2021 MassHealth Pharmacy Formulary

Zero Dollar Copay Age Limit Maintenance 90 drug Prior Authorization Quantity Limit Specialty Drug Step Therapy Preferred DrugBrand Name PreferredAvailable on the medical benefit only Available on medical and pharmacy benefitIndicates a brand name drug Indicates a generic drug

$0 AL M90 PA QL SP STPDBPMBDualCAPITALIZED lowercase

NOTICE The information contained in this document is proprietary. The information may not be copied in

whole or in part without written permission. ©2019 All rights reserved. This document contains

references to brand-name prescription drugs that are trademarks or registered trademarks of

pharmaceutical manufacturers.

When viewing the document via the Internet, please be advised that the document is updated

periodically, and changes may appear prior to their effective date to allow for client notification.

This list is subject to change at any time.

AllWays Health Partners complies with applicable federal civil rights laws and does not discriminate

or exclude people on the basis of race, color, national origin, age, disability, or sex.

399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org

AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company

2021MassHealth Pharmacy Formulary

INTRODUCTION

AllWays Health Partners covers a wide variety of safe and effective medications for treating our

members' medical needs. This list of AllWays Health Partners’ covered medications shows the tier in

which medications are placed. You can use this list to find out if your drug is covered and at which tier.

Check the plan documents such as the schedule of benefits, the summary of benefits and coverage, or the

benefit handbook for details on coverage and cost sharing. If you are a member, you also can view your

prescription drug coverage information by logging in to allwaysmember.org. This list of covered

medications is continually updated based on recommendations by AllWays Health Partners’ Pharmacy

& Therapeutics Committee.

It is always a good idea to discuss your medication options with your doctor to decide which is the most

appropriate to treat your specific medical condition.

LEGEND

Covered Product Reference Tier Status Notes1st Tier Unifine Pentips 29G X 12MM , 31G X 6 MM

CareFine Pen Needles $0 M90

1st Tier Unifine Pentips 31G X 5 MM , 31G X 8 MM

Advocate Insulin Pen Needles

$0 M90

1st Tier Unifine Pentips 32G X 4 MM BD Pen Needle Nano U/F $0 M90

1st Tier Unifine Pentips Plus 29G X 12MM , 31G X 6 MM


1st Tier Unifine Pentips Plus 31G X 5 MM , 31G X 8 MM


$0 M90

1st Tier Unifine Pentips Plus 32G X 4 MM

BD Pen Needle Nano U/F $0 M90

3 Day Vaginal Gyne-Lotrimin 3 Tier 2 M90

50+ Adult Eye Health DEKAs Plus Tier 2 M90

7 Series BP Monitor/Upper Arm $0M90; QL (QL Flag); QL (1 EA per 3 YEARs)

8 Hour Pain Relief Midol Tier 2 M90

8 Hour Pain Reliever Midol Tier 2 M90

A + D Personal Care Lotion Tier 2 M90

A Thru Z Advanced ABC Plus Senior Tier 2 M90

A Thru Z High Potency ABC Plus Senior Tier 2 M90

A Thru Z Select 50+ Advanced ABC Plus Senior Tier 2 M90

A Thru Z Select 50+ Mens ABC Plus Senior Tier 2 M90

A Thru Z Select Advanced ABC Plus Senior Tier 2 M90

A Thru Z Select Oral Tablet ABC Plus Senior Tier 2 M90

A Thru Z Select Ultimate Women ABC Plus Senior Tier 2 M90

A Thru Z Ultimate Mens ABC Plus Senior Tier 2 M90

Abacavir Sulfate Oral Solution Ziagen Tier 2

Abacavir Sulfate Oral Tablet Ziagen Tier 2 M90

Abacavir Sulfate-lamiVUDine Epzicom Tier 2 M90

Abacavir-Lamivudine-Zidovudine Trizivir Tier 2 M90

Abatron AF Tier 2 M90

ABC Plus ABC Plus Senior Tier 2 M90

Abilify Maintena Intramuscular Prefilled Syringe

Tier 2PA; QL (Quantity Limit Applies); QL (1 INJ per 30 days)

Abilify Maintena Intramuscular Suspension Reconstituted ER

Tier 2PA; QL (Quantity Limit Applies); QL (1 INJ per 30 days)

Abilify MyCite Oral Tablet 10 MG, 2 MG, 5 MG

Tier 2PA; QL (60 EA per 30 days)

1

Covered Product Reference Tier Status NotesAbilify MyCite Oral Tablet 15 MG, 20 MG, 30 MG


Abiraterone Acetate Oral Tablet 250 MG Zytiga $0 SP; QL (QL Applies)

Abiraterone Acetate Oral Tablet 500 MG Zytiga $0QL (60 EA per 30 days)

Abraxane $0 M90

Acamprosate Calcium Tier 2 M90

Acarbose Oral Precose Tier 1 M90

Acebutolol HCl Oral Tier 1 M90

Acephen Rectal Suppository 120 MG, 325 MG

Tier 2 M90

Acetaminophen ER Midol Tier 2 M90

Acetaminophen Extra Strength Oral Liquid

Mapap Acetaminophen Extra Str

Tier 2 M90

Acetaminophen Extra Strength Oral Tablet

Healthy Mama Shake That Ache

Tier 2 M90

Acetaminophen Oral Liquid Little Remedies for Fever Tier 2 M90

Acetaminophen Oral Solution 160 MG/5ML

Tier 2 M90

Acetaminophen Oral Tablet Aphen Tier 2 M90

Acetaminophen Oral Tablet Chewable 80 MG

Childrens Medi-Tabs Tier 2 M90

Acetaminophen Rectal Suppository 120 MG

FeverAll Childrens Tier 2 M90

Acetaminophen-Codeine #2 Tier 2QL (400 tablets per 30 days. Click;HERE)

Acetaminophen-Codeine #3 Tier 2QL (360 tablets per 30 days. Click;HERE)

Acetaminophen-Codeine #4 Tier 2QL (180 EA per 30 days)

Acetaminophen-Codeine Oral Solution Tier 2M90; QL (2700 mL per 30 days. Click;HERE)

Acetaminophen-Codeine Oral Tablet 300-15 MG

Tier 2M90; QL (400 tablets per 30 days. Click;HERE)


Tier 2 M90


Tier 2M90; QL (180 EA per 30 days)

Acetasol HC Tier 2 M90

acetaZOLAMIDE ER Tier 1 M90

2

Covered Product Reference Tier Status NotesacetaZOLAMIDE Oral Tier 1 M90

Acetic Acid Otic Tier 2 M90

Acetic Acid-Aluminum Acetate Tier 2 M90

Acetylcysteine Inhalation Tier 2 M90

Acid Control Tier 2 M90

Acid Control Maximum Strength Oral Tablet 20 MG

MM Acid-Pep Maximum Strength

Tier 2 M90

Acid Controller Pepcid AC Tier 2 M90

Acid Controller Max StMM Acid-Pep Maximum Strength

Tier 2 M90

Acid Reducer Maximum StrengthMM Acid-Pep Maximum Strength

Tier 2 M90

Acid Reducer Oral Tablet 10 MG Pepcid AC Tier 2 M90

Acid Reducer Oral Tablet 150 MG, 75 MG

Tier 2 M90

AcipHex Sprinkle Oral Capsule Sprinkle 5 MG


Acitretin Soriatane Tier 2 M90

Acne Foaming Wash PanOxyl Foaming Wash Tier 2 M90

Acne Medication 10 External GelClean & Clear Persa-Gel Max St

Tier 2 M90

Acne Medication 5 External Gel Tier 2 M90

Acne-ClearClean & Clear Persa-Gel Max St

Tier 2 M90

Actemra ACTPen Tier 2PA; SP; Dual; QL (4 PENS per 28 days)

Actemra Intravenous Solution 200 MG/10ML

Tier 2PA; SP; Dual; QL (4 VIALS per 14 days)





Actemra Subcutaneous Tier 2PA; SP; Dual; QL (4 SYR per 28 days)

Acthar Tier 2PA; SP; QL (35 ml per 21 days)

ActHIB $0 M90

Actical DEKAs Plus Tier 2 M90

Actimmune $0 SP

Activite EC Tier 2 M90

Actoplus met XR Tier 2 ST; M90

3

Covered Product Reference Tier Status Notes

Acuvail Tier 2ST; M90; QL (60ml per 25 days)

Acyclovir External Ointment Zovirax Tier 2 M90

Acyclovir Oral Tier 2 M90

Acyclovir Sodium Intravenous Solution Tier 2 M90

Adacel Intramuscular Suspension 5-2-15.5 LF-MCG/0.5

$0 M90

Adagen MB PA

Adakveo MB PA

Adapalene External Cream Differin Tier 2 ST; M90

Adapalene External Gel 0.3 % Differin Tier 2 ST; M90

Adapalene External Lotion Differin Tier 2 ST; M90

Adcetris $0 SP

Addaprin Tier 2 M90

Adderall XR Tier 2PD; BP; QL (60 EA per 30 days)

Adefovir Dipivoxil Hepsera Tier 2SP; QL (30 EA per 90 days)

Adempas Tier 2 PA; SP

Adenosine Intravenous Solution 12 MG/4ML, 6 MG/2ML

Tier 2 M90

Admelog Tier 1 PA

Admelog SoloStar Tier 1 PA

Adrenalin Nasal Tier 2

Adrucil $0 M90

Advair Diskus Tier 2 BP

Advair HFA Tier 2 M90

Advanced Diabetic Multivitamin ABC Plus Senior Tier 2 M90

Advate Tier 2 PA; SP; Dual

Advil Junior Strength Tier 2 M90

Advocate Insulin Pen Needles 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM

$0 M90

Adynovate Tier 2 PA; SP; Dual

Adzenys XR-ODT Oral Tablet Extended Release Dispersible 12.5 MG, 15.7 MG, 18.8 MG, 6.3 MG, 9.4 MG

Tier 2QL (30 EA per 90 days)

Adzenys XR-ODT Oral Tablet Extended Release Dispersible 3.1 MG


Aerospan Tier 2 M90

Afeditab CR Tier 1 M90

4


Afinitor Oral Tablet 10 MG $0PA; SP; BP; QL (30 EA per 30 days)

Afinitor Oral Tablet 2.5 MG, 5 MG, 7.5 MG

$0PA; BP; QL (30 EA per 30 days)

Afluria $0 M90

Afluria Preservative Free Intramuscular Suspension Prefilled Syringe

$0 M90

Afluria Quadrivalent Intramuscular Suspension

$0

Afluria Quadrivalent Intramuscular Suspension Prefilled Syringe 0.25 ML

$0

Afluria Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML

$0 M90

Afrin Saline Nasal Mist Tier 1 M90

Afstyla Tier 2 PA; SP; Dual

Aftera $0 M90

Aimovig Tier 2PA; QL (1 PEN per 30 days)

AirDuo RespiClick 113/14 Tier 2 PA



Ajovy Tier 2PA; PD; QL (3 PENS per 90 days)

Akten Tier 2 M90

AL12 Tier 2 M90

Ala-Cort External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90

Ala-Quin Tier 2 M90

Alavert Oral Tablet Tier 2 M90; QL (QL Flag)

Alavert Oral Tablet Dispersible Tier 2 M90

Alaway Tier 2 M90; QL (QL Flag)

Alaway Childrens Allergy Tier 2 M90; QL (QL Flag)

Albendazole Oral Albenza Tier 2

Albuterol Sulfate ER Tier 2 M90

Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, (5 MG/ML) 0.5%, 0.63 MG/3ML, 1.25 MG/3ML

Tier 2 M90

Albuterol Sulfate Oral Tier 2 M90

Alclometasone Dipropionate External Cream

Tier 2ST; M90; QL (QL Applies)

5

Covered Product Reference Tier Status NotesAlclometasone Dipropionate External Ointment

Tier 2 M90

Aldactazide Oral Tablet 50-50 MG Tier 2 M90

Aldurazyme Tier 2 PA; SP; Dual

Alecensa $0SP; QL (240 EA per 30 days)

Alendronate Sodium Oral Solution Tier 2 M90

Alendronate Sodium Oral Tablet 10 MG, 40 MG, 5 MG


Alendronate Sodium Oral Tablet 35 MG Tier 2M90; QL (4 tablets per 28 days; 13 tablets per 90 days)

Alendronate Sodium Oral Tablet 70 MG Fosamax Tier 2M90; QL (4 tablets per 28 days; 13 tablets per 90 days)

Aler-Cap Banophen Tier 2 M90

AlerTab Alka-Seltzer Plus Allergy Tier 2 M90

Alferon N $0 SP

Alfuzosin HCl ER Uroxatral Tier 2M90; QL (30 EA per 90 days)

Alimta MB PA

Alinia Oral Suspension Reconstituted Tier 2 M90

Aliqopa $0 PA

Alka-Seltzer Plus Allergy Tier 2 M90

Alkeran Oral Tier 1 M90

All Day Allergy Childrens Oral Solution KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

All Day Allergy Childrens Oral Tablet Chewable 10 MG

Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)

All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)

All Day Pain Relief Mediproxen Tier 2 M90

All Day Relief Mediproxen Tier 2 M90

Allegra Allergy Childrens Oral Tablet Dispersible

Tier 2 M90; QL (QL Flag)

Aller-Chlor Diabetic Tussin Allergy Tier 2 M90

Aller-Ease Oral Tablet 60 MG Wal-Fex Allergy Tier 2M90; QL (60 EA per 30 days)

Allergy 24-HR KLS Aller-Fex Tier 2 M90; QL (QL Flag)

Allergy 4 Hour Wal-finate Tier 2 M90

Allergy Childrens Oral Liquid Banophen Tier 2 M90

Allergy Eye Naphcon-A Tier 2 M90

Allergy Eye Drops Alaway Tier 2 M90; QL (QL Flag)

6

Covered Product Reference Tier Status NotesAllergy Medication Banophen Tier 2 M90

Allergy Medication Childrens Banophen Tier 2 M90

Allergy Oral Capsule Banophen Tier 2 M90

Allergy Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)

Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

Allergy Oral Tablet 4 MG Wal-finate Tier 2 M90

Allergy Oral Tablet Dispersible Alavert Tier 2 M90

Allergy Oral Tablet Extended Release Chlor-Trimeton Allergy Tier 2 M90

Allergy Relief Child Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Allergy Relief Childrens Oral Liquid Banophen Tier 2 M90

Allergy Relief Childrens Oral Solution 5 MG/5ML

Claritin Allergy Childrens Tier 2 M90; QL (QL Flag)

Allergy Relief Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Allergy Relief Childrens Oral Tablet Chewable

Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)

Allergy Relief Childrens Oral Tablet Dispersible 10 MG

Alavert Tier 2 M90

Allergy Relief Nighttime Alka-Seltzer Plus Allergy Tier 2 M90

Allergy Spray 24 Hour Nasal Suspension ClariSpray Tier 2 M90

Allergy-Time Wal-finate Tier 2 M90

Allopurinol Oral Zyloprim Tier 2 M90

Almotriptan Malate Tier 2M90; QL (12 tablets per month)

Alocril Tier 2 M90

Aloe Aftersun External Lotion Tier 2 M90

Alogliptin Benzoate Nesina Tier 1PA; M90; QL (30 EA per 90 days)

Alogliptin-Metformin HCl Kazano Tier 2ST; M90; QL (60 EA per 30 days)

Alogliptin-Pioglitazone Oseni Tier 1PA; M90; QL (30 EA per 90 days)

Alomide Tier 2 M90

Alophen Tier 2 M90

Alora Tier 2 M90

Alosetron HCl Lotronex Tier 2 M90

Alphagan P Ophthalmic Solution 0.1 % Tier 2 M90

Alphanate/VWF Complex/Human Tier 2 PA; SP; Dual

AlphaNine SD Tier 2 PA; SP; Dual

7

Covered Product Reference Tier Status NotesALPRAZolam Intensol Tier 2

ALPRAZolam Oral Tablet Xanax Tier 2

Alprolix Tier 2 PA; SP; Dual

Alrex Tier 2 M90

Altabax Tier 2 PA; M90

Altacaine Tier 2 M90

Altafluor Tier 2 M90

Altafrin Ophthalmic Solution 10 %, 2.5 % Tier 2 M90

Altamist Spray Afrin Saline Nasal Mist Tier 1 M90

Altaryl Tier 2 M90

Altavera $0 M90

Alunbrig Oral Tablet 180 MG, 90 MG $0SP; QL (30 EA per 30 days)

Alunbrig Oral Tablet 30 MG $0SP; QL (120 EA per 30 days)

Alunbrig Oral Tablet Therapy Pack $0SP; QL (30 EA per 30 days)

Alvesco Tier 2 PA; M90

Alyacen 1/35 Cyclafem 1/35 $0 M90

Alyacen 7/7/7 Cyclafem 7/7/7 $0 M90

Amabelz Tier 2 M90

Amantadine HCl Oral Capsule Tier 2 M90

Amantadine HCl Oral Syrup Tier 2 M90

Amantadine HCl Oral Tablet Tier 2 M90

Ambrisentan Letairis Tier 2PA; SP; QL (30 EA per 90 days)

Amethia $0 M90

Amethia Lo $0 M90

Amethyst $0 M90

Amifostine Ethyol Tier 1 M90

aMILoride HCl Oral Tier 1 M90

Amiloride-Hydrochlorothiazide Tier 1 M90

Aminoacetic Acid Tier 2 M90

Aminobenzoate Potassium Oral Packet Tier 2 M90

Aminocaproic Acid Intravenous Tier 2 M90

Aminocaproic Acid Oral Solution Amicar Tier 2

Aminocaproic Acid Oral Tablet Amicar Tier 2

Aminofen Aphen Tier 2 M90

8

Covered Product Reference Tier Status NotesAmiodarone HCl Intravenous Solution 150 MG/3ML, 450 MG/9ML

Tier 2 M90

Amiodarone HCl Oral Pacerone Tier 2 M90

Amitriptyline HCl Oral Tier 2 M90

AmLactin Cerapeutic Tier 2 M90

AmLactin External Lotion Tier 2 M90

Amlodipine Besy-Benazepril HCl Tier 1 M90

AmLODIPine Besylate Oral Norvasc Tier 1 M90

Amlodipine-Olmesartan Azor Tier 2 PA; ST; M90

Amlodipine-Valsartan-HCTZ Exforge HCT Tier 1 ST; M90

Ammonium Lactate External AL12 Tier 2 M90

Amondys 45 MB PA

Amoxapine Tier 2 M90

Amoxicill-Clarithro-Lansopraz Tier 2 M90

Amoxicillin Oral Capsule Tier 2 M90

Amoxicillin Oral Suspension Reconstituted

Tier 2 M90

Amoxicillin Oral Tablet Tier 2 M90

Amoxicillin Oral Tablet Chewable 125 MG, 250 MG

Tier 2 M90

Amoxicillin-Pot Clavulanate ER Tier 2 M90

Amoxicillin-Pot Clavulanate Oral Tier 2 M90

Amphadase Tier 2 M90

Amphetamine ER Tier 2 PA

Amphetamine Sulfate Evekeo Tier 2

Amphetamine-Dextroamphetamine Adderall Tier 2QL (90 EA per 30 days)

Ampicillin Tier 2 M90

Anagrelide HCl Agrylin Tier 2 M90

Anastrozole Oral Arimidex $0 M90

Androderm Transdermal Patch 24 Hour Tier 2 ST

AndroGel Transdermal Gel 50 MG/5GM (1%)

Tier 2

Androxy Tier 2

Angeliq Tier 2 M90

Animal Chews Oral Tablet Chewable Bounty Bears/C Tier 2 M90

Animal Shapes Tier 2 M90

Animal Shapes Plus IronLand Before Time Multivitamin

Tier 2 M90

Anoro Ellipta Tier 2 M90

9

Covered Product Reference Tier Status NotesAntacid Calcium Cal-Gest Antacid Tier 2 M90

Antacid Calcium Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

Antacid Extra Strength Oral Tablet Chewable 750 MG

CVS Chewy Not Chalky Flavor

Tier 2 M90

Antacid Maximum Tums Ultra 1000 Tier 2 M90

Antacid Oral Tablet Chewable 500 MG Cal-Gest Antacid Tier 2 M90

Antacid Ultra Strength Oral Tablet Chewable 1000 MG

Tums Ultra 1000 Tier 2 M90

Antara Oral Capsule 30 MG, 90 MG Tier 2 M90

Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

Antifungal (Tolnaftate) Tinactin Tier 2 M90

Anti-Fungal External Cream 1 % Desenex Tier 2 M90

Anti-Hist Allergy Alka-Seltzer Plus Allergy Tier 2 M90

Anti-Itch Maximum Strength External Cream 1 %

Aveeno Anti-Itch Max St Tier 2 M90

Antioxidant A/C/E/Selenium ABC Plus Senior Tier 2 M90

Anti-Oxidant Formula DEKAs Plus Tier 2 M90

Antioxidant Formula Oral Tablet ABC Plus Senior Tier 2 M90

Antioxidant Formula/Minerals DEKAs Plus Tier 2 M90

AntiOxidant Forte ABC Plus Senior Tier 2 M90

Antioxidant Oral Capsule DEKAs Plus Tier 2 M90

Antioxidant Protection Formula ABC Plus Senior Tier 2 M90

Antioxidant Vitamins ABC Plus Senior Tier 2 M90

Anzemet Oral Tier 2M90; QL (1 EA per 30 days)

APAP Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

APAP Oral Tablet 325 MG Aphen Tier 2 M90

APAP Oral Tablet Chewable Childrens Medi-Tabs Tier 2 M90

APAP-Caff-Dihydrocodeine Oral Capsule Trezix Tier 2QL (300 Capsules per 30 days. Click;HERE)

Apatate Forte Tier 2 M90

Aphen Tier 2 M90

Apidra Tier 1 M90

Apidra SoloStar Subcutaneous Solution Pen-Injector

Tier 1 M90

Apokyn Subcutaneous Solution Cartridge Tier 2SP; QL (20 EA per 30 days)

Apra Medi-Tabs Childrens Tier 2 M90

10

Covered Product Reference Tier Status NotesApraclonidine HCl Tier 2 M90

Aprepitant Oral Capsule 125 MG Tier 2M90; QL (4 capsules per 25 days)

Aprepitant Oral Capsule 40 MG Tier 2M90; QL (1 capsule per 25 days)

Aprepitant Oral Capsule 80 MG Emend Tier 2M90; QL (8 capsules per 25 days)

Apri $0 M90

Aptiom Tier 2 M90

Aptivus Oral Capsule Tier 2QL (120 EA per 30 days)

Aptivus Oral Solution Tier 2 QL (300 ml/30 days)

AP-Zel ABC Plus Senior Tier 2 M90

Aqua Glycolic Hand/Body Tier 2 M90

Aqua Lacten Tier 2 M90

Aquaderm Treatment/Moisturizer Tier 2 M90

Aquamed Tier 2 M90

Aralast NP Intravenous Solution Reconstituted 1000 MG, 500 MG

Tier 2 PA; SP; Dual

Aranelle $0 M90

Aranesp (Albumin Free) Injection Solution 10 MCG/0.4ML

Tier 2 PA; SP

Aranesp (Albumin Free) Injection Solution 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 2 PA; SP; Dual

Aranesp (Albumin Free) Injection Solution Prefilled Syringe

Tier 2 PA; SP; Dual

Arbinoxa Oral Tablet Tier 2 M90

Arcalyst Tier 2PA; SP; Dual; QL (8 VIALS per 28 days)

Arcapta Neohaler Tier 2 M90

Arformoterol Tartrate Brovana Tier 2PA; QL (60 ML per 30 days)

Argyle Sterile Saline Tier 2 M90

ARIPiprazole Oral Solution Tier 2M90; QL (150ml per month)

ARIPiprazole Oral Tablet 10 MG, 2 MG, 5 MG

Abilify Tier 2M90; QL (60 EA per 30 days)

ARIPiprazole Oral Tablet 15 MG, 20 MG, 30 MG

Abilify Tier 2M90; QL (30 EA per 90 days)

11


ARIPiprazole Oral Tablet Dispersible Tier 2M90; QL (30 EA per 90 days)

Aristada Initio Tier 2PD; QL (1 SYR per 30 days)

Aristada Intramuscular Prefilled Syringe 1064 MG/3.9ML

Tier 2PD; QL (1 SYR per 60 days)

Aristada Intramuscular Prefilled Syringe 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML


Armodafinil Oral Tablet 150 MG, 200 MG, 250 MG

Nuvigil Tier 2PA; QL (30 EA per 90 days)

Armodafinil Oral Tablet 50 MG Nuvigil Tier 2PA; QL (60 EA per 30 days)

Armour Thyroid Oral Tablet 120 MG, 180 MG, 240 MG, 300 MG

Tier 2 M90

Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 100 MCG/ACT, 50 MCG/ACT

Tier 2 PA

Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 200 MCG/ACT

Tier 2 PA; M90

Arranon $0 M90

Arsenic Trioxide Intravenous Solution 12 MG/6ML

Trisenox $0

Arthritis Pain Midol Tier 2 M90

Arthritis Pain Relief Oral Midol Tier 2 M90

Arthritis Pain Reliever Oral Midol Tier 2 M90

Artificial Tears Ophthalmic Solution 1.4 %

Tier 2 M90

Arzerra $0 SP

Asceniv Tier 2 PA; SP; Dual

Ascomp-Codeine Tier 2 M90

Asenapine Maleate Saphris Tier 2QL (60 EA per 30 days)

Ashlyna $0 M90

Asmanex (120 Metered Doses) Tier 2 M90





Asmanex HFA Inhalation Aerosol 100 MCG/ACT, 200 MCG/ACT

Tier 2 M90

12

Covered Product Reference Tier Status NotesAsmanex HFA Inhalation Aerosol 50 MCG/ACT

Tier 2

Aspirin-Caff-Dihydrocodeine Tier 2M90; QL (300 capsules per 30 days. Click;HERE)

Aspirin-Dipyridamole ER Tier 2 M90

Aspirtab Maximum StrengthBayer Advanced Aspirin Ex St

Tier 2 M90

Astagraf XL Tier 2 SP

Atazanavir Sulfate Reyataz Tier 2 SP

Atenolol Oral Tenormin Tier 1 M90

Atenolol-Chlorthalidone Tenoretic 100 Tier 1 M90

Athletes Foot Spray External Aerosol Tinactin Tier 2 M90

Atomoxetine HCl Strattera Tier 2 ST

Atorvastatin Calcium Oral Lipitor Tier 2M90; QL (30 EA per 90 days)

Atovaquone Oral Mepron Tier 2 M90

Atovaquone-Proguanil HCl Malarone Tier 2 M90

Atropine Sulfate Injection Solution 0.4 MG/ML, 1 MG/ML

Tier 2 M90

Atropine Sulfate Ophthalmic Ointment Tier 2 M90

Atropine Sulfate Ophthalmic Solution 1 % Isopto Atropine Tier 2 M90

Atrovent HFA Tier 2 M90

Aubagio Tier 2PA; SP; QL (30 EA per 90 days)

Aubra $0 M90

Augmentin Oral Suspension Reconstituted 125-31.25 MG/5ML

Tier 2 M90

Auraphene-B Murine Ear Tier 2 M90

Aurora Pen Needles CareFine Pen Needles $0 M90

Aurora Unifine PentipsAdvocate Insulin Pen Needles

$0 M90

Austedo Tier 2 PA

Avandia Oral Tablet 2 MG, 4 MG Tier 2 ST; M90

Avastin $0 PA; SP; Dual

AVC Vaginal Tier 2 M90

Aveed MB PA

Aveeno Active Naturals Daily Tier 2 M90


Aveeno Daily Moisturizing External Lotion

Tier 2 M90

13

Covered Product Reference Tier Status NotesAveeno Positively Ageless Body Tier 2 M90

Aveeno Stress Relief Tier 2 M90

Aviane $0 M90

Avidoxy Tier 2 M90

Avita External Cream Tier 2 M90

Avita External Gel Tier 2 ST; M90

Avonex Tier 2SP; QL (4 SYR per 28 days)

Avonex Pen Intramuscular Auto-Injector Kit

Tier 2SP; QL (1 KIT per 28 days)

Avonex Prefilled Intramuscular Prefilled Syringe Kit

Tier 2SP; QL (1 KIT per 28 days)

Av-Phos 250 Neutral Phospha 250 Neutral Tier 2 M90

Avsola Tier 2PA; SP; Dual; QL (5 VIALS per 42 days)

Ayr Nasal Tier 1 M90

Ayvakit Oral Tablet 100 MG, 200 MG, 300 MG

$0QL (30 EA per 30 days)

Ayvakit Oral Tablet 25 MG $0QL (120 EA per 30 days)

Ayvakit Oral Tablet 50 MG $0QL (60 EA per 30 days)

AzaCITIDine Vidaza $0 SP; QL (QL Flag)

Azasan Tier 2 M90

AzaSite Tier 2 M90

azaTHIOprine Oral Tablet 50 MG Imuran Tier 2 M90

Azelaic Acid External Finacea Tier 2 ST

Azelastine HCl Nasal Solution 0.1 %, 0.15 %

Tier 2 M90

Azelastine HCl Ophthalmic Tier 2ST; M90; QL (6ml per 25 days)

Azelex Tier 2 ST; M90

Azilect Tier 2 M90; QL (QL Flag)

Azithromycin Oral Suspension Reconstituted

Zithromax Tier 2 M90

Azithromycin Oral Tablet 250 MG, 500 MG

Zithromax Tier 2 M90

Azithromycin Oral Tablet 600 MG Tier 2 M90

B-6 (pyridoxine) TABLET 500 MG ORAL

Tier 2 M90

B6 Natural Tier 2 M90

14

Covered Product Reference Tier Status NotesBaby Ayr Saline Tier 1 M90

Baby Ease Tier 2 M90

Baby Super Daily D3 Oral Liquid 400 UT/0.028ML

Baby Ddrops Tier 2 M90

Baby Vitamin D3 Oral Liquid 400 UT/0.028ML

Baby Ddrops Tier 2 M90

Bacitracin External Bacitraycin Plus Tier 2 M90

Bacitracin Ophthalmic Tier 2 M90

Bacitracin-Polymyxin B Ophthalmic Ointment 500-10000 UNIT/GM

Polycin Tier 2 M90

Bacitra-Neomycin-Polymyxin-HC Neo-Polycin HC Tier 2 M90

Bacitraycin Plus External Ointment 500 UNIT/GM

Tier 2 M90

Baclofen Oral Tablet 10 MG, 20 MG Tier 2 M90

Bactroban Nasal Tier 2 PA; M90

Bafiertam Tier 2PA; SP; QL (120 EA per 30 days)

Balcoltra $0

Balsalazide Disodium Colazal Tier 2 M90

Balversa Oral Tablet 3 MG $0PA; SP; QL (84 EA per 28 days)



Balziva $0 M90

Banophen Oral Tier 2 M90

Banzel Oral Tablet 200 MG Tier 2M90; QL (120 EA per 30 days)

Banzel Oral Tablet 400 MG Tier 2M90; QL (240 tablets per month)

Baqsimi One Pack Tier 2 PD

Baqsimi Two Pack Tier 2 PD

Baraclude Oral Solution Tier 2 SP; QL (QL Flag)

Basaglar KwikPen Tier 1 PA

Basic AM ABC Plus Senior Tier 2 M90

Basic PM ABC Plus Senior Tier 2 M90

Bavencio MB PA

Baxdela Oral Tier 2

Bayer Advanced Aspirin Ex St Tier 2 M90

Bayer Aspirin Extra Strength Tier 2 M90

15

Covered Product Reference Tier Status NotesBayer Low Dose Oral Tablet Chewable Tier 2 M90

Baza Antifungal Tineacide Tier 2 M90

BCG Vaccine $0 M90

BD AutoShield 29G X 5MM , 29G X 8MM

Tier 1 M90

BD AutoShield Duo $0 M90

BD Pen Needle Mini U/F $0 M90

BD Pen Needle Original U/F $0 M90

BD PosiFlush Intravenous Tier 2 M90

Beauty LotionA + D Personal Care Lotion

Tier 2 M90

Bebulin Tier 2 PA; SP

Bedding Spray Lice Treatment RID Tier 2 M90

Bekyree $0 M90

Beleodaq $0 SP

Belladonna Alkaloids-Opium Rectal Suppository 16.2-60 MG

Tier 2

Belsomra Tier 2PA; QL (30 EA per 30 days)

Benazepril HCl Oral Lotensin Tier 1 M90

Benazepril-hydroCHLOROthiazide Tier 1 M90

Bendeka $0 SP

BeneFIX Intravenous Kit Tier 2 PA; SP; PD; Dual

Benlysta Intravenous MB PA

Benlysta Subcutaneous Solution Auto-Injector

MBPA; QL (4 PENS per 28 days)

Benlysta Subcutaneous Solution Prefilled Syringe

MBPA; QL (4 SYR per 28 days)

Bensal HP Tier 2 M90

BenzePrO Creamy Wash Tier 2 M90

Benznidazole Tier 2

Benzoyl Peroxide Cleanser External Lotion 6 %

Tier 2 M90

Benzoyl Peroxide External Gel 10 %Clean & Clear Persa-Gel Max St

Tier 2 M90

Benzoyl Peroxide External Gel 2.5 %, 5 % Tier 2 M90

Benzoyl Peroxide Wash External Liquid 10 %

PanOxyl Foaming Wash Tier 2 M90

Benzoyl Peroxide Wash Liquid 10 % External External Liquid 10 %

PanOxyl Foaming Wash Tier 2 M90

Benztropine Mesylate Oral Tier 2 M90

16

Covered Product Reference Tier Status NotesBeovu Tier 2 PA; SP; Dual

Bepreve Tier 2ST; M90; QL (5ml per 25 days)

Berinert Tier 2PA; SP; QL (QL Flag); Dual

Besivance Tier 2 M90

Besponsa MB PA

Beta Care External LotionA + D Personal Care Lotion

Tier 2 M90

Betadine Ophthalmic Prep Tier 2 M90

Betamethasone Dipropionate Aug External Cream

Diprolene AF Tier 2 M90

Betamethasone Dipropionate Aug External Gel


Betamethasone Dipropionate Aug External Lotion


Betamethasone Dipropionate Aug External Ointment

Diprolene Tier 2 M90

Betamethasone Dipropionate External Cream

Tier 2 M90

Betamethasone Dipropionate External Lotion

Tier 2 M90

Betamethasone Dipropionate External Ointment


Betamethasone Valerate External Cream Tier 2 M90

Betamethasone Valerate External Foam Luxiq Tier 2 ST; QL (QL Applies)

Betamethasone Valerate External Lotion Tier 2 M90

Betamethasone Valerate External Ointment

Tier 2 M90

Betaseron Subcutaneous Kit Tier 2SP; QL (14 per 28 days)

BetaTemp Childrens PediaCare Children Tier 2 M90

Betaxolol HCl Ophthalmic Tier 2 M90

Betaxolol HCl Oral Tier 1 M90

Bethanechol Chloride Oral Tier 2 M90

Betimol Tier 2 M90

Betoptic-S Tier 2 M90

Bevacizumab Intraocular Tier 2 PA; SP

Bevespi Aerosphere Tier 2

Bexarotene Targretin $0 SP; QL (QL Flag)

Bexsero $0 M90

17

Covered Product Reference Tier Status NotesBicalutamide Casodex $0 M90

Bicarsim Oral Tablet 80 MG Tier 2 M90

BiCNU $0 M90

Bijuva Tier 2 PA

Biktarvy Tier 2PD; QL (30 EA per 30 days)

Bimatoprost External Latisse Tier 2 M90

Bimatoprost Ophthalmic Tier 2 M90

Bio Glo Tier 2 M90

Biocal DEKAs Plus Tier 2 M90

Biocel ABC Plus Senior Tier 2 M90

Bio-Statin Tier 2 M90

Biosupp BProtected Multi-Vite Tier 2 M90

Biotect Plus Oral Liquid Tier 2 M90

BioThrax $0 M90

Biotin Plus/Calcium/Vit D3 ABC Plus Senior Tier 2 M90

Bisac-Evac Rectal Tier 2 M90

Bisacodyl EC Alophen Tier 2 M90

Bisacodyl Laxative Rectal The Magic Bullet Tier 2 M90

Bisacodyl Rectal The Magic Bullet Tier 2 M90

Biscolax The Magic Bullet Tier 2 M90

Bismatrol Oral Suspension Kaopectate Tier 2 M90

Bisoprolol Fumarate Oral Tier 1 M90

Bisoprolol-Hydrochlorothiazide Ziac Tier 1 M90

Bite-A-Mins Bounty Bears/C Tier 2 M90

Bite-A-Mins/IronLand Before Time Multivitamin

Tier 2 M90

Bivigam Tier 2 PA; SP; Dual

Blenrep MB PA

Bleo 15K Tier 1 M90

Bleomycin Sulfate $0 M90

Blephamide Tier 2 M90

Blephamide S.O.P. Tier 2 M90

Blincyto $0 SP

Blisovi 24 Fe $0 M90

Blisovi Fe 1.5/30 $0 M90

Blisovi FE 1/20 $0 M90

Blis-To-Sol External Liquid Tier 2 M90

18


Blood Pressure Monitor 7 $0M90; QL (QL Flag); QL (1 EA per 3 YEARs)

Body/Hair/Skin/Nails DEKAs Plus Tier 2 M90

Bonjesta Tier 2PA; QL (60 EA per 30 days)

Boostrix Intramuscular Suspension 5-2.5-18.5

$0 M90

Boric Acid External Granules Tier 2 M90

Bosentan Tracleer Tier 2PA; SP; QL (60 EA per 30 days)

Bosulif Oral Tablet 100 MG $0SP; PD; QL (90 EA per 30 days)

Bosulif Oral Tablet 400 MG, 500 MG $0SP; PD; QL (30 EA per 30 days)

Botox Tier 2PA; QL (QL Flag); Dual

Boudreauxs Butt Paste Tier 2 M90

Bounty Bears/C Tier 2 M90

BP 10-1 Tier 2 M90

BP Foaming Wash PanOxyl Foaming Wash Tier 2 M90

BP Gel External Gel 10 %Clean & Clear Persa-Gel Max St

Tier 2 M90

BP Gel External Gel 5 % Tier 2 M90

BP Wash External Liquid 10 % PanOxyl Foaming Wash Tier 2 M90

BP Wash External Liquid 2.5 % PanOxyl Tier 2 M90

BP Wash External Liquid 7 % BenzePrO Creamy Wash Tier 2 M90

B-Plex Plus ABC Plus Senior Tier 2 M90

BPO-10 Wash PanOxyl Foaming Wash Tier 2 M90

BProtected Multi-Vite Tier 2 M90

BProtected Pedia Iron $0 M90

BProtected Pedia Poly-Vite/Fe Tier 2 M90

Braftovi Oral Capsule 75 MG $0SP; QL (180 EA per 30 days)

B-Redi/Red Hearts/Red Roosters ABC Plus Senior Tier 2 M90

Breo Ellipta Tier 2PA; M90; QL (1 EA per 30 days)

Briellyn Balziva $0 M90

Brilinta Tier 2M90; QL (60 EA per 30 days)

Brimonidine Tartrate Ophthalmic Tier 2 M90

19

Covered Product Reference Tier Status NotesBrineura MB PA

Brinzolamide Azopt Tier 2

Bromfenac Sodium (Once-Daily) Tier 2ST; M90; QL (1.7ml per 25 days)

Bromfenac Sodium Ophthalmic Tier 2ST; M90; QL (5ml per 25 days)

Bromocriptine Mesylate Oral Parlodel Tier 2 M90

Brompheniramine Tannate Oral Tablet Chewable

Tier 2 M90

Bronchitol Tier 2PA; QL (600 EA per 30 days)

Brukinsa $0PA; SP; QL (120 EA per 30 days)

Bucalsep Tier 2 M90

Budesonide ER Oral Tablet Extended Release 24 Hour

Uceris Tier 2QL (112 tablets per year (a rolling 365 days))

Budesonide Inhalation Pulmicort Tier 2 M90

Budesonide Nasal Tier 2 ST; M90

Budesonide Oral Entocort EC Tier 2 M90

Bumetanide Injection Tier 1 M90

Bumetanide Oral Bumex Tier 1 M90

Bunavail Tier 2PA; QL (60 EA per 30 days)

Buphenyl Oral Tablet Tier 2 SP; QL (QL Flag)

Bupivacaine HCl (PF) Injection Solution 0.75 %

Sensorcaine-MPF Tier 2 M90

Bupivacaine HCl Injection Solution 0.25 %, 0.5 %

Sensorcaine Tier 2 M90

Bupivacaine-Epinephrine Injection Solution 0.25% -1:200000, 0.5% -1:200000

Sensorcaine/EPINEPHrine

Tier 2 M90

Buprenex Tier 2 PA; M90

Buprenorphine HCl Injection Solution 0.3 MG/ML

Buprenex Tier 2 PA

Buprenorphine HCl Sublingual Tier 2PA; QL (90 EA per 30 days)

Buprenorphine HCl-Naloxone HCl Sublingual Tablet Sublingual


Buprenorphine Transdermal Butrans Tier 2ST; QL (4 patches per 30 days)

BuPROPion HCl ER (Smoking Det) $0 M90

20

Covered Product Reference Tier Status NotesbuPROPion HCl ER (SR) Wellbutrin SR Tier 2 M90

BuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG, 300 MG

Wellbutrin XL Tier 2 M90

buPROPion HCl Oral Tier 2 M90

Buried Treasure Active 55 Plus Tier 2 M90

busPIRone HCl Oral Tier 2 M90

Busulfex Tier 1 M90

Butalbital-Acetaminophen Oral Tablet 50-325 MG

Tencon Tier 2 M90

Butalbital-APAP-Caff-Cod Oral Capsule 50-300-40-30 MG

Fioricet/Codeine Tier 2

Butalbital-APAP-Caff-Cod Oral Capsule 50-325-40-30 MG

Tier 2 M90

Butalbital-APAP-Caffeine Oral Capsule Esgic Tier 2 M90

Butalbital-APAP-Caffeine Oral Tablet 50-325-40 MG

Bac Tier 2 M90

Butalbital-ASA-Caff-Codeine Ascomp-Codeine Tier 2

Butalbital-ASA-Caffeine Tier 2 M90

Butalbital-Aspirin-Caffeine Oral Capsule Tier 2

Butisol Sodium Oral Tablet 30 MG Tier 2

Butorphanol Tartrate Injection Tier 2

Butorphanol Tartrate Nasal Tier 2

Bydureon BCise Tier 2 PA

Bydureon Subcutaneous Pen-Injector Tier 2QL (4 pens per 28 days)

Byetta 10 MCG Pen Subcutaneous Solution Pen-Injector

Tier 2BP; QL (2 pens per 28 days)

Byetta 5 MCG Pen Subcutaneous Solution Pen-Injector

Tier 2BP; QL (1 pen per 28 days)

Bynfezia Pen Tier 2PA; SP; Dual; QL (6 PENS per 30 days)

Cabenuva MB PD

Cabergoline Tier 2 M90

Cablivi Tier 2 PA; SP; Dual

Cabometyx $0PA; SP; QL (30 EA per 30 days)

Caffeine Citrate Oral Tier 2 M90

Calamine External Lotion Tier 2 M90

Calamine-Zinc Oxide External Lotion Tier 2 M90

Calcidol Oral Solution 8000 UNIT/ML Tier 2 M90

21

Covered Product Reference Tier Status NotesCalciferol Oral Solution 8000 UNIT/ML Tier 2 M90

CalciFol Tier 2 M90

Calcipotriene External Cream Dovonex Tier 2PA; M90; QL (60 GM per 30 days)

Calcipotriene External Ointment Calcitrene Tier 2 PA; M90

Calcipotriene External Solution Tier 2PA; M90; QL (60 ML per 30 days)

Calcipotriene-Betameth Diprop External Ointment

Taclonex Tier 2PA; M90; QL (60 GM per 30 days)

Calcitonin (Salmon) Nasal Miacalcin Tier 2 M90

Calcitrate Oral Tablet 315-250 MG-UNIT, 950 MG

Tier 2 M90

Calcitrate Plus D Tier 2 M90

Cal-Citrate Plus Vitamin D Tier 2 M90

Calcitrene Tier 2 PA; M90

Calcitriol External Vectical Tier 2PA; M90; QL (60 GM per 30 days)

Calcitriol Oral Rocaltrol Tier 2 M90

Calcium + D Oral Tablet 315-200 MG-UNIT

Tier 2 M90

Calcium + D3 Oral Tablet 600-200 MG-UNIT

Tier 2 M90

Calcium 1000 + D Tier 2 M90

Calcium 1200 Tier 2 M90

Calcium 500 + D Oral Tablet 500-125 MG-UNIT

Tier 2 M90

Calcium 500 + D3 Oral Tablet 500-600 MG-UNIT

Os-Cal Extra D3 Tier 2 M90

Calcium 500 +D Oystercal-D Tier 2 M90

Calcium 500/D Os-Cal Calcium + D3 Tier 2 M90

Calcium 500/Vitamin D Tier 2 M90

Calcium 500+D Oystercal-D Tier 2 M90

Calcium 500+D High Potency Oystercal-D Tier 2 M90

Calcium 500+D3 Oral Tablet 500-400 MG-UNIT

Oystercal-D Tier 2 M90

Calcium 600 Tier 2 M90

Calcium 600 + D Tier 2 M90

Calcium 600 + Minerals Tier 2 M90

Calcium 600 High Potency Tier 2 M90

Calcium 600/Vitamin D Oral Tablet Tier 2 M90

Calcium 600/Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90

22

Covered Product Reference Tier Status NotesCalcium 600+D Tier 2 M90

Calcium 600+D High Potency Tier 2 M90

Calcium 600+D Plus Minerals Tier 2 M90

Calcium 600+D3 Tier 2 M90

Calcium 600+D3 Plus MineralsCaltrate 600+D Plus Minerals

Tier 2 M90

Calcium 600-D Tier 2 M90

Calcium Acetate (Phos Binder) Calphron Tier 2 M90

Calcium Antacid Cal-Gest Antacid Tier 2 M90

Calcium Antacid Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

Calcium Antacid Ultra Tums Ultra 1000 Tier 2 M90

Calcium Antacid Ultra Max St Tums Ultra 1000 Tier 2 M90

Calcium Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

Calcium Carb-Cholecalciferol Oral Tablet 500-125 MG-UNIT

Tier 2 M90

Calcium Carbonate Antacid Oral Tablet Chewable

Cal-Gest Antacid Tier 2 M90

Calcium Carbonate Oral Tablet 1500 (600 Ca) MG, 600 MG

Tier 2 M90

Calcium Carbonate-Vitamin D Oral Capsule

Tier 2 M90

Calcium Carbonate-Vitamin D Oral Tablet 500-400 MG-UNIT, 600-400 MG-UNIT

Tier 2 M90

Calcium Carbonate-Vitamin D3 Tier 2 M90

Calcium Citrate + D Oral Tablet 250-200 MG-UNIT, 315-200 MG-UNIT

Tier 2 M90

Calcium Citrate + D Oral Tablet 315-250 MG-UNIT

Calcitrate Tier 2 M90

Calcium Citrate + D3 Maximum Calcitrate Tier 2 M90

Calcium Citrate + D3 Oral Tablet 200-250 MG-UNIT

Citracal Petites/Vitamin D

Tier 2 M90

Calcium Citrate + D3 Oral Tablet 250-200 MG-UNIT

Tier 2 M90

Calcium Citrate + Oral Tablet 315-200 MG-UNIT

Tier 2 M90

Calcium Citrate +D Calcitrate Tier 2 M90

Calcium Citrate Maximum/Vit D Calcitrate Tier 2 M90

Calcium Citrate Oral Tablet 1040 MG, 200 MG, 250 MG, 950 (200 Ca) MG

Tier 2 M90

Calcium Citrate Petite/Vit DCitracal Petites/Vitamin D

Tier 2 M90

23

Covered Product Reference Tier Status NotesCalcium Citrate+D3 Calcitrate Tier 2 M90

Calcium Citrate+D3 PetitesCitracal Petites/Vitamin D

Tier 2 M90

Calcium Citrate-Vitamin D Oral Tablet 200-125 MG-UNIT, 250-50 MG-UNIT, 315-200 MG-UNIT

Tier 2 M90

Calcium Citrate-Vitamin D Oral Tablet 315-250 MG-UNIT

Calcitrate Tier 2 M90

Calcium Citrate-Vitamin D3 Calcitrate Tier 2 M90

Calcium High Potency Tier 2 M90

Calcium High Potency/Vitamin D Tier 2 M90

Calcium Oral Tablet 500-125 MG-UNIT, 600-200 MG-UNIT

Tier 2 M90

Calcium Oral Tablet Chewable 500-100 MG-UNIT, 600-400 MG-UNIT

Tier 2 M90

Calcium Oyster Shell Oral Tablet 500 MG Oystercal Tier 2 M90

Calcium Plus Vitamin D Oral Capsule Tier 2 M90

Calcium Plus Vitamin D3 Tier 2 M90

Calcium+D3 Oral Tablet 600-800 MG-UNIT

Pronutrients Calcium+D3 Tier 2 M90

Calcium-Carb 600 Tier 2 M90

Calcium-Carb 600 + D Tier 2 M90

Calcium-Vitamin D Oral Tablet 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT, 600-400 MG-UNIT

Tier 2 M90

Calcium-Vitamin D Oral Tablet 500-200 MG-UNIT

Os-Cal Calcium + D3 Tier 2 M90

Calcium-Vitamin D Oral Tablet 500-400 MG-UNIT


Calcium-Vitamin D3 Oral Capsule 600-500 MG-UNIT

Tier 2 M90

Calcium-Vitamin D3 Oral Tablet 500-400 MG-UNIT


Calcium-Vitamin D3 Oral Tablet 600-125 MG-UNIT, 600-400 MG-UNIT

Tier 2 M90

Calcium-Vitamin D-Minerals Oral Tablet Chewable 600-400 MG-UNIT

Tier 2 M90


Calquence $0SP; QL (120 EA per 30 days)

Cal-Quick Tier 2 M90

Caltrate 600+D3 Soft Tier 2 M90

24

Covered Product Reference Tier Status NotesCam Tier 2 M90

Camila $0 M90

Camrese $0 M90

Camrese Lo $0 M90

Candesartan Cilexetil Atacand Tier 1 ST; M90

Candesartan Cilexetil-HCTZ Atacand HCT Tier 1 ST; M90

Capacet Tier 2 M90

Capecitabine Oral Tablet 150 MG Xeloda $0SP; QL (120 EA per 30 days)

Capecitabine Oral Tablet 500 MG Xeloda $0SP; QL (300 tablets per 30 days)

Capex Tier 2 ST; QL (QL Applies)

Caplyta Tier 2PA; QL (30 EA per 30 days)

Caprelsa Oral Tablet 100 MG $0QL (60 EA per 30 days)

Caprelsa Oral Tablet 300 MG $0QL (30 EA per 30 days)

Capsaicin External Cream 0.025 % DermacinRx Penetral Tier 2 M90

Capsaicin External Cream 0.1 % Capzasin-HP Tier 2 M90

Capsaicin HP Capzasin-HP Tier 2 M90

Captopril Oral Tier 1 M90

Captopril-hydroCHLOROthiazide Tier 1 M90

Capzasin-P Tier 2 M90

Carbaglu Tier 2 PA; M90

CarBAMazepine ER Carbatrol Tier 2 M90

carBAMazepine Oral Tier 2 M90

Carbidopa Oral Lodosyn Tier 2 M90

Carbidopa-Levodopa Sinemet Tier 2 M90

Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG, 50-200 MG

Tier 2 M90

Carbidopa-Levodopa-Entacapone Stalevo 50 Tier 2 M90

Carbinoxamine Maleate Oral Solution Tier 2 M90

Carbinoxamine Maleate Oral Tablet 4 MG Tier 2 M90

CARBOplatin Intravenous Solution Paraplatin $0 M90

Cardizem LA Oral Tablet Extended Release 24 Hour 120 MG

Tier 2 M90


CareOne Unifine Pentips CareFine Pen Needles $0 M90

25

Covered Product Reference Tier Status NotesCareOne Unifine Pentips Plus 29G X 12MM , 31G X 6 MM


CareOne Unifine Pentips Plus 31G X 5 MM , 31G X 8 MM


$0 M90

CareOne Unifine Pentips Plus 32G X 4 MM


Carimune NF Intravenous Solution Reconstituted 12 GM, 6 GM

Tier 2 PA; SP; Dual

Carisoprodol Oral Tablet 350 MG Soma Tier 2M90; QL (90 EA per 30 days)

Carisoprodol-Aspirin Tier 2 ST

Carisoprodol-Aspirin-Codeine Tier 2 ST

Carrington Antifungal Tier 2 M90

Carteolol HCl Tier 2 M90

Carters Little Pills Tier 2 M90

Cartia XT Tier 1 M90

Carvedilol Coreg Tier 1 M90

Carvedilol Phosphate ER Coreg CR Tier 2

Cavarest Tier 2 M90

Caya Tier 2 M90; QL (QL Flag)

Cayston Tier 2 QL (84 per 28 days)

Caziant $0 M90

Cefaclor Tier 2 M90

Cefadroxil Tier 2 M90

Cefdinir Tier 2 M90

Cefditoren Pivoxil Tier 2 M90

Cefixime Oral Capsule Suprax Tier 2

Cefixime Oral Suspension Reconstituted Suprax Tier 2 M90

Cefpodoxime Proxetil Tier 2 M90

Cefprozil Tier 2 M90

Ceftibuten Tier 2 M90

Ceftin Oral Suspension Reconstituted Tier 2 M90

CefTRIAXone Sodium Injection Tier 2 M90

CefTRIAXone Sodium Intravenous Tier 2 M90

Cefuroxime Axetil Oral Tablet Tier 2 M90

Celecoxib Oral CeleBREX Tier 2 PA; M90

Cellular Security DEKAs Plus Tier 2 M90

Celontin Tier 2 M90

Centamin BProtected Multi-Vite Tier 2 M90

26

Covered Product Reference Tier Status NotesCentaVite BProtected Multi-Vite Tier 2 M90

Centavite A-Z Complete-Mineral ABC Plus Senior Tier 2 M90

Centravites ABC Plus Senior Tier 2 M90

Centravites 50 Plus ABC Plus Senior Tier 2 M90

Century Mature ABC Plus Senior Tier 2 M90

Cephalexin Oral Capsule 250 MG, 500 MG

Tier 2 M90

Cephalexin Oral Suspension Reconstituted Tier 2 M90

CeraLyte 70 Oral Solution Tier 2 M90

CeraSport EX1 Oral Solution Tier 2 M90

CeraSport Oral Solution Tier 2 M90

CeraVe AM SPF 30 Tier 2 M90

CeraVe External Lotion Tier 2 M90

CeraVe PM Tier 2 M90

CeraVe SA Renewing External Lotion Tier 2 M90

Cerdelga Tier 2PA; SP; QL (60 EA per 30 days)

Cerezyme MB PA

Cerisa Wash Tier 2 M90

Cerovel External Gel Tier 2 M90

Cerovel External Lotion Tier 2 M90

Cerovite Advanced Formula Oral Liquid Tier 2 M90

Certa Plus ABC Plus Senior Tier 2 M90

Certagen Oral Tablet ABC Plus Senior Tier 2 M90

CertaVite/Antioxidants Oral Liquid Tier 2 M90

Cervarix Tier 1 M90

Cervidil Tier 2 M90

Cesamet Tier 2QL (60 EA per 30 days)

Cetaphil Daily Advance Tier 2 M90

Cetaphil Daily Facial Moist Tier 2 M90

Cetaphil DermaControl/SPF 30 Tier 2 M90

Cetaphil Moisturizing External Lotion Tier 2 M90

Cetaphil RestoraDerm External Lotion Tier 2 M90

Cetirizine HCl Allergy Child KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

Cetirizine HCl Childrens Alrgy Oral Syrup 1 MG/ML

KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

Cetirizine HCl Childrens Oral Solution 1 MG/ML


27

Covered Product Reference Tier Status NotesCetirizine HCl Hives Relief KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

Cetirizine HCl Oral Solution 1 MG/ML KLS Aller-Tec Childrens Tier 2 M90

Cetirizine HCl Oral Syrup 1 MG/ML KLS Aller-Tec Childrens Tier 2 M90

Cetirizine HCl Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)

Cetirizine HCl Oral Tablet Chewable Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)

Cevimeline HCl Evoxac Tier 2 M90

Chantix $0 M90; QL (QL Flag)

Chantix Continuing Month Pak $0 M90; QL (QL Flag)

Chantix Starting Month Pak $0 M90; QL (QL Flag)

Chateal $0 M90

Chelated Zinc IS-ZC 50 Tier 2 M90

Chemet Tier 2 M90

Chenodal Tier 2 M90

Chewable Vite Childrens Bounty Bears/C Tier 2 M90

Chewable Vite/Iron ChildrensLand Before Time Multivitamin

Tier 2 M90

Child Chewable Vitamins/IronLand Before Time Multivitamin

Tier 2 M90

Childrens Acetaminophen Oral Suspension 160 MG/5ML

PediaCare Children Tier 2 M90

Childrens Allergy Banophen Tier 2 M90

Childrens APAP Childrens Medi-Tabs Tier 2 M90

Childrens Aspirin Free PediaCare Children Tier 2 M90

Childrens Chewable Multi Vits Bounty Bears/C Tier 2 M90

Childrens Chewable Vitamins Bounty Bears/C Tier 2 M90

Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

Childrens Ibuprofen 100 Childrens Medi-Profen Tier 2 M90

Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Childrens Medi-Profen Tier 2 M90


Childrens Multivitamin/IronLand Before Time Multivitamin

Tier 2 M90

Childrens Non-ASA Pain Relief Childrens Medi-Tabs Tier 2 M90

Childrens Non-Aspirin Oral Suspension PediaCare Children Tier 2 M90

Childrens Non-Aspirin Oral Tablet Chewable


Childrens Pain Reliever Oral Suspension PediaCare Children Tier 2 M90

Childrens Pain Reliever Oral Tablet Chewable


28

Covered Product Reference Tier Status NotesChildrens Silapap Little Remedies for Fever Tier 2 M90

Childrens Silfedrine Sudafed Childrens Tier 2 M90

Childrens Tactinal Childrens Medi-Tabs Tier 2 M90

Childrens Vitamins/IronLand Before Time Multivitamin

Tier 2 M90

Childs Ibuprofen Childrens Medi-Profen Tier 2 M90

Chloraseptic Sore Throat Oral Tier 2 M90

ChlordiazePOXIDE HCl Tier 2 M90

Chlordiazepoxide-Amitriptyline Tier 2

chlordiazePOXIDE-Clidinium Librax Tier 2 M90

Chlorhexidine Gluconate Mouth/Throat Paroex Tier 2 M90

ChlorHist Wal-finate Tier 2 M90

Chloromag Tier 2 M90

Chloroquine Phosphate Oral Tier 2

Chlorothiazide Oral Tier 1 M90

Chlorphen SR Tier 2 M90

Chlorpheniramine Maleate ER Chlor-Trimeton Allergy Tier 2 M90

Chlorpheniramine Maleate Oral Wal-finate Tier 2 M90

Chlorpheniramine Maleate Syrup 2 MG/5ML

Diabetic Tussin Allergy Tier 2 M90

chlorproMAZINE HCl Injection Tier 2 M90

chlorproMAZINE HCl Oral Tablet Tier 2 M90

chlorproPAMIDE Tier 1 M90

Chlorthalidone Oral Tablet 100 MG, 25 MG

Tier 1 M90

Chlorthalidone Oral Tablet 50 MG Tier 2 M90

Chlorzoxazone Oral Tablet 500 MG Tier 2 M90

Cholestyramine Light Prevalite Tier 1 M90

Cholestyramine Oral Questran Tier 1 M90

Choline & Mag Trisalicylate Oral Tablet 1000 MG

Tier 2 M90

Choline-Mag Trisalicylate Tier 2 M90

Ciclodan External Cream Tier 2 M90

Ciclodan External Solution Tier 2 M90; QL (QL Flag)

Ciclopirox External Gel Tier 2 PA; M90

Ciclopirox External Shampoo Loprox Tier 2 PA; M90

Ciclopirox External Solution Ciclodan Tier 2PA; M90; QL (6.6ml per 90 days)

Ciclopirox Olamine External Loprox Tier 2 PA; M90

29

Covered Product Reference Tier Status NotesCilostazol Tier 2 M90

Cimduo Tier 2

Cimetidine 200 Tagamet HB Tier 2 M90

Cimetidine Acid Reducer Tagamet HB Tier 2 M90

Cimetidine HCl Oral Solution 300 MG/5ML

Tier 2 M90

Cimetidine Oral Tagamet HB Tier 2 M90

Cimzia Prefilled Tier 2PA; SP; QL (4 SYR per 28 days)

Cimzia Starter Kit Tier 2PA; SP; QL (1 KIT per 28 days)

Cimzia Subcutaneous Kit 2 X 200 MG Tier 2PA; SP; QL (4 SYR per 28 days)

Cinacalcet HCl Oral Tablet 30 MG, 60 MG

Sensipar Tier 2PA; SP; QL (60 EA per 30 days)

Cinacalcet HCl Oral Tablet 90 MG Sensipar Tier 2PA; SP; QL (120 EA per 30 days)

Cinqair MBPA; QL (3 VIALS per 28 days)

Cinryze Tier 2PA; SP; QL (QL Flag); Dual

Cinvanti Tier 2

Cipro HC Tier 2 M90

Ciprofloxacin HCl Ophthalmic Ciloxan Tier 2 M90

Ciprofloxacin HCl Oral Tier 2 M90

Ciprofloxacin HCl Otic Cetraxal Tier 2 M90

Ciprofloxacin Oral Cipro Tier 2 M90

Ciprofloxacin-Ciproflox HCl ER Tier 2 M90

Ciprofloxacin-Dexamethasone Ciprodex Tier 2

CISplatin Intravenous Solution 100 MG/100ML, 200 MG/200ML, 50 MG/50ML

$0 M90

Citalopram Hydrobromide Oral Solution Tier 2 M90

Citalopram Hydrobromide Oral Tablet 10 MG

CeleXA Tier 2M90; QL (90 EA per 30 days)


CeleXA Tier 2M90; QL (75 tablets per month)


CeleXA Tier 2M90; QL (45 tablets per month)

Citric Acid-Sodium Citrate Tier 2 M90

Citroma Tier 2 M90

30

Covered Product Reference Tier Status NotesCitrus Calcium +D Calcitrate Tier 2 M90

Citrus Calcium/Vitamin D Oral Tablet 200-250 MG-UNIT

Citracal Petites/Vitamin D

Tier 2 M90

Cladribine Intravenous Solution 10 MG/10ML

$0 M90

Claravis Tier 2 M90

Clarinex Oral Syrup Tier 2 QL (300ml per month)

Clarinex-D 12 Hour Tier 2M90; QL (60 EA per 30 days)

ClariSpray Tier 2 M90

Clarithromycin ER Tier 2 M90

Clarithromycin Oral Tier 2 M90

Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Claritin Eye Tier 2 M90; QL (QL Flag)

Classic Prenatal Tier 1 M90

Clean & Clear Persa-Gel Max St Tier 2 M90

ClearLax Oral Powder Tier 2 M90

Clearplex V Tier 2 M90

Clearplex X Tier 2 M90

Clemastine Fumarate Oral Tablet 2.68 MG

Tier 2 M90

Clever Choice Comfort EZ 29G X 12MM $0 M90

Clever Choice Comfort EZ 33G X 4 MM Tier 1 M90

Clickfine Pen Needles 31G X 6 MM CareFine Pen Needles $0 M90

Clickfine Pen Needles 31G X 8 MMAdvocate Insulin Pen Needles

$0 M90

Clickfine Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90

Climara Pro Tier 2 M90

Clindacin ETZ External Swab Tier 2 M90

Clindacin-P Tier 2 M90

ClindaMax External Gel Tier 2 M90

Clindamycin HCl Oral Cleocin Tier 2 M90

Clindamycin Palmitate HCl Cleocin Tier 2 M90

Clindamycin Phosphate External Gel Clindagel Tier 2 M90

Clindamycin Phosphate External Lotion Cleocin-T Tier 2 M90

Clindamycin Phosphate External Solution Tier 2 M90

Clindamycin Phosphate External Swab Clindacin ETZ Tier 2 M90

Clindamycin Phosphate Vaginal Cleocin Tier 2 M90

CLn Facial Moisturizer Nourish Tier 2 M90

31

Covered Product Reference Tier Status NotesCloBAZam Oral Suspension Onfi Tier 2 QL (480ml per month)

CloBAZam Oral Tablet 10 MG Onfi Tier 2QL (90 EA per 30 days)

CloBAZam Oral Tablet 20 MG Onfi Tier 2QL (60 EA per 30 days)

Clobetasol Propionate E Tier 2 PA; M90

Clobetasol Propionate Emulsion Olux-E Tier 2 PA; M90

Clobetasol Propionate External Cream Temovate Tier 2ST; M90; QL (QL Applies)

Clobetasol Propionate External Foam Olux Tier 2 PA; M90

Clobetasol Propionate External Gel Tier 2ST; M90; QL (QL Applies)

Clobetasol Propionate External Liquid Clobex Spray Tier 2 ST; QL (QL Applies)

Clobetasol Propionate External Lotion Clobex Tier 2 ST; QL (QL Applies)

Clobetasol Propionate External Ointment Temovate Tier 2ST; M90; QL (QL Applies)

Clobetasol Propionate External Shampoo Clobex Tier 2ST; M90; QL (QL Applies)

Clobetasol Propionate External Solution Tier 2 PA; M90

Clocortolone Pivalate Cloderm Tier 2 QL (QL Applies)

Clocortolone Pivalate Pump Cloderm Tier 2 PA; M90

Clolar Tier 1 M90

ClomiPRAMINE HCl Oral Anafranil Tier 2 M90

clonazePAM Oral Tablet KlonoPIN Tier 2

CloNIDine Catapres-TTS-3 Tier 2

cloNIDine HCl ER Kapvay Tier 2 PA; ST; M90

cloNIDine HCl Oral Tier 1 M90

Clopidogrel Bisulfate Oral Plavix Tier 2 M90

Clorazepate Dipotassium Tier 2

Clorpres Tier 1 M90

Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90

Clotrimazole AF Desenex Tier 2 M90

Clotrimazole Anti-Fungal Desenex Tier 2 M90

Clotrimazole External Cream Desenex Tier 2 M90

Clotrimazole External Solution Tier 2 M90

Clotrimazole GRx Tier 2 M90

Clotrimazole Mouth/Throat Tier 2 M90

Clotrimazole Soln 1% Tier 2 M90

Clotrimazole Vaginal Cream 1 % Gyne-Lotrimin Tier 2 M90

Clotrimazole-7 Gyne-Lotrimin Tier 2 M90

32

Covered Product Reference Tier Status NotesClotrimazole-Betamethasone Tier 2 PA; M90

cloZAPine Oral Tablet 100 MG Clozaril Tier 2M90; QL (270 tablets per month)

cloZAPine Oral Tablet 25 MG Clozaril Tier 2M90; QL (90 EA per 30 days)

CloZAPine Oral Tablet 50 MG Clozaril Tier 2M90; QL (135 tablets per month)

Coagadex Tier 2 PA; SP; Dual

Coal Tar External Solution Tier 2 M90

Coartem Tier 2 M90

Cocoa Butter ExternalA + D Personal Care Lotion

Tier 2 M90

Cocoa Butter Hand & BodyA + D Personal Care Lotion

Tier 2 M90

Codeine Sulfate Oral Tablet Tier 2QL (42 tablets per 30 days. Click;HERE)

Colchicine Oral Colcrys Tier 2 M90

Colchicine-Probenecid Tier 2 M90

Colesevelam HCl Oral Packet Welchol Tier 1

Colesevelam HCl Oral Tablet Welchol Tier 2

Colestipol HCl Colestid Tier 1 M90

Colocort Tier 2 M90

Coly-Mycin S Tier 2 M90

Combigan Tier 2 M90

CombiPatch Tier 2 M90

Combivent Respimat Tier 2 M90

Cometriq (100 MG Daily Dose) Oral Kit 80 & 20 MG

$0SP; QL (56 EA per 28 days)

Cometriq (140 MG Daily Dose) Oral Kit 3 x 20 MG & 80 MG


Cometriq (60 MG Daily Dose) $0SP; QL (84 EA per 28 days)

Comfort EZ Pen Needles 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM

$0 M90

Comfort EZ Pen Needles 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM

Tier 1 M90

Companion ABC Plus Senior Tier 2 M90

Complera Tier 2

Complere ABC Plus Senior Tier 2 M90

33

Covered Product Reference Tier Status NotesComplete ABC Plus Senior Tier 2 M90

Complete Allergy Medication Alka-Seltzer Plus Allergy Tier 2 M90

Complete Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90

Complete Allergy Relief Alka-Seltzer Plus Allergy Tier 2 M90

Complete Daily/Lutein ABC Plus Senior Tier 2 M90

Complete Energy ABC Plus Senior Tier 2 M90

Complete MoistureA + D Personal Care Lotion

Tier 2 M90

Complete Multivitamin/Mineral BProtected Multi-Vite Tier 2 M90

Complete PMS Support Complex DEKAs Plus Tier 2 M90

Complete Senior ABC Plus Senior Tier 2 M90

Complete Womens ABC Plus Senior Tier 2 M90

CompleteNate $0 M90

Compro Tier 2 M90

Concept OB $0 M90

Concerta Tier 2BP; QL (60 EA per 30 days)

Condylox External Gel Tier 2 M90

Constulose Tier 2 M90

ControlRx Dental Cream Tier 2 M90

Copaxone Subcutaneous Solution Prefilled Syringe 20 MG/ML

Tier 2SP; BP; QL (30 SYR per 30 days)

Copaxone Subcutaneous Solution Prefilled Syringe 40 MG/ML

Tier 2SP; BP; QL (12 SYR per 28 days)

Copiktra $0

Coral Calcium Plus Oral Capsule DEKAs Plus Tier 2 M90

Cordran External Ointment Tier 2 M90

Corifact Tier 2 PA; SP; Dual

Corlanor Tier 2 PA

Cormax Scalp Application Tier 2 PA; M90

Correct Alophen Tier 2 M90

Correctol Tier 2 M90

Correctol Extra Gentle Tier 2 M90

Cortaid Maximum Strength External Cream

Tier 2 M90

Cortane-B Aqueous Tier 2 M90

Cortane-B External Tier 2 M90

Cortic-ND Tier 2 M90

Cortisone Acetate Oral Tier 2 M90

34

Covered Product Reference Tier Status NotesCortisporin External Tier 2 M90

Cortizone-10 External Ointment Tier 2 M90

Corvite 150 Oral Tablet Tier 2 M90

Corvite Fe Corvite 150 Tier 2 M90

Cosentyx (300 MG Dose) Tier 2 PA; SP

Cosentyx Sensoready (300 MG) Tier 2PA; SP; QL (300 mg (2 ml) per 28 days.)

Cosentyx Sensoready Pen Subcutaneous Solution Auto-Injector 150 MG/ML

Tier 2PA; SP; QL (150 mg ( 1 ml) per 28 days.)

Cosentyx Subcutaneous Solution Prefilled Syringe 150 MG/ML

Tier 2PA; SP; QL (2 SYR per 28 days)

Cosentyx Subcutaneous Solution Prefilled Syringe 75 MG/0.5ML

Tier 2 PA; SP

Cosmegen Tier 1 M90

Cotellic $0SP; QL (63 EA per 21 days)

Cotempla XR-ODT Tier 2PA; QL (30 EA per 30 days)

Cottontails Diaper Rash Tier 2 M90

Covaryx Tier 2 M90

Covaryx HS Tier 2 M90

Creon Tier 2 M90

Cresemba Oral Tier 2 PA; M90

Crixivan Oral Capsule 200 MG Tier 2 QL (450 per 30 days)

Crixivan Oral Capsule 400 MG Tier 2QL (180 EA per 30 days)

Cromolyn Sodium Inhalation Tier 2 M90

Cromolyn Sodium Nasal NasalCrom Tier 2 M90

Cromolyn Sodium Ophthalmic Tier 2 M90

Cromolyn Sodium Oral Gastrocrom Tier 2 M90

Cryselle-28 $0 M90

Crysvita Subcutaneous Solution 10 MG/ML

MB PA


MBPA; QL (9 VIALS per 14 days)


MBPA; QL (6 VIALS per 14 days)

Curity Sterile Saline Tier 2 M90

Cutaquig Tier 2 PA; SP; Dual

Cuvitru Tier 2 PA; SP; Dual

Cuvposa Tier 2 M90

35

Covered Product Reference Tier Status NotesCVS 3-Day Vaginal Gyne-Lotrimin 3 Tier 2 M90

CVS 8 Hour Pain Relief Midol Tier 2 M90

CVS Acetaminophen Oral Tablet Aphen Tier 2 M90

CVS Acid Controller Max StMM Acid-Pep Maximum Strength

Tier 2 M90

CVS Acid Reducer Max St Tier 2 M90

CVS Acid Reducer Oral Tablet 10 MG Pepcid AC Tier 2 M90

CVS Acne Foaming Face Wash PanOxyl Foaming Wash Tier 2 M90

CVS Acne TreatmentClean & Clear Persa-Gel Max St

Tier 2 M90

CVS All Day Pain Relief Mediproxen Tier 2 M90

CVS Allergy Eye Drops Alaway Tier 2 M90; QL (QL Flag)

CVS Allergy Oral Capsule Banophen Tier 2 M90

CVS Allergy Oral Liquid Banophen Tier 2 M90

CVS Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

CVS Allergy Relief Adult Banophen Tier 2 M90

CVS Allergy Relief Childrens Oral Solution


CVS Allergy Relief Childrens Oral Suspension

Allegra Allergy Childrens Tier 2M90; QL (300ml per month)

CVS Allergy Relief Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

CVS Allergy Relief D Oral Tablet Extended Release 12 Hour

Wal-Fex D Allergy & Congestion


CVS Allergy Relief Nighttime Alka-Seltzer Plus Allergy Tier 2 M90

CVS Allergy Relief Oral Liquid Banophen Tier 2 M90

CVS Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)

CVS Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

CVS Allergy Relief Oral Tablet 4 MG Wal-finate Tier 2 M90

CVS Allergy Relief Oral Tablet 60 MG Wal-Fex Allergy Tier 2 M90; QL (QL Flag)

CVS Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

CVS Allergy Relief Oral Tablet Extended Release

Chlor-Trimeton Allergy Tier 2 M90

CVS Antacid ExtraCVS Chewy Not Chalky Flavor

Tier 2 M90

CVS Antacid Extra Strength Oral Tablet Chewable 750 MG


Tier 2 M90

CVS Antacid KidsCVS Chewy Not Chalky Flavor

Tier 2 M90

CVS Antacid Maximum Strength Tums Ultra 1000 Tier 2 M90

36

Covered Product Reference Tier Status NotesCVS Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

CVS Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

CVS Anti-Diarrheal Oral Suspension Kaopectate Tier 2 M90

CVS Antifungal Tinactin Tier 2 M90

CVS Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90

CVS Arthritis Pain Relief Oral Midol Tier 2 M90

CVS B-6 Tier 2 M90

CVS Bedding Spray Lice Treat RID Tier 2 M90

CVS Bisacodyl Alophen Tier 2 M90

CVS Bismuth Oral Suspension Kaopectate Tier 2 M90

CVS Calcium 600 & Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90

CVS Calcium 600 + D/Minerals Oral Tablet 600-800 MG-UNIT

Caltrate 600+D Plus Minerals

Tier 2 M90

CVS Calcium 600+D Oral Tablet 600-800 MG-UNIT


CVS Calcium Citrate +D Calcitrate Tier 2 M90

CVS Calcium Citrate +D3 MiniCitracal Petites/Vitamin D

Tier 2 M90

CVS Capsaicin HP Capzasin-HP Tier 2 M90

CVS Chewy Not Chalky Flavor Tier 2 M90

CVS Children Multivitamin/IronLand Before Time Multivitamin

Tier 2 M90

CVS Childrens Allergy Banophen Tier 2 M90

CVS Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

CVS Childs Non-Aspirin Childrens Medi-Tabs Tier 2 M90

CVS Citrate of Magnesia Citroma Tier 2 M90

CVS Clotrimazole External Cream Desenex Tier 2 M90

CVS Cortisone Intense Healing Aveeno Anti-Itch Max St Tier 2 M90

CVS Cortisone Maximum Strength External Cream


CVS Cortisone Maximum Strength External Ointment

Cortizone-10 Tier 2 M90

CVS D3 Oral Capsule 125 MCG (5000 UT)

Dialyvite Vitamin D 5000 Tier 2 M90

CVS D3 Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

CVS D3 Oral Tablet ChewableVitaJoy Daily D Gummies

Tier 2 M90

CVS Daily Multiple FE/CA/ZN ABC Plus Senior Tier 2 M90

CVS Daily Multiple For Men ABC Plus Senior Tier 2 M90

37

Covered Product Reference Tier Status NotesCVS Daily Multiple For Men 50+ ABC Plus Senior Tier 2 M90

CVS Daily Multiple For Women ABC Plus Senior Tier 2 M90

CVS Daily Multiple Women 50+ ABC Plus Senior Tier 2 M90

CVS Daily Ultra MoistureA + D Personal Care Lotion

Tier 2 M90

CVS Diaper Rash External Ointment 40 % Boudreauxs Butt Paste Tier 2 M90

CVS Dry Skin CareA + D Personal Care Lotion

Tier 2 M90

CVS Dye-Free Allergy Alka-Seltzer Plus Allergy Tier 2 M90

CVS Ear Drops Murine Ear Tier 2 M90

CVS Ear Wax Removal System Murine Ear Tier 2 M90

CVS Eczema Anti-Itch Aveeno Anti-Itch Max St Tier 2 M90

CVS Electrolyte Solution CeraLyte 70 Tier 2 M90

CVS Enema Disposable Fleet Enema Tier 2 M90

CVS Extra MoisturizingA + D Personal Care Lotion

Tier 2 M90

CVS Eye Allergy Relief Ophthalmic Solution 0.025-0.3 %

Naphcon-A Tier 2 M90

CVS Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

CVS Fever Reducing Childrens FeverAll Childrens Tier 2 M90

CVS Fluticasone Propionate ClariSpray Tier 2 M90

CVS Foaming Acne Face Wash PanOxyl Foaming Wash Tier 2 M90

CVS Gas Relief Drops Ex St Gas-X Infant Drops Tier 2 M90

CVS Gas Relief Oral Tablet Chewable Tier 2 M90

CVS Gentle Laxative Alophen Tier 2 M90

CVS Gentle Laxative Womens Alophen Tier 2 M90

CVS Gentle Skin CleanserA + D Personal Care Lotion

Tier 2 M90

CVS Heartburn Relief Oral Tablet Tagamet HB Tier 2 M90

CVS Hydrocortisone Anti-Itch External Cream 1 %


CVS Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90

CVS Ibuprofen IB Medi-Profen Tier 2 M90

CVS Ibuprofen Infants Medi-Profen Tier 2 M90

CVS Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

CVS Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

CVS Indoor/Outdoor Allergy Rlf KLS Aller-Tec Tier 2 M90; QL (QL Flag)

CVS Infants Gas ReliefLittle Remedies for Tummys

Tier 2 M90

38

Covered Product Reference Tier Status NotesCVS Infants Pain Relief Drops Oral Suspension 160 MG/5ML


CVS Iron Oral Tablet 240 (27 Fe) MG Ferate Tier 2 M90

CVS Itch Relief External Cream 1 % Desenex Tier 2 M90

CVS Laxative Pills Tier 2 M90

CVS Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

CVS Lubricant Drops Ophthalmic Gel 0.25-0.3 %

Tier 2

CVS Lubricant Drops Ophthalmic Solution

Systane Complete Tier 2 M90

CVS Magnesium Citrate Oral Solution Citroma Tier 2 M90

CVS Miconazole 1 Combo Pack Monistat 1 Combo Pack Tier 2 M90

CVS Miconazole 3 Combo PackMonistat 3 Combo Pack App

Tier 2 M90

CVS Miconazole 3-Day Combo AppMonistat 3 Combo Pack App

Tier 2 M90

CVS Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

CVS Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

CVS Mineral Oil Tier 2 M90

CVS Moisturizing External LotionA + D Personal Care Lotion

Tier 2 M90

CVS Motion Sickness II Wal-Dram II Tier 2 M90

CVS Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

CVS Nasal Allergy Spray KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)

CVS Nasal Decongestant Oral Tablet SudoGest Tier 2 M90

CVS Nicotine Mouth/Throat Lozenge KLS Quit2 $0 M90

CVS Nicotine Polacrilex KLS Quit2 $0 M90

CVS Nicotine Transdermal Patch 24 Hour 14 MG/24HR, 7 MG/24HR

Nicoderm CQ $0 M90

CVS Non-Aspirin Childrens Childrens Medi-Tabs Tier 2 M90

CVS Non-Aspirin Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

CVS NTS Step 1 Habitrol Tier 1 M90

CVS Oyster Shell Calcium+Vit D Tier 2 M90

CVS Pain & Fever Childrens PediaCare Children Tier 2 M90

CVS Pain & Fever Infants PediaCare Children Tier 2 M90

CVS Pain Relief AdultMapap Acetaminophen Extra Str

Tier 2 M90

39

Covered Product Reference Tier Status NotesCVS Pain Relief Childrens Oral Suspension


CVS Pain Relief Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

CVS Ped Electrolyte Freeze Pop CeraLyte 70 Tier 2 M90

CVS Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90

CVS Permethrin Tier 2 M90

CVS Prenatal Oral Tablet 28-0.8 MG Tier 1 M90

CVS Purelax Tier 2 M90

CVS Ringworm Desenex Tier 2 M90

CVS Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

CVS Saline Nose Spray Afrin Saline Nasal Mist Tier 1 M90

CVS Senna Evac-U-Gen Tier 2 M90

CVS Senna-Extra Senokot Extra Strength Tier 2 M90

CVS Skin Treatment AL12 Tier 2 M90

CVS Special CareA + D Personal Care Lotion

Tier 2 M90

CVS Spectravite Adult 50+ Oral Tablet ABC Plus Senior Tier 2 M90

CVS Spectravite Advanced Oral Tablet ABC Plus Senior Tier 2 M90

CVS Spectravite Senior ABC Plus Senior Tier 2 M90

CVS Spectravite Ultra Men 50+ ABC Plus Senior Tier 2 M90

CVS Spectravite Ultra Mens ABC Plus Senior Tier 2 M90

CVS Spectravite Ultra Women ABC Plus Senior Tier 2 M90

CVS Spectravite Womens Senior ABC Plus Senior Tier 2 M90

CVS Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

CVS Vision Formula ABC Plus Senior Tier 2 M90

CVS Vitamin B-6 Oral Tablet 100 MG Tier 2 M90

CVS Vitamin D Child GummiesVitaJoy Daily D Gummies

Tier 2 M90

CVS Vitamin D3 Oral Tablet Chewable 25 MCG (1000 UT)

VitaJoy Daily D Gummies

Tier 2 M90

CVS Womens Active Daily ABC Plus Senior Tier 2 M90

CVS Zinc Oral Tier 2 M90

CVS Zinc Oxide Tier 2 M90

Cyanocobalamin Injection Solution 1000 MCG/ML

Tier 2 M90

Cyclafem 1/35 $0 M90

Cyclafem 7/7/7 $0 M90

Cyclobenzaprine HCl Oral Tier 2 M90

Cyclomydril Tier 2 M90

40

Covered Product Reference Tier Status NotesCyclopentolate HCl Ophthalmic Cyclogyl Tier 2 M90

Cyclophosphamide Injection $0 M90

Cyclophosphamide Intravenous $0

Cyclophosphamide Oral Capsule $0 M90

Cyclosporine in Klarity Tier 2

CycloSPORINE Intravenous SandIMMUNE Tier 2 SP

CycloSPORINE Modified Gengraf Tier 2 SP

CycloSPORINE Oral Capsule SandIMMUNE Tier 2 SP

Cyotic Tier 2 M90

Cyproheptadine HCl Oral Tier 2 M90

Cyred $0 M90

Cystadane Tier 2 M90

Cystagon Tier 2 SP; QL (QL Flag)

Cystaran Tier 2 M90

Cytarabine (PF) $0 M90

Cytarabine Injection Solution $0 M90

Cytogam MB PA

Cytra K Crystals Tier 2 M90

D 1000 Pronutrients Vitamin D3 Tier 2 M90

D 10000 Decara Tier 2 M90

D 5000Radiance Platinum Vitamin D3

Tier 2 M90

D-1000 Vitamin D-1000 Max St Tier 2 M90

D-1000 Extra Strength Vitamin D-1000 Max St Tier 2 M90

D-2000 Maximum Strength Thera-D 2000 Tier 2 M90

D2000 Ultra Strength Tier 2 M90

D3 Thera-D 2000 Tier 2 M90

D3 (cholecalciferol) Capsule 125 MCG (5000 UT) Oral Oral Capsule


D3 (cholecalciferol) Capsule 125 MCG (5000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

D3 AdultVitaJoy Daily D Gummies

Tier 2 M90

D3 High Potency Oral Capsule 25 MCG (1000 UT)

Pronutrients Vitamin D3 Tier 2 M90

D3 Super Strength Tier 2 M90

D3-1000 Pronutrients Vitamin D3 Tier 2 M90

D-3-5 Dialyvite Vitamin D 5000 Tier 2 M90

D3-50 Tier 2 M90

41


D-5000Radiance Platinum Vitamin D3

Tier 2 M90

Dacarbazine Intravenous $0 M90

Daily Betic ABC Plus Senior Tier 2 M90

Daily Combo Multi Vitamins ABC Plus Senior Tier 2 M90

Daily Mens Health Formula ABC Plus Senior Tier 2 M90

Daily Multi ABC Plus Senior Tier 2 M90

Daily Multi 50+ ABC Plus Senior Tier 2 M90

Daily Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Daily Multiple Vitamins/Min ABC Plus Senior Tier 2 M90

Daily Multivitamin DEKAs Plus Tier 2 M90

Daily Vitamin Formula+IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Daily Vitamin Formula+Minerals ABC Plus Senior Tier 2 M90

Daily Vitamin Plus DEKAs Plus Tier 2 M90

Daily Womens Health Formula ABC Plus Senior Tier 2 M90

Daily-Vitamin Maximum Formula ABC Plus Senior Tier 2 M90

Daily-Vitamin/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Daily-Vite/Iron/Beta-CaroteneTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Dairy Digest Extra Tier 2

Dalfampridine ER Ampyra Tier 2PA; SP; QL (60 EA per 30 days)

Daliresp Oral Tablet 250 MCG Tier 2 PA

Daliresp Oral Tablet 500 MCG Tier 2 PA; M90

Danazol Oral Tier 2 M90

Dantrolene Sodium Oral Tier 2 M90

Danyelza MB PA

Dapsone External Aczone Tier 2 ST

Dapsone Oral Tier 2 M90

Daptacel Intramuscular Suspension 10-15-5

Tier 2 M90

Darifenacin Hydrobromide ER Enablex Tier 2ST; M90; QL (30 EA per 90 days)

Darzalex $0 SP

Dasetta 1/35 $0 M90

Dasetta 7/7/7 $0 M90

42

Covered Product Reference Tier Status NotesDAUNOrubicin HCl Intravenous Injectable

$0 M90

Daurismo Oral Tablet 100 MG $0PA; SP; QL (30 EA per 90 days)

Daurismo Oral Tablet 25 MG $0PA; SP; QL (60 EA per 30 days)

Daysee $0 M90

Daytrana Tier 2PA; ST; M90; QL (30 EA per 90 days)

DayVigo Tier 2PA; QL (30 EA per 30 days)

Deblitane $0 M90

Decara Oral Capsule 1.25 MG (50000 UT)

Tier 2 M90

Decitabine Dacogen $0 SP

Decon-A Oral Elixir Tier 2 M90

Decon-G Tier 2 M90

Decongestant Oral Tablet 30 MG SudoGest Tier 2 M90

Deep Sea Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

Deferasirox Granules Jadenu Sprinkle Tier 2 PA; SP

Deferasirox Oral Tablet Jadenu Tier 2 PA; SP

Deferasirox Oral Tablet Soluble Exjade Tier 2 PA; SP

Deferiprone Ferriprox Tier 2 PA

DEKAs Plus Ocean Tier 2 M90

DEKAs Plus Oral Capsule Tier 2 M90

Delazinc Tier 2 M90

Delestrogen Intramuscular Oil 10 MG/ML Tier 2 M90

Delstrigo Tier 2PD; QL (30 EA per 30 days)

Deltasone Tier 2 M90

Delyla $0 M90

Demeclocycline HCl Oral Tier 2 M90

Demser Tier 2 M90

Denavir Tier 2 M90

Denta 5000 Plus Tier 2 M90

DentaGel Tier 2 M90

DepoCyt Tier 1 M90

Depo-Estradiol Tier 2 M90

Depo-Medrol Injection Suspension 20 MG/ML

Tier 2 M90

43

Covered Product Reference Tier Status NotesDepo-Provera Intramuscular Suspension 400 MG/ML

$0 M90

Depo-SubQ Provera 104 Subcutaneous Suspension Prefilled Syringe

$0M90; QL (4 syringes every 300 days)

DermaDaily Tier 2 M90

Dermal Therapy Extra Strength Tier 2 M90

Dermal Therapy Face Care Tier 2 M90

Dermal Therapy Foot Massage Tier 2 M90

Dermal Therapy Hand/Elbow Tier 2 M90

Dermal Therapy Heel Care Tier 2 M90

Dermasorb AF Tier 2 M90

Dermasorb XM Tier 2 M90

DermaVantage Tier 2 M90

Descovy $0PD; QL (30 EA per 30 days)

Desenex External Cream Tier 2 M90

Desipramine HCl Oral Norpramin Tier 2 M90

Desloratadine Clarinex Tier 2M90; QL (30 EA per 90 days)

Desmopressin Ace Rhinal Tube Tier 2 M90

Desmopressin Ace Spray Refrig Tier 2 M90

Desmopressin Acetate Injection DDAVP Tier 2 M90

Desmopressin Acetate Oral DDAVP Tier 2 M90

Desmopressin Acetate PF DDAVP PF Tier 2 M90

Desmopressin Acetate Spray Tier 2 M90

Desogestrel-Ethinyl Estradiol Kariva $0 M90

Desonide External Cream DesOwen Tier 2ST; M90; QL (QL Applies)

Desonide External Lotion Tier 2ST; M90; QL (QL Applies)

Desonide External Ointment Tier 2ST; M90; QL (QL Applies)

Desoximetasone External Cream 0.05 % Topicort Tier 2 M90

Desoximetasone External Cream 0.25 % Topicort Tier 2ST; M90; QL (QL Applies)

Desoximetasone External Gel Topicort Tier 2ST; M90; QL (QL Applies)

Desoximetasone External Ointment 0.05 %

Topicort Tier 2 M90

Desoximetasone External Ointment 0.25 %

Topicort Tier 2ST; M90; QL (QL Applies)

44


Desvenlafaxine ER Tier 2ST; M90; QL (30 EA per 90 days)

Desvenlafaxine Fumarate ER Tier 2 ST; M90

Dex LA 16 Tier 2 M90

Dexamethasone Intensol Tier 2 M90

Dexamethasone Oral Elixir Tier 2 M90

Dexamethasone Oral Solution Tier 2 M90

Dexamethasone Oral Tablet Decadron Tier 2 M90

Dexamethasone Oral Tablet Therapy Pack HiDex 6-Day Tier 2

Dexamethasone Sodium Phosphate Injection Solution 10 MG/ML, 100 MG/10ML, 120 MG/30ML, 20 MG/5ML

Tier 2 M90

Dexamethasone Sodium Phosphate Ophthalmic

Tier 2 M90

Dexcom G6 Receiver Tier 2PA; PD; QL (1 EA per 365 days)

Dexcom G6 Sensor Tier 2PA; PD; QL (3 EA per 30 days)

Dexcom G6 Transmitter Tier 2PA; PD; QL (1 EA per 90 days)

Dexedrine Oral Tablet Tier 2 M90; QL (QL Flag)

Dexilant Tier 2ST; M90; QL (30 EA per 90 days)

Dexmethylphenidate HCl Focalin Tier 2QL (90 EA per 30 days)

Dexrazoxane $0 M90

Dextroamphetamine Sulfate ER Dexedrine Tier 2QL (90 EA per 30 days)

Dextroamphetamine Sulfate Oral Solution ProCentra Tier 2QL (900 ML per 30 days)

Dextroamphetamine Sulfate Oral Tablet 10 MG, 5 MG

Zenzedi Tier 2QL (90 EA per 30 days)

Diabetes Health Formula ABC Plus Senior Tier 2 M90

Diabetic Tussin Allergy Tier 2 M90

DiabetiDerm External Lotion Tier 2 M90

DiabetiDerm Hand & Body Tier 2 M90

Diacomit Oral Capsule 250 MG Tier 2PA; SP; QL (360 capsules per month)

Diacomit Oral Capsule 500 MG Tier 2PA; SP; QL (180 EA per 30 days)

Diacomit Oral Packet 250 MG Tier 2PA; SP; QL (360 per month)

45


Diacomit Oral Packet 500 MG Tier 2PA; SP; QL (180 EA per 30 days)

Dialyvite 800/Ultra D ABC Plus Senior Tier 2 M90

Dialyvite Supreme D Tier 2 M90


Dialyvite Vitamin D3 Max Tier 2 M90

Diaper Rash External Ointment Boudreauxs Butt Paste Tier 2 M90

Diarrhea Kaopectate Tier 2 M90

diazePAM Injection Tier 2

Diazepam Intensol Tier 2

Diazepam Oral Concentrate Diazepam Intensol Tier 2

diazePAM Oral Solution 1 MG/ML Tier 2

diazePAM Oral Tablet Valium Tier 2

DiazePAM Rectal Diastat Pediatric Tier 2

Diazoxide Oral Proglycem Tier 2

Diclofenac Potassium Oral Tablet 50 MG Cataflam Tier 2 M90

Diclofenac Sodium ER Tier 2 M90

Diclofenac Sodium Ophthalmic Tier 2 M90

Diclofenac Sodium Oral Tier 2 M90

Diclofenac Sodium Transdermal Gel 1 % Aspercreme Arthritis Pain Tier 2M90; QL (100gm per month)

Diclofenac Sodium Transdermal Gel 3 % Tier 2 PA; M90

Diclofex DC Combination Therapy Pack 1.5 & 0.025 %

Tier 2 M90

Diclofex DC External Therapy Pack 1.5 & 0.025 %

Tier 2 M90

Diclotral Tier 2 M90

Dicloxacillin Sodium Tier 2 M90

Dicyclomine HCl Oral Tier 2 M90

Didanosine Tier 2 M90

Differin External Gel 0.1 % Tier 2

Dificid Oral Suspension Reconstituted Tier 2PA; QL (136 ML per 8 days)

Dificid Oral Tablet Tier 2PA; M90; QL (180 EA per 30 days)

Difil-G Forte Tier 2 M90

Diflunisal Oral Tier 2 M90

Difluprednate Durezol Tier 2ST; QL (5 ML per 30 days)

Digitek Tier 2 M90

46

Covered Product Reference Tier Status NotesDigox Tier 2 M90

Digoxin Oral Digitek Tier 2 M90

Dihydroergotamine Mesylate Nasal Migranal Tier 2 PA; M90

Dilantin Oral Capsule 30 MG Tier 2 M90

Dilatrate-SR Tier 2 M90

DilTIAZem CD Cartia XT Tier 1 M90

Diltiazem HCl ER Beads Taztia XT Tier 1 M90

Diltiazem HCl ER Coated Beads Cartia XT Tier 1 M90

dilTIAZem HCl ER Oral Capsule Extended Release 12 Hour

Tier 1 M90

dilTIAZem HCl ER Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG

Tier 1 M90

Diltiazem HCl Oral Cardizem Tier 1 M90

Dilt-XR Tier 1 M90

Dino-Life Tier 2 M90

Diocto Oral Liquid Docu Liquid Tier 2 M90

Diocto Oral Syrup Tier 2 M90

Dipentum Tier 2 M90

Diphen Oral Tablet Alka-Seltzer Plus Allergy Tier 2 M90

Diphenhydramine HCl Cap 25 MG Banophen Tier 2 M90

Diphenhydramine HCl Cap 50 MG Banophen Tier 2 M90

Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Elixir 12.5 MG/5ML

Tier 2 M90

Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Liquid 12.5 MG/5ML

Banophen Tier 2 M90

Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Solution 5 MG/5ML


Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Syrup 5 MG/5ML


DiphenhydrAMINE HCl Injection Tier 2 M90

Diphenhydramine HCl Liquid 12.5 MG/5ML

Banophen Tier 2 M90

DiphenhydrAMINE HCl Oral Capsule Banophen Tier 2 M90

DiphenhydrAMINE HCl Oral Elixir Tier 2 M90

DiphenhydrAMINE HCl Oral Liquid 12.5 MG/5ML

Banophen Tier 2 M90

DiphenhydrAMINE HCl Oral Tablet 25 MG


Diphenoxylate-Atropine Oral Liquid Tier 2 M90

47

Covered Product Reference Tier Status NotesDiphenoxylate-Atropine Oral Tablet 2.5-0.025 MG

Lomotil Tier 2 M90

Diphtheria-Tetanus Toxoids DT $0 M90

Dipyridamole Intravenous Tier 2 M90

Dipyridamole Oral Tier 2 M90

Disopyramide Phosphate Oral Norpace Tier 2 M90

Disulfiram Oral Tier 2 M90

Diuril Tier 2 M90

Divalproex Sodium ER Oral Tablet Extended Release 24 Hour

Depakote ER Tier 2 M90

Divalproex Sodium Oral Capsule Delayed Release Sprinkle

Depakote Sprinkles Tier 2 M90

Divalproex Sodium Oral Tablet Delayed Release

Depakote Tier 2 M90

Divigel Transdermal Gel 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM

Tier 2 M90

Divigel Transdermal Gel 0.75 MG/0.75GM

Tier 2

DML Tier 2 M90

DocQLace Correctol Extra Gentle Tier 2 M90

Docu Oral Liquid Docu Liquid Tier 2 M90

Docu Soft Correctol Extra Gentle Tier 2 M90

Docuprene DOK Tier 2 M90

Docusate Sodium Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

Docusate Sodium Oral Liquid 50 MG/5ML

Docu Liquid Tier 2 M90

Docusate Sodium Oral Tablet DOK Tier 2 M90

Docusil Tier 2 M90

Dofetilide Tikosyn Tier 2 SP; QL (QL Flag)

Dojolvi Tier 2 PA; SP

DOK Oral Capsule 100 MG Tier 2 M90

DOK Oral Tablet Tier 2 M90

Dologesic Oral Tablet 30-500 MG Tier 2 M90

Donepezil HCl Aricept Tier 2 M90

Donnatal Oral Elixir Tier 2 M90

Doptelet Oral Tablet 20 MG Tier 2 PA; SP

Dorzolamide HCl Ophthalmic Trusopt Tier 2 M90

Dorzolamide HCl-Timolol Mal Cosopt Tier 2 M90

Dovato Tier 2PD; QL (30 EA per 30 days)

48

Covered Product Reference Tier Status NotesDoxazosin Mesylate Oral Cardura Tier 1 M90

Doxepin HCl External Prudoxin Tier 2

ST; M90; QL (45 grams with a maximum fill of 30 days)

Doxepin HCl Oral Capsule Tier 2 M90

Doxepin HCl Oral Concentrate Tier 2 M90

Doxercalciferol Oral Tier 2 M90

DOXOrubicin HCl Adriamycin $0 M90

DOXOrubicin HCl Liposomal Doxil $0 M90

Doxycycline Hyclate Oral Capsule Vibramycin Tier 2 M90

Doxycycline Hyclate Oral Tablet 100 MG Lymepak Tier 2 M90

Doxycycline Hyclate Oral Tablet 150 MG, 75 MG

Acticlate Tier 2 M90

Doxycycline Hyclate Oral Tablet 20 MG Tier 2 M90

Doxycycline Monohydrate Oral Capsule 100 MG

Mondoxyne NL Tier 2 M90

Doxycycline Monohydrate Oral Capsule 50 MG

Tier 2 M90

Doxycycline Monohydrate Oral Suspension Reconstituted

Vibramycin Tier 2 M90

Doxycycline Monohydrate Oral Tablet Tier 2 M90

Doxylamine-Pyridoxine Diclegis Tier 2PA; QL (120 EA per 30 days)

Dr Edwards Olive Laxative Tier 2 M90

Dr Gs Clear Nail Tier 2 M90

Dr Smiths Diaper Tier 2

Dramamine Less Drowsy Tier 2 M90

Drihep Arterial Line Syringe Tier 2 M90

Drihep Plus Prefilled Syringe Tier 2 M90

Dritho-Creme HP Tier 2 M90

Dronabinol Marinol Tier 2QL (60 capsules per month)

Droplet Pen Needles 29G X 10MM Tier 2 M90

Droplet Pen Needles 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM

$0 M90

Droplet Pen Needles 32G X 8 MM Tier 1 M90

Drospiren-Eth Estrad-Levomefol Oral Tablet 3-0.02-0.451 MG

Beyaz $0 M90

49

Covered Product Reference Tier Status NotesDrospirenone-Ethinyl Estradiol Ocella $0 M90

Droxia Tier 2 M90

Drug Mart Unifine Pentips CareFine Pen Needles $0 M90

Drug Mart Unifine Pentips Plus BD Pen Needle Nano U/F $0 M90

Drysol Tier 2 M90

DSS Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

Duavee Tier 2M90; QL (30 EA per 90 days)

Ducodyl Alophen Tier 2 M90

Dulcolax Balance Tier 2 M90

Dulcolax Milk of Magnesia Tier 2 M90

Dulcolax Stool Softener Tier 2 M90

Dulera Inhalation Aerosol 100-5 MCG/ACT, 200-5 MCG/ACT

Tier 2 M90

Dulera Inhalation Aerosol 50-5 MCG/ACT

Tier 2

DULoxetine HCl Oral Capsule Delayed Release Particles 20 MG

Cymbalta Tier 2M90; QL (60 EA per 30 days)

DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG, 60 MG

Cymbalta Tier 2M90; QL (30 EA per 90 days)

Dupixent Subcutaneous Solution Pen-Injector

Tier 2PA; SP; QL (2 PENS per 28 days)

Dupixent Subcutaneous Solution Prefilled Syringe


Duraxin Tier 2 M90

Durolane Intra-Articular Tier 2PA; SP; Dual; QL (1 SYR per 1 APPROVAL)

Durysta MB PA

Dutasteride Oral Avodart Tier 2 M90

Dutoprol Tier 2 M90

Dyanavel XR Tier 2 PA

Dyspel Medi-Profen Tier 2 M90

Dysport Tier 2PA; SP; QL (QL Flag); Dual

Ear Drops Murine Ear Tier 2 M90

Ear Wax Removal Drops Murine Ear Tier 2 M90

Ear Wax Removal Kit Murine Ear Tier 2 M90

Ear Wax Removal System Otic Solution Murine Ear Tier 2 M90

Earwax Treatment Drops Murine Ear Tier 2 M90

50

Covered Product Reference Tier Status NotesEasy Comfort Pen Needles 31G X 5 MM , 31G X 8 MM


$0 M90

Easy Comfort Pen Needles 31G X 6 MM CareFine Pen Needles $0 M90

Easy Comfort Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90

Easy Touch Pen Needles 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM

$0 M90

Easygel Dental Tier 2 M90

Easy-Lax Correctol Extra Gentle Tier 2 M90

Ecolovit ABC Plus Senior Tier 2 M90

Econazole Nitrate External Tier 2 PA; M90

EContra EZ $0 M90

EContra One-Step $0

ED Cyte F Tier 2 M90

Ed-APAP Little Remedies for Fever Tier 2 M90

Edarbi Tier 2 ST; M90

Ed-Chlortan Wal-finate Tier 2 M90

Ed-Flex Tier 2 M90

Ed-Spaz NuLev Tier 2 M90

Edurant Tier 2QL (60 EA per 30 days)

EEMT Tier 2 M90

EEMT HS Tier 2 M90

Efavirenz Oral Capsule Sustiva Tier 2 SP

Efavirenz-Emtricitab-Tenofovir Atripla Tier 2QL (30 EA per 30 days)

Efavirenz-lamiVUDine-Tenofovir Symfi Tier 2QL (30 EA per 30 days)

Effer-K Tier 2 M90

Effervescent Pot Chloride Tier 2 M90

Effient Tier 2 M90

Elaprase MB PA

Elelyso MB PA

Elestrin Tier 2 M90

Eletriptan Hydrobromide Relpax Tier 2M90; QL (12 tablets per month)

Elidel Tier 2BP; QL (60 GM per 30 days)

Eligard $0 PA; SP; Dual

51

Covered Product Reference Tier Status NotesElinest $0 M90

Eliquis Tier 2 PD

Eliquis DVT/PE Starter Pack Oral Tablet Therapy Pack

Tier 2 PD

Elite Zinc Tier 2 M90

Elitek $0 M90

Elixophyllin Tier 2 M90

Ella $0 M90

Elmiron Tier 2 M90

Eloctate Tier 2 PA; SP; Dual

Elta External Lotion Tier 2 M90

Emadine Tier 2ST; M90; QL (10ml per 25 days)

Embeda Oral Capsule Extended Release 100-4 MG

Tier 2ST; QL (QL applies. Click;HERE)

Embeda Oral Capsule Extended Release 20-0.8 MG, 30-1.2 MG

Tier 2ST; QL (60 EA per 30 days)

Embeda Oral Capsule Extended Release 50-2 MG, 60-2.4 MG, 80-3.2 MG


Emcyt $0 M90

Emend Oral Capsule Tier 2 M90; QL (QL Flag)

Emflaza Tier 2 PA; SP

Emgality Tier 2PA; QL (1 PEN per 30 days)

Emgality (300 MG Dose) Tier 2PA; PD; QL (3 PENS per 30 days)

Emollia-Lotion Tier 2 M90

Emoquette $0 M90

Empliciti $0 SP

Emsam Tier 2PA; M90; QL (30 EA per 90 days)

Emtricitabine Emtriva Tier 2QL (30 EA per 30 days)

Emtricitabine-Tenofovir DF Truvada $0QL (30 EA per 30 days)

Emtriva Oral Solution Tier 2SP; QL (680 ml per 28 days)

Enalapril Maleate Oral Solution Epaned Tier 1

Enalapril Maleate Oral Tablet Vasotec Tier 1 M90

Enalapril-Hydrochlorothiazide Vaseretic Tier 1 M90

52


Enbrel Mini Tier 2PA; SP; PD; QL (4 EA per 28 days)

Enbrel Subcutaneous Solution 25 MG/0.5ML

Tier 2PA; SP; PD; QL (4 VIALS per 28 days)

Enbrel Subcutaneous Solution Prefilled Syringe

Tier 2PA; SP; PD; QL (4 SYR per 28 days)

Enbrel Subcutaneous Solution Reconstituted

Tier 2PA; SP; PD; QL (4 VIALS per 28 days)

Enbrel SureClick Subcutaneous Solution Auto-Injector

Tier 2PA; SP; PD; QL (4 PENS per 28 days)

Encare Vaginal Suppository $0 M90

Endocet Oral Tablet 10-325 MG Tier 2M90; QL (180 EA per 30 days)

Endocet Oral Tablet 2.5-325 MG, 5-325 MG

Tier 2M90; QL (360 tablets per 30 days. Click;HERE)

Endocet Oral Tablet 7.5-325 MG Tier 2M90; QL (240 tablets per 30 days. Click;HERE)

Endometrin Tier 2 M90

Endur-Acin Oral Tablet Extended Release 250 MG, 500 MG

Tier 1 M90

Enema Fleet Enema Tier 2 M90

Enema Disposable Rectal Fleet Enema Tier 2 M90

Enema Pediatric Fleet Pediatric Tier 2 M90

Enfamil Enfalyte Tier 2 M90

Engerix-B Injection Suspension 10 MCG/0.5ML, 20 MCG/ML

$0 M90

Engerix-B Intramuscular $0 M90

Enlon Tier 2 M90

Enoxaparin Sodium Lovenox Tier 2 M90

Enpresse-28 $0 M90

Enskyce Oral Tablet 0.15-30 MG-MCG $0 M90

Enspryng Tier 2PA; SP; QL (1 SYR per 28 days)

Entacapone Comtan Tier 2 M90

Entecavir Baraclude Tier 2SP; QL (30 EA per 90 days)

Entresto Tier 2PA; QL (60 EA per 30 days)

Entyvio Tier 2PA; SP; QL (Quantity Limit Applies); Dual

53

Covered Product Reference Tier Status NotesEnulose Tier 2 M90

Envarsus XR Tier 2 SP; QL (QL Flag)

Epaned Oral Solution Reconstituted Tier 2 M90

Epclusa Oral Tablet 200-50 MG Tier 2PA; SP; QL (28 EA per 28 days)

Epidiolex Tier 2 PA; SP

Epifoam Tier 2 ST; M90

Epilyt Tier 2 M90

Epinastine HCl Tier 2ST; M90; QL (5ml per 25 days)

EPINEPHrine HCl Injection Solution 1 MG/ML

Tier 2 M90

EPINEPHrine Injection Solution Auto-Injector 0.15 MG/0.15ML

Auvi-Q Tier 2QL (2 pens per fill, 1 fill per day)


EpiPen Jr 2-Pak Tier 2QL (2 pens per fill, 1 fill per day)


Auvi-Q Tier 2QL (2 PENS per 28 days)

EPINEPHrine Intravenous Solution Prefilled Syringe 0.1 MG/10ML

Tier 2 QL (2 PENS per 1 Fill)

EpiRUBicin HCl Intravenous Solution 200 MG/100ML, 50 MG/25ML

Ellence $0 M90

Epitol Tier 2 M90

Epivir HBV Oral Solution Tier 2 QL (600ml per month)

Eplerenone Inspra Tier 1 M90

Epogen Injection Solution 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier 2 PA; SP; Dual

Epoprostenol Sodium Flolan Tier 2 PA; SP; Dual

Eprosartan Mesylate Tier 1 ST; M90

EQ AcetaminophenHealthy Mama Shake That Ache

Tier 2 M90

EQ Acetaminophen Childrens Oral Suspension


EQ Acid Reducer Tier 2 M90

EQ Acid Reducer Max StMM Acid-Pep Maximum Strength

Tier 2 M90

EQ Allergy Banophen Tier 2 M90

EQ Allergy Relief (Cetirizine) KLS Aller-Tec Tier 2 M90; QL (QL Flag)

EQ Allergy Relief Nasal ClariSpray Tier 2 M90

EQ Allergy Relief Oral Capsule Banophen Tier 2 M90

54

Covered Product Reference Tier Status NotesEQ Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)

EQ Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

EQ Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

EQ Antacid Extra Strength Oral Tablet Chewable 750 MG


Tier 2 M90

EQ Antacid Oral Tablet Chewable Cal-Gest Antacid Tier 2 M90

EQ Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

EQ Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

EQ Antifungal Desenex Tier 2 M90

EQ Anti-Itch Max Strength Aveeno Anti-Itch Max St Tier 2 M90

EQ Arthritis Pain Midol Tier 2 M90

EQ Aspirin Oral Tablet Delayed Release 500 MG

Tier 2 M90

EQ Athletes Foot (tolnaftate) Tinactin Tier 2 M90

EQ Athletes Foot External Cream Desenex Tier 2 M90

EQ Calcium 500+D Os-Cal Calcium + D3 Tier 2 M90

EQ Calcium 600+D Oral Tablet 600-800 MG-UNIT


EQ Calcium 600+D+MineralsCaltrate 600+D Plus Minerals

Tier 2 M90

EQ Calcium Citrate+D Calcitrate Tier 2 M90

EQ Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

EQ Childrens Pain Reliever PediaCare Children Tier 2 M90

EQ Chlortabs Wal-finate Tier 2 M90

EQ ClearLax Tier 2 M90

EQ Complete Multivit Adult 50+ ABC Plus Senior Tier 2 M90

EQ Complete Multivitamin-Adult ABC Plus Senior Tier 2 M90

EQ Ear Wax Removal Aid Murine Ear Tier 2 M90

EQ Enema Fleet Enema Tier 2 M90

EQ Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

EQ Gentle Laxative Alophen Tier 2 M90

EQ Heartburn Relief Tagamet HB Tier 2 M90

EQ Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90

EQ Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90

EQ Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90

EQ Ibuprofen Infants Medi-Profen Tier 2 M90

EQ Ibuprofen Junior Advil Junior Strength Tier 2 M90

EQ Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

55


EQ Infants Gas ReliefLittle Remedies for Tummys

Tier 2 M90

EQ Itchy Eye Drops Alaway Tier 2 M90; QL (QL Flag)

EQ Jock Itch Desenex Tier 2 M90

EQ Laxative Maximum Strength Tier 2 M90

EQ Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

EQ Magnesium Citrate Citroma Tier 2 M90

EQ Miconazole 1 Monistat 1 Combo Pack Tier 2 M90

EQ Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90

EQ Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

EQ Miconazole 7 Day Treatment Monistat 7 Simply Cure Tier 2 M90

EQ Milk of Magnesia Oral Suspension 1200 MG/15ML

Dulcolax Milk of Magnesia

Tier 2 M90

EQ Mineral Oil Tier 2 M90

EQ Motion Sickness Relief Oral Tablet 25 MG

Wal-Dram II Tier 2 M90

EQ Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

EQ Natural Laxative Evac-U-Gen Tier 2 M90

EQ Natural Vegetable Laxative Evac-U-Gen Tier 2 M90

EQ Nicotine Mouth/Throat Gum 4 MG KLS Quit4 $0 M90

EQ Nicotine Mouth/Throat Lozenge KLS Quit4 $0 M90

EQ Nicotine Polacrilex KLS Quit2 $0 M90

EQ Nicotine Step 3 Nicoderm CQ $0 M90

EQ Nicotine Transdermal Nicoderm CQ $0 M90

EQ One Daily Mens Health ABC Plus Senior Tier 2 M90

EQ One Daily Womens Health ABC Plus Senior Tier 2 M90

EQ Pain & Fever Childrens Oral Suspension


EQ Pain & Fever Infants PediaCare Children Tier 2 M90

EQ Pain Reliever Oral Tablet 325 MG Aphen Tier 2 M90

EQ raNITIdine Oral Tablet 75 MG Tier 2 M90

EQ Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

EQ Stomach Relief Oral Suspension Kaopectate Tier 2 M90

EQ Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

EQ Suphedrine Oral Tablet SudoGest Tier 2 M90

EQ Tolnaftate Tinactin Tier 2 M90

EQ Vegetable Laxative Evac-U-Gen Tier 2 M90

EQ Womans Laxative Alophen Tier 2 M90

EQ Womens Laxative Alophen Tier 2 M90

56


EQL Absolute Moisture Dry SkinA + D Personal Care Lotion

Tier 2 M90

EQL Acetaminophen Childrens PediaCare Children Tier 2 M90

EQL Acetaminophen Ex StHealthy Mama Shake That Ache

Tier 2 M90

EQL Acetaminophen Oral Tablet Aphen Tier 2 M90

EQL Acid Reducer Oral Tablet 150 MG, 75 MG

Tier 2 M90

EQL All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)

EQL All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

EQL Aller-ease KLS Aller-Fex Tier 2 M90; QL (QL Flag)

EQL Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

EQL Allergy Relief Oral Capsule Banophen Tier 2 M90

EQL Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)

EQL Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

EQL Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

EQL Antifungal Desenex Tier 2 M90

EQL Antifungal (Tolnaftate) Tinactin Tier 2 M90

EQL Anti-Itch Intensive Heal Aveeno Anti-Itch Max St Tier 2 M90

EQL Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90

EQL Arthritis Pain Relief Midol Tier 2 M90

EQL Athletes Foot External Cream Desenex Tier 2 M90

EQL B-6 Tier 2 M90

EQL Baby Basics Diaper Rash Boudreauxs Butt Paste Tier 2 M90

EQL Calcium Citrate/Vitamin D Calcitrate Tier 2 M90

EQL Calcium Citrate/Vitamin D3 Calcitrate Tier 2 M90

EQL Calcium/Vitamin D Tier 2 M90

EQL Calcium/Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90

EQL Century ABC Plus Senior Tier 2 M90

EQL Century Mature ABC Plus Senior Tier 2 M90

EQL Century Mature Adults 50+ ABC Plus Senior Tier 2 M90

EQL Century Mature Men 50+ ABC Plus Senior Tier 2 M90

EQL Century Mature Women 50+ ABC Plus Senior Tier 2 M90

EQL Century Mens ABC Plus Senior Tier 2 M90

EQL Century Womens ABC Plus Senior Tier 2 M90

EQL Childrens Allergy Banophen Tier 2 M90

EQL Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

EQL ClearLax Tier 2 M90

EQL Fluticasone Propionate ClariSpray Tier 2 M90

57

Covered Product Reference Tier Status NotesEQL Gentle Laxative Alophen Tier 2 M90

EQL Heartburn Prevention Pepcid AC Tier 2 M90

EQL Ibuprofen Infants Medi-Profen Tier 2 M90

EQL Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

EQL Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

EQL Infants Gas ReliefLittle Remedies for Tummys

Tier 2 M90

EQL Laxative Maximum Strength Tier 2 M90

EQL Laxative Oral Tablet Tier 2 M90

EQL Laxative Oral Tablet Delayed Release

Alophen Tier 2 M90

EQL Miconazole 1 Monistat 1 Combo Pack Tier 2 M90

EQL Miconazole 3 Vagistat-3 Tier 2 M90

EQL Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

EQL Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

EQL Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

EQL Nasal Decongestant SudoGest Tier 2 M90

EQL Natural Zinc IS-ZC 50 Tier 2 M90

EQL Nicotine Mouth/Throat KLS Quit4 Tier 1 M90

EQL Nicotine Polacrilex KLS Quit4 $0 M90

EQL One Daily Mens ABC Plus Senior Tier 2 M90

EQL One Daily Mens 50+ Advance ABC Plus Senior Tier 2 M90

EQL One Daily Mens Health ABC Plus Senior Tier 2 M90

EQL One Daily Womens 50+ Adv ABC Plus Senior Tier 2 M90

EQL Pain & Fever Infants PediaCare Children Tier 2 M90

EQL Prenatal Formula Tier 1 M90

EQL Ready-to-Use Enema Rectal Enema 7-19 GM/118ML

Fleet Enema Tier 2 M90

EQL Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

EQL Senna Laxative Evac-U-Gen Tier 2 M90

EQL Stomach Relief Oral Suspension Kaopectate Tier 2 M90

EQL Stool Softener Correctol Extra Gentle Tier 2 M90

EQL Ultra Moisturizing DailyA + D Personal Care Lotion

Tier 2 M90

EQL Vision Formula ABC Plus Senior Tier 2 M90

EQL Vitamin D3 GummiesVitaJoy Daily D Gummies

Tier 2 M90

EQL Vitamin D3 Oral Capsule 125 MCG (5000 UT)


58

Covered Product Reference Tier Status NotesEQL Vitamin D3 Oral Capsule 25 MCG (1000 UT)


EQL Vitamin D3 Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

Equetro Tier 2 M90

Erbitux MB PA

Ergocalciferol Oral Solution 8000 UNIT/ML

Calcidol Tier 2 M90

Ergoloid Mesylates Oral Tier 2 M90

Ergomar Tier 2 M90

Erivedge $0SP; QL (30 EA per 90 days)

Erleada $0QL (120 EA per 30 days)

Erlotinib HCl Tarceva $0

E-R-O Ear Drops Tier 2 M90

E-R-O Ear Wax Removal System Tier 2 M90

Errin $0 M90

Ertaczo Tier 2 ST; M90

Ery Tier 2 M90

Ery-Tab Tier 2 M90

Erythrocin Stearate Oral Tablet 250 MG Tier 2 M90

Erythromycin Base Oral Capsule Delayed Release Particles

Tier 2 M90

Erythromycin Base Oral Tablet Tier 2 M90

Erythromycin Ethylsuccinate Oral Suspension Reconstituted 200 MG/5ML

E.E.S. Granules Tier 2 M90

Erythromycin Ethylsuccinate Oral Suspension Reconstituted 400 MG/5ML

EryPed 400 Tier 2

Erythromycin Ethylsuccinate Oral Tablet E.E.S. 400 Tier 2 M90

Erythromycin External Erygel Tier 2 M90

Erythromycin Ophthalmic Tier 2 M90

Esbriet Oral Capsule Tier 2PA; SP; QL (270 capsules per 30 days)

Esbriet Oral Tablet 267 MG Tier 2PA; SP; QL (QL Applies)

Esbriet Oral Tablet 801 MG Tier 2PA; SP; QL (90 EA per 30 days)

Escitalopram Oxalate Oral Solution Tier 2 M90

Escitalopram Oxalate Oral Tablet 10 MG, 5 MG

Lexapro Tier 2QL (30 EA per 90 days)

59


Escitalopram Oxalate Oral Tablet 20 MG Lexapro Tier 2QL (60 EA per 30 days)

Esgic Oral Capsule Tier 2 M90

Esomeprazole Magnesium Oral Packet NexIUM Tier 2ST; QL (30 EA per 30 days)

Esperoct Tier 2 PA; SP; Dual

Essential Balance ABC Plus Senior Tier 2 M90

Est Estrogens-Methyltest DS Covaryx Tier 2 M90

Est Estrogens-Methyltest HS Covaryx HS Tier 2 M90

Est Estrogens-Methyltest Oral Tablet 1.25-2.5 MG

Covaryx Tier 2 M90

Estarylla $0 M90

Estazolam Oral Tablet 1 MG Tier 2

Estazolam Oral Tablet 2 MG Tier 2 M90

Estradiol Oral Estrace Tier 2 M90

Estradiol Transdermal Alora Tier 2 M90

Estradiol Vaginal Cream Estrace Tier 2

Estradiol Valerate Intramuscular Oil 20 MG/ML, 40 MG/ML

Delestrogen Tier 2 M90

Estradiol-Norethindrone Acet Amabelz Tier 2 M90

Estring Tier 2 M90

Estrogel Tier 2 M90

Estropipate Oral Tier 2 M90

Eszopiclone Lunesta Tier 2ST; QL (30 EA per 30 days)

Ethacrynic Acid Oral Edecrin Tier 1 M90

Ethambutol HCl Oral Tier 2 M90

Ethosuximide Oral Zarontin Tier 2 M90

Ethynodiol Diac-Eth Estradiol Kelnor 1/35 $0

Etidronate Disodium Tier 2 M90

Etodolac ER Tier 2 M90

Etodolac Oral Tier 2 M90

Etonogestrel-Ethinyl Estradiol EluRyng $0

Etopophos $0 M90

Etoposide Intravenous Solution 1 GM/50ML, 100 MG/5ML, 500 MG/25ML

Toposar $0 M90

Etoposide Oral $0 M90

Etravirine Oral Tablet 100 MG Intelence Tier 2QL (120 EA per 30 days)

60


Etravirine Oral Tablet 200 MG Intelence Tier 2QL (60 EA per 30 days)

Eucerin Daily Protection/SPF30 Tier 2 M90

Eucerin External Lotion Tier 2 M90

Eucerin Intensive Repair Tier 2 M90

Eucerin Original Healing Tier 2 M90

Eucerin Plus External Lotion Tier 2 M90

Eucerin Smoothing Repair Tier 2 M90

Eucrisa Tier 2PA; PD; QL (60 GM per 30 days)

Euflexxa Intra-Articular Solution Prefilled Syringe

Tier 2PA; SP; QL (QL Applies); Dual

Eurax Tier 2 M90

Evac-U-Gen Oral Tablet Tier 2 M90

Evamist Tier 2 M90

Everolimus Oral Tablet 0.25 MG, 0.5 MG, 0.75 MG

Zortress Tier 2 QL (QL Applies)

Everolimus Oral Tablet Soluble 2 MG Afinitor Disperz $0PA; QL (60 EA per 30 days)



Evkeeza MB PA

Evomela $0 SP

Evotaz Tier 2QL (30 EA per 90 days)

Evrysdi Tier 2PA; SP; QL (2 BOTTLES per 24 Days)

Evzio Tier 2PA; QL (1 FILL per 365 days)

Exel Comfort Point Pen Needle 29G X 12MM , 31G X 6 MM , 31G X 8 MM

$0 M90

Exel Comfort Point Pen Needle 31G X 4 MM

Tier 1 M90

Exemestane Aromasin $0 M90

Ex-Lax Ultra Tier 2 M90

Exoderm External Lotion Tier 2 M90

Exondys 51 MB PA

Exotic-HC Cortic-ND Tier 2 M90

61


Extavia Subcutaneous Kit Tier 2SP; QL (15 per 30 days)

Extra Strength Pain ReliefHealthy Mama Shake That Ache

Tier 2 M90

Eye Allergy Relief Ophthalmic Solution 0.025-0.3 %

Naphcon-A Tier 2 M90

Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

Eye Vitamins & Minerals ABC Plus Senior Tier 2 M90

EyeProtect ABC Plus Senior Tier 2 M90

Eylea Intraocular Tier 2 PA; SP; QL (QL Flag)

Eylea Intravitreal Tier 2 PA; SP; Dual

E-Z-Cat Dry Tier 2 M90

Ezetimibe Zetia Tier 2ST; QL (30 EA per 90 days)

Fabior Tier 2 ST; M90

Fabrazyme Tier 2 PA; SP; Dual

Factive Tier 2 M90

FaLessa Oral Kit 20-1-0.1 MCG-MG $0 M90

Fallback Solo $0 M90

Falmina $0 M90

Famciclovir Oral Tier 2 M90

Famotidine OralMM Acid-Pep Maximum Strength

Tier 2 M90

Famotidine Tab 20 MGMM Acid-Pep Maximum Strength

Tier 2 M90

Fanapt Tier 2M90; QL (60 EA per 30 days)

Fanapt Titration Pack Tier 2M90; QL (1 PACK per 28 days)

Farxiga Tier 2M90; QL (30 EA per 30 days)

Farydak $0 SP; QL (QL Flag)

Fasenra Tier 2PA; SP; Dual; QL (1 SYR per 56 days)

Fasenra Pen Tier 2PA; SP; Dual; QL (1 PEN per 56 days)

FC Female Condom Tier 1M90; QL (4 EA per 30 days)

FE C Tab Plus Icar-C Plus Tier 2 M90

FE Plus Protein Tier 2 M90

Fe Tabs Tier 2 M90

62

Covered Product Reference Tier Status NotesFebrol Tier 2 M90

Febuxostat Uloric Tier 2ST; QL (30 EA per 90 days)

Feenamint Tier 2 M90

Feiba Tier 2 PA; SP; Dual

Feiba NF Tier 2 PA; SP; Dual

Feiba VH Immuno Tier 2 PA; SP; Dual

Felbamate Felbatol Tier 2 M90

Felodipine ER Tier 1 M90

FemCap Tier 2 M90

Femring Tier 2 M90

Femynor $0 M90

Fenofibrate Micronized Oral Capsule 130 MG, 134 MG, 200 MG, 43 MG, 67 MG

Tier 1 M90

Fenofibrate Oral Capsule 150 MG, 50 MG Lipofen Tier 1 M90

Fenofibrate Oral Tablet 145 MG, 48 MG Tricor Tier 1 M90

Fenofibrate Oral Tablet 160 MG, 54 MG Tier 1 M90

Fenofibrate Oral Tablet 40 MG Fenoglide Tier 1 M90

Fenofibric Acid Fibricor Tier 1 M90

Fenoprofen Calcium Oral Tablet Nalfon Tier 2

Fensolvi (6 Month) Tier 2PA; SP; Dual; QL (1 KIT per 180 Days)

FentaNYL Citrate Buccal Lozenge On A Handle

Actiq Tier 2 PA

fentaNYL Citrate Buccal Tablet Fentora Tier 2 PA; QL (QL Applies)

FentaNYL Transdermal Patch 72 Hour 100 MCG/HR, 50 MCG/HR, 75 MCG/HR

Tier 2 ST; QL (QL applies)

FentaNYL Transdermal Patch 72 Hour 12 MCG/HR, 25 MCG/HR


Ferate Oral Tablet 240 (27 Fe) MG Tier 2 M90

Fergon Tier 2 M90

Fer-Iron BProtected Pedia Iron Tier 2 M90

Ferocon Tricon Tier 2 M90

FeroSul Oral Elixir $0 M90

Ferotrinsic Tricon Tier 2 M90

Ferrex 150 Forte Oral Capsule 150-25-1 MG-MCG-MG

iFerex 150 Forte Tier 2 M90

Ferriprox Oral Tablet 1000 MG Tier 2 PA; SP

Ferriprox Twice-A-Day Tier 2 PA; SP

Ferrotabs Ferate Tier 2 M90

63

Covered Product Reference Tier Status NotesFerrous Aspartate Tier 2 M90

Ferrous Gluconate Oral Tablet 240 (27 Fe) MG

Ferate Tier 2 M90

Ferrous Gluconate Oral Tablet 324 (38 Fe) MG, 325 (36 Fe) MG

Tier 2 M90

Ferrous Sulfate Oral Elixir $0 M90

Ferrous Sulfate Oral Liquid $0 M90

Ferrous Sulfate Oral Solution 75 (15 Fe) MG/ML

BProtected Pedia Iron $0 M90

Ferrous Sulfate Oral Syrup Tier 1 M90

Ferrous Sulfate Oral Tablet 27 MG Tier 2 M90

Ferrous Sulfate Oral Tablet Delayed Release 324 (65 Fe) MG, 325 (65 Fe) MG

Tier 2 M90

Fetzima Tier 2ST; M90; QL (30 EA per 90 days)

Fetzima Titration Tier 2ST; M90; QL (1 PACK per 28 days)

Fever Reducer Childrens FeverAll Childrens Tier 2 M90

FeverAll Childrens Tier 2 M90

FeverAll Junior Strength Tier 2 M90

Fexofenadine HCl Childrens Allegra Allergy Childrens Tier 2M90; QL (300ml per month)

Fexofenadine HCl Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

Fexofenadine HCl Oral Tablet 60 MG Wal-Fex Allergy Tier 2 M90; QL (QL Flag)

Fexofenadine-Pseudoephed ER Oral Tablet Extended Release 12 Hour



Fexofenadine-Pseudoephed ER Oral Tablet Extended Release 24 Hour



Fibryga Tier 2 PA; SP; Dual

Fifty50 Pen Needles $0 M90

Finacea External Foam Tier 2 M90

Finasteride Oral Tablet 5 MG Proscar Tier 2 M90

Fintepla Tier 2PA; SP; QL (360 ML per 30 days)

Firdapse Tier 2PA; SP; QL (240 EA per 30 days)

Firmagon $0 PA; SP; Dual

First-Omeprazole Tier 2

First-Testosterone Tier 2 M90

First-Testosterone MC Tier 2 M90

64

Covered Product Reference Tier Status NotesFirvanq Oral Solution Reconstituted 25 MG/ML

Tier 2

Flanax Pain Relief Oral Tier 2 M90

Flarex Tier 2 M90

FlavoxATE HCl Tier 2 M90

Flebogamma DIF Tier 2 PA; SP; Dual

Flecainide Acetate Tier 2 M90

Fleet Laxative Oral Tier 2 M90

Flinstones Gummies Omega-3 DHA Tier 2 M90

Flintstones Plus Calcium Tier 2 M90

Flintstones Plus Iron Tier 2 M90

Flintstones/My First Tier 2 M90

Floriva Plus Tier 2 M90

Flovent Diskus Tier 2 M90

Flovent HFA Tier 2 M90

Floxuridine Injection $0 M90

Fluad $0 M90

Fluad Quadrivalent $0

Fluarix Quadrivalent Intramuscular Suspension Prefilled Syringe

$0 M90

Flublok $0 M90

Flublok Quadrivalent $0

Flucaine Tier 2 M90

Flucelvax Intramuscular Suspension Prefilled Syringe

Tier 1 M90

Flucelvax Quadrivalent Intramuscular Suspension

$0

Flucelvax Quadrivalent Intramuscular Suspension Prefilled Syringe

$0 M90

Fluconazole in Sodium Chloride Tier 2 M90

Fluconazole Oral Diflucan Tier 2 M90

Flucytosine Oral Ancobon Tier 2 M90

Fludarabine Phosphate $0 M90

Fludrocortisone Acetate Oral Tier 2 M90

Flulaval Quadrivalent Intramuscular Suspension

$0 M90

Flulaval Quadrivalent Intramuscular Suspension Prefilled Syringe

$0 M90

FluMist Quadrivalent $0 M90

65

Covered Product Reference Tier Status NotesFlunisolide Nasal Solution 25 MCG/ACT (0.025%)

Tier 2 M90

Fluocinolone Acetonide Body Derma-Smoothe/FS Body Tier 2ST; M90; QL (QL Applies)

Fluocinolone Acetonide External Cream 0.01 %


Fluocinolone Acetonide External Cream 0.025 %

Synalar Tier 2 M90

Fluocinolone Acetonide External Ointment

Synalar Tier 2 M90

Fluocinolone Acetonide External Solution Synalar Tier 2ST; M90; QL (QL Applies)

Fluocinolone Acetonide Otic DermOtic Tier 2 M90

Fluocinolone Acetonide Scalp Derma-Smoothe/FS Scalp Tier 2 M90

Fluocinonide Emulsified Base Tier 2ST; QL (120 GM per 30 days)

Fluocinonide External Cream 0.05 % Tier 2 PA; M90

Fluocinonide External Gel Tier 2ST; M90; QL (QL Applies)

Fluocinonide External Ointment Tier 2ST; M90; QL (QL Applies)

Fluocinonide External Solution Tier 2 PA; M90

Fluorabon Tier 1 M90

Fluor-a-day Oral Solution Tier 1 M90

Fluorescein-Benoxinate Tier 2 M90

Fluoridex Daily Defense Tier 2 M90

Fluoridex Enhanced Whitening Dental Gel Tier 2 M90

Fluoridex Sensitivity Relief Dental Paste Tier 2 M90

Fluor-I-Strips A.T. Tier 2 M90

Fluoritab Oral Solution NaFrinse Drops Tier 1 M90

Fluoritab Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG

Tier 1 M90

Fluoritab Oral Tablet Chewable 2.2 (1 F) MG

NaFrinse Tier 2 M90

Fluorometholone Ophthalmic FML Liquifilm Tier 2 M90

Fluoroplex Tier 2 PA; M90

Fluorouracil External Efudex Tier 2 PA; M90

Fluorouracil Intravenous $0 M90

FLUoxetine HCl Oral Capsule 10 MG PROzac Tier 2M90; QL (90 EA per 30 days)

66


FLUoxetine HCl Oral Capsule 20 MG PROzac Tier 2M90; QL (150 EA per 30 days)

FLUoxetine HCl Oral Solution Tier 2 M90

FLUoxetine HCl Oral Tablet 10 MG Tier 2M90; QL (90 EA per 30 days)

FluPHENAZine Decanoate Injection Tier 2 M90

FluPHENAZine HCl Injection Tier 2 M90

FluPHENAZine HCl Oral Tier 2 M90

Flura-Drops Tier 1 M90

Flurazepam HCl Tier 2

Flurbiprofen Oral Tier 2 M90

Flurbiprofen Sodium Tier 2 M90

Flurox Tier 2 M90

Flutamide $0 M90

Fluticasone Propionate External Cream Tier 2 PA; M90

Fluticasone Propionate External Ointment Tier 2 PA; M90

Fluticasone Propionate Nasal ClariSpray Tier 2 M90

Fluticasone Propionate Nasal Susp 50 MCG/ACT

ClariSpray Tier 2 M90

Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

Advair Diskus Tier 2PA; QL (60 EA per 30 days)

Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 113-14 MCG/ACT

AirDuo RespiClick 113/14

Tier 2 PA


AirDuo RespiClick 232/14

Tier 2 PA



Fluvastatin Sodium Tier 2ST; M90; QL (30 EA per 90 days)

Fluvastatin Sodium ER Lescol XL Tier 1ST; M90; QL (30 EA per 90 days)

Fluvirin Intramuscular Suspension $0 M90

Fluvirin Intramuscular Suspension Prefilled Syringe

$0 M90

Fluvirin Preservative Free Intramuscular Suspension Prefilled Syringe

Tier 1 M90

67

Covered Product Reference Tier Status NotesFluvoxaMINE Maleate Oral Tablet 100 MG


FluvoxaMINE Maleate Oral Tablet 25 MG

Tier 2M90; QL (45 tablets per month)

FluvoxaMINE Maleate Oral Tablet 50 MG

Tier 2M90; QL (75 tablets per month)

Fluzone High-Dose Intramuscular Suspension Prefilled Syringe

$0 M90

Fluzone High-Dose Quadrivalent $0

Fluzone Quadrivalent Intradermal $0 M90

Fluzone Quadrivalent Intramuscular Suspension , 0.5 ML

$0 M90

Fluzone Quadrivalent Intramuscular Suspension Prefilled Syringe

$0 M90

FML Tier 2 M90

FML Forte Tier 2 M90

Focalin XR Tier 2PD; BP; QL (60 EA per 30 days)

Folic Acid Injection $0 M90

Folic Acid Oral Capsule 20 MG $0 M90

Folic Acid Oral Capsule 5 MG Tier 2 M90

Folic Acid Oral Tablet 1 MG Tier 2 M90

Folivane-OB Oral Capsule 130-92.4-1 MG

$0 M90

Folotyn $0 SP

Foltrin Tricon Tier 2 M90

Formoterol Fumarate Inhalation Perforomist Tier 2 PA

Formula 3 The Treatment Tier 2 M90

Formula 405 Body Smoothing Tier 2 M90

Formula 405 Moisturizing Tier 2 M90

Fortamet Tier 1 PA

Fortavit Oral Liquid Tier 2 M90

Fosamprenavir Calcium Lexiva Tier 2

Fosaprepitant Dimeglumine Emend Tier 2

Fosinopril Sodium Tier 1 M90

Fosinopril Sodium-HCTZ Tier 1 M90

Fosrenol Oral Packet Tier 2 M90

Fosrenol Oral Tablet Chewable 1000 MG, 500 MG, 750 MG

Tier 2 M90

68

Covered Product Reference Tier Status NotesFragmin Subcutaneous Solution 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

Tier 2 M90

Freds Pharmacy Unifine Pentip+Advocate Insulin Pen Needles

$0 M90

Freds Pharmacy Unifine Pentips BD Pen Needle Nano U/F $0 M90

Freedavite ABC Plus Senior Tier 2 M90

FreeStyle Freedom Lite $0M90; QL (1 EA per 365 days)

FreeStyle InsuLinx System $0M90; QL (1 EA per 365 days)

FreeStyle InsuLinx Test $0M90; PD; QL (100 EA per 30 days)

FreeStyle Libre 14 Day Reader Tier 2PA; PD; QL (1 EA per 365 days)

FreeStyle Libre 14 Day Sensor Tier 2PA; PD; QL (3 EA per 30 days)

FreeStyle Libre 2 Reader Tier 2PA; PD; QL (1 EA per 365 days)

FreeStyle Libre 2 Sensor Tier 2PA; PD; QL (3 EA per 30 days)

FreeStyle Libre Reader Tier 2PA; PD; QL (1 EA per 365 days)

FreeStyle Libre Sensor System Tier 2PA; PD; QL (1 EA per 365 days)

FreeStyle Lite Device $0M90; QL (1 EA per 365 days)

FreeStyle Lite Test $0M90; PD; QL (100 EA per 30 days)

FreeStyle Precision Neo System $0PA; QL (1 EA per 365 days)

FreeStyle Precision Neo Test $0PA; PD; QL (100 EA per 30 days)

FreeStyle Test $0M90; PD; QL (100 EA per 30 days)

Frovatriptan Succinate Frova Tier 2M90; QL (12 tablets per month)

Fruity Chews Bounty Bears/C Tier 2 M90

Fruity Chews/IronLand Before Time Multivitamin

Tier 2 M90

Ful-Glo Tier 2 M90

69


Fulphila Tier 2SP; Dual; QL (2 SYR per 28 days)

Fulvestrant Faslodex $0 QL (QL Applies)

Fungi-Guard Tinactin Tier 2 M90

Fungoid-D Tier 2 M90

Furosemide Injection Solution 10 MG/ML Tier 1 M90

Furosemide Oral Solution 10 MG/ML, 8 MG/ML

Tier 1 M90

Furosemide Oral Tablet Lasix Tier 1 M90

Fusion Plus Tier 2 M90

Fuzeon Subcutaneous Solution Reconstituted

Tier 2QL (60 VIALS per 30 days)

Fyavolv Tier 2 M90

Fycompa Oral Suspension Tier 2 M90

Fycompa Oral Tablet 10 MG, 12 MG, 2 MG, 4 MG


Fycompa Oral Tablet 6 MG, 8 MG Tier 2M90; QL (30 EA per 90 days)

Gabapentin Oral Neurontin Tier 2 M90

Galafold Tier 2 PA; SP

Galantamine Hydrobromide Tier 2 M90

Galantamine Hydrobromide ER Razadyne ER Tier 2 M90

Galzin Tier 2 M90

Gammagard Tier 2 PA; SP; Dual

Gammagard S/D Less IgA Tier 2 PA; SP; Dual

Gammaked Tier 2 PA; SP; Dual

Gammaplex Intravenous Solution 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

Tier 2 PA; SP; Dual

Gamunex-C Tier 2 PA; SP; Dual

Ganciclovir Sodium Intravenous Solution Reconstituted

Tier 2 M90

Gardasil 9 $0 M90

Gas Relief Oral Liquid Gas-X Infant Drops Tier 2 M90

Gas Relief Oral SuspensionLittle Remedies for Tummys

Tier 2 M90

Gas Relief Oral Tablet Chewable Tier 2 M90

Gas-X Infant Drops Tier 2 M90

Gatifloxacin Ophthalmic Zymaxid Tier 2 M90

70


Gattex Tier 2SP; QL (1 KIT per 30 Days)

GaviLAX Oral Powder ClearLax Tier 2 M90

GaviLyte-C Tier 2 M90

GaviLyte-G Tier 2 M90

GaviLyte-H $0 M90

GaviLyte-N with Flavor Pack Tier 2 M90

Gavreto Tier 2PA; SP; QL (120 EA per 30 days)

Gazyva $0 SP

Gelfilm Ophthalmic Tier 2 M90

Gelnique Transdermal Gel 10 % Tier 2 ST; M90

Gel-One Intra-Articular Prefilled Syringe Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)

Gelsyn-3 Tier 2PA; SP; QL (QL Applies); Dual

Gel-Tin Dental Tier 2 M90

Gemcitabine HCl Intravenous Solution 1 GM/10ML

$0

Gemcitabine HCl Intravenous Solution 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML

$0 M90

Gemcitabine HCl Intravenous Solution Reconstituted

$0 M90

Gemfibrozil Oral Lopid Tier 1 M90

Genahist Oral Capsule Banophen Tier 2 M90

Genaphed SudoGest Tier 2 M90

Generlac Tier 2 M90

Gengraf Oral Capsule 100 MG, 25 MG Tier 2 SP

Gengraf Oral Solution Tier 2 SP

Genotropin Tier 2 PA; SP; PD

Genotropin MiniQuick Tier 2 PA; SP; PD

Genpril Medi-Profen Tier 2 M90

Gentak Ophthalmic Ointment Tier 2 M90

Gentamicin Sulfate External Tier 2 M90

Gentamicin Sulfate Ophthalmic Gentak Tier 2 M90

Gentle Laxative Alophen Tier 2 M90

Gentle Laxative For Women Alophen Tier 2 M90

GenVisc 850 Tier 2PA; SP; QL (QL Applies); Dual

71


Genvoya Tier 2PD; QL (30 EA per 30 days)

Geri-Dryl Oral Capsule Banophen Tier 2 M90

Geri-Dryl Oral Tablet Alka-Seltzer Plus Allergy Tier 2 M90

Geri-Freeda Senior Formula ABC Plus Senior Tier 2 M90

Geri-Hydrolac 12 Tier 2 M90

Geri-kot Evac-U-Gen Tier 2 M90

Geri-Pectate Kaopectate Tier 2 M90

Gerivite Complete ABC Plus Senior Tier 2 M90

Gianvi $0 M90

Giazo Tier 2 M90

Gildagia Tier 2 M90

Gilenya Tier 2PA; SP; BP; QL (28 EA per 28 days)

Gilotrif $0SP; QL (30 EA per 30 days)

Gimoti Tier 2PA; QL (9.8 ML per 28 days)

Givlaari MB PA; PD

Glass Syringe 3 ML Tier 2 M90

Glass Syringe 5 ML Tier 2 M90

Glassia Tier 2 PA; SP; Dual

Gleostine $0 M90

Gliadel Wafer $0 M90

Glimepiride Amaryl Tier 1 M90

glipiZIDE ER Glucotrol XL Tier 1 M90

glipiZIDE Oral Tier 1 M90

GlipiZIDE XL Glucotrol XL Tier 1 M90

glipiZIDE-metFORMIN HCl Tier 1 M90

Global Ease Inject Pen Needles CareFine Pen Needles $0 M90

Global Easy Glide Pen Needles BD Pen Needle Nano U/F $0 M90

Glucagon Emergency Injection Kit Tier 2 M90

Glucagon Emergency Injection Solution Reconstituted

Tier 2

Glucoten DEKAs Plus Tier 2 M90

Glumetza Tier 1 PA

GlyBURIDE Micronized Glynase Tier 1 M90

GlyBURIDE Oral Tier 1 M90

GlyBURIDE-MetFORMIN Tier 1 M90

72

Covered Product Reference Tier Status NotesGlycine Irrigation Tier 2 M90

Glycine Urologic Tier 2 M90

GlycoLax Tier 2 M90

Glycopyrrolate Oral Tablet 1 MG, 2 MG Tier 2 M90

Glydo External Gel Tier 2 M90

Glyxambi Tier 2PA; ST; M90; QL (30 EA per 90 days)

GNP 8 Hour Pain Relief Midol Tier 2 M90

GNP 8 Hour Pain Reliever Midol Tier 2 M90

GNP Acid Control 150 Max St Tier 2 M90

GNP Acid Control 75 Tier 2 M90

GNP Acid Reducer Pepcid AC Tier 2 M90

GNP Acid Reducer Max StMM Acid-Pep Maximum Strength

Tier 2 M90

GNP Advanced RecoveryA + D Personal Care Lotion

Tier 2 M90

GNP All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)

GNP All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

GNP All Day Pain Relief Mediproxen Tier 2 M90

GNP Allergy Wal-finate Tier 2 M90

GNP Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

GNP Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

GNP Allergy-D Allergy & CongesWal-Fex D Allergy & Congestion


GNP Animal Shapes Bounty Bears/C Tier 2 M90

GNP Animal Shapes Plus IronLand Before Time Multivitamin

Tier 2 M90

GNP Antacid Extra Strength Oral Tablet Chewable 750 MG


Tier 2 M90

GNP Antacid Oral Tablet Chewable 500 MG


GNP Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

GNP Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

GNP Arthritis Pain Relief Oral Midol Tier 2 M90

GNP Athletes Foot External Cream Desenex Tier 2 M90

GNP Bisa-Lax Oral Tier 2 M90

GNP Calcium Tier 2 M90

GNP Calcium 1200 Tier 2 M90

GNP Calcium 500 +D3 Os-Cal Extra D3 Tier 2 M90

73

Covered Product Reference Tier Status NotesGNP Calcium 500/D Os-Cal Calcium + D3 Tier 2 M90

GNP Calcium 600 +D/Minerals Tier 2 M90

GNP Calcium 600 +D3 Pronutrients Calcium+D3 Tier 2 M90

GNP Calcium 600 +D3/MineralsCaltrate 600+D Plus Minerals

Tier 2 M90

GNP Calcium 600 Plus D/Mineral Tier 2 M90

GNP Calcium 600/D Tier 2 M90

GNP Calcium Citrate +D3 Calcitrate Tier 2 M90

GNP Calcium Citrate+D Maximum Calcitrate Tier 2 M90

GNP Calcium Plus 600 +D Tier 2 M90

GNP Calcium/Vitamin D/Minerals Tier 2 M90

GNP Capsaicin External Cream Capzasin-HP Tier 2 M90

GNP Century ABC Plus Senior Tier 2 M90

GNP Century Active Performance ABC Plus Senior Tier 2 M90

GNP Century Adults 50+ Senior ABC Plus Senior Tier 2 M90

GNP Century Cardio Health ABC Plus Senior Tier 2 M90

GNP Century Mature ABC Plus Senior Tier 2 M90

GNP Century Ultimate Mens ABC Plus Senior Tier 2 M90

GNP Century Ultimate Womens ABC Plus Senior Tier 2 M90

GNP Childrens Allergy Banophen Tier 2 M90

GNP Childrens Chewables/IronLand Before Time Multivitamin

Tier 2 M90

GNP Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

GNP Childrens Pain Relief Oral Suspension


GNP ClearLax Oral Powder Tier 2 M90

GNP Clickfine Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

GNP Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90

GNP D 2000VitaJoy Daily D Gummies

Tier 2 M90

GNP Diabetic Support Formula ABC Plus Senior Tier 2 M90

GNP Ear Drops Murine Ear Tier 2 M90

GNP Ear Systems Murine Ear Tier 2 M90

GNP Enema Rectal Enema 7-19 GM/118ML

Fleet Enema Tier 2 M90

GNP Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

GNP Gas Relief Tier 2 M90

GNP Hair/Skin/Nails ABC Plus Senior Tier 2 M90

GNP Healthy Eyes ABC Plus Senior Tier 2 M90

74

Covered Product Reference Tier Status NotesGNP Healthy Eyes SuperVision DEKAs Plus Tier 2 M90

GNP Heartburn Relief Tagamet HB Tier 2 M90

GNP Heartburn Relief 200 Tagamet HB Tier 2 M90

GNP Hydrocortisone Max St Cortizone-10 Tier 2 M90

GNP Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90

GNP Ibuprofen Infants Medi-Profen Tier 2 M90

GNP Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

GNP Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

GNP Infants Gas ReliefLittle Remedies for Tummys

Tier 2 M90

GNP Infants Pain Relief Oral Suspension PediaCare Children Tier 2 M90

GNP Infants Pain/Fever PediaCare Children Tier 2 M90

GNP Iodides Tier 2 M90

GNP Iodine Tier 2 M90

GNP Itchy Eye Alaway Tier 2 M90; QL (QL Flag)

GNP K-Pec Kaopectate Tier 2 M90

GNP Laxative The Magic Bullet Tier 2 M90

GNP Laxative Pills Tier 2 M90

GNP Lice Bedding RID Tier 2 M90

GNP Lice Treatment External Liquid Nix Creme Rinse Tier 2 M90

GNP Little Ones Childrens Bounty Bears/C Tier 2 M90

GNP Loratadine Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

GNP Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

GNP Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

GNP Magnesium Citrate Citroma Tier 2 M90

GNP Magnesium Oxide Tier 2 M90

GNP Maximum One Daily ABC Plus Senior Tier 2 M90

GNP Mega Multi for Men ABC Plus Senior Tier 2 M90

GNP Mega Multi for Women ABC Plus Senior Tier 2 M90

GNP Miconazole 1 Monistat 1 Combo Pack Tier 2 M90

GNP Miconazole 3 Vagistat-3 Tier 2 M90

GNP Miconazole 3 ApplicatorMonistat 3 Combo Pack App

Tier 2 M90

GNP Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

GNP Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

GNP Mineral Oil Heavy Tier 2 M90

75

Covered Product Reference Tier Status NotesGNP Motion Sickness Relief Oral Tablet 25 MG


GNP Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

GNP Nasal Decongestant SudoGest Tier 2 M90

GNP Nasal Moisturizing Afrin Saline Nasal Mist Tier 1 M90

GNP Niacin Tier 1 M90

GNP Niacin TR Endur-Acin Tier 1 M90

GNP Nicotine Mini Mouth/Throat Lozenge 2 MG

KLS Quit2 $0 M90

GNP Nicotine Polacrilex KLS Quit2 $0 M90

GNP One Daily Maximum ABC Plus Senior Tier 2 M90

GNP One Daily Mens 50+Advanced ABC Plus Senior Tier 2 M90

GNP One Daily Mens Health 50+ ABC Plus Senior Tier 2 M90

GNP One Daily Mens/Lycopene ABC Plus Senior Tier 2 M90

GNP One Daily Plus IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

GNP One Daily Womens ABC Plus Senior Tier 2 M90

GNP One Daily Womens 50+ ABC Plus Senior Tier 2 M90

GNP Opti-Vitamins ABC Plus Senior Tier 2 M90

GNP Pain & Fever Childrens Oral Suspension 160 MG/5ML


GNP Pain Relief Aphen Tier 2 M90

GNP Pain Relief Extra Strength Oral Tablet


Tier 2 M90

GNP Pain Reliever Ex StHealthy Mama Shake That Ache

Tier 2 M90

GNP Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90

GNP PreNatal Tier 1 M90

GNP Senna-Lax Evac-U-Gen Tier 2 M90

GNP Stomach Relief Kaopectate Tier 2 M90

GNP Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

GNP Stool Softener Oral Liquid Docu Liquid Tier 2 M90

GNP Stool Softener Oral Syrup Tier 2 M90

GNP Therapeutic-M ABC Plus Senior Tier 2 M90

GNP Tolnaftate Tinactin Tier 2 M90

GNP Vitamin B-6 Oral Tablet 100 MG Tier 2 M90

GNP Vitamin D Maximum Strength Thera-D 2000 Tier 2 M90

GNP Vitamin D Oral Tablet 25 MCG (1000 UT)

Vitamin D-1000 Max St Tier 2 M90

76


GNP Vitamin D Super StrengthRadiance Platinum Vitamin D3

Tier 2 M90

GNP Vitamin D3 Extra Strength Vitamin D-1000 Max St Tier 2 M90

GNP Womens Laxative Alophen Tier 2 M90

GNP Womens One Daily ABC Plus Senior Tier 2 M90

GNP Zinc Chelated IS-ZC 50 Tier 2 M90

GNP Zinc Oxide Tier 2 M90

Gold Bond Medicated Body Tier 2 M90

Gold Bond Medicated Body Ex St Tier 2 M90

Gold Bond Ult Sheer Ribbons Tier 2 M90

Gold Bond Ultimate External Lotion Tier 2 M90

Gold Bond Ultimate Healing External Lotion

Tier 2 M90

Gold Bond Ultimate Protection Tier 2 M90

Gold Bond Ultimate Restoring Tier 2 M90

Gold Bond Ultimate Softening Tier 2 M90

Gold Bond Ultimate Soothing External Lotion

Tier 2 M90

Golytely Oral Solution Reconstituted 227.1 GM

Tier 2 M90

GoodSense Acid Reducer Tier 2 M90

GoodSense All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)

GoodSense Aller-Ease KLS Aller-Fex Tier 2M90; QL (30 EA per 90 days)

GoodSense Allergy Relief Oral Capsule 25 MG

Banophen Tier 2 M90

GoodSense Magnesium Citrate Citroma Tier 2 M90

GoodSense Mineral Oil Tier 2 M90

GoodSense Nasoflow ClariSpray Tier 2 M90

GoodSense Nicotine Mouth/Throat Gum 4 MG

KLS Quit4 $0 M90

GoodSense Pain & Fever Child PediaCare Children Tier 2 M90

GoodSense Pain & Fever Infants PediaCare Children Tier 2 M90

GoodSense Pain Relief Oral Tablet Aphen Tier 2 M90

GoodSense Prenatal Vitamins Tier 1 M90

GoodSense Senna Laxative Oral Tablet 8.6 MG

Evac-U-Gen Tier 2 M90

Gordofilm Tier 2 M90

Gordomatic External LotionA + D Personal Care Lotion

Tier 2 M90

77

Covered Product Reference Tier Status NotesGranisetron HCl Intravenous Solution 4 MG/4ML

Tier 2 M90

Granisetron HCl Oral Tier 2M90; QL (2 EA per 28 days)

Granix Tier 2 PA; SP; Dual

Grastek Tier 2 PA; M90

Griseofulvin Microsize Oral Tier 2 M90

Griseofulvin Ultramicrosize Tier 2 M90

GRX Vitamin E External Lotion Tier 2 M90

GuanFACINE HCl ER Intuniv Tier 2 ST; M90

guanFACINE HCl Oral Tier 1 M90

Guanidine HCl Oral Tier 2 M90

Gvoke HypoPen 1-Pack Tier 2 PA

Gvoke HypoPen 2-Pack Tier 2 PA

Gvoke PFS Tier 2 PA

Gynazole-1 Tier 2 M90

Haegarda Tier 2 PA; SP; Dual

Hair Formula Extra Strength ABC Plus Senior Tier 2 M90

Hair Skin and Nails Formula ABC Plus Senior Tier 2 M90

Hair Vitamins ABC Plus Senior Tier 2 M90

Hair/Skin/Nails Oral Tablet ABC Plus Senior Tier 2 M90

Hair/Skin/Nails/Biotin ABC Plus Senior Tier 2 M90

Hair-Vites ABC Plus Senior Tier 2 M90

Halaven $0 SP

Halobetasol Propionate External Cream Tier 2ST; M90; QL (QL Applies)

Halobetasol Propionate External Ointment Tier 2ST; M90; QL (QL Applies)

Haloperidol Decanoate Intramuscular Solution 100 MG/ML, 50 MG/ML

Haldol Decanoate Tier 2 M90

Haloperidol Lactate Injection Solution 5 MG/ML

Tier 2 M90

Haloperidol Lactate Oral Tier 2 M90

Haloperidol Oral Tier 2 M90

Halotin Tier 2 ST; M90

Harvoni Oral Packet Tier 2PA; SP; QL (28 EA per 28 days)

Harvoni Oral Tablet 45-200 MG Tier 2PA; SP; QL (28 tablets per 28 days)

78

Covered Product Reference Tier Status NotesHavrix Intramuscular Suspension 1440 EL U/ML, 720 EL U/0.5ML

$0 M90

HealthWise Mini Pen Needles CareFine Pen Needles $0 M90

HealthWise Pen Needles CareFine Pen Needles $0 M90

HealthWise Short Pen Needles 31G X 8 MM


$0 M90

HealthWise Unifine Pentips BD Pen Needle Nano U/F $0 M90

Healthy Accents Unifine PentipAdvocate Insulin Pen Needles

$0 M90

Healthy Eyes ABC Plus Senior Tier 2 M90

Healthy Mama Move It Along Tier 2 M90

Healthy Mama Shake That Ache Tier 2 M90

Healthy Mama Tame the Flame Tier 2 M90

HealthyLax Tier 2 M90

Heartburn Relief Pepcid AC Tier 2 M90

Heartburn Relief 150 Max St Tier 2 M90

Heather $0 M90

H-E-B inControl Pen Needles CareFine Pen Needles $0 M90

H-E-B inControl Unifine Pentip 32G X 4 MM

$0 M90

H-E-B Oral Electrolyte CeraLyte 70 Tier 2 M90

Helixate FS Tier 2 PA; SP; Dual

Hemangeol Tier 2 M90

Hemax Oral Tablet Tier 2 M90

Hemlibra Tier 2 PA; SP; Dual

Hemmorex-HC Rectal Suppository 30 MG

Tier 2 M90

Hemocyte-F Oral Elixir Tier 2 M90

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

Tier 2 PA; SP; Dual

Heparin Lock Flush Intravenous Solution 10 UNIT/ML, 100 UNIT/ML

Tier 2 M90

Heparin Sodium (Porcine) Injection Solution 1000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML, 5000 UNIT/ML

Tier 2 M90

Heparin Sodium Flush Tier 2 M90

Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML

Tier 2 M90

Heplisav-B Intramuscular Solution $0

79

Covered Product Reference Tier Status NotesHetastarch-NaCl Hespan Tier 2 M90

Hetlioz Tier 2PA; SP; QL (30 EA per 90 days)

Hetlioz LQ Tier 2PA; SP; QL (150 ML per 30 days)

Hexalen $0 M90

Hiberix Injection $0 M90

High Potency Calcium Oral Tablet 600 MG

Tier 2 M90

High Potency Iron Oral Tablet 134 MG Tier 2 M90

Hi-Kovite 2-Part Formula ABC Plus Senior Tier 2 M90

Hi-Potency Multi-Vitamin ABC Plus Senior Tier 2 M90

Hizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

Tier 2 PA; SP; Dual

Hizentra Subcutaneous Solution Prefilled Syringe

Tier 2 PA; SP; Dual

HM Acid Reducer Tier 2 M90

HM Acid Reducer Max Strength Tier 2 M90

HM All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)

HM Allergy Alka-Seltzer Plus Allergy Tier 2 M90

HM Allergy Childrens Banophen Tier 2 M90

HM Allergy Complete Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

HM Allergy Multi Symptom Banophen Tier 2 M90

HM Allergy Relief (Loratadine) KLS AllerClear Tier 2 M90; QL (QL Flag)

HM Allergy Relief Childrens Banophen Tier 2 M90

HM Allergy Relief Nasal ClariSpray Tier 2 M90

HM Allergy Relief Oral Capsule Banophen Tier 2 M90

HM Allergy Relief Oral Tablet 4 MG Wal-finate Tier 2 M90

HM Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

HM Antioxidant Vitamins ABC Plus Senior Tier 2 M90

HM Arthritis Pain Relief Midol Tier 2 M90

HM Bacitracin Bacitraycin Plus Tier 2 M90

HM Calcium 600+D Plus MineralsCaltrate 600+D Plus Minerals

Tier 2 M90

HM Calcium Antacid Cal-Gest Antacid Tier 2 M90

HM Calcium Antacid Ex StCVS Chewy Not Chalky Flavor

Tier 2 M90

HM Calcium Antacid Ultra St Tums Ultra 1000 Tier 2 M90

80


HM Calcium Citrate+D3 PetiteCitracal Petites/Vitamin D

Tier 2 M90

HM Calcium Citrate+Vitamin D Calcitrate Tier 2 M90

HM Calcium-Vitamin D Oral Tablet 500-200 MG-UNIT


HM Calcium-Vitamin D Oral Tablet 600-400 MG-UNIT

Tier 2 M90

HM Calcium-Vitamin D-Minerals Tier 2 M90

HM Cetirizine HCl Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

HM ClearLax Oral Powder Tier 2 M90

HM Complete ABC Plus Senior Tier 2 M90

HM Complete 50+ ABC Plus Senior Tier 2 M90

HM Complete 50+ Mens Ultimate ABC Plus Senior Tier 2 M90

HM Complete 50+ Women Ultimate ABC Plus Senior Tier 2 M90

HM Earwax Removal Aid Murine Ear Tier 2 M90

HM Earwax Removal Kit Murine Ear Tier 2 M90

HM Enema Fleet Enema Tier 2 M90

HM Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

HM Famotidine Pepcid AC Tier 2 M90

HM Fexofenadine HCl KLS Aller-Fex Tier 2 M90; QL (QL Flag)

HM Gas Relief Infants DropsLittle Remedies for Tummys

Tier 2 M90

HM Gas Relief Oral Tablet Chewable 80 MG

Tier 2 M90

HM Hair/Skin/Nails ABC Plus Senior Tier 2 M90

HM Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90

HM Ibuprofen IB Oral Tablet Medi-Profen Tier 2 M90

HM Ibuprofen Infants Medi-Profen Tier 2 M90

HM Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

HM Iodides Tier 2 M90

HM Iodine Tier 2 M90

HM Laxative The Magic Bullet Tier 2 M90

HM Lice Treatment Tier 2 M90

HM Loperamide HCl Oral Capsule Imodium A-D Tier 2 M90

HM Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)

HM Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

HM Magnesium Citrate Citroma Tier 2 M90

HM Magnesium Oral Tablet 250 MG Tier 2 M90

81


HM Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

HM Mineral Oil Tier 2 M90

HM Motion Relief Wal-Dram II Tier 2 M90

HM Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

HM Nasal Decongestant SudoGest Tier 2 M90

HM Niacin Endur-Acin Tier 1 M90

HM Nicotine Nicoderm CQ $0 M90

HM Nicotine Polacrilex KLS Quit2 $0 M90

HM One Daily Mens ABC Plus Senior Tier 2 M90

HM One Daily Womens ABC Plus Senior Tier 2 M90

HM One Daily/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

HM Pain & Fever Childrens PediaCare Children Tier 2 M90

HM Pain & Fever Infants PediaCare Children Tier 2 M90

HM Pain Relief Childrens PediaCare Children Tier 2 M90

HM Pain Relief Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

HM Pain Reliever Aphen Tier 2 M90

HM Pediatric Electrolyte CeraLyte 70 Tier 2 M90

HM Prenatal Tier 1 M90

HM Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

HM Senna Evac-U-Gen Tier 2 M90

HM Stomach Relief Oral Suspension Kaopectate Tier 2 M90

HM Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

HM Stool Softener Oral Tablet DOK Tier 2 M90

HM Vitamin B6 Tier 2 M90

HM Vitamin D Oral Tablet 25 MCG (1000 UT)


HM Vitamin D3 Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

HM Zinc IS-ZC 50 Tier 2 M90

Homatropaire Tier 2 M90

Homatropine HBr Ophthalmic Homatropaire Tier 2 M90

HumaLOG Junior KwikPen Tier 1 BP

HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML, 200 UNIT/ML

Tier 1 BP

HumaLOG Mix 50/50 Tier 1 M90; BP

82

Covered Product Reference Tier Status NotesHumaLOG Mix 50/50 KwikPen Subcutaneous Suspension Pen-Injector

Tier 1 M90; BP

HumaLOG Mix 75/25 Tier 1 M90; BP

HumaLOG Mix 75/25 KwikPen Subcutaneous Suspension Pen-Injector

Tier 1 BP

HumaLOG Subcutaneous Solution Tier 2 BP

HumaLOG Subcutaneous Solution Cartridge

Tier 1 BP

Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

Tier 2 PA; SP; Dual

Humatrope Tier 2 PA; SP

Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 40 MG/0.8ML


Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML


Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML & 40MG/0.4ML


Humira Pen Subcutaneous Pen-Injector Kit 40 MG/0.4ML, 40 MG/0.8ML


Humira Pen-CD/UC/HS Starter Subcutaneous Pen-Injector Kit 40 MG/0.8ML


Humira Pen-Ps/UV/Adol HS Start Subcutaneous Pen-Injector Kit 40 MG/0.8ML


Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML


Humira Subcutaneous Prefilled Syringe Kit 40 MG/0.4ML, 40 MG/0.8ML


Humist Tier 1 M90

HumuLIN 70/30 Tier 1 M90

HumuLIN 70/30 KwikPen Subcutaneous Suspension Pen-Injector

Tier 1 M90

HumuLIN N Tier 1 M90

HumuLIN N KwikPen Subcutaneous Suspension Pen-Injector

Tier 1 M90

HumuLIN R Tier 1 M90

HumuLIN R U-500 (CONCENTRATED) Tier 1 M90

83

Covered Product Reference Tier Status NotesHumuLIN R U-500 KwikPen Subcutaneous Solution Pen-Injector

Tier 1 M90

Hyalgan Intra-Articular Solution Tier 2PA; SP; QL (QL Flag); Dual

Hyalgan Intra-Articular Solution Prefilled Syringe


Hycamtin Oral $0 SP; QL (QL Flag)

HydrALAZINE HCl Oral Tier 1 M90

HydroCHLOROthiazide Oral Tier 1 M90

HYDROcodone Bitartrate ER Oral Tablet ER 24 Hour Abuse-Deterrent

Hysingla ER Tier 2ST; QL (30 EA per 90 days)

HYDROcodone-Acetaminophen Oral Solution 10-325 MG/15ML, 2.5-108 MG/5ML, 5-217 MG/10ML, 7.5-325 MG/15ML

Tier 2PA; QL (2700 ML per 30 days)

HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, 10-325 MG, 7.5-300 MG, 7.5-325 MG


HYDROcodone-Acetaminophen Oral Tablet 5-300 MG

Xodol Tier 2QL (240 tablets per 30 days. Click;HERE)

HYDROcodone-Acetaminophen Oral Tablet 5-325 MG

Tier 2QL (240 tablets per 30 days. Click;HERE)

HYDROcodone-Ibuprofen Oral Tablet 10-200 MG, 5-200 MG, 7.5-200 MG


Hydrocortisone Ace-Pramoxine External Cream 2.5-1 %

Pramosone Tier 2 M90

Hydrocortisone Acetate Rectal Anusol-HC Tier 2 M90

Hydrocortisone Butyrate External Cream Tier 2ST; M90; QL (QL Applies)

Hydrocortisone Butyrate External Ointment


Hydrocortisone Butyrate External Solution

Tier 2 M90

Hydrocortisone External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90

Hydrocortisone External Cream 2.5 % Tier 2 M90

Hydrocortisone External Lotion 2.5 % Tier 2 M90

Hydrocortisone External Ointment 1 % Cortizone-10 Tier 2 M90

Hydrocortisone External Ointment 2.5 % Tier 2 M90

Hydrocortisone in Absorbase Tier 2 M90

Hydrocortisone Intensive Heal Aveeno Anti-Itch Max St Tier 2 M90

Hydrocortisone Max St External Cream Aveeno Anti-Itch Max St Tier 2 M90

Hydrocortisone Max St/12 Moist Aveeno Anti-Itch Max St Tier 2 M90

84

Covered Product Reference Tier Status NotesHydrocortisone Oint 1% Cortizone-10 Tier 2 M90

Hydrocortisone Oral Cortef Tier 2 M90

Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90

Hydrocortisone Rectal Enema Cortenema Tier 2 M90

Hydrocortisone Valerate Tier 2ST; M90; QL (QL Applies)

Hydrocortisone-Acetic Acid Acetasol HC Tier 2 M90

HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent


HYDROmorphone HCl Oral Liquid Dilaudid Tier 2QL (600 mL per 30 days. Click;HERE)

HYDROmorphone HCl Oral Tablet 2 MG Dilaudid Tier 2QL (180 EA per 30 days)



HYDROmorphone HCl Rectal Tier 2QL (120 EA per 30 days)

HydroSKIN External Cream Tier 2 M90

Hydroxocobalamin Intramuscular Tier 2 M90

Hydroxychloroquine Sulfate Oral Plaquenil Tier 2

HYDROXYprogesterone Caproate Intramuscular Oil

Makena Tier 2 PA; SP; Dual

Hydroxyprogesterone Caproate Intramuscular Solution

$0 PA; SP; M90; Dual

Hydroxyurea Oral Hydrea $0 M90

hydrOXYzine HCl Intramuscular Solution 50 MG/ML

Tier 2 M90

HydrOXYzine HCl Oral Syrup Tier 2 M90

hydrOXYzine HCl Oral Tablet Tier 2 M90

HydrOXYzine Pamoate Oral Tier 2 M90

Hymovis Tier 2PA; SP; Dual; QL (2 SYR per 14 days)

Hyoscyamine Sulfate ER Oral Tablet Extended Release 12 Hour

Levbid Tier 2 M90

Hyoscyamine Sulfate Oral Tier 2 M90

Hyoscyamine Sulfate Sublingual Levsin/SL Tier 2 M90

Hyosyne Tier 2 M90

Hyqvia Tier 2 PA; SP; Dual

Hy-Vee All Day Relief Mediproxen Tier 2 M90

85

Covered Product Reference Tier Status NotesHyVee Ibuprofen Childrens Tier 2 M90

I.L.X. B-12 Oral Elixir Tier 2 M90

Ibandronate Sodium Intravenous Solution 3 MG/3ML

Tier 2 M90

Ibandronate Sodium Oral Boniva Tier 2M90; QL (1 tablet per 28 days; 13 tablets per 365 days)

Ibrance $0SP; PD; QL (21 EA per 28 days)

IBU-200 Medi-Profen Tier 2 M90

Ibudone Tier 2M90; QL (50 tablets per 30 days. Click;HERE)

Ibu-Drops Medi-Profen Tier 2 M90

Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90

Ibuprofen Junior Strength Oral Tablet Chewable

Advil Junior Strength Tier 2 M90

Ibuprofen Oral Suspension Childrens Medi-Profen Tier 2 M90

Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

Icar Oral Suspension Tier 1 M90

Icar-C Plus Tier 2 M90

Icatibant Acetate Firazyr Tier 2PA; SP; QL (QL Applies); Dual

Iclusig Oral Tablet 10 MG, 30 MG $0 PA; SP

Iclusig Oral Tablet 15 MG $0PA; SP; QL (60 EA per 30 days)

Iclusig Oral Tablet 45 MG $0PA; SP; QL (30 EA per 30 days)

Icosapent Ethyl Vascepa Tier 2PA; QL (120 EA per 30 days)

IDArubicin HCl Idamycin PFS $0 M90

Idelvion Tier 2 PA; SP; Dual

iFerex 150 Forte Tier 2 M90

Ifex Intravenous Solution Reconstituted 3 GM

$0 M90

Ifosfamide Ifex $0 M90

Ilaris (150mg Delivered) Tier 2 PA; SP

Ilaris Subcutaneous Solution Tier 2 PA; SP; Dual

Ilevro Tier 2ST; M90; QL (1.7ml per 25 days)

Ilotycin Tier 2 M90

86


Ilumya Tier 2PA; Dual; QL (1 SYR per 12 Weeks)

Iluvien Intraocular Tier 2 SP

Imatinib Mesylate Oral Tablet 100 MG Gleevec $0SP; QL (90 EA per 30 days)

Imatinib Mesylate Oral Tablet 400 MG Gleevec $0SP; QL (60 EA per 30 days)

Imbruvica Oral Capsule 140 MG $0QL (90 EA per 30 days)

Imbruvica Oral Capsule 70 MG $0QL (30 EA per 30 days)

Imbruvica Oral Tablet 420 MG, 560 MG $0QL (30 EA per 30 days)

Imcivree Tier 2PA; SP; QL (10 ML per 30 days)

Imfinzi MB PA

Imipramine HCl Oral Tier 2 M90

Imipramine Pamoate Tier 2 M90

Imiquimod External Cream 5 % Aldara Tier 2 PA; M90

Imiquimod Pump Zyclara Tier 2 ST

Inbrija Tier 2PA; SP; QL (300 capsules per month)

Increlex Tier 2 PA; SP; QL (QL Flag)

Incruse Ellipta Tier 2

Indapamide Oral Tier 1 M90

Inderal XL Tier 2 M90

Indocin Oral Tier 2 M90

Indomethacin Oral Capsule 25 MG, 50 MG

Tier 2 M90

Infanrix $0 M90

Infants Gas ReliefLittle Remedies for Tummys

Tier 2 M90

Infants Ibuprofen Medi-Profen Tier 2 M90

Infants Pain & Fever PediaCare Children Tier 2 M90

Infants Pain Reliever Tier 2 M90

Infants Silapap Tier 2 M90

Infants Simethicone Oral Suspension 20 MG/0.3ML

Little Remedies for Tummys

Tier 2 M90

Infed Tier 2M90; QL (1 FILL per 365 days)

87


Inflectra Tier 2

PA; SP; QL (Quantity Limit Applies); Dual; QL (5 VIALS per 28 days)

Ingrezza Oral Capsule Tier 2PA; SP; QL (30 EA per 30 days)

Inlyta Oral Tablet 1 MG $0PA; SP; PD; QL (240 EA per 30 days)

Inlyta Oral Tablet 5 MG $0PA; SP; PD; QL (120 EA per 30 days)

InnoPran XL Tier 2 M90

Inqovi $0

Inrebic $0PA; SP; QL (120 EA per 30 days)

Insulin Pen Needle 29 G X 12 MM (1/2") $0 M90

Insulin Pen Needle 31 G X 5 MM (1/5" or 3/16")

$0 M90


$0 M90


$0 M90

Insulin Pen Needle 32 G X 5 MM (1/5" or 3/16") 32G X 5 MM

$0 M90

Insupen Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90

Insupen Pen Needles 33G X 4 MMClever Choice Comfort EZ

Tier 1 M90

Insupen Sensitive 32G X 6 MM $0 M90

Insupen Sensitive 32G X 8 MM Tier 1 M90

Insupen Ultrafin $0 M90

Intelence Oral Tablet 25 MG Tier 2QL (120 EA per 30 days)

Intralipid Intravenous Emulsion 20 % Tier 2 M90

Intron A $0 SP

Introvale $0 M90

Inulin Tier 2 M90

Invega Sustenna Intramuscular Suspension Prefilled Syringe


Invega Trinza Intramuscular Suspension Prefilled Syringe


Invirase Oral Capsule Tier 2SP; QL (300 per 30 days)

88


Invirase Oral Tablet Tier 2QL (120 EA per 30 days)

Invokamet Tier 2M90; QL (60 EA per 30 days)

Invokamet XR Tier 2

Invokana Tier 2M90; QL (30 EA per 30 days)

Iodides Tincture Tier 2 M90

Iodine External Tincture , 2 %, 2-2.4 % Tier 2 M90

Iodine Tincture External Tincture Tier 2 M90

Ipol Injection Injectable $0 M90

Ipratropium Bromide Inhalation Tier 2 M90

Ipratropium Bromide Nasal Tier 2 M90

Ipratropium-Albuterol Tier 2 M90

I-Prin Medi-Profen Tier 2 M90

Irbesartan Avapro Tier 1 M90

Irbesartan-Hydrochlorothiazide Avalide Tier 1 M90

Iressa $0SP; QL (30 EA per 30 days)

Irinotecan HCl Intravenous Solution 100 MG/5ML, 40 MG/2ML

Camptosar $0 M90

Irinotecan HCl Intravenous Solution 300 MG/15ML

Camptosar $0

Irinotecan HCl Intravenous Solution 500 MG/25ML

$0 M90

Iron 100 Plus Icar-C Plus Tier 2 M90

Iron Oral Tablet 240 (27 Fe) MG Ferate Tier 2 M90

Iron Oral Tablet 28 MG, 90 (18 Fe) MG Tier 2 M90

Iron Supplement Childrens BProtected Pedia Iron $0 M90

Isentress Oral Packet Tier 2QL (60 EA per 30 days)

Isentress Oral Tablet Tier 2QL (120 EA per 30 days)

Isentress Oral Tablet Chewable Tier 2QL (180 EA per 30 days)

Isometheptene-Caffeine-APAP Oral Tablet 65-20-325 MG

Tier 2 M90

Isometheptene-Dichloral-APAP Tier 2 M90

Isoniazid Injection Tier 2 M90

Isoniazid Oral Tier 2 M90

Isosorbide Dinitrate ER Tier 2 M90

89

Covered Product Reference Tier Status NotesIsosorbide Dinitrate Oral Tablet 10 MG, 20 MG, 30 MG

Tier 2 M90

Isosorbide Dinitrate Oral Tablet 40 MG Isordil Titradose Tier 2

Isosorbide Dinitrate Oral Tablet 5 MG Isordil Titradose Tier 2 M90

Isosorbide Mononitrate Tier 2 M90

Isosorbide Mononitrate ER Tier 2 M90

Isoxsuprine HCl Oral Tier 2 M90

Isradipine Tier 1 M90

Istodax Tier 1 SP

Istodax (Overfill) $0 SP

Isturisa Oral Tablet 1 MG Tier 2PA; SP; QL (240 EA per 30 Days)



Itraconazole Oral Capsule Sporanox Tier 2PA; M90; QL (60 EA per 30 days)

Itraconazole Oral Solution Sporanox Tier 2PA; SP; QL (450ml per 21 days)

Ivermectin External Cream Soolantra Tier 2 PA

Ivermectin External Lotion Tier 2

Ivermectin Oral Stromectol Tier 2M90; QL (20 EA per 90 days)

I-Vite ABC Plus Senior Tier 2 M90

I-Vite Protect ABC Plus Senior Tier 2 M90

Ixempra Kit $0 SP

Ixiaro $0 M90

Ixinity Tier 2 PA; SP; Dual

Jakafi $0SP; QL (60 EA per 30 days)

Jantoven Tier 2 M90

Janumet Tier 2M90; QL (60 EA per 60 days)

Janumet XR Tier 2M90; QL (30 EA per 30 days)

Januvia Tier 2M90; QL (30 EA per 30 days)

Jardiance Tier 2M90; QL (30 EA per 30 days)

Jatenzo Tier 2 ST

90

Covered Product Reference Tier Status NotesJencycla $0 M90

Jentadueto Tier 2QL (30 EA per 30 days)

Jentadueto XR Tier 2

Jevantique Lo Fyavolv Tier 2 M90

Jevtana $0 SP

Jinteli Tier 2 M90

Jivi Tier 2 PA; SP; Dual

Jock Itch Desenex Tier 2 M90

Jock Itch Relief Desenex Tier 2 M90

Jolessa $0 M90

Jolivette $0 M90

Juleber $0 M90

Juluca Tier 2PD; QL (30 EA per 30 days)

Junel 1.5/30 $0 M90

Junel 1/20 $0 M90

Junel FE 1.5/30 $0 M90

Junel FE 1/20 $0 M90

Junel Fe 24 $0 M90

Just for Kids Dental Tier 2 M90

Juxtapid Tier 2PA; QL (30 EA per 90 days)

Jynarque Oral Tablet Tier 2 SP

Jynarque Oral Tablet Therapy Pack 15 MG, 30 & 15 MG

Tier 2SP; QL (56 EA per 28 days)

Jynarque Oral Tablet Therapy Pack 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

Tier 2SP; QL (56 tablets per month); QL (56 EA per 28 days)

Kadcyla $0 SP

Kadian Oral Capsule Extended Release 24 Hour 200 MG

Tier 2ST; M90; QL (QL applies)

Kaitlib Fe $0 M90

Kalbitor Tier 2PA; SP; QL (QL Flag); Dual

Kaletra Oral Solution Tier 2SP; QL (390 per 30 days)

Kalydeco Oral Packet 25 MG Tier 2 PA; PD

Kalydeco Oral Packet 50 MG, 75 MG Tier 2PA; SP; PD; QL (60 PACKS per 30 days)

91


Kalydeco Oral Tablet Tier 2PA; SP; PD; QL (60 EA per 30 days)

Kanuma MB PA

Kaopectate Oral Suspension Tier 2 M90

Kao-Tin Oral Suspension Tier 2 M90

Karbinal ER Oral Suspension Extended Release

Tier 2 M90

Karidium Tier 1 M90

Karigel Tier 2 M90

Karigel-N Tier 2 M90

Kariva $0 M90

Kaz HealthMist Humidifier $0 QL (1 EA per 1 Year)

Kaz Vicks Vaporizer V150 $0M90; QL (QL Flag); QL (1 EA per 1 Year)

Kazano Tier 2PA; QL (30 EA per 30 days)

K-Effervescent Effer-K Tier 2 M90

Kelnor 1/35 $0 M90

Kenalog Injection Tier 2 M90

Kendall Sodium Chloride Flush Tier 2 M90

Kepivance $0 M90

Keri Advanced Moisture Therapy Tier 2 M90

Keri Basic Essentials Tier 2 M90

Keri Nourishing Shea Butter Tier 2 M90

Keri Original Tier 2 M90

Keri Overnight Tier 2 M90

Keri Renewal Milk Body Tier 2 M90

Keri Renewal Skin Firming Tier 2 M90

Keri Renewal Stretch Mark Tier 2 M90

Keri Sensitive Skin Tier 2 M90

KeriCort 10 Tier 2 M90

Ketoconazole External Cream Tier 2 PA; M90

Ketoconazole External Shampoo 2 % Tier 2 PA; M90

Ketoconazole Oral Tier 2 PA; M90

Ketoprofen ER Tier 2 M90

Ketoprofen Oral Capsule 50 MG, 75 MG Tier 2 M90

Ketorolac Tromethamine Injection Solution 15 MG/ML, 30 MG/ML, 60 MG/2ML

Tier 2 M90

92

Covered Product Reference Tier Status NotesKetorolac Tromethamine Ophthalmic Solution 0.4 %

Acular LS Tier 2M90; QL (5ml per 25 days)

Ketorolac Tromethamine Ophthalmic Solution 0.5 %

Acular Tier 2M90; QL (10ml per 25 days)

Ketorolac Tromethamine Oral Tier 2M90; QL (30 EA per 90 days)

Ketotifen Fumarate Ophthalmic Alaway Tier 2 M90; QL (QL Flag)

Kevzara Subcutaneous Solution Auto-Injector

Tier 2PA; SP; QL (2 ML per 28 PENSs)

Kevzara Subcutaneous Solution Prefilled Syringe

Tier 2PA; SP; QL (2 ML per 28 SYRs)

Keytruda Intravenous Solution MB PA

Khedezla Oral Tablet Extended Release 24 Hour 50 MG

Tier 2 ST; M90

Kimidess $0 M90

Kineret Subcutaneous Solution Prefilled Syringe


Kinrix Intramuscular Suspension $0 M90

Kionex Tier 2 M90

Kisqali 200 Dose $0SP; QL (63 EA per 28 days)

Kisqali 400 Dose $0 SP

Kisqali 600 Dose $0 SP

Kisqali Femara (400 MG Dose) $0 SP

Kisqali Femara (600 MG Dose) $0 SP

Kisqali Femara(200 MG Dose) $0 SP

Klor-Con Tier 2 M90

Klor-Con 10 Tier 2 M90

Klor-Con M10 Tier 2 M90



Klor-Con Sprinkle Tier 2 M90

Klor-Con/EF Tier 2 M90

KLS Acetaminophen Ex StHealthy Mama Shake That Ache

Tier 2 M90

KLS Acid Controller Max StMM Acid-Pep Maximum Strength

Tier 2 M90

KLS Acid Reducer Tier 2 M90

KLS Acid Reducer Max St Tier 2 M90

KLS AllerClear Tier 2 M90; QL (QL Flag)

KLS Aller-Fex Tier 2 M90; QL (QL Flag)

93

Covered Product Reference Tier Status NotesKLS Aller-Flo Tier 2 M90

KLS Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90

KLS Aller-Tec Tier 2M90; QL (30 EA per 90 days)


KLS Antacid Cal-Gest Antacid Tier 2 M90

KLS Arthritis Pain Midol Tier 2 M90

KLS Ibuprofen Medi-Profen Tier 2 M90

KLS Ibuprofen IB Medi-Profen Tier 2 M90

KLS LaxaClear Tier 2 M90

KLS Naproxen Sodium Mediproxen Tier 2 M90

KLS Non AspirinHealthy Mama Shake That Ache

Tier 2 M90

KLS Pain & Fever Infants PediaCare Children Tier 2 M90

KLS Pain Relief Childrens PediaCare Children Tier 2 M90

KLS Quit2 $0 M90

KLS Quit4 $0 M90

KLS Rapid Release PainHealthy Mama Shake That Ache

Tier 2 M90

KLS Stool Softener Correctol Extra Gentle Tier 2 M90

Koate Tier 2 PA; SP; Dual

Koate-DVI Tier 2 PA; SP; Dual

Kogenate FS Tier 2 PA; SP; Dual

Kogenate FS Bio-Set Tier 2 PA; SP

Kombiglyze XR Oral Tablet Extended Release 24 Hour 2.5-1000 MG


Kombiglyze XR Oral Tablet Extended Release 24 Hour 5-1000 MG, 5-500 MG


Korlym Tier 2PA; QL (120 EA per 30 days)

Koselugo $0

Kovaltry Tier 2 PA; SP; Dual

KP Adults 50+ Daily Formula ABC Plus Senior Tier 2 M90

KP Adults Daily Formula ABC Plus Senior Tier 2 M90

KP Benzoyl Peroxide Tier 2 M90

KP Bisacodyl Alophen Tier 2 M90

KP Calcium 600+D Oral Capsule Tier 2 M90

KP Calcium 600+D Oral Tablet 600-400 MG-UNIT

Tier 2 M90

KP Cetirizine HCl Oral Tablet 10 MG KLS Aller-Tec Tier 2 M90; QL (QL Flag)

94


KP Cetirizine HCl Oral Tablet 5 MG Tier 2M90; QL (30 EA per 90 days)

KP Clotrimazole Desenex Tier 2 M90

KP Fexofenadine HCl Wal-Fex Allergy Tier 2 M90; QL (QL Flag)

KP Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90

KP Hydrocortisone Max St Cortizone-10 Tier 2 M90

KP Ketotifen Fumarate Alaway Tier 2M90; QL (10ml per 25 days)

KP Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)

KP Mens 50+ Daily Formula ABC Plus Senior Tier 2 M90

KP Mens Daily Formula ABC Plus Senior Tier 2 M90

KP Miconazole Nitrate Tineacide Tier 2 M90

KP Prenatal Multivitamins Tier 1 M90

KP Vitamin D Oral Capsule 25 MCG (1000 UT)


KP Womens 50+ Daily Formula ABC Plus Senior Tier 2 M90

KP Womens Daily Formula ABC Plus Senior Tier 2 M90

K-Phos Tier 2 M90

K-Phos No 2 Tier 2 M90

K-Prime Tier 2 M90

Krintafel Tier 2PA; QL (2 tablets per request)

Kroger Pen Needles 29G X 12MM , 31G X 6 MM


Kroger Pen Needles 31G X 8 MMAdvocate Insulin Pen Needles

$0 M90

Krystexxa MB PA

KS Stool Softener Correctol Extra Gentle Tier 2 M90

Kurvelo $0 M90

K-Vescent Oral Tablet Effervescent Effer-K Tier 2 M90

Kyleena $0SP; QL (1 FILL per 365 days)

Kynamro Subcutaneous Solution Prefilled Syringe

Tier 2PA; SP; QL (4 per 28 days)

Kynmobi Tier 2PA; SP; QL (150 EA per 30 days)

Labetalol HCl Intravenous Solution Tier 1 M90

Labetalol HCl Oral Tier 1 M90

Lacrisert Tier 2 M90

Lactaid Oral Tablet Tier 2

95

Covered Product Reference Tier Status NotesLactase Fast Acting Lactaid Fast Act Tier 2

Lactated Ringers Irrigation Tier 2 M90

Lactic Acid (Ammonium Lactate) Lotion 12%

AL12 Tier 2 M90

Lactic Acid E Tier 2 M90

Lactic Acid External Lotion Tier 2 M90

Lactulose Encephalopathy Tier 2 M90

Lactulose Oral Solution Tier 2 M90

LamiVUDine Oral Solution Epivir Tier 2 SP; M90

LamiVUDine Oral Tablet 100 MG Epivir HBV Tier 2M90; QL (30 EA per 90 days)

LamiVUDine Oral Tablet 150 MG, 300 MG

Epivir Tier 2 SP; M90

lamiVUDine-Zidovudine Combivir Tier 2 M90

LamoTRIgine ER LaMICtal XR Tier 2 M90

lamoTRIgine Oral Tablet LaMICtal Tier 2 M90

LamoTRIgine Oral Tablet Chewable LaMICtal Tier 2 M90

LamoTRIgine Oral Tablet Dispersible LaMICtal ODT Tier 2 M90

Lampit Tier 2

Lancets $0

Land Before Time Multivitamin Oral Tablet Chewable 15 MG

Tier 2 M90

Lan-O-Soothe External Cream Tier 2 M90

Lansoprazole Oral Capsule Delayed Release 15 MG

Prevacid 24HR Tier 2ST; M90; QL (120 EA per 30 days)

Lansoprazole Oral Capsule Delayed Release 30 MG

Prevacid Tier 2 ST

Lanthanum Carbonate Fosrenol Tier 2

Lantus Tier 1

Lantus SoloStar Subcutaneous Solution Pen-Injector

Tier 1

Larin 1.5/30 $0 M90

Larin 1/20 $0 M90

Larin 24 FE $0 M90

Larin Fe 1.5/30 $0 M90

Larin Fe 1/20 $0 M90

Larissia $0 M90

Lastacaft Tier 2ST; M90; QL (3ml per 25 days)

Latanoprost Ophthalmic Xalatan Tier 2 M90

96

Covered Product Reference Tier Status NotesLatuda Oral Tablet 120 MG, 20 MG, 40 MG, 60 MG


Latuda Oral Tablet 80 MG Tier 2M90; QL (60 EA per 30 days)

Laxa Basic Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

Laxative Feminine Alophen Tier 2 M90

Laxative Oral Tablet 25 MG Tier 2 M90

Laxative Oral Tablet Delayed Release Alophen Tier 2 M90

Laxative Pills Tier 2 M90

Laxative Rectal The Magic Bullet Tier 2 M90

Layolis FE $0 M90

Lazanda Nasal Solution 100 MCG/ACT, 400 MCG/ACT

Tier 2 PA; M90

L-Cysteine HCl Intravenous Elcys Tier 2 M90

Leader Unifine Pentips $0 M90

Leader Unifine Pentips Plus $0 M90

Lecithin Oral Granules Tier 2 M90

Ledipasvir-Sofosbuvir Harvoni Tier 2PA; SP; PD; QL (28 EA per 28 days)

Leena $0 M90

Leflunomide Oral Arava Tier 2 M90

Lemtrada MB PA

Lenvima (10 MG Daily Dose) $0PA; SP; QL (30 EA per 30 days)








Lessina $0 M90

Letrozole Oral Femara $0 M90

97

Covered Product Reference Tier Status NotesLeucovorin Calcium Injection Solution 100 MG/10ML

$0

Leucovorin Calcium Injection Solution Reconstituted

$0 M90

Leucovorin Calcium Oral $0 M90

Leukeran $0 M90

Leukine Injection Solution Reconstituted Tier 2 SP; Dual

Leuprolide Acetate Injection $0 PA; SP

Levacet Tier 2 M90

Levalbuterol HCl Inhalation Nebulization Solution 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML

Xopenex Tier 2PA; M90; QL (4 PACKS per 30 days)

Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/0.5ML

Xopenex Concentrate Tier 2PA; M90; QL (3 PACKS per 30 days)

Levalbuterol Tartrate Xopenex HFA Tier 2 PA

LevETIRAcetam ER Keppra XR Tier 2 M90

levETIRAcetam Oral Keppra Tier 2 M90

Levobunolol HCl Ophthalmic Solution 0.5 %

Tier 2 M90

levOCARNitine Intravenous Carnitor Tier 2 M90

levOCARNitine Oral Solution Carnitor Tier 2 M90

levOCARNitine Oral Tablet Carnitor Tier 2 M90

Levocetirizine Dihydrochloride Oral Solution

Xyzal Allergy 24HR Childrens

Tier 2M90; QL (300ml per month)

Levocetirizine Dihydrochloride Oral Tablet

Xyzal Allergy 24HR Tier 2M90; QL (30 EA per 90 days)

LevoFLOXacin Intravenous Tier 2 M90

Levofloxacin Ophthalmic Tier 2 M90

Levofloxacin Oral Levaquin Tier 2 M90

Levoleucovorin Calcium Intravenous Solution

$0 SP

LEVOleucovorin Calcium Intravenous Solution Reconstituted 50 MG

$0 SP

LEVOleucovorin Calcium PF Intravenous Solution 250 MG/25ML

$0 SP

Levonest $0 M90

Levonorgest-Eth Estrad 91-Day Introvale $0 M90

Levonorgestrel Oral Tablet 1.5 MG Aftera $0 M90

Levonorgestrel-Ethinyl Estrad Altavera $0 M90

Levonorg-Eth Estrad Triphasic Oral Tablet

Enpresse-28 $0 M90

98

Covered Product Reference Tier Status NotesLevora 0.15/30 (28) $0 M90

Levorphanol Tartrate Oral Tablet 2 MG Tier 2

Levo-T Tier 2 M90

Levothyroxine Sodium Oral Capsule Tirosint Tier 2

Levothyroxine Sodium Oral Tablet Levo-T Tier 2 M90

Levoxyl Tier 2 M90

Levulan Kerastick Tier 2 M90

Lexiva Oral Suspension Tier 2QL (1680 ml per 30 days)

Lexiva Oral Tablet Tier 2QL (120 EA per 30 days)

Lexuss 210 Tier 2 M90

Libtayo MBPA; QL (1 VIAL per 21 days)

Lice Treatment External Liquid RID Tier 2 M90

Lice Treatment External Lotion Tier 2 M90

Licide Tier 2 M90

Licide Maximum Strength Tier 2 M90

Lidocaine External Ointment 5 % Tier 2 M90

Lidocaine External Patch 5 % Lidoderm Tier 2QL (90 EA per 30 days)

Lidocaine HCl External Gel 2 % Regenecare HA Tier 2 M90

Lidocaine HCl External Solution Tier 2 M90

Lidocaine HCl Injection Solution 0.5 %, 1 %, 2 %

Xylocaine Tier 2 M90

Lidocaine HCl Mouth/Throat Tier 2 M90

Lidocaine PAK Tier 2 M90

Lidocaine Viscous Tier 2 M90

Lidocaine-Epinephrine Injection Solution 0.5 %-1:200000

Xylocaine/EPINEPHrine Tier 2 M90

Lidocaine-Epinephrine Injection Solution 1 %-1:100000, 2 %-1:100000

Xylocaine/Epinephrine Tier 2 M90

Lidocaine-Epinephrine Injection Solution 1.5 %-1:200000

Xylocaine-MPF/Epinephrine

Tier 2 M90

Lidocaine-Hydrocortisone Ace Rectal Gel Tier 2 M90

Lidocaine-Hydrocortisone Ace Rectal Kit 3-0.5 %, 3-1 %

Tier 2 M90

Lidocaine-Prilocaine External Cream Tier 2 M90

LifEMS Naloxone $0

Liletta (52 MG) Intrauterine Intrauterine Device 18.6 MCG/DAY

$0SP; QL (1 FILL per 365 days)

99

Covered Product Reference Tier Status NotesLiletta (52 MG) Intrauterine Intrauterine Device 19.5 MCG/DAY

$0

Lincomycin HCl Injection Lincocin Tier 2 M90

Lindane External Shampoo Tier 2 M90

Linezolid Oral Suspension Reconstituted Zyvox Tier 2PA; M90; QL (1800ml per 75 days)

Linezolid Oral Tablet Zyvox Tier 2PA; M90; QL (56 tablets per 75 days)

Linzess Oral Capsule 145 MCG, 290 MCG


Linzess Oral Capsule 72 MCG Tier 2PA; QL (30 EA per 30 days)

Liothyronine Sodium Oral Cytomel Tier 2 M90

Lipodox 50 $0 M90

Liquid Calcium with D3 Tier 2 M90

Liquid Calcium/Vitamin D Tier 2 M90

Liquid Pain Relief Little Remedies for Fever Tier 2 M90

Liquihep II Prefilled Syringe Tier 2 M90

Liquihep Prefilled Syringe Tier 2 M90

LiquiTears Tier 2 M90

Lisinopril Oral Prinivil Tier 1 M90

Lisinopril-hydroCHLOROthiazide Zestoretic Tier 1 M90

Litetouch Pen Needles 29G X 12.7MM , 31G X 6 MM , 31G X 8 MM

$0 M90

Lithium Tier 2 M90

Lithium Carbonate ER Lithobid Tier 2 M90

Lithium Carbonate Oral Tier 2 M90

Lithium Heparin Prefilled Syr Tier 2 M90

Lithostat Tier 2 M90

Little Animals Bounty Bears/C Tier 2 M90

Little Animals Plus IronLand Before Time Multivitamin

Tier 2 M90

Little Fevers Fever-Pain Rel Oral Solution 160 MG/5ML

Tier 2 M90

Little Noses Saline Tier 1 M90

Little Noses Stuffy Nose Kit Tier 1 M90

Little Remedies for Fever Oral Liquid Tier 2 M90

Little Remedies for Tummys Oral Suspension

Tier 2 M90

Little Tummys Gas Relief Tier 2 M90

100

Covered Product Reference Tier Status NotesLo Loestrin Fe $0 M90

Lomedia 24 FE Tier 2 M90

Long Lasting Antacid Cal-Gest Antacid Tier 2 M90

Lonhala Magnair Refill Kit Tier 2 PA

Lonhala Magnair Starter Kit Tier 2 PA

Lonsurf $0 SP; QL (QL Flag)

Loperamide HCl Oral Capsule Imodium A-D Tier 2 M90

Lopinavir-Ritonavir Oral Tablet 100-25 MG

Kaletra Tier 2QL (240 EA per 30 days)

Lopinavir-Ritonavir Oral Tablet 200-50 MG

Kaletra Tier 2QL (120 EA per 30 days)

Loradamed KLS AllerClear Tier 2 M90; QL (QL Flag)

Loratadine Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

Loratadine Childrens Oral Solution Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Loratadine Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Loratadine Oral Tablet KLS AllerClear Tier 2M90; QL (30 EA per 90 days)

Loratadine Rapidly-Disintegrating Tab 10 MG Oral Capsule 25 MG

Banophen Tier 2 M90

Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet 10 MG

KLS AllerClear Tier 2 M90; QL (QL Flag)




Wal-finate Tier 2 M90


Wal-Fex Allergy Tier 2 M90; QL (QL Flag)

Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet Dispersible 10 MG

Alavert Tier 2 M90

LORazepam Injection Ativan Tier 2

LORazepam Intensol Tier 2

LORazepam Oral Concentrate 2 MG/ML LORazepam Intensol Tier 2

LORazepam Oral Tablet Ativan Tier 2

Lorbrena Oral Tablet 100 MG $0PA; SP; QL (30 EA per 30 days)

Lorbrena Oral Tablet 25 MG $0PA; SP; QL (90 EA per 30 days)

101


Lorcet Tier 2M90; QL (240 tablets per 30 days. Click;HERE)

Lorcet HD Tier 2M90; QL (180 EA per 30 days)

Lorcet Plus Oral Tablet 7.5-325 MG Tier 2M90; QL (180 EA per 30 days)

Lortab Oral Elixir 10-300 MG/15ML Tier 2PA; M90; QL (2025 ML per 30 days)

Lortab Oral Tablet 10-325 MG, 7.5-325 MG


Lortab Oral Tablet 5-325 MG Tier 2M90; QL (240 tablets per 30 days. Click;HERE)

Loryna $0 M90

Losartan Potassium Oral Cozaar Tier 1 M90

Losartan Potassium-HCTZ Hyzaar Tier 1 M90

Lotemax Ophthalmic Ointment Tier 2 ST; M90

Lotemax SM Tier 2 ST

Loteprednol Etabonate Lotemax Tier 2 ST

Lovastatin Oral Tier 2M90; QL (30 EA per 90 days)

Low-Ogestrel $0 M90

Loxapine Succinate Oral Tier 2 M90

Lubiprostone Amitiza Tier 2PA; QL (60 EA per 30 days)

Lubricant Eye Drops Ophthalmic Solution 0.6 %

Systane Complete Tier 2 M90

Lubricating LotionA + D Personal Care Lotion

Tier 2 M90

Lubriderm Tier 2 M90

Lubriderm Advanced Therapy External Lotion

Tier 2 M90

Lubriderm Daily Moisture Tier 2 M90

Lubriderm Intense Skin Repair External Lotion

Tier 2 M90

Lubriderm Mens 3-in-1 Tier 2 M90

Lubriderm Seriously Sensitive Tier 2 M90

Lubriderm Skin Nourishing Tier 2 M90

LubriSilk Tier 2 M90

Lubriskin Tier 2 M90

LubriSoft Tier 2 M90

102

Covered Product Reference Tier Status NotesLucemyra Tier 2 PA

Lucentis Intravitreal Tier 2 PA; SP; Dual

Ludent Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG

Tier 1 M90

Ludent Oral Tablet Chewable 2.2 (1 F) MG

Tier 2 M90

Lugols External Tier 2 M90

Lumigan Ophthalmic Solution 0.01 % Tier 2 ST

Lumizyme MB PA

Lumoxiti MB PA

Lupaneta Pack MB PA

Lupkynis Tier 2PA; SP; QL (180 EA per 30 days)

Lupron Depot (1-Month) $0 PA; SP; Dual




Lupron Depot-Ped (1-Month) Tier 2 PA; SP; Dual

Lupron Depot-Ped (3-Month) Tier 2 PA; SP; Dual

Luride Oral Solution Tier 1 M90

Lutera $0 M90

Lynparza Oral Capsule $0PA; SP; QL (480 capsules per 30 days)

Lynparza Oral Tablet Tier 2 PA; SP

Lyophil Lith Hep Prefilled Syr Tier 2 M90

Lysiplex Plus Oral Liquid Tier 2 M90

Lysodren $0 SP; M90

Lyza $0 M90

M2 Zinc-50 Tier 2 M90

Maalox Tier 2 M90

Macular Vitamin Benefit ABC Plus Senior Tier 2 M90

MagneBind 400 Tier 2 M90

Magnesium Chloride Injection Tier 2 M90

Magnesium Citrate Oral Solution 1.745 GM/30ML

Citroma Tier 2 M90

Magnesium Citrate SOLUTION 1.745 GM/30ML Oral

Citroma Tier 2 M90

Magnesium Oxide -Mg Supplement Oral Tablet

Tier 2 M90

Magnesium Oxide Oral Capsule 400 MG Tier 2 M90

103

Covered Product Reference Tier Status NotesMagnesium Oxide Oral Tablet 250 MG, 400 (240 Mg) MG, 400 MG

Tier 2 M90

Magnesium Oxide Oral Tablet 400 (241.3 Mg) MG

MAGnesium-Oxide Tier 2 M90

Magnesium Oxide Oral Tablet 420 MG Maox Tier 2

Magnesium Sulfate Injection Solution 50 %

Tier 2 M90

MAGnesium-Oxide Tier 2 M90

Malathion External Ovide Tier 2 M90

Mapap Acetaminophen Extra Str Tier 2 M90

Mapap Arthritis Pain Midol Tier 2 M90

Mapap Childrens Oral Suspension Tier 2 M90

Mapap Extra Strength Tier 2 M90

Mapap Oral Liquid Little Remedies for Fever Tier 2 M90

Mapap Oral Tablet Aphen Tier 2 M90

Mapap Oral Tablet Chewable Childrens Medi-Tabs Tier 2 M90

Maprotiline HCl Tier 2 M90

Margenza MB PA

Margesic Esgic Tier 2 M90

Marlissa Altavera $0 M90

Marplan Tier 2 M90

Marqibo $0 M90

Matulane $0 M90

Matzim LA Tier 1 M90

Mavenclad (10 Tabs) Tier 2 PA; SP







Mavyret Oral Tablet Tier 2PA; SP; PD; QL (84 EA per 28 days)

Maxam Tier 2 M90

Maxapap Maximum StrengthHealthy Mama Shake That Ache

Tier 2 M90

Maxapap Regular Strength Aphen Tier 2 M90

Maxidex Tier 2 M90

Maximum D3 Oral Capsule 10000 UNIT Tier 2 M90

104

Covered Product Reference Tier Status NotesMaximum Daily Green ABC Plus Senior Tier 2 M90

Mayzent Tier 2 PA; SP

Mayzent Starter Pack Tier 2PA; SP; QL (12 EA per 1 Fill)

McCarnitine Tier 2 M90

Meclizine HCl Oral Tablet 12.5 MG Tier 2 M90

Meclofenamate Sodium Oral Tier 2 M90

Med-Derm Hydrocortisone External Cream 1 %


Medical Provider EZ Afluria PF Tier 1 M90

Medical Provider EZ Flu PF Intramuscular Prefilled Syringe Kit

Tier 1 M90

Medical Provider EZ Flu Shot Intramuscular Prefilled Syringe Kit 0.25 ML

Tier 1 M90

Medical Provider EZ Fluvirin Tier 1 M90

Medicated Anti-Fungal Blis-To-Sol Tier 2 M90

Medicine Shoppe Pen Needles CareFine Pen Needles $0 M90

Medi-First Anti-Fungal Tier 2 M90

Medi-Lax Tier 2 M90

Medi-Natural Evac-U-Gen Tier 2 M90

Medi-Phedryl Oral Capsule Tier 2 M90

Medi-Profen Oral Suspension Tier 2 M90

Medi-Profen Oral Tablet Tier 2 M90

Mediproxen Tier 2 M90

Medi-Tabs Childrens Tier 2 M90

Medi-Tabs Extra Strength Tier 2 M90

Medrol Oral Tablet 2 MG Tier 2 M90

MedroxyPROGESTERone Acetate Intramuscular

Depo-Provera $0 M90

MedroxyPROGESTERone Acetate Oral Provera Tier 2 M90

Mefloquine HCl Tier 2 M90

Mega Multivitamin for Men ABC Plus Senior Tier 2 M90

Mega Multivitamin for Women ABC Plus Senior Tier 2 M90

Mega VM-80 ABC Plus Senior Tier 2 M90

Megavite Fruits & Veggies ABC Plus Senior Tier 2 M90

Megavite Golden Years 55+ ABC Plus Senior Tier 2 M90

Megestrol Acetate Oral Suspension 40 MG/ML, 400 MG/10ML

$0 M90

105

Covered Product Reference Tier Status NotesMegestrol Acetate Oral Suspension 625 MG/5ML

Tier 2 M90

Megestrol Acetate Oral Tablet $0 M90

Meijer Advanced Formula ABC Plus Senior Tier 2 M90

Meijer Allergy Relief Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

Meijer Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

Meijer Antihistamine Allergy Banophen Tier 2 M90

Meijer Aspirin Free Aphen Tier 2 M90

Meijer Calamine Tier 2 M90

Meijer Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90

Meijer Ibuprofen Medi-Profen Tier 2 M90

Meijer Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

Meijer Nasal Decongestant SudoGest Tier 2 M90

Meijer Pen Needles CareFine Pen Needles $0 M90

Meijer Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

Meijer Zinc Oxide Tier 2 M90

Mekinist Oral Tablet 0.5 MG $0SP; QL (90 EA per 30 days)

Mekinist Oral Tablet 2 MG $0SP; QL (30 EA per 90 days)

Mektovi $0SP; QL (180 EA per 30 days)

Meloxicam Oral Tablet Mobic Tier 2 M90

Melphalan HCl Alkeran $0 M90

Memantine HCl ER Namenda XR Tier 2

Memantine HCl Oral Solution 2 MG/ML Tier 2 M90

Memantine HCl Oral Tablet Tier 2 M90

Menactra Intramuscular Injectable $0 M90

Menest Tier 2 M90

Menomune Subcutaneous Injectable Tier 1 M90

Menostar Tier 2 M90

Mens 50+ Advanced DEKAs Plus Tier 2 M90

Mens 50+ Multi Vitamin/Min ABC Plus Senior Tier 2 M90

Mens Daily Formula/Lycopene DEKAs Plus Tier 2 M90

Mens Multi Vitamin & Mineral ABC Plus Senior Tier 2 M90

Menveo $0 M90

Meperidine HCl Oral Solution Tier 2QL (90 mL per 30 days. Click;HERE)

106

Covered Product Reference Tier Status NotesMeperidine HCl Oral Tablet Tier 2

Meperidine-Promethazine Tier 2 M90

Meprobamate Tier 2 M90

Mepsevii MB PA

Mercaptopurine Oral $0 M90

Mesalamine ER Apriso Tier 2

Mesalamine Oral Capsule Delayed Release

Delzicol Tier 2

Mesalamine Oral Tablet Delayed Release 1.2 GM

Lialda Tier 2

Mesalamine Oral Tablet Delayed Release 800 MG

Asacol HD Tier 2 M90

Mesalamine Rectal Tier 2

Mesna Mesnex $0 M90

Mesnex Oral $0 M90

Mestinon Oral Syrup Tier 2 M90

Metaproterenol Sulfate Oral Tier 2 M90

Metaxall Tier 2 ST; M90

Metaxalone Tier 2 ST; M90

metFORMIN HCl ER Tier 1 M90

MetFORMIN HCl ER (MOD) Glumetza Tier 1 PA; M90

MetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 1000 MG, 500 MG

Tier 1 PA; M90

MetFORMIN HCl Oral Tablet Tier 1 M90

Methadone HCl Injection Tier 2ST; M90; QL (20 mL per 30 days. Click;HERE)

Methadone HCl Intensol Tier 2ST; QL (90 mL per 30 days. Click;HERE)

Methadone HCl Oral Concentrate Methadone HCl Intensol Tier 2 ST

Methadone HCl Oral Solution Tier 2ST; QL (450 mL per 30 days. Click;HERE)

Methadone HCl Oral Tablet Tier 2ST; QL (90 EA per 30 days)

Methadone HCl Oral Tablet Soluble Methadose Tier 2 ST

Methadose Oral Tablet Soluble Tier 2 ST

Methamphetamine HCl Desoxyn Tier 2 PA

methazolAMIDE Oral Tier 1 M90

Methenamine Hippurate Hiprex Tier 2 M90

107

Covered Product Reference Tier Status NotesMethenamine Mandelate Oral Tablet 0.5 GM

Tier 2 M90

methIMAzole Oral Tier 2 M90

Methitest Tier 2

Methocarbamol Oral Tier 2 M90

Methotrexate Sodium (PF) Injection Solution 1 GM/40ML, 100 MG/4ML, 200 MG/8ML, 250 MG/10ML, 50 MG/2ML

$0 M90

Methotrexate Sodium Injection Solution 250 MG/10ML, 50 MG/2ML

$0 M90

Methotrexate Sodium Injection Solution Reconstituted

$0 M90

Methotrexate Sodium Oral $0

Methoxsalen Oral Tier 2 M90

Methoxsalen Rapid Tier 2 M90

Methscopolamine Bromide Oral Tier 2 M90

Methyclothiazide Oral Tier 1 M90

Methyldopa Oral Tier 1 M90

Methyldopa-hydroCHLOROthiazide Tier 1 M90

Methylergonovine Maleate Oral Methergine Tier 2 M90

Methylphenidate HCl ER (CD) Tier 2PA; QL (60 EA per 30 days)

Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 10 MG

Ritalin LA Tier 2

Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 20 MG, 30 MG, 40 MG

Ritalin LA Tier 2QL (60 EA per 30 days)

Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 60 MG


Methylphenidate HCl ER (XR) Oral Capsule Extended Release 24 Hour 10 MG

Aptensio XR Tier 2PA; QL (30 EA per 30 days)

Methylphenidate HCl ER (XR) Oral Capsule Extended Release 24 Hour 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

Aptensio XR Tier 2PA; QL (30 EA per 30 Days)

Methylphenidate HCl ER Oral Tablet Extended Release 10 MG


Methylphenidate HCl ER Oral Tablet Extended Release 20 MG

Tier 2 QL (QL Flag)

108

Covered Product Reference Tier Status NotesMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 18 MG


Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 27 MG, 54 MG


Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 36 MG


Methylphenidate HCl Oral Solution Methylin Tier 2QL (900 ML per 30 days)

Methylphenidate HCl Oral Tablet Ritalin Tier 2QL (90 EA per 30 days)

Methylphenidate HCl Oral Tablet Chewable


MethylPREDNISolone Acetate Injection Suspension 40 MG/ML

Depo-Medrol Tier 2 M90

MethylPREDNISolone Acetate Injection Suspension 80 MG/ML

DEPO-Medrol Tier 2 M90

MethylPREDNISolone Oral Medrol Tier 2 M90

MethylPREDNISolone Sodium Succ Injection Solution Reconstituted 1000 MG

Solu-MEDROL Tier 2 M90

MethylPREDNISolone Sodium Succ Injection Solution Reconstituted 125 MG, 40 MG

SOLU-medrol Tier 2 M90

MethylTESTOSTERone Oral Tier 2

Metipranolol Tier 2 M90

Metoclopramide HCl Oral Solution 10 MG/10ML, 5 MG/5ML

Tier 2 M90

Metoclopramide HCl Oral Tablet Reglan Tier 2 M90

Metolazone Tier 1 M90

Metoprolol Succinate ER Toprol XL Tier 1 M90

Metoprolol Tartrate Oral Tablet 100 MG, 50 MG

Lopressor Tier 1 M90

Metoprolol Tartrate Oral Tablet 25 MG Tier 1 M90

Metoprolol-HCTZ ER Oral Tablet Extended Release 24 Hour 25-12.5 MG

Dutoprol Tier 2 M90

Metoprolol-Hydrochlorothiazide Tier 1 M90

MetroNIDAZOLE External Cream Rosadan Tier 2 M90

MetroNIDAZOLE External Gel 0.75 % Rosadan Tier 2 M90

MetroNIDAZOLE External Gel 1 % Metrogel Tier 2 ST; M90

MetroNIDAZOLE External Lotion MetroLotion Tier 2 M90

metroNIDAZOLE Oral Tier 2 M90

MetroNIDAZOLE Vaginal Vandazole Tier 2 M90

Mexiletine HCl Oral Tier 2 M90

109

Covered Product Reference Tier Status NotesMgO MAGnesium-Oxide Tier 2 M90

Miacalcin Injection Tier 2 M90

Mi-Acid Gas Relief Tier 2 M90

Micaderm Tineacide Tier 2 M90

Miconazole 1 Monistat 1 Combo Pack Tier 2 M90

Miconazole 3 ApplicatorMonistat 3 Combo Pack App

Tier 2 M90

Miconazole 3 Combo PackMonistat 3 Combo Pack App

Tier 2 M90

Miconazole 3 Combo Pack AppMonistat 3 Combo Pack App

Tier 2 M90

Miconazole 3 Vaginal Cream Monistat 3 Tier 2 M90

Miconazole 3 Vaginal Suppository Tier 2 M90

Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

Miconazole Nitrate Cream 2 % External External Aerosol

Tinactin Tier 2 M90

Miconazole Nitrate Cream 2 % External External Cream

Tinactin Tier 2 M90

Miconazole Nitrate External Cream Tineacide Tier 2 M90

Miconazole Nitrate Vaginal Monistat 7 Simply Cure Tier 2 M90

Microgestin 1.5/30 $0 M90

Microgestin 1/20 $0 M90

Microgestin 24 Fe Tier 2 M90

Microgestin FE 1.5/30 $0 M90

Microgestin FE 1/20 $0 M90

Midazolam HCl Oral Tier 2

Midodrine HCl Tier 2 M90

miFEPRIStone Mifeprex Tier 2

Migergot Tier 2 M90

Miglitol Tier 1 M90

Miglustat Zavesca Tier 2

Milk of Magnesia Concentrate Tier 2 M90

Milk of Magnesia Oral Suspension 1200 MG/15ML, 400 MG/5ML, 7.75 %

Dulcolax Milk of Magnesia

Tier 2 M90

Millipred Tier 2 M90

Mimvey Tier 2 M90

Mimvey Lo Tier 2 M90

Mineral Oil Heavy Oral Tier 2 M90

Mineral Oil Oral Oil Tier 2 M90

Minerin Tier 2 M90

110

Covered Product Reference Tier Status NotesMinitran Tier 2 M90

Minivelle Transdermal Patch Twice Weekly 0.025 MG/24HR

Tier 2 M90

Minocycline HCl Oral Minocin Tier 2 M90

Minoxidil Oral Tier 1 M90

Mircera Injection Solution Prefilled Syringe

MB PA

Mirena (52 MG) $0SP; QL (1 FILL per 365 days)

Mirtazapine Oral Remeron Tier 2 M90

miSOPROStol Oral Cytotec Tier 2 M90

Mitomycin Intravenous Mutamycin $0 M90

Mitoxantrone HCl $0 SP

M-M-R II Subcutaneous $0 M90

Modafinil Provigil Tier 2PA; QL (30 EA per 90 days)

Moderiba 1200 Dose Pack Tier 2 SP

Moderiba Oral Tier 2 PA; SP

Moderiba Oral Tablet 200 MG Tier 2 SP

Moexipril HCl Tier 1 M90

Moexipril-hydroCHLOROthiazide Tier 1 M90

Moisture External LotionA + D Personal Care Lotion

Tier 2 M90

Moisture RecoveryA + D Personal Care Lotion

Tier 2 M90

Moisturel External Lotion Tier 2 M90

Moisturizing LotionA + D Personal Care Lotion

Tier 2 M90

Moisturizing Sensitive SkinA + D Personal Care Lotion

Tier 2 M90

Moisturizing Vitamin E/AloeA + D Personal Care Lotion

Tier 2 M90

Mometasone Furoate External Tier 2 M90

Mometasone Furoate Nasal Nasonex Tier 2ST; M90; QL (17ml per 25 days)

Mondoxyne NL Oral Capsule 100 MG, 50 MG

Tier 2 M90

Monistat 7 Combo Pack App Tier 2 M90

Monjuvi MB PA

Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT

Tier 2 PA; SP; Dual

111

Covered Product Reference Tier Status NotesMonoject Flush Syringe Intravenous Tier 2 M90

Monoject Sodium Chloride Flush Intravenous

Tier 2 M90

Mono-Linyah $0 M90

MonoNessa $0 M90

Mononine Intravenous Solution Reconstituted 1000 UNIT

Tier 2 PA; SP; Dual

Monovisc Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)

Monsels Ferric Subsulfate External Tier 2 M90

Montelukast Sodium Oral Packet Singulair Tier 2ST; M90; QL (30 EA per 90 days)

Montelukast Sodium Oral Tablet Singulair Tier 2M90; QL (30 EA per 90 days)

Montelukast Sodium Oral Tablet Chewable

Singulair Tier 2M90; QL (30 EA per 90 days)

Morgidox Oral Tier 2 M90

MorphaBond ER Oral Tablet ER 12 Hour Abuse-Deterrent 100 MG, 60 MG


MorphaBond ER Oral Tablet ER 12 Hour Abuse-Deterrent 15 MG, 30 MG


Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML

Tier 2QL (135 mL per 30 days. Click;HERE)

Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 120 MG


Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 30 MG, 45 MG, 60 MG, 75 MG, 90 MG


Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG, 20 MG, 30 MG


Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 100 MG


Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 40 MG

Tier 1ST; M90; QL (180 EA per 30 days)

Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 50 MG, 60 MG, 80 MG


Morphine Sulfate ER Oral Tablet Extended Release 100 MG, 200 MG, 60 MG

MS Contin Tier 2ST; QL (QL applies. Click;HERE)

Morphine Sulfate ER Oral Tablet Extended Release 15 MG, 30 MG

MS Contin Tier 2ST; QL (90 EA per 30 days)

112

Covered Product Reference Tier Status NotesMorphine Sulfate Oral Solution 10 MG/5ML


Morphine Sulfate Oral Solution 20 MG/5ML


Morphine Sulfate Oral Tablet 15 MG Tier 2QL (180 EA per 30 days)

Morphine Sulfate Oral Tablet 30 MG Tier 2QL (90 EA per 30 days)

Morphine Sulfate Rectal Suppository 10 MG, 5 MG


Morphine Sulfate Rectal Suppository 20 MG


Morphine Sulfate Rectal Suppository 30 MG


Motegrity Tier 2PA; QL (30 EA per 30 days)

Mothers Friend External Lotion Tier 2 M90

Motrin IB Oral Tablet Tier 2 M90

Movantik Tier 2PA; M90; QL (30 EA per 90 days)

Moxifloxacin HCl (2X Day) Moxeza Tier 2

Moxifloxacin HCl Ophthalmic Solution Vigamox Tier 2

Moxifloxacin HCl Oral Tier 2 M90

Mozobil Tier 2 SP; QL (QL Flag)

MSM SkinA + D Personal Care Lotion

Tier 2 M90

Mulpleta Tier 2 PA; SP

Multaq Tier 2 M90

Multi Complete/Iron ABC Plus Senior Tier 2 M90

Multi For Her 50+ ABC Plus Senior Tier 2 M90

Multi For Her Oral Capsule DEKAs Plus Tier 2 M90

Multi For Her Oral Tablet ABC Plus Senior Tier 2 M90

Multi For Him 50+ ABC Plus Senior Tier 2 M90

Multi Prenatal Right Step Prenatal Tier 1 M90

Multi Vitamin/Minerals ABC Plus Senior Tier 2 M90

Multi-Day Plus IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Multi-Day Plus Minerals ABC Plus Senior Tier 2 M90

Multigen Folic Tier 2 M90

Multilex ABC Plus Senior Tier 2 M90

Multilex-T ABC Plus Senior Tier 2 M90

113

Covered Product Reference Tier Status NotesMultimineral Plus ABC Plus Senior Tier 2 M90

Multiple Vit/Minerals/No Iron ABC Plus Senior Tier 2 M90

Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Multiple Vitamins/Womens ABC Plus Senior Tier 2 M90

Multi-Symptom Allergy Banophen Tier 2 M90

Multi-Vit/Fluoride Oral Solution Quflora Pediatric Tier 2 M90

Multi-Vit/Fluoride/Iron Tier 2 M90

Multivitamin ABC Plus Senior Tier 2 M90

Multivitamin & Mineral BProtected Multi-Vite Tier 2 M90

Multivitamin Adult Oral Tablet EstroFactors Tier 2 M90

Multivitamin Adults 50+ ABC Plus Senior Tier 2 M90

Multivitamin Childrens Culturelle Kids Complete Tier 2

Multivitamin Men ABC Plus Senior Tier 2 M90

Multi-Vitamin Menopausal ABC Plus Senior Tier 2 M90

Multi-Vitamin Monocaps ABC Plus Senior Tier 2 M90

Multivitamin Oral Liquid BProtected Multi-Vite Tier 2 M90

Multivitamin Women ABC Plus Senior Tier 2 M90

Multivitamin Women 50+ ABC Plus Senior Tier 2 M90

Multivitamin/Fluoride Oral Tablet Chewable 0.25 MG, 0.5 MG, 1 MG

Quflora Pediatric Tier 2 M90

Multi-Vitamin/Fluoride/Iron Tier 2 M90

Multi-Vitamin/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Multi-Vitamin/Minerals ABC Plus Senior Tier 2 M90

Multivitamins/Fluoride Quflora Pediatric Tier 2 M90

Mupirocin Calcium Tier 2 PA; M90

Mupirocin External Centany Tier 2 M90

Murine Ear Tier 2 M90

Murine Ear Wax Removal System Tier 2 M90

Mustargen $0 M90

Mvasi Tier 2 PA; SP; Dual

MVC-Fluoride Tier 2 M90

M-Vit Tier 1 M90

My Choice $0

My Way $0 M90

Myamulti ABC Plus Senior Tier 2 M90

Mycapssa Tier 2PA; SP; QL (120 EA per 30 days)

114

Covered Product Reference Tier Status NotesMycocide Clinical NS Tier 2 M90

Mycophenolate Mofetil Oral CellCept Tier 2 SP; QL (QL Flag)

Mycophenolate Sodium Myfortic Tier 2 SP; QL (QL Flag)

Mydayis Tier 2PA; QL (30 EA per 90 days)

Myferon 150 Forte iFerex 150 Forte Tier 2 M90

MyKidz Iron 10 Tier 1 M90

Myleran $0 M90

Myobloc Tier 2PA; SP; QL (QL Flag); Dual

Myorisan Tier 2 M90

Myrbetriq Oral Tablet Extended Release 24 Hour


Mytab Gas Tier 2 M90

Mytesi Tier 2PA; M90; QL (60 EA per 30 days)

My-Vitalife DEKAs Plus Tier 2 M90

Myzilra $0 M90

Na Ferric Gluc Cplx in Sucrose Ferrlecit Tier 2 M90

Nabumetone Oral Relafen Tier 2 M90

Nadolol Oral Tablet 20 MG, 40 MG, 80 MG

Corgard Tier 1 M90

Nadolol-Bendroflumethiazide Tier 1 M90

NaFrinse Tier 2 M90

NaFrinse Drops Tier 1 M90

Naftifine HCl External Cream Tier 2 ST; M90

Naftifine HCl External Gel Naftin Tier 2 ST

Naftin External Gel 2 % Tier 2 ST; M90

Nalbuphine HCl Injection Tier 2 M90

Naloxone HCl Injection Solution 0.4 MG/ML, 4 MG/10ML

Tier 2 M90

Naloxone HCl Injection Solution Cartridge

Tier 2 M90

Naloxone HCl Injection Solution Prefilled Syringe

$0 M90

Naltrexone HCl Oral Tier 2 M90

Namenda XR Titration Pack Tier 2 M90

Namzaric Oral Capsule Extended Release 24 Hour 14-10 MG, 28-10 MG

Tier 2 M90

Naproxen DR EC-Naprosyn Tier 2 M90

115

Covered Product Reference Tier Status NotesNaproxen Oral Suspension Naprosyn Tier 2 M90

Naproxen Oral Tablet Tier 2 M90

Naproxen Sodium Oral Tablet 220 MG Mediproxen Tier 2 M90

Naproxen Sodium Oral Tablet 275 MG Tier 2 M90

Naproxen Sodium Oral Tablet 550 MG Anaprox DS Tier 2

Naramin Tier 2 M90

Naratriptan HCl Amerge Tier 2M90; QL (12 tablets per month)

Narcan Tier 2 M90

Nasal Allergy 24 Hour KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)

Nasal Decongestant Oral Syrup Tier 2 M90

Nasal Decongestant Oral Tablet 30 MG SudoGest Tier 2 M90

Nasal Moist Nasal Solution Tier 1 M90

Nasal Moisturizing Spray Afrin Saline Nasal Mist Tier 1 M90

Nascobal Tier 2 PA; QL (4 per 28 days)

Natacyn Tier 2 M90

Natazia $0 M90

Nateglinide Tier 1 M90

Nat-Rul Prenatal Vitamins Tier 1 M90

Nat-Rul Vitamin D Vitamin D-1000 Max St Tier 2 M90

Natrul-Mega-75 ABC Plus Senior Tier 2 M90

Natrul-Vites ABC Plus Senior Tier 2 M90

Natural Vitamin D-3Radiance Platinum Vitamin D3

Tier 2 M90

Naturalyte Tier 2 M90

Nature-Throid Tier 2 M90

Nayzilam Tier 2PA; QL (10 EA per 30 days)

Na-Zone Afrin Saline Nasal Mist Tier 1 M90

Nebivolol HCl Bystolic Tier 2

Nebusal Inhalation Nebulization Solution 3 %

Tier 2 M90

Necon 0.5/35 (28) $0 M90

Necon 1/35 (28) $0 M90

Necon 1/50 (28) Tier 2 M90

Necon 10/11 (28) Tier 2 M90

Necon 7/7/7 $0 M90

Nefazodone HCl Tier 2 M90

116

Covered Product Reference Tier Status NotesNembutal Tier 2 M90

Neomycin Sulfate Oral Tier 2 M90

Neomycin-Bacitracin Zn-Polymyx Ophthalmic Ointment 5-400-10000

Neo-Polycin Tier 2 M90

Neomycin-Polymyxin B GU Tier 2 M90

Neomycin-Polymyxin-Dexameth Ophthalmic Ointment

Maxitrol Tier 2 M90

Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 3.5-10000-0.1

Maxitrol Tier 2 M90

Neomycin-Polymyxin-Gramicidin Ophthalmic Solution 1.75-10000-.025

Tier 2 M90

Neomycin-Polymyxin-HC Ophthalmic Suspension 3.5-10000-1

Tier 2 M90

Neomycin-Polymyxin-HC Otic Tier 2 M90

Neo-Polycin Tier 2 M90

Neo-Polycin HC Tier 2 M90

Neosalus External Lotion Tier 2 M90

Neosporin Eczema Essent Max St Tier 2 M90

Neostigmine Methylsulfate Injection Tier 2 M90

Neostigmine Methylsulfate Intravenous Solution 10 MG/10ML, 5 MG/10ML

Bloxiverz Tier 2 M90

Neo-Synalar External Cream Tier 2 M90

Nerlynx $0 PA; SP

Nesina Tier 2 PA

Neulasta Onpro Tier 2SP; Dual; QL (2 SYR per 28 days)

Neulasta Subcutaneous Solution Prefilled Syringe

Tier 2SP; Dual; QL (2 SYR per 28 days)

Neupogen Injection Solution 300 MCG/ML, 480 MCG/1.6ML

Tier 2 SP; Dual

Neupogen Injection Solution Prefilled Syringe

Tier 2 SP; Dual

Neupro Tier 2 PA; M90

Neuro-K-250 Vitamin B6 Tier 2 M90

Neuro-K-50 Tier 2 M90

NeutraGard Advanced Tier 2 M90

Neutrogena Body External Lotion Tier 2 M90

Neutrogena Healthy Skin Face Tier 2 M90

Neutrogena Moisture Sens Skin Tier 2 M90

Nevanac Tier 2ST; M90; QL (3ml per 25 days)

117

Covered Product Reference Tier Status NotesNevirapine Tier 2 M90

Nevirapine ER Viramune XR Tier 2 M90

New Day $0

NexAVAR $0PA; SP; QL (120 EA per 30 days)

NexIUM Oral Packet 2.5 MG, 5 MG Tier 2ST; QL (30 EA per 30 days)

Nexletol Tier 2PA; QL (30 EA per 30 days)

Nexlizet Tier 2PA; QL (30 EA per 30 days)

Nexplanon $0SP; QL (1 FILL per 365 days)

Next Choice One Dose $0 M90

Niacin ER (Antihyperlipidemic) Niaspan Tier 1 M90

Niacin ER Oral Capsule Extended Release Tier 1 M90

Niacin ER Oral Tablet Extended Release 1000 MG

Tier 2 M90

Niacin ER Oral Tablet Extended Release 250 MG, 500 MG, 750 MG

Endur-Acin Tier 1 M90

Niacin Oral Tablet Tier 1 M90

Niacin-50 Tier 1 M90

Niacor Tier 1 M90

NiCARdipine HCl Oral Tier 1 M90

Nicorelief Mouth/Throat Gum $0 M90

Nicotine Mini KLS Quit2 $0 M90

Nicotine Polacrilex Mouth/Throat KLS Quit2 $0 M90

Nicotine Step 1 Habitrol $0 M90

Nicotine Step 2 Nicoderm CQ $0 M90

Nicotine Step 3 Nicoderm CQ $0 M90

Nicotine Transdermal Kit Tier 1 M90

Nicotine Transdermal Patch 24 Hour Nicoderm CQ $0 M90

Nicotrol $0 M90

Nicotrol NS Tier 2 M90

Nifedical XL Tier 1 M90

NIFEdipine ER Afeditab CR Tier 1 M90

NIFEdipine ER Osmotic Release Procardia XL Tier 1 M90

NIFEdipine Oral Tier 1 M90

Nikki $0 M90

Nilutamide Nilandron $0 M90

118

Covered Product Reference Tier Status NotesNiMODipine Oral Tier 1 M90

Ninlaro $0 SP; QL (QL Flag)

Nipent $0 M90

Nisoldipine ER Tier 1 M90

Nitazoxanide Oral Alinia Tier 2

Nitro-Bid Tier 2 M90

Nitro-Dur Transdermal Patch 24 Hour 0.3 MG/HR, 0.8 MG/HR

Tier 2 M90

Nitrofurantoin Macrocrystal Oral Macrodantin Tier 2 M90

Nitrofurantoin Monohyd Macro Macrobid Tier 2 M90

Nitroglycerin ER Nitro-Time Tier 2 M90

Nitroglycerin Transdermal Patch 24 Hour Nitro-Dur Tier 2 M90

Nitroglycerin Translingual Nitrolingual Tier 2 M90

Nitro-Time Tier 2 M90

Niva-Plus Tier 1 M90

Nivea External Lotion Tier 2 M90

Nivea Original Moisture Tier 2 M90

Nivea Visage External Lotion Tier 2 M90

Nivestym Injection Solution Prefilled Syringe

Tier 2 PA; SP; Dual

Nizatidine Tier 2 M90

No Iron Mult Vitamin-Minerals ABC Plus Senior Tier 2 M90

Noble Formula HC External Cream Tier 2 M90

Noctiva Tier 2 PA

Nodolor Tier 2 M90

Non-Aspirin Childrens Oral Suspension PediaCare Children Tier 2 M90

Non-Aspirin Extra Strength Oral TabletHealthy Mama Shake That Ache

Tier 2 M90

Non-Aspirin Oral Tablet 325 MG Aphen Tier 2 M90

Non-Aspirin Pain Relief Aphen Tier 2 M90

Nora-BE $0 M90

Norepinephrine Bitartrate Intravenous Levophed Tier 2 M90

Norethin Ace-Eth Estrad-FE Oral Tablet 1-20 MG-MCG

Blisovi FE 1/20 $0 M90

Norethin Ace-Eth Estrad-FE Oral Tablet 1-20 MG-MCG(24)

Microgestin 24 Fe $0 M90

Norethin Ace-Eth Estrad-FE Oral Tablet Chewable

Charlotte 24 Fe $0

Norethindrone Acetate Oral Aygestin Tier 2 M90

119

Covered Product Reference Tier Status NotesNorethindrone Acet-Ethinyl Est Oral Tablet 1.5-30 MG-MCG

Junel 1.5/30 $0

Norethindrone Acet-Ethinyl Est Oral Tablet 1-20 MG-MCG

Junel 1/20 $0 M90

Norethindrone Oral Camila $0 M90

Norethindrone-Eth Estradiol Fyavolv Tier 2 M90

Norethin-Eth Estradiol-Fe Wymzya Fe $0 M90

Norgestimate-Eth Estradiol Oral Tablet 0.25-35 MG-MCG

Estarylla $0 M90

Norgestim-Eth Estrad Triphasic Tri-Lo-Estarylla $0 M90

Noritate Tier 2 ST; M90

Norlyroc $0 M90

Normal Saline Flush Intravenous Monoject Flush Syringe Tier 2 M90

Norpace CR Tier 2 M90

Nortemp Infants Tier 2 M90

Nortemp Oral Suspension Tier 2 M90

Nortrel 0.5/35 (28) $0 M90

Nortrel 1/35 (21) $0 M90

Nortrel 1/35 (28) $0 M90

Nortrel 7/7/7 $0 M90

Nortriptyline HCl Oral Pamelor Tier 2 M90

Norvir Oral Capsule Tier 2 QL (360 per 30 days)

Norvir Oral Packet Tier 2

Norvir Oral Solution Tier 2QL (450 ml per 30 days)

Norvir Oral Tablet Tier 2PD; BP; QL (360 EA per 30 days)

Nourianz Tier 2PA; QL (30 EA per 30 days)

Novavax COVID-19 Vaccine $0

Novoeight Tier 2 PA; SP; Dual

NovoFine $0 M90

NovoFine Autocover $0 M90

NovoFine Autocover Pen Needle $0 M90

Novofine Pen Needle $0 M90

NovoFine Plus $0 M90

NovoFine Plus Pen Needle $0 M90

NovoLIN 70/30 Tier 1 M90

NovoLIN 70/30 ReliOn Tier 1 M90

NovoLIN N Tier 1 M90

120

Covered Product Reference Tier Status NotesNovoLIN N ReliOn Tier 1 M90

NovoLIN R Tier 1 M90

NovoLIN R ReliOn Tier 1 M90

NovoLOG Tier 1 BP

NovoLOG FlexPen Subcutaneous Solution Pen-Injector

Tier 1 BP

NovoLOG Mix 70/30 Tier 1 M90; BP

NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector

Tier 1 M90; BP

NovoLOG PenFill Subcutaneous Solution Cartridge

Tier 1 BP

NovoSeven RT Tier 2 PA; SP; Dual

NovoTwist Pen Needle $0 M90

Noxafil Oral Suspension Tier 2 PA; M90

NP Thyroid Oral Tablet 15 MG, 30 MG, 60 MG, 90 MG

Armour Thyroid Tier 2 M90

Nplate MB PA

Nubeqa $0PA; SP; QL (120 EA per 30 days)

Nucala Subcutaneous Solution Auto-Injector

Tier 2PA; QL (3 PENS per 28 days)

Nucala Subcutaneous Solution Prefilled Syringe

Tier 2PA; QL (3 SYR per 28 days)

Nucala Subcutaneous Solution Reconstituted


Nucynta ER Oral Tablet Extended Release 12 Hour 100 MG, 50 MG


Nucynta ER Oral Tablet Extended Release 12 Hour 150 MG, 200 MG, 250 MG

Tier 2ST; M90; QL (QL applies. Click;HERE)

NuDiclo SoluPak Tier 2 M90

Nuedexta Tier 2PA; M90; QL (60 EA per 30 days)

NuFera Tier 2 M90

NuLev Tier 2 M90

Nulibry MB PA

Nutraderm Advanced Formula Tier 2 M90

Nutraderm External Lotion Tier 2 M90

Nutrilipid Intravenous Emulsion 20 % Tier 2 M90

Nutrilyte Hyperlyte-CR Tier 2 M90

Nutropin AQ NuSpin 10 Subcutaneous Solution

Tier 2 PA; SP

121

Covered Product Reference Tier Status NotesNutropin AQ NuSpin 20 Subcutaneous Solution

Tier 2 PA; SP

Nutropin AQ NuSpin 5 Subcutaneous Solution

Tier 2 PA; SP

Nutropin AQ Pen Subcutaneous Solution 10 MG/2ML

Tier 2 PA; SP

Nuwiq Tier 2 PA; SP; Dual

Nuzyra Oral Tablet 150 MG Tier 2PA; QL (30 EA per 90 days)

Nyamyc Tier 2 M90

Nystatin External Tier 2 M90

Nystatin Mouth/Throat Tier 2 M90

Nystatin Oral Tier 2 M90

Nystatin-Triamcinolone Tier 2 M90

Nystop Tier 2 M90

Nyvepria Tier 2SP; Dual; QL (2 SYR per 28 days)

Obizur Tier 2 PA; SP; Dual

O-Cal FA Tier 1 M90

O-Cal Prenatal $0 M90

Ocaliva Tier 2PA; SP; QL (30 EA per 90 days)

Ocean for Kids Tier 1 M90

Ocella $0 M90

Ocrevus MB PA

Octagam Tier 2 PA; SP; Dual

Octaplas Blood Group A Tier 2 M90

Octaplas Blood Group AB Tier 2 M90

Octaplas Blood Group B Tier 2 M90

Octaplas Blood Group O Tier 2 M90

Octreotide Acetate Injection Solution 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

SandoSTATIN Tier 2PA; SP; QL (QL Flag); Dual

Octreotide Acetate Injection Solution 1000 MCG/ML, 200 MCG/ML

Tier 2PA; SP; QL (QL Flag); Dual

Ocutabs ABC Plus Senior Tier 2 M90

Ocutabs-Lutein ABC Plus Senior Tier 2 M90

Odactra Tier 2 PA; SP

Odefsey Tier 2PD; QL (30 EA per 30 days)

Odomzo $0SP; QL (30 EA per 90 days)

122


Ofev Tier 2PA; SP; QL (60 EA per 30 days)

Ofloxacin Ophthalmic Ocuflox Tier 2 M90

Ofloxacin Oral Tablet 400 MG Tier 2 M90

Ofloxacin Otic Tier 2 M90

Ogestrel $0 M90

OLANZapine Intramuscular ZyPREXA Tier 2 M90

OLANZapine Oral Tablet 10 MG, 15 MG, 20 MG, 7.5 MG

ZyPREXA Tier 2M90; QL (30 EA per 90 days)

OLANZapine Oral Tablet 2.5 MG, 5 MG ZyPREXA Tier 2M90; QL (60 EA per 30 days)

OLANZapine Oral Tablet Dispersible ZyPREXA Zydis Tier 2M90; QL (30 EA per 90 days)

Olmesartan Medoxomil Oral Benicar Tier 1 ST; M90

Olmesartan Medoxomil-HCTZ Benicar HCT Tier 1 ST; M90

Olopatadine HCl Nasal Patanase Tier 2 M90

Olopatadine HCl Ophthalmic Solution 0.1 %

Pataday Tier 2ST; M90; QL (5ml per 25 days)

Olopatadine HCl Ophthalmic Solution 0.2 %

Pataday Tier 2ST; QL (2.5ml per 25 days)

Olumiant Tier 2 PA; SP

Omeclamox-Pak Tier 2 M90

Omega-3-acid Ethyl Esters Lovaza Tier 1PA; M90; QL (120 EA per 30 days)

Omeprazole Magnesium Oral Tablet Delayed Release

PriLOSEC OTC Tier 2

Omeprazole Oral Capsule Delayed Release 10 MG






Omeprazole-Sodium Bicarbonate Cap 20-1100 MG

Zegerid Tier 2ST; M90; QL (QL Flag)

Omniflex Diaphragm Tier 2 M90

OmniPod 5 Pack Tier 2PA; PD; QL (10 EA per 30 days)

OmniPod Dash 5 Pack Pods Tier 2PA; PD; QL (10 EA per 30 days)

OmniPod Starter Tier 2PA; PD; QL (1 EA per 5 Years)

Omnitrope Subcutaneous Solution Tier 2 PA; SP

123

Covered Product Reference Tier Status NotesOmnitrope Subcutaneous Solution Reconstituted

Tier 2 PA

Omron 3 Series BP Monitor $0QL (1 EA per 3 YEARs)

Omron 5 Series BP Monitor $0QL (1 EA per 3 YEARs)

Oncaspar Injection $0 SP; QL (QL Flag)

Once Daily/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Ondansetron Tier 2M90; QL (60 EA per 30 days)

Ondansetron HCl Oral Tablet 4 MG Zofran Tier 2M90; QL (60 EA per 30 days)

Ondansetron HCl Oral Tablet 8 MG Tier 2M90; QL (60 EA per 30 days)

One Daily 50 Plus ABC Plus Senior Tier 2 M90

One Daily Adults 50+ ABC Plus Senior Tier 2 M90

One Daily Calcium/Iron ABC Plus Senior Tier 2 M90

One Daily Complete ABC Plus Senior Tier 2 M90

One Daily Complete for Men ABC Plus Senior Tier 2 M90

One Daily For Men 50+ Advanced ABC Plus Senior Tier 2 M90

One Daily For Men/Lycopene ABC Plus Senior Tier 2 M90

One Daily For Women ABC Plus Senior Tier 2 M90

One Daily For Women 50+ Adv ABC Plus Senior Tier 2 M90

One Daily Healthy Weight ABC Plus Senior Tier 2 M90

One Daily Healthy Weight Adv ABC Plus Senior Tier 2 M90

One Daily Maximum ABC Plus Senior Tier 2 M90

One Daily Men Formula w/o Iron ABC Plus Senior Tier 2 M90

One Daily Mens ABC Plus Senior Tier 2 M90

One Daily Mens Health ABC Plus Senior Tier 2 M90

One Daily Multivit/Iron-Free ABC Plus Senior Tier 2 M90

One Daily Multivitamin Men ABC Plus Senior Tier 2 M90

One Daily Multivitamin Women ABC Plus Senior Tier 2 M90

One Daily Multivitamin/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

One Daily Plus Minerals ABC Plus Senior Tier 2 M90

One Daily Womens ABC Plus Senior Tier 2 M90

One Daily Womens 50 Plus ABC Plus Senior Tier 2 M90

One Daily Womens 50+ ABC Plus Senior Tier 2 M90

One Daily/Minerals ABC Plus Senior Tier 2 M90

124


One-Daily/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Onglyza Tier 2M90; QL (30 EA per 30 days)

Onmel Tier 2 M90

Onpattro MB PA; PD

Onureg $0QL (14 EA per 28 days)

Opcicon One-Step $0 M90

Opdivo MB PA

Opium Tier 2

Opsumit Tier 2PA; SP; QL (30 EA per 90 days)

Optic-Vites ABC Plus Senior Tier 2 M90

Optic-Vites with Lutein ABC Plus Senior Tier 2 M90

Optimal-D Tier 2 M90

Optimum PMS ABC Plus Senior Tier 2 M90

Option 2 $0 M90

Options Gynol II Contraceptive $0 M90

Opti-Woman ABC Plus Senior Tier 2 M90

Opurity Vitamin D Tier 2 M90

Oracit Tier 2 M90

Oralair Tier 2PA; SP; QL (Quantity Limit Applies)

Oralone Tier 2 M90

Oralyte Tier 2 M90

Oralyte Freezer Pops Tier 2 M90

Orazinc Oral Capsule Tier 2 M90

Orencia ClickJect Tier 2PA; SP; Dual; QL (4 PENS per 28 days)

Orencia Intravenous Tier 2PA; SP; Dual; QL (4 VIALS per 28 days)

Orencia Subcutaneous Solution Prefilled Syringe

Tier 2PA; SP; Dual; QL (4 SYR per 28 days)

Orenitram Tier 2 PA; SP

Orgovyx $0PA; SP; QL (30 EA per 30 days)

Oriahnn Tier 2 PA

Orilissa Tier 2 PA

Orkambi Oral Packet Tier 2PA; PD; QL (56 EA per 28 days)

125


Orkambi Oral Tablet Tier 2PA; PD; QL (112 EA per 28 days)

Orladeyo Tier 2PA; SP; QL (30 EA per 30 days)

Ormir Unisom Sleepgels Tier 2 M90

Orphenadrine Citrate ER Tier 2 M90

Orsythia $0 M90

Ortho-CS 250 Tier 2 M90

OrthoVisc Intra-Articular Solution Prefilled Syringe


Oscal 500/200 D-3 Tier 2 M90


Os-Cal Extra D3 Tier 2 M90

Os-Cal Oral Tablet Chewable 500-600 MG-UNIT

Tier 2 M90

Oscimin Levsin Tier 2 M90

Oscimin SR Levbid Tier 2 M90

Oscion Cleanser External Lotion 6 % Tier 2 M90

Oseltamivir Phosphate Oral Capsule 30 MG

Tamiflu Tier 2QL (28 EA per 90 days)

Oseltamivir Phosphate Oral Capsule 45 MG, 75 MG

Tamiflu Tier 2QL (14 EA per 90 days)

Oseltamivir Phosphate Oral Suspension Reconstituted

Tamiflu Tier 2QL (180ml per 25 days)

Osmolex ER Oral Tablet Extended Release 24 Hour


OsmoPrep Tier 2 M90

Otezla Oral Tablet Tier 2PA; SP; QL (60 EA per 30 days)

Otezla Oral Tablet Therapy Pack Tier 2PA; SP; QL (55 EA per 28 days)

Otix Tier 2 M90

Otomax-HC Cortic-ND Tier 2 M90

Oxaliplatin Intravenous Solution 100 MG/20ML, 50 MG/10ML

$0 M90

Oxaliplatin Intravenous Solution 200 MG/40ML

$0

Oxaliplatin Intravenous Solution Reconstituted

$0 M90

Oxaprozin Daypro Tier 2 M90

Oxaydo Oral Tablet Abuse-Deterrent Tier 2ST; QL (180 EA per 30 days)

126

Covered Product Reference Tier Status NotesOxazepam Tier 2

Oxbryta Tier 2PA; SP; QL (90 EA per 30 days)

OXcarbazepine Trileptal Tier 2 M90

Oxervate Tier 2PA; SP; QL (56 ML per 30 days)

Oxiconazole Nitrate Oxistat Tier 2 ST; M90

Oxistat External Lotion Tier 2 ST; M90

Oxlumo MB PA

Oxtellar XR Tier 2 PA; M90

Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG

Ditropan XL Tier 2M90; QL (60 EA per 30 days)




Ditropan XL Tier 2M90; QL (30 EA per 90 days)

Oxybutynin Chloride Oral Tier 2 M90

oxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent

OxyCONTIN Tier 2ST; QL (Quantity Limit)

OxyCODONE HCl Oral Capsule Tier 2QL (180 EA per 30 days)

OxyCODONE HCl Oral Concentrate 100 MG/5ML


OxyCODONE HCl Oral Solution Tier 2QL (900 mL per 30 days. Click;HERE)

oxyCODONE HCl Oral Tablet 10 MG Tier 2QL (180 EA per 30 days)

oxyCODONE HCl Oral Tablet 15 MG Roxicodone Tier 2QL (120 EA per 30 days)

oxyCODONE HCl Oral Tablet 20 MG Tier 2QL (90 EA per 30 days)

oxyCODONE HCl Oral Tablet 30 MG Roxicodone Tier 2QL (60 EA per 30 days)

oxyCODONE HCl Oral Tablet 5 MG Oxaydo Tier 2QL (180 EA per 30 days)

Oxycodone-Acetaminophen Oral Solution 5-325 MG/5ML


oxyCODONE-Acetaminophen Oral Tablet 10-325 MG

Endocet Tier 2QL (180 EA per 30 days)

Oxycodone-Acetaminophen Oral Tablet 2.5-325 MG, 5-325 MG

Endocet Tier 2QL (360 tablets per 30 days. Click;HERE)

oxyCODONE-Acetaminophen Oral Tablet 7.5-325 MG

Endocet Tier 2QL (240 tablets per 30 days. Click;HERE)

127

Covered Product Reference Tier Status NotesoxyCODONE-Aspirin Oral Tablet 4.8355-325 MG


OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 10 MG, 15 MG, 20 MG, 30 MG


OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 40 MG, 60 MG, 80 MG

Tier 2ST; M90; QL (QL applies)

oxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 10 MG, 15 MG, 5 MG, 7.5 MG


OxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 20 MG, 30 MG, 40 MG


Oxytrol For Women Tier 2M90; QL (8 patches per 28 days)

Oysco 500 Oral Tablet 500 MG Tier 2 M90

Oysco 500+D Tier 2 M90

Oysco D Tier 2 M90

Oyst-Cal D Tier 2 M90

Oyster Calcium + D Tier 2 M90

Oyster Shell Calcium + D Os-Cal Calcium + D3 Tier 2 M90

Oyster Shell Calcium + D3 Oystercal-D Tier 2 M90

Oyster Shell Calcium 250+D Tier 2 M90

Oyster Shell Calcium 500 + D Oral Tablet 500-125 MG-UNIT

Tier 2 M90

Oyster Shell Calcium 500+D Tier 2 M90

Oyster Shell Calcium Oral Tablet 500 MG Oystercal Tier 2 M90

Oyster Shell Calcium Oral Tablet 500-400 MG-UNIT


Oyster Shell Calcium Plus D Tier 2 M90

Oyster Shell Calcium/D Oral Tablet 250-125 MG-UNIT, 250-250 MG-UNIT, 500-200 MG-UNIT

Tier 2 M90

Oyster Shell Calcium/D Oral Tablet 500-400 MG-UNIT


Oyster Shell Calcium/D3 Oystercal-D Tier 2 M90

Oyster Shell Calcium/Vitamin D Oral Tablet


Oyster Shell/Vitamin D Tier 2 M90

Oystercal Tier 2 M90

Oyster-Cal 250 + D Tier 2 M90

Oyster-Cal 500 + D Tier 2 M90

128

Covered Product Reference Tier Status NotesOystercal-D Tier 2 M90

Ozempic (0.25 or 0.5 MG/DOSE) Tier 1PA; QL (3 mL per 28 days); QL (2 PENS per 30 days)

Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-Injector 2 MG/1.5ML

Tier 1PA; QL (3 mL per 28 days); QL (2 PENS per 30 days)

Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-Injector 4 MG/3ML


PA Calcium/Vitamin D Tier 2 M90

PA Oyster Shell Calcium Tier 2 M90

PA Vitamin D-3 Tier 2 M90

Pacerone Oral Tablet 100 MG, 200 MG, 400 MG

Tier 2 M90

PACLitaxel Intravenous Concentrate 100 MG/16.7ML, 150 MG/25ML, 30 MG/5ML, 300 MG/50ML

$0 M90

Pain & Fever Aphen Tier 2 M90

Pain & Fever Childrens Oral Solution Tier 2 M90

Pain & Fever Childrens Oral Suspension PediaCare Children Tier 2 M90

Pain & Fever Childrens Oral Tablet Chewable 80 MG


Pain & Fever Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

Pain & Fever Infants PediaCare Children Tier 2 M90

Pain Relief 8 Hour Midol Tier 2 M90

Pain Relief Childrens Oral Suspension PediaCare Children Tier 2 M90

Pain Relief Extra Strength Oral Tablet 500 MG


Tier 2 M90

Pain Relief Oral Tablet 325 MG Aphen Tier 2 M90

Pain Relief Oral Tablet 500 MGHealthy Mama Shake That Ache

Tier 2 M90

Pain Relief Regular Strength Aphen Tier 2 M90

Pain Reliever Extra Strength Oral Tablet 500 MG


Tier 2 M90

Pain Reliever Oral Tablet Aphen Tier 2 M90

Pain Reliever/Fever Reducer FeverAll Childrens Tier 2 M90

Palforzia (12 MG Daily Dose) Tier 2 PA




129

Covered Product Reference Tier Status NotesPalforzia (200 MG Daily Dose) Tier 2 PA






Palforzia Initial Escalation Tier 2 PA

Paliperidone ER Oral Tablet Extended Release 24 Hour 1.5 MG, 3 MG, 6 MG

Invega Tier 2M90; QL (30 EA per 90 days)

Paliperidone ER Oral Tablet Extended Release 24 Hour 9 MG

Invega Tier 2M90; QL (60 EA per 30 days)

Palynziq Subcutaneous Solution Prefilled Syringe 10 MG/0.5ML


Palynziq Subcutaneous Solution Prefilled Syringe 2.5 MG/0.5ML, 20 MG/ML


Pamidronate Disodium Intravenous Solution 30 MG/10ML, 90 MG/10ML

Tier 2 M90

Pamidronate Disodium Intravenous Solution Reconstituted

Tier 2 M90

Pamprin All Day Relief Max St Tier 2 M90

Pancreaze Oral Capsule Delayed Release Particles 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 4200-14200 UNIT

Tier 2 PA; M90

Pancreaze Oral Capsule Delayed Release Particles 2600-6200 UNIT, 2600-8800 UNIT, 37000-97300 UNIT

Tier 2 PA

Pancuronium Bromide Intravenous Tier 2 M90

PanOxyl Wash Tier 2 M90

Panretin Tier 2 M90

Pantoprazole Sodium Oral Packet Protonix Tier 2 ST

Pantoprazole Sodium Oral Tablet Delayed Release

Protonix Tier 2M90; QL (60 EA per 30 days)

Panzyga Tier 2 PA; SP; Dual

Papaverine HCl Injection Tier 2 M90

Paragard Intrauterine Copper $0 M90

Paregoric Tier 2 M90

Paremyd Tier 2 M90

Paricalcitol Oral Zemplar Tier 2 M90

Paroex Tier 2 M90

Paromomycin Sulfate Oral Humatin Tier 2 M90

130

Covered Product Reference Tier Status NotesPARoxetine HCl ER Oral Tablet Extended Release 24 Hour 12.5 MG

Paxil CR Tier 2M90; QL (30 EA per 90 days)

PARoxetine HCl ER Oral Tablet Extended Release 24 Hour 25 MG, 37.5 MG

Paxil CR Tier 2M90; QL (60 EA per 30 days)

PARoxetine HCl Oral Tablet 10 MG, 20 MG

Paxil Tier 2M90; QL (45 tablets per month)

PARoxetine HCl Oral Tablet 30 MG Paxil Tier 2M90; QL (75 tablets per month)

PARoxetine HCl Oral Tablet 40 MG Paxil Tier 2M90; QL (60 EA per 30 days)

Parvlex ABC Plus Senior Tier 2 M90

Pazeo Tier 2 ST

PC Pediatric Electrolyte CeraLyte 70 Tier 2 M90

PC Unifine Pentips CareFine Pen Needles $0 M90

PCE Tier 2 M90

Ped Electrolyte Freeze Pops CeraLyte 70 Tier 2 M90

Ped Electrolyte Freezer Pops CeraLyte 70 Tier 2 M90

Pedia Vance Tier 2 M90


PediaCare Childrens Allergy Tier 2 M90

PediaCare Infants Tier 2 M90

PediaCare Infants Gas Relief Tier 2 M90

Pedia-Lax Oral Liquid Tier 2 M90

Pediarix $0 M90

Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90

Pediatric Electrolyte-Zinc CeraLyte 70 Tier 2 M90

Pedvax HIB Intramuscular Suspension $0 M90

PEG 3350/Electrolytes GaviLyte-C Tier 2 M90

PEG 3350-KCl-Na Bicarb-NaClGaviLyte-N with Flavor Pack

Tier 2 M90

PEG-3350/Electrolytes GaviLyte-G Tier 2 M90

PEG-3350/Electrolytes/Ascorbat MoviPrep Tier 2

Peganone Tier 2 M90

Pegasys ProClick Subcutaneous Solution 135 MCG/0.5ML

Tier 2PA; SP; QL (4 per 28 days)

Pegasys ProClick Subcutaneous Solution 180 MCG/0.5ML

Tier 2 PA; SP

Pegasys Subcutaneous Solution Tier 2 PA; SP

PegIntron Tier 2 PA; SP

131

Covered Product Reference Tier Status NotesPeg-Intron Redipen Tier 2 PA; SP

Peg-Intron Redipen Pak 4 Subcutaneous Kit 120 MCG/0.5ML

Tier 2 PA; SP

PEG-Prep $0 M90

PEGyLAX Tier 2 M90

Pen Needles 1/2" CareFine Pen Needles $0 M90

Pen Needles 29G X 12MM , 31G X 6 MM CareFine Pen Needles $0 M90

Pen Needles 3/16"Advocate Insulin Pen Needles

$0 M90

Pen Needles 31G X 5 MM , 31G X 8 MMAdvocate Insulin Pen Needles

$0 M90

Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90

Pen Needles 5/16"Advocate Insulin Pen Needles

$0 M90

penicillAMINE Oral Cuprimine Tier 2

Penicillin V Potassium Tier 2 M90

Pentacel $0 M90

Pentasa Tier 2 M90

Pentazocine-Naloxone HCl Tier 2QL (120 EA per 30 days)

Pentoxifylline ER Tier 2 M90

Peptic Relief Oral Suspension Kaopectate Tier 2 M90

Perdiem Overnight Relief Tier 2 M90

Perindopril Erbumine Tier 1 M90

Periogard Tier 2 M90

PerioMed Tier 2 M90

Perjeta MB PA

Permethrin External Cream Tier 2 M90

Perphenazine Oral Tier 2 M90

Perphenazine-Amitriptyline Tier 2 M90

Perseris Tier 2

Pertzye Oral Capsule Delayed Release Particles 16000-57500 UNIT, 4000-14375 UNIT, 8000-28750 UNIT

Tier 2 PA; M90

Pharbechlor Wal-finate Tier 2 M90

Pharbedryl Banophen Tier 2 M90

Pharbetol Extra Strength Tier 2 M90

Pharbetol Oral Tablet 325 MG Tier 2 M90

Pharmabase Barrier Tier 2 M90

Phenadoz Tier 2 M90

132

Covered Product Reference Tier Status NotesPhenazopyridine HCl Oral Tablet 200 MG Phenazo Tier 2 M90

Phenelzine Sulfate Oral Nardil Tier 2 M90

Phenergan Rectal Tier 2 M90

PHENobarbital Oral Elixir Tier 2

PHENobarbital Oral Solution Tier 2 M90

PHENobarbital Oral Tablet Tier 2

PHENobarbital Sodium Injection Solution 130 MG/ML

Tier 2

Phenohytro Oral Tablet Tier 2 M90

Phenoxybenzamine HCl Oral Dibenzyline Tier 2 M90

Phenylephrine HCl Injection Tier 2 M90

Phenylephrine HCl Ophthalmic Solution 10 %, 2.5 %

Altafrin Tier 2 M90

Phenylephrine-guaiFENesin Oral Liquid Tier 2 M90

Phenytoin Infatabs Tier 2 M90

Phenytoin Oral Suspension 125 MG/5ML Dilantin Tier 2 M90

Phenytoin Oral Tablet Chewable Phenytoin Infatabs Tier 2 M90

Phenytoin Sodium Extended Dilantin Tier 2 M90

Phexxi Tier 2QL (60 GM per 30 days)

Philith $0 M90

Phillips Milk of Magnesia Oral Suspension 400 MG/5ML

Tier 2 M90

Phillips Stool Softener Tier 2 M90

Phos-Flur Tier 2 M90

Phoslyra Tier 2 M90

Phos-NaK Tier 2 M90

Phospha 250 Neutral Tier 2 M90

Phospholine Iodide Tier 2 M90

Photofrin $0 M90

Phytonadione Oral Mephyton Tier 2

Picato Tier 2PA; M90; QL (QL Flag)

Pifeltro Tier 2PD; QL (60 EA per 30 days)

Pilocarpine HCl Ophthalmic Solution 1 %, 2 %

Isopto Carpine Tier 2 M90

Pilocarpine HCl Ophthalmic Solution 4 % Tier 2 M90

Pilocarpine HCl Oral Salagen Tier 2 M90

Pimozide Tier 2 M90

133

Covered Product Reference Tier Status NotesPimtrea $0 M90

Pindolol Tier 1 M90

Pink Bismuth Oral Suspension 262 MG/15ML

Kaopectate Tier 2 M90

Pin-X Oral Suspension Tier 2 M90

Pinxav External Ointment 30 % Tier 2 M90

Pioglitazone HCl Actos Tier 1 ST; M90

Pioglitazone HCl-Glimepiride Duetact Tier 1 ST; M90

Pioglitazone HCl-Metformin HCl Actoplus Met Tier 1 ST; M90

Piqray (200 MG Daily Dose) $0SP; QL (28 EA per 28 days)



Pirmella 1/35 $0 M90

Pirmella 7/7/7 $0 M90

Piroxicam Oral Feldene Tier 2 M90

Plan B One-Step $0

Plasmanate Tier 2 M90

Plegridy Intramuscular Tier 2SP; QL (2 SYR per 28 days)

Plegridy Starter Pack Subcutaneous Solution Pen-Injector

Tier 2 SP; QL (QL Flag)

Plegridy Starter Pack Subcutaneous Solution Prefilled Syringe

Tier 2SP; QL (2 SYR per 28 days)

Plegridy Subcutaneous Solution Pen-Injector

Tier 2SP; QL (1 PEN per 28 days)

Plegridy Subcutaneous Solution Prefilled Syringe

Tier 2SP; QL (2 SYR per 28 days)

Plenvu Tier 2

Pneumovax 23 $0 M90

PNV Folic Acid + Iron Niva-Plus Tier 1 M90

PNV Prenatal Plus Multivitamin Niva-Plus Tier 1 M90

PNV Tabs 29-1 Prenatabs Rx $0 M90

Podactin External Cream Tineacide Tier 2 M90

Podofilox External Tier 2 M90

Polivy Intravenous Solution Reconstituted 140 MG

MB PA; SP

Polivy Intravenous Solution Reconstituted 30 MG

MB PA

134

Covered Product Reference Tier Status NotesPolocaine Tier 2 M90

Poly Vitamin Bounty Bears/C Tier 2 M90

Polycin Tier 2 M90

Polyethylene Glycol 3350 Oral Packet 17 GM

CVS Purelax Tier 2 M90

Polyethylene Glycol 3350 Oral Packet 17 GM

ClearLax Tier 2 M90

Polyethylene Glycol 3350 Oral Powder ClearLax Tier 2 M90

Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP Oral Powder

ClearLax Tier 2 M90

Poly-Iron 150 Forte iFerex 150 Forte Tier 2 M90

Polymyxin B-Trimethoprim Polytrim Tier 2 M90

Polysaccharide Iron Forte iFerex 150 Forte Tier 2 M90

Poly-Vi-Flor Oral Tablet Chewable Tier 2 M90

Poly-Vi-Flor/Iron Oral Tablet Chewable Tier 2 M90

Polyvinyl Alcohol Ophthalmic Tier 2 M90

Poly-Vita/IronBProtected Pedia Poly-Vite/Fe

Tier 2 M90

Polyvitamin/Iron Oral SolutionBProtected Pedia Poly-Vite/Fe

Tier 2 M90

Pomalyst $0SP; QL (21 per 21 days)

Portia-28 $0 M90

Posaconazole Noxafil Tier 2 PA

Pot Bicarb-Pot Chloride Tier 2 M90

Potaba Oral Capsule Tier 2 M90

Potassium Bicarbonate Oral Effer-K Tier 2 M90

Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ


Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ


Potassium Chloride ER Klor-Con 10 Tier 2 M90

Potassium Chloride Oral Packet Klor-Con Tier 2 M90

Potassium Chloride Oral Solution 20 MEQ/15ML (10%), 40 MEQ/15ML (20%)

Tier 2 M90

Potassium Citrate ER Urocit-K 10 Tier 2 M90

Potassium Citrate-Citric Acid Tier 2 M90

Potassium Phosphates Intravenous Solution 150 MMOLE/50ML

Tier 2 M90

Poteligeo MB PA

135

Covered Product Reference Tier Status NotesPotiga Tier 2 M90

PR Benzoyl Peroxide Wash Tier 2 M90

Pradaxa Oral Capsule 110 MG Tier 2PA; QL (70 EA per 365 days)

Pradaxa Oral Capsule 150 MG, 75 MG Tier 2 PA

Praluent Subcutaneous Solution Auto-Injector


PrameGel Tier 2 M90

Pramipexole Dihydrochloride Tier 2 M90

Pramipexole Dihydrochloride ER Mirapex ER Tier 2 M90

Pramosone E Tier 2 M90

Pramosone External Cream 1-1 % Tier 2 M90

Pramosone External Lotion 1-1 % Tier 2 M90

Pramosone External Lotion 1-2.5 % Tier 2 ST; M90

Pramosone External Ointment Tier 2 M90

PramOtic Tier 2 M90

Pravastatin Sodium Tier 2M90; QL (30 EA per 90 days)

Praziquantel Oral Biltricide Tier 2

Prazosin HCl Oral Minipress Tier 1 M90

Precision Xtra Blood Glucose $0PD; QL (100 EA per 30 days)

Precision Xtra Device $0M90; PD; QL (1 EA per 365 days)

Precision Xtra Ketone $0M90; PD; QL (100 EA per 30 days)

Pred Mild Tier 2 M90

Pred-G Tier 2 M90

Pred-G S.O.P. Tier 2 M90

Prednicarbate Tier 2 M90

prednisoLONE Acetate Ophthalmic Pred Forte Tier 2 M90

PrednisoLONE Oral Solution Tier 2 M90

PrednisoLONE Oral Syrup 15 MG/5ML Tier 2 M90

PrednisoLONE Sodium Phosphate Ophthalmic

Tier 2 M90

PrednisoLONE Sodium Phosphate Oral Solution 15 MG/5ML, 25 MG/5ML

Tier 2 M90

PrednisoLONE Sodium Phosphate Oral Solution 6.7 (5 Base) MG/5ML

Pediapred Tier 2 M90

prednisoLONE Sodium Phosphate Oral Tablet Dispersible

Orapred ODT Tier 2 M90

136

Covered Product Reference Tier Status NotesPredniSONE Intensol Tier 2 M90

PredniSONE Oral Tier 2 M90

Preferred Plus Unifine PentipsAdvocate Insulin Pen Needles

$0 M90

Prefest Tier 2 M90

Pregabalin Oral Lyrica Tier 2 ST

Premarin Oral Tier 2 M90

Premarin Vaginal Tier 2 M90

Premium Lidocaine Tier 2 M90

Premphase Tier 2 M90

Prempro Tier 2 M90

Prenatabs FA Oral Tablet 29-1 MG Co-Natal FA $0

Prenatabs Rx $0 M90

Prenatal (w/Iron & FA) Tier 1 M90

Prenatal 19 Oral Tablet Chewable $0 M90

Prenatal Low Iron Oral Tablet 27-0.8 MG Right Step Prenatal Tier 1 M90

Prenatal One Daily Right Step Prenatal Tier 1 M90

Prenatal Oral Tablet 27-0.8 MG Right Step Prenatal Tier 1 M90

Prenatal Oral Tablet 27-1 MG Niva-Plus Tier 1 M90

Prenatal Oral Tablet 28-0.8 MG Tier 1 M90

Prenatal Plus Niva-Plus Tier 1 M90

Prenatal Plus Iron Prenatabs Rx $0 M90

Prenatal Vitamin Right Step Prenatal Tier 1 M90

Prenatal Vitamin Plus Low Iron Niva-Plus Tier 1 M90

Prenatal Vitamins Oral Tablet 28-0.8 MG Tier 1 M90

Prenatal/Iron Oral Tablet 28-0.8 MG Tier 1 M90

Preparation H External Cream 1 % Tier 2 M90

PrePLUS Niva-Plus Tier 1 M90

Pretomanid Tier 2 PA

Prevalite Tier 1 M90

Prevent DEKAs Plus Tier 2 M90

Preventeza $0

Previfem $0 M90

Prevnar 13 $0 M90

Prevymis Intravenous Tier 2 PA; SP

Prevymis Oral Tier 2 PA

Prezcobix Tier 2PD; QL (30 EA per 30 days)

137


Prezista Oral Suspension Tier 2PD; BP; QL (400 ML per 30 days)

Prezista Oral Tablet 150 MG Tier 2PD; BP; QL (180 EA per 30 days)




Priftin Tier 2 M90

PriLOSEC Oral Packet Tier 2ST; M90; QL (60 PACKS per 30 days)

Primaquine Phosphate Oral Tier 2 M90

Primidone Oral Mysoline Tier 2 M90

Primsol Tier 2 M90

Pristiq Oral Tablet Extended Release 24 Hour 100 MG, 50 MG

Tier 2 ST; M90

Pristiq Oral Tablet Extended Release 24 Hour 25 MG

Tier 2ST; M90; QL (QL Flag)

Privigen Tier 2 PA; SP; Dual

ProAir Digihaler Tier 2 PA

ProAir HFA Tier 2 BP

ProAir RespiClick Tier 2

Probenecid Oral Tier 2 M90

Probuphine Implant Kit MB PA

Prochlorperazine Compro Tier 2 M90

Prochlorperazine Edisylate Injection Solution 5 MG/ML

Tier 2 M90

Prochlorperazine Maleate Oral Tier 2 M90

Procrit Tier 2 PA; SP; Dual

Procysbi Oral Capsule Delayed Release Tier 2 SP; QL (QL Flag)

Procysbi Oral Packet Tier 2

Pro-Ex Antifungal Desenex Tier 2 M90

Proferrin-Forte Tier 2 M90

Profilnine Tier 2 PA; SP; Dual

Profilnine SD Tier 2 PA; SP; Dual

Progesterone Intramuscular Tier 2 M90

Progesterone Micronized Oral Tier 2 M90

Progesterone Micronized Transdermal Tier 2 M90

138

Covered Product Reference Tier Status NotesProgesterone Oral Prometrium Tier 2 M90

Prograf Oral Packet Tier 2 SP

Prolastin-C Intravenous Solution Tier 2 PA; SP; Dual

Prolastin-C Intravenous Solution Reconstituted 1000 MG

Tier 2 PA; SP; Dual

Prolensa Tier 2 ST; M90

Proleukin $0 SP

Prolia Subcutaneous Solution Prefilled Syringe


Promacta Oral Packet Tier 2 PA; SP

Promacta Oral Tablet 12.5 MG, 25 MG Tier 2PA; SP; QL (30 EA per 90 days)

Promacta Oral Tablet 50 MG, 75 MG Tier 2PA; SP; QL (60 EA per 30 days)

Promethazine HCl Oral Tier 2 M90

Promethazine HCl Rectal Promethegan Tier 2 M90

Promethazine VC Plain Oral Syrup Tier 2 M90

Promethazine-Phenylephrine Tier 2 M90

Promethegan Tier 2 M90

Promolaxin Tier 2 M90



Propafenone HCl Tier 2 M90

Propafenone HCl ER Rythmol SR Tier 2 M90

Propantheline Bromide Oral Tier 2 M90

Proparacaine HCl Ophthalmic Alcaine Tier 2 M90

Proparacaine-Fluorescein Flucaine Tier 2 M90

Propranolol HCl ER Inderal LA Tier 1 M90

Propranolol HCl Intravenous Tier 1 M90

Propranolol HCl Oral Tier 1 M90

Propranolol-HCTZ Tier 1 M90

Propylthiouracil Oral Tier 2 M90

ProQuad Subcutaneous Injectable $0 M90

Prostin E2 Tier 2 M90

Protect Plus NF Tier 2 M90

ProtectIron Tier 2 M90

Protopic Tier 2BP; QL (60 GM per 30 days)

Protriptyline HCl Tier 2 M90

139

Covered Product Reference Tier Status NotesProvil Tier 2 M90

Pseudoephedrine HCl Liq 15 MG/5ML Oral Liquid

Sudafed Childrens Tier 2 M90

Pseudoephedrine HCl Oral Tablet SudoGest Tier 2 M90

Pseudoephedrine HCl Tab 60 MG SudoGest Tier 2 M90

Psorcon Tier 2 M90

Psudatabs SudoGest Tier 2 M90

Pulmicort Flexhaler Tier 2 M90

Pulmicort Inhalation Suspension 0.25 MG/2ML

Tier 2

Pulmozyme Inhalation Solution 1 MG/ML Tier 2SP; QL (150 ml per 30 days)

Purixan $0 SP; QL (QL Flag)

PX Acid Reducer Pepcid AC Tier 2 M90

PX Acid Reducer Max St Tier 2 M90

PX Advanced Formula Multivits ABC Plus Senior Tier 2 M90

PX All Day Relief Mediproxen Tier 2 M90

PX Allergy Banophen Tier 2 M90

PX Allergy Relief Cetirizine KLS Aller-Tec Tier 2 M90; QL (QL Flag)

PX Allergy Relief Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)

PX Allergy Relief Oral Tablet KLS Aller-Fex Tier 2 M90; QL (QL Flag)

PX Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90

PX Antacid Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

PX Antacid Maximum Strength Oral Tablet Chewable

Tums Ultra 1000 Tier 2 M90

PX Arthritis Pain Relief Midol Tier 2 M90

PX Athletic Foot Desenex Tier 2 M90

PX Calcium Antacid Cal-Gest Antacid Tier 2 M90

PX Calcium Tier 2 M90

PX Childrens Allergy KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

PX Childrens Pain Relief PediaCare Children Tier 2 M90

PX Childrens Profen IB Childrens Medi-Profen Tier 2 M90

PX Complete Senior Multivits ABC Plus Senior Tier 2 M90

PX Docusate Sodium Correctol Extra Gentle Tier 2 M90

PX Extra Short Pen Needles CareFine Pen Needles $0 M90

PX Gas Relief InfantsLittle Remedies for Tummys

Tier 2 M90

PX Hydrocream Aveeno Anti-Itch Max St Tier 2 M90

PX Ibuprofen Medi-Profen Tier 2 M90

140

Covered Product Reference Tier Status NotesPX Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

PX Infants Profen IB Medi-Profen Tier 2 M90

PX Iron Oral Tablet 27 MG Tier 2 M90

PX Laxative Alophen Tier 2 M90

PX Mens Multivitamins ABC Plus Senior Tier 2 M90

PX Miconazole 3-Day Combo Vagistat-3 Tier 2 M90

PX Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

PX Mini Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

PX Nasal Decongestant Oral Tablet SudoGest Tier 2 M90

PX Niacin Tier 1 M90

PX Pain Relief Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

PX Pen NeedleAdvocate Insulin Pen Needles

$0 M90

PX Prenatal Multivitamins Tier 1 M90

PX raNITIdine Tier 2 M90

PX Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

PX Shortlength Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

PX Stomach Relief Oral Suspension Kaopectate Tier 2 M90

PX Stop Smoking Aid KLS Quit4 $0 M90

PX Vegetable Laxative Evac-U-Gen Tier 2 M90

Pylera Tier 2 M90

Pyrazinamide Oral Tier 2 M90

Pyridostigmine Bromide ER Mestinon Tier 2 M90

Pyridostigmine Bromide Oral Tablet 60 MG

Mestinon Tier 2 M90

Pyridoxine HCl Injection Tier 2 M90

Pyridoxine HCl Oral Tier 2 M90

Pyrimethamine Oral Daraprim Tier 2

Pyrogallic Acid Tier 2 M90

QC 3 Day Monistat 3 Tier 2 M90

QC Acetaminophen 8 Hours Midol Tier 2 M90

QC Acid Controller Pepcid AC Tier 2 M90

QC Acid Controller Max StMM Acid-Pep Maximum Strength

Tier 2 M90

QC All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)

141

Covered Product Reference Tier Status NotesQC Allergy Relief Childrens Oral Syrup 1 MG/ML


QC Allergy Relief Childrens Oral Syrup 5 MG/5ML


QC Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90

QC Antacid Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

QC Antacid Oral Tablet Chewable Cal-Gest Antacid Tier 2 M90

QC Arthritis Pain Relief Midol Tier 2 M90

QC Bacitracin Bacitraycin Plus Tier 2 M90

QC Calamine Tier 2 M90

QC Calcium Fast Dissolution Tier 2 M90

QC Calcium/Minerals/Vitamin D Tier 2 M90

QC Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

QC Childrens Vitamins/IronLand Before Time Multivitamin

Tier 2 M90

QC Chlor-Pheniramine Wal-finate Tier 2 M90

QC Clotrimazole Desenex Tier 2 M90

QC Complete Allergy Medicine Oral Tablet


QC Daily Multivit/Multimineral ABC Plus Senior Tier 2 M90

QC Daily Multivitamins/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

QC Diarrhea Relief Kaopectate Tier 2 M90

QC Ear Wax Removal Murine Ear Tier 2 M90

QC Enema Fleet Enema Tier 2 M90

QC Gas Relief Oral Tablet Chewable Tier 2 M90

QC Gentle Laxative Alophen Tier 2 M90

QC Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90

QC Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90

QC Ibuprofen IB Medi-Profen Tier 2 M90

QC Ibuprofen Infants Medi-Profen Tier 2 M90

QC Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

QC Iodides Tier 2 M90

QC Iodine Tincture Tier 2 M90

QC Laxative Tier 2 M90

QC Loratadine Allergy Relief KLS AllerClear Tier 2 M90; QL (QL Flag)

QC Magnesium Citrate Citroma Tier 2 M90

QC Mens Daily Multivitamin ABC Plus Senior Tier 2 M90

QC Miconazole 7 Vaginal Cream Monistat 7 Simply Cure Tier 2 M90

142


QC Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

QC Mineral Oil Heavy Tier 2 M90

QC Multi-Vite ABC Plus Senior Tier 2 M90

QC Multi-Vite 50 & Over ABC Plus Senior Tier 2 M90

QC Multi-Vite Plus ABC Plus Senior Tier 2 M90

QC Naproxen Sodium Mediproxen Tier 2 M90

QC Natural Vegetable Laxative Evac-U-Gen Tier 2 M90

QC Natura-LAX ClearLax Tier 2 M90

QC Nicotine Polacrilex KLS Quit4 $0 M90

QC Non-Aspirin 8 Hour Midol Tier 2 M90

QC Non-Aspirin Childrens Oral Suspension


QC Non-Aspirin Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

QC Pain Relief Aphen Tier 2 M90

QC Pain Relief Childrens PediaCare Children Tier 2 M90

QC Pain Relief Infants PediaCare Children Tier 2 M90

QC Pen Needles CareFine Pen Needles $0 M90

QC Pink Bismuth Oral Suspension Kaopectate Tier 2 M90

QC Prenatal Tier 1 M90

QC Saline Nasal Relief Afrin Saline Nasal Mist Tier 1 M90

QC Senna Evac-U-Gen Tier 2 M90

QC Stool Softener Correctol Extra Gentle Tier 2 M90

QC Suphedrine SudoGest Tier 2 M90

QC Therin-M ABC Plus Senior Tier 2 M90

QC Tolnaftate Tinactin Tier 2 M90

QC Unifine Pentips BD Pen Needle Nano U/F $0 M90

QC Womens Daily Multivitamin ABC Plus Senior Tier 2 M90

Q-Dryl Banophen Tier 2 M90

Q-PAP Childrens PediaCare Children Tier 2 M90

Q-PAP Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

Q-PAP Oral Tablet Aphen Tier 2 M90

Quadracel $0 M90

Quartette $0 M90

Quasense $0 M90

Quazepam Doral Tier 2ST; QL (30 EA per 30 days)

143

Covered Product Reference Tier Status NotesQuench ABC Plus Senior Tier 2 M90

QUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG, 200 MG

SEROquel XR Tier 2M90; QL (30 EA per 90 days)

QUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 300 MG, 400 MG, 50 MG

SEROquel XR Tier 2M90; QL (60 EA per 30 days)

QUEtiapine Fumarate Oral Tablet 100 MG, 200 MG, 50 MG

SEROquel Tier 2M90; QL (90 EA per 30 days)

QUEtiapine Fumarate Oral Tablet 25 MG SEROquel Tier 2M90; QL (120 EA per 30 days)

QUEtiapine Fumarate Oral Tablet 300 MG, 400 MG

SEROquel Tier 2M90; QL (60 EA per 30 days)

Quflora Pediatric Tier 2 M90

QuilliChew ER Tier 2PA; QL (60 EA per 30 days)

Quillivant XR Oral Suspension Reconstituted

Tier 2 PA; ST

Quin B Strong ABC Plus Senior Tier 2 M90

Quinapril HCl Accupril Tier 1 M90

Quinapril-Hydrochlorothiazide Accuretic Tier 1 M90

quiNIDine Gluconate ER Tier 2 M90

QuiNIDine Sulfate Oral Tier 2 M90

QuiNINE Sulfate Oral Qualaquin Tier 2 M90

Quintabs-M ABC Plus Senior Tier 2 M90

Qvar Inhalation Aerosol Solution Tier 2 M90

Qvar RediHaler Tier 2 PA

RA 8 Hour Pain Relief Midol Tier 2 M90

RA Acetaminophen Aphen Tier 2 M90

RA Acetaminophen Ex StHealthy Mama Shake That Ache

Tier 2 M90

RA Acid Reducer Pepcid AC Tier 2 M90

RA Acid Reducer Max StMM Acid-Pep Maximum Strength

Tier 2 M90

RA Advanced RecoveryA + D Personal Care Lotion

Tier 2 M90

RA Allergy Medication Banophen Tier 2 M90

RA Allergy Oral Alka-Seltzer Plus Allergy Tier 2 M90

RA Allergy Relief Childrens Oral Liquid Banophen Tier 2 M90

RA Allergy Relief Childrens Oral Syrup KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

RA Allergy Relief Oral Tablet 10 MG KLS Aller-Tec Tier 2 M90; QL (QL Flag)

144

Covered Product Reference Tier Status NotesRA Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

RA Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

RA Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90

RA Allergy Relief-DWal-Fex D Allergy & Congestion


RA Antacid Cal-Gest Antacid Tier 2 M90

RA Antacid Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

RA Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90

RA Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

RA Antifungal Tineacide Tier 2 M90

RA Antihistamine Eye Drops Alaway Tier 2 M90; QL (QL Flag)

RA Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90

RA Arthritis Pain Relief Midol Tier 2 M90

RA Aspirin Oral Tablet 500 MGBayer Advanced Aspirin Ex St

Tier 2 M90

RA Athletes Foot Desenex Tier 2 M90

RA Athletes Foot (Tolnaftate) Tinactin Tier 2 M90

RA Calcium 600 Tier 2 M90

RA Calcium 600/Vit D/Minerals Tier 2 M90

RA Calcium 600/Vitamin D-3 Tier 2 M90

RA Calcium Cit Plus Vit D-3 Calcitrate Tier 2 M90

RA Calcium Citrate Plus Vit D Tier 2 M90

RA Calcium Cit-Vit D-3 PetitesCitracal Petites/Vitamin D

Tier 2 M90

RA Calcium Plus Vitamin D Oral Tablet 600-200 MG-UNIT, 600-400 MG-UNIT

Tier 2 M90

RA Calcium Plus Vitamin D3 Tier 2 M90

RA Calcium/Vitamin D/Minerals Tier 2 M90

RA Central-Vite Energy ABC Plus Senior Tier 2 M90

RA Central-Vite Mens Mature ABC Plus Senior Tier 2 M90

RA Central-Vite Senior ABC Plus Senior Tier 2 M90

RA Central-Vite Under 50 Mens ABC Plus Senior Tier 2 M90

RA Central-Vite Under 50 Women ABC Plus Senior Tier 2 M90

RA Central-Vite Womens Mature ABC Plus Senior Tier 2 M90

RA Cetirizine KLS Aller-Tec Tier 2 M90; QL (QL Flag)

RA Cetirizine Childrens Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)

RA Cetirizine HCl Child Allrgy Oral Syrup


145


RA Childrens Chewable Vit/IronLand Before Time Multivitamin

Tier 2 M90

RA Childrens Non-Aspirin PediaCare Children Tier 2 M90

RA Chlorpheniramine Maleate Wal-finate Tier 2 M90

RA Clotrimazole Desenex Tier 2 M90

RA Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90

RA Clotrimazole 7 Gyne-Lotrimin Tier 2 M90

RA Col-Rite Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

RA Complete Allergy Alka-Seltzer Plus Allergy Tier 2 M90

RA DermaA + D Personal Care Lotion

Tier 2 M90

RA Diaper Rash Boudreauxs Butt Paste Tier 2 M90

RA Diphedryl Allergy Tier 2 M90

RA Ear Drops Murine Ear Tier 2 M90

RA Earwax Removal Kit Murine Ear Tier 2 M90

RA Enema Fleet Enema Tier 2 M90

RA Esomeprazole Magnesium GoodSense Esomeprazole Tier 2 ST; QL (QL)

RA Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

RA Fast Relief Laxative The Magic Bullet Tier 2 M90

RA Fever Reducer/Pain Reliever PediaCare Children Tier 2 M90

RA First Aid Iodine Tier 2 M90

RA Gas Relief Oral SuspensionLittle Remedies for Tummys

Tier 2 M90

RA Gas Relief Oral Tablet Chewable Tier 2 M90

RA Gas Relief/InfantsLittle Remedies for Tummys

Tier 2 M90

RA Gentle Skin External LotionA + D Personal Care Lotion

Tier 2 M90

RA Hair/Skin/Nails ABC Plus Senior Tier 2 M90

RA Hi Cal Tier 2 M90

RA Hi-Cal Tier 2 M90

RA Hi-Cal Plus Vitamin D Tier 2 M90

RA High Potency Iron Tier 2 M90

RA Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90

RA Hydrocortisone Plus 12 Aveeno Anti-Itch Max St Tier 2 M90

RA Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90

RA Ibuprofen Infants Medi-Profen Tier 2 M90

RA Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

RA Ibuprofen Oral Suspension Childrens Medi-Profen Tier 2 M90

146

Covered Product Reference Tier Status NotesRA Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

RA Iron Oral Tablet 27 MG Tier 2 M90

RA Jock Itch Desenex Tier 2 M90

RA K-Pec Kaopectate Tier 2 M90

RA Laxative Extra Strength Senokot Extra Strength Tier 2 M90

RA Laxative Maximum Strength Tier 2 M90

RA Laxative Oral Powder ClearLax Tier 2 M90

RA Laxative Oral Tablet Tier 2 M90

RA Laxative Oral Tablet Delayed Release Alophen Tier 2 M90

RA Lice Bedding RID Tier 2 M90

RA Lice Maximum Strength External Liquid

RID Tier 2 M90

RA Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

RA Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

RA Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

RA Loratadine Oral Tablet Dispersible Alavert Tier 2 M90

RA Magnesium Citrate Citroma Tier 2 M90

RA Mature Womens Dietary Supp ABC Plus Senior Tier 2 M90

RA Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90

RA Miconazole 3 Combo Pack AppMonistat 3 Combo Pack App

Tier 2 M90

RA Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

RA Milk of Magnesia Oral SuspensionDulcolax Milk of Magnesia

Tier 2 M90

RA Mineral Oil Tier 2 M90

RA Mini Nicotine KLS Quit2 $0 M90

RA Moisturizing OatmealA + D Personal Care Lotion

Tier 2 M90

RA Motion Sickness Relief Oral Tablet 25 MG


RA Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

RA Niacin Tier 1 M90

RA Nicotine Nicoderm CQ $0 M90

RA Nicotine Polacrilex KLS Quit2 $0 M90

RA No Flush Niacin Tier 1 M90

RA One Daily Energy Formula ABC Plus Senior Tier 2 M90

RA One Daily Maximum ABC Plus Senior Tier 2 M90

RA One Daily Mens 50+ w/Vit D3 ABC Plus Senior Tier 2 M90

147

Covered Product Reference Tier Status NotesRA One Daily Mens Multi ABC Plus Senior Tier 2 M90

RA One Daily Mens/Vit D-3 ABC Plus Senior Tier 2 M90

RA One Daily Multi-Vit Plus FeTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

RA One Daily Womens ABC Plus Senior Tier 2 M90

RA Oyster Shell Calcium Oystercal Tier 2 M90

RA Oyster Shell Calcium/D Tier 2 M90

RA Ped Electrolyte Freezer Pop CeraLyte 70 Tier 2 M90

RA Pediatric Electrolyte CeraLyte 70 Tier 2 M90

RA Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

RA Prenatal Tier 1 M90

RA Prenatal Formula Tier 1 M90

RA Renewal Acne Treatment Tier 2 M90

RA Renewal Cocoa Butter Tier 2 M90

RA Renewal Dry Skin TherapyA + D Personal Care Lotion

Tier 2 M90

RA Saline Enema Fleet Enema Tier 2 M90

RA Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

RA Senna Oral Tablet Evac-U-Gen Tier 2 M90

RA Smooth Antacid Ex StCVS Chewy Not Chalky Flavor

Tier 2 M90

RA Stimulant Laxative The Magic Bullet Tier 2 M90

RA Stomach Relief Oral Suspension Kaopectate Tier 2 M90

RA Stool Softener Correctol Extra Gentle Tier 2 M90

RA Stress Formula Advanced ABC Plus Senior Tier 2 M90

RA Stress Formula Energy ABC Plus Senior Tier 2 M90

RA Suphedrine Oral Tablet 30 MG SudoGest Tier 2 M90

RA Therapeutic M Plus Beta Car ABC Plus Senior Tier 2 M90

RA Total MoistureA + D Personal Care Lotion

Tier 2 M90

RA Vision Vite Plus Zinc ABC Plus Senior Tier 2 M90

RA Vitamin B-6 Tier 2 M90

RA Vitamin D-3 Tier 2 M90

RA Womens Laxative Alophen Tier 2 M90

RA Zinc Oxide Tier 2 M90

RABEprazole Sodium Oral Capsule Sprinkle

AcipHex Sprinkle Tier 2 ST; QL (QL)

RABEprazole Sodium Oral Tablet Delayed Release

Aciphex Tier 2ST; M90; QL (30 EA per 90 days)

148


RadiaGuard Advanced External LotionA + D Personal Care Lotion

Tier 2 M90

Radicava MB PA

Ragwitek Tier 2 PA

Rajani $0 M90

Ramelteon Rozerem Tier 2ST; QL (30 EA per 30 days)

Ramipril Altace Tier 1 M90

raNITIdine Acid Reducer Tier 2 M90

raNITIdine HCl Injection Solution 1000 MG/40ML

Tier 2QL (1 FILL per 365 days)

raNITIdine HCl Oral Syrup Tier 2 M90

raNITIdine HCl Oral Tablet Tier 2 M90

Ranitidine HCl Tab 150 MGMM Acid-Pep Maximum Strength

Tier 2 M90

Ranitidine HCl Tab 75 MG Tier 2 M90

Ranolazine ER Oral Tablet Extended Release 12 Hour 1000 MG

Ranexa Tier 2PA; QL (60 EA per 30 days)

Ranolazine ER Oral Tablet Extended Release 12 Hour 500 MG

Ranexa Tier 2PA; QL (120 EA per 30 days)

Rasagiline Mesylate Oral Azilect Tier 2PA; QL (30 EA per 90 days)

Rea Lo 39 Tier 2 M90

React $0 M90

Rebetol Oral Solution Tier 2 SP

Rebif Rebidose Subcutaneous Solution Auto-Injector


Rebif Rebidose Titration Pack Subcutaneous Solution Auto-Injector

Tier 2SP; QL (12 (4.2 ml) per 28 days)

Rebif Subcutaneous Solution Prefilled Syringe

Tier 2SP; QL (12 (6 ml)per 28 days)

Rebif Titration Pack Subcutaneous Solution Prefilled Syringe


Rebinyn Tier 2 PA; SP; Dual

Reblozyl MB PA

Reclipsen $0 M90

Recombinate Tier 2 PA; SP; Dual

Recombivax HB Injection Suspension 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

$0 M90

Recort Plus Aveeno Anti-Itch Max St Tier 2 M90

Rectiv Tier 2 M90

149

Covered Product Reference Tier Status NotesReeses Pinworm Medicine Oral Suspension

Tier 2 M90

Refreshing AloeA + D Personal Care Lotion

Tier 2 M90

Regenecare HA External Gel Tier 2 M90

Regranex Tier 2M90; QL (15gm per month)

Rehydralyte Tier 2 M90

Relagard Tier 2 M90

Relenza Diskhaler Tier 2PA; M90; QL (40 EA per 90 days)

ReliOn Mini Pen Needles $0 M90

ReliOn Pen Needles $0 M90

ReliOn Short Pen Needles $0 M90

Relistor Oral Tier 2 PA; M90

Relistor Subcutaneous Solution 12 MG/0.6ML, 8 MG/0.4ML

Tier 2 PA; M90

Remedy Antifungal External Cream Tier 2 M90

Remeven Tier 2 M90

Remicade Tier 2PA; SP; Dual; QL (5 VIALS per 42 days)

Remodulin Injection Solution 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

Tier 2 PA; SP

Renacidin Tier 2 M90

Renagel Oral Tablet 400 MG Tier 2 M90

Renagel Oral Tablet 800 MG Tier 2

Renflexis Tier 2PA; SP; Dual; QL (5 VIALS per 28 days)

Renvela Tier 2 M90

Repaglinide Tier 1 M90

Repaglinide-metFORMIN HCl Tier 1 M90

Repatha Tier 2 PA; QL (2 per 28 days)

Repatha Pushtronex System Tier 2PA; QL (1 EA per 28 days)

Repatha SureClick Tier 2PA; QL (2 PENS per 28 days)

Replace DEKAs Plus Tier 2 M90

Reprexain Oral Tablet 10-200 MG Tier 2M90; QL (50 tablets per 30 days. Click;HERE)

Rescriptor Oral Tablet 100 MG Tier 2 SP

150


Rescriptor Oral Tablet 200 MG Tier 2SP; QL (450 per 30 days)

Rescula Tier 2 M90

Reserpine Tier 2

Restasis Tier 2 PA; M90

Restasis Multidose Ophthalmic Emulsion 0.05 %

Tier 2 PA; M90

Retacrit Injection Solution 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

Tier 2 PA; SP; Dual

Retevmo Oral Capsule 40 MG $0SP; QL (160 EA per 30 days)

Retevmo Oral Capsule 80 MG $0SP; QL (120 EA per 30 days)

Retisert Intraocular Tier 2 SP

Retrovir Intravenous Tier 2 M90

Revcovi Tier 2 PA; SP; Dual

ReVital Freezer Pops CeraLyte 70 Tier 2 M90

ReVital Jell Cups CeraLyte 70 Tier 2 M90

ReVital Liquid Squeezers CeraLyte 70 Tier 2 M90

Revlimid Oral Capsule 10 MG, 2.5 MG, 5 MG

$0SP; QL (28 per 28 days)

Revlimid Oral Capsule 15 MG, 20 MG, 25 MG

$0SP; QL (21 per 28 days)

Rexulti Oral Tablet 0.25 MG, 0.5 MG, 1 MG


Rexulti Oral Tablet 2 MG, 3 MG, 4 MG Tier 2M90; QL (60 EA per 30 days)

Reyataz Oral Packet Tier 2QL (180 packets per 30 days)

Rezira Tier 2 M90

Rhinocort Allergy Tier 2 ST; M90

Rhopressa Tier 2 ST

Riabni $0 PA; Dual

RiaSTAP Tier 2 PA; SP; Dual

Ribasphere Oral Capsule Tier 2 SP

Ribasphere Oral Tablet 200 MG, 600 MG Tier 2 SP

Ribasphere RibaPak Oral Tablet 200 & 400 MG, 400 & 600 MG

Tier 2 PA; SP

Ribasphere RibaPak Oral Tablet 600 MG Tier 2 SP

151

Covered Product Reference Tier Status NotesRibavirin Oral Capsule Tier 2 SP

Ribavirin Oral Tablet 200 MG, 400 MG Tier 2 SP

Ridaura Tier 2 M90

Rifabutin Mycobutin Tier 2 M90

Rifamate Tier 2 M90

rifAMPin Oral Tier 2 M90

Rifater Tier 2 M90

Right Step Prenatal Tier 1 M90

Riluzole Rilutek Tier 2 M90

riMANTAdine HCl Tier 2 M90

Rimso-50 Tier 2 M90

Rinvoq Tier 2PA; SP; QL (QL Applies)

Riomet Tier 1 M90; BP

Riomet ER Tier 1 PA

Risedronate Sodium Oral Tablet 150 MG Actonel Tier 2ST; M90; QL (1 tablet per 28 days; 13 tablets per 365 days)

Risedronate Sodium Oral Tablet 30 MG, 5 MG


Risedronate Sodium Oral Tablet 35 MG Actonel Tier 2ST; M90; QL (4 tablets per 28 days; 13 tablets per 90 days)

Risedronate Sodium Oral Tablet Delayed Release

Atelvia Tier 2ST; M90; QL (QL Flag)

RisperDAL Consta Intramuscular Suspension Reconstituted

Tier 2M90; QL (2 KITS per 28 days)

risperiDONE M-TAB Tier 2 M90; QL (QL Flag)

risperiDONE Oral Solution RisperDAL Tier 2M90; QL (60ml per month)

risperiDONE Oral Tablet 0.25 MG Tier 2M90; QL (90 EA per 30 days)

RisperiDONE Oral Tablet 0.5 MG, 1 MG RisperDAL Tier 2M90; QL (90 EA per 30 days)

RisperiDONE Oral Tablet 2 MG, 3 MG, 4 MG

RisperDAL Tier 2M90; QL (60 EA per 30 days)

RisperiDONE Oral Tablet Dispersible 0.25 MG, 0.5 MG, 1 MG


RisperiDONE Oral Tablet Dispersible 2 MG, 3 MG, 4 MG


Rituxan Hycela $0 PA; SP; Dual

Rituxan Intravenous Solution $0 PA; SP; Dual

152

Covered Product Reference Tier Status NotesRivastigmine Exelon Tier 2 M90

Rivastigmine Tartrate Tier 2 M90

Rixubis Ixinity Tier 2 PA; SP; Dual

Rizatriptan Benzoate Tier 2M90; QL (12 tablets per month)

RoC Deep Wrinkle Serum Tier 2 M90

rocklatan Tier 2 ST

rOPINIRole HCl Tier 2 M90

ROPINIRole HCl ER Tier 2 M90

Rosadan External Cream Tier 2 M90

Rosadan External Gel Tier 2 M90

Rose Milk Tier 2 M90

Rosuvastatin Calcium Crestor Tier 2ST; M90; QL (30 EA per 90 days)

Rotarix $0 M90

RotaTeq Oral Solution $0 M90

Roweepra Oral Tablet 500 MG Tier 2 M90

Rozlytrek Oral Capsule 100 MG $0PA; SP; QL (60 EA per 30 days)

Rozlytrek Oral Capsule 200 MG $0PA; SP; QL (90 EA per 30 days)

Rubraca $0 PA; SP

Ruconest Tier 2PA; SP; QL (QL Flag); Dual

Rufinamide Oral Suspension Banzel Tier 2QL (2400 ML per 30 days)

Rukobia Tier 2PA; SP; PD; QL (60 EA per 30 days)

Ruxience $0 PA; SP; Dual

Ruzurgi Tier 2PA; SP; QL (300 EA per 30 days)

Rybelsus Tier 2 PA

Rydapt $0 PA

Rytary Oral Capsule Extended Release 23.75-95 MG, 36.25-145 MG

Tier 2 PA; M90

Sabril Tier 2PA; SP; BP; QL (180 EA per 30 days)

Safyral $0 M90

Saizen Tier 2PA; SP; QL (Quantity Limit Applies)

Saizen Click.Easy Tier 2 PA; SP

153

Covered Product Reference Tier Status NotesSalacyn External Lotion Tier 2 M90

Salicylic Acid External Lotion Tier 2 M90

Salicylic Acid External Shampoo Keralyt Tier 2 M90

Salimez Tier 2

Saline Flush Intravenous Monoject Flush Syringe Tier 2 M90

Saline Flush ZR Tier 2 M90

Saline Mist Spray Afrin Saline Nasal Mist Tier 1 M90

Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

Salsalate Oral Tier 2 M90

SandoSTATIN LAR Depot Intramuscular Kit 10 MG, 30 MG

Tier 2PA; SP; Dual; QL (1 KIT per 28 days)

SandoSTATIN LAR Depot Intramuscular Kit 20 MG

Tier 2PA; SP; Dual; QL (2 KITS per 28 days)

Santyl Tier 2 M90

Sapropterin Dihydrochloride Tier 2 SP

Sash Kit Tier 2 M90

Savaysa Tier 2PA; QL (Quantity Limit Applies)

Savella Tier 2PA; M90; QL (60 EA per 30 days)

Savella Titration Pack Tier 2PA; M90; QL (60 EA per 30 days)

SB Acid Controller Pepcid AC Tier 2 M90

SB Acid Controller Max StMM Acid-Pep Maximum Strength

Tier 2 M90

SB Acid Reducer Pepcid AC Tier 2 M90

SB Acid Reducer raNITIdine Tier 2 M90

SB Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90

SB Allergy Oral Capsule Banophen Tier 2 M90

SB Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)

SB Allergy Relief Alavert Tier 2 M90

SB Antacid Cal-Gest Antacid Tier 2 M90

SB Antacid Extra StrengthCVS Chewy Not Chalky Flavor

Tier 2 M90

SB Anti-Fungal Tinactin Tier 2 M90

SB Arthritis Pain Relief Midol Tier 2 M90

SB Bacitracin Bacitraycin Plus Tier 2 M90

SB Bisacodyl Laxative EC Alophen Tier 2 M90

SB Bismuth Oral Suspension Kaopectate Tier 2 M90

SB Calcium + D Tier 2 M90

154

Covered Product Reference Tier Status NotesSB Cetirizine HCl Childrens Oral Syrup KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

SB Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

SB Chlorpheniramine Wal-finate Tier 2 M90

SB Cimetidine Tagamet HB Tier 2 M90

SB Clotrimazole Foot Desenex Tier 2 M90

SB Docusate Sodium Correctol Extra Gentle Tier 2 M90

SB Ear Wax Remover Murine Ear Tier 2 M90

SB Gas Relief Oral SuspensionLittle Remedies for Tummys

Tier 2 M90

SB Gentle Laxative Womens Alophen Tier 2 M90

SB Gentle Lax-Women Alophen Tier 2 M90

SB Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90

SB Hydrocortisone Max St Cortizone-10 Tier 2 M90

SB Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90

SB Ibuprofen Medi-Profen Tier 2 M90

SB Infants Ibuprofen Medi-Profen Tier 2 M90

SB Laxative The Magic Bullet Tier 2 M90

SB Lice Treatment Tier 2 M90

SB Loratadine Allergy Relief KLS AllerClear Tier 2 M90; QL (QL Flag)

SB Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

SB Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

SB Magnesium Citrate Citroma Tier 2 M90

SB Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

SB Naproxen Sodium Mediproxen Tier 2 M90

SB Non-Aspirin Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

SB Non-Aspirin Oral Tablet Aphen Tier 2 M90

SB Non-Aspirin Oral Tablet Chewable 80 MG


SB Oyster Shell Calcium Oystercal Tier 2 M90

SB Pain Reliever Childrens PediaCare Children Tier 2 M90

SB Pain Reliever Ex StHealthy Mama Shake That Ache

Tier 2 M90

SB Pediatric Electrolyte CeraLyte 70 Tier 2 M90

SB Peptic Relief Kaopectate Tier 2 M90

SB Polyethylene Glycol 3350 ClearLax Tier 2 M90

SB Saline Nose Afrin Saline Nasal Mist Tier 1 M90

SB Senna-Lax Evac-U-Gen Tier 2 M90

155


Scalacort Ala Scalp Tier 2ST; M90; QL (QL Applies)

Scenesse MB PA

ScopolamineTransderm-Scop (1.5 MG)

Tier 2

Scot-Tussin Allergy Relief Tier 2 M90

Sea Soft Nasal Mist Afrin Saline Nasal Mist Tier 1 M90

Seb-Prev Wash Tier 2 M90

Seconal Tier 2

Secuado Tier 2 ST

Secura Antifungal Tier 2 M90

Secura Antifungal Extra Thick Tier 2 M90

Seebri Neohaler Tier 2

Segluromet Tier 2 PA

Selegiline HCl Oral Tier 2 M90

Selenium Sulfide External Lotion Tier 2 M90

Selenium Sulfide External Shampoo 2.25 %

Tier 2 M90

Selenium Sulf-Pyrithione-Urea Tier 2 M90

Selzentry Oral Solution Tier 2 PA

Selzentry Oral Tablet 150 MG, 75 MG Tier 2PA; QL (60 EA per 30 days)

Selzentry Oral Tablet 25 MG Tier 2PA; QL (240 per 30 days)

Selzentry Oral Tablet 300 MG Tier 2PA; QL (120 EA per 30 days)

Semglee Tier 1 PA

Semprex-D Tier 2 M90

Se-Natal 19 Oral Tablet Chewable $0 M90

Senexon Evac-U-Gen Tier 2 M90

Senior Tabs ABC Plus Senior Tier 2 M90

Senna Lax Evac-U-Gen Tier 2 M90

Senna Laxative Evac-U-Gen Tier 2 M90

Senna Oral Syrup 8.8 MG/5ML Tier 2 M90

Senna Oral Tablet 8.6 MG Evac-U-Gen Tier 2 M90

Senna Smooth Tier 2 M90

SennaCon Tier 2 M90

Senna-GRX Tier 2 M90

Senna-Lax Evac-U-Gen Tier 2 M90

Senna-Tabs Evac-U-Gen Tier 2 M90

156

Covered Product Reference Tier Status NotesSenna-Time Evac-U-Gen Tier 2 M90

Sennazon Tier 2 M90

Senno Tier 2 M90

Sensorcaine Tier 2 M90

Sensorcaine/EPINEPHrine Tier 2 M90

Sensorcaine-MPF Injection Solution 0.75 %

Tier 2 M90

Sentry ABC Plus Senior Tier 2 M90

Sentry Adult ABC Plus Senior Tier 2 M90

Sentry Senior ABC Plus Senior Tier 2 M90

Sentry Senior/Lutein ABC Plus Senior Tier 2 M90

Serevent Diskus Tier 2 M90

Serostim Subcutaneous Solution Reconstituted 4 MG, 5 MG, 6 MG

Tier 2 PA; SP; QL (QL Flag)

Sertraline HCl Oral Concentrate Zoloft Tier 2 M90

Sertraline HCl Oral Tablet 100 MG Zoloft Tier 2M90; QL (90 EA per 30 days)

Sertraline HCl Oral Tablet 25 MG, 50 MG Zoloft Tier 2M90; QL (75 tablets per month)

Setlakin $0 M90

Sevelamer Carbonate Oral Packet Renvela Tier 2

Sevenfact Tier 2 PA; SP; Dual

SF Cavarest Tier 2 M90

SF 5000 Plus Denta 5000 Plus Tier 2 M90

SfRowasa Tier 2 M90

Sharobel $0 M90

Shingrix Intramuscular Suspension Reconstituted 50 MCG

$0

Shopko Athletes Foot Tier 2 M90

Shopko Nasal Decongestant Max Tier 2 M90

Shopko Unifine Pentips $0 M90

Shopko Unifine Pentips Plus $0 M90

Shur-Seal Contraceptive $0 M90

Signifor LAR Intramuscular Suspension Reconstituted ER

MB PA

Silace Tier 2 M90

Siladryl Allergy Banophen Tier 2 M90

Sildenafil Citrate Oral Suspension Reconstituted

Revatio Tier 2PA; SP; QL (224 ml per 30 days)

157


Sildenafil Citrate Oral Tablet 20 MG Revatio Tier 2PA; SP; QL (90 EA per 30 days)

Siliq Tier 2PA; QL (2 ML per 28 SYRs)

Silodosin Rapaflo Tier 2PA; QL (30 EA per 90 days)

Silphen Cough Tier 2 M90

Silver Sulfadiazine External SSD Tier 2 M90

Simbrinza Tier 2 M90

SimepedLittle Remedies for Tummys

Tier 2 M90

Simethicone Oral SuspensionLittle Remedies for Tummys

Tier 2 M90

Simethicone Oral Tablet Chewable 80 MG

Tier 2 M90

Simponi Aria Tier 2PA; SP; QL (200 mg every 8 weeks; Based on 100 kg pt); Dual

Simponi Subcutaneous Solution Auto-Injector 100 MG/ML

Tier 2PA; SP; QL (1 PEN per 28 days)

Simponi Subcutaneous Solution Auto-Injector 50 MG/0.5ML

Tier 2PA; SP; QL (Quantity Limit Applies)

Simponi Subcutaneous Solution Prefilled Syringe 100 MG/ML

Tier 2PA; SP; QL (Quantity Limit Applies)

Simponi Subcutaneous Solution Prefilled Syringe 50 MG/0.5ML


Simvastatin Oral Tablet Zocor Tier 2M90; QL (30 EA per 90 days)

Sirolimus Oral Solution Rapamune Tier 2 SP; QL (QL Applies)

Sirolimus Oral Tablet Rapamune Tier 2 SP; QL (QL Flag)

Sirturo Oral Tablet 100 MG Tier 2 M90

Sirturo Oral Tablet 20 MG Tier 2

Sitavig Tier 2 PA; M90

Sivextro Oral Tier 2PA; M90; QL (QL Flag)

Skin Repair Tier 2 M90

Skyla $0SP; QL (1 FILL per 365 days)

Skyrizi Tier 2PA; SP; QL (2 SYR per 84 days)

Skyrizi (150 MG Dose) Tier 2PA; SP; QL (2 SYR per 12 Weeks)

158

Covered Product Reference Tier Status NotesSlo-Niacin Oral Tablet Extended Release 250 MG

Tier 1 M90

Slynd $0

SM 3-Day Vaginal Gyne-Lotrimin 3 Tier 2 M90

SM 8 Hour Pain Relief Midol Tier 2 M90

SM Acid Reducer Tier 2 M90

SM All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)

SM All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

SM All Day Pain Relief Mediproxen Tier 2 M90

SM Allergy 4 Hour Wal-finate Tier 2 M90

SM Allergy Relief Childrens Banophen Tier 2 M90

SM Allergy Relief Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)

SM Allergy Relief Nasal ClariSpray Tier 2 M90

SM Allergy Relief Oral Capsule Banophen Tier 2 M90

SM Allergy Relief Oral Liquid Banophen Tier 2 M90

SM Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

SM Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90

SM Animal Shapes Kids First Bounty Bears/C Tier 2 M90

SM Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90

SM Antifungal Clotrimazole Desenex Tier 2 M90

SM Antifungal Miconazole Tineacide Tier 2 M90

SM Antifungal Tolnaftate Tinactin Tier 2 M90

SM Antioxidant Vitamins ABC Plus Senior Tier 2 M90

SM Arthritis Pain Relief Midol Tier 2 M90

SM Athletes Foot External Aerosol Tinactin Tier 2 M90

SM Bedding Lice Treatment RID Tier 2 M90

SM Calamine Tier 2 M90

SM Calcium 500/Vitamin D3 Oystercal-D Tier 2 M90

SM Calcium 600/Vitamin D Tier 2 M90

SM Calcium 600+D Plus MineralsCaltrate 600+D Plus Minerals

Tier 2 M90

SM Calcium 600+D3 Pronutrients Calcium+D3 Tier 2 M90

SM Calcium Antacid Cal-Gest Antacid Tier 2 M90

SM Calcium Antacid Ex StCVS Chewy Not Chalky Flavor

Tier 2 M90

SM Calcium Antacid Ultra St Tums Ultra 1000 Tier 2 M90

SM Calcium Citrate w/Vit D3 Calcitrate Tier 2 M90

SM Calcium Citrate+/Vit D3 Calcitrate Tier 2 M90

159


SM Calcium Citrate+D3 PetiteCitracal Petites/Vitamin D

Tier 2 M90

SM Calcium Citrate-Vit D Tier 2 M90

SM Calcium/Vitamin D Os-Cal Calcium + D3 Tier 2 M90

SM Calcium/Vitamin D3Caltrate 600+D Plus Minerals

Tier 2 M90

SM Calcium-Vitamin D Tier 2 M90

SM Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

SM Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

SM ClearLax Tier 2 M90

SM Clotrimazole Vaginal Gyne-Lotrimin Tier 2 M90

SM Complete ABC Plus Senior Tier 2 M90

SM Complete 50+ ABC Plus Senior Tier 2 M90

SM Complete 50+ Ultimate Mens ABC Plus Senior Tier 2 M90

SM Complete 50+ Ultimate Women ABC Plus Senior Tier 2 M90

SM Complete Advanced Formula ABC Plus Senior Tier 2 M90

SM Complete Senior Formula ABC Plus Senior Tier 2 M90

SM Daily Diet Support ABC Plus Senior Tier 2 M90

SM Dry Skin TherapyA + D Personal Care Lotion

Tier 2 M90

SM Ear Drops Murine Ear Tier 2 M90

SM Enema Fleet Enema Tier 2 M90

SM Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

SM Fexofenadine HCl KLS Aller-Fex Tier 2 M90; QL (QL Flag)

SM First Aid Antibiotic Bacitraycin Plus Tier 2 M90

SM Gas Relief InfantsLittle Remedies for Tummys

Tier 2 M90

SM Gas Relief Infants DropsLittle Remedies for Tummys

Tier 2 M90

SM Gas Relief Oral Tablet Chewable 80 MG

Tier 2 M90

SM Gentle Laxative Alophen Tier 2 M90

SM Hair/Skin/Nails ABC Plus Senior Tier 2 M90

SM Hydrocortisone External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90

SM Ibuprofen IB Advil Junior Strength Tier 2 M90

SM Ibuprofen Jr Advil Junior Strength Tier 2 M90

SM Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

SM Infants Ibuprofen Medi-Profen Tier 2 M90

SM Infants Pain Reliever PediaCare Children Tier 2 M90

160

Covered Product Reference Tier Status NotesSM Iodides Tier 2 M90

SM Iodine Tincture Tier 2 M90

SM Iron Oral Tablet 134 MG Tier 2 M90

SM Laxative Maximum Strength Tier 2 M90

SM Laxative Rectal The Magic Bullet Tier 2 M90

SM Lice Killing RID Tier 2 M90

SM Lice Treatment Tier 2 M90

SM Loratadine Allergy Relief Alavert Tier 2 M90

SM Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

SM Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)

SM Loratadine Oral Tablet Dispersible Alavert Tier 2 M90

SM Magnesium Citrate Citroma Tier 2 M90

SM Miconazole 3 Vagistat-3 Tier 2 M90

SM Miconazole 3 ApplicatorMonistat 3 Combo Pack App

Tier 2 M90

SM Miconazole 7 Tier 2 M90

SM Milk of MagnesiaDulcolax Milk of Magnesia

Tier 2 M90

SM Mineral Oil Oral Tier 2 M90

SM Motion Sickness Oral Tablet 25 MG Wal-Dram II Tier 2 M90

SM Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

SM Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

SM Nasal Decongestant Max St SudoGest Tier 2 M90

SM Nasal Spray Saline Afrin Saline Nasal Mist Tier 1 M90

SM Niacin CR Endur-Acin Tier 1 M90

SM Nicotine Habitrol $0 M90

SM Nicotine Polacrilex Mouth/Throat Gum

KLS Quit2 $0 M90

SM Nicotine Polacrilex Mouth/Throat Lozenge 4 MG

KLS Quit4 $0 M90

SM One Daily Mens ABC Plus Senior Tier 2 M90

SM One Daily Womens ABC Plus Senior Tier 2 M90

SM Opti-Vitamins ABC Plus Senior Tier 2 M90

SM Oyster Shell Calcium/Vit D Oystercal-D Tier 2 M90

SM Oyster Shell Calcium/Vit D3 Oystercal-D Tier 2 M90

SM Pain & Fever Childrens PediaCare Children Tier 2 M90

SM Pain & Fever Infants PediaCare Children Tier 2 M90

161


SM Pain Relief Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

SM Pain Reliever 8 Hour Ex St Midol Tier 2 M90

SM Pain Reliever Childrens PediaCare Children Tier 2 M90

SM Pain Reliever Ex St Oral TabletHealthy Mama Shake That Ache

Tier 2 M90

SM Pain Reliever Oral Tablet 325 MG Aphen Tier 2 M90

SM Pediatric Electrolyte CeraLyte 70 Tier 2 M90

SM Prenatal Vitamins Tier 1 M90

SM Senna Laxative Evac-U-Gen Tier 2 M90

SM Senna Laxative Max St Tier 2 M90

SM Smooth Antacid Ex StCVS Chewy Not Chalky Flavor

Tier 2 M90

SM Stomach Relief Oral Suspension Kaopectate Tier 2 M90

SM Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

SM Vitamin B-6 Tier 2 M90

SM Vitamin D3 Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

SM Vitamin D3 Oral Tablet Vitamin D-1000 Max St Tier 2 M90

SM Womans Laxative Alophen Tier 2 M90

Smooth LAX Tier 2 M90

Sodium Acetate Intravenous Solution 2 MEQ/ML

Tier 2

Sodium Ascorbate Injection Solution 250 MG/ML

Tier 2 M90

Sodium Chloride Flush Monoject Flush Syringe Tier 2 M90

Sodium Chloride Inhalation Nebulization Solution 0.9 %, 3 %

Tier 2 M90

Sodium Chloride Intravenous Solution 0.9 %

Tier 2 M90

Sodium Chloride Irrigation Solution 0.9 % Argyle Sterile Saline Tier 2 M90

Sodium Fluoride Mouth/Throat PreviDent Tier 2

Sodium Fluoride Oral Solution 1.1 (0.5 F) MG/ML

Tier 1 M90

Sodium Fluoride Oral Tablet 1.1 (0.5 F) MG

Tier 1 M90

Sodium Fluoride Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG

Tier 1 M90

Sodium Fluoride Oral Tablet Chewable 2.2 (1 F) MG

NaFrinse Tier 2 M90

Sodium Hyaluronate External Gel Tier 2 M90

162


Sodium Hyaluronate Intra-Articular Euflexxa Tier 2PA; SP; QL (QL Applies); Dual

Sodium Phenylbutyrate Oral Powder 3 GM/TSP

Buphenyl Tier 2 SP; QL (QL Flag)

Sodium Phenylbutyrate Oral Tablet Buphenyl Tier 2

Sodium Polystyrene Sulfonate Oral Tier 2 M90

Sodium Polystyrene Sulfonate Rectal Tier 2 M90

Sodium Sulfacetamide External Shampoo 10 %

Ovace Plus Tier 2 M90

Sodium Sulfacetamide External Shampoo 9.8 %

Plexion NS Tier 2

Sof-Lax Tier 2 M90

Sofosbuvir-Velpatasvir Epclusa Tier 2PA; SP; PD; QL (28 EA per 28 days)

Softden Tier 2 M90

Solifenacin Succinate VESIcare Tier 2ST; QL (30 EA per 90 days)

Soliqua Tier 2 PA

Soliris Tier 2 PA; SP; Dual

Solo ABC Plus Senior Tier 2 M90

Soltamox $0 M90

Solu-CORTEF Tier 2 M90

Solu-MEDROL Injection Solution Reconstituted 2 GM

Tier 2 M90

Somatuline Depot Subcutaneous Solution 120 MG/0.5ML

Tier 2PA; SP; Dual; QL (120 ML per 28 days)




Tier 2PA; SP; QL (90 mg per 28 days); Dual

Somavert MB PA

Soothe & Cool INZO Antifungal Tier 2 M90

Soothe & Cool Moisturizing Tier 2 M90

Soothe Oral Suspension 262 MG/15ML Tier 2 M90

Sorilux Tier 2PA; M90; QL (120 GM per 30 days)

Sorine Tier 1 M90

Sotalol HCl (AF) Betapace AF Tier 1 M90

Sotalol HCl Oral Sorine Tier 1 M90

Sotylize Tier 2 M90

163


Sovaldi Oral Packet Tier 2PA; SP; QL (28 EA per 28 days)

Spinosad Natroba Tier 2

Spinraza MB PA

Spiriva HandiHaler Tier 2 M90

Spiriva Respimat Inhalation Aerosol Solution 1.25 MCG/ACT, 2.5 MCG/ACT

Tier 2 M90

Spironolactone Oral Aldactone Tier 1 M90

Spironolactone-HCTZ Aldactazide Tier 1 M90

Spravato (56 MG Dose) MB PA

Spravato (84 MG Dose) MB PA

Sprintec 28 $0 M90

Sprycel Oral Tablet 100 MG, 140 MG, 50 MG, 70 MG, 80 MG


Sprycel Oral Tablet 20 MG $0SP; QL (90 EA per 30 days)

SPS Tier 2 M90

SR Nicotine KLS Quit2 $0 M90

Sronyx $0 M90

SSD Tier 2 M90

SSD (silver sulfADIAZINE) Tier 2 M90

SSKI Tier 2 M90

St Ives Swiss Formula Moisture Tier 2 M90

St Joseph Adult Tier 1 M90

St Joseph Adult Low Dose Tier 1 M90

Stavudine Tier 2 M90

Steglatro Tier 2 PA

Stelara Intravenous Tier 2PA; SP; Dual; QL (4 VIALS per 56 days)

Stelara Subcutaneous Solution 45 MG/0.5ML

Tier 2PA; SP; PD; Dual; QL (1 VIAL per 84 days)

Stelara Subcutaneous Solution Prefilled Syringe


Stimate Tier 2 SP; QL (QL Flag)

Stimulant Laxative Oral Tablet Delayed Release

Alophen Tier 2 M90

Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT


Stivarga $0PA; SP; QL (112 EA per 28 days)

164

Covered Product Reference Tier Status NotesStomach Relief Oral Suspension 262 MG/15ML, 527 MG/30ML

Kaopectate Tier 2 M90

Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90

Stool Softener Oral Tablet DOK Tier 2 M90

Stop Lice RID Tier 2 M90

Stop Lice Maximum Strength External Liquid

RID Tier 2 M90

Stop Lice Step 3 RID Tier 2 M90

Stress B Complex/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Stress B-Complex/C/Zinc ABC Plus Senior Tier 2 M90

Stress Formula EstroFactors Tier 2 M90

Stress Formula (Folic Acid) Tier 2 M90

Stress Formula/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Stress Formula/Zinc ABC Plus Senior Tier 2 M90

Stress Formula/Zinc (B-Compl) Tier 2 M90

Stribild Tier 2

Striverdi Respimat Tier 2 M90

Strovite Forte Oral Syrup Tier 2 M90

Sublocade MB PD

Suboxone Sublingual Film 12-3 MG Tier 2PD; BP; QL (60 EA per 30 days)

Suboxone Sublingual Film 2-0.5 MG Tier 2PD; BP; QL (360 EA per 30 days)



Sucraid Tier 2 M90

Sucralfate Oral Tablet Carafate Tier 2 M90

SudoGest Tier 2 M90

SUFentanil Citrate Intravenous Solution 100 MCG/2ML, 50 MCG/ML

Tier 2

Sulconazole Nitrate Exelderm Tier 2 ST

Sulfacetamide Sodium (Acne) Klaron Tier 2 M90

Sulfacetamide Sodium External Gel Ovace Plus Wash Tier 2 M90

Sulfacetamide Sodium External Liquid Ovace Plus Wash Tier 2 M90

Sulfacetamide Sodium External Suspension

Klaron Tier 2 M90

165

Covered Product Reference Tier Status NotesSulfacetamide Sodium Ophthalmic Solution

Bleph-10 Tier 2 M90

Sulfacetamide Sodium-Sulfur External Emulsion

Tier 2

Sulfacetamide Sodium-Sulfur External Lotion 10-5 %

Tier 2 M90

Sulfacetamide-Prednisolone Ophthalmic Solution

Tier 2 M90

SulfADIAZINE Oral Tier 2 M90

Sulfamethoxazole-Trimethoprim Intravenous

Tier 2 M90

Sulfamethoxazole-Trimethoprim Oral Suspension 200-40 MG/5ML

Sulfatrim Pediatric Tier 2 M90

Sulfamethoxazole-Trimethoprim Oral Tablet

Bactrim Tier 2 M90

Sulfamylon External Cream Tier 2 M90

SulfaSALAzine Oral Azulfidine Tier 2 M90

Sulfatrim Pediatric Tier 2 M90

Sulfoam Tier 2 M90

Sulindac Oral Tier 2 M90

SUMAtriptan Nasal Solution 20 MG/ACT Imitrex Tier 2M90; QL (12ml (2 nasal sprays) per 25 days)

SUMAtriptan Succinate Oral Imitrex Tier 2M90; QL (12 tablets per month)

SUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 6 MG/0.5ML

Imitrex STATdose Refill Tier 2 M90; QL (QL Flag)

SUMAtriptan Succinate Subcutaneous Solution 6 MG/0.5ML

Imitrex Tier 2 M90

SUMAtriptan Succinate Subcutaneous Solution Auto-Injector 6 MG/0.5ML

Imitrex STATdose System

Tier 2 M90

SUMAtriptan Succinate Subcutaneous Solution Prefilled Syringe 6 MG/0.5ML

Tier 2M90; QL (6 kits (12 syringes) per month)

Sunosi Tier 2 PA

Supartz FX Tier 2PA; SP; QL (QL Applies); Dual

Super 28 Formula ABC Plus Senior Tier 2 M90

Super Antioxidant Oral Capsule DEKAs Plus Tier 2 M90

Super Antioxidants Protector DEKAs Plus Tier 2 M90

Super Aytinal ABC Plus Senior Tier 2 M90

Super Aytinal 50 Plus ABC Plus Senior Tier 2 M90

166

Covered Product Reference Tier Status NotesSuper Calcium 600 + D 400 Tier 2 M90

Super Calcium 600 + D3 Tier 2 M90

Super Calcium Oral Tablet 1500 (600 Ca) MG, 600 MG

Tier 2 M90

Super Daily D3 Oral Liquid 1000 UNT/0.03ML

Ddrops Tier 2

Super Multiple ABC Plus Senior Tier 2 M90

Super Nu-Thera Oral Liquid Tier 2 M90

Super Thera Vite M ABC Plus Senior Tier 2 M90

Super Vikaps ABC Plus Senior Tier 2 M90

Super Vita-Mins ABC Plus Senior Tier 2 M90

Superb Nails ABC Plus Senior Tier 2 M90

Suphedrine SudoGest Tier 2 M90

Support BProtected Multi-Vite Tier 2 M90

Supprelin LA Tier 2 PA; SP; Dual

Suprax Oral Suspension Reconstituted 500 MG/5ML

Tier 2 M90

Suprep Bowel Prep Kit $0

Sure Comfort Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

Sure Guard Anti-Oxidant Plus ABC Plus Senior Tier 2 M90

Sure Guard Multi Vit/Mineral ABC Plus Senior Tier 2 M90

Sure Result DSS Premium Pack NuDiclo SoluPak Tier 2 M90

Sure-Fine Pen Needles $0 M90

Surgilube Tier 2 PA; SP

Surmontil Oral Capsule 25 MG, 50 MG Tier 2 M90

Sustiva Oral Tablet Tier 2QL (30 EA per 90 days)

Sutab $0

Sutent $0PA; SP; PD; QL (30 EA per 30 days)

SW Acid Reducer 150 Max St Tier 2 M90

SW Allergy Relief KLS Aller-Tec Tier 2 M90; QL (QL Flag)

SW ClearLax Tier 2 M90

SW Nasal Decongestant Max St SudoGest Tier 2 M90

SW Nicotine Polacrilex KLS Quit4 Tier 1 M90

SwabFlush Saline Flush Tier 2 M90

Syeda $0 M90

Sylatron Subcutaneous Kit 200 MCG, 300 MCG, 600 MCG

$0 SP; QL (4 per 28 days)

167

Covered Product Reference Tier Status NotesSymax Duotab Tier 2 M90

Symax-SL Tier 2 M90

Symax-SR Tier 2 M90

Symbicort Tier 2 BP

Symdeko Tier 2PA; PD; QL (60 EA per 30 days)

Symjepi Injection Solution Prefilled Syringe 0.15 MG/0.3ML

Tier 2

QL (1 pack (2 pens) per fill with a maximum of 1 fill per day)

Symjepi Injection Solution Prefilled Syringe 0.3 MG/0.3ML

Tier 2QL (2 pens per fill, 1 fill per day)

SymlinPen 120 Subcutaneous Solution Pen-Injector

Tier 2 PA; M90

SymlinPen 60 Subcutaneous Solution Pen-Injector

Tier 2 PA; M90

Symtuza Tier 2PD; QL (30 EA per 30 days)

Synagex Tier 2 M90

Synagis $0PA; SP; QL (5 DOSES per 1 RSV SEASON)

Synarel Tier 2 M90

SynaTek Tier 2 M90

Synercid Tier 2 M90

Synjardy Tier 2QL (60 EA per 30 days)

Synjardy XR Tier 2QL (60 EA per 30 days)

Synthroid Tier 2

Synvisc Intra-Articular Solution Prefilled Syringe


Synvisc One Intra-Articular Solution Prefilled Syringe

Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)

T.R.U.E. Test Tier 2 M90

Tab-A-Vite/IronTab-A-Vite/Iron/Beta Carotene

Tier 2 M90

Tabloid $0 M90

Tabrecta $0SP; QL (112 EA per 28 days)

Tacrolimus Oral Prograf Tier 2 SP; QL (QL Flag)

168

Covered Product Reference Tier Status NotesTactinal Aphen Tier 2 M90

Tactinal Extra StrengthHealthy Mama Shake That Ache

Tier 2 M90

Tadalafil (PAH) Adcirca Tier 2PA; SP; QL (60 EA per 30 days)

Tadalafil Oral Tablet 5 MG Cialis Tier 1PA; M90; QL (QL Applies)

Tafinlar $0SP; QL (120 EA per 30 days)

Tagrisso $0PA; SP; QL (30 EA per 30 days)

Take Action $0 M90

Takhzyro Tier 2PA; SP; QL (2 VIALS per 28 days)

Taltz Subcutaneous Solution Auto-Injector

Tier 2PA; SP; PD; QL (1 INJ per 28 days)

Taltz Subcutaneous Solution Prefilled Syringe


Talwin Tier 2

Talzenna $0 SP

Tamsulosin HCl Flomax Tier 2M90; QL (60 EA per 30 days)

TargaDOX Tier 2 M90

Targretin External Tier 2 SP; QL (QL Flag)

Tarina FE 1/20 $0 M90

Taron Forte Tier 2 M90

Taron-Crystals Tier 2 M90

Tasigna $0SP; QL (120 EA per 30 days)

Tavalisse Oral Tablet 100 MG Tier 2 PA; SP

Taytulla $0 M90

Tazarotene External Cream Tazorac Tier 2 ST; M90

Tazorac External Cream 0.05 % Tier 2 ST; M90

Tazorac External Gel Tier 2 ST; M90

Taztia XT Tier 1 M90

Tazverik $0SP; QL (240 EA per 30 days)

TBC Tier 2 M90

Tecentriq Intravenous Solution 1200 MG/20ML

$0 PA; SP

169

Covered Product Reference Tier Status NotesTecentriq Intravenous Solution 840 MG/14ML

$0 PA; SP; Dual

Tecfidera Oral Tier 2PA; SP; PD; BP; QL (60 EA per 30 days)

Tecfidera Oral Capsule Delayed Release 120 MG

Tier 2PA; SP; PD; BP; QL (14 EA per 30 days)

Tecfidera Oral Capsule Delayed Release 240 MG

Tier 2PA; SP; PD; BP; QL (60 EA per 30 days)

TechLite Pen Needles 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

$0 M90

TechLite Pen Needles 32G X 8 MM Tier 1 M90

Telmisartan Micardis Tier 1 ST; M90

Telmisartan-HCTZ Micardis HCT Tier 1 ST; M90

Temazepam Restoril Tier 2

Temodar Intravenous $0 SP

Temozolomide $0 SP

Temsirolimus Torisel $0 SP

Teniposide $0 M90

Tenivac $0 M90

Tenofovir Disoproxil Fumarate Viread Tier 2QL (30 EA per 90 days)

Tepadina Tier 2 SP

Tepezza MB PA

Tepmetko $0PA; SP; QL (60 EA per 30 days)

Terazosin HCl Oral Tier 1 M90

Terbinafine HCl Oral Tier 2M90; QL (30 EA per 90 days)

Terbutaline Sulfate Oral Tier 2 M90

Terconazole Tier 2 M90

Tersaseptic Tier 2 M90

Tersi Tier 2 M90

Testopel MB PA

Testosterone Cypionate Intramuscular Solution 100 MG/ML, 200 MG/ML

Depo-Testosterone Tier 2

Testosterone Enanthate Intramuscular Solution

Tier 2

Testosterone Transdermal Gel 10 MG/ACT (2%)

Fortesta Tier 2

170

Covered Product Reference Tier Status NotesTestosterone Transdermal Gel 12.5 MG/ACT (1%)

Vogelxo Pump Tier 2

Testosterone Transdermal Gel 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

AndroGel Tier 2 ST

Testosterone Transdermal Gel 20.25 MG/ACT (1.62%)

AndroGel Pump Tier 2 ST

Testosterone Transdermal Gel 25 MG/2.5GM (1%), 50 MG/5GM (1%)

AndroGel Tier 2

Testosterone Transdermal Solution Tier 2 ST

Tetanus-Diphtheria Toxoids Td TDVAX $0 M90

Tetcaine Tier 2 M90

Tetrabenazine Xenazine Tier 2 PA; SP; QL (QL Flag)

Tetracaine HCl Ophthalmic Altacaine Tier 2 M90

Tetracycline HCl Oral Tier 2 M90

TetraVisc Tier 2 M90

TetraVisc Forte Tier 2 M90

TexaVite LQ Tier 2 M90

TGT Acetaminophen Childrens PediaCare Children Tier 2 M90

TGT Acetaminophen Ex StHealthy Mama Shake That Ache

Tier 2 M90

TGT Acetaminophen Infants Tier 2 M90

TGT Acid Reducer Pepcid AC Tier 2 M90

TGT All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)

TGT All Day Allergy Relief KLS Aller-Tec Tier 2 M90; QL (QL Flag)

TGT Allergy Childrens Banophen Tier 2 M90

TGT Allergy Relief Childrens Banophen Tier 2 M90

TGT Allergy Relief Oral Capsule Banophen Tier 2 M90

TGT Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)

TGT Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)

TGT Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90

TGT Allergy Relief Oral Tablet Dispersible

Alavert Tier 2 M90

TGT Allergy+ Congestion Relief Oral Tablet Extended Release 12 Hour 60-120 MG



TGT Antacid Tums Ultra 1000 Tier 2 M90

TGT Antacid Extra Strength Oral Tablet Chewable 750 MG


Tier 2 M90

TGT Antifungal Tinactin Tier 2 M90

TGT Anti-Itch Maximum Strength Cortizone-10 Tier 2 M90

171

Covered Product Reference Tier Status NotesTGT Anti-Itch Plus Oatmeal Aveeno Anti-Itch Max St Tier 2 M90

TGT Anti-Itch/Aloe/Vit E Aveeno Anti-Itch Max St Tier 2 M90

TGT Arthritis Pain Relief Midol Tier 2 M90

TGT Bacitracin Bacitraycin Plus Tier 2 M90

TGT Calcium + Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90

TGT Childrens Acetaminophen PediaCare Children Tier 2 M90

TGT Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90

TGT Clotrimazole Desenex Tier 2 M90

TGT Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)

TGT Gas Relief Infants Gas-X Infant Drops Tier 2 M90

TGT Gentle Laxative Alophen Tier 2 M90

TGT Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90

TGT Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90

TGT Ibuprofen Oral Tablet Medi-Profen Tier 2 M90

TGT Infants Ibuprofen Medi-Profen Tier 2 M90

TGT Laxative Pills Max St Tier 2 M90

TGT Loperamide HCl Imodium A-D Tier 2 M90

TGT Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)

TGT Miconazole 1 Monistat 1 Combo Pack Tier 2 M90

TGT Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90

TGT Miconazole 7 Monistat 7 Simply Cure Tier 2 M90

TGT Multivitamin/Multimineral ABC Plus Senior Tier 2 M90

TGT Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90

TGT Nasal Decongestant SudoGest Tier 2 M90

TGT Nasal Spray Nasal Solution 0.65 % Afrin Saline Nasal Mist Tier 1 M90

TGT Natural Laxative Pills Tier 2 M90

TGT Nicotine KLS Quit2 $0 M90

TGT Nicotine Polacrilex KLS Quit4 $0 M90

TGT Nicotine Step One Habitrol $0 M90

TGT Nicotine Step Three Nicoderm CQ $0 M90

TGT Nicotine Step Two Nicoderm CQ $0 M90

TGT Pain/Fever Acetaminophen PediaCare Children Tier 2 M90

TGT Powderlax Oral Powder Tier 2 M90

TGT Saline Laxative Fleet Enema Tier 2 M90

TGT Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90

TGT Senna Evac-U-Gen Tier 2 M90

TGT Senna Laxative Oral Tablet 8.6 MG Evac-U-Gen Tier 2 M90

172

Covered Product Reference Tier Status NotesTGT Stool Softener Correctol Extra Gentle Tier 2 M90

TGT Womens Laxative Alophen Tier 2 M90

Thalomid Oral Capsule 100 MG, 50 MG Tier 2SP; QL (30 EA per 90 days)

Thalomid Oral Capsule 150 MG, 200 MG Tier 2SP; QL (60 EA per 30 days)

The Magic Bullet Tier 2 M90

The Treatment Formula 3 Tier 2 M90

Theo-24 Tier 2 M90

Theophylline Tier 2 M90

Theophylline ER Oral Tablet Extended Release 12 Hour 300 MG, 450 MG

Tier 2 M90

Theophylline ER Oral Tablet Extended Release 24 Hour

Tier 2 M90

Thera Vital M ABC Plus Senior Tier 2 M90

Thera vital-M ABC Plus Senior Tier 2 M90

Therabasic-M ABC Plus Senior Tier 2 M90

TheraBetic Skin Care Tier 2 M90

TheraCys $0 M90

Thera-D 2000 Tier 2 M90

Thera-D Rapid Repletion Tier 2 M90

Thera-DermA + D Personal Care Lotion

Tier 2 M90

Thera-M ABC Plus Senior Tier 2 M90

TheraNatal Core Nutrition Tier 1 M90

Therapeutic Formula/Hematinics ABC Plus Senior Tier 2 M90

Therapeutic Liquid BProtected Multi-Vite Tier 2 M90

Therapeutic M ABC Plus Senior Tier 2 M90

Therapeutic-M ABC Plus Senior Tier 2 M90

Therapeutic-M/Lutein ABC Plus Senior Tier 2 M90

Theraplex Hydrolotion Tier 2 M90

Thera-Tabs M ABC Plus Senior Tier 2 M90

TheraTears Allergy Tier 2 M90; QL (QL Flag)

Theravim-M ABC Plus Senior Tier 2 M90

Thiamine HCl Injection Tier 2 M90

Thiola Tier 2 M90

Thiola EC Tier 2

Thioridazine HCl Oral Tier 2 M90

Thiothixene Oral Tier 2 M90

173

Covered Product Reference Tier Status NotesThrive Mouth/Throat Gum 2 MG $0 M90

Thrivite Rx Prenatabs Rx $0 M90

Thrombogen Tier 2 M90

Thyrogen Intramuscular Solution Reconstituted 1.1 MG


Thyrolar-1 Oral Tablet 60 (12.5-50) MG (MCG)

Tier 2 M90

Thyrolar-1/2 Oral Tablet 30 (6.25-25) MG (MCG)

Tier 2 M90

Thyrolar-1/4 Oral Tablet 15 (3.1-12.5) MG (MCG)

Tier 2 M90

Thyrolar-2 Oral Tablet 120 (25-100) MG (MCG)

Tier 2 M90

Thyrolar-3 Oral Tablet 180 (37.5-150) MG (MCG)

Tier 2 M90

TiaGABine HCl Oral Tablet 12 MG, 16 MG

Gabitril Tier 2

TiaGABine HCl Oral Tablet 2 MG, 4 MG Gabitril Tier 2 M90

Tibsovo $0 PA; SP

Tice BCG $0 M90

Tigan Intramuscular Tier 2 M90

Tiglutik Tier 2 PA

Tilia Fe $0 M90

Timolol Maleate Ophthalmic Gel Forming Solution

Timoptic-XE Tier 2 M90

Timolol Maleate Ophthalmic Solution 0.25 %, 0.5 %

Timoptic Tier 2 M90

Timolol Maleate Ophthalmic Solution 0.5 % (DAILY)

Istalol Tier 2

Timolol Maleate Oral Tier 1 M90

Timolol Maleate PF Timoptic Ocudose Tier 2

Timoptic Ocudose Ophthalmic Solution 0.25 %

Tier 2 M90

Tinaspore Blis-To-Sol Tier 2 M90

Tineacide External Cream 2 % Tier 2 M90

Tinidazole Oral Tier 2 M90

Tivicay Tier 2QL (30 EA per 90 days)

Tivicay PD Tier 2QL (300 EA per 30 days)

tiZANidine HCl Oral Tier 2 M90

174

Covered Product Reference Tier Status NotesTL Icon Tricon Tier 2 M90

TL-Hem 150 Abatron AF Tier 2 M90

Tobi Podhaler Tier 2SP; QL (224 caps per 28 days)

TobraDex ST Tier 2 M90

Tobramycin Inhalation Nebulization Solution 300 MG/5ML

Kitabis Pak Tier 2SP; QL (280 per 28 days)

Tobramycin Ophthalmic Tobrex Tier 2 M90

Tobramycin Sulfate Injection Tier 2 M90

Tobramycin-Dexamethasone TobraDex Tier 2 M90

Tobrex Ophthalmic Ointment Tier 2 M90

Today Sponge $0 M90

Todays Health Mini Pen Needles CareFine Pen Needles $0 M90

Todays Health Pen Needles CareFine Pen Needles $0 M90

Todays Health Short Pen NeedleAdvocate Insulin Pen Needles

$0 M90

TOLAZamide Tier 1 M90

TOLBUTamide Tier 1 M90

Tolcapone Tasmar Tier 2 M90

Tolmetin Sodium Tier 2 M90

Tolnaftate Aerosol 1% External Aerosol Tinactin Tier 2 M90

Tolnaftate Aerosol 1% External Cream Tinactin Tier 2 M90

Tolnaftate Antifungal Tinactin Tier 2 M90

Tolnaftate External Cream Tinactin Tier 2 M90

Tolnaftate External Solution Blis-To-Sol Tier 2 M90

Tolterodine Tartrate Detrol Tier 2 M90

Tolterodine Tartrate ER Detrol LA Tier 2ST; M90; QL (30 EA per 90 days)

Tolvaptan Oral Tablet 15 MG Jynarque Tier 2 QL (QL Flag)

Tolvaptan Oral Tablet 30 MG Jynarque Tier 2 SP; QL (QL)

TopCare Clickfine Pen NeedlesAdvocate Insulin Pen Needles

$0 M90

Topiramate ER Qudexy XR Tier 2 ST

Topiramate Oral Topamax Tier 2 M90

Toposar Intravenous Solution 1 GM/50ML, 100 MG/5ML, 500 MG/25ML

$0 M90

Topotecan HCl Hycamtin $0 M90

Toprol XL Oral Tablet Extended Release 24 Hour 100 MG, 25 MG

Tier 1 M90

175

Covered Product Reference Tier Status NotesToremifene Citrate Fareston $0

Torsemide Oral Tier 1 M90

Total Allergy Alka-Seltzer Plus Allergy Tier 2 M90

Total Allergy Medicine Tier 2 M90

Toviaz Tier 2ST; M90; QL (30 EA per 90 days)

TPN Electrolytes Intravenous Solution Tier 2 M90

Tradjenta Tier 2M90; QL (30 EA per 30 days)

traMADol HCl Oral Tablet 50 MG Ultram Tier 2QL (180 EA per 30 days)

Tramadol-Acetaminophen Ultracet Tier 2QL (40 tablets per 30 days. Click;HERE)

Trandolapril Tier 1 M90

Trandolapril-Verapamil HCl ER Oral Tablet Extended Release 1-240 MG, 2-240 MG, 4-240 MG

Tier 1 M90

Trandolapril-Verapamil HCl ER Oral Tablet Extended Release 2-180 MG

Tier 1

Tranexamic Acid Intravenous Solution 1000 MG/10ML

Cyklokapron Tier 2 M90

Tranexamic Acid Oral Lysteda Tier 2M90; QL (30 EA per 90 days)

Transderm-Scop (1.5 MG) Tier 2

Tranylcypromine Sulfate Parnate Tier 2 M90

Travoprost (BAK Free) Travatan Z Tier 2 ST

traZODone HCl Oral Tier 2 M90

Treanda Intravenous Solution Reconstituted

$0 SP

Trecator Tier 2 M90

Trelstar Tier 1 SP

Trelstar Mixject $0 SP

Tremfya Subcutaneous Solution Pen-Injector

Tier 2PA; SP; QL (1 PEN per 28 days)

Tremfya Subcutaneous Solution Prefilled Syringe


Treprostinil Remodulin Tier 2 PA; SP; Dual

Tresiba Tier 1

Tresiba FlexTouch Tier 1 M90

Tretinoin External Cream Avita Tier 2 M90

Tretinoin External Gel 0.01 % Retin-A Tier 2 M90

176

Covered Product Reference Tier Status NotesTretinoin External Gel 0.025 % Avita Tier 2 M90

Tretinoin External Gel 0.05 % Atralin Tier 2 ST; M90

Tretinoin Microsphere Retin-A Micro Tier 2 ST; M90

Tretinoin Microsphere Pump Retin-A Micro Tier 2 ST; M90

Tretinoin Oral $0 M90

Tretten Tier 2 PA; SP; Dual

Trexall $0 M90

TriAdvance Inatal GT Tier 1 M90

Triamcinolone Acetonide External Aerosol Solution

Kenalog Tier 2ST; M90; QL (QL Applies)

Triamcinolone Acetonide External Cream Tier 2 M90

Triamcinolone Acetonide External Lotion Tier 2 M90

Triamcinolone Acetonide External Ointment 0.025 %, 0.1 %, 0.5 %

Tier 2 M90

Triamcinolone Acetonide Mouth/Throat Oralone Tier 2 M90

Triamcinolone Acetonide Nasal Aerosol KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)

Triamcinolone Diacetate Injection Suspension 40 MG/ML

Tier 2 M90

Triaminic Allerchews Tier 2 M90

Triamterene Oral Dyrenium Tier 2

Triamterene-HCTZ Maxzide-25 Tier 1 M90

Triazolam Tier 2 M90

TriCare Tier 1 M90

TriCitrasol Tier 2 M90

Tricitrates Tier 2 M90

Tricon Tier 2 M90

Triderm External Cream 0.1 % Tier 2 M90

Trientine HCl Syprine Tier 2 SP

Tri-Estarylla $0 M90

Trifluoperazine HCl Oral Tier 2 M90

Trifluridine Ophthalmic Tier 2 M90

Trihexyphenidyl HCl Oral Tablet Tier 2 M90

Trijardy XR Tier 2 PA

Trikafta Tier 2PA; PD; QL (84 EA per 28 days)

Tri-Legest Fe $0 M90

Tri-Linyah $0 M90

Tri-Lo-Estarylla $0 M90

177

Covered Product Reference Tier Status NotesTri-Lo-Marzia $0 M90

Tri-Lo-Sprintec $0 M90

Triluron Tier 2PA; SP; QL (QL Applies); Dual

TriLyte Tier 2 M90

Trimethobenzamide HCl Oral Tier 2 M90

Trimethoprim Oral Tier 2 M90

Trimipramine Maleate Oral Tier 2 M90

Trinatal GT Inatal GT Tier 1 M90

Trinatal Rx 1 Vinate One $0 M90

Trinate $0 M90

TriNessa (28) $0 M90

TriNessa Lo $0 M90

Trintellix Tier 2ST; M90; QL (30 EA per 90 days)

Tri-Previfem $0 M90

Triptodur MB PA

Trisenox Intravenous Solution 10 MG/10ML

Tier 1 M90

Tri-Sprintec $0 M90

Triumeq Tier 2PD; QL (30 EA per 30 days)

TriVisc Tier 2PA; SP; QL (QL Applies); Dual

Tri-Vit/Fluoride Tier 2 M90

Tri-Vit/Fluoride/Iron Tier 2 M90

Tri-Vitamin/Fluoride Tier 2 M90

Trivora (28) $0 M90

Trogarzo MB PA

Trokendi XR Tier 2 ST; M90

Tropical Liquid Nutrition BProtected Multi-Vite Tier 2 M90

Tropicamide Ophthalmic Tier 2 M90

Trospium Chloride Tier 2M90; QL (60 EA per 30 days)

Trospium Chloride ER Tier 2M90; QL (30 EA per 90 days)

Trulance Tier 2PA; QL (30 EA per 30 days)

Trulicity Subcutaneous Solution Pen-Injector 0.75 MG/0.5ML, 1.5 MG/0.5ML

Tier 2PD; QL (4 pens per 28 days)

178

Covered Product Reference Tier Status NotesTrumenba $0 M90

Truxima $0 PA; SP; Dual

Tudorza Pressair Inhalation Aerosol Powder Breath Activated 400 MCG/ACT

Tier 2 M90

Tukysa $0SP; QL (120 EA per 30 days)

Tums Freshers Tier 2 M90

Tums Smoothies Tier 2 M90

Turalio $0 PA

Tusnel Oral Capsule Tier 2 M90

T-Vites ABC Plus Senior Tier 2 M90

Twinrix Intramuscular Suspension 720-20 $0 M90

Tybost Tier 2QL (30 EA per 90 days)

Tykerb $0SP; BP; QL (180 EA per 30 days)

Tymlos Tier 2 PA

Typhim VI Intramuscular Solution 25 MCG/0.5ML

$0 M90

Tysabri Tier 2PA; SP; QL (300 mg/15 ml per 28 days); Dual

Tyvaso Tier 2PA; SP; QL (81.2 ml (28 amps) per 28 days)

Tyvaso Refill Tier 2 PA; SP; QL (QL Flag)

Tyvaso Starter Tier 2 PA; SP; QL (QL Flag)

Tyzine Nasal Solution 0.05 % Tier 2 M90

Uceris Rectal Tier 2 M90; QL (QL Flag)

Udamin SP Tier 2 M90

Udenyca Tier 2SP; Dual; QL (2 SYR per 28 days)

Ulesfia Tier 2 M90

UltiCare Micro Pen Needles 31G X 8 MM , 32G X 4 MM

$0 M90

UltiCare Mini Pen Needles 31G X 6 MM $0 M90

UltiCare Pen Needles 29G X 12.7MM $0 M90

UltiCare Short Pen Needles 31G X 8 MM $0 M90

UltiGuard SafePack Pen Needle 32G X 4 MM


Ultilet Pen Needle 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

$0 M90

179

Covered Product Reference Tier Status NotesUltomiris MB PA

Ultra Antioxidant Formula ABC Plus Senior Tier 2 M90

Ultra Freeda ABC Plus Senior Tier 2 M90

Ultra Freeda/Iron ABC Plus Senior Tier 2 M90

Ultra Multi Formula/Iron DEKAs Plus Tier 2 M90

Ultra-Thin II Mini Pen Needle $0 M90

Ultra-Thin II Pen Needle Short $0 M90

Ultra-Thin II Pen Needles $0 M90

Unicomplex-M ABC Plus Senior Tier 2 M90

Unifine Pentips 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

$0 M90

Unifine Pentips Plus 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

$0 M90

Unithroid Tier 2 M90

Unithroid Direct Tier 2 M90

UPCal D Oral Packet 500-500 MG-UNIT Tier 2 M90

UPCal D Oral Powder 500-500 MG-UNT/5GM

Tier 2 M90

Uplizna Tier 2PA; SP; Dual; QL (30 ML per 180 days)

Uptravi Oral Tier 2 PA; SP; QL (QL Flag)

Urea External Cream 39 % Uredeb Tier 2 M90

Urea External Cream 40 %, 45 %, 50 % Tier 2 M90

Urea External Cream 47 % Keralac Tier 2 M90

Urea External Gel Tier 2 M90

Urea External Suspension 40 % Tier 2 M90

Urea Nail Film Tier 2 M90

Ure-K Tier 2 M90

Uretron D/S Oral Tablet Tier 2 M90

Urin DS Oral Tablet Tier 2 M90

Uro-Mag Tier 2 M90

Ursodiol Oral Capsule 300 MG Tier 2 M90

Ursodiol Oral Tablet Urso 250 Tier 2 M90

Utibron Neohaler Tier 2QL (60 EA per 30 days)

Uvadex Tier 1 M90

Vagistat-3 Tier 2 M90

valACYclovir HCl Oral Valtrex Tier 2 M90

180

Covered Product Reference Tier Status NotesValchlor $0 M90

ValGANciclovir HCl Valcyte Tier 2 M90

Valproate Sodium Intravenous Tier 2 M90

Valproate Sodium Oral Syrup Tier 2 M90

Valproic Acid Oral Capsule Tier 2 M90

Valproic Acid Oral Solution Tier 2 M90

Valrubicin Valstar $0 SP

Valsartan Diovan Tier 1 M90

Valsartan-Hydrochlorothiazide Diovan HCT Tier 1 M90

Valtoco 10 MG Dose Tier 2PA; QL (5 BOXES per 30 days)




ValuMark Pen Needles CareFine Pen Needles $0 M90

Vancomycin HCl Intravenous Solution Reconstituted 5000 MG

Tier 2 M90

Vancomycin HCl Oral Capsule Vancocin HCl Tier 2 M90

Vanicream External Lotion Tier 2 M90

Vantas $0 SP; QL (QL Flag)

Vaqta Intramuscular Suspension 25 UNIT/0.5ML, 50 UNIT/ML

$0 M90

Varivax $0 M90

Varubi Intravenous Tier 2

Varubi Oral Tier 2 M90; QL (QL Flag)

Vascepa Oral Capsule 0.5 GM Tier 2PA; QL (120 EA per 30 days)

Vaxchora $0 M90

V-C Forte DEKAs Plus Tier 2 M90

VCF Vaginal Contraceptive $0 M90

Vectibix Intravenous Solution 100 MG/5ML, 400 MG/20ML

$0 SP

Velcade Injection $0PA; SP; QL (QL Flag); Dual

Velivet $0 M90

Venclexta $0 M90

Venclexta Starting Pack $0 M90

181


Venlafaxine HCl Tier 2M90; QL (90 EA per 30 days)

Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour

Effexor XR Tier 2M90; QL (60 EA per 30 days)

Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MG, 37.5 MG, 75 MG


Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 225 MG

Tier 2 QL (QL Applies)

Ventavis Tier 2PA; SP; QL (270 per 30 days)

Ventolin HFA Tier 2 PA

Veracolate Alophen Tier 2 M90

Verapamil HCl ER Oral Capsule Extended Release 24 Hour

Verelan Tier 1 M90

Verapamil HCl ER Oral Tablet Extended Release 120 MG, 180 MG, 240 MG

Calan SR Tier 1 M90

Verapamil HCl Oral Tier 1 M90

Veripred 20 Tier 2 M90

Verquvo Tier 2PA; QL (30 EA per 30 days)

Verzenio $0 SP; QL (QL Applies)

Vestura $0 M90

V-Go 20 Tier 2PA; PD; QL (30 EA per 30 days)



Viberzi Tier 2PA; M90; QL (60 EA per 30 days)

Vibramycin Oral Syrup Tier 2 M90

Vicks Humidifier Tier 1 M90

Vicks Warm Mist Humidifier $0M90; QL (QL Flag); QL (1 EA per 1 Year)

Vicodin ES Oral Tablet 7.5-300 MG Tier 2QL (180 EA per 30 days)

Vicodin HP Oral Tablet 10-300 MG Tier 2QL (180 EA per 30 days)

Vicodin Oral Tablet 5-300 MG Tier 2QL (240 tablets per 30 days. Click;HERE)

Victoza Subcutaneous Solution Pen-Injector

Tier 2QL (3 pens per 28 days)

182

Covered Product Reference Tier Status NotesVida Mia Unifine Pentips $0 M90

Videx Tier 2QL (1200 ml per 30 days)

Vienva $0 M90

Vigabatrin Sabril Tier 2PA; SP; QL (180 EA per 30 days)

Vigamox Tier 2 M90

Viibryd Oral Tablet Tier 2ST; M90; QL (30 EA per 90 days)

Viibryd Starter Pack Tier 2 ST; M90

Viltepso MB PA

Vimizim MB PA

Vimpat Oral Solution Tier 2M90; QL (60ml per month)

Vimpat Oral Tablet Tier 2M90; QL (60 EA per 30 days)

Vinate M $0 M90

Vinate One $0 M90

VinBLAStine Sulfate Intravenous Solution

$0 M90

Vincasar PFS $0 M90

vinCRIStine Sulfate Intravenous $0 M90

Vinorelbine Tartrate Navelbine $0 M90

Viokace Tier 2 M90

Viorele Kariva $0 M90

Viracept Oral Tablet 250 MG Tier 2 QL (300 per 30 days)

Viracept Oral Tablet 625 MG Tier 2QL (120 EA per 30 days)

Viread Oral Powder Tier 2 QL (QL Applies)

Viread Oral Tablet 150 MG, 200 MG, 250 MG


Virt Nate Trinate $0 M90

Virt-Advance Inatal GT Tier 1 M90

Virt-Phos 250 Neutral Phospha 250 Neutral Tier 2 M90

Virtrate-2 Tier 2 M90

Virtrate-3 Tier 2 M90

Virtrate-K Tier 2 M90

Virt-Vite GT Inatal GT Tier 1 M90

Visco-3 Intra-Articular Solution Prefilled Syringe


183

Covered Product Reference Tier Status NotesVisine-A Tier 2 M90

Vision Formula/Lutein ABC Plus Senior Tier 2 M90

Vision Plus DEKAs Plus Tier 2 M90

Vision Vitamins ABC Plus Senior Tier 2 M90

VisiVites ABC Plus Senior Tier 2 M90

VisiVites/Lutein ABC Plus Senior Tier 2 M90

Vit B3-AzelAc-Turm-FA-B6-Zn-CU ABC Plus Senior Tier 2 M90

Vita Hair ABC Plus Senior Tier 2 M90

Vitabasic Complete ABC Plus Senior Tier 2 M90

Vitabasic Senior ABC Plus Senior Tier 2 M90

Vitabex DEKAs Plus Tier 2 M90

VitaJoy Daily D Gummies Tier 2 M90

Vita-Min DEKAs Plus Tier 2 M90

Vitamin B-6 (pyridoxine) Tablet 100 MG Oral Oral Tablet 100 MG, 25 MG, 250 MG, 50 MG

Tier 2 M90


Tier 2 M90

Vitamin B6 (pyridoxine) TABLET 250 MG ORAL Oral Tablet 200 MG, 250 MG

Tier 2 M90


Tier 2 M90

Vitamin D (Cholecalciferol) Oral Capsule 25 MCG (1000 UT)


Vitamin D (Cholecalciferol) Oral Tablet 25 MCG (1000 UT)


Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Tablet 1000 UNIT


Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Tablet 50 MCG (2000 UT)



Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

184

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 125 MCG (5000 UT)


Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 25 MCG (1000 UT)



Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 1.25 MG (50000 UT)

Dialyvite Vitamin D3 Max

Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 125 MCG (5000 UT)

Radiance Platinum Vitamin D3

Tier 2 M90





Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 125 MCG (5000 UT)




185

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 250 MCG (10000 UT)

Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90


Tier 2 M90

186

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90






Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

187

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90









Tier 2 M90


Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90

Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 25 MCG (1000 UT)


188

Covered Product Reference Tier Status NotesVitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 50 MCG (2000 UT)


Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet Chewable 125 MCG (5000 UT)


189

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet Chewable 25 MCG (1000 UT)


Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90






Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90



Tier 2 M90









Tier 2 M90


Tier 2 M90

190

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 125 MCG (5000 UT)


191

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 25 MCG (1000 UT)



Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90

192

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 50 MCG (2000 UT)

Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90





Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90






Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

193

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90



Tier 2 M90









Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)

D3-50 Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 125 MCG (5000 UT)





Decara Tier 2 M90


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML

Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)


Tier 2 M90

Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 125 MCG (5000 UT)


Tier 2 M90

194

Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 25 MCG (1000 UT)


Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 50 MCG (2000 UT)


Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)




Tier 2 M90


Tier 2 M90

Vitamin D3 Adult GummiesVitaJoy Daily D Gummies

Tier 2 M90

Vitamin D3 Complete ABC Plus Senior Tier 2 M90

Vitamin D3 Maximum Strength Dialyvite Vitamin D 5000 Tier 2 M90

Vitamin D-3 Oral Capsule Pronutrients Vitamin D3 Tier 2 M90

Vitamins A-D-E/Selenium ABC Plus Senior Tier 2 M90

Vitamins/Minerals ABC Plus Senior Tier 2 M90

VitaTRUM Oral Tablet ABC Plus Senior Tier 2 M90

Vitekta Tier 2QL (30 EA per 90 days)

Vitrakvi Oral Capsule $0 PA; SP

Vitrakvi Oral Solution $0 PA

VITRUM 50+ Senior Multi ABC Plus Senior Tier 2 M90

Vivitrol Tier 2QL (1 VIAL per 28 days)

Vivotif $0 M90

Vizimpro $0PA; SP; QL (30 EA per 30 days)

Vol-Nate Trinate $0 M90

Vol-Plus Niva-Plus Tier 1 M90

Vol-Tab Rx Prenatabs Rx $0 M90

Vonvendi Tier 2 PA; SP; Dual

Voriconazole Oral Vfend Tier 2 M90

Vosevi Tier 2PA; SP; QL (28 EA per 28 days)

Votrient $0PA; SP; QL (120 EA per 30 days)

195

Covered Product Reference Tier Status NotesVpriv MB PA

VP-ZEL ABC Plus Senior Tier 2 M90

Vraylar Oral Capsule 1.5 MG Tier 2M90; QL (60 EA per 30 days)

Vraylar Oral Capsule 3 MG, 4.5 MG, 6 MG


Vumerity Tier 2PA; SP; QL (120 EA per 30 days)

Vumerity (Starter) Tier 2PA; SP; QL (120 EA per 30 days)

Vyepti MB PA

Vyfemla $0 M90

Vyndamax Tier 2PA; SP; QL (30 EA per 30 days)

Vyndaqel Tier 2PA; SP; QL (120 EA per 30 days)

Vyondys 53 MB PA

Vyvanse Tier 2PD; QL (60 EA per 30 days)


Wal-Dryl Allergy Tier 2 M90

Wal-Dryl Allergy Childrens Tier 2 M90

Wal-Fex Allergy Tier 2 M90; QL (QL Flag)

Wal-Fex Childrens Tier 2M90; QL (300ml per month)

Wal-Fex D Allergy & Congestion Oral Tablet Extended Release 12 Hour


Wal-Fex D Allergy & Congestion Oral Tablet Extended Release 24 Hour


Wal-finate Tier 2 M90

Wal-itin Allergy Reditabs Tier 2 M90

Wal-itin Aller-Melts Tier 2 M90

Wal-itin Childrens Tier 2M90; QL (300ml per month)

Wal-itin Oral Syrup Tier 2M90; QL (300ml per month)

Wal-itin Oral Tablet Tier 2 M90; QL (QL Flag)

Wal-itin Oral Tablet Dispersible Tier 2 M90

Wal-phed Tier 2 M90

Wal-Profen Oral Tablet Tier 2 M90

Wal-Tap Childrens Tier 2 M90; QL (QL Flag)

196

Covered Product Reference Tier Status NotesWal-Tussin Pediatric Cgh/Cold Tier 2 M90

Wal-vert Tier 2 M90

Wal-Zan 150 Maximum Strength Tier 2 M90

Wal-Zan 75 Tier 2 M90

Wal-Zyr All Day Allergy Child Tier 2 M90; QL (QL Flag)

Wal-Zyr Childrens Oral Solution Tier 2 M90; QL (QL Flag)

Wal-Zyr Childrens Oral Tablet Chewable 10 MG


Wal-Zyr Childrens Oral Tablet Chewable 5 MG


Wal-Zyr Ophthalmic Tier 2 M90; QL (QL Flag)

Wal-Zyr Oral Tablet Tier 2 M90; QL (QL Flag)

Warfarin Sodium Oral Jantoven Tier 2 M90

Wee Care Icar Tier 1 M90

Wegmans Unifine Pentips PlusAdvocate Insulin Pen Needles

$0 M90

Wera $0 M90

Westhroid Oral Tablet 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

Tier 2 M90

Whole Food Multivitamin ABC Plus Senior Tier 2 M90

Wibi Tier 2 M90

Wide-Seal Diaphragm 60 Tier 2 M90








Wilate Intravenous Kit Tier 2 PA; SP; Dual

Wixela Inhub Tier 2

Womans Laxative Oral Tablet Delayed Release

Alophen Tier 2 M90

Womens 50+ Advanced DEKAs Plus Tier 2 M90

Womens 50+ Multi Vitamin/Min ABC Plus Senior Tier 2 M90

Womens Biomultiple ABC Plus Senior Tier 2 M90

Womens Daily Form/FA/Ca/Fe ABC Plus Senior Tier 2 M90

Womens Daily Formula ABC Plus Senior Tier 2 M90

Womens Laxative Alophen Tier 2 M90

197

Covered Product Reference Tier Status NotesWomens Multi DEKAs Plus Tier 2 M90

Womens Multi Vitamin & Mineral ABC Plus Senior Tier 2 M90

Womens One Daily ABC Plus Senior Tier 2 M90

WP Thyroid Tier 2 M90

Wymzya Fe $0 M90

Xadago Tier 2 PA

Xalkori $0SP; QL (60 EA per 30 days)

Xarelto Oral Tablet 10 MG, 15 MG, 20 MG

Tier 2

Xarelto Oral Tablet 2.5 MG Tier 2 PA

Xarelto Starter Pack Tier 2QL (51 EA per 28 days)

Xatmep $0PA; QL (60 ML per 30 days)

Xcopri Tier 2

Xcopri (250 MG Daily Dose) Tier 2

Xcopri (350 MG Daily Dose) Tier 2

Xelitral Tier 2 M90

Xeljanz Oral Solution Tier 2PA; SP; QL (300 ML per 30 days)

Xeljanz Oral Tablet Tier 2PA; SP; PD; QL (60 EA per 30 days)

Xeljanz XR Tier 2PA; SP; PD; QL (30 EA per 30 days)

Xembify Tier 2 PA; SP; Dual

Xenleta Oral Tier 2PA; SP; QL (10 EA per 5 days)

Xeomin Tier 2PA; SP; QL (QL Flag); Dual

Xermelo Tier 2 PA

Xgeva Tier 2PA; SP; QL (QL Flag); Dual

Xiaflex Tier 2 PA; SP; QL (QL Flag)

Xifaxan Oral Tablet 200 MG Tier 2M90; QL (9 tablets per 3 days)

Xifaxan Oral Tablet 550 MG Tier 2 PA; M90

Xigduo XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 10-500 MG, 5-500 MG


Xigduo XR Oral Tablet Extended Release 24 Hour 2.5-1000 MG


198

Covered Product Reference Tier Status NotesXigduo XR Oral Tablet Extended Release 24 Hour 5-1000 MG


Xiidra Tier 2 PA; M90

Xofigo Intravenous Solution 30 MCCI/ML

$0 M90

Xofluza (40 MG Dose) Oral Tablet Therapy Pack 2 x 20 MG

Tier 2

Xofluza (80 MG Dose) Oral Tablet Therapy Pack 2 x 40 MG

Tier 2

Xolair Subcutaneous Solution Prefilled Syringe 150 MG/ML


Xolair Subcutaneous Solution Prefilled Syringe 75 MG/0.5ML


Xolair Subcutaneous Solution Reconstituted


Xolegel Tier 2 ST; M90

Xopenex HFA Tier 2 BP

Xospata $0PA; SP; QL (90 EA per 30 days)

Xpovio (100 MG Once Weekly) Oral Tablet Therapy Pack 20 MG

$0 SP


$0 SP


$0 SP

Xpovio (80 MG Twice Weekly) $0 SP

Xtandi Oral Capsule $0SP; QL (120 EA per 30 days)

Xtandi Oral Tablet 40 MG Tier 2SP; QL (120 EA per 30 days)

Xtandi Oral Tablet 80 MG Tier 2SP; QL (60 EA per 30 days)

Xulane $0 M90

Xultophy Tier 2 PA

Xylocaine Dental Injection Solution 2 %-1:100000

Tier 2 M90

Xylon Tier 2M90; QL (50 tablets per 30 days. Click;HERE)

Xyntha Intravenous Kit 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

Tier 2 PA; SP; PD; Dual

Xyntha Solofuse Tier 2 PA; SP; PD; Dual

Xyrem Tier 2 PA; SP

199


Xywav Tier 2PA; QL (540 ML per 30 days)

Yervoy MB PA

YF-VAX $0 M90

YL Vitamin B-6 Tier 2 M90

Yondelis $0 SP

Yupelri Tier 2 PA

Yuvafem Tier 2 M90

Zaclir Cleansing External Lotion 8 % Tier 2 M90

Zafirlukast Accolate Tier 2ST; M90; QL (60 EA per 30 days)

Zaleplon Tier 2QL (30 EA per 90 days)

Zaltrap $0 SP

Zanosar $0 M90

Zantac Injection Solution 150 MG/6ML Tier 2 M90; QL (QL Flag)

Zantac Injection Solution 50 MG/2ML Tier 2 M90

Zarah $0 M90

Zarxio Tier 2 PA; SP; Dual

Zebutal Oral Capsule 50-325-40 MG Tier 2 M90

Zejula Tier 2 PA; SP

Zelapar Tier 2ST; M90; QL (60 EA per 30 days)

Zelboraf $0SP; QL (240 per 30 days)

Zemaira Tier 2 PA; SP; Dual

Zenatane Tier 2 M90

Zenchent $0 M90

Zenchent FE Tier 2 M90

Zenpep Oral Capsule Delayed Release Particles 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT

Tier 2 PA; M90

Zenpep Oral Capsule Delayed Release Particles 10000-32000 UNIT, 25000-79000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

Tier 2

Zenzedi Oral Tablet 10 MG, 5 MG Tier 2 M90; QL (QL Flag)

Zenzedi Oral Tablet 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG


200


Zepatier Tier 2PA; SP; QL (28 EA per 28 days)

Zeposia Tier 2PA; SP; QL (30 EA per 30 days)

Zeposia 7-Day Starter Pack Tier 2PA; SP; QL (7 EA per 7 days)

Zeposia Starter Kit Tier 2PA; SP; QL (30 EA per 30 days)

Zerviate Tier 2ST; QL (30 EA per 5 days)

Zevalin Y-90 $0 M90

Ziagen Oral Solution Tier 2 QL (900 per 30 days)

Zidovudine Retrovir Tier 2 SP; M90

Ziextenzo Tier 2SP; Dual; QL (2 SYR per 28 days)

Zileuton ER Tier 2

Zinc Aspartate Tier 2 M90

Zinc Chelated Tier 2 M90

Zinc Methionate Tier 2 M90

Zinc Oral Capsule 30 MG Tier 2 M90

Zinc Oral Tablet 100 MG, 25 MG Tier 2 M90

Zinc Oral Tablet 50 MG IS-ZC 50 Tier 2 M90

Zinc Oxide External Ointment 20 % Tier 2 M90

Zinc Oxide External Ointment 40 % Boudreauxs Butt Paste Tier 2 M90

Zinc Picolinate Oral Tablet 25 MG Tier 2 M90

Zinc Sulfate Oral Capsule 220 (50 Zn) MG

Orazinc Tier 2 M90

Zinc Sulfate Oral Tablet 220 (50 Zn) MG Tier 2 M90

Zinc-220 Orazinc Tier 2 M90

Zinplava Tier 2 SP

Zioptan Tier 2 ST

Ziprasidone HCl Oral Capsule 20 MG Geodon Tier 2M90; QL (90 EA per 30 days)

Ziprasidone HCl Oral Capsule 40 MG, 60 MG, 80 MG

Geodon Tier 2M90; QL (60 EA per 30 days)

Ziprasidone Mesylate Geodon Tier 2

Zirabev $0 PA; SP; Dual

Zirgan Tier 2 M90

Zithranol Tier 2 M90

Zithranol-RR Tier 2 M90

201

Covered Product Reference Tier Status NotesZodex 12-Day Tier 2

Zokinvy Tier 2PA; SP; QL (120 EA per 30 days)

Zoladex $0 PA; SP; Dual

Zoledronic Acid Intravenous Concentrate Tier 2 PA; SP; Dual

Zoledronic Acid Intravenous Solution Reclast Tier 2 PA; SP; Dual

Zolgensma 10.1-10.5 kg MB PA; PD






















Zolinza $0PA; SP; QL (120 EA per 30 days)

ZOLMitriptan Nasal Zomig Tier 2QL (12 EA per 30 days)

ZOLMitriptan Oral Zomig Tier 2M90; QL (12 tablets per month)

Zolpidem Tartrate ER Ambien CR Tier 2ST; QL (30 EA per 30 days)

Zolpidem Tartrate Oral Ambien Tier 2QL (30 EA per 90 days)

Zomacton Tier 2 PA; SP

Zonisamide Oral Zonegran Tier 2 M90

202


Zoo Friends Plus IronLand Before Time Multivitamin

Tier 2 M90

Zorbtive Tier 2 PA; SP; QL (QL Flag)

Zortress Tier 2

Zostavax Subcutaneous Solution Reconstituted

Tier 1 M90

Zostrix HP External Cream 0.075 % Tier 2 M90

Zovia 1/35E (28) $0 M90

Zovia 1/50E (28) Tier 2 M90

Zubsolv Tier 2PA; M90; QL (60 EA per 30 days)

Zulresso MB PA

Zyclara Pump External Cream 2.5 % Tier 2ST; M90; QL (1 pump (7.5mg) per 28 days)

Zydelig $0QL (60 EA per 30 days)

Zyflo Tier 2ST; M90; QL (120 EA per 30 days)

Zyflo CR Tier 2ST; M90; QL (QL Flag)

Zykadia $0SP; QL (90 EA per 30 days)

Zylet Tier 2 M90

ZyPREXA Relprevv Tier 2M90; QL (2 VIALS per 28 days)

203

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Documents

2021 MassHealth Pharmacy Formulary