2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

Plans coveredCigna Preferred Medicare (HMO) Cigna Alliance Medicare (HMO)

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

2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

HPMS Approved Formulary File Submission ID 21121, Version 18This formulary was updated on 10/01/2021. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. 21_F_04_AZ_04_V10October 2021 INT_21_87406_C_Final_6m

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

Can the Drug List (formulary) change?Most changes in drug coverage happen on January 1, but we 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 specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and

you can also find information in the section entitled “How do I request an exception to the Cigna Drug List?”

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

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

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these

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

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

This document includes a list of the drugs (formulary) for our plans, which is current as of October 2021. 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, 2022, and from time to time during the year.

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drugs will remain available at the same cost-sharing and with no new restrictions for those customers taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the drug list for the new benefit year for any changes to drugs. The enclosed drug list is current as of October 2021. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 8. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR, HYPERTENSION / LIPIDS.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index that begins on page 56. The Covered Drugs 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 Covered Drug Index and find the name of your drug in the drug name column of the list.

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

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

• Prior Authorization: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you

will need to get approval from Cigna before you fill these prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for atorvastatin 40mg. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 108 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not opioid naïve) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna drug list?” on page 3 for information about how to request an exception.

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

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

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

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

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

cost generic alternatives available for any of your current medications.

• Some plans may offer a $0 copay for Tier 1 and 2 generic drugs filled at a preferred retail and/or mail-order pharmacies. Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings.

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

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

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

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

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

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

list. If approved, this drug will be covered at a pre-determined

cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

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

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.

– If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

– If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

These exceptions would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

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

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days).

Cigna’s Drug ListThe comprehensive drug list that begins on page 8 provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 56. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., atorvastatin).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. This plan offers additional prescription drug coverage in the coverage gap. Please refer to your Evidence of Coverage to see this coverage and for more information. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 8 along with the amount dispensed per the days supplied. (For example: atorvastatin 40mg QL 30/30; this means the drug atorvastatin 40mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. If you need help finding a network pharmacy, please call Customer Service at 1-800-627-7534 (TTY 711), or you can visit CignaMedicare.com for the most current Pharmacy Directory.

For more information

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

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

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

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.If you qualified for Extra Help with your drug costs, your costs may be different from those described below. Please refer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are.Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

Service Area: Arizona H0354-001 – Cigna Preferred Medicare (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), ArizonaH0354-028 – Cigna Alliance Medicare (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), ArizonaH0354-024 – Cigna Preferred Medicare (HMO): Pima, Arizona

Drug Tier

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Preferred Mail-Order Cost-Sharing

Standard Mail-Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $10 / $20 / $30 $0 / $0 / $0 $10 / $20 / $30Tier 2: Generic Drugs (GC) $0 / $0 / $0 $15 / $30 / $45 $0 / $0 / $0 $15 / $30 / $45Tier 3: Preferred Brand Drugs $47 / $94 / $141 $47 / $94 / $141 $47 / $94 / $141 $47 / $94 / $141Tier 4: Non-Preferred Drugs $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

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

My Medications Page Number in the Drug List Cost-Share through Cigna

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Drug List Table of Contents:The drugs in the drug list are grouped into categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list below. Then look under the category name in the drug list for your drug. Page

ANTI - INFECTIVES .....................................................................................................................................................................8

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ........................................................................................................15

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...........................................................................................................21

CARDIOVASCULAR, HYPERTENSION / LIPIDS ....................................................................................................................30

DERMATOLOGICALS/TOPICAL THERAPY ...........................................................................................................................34

DIAGNOSTICS / MISCELLANEOUS AGENTS ........................................................................................................................37

EAR, NOSE / THROAT MEDICATIONS ....................................................................................................................................38

ENDOCRINE/DIABETES ...........................................................................................................................................................38

GASTROENTEROLOGY ...........................................................................................................................................................43

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...................................................................................................................44

MUSCULOSKELETAL / RHEUMATOLOGY ............................................................................................................................46

OBSTETRICS / GYNECOLOGY ...............................................................................................................................................47

OPHTHALMOLOGY ..................................................................................................................................................................50

RESPIRATORY AND ALLERGY ...............................................................................................................................................52

UROLOGICALS .........................................................................................................................................................................54

VITAMINS, HEMATINICS / ELECTROLYTES ..........................................................................................................................54

Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.GC – We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.HI (Home Infusion) – This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. - 8 p.m. local time. TTY users should call 711. LA – Limited Availability. This prescription may be available only at certain pharmacies. For more information consult

your Pharmacy Directory or call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711. NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.PA – This drug requires prior authorizationQL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally all medications in the drug list are available through mail-order, except when special circumstances or situations prohibit mailing a particular medication to your home.

8

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugYou can find information on what the symbols and abbreviations on this table mean by going to page 7.

October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 4 PAAMBISOME 5 PA; NDSamphotericin b 4 PAcaspofungin 5 PA; HI; NDSclotrimazole mucous membrane

2

CRESEMBA ORAL 5 NDSfluconazole 2fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

4 PA; HI

flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 QL (120/30)itraconazole oral solution 5 NDSketoconazole oral 2micafungin 5 HI; NDSnystatin oral 2posaconazole oral tablet, delayed release (dr/ec)

5 QL (96/30); NDS

terbinafine hcl oral 2voriconazole intravenous 5 PA; HI; NDSvoriconazole oral suspension for reconstitution

5 NDS

voriconazole oral tablet 200 mg 5 NDSvoriconazole oral tablet 50 mg 4ANTIVIRALSabacavir oral solution 3 QL (960/30)abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2acyclovir oral suspension 200 mg/5 ml

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acyclovir oral tablet 2acyclovir sodium intravenous solution

4 B/D PA

adefovir 5 NDSamantadine hcl 3APTIVUS 5 QL (120/30); NDSatazanavir oral capsule 150 mg, 300 mg

4 QL (30/30)

atazanavir oral capsule 200 mg 4 QL (60/30)ATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 NDSCABENUVA 5 NDSCIMDUO 5 NDSCOMPLERA 5 QL (30/30); NDSDELSTRIGO 5 NDSDESCOVY 5 QL (30/30); NDSdidanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 NDSEDURANT 5 QL (30/30); NDSefavirenz oral capsule 200 mg 5 QL (120/30); NDSefavirenz oral capsule 50 mg 3 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDSefavirenz-emtricitabin-tenofov 5 QL (30/30); NDSefavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg

5 QL (30/30); NDS

efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg

5 NDS

emtricitabine 3 QL (30/30)emtricitabine-tenofovir (tdf) 5 QL (30/30); NDSEMTRIVA ORAL CAPSULE 4 QL (30/30)EMTRIVA ORAL SOLUTION 4 QL (680/28)entecavir 4 QL (30/30)EPCLUSA 5 PA; QL (28/28);

NDS

9



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LEXIVA ORAL SUSPENSION 4 QL (1575/28)lopinavir-ritonavir oral solution 3lopinavir-ritonavir oral tablet 100-25 mg

4 QL (300/30)

lopinavir-ritonavir oral tablet 200-50 mg

4 QL (120/30)

MAVYRET 5 PA; QL (84/28); NDS

nevirapine oral suspension 4 QL (1200/30)nevirapine oral tablet 3 QL (60/30)nevirapine oral tablet extended release 24 hr 100 mg

4 QL (90/30)

nevirapine oral tablet extended release 24 hr 400 mg

4 QL (30/30)

NORVIR ORAL POWDER IN PACKET

4

NORVIR ORAL SOLUTION 3 QL (480/30)ODEFSEY 5 QL (30/30); NDSoseltamivir 3PIFELTRO 5 NDSPREVYMIS ORAL 5 QL (30/30); NDSPREZCOBIX 5 QL (30/30); NDSPREZISTA ORAL SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (240/30)


5 QL (60/30); NDS


3 QL (480/30)


5 QL (30/30); NDS

RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (240/30); NDS

ribavirin oral capsule 3ribavirin oral tablet 200 mg 3rimantadine 2ritonavir 3 QL (360/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EPIVIR HBV ORAL SOLUTION 4etravirine 5 QL (60/30); NDSEVOTAZ 5 QL (30/30); NDSfamciclovir 3 QL (60/30)fosamprenavir 5 QL (120/30); NDSFUZEON SUBCUTANEOUS RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDSHARVONI ORAL PELLETS IN PACKET 33.75-150 MG

5 PA; QL (28/28); NDS

HARVONI ORAL PELLETS IN PACKET 45-200 MG

5 PA; QL (56/28); NDS

HARVONI ORAL TABLET 45-200 MG

5 PA; QL (60/30); NDS

HARVONI ORAL TABLET 90-400 MG

5 PA; QL (28/28); NDS

INTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 5 QL (120/30); NDSISENTRESS HD 5 NDSISENTRESS ORAL POWDER IN PACKET

4 QL (60/30)

ISENTRESS ORAL TABLET 5 QL (120/30); NDSISENTRESS ORAL TABLET, CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET, CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

4 QL (300/30)

KALETRA ORAL TABLET 200-50 MG

5 QL (120/30); NDS

lamivudine oral solution 3 QL (900/30)lamivudine oral tablet 100 mg, 300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)lamivudine-zidovudine 3 QL (60/30)

10



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XOFLUZA ORAL TABLET 20 MG, 40 MG

4

XOFLUZA ORAL TABLET 80 MG

4

zidovudine oral capsule 4 QL (180/30)zidovudine oral syrup 3 QL (1680/28)zidovudine oral tablet 3 QL (60/30)CEPHALOSPORINScefaclor oral capsule 2cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

3

cefaclor oral tablet extended release 12 hr

3

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3

cefadroxil oral tablet 3cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4 HI

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4 HI

cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg

4 HI

cefazolin intravenous 4 HIcefdinir oral capsule 2cefdinir oral suspension for reconstitution

3

CEFEPIME IN DEXTROSE 5% 4 HIcefepime in dextrose,iso-osm 4 HIcefepime injection 4 HICEFEPIME INTRAVENOUS 4 PAcefixime 4CEFOTETAN IN DEXTROSE, ISO-OSM

4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RUKOBIA 5 NDSSELZENTRY ORAL SOLUTION

5 NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

3 QL (120/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

stavudine oral capsule 3 QL (60/30)STRIBILD 5 QL (30/30); NDSSYMFI 5 NDSSYMFI LO 5 QL (30/30); NDSSYMTUZA 5 NDSTEMIXYS 5 NDStenofovir disoproxil fumarate 4 QL (30/30)TIVICAY ORAL TABLET 10 MG 4 QL (60/30)TIVICAY ORAL TABLET 25 MG, 50 MG

5 QL (60/30); NDS

TIVICAY PD 5 QL (180/30); NDSTRIUMEQ 5 QL (30/30); NDSTROGARZO 5 NDSTRUVADA 5 QL (30/30); NDSTYBOST 3valacyclovir oral tablet 1 gram 2 QL (120/30)valacyclovir oral tablet 500 mg 2 QL (60/30)valganciclovir 5 NDSVEMLIDY 5 NDSVIRACEPT ORAL TABLET 250 MG

5 QL (270/30); NDS

VIRACEPT ORAL TABLET 625 MG

5 QL (120/30); NDS

VIREAD ORAL POWDER 5 QL (240/30); NDSVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (28/28); NDS

11



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIFICID ORAL SUSPENSION FOR RECONSTITUTION

5 QL (136/10); NDS

DIFICID ORAL TABLET 5 QL (20/10); NDSe.e.s. 400 oral tablet 3ERYPED 400 5 NDSery-tab oral tablet,delayed release (dr/ec) 250 mg

3

ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG, 500 MG

3

erythrocin (as stearate) oral tablet 250 mg

3

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4 PA

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

3

erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml

5 NDS

erythromycin ethylsuccinate oral tablet

3

erythromycin oral tablet 4erythromycin oral tablet, delayed release (dr/ec)

3

MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSamikacin injection solution 1,000 mg/4 ml

4 HI

amikacin injection solution 500 mg/2 ml

4 PA; HI

ARIKAYCE 5 PA; LA; NDSatovaquone 5 NDSatovaquone-proguanil 2aztreonam injection recon soln 1 gram

3 PA; HI

aztreonam injection recon soln 2 gram

4 HI

bacitracin intramuscular 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefotetan injection 4 PAcefoxitin 4 PA; HIcefoxitin in dextrose, iso-osm 4 HIcefpodoxime 2cefprozil 2ceftazidime 4 PA; HICEFTAZIDIME IN D5W 4 HIceftriaxone in dextrose,iso-os 4ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

4

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous 4cefuroxime axetil oral tablet 2cefuroxime sodium injection recon soln 750 mg

4 PA

cefuroxime sodium intravenous 4 PAcephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension for reconstitution

2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

4

tazicef injection 4 PA; HItazicef intravenous 4 HITEFLARO 5 PA; HI; NDSERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4 PA; HIazithromycin oral packet 3azithromycin oral suspension for reconstitution

2

azithromycin oral tablet 2clarithromycin oral suspension for reconstitution

3

clarithromycin oral tablet 2clarithromycin oral tablet extended release 24 hr

2

12



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydroxychloroquine 2imipenem-cilastatin 4 HIisoniazid oral solution 3isoniazid oral tablet 2ivermectin oral 3lincomycin 4 PAlinezolid in dextrose 5% 4 PA; HIlinezolid oral suspension for reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)linezolid-0.9% sodium chloride 4 HImefloquine 2meropenem 4 HIMEROPENEM-0.9% SODIUM CHLORIDE

4 HI

metro i.v. 4 HImetronidazole in nacl (iso-os) 4 PA; HImetronidazole oral tablet 1neomycin 2nitazoxanide 5 QL (20/10); NDSORBACTIV 5 PA; QL (3/30); NDSparomomycin 4PASER 4PENTAM 3pentamidine inhalation 3 B/D PA; QL (1/28)pentamidine injection 3polymyxin b sulfate 4 PApraziquantel 4PRIFTIN 4PRIMAQUINE 3pyrazinamide 3pyrimethamine 5 PA; NDSquinine sulfate 4 PA; QL (42/7)rifabutin 3rifampin intravenous 4rifampin oral 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAYSTON 5 PA; LA; QL (84/28); NDS

chloramphenicol sod succinate 4chloroquine phosphate 2clindamycin hcl 2CLINDAMYCIN IN 0.9% SOD CHLOR

4 HI

clindamycin in 5% dextrose 4 PA; HIclindamycin pediatric 4clindamycin phosphate injection 4 PA; HIclindamycin phosphate intravenous solution 600 mg/4 ml

4 PA; HI

COARTEM 4 QL (24/30)colistin (colistimethate na) 5 PA; NDSCYCLOSERINE 2dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 HI; NDS

daptomycin intravenous recon soln 500 mg

5 HI; NDS

EMVERM 5 NDSertapenem 4 HIethambutol 3FIRVANQ ORAL RECON SOLN 25 MG/ML

4 QL (300/10)

FIRVANQ ORAL RECON SOLN 50 MG/ML

4 QL (450/10)

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4 PA

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

4 PA

gentamicin injection solution 40 mg/ml

4 PA

gentamicin sulfate (ped) (pf) 4 PA

13



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amoxicillin oral tablet,chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule 500 mg 2ampicillin sodium injection recon soln 1 gram, 10 gram

4 PA; HI

ampicillin sodium injection recon soln 125 mg, 250 mg, 500 mg

4 PA

ampicillin sodium injection recon soln 2 gram

4 HI

ampicillin sodium intravenous 4 HIampicillin-sulbactam injection 4 PA; HIampicillin-sulbactam intravenous

4 HI

BICILLIN L-A 4 PAdicloxacillin 2nafcillin in dextrose iso-osm 4 HInafcillin injection 4 PA; HInafcillin intravenous 4 HIoxacillin injection 4 PA; HIpenicillin g potassium injection recon soln 20 million unit

4 PA; HI

penicillin g potassium injection recon soln 5 million unit

4 HI

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet 250 mg

1

penicillin v potassium oral tablet 500 mg

2

pfizerpen-g 4 HI

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SIRTURO 4 PA; LASIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDSSIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 5 PA; NDSSYNERCID 5 HI; NDStigecycline 5 PA; HI; NDSTOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

5 QL (224/28); NDS

tobramycin in 0.225% nacl 5 B/D PA; QL (280/28); NDS

tobramycin sulfate 4 PATRECATOR 3VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK

4 HI

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK

4 HI

VANCOMYCIN INJECTION 4 HIvancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

4 HI

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM

4 HI

vancomycin oral capsule 125 mg

3 PA; QL (40/10)

vancomycin oral capsule 250 mg

3 PA; QL (80/10)

vancomycin oral recon soln 2 QL (450/10)VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA; QL (90/30); NDS

PENICILLINSamoxicillin oral capsule 1amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet 2

14



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfamethoxazole-trimethoprim oral tablet

1

TETRACYCLINESdemeclocycline 3doxy-100 4 PAdoxycycline hyclate intravenous 4 PAdoxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg

1

doxycycline hyclate oral tablet 20 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

2

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

4

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2minocycline oral tablet 2mondoxyne nl oral capsule 100 mg, 75 mg

3

morgidox oral capsule 100 mg 1NUZYRA INTRAVENOUS 5 PA; NDSNUZYRA ORAL 5 NDStetracycline 2URINARY TRACT AGENTSfosfomycin tromethamine 4methenamine hippurate 2MONUROL 4nitrofurantoin 4nitrofurantoin macrocrystal 2nitrofurantoin monohyd/m-cryst 2trimethoprim 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4 HI

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4 HI

ZOSYN IN DEXTROSE (ISO-OSM)

4 HI

QUINOLONESCIPRO ORAL SUSPENSION, MICROCAPSULE RECON

4

ciprofloxacin hcl oral tablet 100 mg

3

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

2

ciprofloxacin in 5% dextrose intravenous piggyback 200 mg/100 ml

4 PA; HI

ciprofloxacin in 5% dextrose intravenous piggyback 400 mg/200 ml

4 HI

levofloxacin in d5w intravenous piggyback 250 mg/50 ml

4 HI

levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml

4 PA; HI

levofloxacin intravenous 4 PA; HIlevofloxacin oral solution 4levofloxacin oral tablet 2moxifloxacin oral 4MOXIFLOXACIN-SOD.ACE, SUL-WATER

4 PA

moxifloxacin-sod.chloride(iso) 4 PASULFAS / RELATED AGENTSsulfadiazine 3sulfamethoxazole-trimethoprim intravenous

4 PA

sulfamethoxazole-trimethoprim oral suspension

4

15



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARRANON 4 B/D PAarsenic trioxide 5 B/D PA; NDSARZERRA 5 B/D PA; NDSASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG

4 B/D PA

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 5 MG

5 B/D PA; NDS

AYVAKIT 5 PA; LA; QL (30/30); NDS

azacitidine 5 B/D PA; NDSAZASAN 3 B/D PAazathioprine 2 B/D PAazathioprine sodium 4 B/D PABALVERSA 5 PA; LA; NDSBAVENCIO 5 PA; NDSBELEODAQ 5 B/D PA; NDSBENDEKA 5 B/D PA; NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 2BLENREP 5 PA; NDSbleomycin 4 B/D PABLINCYTO INTRAVENOUS KIT

5 B/D PA; NDS

BORTEZOMIB 5 PA; NDSBOSULIF ORAL TABLET 100 MG

5 PA; QL (90/30); NDS

BOSULIF ORAL TABLET 400 MG, 500 MG

5 PA; QL (30/30); NDS

BRAFTOVI ORAL CAPSULE 75 MG

5 PA; LA; QL (180/30); NDS

BRUKINSA 5 PA; LA; NDSbusulfan 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

5 PA; LA; QL (30/30); NDS

CABOMETYX ORAL TABLET 40 MG

5 PA; LA; QL (60/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection 4leucovorin calcium oral 3mesna 4 B/D PAMESNEX ORAL 5 NDSXGEVA 5 PA; QL (1.7/28);

NDSANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSabiraterone oral tablet 250 mg 5 PA; QL (120/30);

NDSabiraterone oral tablet 500 mg 5 PA; QL (60/30);

NDSABRAXANE 5 PA; NDSADCETRIS 5 PA; NDSadriamycin intravenous recon soln 10 mg

4 B/D PA

adriamycin intravenous solution 4 B/D PAadrucil intravenous solution 2.5 gram/50 ml

4 B/D PA

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG

5 PA; QL (150/30); NDS

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG, 5 MG

5 PA; QL (56/28); NDS

AFINITOR ORAL TABLET 10 MG

5 PA; QL (30/30); NDS

ALECENSA 5 PA; QL (240/30); NDS

ALIMTA 5 PA; NDSALIQOPA 5 PA; NDSALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

ALUNBRIG ORAL TABLETS, DOSE PACK

5 PA; QL (30/30); NDS

anastrozole 2

16



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DARZALEX FASPRO 5 PA; NDSdaunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

DAURISMO ORAL TABLET 25 MG

5 PA; QL (60/30); NDS

decitabine 5 B/D PA; NDSdocetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

4 B/D PA

doxorubicin 4 B/D PAdoxorubicin, peg-liposomal 5 B/D PA; NDSDROXIA 3ELIGARD 4 PAELIGARD (3 MONTH) 4 PAELIGARD (4 MONTH) 4 PAELIGARD (6 MONTH) 4 PAELLENCE 4 B/D PAELZONRIS 5 PA; NDSEMCYT 5 NDSEMPLICITI 4 PAENHERTU 5 PA; NDSENVARSUS XR 4 B/D PAepirubicin intravenous solution 4 B/D PAERBITUX 5 B/D PA; NDSERIVEDGE 5 PA; QL (30/30);

NDSERLEADA 5 PA; QL (120/30);

NDSerlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30); NDS

ETOPOPHOS 4 B/D PAetoposide intravenous 3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CALQUENCE 5 PA; LA; QL (60/30); NDS

CAPRELSA ORAL TABLET 100 MG

5 PA; LA; QL (60/30); NDS

CAPRELSA ORAL TABLET 300 MG

5 PA; LA; QL (30/30); NDS

carboplatin intravenous solution 4 B/D PAcarmustine 4 B/D PAcisplatin intravenous solution 4 B/D PAcladribine 4 B/D PAclofarabine 4 B/D PACOMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

5 PA; QL (112/28); NDS

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28); NDS

COPIKTRA 5 PA; LA; QL (60/30); NDS

COSMEGEN 5 B/D PA; NDSCOTELLIC 5 PA; LA; QL (63/28);

NDScyclophosphamide intravenous recon soln

5 B/D PA; NDS

CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION

5 B/D PA; NDS

cyclophosphamide oral 3 B/D PAcyclosporine intravenous 4 B/D PAcyclosporine modified 4 B/D PAcyclosporine oral capsule 4 B/D PACYRAMZA 5 PA; NDScytarabine 4 B/D PAcytarabine (pf) 4 B/D PAdacarbazine 4 B/D PAdactinomycin 4 B/D PADANYELZA 5 PA; NDSDARZALEX 5 PA; NDS

17



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HALAVEN 5 PA; NDShydroxyurea 2IBRANCE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG

5 PA; QL (30/30); NDS

ICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

idarubicin 4 B/D PAIDHIFA 5 PA; LA; QL (30/30);

NDSifosfamide 4 B/D PAimatinib oral tablet 100 mg 5 PA; QL (180/30);

NDSimatinib oral tablet 400 mg 5 PA; QL (60/30);

NDSIMBRUVICA ORAL CAPSULE 140 MG

5 PA; QL (120/30); NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA; QL (30/30); NDS

IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS

IMFINZI 5 PA; NDSINFUGEM 5 B/D PA; NDSINLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDSINLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDSINQOVI 5 PA; QL (5/28); NDSINREBIC 5 PA; LA; QL

(120/30); NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAIXEMPRA 5 B/D PA; NDSJAKAFI 5 PA; QL (60/30);

NDSJEMPERLI 5 PA; NDSJEVTANA 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

everolimus (antineoplastic) 5 PA; QL (30/30); NDS

everolimus (immunosuppressive) oral tablet 0.25 mg, 0.75 mg

5 B/D PA; QL (60/30); NDS

everolimus (immunosuppressive) oral tablet 0.5 mg

5 B/D PA; QL (120/30); NDS

EVOMELA 5 PA; NDSexemestane 2FARYDAK 5 PA; QL (6/21); NDSFIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

5 B/D PA; NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 B/D PA

floxuridine 4 B/D PAfludarabine 4 B/D PAfluorouracil intravenous 4 B/D PAflutamide 2FOLOTYN 5 B/D PA; NDSFOTIVDA 5 PA; LA; QL (21/28);

NDSfulvestrant 5 B/D PA; NDSGAVRETO 5 PA; LA; QL

(120/30); NDSGAZYVA 5 PA; NDSgemcitabine intravenous recon soln

4 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA; NDS

gengraf 4 B/D PAGILOTRIF 5 PA; QL (30/30);

NDS

18



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMAKRAS 5 PA; QL (240/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; NDSLUPRON DEPOT (3 MONTH) 5 PA; NDSLUPRON DEPOT (4 MONTH) 5 PA; NDSLUPRON DEPOT (6 MONTH) 5 PA; NDSLUPRON DEPOT-PED 5 PA; NDSLUPRON DEPOT-PED (3 MONTH)

5 PA; NDS

LYNPARZA 5 PA; QL (120/30); NDS

LYSODREN 5 NDSMARQIBO 5 B/D PA; NDSMATULANE 5 NDSmegestrol oral suspension 400 mg/10 ml (10 ml)

3 B/D PA

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

3 PA

megestrol oral tablet 3 PAMEKINIST ORAL TABLET 0.5 MG

5 PA; QL (90/30); NDS

MEKINIST ORAL TABLET 2 MG

5 PA; QL (30/30); NDS

MEKTOVI 5 PA; LA; QL (180/30); NDS

melphalan 4 B/D PAmelphalan hcl 5 B/D PA; NDSmercaptopurine 2methotrexate sodium (pf) 4 B/D PAmethotrexate sodium injection 4 B/D PAmethotrexate sodium oral 2mitomycin intravenous 4 B/D PAmitoxantrone 4 B/D PAMONJUVI 5 PA; NDSMVASI 5 B/D PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KADCYLA 5 PA; NDSKANJINTI 5 B/D PA; NDSKEYTRUDA 5 PA; NDSKISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG

5 PA; QL (70/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG

5 PA; QL (91/28); NDS

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (21/28); NDS


5 PA; QL (42/28); NDS


5 PA; QL (63/28); NDS

KYPROLIS 5 B/D PA; NDSlapatinib 5 PA; QL (180/30);

NDSLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30); NDS

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; QL (90/30); NDS

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)

5 PA; QL (60/30); NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 5 PA; NDSLIBTAYO 5 PA; NDSLONSURF ORAL TABLET 15-6.14 MG

5 PA; QL (100/28); NDS

LONSURF ORAL TABLET 20-8.19 MG

5 PA; QL (80/28); NDS

LORBRENA ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

19



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ORGOVYX 5 PA; LA; QL (30/30); NDS

oxaliplatin 4 B/D PApaclitaxel 4 B/D PAPADCEV 5 PA; NDSPEMAZYRE 5 PA; LA; QL (14/21);

NDSPEPAXTO 5 PA; NDSPERJETA 5 PA; NDSPHESGO 5 PA; NDSPIQRAY 5 PA; NDSPOLIVY 5 PA; NDSPOMALYST 5 PA; LA; QL (21/28);

NDSPORTRAZZA 4 B/D PAPOTELIGEO 5 PA; NDSPROGRAF INTRAVENOUS 4 B/D PAPROGRAF ORAL GRANULES IN PACKET

4 B/D PA

PURIXAN 5 NDSQINLOCK 5 PA; LA; NDSRETEVMO 5 PA; LA; NDSREVLIMID 5 PA; LA; QL (28/28);

NDSROMIDEPSIN INTRAVENOUS SOLUTION

5 PA; NDS

ROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

RUBRACA 5 PA; LA; QL (120/30); NDS

RUXIENCE 5 PA; NDSRYBREVANT 5 PA; NDSRYDAPT 5 PA; QL (240/30);

NDSSANDIMMUNE ORAL SOLUTION

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mycophenolate mofetil (hcl) 4 B/D PAmycophenolate mofetil oral capsule

2 B/D PA

mycophenolate mofetil oral suspension for reconstitution

5 B/D PA; NDS

mycophenolate mofetil oral tablet

2 B/D PA

mycophenolate sodium 2 B/D PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; LA; NDSNEXAVAR 5 PA; LA; QL

(120/30); NDSnilutamide 5 NDSNINLARO 5 PA; QL (3/28); NDSNIPENT 4 B/D PANUBEQA 5 PA; LA; QL

(120/30); NDSNULOJIX 5 B/D PA; QL (26/28);

NDSoctreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml

5 PA; NDS

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml

4 PA

octreotide acetate injection solution 50 mcg/ml

3 PA

ODOMZO 5 PA; LA; QL (30/30); NDS

OGIVRI 5 PA; NDSONCASPAR 5 B/D PA; NDSONIVYDE 5 PA; NDSONUREG 5 PA; QL (14/28);

NDSOPDIVO 5 PA; QL (80/28);

NDS

20



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TEMODAR INTRAVENOUS 5 B/D PA; NDStemsirolimus 5 B/D PA; NDSTEPMETKO 5 PA; LA; QL (60/30);

NDSTHALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG

5 PA; QL (28/28); NDS

THALOMID ORAL CAPSULE 200 MG

5 PA; QL (56/28); NDS

thiotepa 4 PATIBSOVO 5 PA; NDStoposar 3 B/D PAtopotecan intravenous recon soln

5 B/D PA; NDS

topotecan intravenous solution 4 mg/4 ml (1 mg/ml)

4 B/D PA

toremifene 5 NDSTRAZIMERA 5 PA; NDSTREANDA 5 B/D PA; NDSTRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5 PA; NDS

tretinoin (antineoplastic) 5 NDSTRIPTODUR 5 B/D PA; QL (1/168);

NDSTRODELVY 5 PA; NDSTRUSELTIQ ORAL CAPSULE 100 MG/DAY (100 MG X 1)

5 PA; QL (21/28); NDS

TRUSELTIQ ORAL CAPSULE 125 MG/DAY(100 MG X1-25MG X1), 50 MG/DAY (25 MG X 2)

5 PA; QL (42/28); NDS

TRUSELTIQ ORAL CAPSULE 75 MG/DAY (25 MG X 3)

5 PA; QL (63/28); NDS

TRUXIMA 5 PA; NDSTUKYSA ORAL TABLET 150 MG

5 PA; LA; QL (120/30); NDS

TUKYSA ORAL TABLET 50 MG

5 PA; LA; QL (300/30); NDS

TURALIO 5 PA; LA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5 PA; NDS

SARCLISA 5 PA; NDSSIGNIFOR 5 PA; NDSSIMULECT 5 NDSsirolimus oral solution 5 B/D PA; NDSsirolimus oral tablet 4 B/D PASOLTAMOX 5 NDSSOMATULINE DEPOT 5 PA; NDSSPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG

5 PA; QL (30/30); NDS

SPRYCEL ORAL TABLET 20 MG, 70 MG

5 PA; QL (60/30); NDS

STIVARGA 5 PA; QL (84/28); NDS

SUTENT 5 PA; QL (30/30); NDS

SYNRIBO 5 PA; NDSTABLOID 4TABRECTA 5 PA; NDStacrolimus oral 2 B/D PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; LA; QL (30/30);

NDSTALZENNA ORAL CAPSULE 0.25 MG

5 PA; QL (90/30); NDS

TALZENNA ORAL CAPSULE 1 MG

5 PA; QL (30/30); NDS

tamoxifen 2TARGRETIN TOPICAL 5 PA; NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (120/30); NDS

TAZVERIK 5 PA; LA; NDSTECENTRIQ 5 PA; NDS

21



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XPOVIO ORAL TABLET 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (40 MG X 1), 40MG TWICE WEEK (40 MG X 2), 60 MG/WEEK (60 MG X 1), 60MG TWICE WEEK (120 MG/WEEK), 80 MG/WEEK (40 MG X 2), 80MG TWICE WEEK (160 MG/WEEK)

5 PA; LA; NDS

XTANDI ORAL CAPSULE 5 PA; QL (120/30); NDS

XTANDI ORAL TABLET 40 MG 5 PA; QL (120/30); NDS

XTANDI ORAL TABLET 80 MG 5 PA; QL (60/30); NDS

YERVOY 5 PA; NDSYONDELIS 5 PA; NDSZALTRAP 4 B/D PAZANOSAR 4 B/D PAZEJULA 5 PA; LA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZEPZELCA 5 PA; NDSZIRABEV 5 PA; NDSZOLADEX 4 B/D PAZOLINZA 5 PA; QL (120/30);

NDSZORTRESS ORAL TABLET 1 MG

5 B/D PA; NDS

ZYDELIG 5 PA; QL (60/30); NDS

ZYKADIA ORAL TABLET 5 PA; QL (90/30); NDS

ZYNLONTA 5 PA; NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

5 QL (180/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TYKERB 5 PA; LA; QL (180/30); NDS

UKONIQ 5 PA; LA; QL (120/30); NDS

UNITUXIN 5 PA; NDSvalrubicin 4 B/D PAVECTIBIX 5 PA; NDSVELCADE 5 PA; NDSVENCLEXTA ORAL TABLET 10 MG

4 PA; LA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

5 PA; LA; QL (120/30); NDS

VENCLEXTA ORAL TABLET 50 MG

5 PA; LA; QL (30/30); NDS

VENCLEXTA STARTING PACK 5 PA; LA; QL (42/30); NDS

VERZENIO 5 PA; LA; QL (60/30); NDS

vinblastine 4 B/D PAvincasar pfs 4 B/D PAvincristine 4 B/D PAvinorelbine 4 B/D PAVITRAKVI ORAL CAPSULE 100 MG

5 PA; LA; QL (60/30); NDS

VITRAKVI ORAL CAPSULE 25 MG

5 PA; LA; QL (180/30); NDS

VITRAKVI ORAL SOLUTION 5 PA; LA; QL (300/30); NDS

VIZIMPRO 5 PA; QL (30/30); NDS

VOTRIENT 5 PA; QL (120/30); NDS

VYXEOS 5 B/D PA; NDSXALKORI 5 PA; QL (60/30);

NDSXATMEP 4 PAXOSPATA 5 PA; LA; NDS

22



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diazepam rectal 4DILANTIN 30 MG 3divalproex 2EPIDIOLEX 5 PA; LA; NDSepitol 2ethosuximide 3felbamate oral suspension 5 NDSfelbamate oral tablet 4FINTEPLA 5 PA; LA; NDSfosphenytoin 3FYCOMPA ORAL SUSPENSION

4 QL (720/30)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

4 QL (30/30)

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG

4 QL (60/30)

gabapentin oral capsule 100 mg, 400 mg

2 QL (270/30)

gabapentin oral capsule 300 mg

2 QL (360/30)

gabapentin oral solution 4 QL (2160/30)gabapentin oral tablet 600 mg 2 QL (180/30)gabapentin oral tablet 800 mg 2 QL (120/30)lamotrigine oral tablet 2lamotrigine oral tablet extended release 24hr

2

lamotrigine oral tablet, chewable dispersible

2

lamotrigine oral tablet, disintegrating

2

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 3levetiracetam oral 2LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG

3 QL (30/30)

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG

3 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

APTIOM ORAL TABLET 400 MG

5 QL (90/30); NDS

APTIOM ORAL TABLET 600 MG, 800 MG

5 QL (60/30); NDS

BANZEL 5 PA; NDSBRIVIACT INTRAVENOUS 5 NDSBRIVIACT ORAL SOLUTION 5 QL (600/30); NDSBRIVIACT ORAL TABLET 5 QL (60/30); NDScarbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml, 200 mg/10 ml

2

carbamazepine oral tablet 2carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet, chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 4 PA; QL (480/30)clobazam oral tablet 4 PA; QL (60/30)clonazepam oral tablet 0.5 mg, 1 mg

2 QL (90/30)

clonazepam oral tablet 2 mg 2 QL (300/30)clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg

2 QL (90/30)

clonazepam oral tablet, disintegrating 2 mg

2 QL (300/30)

DIACOMIT ORAL CAPSULE 250 MG

4 PA; LA; QL (360/30)

DIACOMIT ORAL CAPSULE 500 MG

4 PA; LA; QL (180/30)

DIACOMIT ORAL POWDER IN PACKET 250 MG

4 PA; LA; QL (360/30)

DIACOMIT ORAL POWDER IN PACKET 500 MG

4 PA; LA; QL (180/30)

DIASTAT 4DIASTAT ACUDIAL 4

23



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG

4

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG

5 NDS

valproate sodium 3valproic acid 2valproic acid (as sodium salt) 2VALTOCO 5 PA; QL (10/30);

NDSvigabatrin 5 PA; LA; QL

(180/30); NDSvigadrone 5 PA; LA; QL

(180/30); NDSVIMPAT INTRAVENOUS 5 QL (1200/30); NDSVIMPAT ORAL SOLUTION 5 QL (1200/30); NDSVIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

5 QL (60/30); NDS

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)XCOPRI 5 PA; NDSXCOPRI MAINTENANCE PACK

5 PA; NDS

XCOPRI TITRATION PACK 4 PAzonisamide 2 PAANTIPARKINSONISM AGENTSAPOKYN 5 PA; LA; QL (60/30);

NDSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 4carbidopa-levodopa oral tablet 2carbidopa-levodopa oral tablet extended release

3

carbidopa-levodopa oral tablet, disintegrating

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NAYZILAM 5 PA; QL (10/30); NDS

oxcarbazepine 2phenobarbital oral elixir 3 PA; QL (1500/30)phenobarbital oral tablet 3 PA; QL (120/30)phenobarbital sodium injection solution

3

phenytoin oral suspension 2phenytoin oral tablet,chewable 2phenytoin sodium extended 2phenytoin sodium intravenous solution

3

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg

2 QL (90/30)

pregabalin oral capsule 225 mg, 300 mg

2 QL (60/30)

pregabalin oral solution 3 QL (900/30)pregabalin oral tablet extended release 24 hr 165 mg, 82.5 mg

3 QL (30/30)

pregabalin oral tablet extended release 24 hr 330 mg

3 QL (60/30)

primidone 2roweepra 2rufinamide 5 PA; NDSSPRITAM 4subvenite 3subvenite starter (blue) kit 3subvenite starter (green) kit 3subvenite starter (orange) kit 3SYMPAZAN 5 PA; QL (60/30);

NDStiagabine 4topiramate oral capsule, sprinkle

2 PA

topiramate oral tablet 2 PA

24



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

5 PA; QL (30/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

5 PA; QL (12/28); NDS

dalfampridine 3 PA; QL (60/30)dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg

5 PA; QL (14/30); NDS

dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg (14)- 240 mg (46)

5 PA; QL (120/180); NDS

dimethyl fumarate oral capsule, delayed release(dr/ec) 240 mg

5 PA; QL (60/30); NDS

donepezil oral tablet 10 mg 2 QL (60/30)donepezil oral tablet 23 mg 4donepezil oral tablet 5 mg 2 QL (30/30)donepezil oral tablet, disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet, disintegrating 5 mg

2 QL (30/30)

FIRDAPSE 5 PA; LA; NDSgalantamine oral capsule,ext rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)galantamine oral tablet 4 QL (60/30)GILENYA ORAL CAPSULE 0.5 MG

5 PA; QL (30/30); NDS

memantine oral capsule, sprinkle,er 24hr

4 PA

memantine oral solution 2 PA; QL (300/30)memantine oral tablet 10 mg 2 PA; QL (60/30)memantine oral tablet 5 mg 2 PA; QL (90/30)memantine oral tablets,dose pack

3 PA; QL (98/28)

NAMZARIC 3 PANUEDEXTA 5 PA; NDSOCREVUS 5 B/D PA; NDSrivastigmine 4rivastigmine tartrate 4 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbidopa-levodopa-entacapone

3

entacapone 4KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

5 PA; QL (150/30); NDS

NEUPRO 4pramipexole oral tablet 2pramipexole oral tablet extended release 24 hr

4

rasagiline 3ropinirole oral tablet 2RYTARY 4 STselegiline hcl 3tolcapone 5 NDStrihexyphenidyl 2 PAMIGRAINE / CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA; QL (1/30)dihydroergotamine nasal 5 PA; QL (8/28); NDSergotamine-caffeine 3migergot 5 NDSnaratriptan 3 QL (18/28)rizatriptan 3 QL (36/28)sumatriptan nasal spray,non-aerosol 20 mg/actuation

4 QL (18/28)

sumatriptan nasal spray,non-aerosol 5 mg/actuation

4 QL (36/28)

sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

sumatriptan succinate subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate subcutaneous solution

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG, 9 MG

5 PA; LA; QL (120/30); NDS

AUSTEDO ORAL TABLET 6 MG

5 PA; LA; QL (60/30); NDS

25



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

buprenorphine hcl injection 4 NDSbuprenorphine hcl sublingual 4 PABUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR

4 QL (4/28); NDS

buprenorphine transdermal patch weekly 7.5 mcg/hour

4 QL (4/28); NDS

endocet 3 QL (360/30); NDSfentanyl 4 QL (10/30); NDSfentanyl citrate (pf) injection solution

4 NDS

fentanyl citrate (pf) injection syringe 50 mcg/ml

4 NDS

fentanyl citrate buccal lozenge on a handle

5 PA; QL (120/30); NDS

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

3 NDS

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

3 QL (5550/30); NDS

HYDROCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG

3 QL (390/30); NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen 3 QL (50/30); NDShydromorphone oral liquid 4 QL (2400/30); NDShydromorphone oral tablet 3 QL (180/30); NDSINFUMORPH P/F 5 B/D PA; NDSmethadone injection solution 4 NDSmethadone intensol 4 NDSmethadone oral concentrate 4 NDSmethadone oral solution 10 mg/5 ml

4 QL (600/30); NDS

methadone oral solution 5 mg/5 ml

4 QL (1200/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 120 MG

5 PA; LA; QL (14/30); NDS

TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

5 PA; LA; QL (120/180); NDS

TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 240 MG

5 PA; LA; QL (60/30); NDS

tetrabenazine oral tablet 12.5 mg

5 PA; QL (240/30); NDS

tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS

TYSABRI 5 PA; NDSMUSCLE RELAXANTS / ANTISPASMODIC THERAPYbaclofen oral tablet 10 mg, 5 mg

1

baclofen oral tablet 20 mg 2cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA

dantrolene oral 3methocarbamol oral 2 PApyridostigmine bromide oral syrup

5 NDS

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

3

regonol 4tizanidine oral capsule 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 QL (4500/30); NDS

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (360/30); NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (180/30); NDS

26



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NON-NARCOTIC ANALGESICSbuprenorphine-naloxone sublingual film 12-3 mg

4 QL (60/30)

buprenorphine-naloxone sublingual film 2-0.5 mg

4 QL (360/30)

buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg

4 QL (90/30)

buprenorphine-naloxone sublingual tablet 2-0.5 mg

2 QL (360/30)

buprenorphine-naloxone sublingual tablet 8-2 mg

2 QL (90/30)

butorphanol nasal 3 QL (10/28); NDScelecoxib 2 QL (60/30)diclofenac potassium 2diclofenac sodium oral 2diclofenac sodium topical drops 4 QL (300/28)diclofenac sodium topical gel 1%

3 QL (1000/28)

diflunisal 2ec-naproxen 2etodolac 4flurbiprofen oral tablet 100 mg 2ibu 1ibuprofen oral suspension 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

KLOXXADO 3meloxicam oral tablet 15 mg 1meloxicam oral tablet 7.5 mg 1 QL (60/30)nabumetone 2naloxone injection solution 2naloxone injection syringe 1 mg/ml

2

naltrexone 2naproxen oral suspension 3naproxen oral tablet 1naproxen oral tablet,delayed release (dr/ec)

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methadone oral tablet 10 mg 3 QL (120/30); NDSmethadone oral tablet 5 mg 3 QL (240/30); NDSmorphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

4 NDS

morphine concentrate oral solution

3 QL (900/30); NDS

MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML

4 NDS

morphine injection solution 8 mg/ml

4 NDS

MORPHINE INJECTION SYRINGE 2 MG/ML

4 NDS

morphine injection syringe 4 mg/ml

4 NDS

morphine intravenous solution 10 mg/ml

4 NDS

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

4 NDS

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML

4 NDS

morphine intravenous syringe 2 mg/ml, 4 mg/ml

4 NDS

morphine oral solution 3 QL (900/30); NDSMORPHINE ORAL TABLET 3 QL (180/30); NDSmorphine oral tablet extended release

3 QL (120/30); NDS

oxycodone oral concentrate 3 QL (180/30); NDSoxycodone oral solution 3 QL (1200/30); NDSoxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg

3 QL (180/30); NDS

oxycodone oral tablet 5 mg 3 QL (360/30); NDSoxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

oxymorphone oral tablet extended release 12 hr

3 QL (90/30); NDS

XTAMPZA ER 3 QL (90/30); NDS

27



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARISTADA INITIO 5 NDSarmodafinil 3 PA; QL (30/30)asenapine maleate 4 QL (60/30)atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

4 QL (30/30)

bupropion hcl oral tablet 100 mg

3 QL (120/30)

bupropion hcl oral tablet 75 mg 3 QL (180/30)bupropion hcl oral tablet extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet sustained-release 12 hr

3 QL (60/30)

buspirone 2CAPLYTA 5 PA; QL (30/30);

NDSchlorpromazine injection 4chlorpromazine oral tablet 2citalopram oral solution 3citalopram oral tablet 1clomipramine 3clonidine hcl oral tablet extended release 12 hr

4

clorazepate dipotassium oral tablet 15 mg

3 QL (180/30)

clorazepate dipotassium oral tablet 3.75 mg

3 QL (90/30)

clorazepate dipotassium oral tablet 7.5 mg

3 QL (360/30)

clozapine oral tablet 3clozapine oral tablet, disintegrating

4

desipramine 3desvenlafaxine succinate 4 QL (30/30)dexmethylphenidate oral tablet 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

naproxen sodium oral tablet 275 mg, 550 mg

4

NARCAN 3oxaprozin 4salsalate 2SUBOXONE SUBLINGUAL FILM 12-3 MG

3 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG

3 QL (360/30)

SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG

3 QL (90/30)

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 3 QL (240/30); NDSVIVITROL 5 NDSZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG

3 QL (60/30)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 5 NDSADASUVE 4alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)alprazolam oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg

3 QL (90/30)

alprazolam oral tablet, disintegrating 2 mg

3 QL (150/30)

amitriptyline 3amoxapine 3aripiprazole oral solution 3aripiprazole oral tablet 2 QL (30/30)aripiprazole oral tablet, disintegrating

5 QL (60/30); NDS

ARISTADA 5 NDS

28



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

escitalopram oxalate oral tablet 2FANAPT ORAL TABLET 1 MG 4 PA; QL (60/30)FANAPT ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

5 PA; QL (60/30); NDS

FANAPT ORAL TABLETS, DOSE PACK

4 PA; QL (8/28)

FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK

4 ST; QL (28/28)

FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine (pmdd) oral tablet 10 mg

3 QL (30/30)

fluoxetine (pmdd) oral tablet 20 mg

3

fluoxetine oral capsule 10 mg 2 QL (30/30)fluoxetine oral capsule 20 mg 2fluoxetine oral capsule 40 mg 2 QL (60/30)fluoxetine oral capsule,delayed release(dr/ec)

3 QL (4/28)

fluoxetine oral solution 2fluoxetine oral tablet 10 mg 3 QL (30/30)fluoxetine oral tablet 20 mg 3fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 100 mg 2 QL (90/30)fluvoxamine oral tablet 25 mg 2 QL (30/30)fluvoxamine oral tablet 50 mg 2 QL (60/30)haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg

1

haloperidol oral tablet 10 mg, 20 mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextroamphetamine oral capsule, extended release

4

dextroamphetamine oral solution

4 QL (1800/30)

dextroamphetamine oral tablet 4dextroamphetamine-amphetamine oral capsule, extended release 24hr

4 QL (60/30)

dextroamphetamine-amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg

3 QL (60/30)


3 QL (120/30)


3 QL (90/30)


3 QL (360/30)

diazepam injection 2diazepam intensol 2 QL (240/30)diazepam oral concentrate 2 QL (240/30)diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3doxepin oral concentrate 3doxepin oral tablet 3 QL (30/30)DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG

4 QL (60/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG

4 QL (90/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

2 QL (60/30)

EMSAM 5 QL (30/30); NDSescitalopram oxalate oral solution

3 QL (600/30)

29



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUPLAZID ORAL CAPSULE 5 PA; QL (30/30); NDS

NUPLAZID ORAL TABLET 10 MG

5 PA; QL (30/30); NDS

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 2olanzapine oral tablet, disintegrating

3 QL (30/30)

olanzapine-fluoxetine 4oxazepam 2 QL (120/30)paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

4 PA; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 PA; QL (60/30)

paroxetine hcl oral tablet 2paroxetine hcl oral tablet extended release 24 hr

3 QL (60/30)

PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4perphenazine-amitriptyline 4PERSERIS 5 QL (1/30); NDSphenelzine 3pimozide 3protriptyline 4quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 QL (90/30)

quetiapine oral tablet 300 mg, 400 mg

2 QL (60/30)

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg

3 QL (30/30)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg

3 QL (60/30)

ramelteon 3 QL (30/30)REXULTI 5 QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HETLIOZ 5 PA; QL (30/30); NDS

imipramine hcl 3INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML

5 NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML

4

INVEGA TRINZA 5 NDSLATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

5 QL (30/30); NDS

LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDSlithium carbonate 2lorazepam injection 4lorazepam intensol 3 QL (150/30)lorazepam oral concentrate 3 QL (150/30)lorazepam oral tablet 0.5 mg, 1 mg

2 QL (90/30)

lorazepam oral tablet 2 mg 2 QL (150/30)loxapine succinate 2maprotiline 4MARPLAN 4 QL (180/30)methylphenidate hcl oral tablet 3 QL (90/30)methylphenidate hcl oral tablet extended release

3

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating)

3

mirtazapine oral tablet 2mirtazapine oral tablet, disintegrating

2 QL (30/30)

molindone 2nefazodone 3nortriptyline 2

30



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VRAYLAR ORAL CAPSULE 5 PA; QL (30/30); NDS

VRAYLAR ORAL CAPSULE, DOSE PACK

4 PA; QL (7/30)

XYREM 5 PA; LA; QL (540/30); NDS

zaleplon oral capsule 10 mg 3 QL (60/30)zaleplon oral capsule 5 mg 3 QL (30/30)ziprasidone hcl 3 QL (60/30)ziprasidone mesylate 4 QL (6/30)zolpidem oral tablet 3 QL (30/30)ZYPREXA RELPREVV 5 PA; NDS

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 B/D PA

amiodarone oral 2dofetilide 3flecainide 2lidocaine (pf) intravenous syringe

4

mexiletine 2pacerone oral tablet 100 mg, 200 mg, 400 mg

2

propafenone oral capsule, extended release 12 hr

4

propafenone oral tablet 2quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2aliskiren 4amiloride 2amiloride-hydrochlorothiazide 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML

4

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

5 NDS

risperidone oral solution 2risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

2 QL (60/30)

risperidone oral tablet 4 mg 2 QL (120/30)risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

3 QL (60/30)

risperidone oral tablet, disintegrating 4 mg

3 QL (120/30)

SAPHRIS 5 QL (60/30); NDSSECUADO 4 QL (30/30)sertraline oral concentrate 4sertraline oral tablet 1temazepam 4 QL (60/365)thioridazine 3thiothixene 4tranylcypromine 4trazodone 2trifluoperazine 3trimipramine 4TRINTELLIX 4 ST; QL (30/30)venlafaxine oral capsule, extended release 24hr

2

venlafaxine oral tablet 2 QL (90/30)VERSACLOZ 5 NDSVIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (30/30)

31



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

2

diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 2doxazosin oral tablet 1 mg, 2 mg, 4 mg

2 QL (30/30)

doxazosin oral tablet 8 mg 2 QL (60/30)EDARBI 4EDARBYCLOR 4enalapril maleate oral tablet 1enalapril-hydrochlorothiazide 1ethacrynate sodium 4felodipine 2fosinopril 1fosinopril-hydrochlorothiazide 1furosemide injection 4furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 1irbesartan 1 QL (30/30)irbesartan-hydrochlorothiazide 1 QL (30/30)isradipine 3labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amlodipine 1amlodipine-benazepril 1amlodipine-valsartan 1amlodipine-valsartan-hcthiazid 1atenolol 1atenolol-chlorthalidone 1benazepril 1benazepril-hydrochlorothiazide 1betaxolol oral 2BIDIL 3bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4bumetanide oral 3BYSTOLIC 3candesartan oral tablet 16 mg, 4 mg, 8 mg

1 QL (60/30)

candesartan oral tablet 32 mg 1 QL (30/30)candesartan-hydrochlorothiazid 1cartia xt 2carvedilol 1carvedilol phosphate 3chlorothiazide sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

clonidine 4 QL (4/28)clonidine hcl oral tablet 0.1 mg, 0.2 mg

1

clonidine hcl oral tablet 0.3 mg 2DEMSER 5 PA; NDSdiltiazem hcl intravenous 4diltiazem hcl oral capsule,ext.rel 24h degradable

2

diltiazem hcl oral capsule, extended release 12 hr

2

32



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ramipril 1spironolactone 1spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

2

TEKTURNA HCT 4telmisartan 1telmisartan-amlodipine 1telmisartan-hydrochlorothiazid 1terazosin oral capsule 1 mg, 2 mg, 5 mg

1 QL (30/30)

terazosin oral capsule 10 mg 1 QL (60/30)tiadylt er 2timolol maleate oral 4torsemide oral 2trandolapril 1triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI ORAL 5 PA; LA; NDSvalsartan oral tablet 160 mg, 40 mg, 80 mg

1 QL (60/30)

valsartan oral tablet 320 mg 1 QL (30/30)valsartan-hydrochlorothiazide 1 QL (30/30)verapamil intravenous solution 4verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2

VERAPAMIL ORAL CAPSULE, EXT REL. PELLETS 24 HR 360 MG

3

verapamil oral tablet 1verapamil oral tablet extended release

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 2methyldopa 4metolazone 2metoprolol succinate 1metoprolol ta-hydrochlorothiaz 2metoprolol tartrate oral 1metyrosine 5 PA; NDSminoxidil oral 2moexipril 1nadolol 3nadolol-bendroflumethiazide oral tablet 80-5 mg

3

nicardipine intravenous solution 4nicardipine oral 2nifedipine oral tablet extended release

2

nifedipine oral tablet extended release 24hr

2

nimodipine 4nisoldipine 4olmesartan 1olmesartan-hydrochlorothiazide 1perindopril erbumine 1phenoxybenzamine 5 NDSpindolol 1prazosin 3propranolol oral capsule, extended release 24 hr

3

propranolol oral solution 2propranolol oral tablet 1propranolol-hydrochlorothiazid 2quinapril 1quinapril-hydrochlorothiazide 1

33



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA; LA; QL (360/30); NDS

PROMACTA ORAL POWDER IN PACKET 25 MG

5 PA; LA; QL (180/30); NDS

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG

5 PA; LA; QL (30/30); NDS

PROMACTA ORAL TABLET 75 MG

5 PA; LA; QL (60/30); NDS

warfarin 1XARELTO 3XARELTO DVT-PE TREAT 30D START

3

LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin 1 QL (30/30)cholestyramine (with sugar) 3cholestyramine light 3colesevelam 3colestipol 3ezetimibe 2 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral tablet 160 mg, 54 mg

2

fenofibric acid (choline) 4gemfibrozil 1LIVALO 3 QL (30/30)lovastatin oral tablet 10 mg 1 QL (30/30)lovastatin oral tablet 20 mg, 40 mg

1 QL (60/30)

niacin oral tablet 500 mg 2niacin oral tablet extended release 24 hr

2

niacor 2omega-3 acid ethyl esters 4pravastatin 1 QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COAGULATION THERAPYaminocaproic acid oral 4aspirin-dipyridamole 4BRILINTA 3 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 1clopidogrel oral tablet 75 mg 1 QL (30/30)dipyridamole oral 3ELIQUIS 3ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin 3fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

4

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4

HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML

4

jantoven 1pentoxifylline 2phytonadione (vitamin k1) oral tablet 5 mg

2 QL (3/30)

PRADAXA 4PRASUGREL 3

34



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SKYRIZI SUBCUTANEOUS PEN INJECTOR

5 PA; QL (1/28); NDS

SKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML

5 PA; QL (1/28); NDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA; QL (2/28); NDS

STELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

TALTZ SYRINGE 5 PA; QL (4/28); NDSMISCELLANEOUS DERMATOLOGICALSammonium lactate 3DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML

5 PA; QL (4.56/28); NDS

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML

5 PA; QL (8/28); NDS

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML

5 PA; QL (4.56/28); NDS

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML

5 PA; QL (8/28); NDS

FLUOROURACIL TOPICAL CREAM 0.5%

5 NDS

fluorouracil topical cream 5% 3fluorouracil topical solution 2glydo 3 QL (60/30)IMIQUIMOD TOPICAL CREAM IN METERED-DOSE PUMP

5 NDS

imiquimod topical cream in packet 3.75%

5 NDS

imiquimod topical cream in packet 5%

3

lidocaine (pf) injection solution 4lidocaine hcl injection solution 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prevalite 3REPATHA 3 PA; QL (3/28)REPATHA PUSHTRONEX 3 PA; QL (3.5/28)REPATHA SURECLICK 3 PA; QL (3/28)rosuvastatin 1 QL (30/30)simvastatin oral tablet 1 QL (30/30)VASCEPA 3MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PAdigitek 2digox 2digoxin oral solution 3digoxin oral tablet 2ENTRESTO 3 QL (60/30)LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG)

4

ranolazine 4 QL (60/30)VYNDAMAX 5 PA; NDSVYNDAQEL 5 PA; NDSNITRATESisosorbide dinitrate oral tablet 3isosorbide mononitrate 2minitran 2nitroglycerin intravenous 4 B/D PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual 4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3 QL (120/30)calcipotriene topical cream 4 QL (120/30)calcipotriene topical ointment 4 QL (120/30)calcitriol topical 4selenium sulfide topical lotion 2

35



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate topical lotion

4 QL (120/30)

clindamycin phosphate topical solution

3 QL (120/30)

clindamycin phosphate topical swab

2 QL (60/30)

ery pads 3ERYTHROMYCIN WITH ETHANOL TOPICAL GEL

4

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

4

metronidazole topical 3myorisan 4rosadan topical cream 3rosadan topical gel 3tazarotene topical cream 4 PATAZORAC 4 PAtretinoin microspheres 4 PAtretinoin topical cream 0.025%, 0.05%, 0.1%

4 PA

tretinoin topical topical gel 0.01%

3 PA

tretinoin topical topical gel 0.025%, 0.05%

4 PA

zenatane 4TOPICAL ANTIBACTERIALSgentamicin topical 3mupirocin 2 QL (44/30)mupirocin calcium 4 QL (30/30)sulfacetamide sodium (acne) 3TOPICAL ANTIFUNGALSciclodan topical solution 3ciclopirox topical cream 3 QL (90/28)ciclopirox topical shampoo 3 QL (120/28)ciclopirox topical solution 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine hcl laryngotracheal 2lidocaine hcl mucous membrane jelly

3 QL (60/30)

lidocaine hcl mucous membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous membrane solution 2%

1

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

2

lidocaine topical adhesive patch,medicated 5%

4 PA; QL (90/30)

lidocaine topical ointment 4 QL (50/30)lidocaine viscous 1lidocaine-prilocaine topical cream

4 QL (30/30)

methoxsalen 4PANRETIN 5 NDSPICATO 5 NDSpimecrolimus 4 QL (100/30)podofilox 2REGRANEX 5 PA; NDSSANTYL 4silver sulfadiazine 3ssd 3tacrolimus topical 3 PA; QL (100/30)VALCHLOR 5 PA; NDSZTLIDO 4 PA; QL (90/30)THERAPY FOR ACNEamnesteem 4avita 4 PAclaravis 4clindacin etz topical swab 2 QL (60/30)clindacin p 2 QL (60/30)clindamycin phosphate topical gel

3 QL (120/30)

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

3

36



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clobetasol topical gel 2 QL (120/28)clobetasol topical ointment 2 QL (120/28)clobetasol topical shampoo 4 QL (236/28)clobetasol-emollient topical cream

2 QL (120/28)

clobetasol-emollient topical foam

4 QL (100/28)

CLOCORTOLONE PIVALATE 4clodan 4 QL (236/28)desonide topical cream 3desonide topical lotion 3desonide topical ointment 3desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone and shower cap 3fluocinolone topical cream 2fluocinolone topical oil 3fluocinolone topical ointment 2fluocinolone topical solution 2fluocinonide topical cream 0.05%

2

fluocinonide topical cream 0.1% 4 QL (120/30)fluocinonide topical gel 2 QL (120/30)fluocinonide topical ointment 3 QL (120/30)fluocinonide topical solution 3 QL (120/30)fluticasone propionate topical cream

2

fluticasone propionate topical ointment

2

halobetasol propionate topical cream

3

halobetasol propionate topical ointment

3

hydrocortisone butyrate topical cream

4 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciclopirox topical suspension 3 QL (60/28)clotrimazole topical cream 2 QL (45/28)clotrimazole topical solution 2 QL (30/28)clotrimazole-betamethasone topical cream

2 QL (45/28)

clotrimazole-betamethasone topical lotion

2 QL (60/28)

econazole 3 QL (85/28)ketoconazole topical cream 2 QL (60/28)ketoconazole topical shampoo 2 QL (120/28)naftifine 3 QL (60/28)NAFTIN TOPICAL GEL 3 QL (60/28)nyamyc 2nystatin topical cream 2 QL (30/28)nystatin topical ointment 2 QL (30/28)nystatin topical powder 2nystatin-triamcinolone 4 QL (60/28)nystop 2TOPICAL ANTIVIRALSacyclovir topical ointment 4 QL (30/30)DENAVIR 5 NDSTOPICAL CORTICOSTEROIDSala-cort topical cream 1% 1alclometasone 2betamethasone dipropionate 3betamethasone valerate topical cream

2

betamethasone valerate topical foam

3

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented 2clobetasol scalp 2 QL (100/28)clobetasol topical cream 2 QL (120/28)clobetasol topical foam 4 QL (100/28)

37



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARALAST NP 5 LA; NDSAURYXIA 5 PA; QL (360/30);

NDSCARBAGLU 5 PA; LA; NDSCARNITOR INTRAVENOUS 5 B/D PA; NDSCHEMET 4 PACLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10%-0.45% sodium chloride 4d2.5%-0.45% sodium chloride 4d5% and 0.9% sodium chloride 4d5%-0.45% sodium chloride 4deferasirox oral granules in packet

5 PA; NDS

deferasirox oral tablet 5 PA; NDSdeferiprone 5 PA; NDSdextrose 10% and 0.2% nacl 4DEXTROSE 10% IN WATER (D10W)

4

dextrose 25% in water (d25w) 4dextrose 30% in water (d30w) 4DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

dextrose 5%-lactated ringers 4dextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4dextrose 70% in water (d70w) 4disulfiram 2droxidopa oral capsule 100 mg 4 PA; QL (90/30)droxidopa oral capsule 200 mg, 300 mg

4 PA; QL (180/30)

FERRIPROX 5 PA; NDSFERRIPROX (2 TIMES A DAY) 5 PA; NDSINCRELEX 4 PA; LA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocortisone butyrate topical ointment

3

hydrocortisone butyrate topical solution

3 QL (120/30)

hydrocortisone butyr-emollient 4 QL (120/30)hydrocortisone topical cream 1%, 2.5%

1

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 3mometasone topical 2prednicarbate topical ointment 2triamcinolone acetonide topical cream 0.025%, 0.5%

2

triamcinolone acetonide topical cream 0.1%

1

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment

2

triderm topical cream 0.1% 1tritocin 2TOPICAL SCABICIDES / PEDICULICIDESlindane topical shampoo 3malathion 4permethrin 2

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4ringer's irrigation 4tis-u-sol pentalyte 4MISCELLANEOUS AGENTSacamprosate 2anagrelide 2

38



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CHANTIX CONTINUING MONTH BOX

4

CHANTIX STARTING MONTH BOX

4

NICOTROL 4NICOTROL NS 4VARENICLINE 4

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (60/30)chlorhexidine gluconate mucous membrane

1

fluoride (sodium) dental paste 4ipratropium bromide nasal 2 QL (30/30)oralone 3paroex oral rinse 1sodium fluoride 5000 dry mouth 4sodium fluoride-pot nitrate 4triamcinolone acetonide dental 3MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 2flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 2ofloxacin otic (ear) 2OTIC STEROID / ANTIBIOTICCIPRO HC 3CIPRODEX 3ciprofloxacin-dexamethasone 3CORTISPORIN-TC 4neomycin-polymyxin-hc otic (ear)

3

ENDOCRINE/DIABETES

ADRENAL HORMONESDEPO-MEDROL 4dexamethasone intensol 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levocarnitine (with sugar) 3levocarnitine oral solution 100 mg/ml

3

levocarnitine oral tablet 3LOKELMA 3midodrine 3nitisinone 5 NDSNORTHERA ORAL CAPSULE 100 MG

5 PA; QL (90/30); NDS

NORTHERA ORAL CAPSULE 200 MG, 300 MG

5 PA; QL (180/30); NDS

pilocarpine hcl oral 3PROLASTIN-C 5 PA; LA; NDSriluzole 3risedronate oral tablet 30 mg 3 QL (30/30)SEVELAMER CARBONATE ORAL POWDER IN PACKET

5 NDS

SEVELAMER CARBONATE ORAL TABLET

4

sodium chloride 0.9% intravenous

4

sodium chloride irrigation 4sodium phenylbutyrate 5 PA; NDSsodium polystyrene sulfonate oral powder

3

sps (with sorbitol) 3trientine 5 PA; QL (240/30);

NDSVELTASSA 3water for irrigation, sterile 4XIAFLEX 5 PA; NDSZEMAIRA 5 LA; NDSzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (60/30)CHANTIX 4

39



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg 2 QL (90/30)acarbose oral tablet 25 mg 2 QL (360/30)acarbose oral tablet 50 mg 2 QL (180/30)ALCOHOL PADS 2BAQSIMI 3BD PEN NEEDLE 2 QL(200/30)BYDUREON BCISE 4 QL (4/28)CYCLOSET 4 QL (180/30)diazoxide 4FARXIGA ORAL TABLET 10 MG

3 QL (30/30)

FARXIGA ORAL TABLET 5 MG 3 QL (60/30)GAUZE PADS 2 X 2 2glimepiride oral tablet 1 mg 1 QL (240/30)glimepiride oral tablet 2 mg 1 QL (120/30)glimepiride oral tablet 4 mg 1 QL (60/30)glipizide oral tablet 10 mg 1 QL (120/30)glipizide oral tablet 5 mg 1 QL (240/30)glipizide oral tablet extended release 24hr 10 mg

1 QL (60/30)

glipizide oral tablet extended release 24hr 2.5 mg

1 QL (240/30)

glipizide oral tablet extended release 24hr 5 mg

1 QL (120/30)

glipizide-metformin oral tablet 2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

GLYXAMBI 3 QL (30/30)GVOKE HYPOPEN 1-PACK 3GVOKE HYPOPEN 2-PACK 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg

1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg

2

dexamethasone sodium phos (pf) injection solution

4

dexamethasone sodium phosphate injection solution

4

fludrocortisone 2hydrocortisone oral 3MEDROL ORAL TABLET 2 MG 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

4

methylprednisolone sodium succ intravenous

4

prednisolone oral solution 3prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

3

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

1 B/D PA

prednisone oral tablet 50 mg 2 B/D PAprednisone oral tablets,dose pack

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection suspension 40 mg/ml

2

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

40



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)JARDIANCE 3 QL (30/30)JENTADUETO 3 QL (60/30)JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

3 QL (60/30)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG

3 QL (30/30)

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN 3LEVEMIR FLEXTOUCH U-100 INSULN

3

LEVEMIR U-100 INSULIN 3LYUMJEV KWIKPEN U-100 INSULIN

3

LYUMJEV KWIKPEN U-200 INSULIN

3

LYUMJEV U-100 INSULIN 3METFORMIN ORAL SOLUTION

3 QL (750/30)

metformin oral tablet 1,000 mg 1 QL (75/30)metformin oral tablet 500 mg 1 QL (150/30)metformin oral tablet 850 mg 1 QL (90/30)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (120/30)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (60/30)

metformin oral tablet extended release 24hr 1,000 mg

1 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GVOKE PFS 1-PACK SYRINGE

3

GVOKE PFS 2-PACK SYRINGE

3

HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN INSULIN

3

HUMALOG MIX 50-50 INSULN U-100

3

HUMALOG MIX 50-50 KWIKPEN

3

HUMALOG MIX 75-25 KWIKPEN

3

HUMALOG MIX 75-25(U-100)INSULN

3

HUMALOG U-100 INSULIN 3HUMULIN 70/30 U-100 INSULIN

3

HUMULIN 70/30 U-100 KWIKPEN

3

HUMULIN N NPH INSULIN KWIKPEN

3

HUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

HUMULIN R U-500 (CONC) INSULIN

5 B/D PA; NDS

HUMULIN R U-500 (CONC) KWIKPEN

5 NDS

INSULIN PEN NEEDLE 2 QL (200/30)INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

2 QL (200/30)

INVOKAMET 4 QL (60/30)INVOKAMET XR 4 QL (60/30)INVOKANA 4 QL (30/30)JANUMET 3 QL (60/30)

41



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG

3 QL (30/30)

TECHLITE PEN NEEDLE 2 QL(200/30)TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

TRADJENTA 3 QL (30/30)TRESIBA FLEXTOUCH U-100 3TRESIBA FLEXTOUCH U-200 3TRESIBA U-100 INSULIN 3TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG

3 QL (30/30)

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG

3 QL (60/30)

TRULICITY 3 QL (2/28)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 2-PAK 3 QL (9/30)VICTOZA 3-PAK 3 QL (9/30)XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG

3 QL (30/30)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

3 QL (60/30)

XULTOPHY 100/3.6 3 QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDScabergoline 3calcitonin (salmon) injection 5 NDScalcitonin (salmon) nasal 3calcitriol intravenous solution 1 mcg/ml

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metformin oral tablet extended release 24hr 500 mg

1 QL (150/30)

miglitol oral tablet 100 mg 4 QL (90/30)miglitol oral tablet 25 mg 4 QL (360/30)miglitol oral tablet 50 mg 4 QL (180/30)nateglinide oral tablet 120 mg 1 QL (90/30)nateglinide oral tablet 60 mg 1 QL (180/30)NEEDLES, INSULIN DISP.,SAFETY

2 QL (200/30)

NOVOFINE PEN NEEDLE 2 QL(200/30)NOVOTWIST PEN NEEDLE 2 QL(200/30)OMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)

3 QL (1.5/28)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML)

3 QL (3/28)

pioglitazone 1 QL (30/30)pioglitazone-metformin 1 QL (90/30)PROGLYCEM 5 NDSrepaglinide oral tablet 0.5 mg 1 QL (960/30)repaglinide oral tablet 1 mg 1 QL (480/30)repaglinide oral tablet 2 mg 1 QL (240/30)RIOMET 3 QL (765/30)RIOMET ER 3 QL (600/30)RYBELSUS 3 QL (30/30)SOLIQUA 100/33 3 QL (15/30)SYMLINPEN 120 5 PA; QL (10.8/30);

NDSSYMLINPEN 60 5 PA; QL (6/30); NDSSYNJARDY 3 QL (60/30)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

3 QL (60/30)

42



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SOMAVERT 5 PA; QL (30/30); NDS

SYNAREL 5 NDStestosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml)

3

TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML

3

testosterone enanthate 4testosterone transdermal gel 4 PAtestosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram)

4 PA; QL (300/30)

tolvaptan oral tablet 30 mg 5 PA; QL (60/30); NDS

zoledronic acid intravenous solution

4 B/D PA

zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml

4 B/D PA

ZOLEDRONIC AC-MANNITOL-0.9NACL

4 B/D PA

THYROID HORMONESEUTHYROX 3LEVO-T 3levothyroxine oral tablet 1levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg

3

LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

liothyronine oral 2SYNTHROID 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

calcitriol oral 3CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 PA; NDS

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg, 60 mg

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)danazol 4desmopressin injection 5 NDSdesmopressin nasal spray with pump

4

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

4

desmopressin oral 3doxercalciferol 4ELAPRASE 5 PA; NDSFABRAZYME 5 NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSMIACALCIN INJECTION 5 NDSmiglustat 5 LA; NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; LA; QL (2/28);

NDSoxandrolone oral tablet 10 mg 4 PA; QL (60/30)oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30)pamidronate intravenous solution

4

paricalcitol oral 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

sapropterin 5 PA; NDS

43



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CORTIFOAM 4CREON 3cromolyn oral 3CYSTADANE 5 NDSdronabinol 4 B/D PA; QL (60/30)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 3GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2gavilyte-n 2generlac 3granisetron (pf) intravenous solution 1 mg/ml (1 ml)

4 HI

granisetron hcl intravenous 4 HIgranisetron hcl oral 3 B/D PA; QL (60/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

1

lactulose oral solution 2LINZESS 3 QL (30/30)meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule, extended release 24hr

3

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4

mesalamine rectal enema 4mesalamine with cleansing wipe

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2MOVANTIK 4 QL (30/30)OCALIVA 5 PA; LA; QL (30/30);

NDSondansetron 2 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

unithroid oral tablet 137 mcg 3

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICSatropine injection solution 0.4 mg/ml

4

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

4

dicyclomine oral capsule 1dicyclomine oral solution 3dicyclomine oral tablet 1diphenoxylate-atropine oral liquid

3

diphenoxylate-atropine oral tablet

2

GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate injection 4glycopyrrolate oral tablet 1 mg, 2 mg

2

loperamide oral capsule 2MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron 5 PA; NDSaprepitant 4 B/D PAAVSOLA 5 PA; NDSbalsalazide 4budesonide oral capsule, delayed,extend.release

4

budesonide oral tablet,delayed and ext.release

5 NDS

compro 2constulose 3

44



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

3

ULCER THERAPYesomeprazole magnesium oral capsule,delayed release(dr/ec)

3

famotidine oral suspension 4famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule, delayed release(dr/ec)

3

misoprostol 3nizatidine oral capsule 2omeprazole oral capsule, delayed release(dr/ec)

2

pantoprazole oral tablet, delayed release (dr/ec) 20 mg

1

pantoprazole oral tablet, delayed release (dr/ec) 40 mg

1 QL (60/30)

sucralfate oral suspension 4sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA; NDSARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML

5 PA; NDS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML

4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ondansetron hcl (pf) 4ondansetron hcl intravenous 4ondansetron hcl oral solution 3 B/D PA; QL

(450/30)ondansetron hcl oral tablet 2 B/D PApalonosetron intravenous solution 0.25 mg/5 ml

5 NDS

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte 2PENTASA 5 NDSPLENVU 4prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 1procto-pak 2proctosol hc topical 1proctozone-hc 1RECTIV 4RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

RENFLEXIS 5 B/D PA; NDSSANCUSO 5 NDSscopolamine base 4 QL (10/30)sulfasalazine 2SUPREP BOWEL PREP KIT 3SUTAB 4ursodiol oral capsule 300 mg 3ursodiol oral tablet 3VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT

4

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT

5 NDS

45



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REBIF TITRATION PACK 5 PA; QL (4.2/180); NDS

RETACRIT 4 PAZARXIO 5 PA; NDSZIEXTENZO 5 PA; NDSVACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3

ATGAM 4 B/D PABCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

ENGERIX-B PEDIATRIC (PF) 3 B/D PAfomepizole 5 NDSGAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%)

5 B/D PA; NDS

GAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 3HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HIBERIX (PF) 3HIZENTRA 5 B/D PA; NDSIMOVAX RABIES VACCINE (PF)

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

IPOL 3IXIARO (PF) 3KINRIX (PF) INTRAMUSCULAR SYRINGE

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML

4 PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML

5 PA; NDS

ARCALYST 5 PA; NDSAVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA; QL (1/28); NDS

BETASERON SUBCUTANEOUS KIT

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK 5 PA; NDSINTRON A INJECTION RECON SOLN

5 B/D PA; NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 B/D PA; NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4 B/D PA

LEUKINE INJECTION RECON SOLN

5 PA; NDS

MOZOBIL 5 B/D PA; NDSNIVESTYM 5 PA; NDSNYVEPRIA 5 PA; NDSREBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDSREBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

5 PA; QL (6/28); NDS

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; QL (4.2/180); NDS

46



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FEBUXOSTAT 3 STMITIGARE 3probenecid 2probenecid-colchicine 2OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

BINOSTO 4 QL (4/28)ibandronate oral 2 QL (1/30)PROLIA 4 QL (1/180)raloxifene 2 QL (30/30)risedronate oral tablet 150 mg 3 QL (1/30)risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)

3 QL (4/28)

risedronate oral tablet 5 mg 3 QL (30/30)TERIPARATIDE 5 PA; QL (2.4/28);

NDSTYMLOS 5 PA; QL (1.56/30);

NDSOTHER RHEUMATOLOGICALSBENLYSTA 5 PA; NDSDEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (16/28); NDS

ENBREL SUBCUTANEOUS SOLUTION

5 PA; QL (4/28); NDS

ENBREL SUBCUTANEOUS SYRINGE

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDSHUMIRA PEN 5 PA; QL (4/28); NDSHUMIRA PEN CROHNS-UC-HS START

5 PA; QL (6/180); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (4/180); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENQUADFI (PF) 3MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3PEDIARIX (PF) 3PEDVAX HIB (PF) 3PENTACEL (PF) INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 MCG/0.5ML

3

PROQUAD (PF) 3QUADRACEL (PF) 3RABAVERT (PF) 3RECOMBIVAX HB (PF) 3 B/D PAROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 3 QL (2/999)STAMARIL (PF) 3TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) 3TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3VARIZIG 4YF-VAX (PF) 3ZOSTAVAX (PF) 3

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral tablet 4 QL (120/30)

47



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XELJANZ ORAL SOLUTION 5 PA; QL (300/30); NDS

XELJANZ ORAL TABLET 5 PA; QL (60/30); NDS

XELJANZ XR 5 PA; QL (30/30); NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINSALORA 3 QL (8/28)camila 2deblitane 2DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

4

DEPO-ESTRADIOL 4dotti 2 QL (8/28)DUAVEE 4 PAerrin 2estradiol oral 2estradiol transdermal patch semiweekly

2 QL (8/28)

estradiol transdermal patch weekly

2 QL (4/28)

estradiol vaginal 4estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

ESTRING 4fyavolv 3heather 2hydroxyprogesterone caproate 5 NDSincassia 2jencycla 2lyza 2medroxyprogesterone intramuscular suspension

4

medroxyprogesterone intramuscular syringe

2

medroxyprogesterone oral 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (3/180); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (2/180); NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (3/180); NDS

HUMIRA(CF) PEN PEDIATRIC UC

5 PA; QL (4/180); NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (3/180); NDS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML

5 PA; QL (3/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML

5 PA; QL (2/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

leflunomide 2 QL (30/30)ORENCIA CLICKJECT 5 PA; QL (4/28); NDSORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML

5 PA; QL (1.6/28); NDS

ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML

5 PA; QL (2.8/28); NDS

penicillamine 5 NDSRIDAURA 5 NDSRINVOQ 5 PA; QL (30/30);

NDS

48



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

aviane 2ayuna 2azurette (28) 2balziva (28) 2blisovi 24 fe 2blisovi fe 1.5/30 (28) 2blisovi fe 1/20 (28) 2briellyn 2camrese 2camrese lo 2caziant (28) 2charlotte 24 fe 2chateal (28) 2chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 2cyred 2cyred eq 2dasetta 1/35 (28) 2dasetta 7/7/7 (28) 2daysee 2desog-e.estradiol/e.estradiol 2desogestrel-ethinyl estradiol 2dolishale 2drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 2ELLA 3emoquette 2enpresse 2enskyce 2estarylla 2ethynodiol diac-eth estradiol 2falmina (28) 2fayosim 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MENEST 3MENOSTAR 3 QL (4/28)nora-be 2norethindrone (contraceptive) 2norethindrone acetate 2norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg

3

PREMARIN INJECTION 4PREMARIN ORAL 3PREMARIN VAGINAL 3progesterone micronized 2sharobel 2yuvafem 4MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 3metronidazole vaginal 3terconazole 3tranexamic acid oral 3vandazole 3ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 2alyacen 7/7/7 (28) 2amethia 2amethyst (28) 2apri 2aranelle (28) 2ashlyna 2aubra 2aubra eq 2aurovela 1.5/30 (21) 2aurovela 1/20 (21) 2aurovela 24 fe 2aurovela fe 1.5/30 (28) 2aurovela fe 1-20 (28) 2

49



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levonorg-eth estrad triphasic 2levora-28 2lillow (28) 2lojaimiess 2loryna (28) 2low-ogestrel (28) 2lo-zumandimine (28) 2lutera (28) 2marlissa (28) 2merzee 2mibelas 24 fe 2microgestin 1.5/30 (21) 2microgestin 1/20 (21) 2microgestin fe 1.5/30 (28) 2microgestin fe 1/20 (28) 2mili 2mono-linyah 2necon 0.5/35 (28) 2nikki (28) 2noreth-ethinyl estradiol-iron 2norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

2

norethindrone-e.estradiol-iron oral capsule

2

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

2

norethindrone-e.estradiol-iron oral tablet,chewable

2

norgestimate-ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 (21) 2nortrel 1/35 (28) 2nortrel 7/7/7 (28) 2nylia 7/7/7 (28) 2nymyo 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

femynor 2gemmily 2hailey 2hailey 24 fe 2hailey fe 1.5/30 (28) 2hailey fe 1/20 (28) 2iclevia 2introvale 2isibloom 2jaimiess 2jasmiel (28) 2jolessa 2juleber 2junel 1.5/30 (21) 2junel 1/20 (21) 2junel fe 1.5/30 (28) 2junel fe 1/20 (28) 2junel fe 24 2kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 (28) 2kurvelo (28) 2l norgest/e.estradiol-e.estrad 2larin 1.5/30 (21) 2larin 1/20 (21) 2larin 24 fe 2larin fe 1.5/30 (28) 2larin fe 1/20 (28) 2larissia 2layolis fe 2leena 28 2lessina 2levonest (28) 2levonorgestrel-ethinyl estrad 2

50



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tydemy 2velivet triphasic regimen (28) 2vestura (28) 2vienva 2viorele (28) 2volnea (28) 2vyfemla (28) 2vylibra 2wera (28) 2wymzya fe 2zarah 2zovia 1/35e (28) 2zovia 1-35 (28) 2zumandimine (28) 2

OPHTHALMOLOGY

ANTIBIOTICSak-poly-bac 2AZASITE 3bacitracin ophthalmic (eye) 2bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye)

2

erythromycin ophthalmic (eye) 2gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

2

moxifloxacin ophthalmic (eye) 3NATACYN 3neomycin-bacitracin-polymyxin 2neomycin-polymyxin-gramicidin 2neo-polycin 2ofloxacin ophthalmic (eye) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ocella 2orsythia 2philith 2pimtrea (28) 2pirmella 2portia 28 2previfem 2reclipsen (28) 2rivelsa 2setlakin 2simliya (28) 2simpesse 2sprintec (28) 2sronyx 2syeda 2tarina 24 fe 2tarina fe 1/20 (28) 2tarina fe 1-20 eq (28) 2taysofy 2tilia fe 2tri femynor 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 2tri-nymyo 2tri-previfem (28) 2tri-sprintec (28) 2trivora (28) 2tri-vylibra 2tri-vylibra lo 2TYBLUME 2

51



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 4bimatoprost ophthalmic (eye) 2brinzolamide 4COMBIGAN 3dorzolamide 2dorzolamide-timolol 2latanoprost 1LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

3

RHOPRESSA 4 STROCKLATAN 4 STSIMBRINZA 4travoprost 3STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 3neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-hc ophthalmic (eye)

2

neo-polycin hc 3PRED-G 3PRED-G S.O.P. 3tobramycin-dexamethasone 3ZYLET 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

polycin 2polymyxin b sulf-trimethoprim 2tobramycin ophthalmic (eye) 2TOBREX OPHTHALMIC (EYE) OINTMENT

4

ANTIVIRALStrifluridine 3ZIRGAN 3BETA-BLOCKERScarteolol 2levobunolol ophthalmic (eye) drops 0.5%

1

timolol maleate ophthalmic (eye) drops

1

TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION

4

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3azelastine ophthalmic (eye) 2BLEPHAMIDE 3BLEPHAMIDE S.O.P. 3cromolyn ophthalmic (eye) 2CYSTARAN 5 PA; NDSepinastine 3EYLEA 5 PA; NDSLACRISERT 4olopatadine ophthalmic (eye) 3OXERVATE 5 PA; QL (112/999);

NDSpilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

3

RESTASIS 3 QL (60/30)RESTASIS MULTIDOSE 3 QL (60/30)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2XIIDRA 3 QL (60/30)

52



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethegan rectal suppository 25 mg, 50 mg

4

PULMONARY AGENTSacetylcysteine 3 B/D PAADEMPAS 5 PA; LA; QL (90/30);

NDSADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair)

4 QL (17/30)

ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL)

4 QL (13.4/30)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin)

4 QL (36/30)

albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 3albuterol sulfate oral tablet extended release 12 hr

2

alyq 5 PA; QL (60/30); NDS

ambrisentan 5 PA; LA; QL (30/30); NDS

ANORO ELLIPTA 3 QL (60/30)arformoterol 4 B/D PAARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)bosentan 5 PA; LA; NDSBREO ELLIPTA 3 QL (60/30)BROVANA 4 B/D PAbudesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

4 B/D PA; QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

DUREZOL 3fluorometholone 3INVELTYS 4LOTEMAX 4LOTEMAX SM 4prednisolone acetate 3prednisolone sodium phosphate ophthalmic (eye)

1

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

3

apraclonidine 3brimonidine ophthalmic (eye) drops 0.15%

3

brimonidine ophthalmic (eye) drops 0.2%

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 2 QL (30/30)diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml

3 QL (2/30)

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml

2 QL (2/30)

epinephrine injection solution 1 mg/ml

4

hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4levocetirizine oral tablet 2 QL (30/30)promethazine oral 2 PApromethazine rectal suppository 12.5 mg, 25 mg

4

53



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ipratropium-albuterol 2 B/D PAKALYDECO ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

KALYDECO ORAL TABLET 5 PA; QL (60/30); NDS

levalbuterol hcl 4 B/D PAmetaproterenol oral syrup 3mometasone nasal 3 QL (34/30)montelukast oral granules in packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)montelukast oral tablet, chewable

2 QL (30/30)

OFEV 5 PA; QL (60/30); NDS

OPSUMIT 5 PA; LA; NDSORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (112/28); NDS

PERFOROMIST 3 B/D PA; QL (120/30)

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML

4 B/D PA; QL (120/30)

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML

4 B/D PA; QL (60/30)

PULMOZYME 5 B/D PA; QL (150/30); NDS

SEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

SYMDEKO 5 PA; QL (56/28); NDS

tadalafil (pulmonary arterial hypertension) oral tablet 20 mg

5 PA; QL (60/30); NDS

terbutaline 4THEO-24 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

budesonide inhalation suspension for nebulization 1 mg/2 ml

4 B/D PA; QL (60/30)

COMBIVENT RESPIMAT 3 QL (8/30)cromolyn inhalation 2 B/D PADALIRESP 4 PA; QL (30/30)ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDSESBRIET ORAL TABLET 267 MG

5 PA; QL (270/30); NDS

ESBRIET ORAL TABLET 801 MG

5 PA; QL (90/30); NDS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL (60/30)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

3 QL (240/30)

FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION

3 QL (12/30)


3 QL (24/30)


3 QL (10.6/30)

flunisolide 3 QL (50/30)fluticasone propionate nasal 2 QL (16/30)fluticasone propion-salmeterol inhalation blister with device

2 QL (60/30)

formoterol fumarate 3 B/D PA; QL (120/30)

HAEGARDA 5 PA; NDSicatibant 5 PA; QL (18/30);

NDSINCRUSE ELLIPTA 3 QL (30/30)ipratropium bromide inhalation 2 B/D PA

54



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dutasteride-tamsulosin 4finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)MISCELLANEOUS UROLOGICALSbethanechol chloride 2CYSTAGON 4 LAELMIRON 5 NDSK-PHOS ORIGINAL 4potassium citrate 4RENACIDIN 4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 2klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 1klor-con m20 1lactated ringers intravenous 4MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4

magnesium sulfate in water 4magnesium sulfate injection 4POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l

4

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4

potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

theophylline oral tablet extended release 12 hr 300 mg, 450 mg

3

theophylline oral tablet extended release 24 hr

3

TRELEGY ELLIPTA 3 QL (60/30)TRIKAFTA 5 PA; NDSVENTAVIS 5 PA; NDSVENTOLIN HFA 3 QL (36/30)wixela inhub 2 QL (60/30)XHANCE 4 ST; QL (32/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; LA; QL (6/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML

5 PA; LA; QL (4/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML

5 PA; LA; QL (1/28); NDS

XOPENEX 4 B/D PAXOPENEX CONCENTRATE 4 B/D PAYUPELRI 4 B/D PA; QL (90/30)zafirlukast 3 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSdarifenacin 4flavoxate 2MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

oxybutynin chloride oral syrup 1oxybutynin chloride oral tablet 1oxybutynin chloride oral tablet extended release 24hr

2 QL (60/30)

solifenacin 2tolterodine 3TOVIAZ 3 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2dutasteride 2

55



October 2021

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

CLINIMIX 6%-D5W (SULFITE-FREE)

4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15% 4 B/D PAelectrolyte-48 in d5w 4INTRALIPID INTRAVENOUS EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PANUTRILIPID 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PAPREMASOL 10% 4 B/D PAPROCALAMINE 3% 4 B/D PAPROSOL 20% 4 B/D PATRAVASOL 10% 4 B/D PATROPHAMINE 10% 4 B/D PAVITAMINS / HEMATINICSfluoride (sodium) oral tablet 1fluoride (sodium) oral tablet, chewable 1 mg (2.2 mg sod. fluoride)

1

PRENATAL VITAMIN ORAL TABLET

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l

4

potassium chloride in water intravenous piggyback

4

potassium chloride intravenous 4potassium chloride oral capsule, extended release

2

potassium chloride oral liquid 4potassium chloride oral packet 2potassium chloride oral tablet extended release

1

potassium chloride oral tablet, er particles/crystals

1

potassium chloride-0.45% nacl 4POTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

4

POTASSIUM CHLORIDE-D5-0.9%NACL

4

ringer's intravenous 4sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml)

4

sodium chloride 0.45% intravenous parenteral solution

4

sodium chloride 3% 4sodium chloride 5% 4sodium chloride intravenous 4TPN ELECTROLYTES 4 B/D PAMISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 15% 4 B/D PAAMINOSYN-PF 7% (SULFITE-FREE)

4 B/D PA

56

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

October 2021

Aabacavir-lamivudine . . . . . . . . . . . . . . . . 8abacavir-lamivudine-zidovudine . . . . . 8abacavir oral solution . . . . . . . . . . . . . . . 8abacavir oral tablet . . . . . . . . . . . . . . . . . 8ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . . 8ABILIFY MAINTENA . . . . . . . . . . . . . . . 27abiraterone oral tablet 250 mg . . . . . . 15abiraterone oral tablet 500 mg . . . . . . 15ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 15acamprosate . . . . . . . . . . . . . . . . . . . . . . 37acarbose oral tablet 25 mg . . . . . . . . . 39acarbose oral tablet 50 mg . . . . . . . . . 39acarbose oral tablet 100 mg . . . . . . . . 39acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . 30acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml . . . . . . . . . . . . 25acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . . . . . 25acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . . . . . 25acetazolamide . . . . . . . . . . . . . . . . . . . . . 51acetazolamide sodium . . . . . . . . . . . . . 51acetic acid otic (ear) . . . . . . . . . . . . . . . 38acetylcysteine . . . . . . . . . . . . . . . . . . . . . 52acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 45ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 44acyclovir oral capsule . . . . . . . . . . . . . . . 8acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 8acyclovir oral tablet . . . . . . . . . . . . . . . . . 8acyclovir sodium intravenous solution . . . . . . . . . . . . . . . . 8acyclovir topical ointment . . . . . . . . . . 36ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 45ADASUVE . . . . . . . . . . . . . . . . . . . . . . . . 27ADCETRIS . . . . . . . . . . . . . . . . . . . . . . . . 15

adefovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 52adriamycin intravenous recon soln 10 mg . . . . . . . . . . . . . . . . . . 15adriamycin intravenous solution . . . . 15adrucil intravenous solution 2.5 gram/50 ml . . . . . . . . . . . . 15ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 52AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG . . . . . . . . . 15AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG, 5 MG . . . 15AFINITOR ORAL TABLET 10 MG . . 15afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 48AIMOVIG AUTOINJECTOR . . . . . . . . 24ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 50ala-cort topical cream 1% . . . . . . . . . . 36albendazole . . . . . . . . . . . . . . . . . . . . . . . 11albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair) . . . . . . . . . . . . . . . . . 52ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL) . . . . . 52albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin) . . . . . . . . . . . . . . . 52albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 52albuterol sulfate oral syrup . . . . . . . . . 52albuterol sulfate oral tablet . . . . . . . . . 52albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 52alclometasone . . . . . . . . . . . . . . . . . . . . . 36ALCOHOL PADS . . . . . . . . . . . . . . . . . . 39ALDURAZYME . . . . . . . . . . . . . . . . . . . . 41ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 15alendronate oral tablet 10 mg, 5 mg . 46alendronate oral tablet 35 mg, 70 mg . . . . . . . . . . . . . . . . . . . . . 46alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 54ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 15aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 30allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 46ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 47alosetron . . . . . . . . . . . . . . . . . . . . . . . . . . 43ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 52alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 27alprazolam oral tablet 2 mg . . . . . . . . 27alprazolam oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 27alprazolam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 27altavera (28) . . . . . . . . . . . . . . . . . . . . . . 48ALUNBRIG ORAL TABLET 30 MG . 15ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 15ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 15alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 48alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 48alyq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52amantadine hcl . . . . . . . . . . . . . . . . . . . . . 8AMBISOME . . . . . . . . . . . . . . . . . . . . . . . . 8ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 52amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 48amethyst (28) . . . . . . . . . . . . . . . . . . . . . 48amikacin injection solution 1,000 mg/4 ml . . . . . . . . . . . . . . . . . . . . . 11amikacin injection solution 500 mg/2 ml . . . . . . . . . . . . . . . . . . . . . . . 11amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 30amiloride-hydrochlorothiazide . . . . . . 30aminocaproic acid oral . . . . . . . . . . . . . 33AMINOSYN II 15% . . . . . . . . . . . . . . . . 55AMINOSYN-PF 7% (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 55amiodarone intravenous solution . . . 30amiodarone oral . . . . . . . . . . . . . . . . . . . 30amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 27

57


Covered Drugs Index

October 2021

atazanavir oral capsule 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . . 8atazanavir oral capsule 200 mg . . . . . . 8atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 31atenolol-chlorthalidone . . . . . . . . . . . . . 31ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 45atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 27atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 27atorvastatin . . . . . . . . . . . . . . . . . . . . . . . 33atovaquone . . . . . . . . . . . . . . . . . . . . . . . 11atovaquone-proguanil . . . . . . . . . . . . . . 11ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . . 8atropine injection solution 0.4 mg/ml . . . . . . . . . . . . . . . . . 43atropine injection syringe 0.05 mg/ml, 0.1 mg/ml . . . . . . . . . . . . . 43atropine ophthalmic (eye) drops . . . . 51ATROVENT HFA . . . . . . . . . . . . . . . . . . 52aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 48aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 48aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 48aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 48aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 48aurovela fe 1-20 (28) . . . . . . . . . . . . . . 48AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 37AUSTEDO ORAL TABLET 6 MG . . . 24AUSTEDO ORAL TABLET 12 MG, 9 MG . . . . . . . . . . . . . . . . . . . . . . 24aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35AVONEX INTRAMUSCULAR PEN INJECTOR KIT . . . . . . . . . . . . . . . 45AVONEX INTRAMUSCULAR SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 45AVSOLA . . . . . . . . . . . . . . . . . . . . . . . . . . 43ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 15azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 15AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 15

APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 22APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . . 8ARALAST NP . . . . . . . . . . . . . . . . . . . . . 37aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 48ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/ 0.42 ML, 40 MCG/0.4 ML . . . . . . . . . . 45ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML . . . . . 45ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 45arformoterol . . . . . . . . . . . . . . . . . . . . . . . 52ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 11aripiprazole oral solution . . . . . . . . . . . 27aripiprazole oral tablet . . . . . . . . . . . . . 27aripiprazole oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 27ARISTADA . . . . . . . . . . . . . . . . . . . . . . . . 27ARISTADA INITIO . . . . . . . . . . . . . . . . . 27armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 27ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 52ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 15arsenic trioxide . . . . . . . . . . . . . . . . . . . . 15ARZERRA . . . . . . . . . . . . . . . . . . . . . . . . 15asenapine maleate . . . . . . . . . . . . . . . . 27ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 48aspirin-dipyridamole . . . . . . . . . . . . . . . 33ASTAGRAF XL ORAL CAPSULE, EXTENDED RELEASE 24HR 0.5 MG, 1 MG . . . . . . . . . . . . . . . . . . . . . 15ASTAGRAF XL ORAL CAPSULE, EXTENDED RELEASE 24HR 5 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 31amlodipine-benazepril . . . . . . . . . . . . . 31amlodipine-valsartan . . . . . . . . . . . . . . . 31amlodipine-valsartan-hcthiazid . . . . . 31ammonium lactate . . . . . . . . . . . . . . . . . 34amnesteem . . . . . . . . . . . . . . . . . . . . . . . 35amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 27amoxicillin oral capsule . . . . . . . . . . . . 13amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 13amoxicillin oral tablet . . . . . . . . . . . . . . 13amoxicillin oral tablet, chewable 125 mg, 250 mg . . . . . . . . . 13amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 13amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 13amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 13amoxicillin-pot clavulanate oral tablet extended release 12 hr . . . . . . . 13amphotericin b . . . . . . . . . . . . . . . . . . . . . 8ampicillin oral capsule 500 mg . . . . . . 13ampicillin sodium injection recon soln 1 gram, 10 gram . . . . . . . . 13ampicillin sodium injection recon soln 2 gram . . . . . . . . . . . . . . . . . 13ampicillin sodium injection recon soln 125 mg, 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 13ampicillin sodium intravenous . . . . . . 13ampicillin-sulbactam injection . . . . . . . 13ampicillin-sulbactam intravenous . . . 13anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 37anastrozole . . . . . . . . . . . . . . . . . . . . . . . 15ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 52APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 23apraclonidine . . . . . . . . . . . . . . . . . . . . . . 52aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 43apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48APTIOM ORAL TABLET 200 MG . . . 21APTIOM ORAL TABLET 400 MG . . . 22

58


Covered Drugs Index

October 2021

BRAFTOVI ORAL CAPSULE 75 MG . . . . . . . . . . . . . . . . . 15BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 52briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 33brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 52brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 52brinzolamide . . . . . . . . . . . . . . . . . . . . . . 51BRIVIACT INTRAVENOUS . . . . . . . . . 22BRIVIACT ORAL SOLUTION . . . . . . . 22BRIVIACT ORAL TABLET . . . . . . . . . . 22bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 51bromocriptine . . . . . . . . . . . . . . . . . . . . . 23BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 52BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 15budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml . . . . . . . . . . . . . . . . . . . . . . . 52budesonide inhalation suspension for nebulization 1 mg/2 ml . . . . . . . . . . 53budesonide oral capsule, delayed,extend.release . . . . . . . . . . . . 43budesonide oral tablet, delayed and ext.release . . . . . . . . . . . . 43bumetanide injection . . . . . . . . . . . . . . . 31bumetanide oral . . . . . . . . . . . . . . . . . . . 31buprenorphine hcl injection . . . . . . . . . 25buprenorphine hcl sublingual . . . . . . . 25buprenorphine-naloxone sublingual film 2-0.5 mg . . . . . . . . . . . . 26buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg . . . . . . 26buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 26buprenorphine-naloxone sublingual tablet 2-0.5 mg . . . . . . . . . . 26buprenorphine-naloxone sublingual tablet 8-2 mg . . . . . . . . . . . . 26buprenorphine transdermal patch weekly 7.5 mcg/hour . . . . . . . . . 25

BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 50BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 15betamethasone, augmented . . . . . . . . 36betamethasone dipropionate . . . . . . . 36betamethasone valerate topical cream . . . . . . . . . . . . . 36betamethasone valerate topical foam . . . . . . . . . . . . . . . 36betamethasone valerate topical lotion . . . . . . . . . . . . . . 36betamethasone valerate topical ointment . . . . . . . . . . . 36BETASERON SUBCUTANEOUS KIT . . . . . . . . . . . . . 45betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 31bethanechol chloride . . . . . . . . . . . . . . . 54bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 15BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 45bicalutamide . . . . . . . . . . . . . . . . . . . . . . 15BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 13BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . . 8bimatoprost ophthalmic (eye) . . . . . . . 51BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 46bisoprolol fumarate . . . . . . . . . . . . . . . . 31bisoprolol-hydrochlorothiazide . . . . . . 31BLENREP . . . . . . . . . . . . . . . . . . . . . . . . 15bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . 15BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 51BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 51BLINCYTO INTRAVENOUS KIT . . . . 15blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 48blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 48blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 48BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 45BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 15bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 52BOSULIF ORAL TABLET 100 MG . . 15BOSULIF ORAL TABLET 400 MG, 500 MG . . . . . . . . . . . . . . . . . . 15BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 50azathioprine . . . . . . . . . . . . . . . . . . . . . . . 15azathioprine sodium . . . . . . . . . . . . . . . 15azelastine nasal . . . . . . . . . . . . . . . . . . . 38azelastine ophthalmic (eye) . . . . . . . . 51azithromycin intravenous . . . . . . . . . . . 11azithromycin oral packet . . . . . . . . . . . 11azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 11azithromycin oral tablet . . . . . . . . . . . . 11AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 51aztreonam injection recon soln 1 gram . . . . . . . . . . . . . . . . . 11aztreonam injection recon soln 2 gram . . . . . . . . . . . . . . . . . 11azurette (28) . . . . . . . . . . . . . . . . . . . . . . 48

Bbacitracin intramuscular . . . . . . . . . . . . 11bacitracin ophthalmic (eye) . . . . . . . . . 50bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 50baclofen oral tablet 10 mg, 5 mg . . . . 25baclofen oral tablet 20 mg . . . . . . . . . . 25balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 43BALVERSA . . . . . . . . . . . . . . . . . . . . . . . 15balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 48BANZEL . . . . . . . . . . . . . . . . . . . . . . . . . . 22BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 39BARACLUDE ORAL SOLUTION . . . . 8BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 15BCG VACCINE, LIVE (PF) . . . . . . . . . 45BD PEN NEEDLE . . . . . . . . . . . . . . . . . 39BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 15benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 31benazepril-hydrochlorothiazide . . . . . 31BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 15BENLYSTA . . . . . . . . . . . . . . . . . . . . . . . . 46benztropine injection . . . . . . . . . . . . . . . 23benztropine oral . . . . . . . . . . . . . . . . . . . 23

59


Covered Drugs Index

October 2021

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 10cefadroxil oral tablet . . . . . . . . . . . . . . . 10cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . 10CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . 10cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg . . . . . . . . . . . . . . . . . . . . . 10cefazolin intravenous . . . . . . . . . . . . . . 10cefdinir oral capsule . . . . . . . . . . . . . . . 10cefdinir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 10CEFEPIME IN DEXTROSE 5% . . . . . 10cefepime in dextrose,iso-osm . . . . . . 10cefepime injection . . . . . . . . . . . . . . . . . 10CEFEPIME INTRAVENOUS . . . . . . . 10cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 10CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . . . . . . . . . . . . . . 10cefotetan injection . . . . . . . . . . . . . . . . . 11cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefoxitin in dextrose, iso-osm . . . . . . . 11cefpodoxime . . . . . . . . . . . . . . . . . . . . . . 11cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 11CEFTAZIDIME IN D5W . . . . . . . . . . . . 11ceftriaxone in dextrose,iso-os . . . . . . 11ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 11CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 11ceftriaxone intravenous . . . . . . . . . . . . 11cefuroxime axetil oral tablet . . . . . . . . 11cefuroxime sodium injection recon soln 750 mg . . . . . . . . . . . . . . . . . 11cefuroxime sodium intravenous . . . . . 11celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 26

candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 31candesartan oral tablet 32 mg . . . . . . 31CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 27CAPRELSA ORAL TABLET 100 MG . 16CAPRELSA ORAL TABLET 300 MG . 16CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 37carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 22carbamazepine oral suspension 100 mg/5 ml, 200 mg/10 ml . . . . . . . . 22carbamazepine oral tablet . . . . . . . . . . 22carbamazepine oral tablet, chewable . . . . . . . . . . . . . . . . . . . . . . . . . 22carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 22carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 23carbidopa-levodopa-entacapone . . . . 24carbidopa-levodopa oral tablet . . . . . 23carbidopa-levodopa oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 23carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . . . . . . . 23carboplatin intravenous solution . . . . 16carmustine . . . . . . . . . . . . . . . . . . . . . . . . 16CARNITOR INTRAVENOUS . . . . . . . 37carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 51cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 31carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 31carvedilol phosphate . . . . . . . . . . . . . . . 31caspofungin . . . . . . . . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 12caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 48cefaclor oral capsule . . . . . . . . . . . . . . . 10cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . 10cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . 10cefadroxil oral capsule . . . . . . . . . . . . . 10

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR . . . . . . . . . . . . . . . . . . . . . 25bupropion hcl oral tablet 75 mg . . . . . 27bupropion hcl oral tablet 100 mg . . . . 27bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . 27bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . 27bupropion hcl oral tablet sustained-release 12 hr . . . . . . . . . . . . 27bupropion hcl (smoking deter) . . . . . . 38buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 27busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 15butorphanol nasal . . . . . . . . . . . . . . . . . 26BYDUREON BCISE . . . . . . . . . . . . . . . 39BYSTOLIC . . . . . . . . . . . . . . . . . . . . . . . . 31

CCABENUVA . . . . . . . . . . . . . . . . . . . . . . . . 8cabergoline . . . . . . . . . . . . . . . . . . . . . . . 41CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . 15CABOMETYX ORAL TABLET 40 MG . . . . . . . . . . . . . . . . . . . 15calcipotriene scalp . . . . . . . . . . . . . . . . . 34calcipotriene topical cream . . . . . . . . . 34calcipotriene topical ointment . . . . . . . 34calcitonin (salmon) injection . . . . . . . . 41calcitonin (salmon) nasal . . . . . . . . . . . 41calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 41calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 42calcitriol topical . . . . . . . . . . . . . . . . . . . . 34calcium acetate(phosphat bind) . . . . . 54CALQUENCE . . . . . . . . . . . . . . . . . . . . . 16camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 48camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 48candesartan-hydrochlorothiazid . . . . 31

60


Covered Drugs Index

October 2021

CLINIMIX 4.25%/D5W SULFIT FREE . . . . . . . . . . . . . . . . . . . . . 37CLINIMIX 4.25%/D10W SULF FREE . . . . . . . . . . . . . . . . . . . . . . . 55CLINIMIX 5%/D15W SULFITE FREE . . . . . . . . . . . . . . . . . . . 55CLINIMIX 5%-D20W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 55CLINIMIX 6%-D5W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 55CLINIMIX 8%-D10W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 55CLINIMIX 8%-D14W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 55CLINIMIX E 4.25%/D10W SUL FREE . . . . . . . . . . . . . . . . . . . . . . . . 55CLINISOL SF 15% . . . . . . . . . . . . . . . . 55clobazam oral suspension . . . . . . . . . . 22clobazam oral tablet . . . . . . . . . . . . . . . 22clobetasol-emollient topical cream . . 36clobetasol-emollient topical foam . . . 36clobetasol scalp . . . . . . . . . . . . . . . . . . . 36clobetasol topical cream . . . . . . . . . . . 36clobetasol topical foam . . . . . . . . . . . . . 36clobetasol topical gel . . . . . . . . . . . . . . 36clobetasol topical ointment . . . . . . . . . 36clobetasol topical shampoo . . . . . . . . 36CLOCORTOLONE PIVALATE . . . . . . 36clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 16clomipramine . . . . . . . . . . . . . . . . . . . . . . 27clonazepam oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 22clonazepam oral tablet 2 mg . . . . . . . 22clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 22clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 22clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . 31clonidine hcl oral tablet 0.1 mg, 0.2 mg . . . . . . . . . . . . . . . . . . . . 31clonidine hcl oral tablet 0.3 mg . . . . . 31

ciprofloxacin hcl ophthalmic (eye) . . . 50ciprofloxacin hcl oral tablet 100 mg . 14ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 14ciprofloxacin in 5% dextrose intravenous piggyback 200 mg/100 ml . . . . . . . . . . . . . . . . . . . . 14ciprofloxacin in 5% dextrose intravenous piggyback 400 mg/200 ml . . . . . . . . . . . . . . . . . . . . 14CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 38CIPRO ORAL SUSPENSION, MICROCAPSULE RECON . . . . . . . . . 14cisplatin intravenous solution . . . . . . . 16citalopram oral solution . . . . . . . . . . . . 27citalopram oral tablet . . . . . . . . . . . . . . 27cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 16claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 35clarithromycin oral suspension for reconstitution . . . . . . . 11clarithromycin oral tablet . . . . . . . . . . . 11clarithromycin oral tablet extended release 24 hr . . . . . . . . . . . . 11clindacin etz topical swab . . . . . . . . . . 35clindacin p . . . . . . . . . . . . . . . . . . . . . . . . 35clindamycin hcl . . . . . . . . . . . . . . . . . . . . 12CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . 12clindamycin in 5% dextrose . . . . . . . . 12clindamycin pediatric . . . . . . . . . . . . . . 12clindamycin phosphate injection . . . . 12clindamycin phosphate intravenous solution 600 mg/4 ml . . . 12clindamycin phosphate topical gel . . 35CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . . . . 35clindamycin phosphate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 35clindamycin phosphate topical solution . . . . . . . . . . . . . . . . . . . . 35clindamycin phosphate topical swab . . . . . . . . . . . . . . . . . . . . . . . 35clindamycin phosphate vaginal . . . . . 48

CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . 22cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 11cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 11CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 42CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 38CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 38CHANTIX STARTING MONTH BOX . 38charlotte 24 fe . . . . . . . . . . . . . . . . . . . . . 48chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 48chateal eq (28) . . . . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 37chloramphenicol sod succinate . . . . . 12chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 38chloroquine phosphate . . . . . . . . . . . . . 12chlorothiazide sodium . . . . . . . . . . . . . . 31chlorpromazine injection . . . . . . . . . . . 27chlorpromazine oral tablet . . . . . . . . . . 27chlorthalidone oral tablet 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 31cholestyramine light . . . . . . . . . . . . . . . 33cholestyramine (with sugar) . . . . . . . . 33CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR . . . . . . . 42ciclodan topical solution . . . . . . . . . . . . 35ciclopirox topical cream . . . . . . . . . . . . 35ciclopirox topical shampoo . . . . . . . . . 35ciclopirox topical solution . . . . . . . . . . . 35ciclopirox topical suspension . . . . . . . 36cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 33CILOXAN OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 50CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . . 8cinacalcet oral tablet 30 mg, 60 mg . 42cinacalcet oral tablet 90 mg . . . . . . . . 42CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 38ciprofloxacin-dexamethasone . . . . . . 38

61


Covered Drugs Index

October 2021

DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 53danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 42dantrolene oral . . . . . . . . . . . . . . . . . . . . 25DANYELZA . . . . . . . . . . . . . . . . . . . . . . . 16dapsone oral . . . . . . . . . . . . . . . . . . . . . . 12DAPTACEL (DTAP PEDIATRIC) (PF) . . . . . . . . . . . 45DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 12daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 12darifenacin . . . . . . . . . . . . . . . . . . . . . . . . 54DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 16DARZALEX FASPRO . . . . . . . . . . . . . . 16dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 48dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 48daunorubicin intravenous solution . . 16DAURISMO ORAL TABLET 25 MG . 16DAURISMO ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 16daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 47decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 16deferasirox oral granules in packet . . 37deferasirox oral tablet . . . . . . . . . . . . . . 37deferiprone . . . . . . . . . . . . . . . . . . . . . . . . 37DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML . 47DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . . 8demeclocycline . . . . . . . . . . . . . . . . . . . . 14DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 31DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 36DEPEN TITRATABS . . . . . . . . . . . . . . . 46DEPO-ESTRADIOL . . . . . . . . . . . . . . . 47DEPO-MEDROL . . . . . . . . . . . . . . . . . . 38DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . . 8desipramine . . . . . . . . . . . . . . . . . . . . . . . 27desloratadine oral tablet . . . . . . . . . . . 52desmopressin injection . . . . . . . . . . . . . 42desmopressin nasal spray, non-aerosol 10 mcg/spray (0.1 ml) . . 42

CORTISPORIN-TC . . . . . . . . . . . . . . . . 38COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 16COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 16CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CRESEMBA ORAL . . . . . . . . . . . . . . . . . 8cromolyn inhalation . . . . . . . . . . . . . . . . 53cromolyn ophthalmic (eye) . . . . . . . . . 51cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 43cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 48cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 48cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 48cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . 25cyclophosphamide intravenous recon soln . . . . . . . . . . . . . 16CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION . . . . . . . 16cyclophosphamide oral . . . . . . . . . . . . 16CYCLOSERINE . . . . . . . . . . . . . . . . . . . 12CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 39cyclosporine intravenous . . . . . . . . . . . 16cyclosporine modified . . . . . . . . . . . . . . 16cyclosporine oral capsule . . . . . . . . . . 16CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 16cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 48CYSTADANE . . . . . . . . . . . . . . . . . . . . . 43CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 54CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 51cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 16cytarabine (pf) . . . . . . . . . . . . . . . . . . . . . 16

Dd2.5%-0.45% sodium chloride . . . . . . 37d5%-0.45% sodium chloride . . . . . . . . 37d5% and 0.9% sodium chloride . . . . . 37d10%-0.45% sodium chloride . . . . . . 37dacarbazine . . . . . . . . . . . . . . . . . . . . . . . 16dactinomycin . . . . . . . . . . . . . . . . . . . . . . 16dalfampridine . . . . . . . . . . . . . . . . . . . . . . 24

clonidine hcl oral tablet extended release 12 hr . . . . . . . . . . . . 27clopidogrel oral tablet 75 mg . . . . . . . 33clopidogrel oral tablet 300 mg . . . . . . 33clorazepate dipotassium oral tablet 3.75 mg . . . . . . . . . . . . . . . . . 27clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 27clorazepate dipotassium oral tablet 15 mg . . . . . . . . . . . . . . . . . . 27clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 36clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 36clotrimazole mucous membrane . . . . . 8clotrimazole topical cream . . . . . . . . . . 36clotrimazole topical solution . . . . . . . . 36clozapine oral tablet . . . . . . . . . . . . . . . 27clozapine oral tablet, disintegrating . 27COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 12colchicine oral tablet . . . . . . . . . . . . . . . 46colesevelam . . . . . . . . . . . . . . . . . . . . . . . 33colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 33colistin (colistimethate na) . . . . . . . . . . 12COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 51COMBIVENT RESPIMAT . . . . . . . . . . 53COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 16COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) . 16COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) . 16COMPLERA . . . . . . . . . . . . . . . . . . . . . . . 8compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 43constulose . . . . . . . . . . . . . . . . . . . . . . . . 43COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML . . . . . . . . . . . . . . 24COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML . . . . . . . . . . . . . . 24COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 16CORLANOR ORAL TABLET . . . . . . . 34CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . 43

62


Covered Drugs Index

October 2021

dicyclomine oral tablet . . . . . . . . . . . . . 43didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg . . . . . . 8DIFICID ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 11DIFICID ORAL TABLET . . . . . . . . . . . . 11diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 26digitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34digox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34digoxin oral solution . . . . . . . . . . . . . . . 34digoxin oral tablet . . . . . . . . . . . . . . . . . . 34dihydroergotamine nasal . . . . . . . . . . . 24DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 22diltiazem hcl intravenous . . . . . . . . . . . 31diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 31diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . 31diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg . . 31diltiazem hcl oral capsule, ext.rel 24h degradable . . . . . . . . . . . . . 31diltiazem hcl oral tablet . . . . . . . . . . . . . 31diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 31dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg . . . . . 24dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg (14)- 240 mg (46) . . . . . . . . . . . . . . . . . . 24dimethyl fumarate oral capsule, delayed release(dr/ec) 240 mg . . . . . 24diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . 52diphenoxylate-atropine oral liquid . . . 43diphenoxylate-atropine oral tablet . . . 43dipyridamole oral . . . . . . . . . . . . . . . . . . 33disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 37divalproex . . . . . . . . . . . . . . . . . . . . . . . . . 22

dextroamphetamine oral tablet . . . . . 28dextrose 5%-0.2% sod chloride . . . . . 37dextrose 5%-0.3% sod.chloride . . . . . 37DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION . . . . . . . . . 37dextrose 5% in water (d5w) intravenous piggyback . . . . . . . . . . . . . 37dextrose 5%-lactated ringers . . . . . . . 37dextrose 10% and 0.2% nacl . . . . . . . 37DEXTROSE 10% IN WATER (D10W) . . . . . . . . . . . . . . . . 37dextrose 25% in water (d25w) . . . . . . 37dextrose 30% in water (d30w) . . . . . . 37dextrose 50% in water (d50w) . . . . . . 37dextrose 70% in water (d70w) . . . . . . 37DIACOMIT ORAL CAPSULE 250 MG . . . . . . . . . . . . . . . . 22DIACOMIT ORAL CAPSULE 500 MG . . . . . . . . . . . . . . . . 22DIACOMIT ORAL POWDER IN PACKET 250 MG . . . . . . . . . . . . . . . 22DIACOMIT ORAL POWDER IN PACKET 500 MG . . . . . . . . . . . . . . . 22DIASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 22DIASTAT ACUDIAL . . . . . . . . . . . . . . . . 22diazepam injection . . . . . . . . . . . . . . . . . 28diazepam intensol . . . . . . . . . . . . . . . . . 28diazepam oral concentrate . . . . . . . . . 28diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 28diazepam oral tablet . . . . . . . . . . . . . . . 28diazepam rectal . . . . . . . . . . . . . . . . . . . 22diazoxide . . . . . . . . . . . . . . . . . . . . . . . . . 39diclofenac potassium . . . . . . . . . . . . . . 26diclofenac sodium ophthalmic (eye) . 51diclofenac sodium oral . . . . . . . . . . . . . 26diclofenac sodium topical drops . . . . 26diclofenac sodium topical gel 1% . . . 26dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 13dicyclomine oral capsule . . . . . . . . . . . 43dicyclomine oral solution . . . . . . . . . . . 43

desmopressin nasal spray with pump . . . . . . . . . . . . . . . . . . . . . . . . . 42desmopressin oral . . . . . . . . . . . . . . . . . 42desog-e.estradiol/e.estradiol . . . . . . . 48desogestrel-ethinyl estradiol . . . . . . . . 48desonide topical cream . . . . . . . . . . . . 36desonide topical lotion . . . . . . . . . . . . . 36desonide topical ointment . . . . . . . . . . 36desoximetasone topical cream . . . . . 36desoximetasone topical gel . . . . . . . . 36desoximetasone topical ointment . . . 36desvenlafaxine succinate . . . . . . . . . . 27dexamethasone intensol . . . . . . . . . . . 38dexamethasone oral elixir . . . . . . . . . . 39dexamethasone oral solution . . . . . . . 39dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg . . . . . . . . . . . . . 39dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg . . . . . . . . . . 39dexamethasone sodium phos (pf) injection solution . . . . . . . . . 39dexamethasone sodium phosphate injection solution . . . . . . . . 39dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 52dexmethylphenidate oral tablet . . . . . 27dextroamphetamine- amphetamine oral capsule, extended release 24hr . . . . . . . . . . . . . 28dextroamphetamine- amphetamine oral tablet 5 mg . . . . . . 28dextroamphetamine- amphetamine oral tablet 10 mg . . . . . 28dextroamphetamine- amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg . . . . . . . . . . . . 28dextroamphetamine- amphetamine oral tablet 15 mg . . . . . 28dextroamphetamine- amphetamine oral tablet 20 mg . . . . . 28dextroamphetamine oral capsule, extended release . . . . . . . . . 28dextroamphetamine oral solution . . . 28

63


Covered Drugs Index

October 2021

efavirenz oral capsule 50 mg . . . . . . . . 8efavirenz oral capsule 200 mg . . . . . . . 8efavirenz oral tablet . . . . . . . . . . . . . . . . . 8ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 42electrolyte-48 in d5w . . . . . . . . . . . . . . . 55ELIGARD . . . . . . . . . . . . . . . . . . . . . . . . . 16ELIGARD (3 MONTH) . . . . . . . . . . . . . 16ELIGARD (4 MONTH) . . . . . . . . . . . . . 16ELIGARD (6 MONTH) . . . . . . . . . . . . . 16elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 33ELIQUIS DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 33ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ELLENCE . . . . . . . . . . . . . . . . . . . . . . . . . 16ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 54ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 16EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 16EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 43emoquette . . . . . . . . . . . . . . . . . . . . . . . . 48EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 16EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 28emtricitabine . . . . . . . . . . . . . . . . . . . . . . . 8emtricitabine-tenofovir (tdf) . . . . . . . . . . 8EMTRIVA ORAL CAPSULE . . . . . . . . . 8EMTRIVA ORAL SOLUTION . . . . . . . . 8EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 12enalapril-hydrochlorothiazide . . . . . . . 31enalapril maleate oral tablet . . . . . . . . 31ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 46ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 46ENBREL SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 46ENBREL SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 46ENBREL SURECLICK . . . . . . . . . . . . . 46endocet . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ENGERIX-B PEDIATRIC (PF) . . . . . . 45

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG . 28DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG . . . . . . . . . . . . . . . . . 28dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 43drospirenone-e.estradiol-lm.fa . . . . . . 48drospirenone-ethinyl estradiol . . . . . . 48DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 16droxidopa oral capsule 100 mg . . . . . 37droxidopa oral capsule 200 mg, 300 mg . . . . . . . . . . . . . . . . . . . 37DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 47duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg, 60 mg . . . . . . . . . . . . . . 28DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML . . 34DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML . . . . . 34DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML . . . . . . . . . . . . . . . . . . 34DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML . . . . . . . . . . . . . . . . . . . . . 34DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 52dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 54dutasteride-tamsulosin . . . . . . . . . . . . . 54

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 26econazole . . . . . . . . . . . . . . . . . . . . . . . . . 36EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 31EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 31EDURANT . . . . . . . . . . . . . . . . . . . . . . . . . 8e.e.s. 400 oral tablet . . . . . . . . . . . . . . . 11efavirenz-emtricitabin-tenofov . . . . . . . 8efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg . . . . . . . . . . 8efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg . . . . . . . . . . 8

docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/ 8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) . . . . . . . . . . . . . 16dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 30dolishale . . . . . . . . . . . . . . . . . . . . . . . . . . 48donepezil oral tablet 5 mg . . . . . . . . . . 24donepezil oral tablet 10 mg . . . . . . . . . 24donepezil oral tablet 23 mg . . . . . . . . . 24donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 24donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 24dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 51dorzolamide-timolol . . . . . . . . . . . . . . . . 51dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . . 8doxazosin oral tablet 1 mg, 2 mg, 4 mg . . . . . . . . . . . . . . . . . . 31doxazosin oral tablet 8 mg . . . . . . . . . 31doxepin oral capsule . . . . . . . . . . . . . . . 28doxepin oral concentrate . . . . . . . . . . . 28doxepin oral tablet . . . . . . . . . . . . . . . . . 28doxercalciferol . . . . . . . . . . . . . . . . . . . . . 42doxorubicin . . . . . . . . . . . . . . . . . . . . . . . 16doxorubicin, peg-liposomal . . . . . . . . . 16doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 14doxycycline hyclate intravenous . . . . 14doxycycline hyclate oral capsule . . . . 14doxycycline hyclate oral tablet 20 mg . . . . . . . . . . . . . . . . . . 14doxycycline hyclate oral tablet 100 mg . . . . . . . . . . . . . . . . . 14doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . 14DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE . . . . . . . . . . . . . . . . . . . . 14doxycycline monohydrate oral suspension for reconstitution . . . . . . . 14doxycycline monohydrate oral tablet . 14

64


Covered Drugs Index

October 2021

everolimus (antineoplastic) . . . . . . . . . 17everolimus (immunosuppressive) oral tablet 0.5 mg . . . . . . . . . . . . . . . . . . 17everolimus (immunosuppressive) oral tablet 0.25 mg, 0.75 mg . . . . . . . . 17EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 17EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 9exemestane . . . . . . . . . . . . . . . . . . . . . . . 17EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 33ezetimibe-simvastatin . . . . . . . . . . . . . . 33

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 42falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 48famciclovir . . . . . . . . . . . . . . . . . . . . . . . . . 9famotidine oral suspension . . . . . . . . . 44famotidine oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 44FANAPT ORAL TABLET 1 MG . . . . . 28FANAPT ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG . . 28FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 28FARXIGA ORAL TABLET 5 MG . . . . 39FARXIGA ORAL TABLET 10 MG . . . 39FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 17fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 48FEBUXOSTAT . . . . . . . . . . . . . . . . . . . . 46felbamate oral suspension . . . . . . . . . 22felbamate oral tablet . . . . . . . . . . . . . . . 22felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 31femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 49fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 33fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 33fenofibrate oral tablet 160 mg, 54 mg . . . . . . . . . . . . . . . . . . . . 33fenofibric acid (choline) . . . . . . . . . . . . 33fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

erythromycin-benzoyl peroxide . . . . . 35erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 11erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 11erythromycin ethylsuccinate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 11erythromycin ophthalmic (eye) . . . . . . 50erythromycin oral tablet . . . . . . . . . . . . 11erythromycin oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 11ERYTHROMYCIN WITH ETHANOL TOPICAL GEL . . . . . . . . . . 35erythromycin with ethanol topical solution . . . . . . . . . . . . . . . . . . . . 35ESBRIET ORAL CAPSULE . . . . . . . . 53ESBRIET ORAL TABLET 267 MG . . 53ESBRIET ORAL TABLET 801 MG . . 53escitalopram oxalate oral solution . . 28escitalopram oxalate oral tablet . . . . . 28esomeprazole magnesium oral capsule,delayed release(dr/ec) . . . . . 44estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 48estradiol oral . . . . . . . . . . . . . . . . . . . . . . 47estradiol transdermal patch semiweekly . . . . . . . . . . . . . . . . . 47estradiol transdermal patch weekly . 47estradiol vaginal . . . . . . . . . . . . . . . . . . . 47estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml . . . . . . . . . . . . . 47ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 47ethacrynate sodium . . . . . . . . . . . . . . . . 31ethambutol . . . . . . . . . . . . . . . . . . . . . . . . 12ethosuximide . . . . . . . . . . . . . . . . . . . . . . 22ethynodiol diac-eth estradiol . . . . . . . . 48etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 26ETOPOPHOS . . . . . . . . . . . . . . . . . . . . . 16etoposide intravenous . . . . . . . . . . . . . 16etravirine . . . . . . . . . . . . . . . . . . . . . . . . . . . 9EUTHYROX . . . . . . . . . . . . . . . . . . . . . . . 42

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 45ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 16enoxaparin . . . . . . . . . . . . . . . . . . . . . . . . 33enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 48enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 48entacapone . . . . . . . . . . . . . . . . . . . . . . . 24entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 34enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ENVARSUS XR . . . . . . . . . . . . . . . . . . . 16EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . . 8EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 22epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 51epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml . . . . . . 52epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml . . . . . 52epinephrine injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 52epirubicin intravenous solution . . . . . 16epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EPIVIR HBV ORAL SOLUTION . . . . . 9ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 16ergotamine-caffeine . . . . . . . . . . . . . . . 24ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 16ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 16erlotinib oral tablet 25 mg . . . . . . . . . . 16erlotinib oral tablet 100 mg, 150 mg . 16errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 12ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 35ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 11ery-tab oral tablet,delayed release (dr/ec) 250 mg . . . . . . . . . . . . . 11ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG, 500 MG . . . . . . . . . 11erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 11ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 11

65


Covered Drugs Index

October 2021

fluphenazine hcl oral concentrate . . . 28fluphenazine hcl oral elixir . . . . . . . . . . 28fluphenazine hcl oral tablet . . . . . . . . . 28flurbiprofen oral tablet 100 mg . . . . . . 26flurbiprofen sodium . . . . . . . . . . . . . . . . 51flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 17fluticasone propionate nasal . . . . . . . . 53fluticasone propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 36fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 36fluticasone propion-salmeterol inhalation blister with device . . . . . . . . 53fluvoxamine oral tablet 25 mg . . . . . . 28fluvoxamine oral tablet 50 mg . . . . . . 28fluvoxamine oral tablet 100 mg . . . . . 28FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 17fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 45fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 33fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 33formoterol fumarate . . . . . . . . . . . . . . . . 53fosamprenavir . . . . . . . . . . . . . . . . . . . . . . 9fosfomycin tromethamine . . . . . . . . . . 14fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 31fosinopril-hydrochlorothiazide . . . . . . 31fosphenytoin . . . . . . . . . . . . . . . . . . . . . . 22FOTIVDA . . . . . . . . . . . . . . . . . . . . . . . . . 17fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 17furosemide injection . . . . . . . . . . . . . . . 31furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 31furosemide oral tablet . . . . . . . . . . . . . . 31FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . . 9fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47FYCOMPA ORAL SUSPENSION . . . 22FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 22

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . . 8flucytosine . . . . . . . . . . . . . . . . . . . . . . . . . 8fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 17fludrocortisone . . . . . . . . . . . . . . . . . . . . 39flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 53fluocinolone acetonide oil . . . . . . . . . . 38fluocinolone and shower cap . . . . . . . 36fluocinolone topical cream . . . . . . . . . . 36fluocinolone topical oil . . . . . . . . . . . . . 36fluocinolone topical ointment . . . . . . . 36fluocinolone topical solution . . . . . . . . 36fluocinonide topical cream 0.1% . . . . 36fluocinonide topical cream 0.05% . . . 36fluocinonide topical gel . . . . . . . . . . . . . 36fluocinonide topical ointment . . . . . . . 36fluocinonide topical solution . . . . . . . . 36fluoride (sodium) dental paste . . . . . . 38fluoride (sodium) oral tablet . . . . . . . . 55fluoride (sodium) oral tablet, chewable 1 mg (2.2 mg sod. fluoride) . . . . . . . . . . . . . . 55fluorometholone . . . . . . . . . . . . . . . . . . . 52fluorouracil intravenous . . . . . . . . . . . . 17FLUOROURACIL TOPICAL CREAM 0.5% . . . . . . . . . . . 34fluorouracil topical cream 5% . . . . . . . 34fluorouracil topical solution . . . . . . . . . 34fluoxetine oral capsule 10 mg . . . . . . 28fluoxetine oral capsule 20 mg . . . . . . 28fluoxetine oral capsule 40 mg . . . . . . 28fluoxetine oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 28fluoxetine oral solution . . . . . . . . . . . . . 28fluoxetine oral tablet 10 mg . . . . . . . . . 28fluoxetine oral tablet 20 mg . . . . . . . . . 28fluoxetine (pmdd) oral tablet 10 mg . 28fluoxetine (pmdd) oral tablet 20 mg . 28fluphenazine decanoate . . . . . . . . . . . . 28fluphenazine hcl injection . . . . . . . . . . 28

fentanyl citrate buccal lozenge on a handle . . . . . . . . . . . . . . . 25fentanyl citrate (pf) injection solution . . . . . . . . . . . . . . . . . . . 25fentanyl citrate (pf) injection syringe 50 mcg/ml . . . . . . . . 25FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 37FERRIPROX (2 TIMES A DAY) . . . . . 37FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 28FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK. . . . . . . 28finasteride oral tablet 5 mg . . . . . . . . . 54FINTEPLA . . . . . . . . . . . . . . . . . . . . . . . . 22FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 24FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG . . . . . . . . . . . . . 17FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG . . . . . . . . . . . . 17FIRVANQ ORAL RECON SOLN 25 MG/ML . . . . . . . . . . . . . . . . . . 12FIRVANQ ORAL RECON SOLN 50 MG/ML . . . . . . . . . . . . . . . . . . 12flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 38flavoxate . . . . . . . . . . . . . . . . . . . . . . . . . . 54flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 30FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . . . . . . . . . . . . . . 53FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION . . . . . . . . . . . . 53FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION . . . . 53FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION . . . 53FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION . . 53floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . 17fluconazole . . . . . . . . . . . . . . . . . . . . . . . . . 8

66


Covered Drugs Index

October 2021

glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 39granisetron hcl intravenous . . . . . . . . . 43granisetron hcl oral . . . . . . . . . . . . . . . . 43granisetron (pf) intravenous solution 1 mg/ml (1 ml) . . . . . . . . . . . . . 43griseofulvin microsize . . . . . . . . . . . . . . . 8griseofulvin ultramicrosize . . . . . . . . . . . 8GVOKE HYPOPEN 1-PACK . . . . . . . 39GVOKE HYPOPEN 2-PACK . . . . . . . 39GVOKE PFS 1-PACK SYRINGE. . . . 40GVOKE PFS 2-PACK SYRINGE. . . . 40

HHAEGARDA . . . . . . . . . . . . . . . . . . . . . . 53hailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 49hailey fe 1.5/30 (28) . . . . . . . . . . . . . . . 49hailey fe 1/20 (28) . . . . . . . . . . . . . . . . . 49HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 17halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 36halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 36haloperidol decanoate . . . . . . . . . . . . . 28haloperidol lactate injection . . . . . . . . 28haloperidol lactate oral . . . . . . . . . . . . . 28haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg . . . . . . . . . . 28haloperidol oral tablet 10 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . 28HARVONI ORAL PELLETS IN PACKET 33.75-150 MG . . . . . . . . . . 9HARVONI ORAL PELLETS IN PACKET 45-200 MG . . . . . . . . . . . . . 9HARVONI ORAL TABLET 45-200 MG . . . . . . . . . . . . . . . . 9HARVONI ORAL TABLET 90-400 MG . . . . . . . . . . . . . . . . 9HAVRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 45heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . 12GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 12gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 12gentamicin ophthalmic (eye) drops . . 50gentamicin sulfate (ped) (pf) . . . . . . . . 12gentamicin topical . . . . . . . . . . . . . . . . . 35GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . . 9GILENYA ORAL CAPSULE 0.5 MG . . . . . . . . . . . . . . . . . 24GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 17glimepiride oral tablet 1 mg . . . . . . . . . 39glimepiride oral tablet 2 mg . . . . . . . . . 39glimepiride oral tablet 4 mg . . . . . . . . . 39glipizide-metformin oral tablet 2.5-250 mg . . . . . . . . . . . . . . . . . . 39glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg . . . . . . . 39glipizide oral tablet 5 mg . . . . . . . . . . . 39glipizide oral tablet 10 mg . . . . . . . . . . 39glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 39glipizide oral tablet extended release 24hr 5 mg . . . . . . . . . . . . . . . . . 39glipizide oral tablet extended release 24hr 10 mg . . . . . . . . . . . . . . . . 39GLUCAGEN HYPOKIT . . . . . . . . . . . . 39GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 39GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 39glycopyrrolate injection . . . . . . . . . . . . . 43glycopyrrolate oral tablet 1 mg, 2 mg . . . . . . . . . . . . . . . . . . . . . . . . 43GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 43glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . 43

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 22

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 22gabapentin oral capsule 300 mg . . . . 22gabapentin oral solution . . . . . . . . . . . . 22gabapentin oral tablet 600 mg . . . . . . 22gabapentin oral tablet 800 mg . . . . . . 22galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 24galantamine oral solution . . . . . . . . . . . 24galantamine oral tablet . . . . . . . . . . . . . 24GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%) . . . . . . 45GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 45GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 45GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 43GATTEX ONE-VIAL . . . . . . . . . . . . . . . 43GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 39gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 43gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 43GAVRETO . . . . . . . . . . . . . . . . . . . . . . . . 17GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 17gemcitabine intravenous recon soln . 17gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) . . . . . . . . . 17GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 17gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 33gemmily . . . . . . . . . . . . . . . . . . . . . . . . . . 49generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 43gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 17GENOTROPIN . . . . . . . . . . . . . . . . . . . . 45GENOTROPIN MINIQUICK . . . . . . . . 45gentak ophthalmic (eye) ointment . . . 50

67


Covered Drugs Index

October 2021

hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 37hydrocortisone butyrate topical solution . . . . . . . . . . . . . . . . . . . . 37hydrocortisone butyr-emollient . . . . . . 37hydrocortisone oral . . . . . . . . . . . . . . . . 39hydrocortisone rectal . . . . . . . . . . . . . . 43hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 37hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 43hydrocortisone topical lotion 2.5% . . 37hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 37hydrocortisone valerate . . . . . . . . . . . . 37hydromorphone oral liquid . . . . . . . . . . 25hydromorphone oral tablet . . . . . . . . . 25hydroxychloroquine . . . . . . . . . . . . . . . . 12hydroxyprogesterone caproate . . . . . 47hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 17hydroxyzine hcl oral tablet . . . . . . . . . . 52

Iibandronate oral . . . . . . . . . . . . . . . . . . . 46IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 17ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ibuprofen oral suspension . . . . . . . . . . 26ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 26icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 53iclevia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG . . . . . . . . . . . . . 17ICLUSIG ORAL TABLET 15 MG . . . . 17idarubicin . . . . . . . . . . . . . . . . . . . . . . . . . 17IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . 17imatinib oral tablet 100 mg . . . . . . . . . 17imatinib oral tablet 400 mg . . . . . . . . . 17IMBRUVICA ORAL CAPSULE 70 MG . . . . . . . . . . . . . . . . . 17

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML . . . . . . 47HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 47HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 47HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 46HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 46HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 46HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 47HUMULIN 70/30 U-100 INSULIN . . . 40HUMULIN 70/30 U-100 KWIKPEN . . 40HUMULIN N NPH INSULIN KWIKPEN . . . . . . . . . . . . . . . 40HUMULIN N NPH U-100 INSULIN . . 40HUMULIN R REGULAR U-100 INSULN . . . . . . . . . . . . . . . . . . . . 40HUMULIN R U-500 (CONC) INSULIN . . . . . . . . . . . . . . . . . . 40HUMULIN R U-500 (CONC) KWIKPEN . . . . . . . . . . . . . . . . 40hydralazine injection . . . . . . . . . . . . . . . 31hydralazine oral . . . . . . . . . . . . . . . . . . . 31hydrochlorothiazide . . . . . . . . . . . . . . . . 31hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml . . . . . . . . . . 25hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 25HYDROCODONE- ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG . . . 25hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . 25hydrocodone-ibuprofen . . . . . . . . . . . . 25hydrocortisone-acetic acid . . . . . . . . . 38hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 36

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml . . . . . . . . . . . . . . . . . 33heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) . . . . . 33heparin (porcine) injection solution . . 33heparin (porcine) in nacl (pf) . . . . . . . . 33heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml . . . . . . . . . . . 33HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML . . . . . . . . . . . . . . . . . . . . 33HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 29HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 45HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . . 45HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 40HUMALOG KWIKPEN INSULIN . . . . 40HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 40HUMALOG MIX 50-50 KWIKPEN. . . 40HUMALOG MIX 75-25 KWIKPEN. . . 40HUMALOG MIX 75-25 (U-100)INSULN . . . . . . . . . . . . . . . . . . . 40HUMALOG U-100 INSULIN . . . . . . . . 40HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML . . . . . . . 47HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML- 40 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 47HUMIRA(CF) PEN CROHNS-UC-HS . . . . . . . . . . . . . . . . . . 47HUMIRA(CF) PEN PEDIATRIC UC . . . . . . . . . . . . . . . . . . . 47HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 47HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . . . . . . . . . . . . 47

68


Covered Drugs Index

October 2021

Jjaimiess . . . . . . . . . . . . . . . . . . . . . . . . . . . 49JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 33JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 40JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG . . . . . . . . . . 40JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG . . . . . . . . . . . . . . . . . . . . . 40JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 40JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 40jasmiel (28) . . . . . . . . . . . . . . . . . . . . . . . 49JEMPERLI . . . . . . . . . . . . . . . . . . . . . . . . 17jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 47JENTADUETO . . . . . . . . . . . . . . . . . . . . 40JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG . . . . . . . . . . . . . . . 40JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG . . . . . . . . . . . . . . . . . 40JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 17jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . . 9junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 49junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 49junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 49junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . 49junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 49

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 55KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 18kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 49KALETRA ORAL TABLET 100-25 MG . . . . . . . . . . . . . . . . 9KALETRA ORAL TABLET 200-50 MG . . . . . . . . . . . . . . . . 9

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML . . . . . 29INVEGA TRINZA . . . . . . . . . . . . . . . . . . 29INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 52INVIRASE ORAL TABLET . . . . . . . . . . 9INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 40INVOKAMET XR . . . . . . . . . . . . . . . . . . 40INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 40IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ipratropium-albuterol . . . . . . . . . . . . . . . 53ipratropium bromide inhalation . . . . . 53ipratropium bromide nasal . . . . . . . . . . 38irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 31irbesartan-hydrochlorothiazide . . . . . 31IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 17irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 17ISENTRESS HD . . . . . . . . . . . . . . . . . . . . 9ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 9ISENTRESS ORAL TABLET . . . . . . . . 9ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . . 9ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . . 9isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 49isoniazid oral solution . . . . . . . . . . . . . . 12isoniazid oral tablet . . . . . . . . . . . . . . . . 12isosorbide dinitrate oral tablet . . . . . . 34isosorbide mononitrate . . . . . . . . . . . . . 34isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg . . . . . . . 35isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 31itraconazole oral capsule . . . . . . . . . . . . 8itraconazole oral solution . . . . . . . . . . . . 8ivermectin oral . . . . . . . . . . . . . . . . . . . . 12IXEMPRA . . . . . . . . . . . . . . . . . . . . . . . . . 17IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 45

IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . 17IMBRUVICA ORAL TABLET . . . . . . . . 17IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17imipenem-cilastatin . . . . . . . . . . . . . . . . 12imipramine hcl . . . . . . . . . . . . . . . . . . . . . 29IMIQUIMOD TOPICAL CREAM IN METERED-DOSE PUMP . . . . . . . . 34imiquimod topical cream in packet 3.75% . . . . . . . . . . . . . . . . . . . 34imiquimod topical cream in packet 5% . . . . . . . . . . . . . . . . . . . . . . 34IMOVAX RABIES VACCINE (PF) . . . 45incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 37INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 53indapamide . . . . . . . . . . . . . . . . . . . . . . . 31INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE . . . . . . 45INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 17INFUMORPH P/F. . . . . . . . . . . . . . . . . . 25INLYTA ORAL TABLET 1 MG . . . . . . . 17INLYTA ORAL TABLET 5 MG . . . . . . . 17INQOVI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 17INSULIN PEN NEEDLE . . . . . . . . . . . . 40INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 40INTELENCE ORAL TABLET 25 MG . 9INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . . . . . . . . . . . 9INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 55INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 45INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . 45INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . 45introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 49INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . 29

69


Covered Drugs Index

October 2021

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 18LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY (10 MG X 2-4 MG X 1) . . . . . . . . . . . . . 18LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) . . . . . . . . . . . . . 18lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 18leucovorin calcium injection . . . . . . . . 15leucovorin calcium oral . . . . . . . . . . . . . 15LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 18LEUKINE INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 45leuprolide subcutaneous kit . . . . . . . . 18levalbuterol hcl . . . . . . . . . . . . . . . . . . . . 53LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 40LEVEMIR U-100 INSULIN . . . . . . . . . 40levetiracetam in nacl (iso-os) . . . . . . . 22levetiracetam intravenous . . . . . . . . . . 22levetiracetam oral . . . . . . . . . . . . . . . . . 22levobunolol ophthalmic (eye) drops 0.5% . . . . . . . . . . . . . . . . . . 51levocarnitine oral solution 100 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . 38levocarnitine oral tablet . . . . . . . . . . . . 38levocarnitine (with sugar) . . . . . . . . . . . 38levocetirizine oral solution . . . . . . . . . . 52levocetirizine oral tablet . . . . . . . . . . . . 52levofloxacin in d5w intravenous piggyback 250 mg/50 ml . . . . . . . . . . . 14levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml . . . . . . . . . . . . . . . . . . . . 14levofloxacin intravenous . . . . . . . . . . . 14levofloxacin oral solution . . . . . . . . . . . 14levofloxacin oral tablet . . . . . . . . . . . . . 14levonest (28) . . . . . . . . . . . . . . . . . . . . . . 49levonorgestrel-ethinyl estrad . . . . . . . 49

KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 18

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 31LACRISERT . . . . . . . . . . . . . . . . . . . . . . 51lactated ringers intravenous . . . . . . . . 54lactated ringers irrigation . . . . . . . . . . . 37lactulose oral solution . . . . . . . . . . . . . . 43lamivudine oral solution . . . . . . . . . . . . . 9lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . . 9lamivudine oral tablet 150 mg . . . . . . . 9lamivudine-zidovudine . . . . . . . . . . . . . . 9lamotrigine oral tablet . . . . . . . . . . . . . . 22lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 22lamotrigine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 22lamotrigine oral tablet extended release 24hr . . . . . . . . . . . . . 22LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG) . . . . . . . . . . . . 34lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 44LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 40LANTUS U-100 INSULIN . . . . . . . . . . 40lapatinib . . . . . . . . . . . . . . . . . . . . . . . . . . 18larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 49larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 49larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 49larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 49larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 49larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 51LATUDA ORAL TABLET 80 MG . . . . 29LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 29layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 49leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 49leflunomide . . . . . . . . . . . . . . . . . . . . . . . 47

kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49KALYDECO ORAL GRANULES IN PACKET . . . . . . . . . . . 53KALYDECO ORAL TABLET . . . . . . . . 53KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 18kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 49kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 49kelnor 1-50 (28) . . . . . . . . . . . . . . . . . . . 49ketoconazole oral . . . . . . . . . . . . . . . . . . . 8ketoconazole topical cream . . . . . . . . 36ketoconazole topical shampoo . . . . . 36ketorolac ophthalmic (eye) . . . . . . . . . 51KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 18KINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 45KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 18KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 18KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 18KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 18KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) . . . . . . . . 18KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) . . . . . . . . 18klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 54KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 54klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 54klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 54KLOXXADO . . . . . . . . . . . . . . . . . . . . . . . 26KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 42K-PHOS ORIGINAL . . . . . . . . . . . . . . . 54kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 49KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 42KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG . . . . . . . . . . . . . 24

70


Covered Drugs Index

October 2021

LUPRON DEPOT (4 MONTH) . . . . . . 18LUPRON DEPOT (6 MONTH) . . . . . . 18LUPRON DEPOT-PED . . . . . . . . . . . . 18LUPRON DEPOT-PED (3 MONTH) . 18lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 49LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 18LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG . . . . . . . . . . . 22LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG . . . . . . . . . . . . . . . . . . . . 22LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 18LYUMJEV KWIKPEN U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 40LYUMJEV KWIKPEN U-200 INSULIN . . . . . . . . . . . . . . . . . . . . 40LYUMJEV U-100 INSULIN . . . . . . . . . 40lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

MMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . . . . . . . . . . . . . . 54magnesium sulfate injection . . . . . . . . 54magnesium sulfate in water . . . . . . . . 54malathion . . . . . . . . . . . . . . . . . . . . . . . . . 37maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 29marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 49MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 29MARQIBO . . . . . . . . . . . . . . . . . . . . . . . . 18MATULANE . . . . . . . . . . . . . . . . . . . . . . . 18matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 32MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . . 9meclizine oral tablet 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 43MEDROL ORAL TABLET 2 MG . . . . . 39medroxyprogesterone intramuscular suspension . . . . . . . . . . 47medroxyprogesterone intramuscular syringe . . . . . . . . . . . . . . 47medroxyprogesterone oral . . . . . . . . . 47

LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 33l norgest/e.estradiol-e.estrad . . . . . . . 49lojaimiess . . . . . . . . . . . . . . . . . . . . . . . . . 49LOKELMA . . . . . . . . . . . . . . . . . . . . . . . . 38LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . 18LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . 18loperamide oral capsule . . . . . . . . . . . . 43lopinavir-ritonavir oral solution . . . . . . . 9lopinavir-ritonavir oral tablet 100-25 mg . . . . . . . . . . . . . . . 9lopinavir-ritonavir oral tablet 200-50 mg . . . . . . . . . . . . . . . 9lorazepam injection . . . . . . . . . . . . . . . . 29lorazepam intensol . . . . . . . . . . . . . . . . 29lorazepam oral concentrate . . . . . . . . 29lorazepam oral tablet 0.5 mg, 1 mg . 29lorazepam oral tablet 2 mg . . . . . . . . . 29LORBRENA ORAL TABLET 25 MG . 18LORBRENA ORAL TABLET 100 MG . 18loryna (28) . . . . . . . . . . . . . . . . . . . . . . . . 49losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . 31losartan-hydrochlorothiazide oral tablet 50-12.5 mg . . . . . . . . . . . . . . 32losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg . . . . . 32LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 52LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 52lovastatin oral tablet 10 mg . . . . . . . . . 33lovastatin oral tablet 20 mg, 40 mg . . 33low-ogestrel (28) . . . . . . . . . . . . . . . . . . 49loxapine succinate . . . . . . . . . . . . . . . . . 29lo-zumandimine (28) . . . . . . . . . . . . . . . 49LUMAKRAS . . . . . . . . . . . . . . . . . . . . . . . 18LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 51LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 42LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 18LUPRON DEPOT . . . . . . . . . . . . . . . . . 18LUPRON DEPOT (3 MONTH) . . . . . . 18

levonorg-eth estrad triphasic . . . . . . . 49levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 49LEVO-T . . . . . . . . . . . . . . . . . . . . . . . . . . . 42levothyroxine oral tablet . . . . . . . . . . . . 42levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg . . . . . . . 42LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 42LEXIVA ORAL SUSPENSION . . . . . . . 9LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 18lidocaine hcl injection solution . . . . . . 34lidocaine hcl laryngotracheal . . . . . . . 35lidocaine hcl mucous membrane jelly . . . . . . . . . . . . . . . . . . . . 35lidocaine hcl mucous membrane jelly in applicator . . . . . . . . 35lidocaine hcl mucous membrane solution 2% . . . . . . . . . . . . 35lidocaine hcl mucous membrane solution 4% (40 mg/ml) . . . . . . . . . . . . 35lidocaine (pf) injection solution . . . . . . 34lidocaine (pf) intravenous syringe . . . 30lidocaine-prilocaine topical cream . . . 35lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 35lidocaine topical ointment . . . . . . . . . . 35lidocaine viscous . . . . . . . . . . . . . . . . . . 35lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 49lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 12lindane topical shampoo . . . . . . . . . . . 37linezolid-0.9% sodium chloride . . . . . 12linezolid in dextrose 5% . . . . . . . . . . . . 12linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 12linezolid oral tablet . . . . . . . . . . . . . . . . . 12LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 43liothyronine oral . . . . . . . . . . . . . . . . . . . 42lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 31lisinopril-hydrochlorothiazide . . . . . . . 31lithium carbonate . . . . . . . . . . . . . . . . . . 29

71


Covered Drugs Index

October 2021

metoclopramide hcl oral solution . . . . 43metoclopramide hcl oral tablet . . . . . . 43metolazone . . . . . . . . . . . . . . . . . . . . . . . 32metoprolol succinate . . . . . . . . . . . . . . . 32metoprolol ta-hydrochlorothiaz . . . . . 32metoprolol tartrate oral . . . . . . . . . . . . . 32metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 12metronidazole in nacl (iso-os) . . . . . . 12metronidazole oral tablet . . . . . . . . . . . 12metronidazole topical . . . . . . . . . . . . . . 35metronidazole vaginal . . . . . . . . . . . . . . 48metyrosine . . . . . . . . . . . . . . . . . . . . . . . . 32mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 30MIACALCIN INJECTION . . . . . . . . . . . 42mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 49micafungin . . . . . . . . . . . . . . . . . . . . . . . . . 8microgestin 1.5/30 (21) . . . . . . . . . . . . 49microgestin 1/20 (21) . . . . . . . . . . . . . . 49microgestin fe 1.5/30 (28) . . . . . . . . . . 49microgestin fe 1/20 (28) . . . . . . . . . . . . 49midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 38migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 24miglitol oral tablet 25 mg . . . . . . . . . . . 41miglitol oral tablet 50 mg . . . . . . . . . . . 41miglitol oral tablet 100 mg . . . . . . . . . . 41miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 42mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 34minocycline oral capsule . . . . . . . . . . . 14minocycline oral tablet . . . . . . . . . . . . . 14minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 32mirtazapine oral tablet . . . . . . . . . . . . . 29mirtazapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 29misoprostol . . . . . . . . . . . . . . . . . . . . . . . 44MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 46mitomycin intravenous . . . . . . . . . . . . . 18mitoxantrone . . . . . . . . . . . . . . . . . . . . . . 18M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 46moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 32

metformin oral tablet 500 mg . . . . . . . 40metformin oral tablet 850 mg . . . . . . . 40metformin oral tablet extended release 24hr 1,000 mg . . . . . . . . . . . . . 40metformin oral tablet extended release 24hr 500 mg . . . . . . . . . . . . . . . 41metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) . . . . . . . . . 40metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr) . . . . . . . . . 40methadone injection solution . . . . . . . 25methadone intensol . . . . . . . . . . . . . . . . 25methadone oral concentrate . . . . . . . . 25methadone oral solution 5 mg/5 ml . 25methadone oral solution 10 mg/5 ml . 25methadone oral tablet 5 mg . . . . . . . . 26methadone oral tablet 10 mg . . . . . . . 26methazolamide . . . . . . . . . . . . . . . . . . . . 51methenamine hippurate . . . . . . . . . . . . 14methimazole oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 39methocarbamol oral . . . . . . . . . . . . . . . 25methotrexate sodium injection . . . . . . 18methotrexate sodium oral . . . . . . . . . . 18methotrexate sodium (pf) . . . . . . . . . . . 18methoxsalen . . . . . . . . . . . . . . . . . . . . . . 35methyldopa . . . . . . . . . . . . . . . . . . . . . . . 32methylphenidate hcl oral tablet . . . . . 29methylphenidate hcl oral tablet extended release . . . . . . . . . . . . . . . . . . 29methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . 29methylprednisolone . . . . . . . . . . . . . . . . 39methylprednisolone acetate . . . . . . . . 39methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . 39methylprednisolone sodium succ intravenous . . . . . . . . . . . . . . . . . . . . . . . 39

mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 12megestrol oral suspension 400 mg/10 ml (10 ml) . . . . . . . . . . . . . . 18megestrol oral suspension 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 18megestrol oral tablet . . . . . . . . . . . . . . . 18MEKINIST ORAL TABLET 0.5 MG . . 18MEKINIST ORAL TABLET 2 MG . . . . 18MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 18meloxicam oral tablet 7.5 mg . . . . . . . 26meloxicam oral tablet 15 mg . . . . . . . . 26melphalan . . . . . . . . . . . . . . . . . . . . . . . . . 18melphalan hcl . . . . . . . . . . . . . . . . . . . . . 18memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 24memantine oral solution . . . . . . . . . . . . 24memantine oral tablet 5 mg . . . . . . . . 24memantine oral tablet 10 mg . . . . . . . 24memantine oral tablets,dose pack . . 24MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 46MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 48MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 48MENQUADFI (PF) . . . . . . . . . . . . . . . . . 46MENVEO A-C-Y-W-135-DIP (PF) . . . 46mercaptopurine . . . . . . . . . . . . . . . . . . . . 18meropenem . . . . . . . . . . . . . . . . . . . . . . . 12MEROPENEM-0.9% SODIUM CHLORIDE . . . . . . . . . . . . . . 12merzee . . . . . . . . . . . . . . . . . . . . . . . . . . . 49mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 43mesalamine oral tablet, delayed release (dr/ec) 1.2 gram . . . 43mesalamine rectal enema . . . . . . . . . . 43mesalamine with cleansing wipe . . . . 43mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15MESNEX ORAL . . . . . . . . . . . . . . . . . . . 15metaproterenol oral syrup . . . . . . . . . . 53METFORMIN ORAL SOLUTION . . . 40metformin oral tablet 1,000 mg . . . . . 40

72


Covered Drugs Index

October 2021

necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 49NEEDLES, INSULIN DISP.,SAFETY . 41nefazodone . . . . . . . . . . . . . . . . . . . . . . . 29neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 12neomycin-bacitracin-poly-hc . . . . . . . . 51neomycin-bacitracin-polymyxin . . . . . 50neomycin-polymyxin b-dexameth . . . 51neomycin-polymyxin b gu . . . . . . . . . . 37neomycin-polymyxin-gramicidin . . . . 50neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 51neomycin-polymyxin-hc otic (ear) . . . 38neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 50neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 51NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 19NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 24nevirapine oral suspension . . . . . . . . . . 9nevirapine oral tablet . . . . . . . . . . . . . . . 9nevirapine oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . . 9nevirapine oral tablet extended release 24 hr 400 mg . . . . . . . . . . . . . . . 9NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 19niacin oral tablet 500 mg . . . . . . . . . . . 33niacin oral tablet extended release 24 hr . . . . . . . . . . . . . . . . . . . . . . 33niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33nicardipine intravenous solution . . . . 32nicardipine oral . . . . . . . . . . . . . . . . . . . . 32NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 38NICOTROL NS . . . . . . . . . . . . . . . . . . . . 38nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 32nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 32nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 49nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 19nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 32NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 19NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 19nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 32

mupirocin calcium . . . . . . . . . . . . . . . . . 35MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18mycophenolate mofetil (hcl) . . . . . . . . 19mycophenolate mofetil oral capsule . 19mycophenolate mofetil oral suspension for reconstitution . . . . . . . 19mycophenolate mofetil oral tablet . . . 19mycophenolate sodium . . . . . . . . . . . . 19MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 19myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 35MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR. . . . . . 54

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 26nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 32nafcillin in dextrose iso-osm . . . . . . . . 13nafcillin injection . . . . . . . . . . . . . . . . . . . 13nafcillin intravenous . . . . . . . . . . . . . . . . 13naftifine . . . . . . . . . . . . . . . . . . . . . . . . . . . 36NAFTIN TOPICAL GEL . . . . . . . . . . . . 36NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 42naloxone injection solution . . . . . . . . . 26naloxone injection syringe 1 mg/ml . 26naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 26NAMZARIC . . . . . . . . . . . . . . . . . . . . . . . 24naproxen oral suspension . . . . . . . . . . 26naproxen oral tablet . . . . . . . . . . . . . . . 26naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 26naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . 27naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 24NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 27NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 50nateglinide oral tablet 60 mg . . . . . . . 41nateglinide oral tablet 120 mg . . . . . . 41NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 42NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 23

molindone . . . . . . . . . . . . . . . . . . . . . . . . . 29mometasone nasal . . . . . . . . . . . . . . . . 53mometasone topical . . . . . . . . . . . . . . . 37mondoxyne nl oral capsule 100 mg, 75 mg . . . . . . . . . . . . . . . . . . . . 14MONJUVI . . . . . . . . . . . . . . . . . . . . . . . . . 18mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 49montelukast oral granules in packet . 53montelukast oral tablet . . . . . . . . . . . . . 53montelukast oral tablet, chewable . . 53MONUROL . . . . . . . . . . . . . . . . . . . . . . . 14morgidox oral capsule 100 mg . . . . . . 14morphine concentrate oral solution . 26morphine injection solution 8 mg/ml . . 26MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML . . . . . 26MORPHINE INJECTION SYRINGE 2 MG/ML . . . . . . . . . . . . . . . 26morphine injection syringe 4 mg/ml . 26MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML . . . . 26morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . 26morphine intravenous syringe 2 mg/ml, 4 mg/ml . . . . . . . . . . 26MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML . . . . 26morphine oral solution . . . . . . . . . . . . . 26MORPHINE ORAL TABLET . . . . . . . . 26morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 26morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . 26MOVANTIK . . . . . . . . . . . . . . . . . . . . . . . 43moxifloxacin ophthalmic (eye) . . . . . . 50moxifloxacin oral . . . . . . . . . . . . . . . . . . 14MOXIFLOXACIN-SOD. ACE, SUL-WATER . . . . . . . . . . . . . . . . 14moxifloxacin-sod.chloride(iso) . . . . . . 14MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 45mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 35

73


Covered Drugs Index

October 2021

olanzapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 29olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 32olmesartan-hydrochlorothiazide . . . . 32olopatadine ophthalmic (eye) . . . . . . . 51omega-3 acid ethyl esters . . . . . . . . . . 33omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 44OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 41OMNIPOD DASH 5 PACK. . . . . . . . . . 41OMNIPOD STARTER KIT . . . . . . . . . . 41 ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 19 ondansetron . . . . . . . . . . . . . . . . . . . . . . . 43 ondansetron hcl intravenous . . . . . . . 44 ondansetron hcl oral solution . . . . . . . 44 ondansetron hcl oral tablet . . . . . . . . . 44 ondansetron hcl (pf) . . . . . . . . . . . . . . . 44 ONIVYDE . . . . . . . . . . . . . . . . . . . . . . . . . 19 ONUREG . . . . . . . . . . . . . . . . . . . . . . . . . 19 OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 19 OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 53 oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 ORBACTIV . . . . . . . . . . . . . . . . . . . . . . . 12 ORENCIA CLICKJECT . . . . . . . . . . . . 47 ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML . . . . . . . . . . . 47 ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML . . . . . . . . . 47 ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML . . . . . . . . . . . . . 47 ORGOVYX . . . . . . . . . . . . . . . . . . . . . . . . 19 ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . 53 ORKAMBI ORAL TABLET . . . . . . . . . . 53 orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 oseltamivir . . . . . . . . . . . . . . . . . . . . . . . . . 9 oxacillin injection . . . . . . . . . . . . . . . . . . 13 oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . . 19

NOVOTWIST PEN NEEDLE . . . . . . . 41NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 19NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 24NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 19NUPLAZID ORAL CAPSULE . . . . . . . 29NUPLAZID ORAL TABLET 10 MG . . 29NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 55NUZYRA INTRAVENOUS . . . . . . . . . . 14NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 14nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 36nylia 7/7/7 (28) . . . . . . . . . . . . . . . . . . . . 49nymyo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49nystatin oral . . . . . . . . . . . . . . . . . . . . . . . . 8nystatin topical cream . . . . . . . . . . . . . . 36nystatin topical ointment . . . . . . . . . . . 36nystatin topical powder . . . . . . . . . . . . . 36nystatin-triamcinolone . . . . . . . . . . . . . . 36nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36NYVEPRIA . . . . . . . . . . . . . . . . . . . . . . . . 45

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 43ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 24octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml . 19octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 19octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml . . . 19ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . . 9ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 19OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ofloxacin ophthalmic (eye) . . . . . . . . . 50ofloxacin otic (ear) . . . . . . . . . . . . . . . . . 38OGIVRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 19olanzapine-fluoxetine . . . . . . . . . . . . . . 29olanzapine intramuscular . . . . . . . . . . . 29olanzapine oral tablet . . . . . . . . . . . . . . 29

nitazoxanide . . . . . . . . . . . . . . . . . . . . . . 12nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 38nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 14nitrofurantoin macrocrystal . . . . . . . . . 14nitrofurantoin monohyd/m-cryst . . . . . 14nitroglycerin intravenous . . . . . . . . . . . 34nitroglycerin sublingual . . . . . . . . . . . . . 34nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 34nitroglycerin translingual . . . . . . . . . . . 34NIVESTYM . . . . . . . . . . . . . . . . . . . . . . . 45nizatidine oral capsule . . . . . . . . . . . . . 44nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 48noreth-ethinyl estradiol-iron . . . . . . . . 49norethindrone acetate . . . . . . . . . . . . . . 48norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg . . . . . . . . . 48norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg . . . . . . . . . . . . . . . . . . . . 49norethindrone (contraceptive) . . . . . . 48norethindrone-e.estradiol-iron oral capsule . . . . . . . . . . . . . . . . . . . . . . . 49norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) . . 49norethindrone-e.estradiol-iron oral tablet,chewable . . . . . . . . . . . . . . . 49norgestimate-ethinyl estradiol . . . . . . 49NORTHERA ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 38NORTHERA ORAL CAPSULE 200 MG, 300 MG . . . . . . . 38nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 49nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . 49nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . 49nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . 49nortriptyline . . . . . . . . . . . . . . . . . . . . . . . 29NORVIR ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 9NORVIR ORAL SOLUTION . . . . . . . . . 9NOVOFINE PEN NEEDLE . . . . . . . . . 41

74


Covered Drugs Index

October 2021

perphenazine-amitriptyline . . . . . . . . . 29PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 29pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 13phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 29phenobarbital oral elixir . . . . . . . . . . . . 23phenobarbital oral tablet . . . . . . . . . . . 23phenobarbital sodium injection solution . . . . . . . . . . . . . . . . . . . 23phenoxybenzamine . . . . . . . . . . . . . . . . 32phenytoin oral suspension . . . . . . . . . 23phenytoin oral tablet,chewable . . . . . 23phenytoin sodium extended . . . . . . . . 23phenytoin sodium intravenous solution . . . . . . . . . . . . . . . 23PHESGO . . . . . . . . . . . . . . . . . . . . . . . . . 19philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50phytonadione (vitamin k1) oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 33PICATO . . . . . . . . . . . . . . . . . . . . . . . . . . . 35PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . . 9pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 51pilocarpine hcl oral . . . . . . . . . . . . . . . . . 38pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 35pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 29pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 50pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 32pioglitazone . . . . . . . . . . . . . . . . . . . . . . . 41pioglitazone-metformin . . . . . . . . . . . . . 41piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 14PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 14PIQRAY . . . . . . . . . . . . . . . . . . . . . . . . . . . 19pirmella . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 55PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 44podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 35POLIVY . . . . . . . . . . . . . . . . . . . . . . . . . . . 19polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

pantoprazole oral tablet, delayed release (dr/ec) 40 mg . . . . . . 44paricalcitol oral . . . . . . . . . . . . . . . . . . . . 42paroex oral rinse . . . . . . . . . . . . . . . . . . 38paromomycin . . . . . . . . . . . . . . . . . . . . . . 12paroxetine hcl oral tablet . . . . . . . . . . . 29paroxetine hcl oral tablet extended release 24 hr . . . . . . . . . . . . 29PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 12PAXIL ORAL SUSPENSION . . . . . . . 29PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 46PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 46peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 44peg-electrolyte . . . . . . . . . . . . . . . . . . . . 44PEMAZYRE . . . . . . . . . . . . . . . . . . . . . . . 19penicillamine . . . . . . . . . . . . . . . . . . . . . . 47penicillin g potassium injection recon soln 5 million unit . . . . . . . . . . . . 13penicillin g potassium injection recon soln 20 million unit . . . . . . . . . . . 13penicillin v potassium oral recon soln . . . . . . . . . . . . . . . . . . . . 13penicillin v potassium oral tablet 250 mg . . . . . . . . . . . . . . . . . 13penicillin v potassium oral tablet 500 mg . . . . . . . . . . . . . . . . . 13PENTACEL (PF) INTRAMUSCULAR KIT 15LF- 48MCG-62DU -10 MCG/0.5ML . . . . . 46PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 12pentamidine inhalation . . . . . . . . . . . . . 12pentamidine injection . . . . . . . . . . . . . . 12PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 44pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 33PEPAXTO . . . . . . . . . . . . . . . . . . . . . . . . . 19PERFOROMIST . . . . . . . . . . . . . . . . . . . 53PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 55perindopril erbumine . . . . . . . . . . . . . . . 32PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 19permethrin . . . . . . . . . . . . . . . . . . . . . . . . 37perphenazine . . . . . . . . . . . . . . . . . . . . . 29

oxandrolone oral tablet 2.5 mg . . . . . 42oxandrolone oral tablet 10 mg . . . . . . 42oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 27oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 29oxcarbazepine . . . . . . . . . . . . . . . . . . . . 23OXERVATE . . . . . . . . . . . . . . . . . . . . . . . 51oxybutynin chloride oral syrup . . . . . . 54oxybutynin chloride oral tablet . . . . . . 54oxybutynin chloride oral tablet extended release 24hr . . . . . . . . . . . . . 54oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg . . . . . . . . . . . . . 26oxycodone oral concentrate . . . . . . . . 26oxycodone oral solution . . . . . . . . . . . . 26oxycodone oral tablet 5 mg . . . . . . . . . 26oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg . . . . . . . 26oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 26OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) . . . . . . . . . . 41OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) . . . . . . . . . . . . . . . . . . . . . . 41

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 30paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 19PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 19paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 29paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . . . . . . . . . . 29palonosetron intravenous solution 0.25 mg/5 ml . . . . . . . . . . . . . . 44pamidronate intravenous solution . . . 42PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 35pantoprazole oral tablet, delayed release (dr/ec) 20 mg . . . . . . 44

75


Covered Drugs Index

October 2021

prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 34previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 50PREVYMIS ORAL . . . . . . . . . . . . . . . . . . 9PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . . 9PREZISTA ORAL SUSPENSION . . . . 9PREZISTA ORAL TABLET 75 MG . . . 9PREZISTA ORAL TABLET 150 MG . . 9PREZISTA ORAL TABLET 600 MG . . 9PREZISTA ORAL TABLET 800 MG . . 9PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 12PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 12primidone . . . . . . . . . . . . . . . . . . . . . . . . . 23probenecid . . . . . . . . . . . . . . . . . . . . . . . . 46probenecid-colchicine . . . . . . . . . . . . . . 46PROCALAMINE 3% . . . . . . . . . . . . . . . 55prochlorperazine . . . . . . . . . . . . . . . . . . 44prochlorperazine edisylate . . . . . . . . . 44prochlorperazine maleate oral . . . . . . 44procto-med hc . . . . . . . . . . . . . . . . . . . . . 44procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 44proctosol hc topical . . . . . . . . . . . . . . . . 44proctozone-hc . . . . . . . . . . . . . . . . . . . . . 44progesterone micronized . . . . . . . . . . . 48PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 41PROGRAF INTRAVENOUS . . . . . . . . 19PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 19PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 38PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 51PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46PROMACTA ORAL POWDER IN PACKET 12.5 MG . . . . . . . . . . . . . . 33PROMACTA ORAL POWDER IN PACKET 25 MG . . . . . . . . . . . . . . . . 33PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG . . . . . . . . . . . 33PROMACTA ORAL TABLET 75 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33promethazine oral . . . . . . . . . . . . . . . . . 52promethazine rectal suppository 12.5 mg, 25 mg . . . . . . . . 52

POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 19PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 33pramipexole oral tablet . . . . . . . . . . . . . 24pramipexole oral tablet extended release 24 hr . . . . . . . . . . . . 24PRASUGREL . . . . . . . . . . . . . . . . . . . . . 33pravastatin . . . . . . . . . . . . . . . . . . . . . . . . 33praziquantel . . . . . . . . . . . . . . . . . . . . . . . 12prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 32PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 51PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 51prednicarbate topical ointment . . . . . . 37prednisolone acetate . . . . . . . . . . . . . . 52prednisolone oral solution . . . . . . . . . . 39prednisolone sodium phosphate ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 52prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) . . . . . . 39prednisone intensol . . . . . . . . . . . . . . . . 39prednisone oral solution . . . . . . . . . . . . 39prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg . . . . . . . . 39prednisone oral tablet 50 mg . . . . . . . 39prednisone oral tablets,dose pack . . 39pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg . . . . . . . . . . . . . . 23pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 23pregabalin oral solution . . . . . . . . . . . . 23pregabalin oral tablet extended release 24 hr 165 mg, 82.5 mg . . . . . 23pregabalin oral tablet extended release 24 hr 330 mg . . . . . . . . . . . . . . 23PREMARIN INJECTION . . . . . . . . . . . 48PREMARIN ORAL . . . . . . . . . . . . . . . . . 48PREMARIN VAGINAL . . . . . . . . . . . . . 48PREMASOL 10% . . . . . . . . . . . . . . . . . . 55PRENATAL VITAMIN ORAL TABLET . . . . . . . . . . . . . . . . . . . . 55

polymyxin b sulfate . . . . . . . . . . . . . . . . 12polymyxin b sulf-trimethoprim . . . . . . 51POMALYST . . . . . . . . . . . . . . . . . . . . . . . 19portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 50PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 19posaconazole oral tablet, delayed release (dr/ec) . . . . . . . . . . . . . 8POTASSIUM CHLORID-D5- 0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L . . . 54potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l . . . . . . . . . . . . . . . . . . . . . . . . . . 54potassium chloride-0.45% nacl . . . . . 55POTASSIUM CHLORIDE-D5- 0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L . . . . . . . . . . . . . . . . . . . . . . . . . 55potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l . . . . . . . . . . . . . . . . . 55POTASSIUM CHLORIDE- D5-0.9%NACL . . . . . . . . . . . . . . . . . . . . 55potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l . . . . . . . . . . . . . . . . . 54potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l . . . . . . . 54potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l . . . . . . . . . . . . . . . . . . 55potassium chloride intravenous . . . . . 55potassium chloride in water intravenous piggyback . . . . . . . . . . . . . 55potassium chloride oral capsule, extended release . . . . . . . . . . . . . . . . . . 55potassium chloride oral liquid . . . . . . . 55potassium chloride oral packet . . . . . 55potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 55potassium chloride oral tablet extended release . . . . . . . . . . . . . . . . . . 55potassium citrate . . . . . . . . . . . . . . . . . . 54

76


Covered Drugs Index

October 2021

RETROVIR INTRAVENOUS . . . . . . . . 9REVLIMID . . . . . . . . . . . . . . . . . . . . . . . . 19REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 29REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 9RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 51ribavirin oral capsule . . . . . . . . . . . . . . . . 9ribavirin oral tablet 200 mg . . . . . . . . . . 9RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 47rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 12rifampin intravenous . . . . . . . . . . . . . . . 12rifampin oral . . . . . . . . . . . . . . . . . . . . . . . 12riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38rimantadine . . . . . . . . . . . . . . . . . . . . . . . . 9ringer's intravenous . . . . . . . . . . . . . . . . 55ringer's irrigation . . . . . . . . . . . . . . . . . . . 37RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 47RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 41RIOMET ER . . . . . . . . . . . . . . . . . . . . . . . 41risedronate oral tablet 5 mg . . . . . . . . 46risedronate oral tablet 30 mg . . . . . . . 38risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) . . . 46risedronate oral tablet 150 mg . . . . . . 46RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML . . . . . . . . 30RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML . . . . . . . . 30risperidone oral solution . . . . . . . . . . . . 30risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . 30risperidone oral tablet 4 mg . . . . . . . . 30risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . 30risperidone oral tablet, disintegrating 4 mg . . . . . . . . . . . . . . . . 30ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 32quinapril-hydrochlorothiazide . . . . . . . 32quinidine sulfate oral tablet . . . . . . . . . 30quinine sulfate . . . . . . . . . . . . . . . . . . . . . 12

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 46raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 46ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 29ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 34rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 24REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) . 45REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML . . . 45REBIF TITRATION PACK . . . . . . . . . . 45REBIF (WITH ALBUMIN) . . . . . . . . . . . 45reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 50RECOMBIVAX HB (PF) . . . . . . . . . . . . 46RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 44regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 25REGRANEX . . . . . . . . . . . . . . . . . . . . . . 35RELISTOR SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 44RELISTOR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 44RENACIDIN . . . . . . . . . . . . . . . . . . . . . . . 54RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 44repaglinide oral tablet 0.5 mg . . . . . . . 41repaglinide oral tablet 1 mg . . . . . . . . 41repaglinide oral tablet 2 mg . . . . . . . . 41REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 34REPATHA PUSHTRONEX . . . . . . . . . 34REPATHA SURECLICK . . . . . . . . . . . . 34RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 51RESTASIS MULTIDOSE . . . . . . . . . . . 51RETACRIT . . . . . . . . . . . . . . . . . . . . . . . . 45RETEVMO . . . . . . . . . . . . . . . . . . . . . . . . 19

promethegan rectal suppository 25 mg, 50 mg . . . . . . . . . . 52propafenone oral capsule, extended release 12 hr . . . . . . . . . . . . 30propafenone oral tablet . . . . . . . . . . . . 30propranolol-hydrochlorothiazid . . . . . 32propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 32propranolol oral solution . . . . . . . . . . . 32propranolol oral tablet . . . . . . . . . . . . . . 32propylthiouracil . . . . . . . . . . . . . . . . . . . . 39PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 46PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 55protriptyline . . . . . . . . . . . . . . . . . . . . . . . 29PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/ 2 ML, 0.5 MG/2 ML . . . . . . . . . . . . . . . . 53PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML . . . . . . . . 53PULMOZYME . . . . . . . . . . . . . . . . . . . . . 53PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 19pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 12pyridostigmine bromide oral syrup . . 25pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . 25pyridostigmine bromide oral tablet extended release . . . . . . . . 25pyrimethamine . . . . . . . . . . . . . . . . . . . . 12

QQINLOCK . . . . . . . . . . . . . . . . . . . . . . . . . 19QUADRACEL (PF) . . . . . . . . . . . . . . . . 46quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . 29quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 29quetiapine oral tablet extended release 24 hr 150 mg, 200 mg . . . . . . 29quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg . . . . . . . . . . . . . . . . . . . . 29

77


Covered Drugs Index

October 2021

sodium chloride 0.9% intravenous . . 38sodium chloride 0.45% intravenous parenteral solution . . . . . 55sodium chloride 3% . . . . . . . . . . . . . . . . 55sodium chloride 5% . . . . . . . . . . . . . . . . 55sodium chloride intravenous . . . . . . . . 55sodium chloride irrigation . . . . . . . . . . . 38sodium fluoride 5000 dry mouth . . . . 38sodium fluoride-pot nitrate . . . . . . . . . . 38sodium phenylbutyrate . . . . . . . . . . . . . 38sodium polystyrene sulfonate oral powder . . . . . . . . . . . . . . 38solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 54SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 41SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 20SOLU-CORTEF ACT-O-VIAL (PF) . . 39SOMATULINE DEPOT . . . . . . . . . . . . . 20SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 42sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 30SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 30spironolactone . . . . . . . . . . . . . . . . . . . . 32spironolacton-hydrochlorothiaz . . . . . 32sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 50SPRITAM . . . . . . . . . . . . . . . . . . . . . . . . . 23SPRYCEL ORAL TABLET 20 MG, 70 MG . . . . . . . . . . . . . . . . . . . . 20SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG . . . 20sps (with sorbitol) . . . . . . . . . . . . . . . . . . 38sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 46stavudine oral capsule . . . . . . . . . . . . . 10STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 34STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 34STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 34

SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 30selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 24selenium sulfide topical lotion . . . . . . 34SELZENTRY ORAL SOLUTION . . . . 10SELZENTRY ORAL TABLET 25 MG . 10SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . 10SELZENTRY ORAL TABLET 300 MG . . . . . . . . . . . . . . . . . . 10SEREVENT DISKUS . . . . . . . . . . . . . . 53sertraline oral concentrate . . . . . . . . . . 30sertraline oral tablet . . . . . . . . . . . . . . . . 30setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 50SEVELAMER CARBONATE ORAL POWDER IN PACKET . . . . . . . 38SEVELAMER CARBONATE ORAL TABLET . . . . . . . . . . . . . . . . . . . . 38sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 48SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 46SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 20sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 53silver sulfadiazine . . . . . . . . . . . . . . . . . 35SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 51simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 50simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 50SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 20simvastatin oral tablet . . . . . . . . . . . . . . 34sirolimus oral solution . . . . . . . . . . . . . . 20sirolimus oral tablet . . . . . . . . . . . . . . . . 20SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 13SIVEXTRO INTRAVENOUS . . . . . . . . 13SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 13SKYRIZI SUBCUTANEOUS PEN INJECTOR . . . . . . . . . . . . . . . . . . . 34SKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML . . . . . . . . . . . . . 34SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 34sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . . . 55

rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 24rivastigmine tartrate . . . . . . . . . . . . . . . . 24rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50rizatriptan . . . . . . . . . . . . . . . . . . . . . . . . . 24ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 51ROMIDEPSIN INTRAVENOUS SOLUTION . . . . . . . 19ropinirole oral tablet . . . . . . . . . . . . . . . . 24rosadan topical cream . . . . . . . . . . . . . 35rosadan topical gel . . . . . . . . . . . . . . . . 35rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 34ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 46ROTATEQ VACCINE . . . . . . . . . . . . . . 46roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 23ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 19ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 19RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 19rufinamide . . . . . . . . . . . . . . . . . . . . . . . . 23RUKOBIA . . . . . . . . . . . . . . . . . . . . . . . . . 10RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 19RYBELSUS . . . . . . . . . . . . . . . . . . . . . . . 41RYBREVANT . . . . . . . . . . . . . . . . . . . . . . 19RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 19RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Ssalsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 27SAMSCA ORAL TABLET 15 MG . . . . 42SAMSCA ORAL TABLET 30 MG . . . . 42SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 44SANDIMMUNE ORAL SOLUTION . . 19SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION, EXTENDED REL RECON . . . . . . . . . . 20SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 35SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 30sapropterin . . . . . . . . . . . . . . . . . . . . . . . . 42SARCLISA . . . . . . . . . . . . . . . . . . . . . . . . 20scopolamine base . . . . . . . . . . . . . . . . . 44

78


Covered Drugs Index

October 2021

TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 20taysofy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50tazarotene topical cream . . . . . . . . . . . 35tazicef injection . . . . . . . . . . . . . . . . . . . . 11tazicef intravenous . . . . . . . . . . . . . . . . . 11TAZORAC . . . . . . . . . . . . . . . . . . . . . . . . 35taztia xt oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . 32TAZVERIK . . . . . . . . . . . . . . . . . . . . . . . . 20TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 46TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 20TECFIDERA ORAL CAPSULE, DELAYED RELEASE (DR/EC) 120 MG . . . . . . . . . . . . . . . . . . 25TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46) . . . . . . . . . 25TECFIDERA ORAL CAPSULE, DELAYED RELEASE (DR/EC) 240 MG . . . . . . . . . . . . . . . . . . 25TECHLITE PEN NEEDLE . . . . . . . . . . 41TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 11TEKTURNA HCT . . . . . . . . . . . . . . . . . . 32telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 32telmisartan-amlodipine . . . . . . . . . . . . . 32telmisartan-hydrochlorothiazid . . . . . . 32temazepam . . . . . . . . . . . . . . . . . . . . . . . 30TEMIXYS . . . . . . . . . . . . . . . . . . . . . . . . . 10TEMODAR INTRAVENOUS . . . . . . . . 20temsirolimus . . . . . . . . . . . . . . . . . . . . . . 20TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 46tenofovir disoproxil fumarate . . . . . . . 10TEPMETKO . . . . . . . . . . . . . . . . . . . . . . . 20terazosin oral capsule 1 mg, 2 mg, 5 mg . . . . . . . . . . . . . . . . . . 32terazosin oral capsule 10 mg . . . . . . . 32terbinafine hcl oral . . . . . . . . . . . . . . . . . . 8terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . . . . . . . . . 48

SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 20syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50SYMDEKO . . . . . . . . . . . . . . . . . . . . . . . . 53SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 10SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 41SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 41SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 23SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 10SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 42SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 13SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 41SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 41SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 41SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 20SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 42

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 20TABRECTA . . . . . . . . . . . . . . . . . . . . . . . 20tacrolimus oral . . . . . . . . . . . . . . . . . . . . 20tacrolimus topical . . . . . . . . . . . . . . . . . . 35tadalafil (pulmonary arterial hypertension) oral tablet 20 mg . . . . . 53TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 20TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 20TALTZ SYRINGE . . . . . . . . . . . . . . . . . . 34TALZENNA ORAL CAPSULE 0.25 MG . . . . . . . . . . . . . . . . 20TALZENNA ORAL CAPSULE 1 MG . 20tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 20tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 54TARGRETIN TOPICAL . . . . . . . . . . . . 20tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 50tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 50tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 50TASIGNA ORAL CAPSULE 50 MG . 20

STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 20streptomycin . . . . . . . . . . . . . . . . . . . . . . 13STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 10SUBOXONE SUBLINGUAL FILM 2-0.5 MG . . . . . . . . . . . . . . . . . . . . 27SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG . . . . . . . . . . . . . 27SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 27subvenite . . . . . . . . . . . . . . . . . . . . . . . . . 23subvenite starter (blue) kit . . . . . . . . . . 23subvenite starter (green) kit . . . . . . . . 23subvenite starter (orange) kit . . . . . . . 23sucralfate oral suspension . . . . . . . . . 44sucralfate oral tablet . . . . . . . . . . . . . . . 44sulfacetamide-prednisolone . . . . . . . . 51sulfacetamide sodium (acne) . . . . . . . 35sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 51sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 14sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 14sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 14sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 14sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 44sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 27sumatriptan nasal spray, non-aerosol 5 mg/actuation . . . . . . . . 24sumatriptan nasal spray, non-aerosol 20 mg/actuation . . . . . . . 24sumatriptan succinate oral . . . . . . . . . 24sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 24sumatriptan succinate subcutaneous pen injector . . . . . . . . . 24sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 24SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML . . 11SUPREP BOWEL PREP KIT . . . . . . . 44SUTAB . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

79


Covered Drugs Index

October 2021

TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 13TRELEGY ELLIPTA . . . . . . . . . . . . . . . 54TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION . . . . . . . . . . . . . . . 20TRESIBA FLEXTOUCH U-100 . . . . . 41TRESIBA FLEXTOUCH U-200 . . . . . 41TRESIBA U-100 INSULIN . . . . . . . . . . 41tretinoin (antineoplastic) . . . . . . . . . . . . 20tretinoin microspheres . . . . . . . . . . . . . 35tretinoin topical cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . 35tretinoin topical topical gel 0.01% . . . 35tretinoin topical topical gel 0.025%, 0.05% . . . . . . . . . . . . . . . . . . . . 35triamcinolone acetonide dental . . . . . 38triamcinolone acetonide injection suspension 40 mg/ml . . . . . . 39triamcinolone acetonide topical cream 0.1% . . . . . . . . . . . . . . . . 37triamcinolone acetonide topical cream 0.025%, 0.5% . . . . . . . . 37triamcinolone acetonide topical lotion . . . . . . . . . . . . . . . . . . . . . . . 37triamcinolone acetonide topical ointment . . . . . . . . . . . . . . . . . . . 37triamterene-hydrochlorothiazid oral capsule 37.5-25 mg . . . . . . . . . . . 32triamterene-hydrochlorothiazid oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 32triderm topical cream 0.1% . . . . . . . . . 37trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 38tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 50tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 50trifluoperazine . . . . . . . . . . . . . . . . . . . . . 30trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 51trihexyphenidyl . . . . . . . . . . . . . . . . . . . . 24TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG . . . . 41TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5- 2.5-1,000 MG, 5-2.5-1,000 MG . . . . . 41

TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . 10TIVICAY PD . . . . . . . . . . . . . . . . . . . . . . . 10tizanidine oral capsule . . . . . . . . . . . . . 25tizanidine oral tablet . . . . . . . . . . . . . . . 25TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE . . . . . . . . . . 13tobramycin-dexamethasone . . . . . . . . 51tobramycin in 0.225% nacl . . . . . . . . . 13tobramycin ophthalmic (eye) . . . . . . . 51tobramycin sulfate . . . . . . . . . . . . . . . . . 13TOBREX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 51tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 24tolterodine . . . . . . . . . . . . . . . . . . . . . . . . 54tolvaptan oral tablet 30 mg . . . . . . . . . 42topiramate oral capsule, sprinkle . . . 23topiramate oral tablet . . . . . . . . . . . . . . 23toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 20topotecan intravenous recon soln . . . 20topotecan intravenous solution 4 mg/4 ml (1 mg/ml) . . . . . . . 20toremifene . . . . . . . . . . . . . . . . . . . . . . . . 20torsemide oral . . . . . . . . . . . . . . . . . . . . . 32TOUJEO MAX U-300 SOLOSTAR . . 41TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 41TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 54TPN ELECTROLYTES . . . . . . . . . . . . . 55TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 41tramadol-acetaminophen . . . . . . . . . . . 27tramadol oral tablet 50 mg . . . . . . . . . 27trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 32tranexamic acid oral . . . . . . . . . . . . . . . 48tranylcypromine . . . . . . . . . . . . . . . . . . . 30TRAVASOL 10% . . . . . . . . . . . . . . . . . . 55travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 51TRAZIMERA . . . . . . . . . . . . . . . . . . . . . . 20trazodone . . . . . . . . . . . . . . . . . . . . . . . . . 30TREANDA . . . . . . . . . . . . . . . . . . . . . . . . 20

TERIPARATIDE . . . . . . . . . . . . . . . . . . . 46testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml) . . . . . . . . . . . . . . . . . . 42TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML . 42testosterone enanthate . . . . . . . . . . . . 42testosterone transdermal gel . . . . . . . 42testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%) . . . . . . . . . . . 42testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) . . . . . . . . . . . . . . . . 42TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . 46tetrabenazine oral tablet 12.5 mg . . . 25tetrabenazine oral tablet 25 mg . . . . . 25tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 14THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 20THALOMID ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 20THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 53theophylline oral tablet extended release 12 hr 300 mg, 450 mg . . . . . . 54theophylline oral tablet extended release 24 hr . . . . . . . . . . . . . . . . . . . . . . 54thioridazine . . . . . . . . . . . . . . . . . . . . . . . 30thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 20thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 30tiadylt er . . . . . . . . . . . . . . . . . . . . . . . . . . 32tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 23TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 20tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 13tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 51TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION. . 51timolol maleate oral . . . . . . . . . . . . . . . . 32tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 37TIVICAY ORAL TABLET 10 MG . . . . 10

80


Covered Drugs Index

October 2021

VANCOMYCIN INJECTION . . . . . . . . 13vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 13VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM. . . . . . 13vancomycin oral capsule 125 mg . . . 13vancomycin oral capsule 250 mg . . . 13vancomycin oral recon soln . . . . . . . . 13VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 13vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 48VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 46VARENICLINE . . . . . . . . . . . . . . . . . . . . 38VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 46VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 46VASCEPA . . . . . . . . . . . . . . . . . . . . . . . . . 34VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 21VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 21velivet triphasic regimen (28) . . . . . . . 50VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 38VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . 10VENCLEXTA ORAL TABLET 10 MG . . . . . . . . . . . . . . . . . . . 21VENCLEXTA ORAL TABLET 50 MG . . . . . . . . . . . . . . . . . . . 21VENCLEXTA ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 21VENCLEXTA STARTING PACK . . . . 21venlafaxine oral capsule, extended release 24hr . . . . . . . . . . . . . 30venlafaxine oral tablet . . . . . . . . . . . . . . 30VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 54VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 54verapamil intravenous solution . . . . . 32verapamil oral capsule, 24 hr er pellet ct . . . . . . . . . . . . . . . . . . . 32verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg . . . . . . . . . . . 32

TURALIO . . . . . . . . . . . . . . . . . . . . . . . . . 20TWINRIX (PF) . . . . . . . . . . . . . . . . . . . . . 46TYBLUME . . . . . . . . . . . . . . . . . . . . . . . . 50TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 10tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 21TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 46TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 46TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 25

UUKONIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 21UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 43unithroid oral tablet 137 mcg . . . . . . . 43UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 21UPTRAVI ORAL . . . . . . . . . . . . . . . . . . . 32ursodiol oral capsule 300 mg . . . . . . . 44ursodiol oral tablet . . . . . . . . . . . . . . . . . 44

Vvalacyclovir oral tablet 1 gram . . . . . . 10valacyclovir oral tablet 500 mg . . . . . 10VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 35valganciclovir . . . . . . . . . . . . . . . . . . . . . . 10valproate sodium . . . . . . . . . . . . . . . . . . 23valproic acid . . . . . . . . . . . . . . . . . . . . . . . 23valproic acid (as sodium salt) . . . . . . . 23valrubicin . . . . . . . . . . . . . . . . . . . . . . . . . 21valsartan-hydrochlorothiazide . . . . . . 32valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 32valsartan oral tablet 320 mg . . . . . . . . 32VALTOCO . . . . . . . . . . . . . . . . . . . . . . . . . 23VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . 13VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . . . . . 13

TRIKAFTA . . . . . . . . . . . . . . . . . . . . . . . . 54tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 50tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 50tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 50tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 50trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 14tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50trimipramine . . . . . . . . . . . . . . . . . . . . . . . 30TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 30tri-nymyo . . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-previfem (28) . . . . . . . . . . . . . . . . . . . 50TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 20tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 50tritocin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 10trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 50tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 50TRODELVY . . . . . . . . . . . . . . . . . . . . . . . 20TROGARZO . . . . . . . . . . . . . . . . . . . . . . 10TROKENDI XR ORAL CAPSULE, EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG . . . . . . . . . . . 23TROKENDI XR ORAL CAPSULE, EXTENDED RELEASE 24HR 200 MG . . . . . . . . . . . . . . . . . . . . . 23TROPHAMINE 10% . . . . . . . . . . . . . . . 55TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 41TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 46TRUSELTIQ ORAL CAPSULE 75 MG/DAY (25 MG X 3) . . . . . . . . . . . 20TRUSELTIQ ORAL CAPSULE 100 MG/DAY (100 MG X 1) . . . . . . . . 20TRUSELTIQ ORAL CAPSULE 125 MG/DAY(100 MG X1-25MG X1), 50 MG/DAY (25 MG X 2) . . . . . . . . . . . 20TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 10TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 20TUKYSA ORAL TABLET 50 MG . . . . 20TUKYSA ORAL TABLET 150 MG . . . 20

81


Covered Drugs Index

October 2021

XELJANZ ORAL SOLUTION . . . . . . . 47XELJANZ ORAL TABLET . . . . . . . . . . 47XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 47XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 15XHANCE . . . . . . . . . . . . . . . . . . . . . . . . . . 54XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 38XIFAXAN ORAL TABLET 550 MG . . 13XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG . . . . . . . . . . . . . . . . . . . . . . . . . 41XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG . . . . . . . . . . 41XIIDRA . . . . . . . . . . . . . . . . . . . . . . . . . . . 51XOFLUZA ORAL TABLET 20 MG, 40 MG . . . . . . . . . . . . . . . . . . . . 10XOFLUZA ORAL TABLET 80 MG . . . 10XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 54XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML . . . . . . . . . . . 54XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML . . . . . . . . . . . . . 54XOPENEX . . . . . . . . . . . . . . . . . . . . . . . . 54XOPENEX CONCENTRATE . . . . . . . 54XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 21XPOVIO ORAL TABLET 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (40 MG X 1), 40MG TWICE WEEK (40 MG X 2), 60 MG/WEEK (60 MG X 1), 60MG TWICE WEEK (120 MG/WEEK), 80 MG/WEEK (40 MG X 2), 80MG TWICE WEEK (160 MG/WEEK) . . . . . . . . . . . . . . . . . . 21XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 26XTANDI ORAL CAPSULE . . . . . . . . . . 21XTANDI ORAL TABLET 40 MG . . . . . 21XTANDI ORAL TABLET 80 MG . . . . . 21XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 41XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

VITRAKVI ORAL CAPSULE 25 MG . . . . . . . . . . . . . . . . . 21VITRAKVI ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 21VITRAKVI ORAL SOLUTION . . . . . . . 21VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 27VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 21volnea (28) . . . . . . . . . . . . . . . . . . . . . . . . 50voriconazole intravenous . . . . . . . . . . . . 8voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . 8voriconazole oral tablet 50 mg . . . . . . . 8voriconazole oral tablet 200 mg . . . . . . 8VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 10VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 21VRAYLAR ORAL CAPSULE . . . . . . . . 30VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 30vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 50vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50VYNDAMAX . . . . . . . . . . . . . . . . . . . . . . 34VYNDAQEL . . . . . . . . . . . . . . . . . . . . . . . 34VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 33water for irrigation, sterile . . . . . . . . . . 38wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 50wixela inhub . . . . . . . . . . . . . . . . . . . . . . . 54wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 50

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 21XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 33XARELTO DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 33XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 21XCOPRI . . . . . . . . . . . . . . . . . . . . . . . . . . 23XCOPRI MAINTENANCE PACK . . . . 23XCOPRI TITRATION PACK . . . . . . . . 23

VERAPAMIL ORAL CAPSULE, EXT REL. PELLETS 24 HR 360 MG . . . . . . . . . . . . . . . . . . . . 32verapamil oral tablet . . . . . . . . . . . . . . . 32verapamil oral tablet extended release . . . . . . . . . . . . . . . . . . 32VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 30VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 21vestura (28) . . . . . . . . . . . . . . . . . . . . . . . 50V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 41V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 41V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 41VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 41VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 41vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 23vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 23VIIBRYD ORAL TABLET . . . . . . . . . . . 30VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 30VIMPAT INTRAVENOUS . . . . . . . . . . . 23VIMPAT ORAL SOLUTION . . . . . . . . . 23VIMPAT ORAL TABLET 50 MG . . . . . 23VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 23vinblastine . . . . . . . . . . . . . . . . . . . . . . . . 21vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 21vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 21vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 21VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT . . . . . . . 44VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT . . . . . . . 44viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 50VIRACEPT ORAL TABLET 250 MG . . . . . . . . . . . . . . . . . . 10VIRACEPT ORAL TABLET 625 MG . . . . . . . . . . . . . . . . . . 10VIREAD ORAL POWDER . . . . . . . . . . 10VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . 10

82


Covered Drugs Index

October 2021

zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 42zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 38ZOLEDRONIC AC- MANNITOL-0.9NACL . . . . . . . . . . . . . . 42ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 21zolpidem oral tablet . . . . . . . . . . . . . . . . 30zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 23ZORTRESS ORAL TABLET 1 MG . . 21ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 46ZOSYN IN DEXTROSE (ISO-OSM) . . . . . . . . . . . . . . . . . . . . . . . . 14zovia 1-35 (28) . . . . . . . . . . . . . . . . . . . . 50zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 50ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG . . . . . . . . . . . 27ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG . . . . . . . . . . . . . . . 27zumandimine (28) . . . . . . . . . . . . . . . . . 50ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 21ZYKADIA ORAL TABLET . . . . . . . . . . 21ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ZYNLONTA . . . . . . . . . . . . . . . . . . . . . . . 21ZYPREXA RELPREVV . . . . . . . . . . . . 30

YYERVOY . . . . . . . . . . . . . . . . . . . . . . . . . . 21YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 46YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 21YUPELRI . . . . . . . . . . . . . . . . . . . . . . . . . 54yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 54zaleplon oral capsule 5 mg . . . . . . . . . 30zaleplon oral capsule 10 mg . . . . . . . . 30ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 21ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 21zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 45ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 21ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 21ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 38zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 35ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT . . . . . . . . 44ZEPZELCA . . . . . . . . . . . . . . . . . . . . . . . 21zidovudine oral capsule . . . . . . . . . . . . 10zidovudine oral syrup . . . . . . . . . . . . . . 10zidovudine oral tablet . . . . . . . . . . . . . . 10ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 45ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 30ziprasidone mesylate . . . . . . . . . . . . . . 30ZIRABEV . . . . . . . . . . . . . . . . . . . . . . . . . 21ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 51ZOLADEX . . . . . . . . . . . . . . . . . . . . . . . . 21zoledronic acid intravenous solution . . . . . . . . . . . . . . . 42

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• 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 Customer Service at 1-800-627-7534 (TTY 711), October 1 – March 31, 7 days a week 8 a.m. to 8 p.m., local time. From April 1 – September 30, Monday – Friday, 8 a.m. to 8 p.m. local time (a voice-mail system is available on weekends and holidays). If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Cigna Attn: Grievance Department PO Box 188080, Chattanooga, TN 37422 Phone: 1-800-627-7534 (TTY 711) Fax: 1-888-586-9946.

You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available 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 Services 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, 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.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-627-7534 (TTY 711), 8 a.m. to 8 p.m., 7 days a week (hours apply Monday – Friday, April 1 – September 30). ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-7534 (TTY 711), 8 a.m. a 8 p.m., 7 días de la semana (horario se aplica de lunes - viernes, del 1 de abril – 30 de septiembre). Cigna is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal. © 2017 Cigna

INT_17_49135 v05012020 20_NDMLI_AZ

ACCEPTED

English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711).

Chinese – (TTY 711)

Tiếng Việt (Vietnamese) – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711).

Korean – : , .(TTY: 711) .

Arabic

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

).711 رقم ھاتف الصم والبكم(

Gujarati –

まで、お電話にてご連絡ください。

Navajo – ti’go Diné Bizaad, saad(TTY 711).

Urdu خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال:TTY)

توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد711)

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

1-800-627-7534

H0354_17_49951

1-800-627-7534

20_MA_AZ_NDMLI(01142020)

This formulary was updated on 10/01/2021. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit CignaMedicare.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. © 2020 CignaOctober 2021 946454 m

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

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Documents

2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)