone furoate oint 0.1%..................................78mometasone furoate solution 0.1%

(lotion).........................................................................78MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2".................................... 53MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.5ML/29G X 1/2".................................... 53MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/1ML/29G X 1/2"........................................53montelukast sodium chew tab 4 mg........................106montelukast sodium chew tab 5 mg........................106montelukast sodium oral granules packet 4

mg............................................................................. 106montelukast sodium tab 10 mg................................106morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................2morphine sulfate oral soln 10 mg/5ml......................... 2morphine sulfate oral soln 20 mg/5ml......................... 2morphine sulfate tab 15 mg..........................................3

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morphine sulfate tab 30 mg..........................................3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 2morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 2morphine sulfate tab er 60 mg..................................... 2MOVIPREP................................................................... 83MOXEZA..................................................................... 102MOXIFLOXACIN HCL................................................. 10moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................10moxifloxacin hcl ophth soln 0.5%............................ 102moxifloxacin hcl tab 400 mg.......................................10MOZOBIL...................................................................... 58MULTAQ........................................................................ 69mupirocin calcium cream 2%..................................... 78mupirocin oint 2%........................................................ 78MVASI............................................................................ 32MVASI............................................................................ 33MYALEPT...................................................................... 84MYCAMINE...................................................................23MYCAMINE...................................................................23mycophenolate mofetil cap 250 mg...........................97mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................97mycophenolate mofetil hcl for iv soln 500

mg................................................................................97mycophenolate mofetil tab 500 mg........................... 97mycophenolate sodium tab dr 180 mg......................97mycophenolate sodium tab dr 360 mg......................97MYLOTARG.................................................................. 33MYRBETRIQ.................................................................87MYRBETRIQ.................................................................87Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................69nadolol tab 40 mg........................................................69nadolol tab 80 mg........................................................69NAFCILLIN SODIUM...................................................10NAFCILLIN SODIUM...................................................10NAFCILLIN SODIUM...................................................10nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11nafcillin sodium for iv soln 10 gm.............................. 11NAGLAZYME................................................................85NALOXONE HCL........................................................... 4NALOXONE HCL........................................................... 4naloxone hcl inj 0.4 mg/ml............................................4naloxone hcl inj 4 mg/10ml...........................................4naltrexone hcl tab 50 mg.............................................. 4

naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen sodium tab er 24hr 375 mg......................... 3naproxen sodium tab er 24hr 500 mg......................... 3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................24naratriptan hcl tab 2.5 mg...........................................24NARCAN..........................................................................4NARDIL..........................................................................19NATACYN....................................................................102nateglinide tab 120 mg............................................... 53nateglinide tab 60 mg..................................................53NATPARA....................................................................100NATPARA....................................................................100NATPARA....................................................................100NATPARA....................................................................100NEBUPENT...................................................................37NEFAZODONE HCL....................................................19NEFAZODONE HCL....................................................19nefazodone hcl tab 250 mg........................................19nefazodone hcl tab 50 mg..........................................19NEFAZODONE HYDROCHLORIDE.........................19NEOMYCIN/POLYMYXIN/

GRAMICIDIN........................................................... 102NEOMYCIN/POLYMYXIN B

SULFATES................................................................. 11neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin........................102neomycin-polymyxin-dexamethasone ophth oint

0.1%..........................................................................102neomycin-polymyxin-dexamethasone ophth susp

0.1%..........................................................................102neomycin-polymyxin-hc otic soln 1%...................... 103neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 103neomycin sulfate tab 500 mg.....................................11NEPHRAMINE..............................................................81NERLYNX......................................................................33nevirapine susp 50 mg/5ml........................................ 45nevirapine tab 200 mg................................................ 45nevirapine tab er 24hr 100 mg...................................45nevirapine tab er 24hr 400 mg...................................45NEXAVAR......................................................................33NEXIUM.........................................................................84NEXIUM.........................................................................84NEXIUM.........................................................................84NEXIUM.........................................................................84

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NEXIUM.........................................................................84niacin tab er 1000 mg................................................. 69niacin tab er 500 mg................................................... 69niacin tab er 750 mg................................................... 69nicardipine hcl cap 20 mg...........................................69nicardipine hcl cap 30 mg...........................................69NICOTROL INHALER................................................... 4NICOTROL NS............................................................... 4nifedipine tab er 24hr 30 mg...................................... 69nifedipine tab er 24hr 60 mg...................................... 69nifedipine tab er 24hr 90 mg...................................... 69nifedipine tab er 24hr osmotic release 30

mg................................................................................69nifedipine tab er 24hr osmotic release 60

mg................................................................................69nifedipine tab er 24hr osmotic release 90

mg................................................................................69nilutamide tab 150 mg.................................................33nimodipine cap 30 mg.................................................69NINLARO.......................................................................33NINLARO.......................................................................33NINLARO.......................................................................33NIPENT..........................................................................33NISOLDIPINE ER........................................................ 69nisoldipine tab er 24hr 17 mg.................................... 70nisoldipine tab er 24hr 34 mg.................................... 70nisoldipine tab er 24hr 8.5 mg................................... 69nitisinone cap 10 mg................................................... 85nitisinone cap 2 mg..................................................... 85nitisinone cap 5 mg..................................................... 85NITRO-BID....................................................................70nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................11nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11nitroglycerin sl tab 0.3 mg.......................................... 70nitroglycerin sl tab 0.4 mg.......................................... 70nitroglycerin sl tab 0.6 mg.......................................... 70nitroglycerin td patch 24hr 0.1 mg/hr.........................70nitroglycerin td patch 24hr 0.2 mg/hr.........................70nitroglycerin td patch 24hr 0.4 mg/hr.........................70nitroglycerin td patch 24hr 0.6 mg/hr.........................70nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................70NIVESTYM....................................................................58NIVESTYM....................................................................58NIVESTYM....................................................................58NIVESTYM....................................................................58nizatidine cap 150 mg.................................................84

nizatidine cap 300 mg.................................................84norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................90norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................90norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................90norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................90norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................90norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................90norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................90norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................90norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................90norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................90norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg..............................................................................91norethindrone acetate tab 5 mg.................................90norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................90norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................91norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................91norethindrone tab 0.35 mg......................................... 91norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................91norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................91norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................91norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................91NORMOSOL-M IN D5W............................................. 81NORTHERA.................................................................. 70NORTHERA.................................................................. 70NORTHERA.................................................................. 70NORTRIPTYLINE HCL............................................... 19nortriptyline hcl cap 10 mg......................................... 19nortriptyline hcl cap 25 mg......................................... 19nortriptyline hcl cap 50 mg......................................... 19nortriptyline hcl cap 75 mg......................................... 20NORVASC..................................................................... 70NORVASC..................................................................... 70NORVASC..................................................................... 70NORVIR.........................................................................45

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NORVIR.........................................................................45NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NUBEQA........................................................................33NUEDEXTA...................................................................76NULOJIX........................................................................97NULYTELY/FLAVOR PACKS..................................... 84NUPLAZID.....................................................................41NUPLAZID.....................................................................41NUTRILIPID.................................................................. 81nystatin cream 100000 unit/gm..................................23nystatin oint 100000 unit/gm...................................... 23nystatin susp 100000 unit/ml......................................23nystatin tab 500000 unit..............................................23nystatin topical powder 100000 unit/

gm................................................................................23nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................78nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................78OOCALIVA....................................................................... 85OCALIVA....................................................................... 85octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................93octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)................................................................................93OCUFLOX...................................................................102ODEFSEY..................................................................... 45ODOMZO...................................................................... 33OFEV........................................................................... 106OFEV........................................................................... 106ofloxacin ophth soln 0.3%........................................ 102ofloxacin otic soln 0.3%............................................ 103ofloxacin tab 400 mg...................................................11olanzapine for im inj 10 mg........................................ 41olanzapine orally disintegrating tab 10

mg................................................................................41olanzapine orally disintegrating tab 15



mg................................................................................41

olanzapine tab 10 mg..................................................41olanzapine tab 15 mg..................................................41olanzapine tab 2.5 mg.................................................41olanzapine tab 20 mg..................................................41olanzapine tab 5 mg....................................................41olanzapine tab 7.5 mg.................................................41olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg............................................................. 70olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg...........................................................70olmesartan-amlodipine-hydrochlorothiazide tab

40-10-25 mg.............................................................. 70olmesartan-amlodipine-hydrochlorothiazide tab

40-5-12.5 mg............................................................. 70olmesartan-amlodipine-hydrochlorothiazide tab

40-5-25 mg................................................................ 70olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................70olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................70olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................70olmesartan medoxomil tab 20 mg............................. 70olmesartan medoxomil tab 40 mg............................. 70olmesartan medoxomil tab 5 mg............................... 70olopatadine hcl nasal soln 0.6%..............................106olopatadine hcl ophth soln 0.1%..............................102olopatadine hcl ophth soln 0.2%..............................102omega-3-acid ethyl esters cap 1 gm.........................70omeprazole cap delayed release 10

mg................................................................................84omeprazole cap delayed release 20

mg................................................................................84omeprazole cap delayed release 40

mg................................................................................84OMNITROPE................................................................ 88OMNITROPE................................................................ 88OMNITROPE................................................................ 88ONCASPAR.................................................................. 33ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................22ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22ondansetron orally disintegrating tab 8

mg................................................................................22ONGLYZA......................................................................53

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ONGLYZA......................................................................53ONIVYDE...................................................................... 33OPDIVO.........................................................................33OPDIVO.........................................................................33OPDIVO.........................................................................33OPSUMIT....................................................................106ORACEA........................................................................78ORENCIA...................................................................... 97ORENCIA...................................................................... 97ORENCIA...................................................................... 97ORENCIA...................................................................... 97ORENCIA CLICKJECT............................................... 97ORFADIN.......................................................................85ORFADIN.......................................................................85ORFADIN.......................................................................85ORFADIN.......................................................................85ORFADIN.......................................................................85ORKAMBI....................................................................106ORKAMBI....................................................................106ORKAMBI....................................................................106ORKAMBI....................................................................106oseltamivir phosphate cap 30 mg..............................45oseltamivir phosphate cap 45 mg..............................46oseltamivir phosphate cap 75 mg..............................46oseltamivir phosphate for susp 6 mg/

ml.................................................................................46OTEZLA.........................................................................97OTEZLA.........................................................................97oxaliplatin for iv inj 100 mg.........................................33oxaliplatin for iv inj 50 mg...........................................33oxaliplatin iv soln 100 mg/20ml..................................33oxaliplatin iv soln 50 mg/10ml....................................33oxandrolone tab 10 mg............................................... 91oxandrolone tab 2.5 mg..............................................91oxaprozin tab 600 mg....................................................3oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................15oxcarbazepine tab 150 mg.........................................15oxcarbazepine tab 300 mg.........................................15oxcarbazepine tab 600 mg.........................................15oxybutynin chloride syrup 5 mg/5ml..........................87oxybutynin chloride tab 5 mg..................................... 87oxybutynin chloride tab er 24hr 10 mg......................87oxybutynin chloride tab er 24hr 15 mg......................87oxybutynin chloride tab er 24hr 5 mg........................87oxycodone-aspirin tab 4.8355-325 mg........................3oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................3oxycodone hcl tab 20 mg..............................................3oxycodone hcl tab 30 mg..............................................3oxycodone hcl tab 5 mg................................................3

oxycodone w/ acetaminophen tab 10-325mg..................................................................................3

oxycodone w/ acetaminophen tab 2.5-325mg..................................................................................3

oxycodone w/ acetaminophen tab 5-325mg..................................................................................3

oxycodone w/ acetaminophen tab 7.5-325mg..................................................................................3

OZEMPIC...................................................................... 54OZEMPIC...................................................................... 54Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................33paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................33paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................33paliperidone tab er 24hr 1.5 mg.................................41paliperidone tab er 24hr 3 mg....................................41paliperidone tab er 24hr 6 mg....................................41paliperidone tab er 24hr 9 mg....................................41palonosetron hcl iv soln 0.25 mg/5ml........................22palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 22PALONOSETRON

HYDROCHLORIDE.................................................. 22PALYNZIQ..................................................................... 86PALYNZIQ..................................................................... 86PALYNZIQ..................................................................... 86PANRETIN.....................................................................33pantoprazole sodium ec tab 20 mg........................... 84pantoprazole sodium ec tab 40 mg........................... 84pantoprazole sodium for iv soln 40 mg..................... 84paricalcitol cap 1 mcg............................................... 100paricalcitol cap 2 mcg............................................... 100paricalcitol cap 4 mcg............................................... 100paricalcitol iv soln 2 mcg/ml..................................... 100paricalcitol iv soln 5 mcg/ml..................................... 100PARNATE...................................................................... 20paromomycin sulfate cap 250 mg..............................11paroxetine hcl tab 10 mg............................................ 20paroxetine hcl tab 20 mg............................................ 20paroxetine hcl tab 30 mg............................................ 20paroxetine hcl tab 40 mg............................................ 20PASER........................................................................... 25PATANOL.................................................................... 102PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAZEO.........................................................................102

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PEDIARIX......................................................................97PEDVAX HIB................................................................ 97peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................84peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................84peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................84PEGANONE..................................................................15PEGASYS..................................................................... 46PEGASYS..................................................................... 46PEGASYS PROCLICK................................................46penicillin g potassium for inj 20000000

unit...............................................................................11penicillin g potassium for inj 5000000

unit...............................................................................11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G SODIUM............................................. 11PENICILLIN V POTASSIUM...................................... 11PENICILLIN V POTASSIUM...................................... 11penicillin v potassium tab 250 mg............................. 11penicillin v potassium tab 500 mg............................. 11PENTACEL....................................................................97PENTAM 300................................................................37pentamidine isethionate for soln 300

mg................................................................................37PENTASA....................................................................100PENTASA....................................................................100pentoxifylline tab er 400 mg....................................... 70perindopril erbumine tab 2 mg................................... 70perindopril erbumine tab 4 mg................................... 70perindopril erbumine tab 8 mg................................... 70PERJETA.......................................................................33permethrin cream 5%..................................................37perphenazine tab 16 mg.............................................22perphenazine tab 2 mg............................................... 22perphenazine tab 4 mg............................................... 22perphenazine tab 8 mg............................................... 22PERSERIS.................................................................... 41PERSERIS.................................................................... 41phenelzine sulfate tab 15 mg.....................................20phenobarbital elixir 20 mg/5ml...................................15PHENOBARBITAL SODIUM...................................... 15PHENOBARBITAL SODIUM...................................... 15phenobarbital tab 100 mg...........................................15phenobarbital tab 15 mg.............................................15phenobarbital tab 16.2 mg..........................................15

phenobarbital tab 30 mg.............................................15phenobarbital tab 32.4 mg..........................................15phenobarbital tab 60 mg.............................................15phenobarbital tab 64.8 mg..........................................15phenobarbital tab 97.2 mg..........................................15phenoxybenzamine hcl cap 10 mg............................70phenytoin chew tab 50 mg......................................... 15phenytoin sodium extended cap 100

mg................................................................................15phenytoin sodium extended cap 200

mg................................................................................15phenytoin sodium extended cap 300

mg................................................................................15phenytoin susp 125 mg/5ml....................................... 15PHOSLYRA...................................................................81PHOSPHOLINE IODIDE.......................................... 102PICATO..........................................................................79PICATO..........................................................................79PIFELTRO..................................................................... 46pilocarpine hcl ophth soln 1%..................................102pilocarpine hcl ophth soln 2%..................................102pilocarpine hcl ophth soln 4%..................................102pilocarpine hcl tab 5 mg..............................................76pilocarpine hcl tab 7.5 mg.......................................... 76pimecrolimus cream 1%..............................................79PIMOZIDE..................................................................... 41PIMOZIDE..................................................................... 41pindolol tab 10 mg....................................................... 70pindolol tab 5 mg......................................................... 70pioglitazone hcl-glimepiride tab 30-2

mg................................................................................54pioglitazone hcl-glimepiride tab 30-4

mg................................................................................54pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................54pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................54pioglitazone hcl tab 15 mg..........................................54pioglitazone hcl tab 30 mg..........................................54pioglitazone hcl tab 45 mg..........................................54piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................11piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 11piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 11PIQRAY 200MG DAILY DOSE...................................33PIQRAY 250MG DAILY DOSE...................................33PIQRAY 300MG DAILY DOSE...................................33piroxicam cap 10 mg..................................................... 3piroxicam cap 20 mg..................................................... 3PLEGRIDY.................................................................... 76

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PLEGRIDY.................................................................... 76PLEGRIDY STARTER PACK..................................... 76PLEGRIDY STARTER PACK..................................... 76podofilox soln 0.5%..................................................... 79POLIVY..........................................................................33polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 102POLYTRIM.................................................................. 102POMALYST...................................................................33POMALYST...................................................................33POMALYST...................................................................33POMALYST...................................................................33PORTRAZZA................................................................ 33posaconazole tab delayed release 100

mg................................................................................23POTASSIUM CHLORIDE/DEXTROSE.....................81POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................81POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................82POTASSIUM CHLORIDE/DEXTROSE/SODIUM

CHLORIDE.................................................................82potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 81potassium chloride cap er 10 meq............................ 81potassium chloride cap er 8 meq...............................81POTASSIUM CHLORIDE ER.....................................81potassium chloride inj 2 meq/ml................................ 81potassium chloride microencapsulated crys er tab 10

meq............................................................................. 81potassium chloride microencapsulated crys er tab 20

meq............................................................................. 81potassium chloride oral soln 10% (20

meq/15ml).................................................................. 81potassium chloride tab er 10 meq............................. 81potassium chloride tab er 8 meq (600

mg).............................................................................. 81potassium citrate tab er 10 meq (1080



mg).............................................................................. 82POTELIGEO................................................................. 33PRADAXA..................................................................... 58PRADAXA..................................................................... 58PRADAXA..................................................................... 58pramipexole dihydrochloride tab 0.125

mg................................................................................38pramipexole dihydrochloride tab 0.25

mg................................................................................38

pramipexole dihydrochloride tab 0.5mg................................................................................38



pramipexole dihydrochloride tab 1 mg...................... 38prasugrel hcl tab 10 mg..............................................58prasugrel hcl tab 5 mg................................................ 58pravastatin sodium tab 10 mg....................................70pravastatin sodium tab 20 mg....................................70pravastatin sodium tab 40 mg....................................71pravastatin sodium tab 80 mg....................................71praziquantel tab 600 mg............................................. 37prazosin hcl cap 1 mg.................................................71prazosin hcl cap 2 mg.................................................71prazosin hcl cap 5 mg.................................................71PRECOSE.....................................................................54PRECOSE.....................................................................54PRECOSE.....................................................................54PRED FORTE............................................................ 102PREDNICARBATE.......................................................79PREDNICARBATE.......................................................79PREDNISOLONE ACETATE....................................102prednisolone sod phosphate oral soln 10

mg/5ml........................................................................ 88prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 88prednisolone sod phosphate oral soln 20

mg/5ml........................................................................ 88prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................88prednisolone syrup 15 mg/5ml...................................88PREDNISONE.............................................................. 88PREDNISONE.............................................................. 88prednisone tab 10 mg................................................. 88prednisone tab 1 mg................................................... 88prednisone tab 2.5 mg................................................ 88prednisone tab 20 mg................................................. 88prednisone tab 5 mg................................................... 88prednisone tab therapy pack 10 mg

(21)..............................................................................88prednisone tab therapy pack 10 mg

(48)..............................................................................88prednisone tab therapy pack 5 mg (21).................... 88prednisone tab therapy pack 5 mg (48).................... 88pregabalin cap 100 mg............................................... 15pregabalin cap 150 mg............................................... 15pregabalin cap 200 mg............................................... 15pregabalin cap 225 mg............................................... 15pregabalin cap 25 mg................................................. 15pregabalin cap 300 mg............................................... 15

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pregabalin cap 50 mg................................................. 15pregabalin cap 75 mg................................................. 15pregabalin soln 20 mg/ml........................................... 15PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 89PREMARIN................................................................... 91PREMASOL.................................................................. 82PREMPHASE............................................................... 91PREMPRO.................................................................... 91PREMPRO.................................................................... 91PREMPRO.................................................................... 91PREMPRO.................................................................... 91PREVENT SAFETY PEN NEEDLES 31G X

1/4".............................................................................. 54PREVENT SAFETY PEN NEEDLES 31G X

5/16"............................................................................54PREVYMIS....................................................................46PREVYMIS....................................................................46PREZCOBIX................................................................. 46PREZISTA..................................................................... 46PREZISTA..................................................................... 46PREZISTA..................................................................... 46PREZISTA..................................................................... 46PREZISTA..................................................................... 46PRIFTIN.........................................................................25primaquine phosphate tab 26.3 mg...........................37primidone tab 250 mg................................................. 15primidone tab 50 mg................................................... 15PRINIVIL........................................................................71PRINIVIL........................................................................71PRINIVIL........................................................................71PRIVIGEN..................................................................... 97PRIVIGEN..................................................................... 97PRIVIGEN..................................................................... 97PRIVIGEN..................................................................... 97PROAIR HFA..............................................................106PROAIR RESPICLICK..............................................106probenecid tab 500 mg............................................... 24PROCALAMINE........................................................... 82PROCARDIA XL.......................................................... 71PROCARDIA XL.......................................................... 71PROCARDIA XL.......................................................... 71PROCHLORPERAZINE EDISYLATE....................... 22prochlorperazine edisylate inj 10

mg/2ml........................................................................ 22prochlorperazine maleate tab 10 mg.........................22prochlorperazine maleate tab 5 mg...........................22prochlorperazine suppos 25 mg................................ 22PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58

PROCRIT...................................................................... 58PROCRIT...................................................................... 59progesterone micronized cap 100 mg.......................91progesterone micronized cap 200 mg.......................91PROGLYCEM............................................................... 54PROGRAF.....................................................................97PROGRAF.....................................................................97PROGRAF.....................................................................97PROLASTIN-C..............................................................86PROLASTIN-C..............................................................86PROLENSA................................................................ 102PROLEUKIN................................................................. 34PROLIA........................................................................100PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59promethazine hcl suppos 12.5 mg............................ 22promethazine hcl suppos 25 mg................................22promethazine hcl syrup 6.25 mg/5ml........................ 22promethazine hcl tab 12.5 mg....................................22promethazine hcl tab 25 mg.......................................22promethazine hcl tab 50 mg.......................................22propafenone hcl cap er 12hr 225 mg........................ 71propafenone hcl cap er 12hr 325 mg........................ 71propafenone hcl cap er 12hr 425 mg........................ 71propafenone hcl tab 150 mg...................................... 71propafenone hcl tab 225 mg...................................... 71propafenone hcl tab 300 mg...................................... 71propranolol hcl cap er 24hr 120 mg.......................... 71propranolol hcl cap er 24hr 160 mg.......................... 71propranolol hcl cap er 24hr 60 mg.............................71propranolol hcl cap er 24hr 80 mg.............................71propranolol hcl inj 1 mg/ml......................................... 71propranolol hcl tab 10 mg...........................................71propranolol hcl tab 20 mg...........................................71propranolol hcl tab 40 mg...........................................71propranolol hcl tab 60 mg...........................................71propranolol hcl tab 80 mg...........................................71propylthiouracil tab 50 mg.......................................... 94PROQUAD.................................................................... 97PROSCAR.....................................................................87PROSOL........................................................................82protriptyline hcl tab 10 mg.......................................... 20protriptyline hcl tab 5 mg............................................ 20PROZAC........................................................................20PROZAC........................................................................20PROZAC........................................................................20PULMOZYME.............................................................106PURIXAN.......................................................................34PYLERA.........................................................................84

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pyrazinamide tab 500 mg........................................... 25pyridostigmine bromide oral soln 60

mg/5ml........................................................................ 25pyridostigmine bromide tab 60 mg............................ 25pyridostigmine bromide tab er 180 mg......................25QQUADRACEL................................................................97quetiapine fumarate tab 100 mg................................41quetiapine fumarate tab 200 mg................................41quetiapine fumarate tab 25 mg..................................41quetiapine fumarate tab 300 mg................................41quetiapine fumarate tab 400 mg................................42quetiapine fumarate tab 50 mg..................................41quetiapine fumarate tab er 24hr 150

mg................................................................................41quetiapine fumarate tab er 24hr 200



mg................................................................................41quetiapine fumarate tab er 24hr 50 mg.....................41quinapril hcl tab 10 mg............................................... 71quinapril hcl tab 20 mg............................................... 71quinapril hcl tab 40 mg............................................... 71quinapril hcl tab 5 mg..................................................71quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................71quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................71quinapril-hydrochlorothiazide tab 20-25

mg................................................................................71quinidine gluconate tab er 324 mg............................ 71QUINIDINE SULFATE................................................. 71QUINIDINE SULFATE................................................. 71QVAR REDIHALER................................................... 106QVAR REDIHALER................................................... 106RRABAVERT................................................................... 97raloxifene hcl tab 60 mg............................................. 91ramipril cap 1.25 mg....................................................71ramipril cap 10 mg.......................................................72ramipril cap 2.5 mg......................................................72ramipril cap 5 mg.........................................................72ranitidine hcl cap 150 mg........................................... 84ranitidine hcl cap 300 mg........................................... 84ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................84ranitidine hcl tab 150 mg............................................ 84ranitidine hcl tab 300 mg............................................ 84ranolazine tab er 12hr 1000 mg.................................72

ranolazine tab er 12hr 500 mg...................................72rasagiline mesylate tab 0.5 mg.................................. 38rasagiline mesylate tab 1 mg..................................... 38REBETOL......................................................................46RECOMBIVAX HB....................................................... 98RECOMBIVAX HB....................................................... 98RECOMBIVAX HB....................................................... 98RECTIV..........................................................................72REGRANEX.................................................................. 79RELENZA DISKHALER.............................................. 46RELISTOR.....................................................................84RELISTOR.....................................................................84RELISTOR.....................................................................84REMERON....................................................................20REMERON....................................................................20REMERON SOLTAB....................................................20REMERON SOLTAB....................................................20REMERON SOLTAB....................................................20REMODULIN.............................................................. 106REMODULIN.............................................................. 107REMODULIN.............................................................. 107REMODULIN.............................................................. 107RENFLEXIS.................................................................. 98repaglinide tab 0.5 mg................................................ 54repaglinide tab 1 mg....................................................54repaglinide tab 2 mg....................................................54REPATHA...................................................................... 72REPATHA PUSHTRONEX SYSTEM........................72REPATHA SURECLICK.............................................. 72RESCRIPTOR.............................................................. 46RESTASIS...................................................................103RESTASIS MULTIDOSE...........................................103RETACRIT.....................................................................59RETACRIT.....................................................................59RETACRIT.....................................................................59RETACRIT.....................................................................59RETACRIT.....................................................................59RETROVIR IV INFUSION...........................................46REVCOVI...................................................................... 86REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REYATAZ.......................................................................46

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RHOPRESSA............................................................. 103RIBASPHERE...............................................................46RIBASPHERE...............................................................46RIBASPHERE RIBAPAK.............................................46RIBASPHERE RIBAPAK.............................................46ribavirin cap 200 mg....................................................46ribavirin for inhal soln 6 gm......................................107ribavirin tab 200 mg.....................................................46RIDAURA...................................................................... 98rifabutin cap 150 mg....................................................25rifampin cap 150 mg....................................................25rifampin cap 300 mg....................................................25rifampin for inj 600 mg................................................ 25riluzole tab 50 mg........................................................ 76RINVOQ.........................................................................98risedronate sodium tab 150 mg...............................100risedronate sodium tab 30 mg................................. 100risedronate sodium tab 35 mg................................. 100risedronate sodium tab 5 mg................................... 100risedronate sodium tab delayed release 35

mg............................................................................. 100RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERIDONE ODT................................................... 42risperidone orally disintegrating tab 0.5

mg................................................................................42risperidone orally disintegrating tab 1




mg................................................................................42risperidone soln 1 mg/ml............................................ 42risperidone tab 0.25 mg..............................................42risperidone tab 0.5 mg................................................ 42risperidone tab 1 mg................................................... 42risperidone tab 2 mg................................................... 42risperidone tab 3 mg................................................... 42risperidone tab 4 mg................................................... 42ritonavir tab 100 mg.................................................... 46RITUXAN.......................................................................34RITUXAN.......................................................................34RITUXAN HYCELA......................................................34RITUXAN HYCELA......................................................34rivastigmine tartrate cap 1.5 mg................................ 17rivastigmine tartrate cap 3 mg....................................17rivastigmine tartrate cap 4.5 mg................................ 17rivastigmine tartrate cap 6 mg....................................17

rivastigmine td patch 24hr 13.3mg/24hr...................................................................... 17

rivastigmine td patch 24hr 4.6 mg/24hr.....................17rivastigmine td patch 24hr 9.5 mg/24hr.....................17rizatriptan benzoate oral disintegrating tab 10

mg................................................................................24rizatriptan benzoate oral disintegrating tab 5

mg................................................................................24rizatriptan benzoate tab 10 mg.................................. 24rizatriptan benzoate tab 5 mg.................................... 24ropinirole hydrochloride tab 0.25 mg.........................38ropinirole hydrochloride tab 0.5 mg...........................38ropinirole hydrochloride tab 1 mg.............................. 38ropinirole hydrochloride tab 2 mg.............................. 38ropinirole hydrochloride tab 3 mg.............................. 38ropinirole hydrochloride tab 4 mg.............................. 38ropinirole hydrochloride tab 5 mg.............................. 38rosuvastatin calcium tab 10 mg................................. 72rosuvastatin calcium tab 20 mg................................. 72rosuvastatin calcium tab 40 mg................................. 72rosuvastatin calcium tab 5 mg................................... 72ROTARIX.......................................................................98ROTATEQ......................................................................98RUBRACA.....................................................................34RUBRACA.....................................................................34RUBRACA.....................................................................34RYDAPT........................................................................ 34RYTARY.........................................................................38RYTARY.........................................................................38RYTARY.........................................................................38RYTARY.........................................................................38SSAFETY INSULIN SYRINGES 1ML/30G X

1/2".............................................................................. 54SAMSCA........................................................................82SAMSCA........................................................................82SANDIMMUNE............................................................. 98SANTYL.........................................................................79SAPHRIS.......................................................................42SAPHRIS.......................................................................42SAPHRIS.......................................................................42scopolamine td patch 72hr 1 mg/3days.................... 22selegiline hcl cap 5 mg............................................... 38selegiline hcl tab 5 mg................................................ 38selenium sulfide lotion 2.5%.......................................79SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SEREVENT DISKUS.................................................107

2020

145

sertraline hcl oral concentrate for solution 20 mg/ml.................................................................................20

sertraline hcl tab 100 mg............................................ 20sertraline hcl tab 25 mg.............................................. 20sertraline hcl tab 50 mg.............................................. 20sevelamer carbonate packet 0.8 gm......................... 82sevelamer carbonate packet 2.4 gm......................... 82sevelamer carbonate tab 800 mg..............................82SHINGRIX..................................................................... 98SIGNIFOR..................................................................... 93SIGNIFOR..................................................................... 93SIGNIFOR..................................................................... 93SIGNIFOR LAR............................................................93SIGNIFOR LAR............................................................93SIGNIFOR LAR............................................................93SIGNIFOR LAR............................................................93SIGNIFOR LAR............................................................93sildenafil citrate tab 20 mg....................................... 107SILENOR.....................................................................108SILENOR.....................................................................108silodosin cap 4 mg.......................................................87silodosin cap 8 mg.......................................................87silver sulfadiazine cream 1%......................................79SIMBRINZA................................................................ 103SIMULECT.................................................................... 98SIMULECT.................................................................... 98simvastatin tab 10 mg.................................................72simvastatin tab 20 mg.................................................72simvastatin tab 40 mg.................................................72simvastatin tab 5 mg................................................... 72simvastatin tab 80 mg.................................................72sirolimus oral soln 1 mg/ml.........................................98sirolimus tab 0.5 mg.................................................... 98sirolimus tab 1 mg....................................................... 98sirolimus tab 2 mg....................................................... 98SIRTURO.......................................................................25SIVEXTRO.................................................................... 11SIVEXTRO.................................................................... 11SKYRIZI.........................................................................98sodium chloride irrigation soln 0.9%......................... 82sodium chloride iv soln 0.45%................................... 82sodium chloride iv soln 0.9%..................................... 82sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................86sodium phenylbutyrate tab 500 mg........................... 86sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................82sodium polystyrene sulfonate powder.......................82sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................82SOFOSBUVIR/VELPATASVIR...................................46SOLTAMOX...................................................................34

SOMATULINE DEPOT................................................93SOMATULINE DEPOT................................................93SOMATULINE DEPOT................................................93SOMAVERT.................................................................. 93SOMAVERT.................................................................. 93SOMAVERT.................................................................. 93SOMAVERT.................................................................. 93SOMAVERT.................................................................. 93sotalol hcl (afib/afl) tab 120 mg..................................72sotalol hcl (afib/afl) tab 160 mg..................................72sotalol hcl (afib/afl) tab 80 mg....................................72sotalol hcl tab 120 mg.................................................72sotalol hcl tab 160 mg.................................................72sotalol hcl tab 240 mg.................................................72sotalol hcl tab 80 mg...................................................72SPIRIVA HANDIHALER............................................107SPIRIVA RESPIMAT................................................. 107SPIRIVA RESPIMAT................................................. 107spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................72spironolactone tab 100 mg.........................................72spironolactone tab 25 mg........................................... 72spironolactone tab 50 mg........................................... 72SPRAVATO 56MG DOSE........................................... 20SPRAVATO 84MG DOSE........................................... 20SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRYCEL......................................................................34SPRYCEL......................................................................34SPRYCEL......................................................................34SPRYCEL......................................................................34SPRYCEL......................................................................34SPRYCEL......................................................................34STAMARIL.....................................................................98STARLIX........................................................................ 54STARLIX........................................................................ 54stavudine cap 15 mg...................................................46stavudine cap 20 mg...................................................46stavudine cap 30 mg...................................................47stavudine cap 40 mg...................................................47STELARA...................................................................... 98STELARA...................................................................... 98STELARA...................................................................... 98STELARA...................................................................... 98STIMATE....................................................................... 89STIOLTO RESPIMAT................................................ 107STIVARGA.....................................................................34STRENSIQ....................................................................86STRENSIQ....................................................................86STRENSIQ....................................................................86

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STRENSIQ....................................................................86STREPTOMYCIN SULFATE...................................... 11STRIBILD...................................................................... 47sucralfate tab 1 gm......................................................84sulfacetamide sodium lotion 10%.............................. 11sulfacetamide sodium ophth soln

10%...........................................................................103sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 103SULFADIAZINE............................................................ 11sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 11sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 11sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................11sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................11sulfasalazine tab 500 mg..........................................100sulfasalazine tab delayed release 500

mg............................................................................. 100sulindac tab 150 mg...................................................... 3sulindac tab 200 mg...................................................... 3sumatriptan nasal spray 20 mg/act........................... 24sumatriptan nasal spray 5 mg/act..............................24SUMATRIPTAN SUCCINATE.....................................25sumatriptan succinate inj 6 mg/0.5ml........................25sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................25sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................25sumatriptan succinate tab 100 mg............................ 25sumatriptan succinate tab 25 mg...............................25sumatriptan succinate tab 50 mg...............................25SUPRAX........................................................................11SUPRAX........................................................................12SUPREP BOWEL PREP KIT.....................................84SUTENT........................................................................ 34SUTENT........................................................................ 34SUTENT........................................................................ 34SUTENT........................................................................ 34SYLATRON................................................................... 47SYLATRON................................................................... 47SYLATRON................................................................... 47SYLVANT.......................................................................98SYLVANT.......................................................................98SYMBICORT...............................................................107SYMBICORT...............................................................107

SYMDEKO.................................................................. 107SYMDEKO.................................................................. 107SYMFI............................................................................ 47SYMFI LO..................................................................... 47SYMLINPEN 120......................................................... 54SYMLINPEN 60............................................................54SYMPAZAN...................................................................16SYMPAZAN...................................................................16SYMPAZAN...................................................................16SYMTUZA..................................................................... 47SYNAGIS.......................................................................98SYNAGIS.......................................................................98SYNAREL......................................................................94SYNERCID....................................................................12SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNRIBO...................................................................... 34SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92SYNTHROID.................................................................92TTABLOID........................................................................34tacrolimus cap 0.5 mg.................................................98tacrolimus cap 1 mg....................................................98tacrolimus cap 5 mg....................................................98tacrolimus oint 0.03%..................................................79tacrolimus oint 0.1%.................................................... 79tadalafil tab 20 mg (pah)...........................................107TAFINLAR..................................................................... 34TAFINLAR..................................................................... 34TAGRISSO.................................................................... 34TAGRISSO.................................................................... 34TALZENNA....................................................................34TALZENNA....................................................................34tamoxifen citrate tab 10 mg........................................34tamoxifen citrate tab 20 mg........................................35tamsulosin hcl cap 0.4 mg..........................................87

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TARGRETIN..................................................................35TASIGNA....................................................................... 35TASIGNA....................................................................... 35TASIGNA....................................................................... 35tazarotene cream 0.1%...............................................79TAZICEF........................................................................ 12TAZICEF........................................................................ 12TAZORAC......................................................................79TAZORAC......................................................................79TAZORAC......................................................................79TDVAX........................................................................... 98TECENTRIQ................................................................. 35TECENTRIQ................................................................. 35TECFIDERA..................................................................76TECFIDERA..................................................................76TECFIDERA STARTER PACK...................................76TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X

1/2".............................................................................. 54TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X


5/16"............................................................................55TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X

15/64"..........................................................................55TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X





15/64"..........................................................................55TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X

5/16"............................................................................55TECHLITE INSULIN SYRINGE U-100/1ML/29G X

1/2".............................................................................. 55TECHLITE INSULIN SYRINGE U-100/1ML/30G X

1/2".............................................................................. 55TECHLITE INSULIN SYRINGE U-100/1ML/30G X

5/16"............................................................................55TECHLITE INSULIN SYRINGE U-100/1ML/31G X

15/64"..........................................................................55TECHLITE INSULIN SYRINGE U-100/1ML/31G X

5/16"............................................................................55TECHLITE PEN NEEDLES/31G X

6MM............................................................................ 55TECHLITE PEN NEEDLES/31G X

8MM............................................................................ 55TECHLITE PEN NEEDLES/32G X

4MM............................................................................ 55

TECHLITE PEN NEEDLES/32G X6MM............................................................................ 55

TECHLITE PEN NEEDLES/32G X8MM............................................................................ 55

TECHLITE PEN NEEDLES 29G X10MM..........................................................................55

TECHLITE PEN NEEDLES 29G X12MM..........................................................................55

TECHLITE PEN NEEDLES 31G X5MM............................................................................ 55

TEFLARO......................................................................12TEFLARO......................................................................12TEKTURNA HCT......................................................... 72TEKTURNA HCT......................................................... 72TEKTURNA HCT......................................................... 72TEKTURNA HCT......................................................... 72telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................73telmisartan tab 20 mg................................................. 72telmisartan tab 40 mg................................................. 72telmisartan tab 80 mg................................................. 72temazepam cap 15 mg............................................. 108temazepam cap 30 mg............................................. 108TEMODAR.................................................................... 35temsirolimus soln for iv infusion 25 mg/

ml.................................................................................35TENCON..........................................................................3TENIVAC....................................................................... 98tenofovir disoproxil fumarate tab 300

mg................................................................................47terazosin hcl cap 10 mg..............................................73terazosin hcl cap 1 mg................................................73terazosin hcl cap 2 mg................................................73terazosin hcl cap 5 mg................................................73terbinafine hcl tab 250 mg..........................................23terbutaline sulfate tab 2.5 mg.................................. 107terbutaline sulfate tab 5 mg......................................107TERCONAZOLE...........................................................24terconazole vaginal cream 0.4%................................24terconazole vaginal suppos 80 mg............................24testosterone cypionate im inj in oil 100 mg/

ml.................................................................................91testosterone cypionate im inj in oil 200 mg/

ml.................................................................................91testosterone enanthate im inj in oil 200 mg/

ml.................................................................................91testosterone td gel 12.5 mg/act (1%)........................ 91

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testosterone td gel 20.25 mg/1.25gm(1.62%)....................................................................... 91

testosterone td gel 20.25 mg/act(1.62%)....................................................................... 91

testosterone td gel 25 mg/2.5gm (1%)......................91testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 91testosterone td gel 50 mg/5gm (1%).........................91testosterone td soln 30 mg/act...................................91tetrabenazine tab 12.5 mg..........................................76tetrabenazine tab 25 mg.............................................76tetracycline hcl cap 250 mg........................................12tetracycline hcl cap 500 mg........................................12THALOMID....................................................................35THALOMID....................................................................35THALOMID....................................................................35THALOMID....................................................................35theophylline tab er 12hr 300 mg..............................107theophylline tab er 12hr 450 mg..............................107theophylline tab er 24hr 400 mg..............................107theophylline tab er 24hr 600 mg..............................107thioridazine hcl tab 100 mg........................................ 42thioridazine hcl tab 10 mg.......................................... 42thioridazine hcl tab 25 mg.......................................... 42thioridazine hcl tab 50 mg.......................................... 42thiotepa for inj 15 mg.................................................. 35thiothixene cap 10 mg.................................................42thiothixene cap 1 mg...................................................42thiothixene cap 2 mg...................................................42thiothixene cap 5 mg...................................................42THYMOGLOBULIN......................................................98tiagabine hcl tab 12 mg.............................................. 16tiagabine hcl tab 16 mg.............................................. 16tiagabine hcl tab 2 mg.................................................16tiagabine hcl tab 4 mg.................................................16TIAZAC.......................................................................... 73TIAZAC.......................................................................... 73TIAZAC.......................................................................... 73TIAZAC.......................................................................... 73TIAZAC.......................................................................... 73TIAZAC.......................................................................... 73TIBSOVO.......................................................................35tigecycline for iv soln 50 mg.......................................12TIMOLOL MALEATE................................................... 73TIMOLOL MALEATE................................................... 73TIMOLOL MALEATE OPHTHALMIC GEL

FORMING................................................................ 103TIMOLOL MALEATE OPHTHALMIC GEL

FORMING................................................................ 103timolol maleate ophth soln 0.25%........................... 103timolol maleate ophth soln 0.5%..............................103

timolol maleate ophth soln 0.5% (once-daily)......................................................................... 103

timolol maleate tab 5 mg............................................ 73TIMOPTIC................................................................... 103TIMOPTIC................................................................... 103TIMOPTIC-XE.............................................................103tinidazole tab 250 mg..................................................12tinidazole tab 500 mg..................................................12TIVICAY......................................................................... 47TIVICAY......................................................................... 47TIVICAY......................................................................... 47tizanidine hcl cap 2 mg............................................... 43tizanidine hcl cap 4 mg............................................... 43tizanidine hcl cap 6 mg............................................... 43tizanidine hcl tab 2 mg................................................43tizanidine hcl tab 4 mg................................................43TOBRADEX................................................................ 103TOBRADEX................................................................ 103tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................103tobramycin nebu soln 300 mg/5ml.......................... 107tobramycin ophth soln 0.3%.....................................103TOBRAMYCIN SULFATE........................................... 12TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................12tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................12TOBREX......................................................................103tolcapone tab 100 mg................................................. 38TOLMETIN SODIUM..................................................... 3tolterodine tartrate cap er 24hr 2 mg.........................87tolterodine tartrate cap er 24hr 4 mg.........................87tolterodine tartrate tab 1 mg.......................................87tolterodine tartrate tab 2 mg.......................................87topiramate sprinkle cap 15 mg...................................16topiramate sprinkle cap 25 mg...................................16topiramate tab 100 mg................................................16topiramate tab 200 mg................................................16topiramate tab 25 mg.................................................. 16topiramate tab 50 mg.................................................. 16topotecan hcl for inj 4 mg........................................... 35topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 35toremifene citrate tab 60 mg...................................... 35torsemide tab 100 mg................................................. 73torsemide tab 10 mg................................................... 73torsemide tab 20 mg................................................... 73torsemide tab 5 mg......................................................73TOUJEO MAX SOLOSTAR........................................55TOUJEO SOLOSTAR..................................................55

2020

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TOVIAZ.......................................................................... 87TOVIAZ.......................................................................... 87TRACLEER.................................................................107TRADJENTA................................................................. 55tramadol-acetaminophen tab 37.5-325

mg..................................................................................3tramadol hcl tab 50 mg................................................. 3tramadol hcl tab er 24hr 100 mg..................................3tramadol hcl tab er 24hr 200 mg..................................3tramadol hcl tab er 24hr 300 mg..................................3trandolapril tab 1 mg................................................... 73trandolapril tab 2 mg................................................... 73trandolapril tab 4 mg................................................... 73tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................59tranexamic acid tab 650 mg.......................................59tranylcypromine sulfate tab 10 mg............................ 20TRAVASOL....................................................................82TRAVATAN Z.............................................................. 103trazodone hcl tab 100 mg...........................................20trazodone hcl tab 150 mg...........................................20trazodone hcl tab 300 mg...........................................20trazodone hcl tab 50 mg.............................................20TREANDA..................................................................... 35TREANDA..................................................................... 35TRECATOR...................................................................25TRELEGY ELLIPTA...................................................107TRELSTAR MIXJECT..................................................94TRELSTAR MIXJECT..................................................94TRELSTAR MIXJECT..................................................94TREMFYA......................................................................98TREMFYA......................................................................99treprostinil inj soln 100 mg/20ml (5 mg/

ml)............................................................................. 107treprostinil inj soln 200 mg/20ml (10 mg/

ml)............................................................................. 107treprostinil inj soln 20 mg/20ml (1 mg/

ml)............................................................................. 107treprostinil inj soln 50 mg/20ml (2.5 mg/

ml)............................................................................. 107TRESIBA....................................................................... 55TRESIBA FLEXTOUCH.............................................. 55TRESIBA FLEXTOUCH.............................................. 55tretinoin cap 10 mg......................................................35tretinoin cream 0.025%............................................... 79tretinoin cream 0.05%................................................. 79tretinoin cream 0.1%................................................... 79tretinoin gel 0.01%.......................................................79tretinoin gel 0.025%.....................................................79triamcinolone acetonide cream

0.025%........................................................................79triamcinolone acetonide cream 0.1%........................79

triamcinolone acetonide cream 0.5%........................79triamcinolone acetonide dental paste

0.1%............................................................................76triamcinolone acetonide lotion 0.025%..................... 79triamcinolone acetonide lotion 0.1%..........................79triamcinolone acetonide oint 0.025%........................ 79triamcinolone acetonide oint 0.1%.............................79triamcinolone acetonide oint 0.5%.............................79triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................73triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................73triamterene & hydrochlorothiazide tab 75-50

mg................................................................................73TRIBENZOR................................................................. 73TRIBENZOR................................................................. 73TRIBENZOR................................................................. 73TRIBENZOR................................................................. 73TRIBENZOR................................................................. 73trientine hcl cap 250 mg............................................. 82trifluoperazine hcl tab 10 mg......................................43trifluoperazine hcl tab 1 mg........................................43trifluoperazine hcl tab 2 mg........................................43trifluoperazine hcl tab 5 mg........................................43TRIFLURIDINE...........................................................103trimethobenzamide hcl cap 300 mg.......................... 22trimethoprim tab 100 mg.............................................12trimipramine maleate cap 100 mg............................. 20trimipramine maleate cap 25 mg............................... 20trimipramine maleate cap 50 mg............................... 20TRINTELLIX..................................................................20TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRISENOX....................................................................35TRIUMEQ......................................................................47TROGARZO..................................................................47TROPHAMINE..............................................................82trospium chloride cap er 24hr 60 mg.........................87trospium chloride tab 20 mg.......................................87TRUEPLUS 5-BEVEL PEN NEEDLES

31GX5MM.................................................................. 56TRUEPLUS 5-BEVEL PEN NEEDLES



32GX4MM.................................................................. 56TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G

X 1/2"..........................................................................55TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G

X 5/16"........................................................................55

2020

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TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31GX 5/16"........................................................................55

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28GX 1/2"..........................................................................55

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29GX 1/2"..........................................................................55



TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X1/2".............................................................................. 55

TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2".............................................................................. 56

TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16"............................................................................56

TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16"............................................................................56

TRUEPLUS PEN NEEDLES 29G X12MM..........................................................................56

TRUEPLUS PEN NEEDLES 31G X5MM............................................................................ 56




TRULICITY....................................................................56TRULICITY....................................................................56TRUMENBA.................................................................. 99TRUVADA......................................................................47TRUVADA......................................................................47TRUVADA......................................................................47TRUVADA......................................................................47TURALIO....................................................................... 35TWINRIX........................................................................99TYBOST........................................................................ 47TYKERB........................................................................ 35TYMLOS......................................................................101TYPHIM VI.................................................................... 99TYSABRI....................................................................... 76UUDENYCA.....................................................................59ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G

X 1/2"..........................................................................56ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X

1/2".............................................................................. 56UNITUXIN......................................................................35UPTRAVI..................................................................... 107UPTRAVI..................................................................... 107UPTRAVI..................................................................... 108

UPTRAVI..................................................................... 108UPTRAVI..................................................................... 108UPTRAVI..................................................................... 108UPTRAVI..................................................................... 108UPTRAVI..................................................................... 108UPTRAVI..................................................................... 108ursodiol cap 300 mg....................................................84ursodiol tab 250 mg.....................................................84ursodiol tab 500 mg.....................................................84Vvalacyclovir hcl tab 1 gm............................................ 47valacyclovir hcl tab 500 mg........................................47VALCHLOR................................................................... 35valganciclovir hcl for soln 50 mg/ml.......................... 47valganciclovir hcl tab 450 mg.....................................47valproate sodium inj 100 mg/ml.................................16valproate sodium oral soln 250 mg/5ml.................... 16valproic acid cap 250 mg............................................16valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................74valsartan-hydrochlorothiazide tab 160-25

mg................................................................................74valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................74valsartan-hydrochlorothiazide tab 320-25

mg................................................................................74valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................74valsartan tab 160 mg...................................................73valsartan tab 320 mg...................................................73valsartan tab 40 mg.....................................................73valsartan tab 80 mg.....................................................73VANCOMYCIN HCL.................................................... 12vancomycin hcl cap 125 mg.......................................12vancomycin hcl cap 250 mg.......................................12vancomycin hcl for iv soln 10 gm.............................. 12vancomycin hcl for iv soln 1 gm.................................12vancomycin hcl for iv soln 500 mg............................ 12vancomycin hcl for iv soln 5 gm.................................12vancomycin hcl for iv soln 750 mg............................ 12VANCOMYCIN HCL IN DEXTROSE.........................12VANCOMYCIN HCL IN DEXTROSE.........................12VANCOMYCIN HCL IN DEXTROSE.........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANISHPOINT INSULIN SYRINGE/0.5ML/30G X

1/2".............................................................................. 56VAQTA........................................................................... 99VAQTA........................................................................... 99VARIVAX........................................................................99

2020

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VARIZIG.........................................................................99VASCEPA...................................................................... 74VASCEPA...................................................................... 74VASERETIC.................................................................. 74VASOTEC......................................................................74VASOTEC......................................................................74VASOTEC......................................................................74VASOTEC......................................................................74VECTIBIX...................................................................... 35VECTIBIX...................................................................... 35VELCADE......................................................................35VELPHORO.................................................................. 82VELTASSA.................................................................... 82VELTASSA.................................................................... 82VELTASSA.................................................................... 82VENCLEXTA.................................................................35VENCLEXTA.................................................................35VENCLEXTA.................................................................35VENCLEXTA STARTING PACK................................ 35venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 75 mg...........................................21VENTAVIS................................................................... 108VENTAVIS................................................................... 108VENTOLIN HFA......................................................... 108verapamil hcl cap er 24hr 120 mg.............................74verapamil hcl cap er 24hr 180 mg.............................74verapamil hcl cap er 24hr 200 mg.............................74verapamil hcl cap er 24hr 240 mg.............................74verapamil hcl cap er 24hr 300 mg.............................74VERAPAMIL HCL ER..................................................74VERAPAMIL HCL SR..................................................74verapamil hcl tab 120 mg........................................... 74verapamil hcl tab 40 mg............................................. 74verapamil hcl tab 80 mg............................................. 74verapamil hcl tab er 120 mg.......................................74verapamil hcl tab er 180 mg.......................................74verapamil hcl tab er 240 mg.......................................74VERSACLOZ................................................................ 43VERZENIO....................................................................35VERZENIO....................................................................35VERZENIO....................................................................35VERZENIO....................................................................35VICTOZA....................................................................... 56VIDEX............................................................................ 47VIDEX............................................................................ 47VIDEX EC..................................................................... 47

VIDEX EC..................................................................... 47VIDEX EC..................................................................... 47VIDEX EC..................................................................... 47vigabatrin powd pack 500 mg.................................... 16vigabatrin tab 500 mg................................................. 16VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD STARTER PACK......................................... 21VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VINBLASTINE SULFATE............................................35vincristine sulfate iv soln 1 mg/ml..............................36vinorelbine tartrate inj 10 mg/ml.................................36vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................36VIRACEPT.................................................................... 47VIRACEPT.................................................................... 47VIREAD..........................................................................47VIREAD..........................................................................47VIREAD..........................................................................48VIREAD..........................................................................48VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VIVITROL........................................................................ 4VIZIMPRO..................................................................... 36VIZIMPRO..................................................................... 36VIZIMPRO..................................................................... 36voriconazole for inj 200 mg........................................ 24voriconazole for susp 40 mg/ml.................................24voriconazole tab 200 mg............................................ 24voriconazole tab 50 mg...............................................24VOTRIENT.................................................................... 36VPRIV............................................................................ 86VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VYNDAMAX.................................................................. 74VYNDAQEL...................................................................74VYXEOS........................................................................36Wwarfarin sodium tab 10 mg.........................................59warfarin sodium tab 1 mg...........................................59warfarin sodium tab 2.5 mg........................................59warfarin sodium tab 2 mg...........................................59warfarin sodium tab 3 mg...........................................59

2020

152

warfarin sodium tab 4 mg...........................................59warfarin sodium tab 5 mg...........................................59warfarin sodium tab 6 mg...........................................59warfarin sodium tab 7.5 mg........................................59water for irrigation, sterile irrigation

soln..............................................................................82XXALKORI....................................................................... 36XALKORI....................................................................... 36XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO STARTER PACK.......................................59XATMEP........................................................................ 99XELJANZ.......................................................................99XELJANZ.......................................................................99XGEVA.........................................................................101XIFAXAN........................................................................84XOFLUZA......................................................................48XOFLUZA......................................................................48XOLAIR..........................................................................99XOLAIR..........................................................................99XOLAIR..........................................................................99XOPENEX HFA..........................................................108XOSPATA...................................................................... 36XPOVIO 100 MG ONCE WEEKLY............................36XPOVIO 60 MG ONCE WEEKLY..............................36XPOVIO 80 MG ONCE WEEKLY..............................36XPOVIO 80 MG TWICE WEEKLY.............................36XTANDI.......................................................................... 36XYREM........................................................................108YYERVOY........................................................................36YERVOY........................................................................36YF-VAX.......................................................................... 99YONDELIS.................................................................... 36YONSA.......................................................................... 36Zzafirlukast tab 10 mg.................................................108zafirlukast tab 20 mg.................................................108zaleplon cap 10 mg...................................................108zaleplon cap 5 mg..................................................... 108ZALTRAP.......................................................................36ZALTRAP.......................................................................36ZANOSAR..................................................................... 36ZARXIO..........................................................................59ZARXIO..........................................................................59ZEJULA..........................................................................36ZELBORAF................................................................... 36

ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZENPEP........................................................................ 86ZESTORETIC............................................................... 74ZESTORETIC............................................................... 74ZESTORETIC............................................................... 74ZESTRIL........................................................................74ZESTRIL........................................................................74ZESTRIL........................................................................74ZESTRIL........................................................................74ZESTRIL........................................................................74ZESTRIL........................................................................74zidovudine cap 100 mg...............................................48zidovudine syrup 10 mg/ml.........................................48zidovudine tab 300 mg................................................48ziprasidone hcl cap 20 mg..........................................43ziprasidone hcl cap 40 mg..........................................43ziprasidone hcl cap 60 mg..........................................43ziprasidone hcl cap 80 mg..........................................43zoledronic acid inj conc for iv infusion 4

mg/5ml......................................................................101zoledronic acid iv soln 5 mg/100ml......................... 101ZOLINZA........................................................................36ZOLOFT.........................................................................21ZOLOFT.........................................................................21ZOLOFT.........................................................................21zolpidem tartrate tab 10 mg..................................... 108zolpidem tartrate tab 5 mg....................................... 108zonisamide cap 100 mg..............................................16zonisamide cap 25 mg................................................16zonisamide cap 50 mg................................................16ZONTIVITY....................................................................59ZORTRESS...................................................................99ZORTRESS...................................................................99ZORTRESS...................................................................99ZORTRESS...................................................................99ZOSTAVAX....................................................................99ZOSYN...........................................................................12ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 36ZYDELIG....................................................................... 36ZYKADIA....................................................................... 36ZYKADIA....................................................................... 36ZYLOPRIM....................................................................24ZYLOPRIM....................................................................24ZYPREXA RELPREVV............................................... 43ZYPREXA RELPREVV............................................... 43

2020

153

ZYPREXA RELPREVV............................................... 43ZYTIGA..........................................................................36

Blue Cross and Blue Shield of Oklahoma complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield ofOklahoma does not exclude people or treat them differently because of race, color, national origin, age, disability,or sex.

Blue Cross and Blue Shield of Oklahoma:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact Civil Rights Coordinator.

If you believe that Blue Cross and Blue Shield of Oklahoma has failed to provide these services or discriminatedin another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601,1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can filea grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator isavailable to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SW

Room 509F, HHH BuildingWashington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee ofthe Blue Cross and Blue Shield Association

http://[email protected]

http://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711)

1-877-838-3833 (TTY: 711)

1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833 (ATS: 711).

1-877-838-3833 (TTY: 711).

1-877-838-3833

.(TTY: 711)

1-877-838-3833 (TTY: 711)

1-877-838-3833 (TTY: 711).

1-877-838-3833.(711

1-877-838-3833 (TTY: 711).

This formulary was updated on 10/16/2019. For more recent information or other questions, please contact Blue Cross Group MedicareRx Customer Service at 1-877-838-3833 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.myprime.com.

Prescription drug plans provided by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plans depends on contract renewal.

http://www.myprime.com

Documents

2020 Group Formulary - Blue Cross Blue Shield …2019/10/16 · formulary, appears on the front and back cover pages. You can ask Blue Cross Group MedicareRx to make an exception