HMSA Medicare Advantage 2020 Formulary...HMSA Akamai Advantage List of Covered Drugs Formulary ID 00020361, version 8 This formulary was updated on 02/01/2020. For more recent information

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

2020 Formulary

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HMSA Akamai Advantage

List of Covered DrugsFormulary ID 00020361, version 8

This formulary was updated on 02/01/2020. 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_110177_2_C

http://www.hmsa.com/advantage

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means HMSA. When it refers to “plan” or “our plan,” it means HMSA Aka-mai Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of February 1, 2020. 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, 2021, and from time to time during the year.

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

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

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

- If we make such a change, you or your pre-scriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find informa-tion in the section below entitled “How do I request an exception to the HMSA Akamai Advantage Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s 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.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guide-lines. 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 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.

- If we make these other changes, you or your prescriber can ask us to make an exception

i

and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find informa-tion in the section below entitled “How do I request an exception to the HMSA Akamai Advantage Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those mem-bers taking them for the remainder of the coverage year.

The enclosed formulary is current as of Febru-ary 1, 2020. To get updated information about the drugs covered by HMSA Akamai Advan-tage, please contact us. Our contact infor-mation appears on the front and back cover pages. We will inform members of any formu-lary 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 45. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you

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

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

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

• Prior Authorization: HMSA Akamai Advantage 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 before you fill your pre-scriptions. If you don’t get approval, HMSA Akamai Advantage may not cover the drug.

• Quantity Limits: For certain drugs, HMSA Akamai Advantage limits the amount of the drug that HMSA Akamai Advantage will cover. For example, HMSA Akamai Advantage pro-vides 30 tablets per prescription for simvas-tatin 80mg. This may be in addition to a stan-dard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the for-mulary 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 docu-ments that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information,

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along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask HMSA Akamai Advantage 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 Advantage 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 Customer Relations department and ask if your drug is covered. If you learn that HMSA Akamai Advantage 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 Aka-mai Advantage. 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.

• You can ask HMSA Akamai Advantage 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 Formulary?You can ask HMSA Akamai Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on tier 5. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain

drugs, HMSA Akamai Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropri-ate 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 for-mulary or if your ability to get your drugs is limited, we will cover a temporary 30-day sup-ply (unless you have a prescription written for

iii

fewer days) when you go to a network phar-macy. 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 dispens-ing increment (unless you have a prescription written 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 authoriza-tion. Current members may also be affected by changes 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 excep-tion in order to get coverage for the drug. See the section, “How do I request an exception to HMSA Akamai Advantage formulary?” to learn more about how to request an exception. Please contact 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-for-mulary 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 mem-ber 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 consid-ered a Part D drug), we will cover a 30-day sup-ply (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 transition policy again. We will provide you with a written notice after we cover your temporary supply. 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 appropriate 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 tempo-rary 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 supply of non-formulary drugs, we will cover a temporary 31-day transition supply (unless the prescription 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 Medicare Part D. For current members expe-riencing a level of care change, we will also cover a temporary 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

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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 prescription drug coverage, please review your Evidence of Cov-erage and other plan materials.

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

If you have general questions about Medicare prescription drug coverage, please call Medi-care 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 FormularyThe formulary that begins on page 1 provides coverage information about the drugs cov-ered by HMSA Akamai Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 45.

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

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

Drug tier index:

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand

Tier 4 - Non-Preferred Drug

Tier 5 - Specialty Tier

Please refer to the Summary of Benefits or Evidence of Coverage for the specific copay-ment 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 before we will cover your prescription.

QL – Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage 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 con-dition.

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 circumstances. 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.

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

Prescription drugs can be shipped to your home from HMSA’s mail-order pharmacy, CVS Caremark. 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 2 M

COLCRYS QL (120 tabs / 30 days)

3 QL M

MITIGARE QL (60 caps / 30 days)

3 QL M

probenecid 2 M

NSAIDS celecoxib CAPS 50mg

QL (240 caps / 30 days) 2 QL M

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

2 QL M


2 QL M


2 QL M

diclofenac potassium QL (120 tabs / 30 days)

2 QL M

diclofenac sodium TB24; TBEC

2 M

diclofenac w/ misoprostol 2 M

diflunisal TABS 2 M

etodolac 2 M

etodolac er 2 M

flurbiprofen TABS 2 M

ibu tab 600mg 1 M

ibu tab 800mg 1 M

ibuprofen SUSP 2 M

ibuprofen TABS 400mg, 600mg, 800mg

1 M

ketoprofen CAPS; CP24 2 M

meloxicam tabs 1 M

nabumetone TABS 1 M

naproxen TABS 1 M

naproxen dr 2 M

naproxen sodium TABS 275mg, 550mg

2 M

oxaprozin 2 M

piroxicam CAPS 2 M

sulindac TABS 2 M

tolmetin sodium 2 M

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

acetaminophen w/ codeine 300-30mg


2 QL M

acetaminophen w/ codeine 300-60mg


2 QL M

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

2 QL M

acetaminophen-caff-dihydrocod

QL (300 caps / 30 days)

2 QL M

BELBUCA 75mcg, 150mcg, 300mcg, 450mcg, 600mcg

QL (60 buccal films / 30 days)

4 QL M PA

BELBUCA 750mcg, 900mcg QL (60 buccal films / 30 days)

5 QL M PA

buprenorphine patch QL (4 patches / 28 days)

2 QL M PA

butorphanol nasal spray QL (10 mL / 30 days)

2 QL M

butorphanol tartrate SOLN 4 M

dvorah QL (300 tabs / 30 days)

2 QL M

nalbuphine hcl SOLN 4 M

tramadol hcl CP24 QL (30 caps / 30 days)

2 QL M PA

tramadol hcl er TB24 QL (30 tabs / 30 days)

2 QL M PA

tramadol hcl er (biphasic) 100mg


2 QL M PA



2 QL M PA



2 QL M PA

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

2 QL M

tramadol-acetaminophen QL (240 tabs / 30 days)

2 QL M

trezix QL (300 caps / 30 days)

2 QL M

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 5 QL M PA


2

Drug Name Drug Tier

Requirements/Limits

ARYMO ER 15mg, 30mg QL (90 tabs / 30 days)

4 QL M PA

ARYMO ER 60mg QL (90 tabs / 30 days)

5 QL M PA

codeine sulfate 30mg QL (180 tabs / 30 days)

2 QL M

CODEINE SULFATE 60mg QL (180 tabs / 30 days)

4 QL M

EMBEDA CAP 20-0.8MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA

EMBEDA CAP 50-2MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA


4 QL M PA

EMBEDA CAP 100-4MG QL (60 caps / 30 days)

5 QL M PA

endocet 2.5-325mg QL (360 tabs / 30 days)

2 QL M

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

2 QL M

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

2 QL M

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

2 QL M

fentanyl citrate LPOP QL (120 lozenges / 30 days)

5 QL M PA

fentanyl citrate TABS QL (120 tabs / 30 days)

5 QL M PA

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

2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA

Drug Name Drug Tier

Requirements/Limits

hydrocodone-acetaminophen 5-300mg


2 QL M



2 QL M

hydrocodone-acetaminophen 7.5-300mg


2 QL M

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

2 QL M

hydrocodone-acetaminophen 7.5-325mg


2 QL M



2 QL M

hydrocodone-acetaminophen tab 10-325mg


2 QL M

hydrocodone-ibuprofen tab 5-200mg


2 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL M

hydrocodone-ibuprofen tab 10-200mg


2 QL M

hydromorphone hcl LIQD QL (600 mL / 30 days)

2 QL M

hydromorphone hcl SOLN 4 B/D M

hydromorphone hcl TABS QL (180 tabs / 30 days)

2 QL M

HYDROMORPHONE HYDROCHLORI SOLN 1mg/ml, 2mg/ml, 4mg/ml

4 B/D M

hydromorphone tab 8mg er QL (30 tabs / 30 days)

2 QL M PA


2 QL M PA


4 QL M PA

hydromorphone tabs 32mg er QL (30 tabs / 30 days)

5 QL M PA

HYSINGLA ER QL (30 tabs / 30 days)

3 QL M PA

KADIAN 200mg QL (60 caps / 30 days)

5 QL M PA


3

Drug Name Drug Tier

Requirements/Limits

LAZANDA QL (30 bottles / 30 days)

5 QL M PA

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

2 QL M

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

2 QL M

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

2 QL M

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

QL (450 mL / 30 days)

2 QL M PA

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

2 QL M PA

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

2 QL M PA

methadone hcl intensol QL (90 mL / 30 days)

2 QL M PA

MORPHABOND ER 15mg QL (90 tabs / 30 days)

4 QL M PA

MORPHABOND ER 30mg, 60mg, 100mg


5 QL M PA

morphine sul inj 1mg/ml 4 B/D M

morphine sulfate CP24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


2 QL M PA

morphine sulfate CP24 100mg


5 QL M PA

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

4 B/D M

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

4 B/D M

morphine sulfate TABS QL (180 tabs / 30 days)

2 QL M

morphine sulfate beads QL (30 caps / 30 days)

2 QL M PA

morphine sulfate ext-rel tab QL (90 tabs / 30 days)

2 QL M PA

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

2 QL M


QL (900 mL / 30 days)

2 QL M


QL (180 mL / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

NUCYNTA 50mg, 75mg QL (180 tabs / 30 days)

4 QL M

NUCYNTA 100mg QL (180 tabs / 30 days)

5 QL M

NUCYNTA ER QL (60 tabs / 30 days)

3 QL M PA

OXAYDO 5mg QL (540 tabs / 30 days)

4 QL M

OXAYDO 7.5mg QL (360 tabs / 30 days)

5 QL M

oxycodone hcl CAPS QL (180 caps / 30 days)

2 QL M

oxycodone hcl CONC QL (180 mL / 30 days)

2 QL M

oxycodone hcl SOLN QL (900 mL / 30 days)

2 QL M

oxycodone hcl TABS QL (180 tabs / 30 days)

2 QL M

oxycodone w/ acetaminophen 2.5-325mg


2 QL M

oxycodone w/ acetaminophen 5-325mg


2 QL M

oxycodone w/ acetaminophen 7.5-325mg


2 QL M

oxycodone w/ acetaminophen 10-325mg


2 QL M

oxycodone-aspirin QL (360 tabs / 30 days)

2 QL M

oxycodone-ibuprofen QL (120 tabs / 30 days)

2 QL M

OXYCONTIN 10mg, 15mg, 20mg, 30mg


4 QL M PA

OXYCONTIN 40mg, 60mg, 80mg


5 QL M PA

oxymorphone tabs QL (180 tabs / 30 days)

2 QL M

SUBSYS SPRAY 100MCG QL (120 spray units / 30 days)

5 QL M PA


5 QL M PA


4

Drug Name Drug Tier

Requirements/Limits


5 QL M PA

SUBSYS SPRAY 600MCG QL (120 sprays / 30 days)

5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA

XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg


4 QL M PA

XTAMPZA ER 36mg QL (240 caps / 30 days)

5 QL M PA

ZOHYDRO ER (ABUSE DETERRENT)


4 QL M PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 B/D M

lidocaine inj 0.5% 2 B/D M

lidocaine inj 1% 2 B/D M

lidocaine inj 1.5% preservative free (pf)

2 B/D M

lidocaine inj 2% preservative free (pf)

2 B/D M

lidocaine inj 4% preservative free (pf)

2 M

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 M

ARIKAYCE 5 LA PA

BETHKIS 5 PA

gentamicin in saline 2 M

gentamicin sulfate SOLN 2 M

neomycin sulfate TABS 2 M

paromomycin sulfate CAPS 2 M

streptomycin sulfate SOLR 5 M

SULFADIAZINE TABS 4 M

TOBI PODHALER 5 LA PA

tobramycin NEBU 5 PA

tobramycin inj 1.2 gm/30ml 2 M

tobramycin inj 1.2gm 5 M

tobramycin inj 10mg/ml 2 M

Drug Name Drug Tier

Requirements/Limits

tobramycin inj 80mg/2ml 2 M

tobramycin sulfate SOLN 2 M

ZEMDRI 5 M

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 5 M

ALINIA 5 M

atovaquone SUSP 5 M

aztreonam 2 M

CAYSTON 5 LA PA

clindamycin hcl CAPS 1 M

clindamycin phosphate in d5w 2 M

CLINDAMYCIN PHOSPHATE IN NACL

4 M

clindamycin phosphate inj 2 M

clindamycin soln 75mg/5ml 2 M

colistimethate sodium SOLR 2 M

DALVANCE 5 M

dapsone TABS 2 M

daptomycin 5 M

EMVERM QL (12 tabs / 365 days)

5 QL M

ertapenem sodium 2 M

FIRVANQ 4 M

imipenem-cilastatin 2 M

ivermectin TABS 2 M

linezolid in sodium chloride 4 M

linezolid inj 2 M

linezolid susp 5 M

linezolid tab 600mg 2 M

meropenem 2 M

MEROPENEM/SODIUM CHLORIDE

4 M

methenamine hippurate 2 M

metronidazole CAPS 2 M

METRONIDAZOLE SOLN 3 M

metronidazole TABS 1 M

metronidazole in nacl 2 M

NEBUPENT 4 B/D M

nitrofurantoin SUSP 4 M

nitrofurantoin macrocrystal 3 M

nitrofurantoin monohyd macro 3 M

ORBACTIV 5 M

PENTAM 300 4 M

pentamidine isethionate inh 2 B/D M

pentamidine isethionate inj 2 M

polymyxin b sulfate SOLR 2 M

praziquantel TABS 2 M

SIVEXTRO 5 M

SOLOSEC 4 M


5

Drug Name Drug Tier

Requirements/Limits

sulfamethoxazole-trimethop ds

1 M

sulfamethoxazole-trimethoprim inj

2 M

sulfamethoxazole-trimethoprim susp

2 M

sulfamethoxazole-trimethoprim tab 400-80mg

1 M

SYNERCID 5 M

tigecycline 5 M

tinidazole TABS 2 M

trimethoprim TABS 1 M

VABOMERE 5 M

vancomycin hcl CAPS 125mg


2 QL M

vancomycin hcl CAPS 250mg


5 QL M

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

2 M

VANCOMYCIN HYDROCHLORIDE SOLR

4 M

VANCOMYCIN IN NACL 4 M

VANCOMYCIN INJ 250MG 4 M

VIBATIV 5 M

XIFAXAN TAB 200MG QL (9 tabs / 30 days)

5 QL M

ANTIFUNGALS ABELCET 5 B/D M

AMBISOME 5 B/D M

amphotericin b SOLR 2 B/D M

caspofungin acetate 5 M

CRESEMBA 5 M

ERAXIS 50mg 4 M

ERAXIS 100mg 5 M

fluconazole SUSR 2 M

fluconazole TABS 50mg, 100mg, 200mg

2 M

fluconazole TABS 150mg 1 M

fluconazole inj nacl 200 2 M

fluconazole inj nacl 400 2 M

flucytosine CAPS 5 M

griseofulvin microsize 2 M

griseofulvin ultramicrosize 2 M

itraconazole CAPS 2 M PA

itraconazole SOLN 5 M

ketoconazole TABS 2 M PA

MYCAMINE 5 M

Drug Name Drug Tier

Requirements/Limits

NOXAFIL SOLN 5 M

NOXAFIL SUSP QL (630 mL / 30 days)

5 QL M

NOXAFIL TBEC QL (93 tabs / 30 days)

5 QL M

nystatin TABS 2 M

posaconazole QL (93 tabs / 30 days)

5 QL M

terbinafine hcl TABS QL (90 tabs / year)

1 QL M

TOLSURA 5 M PA

voriconazole SUSR 5 M PA

voriconazole TABS 50mg 2 M

voriconazole TABS 200mg 5 M

voriconazole inj 200mg 5 M PA

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg

2 M

atovaquone-proguanil hcl tab 250-100 mg

2 M

chloroquine phosphate TABS

2 M

COARTEM 4 M

mefloquine hcl 2 M

primaquine phosphate 26.3mg

2 M

PRIMAQUINE PHOSPHATE 26.3mg

3 M

quinine sulfate CAPS 2 M PA

ANTIRETROVIRAL AGENTS abacavir sulfate 2 M

APTIVUS 5 M

atazanavir sulfate 2 M

CRIXIVAN 4 M

didanosine 2 M

EDURANT 5 M

efavirenz CAPS 50mg 2 M

efavirenz CAPS 200mg 5 M

efavirenz TABS 5 M

EMTRIVA 3 M

fosamprenavir tab 700 mg 5 M

FUZEON 5

INTELENCE 25mg 4 M

INTELENCE 100mg, 200mg 5 M

INVIRASE 5 M

ISENTRESS CHEW 25mg 3 M

ISENTRESS CHEW 100mg 5 M

ISENTRESS PACK 3 M

ISENTRESS TABS 5 M


6

Drug Name Drug Tier

Requirements/Limits

ISENTRESS HD 5 M

lamivudine 2 M

LEXIVA SUSP 4 M

nevirapine susp 50 mg/5ml 2 M

nevirapine tab 100mg er 2 M

nevirapine tab 200mg 2 M

nevirapine tab 400mg er 2 M

NORVIR PACK 4 M

NORVIR SOLN 4 M

PIFELTRO 5 M

PREZISTA SUSP QL (400 mL / 30 days)

5 QL M

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

4 QL M


5 QL M


5 QL M


5 QL M

RESCRIPTOR 4 M

REYATAZ PACK 5 M

ritonavir 2 M

SELZENTRY SOLN 5 M

SELZENTRY TABS 25mg 4 M

SELZENTRY TABS 75mg, 150mg, 300mg

5 M

stavudine 2 M

tenofovir disoproxil fumarate 2 M

TIVICAY 10mg 3 M

TIVICAY 25mg, 50mg 5 M

TROGARZO 5 LA

TYBOST 4 M

VIDEX EC 125mg 4 M

VIDEX PEDIATRIC 4 M

VIRACEPT 5 M

VIREAD POWD 5 M

VIREAD TABS 150mg, 200mg, 250mg

5 M

zidovudine cap 100mg 2 M

zidovudine syp 50mg/5ml 2 M

zidovudine tab 300mg 2 M

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine 2 M

abacavir sulfate-lamivudine-zidovudine

5 M

ATRIPLA 5 M

BIKTARVY 5 M

Drug Name Drug Tier

Requirements/Limits

CIMDUO 5 M

COMPLERA 5 M

DELSTRIGO 5 M

DESCOVY 5 M

DOVATO 5 M

EVOTAZ 5 M

GENVOYA 5 M

JULUCA 5 M

KALETRA TAB 100-25MG 4 M

KALETRA TAB 200-50MG 5 M

lamivudine-zidovudine 2 M

lopinavir-ritonavir 2 M

ODEFSEY 5 M

PREZCOBIX 5 M

STRIBILD 5 M

SYMFI 5 M

SYMFI LO 5 M

SYMTUZA 5 M

TEMIXYS 5 M

TRIUMEQ 5 M

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

5 QL M


5 QL M


5 QL M


5 QL M

ANTITUBERCULAR AGENTS cycloserine CAPS 5 M

ethambutol hcl TABS 2 M

isoniazid SYRP 2 M

isoniazid tabs 1 M

PASER D/R 4 M

PRIFTIN 4 M

pyrazinamide TABS 2 M

rifabutin 2 M

RIFAMATE 4 M

rifampin CAPS; SOLR 2 M

RIFATER 4 M

SIRTURO 5 M LA PA

TRECATOR 4 M

ANTIVIRALS acyclovir CAPS; TABS 1 M

acyclovir SUSP 2 M

acyclovir sodium 2 B/D M

adefovir dipivoxil 5 M

BARACLUDE SOLN 5 M

cidofovir 5 M


7

Drug Name Drug Tier

Requirements/Limits

entecavir 2 M

EPCLUSA 5 PA

EPIVIR HBV SOLN 4 M

famciclovir 2 M

GANCICLOVIR INJ 500MG/10ML

4 B/D M

ganciclovir sodium 2 B/D M

HARVONI 5 PA

lamivudine (hbv) 2 M

MAVYRET 5 PA

oseltamivir phosphate CAPS; SUSR

2 M

PEGASYS 5 PA

PEGASYS PROCLICK 5 PA

PREVYMIS INJ 5 M

PREVYMIS TABS QL (28 tabs / 28 days)

5 QL M

RELENZA DISKHALER 3 M

ribavirin 200mg 2

rimantadine hydrochloride 2 M

valacyclovir hcl TABS 2 M

valganciclovir hcl 5 M

VEMLIDY 5 M

VOSEVI 5 PA

XOFLUZA 4 M

CEPHALOSPORINS AVYCAZ 5 M

cefaclor 2 M

CEFACLOR ER TAB 500MG 4 M

cefadroxil CAPS 1 M

cefadroxil SUSR; TABS 2 M

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3 M

cefazolin inj 2 M

cefazolin sodium SOLR 1gm 2 M

CEFAZOLIN SODIUM 1 GM/50ML

3 M

cefdinir 2 M

CEFEPIME 1GM SOLN 4 M

CEFEPIME 2GM SOLN 4 M

cefepime inj 1gm 2 M

cefepime inj 2gm 2 M

CEFEPIME/DEXTROSE 4 M

cefixime 2 M

cefotetan disodium 2 M

CEFOXITIN SODIUM 4 M

cefoxitin sodium 1gm, 2gm, 10gm

2 M

cefpodoxime proxetil 2 M

Drug Name Drug Tier

Requirements/Limits

cefprozil 2 M

ceftazidime SOLR 2 M

CEFTAZIDIME/DEXTROSE 4 M

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

2 M

cefuroxime axetil 2 M

cefuroxime sodium 2 M

cephalexin CAPS 250mg, 500mg

1 M

cephalexin CAPS 750mg 2 M

cephalexin SUSR 2 M

cephalexin TABS 2 M

MAXIPIME IV 4 M

SUPRAX CHEW 4 M

SUPRAX SUSR 500mg/5ml 4 M

tazicef SOLR 2 M

TEFLARO 5 M

ZERBAXA 5 M

ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR

2 M

azithromycin TABS 1 M

clarithromycin SUSR; TABS; TB24

2 M

DIFICID 5 M

e.e.s 400 2 M

ery-tab 2 M

ERYPED 400 5 M

ERYTHROCIN LACTOBIONATE

4 M

erythrocin stearate 2 M

erythromycin base 2 M

erythromycin cap 250mg ec 2 M

erythromycin ethylsuccinate SUSR 200mg/5ml

2 M

erythromycin ethylsuccinate SUSR 400mg/5ml

5 M

erythromycin ethylsuccinate TABS

2 M

erythromycin tab ec 2 M

FLUOROQUINOLONES BAXDELA 5 M

ciprofloxacin SUSR 2 M

ciprofloxacin hcl TABS 100mg

2 M

ciprofloxacin hcl TABS 250mg, 500mg, 750mg

1 M

ciprofloxacin in d5w 2 M


8

Drug Name Drug Tier

Requirements/Limits

levofloxacin SOLN 2 M

levofloxacin TABS 1 M

levofloxacin in d5w 2 M

MOXIFLOXACIN HCL SOLN 4 M

moxifloxacin hcl TABS 2 M

moxifloxacin hcl in sodium chloride

2 M

PENICILLINS amoxicillin CAPS; SUSR; TABS

1 M

amoxicillin CHEW 2 M

amoxicillin & pot clavulanate 200-28.5 chw tabs

2 M

amoxicillin & pot clavulanate 200/5ml susr

2 M

amoxicillin & pot clavulanate 250-125 tabs

2 M


2 M

amoxicillin & pot clavulanate 400-57 chw tabs

2 M


2 M


2 M


2 M


2 M

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

2 M

ampicillin & sulbactam sodium 2 M

ampicillin cap 500mg 1 M

ampicillin inj 2 M

ampicillin sodium 2 M

AUGMENTIN SUS 125/5ML 5 M

BACTOCILL INJ DEX 1GM 4 M

BACTOCILL INJ DEX 2GM 4 M

BICILLIN C-R 4 M

BICILLIN L-A 4 M

dicloxacillin sodium 2 M

NAFCILLIN IN DEXTROSE 4 M

nafcillin sodium 1gm, 2gm 2 M

nafcillin sodium 10gm 5 M

NAFCILLIN SODIUM FOR INJ 10GM

4 M

oxacillin sodium 1gm, 2gm 2 M

oxacillin sodium 10gm 5 M

Drug Name Drug Tier

Requirements/Limits

PENICILLIN G POT IN DEXTROSE 1MU

4 M


4 M


4 M

PENICILLIN G PROCAINE 4 M

penicillin g sodium 2 M

penicillin v potassium SOLR 2 M

penicillin v potassium TABS 1 M

penicilln gk inj 5mu 2 M

penicilln gk inj 20mu 2 M

pfizerpen-g inj 5mu 2 M

pfizerpen-g inj 20mu 2 M

piper/tazoba inj 2-0.25gm 2 M





ZOSYN SOLN 4 M

TETRACYCLINES demeclocycline hcl 2 M

doxy 100 2 M

doxycycline (monohydrate) CAPS 50mg, 100mg

1 M

doxycycline (monohydrate) CAPS 75mg, 150mg

2 M

doxycycline (monohydrate) SUSR

2 M

doxycycline (monohydrate) TABS

2 M

doxycycline hyclate CAPS 2 M

doxycycline hyclate SOLR 2 M

doxycycline hyclate TABS 20mg, 100mg

2 M

doxycycline hyclate TBEC 2 M

doxycycline hyclate tab 75 mg dr

2 M


2 M


2 M

minocycline hcl CAPS; TABS

2 M

minocycline tab 45mg er 2 M PA



mondoxyne nl cap 75mg 2 M

mondoxyne nl cap 100mg 1 M


9

Drug Name Drug Tier

Requirements/Limits

tetracycline hcl CAPS 2 M

VIBRAMYCIN SYRP 4 M

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D

cyclophosphamide CAPS 2 B/D M

cyclophosphamide SOLR 5 B/D M

EMCYT 4 M

GLEOSTINE 10mg 4 M

GLEOSTINE 40mg, 100mg 5 M

LEUKERAN 5 M

TREANDA 5 B/D M

ANTHRACYCLINES adriamycin SOLN 2 B/D M

doxorubicin hcl 2 B/D M

doxorubicin hcl liposomal 5 B/D M

epirubicin hcl 2 B/D M

ANTIMETABOLITES adrucil inj 2 B/D M

ALIMTA 5 B/D M

azacitidine 5 B/D M

cytarabine 2 B/D M

decitabine 5 B/D M

fludarabine phosphate SOLN 5 B/D M

fludarabine phosphate SOLR 2 B/D M

fluorouracil SOLN 2 B/D M

gemcitabine inj soln 2 B/D M

gemcitabine inj solr 2 B/D M

INFUGEM 5 B/D M

mercaptopurine TABS 2 M

methotrexate sodium inj soln 2 B/D M

methotrexate sodium inj solr 2 B/D M

NIPENT 5 B/D M

PURIXAN 5

TABLOID 5 M

ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D M

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

5 B/D M

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

5 B/D M

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

5 B/D M

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

5 B/D M

paclitaxel 2 B/D M

TAXOTERE 80mg/4ml 5 B/D M

Drug Name Drug Tier

Requirements/Limits

ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate 2 B/D M

vinorelbine tartrate 2 B/D M

BIOLOGIC RESPONSE MODIFIERS ARZERRA 5 B/D M

AVASTIN 5 M LA PA

BELEODAQ 5 PA

BESPONSA 5 LA PA

BORTEZOMIB 5 M PA

DAURISMO 5 LA PA

ERBITUX 5 B/D M

ERIVEDGE 5 LA PA

FARYDAK 5 LA PA

HERCEPTIN 5 M PA

HERCEPTIN HYLECTA 5 M PA

IBRANCE QL (21 caps / 28 days)

5 QL LA PA

IDHIFA QL (30 tabs / 30 days)

5 QL LA PA

KADCYLA 5 B/D M

KEYTRUDA 5 PA

KISQALI 5 PA

KISQALI FEMARA 200 DOSE 5 PA



LIBTAYO 5 LA PA

LYNPARZA 5 LA PA

NINLARO 5 PA

ODOMZO 5 LA PA

PERJETA 5 M PA

POTELIGEO 5 LA PA

RITUXAN 5 M LA PA

RITUXAN HYCELA 5 LA PA

RUBRACA 5 LA PA

TALZENNA 5 LA PA

TECENTRIQ 5 LA PA

temsirolimus 5 B/D M

TIBSOVO 5 LA PA

VECTIBIX 5 B/D M

VELCADE 5 M PA

VENCLEXTA 10mg 4 LA PA

VENCLEXTA 50mg, 100mg 5 LA PA

VENCLEXTA STARTING PACK

5 LA PA

VERZENIO 5 LA PA

YERVOY 5 M PA

ZEJULA 5 LA PA

ZOLINZA 5 PA


10

Drug Name Drug Tier

Requirements/Limits

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 5 PA

anastrozole TABS 1 M

bicalutamide 2 M

DEPO-PROVERA INJ 400/ML 4 B/D M

ELIGARD INJ 7.5MG 4 B/D

ELIGARD INJ 22.5MG 4 B/D

ELIGARD INJ 30MG 4 B/D

ELIGARD INJ 45MG 4 B/D

ERLEADA 5 LA PA

exemestane 2 M

FIRMAGON 80mg 4 B/D

FIRMAGON 120mg 5 B/D

flutamide 2 M

fulvestrant 5 B/D M

hydroxyprogesterone caproate (antineoplastic)

5 B/D M

letrozole TABS 1 M

leuprolide inj 1mg/0.2 2 PA

LUPRON DEPOT (1-MONTH) 5 PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 30MG (4-MONTH)

5 PA

LYSODREN 3 M

megestrol ac sus 40mg/ml 3 M

megestrol ac tab 20mg 3 M

megestrol ac tab 40mg 3 M

megestrol sus 625mg/5ml 4 M PA

nilutamide 5 M

NUBEQA 5 LA PA

SOLTAMOX 5 M

tamoxifen citrate TABS 1 M

toremifene citrate 5 M

TRELSTAR MIXJECT 5 PA

XTANDI 5 LA PA

ZYTIGA 500mg 5 LA PA

IMMUNOMODULATORS POMALYST 1mg, 2mg

QL (21 caps / 21 days) 5 QL LA PA

POMALYST 3mg, 4mg QL (21 caps / 28 days)

5 QL LA PA

REVLIMID 5 LA PA

THALOMID 5 PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) 5 QL PA

Drug Name Drug Tier

Requirements/Limits

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

5 QL PA


5 QL PA


5 QL PA

ALECENSA 5 LA PA

ALIQOPA 5 LA PA

ALUNBRIG 5 LA PA

BALVERSA 5 LA PA

BOSULIF 5 PA

BRAFTOVI 5 LA PA

CABOMETYX QL (30 tabs / 30 days)

5 QL LA PA

CALQUENCE 5 LA PA

CAPRELSA 5 LA PA

COMETRIQ 5 LA PA

COPIKTRA 5 LA PA

COTELLIC 5 LA PA

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

5 QL PA

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

5 QL PA

everolimus QL (30 tabs / 30 days)

5 QL PA

GILOTRIF TAB 20MG 5 LA PA



ICLUSIG 5 LA PA

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

5 QL PA

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

5 QL PA

IMBRUVICA 5 LA PA

INLYTA 1mg QL (180 tabs / 30 days)

5 QL LA PA

INLYTA 5mg QL (120 tabs / 30 days)

5 QL LA PA

INREBIC 5 LA PA

IRESSA 5 LA PA

JAKAFI QL (60 tabs / 30 days)

5 QL LA PA

LENVIMA 4 MG DAILY DOSE 5 LA PA

LENVIMA 8 MG DAILY DOSE 5 LA PA

LENVIMA 10 MG DAILY DOSE

5 LA PA

LENVIMA 12MG DAILY DOSE

5 LA PA


5 LA PA


11

Drug Name Drug Tier

Requirements/Limits


5 LA PA


5 LA PA


5 LA PA

LORBRENA 5 LA PA

MEKINIST 5 LA PA

MEKTOVI 5 LA PA

NERLYNX 5 LA PA

NEXAVAR 5 LA PA

PIQRAY 200MG DAILY DOSE

5 PA


5 PA


5 PA

ROZLYTREK 5 LA PA

RYDAPT 5 PA

SPRYCEL 5 PA

STIVARGA 5 LA PA

SUTENT QL (30 caps / 30 days)

5 QL PA

TAFINLAR 5 LA PA

TAGRISSO QL (30 tabs / 30 days)

5 QL LA PA

TASIGNA 5 PA

TURALIO 5 LA PA

TYKERB 5 LA PA

VITRAKVI 5 LA PA

VIZIMPRO 5 LA PA

VOTRIENT 5 LA PA

XALKORI 5 LA PA

XOSPATA 5 LA PA

ZELBORAF 5 LA PA

ZYDELIG 5 LA PA

ZYKADIA 5 LA PA

MISCELLANEOUS bexarotene 5 PA

HALAVEN 5 B/D M

hydroxyurea CAPS 2 M

IXEMPRA KIT 5 B/D M

LONSURF 5 PA

MATULANE 5 M LA

SIKLOS 100mg 4 M

SIKLOS 1000mg 5 M

SYLATRON 5 M PA

SYNRIBO 5 PA

tretinoin CAPS 5 M

Drug Name Drug Tier

Requirements/Limits

XPOVIO 60 MG ONCE WEEKLY

5 LA PA


5 LA PA

XPOVIO 80 MG TWICE WEEKLY

5 LA PA


5 LA PA

PLATINUM-BASED AGENTS carboplatin 2 B/D M

cisplatin SOLN 2 B/D M

oxaliplatin inj 50mg 5 B/D M

oxaliplatin inj 50mg/10ml 2 B/D M

oxaliplatin inj 100mg 5 B/D M

oxaliplatin inj 100mg/20ml 2 B/D M

PROTECTIVE AGENTS ELITEK 5 B/D M

KHAPZORY 5 B/D M

leucovorin calcium SOLN 500mg/50ml

2 B/D M

leucovorin calcium SOLR 2 B/D M

leucovorin calcium TABS 2 M

levoleucovorin calcium 175mg/17.5ml

5 B/D M

levoleucovorin calcium 250mg/25ml

2 B/D M

levoleucovorin calcium 50mg 5 B/D M

MESNEX TABS 5 M

TOPOISOMERASE INHIBITORS etoposide SOLN 2 B/D M

irinotecan hcl 2 B/D M

ONIVYDE 5 B/D

toposar 2 B/D M

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

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

trandolapril-verapamil hcl 1 M


12

Drug Name Drug Tier

Requirements/Limits

ACE INHIBITORS benazepril hcl TABS 1 M

captopril TABS 1 M

enalapril maleate TABS 1 M

EPANED 5 M

fosinopril sodium 1 M

lisinopril TABS 1 M

moexipril hcl 1 M

perindopril erbumine 1 M

QBRELIS 5 M

quinapril hcl 1 M

ramipril 1 M

trandolapril 1 M

ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR 4 M

eplerenone 2 M

spironolactone TABS 1 M

ALPHA BLOCKERS doxazosin mesylate TABS 1 M

prazosin hcl 2 M

terazosin hcl 1mg, 2mg, 5mg 1 M

terazosin hcl 10mg 2 M

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

1 M

amlodipine besylate-valsartan tab 5-160 mg

1 M


1 M


1 M


1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1 M

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1 M


1 M


1 M

candesartan cilexetil-hydrochlorothiazide

1 M

EDARBYCLOR 4 M

Drug Name Drug Tier

Requirements/Limits

ENTRESTO 3 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

EDARBI 4 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 2 M

amiodarone tab 100mg 2 M



disopyramide phosphate 4 M

dofetilide 2 M

flecainide acetate 2 M

MULTAQ 4 M

NORPACE CR 4 M

pacerone 100mg, 400mg 2 M

pacerone 200mg 1 M

propafenone hcl 2 M

propafenone hcl 12hr 2 M

quinidine sulfate 2 M

sorine 1 M

sotalol hcl 1 M

sotalol hcl (afib/afl) 2 M

SOTYLIZE 4 M

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 5 M ST

atorvastatin calcium TABS 1 M

FLOLIPID 4 M ST

fluvastatin sodium cap 20 mg 1 M


13

Drug Name Drug Tier

Requirements/Limits

fluvastatin sodium cap 40 mg 1 M

fluvastatin sodium tab sr 24 hr 80 mg

1 M

LIVALO 4 M ST

lovastatin 1 M

pravastatin sodium 1 M

rosuvastatin calcium 1 M

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

1 M

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

1 QL M

ZYPITAMAG 4 M ST

ANTILIPEMICS, MISCELLANEOUS ANTARA 4 M

cholestyramine 2 M

cholestyramine light pack 2 M

cholestyramine light powd 2 M

choline fenofibrate 2 M

colesevelam hcl 2 M

colestipol hcl gran 2 M

colestipol hcl pack 2 M

colestipol hcl tabs 2 M

ezetimibe 2 M

ezetimibe-simvastatin 1 M

fenofibrate CAPS 2 M

fenofibrate TABS 40mg, 48mg, 54mg, 145mg, 160mg

2 M

fenofibrate TABS 120mg 5 M

fenofibrate micronized 2 M

fenofibric acid 2 M

gemfibrozil TABS 1 M

JUXTAPID 5 LA PA

niacin (antihyperlipidemic) 2 M

niacin er (antihyperlipidemic) 2 M

niacor 2 M

omega-3-acid ethyl esters 2 M PA

PRALUENT 3 PA

prevalite 2 M

TRIGLIDE 4 M

VASCEPA 4 M

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1 M

bisoprolol & hydrochlorothiazide

1 M

DUTOPROL 4 M

metoprolol & hctz tab 50-25mg

2 M

Drug Name Drug Tier

Requirements/Limits


2 M


2 M

propranolol & hydrochlorothiazide

2 M

BETA-BLOCKERS acebutolol hcl CAPS 1 M

atenolol TABS 1 M

betaxolol hcl 2 M

bisoprolol fumarate 1 M

BYSTOLIC 4 M

carvedilol 1 M

carvedilol er 2 M

KAPSPARGO SPRINKLE 4 M

labetalol hcl SOLN; TABS 2 M

metoprolol succinate 1 M

metoprolol tartrate SOCT 2 M

metoprolol tartrate SOLN 2 M

metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 2 M

pindolol 2 M

propranolol hcl er 2 M

propranolol inj 1mg/ml 2 M

propranolol oral sol 2 M

propranolol tab 2 M

timolol maleate TABS 2 M

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

1 M

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 1 M

CARDIZEM LA 120mg 4 M

cartia xt 2 M

dilt-xr cap 2 M

diltiazem cap 240mg cd 2 M

diltiazem cap 360mg cd 2 M

diltiazem cap er/12hr 2 M

diltiazem er tab 180mg 2 M





diltiazem hcl TABS 1 M

diltiazem hcl coated beads 2 M

diltiazem hcl coated beads cap sr 24hr

2 M


14

Drug Name Drug Tier

Requirements/Limits

diltiazem hcl extended release beads cap sr

2 M

diltiazem inj 2 M

felodipine 2 M

isradipine 2 M

matzim la 2 M

nicardipine hcl CAPS 2 M

nifedipine TB24 2 M

nifedipine er 2 M

nimodipine CAPS 5 M

nisoldipine 2 M

NYMALIZE 5 M

taztia xt 2 M

tiadylt er 2 M

verapamil hcl CP24; SOLN 2 M

verapamil hcl TABS; TBCR 1 M

DIGITALIS GLYCOSIDES digitek .25mg

PA if 70 years and older 2 M PA

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

2 QL M

digox 125mcg QL (30 tabs / 30 days)

2 QL M

digox 250mcg PA if 70 years and older

2 M PA

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

2 QL M

digoxin TABS 250mcg PA if 70 years and older

2 M PA

digoxin inj 2 M

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

2 M PA

LANOXIN PEDIATRIC INJ 4 M

LANOXIN TABS 62.5MCG QL (60 tabs / 30 days)

4 QL M

DIURETICS acetazolamide CP12; TABS 2 M

ALDACTAZIDE TAB 50/50 4 M

amiloride & hydrochlorothiazide

1 M

amiloride hcl TABS 1 M

bumetanide 2 M

chlorothiazide tabs 2 M

chlorthalidone 2 M

DIURIL SUS 250/5ML 4 M

ethacrynic acid 5 M

furosemide SOLN; TABS 1 M

furosemide inj 2 M

furosemide oral soln 8 mg/ml 1 M

Drug Name Drug Tier

Requirements/Limits

hydrochlorothiazide CAPS; TABS

1 M

indapamide 1 M

KEVEYIS 5 PA

methazolamide TABS 2 M

metolazone 2 M

spironolactone & hydrochlorothiazide

2 M

torsemide tabs 1 M

triamt/hctz cap 37.5-25 1 M

triamterene CAPS 2 M

triamterene & hydrochlorothiazide tabs

1 M

MISCELLANEOUS aliskiren fumarate 2 M

BIDIL 3 M

clonidine hcl TABS 1 M

clonidine hcl ptwk 2 M

CORLANOR 4 M

DEMSER 5 M PA

hydralazine hcl SOLN; TABS 2 M

midodrine hcl 2 M

minoxidil TABS 1 M

NORTHERA 100mg QL (90 caps / 30 days)

5 QL LA PA

NORTHERA 200mg, 300mg QL (180 caps / 30 days)

5 QL LA PA

phenoxybenzamine hcl CAPS

5 M PA

ranolazine 2 M

TEKTURNA HCT 4 M

VYNDAMAX QL (30 caps / 30 days)

5 QL LA PA

VYNDAQEL 5 LA PA

NITRATES DILATRATE SR 4 M

GONITRO 4 M

ISORDIL TITRADOSE 40mg 5 M

isosorbide dinitrate 5mg, 10mg, 20mg, 30mg

2 M

isosorbide dinitrate er 2 M

isosorbide mononitrate 1 M

isosorbide mononitrate er 1 M

minitran 2 M

NITRO-BID 3 M

NITRO-DUR .3mg/hr, .8mg/hr

4 M

nitroglycerin SOLN .4mg/spray

2 M


15

Drug Name Drug Tier

Requirements/Limits

nitroglycerin SUBL 2 M

nitroglycerin td patch 2 M

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 5 LA PA

alyq 5 PA

ambrisentan 5 LA PA

bosentan 5 LA PA

OPSUMIT 5 LA PA

ORENITRAM TAB 0.25MG 5 LA PA


ORENITRAM TAB 1MG 5 LA PA


ORENITRAM TAB 5MG 5 LA PA

sildenafil citrate (pulmonary hypertension)

5 PA

sildenafil citrate tab 20 mg (pulmonary hypertension)

2 PA

tadalafil (pulmonary hypertension)

5 PA

TRACLEER TBSO 5 LA PA

treprostinil 5 LA PA

TYVASO 5 PA

UPTRAVI 5 LA PA

VENTAVIS 5 PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM CONC

QL (300 mL / 30 days) 4 QL M

alprazolam TABS QL (150 tabs / 30 days)

2 QL M

buspirone hcl TABS 5mg, 10mg, 15mg

1 M

buspirone hcl TABS 7.5mg, 30mg

2 M

fluvoxamine maleate 2 M

fluvoxamine maleate er 100mg


2 QL M

fluvoxamine maleate er 150mg


2 QL M

lorazepam SOLN 2 M

lorazepam TABS QL (150 tabs / 30 days)

2 QL M

lorazepam intensol QL (150 mL / 30 days)

2 QL M

ANTICONVULSANTS APTIOM 5 M

BANZEL SUS 40MG/ML 5 M PA

Drug Name Drug Tier

Requirements/Limits

BANZEL TAB 200MG 5 M PA

BANZEL TAB 400MG 5 M PA

BRIVIACT INJ 50MG/5ML 4 M PA

BRIVIACT SOL 10MG/ML 5 M PA

BRIVIACT TAB 10MG 5 M PA





carbamazepine CHEW; CP12; SUSP; TABS; TB12

2 M

CELONTIN 4 M

clobazam 2 M PA

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

2 QL M

clonazepam TABS .5mg, 1mg


2 QL M

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

2 QL M

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


2 QL M

clorazepate dipotassium QL (180 tabs / 30 days)

PA if 65 years and older

2 QL M PA

DIASTAT ACUDIAL 4 M

DIASTAT PEDIATRIC 4 M

diazepam TABS QL (120 tabs / 30 days)


2 QL M PA

diazepam gel 2 M

diazepam inj 2 M

diazepam intensol QL (240 mL / 30 days)


2 QL M PA

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


2 QL M PA

DILANTIN CAP 30MG 3 M

DILANTIN CAP 100MG 3 M

DILANTIN CHEW TAB 50MG 3 M

DILANTIN-125 SUSP 4 M

divalproex sodium CSDR; TB24; TBEC

2 M

EPIDIOLEX QL (600 mL / 30 days)

5 QL LA PA

epitol 2 M

ethosuximide CAPS; SOLN 2 M

felbamate SUSP 5 M


16

Drug Name Drug Tier

Requirements/Limits

felbamate TABS 2 M

FYCOMPA SUSP 5 M PA

FYCOMPA TABS 2mg 4 M PA

FYCOMPA TABS 4mg, 6mg, 8mg, 10mg, 12mg

5 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)

2 QL M

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

2 QL M

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

2 QL M

LAMICTAL ODT KIT 4 M

LAMICTAL XR KIT 4 M

lamotrigine CHEW; KIT; TB24; TBDP

2 M

lamotrigine TABS 1 M

levetiracetam SOLN; TABS; TB24

2 M

levetiracetam in sodium chloride

2 M

levetiracetam oral soln 100 mg/ml

2 M

NAYZILAM 4 M

oxcarbazepine 2 M

OXTELLAR XR 150mg, 300mg

4 M

OXTELLAR XR 600mg 5 M

PEGANONE 4 M

phenobarbital ELIX PA if 70 years and older

4 M PA

phenobarbital TABS PA if 70 years and older

3 M PA

PHENOBARBITAL SODIUM SOLN 65mg/ml


4 M PA

phenobarbital sodium SOLN 130mg/ml


4 M PA

PHENYTEK 3 M

phenytoin CHEW; SUSP 2 M

phenytoin sodium extended 2 M

phenytoin sodium inj 50mg/ml 2 M

Drug Name Drug Tier

Requirements/Limits

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


2 QL M PA

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

2 QL M PA

pregabalin CAPS 225mg, 300mg


2 QL M PA

pregabalin SOLN QL (900 mL / 30 days)

2 QL M PA

primidone TABS 1 M

roweepra 2 M

roweepra xr 2 M

SPRITAM 4 M

subvenite starter kit 2 M

subvenite tab 1 M

SYMPAZAN 5mg 4 M PA

SYMPAZAN 10mg, 20mg 5 M PA

tiagabine hcl 2 M

topiramate CPSP 2 M

topiramate CS24 25mg, 50mg, 100mg, 150mg

2 M

topiramate CS24 200mg 5 M

topiramate TABS 1 M

TROKENDI XR 25mg, 50mg 4 M

TROKENDI XR 100mg, 200mg

5 M

valproate sodium SOLN 2 M

valproic acid CAPS 2 M

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

5 QL LA PA

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

5 QL LA PA

vigadrone QL (180 packets / 30 days)

5 QL LA PA

VIMPAT 50mg 4 M

VIMPAT 100mg, 150mg, 200mg

5 M

VIMPAT INJ 200MG/20ML 5 M

VIMPAT SOL 10MG/ML 5 M

zonisamide CAPS 2 M

ANTIDEMENTIA donepezil odt 5mg 1 M

donepezil odt 10mg 1 M

donepezil tab hcl 23mg 2 M

donepezil tabs 5mg 1 M

donepezil tabs 10mg 1 M


17

Drug Name Drug Tier

Requirements/Limits

galantamine hydrobromide 2 M

galantamine hydrobromide er 2 M

memantine hcl cp24 PA if < 30 yrs

2 M PA

memantine soln PA if < 30 yrs

2 M PA

memantine tabs PA if < 30 yrs

2 M PA

NAMZARIC 4 M

rivastigmine tartrate 2 M

rivastigmine td patch 24hr 4.6 mg/24hr

2 M


2 M


2 M

ANTIDEPRESSANTS amitriptyline hcl TABS 3 M

amoxapine 3 M

bupropion hcl TABS 2 M

bupropion hcl TB12 1 M

bupropion hcl TB24 150mg, 300mg

2 M

bupropion hcl TB24 450mg QL (30 tabs / 30 days)

2 QL M

citalopram hydrobromide SOLN

2 M

citalopram hydrobromide TABS

1 M

clomipramine hcl CAPS 4 M PA

desipramine hcl TABS 4 M

desvenlafaxine succinate 2 M PA

doxepin hcl CAPS; CONC 3 M

DRIZALMA SPRINKLE 20mg, 30mg, 60mg


4 QL M PA

DRIZALMA SPRINKLE 40mg


4 QL M PA

duloxetine hcl CPEP 20mg, 30mg, 60mg


2 QL M

EMSAM 5 M PA

escitalopram oxalate SOLN 2 M

escitalopram oxalate TABS 1 M

FETZIMA 4 M PA

FETZIMA TITRATION PACK 4 M PA

fluoxetine cap 10mg 1 M



Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl CPDR; TABS 2 M

fluoxetine hcl SOLN 1 M

imipramine hcl TABS 2 M

imipramine pamoate 4 M

maprotiline hcl 2 M

MARPLAN 4 M

mirtazapine TABS 7.5mg 2 M

mirtazapine TABS 15mg, 30mg, 45mg

1 M

mirtazapine TBDP 2 M

nefazodone hcl 2 M

nortriptyline hcl CAPS 2 M

nortriptyline hcl SOLN 4 M

paroxetine er tab QL (60 tabs / 30 days)

4 QL M

paroxetine hcl tabs 2 M

PAXIL SUSP 4 M

PEXEVA 10mg, 30mg QL (60 tabs / 30 days)

4 QL M

PEXEVA 20mg, 40mg QL (30 tabs / 30 days)

4 QL M

phenelzine sulfate TABS 2 M

protriptyline hcl 4 M

sertraline hcl CONC 2 M

sertraline hcl TABS 1 M

tranylcypromine sulfate 2 M

trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trazodone hcl TABS 300mg 2 M

trimipramine maleate CAPS 4 M

TRINTELLIX 4 M

venlafaxine cap er 1 M

venlafaxine tab 2 M

VIIBRYD STARTER PACK 4 M

VIIBRYD TAB 4 M

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS


amantadine hcl SYRP 1 M

amantadine hcl TABS 2 M

APOKYN QL (20 cartridges / 30 days)

5 QL LA PA

benztropine mesylate inj 2 M

benztropine mesylate tab 0.5mg


3 M PA

benztropine mesylate tab 1mg PA if 70 years and older

3 M PA


18

Drug Name Drug Tier

Requirements/Limits

benztropine mesylate tab 2mg PA if 70 years and older

3 M PA

bromocriptine mesylate CAPS; TABS

2 M

carbidopa TABS 5 M

carbidopa-levodopa 2 M

carbidopa/levodopa/entacapone

2 M

DUOPA 5 B/D

entacapone 2 M

GOCOVRI QL (60 caps / 30 days)

5 QL M LA PA

INBRIJA 5 LA PA

NEUPRO 4 M

OSMOLEX ER QL (30 tabs / 30 days)

4 QL M PA

pramipexole er 2 M

pramipexole tab 0.5mg 1 M





pramipexole tab 1mg 1 M

rasagiline mesylate TABS 2 M

ropinirole er 2 M

ropinirole tab 0.5mg 1 M

ropinirole tab 0.25mg 1 M

ropinirole tab 1mg 1 M





RYTARY 4 M

selegiline hcl CAPS; TABS 2 M

trihexyphenidyl hcl PA if 70 years and older

3 M PA

XADAGO 5 M

ZELAPAR 5 M

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

5 QL M

aripiprazole odt QL (60 tabs / 30 days)

5 QL M

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

5 QL M

aripiprazole tab QL (30 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

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


5 QL M

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

5 QL M

ARISTADA INITIO 5 M

chlorpromazine hcl TABS 2 M

CHLORPROMAZINE INJ 4 M

clozapine odt 12.5mg, 25mg 2 M PA

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

2 QL M PA


2 QL M PA


2 QL M PA

clozapine tab 25mg 2 M

clozapine tab 50mg 2 M

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

2 QL M

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

2 QL M

FANAPT QL (60 tabs / 30 days)

4 QL M PA

FANAPT TITRATION PACK 4 M PA

fluphenazine decanoate SOLN

2 M

fluphenazine hcl 2 M

GEODON INJ QL (6 mL / 3 days)

4 QL M

haloperidol TABS 2 M

haloperidol conc 2mg/ml 1 M

haloperidol decanoate SOLN 2 M

haloperidol lactate inj 5mg/ml 2 M

INVEGA SUST INJ 39 MG/0.25 ML


4 QL M



5 QL M



5 QL M


19

Drug Name Drug Tier

Requirements/Limits

INVEGA SUST INJ 156MG/ML


5 QL M



5 QL M

INVEGA TRINZA QL (1 injection / 90 days)

5 QL M

LATUDA 20mg, 40mg, 60mg, 120mg


4 QL M

LATUDA 80mg QL (60 tabs / 30 days)

4 QL M

loxapine succinate 2 M

molindone hcl 2 M

NUPLAZID CAPS QL (30 caps / 30 days)

5 QL LA PA

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

5 QL LA PA

olanzapine SOLR QL (3 vials / 1 day)

2 QL M

olanzapine TABS 2.5mg, 5mg, 10mg


2 QL M

olanzapine TABS 7.5mg, 15mg, 20mg


2 QL M

olanzapine odt 5mg, 15mg, 20mg


2 QL M

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

2 QL M

paliperidone 1.5mg, 3mg, 9mg


2 QL M

paliperidone 6mg QL (60 tabs / 30 days)

2 QL M

perphenazine TABS 2 M

PERSERIS QL (1 injection / 30 days)

5 QL M

pimozide 2 M

quetiapine fumarate TABS 2 M

quetiapine fumarate TB24 50mg, 300mg, 400mg


2 QL M PA

Drug Name Drug Tier

Requirements/Limits

quetiapine fumarate TB24 150mg, 200mg


2 QL M PA

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

5 QL M

REXULTI .25mg, .5mg, 1mg, 2mg


5 QL M

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

4 QL M

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

4 QL M

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

5 QL M

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

5 QL M

risperidone SOLN QL (240 mL / 30 days)

2 QL M

risperidone TABS 1 M

risperidone odt 1mg, 2mg, 3mg, 4mg


2 QL M

risperidone odt .25mg, .5mg QL (90 tabs / 30 days)

2 QL M

SAPHRIS QL (60 tabs / 30 days)

4 QL M

thioridazine hcl TABS 2 M

thiothixene 2 M

trifluoperazine hcl 2 M

VERSACLOZ QL (600 mL / 30 days)

5 QL M PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

5 QL M PA

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

5 QL M PA

VRAYLAR THERAPY PACK 4 M PA

ziprasidone hcl QL (60 caps / 30 days)

2 QL M

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

5 QL M PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

5 QL M PA


20

Drug Name Drug Tier

Requirements/Limits

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL M PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADZENYS ER SUS 1.25MG

QL (450 ml / 30 days) 4 QL M

ADZENYS XR-ODT 3.1mg, 6.3mg, 9.4mg


4 QL M

ADZENYS XR-ODT 12.5mg, 15.7mg, 18.8mg


4 QL M

amphetamine cap 10mg er QL (90 caps / 30 days)

2 QL M


2 QL M


2 QL M


2 QL M


2 QL M

amphetamine-dextroamphetamine cap sr 24hr 5 mg


2 QL M

amphetamine-dextroamphetamine tab 5 mg


2 QL M

amphetamine-dextroamphetamine tab 7.5 mg


2 QL M



2 QL M

amphetamine-dextroamphetamine tab 12.5 mg


2 QL M



2 QL M



2 QL M



2 QL M

APTENSIO XR 10mg, 15mg, 20mg, 30mg


4 QL M

Drug Name Drug Tier

Requirements/Limits

APTENSIO XR 40mg, 50mg, 60mg


4 QL M

atomoxetine hcl 10mg, 18mg, 25mg


2 QL M

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

2 QL M

atomoxetine hcl 60mg, 80mg, 100mg


2 QL M

COTEMPLA XR-ODT QL (60 tabs / 30 days)

4 QL M

DAYTRANA QL (30 patches / 30 days)

4 QL M

dexmethylphenidate hcl CP24 5mg, 10mg, 15mg, 20mg


2 QL M

dexmethylphenidate hcl CP24 25mg, 30mg, 35mg, 40mg


2 QL M

dexmethylphenidate hcl TABS 2.5mg, 5mg


2 QL M

dexmethylphenidate hcl TABS 10mg


2 QL M

DYANAVEL XR QL (240 ml / 30 days)

4 QL M

guanfacine er (adhd) PA if 70 years and older

3 M PA

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

2 QL M

methylphenidate hcl CHEW QL (180 tabs / 30 days)

2 QL M

methylphenidate hcl CP24 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CP24 40mg, 60mg


2 QL M

methylphenidate hcl CPCR 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CPCR 40mg, 50mg, 60mg


2 QL M


21

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl SOLN 5mg/5ml

QL (1800 mL / 30 days)

2 QL M

methylphenidate hcl SOLN 10mg/5ml

QL (900 mL / 30 days)

2 QL M

methylphenidate hcl TABS 5mg, 10mg


2 QL M

methylphenidate hcl TABS 20mg


2 QL M

methylphenidate hcl TB24 QL (60 tabs / 30 days)

2 QL M

methylphenidate hcl TBCR 18mg, 27mg, 36mg


2 QL M

methylphenidate hcl TBCR 54mg


2 QL M

methylphenidate hcl er 27mg, 36mg


2 QL M

methylphenidate hcl er 54mg QL (30 tabs / 30 days)

2 QL M

methylphenidate hcl tbcr 10 mg


2 QL M

methylphenidate hcl tbcr 20mg


2 QL M

METHYLPHENIDATE HCL TBCR 72MG


2 QL M

MYDAYIS CAP 12.5MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 25MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 37.5MG QL (30 caps / 30 days)

4 QL M

MYDAYIS CAP 50MG QL (30 caps / 30 days)

4 QL M

QUILLICHEW ER 20mg, 30mg


4 QL M

QUILLICHEW ER 40mg QL (30 tabs / 30 days)

4 QL M

QUILLIVANT XR QL (360 mL / 30 days)

4 QL M

RELEXXII QL (30 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

VYVANSE CAPS 10mg, 20mg, 30mg


4 QL M

VYVANSE CAPS 40mg, 50mg, 60mg, 70mg


4 QL M

VYVANSE CHEW 10mg, 20mg, 30mg


4 QL M

VYVANSE CHEW 40mg, 50mg, 60mg


4 QL M

HYPNOTICS HETLIOZ 5 LA PA

SILENOR QL (30 tabs / 30 days)

3 QL M

temazepam 7.5mg QL (30 caps / 30 days)

PA applies if 65 years and older after a 90 day supply in a calendar year

2 QL M PA

temazepam 15mg QL (60 caps / 30 days)


2 QL M PA

zolpidem tartrate TABS QL (30 tabs / 30 days)


2 QL M PA

MIGRAINE AIMOVIG

QL (1 pen / 30 days) 3 QL M PA

almotriptan malate QL (12 tabs / 30 days)

2 QL M

dihydroergotamine mesylate inj 1 mg/ml

5 M

dihydroergotamine mesylate nasal spr 4 mg/ml

QL (8 mL / 30 days)

5 QL M PA

eletriptan hydrobromide QL (12 tabs / 30 days)

2 QL M

EMGALITY SOAJ QL (2 pens / 30 days)

3 QL M PA

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

3 QL M PA

ergotamine w/ caffeine TABS

2 M


22

Drug Name Drug Tier

Requirements/Limits

frovatriptan succinate QL (18 tabs / 30 days)

2 QL M

naratriptan hcl QL (12 tabs / 30 days)

2 QL M

ONZETRA XSAIL QL (16 nosepieces / 30 days)

5 QL M ST

rizatriptan benzoate QL (18 tabs / 30 days)

2 QL M

rizatriptan benzoate odt QL (18 tabs / 30 days)

2 QL M

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

2 QL M

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

2 QL M

sumatriptan succinate SOLN 5mg/act

QL (24 inhalers / 30 days)

2 QL M

sumatriptan succinate SOLN 20mg/act


2 QL M

sumatriptan succinate TABS QL (12 tabs / 30 days)

2 QL M

sumatriptan-naproxen sodium QL (9 tabs / 30 days)

2 QL M

ZEMBRACE SYMTOUCH QL (24 pens / 30 days)

5 QL M ST

zolmitriptan TABS QL (12 tabs / 30 days)

2 QL M

zolmitriptan odt QL (12 tabs / 30 days)

2 QL M

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

4 QL M ST

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) 5 QL PA

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

5 QL PA

EQUETRO 4 M

GRALISE 300mg QL (180 tabs / 30 days)

4 QL M PA

GRALISE 600mg QL (90 tabs / 30 days)

4 QL M PA

GRALISE STARTER 4 M PA

HORIZANT 4 M PA

Drug Name Drug Tier

Requirements/Limits

INGREZZA CAPS QL (30 caps / 30 days)

5 QL PA

INGREZZA CPPK QL (28 caps / 28 days)

5 QL PA

lithium carbonate CAPS; TABS

1 M

lithium carbonate TBCR 2 M

LITHIUM SOLN 8MEQ/5ML 4 M

LYRICA CR QL (60 tabs / 30 days)

3 QL M PA

NUEDEXTA QL (60 caps / 30 days)

4 QL M PA

paroxetine mesylate (vasomotor)


4 QL M

pyridostigmine bromide SOLN

5 M

pyridostigmine bromide TBCR

2 M

pyridostigmine tab 60mg 2 M

riluzole 2 M

SAVELLA QL (60 tabs / 30 days)

4 QL M

SAVELLA TITRATION PACK 4 M

tetrabenazine 12.5mg QL (240 tabs / 30 days)

5 QL PA

tetrabenazine 25mg QL (120 tabs / 30 days)

5 QL PA

TIGLUTIK QL (600 mL / 30 days)

5 QL M PA

MULTIPLE SCLEROSIS AGENTS BETASERON

QL (14 syringes / 28 days)

5 QL PA

dalfampridine 5 PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

5 QL PA

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

5 QL PA

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

5 QL PA

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

5 QL PA

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

5 QL PA


23

Drug Name Drug Tier

Requirements/Limits

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 2 M

BOTOX 5 M PA

cyclobenzaprine hcl TABS 5mg, 10mg


3 M PA

dantrolene sodium CAPS 2 M

tizanidine 2 M

XEOMIN INJ 50 UNITS 4 M PA



NARCOLEPSY/CATAPLEXY armodafinil 50mg

QL (90 tabs / 30 days) 2 QL M PA

armodafinil 150mg, 200mg, 250mg


2 QL M PA

modafinil 100mg QL (30 tabs / 30 days)

2 QL M PA

modafinil 200mg QL (60 tabs / 30 days)

2 QL M PA

XYREM QL (540 mL / 30 days)

5 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 M

BUNAVAIL MIS 2.1-0.3MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 4.2-0.7MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 6.3-1MG QL (60 films / 30 days)

4 QL M

buprenorphine hcl SUBL QL (90 tabs / 30 days)

2 QL M PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

QL (90 films / 30 days)

2 QL M

buprenorphine hcl-naloxone hcl dihydrate 4-1mg


2 QL M



2 QL M



2 QL M

buprenorphine hcl-naloxone hcl sl


2 QL M

bupropion hcl (smoking deterrent)

2 M

Drug Name Drug Tier

Requirements/Limits

CHANTIX 4 M PA

CHANTIX CONTINUING MONTH

4 M PA

CHANTIX STARTER PACK 4 M PA

disulfiram TABS 2 M

fluoxetine hcl (pmdd) (generic of SARAFEM)

2 M

LUCEMYRA QL (228 tabs / 14 days)

5 QL M PA

naloxone inj 0.4mg/ml 2 M

naloxone inj 1mg/ml 2 M

naltrexone hcl TABS 2 M

NARCAN 3 M

NICOTROL INHALER 4 M

NICOTROL NS 4 M

VIVITROL 5 M

ZUBSOLV SUB 0.7-0.18MG QL (90 tabs / 30 days)

4 QL M


4 QL M


4 QL M


4 QL M


4 QL M


4 QL M

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 5 M PA

ANDRODERM QL (30 patches / 30 days)

4 QL M PA

oxandrolone TABS 2 M PA

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

QL (300 grams / 30 days)

2 QL M PA

testosterone GEL 1.62%, 20.25mg/1.25gm, 40.5mg/2.5gm


2 QL M PA

testosterone GEL 10mg/act QL (120 grams / 30 days)

2 QL M PA

testosterone cypionate SOLN

2 M PA


24

Drug Name Drug Tier

Requirements/Limits

testosterone enanthate SOLN

2 M PA

testosterone td soln 30 mg/act QL (180 mL / 30 days)

2 QL M PA

ANTIDIABETICS, INJECTABLE ADMELOG 4 M

ADMELOG SOLOSTAR 4 M

APIDRA 4 M

APIDRA SOLOSTAR 4 M

BASAGLAR KWIKPEN 3 M

BD ALCOHOL SWABS 3 M

BD ULTRAFINE INSULIN SYRINGE

3 M

BD ULTRAFINE/NANO PEN NEEDLES

3 M

BYDUREON BCISE QL (4 pens / 28 days)

3 QL M

BYDUREON PEN QL (4 pens / 28 days)

3 QL M

BYETTA QL (1 pen / 30 days)

4 QL M

FIASP 3 M

FIASP FLEXTOUCH 3 M

GAUZE PADS 2X2 3 M

HUMALOG 4 M

HUMALOG JUNIOR KWIKPEN

4 M

HUMALOG KWIKPEN 4 M

HUMALOG MIX 50/50 4 M

HUMALOG MIX 50/50 KWIKPEN

4 M

HUMALOG MIX 75/25 4 M

HUMALOG MIX 75/25 KWIKPEN

4 M

HUMULIN 70/30 4 M

HUMULIN 70/30 KWIKPEN 4 M

HUMULIN N 4 M

HUMULIN N KWIKPEN 4 M

HUMULIN R 4 M

HUMULIN R U-500 (CONCENTRATE)

5 B/D M

HUMULIN R U-500 KWIKPEN 5 M

INSULIN LISPRO 4 M

INSULIN LISPRO KWIKPEN 4 M

INSULIN PEN NEEDLES 3 M

INSULIN SAFETY NEEDLES 3 M

INSULIN SYRINGES 3 M

LEVEMIR 3 M

LEVEMIR FLEXTOUCH 3 M

Drug Name Drug Tier

Requirements/Limits

NOVOLIN 70/30 3 M

NOVOLIN 70/30 FLEXPEN 3 M

NOVOLIN 70/30 FLEXPEN RELION

4 M

NOVOLIN 70/30 RELION 4 M

NOVOLIN N 3 M

NOVOLIN N RELION 4 M

NOVOLIN R 3 M

NOVOLIN R RELION 4 M

NOVOLOG 3 M

NOVOLOG 70/30 FLEXPEN 3 M

NOVOLOG FLEXPEN 3 M

NOVOLOG MIX 70/30 3 M

NOVOLOG PENFILL 3 M

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

3 QL M

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

3 QL M

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

3 QL M

SYMLINPEN 60 5 M PA

SYMLINPEN 120 5 M PA

TRESIBA FLEXTOUCH 3 M

TRESIBA INJ 3 M

TRULICITY QL (4 pens / 28 days)

3 QL M

VICTOZA QL (3 pens / 30 days)

3 QL M

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

3 QL M

ANTIDIABETICS, ORAL acarbose TABS 2 M

alogliptin benzoate QL (30 tabs / 30 days)

1 QL M

alogliptin-metformin hcl QL (60 tabs / 30 days)

1 QL M

alogliptin-pioglitazone 12.5-15mg


1 QL M



1 QL M



1 QL M

alogliptin-pioglitazone 25-15mg


1 QL M


25

Drug Name Drug Tier

Requirements/Limits



1 QL M



1 QL M

FARXIGA QL (30 tabs / 30 days)

3 QL M

glimepiride 1mg, 2mg QL (90 tabs / 30 days)

2 QL M

glimepiride 4mg QL (60 tabs / 30 days)

2 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 er 2.5mg, 5mg QL (90 tabs / 30 days)

1 QL M

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

1 QL M

glipizide xl 2.5mg, 5mg QL (90 tabs / 30 days)

1 QL M

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

1 QL M

glipizide-metformin 2.5-250 mg


1 QL M

glipizide-metformin 2.5-500 mg


1 QL M

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL M

GLYXAMBI QL (30 tabs / 30 days)

4 QL M

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

4 QL M

INVOKAMET TAB 50-1000MG


4 QL M



4 QL M



4 QL M

INVOKAMET XR TAB 50-500MG


4 QL M

Drug Name Drug Tier

Requirements/Limits



4 QL M



4 QL M



4 QL M

INVOKANA TAB 100MG QL (60 tabs / 30 days)

4 QL M

INVOKANA TAB 300MG QL (30 tabs / 30 days)

4 QL M

JANUMET QL (60 tabs / 30 days)

3 QL M

JANUMET XR TAB 50-500MG


3 QL M

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

3 QL M

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

3 QL M

JANUVIA QL (30 tabs / 30 days)

3 QL M

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL M

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL M

JENTADUETO QL (60 tabs / 30 days)

3 QL M

JENTADUETO TAB XR 2.5-1000 MG


3 QL M

JENTADUETO TAB XR 5-1000 MG


3 QL M

KOMBIGLYZE XR 2.5-1000MG


4 QL M

KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)

4 QL M

KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)

4 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


26

Drug Name Drug Tier

Requirements/Limits

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

1 QL M


1 QL M


1 QL M

miglitol 2 M

nateglinide QL (90 tabs / 30 days)

1 QL M

ONGLYZA QL (30 tabs / 30 days)

4 QL M

pioglitazone hcl QL (30 tabs / 30 days)

1 QL M

pioglitazone hcl-glimepiride QL (30 tabs / 30 days)

2 QL M

pioglitazone hcl-metformin hcl QL (90 tabs / 30 days)

1 QL M

QTERN QL (30 tabs / 30 days)

4 QL M

repaglinide 2mg QL (240 tabs / 30 days)

1 QL M

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

1 QL M

repaglinide-metformin hcl QL (150 tabs / 30 days)

1 QL M

RIOMET QL (780 mL / 30 days)

4 QL M

SEGLUROMET TAB 2.5-500MG


4 QL M



4 QL M



4 QL M



4 QL M

STEGLATRO 5mg QL (90 tabs / 30 days)

4 QL M

STEGLATRO 15mg QL (30 tabs / 30 days)

4 QL M

STEGLUJAN QL (30 tabs / 30 days)

4 QL M

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

3 QL M

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

3 QL M

Drug Name Drug Tier

Requirements/Limits

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

3 QL M

SYNJARDY TAB 12.5-1000MG


3 QL M

SYNJARDY XR TAB 5-1000MG


3 QL M



3 QL M

SYNJARDY XR TAB 12.5-1000MG


3 QL M



3 QL M

TRADJENTA QL (30 tabs / 30 days)

3 QL M

XIGDUO XR TAB 2.5-1000MG


3 QL M

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

3 QL M


3 QL M


3 QL M


3 QL M

BISPHOSPHONATES alendronate sodium SOLN 2 M

alendronate sodium TABS 5mg, 10mg, 35mg, 70mg

1 M

alendronate sodium TABS 40mg

2 M

BINOSTO 4 M ST

FOSAMAX PLUS D 4 M ST

ibandronate sodium inj QL (1 injection / 90 days)

2 B/D QL M

ibandronate sodium tabs 2 B/D M

PAMIDRONATE DISODIUM 6mg/ml

3 B/D M

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

2 B/D M

pamidronate inj 30mg 2 B/D M

pamidronate inj 90mg 2 B/D M

risedronate sodium 2 M

zoledronic acid inj 5mg/100ml 2 B/D


27

Drug Name Drug Tier

Requirements/Limits

zoledronic inj 4mg/5ml 2 B/D

ZOLEDRONIC INJ 4MG/100ML

4 B/D

CHELATING AGENTS CHEMET 4 M

deferasirox 5 PA

DEPEN TITRATABS 5 M

FERRIPROX 5 LA PA

JADENU 5 LA PA

JADENU SPRINKLE 5 LA PA

kionex sus 15gm/60ml 2 M

LOKELMA 3 M

sodium polystyrene sulfonate powder

2 M

sodium polystyrene sulfonate susp

2 M

sps susp 15gm/60ml 2 M

trientine hcl 5 M PA

VELTASSA 5 M LA

CONTRACEPTIVES altavera tab 2 M

alyacen 1/35 2 M

amethia 2 M

amethia lo 2 M

apri 2 M

aranelle 2 M

ashlyna 2 M

aubra 2 M

aviane 2 M

balziva 2 M

bekyree 2 M

blisovi 24 fe 2 M

blisovi fe 1.5/30 2 M

briellyn 2 M

camila 2 M

camrese lo tab 2 M

caziant pak 2 M

cryselle-28 2 M

cyclafem 1/35 2 M

cyclafem 7/7/7 2 M

cyred tab 2 M

dasetta 1/35 2 M

dasetta 7/7/7 2 M

deblitane 2 M

DEPO-SUBQ PROVERA 104 4 M

desogestrel & ethinyl estradiol 2 M

desogestrel-ethinyl estradiol (biphasic)

2 M

drospirenone-ethinyl estradiol 2 M

Drug Name Drug Tier

Requirements/Limits

drospirenone-ethinyl estradiol-levomefolate calcium

2 M

ELLA 3 M

emoquette 2 M

enpresse-28 2 M

enskyce 2 M

errin 2 M

estarylla tab 0.25-35 2 M

ethynodiol diacet & eth estrad 2 M

ethynodiol tab 1-50 2 M

falmina 2 M

fayosim 2 M

femynor 2 M

gianvi tab 3-0.02mg 2 M

hailey 24 fe 2 M

heather 2 M

incassia 2 M

introvale 2 M

isibloom 2 M

jasmiel 2 M

jolessa tab 0.15-0.03 mg 2 M

jolivette 2 M

juleber 2 M

junel 1.5/30 2 M

junel 1/20 2 M

junel fe 1.5/30 2 M

junel fe 1/20 2 M

junel fe 24 2 M

kaitlib fe 2 M

kariva 2 M

kelnor 1/35 2 M

kelnor 1/50 2 M

kurvelo 2 M

larin 1.5/30 2 M

larin 1/20 2 M

larin fe 1.5/30 2 M

larin fe 1/20 2 M

larissia tab 2 M

layolis fe chw 2 M

leena tab 2 M

lessina 2 M

levonest 2 M

levonor/ethi tab 2 M

levonorgestrel & eth estradiol 2 M

levonorgestrel-ethinyl estradiol (91-day)

2 M

levonorgestrel-ethinyl estradiol (continuous)

2 M

levora 0.15/30-28 2 M


28

Drug Name Drug Tier

Requirements/Limits

LO LOESTRIN FE 4 M

loryna 2 M

low-ogestrel 2 M

lutera 2 M

lyza 2 M

marlissa 2 M

medroxyprogesterone acetate (contraceptive)

2 M

melodetta 24 fe 2 M

mibelas 24 fe 2 M

microgestin 1.5/30 2 M

microgestin 1/20 2 M

microgestin fe 1.5/30 2 M

microgestin fe 1/20 2 M

mili 2 M

mono-linyah tab 0.25-35 2 M

NATAZIA 4 M

necon 0.5/35-28 2 M

nikki 2 M

nora-be tab 2 M

nore/eth/fer chw 0.4mg-35 2 M

noreth/ethin chw fe 2 M

norethin acet & estrad-fe 2 M

norethindrone (contraceptive) 2 M

norethindrone acet & eth estra 2 M

norgest/ethi tab 0.25/35 2 M

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

2 M

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

2 M

nortrel 0.5/35 (28) 2 M

nortrel 1/35 2 M

nortrel 7/7/7 2 M

NUVARING 4 M

ocella tab 3-0.03mg 2 M

orsythia 2 M

philith 2 M

pimtrea 2 M

pirmella 1/35 2 M

portia-28 2 M

previfem 2 M

reclipsen 2 M

rivelsa 2 M

setlakin tab 2 M

sharobel 2 M

Drug Name Drug Tier

Requirements/Limits

SLYND 4 M

sprintec 28 2 M

sronyx 2 M

syeda 2 M

tarina 24 fe 2 M

tarina fe 1/20 2 M

TAYTULLA 4 M

tilia fe 2 M

tri-estarylla 2 M

tri-legest fe 2 M

tri-linyah 2 M

tri-lo- tab marzia 2 M

tri-lo-estarylla 2 M

tri-lo-sprintec 2 M

tri-mili 2 M

tri-previfem 2 M

tri-sprintec 2 M

tri-vylibra 2 M

tri-vylibra lo 2 M

trivora-28 2 M

tulana 2 M

tydemy 2 M

velivet 2 M

vienva 2 M

viorele 2 M

vyfemla 2 M

vylibra 2 M

wymzya fe 2 M

xulane dis 150-35 2 M

zarah 2 M

zovia 1/35e 2 M

ENDOMETRIOSIS danazol CAPS 2 M

LUPANETA PACK 5 PA

ORILISSA 5 M PA

SYNAREL 5 M

ENZYME REPLACEMENTS ALDURAZYME 5 LA PA

CARBAGLU 5 LA PA

CERDELGA 5 PA

CEREZYME 5 LA PA

CYSTADANE 5 LA

CYSTAGON 4 LA PA

ELAPRASE 5 LA PA

ELELYSO 5 PA

FABRAZYME 5 LA PA

GALAFOLD 5 LA PA

KUVAN 5 LA PA


29

Drug Name Drug Tier

Requirements/Limits

levocarnitine (metabolic modifiers)

2 B/D M

LUMIZYME 5 LA PA

miglustat 5 PA

NAGLAZYME 5 LA PA

nitisinone 5 PA

NITYR 5 LA PA

ORFADIN 5 LA PA

PALYNZIQ 5 LA PA

PROCYSBI 5 LA PA

RAVICTI 5 LA PA

sodium phenylbutyrate 5 PA

VIMIZIM 5 PA

VPRIV 5 PA

ESTROGENS ALORA 4 M

DELESTROGEN 10mg/ml 4 M

DEPO-ESTRADIOL 4 M

dotti 3 M

estradiol PTTW; PTWK 3 M

estradiol TABS 2 M

estradiol vaginal cream 2 M

estradiol vaginal tab 2 M

estradiol valerate OIL 2 M

ESTRING 4 M

FEMRING 4 M

fyavolv 3 M

IMVEXXY MAINTENANCE PACK

4 M PA

IMVEXXY STARTER PACK 4 M PA

jinteli 3 M

MENOSTAR 4 M

norethindrone acetate-ethinyl estradiol

3 M

PREMARIN CREAM 4 M

PREMARIN INJ 4 M

yuvafem vaginal tablet 10 mcg 2 M

GLUCOCORTICOIDS cortisone acetate TABS 2 M

DEPO-MEDROL 20mg/ml 4 B/D M

DEXAMETHASONE CONC 4 M

dexamethasone ELIX; SOLN 2 M

dexamethasone TABS 1 M

dexamethasone sodium phosphate

2 M

fludrocortisone acetate TABS

2 M

hydrocortisone TABS 2 M

MEDROL TAB 2MG 4 B/D M

Drug Name Drug Tier

Requirements/Limits

methylpr ss inj 2 B/D M

methylpred pak 4mg 2 M

methylpred tab 4mg 2 B/D M




methylprednisolone acetate 2 B/D M

MILLIPRED 4 B/D M

pred sod pho sol 5mg/5ml 2 B/D M

prednisolone sodium phosphate

2 B/D M

prednisolone sol 15mg/5ml 2 B/D M

prednisolone sol 25mg/5ml 2 B/D M

PREDNISONE CON 5MG/ML 4 B/D M

prednisone pak 5mg 2 M

prednisone pak 10mg 2 M

prednisone sol 5mg/5ml 2 B/D M

prednisone tab 1mg 1 B/D M

prednisone tab 2.5mg 1 B/D M





SOLU-CORTEF 100MG 4 M




SOLU-MEDROL 2gm 4 B/D M

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 M

GLUCAGON EMERGENCY KIT

3 M

PROGLYCEM SUS 50MG/ML 4 M

MISCELLANEOUS AFREZZA 4unit, 8unit 4 M

AFREZZA 12unit 5 M

AFREZZA 4/8/12UNITS 5 M

AFREZZA 4/8UNITS 5 M

AFREZZA 8/12 UNITS 5 M

cabergoline 2 M

calcitonin (salmon) nasal spray

2 B/D M

CHORIONIC GONADOTROPIN SOLR

4 PA

cinacalcet hcl 5 B/D

EGRIFTA 5 LA PA

EGRIFTA 1MG 5 LA PA

EVENITY 5 PA

FORTEO 5 PA


30

Drug Name Drug Tier

Requirements/Limits

GENOTROPIN 5 PA

GENOTROPIN MINIQUICK .2mg

3 PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

5 PA

HUMATROPE 5 PA

HUMATROPE COMBO PACK 5 PA

INCRELEX 5 LA PA

JYNARQUE 5 LA PA

KORLYM 5 LA PA

LUPRON DEP-PED INJ 7.5MG

5 PA

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

5 PA

LUPRON DEPOT-PED (1-MONTH

5 PA

LUPRON DEPOT-PED (3-MONTH

5 PA

methergine 5 M PA

methylergonovine maleate TABS

5 M PA

MIACALCIN INJ 200U/ML 5 B/D M

NATPARA 5 PA

NORDITROPIN FLEXPRO 5 PA

NOVAREL 5000unit 4 PA

NUTROPIN AQ NUSPIN 5 5 LA PA



octreotide acetate 50mcg/ml, 200mcg/ml

2 PA

octreotide acetate 500mcg/ml, 1000mcg/ml

5 PA

octreotide inj 100mcg/ml 2 PA

OMNITROPE 5.8MG 5 LA PA

OMNITROPE 5MG 5 LA PA

OMNITROPE 10MG 5 LA PA

OSPHENA 3 M PA

PREGNYL W/DILUENT BENZYL

4 PA

PROLIA QL (1 injection / 180 days)

4 QL

raloxifene hcl 2 M

SAIZEN 5 LA PA

SAIZENPREP RECONSTITUTION

5 LA PA

SAMSCA 5 LA PA

SANDOSTATIN LAR DEPOT 5 PA

Drug Name Drug Tier

Requirements/Limits

SEROSTIM 5 LA PA

SIGNIFOR 5 LA PA

SIGNIFOR LAR 5 LA PA

SOMATULINE DEPOT 5 PA

SOMAVERT 5 LA PA

TYMLOS 5 PA

XGEVA 5 PA

ZOMACTON 5mg 4 PA

ZOMACTON 10mg 5 PA

ZORBTIVE 5 PA

PHOSPHATE BINDER AGENTS AURYXIA 5 M PA

calcium acetate (phosphate binder)

2 M

FOSRENOL PACK 5 M

lanthanum chew tab 5 M

PHOSLYRA 4 M

sevelamer carbonate PACK 5 M

sevelamer carbonate TABS 2 M

sevelamer tab 400mg 2 M

sevelamer tab 800mg 2 M

VELPHORO 5 M

PROGESTINS CRINONE 4 M PA

medroxyprogesterone acetate 1 M

norethindrone acetate TABS 2 M

progesterone micronized CAPS

2 M

THYROID AGENTS levo-t 2 M

levothyroxine sodium TABS 1 M

levoxyl 2 M

liothyronine sodium TABS 2 M

methimazole TABS 1 M

propylthiouracil TABS 2 M

SYNTHROID 3 M

TIROSINT 4 M

TIROSINT-SOL 4 M

unithroid 2 M

VASOPRESSINS desmopressin acetate TABS 2 M

desmopressin acetate spray 2 M

desmopressin acetate spray refrigerated

2 M

desmopressin inj 4mcg/ml 2 M

STIMATE 5


31

Drug Name Drug Tier

Requirements/Limits

GASTROINTESTINAL ANTIEMETICS AKYNZEO CAPS 4 B/D M

AKYNZEO SOLR 4 M

aprepitant 2 B/D M

aprepitant pak 80mg & 125mg 2 B/D M

CESAMET QL (60 caps / 30 days)

5 B/D QL M

CINVANTI 4 M

compro supp 2 M

dronabinol QL (60 caps / 30 days)

2 B/D QL M

EMEND SUSR 4 B/D M

fosaprepitant dimeglumine 2 M

granisetron hcl SOLN 2 M

granisetron hcl TABS 2 B/D M

meclizine hcl TABS 2 M

metoclopramide hcl SOLN; TBDP

2 M

metoclopramide hcl TABS 1 M

metoclopramide hcl inj 2 M

METOCLOPRAMIDE ODT 4 M

ondansetron hcl TABS 2 B/D M

ondansetron hcl inj 2 M

ondansetron hcl oral soln 2 B/D M

ondansetron odt 2 B/D M

palonosetron hcl 2 M

PALONOSETRON HYDROCHLORID 0.25MG/2ML

4 M

phenadoz PA if 70 years and older

4 M PA

prochlorperazine inj 2 M

prochlorperazine maleate TABS

2 M

prochlorperazine supp 2 M

promethazine hcl SUPP PA if 70 years and older

4 M PA

promethazine hcl SYRP; TABS


2 M PA

promethazine hcl inj PA if 70 years and older

4 M PA

promethegan PA if 70 years and older

4 M PA

SANCUSO QL (4 patches / 28 days)

5 QL M

Drug Name Drug Tier

Requirements/Limits

scopolamine QL (10 patches / 30 days)


4 QL M PA

SUSTOL 4 M

SYNDROS QL (120 mL / 30 days)

5 B/D QL M

VARUBI INJ 4 M

VARUBI TAB 90MG 4 B/D M

ZUPLENZ 5 B/D M

ANTISPASMODICS atropine sulfate SOSY .25mg/5ml, 1mg/10ml

4 M

CUVPOSA 4 M

dicyclomine hcl cap 10mg 3 M

dicyclomine hcl inj 4 M

dicyclomine hcl soln 10mg/5ml

4 M

dicyclomine hcl tab 20mg 3 M

GLYCATE 4 M

glycopyrrolate SOLN 2 M

GLYCOPYRROLATE SOSY .2mg/ml, .4mg/2ml

4 M

glycopyrrolate tab 1mg 2 M

glycopyrrolate tab 2mg 2 M

methscopolamine bromide TABS


2 M PA

H2-RECEPTOR ANTAGONISTS cimetidine TABS 2 M

cimetidine sol 300/5ml 2 M

famotidine SUSR 2 M

famotidine TABS 20mg, 40mg

1 M

famotidine in nacl 2 M

famotidine inj 2 M

nizatidine 2 M

ranitidine hcl CAPS 2 M

ranitidine hcl SYRP 2 M

ranitidine hcl TABS 150mg, 300mg

1 M

ranitidine hcl inj 2 M

INFLAMMATORY BOWEL DISEASE APRISO 4 M

balsalazide disodium 2 M

budesonide CPEP 2 M

budesonide TB24 5 M

colocort 2 M

DIPENTUM 5 M


32

Drug Name Drug Tier

Requirements/Limits

ENTYVIO 5 PA

hydrocortisone (enema) 2 M

mesalamine CP24; CPDR; TBEC

2 M

mesalamine SUPP 5 M

mesalamine enema 2 M

mesalamine w/ cleanser 2 M

PENTASA 5 M

SFROWASA 5 M

sulfasalazine dr 2 M

sulfasalazine ir 2 M

UCERISFOAM 4 M

LAXATIVES CLENPIQ 4 M

constulose 2 M

enulose 2 M

gavilyte-c 1 M

gavilyte-g 1 M

gavilyte-n/flavor pack 1 M

generlac 2 M

GOLYTELY 3 M

KRISTALOSE 4 M

lactulose SOLN 2 M

lactulose (encephalopathy) 2 M

NULYTELY/FLAVOR PACKS 3 M

OSMOPREP 4 M

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

1 M

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1 M

PLENVU 4 M

PREPOPIK 4 M

SUPREP BOWEL PREP KIT 4 M

trilyte 1 M

MISCELLANEOUS alosetron hcl 5 M PA

AMITIZA 3 M

amoxicillin-clarithromycin w/ lansoprazole

2 M

CARAFATE SUSP 4 M

cromolyn sodium (mastocytosis)

5 M

diphenoxylate w/ atropine LIQD

4 M

diphenoxylate w/ atropine TABS

3 M

GATTEX 5 LA PA

LINZESS 4 M

Drug Name Drug Tier

Requirements/Limits

loperamide hcl CAPS 2 M

misoprostol TABS 2 M

MOTEGRITY 4 M

MOVANTIK 3 M

OMECLAMOX-PAK 4 M

RELISTOR 5 M PA

SUCRAID 5 M LA

sucralfate SUSP; TABS 2 M

SYMPROIC 4 M

TRULANCE 4 M

ursodiol CAPS; TABS 2 M

VIBERZI 5 M PA

XIFAXAN TAB 550MG 5 M PA

ZELNORM QL (60 tabs / 30 days)

4 QL M PA

PANCREATIC ENZYMES CREON 3 M

PANCREAZE 4 M

PERTZYE 4 M

VIOKACE 10 4 M

VIOKACE 20 5 M

ZENPEP 4 M

PROTON PUMP INHIBITORS DEXILANT


esomeprazole magnesium QL (30 caps / 30 days)

2 QL M ST

esomeprazole sodium inj 2 M

lansoprazole CPDR QL (30 caps / 30 days)

2 QL M

lansoprazole TBDD QL (30 tabs / 30 days)

2 QL M

NEXIUM GRA 2.5MG DR 4 M

NEXIUM GRA 5MG DR 4 M

NEXIUM GRA 10MG DR QL (30 packets / 30 days)

4 QL M


4 QL M


4 QL M

omeprazole cap 10mg 1 M



pantoprazole sodium SOLR 2 M

pantoprazole sodium TBEC 1 M

PRILOSEC 4 M


33

Drug Name Drug Tier

Requirements/Limits

PROTONIX PACK QL (30 packets / 30 days)

4 QL M

rabeprazole sodium QL (30 tabs / 30 days)

2 QL M

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 1 M

CARDURA XL 4 M ST

dutasteride CAPS 2 M

dutasteride-tamsulosin hcl 2 M

finasteride TABS 5mg 1 M

silodosin 2 M

tamsulosin hcl 1 M

MISCELLANEOUS bethanechol chloride TABS 2 M

ELMIRON 5 M

INTRAROSA 4 M PA

potassium citrate (alkalinizer) er tabs

2 M

URINARY ANTISPASMODICS darifenacin hydrobromide 2 M

GELNIQUE PUMP 4 M ST

MYRBETRIQ 4 M

oxybutynin chloride SYRP; TABS; TB24

2 M

OXYTROL 4 M ST

tolterodine tartrate er 2 M ST

tolterodine tartrate tab 1 mg 2 M ST

tolterodine tartrate tab 2 mg 2 M ST

TOVIAZ 3 M

trospium chloride 2 M

trospium chloride er 2 M

VAGINAL ANTI-INFECTIVES AVC 4 M

CLEOCIN VAG SUPP 100MG 4 M

clindamycin cre 2% vag 2 M

CLINDESSE 4 M

metronidazole vaginal 2 M

miconazole 3 sup 200mg 2 M

terconazole vaginal 2 M

vandazole 2 M

HEMATOLOGIC ANTICOAGULANTS BEVYXXA


COUMADIN 3 M

ELIQUIS STARTER PACK QL (74 tabs / 30 days)

3 QL M

Drug Name Drug Tier

Requirements/Limits

ELIQUIS TAB 2.5MG QL (60 tabs / 30 days)

3 QL M

ELIQUIS TAB 5MG QL (74 tabs / 30 days)

3 QL M

enoxaparin sodium 2 M

fondaparinux sodium 2.5mg/0.5ml

2 M

fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5 M

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

4 M

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

5 M

heparin sod (porcine) in d5w 3 M

heparin sod inj 1000u/ml 2 B/D M

heparin sod inj 5000u/0.5ml 2 B/D M




HEPARIN SODIUM INJ 5000U/0.5ML

4 B/D M

HEPARIN SODIUM/NACL 0.45%

3 M

jantoven 1 M

PRADAXA QL (60 caps / 30 days)

4 QL M

SAVAYSA QL (30 tabs / 30 days)

4 QL M

warfarin sodium 1 M

XARELTO 2.5mg QL (60 tabs / 30 days)

3 QL M

XARELTO 10mg, 15mg, 20mg


3 QL M

XARELTO STARTER PACK QL (51 tabs / 30 days)

3 QL M

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, 40mcg/ml

3 PA

ARANESP ALBUMIN FREE SOLN 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml

5 PA

ARANESP ALBUMIN FREE SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml

3 PA


34

Drug Name Drug Tier

Requirements/Limits

ARANESP ALBUMIN FREE SOSY 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

5 PA

EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

4 PA

EPOGEN 20000unit/ml 5 PA

LEUKINE 5 PA

MOZOBIL 5 PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 PA

PROCRIT 20000unit/ml, 40000unit/ml

5 PA

RETACRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

4 PA

RETACRIT 40000unit/ml 5 PA

ZARXIO 5 PA

MISCELLANEOUS anagrelide hcl 2 M

BERINERT QL (24 boxes / 30 days)

5 QL LA PA

cilostazol 1 M

CINRYZE QL (20 vials / 30 days)

5 QL LA PA

DOPTELET 5 LA PA

DROXIA 3 M

ENDARI 5 LA PA

HAEGARDA 2000unit QL (30 vials / 30 days)

5 QL LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

5 QL LA PA

icatibant acetate QL (9 syringes / 30 days)

5 QL PA

MULPLETA 5 PA

pentoxifylline TBCR 1 M

PROMACTA PACK QL (360 packets / 30 days)

5 QL LA PA

PROMACTA TABS 12.5mg, 25mg


5 QL LA PA

PROMACTA TABS 50mg, 75mg


5 QL LA PA

Drug Name Drug Tier

Requirements/Limits

RUCONEST QL (12 vials / 30 days)

5 QL PA

TAKHZYRO QL (2 vials / 28 days)

5 QL LA PA

tranexamic acid SOLN; TABS

2 M

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 2 M

BRILINTA 3 M

clopidogrel tab 75mg 1 M

clopidogrel tab 300mg 2 M

prasugrel hcl 2 M

ZONTIVITY 4 M

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

QL (2 injections / 28 days)

5 QL PA

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

5 QL PA

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

5 QL PA

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

5 QL PA

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

5 QL PA

HUMIRA PEDIATRIC CROHNS DISEASE

5 PA

HUMIRA PEN QL (6 pens / 28 days)

5 QL PA

HUMIRA PEN CD/UC/HS STARTER

5 PA

HUMIRA PEN INJ CD/UC/HS STARTER

5 PA

HUMIRA PEN INJ PS/UV STARTER

5 PA

HUMIRA PEN-PS/UV STARTER

5 PA

hydroxychloroquine sulfate 1 M

leflunomide TABS QL (30 tabs / 30 days)

2 QL M

methotrexate sodium tabs 2 M

REMICADE 5 PA

RENFLEXIS 5 LA PA


35

Drug Name Drug Tier

Requirements/Limits

STELARA SOLN 45mg/0.5ml

QL (1 vial / 28 days)

5 QL LA PA

STELARA SOSY QL (1 syringe / 28 days)

5 QL PA

TREXALL 4 B/D M

XATMEP 4 B/D M

XELJANZ QL (60 tabs / 30 days)

5 QL PA

XELJANZ XR 11mg QL (30 tabs / 30 days)

5 QL PA

IMMUNOGLOBULINS BIVIGAM 5 PA

GAMASTAN S/D 3 B/D

GAMMAGARD LIQUID 5 PA

GAMMAGARD S/D 5 PA

GAMMAKED 5 PA

GAMMAPLEX 5 PA

GAMMAPLEX 10GM/100ML 5 PA

GAMUNEX-C 5 PA

OCTAGAM 5 PA

PANZYGA 5 PA

PRIVIGEN 5 PA

IMMUNOMODULATORS ACTIMMUNE 5 LA PA

ARCALYST 5 PA

INTRON-A INJ 10MU 5 B/D M




ORALAIR 4 M PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 5 B/D M

ASTAGRAF XL .5mg, 1mg 4 B/D M

ATGAM 5 B/D M

AZASAN 4 B/D M

azathioprine TABS 2 B/D M

BENLYSTA 5 PA

cyclosporine CAPS; SOLN 2 B/D M

cyclosporine modified (for microemulsion)

2 B/D M

ENVARSUS XR 4 B/D M

gengraf 2 B/D M

mycophenolate mofetil CAPS; TABS

2 B/D M

mycophenolate mofetil SUSR

5 B/D M

mycophenolate sodium tbec 2 B/D M

NULOJIX 5 B/D M

Drug Name Drug Tier

Requirements/Limits

PROGRAF PACK 4 B/D M

SANDIMMUNE SOLN 3 B/D M

sirolimus SOLN 5 B/D M

sirolimus TABS 2mg 5 B/D M

sirolimus TABS .5mg, 1mg 2 B/D M

tacrolimus CAPS 2 B/D M

ZORTRESS TAB 0.5MG 5 B/D M



ZORTRESS TAB 1MG 5 B/D M

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3 B/D

INFANRIX 3

IPOL INACTIVATED IPV 3

IXIARO 3

KINRIX 3

M-M-R II 3 M

MENACTRA 3

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3 B/D

RECOMBIVAX HB 3 B/D

ROTARIX 3

ROTATEQ 3

SHINGRIX QL (2 vials per lifetime)

3 QL

TDVAX 3 B/D

TENIVAC 3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3


36

Drug Name Drug Tier

Requirements/Limits

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX QL (1 vial per lifetime)

3 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 2 M

klor-con spr cap 8meq 2 M

klor-con spr cap 10meq 2 M

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

3 M

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

3 M

MAGNESIUM SULFATE IN D5W

3 M

magnesium sulfate in dextrose

3 M

magnesium sulfate inj 50% 3 M

potassium chloride PACK 2 M

potassium chloride SOLN 10%, 20%

2 M

potassium chloride TBCR 1 M

potassium chloride caps er 2 M

potassium chloride microencapsulated crystals er

1 M

sodium chloride SOLN 2.5meq/ml

2 M

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

2 M

TPN ELECTROLYTES 4 B/D M

IV NUTRITION AMINOSYN II INJ 10% 4 B/D M

AMINOSYN-PF 7% 4 B/D M

AMINOSYN-PF INJ 10% 4 B/D M

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D M

CLINIMIX 4.25%/DEXTROSE 10%

4 B/D M

Drug Name Drug Tier

Requirements/Limits

CLINIMIX 5%/DEXTROSE 15%

4 B/D M

CLINIMIX 5%/DEXTROSE 20%

4 B/D M

CLINIMIX E 2.75%/DEXTROSE 5%

4 B/D M

CLINIMIX E 4.25%/D10 4 B/D M

CLINIMIX E 4.25%/DEXTROSE 5%

4 B/D M

CLINIMIX E 5%/DEXTROSE 15%

4 B/D M

CLINIMIX E 5%/DEXTROSE 20%

4 B/D M

clinisol sf 15% 2 B/D M

CLINOLIPID 4 B/D M

FREAMINE HBC 6.9% 4 B/D M

FREAMINE III 4 B/D M

hepatamine 4 B/D M

INTRALIPID 30% 4 B/D M

INTRALIPID INJ 20% 4 B/D M

NEPHRAMINE 4 B/D M

NUTRILIPID INJ 20% 4 B/D M

plenamine 2 B/D M

PREMASOL 10% 4 B/D M

PROCALAMINE 4 B/D M

PROSOL 4 B/D M

SMOFLIPID 4 B/D M

TRAVASOL 4 B/D M

TROPHAMINE INJ 10% 4 B/D M

IV REPLACEMENT SOLUTIONS dextrose SOLN 50%, 70% 2 M

dextrose 2.5%/nacl 0.45% 2 M

dextrose 5% 2 M

DEXTROSE 5% /ELECTROLYTE

3 M

dextrose 5%/nacl 0.2% 2 M

DEXTROSE 5%/NACL 0.3% 4 M




dextrose 5%/potassium chl 2 M

dextrose 10% flex contain 2 M

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3 M


dextrose in lactated ringers 2 M

ELECTROLYTE-R IN DEXTROSE

4 M


37

Drug Name Drug Tier

Requirements/Limits

IONOSOL-MB/DEXTROSE 5%

4 M

ISOLYTE P 4 M

ISOLYTE S 4 M

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

KCL 0.3%/D5W/LR 4 M

KCL 0.3%/D5W/NACL 0.9% 4 M

kcl 0.3%/d5w/nacl 0.45% 2 M

KCL 0.15%/D5W/LR 4 M

kcl 0.15%/d5w/nacl 0.9% 2 M

KCL 0.15%/D5W/NACL 0.225%

4 M

kcl 0.075%/d5w/nacl 0.45% 2 M

kcl/d5w/nacl inj 0.22%/0.45% 2 M

kcl/d5w/nacl inj .15/.45% 2 M

kcl/nacl inj 0.15%-0.9% 2 M

lactated ringer's 2 M

NORMOSOL-M IN D5W 4 M

NORMOSOL-R 4 M

PLASMA-LYTE A 4 M

PLASMA-LYTE-148 4 M

pot chloride inj 2meq/ml 2 M

potassium chloride SOLN 2meq/ml

2 M

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

2 M

potassium chloride 0.3%/d 2 M

potassium chloride in nacl 2 M

sodium chloride SOLN .9%, 3%, 5%

2 M

sodium chloride 0.45% 2 M

VITAMINS calcitriol CAPS; SOLN 2 B/D M

calcitriol inj 2 B/D M

doxercalciferol CAPS 2 B/D M

M-NATAL PLUS 3 M

paricalcitol CAPS 2 B/D M

PNV FOLIC ACID + IRON MUL

3 M

PRENATAL 3 M

PRENATAL PLUS 3 M

PRENATAL PLUS LOW IRON 3 M

RAYALDEE 5 M

TRICARE 3 M

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 M

Drug Name Drug Tier

Requirements/Limits

BLEPHAMIDE 4 M

neomycin-polymy-dexameth OINT

1 M

neomycin-polymy-dexameth SUSP

2 M

neomycin-polymyxin-hc (ophth)

2 M

PRED-G 4 M

PRED-G S.O.P. 4 M

sulfacetamide sod-prednisolone

2 M

TOBRADEX OINT 3 M

TOBRADEX ST 3 M

tobramycin-dexamethasone 2 M

ZYLET 3 M

ANTI-INFECTIVES AZASITE 4 M

bacitracin (ophthalmic) 2 M

bacitracin-polymyxin b (ophth) 1 M

BESIVANCE 3 M

CILOXAN OIN 0.3% OP 3 M

ciprofloxacin hcl (ophth) 1 M

erythromycin (ophth) 1 M

gatifloxacin (ophth) 2 M

gentak 2 M

gentamicin sulfate soln (ophth)

1 M

levofloxacin (ophth) 2 M

MOXEZA 3 M

moxifloxacin hcl (ophth) 2 M

NATACYN 4 M

neomycin-bacitracin zn-polymyxin

2 M

neomycin-polymyxin-gramicidin

2 M

ofloxacin (ophth) 2 M

polymyxin b-trimethoprim 1 M

sulfacetamide sodium (ophth) 2 M

tobramycin (ophth) 1 M

TOBREX OINT 0.3% 4 M

trifluridine 2 M

ZIRGAN 4 M

ANTI-INFLAMMATORIES ACUVAIL 4 M

ALREX 3 M

bromfenac sodium (ophth) 2 M

BROMSITE 4 M

dexamethasone sodium phosphate (ophth)

2 M


38

Drug Name Drug Tier

Requirements/Limits

diclofenac sodium (ophth) 2 M

DUREZOL 3 M

FLAREX 4 M

fluorometholone (ophth) 2 M

flurbiprofen sodium 2 M

FML 4 M

FML FORTE 4 M

ILEVRO 3 M

INVELTYS 4 M

ketorolac tromethamine (ophth)

2 M

LOTEMAX GEL; OINT 3 M

LOTEMAX SM 4 M

loteprednol etabonate 2 M

MAXIDEX 4 M

PRED MILD 4 M

prednisolone acetate (ophth) 2 M

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3 M

PROLENSA 3 M

ANTIALLERGICS ALOCRIL 4 M

ALOMIDE 4 M

azelastine drop 0.05% 2 M

BEPREVE 3 M

cromolyn sodium (ophth) 1 M

epinastine hcl (ophth) 2 M

LASTACAFT 4 M

olopatadine hcl 0.1% 2 M

olopatadine hcl 0.2% 2 M

PAZEO 3 M

ANTIGLAUCOMA ALPHAGAN P 0.1% 3 M

AZOPT 3 M

betaxolol hcl (ophth) 2 M

BETIMOL 4 M

BETOPTIC-S 3 M

brimonidine sol 0.2% 1 M

brimonidine sol 0.15% 2 M

carteolol hcl (ophth) 2 M

COMBIGAN 3 M

dorzol/timol sol 22.3-6.8 pf 2 M

dorzolamide hcl 1 M

dorzolamide hcl-timolol maleate

1 M

latanoprost SOLN 1 M

levobunolol hcl 1 M

LUMIGAN 3 M

PHOSPHOLINE IODIDE 4 M

Drug Name Drug Tier

Requirements/Limits

pilocarpine hcl SOLN 2 M

RHOPRESSA 3 M

ROCKLATAN 4 M

SIMBRINZA SUS 1-0.2% 3 M

timolol maleate (ophth) soln 1 M

timolol maleate gel 2 M

timolol maleate ophth soln 0.5% (once-daily)

2 M

TIMOPTIC OCUDOSE 4 M

TRAVATAN Z 4 M

VYZULTA 4 M ST

XELPROS 4 M ST

ZIOPTAN 4 M ST

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

3 M

CYSTARAN 5 LA PA

LACRISERT 4 M

proparacaine hcl SOLN 2 M

RESTASIS 3 M

RESTASIS MULTIDOSE 3 M

XIIDRA 4 M

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

QL (60 blisters / 30 days)

3 QL M

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

3 QL M

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

4 QL M

ipratropium-albuterol 2 B/D M

STIOLTO RESPIMAT QL (1 inhaler / 30 days)

4 QL M

STIOLTO RESPIMAT (INSTITUTIONAL PACK)


4 QL M

TRELEGY ELLIPTA QL (60 blisters / 30 days)

3 QL M

UTIBRON NEOHALER QL (60 caps / 30 days)

4 QL M

ANTICHOLINERGICS ATROVENT HFA

QL (2 inhalers / 30 days) 4 QL M

INCRUSE ELLIPTA QL (30 blisters / 30 days)

3 QL M


39

Drug Name Drug Tier

Requirements/Limits

ipratropium bromide (nasal) 2 M

ipratropium sol inhal 2 B/D M

LONHALA MAGNAIR REFILL KIT

QL (60 mL / 30 days)

5 QL M

LONHALA MAGNAIR STARTER KIT


5 QL M

SEEBRI NEOHALER QL (60 caps / 30 days)

4 QL M

SPIRIVA HANDIHALER QL (30 caps / 30 days)

4 QL M

SPIRIVA RESPIMAT 1.25MCG/ACT

QL (1 inhaler / 30 days)

4 QL M

SPIRIVA RESPIMAT 2.5MCG/ACT

QL (1 inhaler / 30 days)

4 QL M

SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK)


4 QL M

TUDORZA PRESSAIR QL (1 inhaler / 30 days)

4 QL M

TUDORZA PRESSAIR (INSTITUTIONAL PACK)


4 QL M

YUPELRI 5 B/D M

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 4 M

DYMISTA SPR 137-50 QL (1 bottle / 30 days)

4 QL M

SEMPREX-D 4 M

ANTIHISTAMINES azelastine spr 0.1% 2 M

azelastine spr 0.15% 2 M

cetirizine syrup 1 M

cyproheptadine hcl SYRP; TABS


3 M PA

desloratadine 2 M

diphenhydramine hcl inj 50mg/ml

2 M

hydroxyzine hcl SYRP PA if 70 years and older

3 M PA

hydroxyzine hcl TABS PA if 70 years and older

2 M PA

hydroxyzine hcl inj PA if 70 years and older

4 M PA

Drug Name Drug Tier

Requirements/Limits

hydroxyzine pamoate CAPS PA if 70 years and older

2 M PA

levocetirizine soln 2.5mg/5ml 2 M

levocetirizine tab 5 mg 1 M

olopatadine hcl (nasal) 2 M

BETA AGONISTS albuterol sulfate AERS 108mcg/act

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

2 QL M

albuterol sulfate AERS 108mcg/act

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

2 QL M

albuterol sulfate AERS 108mcg/act

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

2 QL M

albuterol sulfate NEBU 2 B/D M

albuterol sulfate SYRP 2 M

albuterol sulfate TABS 2 M

albuterol sulfate er 2 M

ARCAPTA NEOHALER QL (30 caps / 30 days)

4 QL M

BROVANA 5 B/D M

levalbuterol hcl NEBU 2 B/D M

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml

2 B/D M

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

2 QL M

PERFOROMIST 5 B/D M

PROAIR HFA QL (2 inhalers / 30 days)

4 QL M

PROAIR RESPICLICK QL (2 inhalers / 30 days)

4 QL M

PROVENTIL HFA QL (2 inhalers / 30 days)

4 QL M

SEREVENT DISKUS QL (60 inhalations / 30 days)

3 QL M

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

4 QL M

terbutaline sulfate SOLN 5 M

terbutaline sulfate TABS 2 M

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL M

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK

2 M

montelukast sodium TABS 1 M


40

Drug Name Drug Tier

Requirements/Limits

zafirlukast 2 M

MAST CELL STABILIZERS cromolyn sodium NEBU 2 B/D M

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

2 B/D M

ARALAST NP 5 LA PA

CINQAIR 5 LA PA

DALIRESP 4 M

ELIXOPHYLLIN 4 M

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

(generic of EpiPen)

2 M

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

(generic of Adrenaclick)

2 M

ESBRIET 5 PA

GLASSIA 5 LA PA

KALYDECO 5 PA

NUCALA 5 LA PA

OFEV 5 PA

ORKAMBI 5 PA

PROLASTIN-C 5 LA PA

PULMOZYME 5 PA

SYMDEKO 5 LA PA

SYMJEPI 4 M

THEO-24 4 M

theophylline 2 M

theophylline tab er 12hr 300 mg

2 M

theophylline tab er 12hr 450 mg

2 M

theophylline tab sr 24hr 2 M

XOLAIR 5 LA PA

ZEMAIRA 5 LA PA

NASAL STEROIDS BECONASE AQ


flunisolide (nasal) QL (3 bottles / 30 days)

2 QL M

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

1 QL M

mometasone furoate (nasal) QL (2 inhalers / 30 days)

2 QL M

OMNARIS QL (1 inhaler / 30 days)

4 QL M

QNASL QL (1 inhaler / 30 days)

4 QL M

Drug Name Drug Tier

Requirements/Limits

QNASL CHILDRENS QL (1 inhaler / 30 days)

4 QL M

XHANCE QL (2 bottles / 30 days)

4 QL M

ZETONNA QL (1 inhaler / 30 days)

4 QL M

STEROID INHALANTS ALVESCO


ARNUITY ELLIPTA QL (30 inhalations / 30 days)

3 QL M

ASMANEX QL (2 inhalers / 30 days)

4 QL M

ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)

4 QL M

ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)

4 QL M

ASMANEX TWISTHALER 14 MET


4 QL M

budesonide (inhalation) 2 B/D M

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

QL (120 inhalations / 30 days)

3 QL M

FLOVENT DISKUS 250mcg/blist


3 QL M

FLOVENT HFA QL (2 inhalers / 30 days)

3 QL M

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

4 QL M

QVAR REDIHALER QL (2 inhalers / 30 days)

4 QL M

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


3 QL M

ADVAIR HFA QL (1 inhaler / 30 days)

3 QL M

BREO ELLIPTA QL (60 blisters / 30 days)

3 QL M

DULERA QL (1 inhaler / 30 days)

4 QL M

SYMBICORT QL (1 inhaler / 30 days)

3 QL M


41

Drug Name Drug Tier

Requirements/Limits

TOPICAL DERMATOLOGY, ACNE ACZONE 7.5%

QL (90 grams / 30 days) 4 QL M

adapalene CREA; GEL 2 M

ADAPALENE SOLN 4 M

adapalene-benzoyl peroxide gel 0.1-2.5%

2 M

AKTIPAK 4 M

ALTRENO QL (45 grams / 30 days)

4 QL M PA

amnesteem 2 M PA

avita QL (45 grams / 30 days)

2 QL M PA

benzoyl peroxide-erythromycin

2 M

claravis 2 M PA

clindacin-p 2 M

clindam/benz gel 1.2-2.5% QL (50 grams / 30 days)

2 QL M

clindamy/ben gel 1-5% 2 M

clindamycin phosphate (topical) FOAM; LOTN; SWAB

2 M

clindamycin phosphate (topical) GEL


2 QL M

clindamycin phosphate (topical) SOLN


2 QL M

clindamycin phosphate-benzoyl peroxide (refrigerate)

2 M

clindamycin phosphate-tretinoin

2 M

dapsone gel 5% QL (90 grams / 30 days)

2 QL M

DIFFERIN LOTN 4 M

EPIDUO FORTE 4 M

ery pad 2% 2 M

erythromycin (acne aid) 2 M

isotretinoin CAPS 2 M PA

myorisan 2 M PA

neuac gel 1.2-5% 2 M

ONEXTON 4 M

RETIN-A MICRO .06% QL (50 grams / 30 days)

5 QL M PA

RETIN-A MICRO PUMP .08%


5 QL M PA

Drug Name Drug Tier

Requirements/Limits

sulfacetamide sodium (acne) 2 M

tretinoin CREA; GEL QL (45 grams / 30 days)

2 QL M PA

tretinoin microsphere QL (50 grams / 30 days)

2 QL M PA

zenatane 2 M PA

DERMATOLOGY, ANTIBIOTICS CENTANY


4 QL M

CORTISPORIN 4 M

gentamicin sulfate (topical) 2 M

mupirocin OINT QL (220 grams / 30 days)

1 QL M

silver sulfadiazine CREA 2 M

ssd 2 M

SULFAMYLON CREA 4 M

XEPI 4 M

DERMATOLOGY, ANTIFUNGALS ciclopirox cre 0.77%


ciclopirox sus 0.77% QL (60 mL / 30 days)

2 QL M

clotrimazole (topical) CREA 2 M

clotrimazole (topical) SOLN QL (30 mL / 30 days)

2 QL M

clotrimazole w/ betamethasone CREA

2 M

clotrimazole w/ betamethasone LOTN


2 QL M

ERTACZO QL (60 grams / 30 days)

5 QL M

EXELDERM CREA QL (60 grams / 30 days)

4 QL M

EXELDERM SOLN QL (60 mL / 30 days)

4 QL M

ketoconazole (topical) CREA QL (60 grams / 30 days)

2 QL M

ketoconazole (topical) FOAM QL (100 grams / 30 days)

2 QL M

ketodan QL (100 grams / 30 days)

2 QL M

luliconazole QL (60 grams / 30 days)

2 QL M

MENTAX 4 M


42

Drug Name Drug Tier

Requirements/Limits

naftifine hcl CREA 1% QL (90 grams / 30 days)

2 QL M

naftifine hcl CREA 2% QL (60 grams / 30 days)

2 QL M

naftifine hcl GEL QL (90 grams / 30 days)

2 QL M

NAFTIN GEL 1% QL (90 grams / 30 days)

4 QL M

NAFTIN GEL 2% QL (60 grams / 30 days)

4 QL M

nyamyc QL (60 grams / 30 days)

2 QL M

nystatin (topical) 2 M

nystatin pow 100000 QL (60 grams / 30 days)

2 QL M

nystop QL (60 grams / 30 days)

2 QL M

OXISTAT LOTN QL (60 mL / 30 days)

4 QL M PA

DERMATOLOGY, ANTIPSORIATICS acitretin 2 M PA

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

2 QL M PA

calcipotriene SOLN QL (120 mL / 30 days)

2 QL M PA

calcitrene QL (120 grams / 30 days)

2 QL M PA

calcitriol OINT QL (800 grams / 28 days)

2 QL M

methoxsalen rapid 5 M

tazarotene CREA QL (60 grams / 30 days)

2 QL M PA

TAZORAC CREA .05% QL (60 grams / 30 days)

4 QL M PA

TAZORAC GEL QL (100 grams / 30 days)

4 QL M PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 M

selenium sulfide LOTN 1 M

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 M

alclometasone dipropionate 2 M

beser LOTN QL (120 mL / 30 days)

2 QL M

betamethasone dipropionate (topical)

2 M

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented

2 M

betamethasone valerate CREA; FOAM; LOTN; OINT

2 M

BRYHALI QL (100 grams / 30 days)

4 QL M

calcipotriene/betamethasone QL (400 grams / 28 days)

2 QL M PA

CAPEX 4 M

clocortolone pivalate 2 M

CORDRAN TAPE 4 M

DESONATE QL (60 grams / 30 days)

4 QL M

desonide CREA; OINT QL (60 grams / 30 days)

2 QL M

desonide LOTN QL (118 mL / 30 days)

2 QL M

desoximetasone LIQD QL (100 mL / 30 days)

2 QL M

ENSTILAR QL (120 grams / 30 days)

4 QL M PA

fluocinolone acetonide CREA; OIL; OINT

2 M

fluocinolone acetonide SOLN


2 QL M

fluocinolone acetonide oil body

2 M

fluocinonide CREA .05% QL (120 grams / 30 days)

2 QL M

fluocinonide GEL QL (60 grams / 30 days)

2 QL M

fluocinonide OINT QL (60 grams / 30 days)

2 QL M

fluocinonide SOLN QL (60 mL / 30 days)

2 QL M

fluocinonide emulsified base QL (120 grams / 30 days)

2 QL M

flurandrenolide CREA QL (120 grams / 30 days)

2 QL M

flurandrenolide LOTN; OINT 2 M

fluticasone propionate CREA; OINT

2 M


43

Drug Name Drug Tier

Requirements/Limits

fluticasone propionate LOTN QL (120 mL / 30 days)

2 QL M

halcinonide QL (240 grams / 30 days)

2 QL M

halobetasol propionate CREA; OINT


2 QL M

HALOBETASOL PROPIONATE FOAM

5 M

HALOG QL (240 grams / 30 days)

5 QL M

hydrocortisone (topical) cream 1%

1 M

hydrocortisone (topical) cream 2.5%

1 M

hydrocortisone (topical) lotion 2.5%

2 M

hydrocortisone (topical) oint 2.5%

1 M

hydrocortisone butyrate cream 0.1%


2 QL M

hydrocortisone butyrate cream 0.1% lipo base

2 M

hydrocortisone butyrate lotion 0.1%

2 M

hydrocortisone butyrate oint 0.1%


2 QL M

LEXETTE 5 M

MICORT-HC 4 M

mometasone furoate CREA; OINT; SOLN

2 M

nolix CREA QL (120 grams / 30 days)

2 QL M

nolix LOTN 2 M

PANDEL QL (80 grams / 30 days)

5 QL M

prednicarbate 2 M

SERNIVO 5 M

TACLONEX SUSP QL (400 grams / 28 days)

5 QL M PA

TEXACORT 4 M

triamcinolone acetonide (topical) AERS

2 M

Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (topical) CREA .1%


1 QL M

triamcinolone acetonide (topical) CREA .025%, .5%

1 M

triamcinolone acetonide (topical) LOTN

2 M

triamcinolone acetonide (topical) OINT .025%, .1%, .5%

1 M

ULTRAVATE LOTN QL (120 mL / 30 days)

5 QL M

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 2 QL M PA

lidocaine OINT QL (50 grams / 30 days)

2 QL M PA

lidocaine PTCH QL (3 patches / 1 day)

2 QL M PA

lidocaine hcl GEL QL (30 mL / 30 days)

2 QL M PA

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

2 QL M PA

lidocaine-prilocaine QL (30 grams / 30 days)

2 QL M PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical CREA


acyclovir topical OINT QL (30 grams / 30 days)

2 QL M

ammonium lactate CREA; LOTN

2 M

azelaic acid GEL QL (50 grams / 30 days)

2 QL M

CONDYLOX 4 M

CORTIFOAM 4 M

DENAVIR QL (5 grams / 30 days)

5 QL M

diclofenac sodium (topical) 1% gel


2 QL M PA

diclofenac sodium (topical) 1.5% soln

QL (450 mL / 30 days)

2 QL M PA

doxycycline (rosacea) 2 M

EUCRISA 4 M PA

FINACEA AER 15% 4 M


44

Drug Name Drug Tier

Requirements/Limits

fluorouracil (topical) CREA 5%


2 QL M

fluorouracil (topical) SOLN QL (10 mL / 30 days)

2 QL M

imiquimod CREA 5% QL (24 packets / 30 days)

2 QL M

metronidazole (topical) CREA

2 M

metronidazole (topical) GEL .75%

2 M

metronidazole (topical) LOTN

2 M

NORITATE QL (60 grams / 30 days)

5 QL M

PANRETIN QL (60 grams / 30 days)

5 QL M

PENNSAID QL (224 grams / 28 days)

5 QL M PA

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

4 QL M

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

4 QL M

podofilox SOLN 2 M

procto-med hc 2 M

procto-pak 2 M

proctosol hc 2.5 % 2 M

proctozone-hc 2 M

RECTIV 4 M

rosadan cre 0.75% 2 M

tacrolimus (topical) QL (100 grams / 30 days)

2 QL M

TARGRETIN GEL QL (60 grams / 30 days)

5 QL PA

VALCHLOR QL (60 grams / 30 days)

5 QL LA PA

XERESE QL (5 grams / 30 days)

5 QL M

ZYCLARA 2.5% QL (15 grams / 30 days)

5 QL M

DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan


2 QL M

EURAX CREA 4 M

malathion 2 M

Drug Name Drug Tier

Requirements/Limits

NATROBA 4 M

permethrin cre 5% 2 M

SKLICE 4 M

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 2 M

neomycin/polymyxin b gu 2 M

REGRANEX QL (30 grams / 30 days)

5 QL M PA

SANTYL 4 M

sodium chlor sol 0.9% irr 2 M

water for irrigation, sterile 2 M

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 2 M

chlorhexidine gluconate (mouth-throat)

1 M

clotrimazole LOZG 2 M

lidocaine hcl (mouth-throat) 2 M

nystatin (mouth-throat) 2 M

ORAVIG 5 M

paroex sol 0.12% 1 M

periogard 1 M

pilocarpine hcl (oral) 2 M

triamcinolone acetonide (mouth)

2 M

OTIC acetic acid (otic) 2 M

acetic acid sol/hc 2 M

CIPRO HC 4 M

CIPRODEX 3 M

ciprofloxacin hcl (otic) 2 M

CORTISPORIN-TC 4 M

flac 2 M

fluocinolone acetonide (otic) 2 M

neomycin-polymyxin-hc (otic) 2 M

ofloxacin (otic) 2 M

OTOVEL 4 M

45

Index A abacavir sulfate ...................5 abacavir sulfate-lamivudine.6 abacavir sulfate-lamivudine-zidovudine ..........................................6 ABELCET............................5 ABILIFY MAINTENA ......... 18 abiraterone acetate ........... 10 ABRAXANE ........................9 ABSTRAL............................1 acamprosate calcium ........ 23 acarbose ........................... 24 acebutolol hcl .................... 13 acetaminophen w/ codeine 300-15mg ............................1 acetaminophen w/ codeine 300-30mg ............................1 acetaminophen w/ codeine 300-60mg ............................1 acetaminophen w/ codeine soln .....................................1 acetaminophen-caff-dihydrocod ........................................1 acetazolamide ................... 14 acetic acid ......................... 44 acetic acid (otic) ................ 44 acetic acid sol/hc ............... 44 acetylcysteine ................... 40 acitretin ............................. 42 ACTHIB ............................. 35 ACTIMMUNE .................... 35 ACUVAIL........................... 37 acyclovir ..............................6 acyclovir sodium .................6 acyclovir topical ................. 43 ACZONE ........................... 41 ADACEL............................ 35 adapalene ......................... 41 ADAPALENE .................... 41 adapalene-benzoyl peroxide gel 0.1-2.5% ...................... 41 adefovir dipivoxil .................6 ADEMPAS ........................ 15 ADMELOG ........................ 24 ADMELOG SOLOSTAR.... 24 adriamycin...........................9 adrucil inj .............................9 ADVAIR DISKUS .............. 40

ADVAIR HFA .................... 40 ADZENYS ER SUS 1.25MG .......................................... 20 ADZENYS XR-ODT .......... 20 AFINITOR ......................... 10 AFINITOR DISPERZ......... 10 AFREZZA ......................... 29 AFREZZA 4/8/12UNITS .... 29 AFREZZA 4/8UNITS ......... 29 AFREZZA 8/12 UNITS ...... 29 AIMOVIG .......................... 21 AKTIPAK ........................... 41 AKYNZEO ......................... 31 ala-cort .............................. 42 albendazole ........................ 4 albuterol sulfate ................ 39 albuterol sulfate er ............ 39 alclometasone dipropionate .......................................... 42 ALDACTAZIDE TAB 50/50 .......................................... 14 ALDURAZYME ................. 28 ALECENSA ....................... 10 alendronate sodium .......... 26 alfuzosin hcl ...................... 33 ALIMTA ............................... 9 ALINIA ................................ 4 ALIQOPA .......................... 10 aliskiren fumarate ............. 14 allopurinol tab ..................... 1 almotriptan malate ............ 21 ALOCRIL .......................... 38 alogliptin benzoate ............ 24 alogliptin-metformin hcl ..... 24 alogliptin-pioglitazone 12.5-15mg ......................... 24 alogliptin-pioglitazone 12.5-30mg ......................... 24 alogliptin-pioglitazone 12.5-45mg ......................... 24 alogliptin-pioglitazone 25-15mg ............................ 24 alogliptin-pioglitazone 25-30mg ............................ 25 alogliptin-pioglitazone 25-45mg ............................ 25 ALOMIDE .......................... 38 ALORA .............................. 29 alosetron hcl ..................... 32

ALPHAGAN P 0.1% .......... 38 alprazolam ........................ 15 ALPRAZOLAM.................. 15 ALREX .............................. 37 altavera tab ....................... 27 ALTOPREV ...................... 12 ALTRENO ......................... 41 ALUNBRIG ....................... 10 ALVESCO ......................... 40 alyacen 1/35 ..................... 27 alyq ................................... 15 amantadine hcl ................. 17 AMBISOME ........................ 5 ambrisentan ...................... 15 amethia ............................. 27 amethia lo ......................... 27 amikacin sulfate .................. 4 amiloride & hydrochlorothiazide ........... 14 amiloride hcl ..................... 14 AMINOSYN II INJ 10% ..... 36 AMINOSYN-PF 7% ........... 36 AMINOSYN-PF INJ 10% .. 36 amiodarone hcl soln .......... 12 amiodarone tab 100mg ..... 12 amiodarone tab 200mg ..... 12 amiodarone tab 400mg ..... 12 AMITIZA ........................... 32 amitriptyline hcl ................. 17 amlodipine besylate .......... 13 amlodipine besylate-atorvastatin calcium.......................................... 13 amlodipine besylate-benazepril hcl ..... 11 amlodipine besylate-olmesartan medoxomil ........................ 12 amlodipine besylate-valsartan tab 10-160 mg ........................ 12 amlodipine besylate-valsartan tab 10-320 mg ........................ 12 amlodipine besylate-valsartan tab 5-160 mg ..................................... 12 amlodipine besylate-valsartan tab 5-320

46

mg ..................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 12 ammonium lactate ............. 43 amnesteem ....................... 41 amoxapine ........................ 17 amoxicillin ...........................8 amoxicillin & pot clavulanate 200/5ml susr .......................8 amoxicillin & pot clavulanate 200-28.5 chw tabs ...............8 amoxicillin & pot clavulanate 250/5ml susr .......................8 amoxicillin & pot clavulanate 250-125 tabs .......................8 amoxicillin & pot clavulanate 400/5ml susr .......................8 amoxicillin & pot clavulanate 400-57 chw tabs ..................8 amoxicillin & pot clavulanate 500-125 tabs .......................8 amoxicillin & pot clavulanate 600/5ml susr .......................8 amoxicillin & pot clavulanate 875-125 tabs .......................8 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs ........8 amoxicillin-clarithromycin w/ lansoprazole ...................... 32 amphetamine cap 10mg er .......................................... 20 amphetamine cap 15mg er .......................................... 20 amphetamine cap 20mg er .......................................... 20 amphetamine cap 25mg er .......................................... 20 amphetamine cap 30mg er

.......................................... 20 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 20 amphetamine-dextroamphetamine tab 10 mg ............... 20 amphetamine-dextroamphetamine tab 12.5 mg ............ 20 amphetamine-dextroamphetamine tab 15 mg ............... 20 amphetamine-dextroamphetamine tab 20 mg ............... 20 amphetamine-dextroamphetamine tab 30 mg ............... 20 amphetamine-dextroamphetamine tab 5 mg ................. 20 amphetamine-dextroamphetamine tab 7.5 mg .............. 20 amphotericin b .................... 5 ampicillin & sulbactam sodium ................................ 8 ampicillin cap 500mg .......... 8 ampicillin inj ........................ 8 ampicillin sodium ................ 8 ANADROL-50 ................... 23 anagrelide hcl ................... 34 anastrozole ....................... 10 ANDRODERM .................. 23 ANORO ELLIPT AER 62.5-25 .............................. 38 ANTARA ........................... 13 APIDRA ............................ 24 APIDRA SOLOSTAR ........ 24 APOKYN ........................... 17 aprepitant .......................... 31 aprepitant pak 80mg & 125mg ............................... 31 apri .................................... 27 APRISO ............................ 31 APTENSIO XR .................. 20 APTIOM ............................ 15 APTIVUS ............................ 5 ARALAST NP ................... 40 aranelle ............................. 27 ARANESP ALBUMIN FREE .................................... 33, 34 ARCALYST ....................... 35 ARCAPTA NEOHALER .... 39 ARIKAYCE .......................... 4 aripiprazole odt ................. 18 aripiprazole oral solution 1

mg/ml ................................ 18 aripiprazole tab ................. 18 ARISTADA ........................ 18 ARISTADA INITIO ............ 18 armodafinil ........................ 23 ARNUITY ELLIPTA ........... 40 ARYMO ER ........................ 2 ARZERRA .......................... 9 ashlyna ............................. 27 ASMANEX ........................ 40 ASMANEX HFA ................ 40 ASMANEX TWISTHALER 14 MET ............................. 40 aspirin-dipyridamole .......... 34 ASTAGRAF XL ................. 35 atazanavir sulfate................ 5 atenolol ............................. 13 atenolol & chlorthalidone .. 13 ATGAM ............................. 35 atomoxetine hcl................. 20 atorvastatin calcium .......... 12 atovaquone ......................... 4 atovaquone-proguanil hcl tab 250-100 mg ........................ 5 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 5 ATRIPLA ............................. 6 atropine sulfate ................. 31 ATROPINE SULFATE ...... 38 ATROVENT HFA .............. 38 aubra ................................ 27 AUGMENTIN SUS 125/5ML............................................ 8 AURYXIA .......................... 30 AUSTEDO ........................ 22 AVASTIN ............................ 9 AVC .................................. 33 aviane ............................... 27 avita .................................. 41 AVYCAZ ............................. 7 azacitidine ........................... 9 AZASAN ........................... 35 AZASITE ........................... 37 azathioprine ...................... 35 azelaic acid ....................... 43 azelastine drop 0.05% ...... 38 azelastine spr 0.1% .......... 39 azelastine spr 0.15% ........ 39 azithromycin ....................... 7 AZOPT .............................. 38

47

aztreonam ...........................4 B bacitracin (ophthalmic) ...... 37 bacitracin-polymyxin b (ophth) .............................. 37 bacitracin-poly-neomycin-hc .......................................... 37 baclofen ............................ 23 BACTOCILL INJ DEX 1GM.8 BACTOCILL INJ DEX 2GM.8 balsalazide disodium ......... 31 BALVERSA ....................... 10 balziva ............................... 27 BANZEL SUS 40MG/ML ... 15 BANZEL TAB 200MG ....... 15 BANZEL TAB 400MG ....... 15 BARACLUDE ......................6 BASAGLAR KWIKPEN ..... 24 BAXDELA ...........................7 BCG VACCINE ................. 35 BD ALCOHOL SWABS ..... 24 BD ULTRAFINE INSULIN SYRINGE .......................... 24 BD ULTRAFINE/NANO PEN NEEDLES ......................... 24 BECONASE AQ ................ 40 bekyree ............................. 27 BELBUCA ...........................1 BELEODAQ ........................9 benazepril & hydrochlorothiazide ........... 11 benazepril hcl .................... 12 BENDEKA ...........................9 BENLYSTA ....................... 35 benzoyl peroxide-erythromycin ...... 41 benztropine mesylate inj ... 17 benztropine mesylate tab 0.5mg ................................ 17 benztropine mesylate tab 1mg ................................... 17 benztropine mesylate tab 2mg ................................... 18 BEPREVE ......................... 38 BERINERT ........................ 34 beser ................................. 42 BESIVANCE ..................... 37 BESPONSA ........................9 betamethasone dipropionate (topical) ............................. 42

betamethasone dipropionate augmented ........................ 42 betamethasone valerate ... 42 BETASERON .................... 22 betaxolol hcl ...................... 13 betaxolol hcl (ophth) ......... 38 bethanechol chloride ......... 33 BETHKIS ............................ 4 BETIMOL .......................... 38 BETOPTIC-S .................... 38 BEVESPI AEROSPHERE . 38 BEVYXXA ......................... 33 bexarotene ........................ 11 BEXSERO ........................ 35 bicalutamide ...................... 10 BICILLIN C-R ...................... 8 BICILLIN L-A ....................... 8 BIDIL ................................. 14 BIKTARVY .......................... 6 BINOSTO .......................... 26 bisoprolol & hydrochlorothiazide ........... 13 bisoprolol fumarate ........... 13 BIVIGAM ........................... 35 BLEPHAMIDE ................... 37 blisovi 24 fe ....................... 27 blisovi fe 1.5/30 ................. 27 BOOSTRIX ....................... 35 BORTEZOMIB .................... 9 bosentan ........................... 15 BOSULIF .......................... 10 BOTOX ............................. 23 BRAFTOVI ........................ 10 BREO ELLIPTA ................ 40 briellyn .............................. 27 BRILINTA .......................... 34 brimonidine sol 0.15%....... 38 brimonidine sol 0.2%......... 38 BRIVIACT INJ 50MG/5ML 15 BRIVIACT SOL 10MG/ML 15 BRIVIACT TAB 100MG ..... 15 BRIVIACT TAB 10MG....... 15 BRIVIACT TAB 25MG....... 15 BRIVIACT TAB 50MG....... 15 BRIVIACT TAB 75MG....... 15 bromfenac sodium (ophth) 37 bromocriptine mesylate ..... 18 BROMSITE ....................... 37 BROVANA ........................ 39 BRYHALI .......................... 42

budesonide ....................... 31 budesonide (inhalation) .... 40 bumetanide ....................... 14 BUNAVAIL MIS 2.1-0.3MG.......................................... 23 BUNAVAIL MIS 4.2-0.7MG.......................................... 23 BUNAVAIL MIS 6.3-1MG .. 23 buprenorphine hcl ............. 23 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 23 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 23 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 23 buprenorphine hcl-naloxone hcl dihydrate 8-2mg .......... 23 buprenorphine hcl-naloxone hcl sl ................................. 23 buprenorphine patch ........... 1 bupropion hcl .................... 17 bupropion hcl (smoking deterrent) .......................... 23 buspirone hcl .................... 15 butorphanol nasal spray ..... 1 butorphanol tartrate ............ 1 BYDUREON BCISE .......... 24 BYDUREON PEN ............. 24 BYETTA ............................ 24 BYSTOLIC ........................ 13 C cabergoline ....................... 29 CABOMETYX ................... 10 calcipotriene ..................... 42 calcipotriene/betamethasone.......................................... 42 calcitonin (salmon) nasal spray ................................. 29 calcitrene .......................... 42 calcitriol ....................... 37, 42 calcitriol inj ........................ 37 calcium acetate (phosphate binder) .............................. 30 CALQUENCE ................... 10 camila ............................... 27 camrese lo tab .................. 27 candesartan cilexetil ......... 12 candesartan cilexetil-hydrochlorothiazide.......................................... 12

48

CAPEX .............................. 42 CAPRELSA ....................... 10 captopril ............................ 12 captopril & hydrochlorothiazide ........... 11 CARAFATE ....................... 32 CARBAGLU ...................... 28 carbamazepine ................. 15 carbidopa .......................... 18 carbidopa/levodopa/entacapone .................................... 18 carbidopa-levodopa .......... 18 carboplatin ........................ 11 CARDIZEM LA .................. 13 CARDURA XL ................... 33 CAROSPIR ....................... 12 carteolol hcl (ophth) .......... 38 cartia xt ............................. 13 carvedilol ........................... 13 carvedilol er ....................... 13 caspofungin acetate ............5 CAYSTON ...........................4 caziant pak ........................ 27 cefaclor ...............................7 CEFACLOR ER TAB 500MG ............................................7 cefadroxil.............................7 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................7 cefazolin inj .........................7 cefazolin sodium .................7 CEFAZOLIN SODIUM 1 GM/50ML ............................7 cefdinir ................................7 CEFEPIME 1GM SOLN ......7 CEFEPIME 2GM SOLN ......7 cefepime inj 1gm .................7 cefepime inj 2gm .................7 CEFEPIME/DEXTROSE .....7 cefixime ...............................7 cefotetan disodium ..............7 cefoxitin sodium ..................7 CEFOXITIN SODIUM .........7 cefpodoxime proxetil ...........7 cefprozil...............................7 ceftazidime ..........................7 CEFTAZIDIME/DEXTROSE ............................................7 ceftriaxone sodium ..............7 cefuroxime axetil .................7

cefuroxime sodium .............. 7 celecoxib ............................. 1 CELONTIN ........................ 15 CENTANY ......................... 41 cephalexin ........................... 7 CERDELGA ...................... 28 CEREZYME ...................... 28 CESAMET ........................ 31 cetirizine syrup .................. 39 cevimeline hcl ................... 44 CHANTIX .......................... 23 CHANTIX CONTINUING MONTH ............................. 23 CHANTIX STARTER PACK .......................................... 23 CHEMET ........................... 27 chlorhexidine gluconate (mouth-throat) ................... 44 chloroquine phosphate........ 5 chlorothiazide tabs ............ 14 chlorpromazine hcl ............ 18 CHLORPROMAZINE INJ .. 18 chlorthalidone ................... 14 cholestyramine .................. 13 cholestyramine light pack .. 13 cholestyramine light powd . 13 choline fenofibrate ............ 13 CHORIONIC GONADOTROPIN ............ 29 ciclopirox cre 0.77% .......... 41 ciclopirox sus 0.77% ......... 41 cidofovir .............................. 6 cilostazol ........................... 34 CILOXAN OIN 0.3% OP ... 37 CIMDUO ............................. 6 cimetidine .......................... 31 cimetidine sol 300/5ml ...... 31 cinacalcet hcl .................... 29 CINQAIR ........................... 40 CINRYZE .......................... 34 CINVANTI ......................... 31 CIPRO HC ........................ 44 CIPRODEX ....................... 44 ciprofloxacin ........................ 7 ciprofloxacin hcl .................. 7 ciprofloxacin hcl (ophth) .... 37 ciprofloxacin hcl (otic) ....... 44 ciprofloxacin in d5w ............ 7 cisplatin ............................. 11 citalopram hydrobromide .. 17

claravis ............................. 41 CLARINEX-D TAB 2.5-120.......................................... 39 clarithromycin ..................... 7 CLENPIQ .......................... 32 CLEOCIN VAG SUPP 100MG .............................. 33 clindacin-p ........................ 41 clindam/benz gel 1.2-2.5% 41 clindamy/ben gel 1-5% ..... 41 clindamycin cre 2% vag .... 33 clindamycin hcl ................... 4 clindamycin phosphate (topical) ............................. 41 clindamycin phosphate in d5w ..................................... 4 CLINDAMYCIN PHOSPHATE IN NACL ...... 4 clindamycin phosphate inj ... 4 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 41 clindamycin phosphate-tretinoin ........... 41 clindamycin soln 75mg/5ml . 4 CLINDESSE ..................... 33 CLINIMIX 4.25%/DEXTROSE 10% ... 36 CLINIMIX 4.25%/DEXTROSE 5% ..... 36 CLINIMIX 5%/DEXTROSE 15% .................................. 36 CLINIMIX 5%/DEXTROSE 20% .................................. 36 CLINIMIX E 2.75%/DEXTROSE 5% ..... 36 CLINIMIX E 4.25%/D10 .... 36 CLINIMIX E 4.25%/DEXTROSE 5% ..... 36 CLINIMIX E 5%/DEXTROSE 15% .................................. 36 CLINIMIX E 5%/DEXTROSE 20% .................................. 36 clinisol sf 15% ................... 36 CLINOLIPID ...................... 36 clobazam .......................... 15 clocortolone pivalate ......... 42 clomipramine hcl ............... 17 clonazepam ...................... 15 clonidine hcl ...................... 14

49

clonidine hcl ptwk .............. 14 clopidogrel tab 300mg ....... 34 clopidogrel tab 75mg ......... 34 clorazepate dipotassium ... 15 clotrimazole ....................... 44 clotrimazole (topical) ......... 41 clotrimazole w/ betamethasone ................. 41 clozapine odt ..................... 18 clozapine tab 100mg ......... 18 clozapine tab 200mg ......... 18 clozapine tab 25mg ........... 18 clozapine tab 50mg ........... 18 COARTEM ..........................5 codeine sulfate ....................2 CODEINE SULFATE ..........2 colchicine w/ probenecid .....1 COLCRYS ...........................1 colesevelam hcl ................ 13 colestipol hcl gran ............. 13 colestipol hcl pack ............. 13 colestipol hcl tabs .............. 13 colistimethate sodium .........4 colocort ............................. 31 COMBIGAN ...................... 38 COMBIVENT RESPIMAT . 38 COMETRIQ ....................... 10 COMPLERA ........................6 compro supp ..................... 31 CONDYLOX ...................... 43 constulose ......................... 32 COPIKTRA ........................ 10 CORDRAN ........................ 42 CORLANOR ...................... 14 CORTIFOAM .................... 43 cortisone acetate ............... 29 CORTISPORIN ................. 41 CORTISPORIN-TC ........... 44 COTELLIC ........................ 10 COTEMPLA XR-ODT ....... 20 COUMADIN ...................... 33 CREON ............................. 32 CRESEMBA ........................5 CRINONE ......................... 30 CRIXIVAN ...........................5 cromolyn sodium ............... 40 cromolyn sodium (mastocytosis) ................... 32 cromolyn sodium (ophth) .. 38 crotan ................................ 44

cryselle-28 ........................ 27 CUVPOSA ........................ 31 cyclafem 1/35 .................... 27 cyclafem 7/7/7 ................... 27 cyclobenzaprine hcl .......... 23 cyclophosphamide .............. 9 cycloserine .......................... 6 cyclosporine ...................... 35 cyclosporine modified (for microemulsion) ................. 35 cyproheptadine hcl ............ 39 cyred tab ........................... 27 CYSTADANE .................... 28 CYSTAGON ...................... 28 CYSTARAN ...................... 38 cytarabine ........................... 9 D dalfampridine .................... 22 DALIRESP ........................ 40 DALVANCE ........................ 4 danazol ............................. 28 dantrolene sodium ............ 23 dapsone .............................. 4 dapsone gel 5% ................ 41 DAPTACEL ....................... 35 daptomycin ......................... 4 darifenacin hydrobromide . 33 dasetta 1/35 ...................... 27 dasetta 7/7/7 ..................... 27 DAURISMO ........................ 9 DAYTRANA ...................... 20 deblitane ........................... 27 decitabine ........................... 9 deferasirox ........................ 27 DELESTROGEN ............... 29 DELSTRIGO ....................... 6 demeclocycline hcl .............. 8 DEMSER .......................... 14 DENAVIR .......................... 43 DEPEN TITRATABS ......... 27 DEPO-ESTRADIOL .......... 29 DEPO-MEDROL ............... 29 DEPO-PROVERA INJ 400/ML .............................. 10 DEPO-SUBQ PROVERA 104 .................................... 27 DESCOVY .......................... 6 desipramine hcl ................. 17 desloratadine .................... 39 desmopressin acetate ....... 30

desmopressin acetate spray.......................................... 30 desmopressin acetate spray refrigerated ....................... 30 desmopressin inj 4mcg/ml 30 desogestrel & ethinyl estradiol ............................ 27 desogestrel-ethinyl estradiol (biphasic) .......................... 27 DESONATE ...................... 42 desonide ........................... 42 desoximetasone................ 42 desvenlafaxine succinate .. 17 dexamethasone ................ 29 DEXAMETHASONE ......... 29 dexamethasone sodium phosphate ......................... 29 dexamethasone sodium phosphate (ophth)............. 37 DEXILANT ........................ 32 dexmethylphenidate hcl .... 20 dextrose ............................ 36 dextrose 10% flex contain . 36 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 36 dextrose 10%/nacl 0.45% . 36 dextrose 2.5%/nacl 0.45% 36 dextrose 5% ...................... 36 DEXTROSE 5% /ELECTROLYTE ............... 36 dextrose 5%/nacl 0.2% ..... 36 dextrose 5%/nacl 0.225% . 36 DEXTROSE 5%/NACL 0.3%.......................................... 36 dextrose 5%/nacl 0.45% ... 36 dextrose 5%/nacl 0.9% ..... 36 dextrose 5%/potassium chl.......................................... 36 dextrose in lactated ringers.......................................... 36 DIASTAT ACUDIAL .......... 15 DIASTAT PEDIATRIC ...... 15 diazepam .......................... 15 diazepam gel .................... 15 diazepam inj ..................... 15 diazepam intensol ............. 15 diazepam oral soln 1 mg/ml.......................................... 15 diclofenac potassium .......... 1

50

diclofenac sodium ...............1 diclofenac sodium (ophth) . 38 diclofenac sodium (topical) 1% gel ............................... 43 diclofenac sodium (topical) 1.5% soln .......................... 43 diclofenac w/ misoprostol ....1 dicloxacillin sodium .............8 dicyclomine hcl cap 10mg . 31 dicyclomine hcl inj ............. 31 dicyclomine hcl soln 10mg/5ml .......................... 31 dicyclomine hcl tab 20mg .. 31 didanosine...........................5 DIFFERIN ......................... 41 DIFICID ...............................7 diflunisal ..............................1 digitek ............................... 14 digox ................................. 14 digoxin .............................. 14 digoxin inj .......................... 14 digoxin sol 50mcg/ml ........ 14 dihydroergotamine mesylate inj 1 mg/ml ......................... 21 dihydroergotamine mesylate nasal spr 4 mg/ml .............. 21 DILANTIN CAP 100MG .... 15 DILANTIN CAP 30MG ...... 15 DILANTIN CHEW TAB 50MG ................................ 15 DILANTIN-125 SUSP ........ 15 DILATRATE SR ................ 14 diltiazem cap 240mg cd .... 13 diltiazem cap 360mg cd .... 13 diltiazem cap er/12hr ......... 13 diltiazem er tab 180mg ...... 13 diltiazem er tab 240mg ...... 13 diltiazem er tab 300mg ...... 13 diltiazem er tab 360mg ...... 13 diltiazem er tab 420mg ...... 13 diltiazem hcl ...................... 13 diltiazem hcl coated beads 13 diltiazem hcl coated beads cap sr 24hr ........................ 13 diltiazem hcl extended release beads cap sr ......... 14 diltiazem inj ....................... 14 dilt-xr cap .......................... 13 DIPENTUM ....................... 31 diphenhydramine hcl inj

50mg/ml ............................ 39 diphenoxylate w/ atropine . 32 DIPHTHERIA/TETANUS TOXOID ............................ 35 disopyramide phosphate ... 12 disulfiram .......................... 23 DIURIL SUS 250/5ML ....... 14 divalproex sodium ............. 15 docetaxel ............................ 9 DOCETAXEL ...................... 9 dofetilide ........................... 12 donepezil odt 10mg .......... 16 donepezil odt 5mg ............ 16 donepezil tab hcl 23mg ..... 16 donepezil tabs 10mg ......... 16 donepezil tabs 5mg ........... 16 DOPTELET ....................... 34 dorzol/timol sol 22.3-6.8 pf 38 dorzolamide hcl ................. 38 dorzolamide hcl-timolol maleate ............................. 38 dotti ................................... 29 DOVATO ............................. 6 doxazosin mesylate .......... 12 doxepin hcl ........................ 17 doxercalciferol ................... 37 doxorubicin hcl .................... 9 doxorubicin hcl liposomal .... 9 doxy 100 ............................. 8 doxycycline (monohydrate) . 8 doxycycline (rosacea) ....... 43 doxycycline hyclate ............. 8 doxycycline hyclate tab 100 mg dr................................... 8 doxycycline hyclate tab 150 mg dr................................... 8 doxycycline hyclate tab 75 mg dr................................... 8 DRIZALMA SPRINKLE ..... 17 dronabinol ......................... 31 drospirenone-ethinyl estradiol ............................ 27 drospirenone-ethinyl estradiol-levomefolate calcium .............................. 27 DROXIA ............................ 34 DULERA ........................... 40 duloxetine hcl .................... 17 DUOPA ............................. 18 DUREZOL ......................... 38

dutasteride ........................ 33 dutasteride-tamsulosin hcl 33 DUTOPROL ...................... 13 dvorah ................................. 1 DYANAVEL XR................. 20 DYMISTA SPR 137-50 ..... 39 E e.e.s 400 ............................. 7 EDARBI ............................ 12 EDARBYCLOR ................. 12 EDURANT .......................... 5 efavirenz ............................. 5 EGRIFTA .......................... 29 EGRIFTA 1MG ................. 29 ELAPRASE ....................... 28 ELECTROLYTE-R IN DEXTROSE ...................... 36 ELELYSO ......................... 28 eletriptan hydrobromide .... 21 ELIGARD INJ 22.5MG ...... 10 ELIGARD INJ 30MG ......... 10 ELIGARD INJ 45MG ......... 10 ELIGARD INJ 7.5MG ........ 10 ELIQUIS STARTER PACK.......................................... 33 ELIQUIS TAB 2.5MG ........ 33 ELIQUIS TAB 5MG ........... 33 ELITEK ............................. 11 ELIXOPHYLLIN ................ 40 ELLA ................................. 27 ELMIRON ......................... 33 EMBEDA CAP 100-4MG .... 2 EMBEDA CAP 20-0.8MG ... 2 EMBEDA CAP 30-1.2MG ... 2 EMBEDA CAP 50-2MG ...... 2 EMBEDA CAP 60-2.4MG ... 2 EMBEDA CAP 80-3.2MG ... 2 EMCYT ............................... 9 EMEND ............................. 31 EMGALITY ....................... 21 emoquette ......................... 27 EMSAM ............................ 17 EMTRIVA ............................ 5 EMVERM ............................ 4 enalapril maleate .............. 12 enalapril maleate & hydrochlorothiazide ........... 11 ENDARI ............................ 34 endocet 10-325mg .............. 2 endocet 2.5-325mg ............. 2

51

endocet 5-325mg ................2 endocet 7.5-325mg .............2 ENGERIX-B ...................... 35 enoxaparin sodium ............ 33 enpresse-28 ...................... 27 enskyce ............................. 27 ENSTILAR ........................ 42 entacapone ....................... 18 entecavir .............................7 ENTRESTO ...................... 12 ENTYVIO .......................... 32 enulose ............................. 32 ENVARSUS XR ................ 35 EPANED ........................... 12 EPCLUSA ...........................7 EPIDIOLEX ....................... 15 EPIDUO FORTE ............... 41 epinastine hcl (ophth) ........ 38 epinephrine (anaphylaxis) . 40 epirubicin hcl .......................9 epitol ................................. 15 EPIVIR HBV ........................7 eplerenone ........................ 12 EPOGEN........................... 34 eprosartan mesylate ......... 12 EQUETRO ........................ 22 ERAXIS ...............................5 ERBITUX ............................9 ergotamine w/ caffeine ...... 21 ERIVEDGE .........................9 ERLEADA ......................... 10 erlotinib hcl ........................ 10 errin ................................... 27 ERTACZO ......................... 41 ertapenem sodium ..............4 ery pad 2% ........................ 41 ERYPED 400 ......................7 ery-tab .................................7 ERYTHROCIN LACTOBIONATE ................7 erythrocin stearate ..............7 erythromycin (acne aid) .... 41 erythromycin (ophth) ......... 37 erythromycin base ...............7 erythromycin cap 250mg ec 7 erythromycin ethylsuccinate 7 erythromycin tab ec .............7 ESBRIET........................... 40 escitalopram oxalate ......... 17 esomeprazole magnesium 32

esomeprazole sodium inj .. 32 estarylla tab 0.25-35 ......... 27 estradiol ............................ 29 estradiol vaginal cream ..... 29 estradiol vaginal tab .......... 29 estradiol valerate .............. 29 ESTRING .......................... 29 ethacrynic acid .................. 14 ethambutol hcl .................... 6 ethosuximide ..................... 15 ethynodiol diacet & eth estrad ................................ 27 ethynodiol tab 1-50 ........... 27 etodolac .............................. 1 etodolac er .......................... 1 etoposide .......................... 11 EUCRISA .......................... 43 EURAX ............................. 44 EVENITY .......................... 29 everolimus ........................ 10 EVOTAZ ............................. 6 EXELDERM ...................... 41 exemestane ...................... 10 ezetimibe .......................... 13 ezetimibe-simvastatin ....... 13 F FABRAZYME .................... 28 falmina .............................. 27 famciclovir ........................... 7 famotidine ......................... 31 famotidine in nacl .............. 31 famotidine inj ..................... 31 FANAPT ............................ 18 FANAPT TITRATION PACK .......................................... 18 FARXIGA .......................... 25 FARYDAK ........................... 9 fayosim ............................. 27 felbamate .................... 15, 16 felodipine .......................... 14 FEMRING ......................... 29 femynor ............................. 27 fenofibrate ......................... 13 fenofibrate micronized....... 13 fenofibric acid .................... 13 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr ... 2 fentanyl patch 12 mcg/hr ..... 2 fentanyl patch 25 mcg/hr ..... 2 fentanyl patch 50 mcg/hr ..... 2

fentanyl patch 75 mcg/hr .... 2 FERRIPROX ..................... 27 FETZIMA .......................... 17 FETZIMA TITRATION PACK.......................................... 17 FIASP ............................... 24 FIASP FLEXTOUCH ......... 24 FINACEA AER 15% .......... 43 finasteride ......................... 33 FIRMAGON ...................... 10 FIRVANQ ............................ 4 flac .................................... 44 FLAREX ............................ 38 flecainide acetate .............. 12 FLOLIPID .......................... 12 FLOVENT DISKUS ........... 40 FLOVENT HFA ................. 40 fluconazole ......................... 5 fluconazole inj nacl 200 ...... 5 fluconazole inj nacl 400 ...... 5 flucytosine ........................... 5 fludarabine phosphate ........ 9 fludrocortisone acetate ..... 29 flunisolide (nasal) .............. 40 fluocinolone acetonide ...... 42 fluocinolone acetonide (otic).......................................... 44 fluocinolone acetonide oil body .................................. 42 fluocinonide ...................... 42 fluocinonide emulsified base.......................................... 42 fluorometholone (ophth) .... 38 fluorouracil .......................... 9 fluorouracil (topical) .......... 44 fluoxetine cap 10mg .......... 17 fluoxetine cap 20mg .......... 17 fluoxetine cap 40mg .......... 17 fluoxetine hcl ..................... 17 fluoxetine hcl (pmdd) ........ 23 fluphenazine decanoate .... 18 fluphenazine hcl ................ 18 flurandrenolide .................. 42 flurbiprofen .......................... 1 flurbiprofen sodium ........... 38 flutamide ........................... 10 fluticasone propionate . 42, 43 fluticasone propionate (nasal) ............................... 40 fluvastatin sodium cap 20 mg

52

.......................................... 12 fluvastatin sodium cap 40 mg .......................................... 13 fluvastatin sodium tab sr 24 hr 80 mg ............................ 13 fluvoxamine maleate ......... 15 fluvoxamine maleate er ..... 15 FML ................................... 38 FML FORTE ...................... 38 fondaparinux sodium ......... 33 FORTEO ........................... 29 FOSAMAX PLUS D .......... 26 fosamprenavir tab 700 mg ..5 fosaprepitant dimeglumine 31 fosinopril sodium ............... 12 fosinopril sodium & hydrochlorothiazide ........... 11 FOSRENOL ...................... 30 FRAGMIN ......................... 33 FREAMINE HBC 6.9% ...... 36 FREAMINE III ................... 36 frovatriptan succinate ........ 22 fulvestrant ......................... 10 furosemide ........................ 14 furosemide inj .................... 14 furosemide oral soln 8 mg/ml .......................................... 14 FUZEON .............................5 fyavolv ............................... 29 FYCOMPA ........................ 16 G gabapentin ........................ 16 GALAFOLD ....................... 28 galantamine hydrobromide 17 galantamine hydrobromide er ....................................... 17 GAMASTAN S/D ............... 35 GAMMAGARD LIQUID ..... 35 GAMMAGARD S/D ........... 35 GAMMAKED ..................... 35 GAMMAPLEX ................... 35 GAMMAPLEX 10GM/100ML .......................................... 35 GAMUNEX-C .................... 35 GANCICLOVIR INJ 500MG/10ML ......................7 ganciclovir sodium ..............7 GARDASIL 9 ..................... 35 gatifloxacin (ophth) ............ 37 GATTEX............................ 32

GAUZE PADS 2X2 ........... 24 gavilyte-c ........................... 32 gavilyte-g .......................... 32 gavilyte-n/flavor pack ........ 32 GELNIQUE PUMP ............ 33 gemcitabine inj soln ............ 9 gemcitabine inj solr ............. 9 gemfibrozil ........................ 13 generlac ............................ 32 gengraf .............................. 35 GENOTROPIN .................. 30 GENOTROPIN MINIQUICK .......................................... 30 gentak ............................... 37 gentamicin in saline ............ 4 gentamicin sulfate ............... 4 gentamicin sulfate (topical) .......................................... 41 gentamicin sulfate soln (ophth) .............................. 37 GENVOYA .......................... 6 GEODON INJ ................... 18 gianvi tab 3-0.02mg .......... 27 GILENYA CAP 0.5MG ...... 22 GILOTRIF TAB 20MG....... 10 GILOTRIF TAB 30MG....... 10 GILOTRIF TAB 40MG....... 10 GLASSIA .......................... 40 glatiramer acetate 20mg/ml .......................................... 22 glatiramer acetate 40mg/ml .......................................... 22 glatopa .............................. 22 GLEOSTINE ....................... 9 glimepiride ........................ 25 glipizide ............................. 25 glipizide er ......................... 25 glipizide xl ......................... 25 glipizide-metformin 2.5-250 mg ..................................... 25 glipizide-metformin 2.5-500 mg ..................................... 25 glipizide-metformin 5-500mg .......................................... 25 GLUCAGEN HYPOKIT ..... 29 GLUCAGON EMERGENCY KIT .................................... 29 GLYCATE ......................... 31 glycopyrrolate ................... 31 GLYCOPYRROLATE........ 31

glycopyrrolate tab 1mg ..... 31 glycopyrrolate tab 2mg ..... 31 glydo ................................. 43 GLYXAMBI ....................... 25 GOCOVRI ......................... 18 GOLYTELY ....................... 32 GONITRO ......................... 14 GRALISE .......................... 22 GRALISE STARTER ........ 22 granisetron hcl .................. 31 griseofulvin microsize ......... 5 griseofulvin ultramicrosize .. 5 guanfacine er (adhd) ......... 20 H HAEGARDA ..................... 34 hailey 24 fe ....................... 27 HALAVEN ......................... 11 halcinonide ....................... 43 halobetasol propionate ..... 43 HALOBETASOL PROPIONATE .................. 43 HALOG ............................. 43 haloperidol ........................ 18 haloperidol conc 2mg/ml ... 18 haloperidol decanoate ...... 18 haloperidol lactate inj 5mg/ml.......................................... 18 HARVONI ........................... 7 HAVRIX ............................ 35 heather ............................. 27 heparin sod (porcine) in d5w.......................................... 33 heparin sod inj 10000u/ml . 33 heparin sod inj 1000u/ml ... 33 heparin sod inj 20000u/ml . 33 heparin sod inj 5000u/0.5ml.......................................... 33 heparin sod inj 5000u/ml ... 33 HEPARIN SODIUM INJ 5000U/0.5ML .................... 33 HEPARIN SODIUM/NACL 0.45% ............................... 33 hepatamine ....................... 36 HERCEPTIN ....................... 9 HERCEPTIN HYLECTA ..... 9 HETLIOZ .......................... 21 HIBERIX ........................... 35 HORIZANT ....................... 22 HUMALOG ....................... 24 HUMALOG JUNIOR

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KWIKPEN ......................... 24 HUMALOG KWIKPEN ...... 24 HUMALOG MIX 50/50 ...... 24 HUMALOG MIX 50/50 KWIKPEN ......................... 24 HUMALOG MIX 75/25 ...... 24 HUMALOG MIX 75/25 KWIKPEN ......................... 24 HUMATROPE ................... 30 HUMATROPE COMBO PACK ................................ 30 HUMIRA ............................ 34 HUMIRA INJ 10MG/0.2ML 34 HUMIRA KIT 20MG/0.4ML 34 HUMIRA KIT 40MG/0.8ML 34 HUMIRA PEDIATRIC CROHNS DISEASE .......... 34 HUMIRA PEN ................... 34 HUMIRA PEN CD/UC/HS STARTER ......................... 34 HUMIRA PEN INJ CD/UC/HS STARTER ....... 34 HUMIRA PEN INJ PS/UV STARTER ......................... 34 HUMIRA PEN-PS/UV STARTER ......................... 34 HUMULIN 70/30 ................ 24 HUMULIN 70/30 KWIKPEN .......................................... 24 HUMULIN N ...................... 24 HUMULIN N KWIKPEN..... 24 HUMULIN R ...................... 24 HUMULIN R U-500 (CONCENTRATE) ............ 24 HUMULIN R U-500 KWIKPEN ......................... 24 hydralazine hcl .................. 14 hydrochlorothiazide ........... 14 hydrocodone-acetaminophen 10-300mg ............................2 hydrocodone-acetaminophen 5-300mg ..............................2 hydrocodone-acetaminophen 5-325mg ..............................2 hydrocodone-acetaminophen 7.5-300mg ...........................2 hydrocodone-acetaminophen 7.5-325 mg/15ml .................2 hydrocodone-acetaminophen 7.5-325mg ...........................2

hydrocodone-acetaminophen tab 10-325mg ...................... 2 hydrocodone-ibuprofen tab 10-200mg ............................ 2 hydrocodone-ibuprofen tab 5-200mg .............................. 2 hydrocodone-ibuprofen tab 7.5-200 mg .......................... 2 hydrocortisone .................. 29 hydrocortisone (enema) .... 32 hydrocortisone (topical) cream 1% .......................... 43 hydrocortisone (topical) cream 2.5% ....................... 43 hydrocortisone (topical) lotion 2.5% ........................ 43 hydrocortisone (topical) oint 2.5%.................................. 43 hydrocortisone butyrate cream 0.1% ....................... 43 hydrocortisone butyrate cream 0.1% lipo base ....... 43 hydrocortisone butyrate lotion 0.1% ........................ 43 hydrocortisone butyrate oint 0.1%.................................. 43 hydromorphone hcl ............. 2 HYDROMORPHONE HYDROCHLORI ................. 2 hydromorphone tab 12mg er ............................................ 2 hydromorphone tab 16mg er ............................................ 2 hydromorphone tab 8mg er . 2 hydromorphone tabs 32mg er ........................................ 2 hydroxychloroquine sulfate .......................................... 34 hydroxyprogesterone caproate (antineoplastic) ... 10 hydroxyurea ...................... 11 hydroxyzine hcl ................. 39 hydroxyzine hcl inj ............ 39 hydroxyzine pamoate ........ 39 HYSINGLA ER .................... 2 I ibandronate sodium inj ...... 26 ibandronate sodium tabs... 26 IBRANCE ............................ 9 ibu tab 600mg ..................... 1

ibu tab 800mg ..................... 1 ibuprofen ............................. 1 icatibant acetate................ 34 ICLUSIG ........................... 10 IDHIFA ................................ 9 ILEVRO ............................ 38 imatinib mesylate .............. 10 IMBRUVICA ...................... 10 imipenem-cilastatin ............. 4 imipramine hcl .................. 17 imipramine pamoate ......... 17 imiquimod ......................... 44 IMOVAX RABIES (H.D.C.V.).......................................... 35 IMVEXXY MAINTENANCE PACK ................................ 29 IMVEXXY STARTER PACK.......................................... 29 INBRIJA ............................ 18 incassia ............................. 27 INCRELEX ........................ 30 INCRUSE ELLIPTA .......... 38 indapamide ....................... 14 INFANRIX ......................... 35 INFUGEM ........................... 9 INGREZZA ....................... 22 INLYTA ............................. 10 INREBIC ........................... 10 INSULIN LISPRO ............. 24 INSULIN LISPRO KWIKPEN.......................................... 24 INSULIN PEN NEEDLES . 24 INSULIN SAFETY NEEDLES ......................... 24 INSULIN SYRINGES ........ 24 INTELENCE ....................... 5 INTRALIPID 30% .............. 36 INTRALIPID INJ 20% ....... 36 INTRAROSA ..................... 33 INTRON-A INJ 10MU ....... 35 INTRON-A INJ 18MU ....... 35 INTRON-A INJ 25MU ....... 35 INTRON-A INJ 50MU ....... 35 introvale ............................ 27 INVEGA SUST INJ 117 MG/0.75 ML ...................... 18 INVEGA SUST INJ 156MG/ML ........................ 19 INVEGA SUST INJ 234 MG/1.5 ML ........................ 19

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INVEGA SUST INJ 39 MG/0.25 ML ...................... 18 INVEGA SUST INJ 78 MG/0.5 ML ........................ 18 INVEGA TRINZA .............. 19 INVELTYS......................... 38 INVIRASE ...........................5 INVOKAMET TAB 150-1000MG ..................... 25 INVOKAMET TAB 150-500MG ....................... 25 INVOKAMET TAB 50-1000MG ....................... 25 INVOKAMET TAB 50-500MG ......................... 25 INVOKAMET XR TAB 150-1000MG ..................... 25 INVOKAMET XR TAB 150-500MG ....................... 25 INVOKAMET XR TAB 50-1000MG ....................... 25 INVOKAMET XR TAB 50-500MG ......................... 25 INVOKANA TAB 100MG ... 25 INVOKANA TAB 300MG ... 25 IONOSOL-MB/DEXTROSE 5% ..................................... 37 IPOL INACTIVATED IPV .. 35 ipratropium bromide (nasal) .......................................... 39 ipratropium sol inhal .......... 39 ipratropium-albuterol ......... 38 irbesartan .......................... 12 irbesartan-hydrochlorothiazide ........................................ 12 IRESSA ............................. 10 irinotecan hcl ..................... 11 ISENTRESS ........................5 ISENTRESS HD .................6 isibloom ............................. 27 ISOLYTE P ....................... 37 ISOLYTE S ....................... 37 isoniazid ..............................6 isoniazid tabs ......................6 ISORDIL TITRADOSE ...... 14 isosorbide dinitrate ............ 14 isosorbide dinitrate er ........ 14 isosorbide mononitrate ...... 14 isosorbide mononitrate er . 14 isotretinoin......................... 41

isradipine .......................... 14 itraconazole ........................ 5 ivermectin ........................... 4 IXEMPRA KIT ................... 11 IXIARO .............................. 35 J JADENU ........................... 27 JADENU SPRINKLE ......... 27 JAKAFI .............................. 10 jantoven ............................ 33 JANUMET ......................... 25 JANUMET XR TAB 100-1000 ........................... 25 JANUMET XR TAB 50-1000 .......................................... 25 JANUMET XR TAB 50-500MG ......................... 25 JANUVIA ........................... 25 JARDIANCE ..................... 25 jasmiel ............................... 27 JENTADUETO .................. 25 JENTADUETO TAB XR 2.5-1000 MG ..................... 25 JENTADUETO TAB XR 5-1000 MG ........................ 25 jinteli.................................. 29 jolessa tab 0.15-0.03 mg ... 27 jolivette .............................. 27 juleber ............................... 27 JULUCA .............................. 6 junel 1.5/30 ....................... 27 junel 1/20 .......................... 27 junel fe 1.5/30 ................... 27 junel fe 1/20 ...................... 27 junel fe 24 ......................... 27 JUXTAPID ........................ 13 JYNARQUE ...................... 30 K KADCYLA ........................... 9 KADIAN .............................. 2 kaitlib fe ............................. 27 KALETRA TAB 100-25MG .. 6 KALETRA TAB 200-50MG .. 6 KALYDECO ...................... 40 KAPSPARGO SPRINKLE . 13 kariva ................................ 27 kcl 0.075%/d5w/nacl 0.45% .......................................... 37 KCL 0.15%/D5W/LR ......... 37 KCL 0.15%/D5W/NACL

0.225% ............................. 37 kcl 0.15%/d5w/nacl 0.9% .. 37 KCL 0.3%/D5W/LR ........... 37 kcl 0.3%/d5w/nacl 0.45% .. 37 KCL 0.3%/D5W/NACL 0.9%.......................................... 37 kcl/d5w/nacl inj .15/.45% .. 37 kcl/d5w/nacl inj 0.22%/0.45%.......................................... 37 kcl/nacl inj 0.15%-0.9% ..... 37 kcl0.15%/d5w/nacl0.2% .... 37 kelnor 1/35 ........................ 27 kelnor 1/50 ........................ 27 ketoconazole ...................... 5 ketoconazole (topical) ....... 41 ketoconazole shampoo ..... 42 ketodan ............................. 41 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 38 KEVEYIS .......................... 14 KEYTRUDA ........................ 9 KHAPZORY ...................... 11 KINRIX .............................. 35 kionex sus 15gm/60ml ...... 27 KISQALI .............................. 9 KISQALI FEMARA 200 DOSE ................................. 9 KISQALI FEMARA 400 DOSE ................................. 9 KISQALI FEMARA 600 DOSE ................................. 9 klor-con 10 ........................ 36 klor-con 8 .......................... 36 klor-con m10 ..................... 36 klor-con m15 ..................... 36 klor-con m20 ..................... 36 klor-con pak 20meq .......... 36 klor-con spr cap 10meq .... 36 klor-con spr cap 8meq ...... 36 KOMBIGLYZE XR 2.5-1000MG ...................... 25 KOMBIGLYZE XR 5-1000MG ......................... 25 KOMBIGLYZE XR 5-500MG.......................................... 25 KORLYM .......................... 30 KRISTALOSE ................... 32 kurvelo .............................. 27 KUVAN ............................. 28

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L labetalol hcl ....................... 13 LACRISERT ...................... 38 lactated ringer's ................. 37 lactulose ............................ 32 lactulose (encephalopathy) .......................................... 32 LAMICTAL ODT ................ 16 LAMICTAL XR .................. 16 lamivudine ...........................6 lamivudine (hbv) ..................7 lamivudine-zidovudine ........6 lamotrigine ........................ 16 LANOXIN PEDIATRIC INJ 14 LANOXIN TABS 62.5MCG 14 lansoprazole ...................... 32 lanthanum chew tab .......... 30 larin 1.5/30 ........................ 27 larin 1/20 ........................... 27 larin fe 1.5/30 .................... 27 larin fe 1/20 ....................... 27 larissia tab ......................... 27 LASTACAFT ..................... 38 latanoprost ........................ 38 LATUDA ............................ 19 layolis fe chw ..................... 27 LAZANDA ...........................3 leena tab ........................... 27 leflunomide ........................ 34 LENVIMA 10 MG DAILY DOSE ................................ 10 LENVIMA 12MG DAILY DOSE ................................ 10 LENVIMA 14 MG DAILY DOSE ................................ 10 LENVIMA 18 MG DAILY DOSE ................................ 11 LENVIMA 20 MG DAILY DOSE ................................ 11 LENVIMA 24 MG DAILY DOSE ................................ 11 LENVIMA 4 MG DAILY DOSE ................................ 10 LENVIMA 8 MG DAILY DOSE ................................ 10 lessina ............................... 27 letrozole ............................ 10 leucovorin calcium ............ 11 LEUKERAN .........................9 LEUKINE........................... 34

leuprolide inj 1mg/0.2 ........ 10 levalbuterol hcl .................. 39 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 39 levalbuterol tartrate hfa ..... 39 LEVEMIR .......................... 24 LEVEMIR FLEXTOUCH ... 24 levetiracetam .................... 16 levetiracetam in sodium chloride ............................. 16 levetiracetam oral soln 100 mg/ml ................................ 16 levobunolol hcl .................. 38 levocarnitine (metabolic modifiers) .......................... 29 levocetirizine soln 2.5mg/5ml .......................................... 39 levocetirizine tab 5 mg ...... 39 levofloxacin ......................... 8 levofloxacin (ophth) ........... 37 levofloxacin in d5w .............. 8 levoleucovorin calcium ...... 11 levoleucovorin calcium 50mg .......................................... 11 levonest ............................ 27 levonor/ethi tab ................. 27 levonorgestrel & eth estradiol .......................................... 27 levonorgestrel-ethinyl estradiol (91-day) .............. 27 levonorgestrel-ethinyl estradiol (continuous)........ 27 levora 0.15/30-28 .............. 27 levo-t ................................. 30 levothyroxine sodium ........ 30 levoxyl ............................... 30 LEXETTE .......................... 43 LEXIVA ............................... 6 LIBTAYO ............................. 9 lidocaine ............................ 43 lidocaine hcl ...................... 43 lidocaine hcl (local anesth.) . 4 lidocaine hcl (mouth-throat) .......................................... 44 lidocaine inj 0.5% ................ 4 lidocaine inj 1% ................... 4 lidocaine inj 1.5% preservative free (pf) ........... 4 lidocaine inj 2% preservative free (pf) ............................... 4

lidocaine inj 4% preservative free (pf) ............................... 4 lidocaine-prilocaine ........... 43 linezolid in sodium chloride . 4 linezolid inj .......................... 4 linezolid susp ...................... 4 linezolid tab 600mg ............. 4 LINZESS ........................... 32 liothyronine sodium ........... 30 lisinopril ............................. 12 lisinopril & hydrochlorothiazide ........... 11 lithium carbonate .............. 22 LITHIUM SOLN 8MEQ/5ML.......................................... 22 LIVALO ............................. 13 LO LOESTRIN FE ............ 28 LOKELMA ......................... 27 LONHALA MAGNAIR REFILL KIT ....................... 39 LONHALA MAGNAIR STARTER KIT .................. 39 LONSURF ........................ 11 loperamide hcl .................. 32 lopinavir-ritonavir ................ 6 lorazepam ......................... 15 lorazepam intensol ............ 15 LORBRENA ...................... 11 lorcet hd tab 10-325mg ....... 3 lorcet plus tab 7.5-325 ........ 3 lorcet tab 5-325mg .............. 3 loryna ................................ 28 losartan potassium ............ 12 losartan-hydrochlorothiazide.......................................... 12 LOTEMAX ........................ 38 LOTEMAX SM .................. 38 loteprednol etabonate ....... 38 lovastatin .......................... 13 low-ogestrel ...................... 28 loxapine succinate ............ 19 LUCEMYRA ...................... 23 luliconazole ....................... 41 LUMIGAN ......................... 38 LUMIZYME ....................... 29 LUPANETA PACK ............ 28 LUPRON DEPOT (1-MONTH) ....................... 10 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 10

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LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 10 LUPRON DEPOT INJ 30MG (4-MONTH) ....................... 10 LUPRON DEPOT-PED (1-MONTH ........................ 30 LUPRON DEPOT-PED (3-MONTH ........................ 30 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 30 LUPRON DEP-PED INJ 7.5MG ............................... 30 lutera ................................. 28 LYNPARZA .........................9 LYRICA CR ....................... 22 LYSODREN ...................... 10 lyza ................................... 28 M magnesium sulfate ............ 36 MAGNESIUM SULFATE ... 36 MAGNESIUM SULFATE IN D5W .................................. 36 magnesium sulfate in dextrose ............................ 36 magnesium sulfate inj 50% .......................................... 36 malathion .......................... 44 maprotiline hcl ................... 17 marlissa............................. 28 MARPLAN ......................... 17 MATULANE ...................... 11 matzim la........................... 14 MAVYRET ...........................7 MAXIDEX .......................... 38 MAXIPIME IV ......................7 meclizine hcl ..................... 31 MEDROL TAB 2MG .......... 29 medroxyprogesterone acetate .............................. 30 medroxyprogesterone acetate (contraceptive) ..... 28 mefloquine hcl .....................5 megestrol ac sus 40mg/ml 10 megestrol ac tab 20mg ..... 10 megestrol ac tab 40mg ..... 10 megestrol sus 625mg/5ml . 10 MEKINIST ......................... 11 MEKTOVI .......................... 11 melodetta 24 fe ................. 28 meloxicam tabs ...................1

memantine hcl cp24 .......... 17 memantine soln ................ 17 memantine tabs ................ 17 MENACTRA ...................... 35 MENOSTAR ..................... 29 MENTAX ........................... 41 MENVEO .......................... 35 mercaptopurine ................... 9 meropenem ......................... 4 MEROPENEM/SODIUM CHLORIDE ......................... 4 mesalamine ...................... 32 mesalamine enema .......... 32 mesalamine w/ cleanser ... 32 MESNEX ........................... 11 metadate er tab 20mg ....... 20 metformin er ...................... 25 metformin hcl .................... 26 methadone hcl .................... 3 methadone hcl 10mg .......... 3 methadone hcl 5mg ............ 3 methadone hcl intensol ....... 3 methazolamide ................. 14 methenamine hippurate ...... 4 methergine ........................ 30 methimazole ..................... 30 methotrexate sodium inj soln ............................................ 9 methotrexate sodium inj solr ............................................ 9 methotrexate sodium tabs . 34 methoxsalen rapid ............ 42 methscopolamine bromide 31 methylergonovine maleate 30 methylphenidate hcl .... 20, 21 methylphenidate hcl er ...... 21 methylphenidate hcl tbcr 10 mg ..................................... 21 methylphenidate hcl tbcr 20mg ................................. 21 METHYLPHENIDATE HCL TBCR 72MG ..................... 21 methylpr ss inj ................... 29 methylpred pak 4mg ......... 29 methylpred tab 16mg ........ 29 methylpred tab 32mg ........ 29 methylpred tab 4mg .......... 29 methylpred tab 8mg .......... 29 methylprednisolone acetate .......................................... 29

metoclopramide hcl ........... 31 metoclopramide hcl inj ...... 31 METOCLOPRAMIDE ODT.......................................... 31 metolazone ....................... 14 metoprolol & hctz tab 100-25mg ......................... 13 metoprolol & hctz tab 100-50mg ......................... 13 metoprolol & hctz tab 50-25mg ........................... 13 metoprolol succinate ......... 13 metoprolol tartrate............. 13 metronidazole ..................... 4 METRONIDAZOLE ............. 4 metronidazole (topical) ..... 44 metronidazole in nacl .......... 4 metronidazole vaginal ....... 33 MIACALCIN INJ 200U/ML 30 mibelas 24 fe .................... 28 miconazole 3 sup 200mg .. 33 MICORT-HC ..................... 43 microgestin 1.5/30 ............ 28 microgestin 1/20 ............... 28 microgestin fe 1.5/30 ........ 28 microgestin fe 1/20 ........... 28 midodrine hcl .................... 14 miglitol .............................. 26 miglustat ........................... 29 mili .................................... 28 MILLIPRED ....................... 29 minitran ............................. 14 minocycline hcl ................... 8 minocycline tab 135mg er ... 8 minocycline tab 45mg er ..... 8 minocycline tab 90mg er ..... 8 minoxidil ............................ 14 mirtazapine ....................... 17 misoprostol ....................... 32 MITIGARE .......................... 1 M-M-R II ............................ 35 M-NATAL PLUS................ 37 modafinil ........................... 23 moexipril hcl ...................... 12 molindone hcl ................... 19 mometasone furoate ......... 43 mometasone furoate (nasal).......................................... 40 mondoxyne nl cap 100mg ... 8 mondoxyne nl cap 75mg ..... 8

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mono-linyah tab 0.25-35 ... 28 montelukast sodium .......... 39 MORPHABOND ER ............3 morphine sul inj 1mg/ml ......3 morphine sulfate .................3 MORPHINE SULFATE .......3 morphine sulfate beads .......3 morphine sulfate ext-rel tab.3 morphine sulfate oral soln 100mg/5ml ..........................3 morphine sulfate oral soln 10mg/5ml ............................3 morphine sulfate oral soln 20mg/5ml ............................3 MOTEGRITY ..................... 32 MOVANTIK ....................... 32 MOXEZA ........................... 37 moxifloxacin hcl ...................8 MOXIFLOXACIN HCL .........8 moxifloxacin hcl (ophth) .... 37 moxifloxacin hcl in sodium chloride ...............................8 MOZOBIL .......................... 34 MULPLETA ....................... 34 MULTAQ ........................... 12 mupirocin .......................... 41 MYCAMINE .........................5 mycophenolate mofetil ...... 35 mycophenolate sodium tbec .......................................... 35 MYDAYIS CAP 12.5MG .... 21 MYDAYIS CAP 25MG ....... 21 MYDAYIS CAP 37.5MG .... 21 MYDAYIS CAP 50MG ....... 21 myorisan ........................... 41 MYRBETRIQ ..................... 33 N nabumetone ........................1 nadolol .............................. 13 NAFCILLIN IN DEXTROSE 8 nafcillin sodium ...................8 NAFCILLIN SODIUM FOR INJ 10GM ............................8 naftifine hcl ........................ 42 NAFTIN ............................. 42 NAGLAZYME .................... 29 nalbuphine hcl .....................1 naloxone inj 0.4mg/ml ....... 23 naloxone inj 1mg/ml .......... 23 naltrexone hcl .................... 23

NAMZARIC ....................... 17 naproxen ............................. 1 naproxen dr ......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 22 NARCAN ........................... 23 NATACYN ......................... 37 NATAZIA ........................... 28 nateglinide ........................ 26 NATPARA ......................... 30 NATROBA ........................ 44 NAYZILAM ........................ 16 NEBUPENT ........................ 4 necon 0.5/35-28 ................ 28 nefazodone hcl ................. 17 neomycin sulfate ................. 4 neomycin/polymyxin b gu .. 44 neomycin-bacitracin zn-polymyxin ..................... 37 neomycin-polymy-dexameth .......................................... 37 neomycin-polymyxin-gramicidin ..................................... 37 neomycin-polymyxin-hc (ophth) .............................. 37 neomycin-polymyxin-hc (otic) .......................................... 44 NEPHRAMINE .................. 36 NERLYNX ......................... 11 neuac gel 1.2-5% .............. 41 NEUPRO .......................... 18 nevirapine susp 50 mg/5ml . 6 nevirapine tab 100mg er ..... 6 nevirapine tab 200mg ......... 6 nevirapine tab 400mg er ..... 6 NEXAVAR ......................... 11 NEXIUM GRA 10MG DR .. 32 NEXIUM GRA 2.5MG DR . 32 NEXIUM GRA 20MG DR .. 32 NEXIUM GRA 40MG DR .. 32 NEXIUM GRA 5MG DR .... 32 niacin (antihyperlipidemic) 13 niacin er (antihyperlipidemic) .......................................... 13 niacor ................................ 13 nicardipine hcl ................... 14 NICOTROL INHALER ....... 23 NICOTROL NS ................. 23 nifedipine .......................... 14 nifedipine er ...................... 14

nikki .................................. 28 nilutamide ......................... 10 nimodipine ........................ 14 NINLARO ............................ 9 NIPENT .............................. 9 nisoldipine ......................... 14 nitisinone .......................... 29 NITRO-BID ....................... 14 NITRO-DUR ..................... 14 nitrofurantoin ....................... 4 nitrofurantoin macrocrystal . 4 nitrofurantoin monohyd macro .................................. 4 nitroglycerin ................ 14, 15 nitroglycerin td patch ......... 15 NITYR ............................... 29 nizatidine .......................... 31 nolix .................................. 43 nora-be tab ....................... 28 NORDITROPIN FLEXPRO.......................................... 30 nore/eth/fer chw 0.4mg-35 28 noreth/ethin chw fe ........... 28 norethin acet & estrad-fe .. 28 norethindrone (contraceptive) .................. 28 norethindrone acet & eth estra .................................. 28 norethindrone acetate ....... 30 norethindrone acetate-ethinyl estradiol ............................ 29 norgest/ethi tab 0.25/35 .... 28 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 28 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 28 NORITATE ....................... 44 NORMOSOL-M IN D5W ... 37 NORMOSOL-R ................. 37 NORPACE CR .................. 12 NORTHERA ..................... 14 nortrel 0.5/35 (28) ............. 28 nortrel 1/35 ....................... 28 nortrel 7/7/7 ...................... 28 nortriptyline hcl ................. 17 NORVIR PACK ................... 6

58

NORVIR SOLN ...................6 NOVAREL ......................... 30 NOVOLIN 70/30 ................ 24 NOVOLIN 70/30 FLEXPEN .......................................... 24 NOVOLIN 70/30 FLEXPEN RELION............................. 24 NOVOLIN 70/30 RELION.. 24 NOVOLIN N ...................... 24 NOVOLIN N RELION ........ 24 NOVOLIN R ...................... 24 NOVOLIN R RELION ........ 24 NOVOLOG ........................ 24 NOVOLOG 70/30 FLEXPEN .......................................... 24 NOVOLOG FLEXPEN ...... 24 NOVOLOG MIX 70/30 ...... 24 NOVOLOG PENFILL ........ 24 NOXAFIL.............................5 NUBEQA ........................... 10 NUCALA ........................... 40 NUCYNTA ...........................3 NUCYNTA ER .....................3 NUEDEXTA ...................... 22 NULOJIX ........................... 35 NULYTELY/FLAVOR PACKS .............................. 32 NUPLAZID CAPS ............. 19 NUPLAZID TABS 10MG ... 19 NUTRILIPID INJ 20% ....... 36 NUTROPIN AQ NUSPIN 10 .......................................... 30 NUTROPIN AQ NUSPIN 20 .......................................... 30 NUTROPIN AQ NUSPIN 5 30 NUVARING ....................... 28 nyamyc ............................. 42 NYMALIZE ........................ 14 nystatin ...............................5 nystatin (mouth-throat) ...... 44 nystatin (topical) ................ 42 nystatin pow 100000 ......... 42 nystop ............................... 42 O ocella tab 3-0.03mg .......... 28 OCTAGAM ........................ 35 octreotide acetate ............. 30 octreotide inj 100mcg/ml ... 30 ODEFSEY ...........................6 ODOMZO ............................9

OFEV ................................ 40 ofloxacin (ophth) ............... 37 ofloxacin (otic) ................... 44 olanzapine ........................ 19 olanzapine odt .................. 19 olmesartan medoxomil ...... 12 olmesartan medoxomil-amlodipine-hydrochlorothiazide .................... 12 olmesartan medoxomil-hydrochlorothiazide ...................................... 12 olopatadine hcl (nasal) ...... 39 olopatadine hcl 0.1% ........ 38 olopatadine hcl 0.2% ........ 38 OMECLAMOX-PAK .......... 32 omega-3-acid ethyl esters . 13 omeprazole cap 10mg ...... 32 omeprazole cap 20mg ...... 32 omeprazole cap 40mg ...... 32 OMNARIS ......................... 40 OMNITROPE 10MG ......... 30 OMNITROPE 5.8MG ........ 30 OMNITROPE 5MG ........... 30 ondansetron hcl ................ 31 ondansetron hcl inj ............ 31 ondansetron hcl oral soln .. 31 ondansetron odt ................ 31 ONEXTON ........................ 41 ONGLYZA ......................... 26 ONIVYDE .......................... 11 ONZETRA XSAIL ............. 22 OPSUMIT ......................... 15 ORALAIR .......................... 35 ORAVIG ............................ 44 ORBACTIV ......................... 4 ORENITRAM TAB 0.125MG .......................................... 15 ORENITRAM TAB 0.25MG .......................................... 15 ORENITRAM TAB 1MG .... 15 ORENITRAM TAB 2.5MG . 15 ORENITRAM TAB 5MG .... 15 ORFADIN .......................... 29 ORILISSA ......................... 28 ORKAMBI ......................... 40 orsythia ............................. 28 oseltamivir phosphate ......... 7 OSMOLEX ER .................. 18 OSMOPREP ..................... 32

OSPHENA ........................ 30 OTOVEL ........................... 44 oxacillin sodium .................. 8 oxaliplatin inj 100mg ......... 11 oxaliplatin inj 100mg/20ml 11 oxaliplatin inj 50mg ........... 11 oxaliplatin inj 50mg/10ml .. 11 oxandrolone ...................... 23 oxaprozin ............................ 1 OXAYDO ............................ 3 oxcarbazepine .................. 16 OXISTAT .......................... 42 OXTELLAR XR ................. 16 oxybutynin chloride ........... 33 oxycodone hcl ..................... 3 oxycodone w/ acetaminophen 10-325mg .. 3 oxycodone w/ acetaminophen 2.5-325mg . 3 oxycodone w/ acetaminophen 5-325mg .... 3 oxycodone w/ acetaminophen 7.5-325mg . 3 oxycodone-aspirin............... 3 oxycodone-ibuprofen .......... 3 OXYCONTIN ...................... 3 oxymorphone tabs .............. 3 OXYTROL ........................ 33 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 24 OZEMPIC INJ 1MG/DOSE.......................................... 24 P pacerone ........................... 12 paclitaxel ............................. 9 paliperidone ...................... 19 palonosetron hcl ............... 31 PALONOSETRON HYDROCHLORID 0.25MG/2ML ..................... 31 PALYNZIQ ........................ 29 pamidronate disodium ...... 26 PAMIDRONATE DISODIUM.......................................... 26 pamidronate inj 30mg ....... 26 pamidronate inj 90mg ....... 26 PANCREAZE .................... 32 PANDEL ........................... 43 PANRETIN ....................... 44 pantoprazole sodium ........ 32

59

PANZYGA ......................... 35 paricalcitol ......................... 37 paroex sol 0.12% .............. 44 paromomycin sulfate ...........4 paroxetine er tab ............... 17 paroxetine hcl tabs ............ 17 paroxetine mesylate (vasomotor) ....................... 22 PASER D/R .........................6 PAXIL ................................ 17 PAZEO .............................. 38 PEDIARIX ......................... 35 PEDVAX HIB .................... 35 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 32 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 32 PEGANONE ...................... 16 PEGASYS ...........................7 PEGASYS PROCLICK .......7 PENICILLIN G POT IN DEXTROSE 1MU ................8 PENICILLIN G POT IN DEXTROSE 2MU ................8 PENICILLIN G POT IN DEXTROSE 3MU ................8 PENICILLIN G PROCAINE .8 penicillin g sodium ...............8 penicillin v potassium ..........8 penicilln gk inj 20mu ............8 penicilln gk inj 5mu ..............8 PENNSAID ........................ 44 PENTACEL ....................... 35 PENTAM 300 ......................4 pentamidine isethionate inh 4 pentamidine isethionate inj..4 PENTASA ......................... 32 pentoxifylline ..................... 34 PERFOROMIST ................ 39 perindopril erbumine ......... 12 periogard ........................... 44 PERJETA ............................9 permethrin cre 5% ............. 44 perphenazine .................... 19 PERSERIS ........................ 19 PERTZYE ......................... 32 PEXEVA............................ 17 pfizerpen-g inj 20mu ...........8 pfizerpen-g inj 5mu .............8

phenadoz .......................... 31 phenelzine sulfate ............. 17 phenobarbital .................... 16 phenobarbital sodium........ 16 PHENOBARBITAL SODIUM .......................................... 16 phenoxybenzamine hcl ..... 14 PHENYTEK ...................... 16 phenytoin .......................... 16 phenytoin sodium extended .......................................... 16 phenytoin sodium inj 50mg/ml ............................ 16 philith ................................ 28 PHOSLYRA ...................... 30 PHOSPHOLINE IODIDE ... 38 PICATO ............................ 44 PIFELTRO .......................... 6 pilocarpine hcl ................... 38 pilocarpine hcl (oral).......... 44 pimozide ........................... 19 pimtrea .............................. 28 pindolol ............................. 13 pioglitazone hcl ................. 26 pioglitazone hcl-glimepiride .......................................... 26 pioglitazone hcl-metformin hcl ..................................... 26 piper/tazoba inj 12-1.5gm ... 8 piper/tazoba inj 2-0.25gm ... 8 piper/tazoba inj 3-0.375gm . 8 piper/tazoba inj 36-4.5gm ... 8 piper/tazoba inj 4-0.5gm ..... 8 PIQRAY 200MG DAILY DOSE ................................ 11 PIQRAY 250MG DAILY DOSE ................................ 11 PIQRAY 300MG DAILY DOSE ................................ 11 pirmella 1/35 ..................... 28 piroxicam ............................ 1 PLASMA-LYTE A .............. 37 PLASMA-LYTE-148 .......... 37 plenamine ......................... 36 PLENVU ........................... 32 PNV FOLIC ACID + IRON MUL .................................. 37 podofilox ........................... 44 polymyxin b sulfate ............. 4 polymyxin b-trimethoprim .. 37

POMALYST ...................... 10 portia-28 ........................... 28 posaconazole ..................... 5 pot chloride inj 2meq/ml .... 37 potassium chloride ...... 36, 37 POTASSIUM CHLORIDE . 37 potassium chloride 0.3%/d 37 potassium chloride caps er.......................................... 36 potassium chloride in nacl 37 potassium chloride microencapsulated crystals er ...................................... 36 potassium citrate (alkalinizer) er tabs ............................... 33 POTELIGEO ....................... 9 PRADAXA ........................ 33 PRALUENT ...................... 13 pramipexole er .................. 18 pramipexole tab 0.125mg . 18 pramipexole tab 0.25mg ... 18 pramipexole tab 0.5mg ..... 18 pramipexole tab 0.75mg ... 18 pramipexole tab 1.5mg ..... 18 pramipexole tab 1mg ........ 18 prasugrel hcl ..................... 34 pravastatin sodium ............ 13 praziquantel ........................ 4 prazosin hcl ...................... 12 PRED MILD ...................... 38 pred sod pho sol 5mg/5ml 29 PRED-G ............................ 37 PRED-G S.O.P. ................ 37 prednicarbate .................... 43 prednisolone acetate (ophth).......................................... 38 prednisolone sodium phosphate ......................... 29 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 38 prednisolone sol 15mg/5ml.......................................... 29 prednisolone sol 25mg/5ml.......................................... 29 PREDNISONE CON 5MG/ML ............................ 29 prednisone pak 10mg ....... 29 prednisone pak 5mg ......... 29 prednisone sol 5mg/5ml .... 29 prednisone tab 10mg ........ 29

60

prednisone tab 1mg .......... 29 prednisone tab 2.5mg ....... 29 prednisone tab 20mg ........ 29 prednisone tab 50mg ........ 29 prednisone tab 5mg .......... 29 pregabalin ......................... 16 PREGNYL W/DILUENT BENZYL ............................ 30 PREMARIN CREAM ......... 29 PREMARIN INJ ................. 29 PREMASOL 10% .............. 36 PRENATAL ....................... 37 PRENATAL PLUS ............. 37 PRENATAL PLUS LOW IRON ................................. 37 PREPOPIK ........................ 32 prevalite ............................ 13 previfem ............................ 28 PREVYMIS INJ ...................7 PREVYMIS TABS ...............7 PREZCOBIX .......................6 PREZISTA ..........................6 PRIFTIN ..............................6 PRILOSEC ........................ 32 primaquine phosphate ........5 PRIMAQUINE PHOSPHATE ............................................5 primidone .......................... 16 PRIVIGEN ......................... 35 PROAIR HFA .................... 39 PROAIR RESPICLICK ...... 39 probenecid ..........................1 PROCALAMINE ................ 36 prochlorperazine inj ........... 31 prochlorperazine maleate.. 31 prochlorperazine supp ...... 31 PROCRIT .......................... 34 procto-med hc ................... 44 procto-pak ......................... 44 proctosol hc 2.5 % ............ 44 proctozone-hc ................... 44 PROCYSBI ....................... 29 progesterone micronized... 30 PROGLYCEM SUS 50MG/ML .......................... 29 PROGRAF ........................ 35 PROLASTIN-C .................. 40 PROLENSA ...................... 38 PROLIA ............................. 30 PROMACTA ...................... 34

promethazine hcl .............. 31 promethazine hcl inj .......... 31 promethegan ..................... 31 propafenone hcl ................ 12 propafenone hcl 12hr ........ 12 proparacaine hcl ............... 38 propranolol & hydrochlorothiazide ........... 13 propranolol hcl er .............. 13 propranolol inj 1mg/ml....... 13 propranolol oral sol ........... 13 propranolol tab .................. 13 propylthiouracil .................. 30 PROQUAD ........................ 35 PROSOL ........................... 36 PROTONIX ....................... 33 protriptyline hcl .................. 17 PROVENTIL HFA ............. 39 PULMICORT FLEXHALER .......................................... 40 PULMOZYME ................... 40 PURIXAN ............................ 9 pyrazinamide ...................... 6 pyridostigmine bromide ..... 22 pyridostigmine tab 60mg ... 22 Q QBRELIS .......................... 12 QNASL .............................. 40 QNASL CHILDRENS ........ 40 QTERN ............................. 26 QUADRACEL ................... 35 quetiapine fumarate .......... 19 QUILLICHEW ER ............. 21 QUILLIVANT XR ............... 21 quinapril hcl ....................... 12 quinapril-hydrochlorothiazide .......................................... 11 quinidine sulfate ................ 12 quinine sulfate ..................... 5 QVAR REDIHALER .......... 40 R RABAVERT ...................... 35 rabeprazole sodium .......... 33 raloxifene hcl ..................... 30 ramipril .............................. 12 ranitidine hcl ...................... 31 ranitidine hcl inj ................. 31 ranolazine ......................... 14 rasagiline mesylate ........... 18 RAVICTI ............................ 29

RAYALDEE ...................... 37 reclipsen ........................... 28 RECOMBIVAX HB ............ 35 RECTIV ............................ 44 REGRANEX ..................... 44 RELENZA DISKHALER ...... 7 RELEXXII ......................... 21 RELISTOR ........................ 32 REMICADE ....................... 34 RENFLEXIS ...................... 34 repaglinide ........................ 26 repaglinide-metformin hcl . 26 RESCRIPTOR .................... 6 RESTASIS ........................ 38 RESTASIS MULTIDOSE .. 38 RETACRIT ........................ 34 RETIN-A MICRO .............. 41 RETIN-A MICRO PUMP ... 41 REVLIMID ......................... 10 REXULTI .......................... 19 REYATAZ ........................... 6 RHOPRESSA ................... 38 ribavirin 200mg ................... 7 rifabutin ............................... 6 RIFAMATE ......................... 6 rifampin ............................... 6 RIFATER ............................ 6 riluzole .............................. 22 rimantadine hydrochloride .. 7 RIOMET ............................ 26 risedronate sodium ........... 26 RISPERDAL INJ 12.5MG . 19 RISPERDAL INJ 25MG .... 19 RISPERDAL INJ 37.5MG . 19 RISPERDAL INJ 50MG .... 19 risperidone ........................ 19 risperidone odt .................. 19 ritonavir ............................... 6 RITUXAN ............................ 9 RITUXAN HYCELA ............. 9 rivastigmine tartrate .......... 17 rivastigmine td patch 24hr 13.3 mg/24hr .................... 17 rivastigmine td patch 24hr 4.6 mg/24hr ...................... 17 rivastigmine td patch 24hr 9.5 mg/24hr ...................... 17 rivelsa ............................... 28 rizatriptan benzoate .......... 22 rizatriptan benzoate odt .... 22

61

ROCKLATAN .................... 38 ropinirole er ....................... 18 ropinirole tab 0.25mg ........ 18 ropinirole tab 0.5mg .......... 18 ropinirole tab 1mg ............. 18 ropinirole tab 2mg ............. 18 ropinirole tab 3mg ............. 18 ropinirole tab 4mg ............. 18 ropinirole tab 5mg ............. 18 rosadan cre 0.75% ............ 44 rosuvastatin calcium ......... 13 ROTARIX .......................... 35 ROTATEQ ......................... 35 roweepra ........................... 16 roweepra xr ....................... 16 ROZLYTREK .................... 11 RUBRACA ..........................9 RUCONEST ...................... 34 RYDAPT ........................... 11 RYTARY ........................... 18 S SAIZEN ............................. 30 SAIZENPREP RECONSTITUTION .......... 30 SAMSCA ........................... 30 SANCUSO ........................ 31 SANDIMMUNE SOLN ....... 35 SANDOSTATIN LAR DEPOT ............................. 30 SANTYL ............................ 44 SAPHRIS .......................... 19 SAVAYSA ......................... 33 SAVELLA .......................... 22 SAVELLA TITRATION PACK ................................ 22 scopolamine ...................... 31 SEEBRI NEOHALER ........ 39 SEGLUROMET TAB 2.5-1000MG ...................... 26 SEGLUROMET TAB 2.5-500MG ........................ 26 SEGLUROMET TAB 7.5-1000MG ...................... 26 SEGLUROMET TAB 7.5-500MG ........................ 26 selegiline hcl ..................... 18 selenium sulfide ................ 42 SELZENTRY .......................6 SEMPREX-D ..................... 39 SEREVENT DISKUS ........ 39

SERNIVO .......................... 43 SEROSTIM ....................... 30 sertraline hcl ..................... 17 setlakin tab ........................ 28 sevelamer carbonate ........ 30 sevelamer tab 400mg ....... 30 sevelamer tab 800mg ....... 30 SFROWASA ..................... 32 sharobel ............................ 28 SHINGRIX ........................ 35 SIGNIFOR ........................ 30 SIGNIFOR LAR ................ 30 SIKLOS ............................. 11 sildenafil citrate (pulmonary hypertension) .................... 15 sildenafil citrate tab 20 mg (pulmonary hypertension) . 15 SILENOR .......................... 21 silodosin ............................ 33 silver sulfadiazine ............. 41 SIMBRINZA SUS 1-0.2% .. 38 simvastatin ........................ 13 sirolimus ............................ 35 SIRTURO ............................ 6 SIVEXTRO .......................... 4 SKLICE ............................. 44 SLYND .............................. 28 SMOFLIPID ...................... 36 sodium chlor sol 0.9% irr ... 44 sodium chloride ........... 36, 37 sodium chloride 0.45%...... 37 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 36 sodium phenylbutyrate ...... 29 sodium polystyrene sulfonate powder .............................. 27 sodium polystyrene sulfonate susp .................................. 27 SOLIQUA 100/33 .............. 24 SOLOSEC .......................... 4 SOLTAMOX ...................... 10 SOLU-CORTEF 1000MG . 29 SOLU-CORTEF 100MG ... 29 SOLU-CORTEF 250MG ... 29 SOLU-CORTEF 500MG ... 29 SOLU-MEDROL ............... 29 SOMATULINE DEPOT ..... 30 SOMAVERT ...................... 30 sorine ................................ 12 sotalol hcl .......................... 12

sotalol hcl (afib/afl) ............ 12 SOTYLIZE ........................ 12 SPIRIVA HANDIHALER ... 39 SPIRIVA RESPIMAT 1.25MCG/ACT .................. 39 SPIRIVA RESPIMAT 2.5MCG/ACT .................... 39 SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK) .. 39 spironolactone .................. 12 spironolactone & hydrochlorothiazide ........... 14 sprintec 28 ........................ 28 SPRITAM .......................... 16 SPRYCEL ......................... 11 sps susp 15gm/60ml ......... 27 sronyx ............................... 28 ssd .................................... 41 stavudine ............................ 6 STEGLATRO .................... 26 STEGLUJAN .................... 26 STELARA ......................... 35 STIMATE .......................... 30 STIOLTO RESPIMAT ....... 38 STIOLTO RESPIMAT (INSTITUTIONAL PACK) .. 38 STIVARGA ....................... 11 streptomycin sulfate ............ 4 STRIBILD ........................... 6 STRIVERDI RESPIMAT ... 39 SUBSYS SPRAY 100MCG . 3 SUBSYS SPRAY 1200MCG............................................ 4 SUBSYS SPRAY 1600MCG............................................ 4 SUBSYS SPRAY 200MCG . 3 SUBSYS SPRAY 400MCG . 4 SUBSYS SPRAY 600MCG . 4 SUBSYS SPRAY 800MCG . 4 subvenite starter kit ........... 16 subvenite tab .................... 16 SUCRAID ......................... 32 sucralfate .......................... 32 sulfacetamide sodium (acne).......................................... 41 sulfacetamide sodium (ophth) .............................. 37 sulfacetamide sod-prednisolone .............. 37

62

SULFADIAZINE ..................4 sulfamethoxazole-trimethop ds ........................................5 sulfamethoxazole-trimethoprim inj ....................................5 sulfamethoxazole-trimethoprim susp ................................5 sulfamethoxazole-trimethoprim tab 400-80mg ..................5 SULFAMYLON .................. 41 sulfasalazine dr ................. 32 sulfasalazine ir .................. 32 sulindac ...............................1 sumatriptan inj 4mg/0.5ml . 22 sumatriptan inj 6mg/0.5ml . 22 sumatriptan succinate ....... 22 sumatriptan-naproxen sodium .............................. 22 SUPRAX .............................7 SUPREP BOWEL PREP KIT .......................................... 32 SUSTOL............................ 31 SUTENT............................ 11 syeda ................................ 28 SYLATRON ....................... 11 SYMBICORT ..................... 40 SYMDEKO ........................ 40 SYMFI .................................6 SYMFI LO ...........................6 SYMJEPI........................... 40 SYMLINPEN 120 .............. 24 SYMLINPEN 60 ................ 24 SYMPAZAN ...................... 16 SYMPROIC ....................... 32 SYMTUZA ...........................6 SYNAREL ......................... 28 SYNDROS ........................ 31 SYNERCID .........................5 SYNJARDY TAB 12.5-1000MG .................... 26 SYNJARDY TAB 12.5-500MG ...................... 26 SYNJARDY TAB 5-1000MG .......................................... 26 SYNJARDY TAB 5-500MG .......................................... 26 SYNJARDY XR TAB 10-1000MG ....................... 26 SYNJARDY XR TAB 12.5-1000MG .................... 26

SYNJARDY XR TAB 25-1000MG ....................... 26 SYNJARDY XR TAB 5-1000MG ......................... 26 SYNRIBO .......................... 11 SYNTHROID ..................... 30 T TABLOID ............................ 9 TACLONEX ...................... 43 tacrolimus ......................... 35 tacrolimus (topical) ............ 44 tadalafil (pulmonary hypertension) .................... 15 TAFINLAR ........................ 11 TAGRISSO ....................... 11 TAKHZYRO ...................... 34 TALZENNA ......................... 9 tamoxifen citrate ............... 10 tamsulosin hcl ................... 33 TARGRETIN ..................... 44 tarina 24 fe ........................ 28 tarina fe 1/20 ..................... 28 TASIGNA .......................... 11 TAXOTERE ........................ 9 TAYTULLA ........................ 28 tazarotene ......................... 42 tazicef ................................. 7 TAZORAC ......................... 42 taztia xt ............................. 14 TDVAX .............................. 35 TECENTRIQ ....................... 9 TEFLARO ........................... 7 TEKTURNA HCT .............. 14 telmisartan ........................ 12 telmisartan-amlodipine ...... 12 telmisartan-hydrochlorothiazide ...................................... 12 temazepam ....................... 21 TEMIXYS ............................ 6 temsirolimus ........................ 9 TENIVAC .......................... 35 tenofovir disoproxil fumarate ............................................ 6 terazosin hcl ...................... 12 terbinafine hcl ..................... 5 terbutaline sulfate ............. 39 terconazole vaginal ........... 33 testosterone ...................... 23 testosterone cypionate ...... 23 testosterone enanthate ..... 24

testosterone td soln 30 mg/act ............................... 24 tetrabenazine .................... 22 tetracycline hcl .................... 9 TEXACORT ...................... 43 THALOMID ....................... 10 THEO-24 .......................... 40 theophylline ...................... 40 theophylline tab er 12hr 300 mg ..................................... 40 theophylline tab er 12hr 450 mg ..................................... 40 theophylline tab sr 24hr .... 40 thioridazine hcl .................. 19 thiothixene ........................ 19 tiadylt er ............................ 14 tiagabine hcl ..................... 16 TIBSOVO ............................ 9 tigecycline ........................... 5 TIGLUTIK ......................... 22 tilia fe ................................ 28 timolol maleate ................. 13 timolol maleate (ophth) soln.......................................... 38 timolol maleate gel ............ 38 timolol maleate ophth soln 0.5% (once-daily) .............. 38 TIMOPTIC OCUDOSE ..... 38 tinidazole ............................ 5 TIROSINT ......................... 30 TIROSINT-SOL................. 30 TIVICAY .............................. 6 tizanidine .......................... 23 TOBI PODHALER ............... 4 TOBRADEX ...................... 37 TOBRADEX ST ................ 37 tobramycin .......................... 4 tobramycin (ophth) ............ 37 tobramycin inj 1.2 gm/30ml . 4 tobramycin inj 1.2gm ........... 4 tobramycin inj 10mg/ml ....... 4 tobramycin inj 80mg/2ml ..... 4 tobramycin sulfate............... 4 tobramycin-dexamethasone.......................................... 37 TOBREX OINT 0.3% ........ 37 tolmetin sodium................... 1 TOLSURA ........................... 5 tolterodine tartrate er ........ 33 tolterodine tartrate tab 1 mg

63

.......................................... 33 tolterodine tartrate tab 2 mg .......................................... 33 topiramate ......................... 16 toposar .............................. 11 toremifene citrate .............. 10 torsemide tabs .................. 14 TOVIAZ ............................. 33 TPN ELECTROLYTES ..... 36 TRACLEER ....................... 15 TRADJENTA ..................... 26 tramadol hcl ........................1 tramadol hcl er ....................1 tramadol hcl er (biphasic) 100mg .................................1 tramadol hcl er (biphasic) 200mg .................................1 tramadol hcl er (biphasic) 300mg .................................1 tramadol hcl tab 50 mg .......1 tramadol-acetaminophen ....1 trandolapril ........................ 12 trandolapril-verapamil hcl .. 11 tranexamic acid ................. 34 tranylcypromine sulfate ..... 17 TRAVASOL ....................... 36 TRAVATAN Z .................... 38 trazodone hcl .................... 17 TREANDA ...........................9 TRECATOR ........................6 TRELEGY ELLIPTA .......... 38 TRELSTAR MIXJECT ....... 10 treprostinil ......................... 15 TRESIBA FLEXTOUCH .... 24 TRESIBA INJ .................... 24 tretinoin ....................... 11, 41 tretinoin microsphere ........ 41 TREXALL .......................... 35 trezix ...................................1 triamcinolone acetonide (mouth) ............................. 44 triamcinolone acetonide (topical) ............................. 43 triamt/hctz cap 37.5-25 ..... 14 triamterene ........................ 14 triamterene & hydrochlorothiazide tabs ... 14 TRICARE .......................... 37 trientine hcl ........................ 27 tri-estarylla ........................ 28

trifluoperazine hcl .............. 19 trifluridine .......................... 37 TRIGLIDE ......................... 13 trihexyphenidyl hcl ............ 18 tri-legest fe ........................ 28 tri-linyah ............................ 28 tri-lo- tab marzia ................ 28 tri-lo-estarylla .................... 28 tri-lo-sprintec ..................... 28 trilyte ................................. 32 trimethoprim ........................ 5 tri-mili ................................ 28 trimipramine maleate ........ 17 TRINTELLIX ..................... 17 tri-previfem ........................ 28 tri-sprintec ......................... 28 TRIUMEQ ........................... 6 trivora-28 ........................... 28 tri-vylibra ........................... 28 tri-vylibra lo ....................... 28 TROGARZO ....................... 6 TROKENDI XR ................. 16 TROPHAMINE INJ 10% ... 36 trospium chloride .............. 33 trospium chloride er .......... 33 TRULANCE ...................... 32 TRULICITY ....................... 24 TRUMENBA ...................... 35 TRUVADA TAB 100-150 ..... 6 TRUVADA TAB 133-200 ..... 6 TRUVADA TAB 167-250 ..... 6 TRUVADA TAB 200-300 ..... 6 TUDORZA PRESSAIR ..... 39 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 39 tulana ................................ 28 TURALIO .......................... 11 TWINRIX INJ .................... 35 TYBOST ............................. 6 tydemy .............................. 28 TYKERB ........................... 11 TYMLOS ........................... 30 TYPHIM VI ........................ 35 TYVASO ........................... 15 U UCERISFOAM .................. 32 ULTRAVATE LOTN .......... 43 unithroid ............................ 30 UPTRAVI .......................... 15 ursodiol ............................. 32

UTIBRON NEOHALER ..... 38 V VABOMERE ....................... 5 valacyclovir hcl.................... 7 VALCHLOR ...................... 44 valganciclovir hcl................. 7 valproate sodium .............. 16 valproic acid ...................... 16 valsartan ........................... 12 valsartan-hydrochlorothiazide........................................ 12 vancomycin hcl ................... 5 VANCOMYCIN HYDROCHLORIDE ............ 5 VANCOMYCIN IN NACL .... 5 VANCOMYCIN INJ 250MG 5 vandazole ......................... 33 VAQTA ............................. 36 VARIVAX .......................... 36 VARUBI INJ ...................... 31 VARUBI TAB 90MG .......... 31 VASCEPA ......................... 13 VECTIBIX ........................... 9 VELCADE ........................... 9 velivet ............................... 28 VELPHORO ...................... 30 VELTASSA ....................... 27 VEMLIDY ............................ 7 VENCLEXTA ...................... 9 VENCLEXTA STARTING PACK .................................. 9 venlafaxine cap er............. 17 venlafaxine tab ................. 17 VENTAVIS ........................ 15 VENTOLIN HFA................ 39 verapamil hcl .................... 14 VERSACLOZ .................... 19 VERZENIO ......................... 9 VIBATIV .............................. 5 VIBERZI ............................ 32 VIBRAMYCIN ..................... 9 VICTOZA .......................... 24 VIDEX EC ........................... 6 VIDEX PEDIATRIC ............. 6 vienva ............................... 28 vigabatrin powd pack 500mg.......................................... 16 vigabatrin tab 500mg ........ 16 vigadrone .......................... 16 VIIBRYD STARTER PACK

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.......................................... 17 VIIBRYD TAB .................... 17 VIMIZIM ............................ 29 VIMPAT............................. 16 VIMPAT INJ 200MG/20ML 16 VIMPAT SOL 10MG/ML .... 16 vincristine sulfate ................9 vinorelbine tartrate ..............9 VIOKACE 10 ..................... 32 VIOKACE 20 ..................... 32 viorele ............................... 28 VIRACEPT ..........................6 VIREAD...............................6 VITRAKVI.......................... 11 VIVITROL.......................... 23 VIZIMPRO ......................... 11 voriconazole ........................5 voriconazole inj 200mg .......5 VOSEVI...............................7 VOTRIENT ........................ 11 VPRIV ............................... 29 VRAYLAR ......................... 19 VRAYLAR THERAPY PACK .......................................... 19 vyfemla ............................. 28 vylibra ............................... 28 VYNDAMAX ...................... 14 VYNDAQEL ...................... 14 VYVANSE ......................... 21 VYZULTA .......................... 38 W warfarin sodium ................. 33 water for irrigation, sterile 44 wymzya fe ......................... 28 X XADAGO........................... 18 XALKORI .......................... 11 XARELTO ......................... 33 XARELTO STARTER PACK .......................................... 33 XATMEP ........................... 35 XELJANZ .......................... 35 XELJANZ XR .................... 35 XELPROS ......................... 38 XEOMIN INJ 100 UNITS ... 23 XEOMIN INJ 200 UNITS ... 23 XEOMIN INJ 50 UNITS ..... 23 XEPI .................................. 41 XERESE ........................... 44 XGEVA ............................. 30

XHANCE ........................... 40 XIFAXAN TAB 200MG ........ 5 XIFAXAN TAB 550MG ...... 32 XIGDUO XR TAB 10-1000MG ....................... 26 XIGDUO XR TAB 10-500MG .......................................... 26 XIGDUO XR TAB 2.5-1000MG ...................... 26 XIGDUO XR TAB 5-1000MG .......................................... 26 XIGDUO XR TAB 5-500MG .......................................... 26 XIIDRA .............................. 38 XOFLUZA ........................... 7 XOLAIR ............................. 40 XOSPATA ......................... 11 XPOVIO 100 MG ONCE WEEKLY ........................... 11 XPOVIO 60 MG ONCE WEEKLY ........................... 11 XPOVIO 80 MG ONCE WEEKLY ........................... 11 XPOVIO 80 MG TWICE WEEKLY ........................... 11 XTAMPZA ER ..................... 4 XTANDI ............................. 10 xulane dis 150-35 ............. 28 XULTOPHY 100/3.6 ......... 24 XYREM ............................. 23 Y YERVOY ............................. 9 YF-VAX ............................. 36 YUPELRI .......................... 39 yuvafem vaginal tablet 10 mcg ................................... 29 Z zafirlukast .......................... 40 zarah ................................. 28 ZARXIO ............................ 34 ZEJULA .............................. 9 ZELAPAR ......................... 18 ZELBORAF ....................... 11 ZELNORM ........................ 32 ZEMAIRA .......................... 40 ZEMBRACE SYMTOUCH 22 ZEMDRI .............................. 4 zenatane ........................... 41 ZENPEP ........................... 32 ZERBAXA ........................... 7

ZETONNA ........................ 40 zidovudine cap 100mg ........ 6 zidovudine syp 50mg/5ml ... 6 zidovudine tab 300mg ......... 6 ZIOPTAN .......................... 38 ziprasidone hcl .................. 19 ZIRGAN ............................ 37 ZOHYDRO ER (ABUSE DETERRENT)..................... 4 zoledronic acid inj 5mg/100ml ........................ 26 ZOLEDRONIC INJ 4MG/100ML ...................... 27 zoledronic inj 4mg/5ml ...... 27 ZOLINZA ............................ 9 zolmitriptan ....................... 22 zolmitriptan odt ................. 22 zolpidem tartrate ............... 21 ZOMACTON ..................... 30 ZOMIG NASAL SPRAY .... 22 zonisamide ....................... 16 ZONTIVITY ....................... 34 ZORBTIVE ........................ 30 ZORTRESS TAB 0.25MG 35 ZORTRESS TAB 0.5MG .. 35 ZORTRESS TAB 0.75MG 35 ZORTRESS TAB 1MG ..... 35 ZOSTAVAX ...................... 36 ZOSYN ............................... 8 zovia 1/35e ....................... 28 ZUBSOLV SUB 0.7-0.18MG.......................................... 23 ZUBSOLV SUB 1.4-0.36MG.......................................... 23 ZUBSOLV SUB 11.4-2.9MG.......................................... 23 ZUBSOLV SUB 2.9-0.71MG.......................................... 23 ZUBSOLV SUB 5.7-1.4MG.......................................... 23 ZUBSOLV SUB 8.6-2.1MG.......................................... 23 ZUPLENZ ......................... 31 ZYCLARA ......................... 44 ZYDELIG .......................... 11 ZYKADIA .......................... 11 ZYLET .............................. 37 ZYPITAMAG ..................... 13 ZYPREXA RELPREVV ..... 19 ZYPREXA RELPREVV INJ

65

210MG .............................. 20 ZYTIGA ............................. 10

HAWAI‘I MEDICAL SERVICE ASSOCIATIONhmsa.com/advantage

HMSA CENTERSVisit one of our HMSA Centers with convenient evening and Saturday hours.

Honolulu, Oahu818 Keeaumoku St. Monday through Friday, 8 a.m.–5 p.m. | Saturday, 9 a.m.–2 p.m.

Pearl City, OahuPearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Hilo, Hawaii Island Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Kahului, Maui Puunene Shopping Center | 70 Hookele St., Suite 1220Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

OFFICESVisit your nearest HMSA office Monday through Friday, 8 a.m.–4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301Lihue, Kauai | 4366 Kukui Grove St., Suite 103

PHONEOahu: 948-6000Neighbor Islands: 1 (800) 660-4672 toll-freeTTY: 711

(00) 8700-110177FEB 2.20 cs

This formulary was updated on 02/01/2020. For more recent information or other questions, please contact HMSA at:

Documents

HMSA Medicare Advantage 2020 Formulary...HMSA Akamai Advantage List of Covered Drugs Formulary ID 00020361, version 8 This formulary was updated on 02/01/2020. For more recent information