HMSA Akamai Advantage 2018 Formulary · Akamai Advantage Dual Care limits the amount of the drug that HMSA Akamai Advantage Dual Care will cover. For example, HMSA Akamai Advantage

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

Dual Care (PPO SNP)

List of Covered DrugsFormulary ID 00019310, version 17

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact HMSA at 948-6000 on Oahu or 1 (800) 660-4672 toll-free. TTY users, call 711. Telephone hours are 8 a.m. to 8 p.m., seven days a week or visit http://www.hmsa.com/advantage.

H3832_5042_8700_15999_12_C

2019Formulary

HMSA Akamai Advantage

http://www.hmsa.com/advantage

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means HMSA. When it refers to “plan” or “our plan,” it means HMSA Akamai Advantage Dual Care.

This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

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

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce cov-erage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available or when new adverse informa-tion about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for

those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the cover-age year to the formulary drugs that were avail-able when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member re-quests a refill of the drug, at which time the mem-ber will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufac-turer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of Decem-ber 1, 2019. To get updated information about the drugs covered by HMSA Akamai Advantage Dual Care, please contact us. Our contact information appears on the front and back cover pages. We will inform members of any formulary changes to this comprehensive formulary through our website.

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

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

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 35. The Index provides an al-phabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will

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see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?HMSA Akamai Advantage Dual Care covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. General-ly, generic drugs cost less than brand name drugs.

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

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

• Quantity Limits: For certain drugs, HMSA Akamai Advantage Dual Care limits the amount of the drug that HMSA Akamai Advantage Dual Care will cover. For example, HMSA Akamai Advantage Dual Care provides 30 tablets per pre-scription for simvastatin. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions.

You may also ask us to send you a copy. Our con-tact information, along with the date we last up-dated the formulary, appears on the front and back cover pages.

You can ask HMSA Akamai Advantage Dual Care to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition. See the section, “How do I request an exception to the HMSA Akamai Advan-tage Dual Care formulary?” on this page for infor-mation about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact our Cus-tomer Relations and ask if your drug is covered. If you learn that HMSA Akamai Advantage Dual Care does not cover your drug, you have two options:

• You can ask Customer Relations for a list of similar drugs that are covered by HMSA Akamai Advantage Dual Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HMSA Akamai Advantage Dual Care.

• You can ask HMSA Akamai Advantage Dual Care to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the HMSA Akamai Advantage Dual Care Formulary?You can ask HMSA Akamai Advantage Dual Care to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

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Generally, HMSA Akamai Advantage Dual Care will only approve your request for an exception if the alternative drugs included on the plan’s for-mulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial cov-erage decision for a formulary or utilization restric-tion exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours af-ter we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formu-lary but your ability to get it is limited. For exam-ple, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to deter-mine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescrip-

tion until we have provided you with a 31-day transition supply consistent with the dispensing increment (unless you have a prescription writ-ten for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Transition policyNew members in our Plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization. Current members may also be affected by chang-es in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the section above, “How do I request an exception to HMSA’s Akamai Advantage Dual Care formulary?” to learn more about how to request an exception. Please con-tact Customer Relations if your drug is not on our formulary, is subject to certain restrictions such as prior authorization, and you need to switch to a different drug that we cover or request a formulary exception. During the period of time members are talking to their doctors to determine a course of action, we may provide a temporary supply of a non-formulary drug if those members need a refill for the drug during the first 90 days of new mem-bership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transi-tion policy again. We will provide you with a writ-ten notice after we cover your temporary supply.

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This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appro-priate drug that we cover.

If a new member is a resident of a long-term care facility (like a nursing home), we will also cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility, or is in an LTC facility and requires an emergency sup-ply of non-formulary drugs, we will cover a tempo-rary 31-day transition supply (unless the prescrip-tion is written for fewer days). We will cover more than one refill of these drugs for these members for the first 90 days. A member may experience a change in their level of care at an inpatient hospital facility or skilled nursing facility which results in non-coverage of drugs previously covered by Medi-care Part D. For current members experiencing a level of care change, we will also cover a tempo-rary 31-day transition supply as outlined above.

Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.

For more informationFor more detailed information about your HMSA Akamai Advantage Dual Care prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about HMSA Akamai Ad-vantage Dual Care, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare pre-scription drug coverage, please call Medicare at 1 (800) MEDICARE [1 (800) 633-4227] 24 hours a day/seven days a week. TTY users should call 1 (877) 486-2048. Or visit http://www.medicare.gov.

HMSA Akamai Advantage Dual Care FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Akamai Advantage Dual Care. If you have trouble finding your drug in the list, turn to the Index that begins on page 35.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., FORTEO) and generic drugs are listed in lower-case italics (e.g., ibuprofen).

The information in the requirements/limits column tells you if HMSA Akamai Advantage Dual Care has any special requirements for coverage of your drug.

Drug tier index:

Tier 1 - Generic and Brand

Please refer to the Summary of Benefits or Evi-dence of Coverage for the specific copayment or coinsurance amount associated with each tier.

Abbreviations used in this FormularyPA – Prior Authorization: Requires that you or your physician receive approval from HMSA Akamai Advantage Dual Care before we will cover your prescription.

QL – Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage Dual Care will cover.

ST – Step Therapy: Requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

M – Mail Order: These drugs are available through HMSA’s mail order pharmacy, CVS Caremark.

B/D – B or D: This drug may be covered under Medicare Part B or D depending upon the circum-stances. Information may need to be submitted describing the use and setting of the drug to make the determination. For more information, please call Customer Relations.

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http://www.medicare.gov

LA – Limited Availability: This prescription may be available only at certain pharmacies. For more information, please call Customer Relations.

Prescription drugs can be shipped to your home from the HMSA Akamai Advantage Dual Care Mail Order pharmacy. Usually a mail-order pharmacy order will get to you in no more than 14 days after the pharmacy receives the order. If your drugs do not arrive within this timeframe, please call 1 (855) 479-3659 toll-free, 24 hours a day, seven days a week; TTY users, call 711. You can also choose to sign up for our optional automatic delivery program by calling these numbers.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - Available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1 M

colchicine w/ probenecid 1 M

COLCRYS QL (120 tabs / 30 days)

1 QL M

febuxostat 1 M ST

MITIGARE QL (60 caps / 30 days)

1 QL M

probenecid 1 M

ULORIC 1 M ST

NSAIDS celecoxib CAPS 50mg

QL (240 caps / 30 days) 1 QL M

celecoxib CAPS 100mg QL (120 caps / 30 days)

1 QL M


1 QL M


1 QL M

diclofenac potassium QL (120 tabs / 30 days)

1 QL M

diclofenac sodium TB24; TBEC

1 M

diflunisal TABS 1 M

etodolac 1 M

flurbiprofen TABS 1 M

ibu tab 600mg 1 M

ibu tab 800mg 1 M

ibuprofen SUSP 1 M

ibuprofen TABS 400mg, 600mg, 800mg

1 M

meloxicam TABS 1 M

nabumetone TABS 1 M

naproxen TABS 1 M

naproxen dr 1 M

naproxen sodium TABS 275mg, 550mg

1 M

piroxicam CAPS 1 M

sulindac TABS 1 M

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

1 QL M

acetaminophen w/ codeine 300-30mg


1 QL M

Drug Name Drug Tier

Requirements/Limits

acetaminophen w/ codeine 300-60mg


1 QL M

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

1 QL M

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

1 M

nalbuphine hcl SOLN 1 M

tramadol hcl tab 50 mg QL (240 tabs / 30 days)

1 QL M

tramadol-acetaminophen QL (240 tabs / 30 days)

1 QL M

OPIOID ANALGESICS, CII endocet 2.5-325mg

QL (360 tabs / 30 days) 1 QL M

endocet 5-325mg QL (360 tabs / 30 days)

1 QL M

endocet 7.5-325mg QL (240 tabs / 30 days)

1 QL M

endocet 10-325mg QL (180 tabs / 30 days)

1 QL M

fentanyl citrate LPOP QL (120 lozenges / 30 days)

1 QL M PA

fentanyl citrate TABS QL (120 tabs / 30 days)

1 QL M PA

fentanyl patch 12 mcg/hr QL (10 patches / 30 days)

1 QL M PA


1 QL M PA


1 QL M PA


1 QL M PA


1 QL M PA

FENTORA QL (120 tabs / 30 days)

1 QL M PA

hydroco/apap tab 5-325mg QL (240 tabs / 30 days)

1 QL M

hydroco/apap tab 7.5-325 QL (180 tabs / 30 days)

1 QL M

hydroco/apap tab 10-325mg QL (180 tabs / 30 days)

1 QL M


2

Drug Name Drug Tier

Requirements/Limits

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

1 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


1 QL M

hydromorphone hcl LIQD QL (600 mL / 30 days)

1 QL M

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

1 B/D M

hydromorphone hcl TABS QL (180 tabs / 30 days)

1 QL M

HYSINGLA ER QL (30 tabs / 30 days)

1 QL M PA

lorcet hd tab 10-325mg QL (180 tabs / 30 days)

1 QL M

lorcet plus tab 7.5-325 QL (180 tabs / 30 days)

1 QL M

lorcet tab 5-325mg QL (240 tabs / 30 days)

1 QL M

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

1 QL M PA

methadone hcl 5mg QL (90 tabs / 30 days)

1 QL M PA

methadone hcl 10mg QL (90 tabs / 30 days)

1 QL M PA

methadone hcl intensol QL (90 mL / 30 days)

1 QL M PA

morphine ext-rel tab 15mg, 30mg, 60mg, 100mg


1 QL M PA

morphine ext-rel tab 200mg QL (60 tabs / 30 days)

1 QL M PA

morphine sul inj 1mg/ml 1 B/D M

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

1 B/D M

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

1 B/D M

morphine sulfate TABS 15mg


1 QL M

morphine sulfate TABS 30mg


1 QL M

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits


QL (750 mL / 30 days)

1 QL M


QL (180 mL / 30 days)

1 QL M

NUCYNTA ER 50mg, 100mg, 200mg, 250mg


1 QL M PA

NUCYNTA ER 150mg QL (90 tabs / 30 days)

1 QL M PA

oxycodone hcl CAPS QL (180 caps / 30 days)

1 QL M

oxycodone hcl CONC QL (180 mL / 30 days)

1 QL M

oxycodone hcl SOLN QL (900 mL / 30 days)

1 QL M

oxycodone hcl TABS QL (180 tabs / 30 days)

1 QL M

oxycodone w/ acetaminophen 2.5-325mg


1 QL M

oxycodone w/ acetaminophen 5-325mg


1 QL M

oxycodone w/ acetaminophen 7.5-325mg


1 QL M

oxycodone w/ acetaminophen 10-325mg


1 QL M

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 B/D M

lidocaine inj 0.5% 1 B/D M

lidocaine inj 1% 1 B/D M

lidocaine inj 1.5% preservative free (pf)

1 B/D M

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1 M

gentamicin in saline 1 M

gentamicin sulfate SOLN 1 M

neomycin sulfate TABS 1 M

paromomycin sulfate CAPS 1 M

streptomycin sulfate SOLR 1 M

SULFADIAZINE TABS 1 M

tobramycin NEBU 1 PA

tobramycin inj 1.2 gm/30ml 1 M

tobramycin inj 1.2gm 1 M


3

Drug Name Drug Tier

Requirements/Limits

tobramycin inj 10mg/ml 1 M

tobramycin inj 40mg/ml 1 M

tobramycin inj 80mg/2ml 1 M

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 1 M

ALINIA 1 M

atovaquone SUSP 1 M

AZACTAM INJ 1 M

aztreonam 1 M

CAYSTON 1 LA PA

clindamycin cap 75mg 1 M

clindamycin cap 300 mg 1 M

clindamycin hcl cap 150 mg 1 M

clindamycin phosphate in d5w 1 M

CLINDAMYCIN PHOSPHATE IN NACL

1 M

clindamycin phosphate inj 1 M

clindamycin soln 75mg/5ml 1 M

colistimethate sodium SOLR 1 M

dapsone TABS 1 M

DAPTOMYCIN 350mg 1 M

daptomycin 350mg, 500mg 1 M

EMVERM 1 M

ertapenem sodium 1 M

imipenem-cilastatin 1 M

ivermectin TABS 1 M

linezolid in sodium chloride 1 M

linezolid inj 1 M

linezolid susp 1 M

linezolid tab 600mg 1 M

meropenem 1 M

methenamine hippurate 1 M

metronidazole TABS 1 M

metronidazole in nacl 1 M

NEBUPENT 1 B/D M

nitrofurantoin macrocrystal 50mg, 100mg

PA applies if 70 years and older after a 90 day supply in a calendar year

1 M PA

nitrofurantoin monohyd macro PA applies if 70 years and older after a 90 day supply in a calendar year

1 M PA

PENTAM 300 1 M

pentamidine isethionate 1 M

praziquantel TABS 1 M

SIVEXTRO 1 M

Drug Name Drug Tier

Requirements/Limits

sulfamethoxazole-trimethop ds

1 M

sulfamethoxazole-trimethoprim inj

1 M

sulfamethoxazole-trimethoprim susp

1 M

sulfamethoxazole-trimethoprim tab 400-80mg

1 M

SYNERCID 1 M

tigecycline 1 M

trimethoprim TABS 1 M

vancomycin hcl CAPS 1 M

vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

1 M

VANCOMYCIN IN NACL 1 M

ANTIFUNGALS ABELCET 1 B/D M

AMBISOME 1 B/D M

amphotericin b SOLR 1 B/D M

caspofungin acetate 1 M

fluconazole SUSR; TABS 1 M

fluconazole inj nacl 200 1 M

fluconazole inj nacl 400 1 M

flucytosine CAPS 1 M

griseofulvin microsize 1 M

griseofulvin ultramicrosize 1 M

itraconazole CAPS 1 M PA

ketoconazole TABS 1 M PA

MYCAMINE 1 M

NOXAFIL SUSP QL (630 mL / 30 days)

1 QL M

NOXAFIL TBEC QL (93 tabs / 30 days)

1 QL M

nystatin TABS 1 M

posaconazole QL (93 tabs / 30 days)

1 QL M

terbinafine hcl TABS QL (90 tabs / year)

1 QL M

voriconazole SOLR; SUSR; TABS

1 M

ANTIMALARIALS atovaquone-proguanil hcl 1 M

chloroquine phosphate TABS

1 M

COARTEM 1 M

mefloquine hcl 1 M

primaquine phosphate 26.3mg

1 M


4

Drug Name Drug Tier

Requirements/Limits

PRIMAQUINE PHOSPHATE 26.3mg

1 M

quinine sulfate CAPS 1 M PA

ANTIRETROVIRAL AGENTS abacavir sulfate 1 M

APTIVUS 1 M

atazanavir sulfate 1 M

CRIXIVAN 1 M

didanosine 1 M

EDURANT 1 M

efavirenz 1 M

EMTRIVA 1 M

fosamprenavir tab 700 mg 1 M

FUZEON 1

INTELENCE 1 M

INVIRASE 1 M

ISENTRESS 1 M

ISENTRESS HD 1 M

lamivudine 1 M

LEXIVA SUSP 1 M

nevirapine susp 50 mg/5ml 1 M

nevirapine tab 100mg er 1 M

nevirapine tab 200mg 1 M

nevirapine tab 400mg er 1 M

NORVIR PACK 1 M

NORVIR SOLN 1 M

PIFELTRO 1 M

PREZISTA SUSP QL (400 mL / 30 days)

1 QL M

PREZISTA TABS 75mg QL (480 tabs / 30 days)

1 QL M


1 QL M


1 QL M


1 QL M

RESCRIPTOR 1 M

REYATAZ PACK 1 M

ritonavir 1 M

SELZENTRY 1 M

stavudine 1 M

tenofovir disoproxil fumarate 1 M

TIVICAY 1 M

TROGARZO 1 LA

TYBOST 1 M

VIDEX EC 125mg 1 M

VIDEX PEDIATRIC 1 M

VIRACEPT 1 M

Drug Name Drug Tier

Requirements/Limits

VIRAMUNE SUSP 1 M

VIREAD POWD 1 M

VIREAD TABS 150mg, 200mg, 250mg

1 M

zidovudine cap 100mg 1 M

zidovudine syp 50mg/5ml 1 M

zidovudine tab 300mg 1 M

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine 1 M

abacavir sulfate-lamivudine-zidovudine

1 M

ATRIPLA 1 M

BIKTARVY 1 M

CIMDUO 1 M

COMPLERA 1 M

DELSTRIGO 1 M

DESCOVY 1 M

DOVATO 1 M

EVOTAZ 1 M

GENVOYA 1 M

JULUCA 1 M

KALETRA TAB 100-25MG 1 M

KALETRA TAB 200-50MG 1 M

lamivudine-zidovudine 1 M

lopinavir-ritonavir 1 M

ODEFSEY 1 M

PREZCOBIX 1 M

STRIBILD 1 M

SYMFI 1 M

SYMFI LO 1 M

SYMTUZA 1 M

TEMIXYS 1 M

TRIUMEQ 1 M

TRUVADA TAB 100-150 QL (60 tabs / 30 days)

1 QL M


1 QL M


1 QL M


1 QL M

ANTITUBERCULAR AGENTS cycloserine CAPS 1 M

ethambutol hcl TABS 1 M

isoniazid TABS 1 M

isoniazid syp 50mg/5ml 1 M

PASER D/R 1 M

PRIFTIN 1 M


5

Drug Name Drug Tier

Requirements/Limits

pyrazinamide TABS 1 M

rifabutin 1 M

rifampin CAPS; SOLR 1 M

RIFATER 1 M

SIRTURO 1 M LA PA

TRECATOR 1 M

ANTIVIRALS acyclovir CAPS; SUSP; TABS

1 M

acyclovir sodium 1 B/D M

adefovir dipivoxil 1 M

BARACLUDE SOLN 1 M

entecavir 1 M

EPCLUSA 1 PA

EPIVIR HBV SOLN 1 M

famciclovir 1 M

ganciclovir sodium 1 B/D M

HARVONI TAB 90-400MG 1 PA

lamivudine (hbv) 1 M

MAVYRET 1 PA

oseltamivir phosphate CAPS 30mg

QL (168 caps / year)

1 QL M

oseltamivir phosphate CAPS 45mg, 75mg

QL (84 caps / year)

1 QL M

oseltamivir phosphate SUSR QL (1080 mL / year)

1 QL M

PEGASYS 1 PA

PEGASYS PROCLICK 1 PA

RELENZA DISKHALER QL (6 inhalers / year)

1 QL M

ribavirin cap 200mg 1

ribavirin tab 200mg 1

rimantadine hydrochloride 1 M

valacyclovir hcl TABS 1 M

valganciclovir hcl 1 M

VEMLIDY 1 M

VOSEVI 1 PA

ZEPATIER 1 PA

CEPHALOSPORINS cefaclor 1 M

CEFACLOR ER TAB 500MG 1 M

cefadroxil 1 M

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

1 M

cefazolin inj 1 M

cefazolin sodium SOLR 1gm 1 M

Drug Name Drug Tier

Requirements/Limits

CEFAZOLIN SODIUM 1 GM/50ML

1 M

cefdinir 1 M

cefepime for inj 1 M

cefixime cap 400mg 1 M

cefixime susr 1 M

cefotaxime sodium 1gm, 500mg

1 M

cefoxitin for inj 1 M

cefpodoxime proxetil 1 M

cefprozil 1 M

ceftazidime SOLR 1 M

CEFTAZIDIME/DEXTROSE 1 M

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1 M

cefuroxime axetil 1 M

cefuroxime sodium 1 M

cephalexin CAPS 250mg, 500mg

1 M

cephalexin SUSR 1 M

SUPRAX CHEW 1 M

SUPRAX SUSR 500mg/5ml 1 M

tazicef SOLR 1 M

TEFLARO 1 M

ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR; TABS

1 M

clarithromycin TABS 1 M

clarithromycin er 1 M

clarithromycin for susp 1 M

DIFICID 1 M

e.e.s. 400 1 M

ery-tab 1 M

ERYTHROCIN LACTOBIONATE

1 M

erythrocin stearate 1 M

erythromycin base 1 M

erythromycin cap 250mg ec 1 M

erythromycin ethylsuccinate TABS

1 M

erythromycin tab ec 1 M

FLUOROQUINOLONES ciprofloxacin SUSR 1 M

ciprofloxacin hcl tab 1 M

ciprofloxacin in d5w 1 M

levofloxacin TABS 1 M

levofloxacin in d5w 1 M

levofloxacin inj 25mg/ml 1 M


6

Drug Name Drug Tier

Requirements/Limits

levofloxacin oral soln 25 mg/ml

1 M

moxifloxacin hcl TABS 1 M

PENICILLINS amoxicillin 1 M

amoxicillin & pot clavulanate 1 M

ampicillin & sulbactam sodium 1 M

ampicillin cap 500mg 1 M

ampicillin inj 1 M

ampicillin sodium 1 M

BICILLIN L-A 1 M

dicloxacillin sodium 1 M

nafcillin sodium for inj 1 M

NAFCILLIN SODIUM FOR INJ 10GM

1 M

oxacillin sodium 1 M

PENICILLIN G POT IN DEXTROSE 2MU

1 M

PENICILLIN G POT IN DEXTROSE 3MU

1 M

PENICILLIN G PROCAINE 1 M

penicillin g sodium 1 M

penicillin v potassium 1 M

penicilln gk inj 5mu 1 M

penicilln gk inj 20mu 1 M

pfizerpen-g inj 5mu 1 M

pfizerpen-g inj 20mu 1 M

piper/tazoba inj 2-0.25gm 1 M





TETRACYCLINES doxy 100 1 M

doxycycline (monohydrate) CAPS 50mg, 100mg

1 M

doxycycline (monohydrate) TABS

1 M

doxycycline hyclate CAPS; SOLR

1 M

doxycycline hyclate 20 mg 1 M

doxycycline hyclate 100 mg 1 M

minocycline hcl CAPS 1 M

mondoxyne nl cap 100mg 1 M

morgidox cap 1x50mg 1 M

tetracycline hcl CAPS 1 M

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 1 B/D

Drug Name Drug Tier

Requirements/Limits

cyclophosphamide CAPS; SOLR

1 B/D M

dacarbazine 100mg 1 B/D M

EMCYT 1 M

GLEOSTINE 1 M

IFEX INJ 3GM 1 B/D M

ifosfamide inj 1gm/20ml 1 B/D M

IFOSFAMIDE INJ 3GM 1 B/D M

ifosfamide inj 3gm/60ml 1 B/D M

LEUKERAN 1 M

ANTHRACYCLINES adriamycin SOLN 1 B/D M

doxorubicin hcl 1 B/D M

doxorubicin hcl liposomal 1 B/D M

epirubicin hcl 1 B/D M

ANTIBIOTICS bleomycin sulfate 1 B/D M

mitomycin SOLR 1 B/D M

ANTIMETABOLITES adrucil 1 B/D M

adrucil inj 1 B/D M

ALIMTA 1 B/D M

azacitidine 1 B/D M

cytarabine 20mg/ml 1 B/D M

fluorouracil SOLN 1 B/D M

gemcitabine inj soln 1 B/D M

gemcitabine inj solr 1 B/D M

mercaptopurine TABS 1 M

methotrexate sodium inj 1 B/D M

PURIXAN 1

TABLOID 1 M

ANTIMITOTIC, TAXOIDS ABRAXANE 1 B/D M

docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

1 B/D M

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

1 B/D M

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D M

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D M

paclitaxel 1 B/D M

TAXOTERE 80mg/4ml 1 B/D M

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D M

vincristine sulfate 1 B/D M

vinorelbine tartrate 1 B/D M


7

Drug Name Drug Tier

Requirements/Limits

BIOLOGIC RESPONSE MODIFIERS AVASTIN 1 M LA PA

BORTEZOMIB 1 M PA

DAURISMO 1 LA PA

ERIVEDGE 1 LA PA

FARYDAK 1 LA PA

HERCEPTIN 1 M PA

HERCEPTIN HYLECTA 1 M PA

IBRANCE 1 LA PA

IDHIFA 1 LA PA

KADCYLA 1 B/D M

KEYTRUDA SOLN 1 PA

KEYTRUDA SOLR 1 M PA

KISQALI 1 PA

KISQALI FEMARA 200 DOSE 1 PA



LYNPARZA 1 LA PA

MYLOTARG 1 LA PA

NINLARO 1 PA

ODOMZO 1 LA PA

RITUXAN 1 M LA PA

RITUXAN HYCELA 1 LA PA

RUBRACA 1 LA PA

TALZENNA 1 LA PA

TECENTRIQ 1 LA PA

TIBSOVO 1 LA PA

VELCADE 1 M PA

VENCLEXTA 1 LA PA

VENCLEXTA STARTING PACK

1 LA PA

VERZENIO 1 LA PA

ZEJULA 1 LA PA

ZOLINZA 1 PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 1 PA

anastrozole TABS 1 M

bicalutamide 1 M

DEPO-PROVERA INJ 400/ML 1 B/D M

ERLEADA 1 LA PA

exemestane 1 M

FASLODEX 1 B/D M

flutamide 1 M

fulvestrant 1 B/D M

letrozole TABS 1 M

leuprolide inj 1mg/0.2 1 PA

LUPRON DEPOT (1-MONTH) 3.75mg

1 PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT INJ 11.25MG (3-MONTH)

1 PA

LYSODREN 1 M

megestrol ac sus 40mg/ml 1 M

megestrol ac tab 20mg 1 M

megestrol ac tab 40mg 1 M

megestrol sus 625mg/5ml 1 M PA

nilutamide 1 M

NUBEQA 1 LA PA

SOLTAMOX 1 M

tamoxifen citrate TABS 1 M

toremifene citrate 1 M

TRELSTAR DEP INJ 3.75MG 1 PA

TRELSTAR LA INJ 11.25MG 1 PA

XTANDI 1 LA PA

ZYTIGA 500mg 1 LA PA

IMMUNOMODULATORS POMALYST 1 LA PA

REVLIMID QL (28 caps / 28 days)

1 QL LA PA

THALOMID 50mg, 100mg QL (30 caps / 30 days)

1 QL PA

THALOMID 150mg, 200mg QL (60 caps / 30 days)

1 QL PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) 1 QL PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

1 QL PA


1 QL PA


1 QL PA

ALECENSA 1 LA PA

ALUNBRIG 1 LA PA

BALVERSA 1 LA PA

BOSULIF 1 PA

BRAFTOVI 1 LA PA

CABOMETYX QL (30 tabs / 30 days)

1 QL LA PA

CALQUENCE 1 LA PA

CAPRELSA 1 LA PA

COMETRIQ 1 LA PA

COPIKTRA 1 LA PA

COTELLIC 1 LA PA

erlotinib hcl 25mg QL (90 tabs / 30 days)

1 QL PA

erlotinib hcl 100mg, 150mg QL (30 tabs / 30 days)

1 QL PA


8

Drug Name Drug Tier

Requirements/Limits

GILOTRIF TAB 20MG 1 LA PA



ICLUSIG 1 LA PA

imatinib mesylate 100mg QL (90 tabs / 30 days)

1 QL PA

imatinib mesylate 400mg QL (60 tabs / 30 days)

1 QL PA

IMBRUVICA 1 LA PA

INLYTA 1mg QL (180 tabs / 30 days)

1 QL LA PA

INLYTA 5mg QL (120 tabs / 30 days)

1 QL LA PA

INREBIC 1 LA PA

IRESSA 1 LA PA

JAKAFI QL (60 tabs / 30 days)

1 QL LA PA

LENVIMA 4 MG DAILY DOSE 1 LA PA

LENVIMA 8 MG DAILY DOSE 1 LA PA

LENVIMA 10 MG DAILY DOSE

1 LA PA

LENVIMA 12MG DAILY DOSE

1 LA PA


1 LA PA


1 LA PA


1 LA PA


1 LA PA

LORBRENA 1 LA PA

MEKINIST 1 LA PA

MEKTOVI 1 LA PA

NERLYNX 1 LA PA

NEXAVAR 1 LA PA

PIQRAY 200MG DAILY DOSE

1 PA


1 PA


1 PA

ROZLYTREK 1 LA PA

RYDAPT 1 PA

SPRYCEL 1 PA

STIVARGA 1 LA PA

SUTENT 1 PA

TAFINLAR 1 LA PA

TAGRISSO 1 LA PA

Drug Name Drug Tier

Requirements/Limits

TARCEVA 25mg QL (90 tabs / 30 days)

1 QL LA PA

TARCEVA 100mg, 150mg QL (30 tabs / 30 days)

1 QL LA PA

TASIGNA 1 PA

TURALIO 1 LA PA

TYKERB 1 LA PA

VITRAKVI 1 LA PA

VIZIMPRO 1 LA PA

VOTRIENT 1 LA PA

XALKORI 1 LA PA

XOSPATA 1 LA PA

ZELBORAF 1 LA PA

ZYDELIG 1 LA PA

ZYKADIA 1 LA PA

MISCELLANEOUS bexarotene 1 PA

hydroxyurea CAPS 1 M

LONSURF 1 PA

MATULANE 1 M LA

SYLATRON KIT 200MCG 1 M PA



SYNRIBO 1 PA

tretinoin (chemotherapy) 1 M

XPOVIO 60 MG ONCE WEEKLY

1 LA PA


1 LA PA

XPOVIO 80 MG TWICE WEEKLY

1 LA PA


1 LA PA

PLATINUM-BASED AGENTS carboplatin 1 B/D M

cisplatin SOLN 1 B/D M

oxaliplatin inj 50mg 1 B/D M

oxaliplatin inj 50mg/10ml 1 B/D M

oxaliplatin inj 100mg 1 B/D M

oxaliplatin inj 100mg/20ml 1 B/D M

PROTECTIVE AGENTS dexrazoxane hcl 1 B/D M

leucovorin calcium SOLR 1 B/D M

leucovorin calcium TABS 1 M

leucovorin calcium solr 1 B/D M

MESNEX TABS 1 M

TOPOISOMERASE INHIBITORS etoposide SOLN 1 B/D M

irinotecan hcl 1 B/D M


9

Drug Name Drug Tier

Requirements/Limits

toposar 1 B/D M

topotecan hcl 1 B/D M

TOPOTECAN INJ 4MG/4ML 1 B/D M

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg

1 M

amlodipine besylate-benazepril hcl cap 5-10 mg

1 M


1 M


1 M


1 M


1 M

benazepril & hydrochlorothiazide

1 M

captopril & hydrochlorothiazide

1 M

enalapril maleate & hydrochlorothiazide

1 M

fosinopril sodium & hydrochlorothiazide

1 M

lisinopril & hydrochlorothiazide 1 M

quinapril-hydrochlorothiazide 1 M

ACE INHIBITORS benazepril hcl TABS 1 M

captopril TABS 1 M

enalapril maleate TABS 1 M

fosinopril sodium 1 M

lisinopril TABS 1 M

moexipril hcl 1 M

perindopril erbumine 1 M

quinapril hcl 1 M

ramipril 1 M

trandolapril 1 M

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1 M

spironolactone TABS 1 M

Drug Name Drug Tier

Requirements/Limits

ALPHA BLOCKERS doxazosin mesylate TABS 1 M

prazosin hcl 1 M

terazosin hcl 1 M

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

1 M

amlodipine besylate-valsartan tab

1 M

amlodipine-valsartan-hydrochlorothiazide tab

1 M

candesartan cilexetil-hydrochlorothiazide

1 M

ENTRESTO 1 M

irbesartan-hydrochlorothiazide 1 M

losartan-hydrochlorothiazide 1 M

olmesartan medoxomil-amlodipine-hydrochlorothiazide

1 M

olmesartan medoxomil-hydrochlorothiazide

1 M

telmisartan-amlodipine 1 M

telmisartan-hydrochlorothiazide

1 M

valsartan-hydrochlorothiazide 1 M

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 1 M

eprosartan mesylate 1 M

irbesartan 1 M

losartan potassium 1 M

olmesartan medoxomil TABS

1 M

telmisartan 1 M

valsartan 1 M

ANTIARRHYTHMICS amiodarone hcl soln 1 M

amiodarone tab 100mg 1 M



disopyramide phosphate 1 M

dofetilide 1 M

flecainide acetate 1 M

mexiletine hcl 1 M

MULTAQ 1 M

NORPACE CR 1 M


10

Drug Name Drug Tier

Requirements/Limits

pacerone 1 M

propafenone hcl 1 M

propafenone hcl 12hr 1 M

quinidine gluconate 1 M

quinidine sulfate 1 M

sorine 1 M

sotalol hcl 1 M

sotalol hcl (afib/afl) 1 M

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 1 M

lovastatin 1 M

pravastatin sodium 1 M

rosuvastatin calcium QL (30 tabs / 30 days)

1 QL M

simvastatin TABS 5mg, 10mg, 20mg, 40mg

1 M

simvastatin TABS 80mg QL (30 tabs / 30 days)

1 QL M

ANTILIPEMICS, MISCELLANEOUS cholestyramine 1 M

cholestyramine light 1 M

colesevelam hcl 1 M

colestipol hcl gran 1 M

colestipol hcl pack 1 M

colestipol hcl tabs 1 M

ezetimibe 1 M

ezetimibe-simvastatin 1 M

fenofibrate TABS 48mg, 54mg, 145mg, 160mg

1 M

fenofibrate micronized 67mg, 134mg, 200mg

1 M

gemfibrozil TABS 1 M

JUXTAPID 1 LA PA

KYNAMRO 1 M PA

niacin (antihyperlipidemic) 1 M

niacin er (antihyperlipidemic) 500mg


1 QL M

niacin er (antihyperlipidemic) 750mg, 1000mg

1 M

niacor 1 M

PRALUENT 1 M PA

prevalite 1 M

VASCEPA 1 M

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1 M

Drug Name Drug Tier

Requirements/Limits

bisoprolol & hydrochlorothiazide

1 M

metoprolol & hydrochlorothiazide

1 M

propranolol & hydrochlorothiazide

1 M

BETA-BLOCKERS acebutolol hcl CAPS 1 M

atenolol TABS 1 M

betaxolol hcl 1 M

bisoprolol fumarate 1 M

BYSTOLIC 2.5mg, 5mg, 10mg


1 QL M

BYSTOLIC 20mg QL (60 tabs / 30 days)

1 QL M

carvedilol 1 M

labetalol hcl TABS 1 M

metoprolol succinate 1 M

metoprolol tartrate SOCT 1 M

metoprolol tartrate SOLN 1 M

metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 1 M

pindolol 1 M

propranolol cap er 1 M

propranolol hcl TABS 1 M

propranolol oral sol 1 M

timolol maleate TABS 1 M

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 1 M

cartia xt 1 M

dilt-xr cap 1 M

diltiazem cap 180mg cd 1 M



diltiazem cap er/12hr 1 M

diltiazem hcl TABS 1 M

diltiazem hcl coated beads cap sr 24hr

1 M

diltiazem hcl extended release beads cap sr

1 M

diltiazem inj 1 M

felodipine 1 M

isradipine 1 M

nicardipine hcl CAPS 1 M

nifedipine TB24 1 M

nifedipine er 1 M

nimodipine CAPS 1 M


11

Drug Name Drug Tier

Requirements/Limits

NYMALIZE 1 M

taztia xt 1 M

verapamil cap er 1 M

verapamil hcl SOLN; TABS; TBCR

1 M

verapamil tab er 1 M

DIGITALIS GLYCOSIDES digitek .25mg

PA if 70 years and older 1 M PA

digitek .125mg QL (30 tabs / 30 days)

1 QL M

digox 125mcg QL (30 tabs / 30 days)

1 QL M

digox 250mcg PA if 70 years and older

1 M PA

digoxin TABS 125mcg QL (30 tabs / 30 days)

1 QL M

digoxin TABS 250mcg PA if 70 years and older

1 M PA

digoxin inj 1 M

digoxin sol 50mcg/ml PA if 70 years and older

1 M PA

DIRECT RENIN INHIBITORS/COMBINATIONS aliskiren fumarate 1 M

TEKTURNA 1 M

TEKTURNA HCT 1 M

DIURETICS acetazolamide CP12; TABS 1 M

amiloride & hydrochlorothiazide

1 M

amiloride hcl TABS 1 M

bumetanide inj 0.25/ml 1 M

bumetanide tab 1 M

chlorothiazide tabs 1 M

chlorthalidone 1 M

furosemide SOLN; TABS 1 M

furosemide inj 1 M

hydrochlorothiazide CAPS; TABS

1 M

indapamide 1 M

methazolamide TABS 1 M

methyclothiazide 1 M

metolazone 1 M

spironolactone & hydrochlorothiazide

1 M

torsemide tabs 1 M

Drug Name Drug Tier

Requirements/Limits

triamterene & hydrochlorothiazide cap 37.5-25 mg

1 M

triamterene & hydrochlorothiazide tabs

1 M

MISCELLANEOUS clonidine hcl TABS 1 M

clonidine hcl ptwk 1 M

CORLANOR SOLN 1 M

CORLANOR TABS 1 M

DEMSER 1 M PA

hydralazine hcl SOLN; TABS 1 M

midodrine hcl 1 M

minoxidil TABS 1 M

NORTHERA 1 LA PA

ranolazine 1 M

NITRATES isosorb mononitrate tab 1 M

isosorbide dinitrate 1 M

isosorbide dinitrate er 1 M

isosorbide mononitrate er 1 M

minitran 1 M

NITRO-BID 1 M

NITRO-DUR DIS 0.3MG/HR 1 M

NITRO-DUR DIS 0.8MG/HR 1 M

nitroglycerin SOLN .4mg/spray

1 M

nitroglycerin SUBL 1 M

nitroglycerin td patch 1 M

PULMONARY ARTERIAL HYPERTENSION ADEMPAS

QL (90 tabs / 30 days) 1 QL LA PA

ambrisentan QL (30 tabs / 30 days)

1 QL LA PA

bosentan 62.5mg QL (120 tabs / 30 days)

1 QL LA PA

bosentan 125mg QL (60 tabs / 30 days)

1 QL LA PA

OPSUMIT QL (30 tabs / 30 days)

1 QL LA PA

REMODULIN 1 LA PA

sildenafil citrate tab 20 mg (pulmonary hypertension)


1 QL PA

TRACLEER TABS 62.5mg QL (120 tabs / 30 days)

1 QL LA PA

TRACLEER TABS 125mg QL (60 tabs / 30 days)

1 QL LA PA

treprostinil 1 LA PA


12

Drug Name Drug Tier

Requirements/Limits

VENTAVIS 1 PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg


alprazolam tab 0.25mg QL (150 tabs / 30 days)

1 QL M

alprazolam tab 1mg QL (150 tabs / 30 days)

1 QL M

alprazolam tab 2 mg QL (150 tabs / 30 days)

1 QL M

buspirone hcl TABS 1 M

fluvoxamine maleate TABS 1 M

lorazepam SOLN 1 M

lorazepam TABS QL (150 tabs / 30 days)

1 QL M

lorazepam intensol QL (150 mL / 30 days)

1 QL M

ANTICONVULSANTS APTIOM 200mg


APTIOM 400mg QL (90 tabs / 30 days)

1 QL M

APTIOM 600mg, 800mg QL (60 tabs / 30 days)

1 QL M

BANZEL SUS 40MG/ML 1 M PA

BANZEL TAB 200MG 1 M PA

BANZEL TAB 400MG 1 M PA

BRIVIACT INJ 50MG/5ML 1 M PA

BRIVIACT SOL 10MG/ML 1 M PA

BRIVIACT TAB 10MG 1 M PA





carbamazepine CHEW; CP12; SUSP; TABS; TB12

1 M

CELONTIN 1 M

clobazam 1 M PA

clonazepam TABS 2mg QL (300 tabs / 30 days)

1 QL M

clonazepam TABS .5mg, 1mg


1 QL M

clonazepam TBDP 2mg QL (300 tabs / 30 days)

1 QL M

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


1 QL M

Drug Name Drug Tier

Requirements/Limits

clorazepate dipotassium QL (180 tabs / 30 days)

PA if 65 years and older

1 QL M PA

DIASTAT ACUDIAL 1 M

DIASTAT PEDIATRIC 1 M

diazepam TABS QL (120 tabs / 30 days)


1 QL M PA

diazepam gel 1 M

diazepam inj 1 M

diazepam intensol QL (240 mL / 30 days)


1 QL M PA

diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)


1 QL M PA

DILANTIN CAP 30MG 1 M

DILANTIN CAP 100MG 1 M

DILANTIN CHEW TAB 50MG 1 M

DILANTIN-125 SUSP 1 M

divalproex sodium CSDR; TB24; TBEC

1 M

EPIDIOLEX QL (600 mL / 30 days)

1 QL LA PA

epitol 1 M

ethosuximide CAPS; SOLN 1 M

felbamate 1 M

FYCOMPA SUSP QL (720 mL / 30 days)

1 QL M PA

FYCOMPA TABS 2mg, 4mg, 6mg


1 QL M PA

FYCOMPA TABS 8mg, 10mg, 12mg


1 QL M PA

gabapentin CAPS 100mg QL (1080 caps / 30 days)

1 QL M


1 QL M


1 QL M

gabapentin SOLN QL (2160 mL / 30 days)

1 QL M

gabapentin TABS 600mg QL (180 tabs / 30 days)

1 QL M

gabapentin TABS 800mg QL (120 tabs / 30 days)

1 QL M

lamotrigine CHEW; TABS; TB24

1 M


13

Drug Name Drug Tier

Requirements/Limits

levetiracetam SOLN; TABS; TB24

1 M

levetiracetam in sodium chloride

1 M

levetiracetam oral soln 100 mg/ml

1 M

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg

QL (120 caps / 30 days)

1 QL M

LYRICA CAPS 200mg QL (90 caps / 30 days)

1 QL M

LYRICA CAPS 225mg, 300mg


1 QL M

LYRICA SOLN QL (946 mL / 30 days)

1 QL M

NAYZILAM 1 M

oxcarbazepine 1 M

PEGANONE 1 M

phenobarbital ELIX; TABS PA if 70 years and older

1 M PA

PHENOBARBITAL SODIUM SOLN 65mg/ml


1 M PA

phenobarbital sodium SOLN 130mg/ml


1 M PA

PHENYTEK 1 M

phenytoin CHEW; SUSP 1 M

phenytoin sodium extended 1 M

phenytoin sodium inj 50mg/ml 1 M

pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg


1 QL M

pregabalin CAPS 200mg QL (90 caps / 30 days)

1 QL M

pregabalin CAPS 225mg, 300mg


1 QL M

pregabalin SOLN QL (946 mL / 30 days)

1 QL M

primidone TABS 1 M

roweepra 1 M

roweepra xr 1 M

SPRITAM 1 M

subvenite tab 1 M

SYMPAZAN 1 M PA

tiagabine hcl 1 M

topiramate CPSP; TABS 1 M

valproate sodium SOLN 1 M

Drug Name Drug Tier

Requirements/Limits

valproate sodium oral soln 1 M

valproic acid CAPS 1 M

vigabatrin powd pack 500mg QL (180 packets / 30 days)

1 QL LA PA

vigabatrin tab 500mg QL (180 tabs / 30 days)

1 QL LA PA

vigadrone QL (180 packets / 30 days)

1 QL LA PA

VIMPAT 50mg QL (120 tabs / 30 days)

1 QL M

VIMPAT 100mg, 150mg, 200mg


1 QL M

VIMPAT INJ 200MG/20ML 1 M

VIMPAT SOL 10MG/ML QL (1200 mL / 30 days)

1 QL M

zonisamide CAPS 1 M

ANTIDEMENTIA donepezil hydrochloride TABS 5mg


1 QL M

donepezil hydrochloride TABS 10mg

1 M

donepezil hydrochloride TBDP 5mg


1 QL M

donepezil hydrochloride TBDP 10mg

1 M

galantamine hydrobromide SOLN

1 M

galantamine hydrobromide TABS


1 QL M

galantamine hydrobromide er QL (30 caps / 30 days)

1 QL M

memantine hcl cp24 PA if < 30 yrs

1 M PA

memantine soln PA if < 30 yrs

1 M PA

memantine tabs PA if < 30 yrs

1 M PA

memantine titration pak PA if < 30 yrs

1 M PA

NAMZARIC 1 M

rivastigmine tartrate 1.5mg, 3mg


1 QL M


14

Drug Name Drug Tier

Requirements/Limits

rivastigmine tartrate 4.5mg, 6mg


1 QL M

rivastigmine td patch 24hr 4.6 mg/24hr

QL (30 patches / 30 days)

1 QL M



1 QL M



1 QL M

ANTIDEPRESSANTS amitriptyline hcl TABS 1 M

amoxapine 1 M

bupropion hcl TABS 1 M

bupropion hcl TB12 1 M

bupropion hcl TB24 150mg, 300mg

1 M

citalopram hydrobromide 1 M

clomipramine hcl CAPS 1 M PA

desipramine hcl TABS 1 M

desvenlafaxine succinate QL (30 tabs / 30 days)

1 QL M PA

doxepin hcl CAPS; CONC 1 M

duloxetine hcl CPEP 20mg QL (180 caps / 30 days)

1 QL M


1 QL M


1 QL M

EMSAM QL (30 patches / 30 days)

1 QL M PA

escitalopram oxalate 1 M

FETZIMA 20mg QL (180 caps / 30 days)

1 QL M PA

FETZIMA 40mg QL (90 caps / 30 days)

1 QL M PA

FETZIMA 80mg, 120mg QL (30 caps / 30 days)

1 QL M PA

FETZIMA TITRATION PACK 1 M PA

fluoxetine cap 10mg 1 M



fluoxetine hcl SOLN 1 M

imipramine hcl TABS 1 M

Drug Name Drug Tier

Requirements/Limits

maprotiline hcl 1 M

MARPLAN TAB 10MG QL (180 tabs / 30 days)

1 QL M

mirtazapine TABS; TBDP 1 M

nefazodone hcl 1 M

nortriptyline hcl CAPS; SOLN

1 M

paroxetine hcl tabs 1 M

PAXIL SUSP QL (900 mL / 30 days)

1 QL M

phenelzine sulfate TABS 1 M

protriptyline hcl 1 M

sertraline hcl CONC; TABS 1 M

tranylcypromine sulfate 1 M

trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trimipramine maleate CAPS 25mg


1 QL M



1 QL M



1 QL M

TRINTELLIX 5mg QL (120 tabs / 30 days)

1 QL M


1 QL M


1 QL M

venlafaxine hcl CP24; TABS 1 M

VIIBRYD STARTER PACK 1 M

VIIBRYD TAB QL (30 tabs / 30 days)

1 QL M

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS


amantadine hcl SYRP; TABS

1 M

APOKYN QL (20 cartridges / 30 days)

1 QL LA PA

benztropine mesylate inj 1 M

benztropine mesylate tab 0.5mg


1 M PA

benztropine mesylate tab 1mg PA if 70 years and older

1 M PA


15

Drug Name Drug Tier

Requirements/Limits

benztropine mesylate tab 2mg PA if 70 years and older

1 M PA

bromocriptine mesylate CAPS; TABS

1 M

carbidopa-levodopa 1 M

carbidopa/levodopa/entacapone

1 M

entacapone 1 M

NEUPRO 1 M

pramipexole tab 0.5mg 1 M





pramipexole tab 1mg 1 M

rasagiline mesylate TABS 1 M

ropinirole tab 0.5mg 1 M

ropinirole tab 0.25mg 1 M

ropinirole tab 1mg 1 M





selegiline hcl CAPS; TABS 1 M

trihexyphenidyl hcl PA if 70 years and older

1 M PA

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

1 QL M

aripiprazole odt QL (60 tabs / 30 days)

1 QL M

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

1 QL M

aripiprazole tab QL (30 tabs / 30 days)

1 QL M

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


1 QL M

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

1 QL M

ARISTADA INITIO 1 M

chlorpromazine hcl TABS 1 M

CHLORPROMAZINE INJ 1 M

clozapine odt 12.5mg, 25mg 1 M PA

clozapine odt 100mg QL (270 tabs / 30 days)

1 QL M PA

Drug Name Drug Tier

Requirements/Limits


1 QL M PA


1 QL M PA

clozapine tab 25mg 1 M

clozapine tab 50mg 1 M

clozapine tab 100mg QL (270 tabs / 30 days)

1 QL M

clozapine tab 200mg QL (135 tabs / 30 days)

1 QL M

FANAPT QL (60 tabs / 30 days)

1 QL M

FANAPT TITRATION PACK 1 M

fluphenazine decanoate SOLN

1 M

fluphenazine hcl 1 M

GEODON SOLR QL (6 mL / 3 days)

1 QL M

haloperidol TABS 1 M

haloperidol conc 2mg/ml 1 M

haloperidol decanoate SOLN 1 M

haloperidol lactate inj 5mg/ml 1 M

INVEGA SUST INJ 39 MG/0.25 ML


1 QL M



1 QL M



1 QL M

INVEGA SUST INJ 156MG/ML


1 QL M



1 QL M

INVEGA TRINZA QL (1 injection / 90 days)

1 QL M

LATUDA 20mg, 60mg, 80mg QL (60 tabs / 30 days)

1 QL M

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

1 QL M

loxapine succinate 1 M


16

Drug Name Drug Tier

Requirements/Limits

molindone hcl 1 M

NUPLAZID CAPS QL (30 caps / 30 days)

1 QL LA PA

NUPLAZID TABS 10MG QL (30 tabs / 30 days)

1 QL LA PA

NUPLAZID TABS 17MG QL (60 tabs / 30 days)

1 QL LA PA

olanzapine SOLR QL (3 vials / 1 day)

1 QL M

olanzapine TABS 2.5mg QL (240 tabs / 30 days)

1 QL M

olanzapine TABS 5mg QL (120 tabs / 30 days)

1 QL M

olanzapine TABS 7.5mg, 15mg, 20mg


1 QL M

olanzapine TABS 10mg QL (60 tabs / 30 days)

1 QL M

olanzapine TBDP 5mg, 15mg, 20mg


1 QL M

olanzapine TBDP 10mg QL (60 tabs / 30 days)

1 QL M

paliperidone 1.5mg, 3mg, 9mg


1 QL M

paliperidone 6mg QL (60 tabs / 30 days)

1 QL M

perphenazine TABS 1 M

PERSERIS QL (1 injection / 30 days)

1 QL M

pimozide 1 M

quetiapine fumarate TABS 1 M

quetiapine fumarate TB24 50mg, 300mg, 400mg


1 QL M

quetiapine fumarate TB24 150mg, 200mg


1 QL M

REXULTI 1mg QL (90 tabs / 30 days)

1 QL M

REXULTI 2mg QL (60 tabs / 30 days)

1 QL M

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

1 QL M

REXULTI .5mg QL (180 tabs / 30 days)

1 QL M

REXULTI .25mg QL (360 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

1 QL M

RISPERDAL INJ 25MG QL (2 injections / 28 days)

1 QL M

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

1 QL M

RISPERDAL INJ 50MG QL (2 injections / 28 days)

1 QL M

risperidone SOLN QL (240 mL / 30 days)

1 QL M

risperidone TABS 1 M

risperidone TBDP .5mg QL (90 tabs / 30 days)

1 QL M

risperidone TBDP .25mg, 1mg, 2mg, 3mg, 4mg


1 QL M

SAPHRIS 2.5mg QL (240 tabs / 30 days)

1 QL M

SAPHRIS 5mg QL (120 tabs / 30 days)

1 QL M

SAPHRIS 10mg QL (60 tabs / 30 days)

1 QL M

thioridazine hcl TABS 1 M

thiothixene 1 M

trifluoperazine hcl 1 M

VERSACLOZ QL (600 mL / 30 days)

1 QL M PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

1 QL M PA

VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)

1 QL M PA

VRAYLAR THERAPY PACK 1 M PA

ziprasidone hcl QL (60 caps / 30 days)

1 QL M

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

1 QL M PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

1 QL M PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

1 QL M PA


17

Drug Name Drug Tier

Requirements/Limits

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg


1 QL M

amphetamine-dextroamphetamine cap sr 24hr 10 mg


1 QL M



1 QL M



1 QL M



1 QL M



1 QL M

amphetamine-dextroamphetamine tab 5 mg


1 QL M

amphetamine-dextroamphetamine tab 7.5 mg


1 QL M



1 QL M

amphetamine-dextroamphetamine tab 12.5 mg


1 QL M



1 QL M



1 QL M



1 QL M

atomoxetine hcl 10mg, 18mg, 25mg


1 QL M

atomoxetine hcl 40mg QL (60 caps / 30 days)

1 QL M

atomoxetine hcl 60mg, 80mg, 100mg


1 QL M

Drug Name Drug Tier

Requirements/Limits

dexmethylphenidate hcl TABS 2.5mg, 5mg


1 QL M

dexmethylphenidate hcl TABS 10mg


1 QL M

guanfacine er (adhd) PA if 70 years and older

1 M PA

metadate er tab 20mg QL (90 tabs / 30 days)

1 QL M

methylphenidate hcl TABS 5mg, 10mg


1 QL M

methylphenidate hcl TABS 20mg


1 QL M

methylphenidate hcl oral soln 5mg/5ml

QL (1800 mL / 30 days)

1 QL M

methylphenidate hcl oral soln 10mg/5ml

QL (900 mL / 30 days)

1 QL M

methylphenidate tab 10mg er QL (90 tabs / 30 days)

1 QL M

methylphenidate tab 20mg er QL (90 tabs / 30 days)

1 QL M

HYPNOTICS eszopiclone

QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year

1 QL M PA

HETLIOZ 1 LA PA

SILENOR 3mg QL (60 tabs / 30 days)

1 QL M

SILENOR 6mg QL (30 tabs / 30 days)

1 QL M

temazepam 7.5mg QL (30 caps / 30 days)


1 QL M PA

temazepam 15mg QL (60 caps / 30 days)


1 QL M PA


18

Drug Name Drug Tier

Requirements/Limits

zaleplon QL (60 caps / 30 days)


1 QL M PA

zolpidem tartrate TABS QL (30 tabs / 30 days)


1 QL M PA

MIGRAINE AIMOVIG

QL (1 pen / 30 days) 1 QL M PA

dihydroergotamine mesylate inj 1 mg/ml

1 M

dihydroergotamine mesylate nasal

QL (8 mL / 30 days)

1 QL M

eletriptan hydrobromide QL (12 tabs / 30 days)

1 QL M

EMGALITY SOAJ QL (2 pens / 30 days)

1 QL M PA

EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)

1 QL M PA

ergotamine w/ caffeine 1 M

naratriptan hcl QL (12 tabs / 30 days)

1 QL M

rizatriptan benzoate QL (18 tabs / 30 days)

1 QL M

rizatriptan benzoate odt QL (18 tabs / 30 days)

1 QL M

sumatriptan SOLN 5mg/act QL (24 inhalers / 30 days)

1 QL M

sumatriptan SOLN 20mg/act QL (12 inhalers / 30 days)

1 QL M

sumatriptan inj 4mg/0.5ml QL (18 injections / 30 days)

1 QL M

sumatriptan inj 6mg/0.5ml QL (12 injections / 30 days)

1 QL M

sumatriptan succinate TABS QL (12 tabs / 30 days)

1 QL M

zolmitriptan TABS QL (12 tabs / 30 days)

1 QL M

zolmitriptan odt QL (12 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) 1 QL LA PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

1 QL LA PA

lithium carbonate CAPS; TABS

1 M

lithium carbonate er 1 M

LITHIUM SOLN 8MEQ/5ML 1 M

LYRICA CR 82.5mg, 165mg QL (90 tabs / 30 days)

1 QL M PA

LYRICA CR 330mg QL (60 tabs / 30 days)

1 QL M PA

NUEDEXTA QL (60 caps / 30 days)

1 QL M PA

pyridostigmine tab 60mg 1 M

riluzole 1 M

tetrabenazine 12.5mg QL (240 tabs / 30 days)

1 QL PA

tetrabenazine 25mg QL (120 tabs / 30 days)

1 QL PA

MULTIPLE SCLEROSIS AGENTS BETASERON

QL (14 syringes / 28 days)

1 QL PA

dalfampridine 1 PA

GILENYA QL (28 caps / 28 days)

1 QL PA

glatiramer acetate 20mg/ml QL (30 syringes / 30 days)

1 QL PA

glatiramer acetate 40mg/ml QL (12 syringes / 28 days)

1 QL PA

glatopa 20mg/ml QL (30 syringes / 30 days)

1 QL PA

glatopa 40mg/ml QL (12 syringes / 28 days)

1 QL PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg 1 M

carisoprodol TABS 350mg QL (120 tabs / 30 days)


1 QL M PA

cyclobenzaprine hcl TABS 5mg, 10mg


1 M PA

dantrolene sodium CAPS 1 M


19

Drug Name Drug Tier

Requirements/Limits

methocarbamol TABS PA if 70 years and older

1 M PA

tizanidine hcl TABS 1 M

NARCOLEPSY/CATAPLEXY armodafinil 50mg

QL (90 tabs / 30 days) 1 QL M PA

armodafinil 150mg, 200mg, 250mg


1 QL M PA

XYREM QL (540 mL / 30 days)

1 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1 M

buprenorphine hcl SUBL QL (90 tabs / 30 days)

1 QL M PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

QL (90 films / 30 days)

1 QL M

buprenorphine hcl-naloxone hcl dihydrate 4-1mg


1 QL M



1 QL M



1 QL M

buprenorphine hcl-naloxone hcl sl


1 QL M

bupropion hcl (smoking deterrent)

1 M

CHANTIX 1 M PA

CHANTIX CONTINUING MONTH

1 M PA

CHANTIX STARTER PACK 1 M PA

disulfiram TABS 1 M

naloxone inj 0.4mg/ml 1 M

naloxone inj 1mg/ml 1 M

naltrexone hcl TABS 1 M

NARCAN 1 M

NICOTROL INHALER 1 M

NICOTROL NS 1 M

VIVITROL 1 M

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 1 M PA

ANDRODERM QL (30 patches / 30 days)

1 QL M PA

Drug Name Drug Tier

Requirements/Limits

oxandrolone tab 2.5mg 1 M PA

oxandrolone tab 10mg 1 M PA

testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

QL (300 grams / 30 days)

1 QL M PA

testosterone cypionate SOLN

1 M PA

testosterone enanthate SOLN

1 M PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 1 M

BASAGLAR KWIKPEN 1 M

BD ULTRAFINE INSULIN SYRINGE

1 M

BD ULTRAFINE/NANO PEN NEEDLES

1 M

BYDUREON BCISE QL (4 pens / 28 days)

1 QL M

BYDUREON INJ QL (4 vials / 28 days)

1 QL M

BYDUREON PEN QL (4 pens / 28 days)

1 QL M

BYETTA QL (1 pen / 30 days)

1 QL M

FIASP 1 M

FIASP FLEXTOUCH 1 M

GAUZE PADS 2" X 2" 1 M

HUMULIN R INJ U-500 1 B/D M

HUMULIN R U-500 KWIKPEN 1 M

INSULIN PEN NEEDLE 1 M

INSULIN SAFETY NEEDLES 1 M

INSULIN SYRINGE 1 M

LEVEMIR 1 M

LEVEMIR FLEXTOUCH 1 M

NOVOLIN 70/30 (brand RELION not covered)

1 M

NOVOLIN 70/30 FLEXPEN (brand RELION not covered)

1 M

NOVOLIN N (brand RELION not covered)

1 M

NOVOLIN R (brand RELION not covered)

1 M

NOVOLOG 1 M

NOVOLOG 70/30 FLEXPEN 1 M

NOVOLOG FLEXPEN 1 M


20

Drug Name Drug Tier

Requirements/Limits

NOVOLOG MIX 70/30 1 M

NOVOLOG PENFILL 1 M

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

1 QL M

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

1 QL M

SOLIQUA 100/33 QL (10 pens / 30 days)

1 QL M

TRESIBA FLEXTOUCH 1 M

TRESIBA INJ 1 M

TRULICITY QL (4 pens / 28 days)

1 QL M

VICTOZA QL (3 pens / 30 days)

1 QL M

XULTOPHY 100/3.6 QL (5 pens / 30 days)

1 QL M

ANTIDIABETICS, ORAL acarbose TABS 1 M

FARXIGA 5mg QL (60 tabs / 30 days)

1 QL M

FARXIGA 10mg QL (30 tabs / 30 days)

1 QL M

glimepiride 1mg QL (240 tabs / 30 days)

1 QL M


1 QL M


1 QL M

glip/metform tab 2.5-250mg QL (240 tabs / 30 days)

1 QL M

glip/metform tab 2.5-500mg QL (120 tabs / 30 days)

1 QL M

glip/metform tab 5-500mg QL (120 tabs / 30 days)

1 QL M

glipizide TABS 5mg QL (240 tabs / 30 days)

1 QL M

glipizide TABS 10mg QL (120 tabs / 30 days)

1 QL M

glipizide TB24 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide TB24 5mg QL (120 tabs / 30 days)

1 QL M

glipizide TB24 10mg QL (60 tabs / 30 days)

1 QL M

glipizide xl 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide xl 5mg QL (120 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

glipizide xl 10mg QL (60 tabs / 30 days)

1 QL M

glyburide TABS 1.25mg QL (480 tabs / 30 days)


1 QL M PA

glyburide TABS 2.5mg QL (240 tabs / 30 days)


1 QL M PA

glyburide TABS 5mg QL (120 tabs / 30 days)


1 QL M PA

glyburide micronized 1.5mg QL (240 tabs / 30 days)


1 QL M PA

glyburide micronized 3mg QL (120 tabs / 30 days)


1 QL M PA

glyburide micronized 6mg QL (60 tabs / 30 days)


1 QL M PA

glyburide-metformin tab 1.25-250 mg

QL (240 tabs / 30 days) PA if 70 years and older

1 QL M PA

glyburide-metformin tab 2.5-500 mg


1 QL M PA

glyburide-metformin tab 5-500mg


1 QL M PA

JANUMET QL (60 tabs / 30 days)

1 QL M

JANUMET XR TAB 50-500MG


1 QL M

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

1 QL M

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

1 QL M

JANUVIA QL (30 tabs / 30 days)

1 QL M

JARDIANCE 10mg QL (60 tabs / 30 days)

1 QL M

JARDIANCE 25mg QL (30 tabs / 30 days)

1 QL M

JENTADUETO QL (60 tabs / 30 days)

1 QL M


21

Drug Name Drug Tier

Requirements/Limits

JENTADUETO TAB XR 2.5-1000 MG


1 QL M

JENTADUETO TAB XR 5-1000 MG


1 QL M

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin hcl TABS 500mg QL (150 tabs / 30 days)

1 QL M


1 QL M


1 QL M

nateglinide QL (90 tabs / 30 days)

1 QL M

pioglitazone hcl QL (30 tabs / 30 days)

1 QL M

repaglinide 2mg QL (240 tabs / 30 days)

1 QL M

repaglinide .5mg, 1mg QL (120 tabs / 30 days)

1 QL M

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

1 QL M

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

1 QL M

SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days)

1 QL M

SYNJARDY TAB 12.5-1000MG


1 QL M

SYNJARDY XR TAB 5-1000MG


1 QL M



1 QL M

SYNJARDY XR TAB 12.5-1000MG


1 QL M



1 QL M

TRADJENTA QL (30 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

XIGDUO XR TAB 2.5-1000MG


1 QL M

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

1 QL M


1 QL M


1 QL M


1 QL M

BISPHOSPHONATES alendronate sodium 1 M

ibandronate sodium TABS 1 B/D M

PAMIDRONATE DISODIUM 6mg/ml

1 B/D M

pamidronate disodium 30mg/10ml, 90mg/10ml

1 B/D M

pamidronate inj 30mg 1 B/D M

pamidronate inj 90mg 1 B/D M

risedronate sodium TABS 5mg, 35mg, 150mg

1 M

risedronate sodium TBEC 1 M

zoledronic acid inj 5mg/100ml 1 B/D

zoledronic inj 4mg/5ml 1 B/D

CALCIUM RECEPTOR AGONISTS cinacalcet hcl 30mg, 90mg

QL (120 tabs / 30 days) 1 B/D QL

cinacalcet hcl 60mg QL (60 tabs / 30 days)

1 B/D QL

SENSIPAR 30mg, 90mg QL (120 tabs / 30 days)

1 B/D QL

SENSIPAR 60mg QL (60 tabs / 30 days)

1 B/D QL

CHELATING AGENTS CHEMET 1 M

DEPEN TITRATABS 1 M

JADENU 1 LA PA

JADENU SPRINKLE 1 LA PA

kionex sus 15gm/60ml 1 M

LOKELMA 1 M

sodium polystyrene sulfonate powder

1 M

sodium polystyrene sulfonate susp

1 M

sps susp 15gm/60ml 1 M

trientine hcl 1 M PA

CONTRACEPTIVES altavera tab 1 M


22

Drug Name Drug Tier

Requirements/Limits

alyacen 1/35 1 M

amethia 1 M

amethia lo 1 M

apri 1 M

aranelle 1 M

ashlyna 1 M

aubra 1 M

aviane 1 M

balziva 1 M

bekyree 1 M

blisovi 24 fe 1 M

blisovi fe 1.5/30 1 M

briellyn 1 M

camila 1 M

camrese lo 1 M

caziant pak 1 M

cryselle-28 1 M

cyclafem 1/35 1 M

cyclafem 7/7/7 1 M

cyred tab 1 M

dasetta 1/35 1 M

dasetta 7/7/7 1 M

deblitane 1 M

delyla 1 M

desogestrel & ethinyl estradiol 1 M

desogestrel-ethinyl estradiol (biphasic)

1 M

drospirenone-ethinyl estradiol 1 M

drospirenone-ethinyl estradiol-levomefolate calcium

1 M

ELLA 1 M

emoquette 1 M

enpresse-28 1 M

enskyce 1 M

errin 1 M

estarylla tab 0.25-35 1 M

ethynodiol diacet & eth estrad 1 M

ethynodiol tab 1-50 1 M

falmina 1 M

fayosim 1 M

femynor 1 M

gianvi tab 3-0.02mg 1 M

hailey 24 fe 1 M

heather 1 M

incassia 1 M

introvale 1 M

isibloom 1 M

jasmiel 1 M

jolessa tab 0.15-0.03 mg 1 M

Drug Name Drug Tier

Requirements/Limits

jolivette 1 M

juleber 1 M

junel 1.5/30 1 M

junel 1/20 1 M

junel fe 1.5/30 1 M

junel fe 1/20 1 M

junel fe 24 1 M

kaitlib fe 1 M

kariva 1 M

kelnor 1/35 1 M

kelnor 1/50 1 M

kurvelo 1 M

larin 1.5/30 1 M

larin 1/20 1 M

larin fe 1.5/30 1 M

larin fe 1/20 1 M

larissia tab 1 M

layolis fe 1 M

leena tab 1 M

lessina 1 M

levonest 1 M

levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg

1 M

levonor/ethi tab 1 M

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

1 M

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

1 M

levonorgestrel & eth estradiol 1 M

levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day)

1 M

levora 0.15/30-28 1 M

lomedia 24 fe 1 M

loryna 1 M

low-ogestrel 1 M

lutera 1 M

lyza 1 M

marlissa 1 M

medroxyprogesterone acetate (contraceptive)

1 M

melodetta 24 fe 1 M

mibelas 24 fe 1 M

microgestin 1.5/30 1 M

microgestin 1/20 1 M

microgestin fe 1.5/30 1 M


23

Drug Name Drug Tier

Requirements/Limits

microgestin fe 1/20 1 M

mili 1 M

mono-linyah tab 0.25-35 1 M

myzilra 1 M

necon 0.5/35-28 1 M

necon 7/7/7 1 M

nikki 1 M

nora-be tab 0.35mg 1 M

norethin acet & estrad-fe 1 M

norethindrone & ethinyl estradiol-fe

1 M

norethindrone (contraceptive) 1 M

norethindrone acet & eth estra 1 M

norgest/ethi tab 0.25/35 1 M

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

1 M

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

1 M

norlyroc 1 M

nortrel 0.5/35 (28) 1 M

nortrel 1/35 1 M

nortrel 7/7/7 1 M

NUVARING 1 M

ocella tab 3-0.03mg 1 M

orsythia 1 M

philith 1 M

pimtrea 1 M

pirmella 1/35 1 M

portia-28 1 M

previfem 1 M

quasense 1 M

reclipsen 1 M

rivelsa 1 M

setlakin tab 1 M

sharobel 1 M

sprintec 28 1 M

sronyx 1 M

syeda 1 M

tarina 24 fe 1 M

tarina fe 1/20 1 M

tilia fe 1 M

tri-estarylla 1 M

tri-legest fe 1 M

tri-linyah 1 M

tri-lo marzia 1 M

Drug Name Drug Tier

Requirements/Limits

tri-lo-estarylla 1 M

tri-lo-sprintec 1 M

tri-mili 1 M

tri-previfem 1 M

tri-sprintec 1 M

tri-vylibra 1 M

tri-vylibra lo 1 M

trinessa 1 M

trinessa lo 1 M

trivora-28 1 M

tulana 1 M

tydemy 1 M

velivet 1 M

vienva 1 M

viorele 1 M

vyfemla 1 M

vylibra 1 M

wymzya fe 1 M

xulane dis 150-35 1 M

zarah 1 M

zovia 1/35e 1 M

ENDOMETRIOSIS danazol CAPS 1 M

SYNAREL 1 M

ENZYME REPLACEMENTS ALDURAZYME 1 LA PA

CARBAGLU 1 LA PA

CERDELGA 1 PA

CEREZYME 1 LA PA

CYSTADANE 1 LA

CYSTAGON 1 LA PA

FABRAZYME 1 LA PA

KUVAN 1 LA PA

levocarnitine (metabolic modifiers)

1 B/D M

LUMIZYME 1 LA PA

miglustat 1 PA

NAGLAZYME 1 LA PA

NITYR 1 LA PA

ORFADIN 1 LA PA

sodium phenylbutyrate 1 PA

ESTROGENS DELESTROGEN 10mg/ml 1 M

estradiol PTWK; TABS 1 M

estradiol vaginal cream 1 M

estradiol vaginal tab 1 M

estradiol valerate inj 1 M

fyavolv 1 M

jinteli 1 M


24

Drug Name Drug Tier

Requirements/Limits

norethindrone acetate-ethinyl estradiol

1 M

yuvafem vaginal tablet 10 mcg 1 M

GLUCOCORTICOIDS cortisone acetate TABS 1 M

DEXAMETHASONE CONC 1 M

dexamethasone ELIX; SOLN; TABS

1 M

dexamethasone sodium phosphate

1 M

fludrocortisone acetate TABS

1 M

hydrocortisone TABS 1 M

methylpr ss inj 1 B/D M

methylpred pak 4mg 1 M

methylpred tab 4mg 1 B/D M




methylprednisolone acetate 1 B/D M

pred sod pho sol 5mg/5ml 1 B/D M

prednisolone sodium phosphate SOLN 15mg/5ml

1 B/D M

prednisolone sol 15mg/5ml 1 B/D M

prednisolone sol 25mg/5ml 1 B/D M

PREDNISONE CON 5MG/ML 1 B/D M

prednisone pak 5mg 1 M

prednisone pak 10mg 1 M

prednisone sol 5mg/5ml 1 B/D M

prednisone tab 1mg 1 B/D M

prednisone tab 2.5mg 1 B/D M





SOLU-CORTEF 1 M

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 1 M

GLUCAGON EMERGENCY KIT

1 M

PROGLYCEM SUS 50MG/ML 1 M

MISCELLANEOUS cabergoline 1 M

calcitonin (salmon) 1 B/D M

FORTEO 1 PA

GENOTROPIN 1 PA

GENOTROPIN MINIQUICK 1 PA

INCRELEX 1 LA PA

KORLYM 1 LA PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEP-PED INJ 7.5MG

1 PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

1 PA

LUPRON DEPOT-PED (1-MONTH

1 PA

LUPRON DEPOT-PED (3-MONTH

1 PA

NATPARA 1 PA

octreotide acetate 1 PA

PROLIA QL (1 injection / 180 days)

1 QL

raloxifene tab 60mg 1 M

SIGNIFOR 1 LA PA

SOMATULINE DEPOT 1 PA

SOMAVERT 1 LA PA

TYMLOS 1 PA

XGEVA 1 PA

PHOSPHATE BINDER AGENTS AURYXIA

QL (360 tabs / 30 days) 1 QL M PA

calcium acetate (phosphate binder) CAPS


1 QL M

calcium acetate (phosphate binder) TABS


1 QL M

sevelamer carbonate PACK 2.4gm

QL (180 packets / 30 days)

1 QL M

sevelamer carbonate PACK .8gm

QL (540 packets / 30 days)

1 QL M

sevelamer carbonate TABS QL (540 tabs / 30 days)

1 QL M

PROGESTINS medroxyprogesterone acetate tab

1 M

norethindrone acetate TABS 1 M

THYROID AGENTS levo-t 1 M

levothyroxine sodium TABS 1 M

levoxyl 1 M

liothyronine sodium TABS 1 M

methimazole TABS 1 M

propylthiouracil TABS 1 M

SYNTHROID 1 M


25

Drug Name Drug Tier

Requirements/Limits

unithroid 1 M

VASOPRESSINS desmopressin acetate spray 1 M

desmopressin acetate spray refrigerated

1 M

desmopressin acetate tabs 1 M

desmopressin inj 4mcg/ml 1 M

STIMATE 1

GASTROINTESTINAL ANTIEMETICS aprepitant 1 B/D M

aprepitant pak 80mg & 125mg 1 B/D M

compro supp 1 M

dronabinol QL (60 caps / 30 days)

1 B/D QL M

EMEND SUSR 1 B/D M

granisetron hcl SOLN 1 M

granisetron hcl TABS 1 B/D M

meclizine hcl TABS 1 M

metoclopramide hcl SOLN; TABS

1 M

metoclopramide hcl inj 1 M

ondansetron hcl TABS 1 B/D M

ondansetron hcl inj 1 M

ondansetron hcl oral soln 1 B/D M

ondansetron odt 1 B/D M

prochlorperazine inj 1 M

prochlorperazine maleate TABS

1 M

prochlorperazine supp 1 M

promethazine hcl SYRP; TABS


1 M PA

promethazine hcl inj PA if 70 years and older

1 M PA

scopolamine patch QL (10 patches / 30 days)


1 QL M PA

TRANSDERM-SCOP QL (10 patches / 30 days)


1 QL M PA

ANTISPASMODICS dicyclomine hcl cap 10mg 1 M

dicyclomine hcl soln 10mg/5ml

1 M

dicyclomine hcl tab 20mg 1 M

glycopyrrolate tab 1mg 1 M

Drug Name Drug Tier

Requirements/Limits

glycopyrrolate tab 2mg 1 M

H2-RECEPTOR ANTAGONISTS famotidine SUSR 1 M

famotidine TABS 20mg, 40mg

1 M

famotidine in nacl 1 M

famotidine inj 1 M

ranitidine hcl TABS 150mg, 300mg

1 M

ranitidine hcl inj 1 M

ranitidine inj 1 M

ranitidine syrup 1 M

INFLAMMATORY BOWEL DISEASE APRISO


balsalazide disodium 1 M

budesonide ec 1 M

colocort 1 M

DELZICOL 1 M

hydrocortisone (enema) 1 M

mesalamine CPDR 1 M

mesalamine ENEM 1 M

mesalamine SUPP 1 M

mesalamine TBEC 800mg 1 M

mesalamine w/ cleanser 1 M

sulfasalazine TABS 1 M

sulfasalazine ec 1 M

LAXATIVES constulose 1 M

enulose 1 M

gavilyte-c 1 M

gavilyte-g 1 M

gavilyte-n/flavor pack 1 M

generlac 1 M

GOLYTELY 1 M

lactulose SOLN 1 M

lactulose (encephalopathy) 1 M

MOVIPREP 1 M

NULYTELY/FLAVOR PACKS 1 M

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1 M

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1 M

peg 3350/electrolytes 1 M

SUPREP BOWEL PREP KIT 1 M

trilyte 1 M

MISCELLANEOUS alosetron hcl 1 M PA


26

Drug Name Drug Tier

Requirements/Limits

AMITIZA CAP 8MCG QL (180 caps / 30 days)

1 QL M

AMITIZA CAP 24MCG QL (60 caps / 30 days)

1 QL M

cromolyn sodium (mastocytosis)

1 M

diphenoxylate w/ atropine 1 M

GATTEX 1 LA PA

LINZESS QL (30 caps / 30 days)

1 QL M

loperamide hcl CAPS 1 M

misoprostol TABS 1 M

MOVANTIK 12.5mg QL (60 tabs / 30 days)

1 QL M

MOVANTIK 25mg QL (30 tabs / 30 days)

1 QL M

RELISTOR SOLN 1 M PA

sucralfate TABS 1 M

SYMPROIC 1 M

ursodiol CAPS; TABS 1 M

XIFAXAN 550mg 1 M PA

PANCREATIC ENZYMES CREON 1 M

ZENPEP 1 M

PROTON PUMP INHIBITORS DEXILANT


esomeprazole magnesium QL (30 caps / 30 days)

1 QL M

esomeprazole sodium inj 1 M

lansoprazole CPDR QL (30 caps / 30 days)

1 QL M

omeprazole cap 10mg 1 M



pantoprazole sodium SOLR 1 M

pantoprazole sodium tbec 1 M

rabeprazole sodium QL (30 tabs / 30 days)

1 QL M

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl


dutasteride CAPS QL (30 caps / 30 days)

1 QL M

dutasteride-tamsulosin hcl QL (30 caps / 30 days)

1 QL M

finasteride TABS 5mg 1 M

tamsulosin hcl 1 M

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS bethanechol chloride TABS 1 M

potassium citrate (alkalinizer) er tabs

1 M

URINARY ANTISPASMODICS MYRBETRIQ 25mg


MYRBETRIQ 50mg QL (30 tabs / 30 days)

1 QL M

oxybutynin chloride SYRP 1 M

oxybutynin chloride TABS 1 M

oxybutynin chloride TB24 5mg


1 QL M

oxybutynin chloride TB24 10mg, 15mg


1 QL M

solifenacin succinate QL (30 tabs / 30 days)

1 QL M

tolterodine tartrate CP24 QL (30 caps / 30 days)

1 QL M ST

tolterodine tartrate TABS 1 M ST

TOVIAZ QL (30 tabs / 30 days)

1 QL M

trospium chloride TABS QL (60 tabs / 30 days)

1 QL M

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal

1 M

metronidazole vaginal 1 M

terconazole vaginal 1 M

vandazole 1 M

HEMATOLOGIC ANTICOAGULANTS COUMADIN 1 M

ELIQUIS 1 M

ELIQUIS STARTER PACK 1 M

enoxaparin sodium 1 M

fondaparinux sodium 1 M

heparin sod (porcine) in d5w 1 M

heparin sod inj 1000/ml 1 B/D M




HEPARIN SODIUM/NACL 0.45%

1 M

jantoven 1 M

PRADAXA 1 M

warfarin sodium 1 M


27

Drug Name Drug Tier

Requirements/Limits

XARELTO 1 M

XARELTO STARTER PACK 1 M

HEMATOPOIETIC GROWTH FACTORS GRANIX 1 PA

NEUPOGEN 1 PA

PROCRIT 1 PA

MISCELLANEOUS anagrelide hcl 1 M

BERINERT QL (24 boxes / 30 days)

1 QL LA PA

cilostazol 1 M

DROXIA 1 M

ENDARI 1 LA PA

FIRAZYR QL (9 syringes / 30 days)

1 QL PA

HAEGARDA 2000unit QL (30 vials / 30 days)

1 QL LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

1 QL LA PA

icatibant acetate QL (9 syringes / 30 days)

1 QL PA

pentoxifylline TBCR 1 M

PROMACTA PACK QL (360 packets / 30 days)

1 QL LA PA

PROMACTA TABS 12.5mg QL (360 tabs / 30 days)

1 QL LA PA

PROMACTA TABS 25mg QL (180 tabs / 30 days)

1 QL LA PA


1 QL LA PA


1 QL LA PA

tranexamic acid SOLN; TABS

1 M

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 1 M

BRILINTA 1 M

clopidogrel tab 75mg 1 M

prasugrel hcl 1 M

ZONTIVITY 1 M

Drug Name Drug Tier

Requirements/Limits

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) HUMIRA 10mg/0.1ml, 20mg/0.2ml

QL (2 injections / 28 days)

1 QL PA

HUMIRA 40mg/0.4ml QL (6 injections / 28 days)

1 QL PA

HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)

1 QL PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

1 QL PA

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

1 QL PA

HUMIRA PEDIATRIC CROHNS DISEASE

1 PA

HUMIRA PEN QL (6 pens / 28 days)

1 QL PA

HUMIRA PEN CD/UC/HS STARTER

1 PA

HUMIRA PEN INJ CD/UC/HS STARTER

1 PA

HUMIRA PEN INJ PS/UV STARTER

1 PA

HUMIRA PEN-PS/UV STARTER

1 PA

hydroxychloroquine sulfate 1 M

leflunomide TABS 1 M

methotrexate sodium tabs 1 M

REMICADE 1 PA

XATMEP 1 B/D M

XELJANZ QL (60 tabs / 30 days)

1 QL PA

XELJANZ XR QL (30 tabs / 30 days)

1 QL PA

IMMUNOGLOBULINS BIVIGAM 1 PA

CARIMUNE NANOFILTERED 12gm

1 PA

FLEBOGAMMA DIF 1 PA

GAMASTAN S/D 1 B/D

GAMMAGARD LIQUID 1 PA

GAMMAGARD S/D 1 PA

GAMMAKED 1 PA

GAMMAPLEX 1 PA


28

Drug Name Drug Tier

Requirements/Limits

GAMMAPLEX 10GM/100ML 1 PA

GAMUNEX-C 1 PA

OCTAGAM 1 PA

PANZYGA 1 PA

PRIVIGEN 1 PA

IMMUNOMODULATORS ACTIMMUNE 1 LA PA

ARCALYST 1 PA

INTRON-A INJ 10MU 1 B/D M




IMMUNOSUPPRESSANTS azathioprine TABS 1 B/D M

BENLYSTA 1 PA

cyclosporine CAPS; SOLN 1 B/D M

cyclosporine modified (for microemulsion)

1 B/D M

gengraf 1 B/D M

mycophenolate mofetil CAPS; SUSR; TABS

1 B/D M

mycophenolate sodium tbec 1 B/D M

NULOJIX 1 B/D M

PROGRAF PACK 1 B/D M

RAPAMUNE SOLN 1 B/D M

SANDIMMUNE SOLN 100mg/ml

1 B/D M

sirolimus SOLN; TABS 1 B/D M

tacrolimus CAPS 1 B/D M

ZORTRESS TAB 0.5MG 1 B/D M



ZORTRESS TAB 1MG 1 B/D M

VACCINES ACTHIB 1

ADACEL 1

BCG VACCINE 1

BEXSERO 1

BOOSTRIX 1

DAPTACEL 1

DIPHTHERIA/TETANUS TOXOID

1 B/D

ENGERIX-B SUSP 1 B/D

GARDASIL 9 1

HAVRIX 1

HIBERIX 1

IMOVAX RABIES (H.D.C.V.) 1 B/D

INFANRIX 1

Drug Name Drug Tier

Requirements/Limits

IPOL INACTIVATED IPV 1

IXIARO 1

KINRIX 1

M-M-R II 1 M

MENACTRA 1

MENVEO 1

PEDIARIX 1

PEDVAX HIB 1

PENTACEL 1

PROQUAD 1

QUADRACEL 1

RABAVERT 1 B/D

RECOMBIVAX HB 1 B/D

ROTARIX 1

ROTATEQ 1

SHINGRIX QL (2 vials per lifetime)

1 QL

TDVAX 1 B/D

TENIVAC 1 B/D

TRUMENBA 1

TWINRIX INJ 1

TYPHIM VI 1

VAQTA 1

VARIVAX 1

YF-VAX 1

ZOSTAVAX QL (1 vial per lifetime)

1 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 1 M

klor-con 10 1 M

klor-con m10 1 M

klor-con m15 1 M

klor-con m20 1 M

klor-con pak 20meq 1 M

klor-con spr cap 8meq 1 M

klor-con spr cap 10meq 1 M

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

1 M

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

1 M

MAGNESIUM SULFATE IN D5W

1 M


29

Drug Name Drug Tier

Requirements/Limits

magnesium sulfate in dextrose

1 M

magnesium sulfate inj 50% 1 M

potassium chloride CPCR 1 M

potassium chloride PACK 1 M

potassium chloride SOLN 10%, 20%

1 M

potassium chloride TBCR 1 M

potassium chloride microencapsulated crystals er

1 M

potassium chloride tab cr 10 meq

1 M

sodium chloride SOLN 2.5meq/ml

1 M

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

1 M

tpn electrolytes 1 B/D M

IV NUTRITION AMINOSYN II INJ 10% 1 B/D M

AMINOSYN-PF 7% 1 B/D M

AMINOSYN-PF INJ 10% 1 B/D M

CLINIMIX 4.25%/DEXTROSE 5%

1 B/D M

CLINIMIX 4.25%/DEXTROSE 25%

1 B/D M

CLINIMIX 5%/DEXTROSE 15%

1 B/D M


1 B/D M


1 B/D M

CLINIMIX INJ 4.25/D10 1 B/D M

CLINOLIPID 1 B/D M

FREAMINE HBC 6.9% 1 B/D M

FREAMINE III 1 B/D M

hepatamine 1 B/D M

INTRALIPID 30% 1 B/D M

INTRALIPID INJ 20% 1 B/D M

NEPHRAMINE 1 B/D M

NUTRILIPID INJ 20% 1 B/D M

premasol 6% 1 B/D M

PREMASOL 10% 1 B/D M

PROCALAMINE 1 B/D M

PROSOL 1 B/D M

TRAVASOL 1 B/D M

TROPHAMINE INJ 10% 1 B/D M

IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% 1 M

dextrose 5% 1 M

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 5% /ELECTROLYTE

1 M

dextrose 5%/nacl 0.2% 1 M

DEXTROSE 5%/NACL 0.3% 1 M





dextrose 5%/potassium chl 1 M

dextrose 10% flex contain 1 M

DEXTROSE 10%/NACL 0.2% 1 M


dextrose 50% 1 M

dextrose in lactated ringers 1 M

dextrose inj 70% 1 M

IONOSOL-MB/DEXTROSE 5%

1 M

ISOLYTE P 1 M

ISOLYTE S 1 M

kcl0.15%/d5w/nacl0.2% 1 M

KCL 0.3%/D5W/NACL 0.9% 1 M

kcl 0.3%/d5w/nacl 0.45% 1 M

kcl 0.15%/d5w/nacl 0.9% 1 M

KCL 0.15%/D5W/NACL 0.225%

1 M

kcl 0.075%/d5w/nacl 0.45% 1 M

kcl/d5w inj 0.3% 1 M

kcl/d5w/nacl inj 0.22%/0.45% 1 M

kcl/d5w/nacl inj .15/.33% 1 M

kcl/d5w/nacl inj .15/.45% 1 M

kcl/nacl inj 0.3-0.9 1 M

kcl/nacl inj 0.15%-0.9% 1 M

lactated ringer's 1 M

NORMOSOL-M IN D5W 1 M

NORMOSOL-R 1 M

NORMOSOL-R IN D5W 1 M

PLASMA-LYTE A 1 M

PLASMA-LYTE-148 1 M

pot chloride inj 2meq/ml 1 M

potassium chloride SOLN 2meq/ml

1 M

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

1 M

potassium chloride in nacl 1 M

sodium chloride SOLN 3%, 5%

1 M

sodium chloride 0.45% 1 M


30

Drug Name Drug Tier

Requirements/Limits

sodium chloride inj 0.9% 1 M

VITAMINS calcitriol CAPS 1 B/D M

calcitriol inj 1 B/D M

calcitriol oral soln 1 mcg/ml 1 B/D M

M-NATAL PLUS 1 M

paricalcitol CAPS 1 B/D M

PNV FOLIC ACID + IRON MUL

1 M

PRENATAL 1 M

PRENATAL PLUS 1 M

PRENATAL PLUS LOW IRON 1 M

RAYALDEE 1 M

TRICARE 1 M

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1 M

BLEPHAMIDE OINT 1 M

neomycin-polymy-dexameth 1 M

neomycin-polymyxin-hc (ophth)

1 M

sulfacetamide sod-prednisolone

1 M

TOBRADEX OINT 1 M

TOBRADEX ST 1 M

tobramycin-dexamethasone 1 M

ZYLET 1 M

ANTI-INFECTIVES AZASITE 1 M

bacitracin (ophthalmic) 1 M

bacitracin-polymyxin b (ophth) 1 M

BESIVANCE 1 M

CILOXAN OINT 1 M

ciprofloxacin hcl (ophth) 1 M

erythromycin (ophth) 1 M

gatifloxacin (ophth) 1 M

gentak 1 M

gentamicin sulfate soln (ophth)

1 M

MOXEZA 1 M

moxifloxacin hcl (ophth) 1 M

NATACYN 1 M

neomycin-bacitracin zn-polymyxin

1 M

neomycin-polymyxin-gramicidin

1 M

ofloxacin (ophth) 1 M

polymyxin b-trimethoprim 1 M

sulfacetamide sodium (ophth) 1 M

Drug Name Drug Tier

Requirements/Limits

tobramycin (ophth) 1 M

trifluridine 1 M

ZIRGAN 1 M

ANTI-INFLAMMATORIES ALREX 1 M

bromfenac sodium (ophth) 1 M

BROMSITE 1 M

dexamethasone sodium phosphate (ophth)

1 M

diclofenac sodium (ophth) 1 M

DUREZOL 1 M

fluorometholone 1 M

flurbiprofen sodium 1 M

ILEVRO 1 M

ketorolac tromethamine (ophth)

1 M

LOTEMAX 1 M

loteprednol etabonate 1 M

prednisolone acetate (ophth) 1 M

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

1 M

PROLENSA 1 M

ANTIALLERGICS azelastine drop 0.05% 1 M

BEPREVE 1 M

cromolyn sodium (ophth) 1 M

LASTACAFT 1 M

olopatadine hcl 0.2% 1 M

PAZEO 1 M

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 1 M

AZOPT 1 M

betaxolol hcl (ophth) 1 M

BETOPTIC-S 1 M

brimonidine sol 0.2% 1 M

brimonidine sol 0.15% 1 M

carteolol hcl (ophth) 1 M

COMBIGAN 1 M

dorzolamide hcl 1 M

dorzolamide hcl-timolol maleate

1 M

latanoprost SOLN 1 M

levobunolol hcl 1 M

LUMIGAN 1 M

PHOSPHOLINE IODIDE 1 M

pilocarpine hcl SOLN 1 M

RHOPRESSA 1 M

SIMBRINZA 1 M

timolol maleate (ophth) soln 1 M


31

Drug Name Drug Tier

Requirements/Limits

timolol maleate gel 1 M

timolol maleate ophth soln 0.5% (once-daily)

1 M

TRAVATAN Z 1 M

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

1 M

CYSTARAN 1 LA PA

proparacaine hcl SOLN 1 M

RESTASIS QL (60 single use vials / 30 days)

1 QL M

RESTASIS MULTIDOSE QL (1 bottle / 30 days)

1 QL M

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

QL (60 blisters / 30 days)

1 QL M

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

1 QL M

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

1 QL M

ipratropium-albuterol nebu 1 B/D M

TRELEGY ELLIPTA QL (60 blisters / 30 days)

1 QL M

ANTICHOLINERGICS ATROVENT HFA

QL (2 inhalers / 30 days) 1 QL M

INCRUSE ELLIPTA QL (30 blisters / 30 days)

1 QL M

ipratropium bromide SOLN 1 B/D M

ipratropium bromide (nasal) 1 M

ANTIHISTAMINES azelastine spr 0.1% 1 M

azelastine spr 0.15% 1 M

cetirizine syrup 1 M

cyproheptadine hcl SYRP; TABS


1 M PA

diphenhydramine hcl inj 50mg/ml

1 M

hydroxyzine hcl SYRP; TABS


1 M PA

hydroxyzine hcl inj PA if 70 years and older

1 M PA

Drug Name Drug Tier

Requirements/Limits

hydroxyzine pamoate CAPS 25mg, 50mg


1 M PA

levocetirizine dihydrochloride 1 M

BETA AGONISTS albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Proair HFA)

1 QL M

albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Ventolin HFA)

1 QL M

albuterol sulfate NEBU 1 B/D M

albuterol sulfate SYRP 1 M

albuterol sulfate TABS 1 M

albuterol sulfate TB12 1 M

levalbuterol hcl NEBU 1 B/D M

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml

1 B/D M

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

1 QL M

SEREVENT DISKUS QL (60 inhalations / 30 days)

1 QL M

terbutaline sulfate TABS 1 M

VENTOLIN HFA QL (2 inhalers / 30 days)

1 QL M

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS

1 M

zafirlukast 1 M

MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml 1 B/D M

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D M

ARALAST NP 1 LA PA

DALIRESP 1 M

epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

(generic of EpiPen)

1 M

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

1 M

ESBRIET 1 PA

KALYDECO 1 PA

OFEV 1 PA

ORKAMBI 1 PA

PROLASTIN-C 1 LA PA


32

Drug Name Drug Tier

Requirements/Limits

PULMOZYME 1 PA

SYMDEKO 1 LA PA

SYMJEPI 1 M

THEO-24 1 M

theophylline sol 80/15ml 1 M

theophylline tb12 300 mg 1 M

theophylline tb12 450 mg 1 M

theophylline tb24 1 M

XOLAIR 1 LA PA

ZEMAIRA 1 LA PA

NASAL STEROIDS flunisolide (nasal)

QL (3 bottles / 30 days) 1 QL M

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL M

STEROID INHALANTS ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

1 QL M

budesonide (inhalation) .25mg/2ml, .5mg/2ml

1 B/D M

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


1 QL M

FLOVENT DISKUS 250mcg/blist


1 QL M

FLOVENT HFA QL (2 inhalers / 30 days)

1 QL M

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

1 QL M

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


1 QL M

ADVAIR HFA QL (1 inhaler / 30 days)

1 QL M

BREO ELLIPTA QL (60 blisters / 30 days)

1 QL M

SYMBICORT QL (1 inhaler / 30 days)

1 QL M

TOPICAL DERMATOLOGY, ACNE amnesteem 1 M PA

avita 1 M PA

Drug Name Drug Tier

Requirements/Limits

benzoyl peroxide-erythromycin

1 M

claravis 1 M PA

clindacin-p 1 M

clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB

1 M

ery pad 2% 1 M

erythromycin (acne aid) 1 M

isotretinoin CAPS 1 M PA

myorisan 1 M PA

sulfacetamide sodium (acne) 1 M

tretinoin CREA 1 M PA

tretinoin GEL .01%, .025% 1 M PA

zenatane 1 M PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) 1 M

mupirocin OINT 1 M

silver sulfadiazine CREA 1 M

ssd 1 M

SULFAMYLON CREA 1 M

DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; GEL; SUSP

1 M

ciclopirox shampoo 1% 1 M

clotrimazole (topical) 1 M

clotrimazole w/ betamethasone CREA

1 M

ketoconazole cream 1 M

nyamyc 1 M

nystatin (topical) 1 M

nystop 1 M

DERMATOLOGY, ANTIPSORIATICS acitretin 1 M PA

calcipotriene CREA; OINT QL (120 gm / 30 days)

1 QL M PA

calcipotriene SOLN QL (120 mL / 30 days)

1 QL M PA

calcitrene QL (120 gm / 30 days)

1 QL M PA

tazarotene CREA 1 M PA

TAZORAC CREA .05% 1 M PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 M

selenium sulfide LOTN 1 M

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 M

alclometasone dipropionate 1 M


33

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate (topical)

1 M

betamethasone dipropionate augmented

1 M

betamethasone valerate CREA; LOTN; OINT

1 M

ENSTILAR 1 M PA

fluocinolone acetonide CREA; OIL; OINT; SOLN

1 M

fluocinolone acetonide oil body

1 M

fluocinonide CREA .05% 1 M

fluocinonide GEL 1 M

fluocinonide SOLN 1 M

fluocinonide emulsified base 1 M

fluticasone propionate CREA; OINT

1 M

halobetasol propionate CREA; OINT

1 M

hydrocortisone (topical) CREA

1 M

hydrocortisone (topical) LOTN

1 M

hydrocortisone (topical) OINT 2.5%

1 M

hydrocortisone butyrate cream 0.1%

1 M

hydrocortisone butyrate oint 0.1%

1 M

hydrocortisone valerate 1 M

mometasone furoate CREA; OINT; SOLN

1 M

TEXACORT SOLN 2.5% 1 M

triamcinolone acetonide (topical) CREA; LOTN; OINT

1 M

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 1 QL M PA

lidocaine PTCH QL (3 patches / 1 day)

1 QL M PA

lidocaine hcl GEL QL (30 mL / 30 days)

1 QL M PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

1 QL M PA

lidocaine oint 5% QL (50 grams / 30 days)

1 QL M PA

lidocaine-prilocaine QL (30 grams / 30 days)

1 QL M PA

Drug Name Drug Tier

Requirements/Limits

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

1 M

diclofenac sodium (topical) 1% gel

1 M PA

fluorouracil (topical) CREA 5%

1 M

fluorouracil (topical) SOLN 1 M

imiquimod CREA 5% 1 M

metronidazole (topical) CREA; LOTN

1 M

metronidazole gel 0.75% 1 M

PANRETIN 1 M

PICATO .05% QL (2 tubes / 30 days)

1 QL M

PICATO .015% QL (3 tubes / 30 days)

1 QL M

podofilox SOLN 1 M

procto-med hc 1 M

procto-pak 1 M

proctosol hc cre 2.5% 1 M

proctozone-hc 1 M

rosadan cre 0.75% 1 M

tacrolimus (topical) 1 M

TARGRETIN GEL 1 PA

VALCHLOR 1 LA PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion 1 M

permethrin cre 5% 1 M

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1 M

REGRANEX 1 M PA

SANTYL 1 M

sodium chlor sol 0.9% irr 1 M

water for irrigation, sterile 1 M

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 1 M

chlorhexidine gluconate (mouth-throat)

1 M

clotrimazole LOZG 1 M

lidocaine hcl (mouth-throat) 1 M

nystatin (mouth-throat) 1 M

paroex sol 0.12% 1 M

periogard 1 M

pilocarpine hcl (oral) 1 M

triamcinolone acetonide (mouth)

1 M


34

Drug Name Drug Tier

Requirements/Limits

OTIC acetic acid (otic) 1 M

CIPRODEX 1 M

flac 1 M

fluocinolone acetonide (otic) 1 M

neomycin-polymyxin-hc (otic) 1 M

ofloxacin (otic) 1 M

35

Index A abacavir sulfate ...................4 abacavir sulfate-lamivudine.4 abacavir sulfate-lamivudine-zidovudine ..........................................4 ABELCET............................3 ABILIFY MAINTENA ......... 15 abiraterone acetate .............7 ABRAXANE ........................6 acamprosate calcium ........ 19 acarbose ........................... 20 acebutolol hcl .................... 10 acetaminophen w/ codeine 300-15mg ............................1 acetaminophen w/ codeine 300-30mg ............................1 acetaminophen w/ codeine 300-60mg ............................1 acetaminophen w/ codeine soln .....................................1 acetazolamide ................... 11 acetic acid ......................... 33 acetic acid (otic) ................ 34 acetylcysteine ................... 31 acitretin ............................. 32 ACTHIB ............................. 28 ACTIMMUNE .................... 28 acyclovir ..............................5 acyclovir sodium .................5 ADACEL............................ 28 adefovir dipivoxil .................5 ADEMPAS ........................ 11 adriamycin...........................6 adrucil .................................6 adrucil inj .............................6 ADVAIR DISKUS .............. 32 ADVAIR HFA .................... 32 AFINITOR ...........................7 AFINITOR DISPERZ ...........7 AIMOVIG........................... 18 ala-cort .............................. 32 albendazole .........................3 albuterol sulfate ................. 31 alclometasone dipropionate .......................................... 32 ALCOHOL SWABS ........... 19 ALDURAZYME ................. 23 ALECENSA .........................7

alendronate sodium .......... 21 alfuzosin hcl ...................... 26 ALIMTA ............................... 6 ALINIA ................................ 3 aliskiren fumarate ............. 11 allopurinol tab ..................... 1 alosetron hcl ..................... 25 ALPHAGAN P SOL 0.1% .. 30 alprazolam tab 0.25mg ..... 12 alprazolam tab 0.5mg ....... 12 alprazolam tab 1mg .......... 12 alprazolam tab 2 mg ......... 12 ALREX .............................. 30 altavera tab ....................... 21 ALUNBRIG ......................... 7 alyacen 1/35 ..................... 22 amantadine hcl ................. 14 AMBISOME ........................ 3 ambrisentan ...................... 11 amethia ............................. 22 amethia lo ......................... 22 amikacin sulfate .................. 2 amiloride & hydrochlorothiazide ........... 11 amiloride hcl ...................... 11 AMINOSYN II INJ 10% ..... 29 AMINOSYN-PF 7% ........... 29 AMINOSYN-PF INJ 10% .. 29 amiodarone hcl soln ............ 9 amiodarone tab 100mg ....... 9 amiodarone tab 200mg ....... 9 amiodarone tab 400mg ....... 9 AMITIZA CAP 24MCG ...... 26 AMITIZA CAP 8MCG ........ 26 amitriptyline hcl ................. 14 amlodipine besylate .......... 10 amlodipine besylate-benazepril hcl cap 10-20 mg ............................. 9 amlodipine besylate-benazepril hcl cap 10-40 mg ............................. 9 amlodipine besylate-benazepril hcl cap 2.5-10 mg ............................ 9 amlodipine besylate-benazepril hcl cap 5-10 mg ............................... 9 amlodipine

besylate-benazepril hcl cap 5-20 mg .............................. 9 amlodipine besylate-benazepril hcl cap 5-40 mg .............................. 9 amlodipine besylate-olmesartan medoxomil .......................... 9 amlodipine besylate-valsartan tab ......... 9 amlodipine-valsartan-hydrochlorothiazide tab ................. 9 ammonium lactate ............ 33 amnesteem ....................... 32 amoxapine ........................ 14 amoxicillin ........................... 6 amoxicillin & pot clavulanate............................................ 6 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 17 amphetamine-dextroamphetamine tab 10 mg ............... 17 amphetamine-dextroamphetamine tab 12.5 mg ............ 17 amphetamine-dextroamphetamine tab 15 mg ............... 17 amphetamine-dextroamphetamine tab 20 mg ............... 17 amphetamine-dextroamphetamine tab 30 mg ............... 17 amphetamine-dextroamphetamine tab 5 mg ................. 17 amphetamine-dextroamphetamine tab 7.5 mg .............. 17 amphotericin b .................... 3 ampicillin & sulbactam sodium ................................ 6 ampicillin cap 500mg .......... 6 ampicillin inj ........................ 6

36

ampicillin sodium .................6 ANADROL-50 ................... 19 anagrelide hcl .................... 27 anastrozole .........................7 ANDRODERM .................. 19 ANORO ELLIPTA ............. 31 APOKYN ........................... 14 aprepitant .......................... 25 aprepitant pak 80mg & 125mg ............................... 25 apri .................................... 22 APRISO ............................ 25 APTIOM ............................ 12 APTIVUS.............................4 ARALAST NP .................... 31 aranelle ............................. 22 ARCALYST ....................... 28 aripiprazole odt ................. 15 aripiprazole oral solution 1 mg/ml ................................ 15 aripiprazole tab ................. 15 ARISTADA ........................ 15 ARISTADA INITIO ............ 15 armodafinil ........................ 19 ARNUITY ELLIPTA ........... 32 ashlyna ............................. 22 aspirin-dipyridamole .......... 27 atazanavir sulfate ................4 atenolol ............................. 10 atenolol & chlorthalidone ... 10 atomoxetine hcl ................. 17 atorvastatin calcium .......... 10 atovaquone .........................3 atovaquone-proguanil hcl ....3 ATRIPLA .............................4 ATROPINE SULFATE ...... 31 ATROVENT HFA .............. 31 aubra ................................. 22 AURYXIA .......................... 24 AUSTEDO ......................... 18 AVASTIN.............................7 aviane ............................... 22 avita .................................. 32 azacitidine ...........................6 AZACTAM INJ ....................3 AZASITE ........................... 30 azathioprine ...................... 28 azelastine drop 0.05% ...... 30 azelastine spr 0.1% ........... 31 azelastine spr 0.15% ......... 31

azithromycin ........................ 5 AZOPT .............................. 30 aztreonam ........................... 3 B bacitracin (ophthalmic) ...... 30 bacitracin-polymyxin b (ophth) .............................. 30 bacitracin-poly-neomycin-hc .......................................... 30 baclofen ............................ 18 balsalazide disodium......... 25 BALVERSA ......................... 7 balziva ............................... 22 BANZEL SUS 40MG/ML ... 12 BANZEL TAB 200MG ....... 12 BANZEL TAB 400MG ....... 12 BARACLUDE ...................... 5 BASAGLAR KWIKPEN ..... 19 BCG VACCINE ................. 28 BD ULTRAFINE INSULIN SYRINGE .......................... 19 BD ULTRAFINE/NANO PEN NEEDLES ......................... 19 bekyree ............................. 22 benazepril & hydrochlorothiazide ............. 9 benazepril hcl ...................... 9 BENDEKA ........................... 6 BENLYSTA ....................... 28 benzoyl peroxide-erythromycin ...... 32 benztropine mesylate inj ... 14 benztropine mesylate tab 0.5mg ................................ 14 benztropine mesylate tab 1mg ................................... 14 benztropine mesylate tab 2mg ................................... 15 BEPREVE ......................... 30 BERINERT ........................ 27 BESIVANCE ..................... 30 betamethasone dipropionate (topical) ............................. 33 betamethasone dipropionate augmented ........................ 33 betamethasone valerate ... 33 BETASERON .................... 18 betaxolol hcl ...................... 10 betaxolol hcl (ophth) ......... 30 bethanechol chloride ......... 26

BETOPTIC-S .................... 30 BEVESPI AEROSPHERE 31 bexarotene .......................... 8 BEXSERO ........................ 28 bicalutamide ....................... 7 BICILLIN L-A ...................... 6 BIKTARVY .......................... 4 bisoprolol & hydrochlorothiazide ........... 10 bisoprolol fumarate ........... 10 BIVIGAM ........................... 27 bleomycin sulfate ................ 6 BLEPHAMIDE .................. 30 blisovi 24 fe ....................... 22 blisovi fe 1.5/30 ................. 22 BOOSTRIX ....................... 28 BORTEZOMIB .................... 7 bosentan ........................... 11 BOSULIF ............................ 7 BRAFTOVI .......................... 7 BREO ELLIPTA ................ 32 briellyn .............................. 22 BRILINTA ......................... 27 brimonidine sol 0.15% ...... 30 brimonidine sol 0.2% ........ 30 BRIVIACT INJ 50MG/5ML 12 BRIVIACT SOL 10MG/ML 12 BRIVIACT TAB 100MG .... 12 BRIVIACT TAB 10MG ...... 12 BRIVIACT TAB 25MG ...... 12 BRIVIACT TAB 50MG ...... 12 BRIVIACT TAB 75MG ...... 12 bromfenac sodium (ophth) 30 bromocriptine mesylate ..... 15 BROMSITE ....................... 30 budesonide (inhalation) .... 32 budesonide ec .................. 25 bumetanide inj 0.25/ml ...... 11 bumetanide tab ................. 11 buprenorphine hcl ............. 19 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 19 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 19 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 19 buprenorphine hcl-naloxone hcl dihydrate 8-2mg .......... 19 buprenorphine hcl-naloxone hcl sl ................................. 19

37

bupropion hcl .................... 14 bupropion hcl (smoking deterrent) .......................... 19 buspirone hcl ..................... 12 butorphanol tartrate .............1 BYDUREON BCISE .......... 19 BYDUREON INJ ............... 19 BYDUREON PEN ............. 19 BYETTA ............................ 19 BYSTOLIC ........................ 10 C cabergoline ....................... 24 CABOMETYX .....................7 calcipotriene ...................... 32 calcitonin (salmon) ............ 24 calcitrene........................... 32 calcitriol ............................. 30 calcitriol inj ........................ 30 calcitriol oral soln 1 mcg/ml .......................................... 30 calcium acetate (phosphate binder) ............................... 24 CALQUENCE ......................7 camila ............................... 22 camrese lo ........................ 22 candesartan cilexetil ...........9 candesartan cilexetil-hydrochlorothiazide 9 CAPRELSA .........................7 captopril ..............................9 captopril & hydrochlorothiazide .............9 CARBAGLU ...................... 23 carbamazepine ................. 12 carbidopa/levodopa/entacapone .................................... 15 carbidopa-levodopa .......... 15 carboplatin ..........................8 CARIMUNE NANOFILTERED .............. 27 carisoprodol ...................... 18 carteolol hcl (ophth) .......... 30 cartia xt ............................. 10 carvedilol ........................... 10 caspofungin acetate ............3 CAYSTON ...........................3 caziant pak ........................ 22 cefaclor ...............................5 CEFACLOR ER TAB 500MG ............................................5

cefadroxil ............................ 5 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% .................. 5 cefazolin inj ......................... 5 cefazolin sodium ................. 5 CEFAZOLIN SODIUM 1 GM/50ML ............................ 5 cefdinir ................................ 5 cefepime for inj ................... 5 cefixime cap 400mg ............ 5 cefixime susr ....................... 5 cefotaxime sodium .............. 5 cefoxitin for inj ..................... 5 cefpodoxime proxetil ........... 5 cefprozil .............................. 5 ceftazidime .......................... 5 CEFTAZIDIME/DEXTROSE ............................................ 5 ceftriaxone sodium .............. 5 cefuroxime axetil ................. 5 cefuroxime sodium .............. 5 celecoxib ............................. 1 CELONTIN ........................ 12 cephalexin ........................... 5 CERDELGA ...................... 23 CEREZYME ...................... 23 cetirizine syrup .................. 31 cevimeline hcl ................... 33 CHANTIX .......................... 19 CHANTIX CONTINUING MONTH ............................. 19 CHANTIX STARTER PACK .......................................... 19 CHEMET ........................... 21 chlorhexidine gluconate (mouth-throat) ................... 33 chloroquine phosphate........ 3 chlorothiazide tabs ............ 11 chlorpromazine hcl ............ 15 CHLORPROMAZINE INJ .. 15 chlorthalidone ................... 11 cholestyramine .................. 10 cholestyramine light .......... 10 ciclopirox ........................... 32 ciclopirox shampoo 1% ..... 32 cilostazol ........................... 27 CILOXAN .......................... 30 CIMDUO ............................. 4 cinacalcet hcl .................... 21 CIPRODEX ....................... 34

ciprofloxacin ........................ 5 ciprofloxacin hcl (ophth) .... 30 ciprofloxacin hcl tab ............ 5 ciprofloxacin in d5w ............ 5 cisplatin ............................... 8 citalopram hydrobromide .. 14 claravis ............................. 32 clarithromycin ..................... 5 clarithromycin er ................. 5 clarithromycin for susp ........ 5 clindacin-p ........................ 32 clindamycin cap 300 mg ..... 3 clindamycin cap 75mg ........ 3 clindamycin hcl cap 150 mg 3 clindamycin phosphate (topical) ............................. 32 clindamycin phosphate in d5w ..................................... 3 CLINDAMYCIN PHOSPHATE IN NACL ...... 3 clindamycin phosphate inj ... 3 clindamycin phosphate vaginal .............................. 26 clindamycin soln 75mg/5ml . 3 CLINIMIX 4.25%/DEXTROSE 25% ... 29 CLINIMIX 4.25%/DEXTROSE 5% ..... 29 CLINIMIX 5%/DEXTROSE 15% .................................. 29 CLINIMIX 5%/DEXTROSE 20% .................................. 29 CLINIMIX 5%/DEXTROSE 25% .................................. 29 CLINIMIX INJ 4.25/D10 .... 29 CLINOLIPID ...................... 29 clobazam .......................... 12 clomipramine hcl ............... 14 clonazepam ...................... 12 clonidine hcl ...................... 11 clonidine hcl ptwk.............. 11 clopidogrel tab 75mg ........ 27 clorazepate dipotassium ... 12 clotrimazole ...................... 33 clotrimazole (topical) ......... 32 clotrimazole w/ betamethasone ................. 32 clozapine odt .................... 15 clozapine tab 100mg ......... 15 clozapine tab 200mg ......... 15

38

clozapine tab 25mg ........... 15 clozapine tab 50mg ........... 15 COARTEM ..........................3 colchicine w/ probenecid .....1 COLCRYS ...........................1 colesevelam hcl ................ 10 colestipol hcl gran ............. 10 colestipol hcl pack ............. 10 colestipol hcl tabs .............. 10 colistimethate sodium .........3 colocort ............................. 25 COMBIGAN ...................... 30 COMBIVENT RESPIMAT . 31 COMETRIQ .........................7 COMPLERA ........................4 compro supp ..................... 25 constulose ......................... 25 COPIKTRA ..........................7 CORLANOR SOLN ........... 11 CORLANOR TABS ........... 11 cortisone acetate ............... 24 COTELLIC ..........................7 COUMADIN ...................... 26 CREON ............................. 26 CRIXIVAN ...........................4 cromolyn sod neb 20mg/2ml .......................................... 31 cromolyn sodium (mastocytosis) ................... 26 cromolyn sodium (ophth) .. 30 cryselle-28......................... 22 cyclafem 1/35 .................... 22 cyclafem 7/7/7 ................... 22 cyclobenzaprine hcl .......... 18 cyclophosphamide ..............6 cycloserine ..........................4 cyclosporine ...................... 28 cyclosporine modified (for microemulsion) .................. 28 cyproheptadine hcl ............ 31 cyred tab ........................... 22 CYSTADANE .................... 23 CYSTAGON ...................... 23 CYSTARAN ...................... 31 cytarabine ...........................6 D dacarbazine ........................6 dalfampridine .................... 18 DALIRESP ........................ 31 danazol ............................. 23

dantrolene sodium ............ 18 dapsone .............................. 3 DAPTACEL ....................... 28 daptomycin ......................... 3 DAPTOMYCIN .................... 3 dasetta 1/35 ...................... 22 dasetta 7/7/7 ..................... 22 DAURISMO ........................ 7 deblitane ........................... 22 DELESTROGEN ............... 23 DELSTRIGO ....................... 4 delyla ................................ 22 DELZICOL ........................ 25 DEMSER .......................... 11 DEPEN TITRATABS ......... 21 DEPO-PROVERA INJ 400/ML ................................ 7 DESCOVY .......................... 4 desipramine hcl ................. 14 desmopressin acetate spray .......................................... 25 desmopressin acetate spray refrigerated ....................... 25 desmopressin acetate tabs .......................................... 25 desmopressin inj 4mcg/ml 25 desogestrel & ethinyl estradiol ............................ 22 desogestrel-ethinyl estradiol (biphasic) .......................... 22 desvenlafaxine succinate .. 14 dexamethasone ................ 24 DEXAMETHASONE ......... 24 dexamethasone sodium phosphate ......................... 24 dexamethasone sodium phosphate (ophth) ............. 30 DEXILANT ........................ 26 dexmethylphenidate hcl .... 17 dexrazoxane hcl .................. 8 dextrose 10% flex contain . 29 DEXTROSE 10%/NACL 0.2%.................................. 29 dextrose 10%/nacl 0.45% . 29 dextrose 2.5%/nacl 0.45% 29 dextrose 5% ...................... 29 DEXTROSE 5% /ELECTROLYTE ............... 29 dextrose 5%/nacl 0.2% ..... 29 dextrose 5%/nacl 0.225% . 29

DEXTROSE 5%/NACL 0.3%.......................................... 29 dextrose 5%/nacl 0.33% ... 29 dextrose 5%/nacl 0.45% ... 29 dextrose 5%/nacl 0.9% ..... 29 dextrose 5%/potassium chl.......................................... 29 dextrose 50% .................... 29 dextrose in lactated ringers.......................................... 29 dextrose inj 70% ............... 29 DIASTAT ACUDIAL .......... 12 DIASTAT PEDIATRIC ...... 12 diazepam .......................... 12 diazepam gel .................... 12 diazepam inj ..................... 12 diazepam intensol ............. 12 diazepam oral soln 1 mg/ml.......................................... 12 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 30 diclofenac sodium (topical) 1% gel ............................... 33 dicloxacillin sodium ............. 6 dicyclomine hcl cap 10mg . 25 dicyclomine hcl soln 10mg/5ml .......................... 25 dicyclomine hcl tab 20mg . 25 didanosine .......................... 4 DIFICID ............................... 5 diflunisal .............................. 1 digitek ............................... 11 digox ................................. 11 digoxin .............................. 11 digoxin inj .......................... 11 digoxin sol 50mcg/ml ........ 11 dihydroergotamine mesylate inj 1 mg/ml ........................ 18 dihydroergotamine mesylate nasal ................................. 18 DILANTIN CAP 100MG .... 12 DILANTIN CAP 30MG ...... 12 DILANTIN CHEW TAB 50MG ................................ 12 DILANTIN-125 SUSP ....... 12 diltiazem cap 180mg cd .... 10 diltiazem cap 240mg cd .... 10 diltiazem cap 360mg cd .... 10 diltiazem cap er/12hr ........ 10

39

diltiazem hcl ...................... 10 diltiazem hcl coated beads cap sr 24hr ........................ 10 diltiazem hcl extended release beads cap sr ......... 10 diltiazem inj ....................... 10 dilt-xr cap .......................... 10 diphenhydramine hcl inj 50mg/ml ............................ 31 diphenoxylate w/ atropine . 26 DIPHTHERIA/TETANUS TOXOID ............................ 28 disopyramide phosphate .....9 disulfiram........................... 19 divalproex sodium ............. 12 docetaxel.............................6 DOCETAXEL ......................6 dofetilide..............................9 donepezil hydrochloride .... 13 dorzolamide hcl ................. 30 dorzolamide hcl-timolol maleate ............................. 30 DOVATO .............................4 doxazosin mesylate ............9 doxepin hcl ........................ 14 doxorubicin hcl ....................6 doxorubicin hcl liposomal ....6 doxy 100 .............................6 doxycycline (monohydrate) .6 doxycycline hyclate .............6 doxycycline hyclate 100 mg 6 doxycycline hyclate 20 mg ..6 dronabinol ......................... 25 drospirenone-ethinyl estradiol ............................ 22 drospirenone-ethinyl estradiol-levomefolate calcium .............................. 22 DROXIA ............................ 27 duloxetine hcl .................... 14 DUREZOL ......................... 30 dutasteride ........................ 26 dutasteride-tamsulosin hcl 26 E e.e.s. 400 ............................5 EDURANT ...........................4 efavirenz .............................4 eletriptan hydrobromide .... 18 ELIQUIS ............................ 26 ELIQUIS STARTER PACK

.......................................... 26 ELLA ................................. 22 EMCYT ............................... 6 EMEND ............................. 25 EMGALITY ........................ 18 emoquette ......................... 22 EMSAM ............................. 14 EMTRIVA ............................ 4 EMVERM ............................ 3 enalapril maleate ................ 9 enalapril maleate & hydrochlorothiazide ............. 9 ENDARI ............................ 27 endocet 10-325mg .............. 1 endocet 2.5-325mg ............. 1 endocet 5-325mg ................ 1 endocet 7.5-325mg ............. 1 ENGERIX-B ...................... 28 enoxaparin sodium ........... 26 enpresse-28 ...................... 22 enskyce ............................. 22 ENSTILAR ........................ 33 entacapone ....................... 15 entecavir ............................. 5 ENTRESTO ........................ 9 enulose ............................. 25 EPCLUSA ........................... 5 EPIDIOLEX ....................... 12 epinephrine (anaphylaxis) . 31 epirubicin hcl ....................... 6 epitol ................................. 12 EPIVIR HBV ........................ 5 eplerenone .......................... 9 eprosartan mesylate ........... 9 ergotamine w/ caffeine ...... 18 ERIVEDGE ......................... 7 ERLEADA ........................... 7 erlotinib hcl .......................... 7 errin................................... 22 ertapenem sodium .............. 3 ery pad 2% ........................ 32 ery-tab ................................. 5 ERYTHROCIN LACTOBIONATE ................ 5 erythrocin stearate .............. 5 erythromycin (acne aid) .... 32 erythromycin (ophth) ......... 30 erythromycin base .............. 5 erythromycin cap 250mg ec 5 erythromycin ethylsuccinate 5

erythromycin tab ec ............ 5 ESBRIET .......................... 31 escitalopram oxalate ......... 14 esomeprazole magnesium 26 esomeprazole sodium inj .. 26 estarylla tab 0.25-35 ......... 22 estradiol ............................ 23 estradiol vaginal cream ..... 23 estradiol vaginal tab .......... 23 estradiol valerate inj .......... 23 eszopiclone ....................... 17 ethambutol hcl .................... 4 ethosuximide .................... 12 ethynodiol diacet & eth estrad ................................ 22 ethynodiol tab 1-50 ........... 22 etodolac .............................. 1 etoposide ............................ 8 EVOTAZ ............................. 4 exemestane ........................ 7 ezetimibe .......................... 10 ezetimibe-simvastatin ....... 10 F FABRAZYME .................... 23 falmina .............................. 22 famciclovir ........................... 5 famotidine ......................... 25 famotidine in nacl .............. 25 famotidine inj .................... 25 FANAPT ........................... 15 FANAPT TITRATION PACK.......................................... 15 FARXIGA .......................... 20 FARYDAK ........................... 7 FASLODEX ........................ 7 fayosim ............................. 22 febuxostat ........................... 1 felbamate .......................... 12 felodipine .......................... 10 femynor ............................. 22 fenofibrate ......................... 10 fenofibrate micronized ...... 10 fentanyl citrate .................... 1 fentanyl patch 100 mcg/hr .. 1 fentanyl patch 12 mcg/hr .... 1 fentanyl patch 25 mcg/hr .... 1 fentanyl patch 50 mcg/hr .... 1 fentanyl patch 75 mcg/hr .... 1 FENTORA .......................... 1 FETZIMA .......................... 14

40

FETZIMA TITRATION PACK .......................................... 14 FIASP ............................... 19 FIASP FLEXTOUCH ......... 19 finasteride ......................... 26 FIRAZYR........................... 27 flac .................................... 34 FLEBOGAMMA DIF .......... 27 flecainide acetate ................9 FLOVENT DISKUS ........... 32 FLOVENT HFA ................. 32 fluconazole ..........................3 fluconazole inj nacl 200 .......3 fluconazole inj nacl 400 .......3 flucytosine ...........................3 fludrocortisone acetate ...... 24 flunisolide (nasal) .............. 32 fluocinolone acetonide ...... 33 fluocinolone acetonide (otic) .......................................... 34 fluocinolone acetonide oil body .................................. 33 fluocinonide ....................... 33 fluocinonide emulsified base .......................................... 33 fluorometholone ................ 30 fluorouracil ..........................6 fluorouracil (topical) ........... 33 fluoxetine cap 10mg .......... 14 fluoxetine cap 20mg .......... 14 fluoxetine cap 40mg .......... 14 fluoxetine hcl ..................... 14 fluphenazine decanoate .... 15 fluphenazine hcl ................ 15 flurbiprofen ..........................1 flurbiprofen sodium ........... 30 flutamide .............................7 fluticasone propionate ....... 33 fluticasone propionate (nasal) ............................... 32 fluvoxamine maleate ......... 12 fondaparinux sodium ......... 26 FORTEO ........................... 24 fosamprenavir tab 700 mg ..4 fosinopril sodium .................9 fosinopril sodium & hydrochlorothiazide .............9 FREAMINE HBC 6.9% ...... 29 FREAMINE III ................... 29 fulvestrant ...........................7

furosemide ........................ 11 furosemide inj ................... 11 FUZEON ............................. 4 fyavolv ............................... 23 FYCOMPA ........................ 12 G gabapentin ........................ 12 galantamine hydrobromide 13 galantamine hydrobromide er ...................................... 13 GAMASTAN S/D ............... 27 GAMMAGARD LIQUID ..... 27 GAMMAGARD S/D ........... 27 GAMMAKED ..................... 27 GAMMAPLEX ................... 27 GAMMAPLEX 10GM/100ML .......................................... 28 GAMUNEX-C .................... 28 ganciclovir sodium .............. 5 GARDASIL 9 ..................... 28 gatifloxacin (ophth) ........... 30 GATTEX ........................... 26 GAUZE PADS 2 ................ 19 gavilyte-c ........................... 25 gavilyte-g .......................... 25 gavilyte-n/flavor pack ........ 25 gemcitabine inj soln ............ 6 gemcitabine inj solr ............. 6 gemfibrozil ........................ 10 generlac ............................ 25 gengraf .............................. 28 GENOTROPIN .................. 24 GENOTROPIN MINIQUICK .......................................... 24 gentak ............................... 30 gentamicin in saline ............ 2 gentamicin sulfate ............... 2 gentamicin sulfate (topical) .......................................... 32 gentamicin sulfate soln (ophth) .............................. 30 GENVOYA .......................... 4 GEODON .......................... 15 gianvi tab 3-0.02mg .......... 22 GILENYA .......................... 18 GILOTRIF TAB 20MG......... 8 GILOTRIF TAB 30MG......... 8 GILOTRIF TAB 40MG......... 8 glatiramer acetate 20mg/ml .......................................... 18

glatiramer acetate 40mg/ml.......................................... 18 glatopa .............................. 18 GLEOSTINE ....................... 6 glimepiride ........................ 20 glip/metform tab 2.5-250mg.......................................... 20 glip/metform tab 2.5-500mg.......................................... 20 glip/metform tab 5-500mg . 20 glipizide ............................. 20 glipizide xl ......................... 20 GLUCAGEN HYPOKIT ..... 24 GLUCAGON EMERGENCY KIT .................................... 24 glyburide ........................... 20 glyburide micronized ......... 20 glyburide-metformin tab 1.25-250 mg ..................... 20 glyburide-metformin tab 2.5-500 mg ....................... 20 glyburide-metformin tab 5-500mg ........................... 20 glycopyrrolate tab 1mg ..... 25 glycopyrrolate tab 2mg ..... 25 glydo ................................. 33 GOLYTELY ....................... 25 granisetron hcl .................. 25 GRANIX ............................ 27 griseofulvin microsize ......... 3 griseofulvin ultramicrosize .. 3 guanfacine er (adhd) ......... 17 H HAEGARDA ..................... 27 hailey 24 fe ....................... 22 halobetasol propionate ..... 33 haloperidol ........................ 15 haloperidol conc 2mg/ml ... 15 haloperidol decanoate ...... 15 haloperidol lactate inj 5mg/ml.......................................... 15 HARVONI TAB 90-400MG . 5 HAVRIX ............................ 28 heather ............................. 22 heparin sod (porcine) in d5w.......................................... 26 heparin sod inj 1000/ml ..... 26 heparin sod inj 10000/ml ... 26 heparin sod inj 20000/ml ... 26 heparin sod inj 5000/ml ..... 26

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HEPARIN SODIUM/NACL 0.45% ................................ 26 hepatamine ....................... 29 HERCEPTIN .......................7 HERCEPTIN HYLECTA ......7 HETLIOZ ........................... 17 HIBERIX............................ 28 HUMIRA ............................ 27 HUMIRA INJ 10MG/0.2ML 27 HUMIRA KIT 20MG/0.4ML 27 HUMIRA KIT 40MG/0.8ML 27 HUMIRA PEDIATRIC CROHNS DISEASE .......... 27 HUMIRA PEN ................... 27 HUMIRA PEN CD/UC/HS STARTER ......................... 27 HUMIRA PEN INJ CD/UC/HS STARTER ....... 27 HUMIRA PEN INJ PS/UV STARTER ......................... 27 HUMIRA PEN-PS/UV STARTER ......................... 27 HUMULIN R INJ U-500 ..... 19 HUMULIN R U-500 KWIKPEN ......................... 19 hydralazine hcl .................. 11 hydrochlorothiazide ........... 11 hydroco/apap tab 10-325mg ............................................1 hydroco/apap tab 5-325mg .1 hydroco/apap tab 7.5-325 ...1 hydrocodone-acetaminophen 7.5-325 mg/15ml .................2 hydrocodone-ibuprofen tab 7.5-200 mg ..........................2 hydrocortisone .................. 24 hydrocortisone (enema) .... 25 hydrocortisone (topical) ..... 33 hydrocortisone butyrate cream 0.1% ....................... 33 hydrocortisone butyrate oint 0.1% .................................. 33 hydrocortisone valerate ..... 33 hydromorphone hcl .............2 hydroxychloroquine sulfate .......................................... 27 hydroxyurea ........................8 hydroxyzine hcl ................. 31 hydroxyzine hcl inj ............. 31 hydroxyzine pamoate ........ 31

HYSINGLA ER .................... 2 I ibandronate sodium .......... 21 IBRANCE ............................ 7 ibu tab 600mg ..................... 1 ibu tab 800mg ..................... 1 ibuprofen ............................. 1 icatibant acetate ................ 27 ICLUSIG ............................. 8 IDHIFA ................................ 7 IFEX INJ 3GM ..................... 6 ifosfamide inj 1gm/20ml ...... 6 IFOSFAMIDE INJ 3GM ....... 6 ifosfamide inj 3gm/60ml ...... 6 ILEVRO ............................. 30 imatinib mesylate ................ 8 IMBRUVICA ........................ 8 imipenem-cilastatin ............. 3 imipramine hcl ................... 14 imiquimod ......................... 33 IMOVAX RABIES (H.D.C.V.) .......................................... 28 incassia ............................. 22 INCRELEX ........................ 24 INCRUSE ELLIPTA .......... 31 indapamide ....................... 11 INFANRIX ......................... 28 INLYTA ............................... 8 INREBIC ............................. 8 INSULIN PEN NEEDLE .... 19 INSULIN SAFETY NEEDLES ......................... 19 INSULIN SYRINGE........... 19 INTELENCE ........................ 4 INTRALIPID 30% .............. 29 INTRALIPID INJ 20%........ 29 INTRON-A INJ 10MU........ 28 INTRON-A INJ 18MU........ 28 INTRON-A INJ 25MU........ 28 INTRON-A INJ 50MU........ 28 introvale ............................ 22 INVEGA SUST INJ 117 MG/0.75 ML ...................... 15 INVEGA SUST INJ 156MG/ML ........................ 15 INVEGA SUST INJ 234 MG/1.5 ML ........................ 15 INVEGA SUST INJ 39 MG/0.25 ML ...................... 15 INVEGA SUST INJ 78

MG/0.5 ML ........................ 15 INVEGA TRINZA .............. 15 INVIRASE ........................... 4 IONOSOL-MB/DEXTROSE 5% .................................... 29 IPOL INACTIVATED IPV .. 28 ipratropium bromide .......... 31 ipratropium bromide (nasal).......................................... 31 ipratropium-albuterol nebu 31 irbesartan ............................ 9 irbesartan-hydrochlorothiazide.......................................... 9 IRESSA .............................. 8 irinotecan hcl ...................... 8 ISENTRESS ....................... 4 ISENTRESS HD ................. 4 isibloom ............................ 22 ISOLYTE P ....................... 29 ISOLYTE S ....................... 29 isoniazid .............................. 4 isoniazid syp 50mg/5ml ...... 4 isosorb mononitrate tab .... 11 isosorbide dinitrate ............ 11 isosorbide dinitrate er ....... 11 isosorbide mononitrate er . 11 isotretinoin ........................ 32 isradipine .......................... 10 itraconazole ........................ 3 ivermectin ........................... 3 IXIARO ............................. 28 J JADENU ........................... 21 JADENU SPRINKLE ......... 21 JAKAFI ............................... 8 jantoven ............................ 26 JANUMET ......................... 20 JANUMET XR TAB 100-1000 .......................... 20 JANUMET XR TAB 50-1000.......................................... 20 JANUMET XR TAB 50-500MG ......................... 20 JANUVIA .......................... 20 JARDIANCE ..................... 20 jasmiel .............................. 22 JENTADUETO .................. 20 JENTADUETO TAB XR 2.5-1000 MG ..................... 21 JENTADUETO TAB XR

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5-1000 MG ........................ 21 jinteli .................................. 23 jolessa tab 0.15-0.03 mg ... 22 jolivette .............................. 22 juleber ............................... 22 JULUCA ..............................4 junel 1.5/30 ....................... 22 junel 1/20 .......................... 22 junel fe 1.5/30 ................... 22 junel fe 1/20 ...................... 22 junel fe 24 ......................... 22 JUXTAPID ......................... 10 K KADCYLA ...........................7 kaitlib fe ............................. 22 KALETRA TAB 100-25MG ..4 KALETRA TAB 200-50MG ..4 KALYDECO ...................... 31 kariva ................................ 22 kcl 0.075%/d5w/nacl 0.45% .......................................... 29 KCL 0.15%/D5W/NACL 0.225% .............................. 29 kcl 0.15%/d5w/nacl 0.9% .. 29 kcl 0.3%/d5w/nacl 0.45% .. 29 KCL 0.3%/D5W/NACL 0.9% .......................................... 29 kcl/d5w inj 0.3% ................ 29 kcl/d5w/nacl inj .15/.33% ... 29 kcl/d5w/nacl inj .15/.45% ... 29 kcl/d5w/nacl inj 0.22%/0.45% .......................................... 29 kcl/nacl inj 0.15%-0.9% ..... 29 kcl/nacl inj 0.3-0.9 ............. 29 kcl0.15%/d5w/nacl0.2% .... 29 kelnor 1/35 ........................ 22 kelnor 1/50 ........................ 22 ketoconazole .......................3 ketoconazole cream .......... 32 ketoconazole shampoo ..... 32 ketorolac tromethamine (ophth) .............................. 30 KEYTRUDA ........................7 KINRIX .............................. 28 kionex sus 15gm/60ml ...... 21 KISQALI ..............................7 KISQALI FEMARA 200 DOSE ..................................7 KISQALI FEMARA 400 DOSE ..................................7

KISQALI FEMARA 600 DOSE .................................. 7 klor-con 10 ........................ 28 klor-con 8 .......................... 28 klor-con m10 ..................... 28 klor-con m15 ..................... 28 klor-con m20 ..................... 28 klor-con pak 20meq .......... 28 klor-con spr cap 10meq .... 28 klor-con spr cap 8meq ...... 28 KORLYM ........................... 24 kurvelo .............................. 22 KUVAN ............................. 23 KYNAMRO ........................ 10 L labetalol hcl ....................... 10 lactated ringer's ................. 29 lactulose ............................ 25 lactulose (encephalopathy) .......................................... 25 lamivudine ........................... 4 lamivudine (hbv) ................. 5 lamivudine-zidovudine ........ 4 lamotrigine ........................ 12 lansoprazole ..................... 26 larin 1.5/30 ........................ 22 larin 1/20 ........................... 22 larin fe 1.5/30 .................... 22 larin fe 1/20 ....................... 22 larissia tab ......................... 22 LASTACAFT ..................... 30 latanoprost ........................ 30 LATUDA ............................ 15 layolis fe ............................ 22 leena tab ........................... 22 leflunomide ....................... 27 LENVIMA 10 MG DAILY DOSE .................................. 8 LENVIMA 12MG DAILY DOSE .................................. 8 LENVIMA 14 MG DAILY DOSE .................................. 8 LENVIMA 18 MG DAILY DOSE .................................. 8 LENVIMA 20 MG DAILY DOSE .................................. 8 LENVIMA 24 MG DAILY DOSE .................................. 8 LENVIMA 4 MG DAILY DOSE .................................. 8

LENVIMA 8 MG DAILY DOSE ................................. 8 lessina .............................. 22 letrozole .............................. 7 leucovorin calcium .............. 8 leucovorin calcium solr ....... 8 LEUKERAN ........................ 6 leuprolide inj 1mg/0.2 .......... 7 levalbuterol hcl .................. 31 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 31 levalbuterol tartrate hfa ..... 31 LEVEMIR .......................... 19 LEVEMIR FLEXTOUCH ... 19 levetiracetam .................... 13 levetiracetam in sodium chloride ............................. 13 levetiracetam oral soln 100 mg/ml ................................ 13 levobunolol hcl .................. 30 levocarnitine (metabolic modifiers) .......................... 23 levocetirizine dihydrochloride.......................................... 31 levofloxacin ......................... 5 levofloxacin in d5w .............. 5 levofloxacin inj 25mg/ml ...... 5 levofloxacin oral soln 25 mg/ml .................................. 6 levonest ............................ 22 levonor/ethi tab ................. 22 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg .................. 22 levonorgestrel & eth estradiol.......................................... 22 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) ............................ 22 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ......................... 22 levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7) ................... 22 levora 0.15/30-28 .............. 22 levo-t ................................. 24 levothyroxine sodium ........ 24 levoxyl ............................... 24 LEXIVA ............................... 4

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lidocaine ............................ 33 lidocaine hcl ...................... 33 lidocaine hcl (local anesth.) .2 lidocaine hcl (mouth-throat) .......................................... 33 lidocaine inj 0.5% ................2 lidocaine inj 1% ...................2 lidocaine inj 1.5% preservative free (pf) ...........2 lidocaine oint 5% ............... 33 lidocaine-prilocaine ........... 33 linezolid in sodium chloride .3 linezolid inj ..........................3 linezolid susp ......................3 linezolid tab 600mg .............3 LINZESS ........................... 26 liothyronine sodium ........... 24 lisinopril ...............................9 lisinopril & hydrochlorothiazide .............9 lithium carbonate ............... 18 lithium carbonate er .......... 18 LITHIUM SOLN 8MEQ/5ML .......................................... 18 LOKELMA ......................... 21 lomedia 24 fe .................... 22 LONSURF ...........................8 loperamide hcl ................... 26 lopinavir-ritonavir .................4 lorazepam ......................... 12 lorazepam intensol ............ 12 LORBRENA ........................8 lorcet hd tab 10-325mg .......2 lorcet plus tab 7.5-325 ........2 lorcet tab 5-325mg ..............2 loryna ................................ 22 losartan potassium ..............9 losartan-hydrochlorothiazide ............................................9 LOTEMAX ......................... 30 loteprednol etabonate ....... 30 lovastatin ........................... 10 low-ogestrel ....................... 22 loxapine succinate ............ 15 LUMIGAN.......................... 30 LUMIZYME ....................... 23 LUPRON DEPOT (1-MONTH) .........................7 LUPRON DEPOT INJ 11.25MG (3-MONTH) .........7

LUPRON DEPOT-PED (1-MONTH ........................ 24 LUPRON DEPOT-PED (3-MONTH ........................ 24 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 24 LUPRON DEP-PED INJ 7.5MG ............................... 24 lutera ................................. 22 LYNPARZA ......................... 7 LYRICA ............................. 13 LYRICA CR ....................... 18 LYSODREN ........................ 7 lyza ................................... 22 M magnesium sulfate ............ 28 MAGNESIUM SULFATE ... 28 MAGNESIUM SULFATE IN D5W .................................. 28 magnesium sulfate in dextrose ............................ 29 magnesium sulfate inj 50% .......................................... 29 malathion .......................... 33 maprotiline hcl ................... 14 marlissa ............................ 22 MARPLAN TAB 10MG ...... 14 MATULANE ........................ 8 MAVYRET .......................... 5 meclizine hcl ..................... 25 medroxyprogesterone acetate (contraceptive) ..... 22 medroxyprogesterone acetate tab ........................ 24 mefloquine hcl ..................... 3 megestrol ac sus 40mg/ml .. 7 megestrol ac tab 20mg ....... 7 megestrol ac tab 40mg ....... 7 megestrol sus 625mg/5ml ... 7 MEKINIST ........................... 8 MEKTOVI ............................ 8 melodetta 24 fe ................. 22 meloxicam ........................... 1 memantine hcl cp24 .......... 13 memantine soln ................ 13 memantine tabs ................ 13 memantine titration pak ..... 13 MENACTRA ...................... 28 MENVEO .......................... 28 mercaptopurine ................... 6

meropenem ........................ 3 mesalamine ...................... 25 mesalamine w/ cleanser ... 25 MESNEX ............................ 8 metadate er tab 20mg ....... 17 metformin er ..................... 21 metformin hcl .................... 21 methadone hcl .................... 2 methadone hcl 10mg .......... 2 methadone hcl 5mg ............ 2 methadone hcl intensol ....... 2 methazolamide ................. 11 methenamine hippurate ...... 3 methimazole ..................... 24 methocarbamol ................. 19 methotrexate sodium inj ...... 6 methotrexate sodium tabs 27 methyclothiazide ............... 11 methylphenidate hcl .......... 17 methylphenidate hcl oral soln.......................................... 17 methylphenidate tab 10mg er.......................................... 17 methylphenidate tab 20mg er.......................................... 17 methylpr ss inj ................... 24 methylpred pak 4mg ......... 24 methylpred tab 16mg ........ 24 methylpred tab 32mg ........ 24 methylpred tab 4mg .......... 24 methylpred tab 8mg .......... 24 methylprednisolone acetate.......................................... 24 metoclopramide hcl ........... 25 metoclopramide hcl inj ...... 25 metolazone ....................... 11 metoprolol & hydrochlorothiazide ........... 10 metoprolol succinate ......... 10 metoprolol tartrate............. 10 metronidazole ..................... 3 metronidazole (topical) ..... 33 metronidazole gel 0.75% .. 33 metronidazole in nacl .......... 3 metronidazole vaginal ....... 26 mexiletine hcl ...................... 9 mibelas 24 fe .................... 22 microgestin 1.5/30 ............ 22 microgestin 1/20 ............... 22 microgestin fe 1.5/30 ........ 22

44

microgestin fe 1/20 ............ 23 midodrine hcl ..................... 11 miglustat............................ 23 mili .................................... 23 minitran ............................. 11 minocycline hcl ....................6 minoxidil ............................ 11 mirtazapine ....................... 14 misoprostol ........................ 26 MITIGARE ...........................1 mitomycin ............................6 M-M-R II ............................ 28 M-NATAL PLUS ................ 30 moexipril hcl ........................9 molindone hcl .................... 16 mometasone furoate ......... 33 mondoxyne nl cap 100mg ...6 mono-linyah tab 0.25-35 ... 23 montelukast sodium .......... 31 morgidox cap 1x50mg .........6 morphine ext-rel tab ............2 morphine sul inj 1mg/ml ......2 morphine sulfate .................2 MORPHINE SULFATE .......2 morphine sulfate oral soln 100mg/5ml ..........................2 morphine sulfate oral soln 10mg/5ml ............................2 morphine sulfate oral soln 20mg/5ml ............................2 MOVANTIK ....................... 26 MOVIPREP ....................... 25 MOXEZA ........................... 30 moxifloxacin hcl ...................6 moxifloxacin hcl (ophth) .... 30 MULTAQ .............................9 mupirocin .......................... 32 MYCAMINE .........................3 mycophenolate mofetil ...... 28 mycophenolate sodium tbec .......................................... 28 MYLOTARG ........................7 myorisan ........................... 32 MYRBETRIQ ..................... 26 myzilra .............................. 23 N nabumetone ........................1 nadolol .............................. 10 nafcillin sodium for inj ..........6 NAFCILLIN SODIUM FOR

INJ 10GM ............................ 6 NAGLAZYME .................... 23 nalbuphine hcl ..................... 1 naloxone inj 0.4mg/ml ....... 19 naloxone inj 1mg/ml .......... 19 naltrexone hcl ................... 19 NAMZARIC ....................... 13 naproxen ............................. 1 naproxen dr ......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 18 NARCAN ........................... 19 NATACYN ......................... 30 nateglinide ........................ 21 NATPARA ......................... 24 NAYZILAM ........................ 13 NEBUPENT ........................ 3 necon 0.5/35-28 ................ 23 necon 7/7/7 ....................... 23 nefazodone hcl ................. 14 neomycin sulfate ................. 2 neomycin-bacitracin zn-polymyxin ..................... 30 neomycin-polymy-dexameth .......................................... 30 neomycin-polymyxin-gramicidin ..................................... 30 neomycin-polymyxin-hc (ophth) .............................. 30 neomycin-polymyxin-hc (otic) .......................................... 34 NEPHRAMINE .................. 29 NERLYNX ........................... 8 NEUPOGEN ..................... 27 NEUPRO .......................... 15 nevirapine susp 50 mg/5ml . 4 nevirapine tab 100mg er ..... 4 nevirapine tab 200mg ......... 4 nevirapine tab 400mg er ..... 4 NEXAVAR ........................... 8 niacin (antihyperlipidemic) 10 niacin er (antihyperlipidemic) .......................................... 10 niacor ................................ 10 nicardipine hcl ................... 10 NICOTROL INHALER ....... 19 NICOTROL NS ................. 19 nifedipine .......................... 10 nifedipine er ...................... 10 nikki................................... 23

nilutamide ........................... 7 nimodipine ........................ 10 NINLARO ............................ 7 NITRO-BID ....................... 11 NITRO-DUR DIS 0.3MG/HR.......................................... 11 NITRO-DUR DIS 0.8MG/HR.......................................... 11 nitrofurantoin macrocrystal . 3 nitrofurantoin monohyd macro .................................. 3 nitroglycerin ...................... 11 nitroglycerin td patch ......... 11 NITYR ............................... 23 nora-be tab 0.35mg .......... 23 norethin acet & estrad-fe .. 23 norethindrone & ethinyl estradiol-fe ........................ 23 norethindrone (contraceptive) .................. 23 norethindrone acet & eth estra .................................. 23 norethindrone acetate ....... 24 norethindrone acetate-ethinyl estradiol ............................ 24 norgest/ethi tab 0.25/35 .... 23 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 23 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 23 norlyroc ............................. 23 NORMOSOL-M IN D5W ... 29 NORMOSOL-R ................. 29 NORMOSOL-R IN D5W ... 29 NORPACE CR .................... 9 NORTHERA ..................... 11 nortrel 0.5/35 (28) ............. 23 nortrel 1/35 ....................... 23 nortrel 7/7/7 ...................... 23 nortriptyline hcl ................. 14 NORVIR PACK ................... 4 NORVIR SOLN ................... 4 NOVOLIN 70/30................ 19 NOVOLIN 70/30 FLEXPEN.......................................... 19 NOVOLIN N ...................... 19

45

NOVOLIN R ...................... 19 NOVOLOG ........................ 19 NOVOLOG 70/30 FLEXPEN .......................................... 19 NOVOLOG FLEXPEN ...... 19 NOVOLOG MIX 70/30 ...... 20 NOVOLOG PENFILL ........ 20 NOXAFIL.............................3 NUBEQA .............................7 NUCYNTA ER .....................2 NUEDEXTA ...................... 18 NULOJIX ........................... 28 NULYTELY/FLAVOR PACKS .............................. 25 NUPLAZID CAPS ............. 16 NUPLAZID TABS 10MG ... 16 NUPLAZID TABS 17MG ... 16 NUTRILIPID INJ 20% ....... 29 NUVARING ....................... 23 nyamyc ............................. 32 NYMALIZE ........................ 11 nystatin ...............................3 nystatin (mouth-throat) ...... 33 nystatin (topical) ................ 32 nystop ............................... 32 O ocella tab 3-0.03mg .......... 23 OCTAGAM ........................ 28 octreotide acetate ............. 24 ODEFSEY ...........................4 ODOMZO ............................7 OFEV ................................ 31 ofloxacin (ophth) ............... 30 ofloxacin (otic) ................... 34 olanzapine......................... 16 olmesartan medoxomil ........9 olmesartan medoxomil-amlodipine-hydrochlorothiazide ......................9 olmesartan medoxomil-hydrochlorothiazide ........................................9 olopatadine hcl 0.2% ......... 30 omeprazole cap 10mg ...... 26 omeprazole cap 20mg ...... 26 omeprazole cap 40mg ...... 26 ondansetron hcl ................ 25 ondansetron hcl inj ............ 25 ondansetron hcl oral soln .. 25 ondansetron odt ................ 25

OPSUMIT ......................... 11 ORFADIN .......................... 23 ORKAMBI ......................... 31 orsythia ............................. 23 oseltamivir phosphate ......... 5 oxacillin sodium .................. 6 oxaliplatin inj 100mg ........... 8 oxaliplatin inj 100mg/20ml ... 8 oxaliplatin inj 50mg ............. 8 oxaliplatin inj 50mg/10ml..... 8 oxandrolone tab 10mg ...... 19 oxandrolone tab 2.5mg ..... 19 oxcarbazepine .................. 13 oxybutynin chloride ........... 26 oxycodone hcl ..................... 2 oxycodone w/ acetaminophen 10-325mg .. 2 oxycodone w/ acetaminophen 2.5-325mg . 2 oxycodone w/ acetaminophen 5-325mg .... 2 oxycodone w/ acetaminophen 7.5-325mg . 2 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 20 OZEMPIC INJ 1MG/DOSE .......................................... 20 P pacerone ........................... 10 paclitaxel ............................. 6 paliperidone ...................... 16 pamidronate disodium....... 21 PAMIDRONATE DISODIUM .......................................... 21 pamidronate inj 30mg ....... 21 pamidronate inj 90mg ....... 21 PANRETIN ........................ 33 pantoprazole sodium......... 26 pantoprazole sodium tbec . 26 PANZYGA ......................... 28 paricalcitol ......................... 30 paroex sol 0.12% .............. 33 paromomycin sulfate ........... 2 paroxetine hcl tabs ............ 14 PASER D/R ........................ 4 PAXIL................................ 14 PAZEO .............................. 30 PEDIARIX ......................... 28 PEDVAX HIB .................... 28 peg 3350/electrolytes ........ 25

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 25 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 25 PEGANONE ..................... 13 PEGASYS .......................... 5 PEGASYS PROCLICK ....... 5 PENICILLIN G POT IN DEXTROSE 2MU ............... 6 PENICILLIN G POT IN DEXTROSE 3MU ............... 6 PENICILLIN G PROCAINE . 6 penicillin g sodium .............. 6 penicillin v potassium .......... 6 penicilln gk inj 20mu ........... 6 penicilln gk inj 5mu ............. 6 PENTACEL ....................... 28 PENTAM 300 ...................... 3 pentamidine isethionate ...... 3 pentoxifylline ..................... 27 perindopril erbumine ........... 9 periogard .......................... 33 permethrin cre 5% ............ 33 perphenazine .................... 16 PERSERIS ....................... 16 pfizerpen-g inj 20mu ........... 6 pfizerpen-g inj 5mu ............. 6 phenelzine sulfate ............. 14 phenobarbital .................... 13 phenobarbital sodium ....... 13 PHENOBARBITAL SODIUM.......................................... 13 PHENYTEK ...................... 13 phenytoin .......................... 13 phenytoin sodium extended.......................................... 13 phenytoin sodium inj 50mg/ml ............................ 13 philith ................................ 23 PHOSPHOLINE IODIDE .. 30 PICATO ............................ 33 PIFELTRO .......................... 4 pilocarpine hcl ................... 30 pilocarpine hcl (oral) ......... 33 pimozide ........................... 16 pimtrea .............................. 23 pindolol ............................. 10 pioglitazone hcl ................. 21 piper/tazoba inj 12-1.5gm ... 6

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piper/tazoba inj 2-0.25gm ...6 piper/tazoba inj 3-0.375gm .6 piper/tazoba inj 36-4.5gm ...6 piper/tazoba inj 4-0.5gm .....6 PIQRAY 200MG DAILY DOSE ..................................8 PIQRAY 250MG DAILY DOSE ..................................8 PIQRAY 300MG DAILY DOSE ..................................8 pirmella 1/35 ..................... 23 piroxicam.............................1 PLASMA-LYTE A .............. 29 PLASMA-LYTE-148 .......... 29 PNV FOLIC ACID + IRON MUL .................................. 30 podofilox............................ 33 polymyxin b-trimethoprim .. 30 POMALYST ........................7 portia-28 ............................ 23 posaconazole ......................3 pot chloride inj 2meq/ml .... 29 potassium chloride ............ 29 POTASSIUM CHLORIDE . 29 potassium chloride in nacl . 29 potassium chloride microencapsulated crystals er ....................................... 29 potassium chloride tab cr 10 meq ................................... 29 potassium citrate (alkalinizer) er tabs ............................... 26 PRADAXA ......................... 26 PRALUENT ....................... 10 pramipexole tab 0.125mg . 15 pramipexole tab 0.25mg ... 15 pramipexole tab 0.5mg ..... 15 pramipexole tab 0.75mg ... 15 pramipexole tab 1.5mg ..... 15 pramipexole tab 1mg ........ 15 prasugrel hcl ..................... 27 pravastatin sodium ............ 10 praziquantel ........................3 prazosin hcl .........................9 pred sod pho sol 5mg/5ml . 24 prednisolone acetate (ophth) .......................................... 30 prednisolone sodium phosphate ......................... 24 PREDNISOLONE SODIUM

PHOSPHATE (OPHTH) .... 30 prednisolone sol 15mg/5ml .......................................... 24 prednisolone sol 25mg/5ml .......................................... 24 PREDNISONE CON 5MG/ML ............................ 24 prednisone pak 10mg ....... 24 prednisone pak 5mg ......... 24 prednisone sol 5mg/5ml .... 24 prednisone tab 10mg ........ 24 prednisone tab 1mg .......... 24 prednisone tab 2.5mg ....... 24 prednisone tab 20mg ........ 24 prednisone tab 50mg ........ 24 prednisone tab 5mg .......... 24 pregabalin ......................... 13 PREMASOL 10% .............. 29 premasol 6% ..................... 29 PRENATAL ....................... 30 PRENATAL PLUS ............ 30 PRENATAL PLUS LOW IRON ................................. 30 prevalite ............................ 10 previfem ............................ 23 PREZCOBIX ....................... 4 PREZISTA .......................... 4 PRIFTIN .............................. 4 primaquine phosphate ........ 3 PRIMAQUINE PHOSPHATE ............................................ 4 primidone .......................... 13 PRIVIGEN ......................... 28 probenecid .......................... 1 PROCALAMINE ................ 29 prochlorperazine inj .......... 25 prochlorperazine maleate . 25 prochlorperazine supp ...... 25 PROCRIT .......................... 27 procto-med hc ................... 33 procto-pak ......................... 33 proctosol hc cre 2.5% ....... 33 proctozone-hc ................... 33 PROGLYCEM SUS 50MG/ML .......................... 24 PROGRAF ........................ 28 PROLASTIN-C .................. 31 PROLENSA ...................... 30 PROLIA ............................. 24 PROMACTA ..................... 27

promethazine hcl .............. 25 promethazine hcl inj .......... 25 propafenone hcl ................ 10 propafenone hcl 12hr ........ 10 proparacaine hcl ............... 31 propranolol & hydrochlorothiazide ........... 10 propranolol cap er ............. 10 propranolol hcl .................. 10 propranolol oral sol ........... 10 propylthiouracil ................. 24 PROQUAD ....................... 28 PROSOL ........................... 29 protriptyline hcl ................. 14 PULMICORT FLEXHALER.......................................... 32 PULMOZYME ................... 32 PURIXAN ............................ 6 pyrazinamide ...................... 5 pyridostigmine tab 60mg ... 18 Q QUADRACEL ................... 28 quasense .......................... 23 quetiapine fumarate .......... 16 quinapril hcl ........................ 9 quinapril-hydrochlorothiazide............................................ 9 quinidine gluconate ........... 10 quinidine sulfate ................ 10 quinine sulfate .................... 4 R RABAVERT ...................... 28 rabeprazole sodium .......... 26 raloxifene tab 60mg .......... 24 ramipril ................................ 9 ranitidine hcl ..................... 25 ranitidine hcl inj ................. 25 ranitidine inj ...................... 25 ranitidine syrup ................. 25 ranolazine ......................... 11 RAPAMUNE ..................... 28 rasagiline mesylate ........... 15 RAYALDEE ...................... 30 reclipsen ........................... 23 RECOMBIVAX HB ............ 28 REGRANEX ..................... 33 RELENZA DISKHALER ...... 5 RELISTOR ........................ 26 REMICADE ....................... 27 REMODULIN .................... 11

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repaglinide ........................ 21 RESCRIPTOR ....................4 RESTASIS ........................ 31 RESTASIS MULTIDOSE .. 31 REVLIMID ...........................7 REXULTI ........................... 16 REYATAZ ...........................4 RHOPRESSA ................... 30 ribavirin cap 200mg .............5 ribavirin tab 200mg .............5 rifabutin ...............................5 rifampin ...............................5 RIFATER.............................5 riluzole .............................. 18 rimantadine hydrochloride ...5 risedronate sodium ........... 21 RISPERDAL INJ 12.5MG.. 16 RISPERDAL INJ 25MG .... 16 RISPERDAL INJ 37.5MG.. 16 RISPERDAL INJ 50MG .... 16 risperidone ........................ 16 ritonavir ...............................4 RITUXAN ............................7 RITUXAN HYCELA .............7 rivastigmine tartrate .... 13, 14 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 14 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 14 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 14 rivelsa ............................... 23 rizatriptan benzoate .......... 18 rizatriptan benzoate odt .... 18 ropinirole tab 0.25mg ........ 15 ropinirole tab 0.5mg .......... 15 ropinirole tab 1mg ............. 15 ropinirole tab 2mg ............. 15 ropinirole tab 3mg ............. 15 ropinirole tab 4mg ............. 15 ropinirole tab 5mg ............. 15 rosadan cre 0.75% ............ 33 rosuvastatin calcium ......... 10 ROTARIX .......................... 28 ROTATEQ ......................... 28 roweepra ........................... 13 roweepra xr ....................... 13 ROZLYTREK ......................8 RUBRACA ..........................7 RYDAPT .............................8

S SANDIMMUNE ................. 28 SANTYL ............................ 33 SAPHRIS .......................... 16 scopolamine patch ............ 25 selegiline hcl ..................... 15 selenium sulfide ................ 32 SELZENTRY ....................... 4 SENSIPAR ........................ 21 SEREVENT DISKUS ........ 31 sertraline hcl ..................... 14 setlakin tab ........................ 23 sevelamer carbonate ........ 24 sharobel ............................ 23 SHINGRIX ........................ 28 SIGNIFOR ........................ 24 sildenafil citrate tab 20 mg (pulmonary hypertension) . 11 SILENOR .......................... 17 silver sulfadiazine ............. 32 SIMBRINZA ...................... 30 simvastatin ........................ 10 sirolimus ............................ 28 SIRTURO ............................ 5 SIVEXTRO .......................... 3 sodium chlor sol 0.9% irr ... 33 sodium chloride ................. 29 sodium chloride 0.45%...... 29 sodium chloride inj 0.9% ... 30 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 29 sodium phenylbutyrate ...... 23 sodium polystyrene sulfonate powder .............................. 21 sodium polystyrene sulfonate susp .................................. 21 solifenacin succinate ......... 26 SOLIQUA 100/33 .............. 20 SOLTAMOX ........................ 7 SOLU-CORTEF ................ 24 SOMATULINE DEPOT ..... 24 SOMAVERT ...................... 24 sorine ................................ 10 sotalol hcl .......................... 10 sotalol hcl (afib/afl) ............ 10 spironolactone .................... 9 spironolactone & hydrochlorothiazide ........... 11 sprintec 28 ........................ 23 SPRITAM .......................... 13

SPRYCEL ........................... 8 sps susp 15gm/60ml ......... 21 sronyx ............................... 23 ssd .................................... 32 stavudine ............................ 4 STIMATE .......................... 25 STIVARGA ......................... 8 streptomycin sulfate ............ 2 STRIBILD ........................... 4 subvenite tab .................... 13 sucralfate .......................... 26 sulfacetamide sodium (acne).......................................... 32 sulfacetamide sodium (ophth) .............................. 30 sulfacetamide sod-prednisolone .............. 30 SULFADIAZINE .................. 2 sulfamethoxazole-trimethop ds ........................................ 3 sulfamethoxazole-trimethoprim inj .................................... 3 sulfamethoxazole-trimethoprim susp ................................ 3 sulfamethoxazole-trimethoprim tab 400-80mg.................. 3 SULFAMYLON ................. 32 sulfasalazine ..................... 25 sulfasalazine ec ................ 25 sulindac .............................. 1 sumatriptan ....................... 18 sumatriptan inj 4mg/0.5ml . 18 sumatriptan inj 6mg/0.5ml . 18 sumatriptan succinate ....... 18 SUPRAX ............................. 5 SUPREP BOWEL PREP KIT.......................................... 25 SUTENT ............................. 8 syeda ................................ 23 SYLATRON KIT 200MCG .. 8 SYLATRON KIT 300MCG .. 8 SYLATRON KIT 600MCG .. 8 SYMBICORT .................... 32 SYMDEKO ........................ 32 SYMFI ................................. 4 SYMFI LO ........................... 4 SYMJEPI .......................... 32 SYMPAZAN ...................... 13 SYMPROIC ...................... 26 SYMTUZA .......................... 4

48

SYNAREL ......................... 23 SYNERCID .........................3 SYNJARDY TAB 12.5-1000MG .................... 21 SYNJARDY TAB 12.5-500MG ...................... 21 SYNJARDY TAB 5-1000MG .......................................... 21 SYNJARDY TAB 5-500MG .......................................... 21 SYNJARDY XR TAB 10-1000MG ....................... 21 SYNJARDY XR TAB 12.5-1000MG .................... 21 SYNJARDY XR TAB 25-1000MG ....................... 21 SYNJARDY XR TAB 5-1000MG ......................... 21 SYNRIBO ............................8 SYNTHROID ..................... 24 T TABLOID.............................6 tacrolimus.......................... 28 tacrolimus (topical) ............ 33 TAFINLAR ...........................8 TAGRISSO .........................8 TALZENNA .........................7 tamoxifen citrate ..................7 tamsulosin hcl ................... 26 TARCEVA ...........................8 TARGRETIN ..................... 33 tarina 24 fe ........................ 23 tarina fe 1/20 ..................... 23 TASIGNA ............................8 TAXOTERE .........................6 tazarotene ......................... 32 tazicef .................................5 TAZORAC ......................... 32 taztia xt ............................. 11 TDVAX .............................. 28 TECENTRIQ .......................7 TEFLARO ...........................5 TEKTURNA ....................... 11 TEKTURNA HCT .............. 11 telmisartan ..........................9 telmisartan-amlodipine ........9 telmisartan-hydrochlorothiazide ........................................9 temazepam ....................... 17 TEMIXYS ............................4

TENIVAC .......................... 28 tenofovir disoproxil fumarate ............................................ 4 terazosin hcl ........................ 9 terbinafine hcl ..................... 3 terbutaline sulfate ............. 31 terconazole vaginal ........... 26 testosterone ...................... 19 testosterone cypionate ...... 19 testosterone enanthate ..... 19 tetrabenazine .................... 18 tetracycline hcl .................... 6 TEXACORT SOLN 2.5% .. 33 THALOMID ......................... 7 THEO-24 ........................... 32 theophylline sol 80/15ml ... 32 theophylline tb12 300 mg .. 32 theophylline tb12 450 mg .. 32 theophylline tb24 ............... 32 thioridazine hcl .................. 16 thiothixene ........................ 16 tiagabine hcl ...................... 13 TIBSOVO ............................ 7 tigecycline ........................... 3 tilia fe ................................ 23 timolol maleate .................. 10 timolol maleate (ophth) soln .......................................... 30 timolol maleate gel ............ 31 timolol maleate ophth soln 0.5% (once-daily) .............. 31 TIVICAY .............................. 4 tizanidine hcl ..................... 19 TOBRADEX ...................... 30 TOBRADEX ST ................ 30 tobramycin .......................... 2 tobramycin (ophth) ............ 30 tobramycin inj 1.2 gm/30ml . 2 tobramycin inj 1.2gm ........... 2 tobramycin inj 10mg/ml ....... 3 tobramycin inj 40mg/ml ....... 3 tobramycin inj 80mg/2ml ..... 3 tobramycin-dexamethasone .......................................... 30 tolterodine tartrate ............. 26 topiramate ......................... 13 toposar ................................ 9 topotecan hcl ...................... 9 TOPOTECAN INJ 4MG/4ML ............................................ 9

toremifene citrate ................ 7 torsemide tabs .................. 11 TOVIAZ ............................. 26 tpn electrolytes ................. 29 TRACLEER ...................... 11 TRADJENTA .................... 21 tramadol hcl tab 50 mg ....... 1 tramadol-acetaminophen .... 1 trandolapril .......................... 9 tranexamic acid................. 27 TRANSDERM-SCOP ........ 25 tranylcypromine sulfate ..... 14 TRAVASOL ...................... 29 TRAVATAN Z ................... 31 trazodone hcl .................... 14 TRECATOR ........................ 5 TRELEGY ELLIPTA .......... 31 TRELSTAR DEP INJ 3.75MG ............................... 7 TRELSTAR LA INJ 11.25MG............................................ 7 treprostinil ......................... 11 TRESIBA FLEXTOUCH .... 20 TRESIBA INJ .................... 20 tretinoin ............................. 32 tretinoin (chemotherapy) ..... 8 triamcinolone acetonide (mouth) ............................. 33 triamcinolone acetonide (topical) ............................. 33 triamterene & hydrochlorothiazide cap 37.5-25 mg ....................... 11 triamterene & hydrochlorothiazide tabs ... 11 TRICARE .......................... 30 trientine hcl ....................... 21 tri-estarylla ........................ 23 trifluoperazine hcl.............. 16 trifluridine .......................... 30 trihexyphenidyl hcl ............ 15 tri-legest fe ........................ 23 tri-linyah ............................ 23 tri-lo marzia ....................... 23 tri-lo-estarylla .................... 23 tri-lo-sprintec ..................... 23 trilyte ................................. 25 trimethoprim ........................ 3 tri-mili ................................ 23 trimipramine maleate ........ 14

49

trinessa ............................. 23 trinessa lo.......................... 23 TRINTELLIX ...................... 14 tri-previfem ........................ 23 tri-sprintec ......................... 23 TRIUMEQ ...........................4 trivora-28 ........................... 23 tri-vylibra ........................... 23 tri-vylibra lo ........................ 23 TROGARZO ........................4 TROPHAMINE INJ 10% ... 29 trospium chloride ............... 26 TRULICITY ....................... 20 TRUMENBA ...................... 28 TRUVADA TAB 100-150 .....4 TRUVADA TAB 133-200 .....4 TRUVADA TAB 167-250 .....4 TRUVADA TAB 200-300 .....4 tulana ................................ 23 TURALIO ............................8 TWINRIX INJ .................... 28 TYBOST..............................4 tydemy .............................. 23 TYKERB..............................8 TYMLOS ........................... 24 TYPHIM VI ........................ 28 U ULORIC ..............................1 unithroid ............................ 25 ursodiol ............................. 26 V valacyclovir hcl ....................5 VALCHLOR ....................... 33 valganciclovir hcl .................5 valproate sodium ............... 13 valproate sodium oral soln 13 valproic acid ...................... 13 valsartan .............................9 valsartan-hydrochlorothiazide ..........................................9 vancomycin hcl ...................3 VANCOMYCIN IN NACL.....3 vandazole.......................... 26 VAQTA .............................. 28 VARIVAX .......................... 28 VASCEPA ......................... 10 VELCADE ...........................7 velivet ................................ 23 VEMLIDY ............................5 VENCLEXTA .......................7

VENCLEXTA STARTING PACK .................................. 7 venlafaxine hcl .................. 14 VENTAVIS ........................ 12 VENTOLIN HFA ................ 31 verapamil cap er ............... 11 verapamil hcl ..................... 11 verapamil tab er ................ 11 VERSACLOZ .................... 16 VERZENIO ......................... 7 VICTOZA .......................... 20 VIDEX EC ........................... 4 VIDEX PEDIATRIC ............. 4 vienva ............................... 23 vigabatrin powd pack 500mg .......................................... 13 vigabatrin tab 500mg ........ 13 vigadrone .......................... 13 VIIBRYD STARTER PACK .......................................... 14 VIIBRYD TAB ................... 14 VIMPAT ............................ 13 VIMPAT INJ 200MG/20ML 13 VIMPAT SOL 10MG/ML .... 13 vinblastine sulfate ............... 6 vincristine sulfate ................ 6 vinorelbine tartrate .............. 6 viorele ............................... 23 VIRACEPT .......................... 4 VIRAMUNE ......................... 4 VIREAD .............................. 4 VITRAKVI ........................... 8 VIVITROL ......................... 19 VIZIMPRO .......................... 8 voriconazole ........................ 3 VOSEVI .............................. 5 VOTRIENT .......................... 8 VRAYLAR ......................... 16 VRAYLAR THERAPY PACK .......................................... 16 vyfemla ............................. 23 vylibra ............................... 23 W warfarin sodium ................ 26 water for irrigation, sterile 33 wymzya fe ......................... 23 X XALKORI ............................ 8 XARELTO ......................... 27 XARELTO STARTER PACK

.......................................... 27 XATMEP ........................... 27 XELJANZ .......................... 27 XELJANZ XR .................... 27 XGEVA ............................. 24 XIFAXAN .......................... 26 XIGDUO XR TAB 10-1000MG ....................... 21 XIGDUO XR TAB 10-500MG.......................................... 21 XIGDUO XR TAB 2.5-1000MG ...................... 21 XIGDUO XR TAB 5-1000MG.......................................... 21 XIGDUO XR TAB 5-500MG.......................................... 21 XOLAIR ............................ 32 XOSPATA ........................... 8 XPOVIO 100 MG ONCE WEEKLY ............................. 8 XPOVIO 60 MG ONCE WEEKLY ............................. 8 XPOVIO 80 MG ONCE WEEKLY ............................. 8 XPOVIO 80 MG TWICE WEEKLY ............................. 8 XTANDI .............................. 7 xulane dis 150-35 ............. 23 XULTOPHY 100/3.6 ......... 20 XYREM ............................. 19 Y YF-VAX ............................. 28 yuvafem vaginal tablet 10 mcg ................................... 24 Z zafirlukast ......................... 31 zaleplon ............................ 18 zarah ................................. 23 ZEJULA .............................. 7 ZELBORAF ......................... 8 ZEMAIRA .......................... 32 zenatane ........................... 32 ZENPEP ........................... 26 ZEPATIER .......................... 5 zidovudine cap 100mg ........ 4 zidovudine syp 50mg/5ml ... 4 zidovudine tab 300mg ......... 4 ziprasidone hcl .................. 16 ZIRGAN ............................ 30 zoledronic acid inj

50

5mg/100ml ........................ 21 zoledronic inj 4mg/5ml ...... 21 ZOLINZA .............................7 zolmitriptan ........................ 18 zolmitriptan odt .................. 18 zolpidem tartrate ............... 18 zonisamide ........................ 13

ZONTIVITY ....................... 27 ZORTRESS TAB 0.25MG . 28 ZORTRESS TAB 0.5MG ... 28 ZORTRESS TAB 0.75MG . 28 ZORTRESS TAB 1MG ...... 28 ZOSTAVAX ....................... 28 zovia 1/35e ....................... 23

ZYDELIG ............................ 8 ZYKADIA ............................ 8 ZYLET .............................. 30 ZYPREXA RELPREVV ..... 16 ZYPREXA RELPREVV INJ 210MG .............................. 16 ZYTIGA ............................... 7

HAWAI‘I MEDICAL SERVICE ASSOCIATIONhmsa.com/advantage

HMSA Akamai Advantage is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact HMSA at:

(00) 8700-15999 December 12.19 LG


PHONECall 8 a.m. to 8 p.m., seven days a week

948-6000 on Oahu 1 (800) 660-4672 toll-freeTTY users, call 711

ONLINEhttp://www.hmsa.com/advantage

HMSA CENTERSConvenient evening and Saturday hours:

HMSA Center @ Honolulu818 Keeaumoku St.Monday - Friday, 8 a.m. - 5 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl CityPearl City Gateway | 1132 Kuala St., Suite 400 Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ HiloWaiakea Center | 303A E. Makaala St.

Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ KahuluiPuunene Shopping Center | 70 Hookele St.

Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

OFFICESVisit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393



Documents

HMSA Akamai Advantage 2018 Formulary · Akamai Advantage Dual Care limits the amount of the drug that HMSA Akamai Advantage Dual Care will cover. For example, HMSA Akamai Advantage