HMSA Medicare Advantage 2021 Formulary · 2020. 10. 1. · PLEASE READ: THIS DOCUMENT . CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 2021. Formulary. Standard (PPO)

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

2021 Formulary

Standard (PPO)Standard Plus (PPO)

Complete (PPO)Complete Plus (PPO)

HMSA Akamai Advantage

List of Covered DrugsFormulary ID 00021217, version 12

This formulary was updated on 05/01/2021. 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_23001_5_C

http://www.hmsa.com/advantage

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

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

This document includes a list of the drugs (formulary) for our plan, which is current as of May 1, 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, for-mulary, pharmacy network, and/or copayments/coinsurance may change on Jan. 1, 2022, and from time to time during the year.

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

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

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

• New generic drugs. We may immediately remove a brand-name drug on our Drug List if we are replacing it with a new generic drug

that will appear on the same or lower cost sharing tier and with the same or fewer 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 restric-tions. 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 Medicare 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 both. Or we may make changes based on new clinical guidelines.

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 and continue to cover the brand-name drug for you. The notice we provide you will also

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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 Medicare Advantage Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members tak-ing them for the remainder of the coverage year.

You will not get direct notice this year about changes that do not affect you. However, on Jan. 1 of the next year, such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs.

The enclosed formulary is current as of May 1, 2021. To get updated information about the drugs covered by HMSA Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages. We will inform members of any formulary changes to this comprehensive formulary through our website.

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

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

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 48. The Index provides an alpha-betical 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 cover-age 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 Medicare 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 Medicare Advan-tage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HMSA Medicare Advantage before you fill your pre-scriptions. If you don’t get approval, HMSA Medicare Advantage may not cover the drug.

• Quantity Limits: For certain drugs, HMSA Medicare Advantage limits the amount of the drug that HMSA Medicare Advantage will cover. For example, HMSA Medicare Advan-tage provides 30 tablets per prescription for simvastatin 80mg. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formu-lary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website.

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We have posted online documents that explain our prior authorization and step therapy restric-tions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask HMSA Medicare 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 Medicare Advantage formulary?” on this page for informa-tion 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 and ask if your drug is cov-ered. If you learn that HMSA Medicare Advan-tage 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 Medi-care 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 Medicare Advantage.

• You can ask HMSA Medicare 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 Medicare Advantage Formulary?You can ask HMSA Medicare 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 the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, HMSA Medicare 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 Medicare 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 cov-erage decision for a formulary, tiering, or utili-zation restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formu-lary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

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

If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescrip-tion until we have provided you with a 31-day transition supply consistent with the dispensing increment (unless you have a prescription writ-ten for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan.

If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescrip-tion 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 exception in order to get coverage for the drug. See the section above, “How do I request an exception to HMSA’s Medicare 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 restric-tions 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 member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days).

After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your tem-porary 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 mem-ber 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 lim-its, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility, or is in an LTC facility and requires an emergency 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-cov-erage of drugs previously covered by Medicare

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Part D. For current members experiencing a level of care change, we will also cover a tempo-rary 31-day transition supply as outlined above.

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

For more informationFor more detailed information about your HMSA Medicare Advantage prescription drug cover-age, please review your Evidence of Coverage and other plan materials.

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

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

HMSA Medicare Advantage FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Medicare Advantage. If you have trou-ble finding your drug in the list, turn to the Index that begins on page 48.

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

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

Drug tier index:

Tier 1 - Preferred GenericTier 2 - GenericTier 3 - Preferred BrandTier 4 - Non-Preferred DrugTier 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 Medicare Advantage before we will cover your prescription.

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

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

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

B/D – B or D: This drug may be covered under Medicare Part B or D depending upon the cir-cumstances. Information may need to be submit-ted 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 Relations.

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.

http://www.medicare.gov

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

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Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol TABS 100mg, 300mg

1 M

colchicine TABS .6mg QL (120 tabs / 30 days)

2 QL M

colchicine w/ probenecid tab 0.5-500 mg

2 M

MITIGARE CAPS .6mg QL (60 caps / 30 days)

3 QL M

probenecid TABS 500mg 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 TABS 50mg

QL (120 tabs / 30 days)

2 QL M

diclofenac sodium TB24 100mg; TBEC 25mg, 50mg, 75mg

2 M

diflunisal TABS 500mg 2 M

ec-naproxen TBEC 375mg, 500mg

2 M

etodolac CAPS 200mg, 300mg; TABS 400mg, 500mg; TB24 400mg, 500mg, 600mg

2 M

flurbiprofen TABS 100mg 2 M

ibu TABS 600mg, 800mg 1 M

ibuprofen SUSP 100mg/5ml 2 M

ibuprofen TABS 400mg, 600mg, 800mg

1 M

meloxicam TABS 7.5mg, 15mg

1 M

nabumetone TABS 500mg, 750mg

1 M

naproxen TABS 250mg, 375mg, 500mg

1 M

naproxen TBEC 375mg, 500mg

2 M

naproxen sodium TABS 275mg, 550mg

2 M

piroxicam CAPS 10mg, 20mg 2 M

Drug Name Drug Tier

Requirements/Limits

sulindac TABS 150mg, 200mg

2 M

OPIOID ANALGESICS, LONG-ACTING fentanyl PT72 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr

QL (10 patches / 30 days)

2 QL M PA

hydrocodone bitartrate T24A 20mg, 30mg, 40mg, 60mg


2 QL M PA

hydrocodone bitartrate T24A 80mg, 100mg, 120mg


3 QL M PA

HYSINGLA ER T24A 20mg, 30mg, 40mg, 60mg, 80mg, 100mg, 120mg


3 QL M PA

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

QL (450 mL / 30 days)

2 QL M PA

methadone hcl TABS 5mg, 10mg


2 QL M PA

methadone hcl intensol CONC 10mg/ml

QL (90 mL / 30 days)

2 QL M PA

morphine sulfate TBCR 15mg, 30mg, 60mg, 100mg, 200mg


2 QL M PA

OPIOID ANALGESICS, SHORT-ACTING acetaminophen w/ codeine soln 120-12 mg/5ml

QL (2700 mL / 30 days)

2 QL M

acetaminophen w/ codeine tab 300-15 mg


2 QL M



2 QL M



2 QL M

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

4 M

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

2 QL M

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

2 QL M


2

Drug Name Drug Tier

Requirements/Limits

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

2 QL M

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

2 QL M

fentanyl citrate LPOP 200mcg, 600mcg, 800mcg, 1200mcg, 1600mcg

QL (120 lozenges / 30 days)

5 QL M PA

fentanyl citrate LPOP 400mcg

QL (120 lozenges / 30 days)

2 QL M PA

hydrocodone-acetaminophen soln 7.5-325 mg/15ml

QL (2700 mL / 30 days)

2 QL M

hydrocodone-acetaminophen tab 5-325 mg


2 QL M

hydrocodone-acetaminophen tab 7.5-325 mg


2 QL M

hydrocodone-acetaminophen tab 10-325 mg


2 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL M

hydromorphone hcl LIQD 1mg/ml

QL (600 mL / 30 days)

2 QL M

hydromorphone hcl TABS 2mg, 4mg, 8mg


2 QL M

morphine sulfate SOLN 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml

4 B/D M

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

4 B/D M

morphine sulfate 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

morphine sulfate TABS 15mg, 30mg


2 QL M

nalbuphine hcl SOLN 10mg/ml, 20mg/ml

4 M

oxycodone hcl CAPS 5mg QL (180 caps / 30 days)

2 QL M

oxycodone hcl CONC 100mg/5ml

QL (180 mL / 30 days)

2 QL M

oxycodone hcl SOLN 5mg/5ml

QL (900 mL / 30 days)

2 QL M

oxycodone hcl TABS 5mg, 10mg, 15mg, 20mg, 30mg


2 QL M

oxycodone w/ acetaminophen tab 2.5-325 mg


2 QL M

oxycodone w/ acetaminophen tab 5-325 mg


2 QL M

oxycodone w/ acetaminophen tab 7.5-325 mg


2 QL M

oxycodone w/ acetaminophen tab 10-325 mg


2 QL M

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

2 QL M

tramadol-acetaminophen tab 37.5-325 mg


2 QL M

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) SOLN .5%, 1%, 1.5%, 2%

2 B/D M

ANTI-INFECTIVES ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 200mg 5 M

ALINIA SUSR 100mg/5ml QL (180 mL / 30 days)

5 QL M

amikacin sulfate SOLN 1gm/4ml, 500mg/2ml

2 M

atovaquone SUSP 750mg/5ml

5 M

aztreonam SOLR 1gm, 2gm 2 M

CAYSTON SOLR 75mg 5 LA PA


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Drug Name Drug Tier

Requirements/Limits

clindamycin hcl CAPS 75mg, 150mg, 300mg

1 M

clindamycin palmitate hydrochloride SOLR 75mg/5ml

2 M

clindamycin phosphate SOLN 9gm/60ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

2 M

clindamycin phosphate in d5w iv soln 300 mg/50ml

2 M


2 M


2 M

CLINDMYC/NAC INJ 300/50ML

4 M


4 M


4 M

colistimethate sodium SOLR 150mg

2 M

dapsone TABS 25mg, 100mg 2 M

DAPTOMYCIN SOLR 350mg 5 M

daptomycin SOLR 350mg, 500mg

5 M

EMVERM CHEW 100mg QL (12 tabs / 365 days)

5 QL M

ertapenem sodium SOLR 1gm

2 M

gentamicin in saline inj 0.8 mg/ml

2 M

gentamicin in saline inj 1 mg/ml

2 M


2 M


2 M

gentamicin in saline inj 2 mg/ml

2 M

gentamicin sulfate SOLN 10mg/ml, 40mg/ml

2 M

imipenem-cilastatin intravenous for soln 250 mg

2 M

imipenem-cilastatin intravenous for soln 500 mg

2 M

ivermectin TABS 3mg 2 M

linezolid SOLN 600mg/300ml 2 M

Drug Name Drug Tier

Requirements/Limits

linezolid SUSR 100mg/5ml QL (1800 mL / 30 days)

5 QL M

linezolid TABS 600mg QL (60 tabs / 30 days)

2 QL M

linezolid in sodium chloride iv soln 600 mg/300ml-0.9%

2 M

meropenem SOLR 1gm, 500mg

2 M

methenamine hippurate TABS 1gm

2 M

metronidazole TABS 250mg, 500mg

1 M

metronidazole in nacl 0.79% iv soln 500 mg/100ml

2 M

neomycin sulfate TABS 500mg

2 M

nitazoxanide TABS 500mg QL (6 tabs / 30 days)

5 QL M

nitrofurantoin macrocrystal CAPS 50mg, 100mg

3 M

nitrofurantoin monohyd macro CAPS 100mg

3 M

paromomycin sulfate CAPS 250mg

2 M

pentamidine isethionate inh SOLR 300mg

2 B/D M

pentamidine isethionate inj SOLR 300mg

2 M

praziquantel TABS 600mg 2 M

SIVEXTRO SOLR 200mg; TABS 200mg

5 M

streptomycin sulfate SOLR 1gm

5 M

SULFADIAZINE TABS 500mg

4 M

sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml

2 M

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

2 M

sulfamethoxazole-trimethoprim tab 400-80 mg

1 M

sulfamethoxazole-trimethoprim tab 800-160 mg

1 M

SYNERCID INJ 500MG 5 M

tobramycin NEBU 300mg/5ml 5 PA


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Drug Name Drug Tier

Requirements/Limits

tobramycin sulfate SOLN 1.2gm/30ml, 10mg/ml, 40mg/ml, 80mg/2ml

2 M

trimethoprim TABS 100mg 1 M

vancomycin hcl CAPS 125mg QL (80 caps / 180 days)

2 QL M

vancomycin hcl CAPS 250mg QL (160 caps / 180 days)

2 QL M

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

2 M

VANCOMYCIN INJ 1 GM 4 M

VANCOMYCIN INJ 500MG 4 M

VANCOMYCIN INJ 750MG 4 M

ANTIFUNGALS ABELCET SUSP 5mg/ml 4 B/D M

AMBISOME SUSR 50mg 5 B/D M

amphotericin b SOLR 50mg 2 B/D M

caspofungin acetate SOLR 50mg, 70mg

5 M

fluconazole SUSR 10mg/ml, 40mg/ml; TABS 50mg, 100mg, 150mg, 200mg

2 M

fluconazole in nacl 0.9% inj 200 mg/100ml

2 M

fluconazole in nacl 0.9% inj 400 mg/200ml

2 M

flucytosine CAPS 250mg, 500mg

5 M

griseofulvin microsize SUSP 125mg/5ml; TABS 500mg

2 M

griseofulvin ultramicrosize TABS 125mg, 250mg

2 M

itraconazole CAPS 100mg 2 M PA

ketoconazole TABS 200mg 2 M PA

micafungin sodium SOLR 50mg, 100mg

5 M

NOXAFIL SUSP 40mg/ml QL (630 mL / 30 days)

5 QL M

nystatin TABS 500000unit 2 M

posaconazole TBEC 100mg QL (93 tabs / 30 days)

5 QL M

terbinafine hcl TABS 250mg QL (90 tabs / year)

1 QL M

voriconazole SOLR 200mg; SUSR 40mg/ml

5 M PA

voriconazole TABS 50mg QL (480 tabs / 30 days)

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

voriconazole TABS 200mg QL (120 tabs / 30 days)

2 QL 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 250mg, 500mg

2 M

COARTEM TAB 20-120MG 4 M

mefloquine hcl TABS 250mg 2 M

primaquine phosphate TABS 26.3mg

2 M

PRIMAQUINE PHOSPHATE TABS 26.3mg

3 M

quinine sulfate CAPS 324mg 2 M PA

ANTIRETROVIRAL AGENTS abacavir sulfate SOLN 20mg/ml; TABS 300mg

2 M

APTIVUS CAPS 250mg; SOLN 100mg/ml

5 M

atazanavir sulfate CAPS 150mg, 200mg, 300mg

2 M

CRIXIVAN CAPS 200mg, 400mg

4 M

EDURANT TABS 25mg 5 M

efavirenz CAPS 50mg, 200mg; TABS 600mg

2 M

emtricitabine CAPS 200mg 2 M

EMTRIVA SOLN 10mg/ml 3 M

fosamprenavir calcium TABS 700mg

5 M

FUZEON SOLR 90mg 5 M

INTELENCE TABS 25mg 4 M

INTELENCE TABS 100mg, 200mg

5 M

INVIRASE TABS 500mg 5 M

ISENTRESS CHEW 25mg; PACK 100mg

3 M

ISENTRESS CHEW 100mg; TABS 400mg

5 M

ISENTRESS HD TABS 600mg

5 M

lamivudine SOLN 10mg/ml; TABS 150mg, 300mg

2 M

LEXIVA SUSP 50mg/ml 4 M

nevirapine SUSP 50mg/5ml; TABS 200mg; TB24 100mg, 400mg

2 M


5

Drug Name Drug Tier

Requirements/Limits

NORVIR PACK 100mg; SOLN 80mg/ml

4 M

PIFELTRO TABS 100mg 5 M

PREZISTA SUSP 100mg/ml 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

REYATAZ PACK 50mg 5 M

ritonavir TABS 100mg 2 M

RUKOBIA TB12 600mg 5 M

SELZENTRY SOLN 20mg/ml; TABS 75mg, 150mg, 300mg

5 M

SELZENTRY TABS 25mg 3 M

stavudine CAPS 15mg, 20mg, 30mg, 40mg

2 M

tenofovir disoproxil fumarate TABS 300mg

2 M

TIVICAY TABS 10mg 3 M

TIVICAY TABS 25mg, 50mg 5 M

TIVICAY PD TBSO 5mg 3 M

TROGARZO SOLN 200mg/1.33ml

5 M LA

TYBOST TABS 150mg 4 M

VIRACEPT TABS 250mg, 625mg

5 M

VIREAD POWD 40mg/gm; TABS 150mg, 200mg, 250mg

5 M

zidovudine CAPS 100mg; SYRP 50mg/5ml; TABS 300mg

2 M

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab 600-300 mg

2 M

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

5 M

BIKTARVY TAB 5 M

CIMDUO TAB 300-300 5 M

COMPLERA TAB 5 M

DELSTRIGO TAB 5 M

DESCOVY TAB 200/25MG 5 M

Drug Name Drug Tier

Requirements/Limits

DOVATO TAB 50-300MG 5 M

efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg

5 M

efavirenz-lamivudine-tenofovir df tab 400-300-300 mg

5 M

efavirenz-lamivudine-tenofovir df tab 600-300-300 mg

5 M

emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg


5 QL M



5 QL M



5 QL M



5 QL M

EVOTAZ TAB 300-150 5 M

GENVOYA TAB 5 M

JULUCA TAB 50-25MG 5 M

KALETRA TAB 100-25MG 4 M

KALETRA TAB 200-50MG 5 M

lamivudine-zidovudine tab 150-300 mg

2 M

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)

2 M

ODEFSEY TAB 5 M

PREZCOBIX TAB 800-150 5 M

STRIBILD TAB 5 M

SYMTUZA TAB 5 M

TEMIXYS TAB 300-300 5 M

TRIUMEQ TAB 5 M

ANTITUBERCULAR AGENTS cycloserine CAPS 250mg 5 M

ethambutol hcl TABS 100mg, 400mg

2 M

isoniazid SYRP 50mg/5ml 2 M

isoniazid TABS 100mg, 300mg

1 M

PASER PACK 4gm 4 M

PRIFTIN TABS 150mg 4 M

pyrazinamide TABS 500mg 2 M


6

Drug Name Drug Tier

Requirements/Limits

rifabutin CAPS 150mg 2 M

rifampin CAPS 150mg, 300mg; SOLR 600mg

2 M

SIRTURO TABS 20mg, 100mg

5 M LA PA

TRECATOR TABS 250mg 4 M

ANTIVIRALS acyclovir CAPS 200mg; TABS 400mg, 800mg

1 M

acyclovir SUSP 200mg/5ml 2 M

acyclovir sodium SOLN 50mg/ml

2 B/D M

adefovir dipivoxil TABS 10mg 5 M

BARACLUDE SOLN .05mg/ml

5 M

entecavir TABS .5mg, 1mg 2 M

EPCLUSA TAB 200-50MG 5 PA

EPCLUSA TAB 400-100 5 PA

EPIVIR HBV SOLN 5mg/ml 4 M

famciclovir TABS 125mg, 250mg, 500mg

2 M

ganciclovir sodium SOLR 500mg

2 B/D M

HARVONI PAK 33.75-150MG 5 PA

HARVONI PAK 45-200MG 5 PA

HARVONI TAB 45-200MG 5 PA

HARVONI TAB 90-400MG 5 PA

lamivudine (hbv) TABS 100mg

2 M

MAVYRET TAB 100-40MG 5 PA

oseltamivir phosphate CAPS 30mg

QL (168 caps / year)

2 QL M

oseltamivir phosphate CAPS 45mg, 75mg

QL (84 caps / year)

2 QL M

oseltamivir phosphate SUSR 6mg/ml

QL (1080 mL / year)

2 QL M

PEGASYS SOLN 180mcg/0.5ml, 180mcg/ml

5 PA

RELENZA DISKHALER AEPB 5mg/blister

QL (6 inhalers / year)

3 QL M

ribavirin (hepatitis c) CAPS 200mg; TABS 200mg

2

rimantadine hydrochloride TABS 100mg

2 M

Drug Name Drug Tier

Requirements/Limits

valacyclovir hcl TABS 1gm, 500mg

2 M

valganciclovir hcl SOLR 50mg/ml; TABS 450mg

2 M

VEMLIDY TABS 25mg 5 M PA

VOSEVI TAB 5 PA

CEPHALOSPORINS cefaclor CAPS 250mg, 500mg; SUSR 125mg/5ml, 250mg/5ml, 375mg/5ml

2 M

CEFACLOR ER TB12 500mg 4 M

cefadroxil CAPS 500mg 1 M

cefadroxil SUSR 250mg/5ml, 500mg/5ml

2 M

CEFAZOLIN INJ 1GM/50ML 4 M

cefazolin sodium SOLR 1gm, 10gm, 500mg

2 M

CEFAZOLIN SOLN 2GM/100ML-4%

4 M

cefdinir CAPS 300mg; SUSR 125mg/5ml, 250mg/5ml

2 M

cefepime hcl SOLR 1gm, 2gm

2 M

cefixime SUSR 100mg/5ml, 200mg/5ml

2 M

cefoxitin sodium SOLR 1gm, 2gm, 10gm

2 M

cefpodoxime proxetil SUSR 50mg/5ml, 100mg/5ml; TABS 100mg, 200mg

2 M

cefprozil SUSR 125mg/5ml, 250mg/5ml; TABS 250mg, 500mg

2 M

ceftazidime SOLR 1gm, 2gm, 6gm

2 M

CEFTAZIDIME/ SOL D5W 1GM

4 M

CEFTAZIDIME/ SOL D5W 2GM

4 M

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

2 M

cefuroxime axetil TABS 250mg, 500mg

2 M

cefuroxime sodium SOLR 1.5gm, 7.5gm, 750mg

2 M

cephalexin CAPS 250mg, 500mg

1 M


7

Drug Name Drug Tier

Requirements/Limits

cephalexin SUSR 125mg/5ml, 250mg/5ml

2 M

tazicef SOLR 1gm, 2gm, 6gm 2 M

TEFLARO SOLR 400mg, 600mg

5 M

ERYTHROMYCINS/MACROLIDES azithromycin PACK 1gm; SOLR 500mg; SUSR 100mg/5ml, 200mg/5ml

2 M

azithromycin TABS 250mg, 500mg, 600mg

1 M

clarithromycin SUSR 125mg/5ml, 250mg/5ml; TABS 250mg, 500mg; TB24 500mg

2 M

DIFICID SUSR 40mg/ml; TABS 200mg

5 M

ery-tab TBEC 250mg, 333mg, 500mg

2 M

ERYTHROCIN LACTOBIONATE SOLR 500mg

4 M

erythrocin stearate TABS 250mg

2 M

erythromycin base CPEP 250mg; TABS 250mg, 500mg; TBEC 250mg, 333mg, 500mg

2 M

erythromycin ethylsuccinate TABS 400mg

2 M

FLUOROQUINOLONES CIPRO SUSR 500mg/5ml 4 M

ciprofloxacin 200 mg/100ml in d5w

2 M

ciprofloxacin 400 mg/200ml in d5w

2 M

ciprofloxacin hcl TABS 100mg

2 M

ciprofloxacin hcl TABS 250mg, 500mg, 750mg

1 M

levofloxacin SOLN 25mg/ml 2 M

levofloxacin TABS 250mg, 500mg, 750mg

1 M

levofloxacin in d5w iv soln 250 mg/50ml

2 M


2 M


2 M

Drug Name Drug Tier

Requirements/Limits

PENICILLINS amoxicillin CAPS 250mg, 500mg; SUSR 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml; TABS 500mg, 875mg

1 M

amoxicillin CHEW 125mg, 250mg

2 M

amoxicillin & k clavulanate chew tab 200-28.5 mg

2 M

amoxicillin & k clavulanate chew tab 400-57 mg

2 M

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml

2 M


2 M

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

2 M


2 M

amoxicillin & k clavulanate tab 250-125 mg

2 M


2 M


2 M

amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg

2 M

ampicillin CAPS 500mg 1 M

ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm

2 M

ampicillin & sulbactam sodium for inj 3 (2-1) gm

2 M

ampicillin & sulbactam sodium for iv soln 1.5 (1-0.5) gm

2 M

ampicillin & sulbactam sodium for iv soln 3 (2-1) gm

2 M

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm

2 M

ampicillin sodium SOLR 1gm, 2gm, 10gm, 125mg, 250mg, 500mg

2 M

BICILLIN L-A SUSP 600000unit/ml, 1200000unit/2ml, 2400000unit/4ml

4 M

dicloxacillin sodium CAPS 250mg, 500mg

2 M


8

Drug Name Drug Tier

Requirements/Limits

nafcillin sodium SOLR 1gm, 2gm

2 M

nafcillin sodium SOLR 10gm 5 M

NAFCILLIN SODIUM SOLR 10gm

5 M

oxacillin sodium SOLR 1gm, 2gm

2 M

oxacillin sodium SOLR 10gm 5 M

PEN GK/DEXTR INJ 40000/ML

4 M

PEN GK/DEXTR INJ 60000/ML

4 M

penicillin g potassium SOLR 5000000unit, 20000000unit

2 M

PENICILLIN G PROCAINE SUSP 600000unit/ml

4 M

penicillin g sodium SOLR 5000000unit

2 M

penicillin v potassium SOLR 125mg/5ml, 250mg/5ml

2 M

penicillin v potassium TABS 250mg, 500mg

1 M

pfizerpen SOLR 5000000unit, 20000000unit

2 M

piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm)

2 M

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)

2 M


2 M


2 M


2 M

TETRACYCLINES doxy 100 SOLR 100mg 2 M

doxycycline (monohydrate) CAPS 50mg, 100mg; TABS 50mg, 75mg, 100mg

2 M

doxycycline hyclate CAPS 50mg, 100mg; SOLR 100mg; TABS 20mg, 100mg

2 M

minocycline hcl CAPS 50mg, 75mg, 100mg

2 M

mondoxyne nl CAPS 100mg 2 M

Drug Name Drug Tier

Requirements/Limits

tetracycline hcl CAPS 250mg, 500mg

2 M PA

tigecycline SOLR 50mg 5 M

TIGECYCLINE SOLR 50mg 5 M

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA SOLN 100mg/4ml 5 B/D

carboplatin SOLN 50mg/5ml, 150mg/15ml, 450mg/45ml, 600mg/60ml

2 B/D M

cisplatin SOLN 50mg/50ml, 100mg/100ml, 200mg/200ml

2 B/D M

cyclophosphamide CAPS 25mg, 50mg

2 B/D M

CYCLOPHOSPHAMIDE SOLN 1gm/5ml, 500mg/2.5ml

5 B/D M

cyclophosphamide SOLR 1gm, 2gm, 500mg

5 B/D M

LEUKERAN TABS 2mg 5 M

oxaliplatin SOLN 50mg/10ml, 100mg/20ml, 200mg/40ml

2 B/D M

oxaliplatin SOLR 50mg, 100mg

5 B/D M

paraplatin SOLN 1000mg/100ml

2 B/D M

ANTIBIOTICS adriamycin SOLN 2mg/ml 2 B/D M

doxorubicin hcl SOLN 2mg/ml 2 B/D M

doxorubicin hcl liposomal INJ 2mg/ml

5 B/D M

epirubicin hcl SOLN 50mg/25ml, 200mg/100ml

2 B/D M

ANTIMETABOLITES ALIMTA SOLR 100mg, 500mg

5 B/D M

azacitidine SUSR 100mg 5 B/D

cytarabine SOLN 20mg/ml 2 B/D M

fluorouracil SOLN 1gm/20ml, 2.5gm/50ml, 5gm/100ml, 500mg/10ml

2 B/D M

gemcitabine hcl SOLN 1gm/26.3ml, 2gm/52.6ml, 200mg/5.26ml; SOLR 1gm, 2gm, 200mg

2 B/D M

mercaptopurine TABS 50mg 2 M

methotrexate sodium SOLN 1gm/40ml, 50mg/2ml, 250mg/10ml; SOLR 1gm

2 B/D M


9

Drug Name Drug Tier

Requirements/Limits

ONUREG TABS 200mg, 300mg

5 LA PA

PURIXAN SUSP 2000mg/100ml

5

TABLOID TABS 40mg 4 M

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate TABS 250mg, 500mg

5 PA

anastrozole TABS 1mg 1 M

bicalutamide TABS 50mg 2 M

EMCYT CAPS 140mg 4 M

ERLEADA TABS 60mg 5 LA PA

exemestane TABS 25mg 2 M

flutamide CAPS 125mg 2 M

fulvestrant SOLN 250mg/5ml 5 B/D M

letrozole TABS 2.5mg 1 M

leuprolide acetate KIT 1mg/0.2ml

2 PA

LUPRON DEPOT (1-MONTH) KIT 3.75mg

5 PA

LUPRON DEPOT (3-MONTH) KIT 11.25mg

5 PA

LYSODREN TABS 500mg 5 M

megestrol acetate TABS 20mg, 40mg

3 M

nilutamide TABS 150mg 5 M

NUBEQA TABS 300mg 5 LA PA

ORGOVYX TABS 120mg 5 LA PA

SOLTAMOX SOLN 10mg/5ml 5 M

tamoxifen citrate TABS 10mg, 20mg

2 M

toremifene citrate TABS 60mg

5 M

TRELSTAR MIXJECT SUSR 3.75mg, 11.25mg

5 PA

XTANDI CAPS 40mg; TABS 40mg, 80mg

5 LA PA

ZYTIGA TABS 500mg 5 LA PA

IMMUNOMODULATORS POMALYST CAPS 1mg, 2mg

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

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

5 QL LA PA

REVLIMID CAPS 2.5mg, 5mg, 10mg, 15mg, 20mg, 25mg

QL (28 caps / 28 days)

5 QL LA PA

Drug Name Drug Tier

Requirements/Limits

THALOMID CAPS 50mg, 100mg


5 QL PA

THALOMID CAPS 150mg, 200mg


5 QL PA

MISCELLANEOUS bexarotene CAPS 75mg 5 PA

hydroxyurea CAPS 500mg 2 M

INQOVI TAB 35-100MG 5 LA PA

irinotecan hcl SOLN 40mg/2ml, 100mg/5ml, 300mg/15ml, 500mg/25ml

2 B/D M

KISQALI 200 PAK FEMARA 5 PA



LONSURF TAB 15-6.14 5 PA

LONSURF TAB 20-8.19 5 PA

MATULANE CAPS 50mg 5 LA

SYNRIBO SOLR 3.5mg 5 PA

tretinoin (chemotherapy) CAPS 10mg

5 M

MITOTIC INHIBITORS ABRAXANE INJ 100MG 5 B/D M

docetaxel CONC 20mg/ml 2 B/D M

docetaxel CONC 80mg/4ml, 160mg/8ml; SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

DOCETAXEL CONC 80mg/4ml, 160mg/8ml; SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

etoposide SOLN 100mg/5ml, 500mg/25ml

2 B/D M

paclitaxel CONC 30mg/5ml, 100mg/16.7ml, 150mg/25ml, 300mg/50ml

2 B/D M

toposar SOLN 1gm/50ml, 100mg/5ml

2 B/D M

vincristine sulfate SOLN 1mg/ml

2 B/D M

vinorelbine tartrate SOLN 10mg/ml, 50mg/5ml

2 B/D M

MOLECULAR TARGET AGENTS AFINITOR TABS 10mg

QL (30 tabs / 30 days) 5 QL PA

AFINITOR DISPERZ TBSO 2mg


5 QL PA


10

Drug Name Drug Tier

Requirements/Limits



5 QL PA



5 QL PA

ALECENSA CAPS 150mg 5 M LA PA

ALUNBRIG TABS 30mg, 90mg, 180mg

5 M LA PA

ALUNBRIG PAK 5 M LA PA

AVASTIN SOLN 100mg/4ml, 400mg/16ml

5 LA PA

AYVAKIT TABS 100mg, 200mg, 300mg


5 QL M LA PA

BALVERSA TABS 3mg, 4mg, 5mg

5 LA PA

BORTEZOMIB SOLR 3.5mg 5 PA

BOSULIF TABS 100mg, 400mg, 500mg

5 M PA

BRAFTOVI CAPS 75mg 5 LA PA

BRUKINSA CAPS 80mg 5 M LA PA

CABOMETYX TABS 20mg, 40mg, 60mg


5 QL M LA PA

CALQUENCE CAPS 100mg 5 M LA PA

CAPRELSA TABS 100mg, 300mg

5 M LA PA

COMETRIQ (60MG DOSE) KIT 20mg

5 M LA PA

COMETRIQ KIT 100MG 5 M LA PA

COMETRIQ KIT 140MG 5 M LA PA

COPIKTRA CAPS 15mg, 25mg

5 LA PA

COTELLIC TABS 20mg 5 LA PA

DAURISMO TABS 25mg, 100mg

5 LA PA

ERIVEDGE CAPS 150mg 5 LA PA

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

5 QL M PA

erlotinib hcl TABS 100mg, 150mg


5 QL M PA

everolimus TABS 2.5mg, 5mg, 7.5mg


5 QL PA

FARYDAK CAPS 10mg, 15mg, 20mg

5 LA PA

GAVRETO CAPS 100mg 5 M LA PA

Drug Name Drug Tier

Requirements/Limits

GILOTRIF TABS 20mg, 30mg, 40mg

5 M LA PA

HERCEP HYLEC SOL 60-10000

5 PA

HERCEPTIN SOLR 150mg 5 M PA

HERZUMA SOLR 150mg, 420mg

5 M PA

IBRANCE CAPS 75mg, 100mg, 125mg


5 QL LA PA

IBRANCE TABS 75mg, 100mg, 125mg


5 QL LA PA

ICLUSIG TABS 10mg, 15mg QL (60 tabs / 30 days)

5 QL M LA PA

ICLUSIG TABS 30mg, 45mg QL (30 tabs / 30 days)

5 QL M LA PA

IDHIFA TABS 50mg, 100mg QL (30 tabs / 30 days)

5 QL LA PA

imatinib mesylate TABS 100mg


5 QL M PA

imatinib mesylate TABS 400mg


5 QL M PA

IMBRUVICA CAPS 70mg QL (56 caps / 28 days)

5 QL M LA PA

IMBRUVICA CAPS 140mg QL (120 caps / 30 days)

5 QL M LA PA

IMBRUVICA TABS 140mg QL (112 tabs / 28 days)

5 QL M LA PA

IMBRUVICA TABS 280mg QL (56 tabs / 28 days)

5 QL M LA PA

IMBRUVICA TABS 420mg, 560mg


5 QL M LA PA

INLYTA TABS 1mg QL (180 tabs / 30 days)

5 QL M LA PA

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

5 QL M LA PA

INREBIC CAPS 100mg 5 LA PA

IRESSA TABS 250mg 5 M LA PA

JAKAFI TABS 5mg, 10mg, 15mg, 20mg, 25mg


5 QL LA PA

KADCYLA SOLR 100mg, 160mg

5 B/D

KANJINTI SOLR 150mg, 420mg

5 M PA


11

Drug Name Drug Tier

Requirements/Limits

KEYTRUDA SOLN 100mg/4ml

5 M PA

KISQALI TBPK 200mg 5 PA

lapatinib ditosylate TABS 250mg

5 M PA

LENVIMA 4 MG DAILY DOSE CPPK 4mg

5 M LA PA


5 M LA PA


5 M LA PA

LENVIMA 12MG DAILY DOSE CPPK 4mg

5 M LA PA


5 M LA PA

LENVIMA CAP 14 MG 5 M LA PA



LORBRENA TABS 25mg, 100mg

5 M LA PA

LYNPARZA TABS 100mg, 150mg


5 QL LA PA

MEKINIST TABS .5mg, 2mg 5 LA PA

MEKTOVI TABS 15mg 5 LA PA

MONJUVI SOLR 200mg 5 M LA PA

MVASI SOLN 100mg/4ml, 400mg/16ml

5 LA PA

NERLYNX TABS 40mg 5 M LA PA

NEXAVAR TABS 200mg 5 LA PA

NINLARO CAPS 2.3mg, 3mg, 4mg

5 PA

ODOMZO CAPS 200mg 5 LA PA

OGIVRI SOLR 150mg 5 M PA

OGIVRI INJ 420MG 5 M PA

ONTRUZANT SOLR 150mg, 420mg

5 M PA

PEMAZYRE TABS 4.5mg, 9mg, 13.5mg

5 LA PA

PHESGO SOL 5 LA PA

PIQRAY 200MG DAILY DOSE TBPK 200mg

5 PA

PIQRAY 250MG TAB DOSE 5 PA

PIQRAY 300MG DAILY DOSE TBPK 150mg

5 PA

QINLOCK TABS 50mg 5 M LA PA

RETEVMO CAPS 40mg, 80mg

5 M LA PA

Drug Name Drug Tier

Requirements/Limits

RIABNI SOLN 100mg/10ml, 500mg/50ml

5 M LA PA

RITUXAN SOLN 100mg/10ml, 500mg/50ml

5 M LA PA

RITUXAN INJ HYCELA 5 LA PA

ROZLYTREK CAPS 100mg, 200mg

5 LA PA

RUBRACA TABS 200mg, 250mg, 300mg

5 LA PA

RUXIENCE SOLN 100mg/10ml, 500mg/50ml

5 M PA

RYDAPT CAPS 25mg 5 PA

SPRYCEL TABS 20mg, 50mg, 70mg, 80mg, 100mg, 140mg

5 M PA

STIVARGA TABS 40mg 5 LA PA

SUTENT CAPS 12.5mg, 25mg, 37.5mg, 50mg


5 QL PA

TABRECTA TABS 150mg, 200mg

5 M PA

TAFINLAR CAPS 50mg, 75mg

5 LA PA

TAGRISSO TABS 40mg, 80mg


5 QL M LA PA

TALZENNA CAPS .25mg, 1mg

5 LA PA

TASIGNA CAPS 50mg, 150mg, 200mg

5 M PA

TAZVERIK TABS 200mg 5 LA PA

TECENTRIQ SOLN 840mg/14ml, 1200mg/20ml

5 M LA PA

TEPMETKO TABS 225mg 5 LA PA

TIBSOVO TABS 250mg 5 LA PA

TRAZIMERA SOLR 150mg, 420mg

5 M PA

TRUXIMA SOLN 100mg/10ml, 500mg/50ml

5 M PA

TUKYSA TABS 50mg, 150mg

5 M LA PA

TURALIO CAPS 200mg 5 M LA PA

VELCADE SOLR 3.5mg 5 PA

VENCLEXTA TABS 10mg QL (112 tabs / 28 days)

4 QL LA PA


5 QL LA PA


5 QL LA PA


12

Drug Name Drug Tier

Requirements/Limits

VENCLEXTA TAB START PK QL (42 tabs / 28 days)

5 QL LA PA

VERZENIO TABS 50mg, 100mg, 150mg, 200mg

5 LA PA

VITRAKVI CAPS 25mg, 100mg; SOLN 20mg/ml

5 LA PA

VIZIMPRO TABS 15mg, 30mg, 45mg

5 M LA PA

VOTRIENT TABS 200mg 5 M LA PA

XALKORI CAPS 200mg, 250mg

5 M LA PA

XOSPATA TABS 40mg 5 M LA PA

XPOVIO 40 MG ONCE WEEKLY TBPK 20mg

5 LA PA

XPOVIO 40 MG TWICE WEEKLY TBPK 20mg

5 LA PA


5 LA PA


5 LA PA


5 LA PA


5 LA PA


5 LA PA

ZEJULA CAPS 100mg 5 LA PA

ZELBORAF TABS 240mg 5 LA PA

ZIRABEV SOLN 100mg/4ml, 400mg/16ml

5 PA

ZOLINZA CAPS 100mg 5 PA

ZYDELIG TABS 100mg, 150mg

5 LA PA

ZYKADIA TABS 150mg 5 M LA PA

PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml; SOLR 50mg, 100mg, 200mg, 350mg, 500mg

2 B/D M

leucovorin calcium TABS 5mg, 10mg, 15mg, 25mg

2 M

MESNEX TABS 400mg 5 M

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


1 QL M

Drug Name Drug Tier

Requirements/Limits

amlodipine besylate-benazepril hcl cap 5-10 mg


1 QL M



1 QL M



1 QL M



1 QL M



1 QL M

benazepril & hydrochlorothiazide tab 5-6.25 mg

1 M


1 M


1 M

benazepril & hydrochlorothiazide tab 20-25 mg

1 M

captopril & hydrochlorothiazide tab 25-15 mg

1 M


1 M


1 M


1 M

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1 M

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1 M

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1 M


13

Drug Name Drug Tier

Requirements/Limits

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1 M

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1 M

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1 M

lisinopril & hydrochlorothiazide tab 20-25 mg

1 M

quinapril-hydrochlorothiazide tab 10-12.5 mg

1 M

quinapril-hydrochlorothiazide tab 20-12.5 mg

1 M

quinapril-hydrochlorothiazide tab 20-25 mg

1 M

ACE INHIBITORS benazepril hcl TABS 5mg, 10mg, 20mg, 40mg

1 M

captopril TABS 12.5mg, 25mg, 50mg, 100mg

1 M

enalapril maleate TABS 2.5mg, 5mg, 10mg, 20mg

1 M

fosinopril sodium TABS 10mg, 20mg, 40mg

1 M

lisinopril TABS 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg

1 M

moexipril hcl TABS 7.5mg, 15mg

1 M

perindopril erbumine TABS 2mg, 4mg, 8mg

1 M

quinapril hcl TABS 5mg, 10mg, 20mg, 40mg

1 M

ramipril CAPS 1.25mg, 2.5mg, 5mg, 10mg

1 M

trandolapril TABS 1mg, 2mg, 4mg

1 M

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone TABS 25mg, 50mg

2 M

spironolactone TABS 25mg, 50mg, 100mg

1 M

ALPHA BLOCKERS doxazosin mesylate TABS 1mg, 2mg, 4mg, 8mg

1 M

prazosin hcl CAPS 1mg, 2mg, 5mg

2 M

terazosin hcl CAPS 1mg, 2mg, 5mg

1 M

Drug Name Drug Tier

Requirements/Limits

terazosin hcl CAPS 10mg 2 M

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil tab 5-20 mg


1 QL M

amlodipine besylate-olmesartan medoxomil tab 5-40 mg


1 QL M



1 QL M



1 QL M

amlodipine besylate-valsartan tab 5-160 mg


1 QL M



1 QL M



1 QL M



1 QL M

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


1 QL M

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg


1 QL M

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


1 QL M



1 QL M


14

Drug Name Drug Tier

Requirements/Limits



1 QL M

ENTRESTO TAB 24-26MG 3 M



irbesartan-hydrochlorothiazide tab 150-12.5 mg


1 QL M

irbesartan-hydrochlorothiazide tab 300-12.5 mg


1 QL M

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1 M

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1 M

losartan potassium & hydrochlorothiazide tab 100-25 mg

1 M

olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg


1 QL M

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg


1 QL M

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg


1 QL M

olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg


1 QL M



1 QL M

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg


1 QL M



1 QL M

Drug Name Drug Tier

Requirements/Limits

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg


1 QL M

valsartan-hydrochlorothiazide tab 80-12.5 mg


1 QL M



1 QL M

valsartan-hydrochlorothiazide tab 160-25 mg


1 QL M



1 QL M

valsartan-hydrochlorothiazide tab 320-25 mg


1 QL M

ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan TABS 75mg, 150mg, 300mg


1 QL M

losartan potassium TABS 25mg, 50mg, 100mg

1 M

olmesartan medoxomil TABS 5mg


1 QL M

olmesartan medoxomil TABS 20mg, 40mg


1 QL M

telmisartan TABS 20mg, 40mg, 80mg


1 QL M

valsartan TABS 40mg, 80mg, 160mg


1 QL M

valsartan TABS 320mg QL (30 tabs / 30 days)

1 QL M

ANTIARRHYTHMICS amiodarone hcl SOLN 50mg/ml, 900mg/18ml; TABS 100mg, 400mg

2 M

amiodarone hcl TABS 200mg 1 M

disopyramide phosphate CAPS 100mg, 150mg

4 M

dofetilide CAPS 125mcg, 250mcg, 500mcg

2 M


15

Drug Name Drug Tier

Requirements/Limits

flecainide acetate TABS 50mg, 100mg, 150mg

2 M

MULTAQ TABS 400mg 4 M

NORPACE CR CP12 100mg, 150mg

4 M

pacerone TABS 100mg, 400mg

2 M

pacerone TABS 200mg 1 M

propafenone hcl CP12 225mg, 325mg, 425mg; TABS 150mg, 225mg, 300mg

2 M

quinidine sulfate TABS 200mg, 300mg

2 M

sorine TABS 80mg, 120mg, 160mg, 240mg

1 M

sotalol hcl TABS 80mg, 120mg, 160mg, 240mg

1 M

sotalol hcl (afib/afl) TABS 80mg, 120mg, 160mg

2 M

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

2 M

fenofibrate micronized CAPS 67mg, 134mg, 200mg

2 M

gemfibrozil TABS 600mg 1 M

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 10mg, 20mg, 40mg, 80mg


1 QL M

lovastatin TABS 10mg, 20mg, 40mg


1 QL M

pravastatin sodium TABS 10mg, 20mg, 40mg, 80mg


1 QL M

rosuvastatin calcium TABS 5mg, 10mg, 20mg, 40mg


1 QL M

simvastatin TABS 5mg, 10mg, 20mg, 40mg, 80mg


1 QL M

ANTILIPEMICS, MISCELLANEOUS cholestyramine PACK 4gm; POWD 4gm/dose

2 M

cholestyramine light PACK 4gm; POWD 4gm/dose

2 M

colesevelam hcl PACK 3.75gm; TABS 625mg

2 M

Drug Name Drug Tier

Requirements/Limits

colestipol hcl GRAN 5gm; PACK 5gm; TABS 1gm

2 M

ezetimibe TABS 10mg 2 M

JUXTAPID CAPS 5mg, 10mg, 20mg, 30mg

5 LA PA

niacin (antihyperlipidemic) TBCR 500mg, 750mg, 1000mg


2 QL M

PRALUENT SOAJ 75mg/ml, 150mg/ml

3 PA

prevalite PACK 4gm; POWD 4gm/dose

2 M

VASCEPA CAPS .5gm, 1gm 4 M

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg

1 M

atenolol & chlorthalidone tab 100-25 mg

1 M

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

1 M

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1 M

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1 M

metoprolol & hydrochlorothiazide tab 50-25 mg

2 M


2 M


2 M

propranolol & hydrochlorothiazide tab 40-25 mg

2 M

propranolol & hydrochlorothiazide tab 80-25 mg

2 M

BETA-BLOCKERS acebutolol hcl CAPS 200mg, 400mg

2 M

atenolol TABS 25mg, 50mg, 100mg

1 M


16

Drug Name Drug Tier

Requirements/Limits

bisoprolol fumarate TABS 5mg, 10mg

1 M

BYSTOLIC TABS 2.5mg, 5mg, 10mg


4 QL M

BYSTOLIC TABS 20mg QL (60 tabs / 30 days)

4 QL M

carvedilol TABS 3.125mg, 6.25mg, 12.5mg, 25mg

1 M

labetalol hcl TABS 100mg, 200mg, 300mg

2 M

metoprolol succinate TB24 25mg, 50mg, 100mg, 200mg

1 M

metoprolol tartrate SOLN 5mg/5ml

2 M

metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 20mg, 40mg, 80mg

2 M

pindolol TABS 5mg, 10mg 2 M

propranolol hcl CP24 60mg, 80mg, 120mg, 160mg; SOLN 20mg/5ml, 40mg/5ml; TABS 10mg, 20mg, 40mg, 60mg, 80mg

2 M

timolol maleate TABS 5mg, 10mg, 20mg

2 M

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 2.5mg, 5mg, 10mg

1 M

cartia xt CP24 120mg, 180mg, 240mg, 300mg

2 M

dilt-xr CP24 120mg, 180mg, 240mg

2 M

diltiazem hcl CP12 60mg, 90mg, 120mg; SOLN 25mg/5ml, 50mg/10ml, 125mg/25ml

2 M

diltiazem hcl TABS 30mg, 60mg, 90mg, 120mg

1 M

diltiazem hcl coated beads CP24 120mg, 180mg, 240mg, 300mg, 360mg

2 M

diltiazem hcl extended release beads CP24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

2 M

felodipine TB24 2.5mg, 5mg, 10mg

2 M

isradipine CAPS 2.5mg, 5mg 2 M

Drug Name Drug Tier

Requirements/Limits

nicardipine hcl CAPS 20mg, 30mg

2 M

nifedipine TB24 30mg, 60mg, 90mg

2 M

nimodipine CAPS 30mg 2 M

NYMALIZE SOLN 6mg/ml 5 M

taztia xt CP24 120mg, 180mg, 240mg, 300mg, 360mg

2 M

tiadylt er CP24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

2 M

verapamil hcl CP24 100mg, 120mg, 180mg, 200mg, 240mg, 300mg, 360mg; SOLN 2.5mg/ml

2 M

verapamil hcl TABS 40mg, 80mg, 120mg; TBCR 120mg, 180mg, 240mg

1 M

DIURETICS acetazolamide CP12 500mg; TABS 125mg, 250mg

2 M

amiloride & hydrochlorothiazide tab 5-50 mg

1 M

amiloride hcl TABS 5mg 1 M

bumetanide SOLN .25mg/ml; TABS .5mg, 1mg, 2mg

2 M

chlorthalidone TABS 25mg, 50mg

2 M

furosemide SOLN 8mg/ml, 10mg/ml; TABS 20mg, 40mg, 80mg

1 M

furosemide inj SOLN 10mg/ml

2 M

hydrochlorothiazide CAPS 12.5mg; TABS 12.5mg, 25mg, 50mg

1 M

indapamide TABS 1.25mg, 2.5mg

1 M

methazolamide TABS 25mg, 50mg

2 M

metolazone TABS 2.5mg, 5mg, 10mg

2 M

spironolactone & hydrochlorothiazide tab 25-25 mg

2 M

torsemide TABS 5mg, 10mg, 20mg, 100mg

1 M


17

Drug Name Drug Tier

Requirements/Limits

triamterene & hydrochlorothiazide cap 37.5-25 mg

1 M

triamterene & hydrochlorothiazide tab 37.5-25 mg

1 M

triamterene & hydrochlorothiazide tab 75-50 mg

1 M

MISCELLANEOUS ADRENALIN SOLN 1mg/ml 4 M

aliskiren fumarate TABS 150mg, 300mg

2 M

clonidine PTWK .1mg/24hr, .2mg/24hr, .3mg/24hr

2 M

clonidine hcl TABS .1mg, .2mg, .3mg

1 M

CORLANOR SOLN 5mg/5ml; TABS 5mg, 7.5mg

4 M

digitek TABS .125mg, .25mg QL (30 tabs / 30 days)

2 QL M

digox TABS 125mcg, 250mcg QL (30 tabs / 30 days)

2 QL M

digoxin SOLN .05mg/ml, .25mg/ml

2 M

digoxin TABS 125mcg, 250mcg


2 QL M

droxidopa CAPS 100mg QL (90 caps / 30 days)

5 QL PA

droxidopa CAPS 200mg, 300mg


5 QL PA

guanfacine hcl TABS 1mg, 2mg

PA if 70 years and older

3 M PA

hydralazine hcl SOLN 20mg/ml; TABS 10mg, 25mg, 50mg, 100mg

2 M

methyldopa TABS 250mg, 500mg


2 M PA

metyrosine CAPS 250mg 5 M PA

midodrine hcl TABS 2.5mg, 5mg, 10mg

2 M

minoxidil TABS 2.5mg, 10mg 2 M

NORTHERA CAPS 100mg QL (90 caps / 30 days)

5 QL LA PA

Drug Name Drug Tier

Requirements/Limits

NORTHERA CAPS 200mg, 300mg


5 QL LA PA

ranolazine TB12 500mg, 1000mg

2 M

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

2 M

isosorbide mononitrate TABS 10mg, 20mg; TB24 30mg, 60mg, 120mg

1 M

minitran PT24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr

2 M

NITRO-BID OINT 2% 3 M

NITRO-DUR PT24 .3mg/hr, .8mg/hr

4 M

nitroglycerin PT24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr; SUBL .3mg, .4mg, .6mg

2 M

PULMONARY ARTERIAL HYPERTENSION ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg, 2.5mg


5 QL LA PA

ambrisentan TABS 5mg, 10mg


5 QL LA PA

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

5 QL LA PA

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

5 QL LA PA

OPSUMIT TABS 10mg QL (30 tabs / 30 days)

5 QL LA PA

sildenafil citrate (pulmonary hypertension) TABS 20mg


2 QL PA

treprostinil SOLN 20mg/20ml, 50mg/20ml, 100mg/20ml, 200mg/20ml

5 LA PA

VENTAVIS SOLN 10mcg/ml, 20mcg/ml

5 PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam TABS .25mg, .5mg, 1mg, 2mg


2 QL M

buspirone hcl TABS 5mg, 10mg, 15mg

1 M

buspirone hcl TABS 7.5mg, 30mg

2 M


18

Drug Name Drug Tier

Requirements/Limits

fluvoxamine maleate TABS 25mg, 50mg, 100mg

2 M

lorazepam CONC 2mg/ml QL (150 mL / 30 days)

2 QL M

lorazepam SOLN 2mg/ml, 4mg/ml

2 M

lorazepam TABS .5mg, 1mg, 2mg


2 QL M

lorazepam intensol CONC 2mg/ml

QL (150 mL / 30 days)

2 QL M

ANTICONVULSANTS APTIOM TABS 200mg, 400mg, 600mg, 800mg


5 QL M

BANZEL TABS 200mg, 400mg

5 M PA

BRIVIACT SOLN 10mg/ml QL (600 mL / 30 days)

5 QL M PA

BRIVIACT SOLN 50mg/5ml 4 M PA

BRIVIACT TABS 10mg, 25mg, 50mg, 75mg, 100mg


5 QL M PA

carbamazepine CHEW 100mg; CP12 100mg, 200mg, 300mg; SUSP 100mg/5ml; TABS 200mg; TB12 100mg, 200mg, 400mg

2 M

CELONTIN CAPS 300mg 4 M

clobazam SUSP 2.5mg/ml QL (480 mL / 30 days)

2 QL M PA

clobazam TABS 10mg, 20mg QL (60 tabs / 30 days)

2 QL M PA

clonazepam TABS 2mg; TBDP 2mg


2 QL M

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


2 QL M

clorazepate dipotassium TABS 3.75mg, 7.5mg, 15mg

QL (180 tabs / 30 days) PA if 65 years and older

2 QL M PA

DIACOMIT CAPS 250mg, 500mg; PACK 250mg, 500mg

5 LA PA

diazepam CONC 5mg/ml QL (240 mL / 30 days)


2 QL M PA

Drug Name Drug Tier

Requirements/Limits

diazepam SOLN 5mg/5ml QL (1200 mL / 30 days)


2 QL M PA

diazepam TABS 2mg, 5mg, 10mg


2 QL M PA

diazepam (anticonvulsant) GEL 2.5mg, 10mg, 20mg

2 M

diazepam inj SOLN 5mg/ml 2 M

DILANTIN CAPS 30mg, 100mg

4 M

DILANTIN INFATABS CHEW 50mg

4 M

DILANTIN-125 SUSP 125mg/5ml

4 M

divalproex sodium CSDR 125mg; TB24 250mg, 500mg; TBEC 125mg, 250mg, 500mg

2 M

EPIDIOLEX SOLN 100mg/ml QL (600 mL / 30 days)

5 QL LA PA

epitol TABS 200mg 2 M

ethosuximide CAPS 250mg; SOLN 250mg/5ml

2 M

felbamate SUSP 600mg/5ml 5 M

felbamate TABS 400mg, 600mg

2 M

FINTEPLA SOLN 2.2mg/ml QL (360 mL / 30 days)

5 QL LA PA

FYCOMPA SUSP .5mg/ml QL (720 mL / 30 days)

5 QL M PA

FYCOMPA TABS 2mg QL (60 tabs / 30 days)

4 QL M PA

FYCOMPA TABS 4mg, 6mg QL (60 tabs / 30 days)

5 QL M PA

FYCOMPA TABS 8mg, 10mg, 12mg


5 QL M PA

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

1 QL M


1 QL M


1 QL M

gabapentin SOLN 250mg/5ml QL (2160 mL / 30 days)

2 QL M

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

2 QL M


19

Drug Name Drug Tier

Requirements/Limits

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

2 QL M

lamotrigine CHEW 5mg, 25mg; TB24 25mg, 50mg, 100mg, 200mg, 250mg, 300mg

2 M

lamotrigine TABS 25mg, 100mg, 150mg, 200mg

1 M

levetiracetam SOLN 100mg/ml, 500mg/5ml; TABS 250mg, 500mg, 750mg, 1000mg; TB24 500mg, 750mg

2 M

levetiracetam in sodium chloride iv soln 500 mg/100ml

2 M


2 M


2 M

NAYZILAM SOLN 5mg/0.1ml 4 M

oxcarbazepine SUSP 300mg/5ml; TABS 150mg, 300mg, 600mg

2 M

PEGANONE TABS 250mg 4 M

phenobarbital ELIX 20mg/5ml PA if 70 years and older

4 M PA

phenobarbital TABS 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg, 100mg


3 M PA

phenobarbital sodium SOLN 65mg/ml, 130mg/ml


4 M PA

PHENYTEK CAPS 200mg, 300mg

4 M

phenytoin CHEW 50mg; SUSP 125mg/5ml

2 M

phenytoin sodium SOLN 50mg/ml

2 M

phenytoin sodium extended CAPS 100mg, 200mg, 300mg

2 M

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


2 QL M PA

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

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

pregabalin CAPS 225mg, 300mg


2 QL M PA

pregabalin SOLN 20mg/ml QL (900 mL / 30 days)

2 QL M PA

primidone TABS 50mg, 250mg

1 M

roweepra TABS 500mg 2 M

rufinamide SUSP 40mg/ml 5 M PA

SPRITAM TB3D 250mg, 500mg, 750mg, 1000mg

4 M

subvenite TABS 25mg, 100mg, 150mg, 200mg

1 M

SYMPAZAN FILM 5mg QL (60 films / 30 days)

4 QL M PA

SYMPAZAN FILM 10mg, 20mg

QL (60 films / 30 days)

5 QL M PA

tiagabine hcl TABS 2mg, 4mg, 12mg, 16mg

2 M

topiramate CPSP 15mg, 25mg

2 M

topiramate TABS 25mg, 50mg, 100mg, 200mg

1 M

valproate sodium SOLN 100mg/ml, 250mg/5ml

2 M

valproic acid CAPS 250mg 2 M

VALTOCO LIQD 5mg/0.1ml, 10mg/0.1ml; LQPK 7.5mg/0.1ml, 10mg/0.1ml

4 M

vigabatrin PACK 500mg QL (180 packets / 30 days)

5 QL LA PA

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

5 QL LA PA

vigadrone PACK 500mg QL (180 packets / 30 days)

5 QL LA PA

VIMPAT SOLN 10mg/ml QL (1200 mL / 30 days)

5 QL M

VIMPAT SOLN 200mg/20ml 5 M

VIMPAT TABS 50mg QL (120 tabs / 30 days)

4 QL M

VIMPAT TABS 100mg, 150mg, 200mg


5 QL M

XCOPRI TABS 50mg QL (90 tabs / 30 days)

5 QL M


20

Drug Name Drug Tier

Requirements/Limits

XCOPRI TABS 100mg, 150mg, 200mg


5 QL M

XCOPRI PAK 12.5-25 QL (28 tabs / 28 days)

4 QL M

XCOPRI PAK 50-100MG QL (28 tabs / 28 days)

5 QL M

XCOPRI PAK 150-200MG (MAINTENANCE)


5 QL M

XCOPRI PAK 150-200MG (TITRATION)


5 QL M

XCOPRI TAB 50-200MG QL (56 tabs / 28 days)

5 QL M

zonisamide CAPS 25mg, 50mg, 100mg

2 M

ANTIDEMENTIA donepezil hydrochloride TABS 5mg; TBDP 5mg


1 QL M

donepezil hydrochloride TABS 10mg; TBDP 10mg

1 M

galantamine hydrobromide CP24 8mg, 16mg, 24mg


2 QL M

galantamine hydrobromide SOLN 4mg/ml

2 M

galantamine hydrobromide TABS 4mg, 8mg, 12mg


2 QL M

memantine hcl CP24 7mg, 14mg, 21mg, 28mg; SOLN 2mg/ml; TABS 5mg, 10mg

PA if < 30 yrs

2 M PA

NAMZARIC CAP 7-10MG 4 M




NAMZARIC CAP PACK 4 M

rivastigmine PT24 4.6mg/24hr, 9.5mg/24hr, 13.3mg/24hr


2 QL M

rivastigmine tartrate CAPS 1.5mg, 3mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

rivastigmine tartrate CAPS 4.5mg, 6mg


2 QL M

ANTIDEPRESSANTS amitriptyline hcl TABS 10mg, 25mg, 50mg, 75mg, 100mg, 150mg

3 M

amoxapine TABS 25mg, 50mg, 100mg, 150mg

3 M

bupropion hcl TABS 75mg, 100mg; TB24 150mg, 300mg

2 M

bupropion hcl TB12 100mg, 150mg, 200mg

1 M

citalopram hydrobromide SOLN 10mg/5ml

2 M

citalopram hydrobromide TABS 10mg, 20mg, 40mg

1 M

clomipramine hcl CAPS 25mg, 50mg, 75mg

4 M PA

desipramine hcl TABS 10mg, 25mg, 50mg, 75mg, 100mg, 150mg

4 M

desvenlafaxine succinate TB24 25mg, 50mg, 100mg


2 QL M PA

doxepin hcl CAPS 10mg, 25mg, 50mg, 75mg, 100mg; CONC 10mg/ml

3 M

doxepin hcl CAPS 150mg 4 M

DRIZALMA SPRINKLE CSDR 20mg, 30mg, 40mg, 60mg


4 QL M PA

duloxetine hcl CPEP 20mg, 30mg, 60mg


2 QL M

EMSAM PT24 6mg/24hr, 9mg/24hr, 12mg/24hr


5 QL M PA

escitalopram oxalate SOLN 5mg/5ml

2 M

escitalopram oxalate TABS 5mg, 10mg, 20mg

1 M

FETZIMA CP24 20mg, 40mg QL (60 caps / 30 days)

4 QL M PA

FETZIMA CP24 80mg, 120mg


4 QL M PA

FETZIMA CAP TITRATIO 4 M PA


21

Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl CAPS 10mg, 20mg, 40mg

1 M

fluoxetine hcl SOLN 20mg/5ml

2 M

imipramine hcl TABS 10mg, 25mg, 50mg

2 M

maprotiline hcl TABS 25mg, 50mg, 75mg

2 M

MARPLAN TABS 10mg QL (180 tabs / 30 days)

4 QL M

mirtazapine TABS 7.5mg; TBDP 15mg, 30mg, 45mg

2 M

mirtazapine TABS 15mg, 30mg, 45mg

1 M

nefazodone hcl TABS 50mg, 100mg, 150mg, 200mg, 250mg

2 M

nortriptyline hcl CAPS 10mg, 25mg, 50mg, 75mg

2 M

nortriptyline hcl SOLN 10mg/5ml

4 M

paroxetine hcl TABS 10mg, 20mg, 30mg, 40mg

2 M

PAXIL SUSP 10mg/5ml QL (900 mL / 30 days)

4 QL M

phenelzine sulfate TABS 15mg

2 M

protriptyline hcl TABS 5mg, 10mg

4 M

sertraline hcl CONC 20mg/ml 2 M

sertraline hcl TABS 25mg, 50mg, 100mg

1 M

tranylcypromine sulfate TABS 10mg

2 M

trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trimipramine maleate CAPS 25mg


4 QL M



4 QL M



4 QL M

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

4 QL M


4 QL M

Drug Name Drug Tier

Requirements/Limits


4 QL M

venlafaxine hcl CP24 37.5mg, 75mg, 150mg

1 M

venlafaxine hcl TABS 25mg, 37.5mg, 50mg, 75mg, 100mg

2 M

VIIBRYD TABS 10mg, 20mg, 40mg


4 QL M

VIIBRYD KIT STARTER 4 M

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS 100mg

QL (120 caps / 30 days) 2 QL M

amantadine hcl SYRP 50mg/5ml

1 M

amantadine hcl TABS 100mg 2 M

APOKYN SOCT 30mg/3ml QL (20 cartridges / 30 days)

5 QL LA PA

benztropine mesylate SOLN 1mg/ml

2 M

benztropine mesylate TABS .5mg, 1mg, 2mg


3 M PA

bromocriptine mesylate CAPS 5mg; TABS 2.5mg

2 M

carbidopa & levodopa orally disintegrating tab 10-100 mg

2 M


2 M


2 M

carbidopa & levodopa tab 10-100 mg

2 M


2 M


2 M

carbidopa & levodopa tab er 25-100 mg

2 M

carbidopa & levodopa tab er 50-200 mg

2 M

carbidopa-levodopa-entacapone tabs 12.5-50-200 mg

2 M


2 M


22

Drug Name Drug Tier

Requirements/Limits

carbidopa-levodopa-entacapone tabs 25-100-200 mg

2 M


2 M


2 M

carbidopa-levodopa-entacapone tabs 50-200-200 mg

2 M

entacapone TABS 200mg 2 M

KYNMOBI FILM 10mg, 15mg, 20mg, 25mg, 30mg


5 QL PA

NEUPRO PT24 1mg/24hr, 2mg/24hr, 3mg/24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr

4 M

pramipexole dihydrochloride TABS .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg

1 M

rasagiline mesylate TABS 1mg


2 QL M

rasagiline mesylate TABS .5mg


2 QL M

ropinirole hydrochloride TABS .25mg, .5mg, 1mg, 2mg, 3mg, 4mg, 5mg

1 M

selegiline hcl CAPS 5mg; TABS 5mg

2 M

trihexyphenidyl hcl SOLN .4mg/ml; TABS 2mg, 5mg


3 M PA

ANTIPSYCHOTICS ABILIFY MAINTENA PRSY 300mg, 400mg; SRER 300mg, 400mg

QL (1 injection / 28 days)

5 QL M

aripiprazole SOLN 1mg/ml QL (900 mL / 30 days)

5 QL M

aripiprazole TABS 2mg, 5mg, 10mg, 15mg, 20mg, 30mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

aripiprazole TBDP 10mg, 15mg


5 QL M

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


5 QL M

ARISTADA PRSY 1064mg/3.9ml


5 QL M

ARISTADA INITIO PRSY 675mg/2.4ml

5 M

asenapine maleate SUBL 2.5mg, 5mg, 10mg


2 QL M

CAPLYTA CAPS 42mg QL (30 caps / 30 days)

4 QL M

chlorpromazine hcl SOLN 25mg/ml, 50mg/2ml; TABS 10mg, 25mg, 50mg, 100mg, 200mg

2 M

clozapine TABS 25mg, 50mg 2 M

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

2 QL M

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

2 QL M

clozapine TBDP 12.5mg, 25mg

2 M PA

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

2 QL M PA


5 QL M PA


5 QL M PA

FANAPT TABS 1mg, 2mg, 4mg, 6mg, 8mg, 10mg, 12mg


5 QL M PA

FANAPT PAK 4 M PA

fluphenazine decanoate SOLN 25mg/ml

2 M

fluphenazine hcl CONC 5mg/ml; ELIX 2.5mg/5ml; SOLN 2.5mg/ml; TABS 1mg, 2.5mg, 5mg, 10mg

2 M

haloperidol TABS .5mg, 1mg, 2mg, 5mg, 10mg, 20mg

2 M

haloperidol decanoate SOLN 50mg/ml, 100mg/ml

2 M


23

Drug Name Drug Tier

Requirements/Limits

haloperidol lactate CONC 2mg/ml; SOLN 5mg/ml

2 M

INVEGA SUSTENNA SUSY 39mg/0.25ml


4 QL M

INVEGA SUSTENNA SUSY 78mg/0.5ml, 117mg/0.75ml, 156mg/ml, 234mg/1.5ml


5 QL M

INVEGA TRINZA SUSY 273mg/0.875ml, 410mg/1.315ml, 546mg/1.75ml, 819mg/2.625ml


5 QL M

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


4 QL M

LATUDA TABS 80mg QL (60 tabs / 30 days)

4 QL M

loxapine succinate CAPS 5mg, 10mg, 25mg, 50mg

2 M

molindone hcl TABS 5mg, 10mg, 25mg

2 M

NUPLAZID CAPS 34mg QL (30 caps / 30 days)

5 QL LA PA

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

5 QL LA PA

olanzapine SOLR 10mg QL (3 vials / 1 day)

2 QL M

olanzapine TABS 2.5mg, 5mg, 10mg; TBDP 10mg


2 QL M

olanzapine TABS 7.5mg, 15mg, 20mg; TBDP 5mg, 15mg, 20mg


2 QL M

paliperidone TB24 1.5mg, 3mg, 9mg


2 QL M

paliperidone TB24 6mg QL (60 tabs / 30 days)

2 QL M

perphenazine TABS 2mg, 4mg, 8mg, 16mg

2 M

Drug Name Drug Tier

Requirements/Limits

PERSERIS PRSY 90mg, 120mg


5 QL M

pimozide TABS 1mg, 2mg 2 M

quetiapine fumarate TABS 25mg, 50mg, 100mg, 200mg, 300mg, 400mg

2 M

quetiapine fumarate TB24 50mg, 300mg, 400mg


2 QL M PA

quetiapine fumarate TB24 150mg, 200mg


2 QL M PA

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

4 QL M

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


4 QL M

RISPERDAL CONSTA SRER 12.5mg, 25mg

QL (2 injections / 28 days)

4 QL M

RISPERDAL CONSTA SRER 37.5mg, 50mg


5 QL M

risperidone SOLN 1mg/ml QL (240 mL / 30 days)

2 QL M

risperidone TABS .25mg, .5mg, 1mg, 2mg, 3mg, 4mg

1 M

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


2 QL M

risperidone TBDP .25mg, .5mg


2 QL M

SECUADO PT24 3.8mg/24hr, 5.7mg/24hr, 7.6mg/24hr


4 QL M

thioridazine hcl TABS 10mg, 25mg, 50mg, 100mg

2 M

thiothixene CAPS 1mg, 2mg, 5mg, 10mg

2 M

trifluoperazine hcl TABS 1mg, 2mg, 5mg, 10mg

2 M

VERSACLOZ SUSP 50mg/ml QL (600 mL / 30 days)

5 QL M PA


24

Drug Name Drug Tier

Requirements/Limits

VRAYLAR CAPS 1.5mg QL (60 caps / 30 days)

5 QL M PA

VRAYLAR CAPS 3mg, 4.5mg, 6mg


5 QL M PA

VRAYLAR CAP 1.5-3MG 4 M PA

ziprasidone hcl CAPS 20mg, 40mg, 60mg, 80mg


2 QL M

ziprasidone mesylate SOLR 20mg


2 QL M

ZYPREXA RELPREVV SUSR 210mg

QL (2 vials / 28 days)

4 QL M PA



5 QL M PA


QL (1 vial / 28 days)

5 QL M PA

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


2 QL M PA

amphetamine-dextroamphetamine cap er 24hr 10 mg


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

amphetamine-dextroamphetamine tab 5 mg


2 QL M PA

amphetamine-dextroamphetamine tab 7.5 mg


2 QL M PA



2 QL M PA

amphetamine-dextroamphetamine tab 12.5 mg


2 QL M PA



2 QL M PA



2 QL M PA



2 QL M PA

atomoxetine hcl CAPS 10mg, 18mg, 25mg


2 QL M

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

2 QL M

atomoxetine hcl CAPS 60mg, 80mg, 100mg


2 QL M

dexmethylphenidate hcl TABS 2.5mg, 5mg


2 QL M PA

dexmethylphenidate hcl TABS 10mg


2 QL M PA

guanfacine hcl (adhd) TB24 1mg, 2mg, 3mg, 4mg


3 QL M PA

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

2 QL M PA

methylphenidate hcl SOLN 5mg/5ml

QL (1800 mL / 30 days)

2 QL M PA


25

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl SOLN 10mg/5ml

QL (900 mL / 30 days)

2 QL M PA

methylphenidate hcl TABS 5mg, 10mg


2 QL M PA

methylphenidate hcl TABS 20mg; TBCR 10mg, 20mg


2 QL M PA

HYPNOTICS BELSOMRA TABS 5mg, 10mg, 15mg, 20mg


4 QL M

doxepin hcl (sleep) TABS 3mg, 6mg


2 QL M

HETLIOZ CAPS 20mg 5 LA PA

temazepam CAPS 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 CAPS 15mg QL (60 caps / 30 days)

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

2 QL M PA

temazepam CAPS 30mg QL (30 caps / 30 days)


2 QL M PA

zolpidem tartrate TABS 5mg, 10mg

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

2 QL M PA

MIGRAINE AIMOVIG SOAJ 70mg/ml, 140mg/ml

QL (1 pen / 30 days)

3 QL PA

dihydroergotamine mesylate SOLN 1mg/ml

5 M

dihydroergotamine mesylate SOLN 4mg/ml

QL (8 mL / 30 days)

5 QL M PA

ergotamine w/ caffeine tab 1-100 mg

2 M

naratriptan hcl TABS 1mg, 2.5mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

rizatriptan benzoate TABS 5mg, 10mg; TBDP 5mg, 10mg


2 QL M

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

2 QL M

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

2 QL M

sumatriptan succinate SOAJ 4mg/0.5ml; SOCT 4mg/0.5ml


2 QL M

sumatriptan succinate SOAJ 6mg/0.5ml; SOCT 6mg/0.5ml; SOLN 6mg/0.5ml; SOSY 6mg/0.5ml


2 QL M

sumatriptan succinate TABS 25mg, 50mg, 100mg


2 QL M

UBRELVY TABS 50mg, 100mg


5 QL M PA

zolmitriptan TABS 2.5mg, 5mg; TBDP 2.5mg, 5mg


2 QL M

MISCELLANEOUS AUSTEDO TABS 6mg

QL (60 tabs / 30 days) 5 QL PA

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

5 QL PA

INGREZZA CAPS 40mg, 80mg


5 QL PA

INGREZZA CAP 40-80MG QL (28 caps / 28 days)

5 QL PA

LITHIUM SOLN 8meq/5ml 4 M

lithium carbonate CAPS 150mg, 300mg, 600mg; TABS 300mg

1 M

lithium carbonate TBCR 300mg, 450mg

2 M

LYRICA CR TB24 82.5mg, 165mg, 330mg


3 QL M PA

NUEDEXTA CAP 20-10MG QL (60 caps / 30 days)

4 QL M PA


26

Drug Name Drug Tier

Requirements/Limits

pyridostigmine bromide TABS 60mg

2 M

riluzole TABS 50mg 2 M

tetrabenazine TABS 12.5mg QL (90 tabs / 30 days)

5 QL PA

tetrabenazine TABS 25mg QL (120 tabs / 30 days)

5 QL PA

MULTIPLE SCLEROSIS AGENTS BETASERON KIT .3mg

QL (14 syringes / 28 days)

5 QL PA

dalfampridine TB12 10mg 2 PA

GILENYA CAPS .5mg QL (28 caps / 28 days)

5 QL PA

glatiramer acetate SOSY 20mg/ml


5 QL PA

glatiramer acetate SOSY 40mg/ml


5 QL PA

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

5 QL PA

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

5 QL PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg 2 M

cyclobenzaprine hcl TABS 5mg, 10mg


3 M PA

dantrolene sodium CAPS 25mg, 50mg, 100mg

2 M

tizanidine hcl TABS 2mg, 4mg

2 M

NARCOLEPSY/CATAPLEXY armodafinil TABS 50mg

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

armodafinil TABS 150mg, 200mg, 250mg


2 QL M PA

XYREM SOLN 500mg/ml QL (540 mL / 30 days)

5 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium TBEC 333mg

2 M

Drug Name Drug Tier

Requirements/Limits

buprenorphine hcl SUBL 2mg, 8mg


2 QL M PA

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)


2 QL M

buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)


2 QL M



2 QL M



2 QL M

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)


2 QL M

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)


2 QL M

bupropion hcl (smoking deterrent) TB12 150mg

2 M

CHANTIX TABS .5mg, 1mg 4 M PA

CHANTIX CONTINUING MONTH TABS 1mg

4 M PA

CHANTIX PAK 0.5& 1MG 4 M PA

disulfiram TABS 250mg, 500mg

2 M

naloxone hcl SOCT .4mg/ml; SOLN .4mg/ml, 4mg/10ml; SOSY 2mg/2ml

2 M

naltrexone hcl TABS 50mg 2 M

NARCAN LIQD 4mg/0.1ml 3 M

NICOTROL INHALER INHA 10mg

4 M

NICOTROL NS SOLN 10mg/ml

4 M

VIVITROL SUSR 380mg 5

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM PT24 2mg/24hr, 4mg/24hr


4 QL M PA


27

Drug Name Drug Tier

Requirements/Limits

oxandrolone TABS 2.5mg QL (120 tabs / 30 days)

2 QL M PA

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

2 QL M PA

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

QL (300 gm / 30 days)

2 QL M PA

testosterone cypionate SOLN 100mg/ml, 200mg/ml

2 M PA

testosterone enanthate SOLN 200mg/ml

2 M PA

ANTIDIABETICS acarbose TABS 25mg, 50mg, 100mg

2 M

BYDUREON BCISE AUIJ 2mg/0.85ml

QL (4 pens / 28 days)

3 QL M

BYDUREON PEN PEN 2mg QL (4 pens / 28 days)

3 QL M

BYETTA SOPN 5mcg/0.02ml, 10mcg/0.04ml


4 QL M

FARXIGA TABS 5mg, 10mg QL (30 tabs / 30 days)

3 QL M

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

1 QL M

glimepiride TABS 4mg QL (60 tabs / 30 days)

1 QL M

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

1 QL M

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

1 QL M

glipizide TB24 2.5mg, 5mg QL (90 tabs / 30 days)

1 QL M

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

1 QL M

glipizide xl TB24 2.5mg, 5mg QL (90 tabs / 30 days)

1 QL M

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

1 QL M

glipizide-metformin hcl tab 2.5-250 mg


1 QL M

glipizide-metformin hcl tab 2.5-500 mg


1 QL M

glipizide-metformin hcl tab 5-500 mg


1 QL M

Drug Name Drug Tier

Requirements/Limits

GLYXAMBI TAB 10-5 MG QL (30 tabs / 30 days)

3 QL M

GLYXAMBI TAB 25-5 MG QL (30 tabs / 30 days)

3 QL M

JANUMET TAB 50-500MG QL (60 tabs / 30 days)

3 QL M

JANUMET TAB 50-1000 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 TABS 25mg, 50mg, 100mg


3 QL M

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

3 QL M

JARDIANCE TABS 25mg QL (30 tabs / 30 days)

3 QL M

JENTADUETO TAB 2.5-500 QL (60 tabs / 30 days)

3 QL M


3 QL M


3 QL M

JENTADUETO TAB XR 2.5-1000MG


3 QL M

JENTADUETO TAB XR 5-1000MG


3 QL M

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

1 QL M


1 QL M


1 QL M

metformin hcl TB24 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin hcl TB24 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M


28

Drug Name Drug Tier

Requirements/Limits

nateglinide TABS 60mg, 120mg


1 QL M

OZEMPIC (0.25 OR 0.5MG/DOSE) SOPN 2mg/1.5ml


3 QL M

OZEMPIC (1MG/DOSE) SOPN 2mg/1.5ml


3 QL M

OZEMPIC (1MG/DOSE) SOPN 4mg/3ml


3 QL M

pioglitazone hcl TABS 15mg, 30mg, 45mg


1 QL M

repaglinide TABS 2mg QL (240 tabs / 30 days)

1 QL M

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

1 QL M

RYBELSUS TABS 3mg, 7mg, 14mg


3 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

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

3 QL M

SYNJARDY TAB 12.5-1000MG


3 QL M

SYNJARDY XR TAB 5-1000MG


3 QL M

SYNJARDY XR TAB 10-1000 QL (60 tabs / 30 days)

3 QL M

SYNJARDY XR TAB 12.5-1000MG


3 QL M

SYNJARDY XR TAB 25-1000 QL (30 tabs / 30 days)

3 QL M

TRADJENTA TABS 5mg QL (30 tabs / 30 days)

3 QL M

TRIJARDY XR TAB ER 24HR 5-2.5-1000MG


3 QL M

TRIJARDY XR TAB ER 24HR 10-5-1000MG


3 QL M

Drug Name Drug Tier

Requirements/Limits

TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG


3 QL M

TRIJARDY XR TAB ER 24HR 25-5-1000MG


3 QL M

TRULICITY SOPN .75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml


3 QL M

VICTOZA SOPN 18mg/3ml QL (3 pens / 30 days)

3 QL M

XIGDUO XR TAB 2.5-1000 QL (60 tabs / 30 days)

3 QL M

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

3 QL M


3 QL M


3 QL M

XIGDUO XR TAB 10-1000 QL (30 tabs / 30 days)

3 QL M

ANTIDIABETICS, INSULINS BASAGLAR KWIKPEN SOPN 100unit/ml

3 M

BD ALCOHOL SWABS 3 M

FIASP FLEX INJ TOUCH 3 M

FIASP INJ 100/ML 3 M

FIASP PENFIL INJ U-100 3 M

GAUZE PADS 2" X 2" 3 M

HUMULIN R U-500 (CONCENTR SOLN 500unit/ml

5 B/D M

HUMULIN R U-500 KWIKPEN SOPN 500unit/ml

5 M

INSULIN SAFETY NEEDLES 3 M

INSULIN SYRINGES: BD/ULTIMED/ALLISON/TRIVIDIA/MHC

3 M

LEVEMIR SOLN 100unit/ml 3 M

LEVEMIR FLEXTOUCH SOPN 100unit/ml

3 M

NOVOLIN INJ 70/30 (brand RELION not covered)

3 M

NOVOLIN INJ 70/30 FP (brand RELION not covered)

3 M


29

Drug Name Drug Tier

Requirements/Limits

NOVOLIN N SUSP 100unit/ml

(brand RELION not covered)

3 M

NOVOLIN N FLEXPEN SUPN 100unit/ml


3 M

NOVOLIN R SOLN 100unit/ml


3 M

NOVOLIN R FLEXPEN SOPN 100unit/ml


3 M

NOVOLOG SOLN 100unit/ml 3 M

NOVOLOG FLEXPEN SOPN 100unit/ml

3 M

NOVOLOG MIX INJ 70/30 3 M

NOVOLOG MIX INJ FLEXPEN

3 M

NOVOLOG PENFILL SOCT 100unit/ml

3 M

OMNIPOD KIT STARTER QL (1 kit / year)

4 QL M PA

OMNIPOD MIS 5 PACK QL (10 boxes / 30 days)

4 QL M PA

PEN NEEDLES: NOVO/BD/ULTIMED/OWEN/TRIVIDIA

3 M

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

3 QL M

TRESIBA SOLN 100unit/ml 3 M

TRESIBA FLEXTOUCH SOPN 100unit/ml, 200unit/ml

3 M

V-GO 20 KIT QL (1 kit / 30 days)

4 QL M PA


4 QL M PA


4 QL M PA

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

3 QL M

CALCIUM REGULATORS alendronate sodium TABS 10mg, 35mg, 70mg

1 M

calcitonin (salmon) SOLN 200unit/act

2 B/D M

Drug Name Drug Tier

Requirements/Limits

FORTEO SOPN 620mcg/2.48ml

5 PA

ibandronate sodium TABS 150mg

2 B/D M

NATPARA CART 25mcg, 50mcg, 75mcg, 100mcg

5 PA

PAMIDRONATE DISODIUM SOLN 6mg/ml

3 B/D M

pamidronate disodium SOLN 30mg/10ml, 90mg/10ml; SOLR 30mg, 90mg

2 B/D M

PROLIA SOSY 60mg/ml QL (1 injection / 180 days)

4 QL

TYMLOS SOPN 3120mcg/1.56ml

5 PA

XGEVA SOLN 120mg/1.7ml 5 PA

zoledronic acid CONC 4mg/5ml; SOLN 4mg/100ml, 5mg/100ml

2 B/D

CHELATING AGENTS CHEMET CAPS 100mg 4 M

clovique CAPS 250mg 5 M PA

deferasirox PACK 90mg, 180mg, 360mg; TABS 90mg, 180mg, 360mg

5 PA

LOKELMA PACK 5gm, 10gm 3 M

penicillamine TABS 250mg 5 M

sodium polystyrene sulfonate powder

2 M

sps SUSP 15gm/60ml 2 M

trientine hcl CAPS 250mg 5 M PA

VELTASSA PACK 8.4gm, 16.8gm, 25.2gm

4 M PA

CONTRACEPTIVES afirmelle 2 M

altavera 2 M

alyacen 1/35 2 M

alyacen 7/7/7 2 M

apri 2 M

aranelle 2 M

aubra eq 2 M

aurovela 1/20 2 M

aurovela fe 1.5/30 2 M

aurovela fe 1/20 2 M

aviane 2 M

ayuna 2 M

azurette 2 M

balziva 2 M


30

Drug Name Drug Tier

Requirements/Limits

bekyree 2 M

blisovi fe 1.5/30 2 M

briellyn 2 M

camila TABS .35mg 2 M

caziant 2 M

chateal 2 M

cryselle-28 2 M

cyclafem 1/35 2 M

cyclafem 7/7/7 2 M

cyred eq 2 M

dasetta 1/35 2 M

dasetta 7/7/7 2 M

deblitane TABS .35mg 2 M

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)

2 M

drospirenone-ethinyl estradiol tab 3-0.02 mg

2 M

drospirenone-ethinyl estradiol tab 3-0.03 mg

2 M

elinest 2 M

ELLA TABS 30mg 3 M

eluryng 2 M

emoquette 2 M

enpresse-28 2 M

enskyce 2 M

errin TABS .35mg 2 M

estarylla 2 M

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg

2 M

ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg

2 M

etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr

2 M

falmina 2 M

femynor 2 M

gianvi 2 M

hailey 1.5/30 2 M

heather TABS .35mg 2 M

iclevia 2 M

incassia TABS .35mg 2 M

introvale 2 M

isibloom 2 M

jasmiel 2 M

jolessa 2 M

juleber 2 M

junel 1.5/30 2 M

junel 1/20 2 M

Drug Name Drug Tier

Requirements/Limits

junel fe 1.5/30 2 M

junel fe 1/20 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 2 M

leena 2 M

lessina 2 M

levonest 2 M

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

2 M

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg

2 M

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg

2 M

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg

2 M

levora 0.15/30-28 2 M

lillow 2 M

loestrin 1.5/30-21 2 M

loestrin 1/20-21 2 M

loestrin fe 1.5/30 2 M

loestrin fe 1/20 2 M

loryna 2 M

low-ogestrel 2 M

lutera 2 M

lyleq TABS .35mg 2 M

lyza TABS .35mg 2 M

marlissa 2 M

medroxyprogesterone acetate (contraceptive) SUSP 150mg/ml; SUSY 150mg/ml

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 2 M

necon 0.5/35-28 2 M

nikki 2 M

nora-be TABS .35mg 2 M


31

Drug Name Drug Tier

Requirements/Limits

norethindrone (contraceptive) TABS .35mg

2 M

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg

2 M

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg

2 M

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg

2 M

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg

2 M

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg

2 M

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg

2 M

norlyroc TABS .35mg 2 M

nortrel 0.5/35 (28) 2 M

nortrel 1/35 (21) 2 M

nortrel 1/35 (28) 2 M

nortrel 7/7/7 2 M

nylia 7/7/7 2 M

nymyo 2 M

ocella 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

setlakin 2 M

sharobel TABS .35mg 2 M

simliya 2 M

sprintec 28 2 M

sronyx 2 M

syeda 2 M

tarina fe 1/20 eq 2 M

tilia fe 2 M

tri-estarylla 2 M

tri-legest fe 2 M

tri-linyah 2 M

tri-lo-estarylla 2 M

tri-lo-marzia 2 M

tri-lo-mili 2 M

tri-lo-sprintec 2 M

tri-mili 2 M

tri-nymyo 2 M

tri-previfem 2 M

Drug Name Drug Tier

Requirements/Limits

tri-sprintec 2 M

tri-vylibra 2 M

tri-vylibra lo 2 M

trivora-28 2 M

tulana TABS .35mg 2 M

velivet 2 M

vienva 2 M

viorele 2 M

vyfemla 2 M

vylibra 2 M

wera 2 M

xulane 2 M

zarah 2 M

zovia 1/35e 2 M

zumandimine 2 M

ENDOMETRIOSIS danazol CAPS 50mg, 100mg, 200mg

2 M

SYNAREL SOLN 2mg/ml 5 M

ESTROGENS amabelz 3 M

DELESTROGEN OIL 10mg/ml

4 M

dotti PTTW .025mg/24hr, .037mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr

3 M

estradiol PTTW .025mg/24hr, .037mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr; PTWK .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr, 37.5mcg/24hr

3 M

estradiol TABS .5mg, 1mg, 2mg

2 M

estradiol & norethindrone acetate tab 0.5-0.1 mg

3 M

estradiol & norethindrone acetate tab 1-0.5 mg

3 M

estradiol vaginal CREA .1mg/gm; TABS 10mcg

2 M

estradiol valerate OIL 20mg/ml, 40mg/ml

2 M

fyavolv tab 0.5mg-2.5mcg 3 M

fyavolv tab 1mg-5mcg 3 M

jinteli 3 M

lopreeza 3 M


32

Drug Name Drug Tier

Requirements/Limits

lyllana PTTW .025mg/24hr, .037mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr

3 M

mimvey 3 M

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg

3 M

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg

3 M

yuvafem TABS 10mcg 2 M

GLUCOCORTICOIDS cortisone acetate TABS 25mg

2 M

dexamethasone ELIX .5mg/5ml; SOLN .5mg/5ml; TABS .5mg, .75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg

2 M

DEXAMETHASONE INTENSOL CONC 1mg/ml

4 M

dexamethasone sodium phosphate SOLN 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml

2 M

fludrocortisone acetate TABS .1mg

2 M

hydrocortisone TABS 5mg, 10mg, 20mg

2 M

methylprednisolone TABS 4mg, 8mg, 16mg, 32mg

2 B/D M

methylprednisolone TBPK 4mg

2 M

methylprednisolone acetate SUSP 40mg/ml, 80mg/ml

2 B/D M

methylprednisolone sod succ SOLR 40mg, 125mg, 1000mg

2 B/D M

prednisolone SOLN 15mg/5ml

2 B/D M

prednisolone sodium phosphate SOLN 5mg/5ml, 15mg/5ml, 25mg/5ml

2 B/D M

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

prednisone TABS 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg

1 B/D M

prednisone TBPK 5mg, 10mg 2 M

PREDNISONE INTENSOL CONC 5mg/ml

4 B/D M

SOLU-CORTEF SOLR 100mg, 250mg, 500mg, 1000mg

4 M

Drug Name Drug Tier

Requirements/Limits

GLUCOSE ELEVATING AGENTS diazoxide SUSP 50mg/ml 5 M

GVOKE HYPOPEN 2-PACK SOAJ .5mg/0.1ml, 1mg/0.2ml

3 M

GVOKE PFS SOSY .5mg/0.1ml, 1mg/0.2ml

3 M

MISCELLANEOUS ALDURAZYME SOLN 2.9mg/5ml

5 LA PA

cabergoline TABS .5mg 2 M

CARBAGLU TABS 200mg 5 LA PA

CERDELGA CAPS 84mg 5 PA

CEREZYME SOLR 400unit 5 LA PA

cinacalcet hcl TABS 30mg QL (120 tabs / 30 days)

2 B/D QL


5 B/D QL


5 B/D QL

CYSTADANE POW 5 LA

CYSTAGON CAPS 50mg, 150mg

4 LA PA

desmopressin acetate SOLN 4mcg/ml

5 M

desmopressin acetate TABS .1mg, .2mg

2 M

desmopressin acetate spray SOLN .01%

2 M

desmopressin acetate spray refrigerated SOLN .01%

2 M

FABRAZYME SOLR 5mg, 35mg

5 LA PA

GENOTROPIN SOLR 5mg, 12mg

5 PA

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

5 PA

INCRELEX SOLN 40mg/4ml 5 LA PA

KORLYM TABS 300mg 5 LA PA

levocarnitine (metabolic modifiers) SOLN 1gm/10ml; TABS 330mg

2 B/D M

LUMIZYME SOLR 50mg 5 LA PA

LUPRON DEPOT-PED (1-MONTH KIT 7.5mg, 11.25mg, 15mg

5 PA

LUPRON DEPOT-PED (3-MONTH KIT 11.25mg, 30mg

5 PA


33

Drug Name Drug Tier

Requirements/Limits

miglustat CAPS 100mg QL (90 caps / 30 days)

5 QL PA

NAGLAZYME SOLN 1mg/ml 5 LA PA

nitisinone CAPS 2mg, 5mg, 10mg

5 PA

octreotide acetate SOLN 50mcg/ml, 100mcg/ml, 200mcg/ml

2 PA

octreotide acetate SOLN 500mcg/ml, 1000mcg/ml

5 PA

OSPHENA TABS 60mg 3 M PA

raloxifene hcl TABS 60mg 2 M

sapropterin dihydrochloride PACK 100mg, 500mg

5 PA

sapropterin dihydrochloride TABS 100mg

5 M PA

SIGNIFOR SOLN .3mg/ml, .6mg/ml, .9mg/ml

5 LA PA

sodium phenylbutyrate POWD 3gm/tsp; TABS 500mg

5 PA

SOMATULINE DEPOT SOLN 60mg/0.2ml, 90mg/0.3ml, 120mg/0.5ml

5 PA

SOMAVERT SOLR 10mg, 15mg, 20mg, 25mg, 30mg

5 LA PA

STIMATE SOLN 1.5mg/ml 5

PHOSPHATE BINDER AGENTS AURYXIA TABS 210mg


calcium acetate (phosphate binder) CAPS 667mg


2 QL M

calcium acetate (phosphate binder) TABS 667mg


2 QL M

sevelamer carbonate PACK 2.4gm

QL (180 packets / 30 days)

5 QL M

sevelamer carbonate PACK .8gm

QL (540 packets / 30 days)

5 QL M

sevelamer carbonate TABS 800mg


2 QL M

PROGESTINS medroxyprogesterone acetate TABS 2.5mg, 5mg, 10mg

1 M

Drug Name Drug Tier

Requirements/Limits

megestrol acetate SUSP 40mg/ml

3 M

megestrol acetate (appetite) SUSP 625mg/5ml

4 M PA

norethindrone acetate TABS 5mg

2 M

THYROID AGENTS euthyrox TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg

2 M

levo-t TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg

2 M

levothyroxine sodium TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg

1 M

levoxyl TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg

2 M

liothyronine sodium TABS 5mcg, 25mcg, 50mcg

2 M

methimazole TABS 5mg, 10mg

1 M

propylthiouracil TABS 50mg 2 M

SYNTHROID TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg

3 M

unithroid TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg

2 M

VITAMIN D ANALOGS calcitriol CAPS .25mcg, .5mcg; SOLN 1mcg/ml

2 B/D M

paricalcitol CAPS 1mcg, 2mcg, 4mcg

2 B/D M

RAYALDEE CPCR 30mcg 5 M


34

Drug Name Drug Tier

Requirements/Limits

GASTROINTESTINAL ANTIEMETICS aprepitant CAPS 40mg, 80mg, 125mg

2 B/D M

aprepitant capsule therapy pack 80 & 125 mg

2 B/D M

compro SUPP 25mg 2 M

dronabinol CAPS 2.5mg, 5mg, 10mg


2 B/D QL M

EMEND SUSR 125mg/5ml 4 B/D M

granisetron hcl SOLN 1mg/ml, 4mg/4ml

2 M

granisetron hcl TABS 1mg 2 B/D M

meclizine hcl TABS 12.5mg, 25mg

2 M

metoclopramide hcl SOLN 5mg/5ml, 5mg/ml

2 M

metoclopramide hcl TABS 5mg, 10mg

1 M

ondansetron TBDP 4mg, 8mg 2 B/D M

ondansetron hcl SOLN 4mg/2ml, 40mg/20ml

2 M

ondansetron hcl SOLN 4mg/5ml; TABS 4mg, 8mg, 24mg

2 B/D M

prochlorperazine SUPP 25mg 2 M

prochlorperazine edisylate SOLN 10mg/2ml

2 M

prochlorperazine maleate TABS 5mg, 10mg

2 M

promethazine hcl SOLN 25mg/ml, 50mg/ml


3 M PA

promethazine hcl SYRP 6.25mg/5ml; TABS 12.5mg, 25mg, 50mg


2 M PA

scopolamine PT72 1mg/3days



4 QL M PA

ANTISPASMODICS dicyclomine hcl CAPS 10mg; TABS 20mg

3 M

dicyclomine hcl SOLN 10mg/5ml

4 M

Drug Name Drug Tier

Requirements/Limits

glycopyrrolate TABS 1mg, 2mg

2 M

H2-RECEPTOR ANTAGONISTS famotidine SOLN 20mg/2ml, 40mg/4ml, 200mg/20ml

2 M

famotidine SUSR 40mg/5ml QL (300 mL / 30 days)

2 QL M

famotidine TABS 20mg QL (120 tabs / 30 days)

1 QL M

famotidine TABS 40mg QL (60 tabs / 30 days)

1 QL M

famotidine in nacl 0.9% iv soln 20 mg/50ml

2 M

nizatidine CAPS 150mg, 300mg

2 M

INFLAMMATORY BOWEL DISEASE balsalazide disodium CAPS 750mg

2 M

budesonide CPEP 3mg 2 M

budesonide TB24 9mg 5 M

hydrocortisone (intrarectal) ENEM 100mg/60ml

2 M

mesalamine CP24 .375gm QL (120 caps / 30 days)

2 QL M

mesalamine CPDR 400mg QL (180 caps / 30 days)

2 QL M

mesalamine ENEM 4gm; SUPP 1000mg

2 M

mesalamine TBEC 1.2gm QL (120 tabs / 30 days)

2 QL M

mesalamine w/ cleanser KIT 4gm

2 M

sulfasalazine TABS 500mg; TBEC 500mg

2 M

LAXATIVES constulose SOLN 10gm/15ml 2 M

enulose SOLN 10gm/15ml 2 M

gavilyte-c 1 M

gavilyte-g 1 M

gavilyte-n/flavor pack 1 M

generlac SOLN 10gm/15ml 2 M

GOLYTELY SOL 3 M

lactulose SOLN 10gm/15ml 2 M

lactulose (encephalopathy) SOLN 10gm/15ml

2 M

NULYTELY SOL FLAV PKS 3 M

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm

1 M


35

Drug Name Drug Tier

Requirements/Limits

peg 3350-kcl-sod bicarb-nacl for soln 420 gm

1 M

PLENVU SOL 4 M

SUPREP BOWEL SOL PREP KIT

4 M

trilyte 1 M

MISCELLANEOUS alosetron hcl TABS 1mg


alosetron hcl TABS .5mg QL (60 tabs / 30 days)

2 QL M PA

cromolyn sodium (mastocytosis) CONC 100mg/5ml

2 M

diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml

4 M

diphenoxylate w/ atropine tab 2.5-0.025 mg

3 M

GATTEX KIT 5mg 5 LA PA

LINZESS CAPS 72mcg, 145mcg, 290mcg


4 QL M

loperamide hcl CAPS 2mg 2 M

misoprostol TABS 100mcg, 200mcg

2 M

MOVANTIK TABS 12.5mg QL (60 tabs / 30 days)

3 QL M

MOVANTIK TABS 25mg QL (30 tabs / 30 days)

3 QL M

RELISTOR SOLN 8mg/0.4ml, 12mg/0.6ml

5 M PA

sucralfate TABS 1gm 2 M

TRULANCE TABS 3mg QL (30 tabs / 30 days)

4 QL M

ursodiol CAPS 300mg; TABS 250mg, 500mg

2 M

XIFAXAN TABS 550mg 5 M PA

PANCREATIC ENZYMES CREON CAP 3000UNIT 3 M

CREON CAP 6000UNIT 3 M

CREON CAP 12000UNT 3 M



ZENPEP CAP 3000UNIT 4 M

ZENPEP CAP 5000UNIT 4 M

ZENPEP CAP 10000UNT 4 M



ZENPEP CAP 25000 4 M

Drug Name Drug Tier

Requirements/Limits

ZENPEP CAP 40000 4 M

PROTON PUMP INHIBITORS DEXILANT CPDR 30mg, 60mg


4 QL M

esomeprazole magnesium CPDR 20mg, 40mg


2 QL M ST

lansoprazole CPDR 15mg, 30mg


2 QL M

omeprazole CPDR 10mg, 20mg, 40mg

1 M

pantoprazole sodium SOLR 40mg

2 M

pantoprazole sodium TBEC 20mg, 40mg

1 M

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl TB24 10mg

QL (30 tabs / 30 days) 1 QL M

dutasteride CAPS .5mg QL (30 caps / 30 days)

2 QL M

dutasteride-tamsulosin hcl cap 0.5-0.4 mg


2 QL M

finasteride TABS 5mg 1 M

tamsulosin hcl CAPS .4mg 1 M

MISCELLANEOUS acetic acid SOLN .25% 2 M

bethanechol chloride TABS 5mg, 10mg, 25mg, 50mg

2 M

potassium citrate (alkalinizer) TBCR 15meq, 540mg, 1080mg

2 M

URINARY ANTISPASMODICS MYRBETRIQ TB24 25mg, 50mg


4 QL M

oxybutynin chloride SYRP 5mg/5ml; TABS 5mg

2 M

oxybutynin chloride TB24 5mg


2 QL M

oxybutynin chloride TB24 10mg, 15mg


2 QL M


36

Drug Name Drug Tier

Requirements/Limits

solifenacin succinate TABS 5mg, 10mg


2 QL M

tolterodine tartrate CP24 2mg, 4mg


2 QL M ST

tolterodine tartrate TABS 1mg, 2mg


2 QL M ST

TOVIAZ TB24 4mg, 8mg QL (30 tabs / 30 days)

3 QL M

trospium chloride TABS 20mg


2 QL M

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal CREA 2%

2 M

metronidazole vaginal GEL .75%

2 M

terconazole vaginal CREA .4%, .8%; SUPP 80mg

2 M

vandazole GEL .75% 2 M

HEMATOLOGIC ANTICOAGULANTS ELIQUIS TABS 2.5mg

QL (60 tabs / 30 days) 3 QL M

ELIQUIS TABS 5mg QL (74 tabs / 30 days)

3 QL M

ELIQUIS STARTER PACK TBPK 5mg


3 QL M

enoxaparin sodium SOLN 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml, 300mg/3ml

2 M

fondaparinux sodium SOLN 2.5mg/0.5ml

2 M

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

5 M

HEP SOD/NACL INJ 25000UNT

3 M

heparin sodium (porcine) SOLN 1000unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml

2 B/D M

heparin sodium (porcine) 100 unit/ml in d5w

2 M

Drug Name Drug Tier

Requirements/Limits

heparin sodium (porcine)-dextrose iv sol 20000 unit/500ml-5%

2 M

heparin sodium (porcine)-dextrose iv sol 25000 unit/500ml-5%

2 M

HEPARIN/NACL INJ 25000UNT

3 M

jantoven TABS 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg

1 M

PRADAXA CAPS 75mg, 110mg, 150mg


4 QL M

warfarin sodium TABS 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg

1 M

XARELTO TABS 2.5mg QL (60 tabs / 30 days)

3 QL M

XARELTO TABS 10mg, 15mg, 20mg


3 QL M

XARELTO STAR TAB 15/20MG


3 QL M

HEMATOPOIETIC GROWTH FACTORS PROCRIT SOLN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 PA

PROCRIT SOLN 20000unit/ml, 40000unit/ml

5 PA

ZARXIO SOSY 300mcg/0.5ml, 480mcg/0.8ml

5 PA

MISCELLANEOUS anagrelide hcl CAPS .5mg, 1mg

2 M

BERINERT KIT 500unit QL (24 boxes / 30 days)

5 QL LA PA

cilostazol TABS 50mg, 100mg

1 M

DOPTELET TABS 20mg 5 LA PA

DROXIA CAPS 200mg, 300mg, 400mg

3 M

ENDARI PACK 5gm 5 LA PA

HAEGARDA SOLR 2000unit QL (30 vials / 30 days)

5 QL LA PA

HAEGARDA SOLR 3000unit QL (20 vials / 30 days)

5 QL LA PA


37

Drug Name Drug Tier

Requirements/Limits

icatibant acetate SOLN 30mg/3ml


5 QL PA

pentoxifylline TBCR 400mg 1 M

PROMACTA PACK 12.5mg QL (360 packets / 30 days)

5 QL LA PA

PROMACTA PACK 25mg QL (180 packets / 30 days)

5 QL LA PA

PROMACTA TABS 12.5mg, 25mg


5 QL LA PA

PROMACTA TABS 50mg, 75mg


5 QL LA PA

tranexamic acid SOLN 1000mg/10ml; TABS 650mg

2 M

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr 25-200 mg

2 M

BRILINTA TABS 60mg, 90mg 4 M

clopidogrel bisulfate TABS 75mg

1 M

dipyridamole TABS 25mg, 50mg, 75mg


3 M PA

prasugrel hcl TABS 5mg, 10mg

2 M

IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS ENBREL SOLN 25mg/0.5ml; SOLR 25mg


5 QL PA

ENBREL SOSY 25mg/0.5ml QL (16 syringes / 28 days)

5 QL PA

ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)

5 QL PA

ENBREL MINI SOCT 50mg/ml


5 QL PA

ENBREL SURECLICK SOAJ 50mg/ml


5 QL PA

Drug Name Drug Tier

Requirements/Limits

HUMIRA PSKT 10mg/0.1ml, 20mg/0.2ml


5 QL PA

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

5 QL PA

HUMIRA PSKT 40mg/0.8ml QL (6 syringes / 28 days)

5 QL PA

HUMIRA PEDIA INJ CROHNS

5 PA

HUMIRA PEDIATRIC CROHNS D PSKT 80mg/0.8ml

5 PA

HUMIRA PEN PNKT 40mg/0.4ml, 40mg/0.8ml


5 QL PA

HUMIRA PEN PNKT 80mg/0.8ml


5 QL PA

HUMIRA PEN KIT PS/UV 5 PA

HUMIRA PEN-CD/UC/HS START PNKT 40mg/0.8ml, 80mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER PNKT 40mg/0.8ml

5 PA

REMICADE SOLR 100mg 5 PA

RENFLEXIS SOLR 100mg 5 LA PA

RINVOQ TB24 15mg QL (30 tabs / 30 days)

5 QL PA

SKYRIZI PSKT 75mg/0.83ml QL (7 kits / year)

5 QL PA

STELARA SOLN 45mg/0.5ml QL (1 vial / 28 days)

5 QL LA PA

STELARA SOSY 45mg/0.5ml, 90mg/ml

QL (1 syringe / 28 days)

5 QL PA

TALTZ SOAJ 80mg/ml; SOSY 80mg/ml


5 QL LA PA

XELJANZ SOLN 1mg/ml QL (240 mL / 24 days)

5 QL PA

XELJANZ TABS 5mg, 10mg QL (60 tabs / 30 days)

5 QL PA

XELJANZ XR TB24 11mg, 22mg


5 QL PA


38

Drug Name Drug Tier

Requirements/Limits

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) hydroxychloroquine sulfate TABS 200mg

1 M

leflunomide TABS 10mg, 20mg


2 QL M

methotrexate sodium TABS 2.5mg

2 M

XATMEP SOLN 2.5mg/ml 4 B/D M

IMMUNOGLOBULINS BIVIGAM SOLN 5gm/50ml 5 PA

FLEBOGAMMA DIF SOLN 2.5gm/50ml, 5gm/100ml, 5gm/50ml, 10gm/100ml, 10gm/200ml, 20gm/200ml, 20gm/400ml

5 PA

GAMASTAN INJ 4 B/D

GAMMAGARD LIQUID SOLN 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml

5 PA

GAMMAGARD S/D IGA LESS TH SOLR 5gm, 10gm

5 PA

GAMMAKED SOLN 1gm/10ml, 5gm/50ml, 10gm/100ml, 20gm/200ml

5 PA

GAMMAPLEX SOLN 5gm/100ml, 5gm/50ml, 10gm/100ml, 10gm/200ml, 20gm/200ml, 20gm/400ml

5 PA

GAMUNEX-C SOLN 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 40gm/400ml

5 PA

OCTAGAM SOLN 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 5gm/50ml, 10gm/100ml, 10gm/200ml, 20gm/200ml, 25gm/500ml, 30gm/300ml

5 PA

PANZYGA SOLN 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml

5 PA

PRIVIGEN SOLN 5gm/50ml, 10gm/100ml, 20gm/200ml, 40gm/400ml

5 PA

Drug Name Drug Tier

Requirements/Limits

IMMUNOMODULATORS ACTIMMUNE SOLN 2000000unit/0.5ml

5 LA PA

ARCALYST SOLR 220mg 5 PA

INTRON A SOLN 10mu/ml, 6000000unit/ml; SOLR 10mu, 18mu, 50mu

5 B/D

IMMUNOSUPPRESSANTS azathioprine TABS 50mg 2 B/D M

BENLYSTA SOAJ 200mg/ml; SOLR 120mg, 400mg; SOSY 200mg/ml

5 PA

cyclosporine CAPS 25mg, 100mg; SOLN 50mg/ml

2 B/D M

cyclosporine modified (for microemulsion) CAPS 25mg, 50mg, 100mg; SOLN 100mg/ml

2 B/D M

everolimus (immunosuppressant) TABS .5mg, .75mg

5 B/D M

everolimus (immunosuppressant) TABS .25mg

2 B/D M

gengraf CAPS 25mg, 100mg; SOLN 100mg/ml

2 B/D M

mycophenolate mofetil CAPS 250mg; TABS 500mg

2 B/D M

mycophenolate mofetil SUSR 200mg/ml

5 B/D M

mycophenolate sodium TBEC 180mg, 360mg

2 B/D M

NULOJIX SOLR 250mg 5 B/D M

PROGRAF PACK .2mg, 1mg 4 B/D M

SANDIMMUNE SOLN 100mg/ml

3 B/D M

sirolimus SOLN 1mg/ml; TABS 2mg

5 B/D M

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

tacrolimus CAPS .5mg, 1mg, 5mg

2 B/D M

ZORTRESS TABS 1mg 5 B/D M

VACCINES ACTHIB INJ 3

ADACEL INJ 3

BCG VACCINE INJ 3

BEXSERO INJ 3

BOOSTRIX INJ 3


39

Drug Name Drug Tier

Requirements/Limits

DAPTACEL INJ 3

DIP/TET PED INJ 25-5LFU 3 B/D

ENGERIX-B SUSP 10mcg/0.5ml, 20mcg/ml

3 B/D

GARDASIL 9 INJ 3

HAVRIX SUSP 720elu/0.5ml, 1440elu/ml

3

HIBERIX SOLR 10mcg 3

IMOVAX RABIES (H.D.C.V.) INJ 2.5unit/ml

3 B/D

INFANRIX INJ 3

IPOL INJ INACTIVE 3

IXIARO INJ 3

KINRIX INJ 3

M-M-R II INJ 3

MENACTRA INJ 3

MENQUADFI INJ 3

MENVEO INJ 3

PEDIARIX INJ 0.5ML 3

PEDVAX HIB SUSP 7.5mcg/0.5ml

3

PENTACEL INJ 3

PROQUAD INJ 3

QUADRACEL INJ 3

RABAVERT INJ 3 B/D

RECOMBIVAX HB SUSP 5mcg/0.5ml, 10mcg/ml, 40mcg/ml

3 B/D

ROTARIX SUS 3

ROTATEQ SOL 3

SHINGRIX SUSR 50mcg/0.5ml

QL (2 vials per lifetime)

3 QL

TDVAX INJ 2-2 LF 3 B/D

TENIVAC INJ 5-2LF 3 B/D

TRUMENBA INJ 3

TWINRIX INJ 3

TYPHIM VI SOLN 25mcg/0.5ml

3

VAQTA SUSP 25unit/0.5ml, 50unit/ml

3

VARIVAX INJ 1350pfu/0.5ml 3

YF-VAX INJ 3

ZOSTAVAX SUSR 19400unt/0.65ml

QL (1 vial per lifetime)

3 QL

Drug Name Drug Tier

Requirements/Limits

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES/MINERALS, INJECTABLE D5W/LYTES INJ #48 4 M

D5W/NACL INJ 0.3% 3 M

D10W/NACL INJ 0.2% 3 M

dextrose 2.5% w/ sodium chloride 0.45%

2 M

dextrose 5% in lactated ringers

2 M

dextrose 5% w/ sodium chloride 0.2%

2 M


2 M


2 M


2 M

ISOLYTE-P INJ /D5W 4 M

ISOLYTE-S INJ 4 M

kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj

2 M


2 M


2 M


2 M

kcl 20 meq/l (0.15%) in nacl 0.9% inj

2 M

kcl 20 meq/l (0.15%) in nacl 0.45% inj

2 M


2 M


2 M

KCL/D5W/NACL INJ 0.3/0.9% 4 M

KCL/D5W/NACL INJ 0.15/0.2 4 M

lactated ringer's solution 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, 50%

3 M


40

Drug Name Drug Tier

Requirements/Limits

magnesium sulfate in dextrose 5% iv soln 1 gm/100ml

3 M

MG SO4/D5W INJ 10MG/ML 3 M

PLASMA-LYTE INJ -148 4 M

PLASMA-LYTE INJ -A 4 M

POT CHL/NACL INJ 20MEQ/L

2 M

POT CHL/NACL INJ 40MEQ/L

2 M

potassium chloride SOLN 2meq/ml

2 M

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

4 M

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj

2 M

sodium chloride SOLN .45%, .9%, 2.5meq/ml, 3%, 5%

2 M

TPN ELECTROL INJ 4 B/D M

ELECTROLYTES/MINERALS/VITAMINS, ORAL klor-con PACK 20meq 2 M

klor-con 8 TBCR 8meq 1 M

klor-con 10 TBCR 10meq 1 M

klor-con m10 TBCR 10meq 1 M



M-NATAL PLUS TAB 3 M

PNV FOLIC AC TAB + IRON 3 M

potassium chloride CPCR 8meq, 10meq; PACK 20meq; SOLN 10%, 20%

2 M

potassium chloride TBCR 8meq, 10meq, 20meq

1 M

potassium chloride microencapsulated crystals er TBCR 10meq, 20meq

1 M

PRENATAL TAB 27-1MG 3 M

PRENATAL TAB PLUS 3 M

PRENATAL VIT TAB LOW IRON

3 M

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

2 M

TRICARE TAB PRENATAL 3 M

IV NUTRITION AMINOSYN-PF INJ 7% 4 B/D M

CLINIMIX INJ 4.25/D5W 4 B/D M

Drug Name Drug Tier

Requirements/Limits

CLINIMIX INJ 4.25/D10 4 B/D M

CLINIMIX INJ 5%/D15W 4 B/D M

CLINIMIX INJ 5%/D20W 4 B/D M

CLINIMIX INJ 6/5 4 B/D M



clinisol sf 15% 2 B/D M

CLINOLIPID EMU 20% 4 B/D M

dextrose SOLN 5%, 10% 2 M

dextrose SOLN 50%, 70% 2 B/D M

FREAMINE HBC INJ 6.9% 4 B/D M

FREAMINE III INJ 10% 4 B/D M

hepatamine 4 B/D M

INTRALIPID EMUL 20gm/100ml, 30gm/100ml

4 B/D M

NEPHRAMINE INJ 5.4% 4 B/D M

NUTRILIPID EMUL 20gm/100ml

4 B/D M

plenamine 2 B/D M

PREMASOL SOL 10% 4 B/D M

PROCALAMINE INJ 3% 4 B/D M

PROSOL INJ 20% 4 B/D M

TRAVASOL INJ 10% 4 B/D M

TROPHAMINE INJ 10% 4 B/D M

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-polymyxin-neomycin-hc ophth oint 1%

2 M

BLEPHAMIDE OIN S.O.P. 4 M

neomycin-polymyxin-dexamethasone ophth oint 0.1%

1 M

neomycin-polymyxin-dexamethasone ophth susp 0.1%

2 M

neomycin-polymyxin-hc ophth susp

2 M

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%

2 M

TOBRADEX OIN 0.3-0.1% 3 M

TOBRADEX ST SUS 0.3-0.05 3 M

tobramycin-dexamethasone ophth susp 0.3-0.1%

2 M

ZYLET SUS 0.5-0.3% 3 M

ANTI-INFECTIVES bacitracin (ophthalmic) OINT 500unit/gm

2 M


41

Drug Name Drug Tier

Requirements/Limits

bacitracin-polymyxin b ophth oint

1 M

BESIVANCE SUSP .6% 3 M

CILOXAN OINT .3% 3 M

ciprofloxacin hcl (ophth) SOLN .3%

1 M

erythromycin (ophth) OINT 5mg/gm

1 M

gatifloxacin (ophth) SOLN .5%

2 M

gentak OINT .3% 2 M

gentamicin sulfate (ophth) SOLN .3%

1 M

moxifloxacin hcl (ophth) SOLN .5%

2 M

NATACYN SUSP 5% 4 M

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

2 M

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml

2 M

ofloxacin (ophth) SOLN .3% 2 M

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

1 M

sulfacetamide sodium (ophth) OINT 10%; SOLN 10%

2 M

tobramycin (ophth) SOLN .3%

1 M

trifluridine SOLN 1% 2 M

ZIRGAN GEL .15% 4 M

ANTI-INFLAMMATORIES ALREX SUSP .2% 3 M

bromfenac sodium (ophth) SOLN .09%

2 M

BROMSITE SOLN .075% 4 M

dexamethasone sodium phosphate (ophth) SOLN .1%

2 M

diclofenac sodium (ophth) SOLN .1%

2 M

DUREZOL EMUL .05% 3 M

FLAREX SUSP .1% 4 M

fluorometholone (ophth) SUSP .1%

2 M

flurbiprofen sodium SOLN .03%

2 M

ILEVRO SUSP .3% 3 M

ketorolac tromethamine (ophth) SOLN .4%, .5%

2 M

Drug Name Drug Tier

Requirements/Limits

LOTEMAX OINT .5% 3 M

prednisolone acetate (ophth) SUSP 1%

2 M

PREDNISOLONE SODIUM PHOSP SOLN 1%

3 M

PROLENSA SOLN .07% 3 M

ANTIALLERGICS azelastine hcl (ophth) SOLN .05%

2 M

BEPREVE SOLN 1.5% 3 M

cromolyn sodium (ophth) SOLN 4%

1 M

LASTACAFT SOLN .25% 4 M

olopatadine hcl SOLN .2% 2 M

PAZEO SOLN .7% 3 M

ZERVIATE SOLN .24% 4 M

ANTIGLAUCOMA ALPHAGAN P SOLN .1% 3 M

AZOPT SUSP 1% 3 M

betaxolol hcl (ophth) SOLN .5%

2 M

BETOPTIC-S SUSP .25% 3 M

brimonidine tartrate SOLN .2%

1 M

brimonidine tartrate SOLN .15%

2 M

brinzolamide SUSP 1% 2 M

carteolol hcl (ophth) SOLN 1%

2 M

COMBIGAN SOL 0.2/0.5% 3 M

dorzolamide hcl SOLN 2% 1 M

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

1 M

latanoprost SOLN .005% 1 M

levobunolol hcl SOLN .5% 1 M

LUMIGAN SOLN .01% 3 M

PHOSPHOLINE IODIDE SOLR .125%

4 M

pilocarpine hcl SOLN 1%, 2%, 4%

2 M

RHOPRESSA SOLN .02% 3 M

SIMBRINZA SUS 1-0.2% 3 M

timolol maleate (ophth) SOLG .25%, .5%

2 M

timolol maleate (ophth) SOLN .25%, .5%

1 M

timolol maleate (ophth) once-daily SOLN .5%

2 M


42

Drug Name Drug Tier

Requirements/Limits

VYZULTA SOLN .024% 4 M

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

3 M

CYSTADROPS SOLN .37% 5 LA PA

CYSTARAN SOLN .44% 5 LA PA

proparacaine hcl SOLN .5% 2 M

RESTASIS EMUL .05% 3 M

RESTASIS MULTIDOSE EMUL .05%

3 M

XIIDRA SOLN 5% 3 M

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

QL (60 blisters / 30 days)

3 QL M

BEVESPI AER 9-4.8MCG QL (1 inhaler / 30 days)

3 QL M

BREZTRI AERO AER SPHERE

QL (1 inhaler / 30 days)

3 QL M

BREZTRI AERO AER SPHERE (INSTITUTIONAL PACK)

QL (4 inhalers / 28 days)

3 QL M

COMBIVENT AER 20-100 QL (2 inhalers / 30 days)

4 QL M

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml

2 B/D M

TRELEGY AER ELLIPTA 100-62.5-25 MCG


3 QL M

TRELEGY AER ELLIPTA 200-62.5-25 MCG


3 QL M

ANTICHOLINERGICS ATROVENT HFA AERS 17mcg/act


4 QL M

INCRUSE ELLIPTA AEPB 62.5mcg/inh


3 QL M

ipratropium bromide SOLN .02%

2 B/D M

Drug Name Drug Tier

Requirements/Limits

ipratropium bromide (nasal) SOLN .03%, .06%

2 M

ANTIHISTAMINES azelastine hcl SOLN .1%, .15%

2 M

cetirizine hcl SOLN 1mg/ml 1 M

cyproheptadine hcl SYRP 2mg/5ml; TABS 4mg


3 M PA

diphenhydramine hcl SOLN 50mg/ml

2 M

hydroxyzine hcl SOLN 25mg/ml, 50mg/ml


4 M PA

hydroxyzine hcl SYRP 10mg/5ml


3 M PA

hydroxyzine hcl TABS 10mg, 25mg, 50mg


2 M PA

hydroxyzine pamoate CAPS 25mg, 50mg


2 M PA

levocetirizine dihydrochloride SOLN 2.5mg/5ml

2 M

levocetirizine dihydrochloride TABS 5mg

1 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 Ventolin HFA)

2 QL M

albuterol sulfate NEBU .083%, .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

2 B/D M

albuterol sulfate SYRP 2mg/5ml; TABS 2mg, 4mg; TB12 4mg, 8mg

2 M

levalbuterol hcl NEBU 1.25mg/0.5ml, 1.25mg/3ml

2 B/D M

levalbuterol tartrate AERO 45mcg/act


2 QL M


43

Drug Name Drug Tier

Requirements/Limits

SEREVENT DISKUS AEPB 50mcg/dose

QL (60 inhalations / 30 days)

3 QL M

terbutaline sulfate TABS 2.5mg, 5mg

2 M

VENTOLIN HFA AERS 108mcg/act


3 QL M

VENTOLIN HFA (INSTITUTIONAL PACK) AERS 108mcg/act


3 QL M

LEUKOTRIENE MODULATORS montelukast sodium CHEW 4mg, 5mg; PACK 4mg

2 M

montelukast sodium TABS 10mg

1 M

zafirlukast TABS 10mg, 20mg 2 M

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

2 B/D M

ARALAST NP SOLR 500mg, 1000mg

5 LA PA

cromolyn sodium NEBU 20mg/2ml

2 B/D M

DALIRESP TABS 250mcg, 500mcg

4 M

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

(generic of EpiPen)

2 M

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

(generic of Adrenaclick)

2 M

ESBRIET CAPS 267mg QL (270 caps / 30 days)

5 QL PA

ESBRIET TABS 267mg QL (270 tabs / 30 days)

5 QL PA

ESBRIET TABS 801mg QL (90 tabs / 30 days)

5 QL PA

FASENRA SOSY 30mg/ml 5 LA PA

FASENRA PEN SOAJ 30mg/ml

5 LA PA

KALYDECO PACK 25mg, 50mg, 75mg

QL (56 packs / 28 days)

5 QL PA

Drug Name Drug Tier

Requirements/Limits

KALYDECO TABS 150mg QL (60 tabs / 30 days)

5 QL PA

OFEV CAPS 100mg, 150mg QL (60 caps / 30 days)

5 QL PA

ORKAMBI GRA 100-125 QL (56 packs / 28 days)

5 QL PA

ORKAMBI GRA 150-188 QL (56 packs / 28 days)

5 QL PA

ORKAMBI TAB 100-125 QL (112 tabs / 28 days)

5 QL PA

ORKAMBI TAB 200-125 QL (112 tabs / 28 days)

5 QL PA

PROLASTIN-C SOLN 1000mg/20ml; SOLR 1000mg

5 LA PA

PULMOZYME SOLN 1mg/ml 5 PA

SYMDEKO TAB 50-75MG QL (56 tabs / 28 days)

5 QL LA PA

SYMDEKO TAB 100-150 QL (56 tabs / 28 days)

5 QL LA PA

THEO-24 CP24 100mg, 200mg, 300mg, 400mg

4 M

theophylline SOLN 80mg/15ml; TB12 300mg, 450mg; TB24 400mg, 600mg

2 M

TRIKAFTA TAB QL (84 tabs / 28 days)

5 QL LA PA

XOLAIR SOLR 150mg; SOSY 75mg/0.5ml, 150mg/ml

5 LA PA

ZEMAIRA SOLR 1000mg 5 LA PA

NASAL STEROIDS flunisolide (nasal) SOLN .025%

QL (3 bottles / 30 days)

2 QL M

fluticasone propionate (nasal) SUSP 50mcg/act

QL (1 bottle / 30 days)

2 QL M

STEROID INHALANTS ARNUITY ELLIPTA AEPB 50mcg/act, 100mcg/act, 200mcg/act


3 QL M

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

2 B/D M

FLOVENT DISKUS AEPB 50mcg/blist


3 QL M


44

Drug Name Drug Tier

Requirements/Limits

FLOVENT DISKUS AEPB 100mcg/blist, 250mcg/blist


3 QL M

FLOVENT HFA AERO 44mcg/act, 110mcg/act, 220mcg/act


3 QL M

PULMICORT FLEXHALER AEPB 90mcg/act


4 QL M

PULMICORT FLEXHALER AEPB 180mcg/act


4 QL M

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKU AER 100/50


3 QL M

ADVAIR DISKU AER 250/50 QL (60 inhalations / 30 days)

3 QL M

ADVAIR DISKU AER 500/50 QL (60 inhalations / 30 days)

3 QL M

ADVAIR HFA AER 45/21 QL (1 inhaler / 30 days)

3 QL M


3 QL M


3 QL M

BREO ELLIPTA INH 100-25 QL (60 blisters / 30 days)

3 QL M

BREO ELLIPTA INH 200-25 QL (60 blisters / 30 days)

3 QL M

SYMBICORT AER 80-4.5 QL (1 inhaler / 30 days)

3 QL M

SYMBICORT AER 160-4.5 QL (1 inhaler / 30 days)

3 QL M

TOPICAL DERMATOLOGY, ACNE amnesteem CAPS 10mg, 20mg, 40mg

2 M PA

avita CREA .025%; GEL .025%

QL (45 gm / 30 days)

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

benzoyl peroxide-erythromycin gel 5-3%

2 M

claravis CAPS 10mg, 20mg, 30mg, 40mg

2 M PA

clindamycin phosphate (topical) GEL 1%


2 QL M

clindamycin phosphate (topical) LOTN 1%; SOLN 1%


2 QL M

ery PADS 2% 2 M

erythromycin (acne aid) SOLN 2%


2 QL M

isotretinoin CAPS 10mg, 20mg, 30mg, 40mg

2 M PA

myorisan CAPS 10mg, 20mg, 30mg, 40mg

2 M PA

sulfacetamide sodium (acne) LOTN 10%

2 M

tretinoin CREA .025%, .05%, .1%; GEL .01%, .025%


2 QL M PA

zenatane CAPS 10mg, 20mg, 30mg, 40mg

2 M PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) CREA .1%


2 QL M

gentamicin sulfate (topical) OINT .1%

2 M

mupirocin OINT 2% QL (220 gm / 30 days)

1 QL M

silver sulfadiazine CREA 1% 2 M

ssd CREA 1% 2 M

SULFAMYLON CREA 85mg/gm

4 M

DERMATOLOGY, ANTIFUNGALS ciclopirox olamine CREA .77%


2 QL M

ciclopirox olamine SUSP .77%


2 QL M

clotrimazole (topical) CREA 1%


2 QL M


45

Drug Name Drug Tier

Requirements/Limits

clotrimazole (topical) SOLN 1%


2 QL M

clotrimazole w/ betamethasone cream 1-0.05%


2 QL M

ketoconazole (topical) CREA 2%


2 QL M

nyamyc POWD 100000unit/gm


2 QL M

nystatin (topical) CREA 100000unit/gm; OINT 100000unit/gm


2 QL M

nystatin (topical) POWD 100000unit/gm


2 QL M

nystop POWD 100000unit/gm QL (60 gm / 30 days)

2 QL M

DERMATOLOGY, ANTIPSORIATICS acitretin CAPS 10mg, 17.5mg, 25mg

2 M PA

calcipotriene CREA .005%; OINT .005%

QL (120 gm / 30 days)

2 QL M PA

calcipotriene SOLN .005% QL (120 mL / 30 days)

2 QL M PA

calcitrene OINT .005% QL (120 gm / 30 days)

2 QL M PA

tazarotene CREA .1% QL (60 gm / 30 days)

2 QL M PA

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

4 QL M PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole (topical) SHAM 2%

QL (120 mL / 30 days)

1 QL M

selenium sulfide LOTN 2.5% 2 M

DERMATOLOGY, CORTICOSTEROIDS ala-cort CREA 1%, 2.5% 1 M

alclometasone dipropionate CREA .05%; OINT .05%

2 M

betamethasone dipropionate (topical) CREA .05%; LOTN .05%; OINT .05%

2 M

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented CREA .05%; GEL .05%; LOTN .05%; OINT .05%

2 M

betamethasone valerate CREA .1%; LOTN .1%; OINT .1%

2 M

clobetasol propionate CREA .05%; GEL .05%; OINT .05%


2 QL M

clobetasol propionate SOLN .05%


2 QL M

clobetasol propionate e CREA .05%


2 QL M

ENSTILAR AER QL (120 gm / 30 days)

4 QL M PA

fluocinolone acetonide CREA .01%, .025%; OIL .01%; OINT .025%

2 M

fluocinolone acetonide SOLN .01%


2 QL M

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

2 QL M

fluocinonide GEL .05%; OINT .05%


2 QL M

fluocinonide SOLN .05% QL (60 mL / 30 days)

2 QL M

fluocinonide emulsified base CREA .05%

QL (120 gm / 30 days)

2 QL M

fluticasone propionate CREA .05%; OINT .005%

2 M

halobetasol propionate CREA .05%; OINT .05%


2 QL M

hydrocortisone (topical) CREA 1%, 2.5%

1 M

hydrocortisone (topical) LOTN 2.5%; OINT 2.5%

2 M

mometasone furoate CREA .1%; OINT .1%; SOLN .1%

2 M

triamcinolone acetonide (topical) CREA .1%

QL (454 gm / 30 days)

1 QL M


46

Drug Name Drug Tier

Requirements/Limits

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

1 M

triamcinolone acetonide (topical) LOTN .025%, .1%

2 M

triderm CREA .5% 1 M

DERMATOLOGY, LOCAL ANESTHETICS glydo PRSY 2%

QL (60 mL / 30 days) 2 QL M PA

lidocaine OINT 5% QL (50 gm / 30 days)

2 QL M PA

lidocaine PTCH 5% QL (3 patches / 1 day)

2 QL M PA

lidocaine hcl GEL 2% QL (30 mL / 30 days)

2 QL M PA

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

2 QL M PA

lidocaine-prilocaine cream 2.5-2.5%


2 QL M PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE diclofenac sodium (topical) GEL 1%

QL (1000 gm / 30 days)

2 QL M PA

fluorouracil (topical) CREA 5%


2 QL M

fluorouracil (topical) SOLN 2%, 5%


2 QL M

hydrocortisone (rectal) CREA 2.5%

2 M

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

2 QL M

lactic acid (ammonium lactate) CREA 12%; LOTN 12%

2 M

metronidazole (topical) CREA .75%; GEL .75%; LOTN .75%

2 M

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

4 QL M

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

4 QL M

podofilox SOLN .5% 2 M

procto-med hc CREA 2.5% 2 M

procto-pak CREA 1% 2 M

proctosol hc CREA 2.5% 2 M

proctozone-hc CREA 2.5% 2 M

Drug Name Drug Tier

Requirements/Limits

RECTIV OINT .4% QL (30 gm / 30 days)

4 QL M

rosadan CREA .75% 2 M

tacrolimus (topical) OINT .03%, .1%

QL (100 gm / 30 days)

2 QL M

TARGRETIN GEL 1% QL (60 gm / 30 days)

5 QL PA

VALCHLOR GEL .016% QL (60 gm / 30 days)

5 QL LA PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion LOTN .5% 2 M

permethrin CREA 5% 2 M

DERMATOLOGY, WOUND CARE AGENTS REGRANEX GEL .01%

QL (30 gm / 30 days) 5 QL M PA

SANTYL OINT 250unit/gm 4 M

sodium chloride (gu irrigant) SOLN .9%

2 M

water for irrigation, sterile irrigation soln

2 M

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl CAPS 30mg 2 M

chlorhexidine gluconate (mouth-throat) SOLN .12%

1 M

clotrimazole TROC 10mg QL (150 lozenges / 30 days)

2 QL M

lidocaine hcl (mouth-throat) SOLN 2%

2 M

nystatin (mouth-throat) SUSP 100000unit/ml

2 M

paroex SOLN .12% 1 M

periogard SOLN .12% 1 M

pilocarpine hcl (oral) TABS 5mg, 7.5mg

2 M

triamcinolone acetonide (mouth) PSTE .1%

2 M

OTIC acetic acid (otic) SOLN 2% 2 M

ciprofloxacin-dexamethasone otic susp 0.3-0.1%

2 M

flac OIL .01% 2 M

fluocinolone acetonide (otic) OIL .01%

2 M

neomycin-polymyxin-hc otic soln 1%

2 M


47

Drug Name Drug Tier

Requirements/Limits

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

2 M

ofloxacin (otic) SOLN .3% 2 M

48

Index

A abacavir sulfate................. 4 abacavir sulfate-lamivudine

tab 600-300 mg ............. 5 abacavir sulfate-

lamivudine-zidovudine tab 300-150-300 mg ...... 5

ABELCET ......................... 4 ABILIFY MAINTENA ....... 22 abiraterone acetate ........... 9 ABRAXANE INJ 100MG ... 9 acamprosate calcium ...... 26 acarbose ......................... 27 acebutolol hcl .................. 15 acetaminophen w/ codeine

soln 120-12 mg/5ml ....... 1 acetaminophen w/ codeine

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

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

tab 300-60 mg ............... 1 acetazolamide ................ 16 acetic acid ....................... 35 acetic acid (otic) .............. 46 acetylcysteine ................. 43 acitretin ........................... 45 ACTHIB INJ .................... 38 ACTIMMUNE .................. 38 acyclovir ............................ 6 acyclovir sodium ............... 6 ADACEL INJ ................... 38 adefovir dipivoxil ............... 6 ADEMPAS ...................... 17 ADRENALIN ................... 17 adriamycin ........................ 8 ADVAIR DISKU AER

100/50 ......................... 44 ADVAIR DISKU AER

250/50 ......................... 44 ADVAIR DISKU AER

500/50 ......................... 44 ADVAIR HFA AER 115/21

.................................... 44 ADVAIR HFA AER 230/21

.................................... 44 ADVAIR HFA AER 45/21 44

AFINITOR ......................... 9 AFINITOR DISPERZ ........ 9 afirmelle .......................... 29 AIMOVIG ........................ 25 ala-cort ............................ 45 albendazole ...................... 2 albuterol sulfate .............. 42 alclometasone dipropionate

.................................... 45 ALDURAZYME ............... 32 ALECENSA .................... 10 alendronate sodium ........ 29 alfuzosin hcl .................... 35 ALIMTA ............................. 8 ALINIA .............................. 2 aliskiren fumarate ........... 17 allopurinol ......................... 1 alosetron hcl ................... 35 ALPHAGAN P ................. 41 alprazolam ...................... 17 ALREX ............................ 41 altavera ........................... 29 ALUNBRIG ..................... 10 ALUNBRIG PAK ............. 10 alyacen 1/35 ................... 29 alyacen 7/7/7 .................. 29 amabelz .......................... 31 amantadine hcl ............... 21 AMBISOME ...................... 4 ambrisentan .................... 17 amikacin sulfate ................ 2 amiloride &

hydrochlorothiazide tab 5-50 mg ....................... 16

amiloride hcl.................... 16 AMINOSYN-PF INJ 7% .. 40 amiodarone hcl ............... 14 amitriptyline hcl ............... 20 amlodipine besylate ........ 16 amlodipine besylate-

benazepril hcl cap 10-20 mg ............................... 12

amlodipine besylate-benazepril hcl cap 10-40 mg ............................... 12

amlodipine besylate-benazepril hcl cap 2.5-10 mg ............................... 12




amlodipine besylate-olmesartan medoxomil tab 10-20 mg ............... 13

amlodipine besylate-olmesartan medoxomil tab 10-40 mg ............... 13

amlodipine besylate-olmesartan medoxomil tab 5-20 mg ................. 13

amlodipine besylate-olmesartan medoxomil tab 5-40 mg ................. 13

amlodipine besylate-valsartan tab 10-160 mg .................................... 13

amlodipine besylate-valsartan tab 10-320 mg .................................... 13

amlodipine besylate-valsartan tab 5-160 mg 13

amlodipine besylate-valsartan tab 5-320 mg 13

amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ........... 13

amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg .............. 13

amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg .............. 13

amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ............. 13

49

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg ................ 13

amnesteem ..................... 44 amoxapine ...................... 20 amoxicillin ......................... 7 amoxicillin & k clavulanate

chew tab 200-28.5 mg ... 7 amoxicillin & k clavulanate

chew tab 400-57 mg ...... 7 amoxicillin & k clavulanate

for susp 200-28.5 mg/5ml ...................................... 7

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ...................................... 7

amoxicillin & k clavulanate for susp 400-57 mg/5ml 7

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ...................................... 7

amoxicillin & k clavulanate tab 250-125 mg ............. 7



amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg ...................................... 7

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





amphetamine-dextroamphetamine cap er 24hr 5 mg ................ 24

amphetamine-dextroamphetamine tab 10 mg .......................... 24

amphetamine-dextroamphetamine tab 12.5 mg ....................... 24




amphetamine-dextroamphetamine tab 5 mg ............................... 24

amphetamine-dextroamphetamine tab 7.5 mg ......................... 24

amphotericin b .................. 4 ampicillin ........................... 7 ampicillin & sulbactam

sodium for inj 1.5 (1-0.5) gm ................................. 7

ampicillin & sulbactam sodium for inj 3 (2-1) gm ...................................... 7

ampicillin & sulbactam sodium for iv soln 1.5 (1-0.5) gm .......................... 7

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ............................. 7

ampicillin & sulbactam sodium for iv soln 3 (2-1) gm ................................. 7

ampicillin sodium .............. 7 anagrelide hcl ................. 36 anastrozole ....................... 9 ANDRODERM ................ 26 ANORO ELLIPT AER 62.5-

25 ................................ 42 APOKYN ......................... 21 aprepitant ........................ 34 aprepitant capsule therapy

pack 80 & 125 mg ....... 34 apri .................................. 29

APTIOM .......................... 18 APTIVUS .......................... 4 ARALAST NP ................. 43 aranelle ........................... 29 ARCALYST ..................... 38 aripiprazole ..................... 22 ARISTADA ...................... 22 ARISTADA INITIO .......... 22 armodafinil ...................... 26 ARNUITY ELLIPTA ......... 43 asenapine maleate ......... 22 aspirin-dipyridamole cap er

12hr 25-200 mg ........... 37 atazanavir sulfate .............. 4 atenolol ........................... 15 atenolol & chlorthalidone

tab 100-25 mg ............. 15 atenolol & chlorthalidone

tab 50-25 mg ............... 15 atomoxetine hcl ............... 24 atorvastatin calcium ........ 15 atovaquone ....................... 2 atovaquone-proguanil hcl

tab 250-100 mg ............. 4 atovaquone-proguanil hcl

tab 62.5-25 mg .............. 4 ATROPINE SULFATE .... 42 ATROVENT HFA ............ 42 aubra eq ......................... 29 aurovela 1/20 .................. 29 aurovela fe 1.5/30 ........... 29 aurovela fe 1/20 .............. 29 AURYXIA ........................ 33 AUSTEDO ...................... 25 AVASTIN ........................ 10 aviane ............................. 29 avita ................................ 44 ayuna .............................. 29 AYVAKIT......................... 10 azacitidine ......................... 8 azathioprine .................... 38 azelastine hcl .................. 42 azelastine hcl (ophth) ...... 41 azithromycin ...................... 7 AZOPT ............................ 41 aztreonam ......................... 3 azurette ........................... 29 B bacitracin (ophthalmic) .... 40

50

bacitracin-polymyxin b ophth oint .................... 41

bacitracin-polymyxin-neomycin-hc ophth oint 1% ............................... 40

baclofen .......................... 26 balsalazide disodium ...... 34 BALVERSA ..................... 10 balziva ............................ 29 BANZEL .......................... 18 BARACLUDE .................... 6 BASAGLAR KWIKPEN ... 28 BCG VACCINE INJ ......... 38 BD ALCOHOL SWABS ... 28 bekyree ........................... 30 BELSOMRA .................... 25 benazepril &

hydrochlorothiazide tab 10-12.5 mg .................. 12

benazepril & hydrochlorothiazide tab 20-12.5 mg .................. 12

benazepril & hydrochlorothiazide tab 20-25 mg ..................... 12

benazepril & hydrochlorothiazide tab 5-6.25 mg .................... 12

benazepril hcl ................. 13 BENDEKA ........................ 8 BENLYSTA ..................... 38 benzoyl peroxide-

erythromycin gel 5-3% 44 benztropine mesylate ...... 21 BEPREVE ....................... 41 BERINERT ..................... 36 BESIVANCE ................... 41 betamethasone

dipropionate (topical) ... 45 betamethasone

dipropionate augmented .................................... 45

betamethasone valerate . 45 BETASERON ................. 26 betaxolol hcl (ophth) ....... 41 bethanechol chloride ....... 35 BETOPTIC-S .................. 41 BEVESPI AER 9-4.8MCG

.................................... 42

bexarotene ........................ 9 BEXSERO INJ ................ 38 bicalutamide...................... 9 BICILLIN L-A..................... 7 BIKTARVY TAB ................ 5 bisoprolol &


bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ................. 15

bisoprolol & hydrochlorothiazide tab 5-6.25 mg .................... 15

bisoprolol fumarate ......... 15 BIVIGAM ......................... 38 BLEPHAMIDE OIN S.O.P.

.................................... 40 blisovi fe 1.5/30 ............... 30 BOOSTRIX INJ ............... 38 BORTEZOMIB ................ 10 bosentan ......................... 17 BOSULIF ........................ 10 BRAFTOVI ...................... 10 BREO ELLIPTA INH 100-

25 ................................ 44 BREO ELLIPTA INH 200-

25 ................................ 44 BREZTRI AERO AER

SPHERE ..................... 42 BREZTRI AERO AER

SPHERE (INSTITUTIONAL PACK) .................................... 42

briellyn ............................ 30 BRILINTA ....................... 37 brimonidine tartrate ......... 41 brinzolamide ................... 41 BRIVIACT ....................... 18 bromfenac sodium (ophth)

.................................... 41 bromocriptine mesylate ... 21 BROMSITE ..................... 41 BRUKINSA ..................... 10 budesonide ..................... 34 budesonide (inhalation) .. 43 bumetanide ..................... 16 buprenorphine hcl ........... 26

buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv) .......... 26

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv) .......... 26



buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) .......... 26

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) .......... 26

bupropion hcl .................. 20 bupropion hcl (smoking

deterrent)..................... 26 buspirone hcl .................. 17 butorphanol tartrate .......... 1 BYDUREON BCISE ........ 27 BYDUREON PEN ........... 27 BYETTA .......................... 27 BYSTOLIC ................ 15, 16 C cabergoline ..................... 32 CABOMETYX ................. 10 calcipotriene .................... 45 calcitonin (salmon) .......... 29 calcitrene ........................ 45 calcitriol ........................... 33 calcium acetate (phosphate

binder) ......................... 33 CALQUENCE ................. 10 camila ............................. 30 CAPLYTA ....................... 22 CAPRELSA..................... 10 captopril .......................... 13 captopril &

hydrochlorothiazide tab 25-15 mg ..................... 12

captopril & hydrochlorothiazide tab 25-25 mg ..................... 12

51



CARBAGLU .................... 32 carbamazepine ............... 18 carbidopa & levodopa orally

disintegrating tab 10-100 mg ............................... 21

carbidopa & levodopa orally disintegrating tab 25-100 mg ............................... 21

carbidopa & levodopa orally disintegrating tab 25-250 mg ............................... 21

carbidopa & levodopa tab 10-100 mg ................... 21



carbidopa & levodopa tab er 25-100 mg ............... 21

carbidopa & levodopa tab er 50-200 mg ............... 21

carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ................... 21

carbidopa-levodopa-entacapone tabs 18.75-75-200 mg ................... 21

carbidopa-levodopa-entacapone tabs 25-100-200 mg ........................ 22

carbidopa-levodopa-entacapone tabs 31.25-125-200 mg ................. 22

carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ................. 22

carbidopa-levodopa-entacapone tabs 50-200-200 mg ........................ 22

carboplatin ........................ 8 carteolol hcl (ophth) ........ 41 cartia xt ........................... 16 carvedilol ........................ 16

caspofungin acetate .......... 4 CAYSTON ........................ 3 caziant ............................ 30 cefaclor ............................. 6 CEFACLOR ER ................ 6 cefadroxil .......................... 6 CEFAZOLIN INJ

1GM/50ML .................... 6 cefazolin sodium ............... 6 CEFAZOLIN SOLN

2GM/100ML-4% ............ 6 cefdinir .............................. 6 cefepime hcl...................... 6 cefixime ............................ 6 cefoxitin sodium ................ 6 cefpodoxime proxetil ......... 6 cefprozil ............................ 6 ceftazidime ....................... 6 CEFTAZIDIME/ SOL D5W

1GM .............................. 6 CEFTAZIDIME/ SOL D5W

2GM .............................. 6 ceftriaxone sodium ............ 6 cefuroxime axetil ............... 6 cefuroxime sodium ............ 6 celecoxib ........................... 1 CELONTIN ..................... 18 cephalexin .................... 6, 7 CERDELGA .................... 32 CEREZYME .................... 32 cetirizine hcl .................... 42 cevimeline hcl ................. 46 CHANTIX ........................ 26 CHANTIX CONTINUING

MONTH ....................... 26 CHANTIX PAK 0.5& 1MG

.................................... 26 chateal ............................ 30 CHEMET ........................ 29 chlorhexidine gluconate

(mouth-throat) ............. 46 chloroquine phosphate ..... 4 chlorpromazine hcl .......... 22 chlorthalidone ................. 16 cholestyramine................ 15 cholestyramine light ........ 15 ciclopirox olamine ........... 44 cilostazol ......................... 36 CILOXAN ........................ 41

CIMDUO TAB 300-300 ..... 5 cinacalcet hcl .................. 32 CIPRO .............................. 7 ciprofloxacin 200 mg/100ml

in d5w ............................ 7 ciprofloxacin 400 mg/200ml

in d5w ............................ 7 ciprofloxacin hcl ................ 7 ciprofloxacin hcl (ophth) .. 41 ciprofloxacin-

dexamethasone otic susp 0.3-0.1% ...................... 46

cisplatin ............................. 8 citalopram hydrobromide 20 claravis ........................... 44 clarithromycin .................... 7 clindamycin hcl ................. 3 clindamycin palmitate

hydrochloride ................. 3 clindamycin phosphate ..... 3 clindamycin phosphate

(topical) ....................... 44 clindamycin phosphate in

d5w iv soln 300 mg/50ml ...................................... 3

clindamycin phosphate in d5w iv soln 600 mg/50ml ...................................... 3

clindamycin phosphate in d5w iv soln 900 mg/50ml ...................................... 3

clindamycin phosphate vaginal ......................... 36

CLINDMYC/NAC INJ 300/50ML ...................... 3



CLINIMIX INJ 4.25/D10 .. 40 CLINIMIX INJ 4.25/D5W . 40 CLINIMIX INJ 5%/D15W . 40 CLINIMIX INJ 5%/D20W . 40 CLINIMIX INJ 6/5 ............ 40 CLINIMIX INJ 8/10 .......... 40 CLINIMIX INJ 8/14 .......... 40 clinisol sf 15% ................. 40 CLINOLIPID EMU 20% ... 40 clobazam ........................ 18

52

clobetasol propionate ...... 45 clobetasol propionate e ... 45 clomipramine hcl ............. 20 clonazepam .................... 18 clonidine ......................... 17 clonidine hcl .................... 17 clopidogrel bisulfate ........ 37 clorazepate dipotassium . 18 clotrimazole .................... 46 clotrimazole (topical) . 44, 45 clotrimazole w/

betamethasone cream 1-0.05% .......................... 45

clovique .......................... 29 clozapine ........................ 22 COARTEM TAB 20-120MG

...................................... 4 colchicine .......................... 1 colchicine w/ probenecid

tab 0.5-500 mg .............. 1 colesevelam hcl .............. 15 colestipol hcl ................... 15 colistimethate sodium ....... 3 COMBIGAN SOL 0.2/0.5%

.................................... 41 COMBIVENT AER 20-100

.................................... 42 COMETRIQ (60MG DOSE)

.................................... 10 COMETRIQ KIT 100MG . 10 COMETRIQ KIT 140MG . 10 COMPLERA TAB.............. 5 compro ............................ 34 constulose ...................... 34 COPIKTRA ..................... 10 CORLANOR ................... 17 cortisone acetate ............ 32 COTELLIC ...................... 10 CREON CAP 12000UNT 35 CREON CAP 24000UNT 35 CREON CAP 3000UNIT . 35 CREON CAP 36000UNT 35 CREON CAP 6000UNIT . 35 CRIXIVAN ......................... 4 cromolyn sodium............. 43 cromolyn sodium

(mastocytosis) ............. 35 cromolyn sodium (ophth) 41 cryselle-28 ...................... 30

cyclafem 1/35.................. 30 cyclafem 7/7/7................. 30 cyclobenzaprine hcl ........ 26 cyclophosphamide ............ 8 CYCLOPHOSPHAMIDE ... 8 cycloserine ........................ 5 cyclosporine .................... 38 cyclosporine modified (for

microemulsion) ............ 38 cyproheptadine hcl .......... 42 cyred eq .......................... 30 CYSTADANE POW ........ 32 CYSTADROPS ............... 42 CYSTAGON.................... 32 CYSTARAN .................... 42 cytarabine ......................... 8 D D10W/NACL INJ 0.2% .... 39 D5W/LYTES INJ #48 ...... 39 D5W/NACL INJ 0.3% ...... 39 dalfampridine .................. 26 DALIRESP ...................... 43 danazol ........................... 31 dantrolene sodium .......... 26 dapsone ............................ 3 DAPTACEL INJ .............. 39 daptomycin ....................... 3 DAPTOMYCIN .................. 3 dasetta 1/35 .................... 30 dasetta 7/7/7 ................... 30 DAURISMO .................... 10 deblitane ......................... 30 deferasirox ...................... 29 DELESTROGEN ............. 31 DELSTRIGO TAB ............. 5 DESCOVY TAB 200/25MG

...................................... 5 desipramine hcl ............... 20 desmopressin acetate ..... 32 desmopressin acetate

spray ........................... 32 desmopressin acetate

spray refrigerated ........ 32 desogest-eth estrad & eth

estrad tab 0.15-0.02/0.01 mg(21/5) ...................... 30

desvenlafaxine succinate 20 dexamethasone .............. 32

DEXAMETHASONE INTENSOL .................. 32

dexamethasone sodium phosphate ................... 32

dexamethasone sodium phosphate (ophth) ....... 41

DEXILANT ...................... 35 dexmethylphenidate hcl .. 24 dextrose .......................... 40 dextrose 10% w/ sodium

chloride 0.45% ............ 39 dextrose 2.5% w/ sodium

chloride 0.45% ............ 39 dextrose 5% in lactated

ringers ......................... 39 dextrose 5% w/ sodium

chloride 0.2% .............. 39 dextrose 5% w/ sodium

chloride 0.45% ............ 39 dextrose 5% w/ sodium

chloride 0.9% .............. 39 DIACOMIT ...................... 18 diazepam ........................ 18 diazepam (anticonvulsant)

.................................... 18 diazepam inj .................... 18 diazoxide ........................ 32 diclofenac potassium ........ 1 diclofenac sodium ............. 1 diclofenac sodium (ophth)

.................................... 41 diclofenac sodium (topical)

.................................... 46 dicloxacillin sodium ........... 7 dicyclomine hcl ............... 34 DIFICID ............................. 7 diflunisal ............................ 1 digitek ............................. 17 digox ............................... 17 digoxin ............................ 17 dihydroergotamine

mesylate ...................... 25 DILANTIN ....................... 18 DILANTIN INFATABS ..... 18 DILANTIN-125 ................ 18 diltiazem hcl .................... 16 diltiazem hcl coated beads

.................................... 16

53

diltiazem hcl extended release beads.............. 16

dilt-xr ............................... 16 DIP/TET PED INJ 25-5LFU

.................................... 39 diphenhydramine hcl ....... 42 diphenoxylate w/ atropine

liq 2.5-0.025 mg/5ml .... 35 diphenoxylate w/ atropine

tab 2.5-0.025 mg ......... 35 dipyridamole ................... 37 disopyramide phosphate . 14 disulfiram ........................ 26 divalproex sodium ........... 18 docetaxel .......................... 9 DOCETAXEL .................... 9 dofetilide ......................... 14 donepezil hydrochloride .. 20 DOPTELET ..................... 36 dorzolamide hcl............... 41 dorzolamide hcl-timolol

maleate ophth soln 22.3-6.8 mg/ml .................... 41

dotti ................................. 31 DOVATO TAB 50-300MG . 5 doxazosin mesylate ........ 13 doxepin hcl ..................... 20 doxepin hcl (sleep) .......... 25 doxorubicin hcl .................. 8 doxorubicin hcl liposomal .. 8 doxy 100 ........................... 8 doxycycline (monohydrate)

...................................... 8 doxycycline hyclate ........... 8 DRIZALMA SPRINKLE ... 20 dronabinol ....................... 34 drospirenone-ethinyl

estradiol tab 3-0.02 mg 30 drospirenone-ethinyl

estradiol tab 3-0.03 mg 30 DROXIA .......................... 36 droxidopa ........................ 17 duloxetine hcl .................. 20 DUREZOL ...................... 41 dutasteride ...................... 35 dutasteride-tamsulosin hcl

cap 0.5-0.4 mg ............ 35 E ec-naproxen ...................... 1

EDURANT ........................ 4 efavirenz ........................... 4 efavirenz-emtricitabine-

tenofovir df tab 600-200-300 mg .......................... 5

efavirenz-lamivudine-tenofovir df tab 400-300-300 mg .......................... 5

efavirenz-lamivudine-tenofovir df tab 600-300-300 mg .......................... 5

elinest ............................. 30 ELIQUIS ......................... 36 ELIQUIS STARTER PACK

.................................... 36 ELLA ............................... 30 eluryng ............................ 30 EMCYT ............................. 9 EMEND ........................... 34 emoquette ....................... 30 EMSAM .......................... 20 emtricitabine ..................... 4 emtricitabine-tenofovir

disoproxil fumarate tab 100-150 mg ................... 5

emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg ................... 5



EMTRIVA .......................... 4 EMVERM .......................... 3 enalapril maleate ............ 13 enalapril maleate &


enalapril maleate & hydrochlorothiazide tab 5-12.5 mg .................... 12

ENBREL ......................... 37 ENBREL MINI ................. 37 ENBREL SURECLICK .... 37 ENDARI .......................... 36 endocet tab 10-325mg ...... 2 endocet tab 2.5-325mg ..... 2

endocet tab 5-325mg ........ 2 endocet tab 7.5-325mg ..... 2 ENGERIX-B .................... 39 enoxaparin sodium ......... 36 enpresse-28 .................... 30 enskyce .......................... 30 ENSTILAR AER .............. 45 entacapone ..................... 22 entecavir ........................... 6 ENTRESTO TAB 24-26MG

.................................... 13 ENTRESTO TAB 49-51MG

.................................... 13 ENTRESTO TAB 97-

103MG ........................ 13 enulose ........................... 34 EPCLUSA TAB 200-50MG

...................................... 6 EPCLUSA TAB 400-100 ... 6 EPIDIOLEX ..................... 18 epinephrine (anaphylaxis)

.................................... 43 epirubicin hcl ..................... 8 epitol ............................... 18 EPIVIR HBV ...................... 6 eplerenone ...................... 13 ergotamine w/ caffeine tab

1-100 mg ..................... 25 ERIVEDGE ..................... 10 ERLEADA ......................... 9 erlotinib hcl...................... 10 errin ................................ 30 ertapenem sodium ............ 3 ery ................................... 44 ery-tab .............................. 7 ERYTHROCIN

LACTOBIONATE .......... 7 erythrocin stearate ............ 7 erythromycin (acne aid) .. 44 erythromycin (ophth) ....... 41 erythromycin base ............ 7 erythromycin ethylsuccinate

...................................... 7 ESBRIET ........................ 43 escitalopram oxalate ....... 20 esomeprazole magnesium

.................................... 35 estarylla .......................... 30 estradiol .......................... 31

54

estradiol & norethindrone acetate tab 0.5-0.1 mg 31

estradiol & norethindrone acetate tab 1-0.5 mg ... 31

estradiol vaginal .............. 31 estradiol valerate ............ 31 ethambutol hcl .................. 5 ethosuximide .................. 18 ethynodiol diacetate &

ethinyl estradiol tab 1 mg-35 mcg .................. 30

ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg .................. 30

etodolac ............................ 1 etonogestrel-ethinyl

estradiol va ring 0.120-0.015 mg/24hr ............. 30

etoposide .......................... 9 euthyrox .......................... 33 everolimus ...................... 10 everolimus

(immunosuppressant) . 38 EVOTAZ TAB 300-150 ..... 5 exemestane ...................... 9 ezetimibe ........................ 15 F FABRAZYME .................. 32 falmina ............................ 30 famciclovir ......................... 6 famotidine ....................... 34 famotidine in nacl 0.9% iv

soln 20 mg/50ml .......... 34 FANAPT ......................... 22 FANAPT PAK ................. 22 FARXIGA ........................ 27 FARYDAK ....................... 10 FASENRA ....................... 43 FASENRA PEN .............. 43 felbamate ........................ 18 felodipine ........................ 16 femynor ........................... 30 fenofibrate ....................... 15 fenofibrate micronized .... 15 fentanyl ............................. 1 fentanyl citrate .................. 2 FETZIMA ........................ 20 FETZIMA CAP TITRATIO

.................................... 20

FIASP FLEX INJ TOUCH28 FIASP INJ 100/ML .......... 28 FIASP PENFIL INJ U-100

.................................... 28 finasteride ....................... 35 FINTEPLA ...................... 18 flac .................................. 46 FLAREX .......................... 41 FLEBOGAMMA DIF ........ 38 flecainide acetate ............ 14 FLOVENT DISKUS ... 43, 44 FLOVENT HFA ............... 44 fluconazole ....................... 4 fluconazole in nacl 0.9% inj

200 mg/100ml ............... 4 fluconazole in nacl 0.9% inj

400 mg/200ml ............... 4 flucytosine ......................... 4 fludrocortisone acetate ... 32 flunisolide (nasal) ............ 43 fluocinolone acetonide .... 45 fluocinolone acetonide

(otic) ............................ 46 fluocinonide .................... 45 fluocinonide emulsified

base ............................ 45 fluorometholone (ophth) .. 41 fluorouracil ........................ 8 fluorouracil (topical) ........ 46 fluoxetine hcl ................... 21 fluphenazine decanoate .. 22 fluphenazine hcl .............. 22 flurbiprofen ........................ 1 flurbiprofen sodium ......... 41 flutamide ........................... 9 fluticasone propionate ..... 45 fluticasone propionate

(nasal) ......................... 43 fluvoxamine maleate ....... 17 fondaparinux sodium ...... 36 FORTEO ......................... 29 fosamprenavir calcium ...... 4 fosinopril sodium ............. 13 fosinopril sodium &


fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg .................. 12

FREAMINE HBC INJ 6.9% .................................... 40

FREAMINE III INJ 10% ... 40 fulvestrant ......................... 9 furosemide ...................... 16 furosemide inj ................. 16 FUZEON ........................... 4 fyavolv tab 0.5mg-2.5mcg

.................................... 31 fyavolv tab 1mg-5mcg ..... 31 FYCOMPA ...................... 18 G gabapentin ................ 18, 19 galantamine hydrobromide

.................................... 20 GAMASTAN INJ ............. 38 GAMMAGARD LIQUID ... 38 GAMMAGARD S/D IGA

LESS TH ..................... 38 GAMMAKED ................... 38 GAMMAPLEX ................. 38 GAMUNEX-C .................. 38 ganciclovir sodium ............ 6 GARDASIL 9 INJ ............ 39 gatifloxacin (ophth) ......... 41 GATTEX ......................... 35 GAUZE PADS 2 .............. 28 gavilyte-c......................... 34 gavilyte-g ........................ 34 gavilyte-n/flavor pack ...... 34 GAVRETO ...................... 10 gemcitabine hcl ................. 8 gemfibrozil ...................... 15 generlac .......................... 34 gengraf ........................... 38 GENOTROPIN ................ 32 GENOTROPIN MINIQUICK

.................................... 32 gentak ............................. 41 gentamicin in saline inj 0.8

mg/ml ............................ 3 gentamicin in saline inj 1

mg/ml ............................ 3 gentamicin in saline inj 1.2

mg/ml ............................ 3 gentamicin in saline inj 1.6

mg/ml ............................ 3 gentamicin in saline inj 2

mg/ml ............................ 3

55

gentamicin sulfate ............. 3 gentamicin sulfate (ophth)

.................................... 41 gentamicin sulfate (topical)

.................................... 44 GENVOYA TAB ................ 5 gianvi .............................. 30 GILENYA ........................ 26 GILOTRIF ....................... 10 glatiramer acetate ........... 26 glatopa ............................ 26 glimepiride ...................... 27 glipizide ........................... 27 glipizide xl ....................... 27 glipizide-metformin hcl tab

2.5-250 mg .................. 27 glipizide-metformin hcl tab

2.5-500 mg .................. 27 glipizide-metformin hcl tab

5-500 mg ..................... 27 glycopyrrolate ................. 34 glydo ............................... 46 GLYXAMBI TAB 10-5 MG

.................................... 27 GLYXAMBI TAB 25-5 MG

.................................... 27 GOLYTELY SOL............. 34 granisetron hcl ................ 34 griseofulvin microsize ....... 4 griseofulvin ultramicrosize 4 guanfacine hcl ................ 17 guanfacine hcl (adhd) ..... 24 GVOKE HYPOPEN 2-

PACK .......................... 32 GVOKE PFS ................... 32 H HAEGARDA ................... 36 hailey 1.5/30 ................... 30 halobetasol propionate ... 45 haloperidol ...................... 22 haloperidol decanoate .... 22 haloperidol lactate........... 23 HARVONI PAK 33.75-

150MG .......................... 6 HARVONI PAK 45-200MG

...................................... 6 HARVONI TAB 45-200MG 6 HARVONI TAB 90-400MG 6 HAVRIX .......................... 39

heather ........................... 30 HEP SOD/NACL INJ

25000UNT ................... 36 heparin sodium (porcine) 36 heparin sodium (porcine)

100 unit/ml in d5w ....... 36 heparin sodium (porcine)-

dextrose iv sol 20000 unit/500ml-5% ............. 36

heparin sodium (porcine)-dextrose iv sol 25000 unit/500ml-5% ............. 36

HEPARIN/NACL INJ 25000UNT ................... 36

hepatamine ..................... 40 HERCEP HYLEC SOL 60-

10000 .......................... 10 HERCEPTIN ................... 10 HERZUMA ...................... 10 HETLIOZ ........................ 25 HIBERIX ......................... 39 HUMIRA ......................... 37 HUMIRA PEDIA INJ

CROHNS..................... 37 HUMIRA PEDIATRIC

CROHNS D ................. 37 HUMIRA PEN ................. 37 HUMIRA PEN KIT PS/UV

.................................... 37 HUMIRA PEN-CD/UC/HS

START ........................ 37 HUMIRA PEN-PS/UV

STARTER ................... 37 HUMULIN R U-500

(CONCENTR ............... 28 HUMULIN R U-500

KWIKPEN.................... 28 hydralazine hcl ................ 17 hydrochlorothiazide ......... 16 hydrocodone bitartrate ...... 1 hydrocodone-

acetaminophen soln 7.5-325 mg/15ml ................. 2

hydrocodone-acetaminophen tab 10-325 mg .......................... 2

hydrocodone-acetaminophen tab 5-325 mg ................................. 2

hydrocodone-acetaminophen tab 7.5-325 mg .......................... 2

hydrocodone-ibuprofen tab 7.5-200 mg .................... 2

hydrocortisone ................ 32 hydrocortisone (intrarectal)

.................................... 34 hydrocortisone (rectal) .... 46 hydrocortisone (topical) .. 45 hydromorphone hcl ........... 2 hydroxychloroquine sulfate

.................................... 38 hydroxyurea ...................... 9 hydroxyzine hcl ............... 42 hydroxyzine pamoate ...... 42 HYSINGLA ER .................. 1 I ibandronate sodium ........ 29 IBRANCE ........................ 10 ibu ..................................... 1 ibuprofen ........................... 1 icatibant acetate .............. 37 iclevia .............................. 30 ICLUSIG ......................... 10 IDHIFA ............................ 10 ILEVRO .......................... 41 imatinib mesylate ............ 10 IMBRUVICA .................... 10 imipenem-cilastatin

intravenous for soln 250 mg ................................. 3

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

imipramine hcl ................. 21 imiquimod ....................... 46 IMOVAX RABIES

(H.D.C.V.) .................... 39 incassia ........................... 30 INCRELEX ...................... 32 INCRUSE ELLIPTA ........ 42 indapamide ..................... 16 INFANRIX INJ ................. 39 INGREZZA...................... 25 INGREZZA CAP 40-80MG

.................................... 25 INLYTA ........................... 10 INQOVI TAB 35-100MG ... 9

56

INREBIC ......................... 10 INSULIN SAFETY

NEEDLES ................... 28 INSULIN SYRINGES:

BD/ULTIMED/ALLISON/TRIVIDIA/MHC ............ 28

INTELENCE ..................... 4 INTRALIPID .................... 40 INTRON A ...................... 38 introvale .......................... 30 INVEGA SUSTENNA ...... 23 INVEGA TRINZA ............ 23 INVIRASE ......................... 4 IPOL INJ INACTIVE ........ 39 ipratropium bromide ........ 42 ipratropium bromide (nasal)

.................................... 42 ipratropium-albuterol nebu

soln 0.5-2.5(3) mg/3ml 42 irbesartan ........................ 14 irbesartan-

hydrochlorothiazide tab 150-12.5 mg ................ 13

irbesartan-hydrochlorothiazide tab 300-12.5 mg ................ 14

IRESSA .......................... 10 irinotecan hcl .................... 9 ISENTRESS ..................... 4 ISENTRESS HD ............... 4 isibloom .......................... 30 ISOLYTE-P INJ /D5W ..... 39 ISOLYTE-S INJ............... 39 isoniazid ............................ 5 isosorbide dinitrate .......... 17 isosorbide mononitrate ... 17 isotretinoin ...................... 44 isradipine ........................ 16 itraconazole ...................... 4 ivermectin ......................... 3 IXIARO INJ ..................... 39 J JAKAFI ........................... 10 jantoven .......................... 36 JANUMET TAB 50-1000 . 27 JANUMET TAB 50-500MG

.................................... 27 JANUMET XR TAB 100-

1000 ............................ 27

JANUMET XR TAB 50-1000 ............................ 27

JANUMET XR TAB 50-500MG ........................ 27

JANUVIA ........................ 27 JARDIANCE ................... 27 jasmiel ............................ 30 JENTADUETO TAB 2.5-

1000 ............................ 27 JENTADUETO TAB 2.5-

500 .............................. 27 JENTADUETO TAB 2.5-

850 .............................. 27 JENTADUETO TAB XR

2.5-1000MG ................ 27 JENTADUETO TAB XR 5-

1000MG ...................... 27 jinteli ............................... 31 jolessa ............................ 30 juleber ............................. 30 JULUCA TAB 50-25MG .... 5 junel 1.5/30 ..................... 30 junel 1/20 ........................ 30 junel fe 1.5/30 ................. 30 junel fe 1/20 .................... 30 JUXTAPID ...................... 15 K KADCYLA ....................... 10 KALETRA TAB 100-25MG 5 KALETRA TAB 200-50MG 5 KALYDECO .................... 43 KANJINTI ........................ 10 kariva .............................. 30 kcl 10 meq/l (0.075%) in

dextrose 5% & nacl 0.45% inj ..................... 39

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj ................................ 39

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj ..................... 39

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj ................................ 39

kcl 20 meq/l (0.15%) in nacl 0.45% inj ..................... 39

kcl 20 meq/l (0.15%) in nacl 0.9% inj ....................... 39



KCL/D5W/NACL INJ 0.15/0.2 ....................... 39

KCL/D5W/NACL INJ 0.3/0.9% ...................... 39

kelnor 1/35 ...................... 30 kelnor 1/50 ...................... 30 ketoconazole ..................... 4 ketoconazole (topical) ..... 45 ketorolac tromethamine

(ophth) ......................... 41 KEYTRUDA .................... 10 KINRIX INJ ..................... 39 KISQALI .......................... 10 KISQALI 200 PAK

FEMARA ....................... 9 KISQALI 400 PAK

FEMARA ....................... 9 KISQALI 600 PAK

FEMARA ....................... 9 klor-con ........................... 40 klor-con 10 ...................... 40 klor-con 8 ........................ 40 klor-con m10 ................... 40 klor-con m15 ................... 40 klor-con m20 ................... 40 KORLYM......................... 32 kurvelo ............................ 30 KYNMOBI ....................... 22 L labetalol hcl ..................... 16 lactated ringer's solution . 39 lactic acid (ammonium

lactate) ........................ 46 lactulose ......................... 34 lactulose (encephalopathy)

.................................... 34 lamivudine......................... 4 lamivudine (hbv) ............... 6 lamivudine-zidovudine tab

150-300 mg ................... 5 lamotrigine ...................... 19 lansoprazole ................... 35 lapatinib ditosylate .......... 10

57

larin 1.5/30 ...................... 30 larin 1/20 ......................... 30 larin fe 1.5/30 .................. 30 larin fe 1/20 ..................... 30 larissia ............................ 30 LASTACAFT ................... 41 latanoprost ...................... 41 LATUDA ......................... 23 leena ............................... 30 leflunomide ..................... 38 LENVIMA 10 MG DAILY

DOSE .......................... 11 LENVIMA 12MG DAILY

DOSE .......................... 11 LENVIMA 20 MG DAILY



DOSE .......................... 11 LENVIMA CAP 14 MG .... 11 LENVIMA CAP 18 MG .... 11 LENVIMA CAP 24 MG .... 11 lessina ............................ 30 letrozole ............................ 9 leucovorin calcium .......... 12 LEUKERAN ...................... 8 leuprolide acetate ............. 9 levalbuterol hcl ................ 42 levalbuterol tartrate ......... 42 LEVEMIR ........................ 28 LEVEMIR FLEXTOUCH . 28 levetiracetam .................. 19 levetiracetam in sodium

chloride iv soln 1000 mg/100ml .................... 19

levetiracetam in sodium chloride iv soln 1500 mg/100ml .................... 19

levetiracetam in sodium chloride iv soln 500 mg/100ml .................... 19

levobunolol hcl ................ 41 levocarnitine (metabolic

modifiers) .................... 32 levocetirizine

dihydrochloride ............ 42 levofloxacin ....................... 7

levofloxacin in d5w iv soln 250 mg/50ml ................. 7

levofloxacin in d5w iv soln 500 mg/100ml ............... 7

levofloxacin in d5w iv soln 750 mg/150ml ............... 7

levonest .......................... 30 levonorgestrel & ethinyl

estradiol (91-day) tab 0.15-0.03 mg ............... 30

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ............................. 30

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg ............................. 30

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg ................... 30

levora 0.15/30-28 ............ 30 levo-t ............................... 33 levothyroxine sodium ...... 33 levoxyl ............................. 33 LEXIVA ............................. 4 lidocaine ......................... 46 lidocaine hcl .................... 46 lidocaine hcl (local anesth.)

...................................... 2 lidocaine hcl (mouth-throat)

.................................... 46 lidocaine-prilocaine cream

2.5-2.5% ...................... 46 lillow ................................ 30 linezolid ............................. 3 linezolid in sodium chloride

iv soln 600 mg/300ml-0.9% .............................. 3

LINZESS ......................... 35 liothyronine sodium ......... 33 lisinopril ........................... 13 lisinopril &


lisinopril & hydrochlorothiazide tab 20-12.5 mg .................. 12

lisinopril & hydrochlorothiazide tab 20-25 mg ..................... 13

LITHIUM ......................... 25 lithium carbonate ............ 25 loestrin 1.5/30-21 ............ 30 loestrin 1/20-21 ............... 30 loestrin fe 1.5/30 ............. 30 loestrin fe 1/20 ................ 30 LOKELMA ....................... 29 LONSURF TAB 15-6.14 ... 9 LONSURF TAB 20-8.19 ... 9 loperamide hcl ................ 35 lopinavir-ritonavir soln 400-

100 mg/5ml (80-20 mg/ml) ........................... 5

lopreeza .......................... 31 lorazepam ....................... 18 lorazepam intensol .......... 18 LORBRENA .................... 11 loryna .............................. 30 losartan potassium .......... 14 losartan potassium &

hydrochlorothiazide tab 100-12.5 mg ................ 14

losartan potassium & hydrochlorothiazide tab 100-25 mg ................... 14

losartan potassium & hydrochlorothiazide tab 50-12.5 mg .................. 14

LOTEMAX....................... 41 lovastatin......................... 15 low-ogestrel .................... 30 loxapine succinate .......... 23 LUMIGAN ....................... 41 LUMIZYME ..................... 32 LUPRON DEPOT (1-

MONTH) ........................ 9 LUPRON DEPOT (3-

MONTH) ........................ 9 LUPRON DEPOT-PED (1-

MONTH ....................... 32 LUPRON DEPOT-PED (3-

MONTH ....................... 32 lutera ............................... 30 lyleq ................................ 30 lyllana ............................. 32 LYNPARZA ..................... 11 LYRICA CR ..................... 25 LYSODREN ...................... 9 lyza ................................. 30

58

M magnesium sulfate .......... 39 MAGNESIUM SULFATE 39 magnesium sulfate in

dextrose 5% iv soln 1 gm/100ml .................... 40

malathion ........................ 46 maprotiline hcl ................ 21 marlissa .......................... 30 MARPLAN ...................... 21 MATULANE ...................... 9 MAVYRET TAB 100-40MG

...................................... 6 meclizine hcl ................... 34 medroxyprogesterone

acetate ........................ 33 medroxyprogesterone

acetate (contraceptive) 30 mefloquine hcl .................. 4 megestrol acetate ....... 9, 33 megestrol acetate

(appetite) ..................... 33 MEKINIST ....................... 11 MEKTOVI ....................... 11 meloxicam ........................ 1 memantine hcl ................ 20 MENACTRA INJ ............. 39 MENQUADFI INJ ............ 39 MENVEO INJ .................. 39 mercaptopurine ................. 8 meropenem ...................... 3 mesalamine .................... 34 mesalamine w/ cleanser . 34 MESNEX ........................ 12 metadate er .................... 24 metformin hcl .................. 27 methadone hcl .................. 1 methadone hcl intensol ..... 1 methazolamide ............... 16 methenamine hippurate .... 3 methimazole ................... 33 methotrexate sodium .. 8, 38 methyldopa ..................... 17 methylphenidate hcl .. 24, 25 methylprednisolone ......... 32 methylprednisolone acetate

.................................... 32 methylprednisolone sod

succ ............................. 32

metoclopramide hcl ......... 34 metolazone ..................... 16 metoprolol &

hydrochlorothiazide tab 100-25 mg ................... 15

metoprolol & hydrochlorothiazide tab 100-50 mg ................... 15

metoprolol & hydrochlorothiazide tab 50-25 mg ..................... 15

metoprolol succinate ....... 16 metoprolol tartrate ........... 16 metronidazole ................... 3 metronidazole (topical) ... 46 metronidazole in nacl

0.79% iv soln 500 mg/100ml ...................... 3

metronidazole vaginal ..... 36 metyrosine ...................... 17 MG SO4/D5W INJ

10MG/ML .................... 40 micafungin sodium ............ 4 microgestin 1.5/30 .......... 30 microgestin 1/20 ............. 30 microgestin fe 1.5/30 ...... 30 microgestin fe 1/20 ......... 30 midodrine hcl .................. 17 miglustat ......................... 33 mili .................................. 30 mimvey ........................... 32 minitran ........................... 17 minocycline hcl ................. 8 minoxidil .......................... 17 mirtazapine ..................... 21 misoprostol ..................... 35 MITIGARE ........................ 1 M-M-R II INJ ................... 39 M-NATAL PLUS TAB ...... 40 moexipril hcl .................... 13 molindone hcl.................. 23 mometasone furoate ....... 45 mondoxyne nl ................... 8 MONJUVI ....................... 11 mono-linyah .................... 30 montelukast sodium ........ 43 morphine sulfate ........... 1, 2 MORPHINE SULFATE ..... 2 MOVANTIK ..................... 35

moxifloxacin hcl (ophth) .. 41 MULTAQ ......................... 14 mupirocin ........................ 44 MVASI ............................ 11 mycophenolate mofetil .... 38 mycophenolate sodium ... 38 myorisan ......................... 44 MYRBETRIQ .................. 35 N nabumetone ...................... 1 nadolol ............................ 16 nafcillin sodium ............. 7, 8 NAFCILLIN SODIUM ........ 8 NAGLAZYME .................. 33 nalbuphine hcl ................... 2 naloxone hcl.................... 26 naltrexone hcl ................. 26 NAMZARIC CAP 14-10MG

.................................... 20 NAMZARIC CAP 21-10MG

.................................... 20 NAMZARIC CAP 28-10MG

.................................... 20 NAMZARIC CAP 7-10MG

.................................... 20 NAMZARIC CAP PACK .. 20 naproxen ........................... 1 naproxen sodium .............. 1 naratriptan hcl ................. 25 NARCAN......................... 26 NATACYN....................... 41 nateglinide ...................... 28 NATPARA ....................... 29 NAYZILAM ...................... 19 necon 0.5/35-28 .............. 30 nefazodone hcl ............... 21 neomycin sulfate ............... 3 neomycin-bacitrac zn-

polymyx 5(3.5)mg-400unt-10000unt op oin .................................... 41

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ..... 41

neomycin-polymyxin-dexamethasone ophth oint 0.1% ..................... 40

59

neomycin-polymyxin-dexamethasone ophth susp 0.1% ................... 40

neomycin-polymyxin-hc ophth susp .................. 40

neomycin-polymyxin-hc otic soln 1% ....................... 46

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................... 47

NEPHRAMINE INJ 5.4% 40 NERLYNX ....................... 11 NEUPRO ........................ 22 nevirapine ......................... 4 NEXAVAR ...................... 11 niacin (antihyperlipidemic)

.................................... 15 nicardipine hcl ................. 16 NICOTROL INHALER ..... 26 NICOTROL NS ............... 26 nifedipine ........................ 16 nikki ................................ 30 nilutamide ......................... 9 nimodipine ...................... 16 NINLARO ........................ 11 nitazoxanide ..................... 3 nitisinone ........................ 33 NITRO-BID ..................... 17 NITRO-DUR ................... 17 nitrofurantoin macrocrystal3 nitrofurantoin monohyd

macro ............................ 3 nitroglycerin .................... 17 nizatidine ........................ 34 nora-be ........................... 30 norethindrone

(contraceptive) ............ 31 norethindrone ace & ethinyl

estradiol tab 1 mg-20 mcg ............................. 31

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg ............................. 31

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 31

norethindrone acetate ..... 33

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg ................. 32

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg .................... 32

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ............................. 31

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ....................... 31

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ....................... 31

norlyroc ........................... 31 NORPACE CR ................ 14 NORTHERA.................... 17 nortrel 0.5/35 (28) ........... 31 nortrel 1/35 (21) .............. 31 nortrel 1/35 (28) .............. 31 nortrel 7/7/7 .................... 31 nortriptyline hcl................ 21 NORVIR ............................ 5 NOVOLIN INJ 70/30 ....... 28 NOVOLIN INJ 70/30 FP .. 28 NOVOLIN N .................... 29 NOVOLIN N FLEXPEN ... 29 NOVOLIN R .................... 29 NOVOLIN R FLEXPEN ... 29 NOVOLOG ..................... 29 NOVOLOG FLEXPEN .... 29 NOVOLOG MIX INJ 70/30

.................................... 29 NOVOLOG MIX INJ

FLEXPEN .................... 29 NOVOLOG PENFILL ...... 29 NOXAFIL .......................... 4 NUBEQA .......................... 9 NUEDEXTA CAP 20-10MG

.................................... 25 NULOJIX ........................ 38 NULYTELY SOL FLAV

PKS ............................. 34 NUPLAZID ...................... 23 NUTRILIPID .................... 40 nyamyc ........................... 45 nylia 7/7/7 ....................... 31 NYMALIZE ...................... 16

nymyo ............................. 31 nystatin ............................. 4 nystatin (mouth-throat) .... 46 nystatin (topical) .............. 45 nystop ............................. 45 O ocella .............................. 31 OCTAGAM...................... 38 octreotide acetate ........... 33 ODEFSEY TAB ................. 5 ODOMZO........................ 11 OFEV .............................. 43 ofloxacin (ophth) ............. 41 ofloxacin (otic) ................. 47 OGIVRI ........................... 11 OGIVRI INJ 420MG ........ 11 olanzapine ...................... 23 olmesartan medoxomil .... 14 olmesartan medoxomil-


olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg .................. 14

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ..................... 14

olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg ............... 14

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg ............. 14

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg ................ 14

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg ............... 14

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg .................. 14

olopatadine hcl ................ 41 omeprazole ..................... 35 OMNIPOD KIT STARTER

.................................... 29 OMNIPOD MIS 5 PACK . 29 ondansetron .................... 34 ondansetron hcl .............. 34

60

ONTRUZANT ................. 11 ONUREG .......................... 8 OPSUMIT ....................... 17 ORGOVYX ....................... 9 ORKAMBI GRA 100-125 43 ORKAMBI GRA 150-188 43 ORKAMBI TAB 100-125 . 43 ORKAMBI TAB 200-125 . 43 orsythia ........................... 31 oseltamivir phosphate ....... 6 OSPHENA ...................... 33 oxacillin sodium ................ 8 oxaliplatin .......................... 8 oxandrolone .................... 27 oxcarbazepine ................ 19 oxybutynin chloride ......... 35 oxycodone hcl ................... 2 oxycodone w/

acetaminophen tab 10-325 mg .......................... 2

oxycodone w/ acetaminophen tab 2.5-325 mg .......................... 2

oxycodone w/ acetaminophen tab 5-325 mg ................................. 2

oxycodone w/ acetaminophen tab 7.5-325 mg .......................... 2

OZEMPIC (0.25 OR 0.5MG/DOSE) ............. 28

OZEMPIC (1MG/DOSE) . 28 P pacerone ......................... 14 paclitaxel ........................... 9 paliperidone .................... 23 pamidronate disodium .... 29 PAMIDRONATE

DISODIUM .................. 29 pantoprazole sodium ...... 35 PANZYGA ...................... 38 paraplatin .......................... 8 paricalcitol ....................... 33 paroex ............................. 46 paromomycin sulfate ......... 3 paroxetine hcl ................. 21 PASER ............................. 5 PAXIL ............................. 21 PAZEO ........................... 41

PEDIARIX INJ 0.5ML ...... 39 PEDVAX HIB .................. 39 peg 3350-kcl-na bicarb-

nacl-na sulfate for soln 236 gm ........................ 34

peg 3350-kcl-sod bicarb-nacl for soln 420 gm .... 35

PEGANONE ................... 19 PEGASYS ........................ 6 PEMAZYRE .................... 11 PEN GK/DEXTR INJ

40000/ML ...................... 8 PEN GK/DEXTR INJ

60000/ML ...................... 8 PEN NEEDLES:

NOVO/BD/ULTIMED/OWEN/TRIVIDIA ............... 29

penicillamine ................... 29 penicillin g potassium ........ 8 PENICILLIN G PROCAINE

...................................... 8 penicillin g sodium ............ 8 penicillin v potassium ........ 8 PENTACEL INJ .............. 39 pentamidine isethionate inh

...................................... 3 pentamidine isethionate inj

...................................... 3 pentoxifylline ................... 37 perindopril erbumine ....... 13 periogard ........................ 46 permethrin ...................... 46 perphenazine .................. 23 PERSERIS ..................... 23 pfizerpen ........................... 8 phenelzine sulfate ........... 21 phenobarbital .................. 19 phenobarbital sodium ..... 19 PHENYTEK .................... 19 phenytoin ........................ 19 phenytoin sodium ............ 19 phenytoin sodium extended

.................................... 19 PHESGO SOL ................ 11 philith .............................. 31 PHOSPHOLINE IODIDE 41 PICATO .......................... 46 PIFELTRO ........................ 5 pilocarpine hcl ................. 41

pilocarpine hcl (oral) ....... 46 pimozide ......................... 23 pimtrea ............................ 31 pindolol ........................... 16 pioglitazone hcl ............... 28 piperacillin sod-tazobactam

na for inj 3.375 gm (3-0.375 gm) ...................... 8

piperacillin sod-tazobactam sod for inj 13.5 gm (12-1.5 gm) .......................... 8

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ........................ 8

piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) ................................ 8

piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) .......................... 8

PIQRAY 200MG DAILY DOSE .......................... 11

PIQRAY 250MG TAB DOSE .......................... 11

PIQRAY 300MG DAILY DOSE .......................... 11

pirmella 1/35 ................... 31 piroxicam .......................... 1 PLASMA-LYTE INJ -148 40 PLASMA-LYTE INJ -A .... 40 plenamine ....................... 40 PLENVU SOL ................. 35 PNV FOLIC AC TAB +

IRON ........................... 40 podofilox ......................... 46 polymyxin b-trimethoprim

ophth soln 10000 unit/ml-0.1% ............................ 41

POMALYST ...................... 9 portia-28 ......................... 31 posaconazole .................... 4 POT CHL/NACL INJ

20MEQ/L ..................... 40 POT CHL/NACL INJ

40MEQ/L ..................... 40 potassium chloride .......... 40 POTASSIUM CHLORIDE

.................................... 40

61

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj............ 40

potassium chloride microencapsulated crystals er .................... 40

potassium citrate (alkalinizer) .................. 35

PRADAXA ...................... 36 PRALUENT .................... 15 pramipexole

dihydrochloride ............ 22 prasugrel hcl ................... 37 pravastatin sodium .......... 15 praziquantel ...................... 3 prazosin hcl .................... 13 prednisolone ................... 32 prednisolone acetate

(ophth) ......................... 41 PREDNISOLONE SODIUM

PHOSP ....................... 41 prednisolone sodium

phosphate ................... 32 prednisone ...................... 32 PREDNISONE INTENSOL

.................................... 32 pregabalin ....................... 19 PREMASOL SOL 10% ... 40 PRENATAL TAB 27-1MG

.................................... 40 PRENATAL TAB PLUS .. 40 PRENATAL VIT TAB LOW

IRON ........................... 40 prevalite .......................... 15 previfem .......................... 31 PREZCOBIX TAB 800-150

...................................... 5 PREZISTA ........................ 5 PRIFTIN ............................ 5 primaquine phosphate ...... 4 PRIMAQUINE

PHOSPHATE ................ 4 primidone ........................ 19 PRIVIGEN ...................... 38 probenecid ........................ 1 PROCALAMINE INJ 3% . 40 prochlorperazine ............. 34 prochlorperazine edisylate

.................................... 34

prochlorperazine maleate .................................... 34

PROCRIT ....................... 36 procto-med hc ................. 46 procto-pak ....................... 46 proctosol hc .................... 46 proctozone-hc ................. 46 PROGRAF ...................... 38 PROLASTIN-C ................ 43 PROLENSA .................... 41 PROLIA .......................... 29 PROMACTA ................... 37 promethazine hcl ............ 34 propafenone hcl .............. 15 proparacaine hcl ............. 42 propranolol &


propranolol & hydrochlorothiazide tab 80-25 mg ..................... 15

propranolol hcl ................ 16 propylthiouracil................ 33 PROQUAD INJ ............... 39 PROSOL INJ 20% .......... 40 protriptyline hcl................ 21 PULMICORT FLEXHALER

.................................... 44 PULMOZYME ................. 43 PURIXAN .......................... 8 pyrazinamide .................... 5 pyridostigmine bromide ... 26 Q QINLOCK ....................... 11 QUADRACEL INJ ........... 39 quetiapine fumarate ........ 23 quinapril hcl .................... 13 quinapril-


quinapril-hydrochlorothiazide tab 20-12.5 mg .................. 13

quinapril-hydrochlorothiazide tab 20-25 mg ..................... 13

quinidine sulfate .............. 15 quinine sulfate................... 4

R RABAVERT INJ .............. 39 raloxifene hcl ................... 33 ramipril ............................ 13 ranolazine ....................... 17 rasagiline mesylate ......... 22 RAYALDEE..................... 33 reclipsen ......................... 31 RECOMBIVAX HB .......... 39 RECTIV .......................... 46 REGRANEX .................... 46 RELENZA DISKHALER .... 6 RELISTOR ...................... 35 REMICADE ..................... 37 RENFLEXIS .................... 37 repaglinide ...................... 28 RESTASIS ...................... 42 RESTASIS MULTIDOSE 42 RETEVMO ...................... 11 REVLIMID ......................... 9 REXULTI......................... 23 REYATAZ ......................... 5 RHOPRESSA ................. 41 RIABNI ............................ 11 ribavirin (hepatitis c) .......... 6 rifabutin ............................. 6 rifampin ............................. 6 riluzole ............................ 26 rimantadine hydrochloride. 6 RINVOQ ......................... 37 RISPERDAL CONSTA ... 23 risperidone ...................... 23 ritonavir ............................. 5 RITUXAN ........................ 11 RITUXAN INJ HYCELA .. 11 rivastigmine..................... 20 rivastigmine tartrate ........ 20 rizatriptan benzoate ........ 25 ropinirole hydrochloride .. 22 rosadan ........................... 46 rosuvastatin calcium ....... 15 ROTARIX SUS ............... 39 ROTATEQ SOL .............. 39 roweepra ......................... 19 ROZLYTREK .................. 11 RUBRACA ...................... 11 rufinamide ....................... 19 RUKOBIA.......................... 5 RUXIENCE ..................... 11

62

RYBELSUS .................... 28 RYDAPT ......................... 11 S SANDIMMUNE ............... 38 SANTYL .......................... 46 sapropterin dihydrochloride

.................................... 33 scopolamine ................... 34 SECUADO ...................... 23 selegiline hcl ................... 22 selenium sulfide .............. 45 SELZENTRY .................... 5 SEREVENT DISKUS ...... 43 sertraline hcl ................... 21 setlakin ........................... 31 sevelamer carbonate ...... 33 sharobel .......................... 31 SHINGRIX ...................... 39 SIGNIFOR ...................... 33 sildenafil citrate (pulmonary

hypertension) .............. 17 silver sulfadiazine ........... 44 SIMBRINZA SUS 1-0.2% 41 simliya ............................. 31 simvastatin ...................... 15 sirolimus ......................... 38 SIRTURO ......................... 6 SIVEXTRO ....................... 3 SKYRIZI .......................... 37 sodium chloride............... 40 sodium chloride (gu

irrigant) ........................ 46 sodium fluoride chew; tab;

1.1 (0.5 f) mg/ml soln .. 40 sodium phenylbutyrate .... 33 sodium polystyrene

sulfonate powder ......... 29 solifenacin succinate ....... 36 SOLIQUA INJ 100/33 ..... 29 SOLTAMOX ...................... 9 SOLU-CORTEF .............. 32 SOMATULINE DEPOT ... 33 SOMAVERT ................... 33 sorine .............................. 15 sotalol hcl ........................ 15 sotalol hcl (afib/afl) .......... 15 spironolactone ................ 13

spironolactone & hydrochlorothiazide tab 25-25 mg ..................... 16

sprintec 28 ...................... 31 SPRITAM ........................ 19 SPRYCEL ....................... 11 sps .................................. 29 sronyx ............................. 31 ssd .................................. 44 stavudine .......................... 5 STELARA ....................... 37 STIMATE ........................ 33 STIVARGA ..................... 11 streptomycin sulfate .......... 3 STRIBILD TAB .................. 5 subvenite ........................ 19 sucralfate ........................ 35 sulfacetamide sodium

(acne) .......................... 44 sulfacetamide sodium

(ophth) ......................... 41 sulfacetamide sodium-

prednisolone ophth soln 10-0.23(0.25)% ........... 40

SULFADIAZINE ................ 3 sulfamethoxazole-

trimethoprim iv soln 400-80 mg/5ml ..................... 3

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml .......................... 3

sulfamethoxazole-trimethoprim tab 400-80 mg ................................. 3

sulfamethoxazole-trimethoprim tab 800-160 mg ................................. 3

SULFAMYLON ............... 44 sulfasalazine ................... 34 sulindac ............................ 1 sumatriptan ..................... 25 sumatriptan succinate ..... 25 SUPREP BOWEL SOL

PREP KIT .................... 35 SUTENT ......................... 11 syeda .............................. 31 SYMBICORT AER 160-4.5

.................................... 44

SYMBICORT AER 80-4.5 .................................... 44

SYMDEKO TAB 100-150 43 SYMDEKO TAB 50-75MG

.................................... 43 SYMPAZAN .................... 19 SYMTUZA TAB ................. 5 SYNAREL ....................... 31 SYNERCID INJ 500MG .... 3 SYNJARDY TAB 12.5-

1000MG ...................... 28 SYNJARDY TAB 12.5-500

.................................... 28 SYNJARDY TAB 5-

1000MG ...................... 28 SYNJARDY TAB 5-500MG

.................................... 28 SYNJARDY XR TAB 10-

1000 ............................ 28 SYNJARDY XR TAB 12.5-

1000MG ...................... 28 SYNJARDY XR TAB 25-

1000 ............................ 28 SYNJARDY XR TAB 5-

1000MG ...................... 28 SYNRIBO.......................... 9 SYNTHROID ................... 33 T TABLOID .......................... 9 TABRECTA ..................... 11 tacrolimus ....................... 38 tacrolimus (topical) .......... 46 TAFINLAR ...................... 11 TAGRISSO ..................... 11 TALTZ ............................. 37 TALZENNA ..................... 11 tamoxifen citrate ............... 9 tamsulosin hcl ................. 35 TARGRETIN ................... 46 tarina fe 1/20 eq .............. 31 TASIGNA ........................ 11 tazarotene ....................... 45 tazicef ............................... 7 TAZORAC....................... 45 taztia xt ........................... 16 TAZVERIK ...................... 11 TDVAX INJ 2-2 LF .......... 39 TECENTRIQ ................... 11 TEFLARO ......................... 7

63

telmisartan ...................... 14 temazepam ..................... 25 TEMIXYS TAB 300-300 .... 5 TENIVAC INJ 5-2LF ....... 39 tenofovir disoproxil

fumarate ........................ 5 TEPMETKO .................... 11 terazosin hcl ................... 13 terbinafine hcl ................... 4 terbutaline sulfate ........... 43 terconazole vaginal ......... 36 testosterone .................... 27 testosterone cypionate .... 27 testosterone enanthate ... 27 tetrabenazine .................. 26 tetracycline hcl .................. 8 THALOMID ....................... 9 THEO-24 ........................ 43 theophylline .................... 43 thioridazine hcl ................ 23 thiothixene ...................... 23 tiadylt er .......................... 16 tiagabine hcl ................... 19 TIBSOVO ........................ 11 tigecycline ......................... 8 TIGECYCLINE .................. 8 tilia fe .............................. 31 timolol maleate ............... 16 timolol maleate (ophth) ... 41 timolol maleate (ophth)

once-daily .................... 41 TIVICAY ............................ 5 TIVICAY PD ...................... 5 tizanidine hcl ................... 26 TOBRADEX OIN 0.3-0.1%

.................................... 40 TOBRADEX ST SUS 0.3-

0.05 ............................. 40 tobramycin ........................ 3 tobramycin (ophth) .......... 41 tobramycin sulfate............. 4 tobramycin-dexamethasone

ophth susp 0.3-0.1% ... 40 tolterodine tartrate........... 36 topiramate ....................... 19 toposar .............................. 9 toremifene citrate .............. 9 torsemide ........................ 16 TOVIAZ ........................... 36

TPN ELECTROL INJ ...... 40 TRADJENTA................... 28 tramadol hcl ...................... 2 tramadol-acetaminophen

tab 37.5-325 mg ............ 2 trandolapril ...................... 13 tranexamic acid ............... 37 tranylcypromine sulfate ... 21 TRAVASOL INJ 10% ...... 40 TRAZIMERA ................... 11 trazodone hcl .................. 21 TRECATOR ...................... 6 TRELEGY AER ELLIPTA

100-62.5-25 MCG ....... 42 TRELEGY AER ELLIPTA

200-62.5-25 MCG ....... 42 TRELSTAR MIXJECT ....... 9 treprostinil ....................... 17 TRESIBA ........................ 29 TRESIBA FLEXTOUCH .. 29 tretinoin ........................... 44 tretinoin (chemotherapy) ... 9 triamcinolone acetonide

(mouth) ........................ 46 triamcinolone acetonide

(topical) ................. 45, 46 triamterene &

hydrochlorothiazide cap 37.5-25 mg .................. 16

triamterene & hydrochlorothiazide tab 37.5-25 mg .................. 17

triamterene & hydrochlorothiazide tab 75-50 mg ..................... 17

TRICARE TAB PRENATAL .................................... 40

triderm ............................ 46 trientine hcl ..................... 29 tri-estarylla ...................... 31 trifluoperazine hcl ............ 23 trifluridine ........................ 41 trihexyphenidyl hcl .......... 22 TRIJARDY XR TAB ER

24HR 10-5-1000MG .... 28 TRIJARDY XR TAB ER

24HR 12.5-2.5-1000MG .................................... 28

TRIJARDY XR TAB ER 24HR 25-5-1000MG .... 28

TRIJARDY XR TAB ER 24HR 5-2.5-1000MG ... 28

TRIKAFTA TAB .............. 43 tri-legest fe ...................... 31 tri-linyah .......................... 31 tri-lo-estarylla .................. 31 tri-lo-marzia ..................... 31 tri-lo-mili .......................... 31 tri-lo-sprintec ................... 31 trilyte ............................... 35 trimethoprim ...................... 4 tri-mili .............................. 31 trimipramine maleate ...... 21 TRINTELLIX ................... 21 tri-nymyo ......................... 31 tri-previfem ...................... 31 tri-sprintec ....................... 31 TRIUMEQ TAB ................. 5 trivora-28......................... 31 tri-vylibra ......................... 31 tri-vylibra lo ..................... 31 TROGARZO ..................... 5 TROPHAMINE INJ 10% . 40 trospium chloride ............ 36 TRULANCE .................... 35 TRULICITY ..................... 28 TRUMENBA INJ ............. 39 TRUXIMA........................ 11 TUKYSA ......................... 11 tulana .............................. 31 TURALIO ........................ 11 TWINRIX INJ .................. 39 TYBOST ........................... 5 TYMLOS ......................... 29 TYPHIM VI ...................... 39 U UBRELVY ....................... 25 unithroid .......................... 33 ursodiol ........................... 35 V valacyclovir hcl .................. 6 VALCHLOR .................... 46 valganciclovir hcl ............... 6 valproate sodium ............ 19 valproic acid .................... 19 valsartan ......................... 14

64

valsartan-hydrochlorothiazide tab 160-12.5 mg ................ 14

valsartan-hydrochlorothiazide tab 160-25 mg ................... 14

valsartan-hydrochlorothiazide tab 320-12.5 mg ................ 14

valsartan-hydrochlorothiazide tab 320-25 mg ................... 14

valsartan-hydrochlorothiazide tab 80-12.5 mg .................. 14

VALTOCO ...................... 19 vancomycin hcl ................. 4 VANCOMYCIN INJ 1 GM . 4 VANCOMYCIN INJ 500MG

...................................... 4 VANCOMYCIN INJ 750MG

...................................... 4 vandazole ....................... 36 VAQTA ........................... 39 VARIVAX ........................ 39 VASCEPA ....................... 15 VELCADE ....................... 11 velivet ............................. 31 VELTASSA ..................... 29 VEMLIDY .......................... 6 VENCLEXTA .................. 11 VENCLEXTA TAB START

PK ............................... 11 venlafaxine hcl ................ 21 VENTAVIS ...................... 17 VENTOLIN HFA.............. 43 VENTOLIN HFA

(INSTITUTIONAL PACK) .................................... 43

verapamil hcl .................. 16 VERSACLOZ .................. 23 VERZENIO ..................... 11 V-GO 20 KIT ................... 29 V-GO 30 KIT ................... 29 V-GO 40 KIT ................... 29 VICTOZA ........................ 28 vienva ............................. 31 vigabatrin ........................ 19 vigadrone ........................ 19

VIIBRYD ......................... 21 VIIBRYD KIT STARTER . 21 VIMPAT .......................... 19 vincristine sulfate .............. 9 vinorelbine tartrate ............ 9 viorele ............................. 31 VIRACEPT ........................ 5 VIREAD ............................ 5 VITRAKVI ....................... 12 VIVITROL ....................... 26 VIZIMPRO ...................... 12 voriconazole...................... 4 VOSEVI TAB .................... 6 VOTRIENT ..................... 12 VRAYLAR ....................... 24 VRAYLAR CAP 1.5-3MG 24 vyfemla ........................... 31 vylibra ............................. 31 VYZULTA ....................... 42 W warfarin sodium .............. 36 water for irrigation, sterile

irrigation soln ............... 46 wera ................................ 31 X XALKORI ........................ 12 XARELTO ....................... 36 XARELTO STAR TAB

15/20MG ..................... 36 XATMEP ......................... 38 XCOPRI .................... 19, 20 XCOPRI PAK 12.5-25 ..... 20 XCOPRI PAK 150-200MG

(MAINTENANCE) ........ 20 XCOPRI PAK 150-200MG

(TITRATION) ............... 20 XCOPRI PAK 50-100MG 20 XCOPRI TAB 50-200MG 20 XELJANZ ........................ 37 XELJANZ XR .................. 37 XGEVA ........................... 29 XIFAXAN ........................ 35 XIGDUO XR TAB 10-1000

.................................... 28 XIGDUO XR TAB 10-

500MG ........................ 28 XIGDUO XR TAB 2.5-1000

.................................... 28

XIGDUO XR TAB 5-1000MG ...................... 28

XIGDUO XR TAB 5-500MG .................................... 28

XIIDRA ............................ 42 XOLAIR .......................... 43 XOSPATA ....................... 12 XPOVIO 100 MG ONCE

WEEKLY ..................... 12 XPOVIO 40 MG ONCE

WEEKLY ..................... 12 XPOVIO 40 MG TWICE





WEEKLY ..................... 12 XTANDI ............................ 9 xulane ............................. 31 XULTOPHY INJ 100/3.6 . 29 XYREM ........................... 26 Y YF-VAX INJ .................... 39 yuvafem .......................... 32 Z zafirlukast........................ 43 zarah ............................... 31 ZARXIO .......................... 36 ZEJULA .......................... 12 ZELBORAF ..................... 12 ZEMAIRA ........................ 43 zenatane ......................... 44 ZENPEP CAP 10000UNT

.................................... 35 ZENPEP CAP 15000UNT

.................................... 35 ZENPEP CAP 20000UNT

.................................... 35 ZENPEP CAP 25000 ...... 35 ZENPEP CAP 3000UNIT 35 ZENPEP CAP 40000 ...... 35 ZENPEP CAP 5000UNIT 35 ZERVIATE ...................... 41 zidovudine......................... 5 ziprasidone hcl ................ 24

65

ziprasidone mesylate ...... 24 ZIRABEV ........................ 12 ZIRGAN .......................... 41 zoledronic acid ................ 29 ZOLINZA ........................ 12 zolmitriptan ..................... 25

zolpidem tartrate ............. 25 zonisamide ..................... 20 ZORTRESS .................... 38 ZOSTAVAX..................... 39 zovia 1/35e ..................... 31 zumandimine .................. 31

ZYDELIG ........................ 12 ZYKADIA ........................ 12 ZYLET SUS 0.5-0.3% ..... 40 ZYPREXA RELPREVV ... 24 ZYTIGA ............................. 9

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) 8700-230001MAY 4.21 LE

This directory was updated on 05/01/2021. For more recent information or other questions, please contact HMSA.

Due to COVID-19, hours of operation may change. Please go to hmsa.com/contact before your visit.

Documents

HMSA Medicare Advantage 2021 Formulary · 2020. 10. 1. · PLEASE READ: THIS DOCUMENT . CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 2021. Formulary. Standard (PPO)