(List of Covered Drugs) - Blue Cross Blue Shield …...Blue Cross Medicare Advantage 2020 Formulary (List of Covered Drugs) Note to existing members: This formulary has changed since

Blue Cross Medicare Advantage Basic (HMO)SM

Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM

Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM

2020 Formulary (List of Covered Drugs)

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

HPMS Approved Formulary File ID: 00020119, Version 12

This formulary was updated on 03/16/2020. For more recent information or other questions, please contact Blue Cross Medicare AdvantageSM Customer Service at 1-877-774-8592 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/mapd/druglist.

Y0096_BEN_IL_MAPDFRM_HMO20_C 852062.0320

http://www.getblueil.com/mapd/druglist

Blue Cross Medicare Advantage

2020 Formulary (List of Covered Drugs)

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

When this drug list (formulary) refers to “we”, “us”, or “our”, it means Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). When it refers to “plan” or “our plan,” it means Blue Cross Medicare Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of March 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

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

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but “we” or Blue Cross Medicare Advantage may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

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

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Blue Cross Medicare Advantage’s 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 manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or 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 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Blue Cross 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 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of 03/16/2020. To get updated information about the drugs covered by Blue Cross Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages. Formulary publications are updated and posted online on a monthly basis with applicable changes, including negative changes. The web address is located on the front and back cover of this formulary.

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

Medical Condition The 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 Agents. 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 Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 111. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Blue Cross 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: Blue Cross Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Cross Medicare Advantage before you fill your prescriptions. If you don’t get approval, Blue Cross Medicare Advantage may not cover the drug.

Quantity Limits: For certain drugs, Blue Cross Medicare Advantage limits the amount of the drug that Blue Cross Medicare Advantage will cover. For example, Blue Cross Medicare Advantage provides 60 tablets per 30-day prescription for Losartan 25 mg. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue Cross 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 Blue Cross Medicare Advantage’s formulary?” on page iv for information about how to request an exception.

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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 Customer Service and ask if your drug is covered. If you learn that Blue Cross Medicare Advantage does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Blue Cross Medicare 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 Blue Cross Medicare Advantage.

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

What do I do before I can talk to my doctor about changing my drugs orrequesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an 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. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a 30-day supply of medication. 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 facility and 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 while you pursue a formulary exception.

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You may have changes that take you from one treatment setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s exception and appeals processes. However, when you are admitted to, or discharged from, a long-term care setting, you may not have access to the drugs you were previously given. You may get a refill upon admission or discharge to prevent a gap in care.

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

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https://www.medicare.gov

Blue Cross Medicare Advantage’s Formulary The formulary below provides coverage information about the drugs covered by Blue Cross Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 111. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if Blue Cross Medicare Advantage has any special requirements for coverage of your drug.

Most drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contact information appears on the front and back cover pages.

KEY Tier 1 = Preferred Generic Drugs

Tier 2 = Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-877-774-8592, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY users should call 711.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

^ = We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

† = High cost drug, consider Split Fill (2-week supply) for copay management if intolerant or change in therapy.

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Copayment and Coinsurance Amounts: Tier 1 = Preferred Generic Drugs: $0 copay/$5 copay

Tier 2 = Generic Drugs: $8 copay/$19 copay

Tier 3 = Preferred Brand Drugs: $39 copay/$47 copay

Tier 4 = Non-Preferred Brand Drugs: $95 copay/$100 copay

Tier 5 = Specialty Drugs: 33% of the total cost/33% of the total cost

Below is the key for abbreviations used within the drug list.

KEY

act actuation

ad adsorbed

aepb aerosol powder blister

aer, aero aerosol

app applicator

ba, breath act, breath activ breath activated

cal calcium

cap, caps capsules

cart cartridge

cd continuous delivery

chew tab chewable tablets

conc concentrate

conj conjugate, conjugated

crys crystals

deter deterrent

disint, disintegr disintegrating

dr delayed-release

ec enteric coated

el, elu enzyme-linked immunosorbent assay

mcg microgram

meq milliequivalent

misc miscellaneous

mg milligram

ml milliliter

mu million units

nebu nebules

orally disintegr tab

orally disintegrating tablets

oin, oint ointment

op, ophth ophthalmic

osm osmotic

pah pulmonary arterial hypertension

pak pack

pf preservative-free

pfu plaque forming units

pmdd premenstrual dysphoric disorder

pow, powd powder

pref, prefill prefilled

pttw patch twice weekly

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KEY Continued

er, extend-release, extended, extended rel, xr

extended-release

ext extract

gm gram

gu genitourinary

hr hour

im intramuscular

inh, inhal inhalation

inj injection

ir index of reactivity

iv intravenous

l liter

la long acting

lf, Ifu flocculation units

liq, liqd liquid

ptwk patch weekly

recomb recombinant

refrig refrigerate

sl sublingual

sol, soln solution

sqcm square centimeter

supp, suppos suppositories

sus, susp suspension

syr syringe

tab, tabs tablets

td transdermal

tl translingual

unt unit

va vaginal

vac vaccine

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2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

1

Drug Name Drug Tier Requirements/LimitsAnalgesicsacetaminophen w/ codeine soln 120-12 mg/5ml 4 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 4 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg# 3 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 3butorphanol tartrate nasal soln 10 mg/ml 4 QL (87.5 mls/30 days)celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 60 mg 4 QL (180 tablets/30 days)codeine sulfate tab 30 mg 4 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2 QL (120 tablets/30 days)diclofenac sodium gel 1% 3 PAdiclofenac sodium soln 1.5% 3 PAdiclofenac sodium tab delayed release 25 mg 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 QL (90 tablets/30 days)diflunisal tab 500 mg 3 QL (90 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg 2 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg 2 QL (90 tablets/30 days)etodolac cap 200 mg 2 QL (150 capsules/30 days)etodolac cap 300 mg 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg 2 QL (30 tablets/30 days)etodolac tab 400 mg 2 QL (60 tablets/30 days)

2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsetodolac tab 500 mg 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg 2 QL (90 tablets/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydromorphone hcl inj 2 mg/ml 4 BDhydromorphone hcl preservative free inj 2 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 2 QL (240 tablets/30 days)ibuprofen tab 600 mg 2 QL (150 tablets/30 days)ibuprofen tab 800 mg 2 QL (120 tablets/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 3 mg 5 QL (120 tablets/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg 2 QL (60 tablets/30 days)meloxicam tab 15 mg 2 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)morphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab er 15 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 4 PA, QL (90 tablets/30 days)

2020


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Drug Name Drug Tier Requirements/Limitsmorphine sulfate tab er 100 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab er 24hr 375 mg 3 QL (120 tablets/30 days)naproxen sodium tab er 24hr 500 mg 3 QL (90 tablets/30 days)naproxen sodium tab 275 mg 3 QL (150 tablets/30 days)naproxen sodium tab 550 mg 3 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 3 QL (1800 mls/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 2 QL (180 tablets/30 days)naproxen tab 375 mg 2 QL (120 tablets/30 days)naproxen tab 500 mg 2 QL (90 tablets/30 days)oxaprozin tab 600 mg 3 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg 3 QL (60 capsules/30 days)piroxicam cap 20 mg 3 QL (30 capsules/30 days)sulindac tab 150 mg 2 QL (60 tablets/30 days)sulindac tab 200 mg 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsAnestheticslidocaine hcl soln 4% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2% 2 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 2lidocaine oint 5% 2 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg 2 QL (30 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

3

disulfiram tab 250 mg 2disulfiram tab 500 mg 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 2naloxone hcl inj 0.4 mg/ml 2naloxone hcl inj 4 mg/10ml 2naltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3

2020


5

Drug Name Drug Tier Requirements/LimitsAMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 3AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 3amoxicillin (trihydrate) cap 250 mg 2amoxicillin (trihydrate) cap 500 mg 2amoxicillin (trihydrate) for susp 125 mg/5ml 2amoxicillin (trihydrate) for susp 200 mg/5ml 2amoxicillin (trihydrate) for susp 250 mg/5ml 2amoxicillin (trihydrate) for susp 400 mg/5ml 2amoxicillin (trihydrate) tab 500 mg 2amoxicillin (trihydrate) tab 875 mg 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 3amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 3amoxicillin & k clavulanate for susp 400-57 mg/5ml 3amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 3amoxicillin & k clavulanate tab 250-125 mg 3amoxicillin & k clavulanate tab 500-125 mg 3amoxicillin & k clavulanate tab 875-125 mg 3AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

3

AMOXICILLIN/CLAVULANATE POTASSIUM ER - amoxicillin & kclavulanate tab er 12hr 1000-62.5 mg

3

AMPICILLIN - ampicillin cap 500 mg 2ampicillin & sulbactam sodium for inj 3 (2-1) gm 3AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg 3ampicillin sodium for inj 500 mg 3ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm 3ampicillin sodium for iv soln 2 gm 3ampicillin sodium for iv soln 10 gm 3AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm3

AZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZITHROMYCIN - azithromycin powd pack for susp 1 gm 3azithromycin for susp 100 mg/5ml 3azithromycin for susp 200 mg/5ml 3

2020


Drug Name Drug Tier Requirements/Limitsazithromycin iv for soln 500 mg 3azithromycin tab 250 mg 2azithromycin tab 500 mg 2azithromycin tab 600 mg 2aztreonam for inj 1 gm 3aztreonam for inj 2 gm 3BICILLIN C-R - penicillin g benzathine & procaine inj susp 1200000

unit/2ml4

BICILLIN C-R - penicillin g benzathine & procaine inj900000-300000 unt/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 600000unit/ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 2cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 3cefdinir for susp 250 mg/5ml 3cefepime hcl for inj 1 gm 3cefepime hcl for inj 2 gm 3cefixime cap 400 mg 3cefixime for susp 100 mg/5ml 3cefixime for susp 200 mg/5ml 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3cefoxitin sodium for inj 10 gm 3cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml 3cefpodoxime proxetil for susp 100 mg/5ml 3

2020


7

Drug Name Drug Tier Requirements/Limitscefpodoxime proxetil tab 100 mg 3cefpodoxime proxetil tab 200 mg 3cefprozil for susp 125 mg/5ml 3cefprozil for susp 250 mg/5ml 3cefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 3ceftazidime for inj 2 gm 3ceftazidime for inj 6 gm 3CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

3

ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74% 50 ml3

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22% 50 ml

3

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 3cefuroxime sodium for inj 7.5 gm 3cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg 2cephalexin cap 500 mg 2cephalexin cap 750 mg 2cephalexin for susp 125 mg/5ml 3cephalexin for susp 250 mg/5ml 3CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 3ciprofloxacin hcl tab 250 mg 2ciprofloxacin hcl tab 500 mg 2ciprofloxacin hcl tab 750 mg 2

2020


Drug Name Drug Tier Requirements/Limitsciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml 3CLARITHROMYCIN - clarithromycin for susp 250 mg/5ml 3clarithromycin tab er 24hr 500 mg 3clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2CLEOCIN - clindamycin phosphate vaginal cream 2% 4clindamycin hcl cap 75 mg 2clindamycin hcl cap 150 mg 2clindamycin hcl cap 300 mg 2clindamycin palmitate hcl for soln 75 mg/5ml 3clindamycin phosphate gel 1% 2clindamycin phosphate in d5w iv soln 300 mg/50ml 3clindamycin phosphate in d5w iv soln 600 mg/50ml 3clindamycin phosphate in d5w iv soln 900 mg/50ml 3clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 3colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 3demeclocycline hcl tab 300 mg 3dicloxacillin sodium cap 250 mg 3dicloxacillin sodium cap 500 mg 3DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 3

2020


9

Drug Name Drug Tier Requirements/Limitsdoxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 3doxycycline monohydrate cap 75 mg 3doxycycline monohydrate cap 100 mg 3doxycycline monohydrate cap 150 mg 3doxycycline monohydrate tab 50 mg 3doxycycline monohydrate tab 75 mg 3doxycycline monohydrate tab 100 mg 3doxycycline monohydrate tab 150 mg 3ertapenem sodium for inj 1 gm 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 3erythromycin ethylsuccinate for susp 400 mg/5ml 3erythromycin pads 2% 2erythromycin soln 2% 2erythromycin tab delayed release 250 mg 4erythromycin tab delayed release 333 mg 4erythromycin tab delayed release 500 mg 4erythromycin tab 250 mg 3erythromycin tab 500 mg 3erythromycin w/ delayed release particles cap 250 mg 3gentamicin in saline inj 1.2 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 1 mg/ml3

GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin insaline inj 1.6 mg/ml

3

imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3IMPAVIDO - miltefosine cap 50 mg 5ISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 3levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 3

2020


Drug Name Drug Tier Requirements/Limitslevofloxacin oral soln 25 mg/ml 3levofloxacin tab 250 mg 2levofloxacin tab 500 mg 2levofloxacin tab 750 mg 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%4

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 3meropenem iv for soln 1 gm 3methenamine hippurate tab 1 gm 2METRONIDAZOLE - metronidazole iv soln 5 mg/ml 3metronidazole cap 375 mg 3metronidazole in nacl 0.74% iv soln 500 mg/100ml 3metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 3minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 3minocycline hcl tab 50 mg 3minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg 3moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3MOXIFLOXACIN HYDROCHLORIDE - moxifloxacin hcl iv solution

400 mg/250ml3

NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 3nafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 3nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg 2NEOMYCIN/POLYMYXIN B SULFATES - neomycin-polymyxin b gu

irrigation soln3

nitrofurantoin macrocrystalline cap 50 mg# 3

2020


11

Drug Name Drug Tier Requirements/Limitsnitrofurantoin macrocrystalline cap 100 mg# 3nitrofurantoin monohydrate macrocrystalline cap 100 mg# 3nitrofurantoin susp 25 mg/5ml# 4ofloxacin tab 400 mg 2OXACILLIN SODIUM - oxacillin sodium in dextrose inj 1 gm/50ml 4OXACILLIN SODIUM - oxacillin sodium in dextrose inj 2 gm/50ml 4paromomycin sulfate cap 250 mg 3penicillin g potassium for inj 5000000 unit 3penicillin g potassium for inj 20000000 unit 3PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

3

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 3PENICILLIN V POTASSIUM - penicillin v potassium for soln

125 mg/5ml2

PENICILLIN V POTASSIUM - penicillin v potassium for soln250 mg/5ml

2

penicillin v potassium tab 250 mg 2penicillin v potassium tab 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 3sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 3sulfamethoxazole-trimethoprim tab 400-80 mg 2sulfamethoxazole-trimethoprim tab 800-160 mg 2SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm 3TAZICEF - ceftazidime for iv soln 2 gm 3TEFLARO - ceftaroline fosamil for iv soln 400 mg 5

2020


Drug Name Drug Tier Requirements/LimitsTEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5tinidazole tab 250 mg 3tinidazole tab 500 mg 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3trimethoprim tab 100 mg 2VANCOMYCIN - vancomycin hcl iv soln 2000 mg/400ml 4VANCOMYCIN - vancomycin hcl-sodium chloride iv soln

500 mg/100ml-0.9%4

VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm 3VANCOMYCIN HCL - vancomycin hcl-sodium chloride iv soln

1 gm/200ml-0.9%4

vancomycin hcl cap 125 mg 3 QL (120 capsules/30 days)vancomycin hcl cap 250 mg 3 QL (240 capsules/30 days)vancomycin hcl for iv soln 500 mg 3vancomycin hcl for iv soln 750 mg 3vancomycin hcl for iv soln 1 gm 3vancomycin hcl for iv soln 5 gm 3vancomycin hcl for iv soln 10 gm 3VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln

250 mg3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl iv soln500 mg/100ml

4


4


4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-dextrose iv soln 500 mg/100ml-5%

4

2020


13

Drug Name Drug Tier Requirements/LimitsVANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-

dextrose iv soln 750 mg/150ml-5%4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-dextrose iv soln 1 gm/200ml-5%

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln2-0.25gm/50ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg 2carbamazepine cap er 12hr 200 mg 2carbamazepine cap er 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab er 12hr 100 mg 2carbamazepine tab er 12hr 200 mg 2carbamazepine tab er 12hr 400 mg 2carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)

2020


Drug Name Drug Tier Requirements/LimitsDIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 3divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab er 24 hr 250 mg 2divalproex sodium tab er 24 hr 500 mg 2EPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PAethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 3felbamate tab 600 mg 3fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg 2 QL (1080 capsules/30 days)gabapentin cap 300 mg 2 QL (360 capsules/30 days)gabapentin cap 400 mg 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 2 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 2

2020


15

Drug Name Drug Tier Requirements/Limitslamotrigine tab 150 mg 2lamotrigine tab 200 mg 2levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml 2levetiracetam tab er 24hr 500 mg 2levetiracetam tab er 24hr 750 mg 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2NAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 4 QL (10 bottles/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3oxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4 PAphenobarbital sodium inj 65 mg/ml# 4 PAphenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 15 mg# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 30 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 60 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenobarbital tab 100 mg# 4 PAphenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2pregabalin cap 25 mg 3 QL (90 capsules/30 days)pregabalin cap 50 mg 3 QL (90 capsules/30 days)pregabalin cap 75 mg 3 QL (90 capsules/30 days)

2020


Drug Name Drug Tier Requirements/Limitspregabalin cap 100 mg 3 QL (90 capsules/30 days)pregabalin cap 150 mg 3 QL (90 capsules/30 days)pregabalin cap 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg 3 QL (60 capsules/30 days)pregabalin cap 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)primidone tab 50 mg 2primidone tab 250 mg 2SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 3tiagabine hcl tab 12 mg 3tiagabine hcl tab 16 mg 3topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 2topiramate tab 50 mg 2topiramate tab 100 mg 2topiramate tab 200 mg 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml 2valproic acid cap 250 mg 2vigabatrin powd pack 500 mg* 5 QL (180 packets/30 days)vigabatrin tab 500 mg* 5 QL (180 tablets/30 days)VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg 2zonisamide cap 50 mg 2

2020


17

Drug Name Drug Tier Requirements/Limitszonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 2donepezil hydrochloride tab 10 mg 2donepezil hydrochloride tab 23 mg 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml3

galantamine hydrobromide cap er 24hr 8 mg 2galantamine hydrobromide cap er 24hr 16 mg 2galantamine hydrobromide cap er 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2galantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 3 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PArivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2rivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 3rivastigmine td patch 24hr 9.5 mg/24hr 3rivastigmine td patch 24hr 13.3 mg/24hr 3Antidepressantsamitriptyline hcl tab 10 mg# 3amitriptyline hcl tab 25 mg# 3amitriptyline hcl tab 50 mg# 3amitriptyline hcl tab 75 mg# 3amitriptyline hcl tab 100 mg# 3amitriptyline hcl tab 150 mg# 3AMOXAPINE - amoxapine tab 25 mg# 3AMOXAPINE - amoxapine tab 50 mg# 3AMOXAPINE - amoxapine tab 100 mg# 3AMOXAPINE - amoxapine tab 150 mg# 3bupropion hcl tab er 12hr 100 mg 2 QL (90 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsbupropion hcl tab er 12hr 150 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)CELEXA - citalopram hydrobromide tab 10 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 20 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 40 mg 4 QL (30 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg^ 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4clomipramine hcl cap 50 mg# 4clomipramine hcl cap 75 mg# 4desipramine hcl tab 10 mg# 4desipramine hcl tab 25 mg# 4desipramine hcl tab 50 mg# 4desipramine hcl tab 75 mg# 4desipramine hcl tab 100 mg# 4desipramine hcl tab 150 mg# 4desvenlafaxine succinate tab er 24hr 25 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 3 QL (30 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 150 mg# 3doxepin hcl cap 10 mg# 3doxepin hcl cap 25 mg# 3doxepin hcl cap 50 mg# 3doxepin hcl cap 75 mg# 3doxepin hcl cap 100 mg# 3doxepin hcl conc 10 mg/ml# 3DRIZALMA SPRINKLE - duloxetine hcl cap delayed release

sprinkle 20 mg4 QL (60 capsules/30 days)

DRIZALMA SPRINKLE - duloxetine hcl cap delayed releasesprinkle 30 mg

4 QL (90 capsules/30 days)

DRIZALMA SPRINKLE - duloxetine hcl cap delayed releasesprinkle 40 mg

4 QL (60 capsules/30 days)

2020


19

Drug Name Drug Tier Requirements/LimitsDRIZALMA SPRINKLE - duloxetine hcl cap delayed release

sprinkle 60 mg4 QL (60 capsules/30 days)

duloxetine hcl enteric coated pellets cap 20 mg 3 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 3 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 3 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 3 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 3imipramine hcl tab 25 mg# 3imipramine hcl tab 50 mg# 3LEXAPRO - escitalopram oxalate tab 5 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 10 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 20 mg 4 QL (30 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsmirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 15 mg^ 1 QL (45 tablets/30 days)mirtazapine tab 30 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 45 mg^ 1 QL (30 tablets/30 days)NARDIL - phenelzine sulfate tab 15 mg 4NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 250 mg 2nefazodone hcl tab 50 mg 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 3nortriptyline hcl cap 10 mg# 3nortriptyline hcl cap 25 mg# 3nortriptyline hcl cap 50 mg# 3nortriptyline hcl cap 75 mg# 3PARNATE - tranylcypromine sulfate tab 10 mg 4paroxetine hcl tab 10 mg# 3 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 3 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 3 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 3 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)PAXIL - paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)PAXIL - paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)PAXIL - paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)phenelzine sulfate tab 15 mg 2protriptyline hcl tab 5 mg# 3protriptyline hcl tab 10 mg# 3PROZAC - fluoxetine hcl cap 10 mg 4 QL (90 capsules/30 days)PROZAC - fluoxetine hcl cap 20 mg 4 QL (120 capsules/30 days)PROZAC - fluoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)REMERON - mirtazapine tab 15 mg 4 QL (45 tablets/30 days)REMERON - mirtazapine tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 4 QL (30 tablets/30 days)

2020


21

Drug Name Drug Tier Requirements/Limitssertraline hcl oral concentrate for solution 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

x 2 (56 mg dose pack)5 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln 28 mg/devicex 3 (84 mg dose pack)

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg 2trazodone hcl tab 100 mg 2trazodone hcl tab 150 mg 2trazodone hcl tab 300 mg 2trimipramine maleate cap 25 mg# 3trimipramine maleate cap 50 mg# 3trimipramine maleate cap 100 mg# 3TRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

ZOLOFT - sertraline hcl tab 25 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 50 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 100 mg 4 QL (60 tablets/30 days)Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 3 BDaprepitant capsule 40 mg 3 BDaprepitant capsule 80 mg 3 BD

2020


Drug Name Drug Tier Requirements/Limitsaprepitant capsule 125 mg 3 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 3 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 3 PAchlorpromazine hcl tab 100 mg 3 PAchlorpromazine hcl tab 200 mg 3 PAdronabinol cap 2.5 mg 4 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3granisetron hcl tab 1 mg 2 BDmeclizine hcl tab 12.5 mg# 3ondansetron hcl inj 4 mg/2ml (2 mg/ml) 3ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml 3 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

perphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PAPROCHLORPERAZINE EDISYLATE - prochlorperazine edisylate

inj 50 mg/10ml4

prochlorperazine edisylate inj 10 mg/2ml 4prochlorperazine maleate tab 5 mg 2prochlorperazine maleate tab 10 mg 2prochlorperazine suppos 25 mg 3

2020


23

Drug Name Drug Tier Requirements/Limitspromethazine hcl suppos 12.5 mg# 3 PApromethazine hcl suppos 25 mg# 3 PApromethazine hcl syrup 6.25 mg/5ml# 3 PApromethazine hcl tab 12.5 mg# 3 PApromethazine hcl tab 25 mg# 3 PApromethazine hcl tab 50 mg# 3 PAscopolamine td patch 72hr 1 mg/3days# 3 PAtrimethobenzamide hcl cap 300 mg 3AntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 3 BDcaspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2ciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2ciclopirox solution 8% 2clotrimazole cream 1% 2clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1% 3fluconazole for susp 10 mg/ml 3fluconazole for susp 40 mg/ml 3fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 3griseofulvin microsize tab 500 mg 3griseofulvin ultramicrosize tab 125 mg 3

2020


Drug Name Drug Tier Requirements/Limitsgriseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 3ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 2posaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg 2TERCONAZOLE - terconazole vaginal cream 0.8% 3terconazole vaginal cream 0.4% 3terconazole vaginal suppos 80 mg 3voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg 2allopurinol tab 100 mg^ 1allopurinol tab 300 mg^ 1colchicine w/ probenecid tab 0.5-500 mg 2MITIGARE - colchicine cap 0.6 mg 3probenecid tab 500 mg 2ZYLOPRIM - allopurinol tab 100 mg 4ZYLOPRIM - allopurinol tab 300 mg 4Antimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/

ml3 PA, QL (2 pens/30 days)

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector140 mg/ml

3 PA, QL (1 pen/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector120 mg/ml

3 PA, QL (2 pens/30 days)

2020


25

Drug Name Drug Tier Requirements/LimitsEMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr

100 mg/ml3 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr120 mg/ml

3 PA, QL (2 syringes/30 days)

ergotamine w/ caffeine tab 1-100 mg 3frovatriptan succinate tab 2.5 mg 3 QL (18 tablets/30 days)MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg 3 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 3 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 3 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml4

sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 4sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 3pyridostigmine bromide oral soln 60 mg/5ml 5pyridostigmine bromide tab er 180 mg 3pyridostigmine bromide tab 60 mg 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4cycloserine cap 250 mg 5dapsone tab 25 mg 3dapsone tab 100 mg 3ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2

2020


Drug Name Drug Tier Requirements/LimitsISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg 2isoniazid tab 300 mg 2PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 3rifabutin cap 150 mg 4rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg* 5TRECATOR - ethionamide tab 250 mg 4Antineoplasticsabiraterone acetate tab 250 mg† 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAADRIAMYCIN - doxorubicin hcl for inj 10 mg 4 BDADRIAMYCIN - doxorubicin hcl for inj 50 mg 4 BDAFINITOR - everolimus tab 2.5 mg† 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg† 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg† 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg† 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg† 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg† 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg† 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5 PAALIMTA - pemetrexed disodium for iv soln 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg* 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 2ARRANON - nelarabine iv soln 5 mg/ml 5 PAarsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 4arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5 PAARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5 PA

2020


27

Drug Name Drug Tier Requirements/LimitsAVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5 PAAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5 PABALVERSA - erdafitinib tab 3 mg† 5 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg† 5 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg† 5 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5 PABELEODAQ - belinostat for iv inj 500 mg 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg† 5 PAbicalutamide tab 50 mg 2bleomycin sulfate for inj 15 unit 3 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg† 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg† 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg† 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)BRUKINSA - zanubrutinib cap 80 mg 5 PA, QL (120 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg†* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg†* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg†* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg* 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

2020


Drug Name Drug Tier Requirements/LimitsCOMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140

dose) kit*5 PA, QL (112 capsules/28 days)

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*

5 PA, QL (84 capsules/28 days)

COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 3 BDcyclophosphamide cap 50 mg 3 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5 PACYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5 PACYTARABINE - cytarabine inj 20 mg/ml 3 BDcytarabine inj pf 20 mg/ml 3 BDcytarabine inj pf 100 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5 PADARZALEX - daratumumab iv soln 400 mg/20ml* 5 PAdaunorubicin hcl iv soln 20 mg/4ml 3DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml3

DAURISMO - glasdegib maleate tab 25 mg† 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg† 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane hcl for inj 250 mg 5dexrazoxane hcl for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5docetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg 4 BDdoxorubicin hcl for inj 50 mg 4 BD

2020


29

Drug Name Drug Tier Requirements/Limitsdoxorubicin hcl inj 2 mg/ml 3 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PAELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg 5 PAEMPLICITI - elotuzumab for iv soln 400 mg 5 PAENHERTU - fam-trastuzumab deruxtecan-nxki for iv soln 100 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 4epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 4ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5 PAERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg† 5 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg† 5 PA, QL (30 tablets/30 days)erlotinib hcl tab 150 mg† 5 PA, QL (30 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3everolimus tab 2.5 mg† 5 PA, QL (30 tablets/30 days)everolimus tab 5 mg† 5 PA, QL (30 tablets/30 days)everolimus tab 7.5 mg† 5 PA, QL (30 tablets/30 days)EVOMELA - melphalan hcl for inj 50 mg (propylene glycol (pg) free) 5exemestane tab 25 mg 3FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5 PAfludarabine phosphate for inj 50 mg 3fludarabine phosphate inj 25 mg/ml 3fluorouracil iv soln 500 mg/10ml (50 mg/ml) 3 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml) 3 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 3 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 3 BD

2020


Drug Name Drug Tier Requirements/Limitsflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAfulvestrant inj 250 mg/5ml 5 PAGAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 3gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 3gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 3GILOTRIF - afatinib dimaleate tab 20 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg* 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 5HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk inj

600-10000 mg-unit/5ml*5 PA

hydroxyurea cap 500 mg 3IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg†* 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg†* 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg* 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg* 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 4ifosfamide iv inj 3 gm/60ml (50 mg/ml) 4imatinib mesylate tab 100 mg† 5 PA, QL (90 tablets/30 days)

2020


31

Drug Name Drug Tier Requirements/Limitsimatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg†* 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg†* 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg* 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg†* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg†* 5 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg†* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg†* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg†* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg†* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg†* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg†* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 150 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml) 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (42 tablets/28 days)

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mgtab)

5 PA, QL (63 tablets/28 days)

2020


Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk5 PA, QL (49 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KYPROLIS - carfilzomib for inj 10 mg 5 PAKYPROLIS - carfilzomib for inj 30 mg 5 PAKYPROLIS - carfilzomib for inj 60 mg 5 PALARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg 2LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)3

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium inj 500 mg/50ml (10 mg/ml) 3leucovorin calcium tab 5 mg 3leucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 5

2020


33

Drug Name Drug Tier Requirements/LimitsLIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml)* 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg† 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg† 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PALYNPARZA - olaparib tab 100 mg†* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg†* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 5mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MVASI - bevacizumab-awwb iv soln 100 mg/4ml (for infusion) 5 PAMVASI - bevacizumab-awwb iv soln 400 mg/16ml (for infusion) 5 PAMYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg†* 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg†* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5NUBEQA - darolutamide tab 300 mg 5 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)OGIVRI - trastuzumab-dkst for iv soln 150 mg 5 PAOGIVRI - trastuzumab-dkst for iv soln 420 mg 5 PAONCASPAR - pegaspargase inj 750 unit/ml 5

2020


Drug Name Drug Tier Requirements/LimitsONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml 5 PAOPDIVO - nivolumab iv soln 100 mg/10ml 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml 5 PAoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PADCEV - enfortumab vedotin-ejfv for iv soln 20 mg 5 PAPADCEV - enfortumab vedotin-ejfv for iv soln 30 mg 5 PAPANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mgdaily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg dailydose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 140 mg 5 PAPOMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PAPROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PA

2020


35

Drug Name Drug Tier Requirements/LimitsRITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml*5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml*

5 PA

ROZLYTREK - entrectinib cap 100 mg 5 PA, QL (150 capsules/30 days)ROZLYTREK - entrectinib cap 200 mg 5 PA, QL (90 capsules/30 days)RUBRACA - rucaparib camsylate tab 200 mg†* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg†* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg†* 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg† 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg† 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg† 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg† 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg† 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg† 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg† 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg† 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg† 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg† 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg†* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg†* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg†* 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg†* 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg 2tamoxifen citrate tab 20 mg 2TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg† 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 840 mg/14ml* 5 PATECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5

2020


Drug Name Drug Tier Requirements/Limitstemsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 4topotecan hcl inj 4 mg/4ml (for infusion) 4toremifene citrate tab 60 mg 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TRUXIMA - rituximab-abbs iv soln 100 mg/10ml (10 mg/ml) 5 PATRUXIMA - rituximab-abbs iv soln 500 mg/50ml (10 mg/ml) 5 PATURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg* 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BDvincristine sulfate iv soln 1 mg/ml 3 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VITRAKVI - larotrectinib sulfate cap 25 mg† 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg† 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)

2020


37

Drug Name Drug Tier Requirements/LimitsVIZIMPRO - dacomitinib tab 15 mg†* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg†* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg†* 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg†* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg†* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg†* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack

20 mg (100 mg once weekly)5 PA, QL (1 box/28 days)

XPOVIO 60 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (60 mg once weekly)

5 PA, QL (1 box/28 days)

XPOVIO 80 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (80 mg once weekly)


XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapy pack20 mg (80 mg twice weekly)


XTANDI - enzalutamide cap 40 mg†* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5 PAYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5 PAYONDELIS - trabectedin for inj 1 mg 5 PAYONSA - abiraterone acetate tab 125 mg†* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5 PAZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg†* 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg† 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib tab 150 mg†* 5 PA, QL (90 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg†* 5 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 5ALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4

2020


Drug Name Drug Tier Requirements/LimitsCHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg 3COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2LINDANE - lindane shampoo 1% 3malathion lotion 0.5% 3MEFLOQUINE HCL - mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4pentamidine isethionate for nebulization soln 300 mg 3 BDpentamidine isethionate for soln 300 mg 3permethrin cream 5% 3praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg 3Antiparkinson Agentsamantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2amantadine hcl tab 100 mg 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 3bromocriptine mesylate tab 2.5 mg 3carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab er 25-100 mg 2carbidopa & levodopa tab er 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2carbidopa & levodopa tab 25-100 mg 2carbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 4CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

2020


39

Drug Name Drug Tier Requirements/LimitsCARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 18.75-75-200 mg3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 31.25-125-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 37.5-150-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

3

entacapone tab 200 mg 3INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg 2pramipexole dihydrochloride tab 0.25 mg 2pramipexole dihydrochloride tab 0.5 mg 2pramipexole dihydrochloride tab 0.75 mg 2pramipexole dihydrochloride tab 1 mg 2pramipexole dihydrochloride tab 1.5 mg 2rasagiline mesylate tab 0.5 mg 3rasagiline mesylate tab 1 mg 3ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2RYTARY - carbidopa & levodopa cap er 23.75-95 mg 4RYTARY - carbidopa & levodopa cap er 36.25-145 mg 4RYTARY - carbidopa & levodopa cap er 48.75-195 mg 4RYTARY - carbidopa & levodopa cap er 61.25-245 mg 4selegiline hcl cap 5 mg 3selegiline hcl tab 5 mg 3tolcapone tab 100 mg 5AntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 3 QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 QL (60 tablets/30 days)aripiprazole tab 2 mg 3 QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsaripiprazole tab 5 mg 3 QL (45 tablets/30 days)aripiprazole tab 10 mg 3 QL (30 tablets/30 days)aripiprazole tab 15 mg 3 QL (30 tablets/30 days)aripiprazole tab 20 mg 3 QL (30 tablets/30 days)aripiprazole tab 30 mg 3 QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 QL (1 syringe/28 days)





ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml


clozapine orally disintegrating tab 12.5 mg 3 QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 3 QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 3 QL (270 tablets/30 days)clozapine tab 25 mg 2 QL (90 tablets/30 days)clozapine tab 50 mg 2 QL (90 tablets/30 days)clozapine tab 100 mg 2 QL (270 tablets/30 days)clozapine tab 200 mg 2 QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 QL (7 packs (56 tablets)/28 days)

fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PAfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml3 PA

2020


41

Drug Name Drug Tier Requirements/LimitsGEODON - ziprasidone mesylate for inj 20 mg 4 QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PAhaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref syr

39 mg/0.25ml4 QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate er susp pref syr78 mg/0.5ml

5 QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate er susp pref syr156 mg/ml




INVEGA TRINZA - paliperidone palmitate er susp pref syr273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PAloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PA

2020


Drug Name Drug Tier Requirements/LimitsNUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)olanzapine for im inj 10 mg 3 QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 QL (45 tablets/30 days)olanzapine tab 5 mg 2 QL (45 tablets/30 days)olanzapine tab 7.5 mg 2 QL (45 tablets/30 days)olanzapine tab 10 mg 2 QL (45 tablets/30 days)olanzapine tab 15 mg 2 QL (30 tablets/30 days)olanzapine tab 20 mg 2 QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


PIMOZIDE - pimozide tab 1 mg 3PIMOZIDE - pimozide tab 2 mg 3quetiapine fumarate tab er 24hr 50 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 3 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 3 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 3 QL (60 tablets/30 days)quetiapine fumarate tab 25 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 2 QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 QL (30 tablets/30 days)

2020


43

Drug Name Drug Tier Requirements/LimitsREXULTI - brexpiprazole tab 4 mg 5 QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for im extended

rel susp 12.5 mg4 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 25 mg

5 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 50 mg


RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 QL (480 mls/30 days)risperidone tab 0.25 mg 2 QL (60 tablets/30 days)risperidone tab 0.5 mg 2 QL (60 tablets/30 days)risperidone tab 1 mg 2 QL (60 tablets/30 days)risperidone tab 2 mg 2 QL (60 tablets/30 days)risperidone tab 3 mg 2 QL (60 tablets/30 days)risperidone tab 4 mg 2 QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 QL (60 tablets/30 days)SECUADO - asenapine td patch 24 hr 3.8 mg/24hr 5 QL (30 patches/30 days)SECUADO - asenapine td patch 24 hr 5.7 mg/24hr 5 QL (30 patches/30 days)SECUADO - asenapine td patch 24 hr 7.6 mg/24hr 5 QL (30 patches/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PAtrifluoperazine hcl tab 1 mg 2 PAtrifluoperazine hcl tab 2 mg 2 PAtrifluoperazine hcl tab 5 mg 2 PA

2020


Drug Name Drug Tier Requirements/Limitstrifluoperazine hcl tab 10 mg 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 4 QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 2 QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg


ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg^ 1baclofen tab 20 mg^ 1dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 2tizanidine hcl tab 2 mg^ 1tizanidine hcl tab 4 mg^ 1Antiviralsabacavir sulfate soln 20 mg/ml 3 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 3 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir oint 5% 4 PAacyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg 2acyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)

2020


45

Drug Name Drug Tier Requirements/LimitsAPTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg5 QL (30 tablets/30 days)

DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 3 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (120 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 3entecavir tab 1 mg 3EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 3 BD

2020


Drug Name Drug Tier Requirements/LimitsGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg 5 PAHARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 3 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 3 QL (60 tablets/30 days)LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab 90-400 mg 5 PALEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)nevirapine susp 50 mg/5ml 3 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg 2oseltamivir phosphate cap 45 mg 2oseltamivir phosphate cap 75 mg 2

2020


47

Drug Name Drug Tier Requirements/Limitsoseltamivir phosphate for susp 6 mg/ml 3PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 480 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)ribavirin cap 200 mg 3ribavirin tab 200 mg 3ritonavir tab 100 mg 3 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOFOSBUVIR/VELPATASVIR - sofosbuvir-velpatasvir tab

400-100 mg5 PA

stavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)stavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsSYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


TEMIXYS - lamivudine-tenofovir disoproxil fumarate tab300-300 mg

5 QL (30 tablets/30 days)

tenofovir disoproxil fumarate tab 300 mg 4 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg 2valacyclovir hcl tab 1 gm 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 4 QL (30 capsules/30 days)VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)XOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg (80 mgdose)

4

zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 3 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)

2020


49

Drug Name Drug Tier Requirements/LimitsAnxiolyticsalprazolam tab 0.25 mg 4 QL (120 tablets/30 days)alprazolam tab 0.5 mg 4 QL (120 tablets/30 days)alprazolam tab 1 mg 4 QL (120 tablets/30 days)alprazolam tab 2 mg 4 QL (150 tablets/30 days)buspirone hcl tab 5 mg 2buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 2buspirone hcl tab 15 mg 2buspirone hcl tab 30 mg 2chlordiazepoxide hcl cap 5 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 10 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 25 mg 3 PA, QL (360 capsules/30 days)clonazepam orally disintegrating tab 0.125 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 QL (300 tablets/30 days)clonazepam tab 0.5 mg 2 QL (120 tablets/30 days)clonazepam tab 1 mg 2 QL (120 tablets/30 days)clonazepam tab 2 mg 2 QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg 2 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 3 PAhydroxyzine hcl tab 10 mg# 3 PAhydroxyzine hcl tab 25 mg# 3 PAhydroxyzine hcl tab 50 mg# 3 PAlorazepam tab 0.5 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 2 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg 2

2020


Drug Name Drug Tier Requirements/Limitslithium carbonate cap 300 mg 2lithium carbonate cap 600 mg 2lithium carbonate tab er 300 mg 2lithium carbonate tab er 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 15 mg 4 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 30 mg 4 QL (30 tablets/30 days)ACTOS - pioglitazone hcl tab 45 mg 4 QL (30 tablets/30 days)ALCOHOL SWABS 3AMARYL - glimepiride tab 1 mg 4 QL (240 tablets/30 days)AMARYL - glimepiride tab 2 mg 4 QL (120 tablets/30 days)AMARYL - glimepiride tab 4 mg 4 QL (60 tablets/30 days)ASSURE ID INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X 1/2" 3ASSURE ID INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" 3ASSURE ID SAFETY PEN NEEDLES 31G X 5MM (1/5" OR 3/16") 3AUTOPEN - injection device for insulin 3BAQSIMI ONE PACK - glucagon nasal powder 3 mg/dose 4 QL (4 devices/30 days)BAQSIMI TWO PACK - glucagon nasal powder 3 mg/dose 4 QL (4 devices/30 days)BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X 15/64" 3BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30G

X 1/2"3

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X1/2"

3

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X1/2"

3

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE1ML/29G X 1/2"

3

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30G X 1/2" 3GAUZE PADS 2" X 2" 3

2020


51

Drug Name Drug Tier Requirements/Limitsglimepiride tab 1 mg^ 1 QL (240 tablets/30 days)glimepiride tab 2 mg^ 1 QL (120 tablets/30 days)glimepiride tab 4 mg^ 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg^ 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg^ 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg^ 1 QL (60 tablets/30 days)glipizide tab 5 mg^ 1 QL (240 tablets/30 days)glipizide tab 10 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3 QL (4 kits/30 days)GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 4 QL (4 kits/30 days)GLUCOPHAGE - metformin hcl tab 500 mg 4 QL (150 tablets/30 days)GLUCOPHAGE - metformin hcl tab 850 mg 4 QL (90 tablets/30 days)GLUCOPHAGE - metformin hcl tab 1000 mg 4 QL (75 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 500 mg 4 QL (120 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 750 mg 4 QL (60 tablets/30 days)GLUCOTROL - glipizide tab 5 mg 4 QL (240 tablets/30 days)GLUCOTROL - glipizide tab 10 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 2.5 mg 4 QL (240 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 5 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 10 mg 4 QL (60 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 2 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 2 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)2 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml(1 unit dial)

2 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 2 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)


HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)


HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


2020


Drug Name Drug Tier Requirements/LimitsHUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml2 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml2 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

2 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN PEN NEEDLE 29G X 12.7MM (1/2") 3INSULIN PEN NEEDLE 29G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 29G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 30G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 30G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 31G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 32G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 33G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 6MM (1/4" OR 15/64") 3INSULIN PEN NEEDLE 33G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 34G X 3.5MM (9/64") 3INSULIN SYRINGE (DISP) U-100/0.3ML 3INSULIN SYRINGE (DISP) U-100/0.5ML 3INSULIN SYRINGE (DISP) U-100/1ML 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X 1" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/30G 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G 3

2020


53

Drug Name Drug Tier Requirements/LimitsINSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/8" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 1" 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/26G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X 5/8" 3INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X 6MM (15/64") 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsJARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 2 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 2 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml2 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg^ 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg^ 1 QL (60 tablets/30 days)metformin hcl tab 500 mg^ 1 QL (150 tablets/30 days)metformin hcl tab 850 mg^ 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg^ 1 QL (75 tablets/30 days)miglitol tab 25 mg 3 QL (360 tablets/30 days)miglitol tab 50 mg 3 QL (180 tablets/30 days)miglitol tab 100 mg 3 QL (90 tablets/30 days)MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2"3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"

3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"

3

nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg^ 1 QL (30 tablets/30 days)

2020


55

Drug Name Drug Tier Requirements/Limitspioglitazone hcl tab 45 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PRECOSE - acarbose tab 25 mg 4 QL (360 tablets/30 days)PRECOSE - acarbose tab 50 mg 4 QL (180 tablets/30 days)PRECOSE - acarbose tab 100 mg 4 QL (90 tablets/30 days)PREVENT SAFETY PEN NEEDLES 31G X 1/4" 3PREVENT SAFETY PEN NEEDLES 31G X 5/16" 3PROGLYCEM - diazoxide susp 50 mg/ml 3repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SAFETY INSULIN SYRINGES 1ML/30G X 1/2" 3STARLIX - nateglinide tab 60 mg 4 QL (180 tablets/30 days)STARLIX - nateglinide tab 120 mg 4 QL (90 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 3

2020


Drug Name Drug Tier Requirements/LimitsTECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 5/16" 3TECHLITE PEN NEEDLES 29G X 10MM 3TECHLITE PEN NEEDLES 29G X 12MM 3TECHLITE PEN NEEDLES 31G X 5MM 3TECHLITE PEN NEEDLES/31G X 6MM 3TECHLITE PEN NEEDLES/31G X 8MM 3TECHLITE PEN NEEDLES/32G X 4MM 3TECHLITE PEN NEEDLES/32G X 6MM 3TECHLITE PEN NEEDLES/32G X 8MM 3TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300

unit/ml (2 unit dial)2 QL (60 mls/30 days)

TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit dial)

2 QL (60 mls/30 days)

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 2 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml2 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 3TRUEPLUS PEN NEEDLES 29G X 12MM 3TRUEPLUS PEN NEEDLES 31G X 5MM 3

2020


57

Drug Name Drug Tier Requirements/LimitsTRUEPLUS PEN NEEDLES 31G X 6MM 3TRUEPLUS PEN NEEDLES 31G X 8MM 3TRUEPLUS PEN NEEDLES 32G X 4MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 3TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 QL (4 pens/28 days), STULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" 3ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 3VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 3VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 3anagrelide hcl cap 1 mg 3ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA


4 PA


5 PA


5 PA


5 PA


5 PA


5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 3

2020


Drug Name Drug Tier Requirements/Limitsazacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 1cilostazol tab 100 mg^ 1clopidogrel bisulfate tab 75 mg 2clopidogrel bisulfate tab 300 mg 3COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 3dipyridamole tab 50 mg# 3dipyridamole tab 75 mg# 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)

2020


59

Drug Name Drug Tier Requirements/Limitsfondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5 PA

HEPARIN SODIUM - heparin sodium (porcine) inj soln pref syr5000 unit/0.5ml

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3HEPARIN SODIUM/D5W - heparin sodium (porcine)-dextrose iv sol

20000 unit/500ml-5%3

LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PAMOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NIVESTYM - filgrastim-aafi inj 300 mcg/ml 5 PANIVESTYM - filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 5 PAPRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PA

2020


Drug Name Drug Tier Requirements/LimitsPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 3tranexamic acid tab 650 mg 3UDENYCA - pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml 5 PAwarfarin sodium tab 1 mg 2warfarin sodium tab 2 mg 2warfarin sodium tab 2.5 mg 2warfarin sodium tab 3 mg 2warfarin sodium tab 4 mg 2warfarin sodium tab 5 mg 2warfarin sodium tab 6 mg 2warfarin sodium tab 7.5 mg 2warfarin sodium tab 10 mg 2XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml 5 PAZARXIO - filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml 5 PAZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular AgentsACCUPRIL - quinapril hcl tab 5 mg 4ACCUPRIL - quinapril hcl tab 10 mg 4ACCUPRIL - quinapril hcl tab 20 mg 4ACCUPRIL - quinapril hcl tab 40 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-25 mg 4acebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2acetazolamide cap er 12hr 500 mg 3

2020


61

Drug Name Drug Tier Requirements/Limitsacetazolamide tab 125 mg 3acetazolamide tab 250 mg 3ADALAT CC - nifedipine tab er 24hr 30 mg 4ADALAT CC - nifedipine tab er 24hr 60 mg 4ADALAT CC - nifedipine tab er 24hr 90 mg 4ALDACTONE - spironolactone tab 25 mg 4ALDACTONE - spironolactone tab 50 mg 4ALDACTONE - spironolactone tab 100 mg 4aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)ALTACE - ramipril cap 1.25 mg 4ALTACE - ramipril cap 2.5 mg 4ALTACE - ramipril cap 5 mg 4ALTACE - ramipril cap 10 mg 4amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 100 mg 3amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 3amlodipine besylate tab 2.5 mg^ 1amlodipine besylate tab 5 mg^ 1amlodipine besylate tab 10 mg^ 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-10 mg 3amlodipine besylate-atorvastatin calcium tab 5-20 mg 3amlodipine besylate-atorvastatin calcium tab 5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-80 mg 3amlodipine besylate-atorvastatin calcium tab 10-10 mg 3amlodipine besylate-atorvastatin calcium tab 10-20 mg 3amlodipine besylate-atorvastatin calcium tab 10-40 mg 3amlodipine besylate-atorvastatin calcium tab 10-80 mg 3amlodipine besylate-benazepril hcl cap 2.5-10 mg 2amlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2amlodipine besylate-benazepril hcl cap 10-20 mg 2

2020


Drug Name Drug Tier Requirements/Limitsamlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-olmesartan medoxomil tab 5-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 5-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 3 QL (30 tablets/30 days)ATACAND - candesartan cilexetil tab 4 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 8 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 16 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 32 mg 4 QL (30 tablets/30 days)ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab

16-12.5 mg4 QL (30 tablets/30 days)

ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg


ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-25 mg


atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2atenolol tab 25 mg^ 1atenolol tab 50 mg^ 1atenolol tab 100 mg^ 1atorvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg^ 1 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5 mg 4 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 75 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 150 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 300 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg 4 QL (30 tablets/30 days)

2020


63

Drug Name Drug Tier Requirements/LimitsAZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 4 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1BENICAR - olmesartan medoxomil tab 5 mg 4 QL (60 tablets/30 days)BENICAR - olmesartan medoxomil tab 20 mg 4 QL (30 tablets/30 days)BENICAR - olmesartan medoxomil tab 40 mg 4 QL (30 tablets/30 days)BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-25 mg


betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg 2bisoprolol fumarate tab 5 mg 2bisoprolol fumarate tab 10 mg 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2bumetanide tab 2 mg 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4CALAN SR - verapamil hcl tab er 120 mg 4CALAN SR - verapamil hcl tab er 240 mg 4candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitscandesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2captopril tab 50 mg 2captopril tab 100 mg 2CARDIZEM - diltiazem hcl tab 30 mg 4CARDIZEM - diltiazem hcl tab 60 mg 4CARDIZEM - diltiazem hcl tab 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 180 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 240 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 300 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 360 mg 4carvedilol tab 3.125 mg^ 1carvedilol tab 6.25 mg^ 1carvedilol tab 12.5 mg^ 1carvedilol tab 25 mg^ 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg 2chlorthalidone tab 25 mg 2chlorthalidone tab 50 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg^ 1clonidine hcl tab 0.2 mg^ 1clonidine hcl tab 0.3 mg^ 1clonidine td patch weekly 0.1 mg/24hr 2clonidine td patch weekly 0.2 mg/24hr 2clonidine td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2

2020


65

Drug Name Drug Tier Requirements/Limitscolestipol hcl granules 5 gm 2colestipol hcl tab 1 gm 2COREG - carvedilol tab 3.125 mg 4COREG - carvedilol tab 6.25 mg 4COREG - carvedilol tab 12.5 mg 4COREG - carvedilol tab 25 mg 4CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)COZAAR - losartan potassium tab 25 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 50 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 100 mg 4 QL (30 tablets/30 days)DEMSER - metyrosine cap 250 mg 5digoxin oral soln 0.05 mg/ml# 3 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 3 PA, QL (30 tablets/30 days)diltiazem hcl cap er 24hr 120 mg 3diltiazem hcl cap er 12hr 60 mg 3diltiazem hcl cap er 12hr 90 mg 3diltiazem hcl cap er 12hr 120 mg 3diltiazem hcl cap er 24hr 180 mg 3diltiazem hcl cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 120 mg 3diltiazem hcl coated beads cap er 24hr 180 mg 3diltiazem hcl coated beads cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 300 mg 3diltiazem hcl coated beads cap er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 180 mg 3diltiazem hcl coated beads tab er 24hr 240 mg 3diltiazem hcl coated beads tab er 24hr 300 mg 3diltiazem hcl coated beads tab er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 420 mg 3diltiazem hcl extended release beads cap er 24hr 120 mg 3diltiazem hcl extended release beads cap er 24hr 180 mg 3diltiazem hcl extended release beads cap er 24hr 240 mg 3diltiazem hcl extended release beads cap er 24hr 300 mg 3diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg 3

2020


Drug Name Drug Tier Requirements/Limitsdiltiazem hcl tab 30 mg 3diltiazem hcl tab 60 mg 3diltiazem hcl tab 90 mg 3diltiazem hcl tab 120 mg 3DIOVAN - valsartan tab 40 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 80 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 160 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 320 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25 mg 4 QL (30 tablets/30 days)dofetilide cap 125 mcg (0.125 mg) 3dofetilide cap 250 mcg (0.25 mg) 3dofetilide cap 500 mcg (0.5 mg) 3doxazosin mesylate tab 1 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg^ 1enalapril maleate & hydrochlorothiazide tab 10-25 mg^ 1enalapril maleate tab 2.5 mg^ 1enalapril maleate tab 5 mg^ 1enalapril maleate tab 10 mg^ 1enalapril maleate tab 20 mg^ 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (180 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg 2eplerenone tab 50 mg 2EXFORGE - amlodipine besylate-valsartan tab 5-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 5-320 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-320 mg 4 QL (30 tablets/30 days)EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg4 QL (30 tablets/30 days)

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg


2020


67

Drug Name Drug Tier Requirements/LimitsEXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab






ezetimibe tab 10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fluvastatin sodium cap 20 mg 3 QL (60 capsules/30 days)fluvastatin sodium cap 40 mg 3 QL (60 capsules/30 days)fluvastatin sodium tab er 24 hr 80 mg 3 QL (30 tablets/30 days)fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg^ 1fosinopril sodium tab 20 mg^ 1fosinopril sodium tab 40 mg^ 1furosemide inj 10 mg/ml 3furosemide oral soln 10 mg/ml 2furosemide tab 20 mg^ 1furosemide tab 40 mg^ 1furosemide tab 80 mg^ 1gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 2

2020


Drug Name Drug Tier Requirements/Limitshydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg^ 1hydrochlorothiazide tab 12.5 mg^ 1hydrochlorothiazide tab 25 mg^ 1hydrochlorothiazide tab 50 mg^ 1HYZAAR - losartan potassium & hydrochlorothiazide tab


HYZAAR - losartan potassium & hydrochlorothiazide tab100-12.5 mg


HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg 4 QL (30 tablets/30 days)indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg^ 1 QL (30 tablets/30 days)irbesartan tab 150 mg^ 1 QL (30 tablets/30 days)irbesartan tab 300 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg^ 1 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide dinitrate tab 30 mg 2isosorbide mononitrate tab er 24hr 30 mg 2isosorbide mononitrate tab er 24hr 60 mg 2isosorbide mononitrate tab er 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2labetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2labetalol hcl tab 300 mg 2LASIX - furosemide tab 20 mg 4LASIX - furosemide tab 40 mg 4LASIX - furosemide tab 80 mg 4LIDOCAINE HCL - lidocaine hcl (cardiac) iv pf soln pref syr

50 mg/5ml(1%)4

2020


69

Drug Name Drug Tier Requirements/LimitsLIDOCAINE HCL - lidocaine hcl (cardiac) iv soln pref syr 50 mg/5ml

(1%)4

lisinopril & hydrochlorothiazide tab 10-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-25 mg^ 1lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1LOPRESSOR - metoprolol tartrate tab 50 mg 4LOPRESSOR - metoprolol tartrate tab 100 mg 4losartan potassium & hydrochlorothiazide tab 50-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg^ 1 QL (30 tablets/30 days)losartan potassium tab 25 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 50 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 100 mg^ 1 QL (30 tablets/30 days)LOTENSIN - benazepril hcl tab 10 mg 4LOTENSIN - benazepril hcl tab 20 mg 4LOTENSIN - benazepril hcl tab 40 mg 4lovastatin tab 10 mg^ 1 QL (60 tablets/30 days)lovastatin tab 20 mg^ 1 QL (60 tablets/30 days)lovastatin tab 40 mg^ 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 3metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab er 24hr 25 mg 2metoprolol succinate tab er 24hr 50 mg 2metoprolol succinate tab er 24hr 100 mg 2metoprolol succinate tab er 24hr 200 mg 2metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1

2020


Drug Name Drug Tier Requirements/LimitsMEXILETINE HCL - mexiletine hcl cap 150 mg 3MEXILETINE HCL - mexiletine hcl cap 200 mg 3MEXILETINE HCL - mexiletine hcl cap 250 mg 3MICARDIS - telmisartan tab 20 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 40 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 80 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 40-12.5 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (60 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-25 mg 4 QL (30 tablets/30 days)midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2minoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2moexipril hcl tab 15 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2nadolol tab 80 mg 2niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab er 24hr 30 mg 3nifedipine tab er 24hr 60 mg 3nifedipine tab er 24hr 90 mg 3nifedipine tab er 24hr osmotic release 30 mg 3nifedipine tab er 24hr osmotic release 60 mg 3nifedipine tab er 24hr osmotic release 90 mg 3nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg 3nisoldipine tab er 24hr 17 mg 3nisoldipine tab er 24hr 34 mg 3NITRO-BID - nitroglycerin oint 2% 3nitroglycerin sl tab 0.3 mg 2

2020


71

Drug Name Drug Tier Requirements/Limitsnitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 3NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PANORVASC - amlodipine besylate tab 2.5 mg 4NORVASC - amlodipine besylate tab 5 mg 4NORVASC - amlodipine besylate tab 10 mg 4olmesartan medoxomil tab 5 mg^ 1 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil tab 40 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg^ 1 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg 3 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm 3pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 2pravastatin sodium tab 10 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg^ 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2

2020


Drug Name Drug Tier Requirements/Limitsprazosin hcl cap 5 mg 2PRINIVIL - lisinopril tab 5 mg 4PRINIVIL - lisinopril tab 10 mg 4PRINIVIL - lisinopril tab 20 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 30 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 60 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 90 mg 4propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 3propafenone hcl cap er 12hr 425 mg 3propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl cap er 24hr 60 mg 2propranolol hcl cap er 24hr 80 mg 2propranolol hcl cap er 24hr 120 mg 2propranolol hcl cap er 24hr 160 mg 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg^ 1propranolol hcl tab 20 mg^ 1propranolol hcl tab 40 mg^ 1propranolol hcl tab 60 mg^ 1propranolol hcl tab 80 mg^ 1quinapril hcl tab 5 mg^ 1quinapril hcl tab 10 mg^ 1quinapril hcl tab 20 mg^ 1quinapril hcl tab 40 mg^ 1quinapril-hydrochlorothiazide tab 10-12.5 mg 2quinapril-hydrochlorothiazide tab 20-12.5 mg 2quinapril-hydrochlorothiazide tab 20-25 mg 2quinidine gluconate tab er 324 mg 3QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg^ 1ramipril cap 2.5 mg^ 1ramipril cap 5 mg^ 1ramipril cap 10 mg^ 1ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)

2020


73

Drug Name Drug Tier Requirements/Limitsranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)RECTIV - nitroglycerin oint 0.4% 4REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml3 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

3 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

3 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)simvastatin tab 5 mg^ 1 QL (45 tablets/30 days)simvastatin tab 10 mg^ 1 QL (45 tablets/30 days)simvastatin tab 20 mg^ 1 QL (60 tablets/30 days)simvastatin tab 40 mg^ 1 QL (45 tablets/30 days)simvastatin tab 80 mg^ 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 2spironolactone tab 50 mg 2spironolactone tab 100 mg 2TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg^ 1 QL (90 capsules/30 days)

2020


Drug Name Drug Tier Requirements/Limitsterazosin hcl cap 2 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 1 QL (60 capsules/30 days)TIAZAC - diltiazem hcl extended release beads cap er 24hr 120 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 180 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 240 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 300 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 360 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 420 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3timolol maleate tab 5 mg 2torsemide tab 5 mg^ 1torsemide tab 10 mg^ 1torsemide tab 20 mg^ 1torsemide tab 100 mg^ 1trandolapril tab 1 mg^ 1trandolapril tab 2 mg^ 1trandolapril tab 4 mg^ 1triamterene & hydrochlorothiazide cap 37.5-25 mg 2triamterene & hydrochlorothiazide tab 37.5-25 mg 2triamterene & hydrochlorothiazide tab 75-50 mg 2TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg


valsartan tab 40 mg 2 QL (60 tablets/30 days)valsartan tab 80 mg 2 QL (60 tablets/30 days)valsartan tab 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)

2020


75

Drug Name Drug Tier Requirements/Limitsvalsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3VASERETIC - enalapril maleate & hydrochlorothiazide tab

10-25 mg4

VASOTEC - enalapril maleate tab 2.5 mg 4VASOTEC - enalapril maleate tab 5 mg 4VASOTEC - enalapril maleate tab 10 mg 4VASOTEC - enalapril maleate tab 20 mg 4verapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2VERAPAMIL HCL ER- verapamil hcl cap er 24hr 100 mg 2VERAPAMIL HCL SR - verapamil hcl cap er 24hr 360 mg 2verapamil hcl tab er 120 mg 2verapamil hcl tab er 180 mg 2verapamil hcl tab er 240 mg 2verapamil hcl tab 40 mg^ 1verapamil hcl tab 80 mg^ 1verapamil hcl tab 120 mg^ 1VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 4ZESTRIL - lisinopril tab 2.5 mg 4ZESTRIL - lisinopril tab 5 mg 4ZESTRIL - lisinopril tab 10 mg 4ZESTRIL - lisinopril tab 20 mg 4ZESTRIL - lisinopril tab 30 mg 4ZESTRIL - lisinopril tab 40 mg 4Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 4 QL (30 capsules/30 days)

2020


Drug Name Drug Tier Requirements/Limitsamphetamine-dextroamphetamine cap er 24hr 30 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)atomoxetine hcl cap 10 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 3 QL (30 capsules/30 days)AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)dalfampridine tab er 12hr 10 mg 5 PAdexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)MAVENCLAD - cladribine tab therapy pack 10 mg (4 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (5 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (6 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (7 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (8 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (9 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (10 tabs) 5 PA

2020


77

Drug Name Drug Tier Requirements/LimitsMAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack


PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack


REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml) 5 PA, QL (12 syringes/28 days)REBIF - interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml) 5 PA, QL (12 syringes/28 days)REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml

(12mu/ml)5 PA, QL (12 syringes/28 days)

REBIF REBIDOSE - interferon beta-1a soln auto-inj 44 mcg/0.5ml(24mu/ml)


REBIF REBIDOSE TITRATION PACK - interferon beta-1a auto-inj6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml


REBIF TITRATION PACK - interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml


riluzole tab 50 mg 3TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentscevimeline hcl cap 30 mg 3chlorhexidine gluconate soln 0.12%^ 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2

2020


Drug Name Drug Tier Requirements/LimitsDermatological Agentsacitretin cap 10 mg 3acitretin cap 17.5 mg 3acitretin cap 25 mg 3alclometasone dipropionate cream 0.05% 2 QL (120 grams/30 days)alclometasone dipropionate oint 0.05% 2 QL (120 grams/30 days)AUGMENTED BETAMETHASONE DIPROPIONATE -

betamethasone dipropionate augmented gel 0.05%3 QL (200 grams/28 days)

azelaic acid gel 15% 3AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 3betamethasone dipropionate augmented cream 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate augmented lotion 0.05% 2 QL (210 mls/30 days)betamethasone dipropionate augmented oint 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate cream 0.05% 2 QL (135 grams/30 days)betamethasone dipropionate lotion 0.05% 2 QL (120 mls/30 days)betamethasone dipropionate oint 0.05% 2 QL (135 grams/30 days)betamethasone valerate cream 0.1% 2 QL (135 grams/30 days)betamethasone valerate lotion 0.1% 2 QL (120 mls/30 days)betamethasone valerate oint 0.1% 2 QL (135 grams/30 days)calcipotriene cream 0.005% 3calcipotriene oint 0.005% 3calcipotriene soln 0.005% (50 mcg/ml) 3clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 3clindamycin phosphate-benzoyl peroxide gel 1-5% 3clobetasol propionate cream 0.05% 3 QL (210 grams/28 days)clobetasol propionate emollient base cream 0.05% 3 QL (210 grams/28 days)clobetasol propionate gel 0.05% 3 QL (210 grams/28 days)clobetasol propionate oint 0.05% 3 QL (210 grams/28 days)clobetasol propionate soln 0.05% 3 QL (200 mls/28 days)clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2desonide cream 0.05% 3 QL (120 grams/30 days)desonide lotion 0.05% 3 QL (118 mls/30 days)desonide oint 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.25% 3 QL (120 grams/30 days)desoximetasone gel 0.05% 3 QL (120 grams/30 days)desoximetasone oint 0.25% 3 QL (120 grams/30 days)

2020


79

Drug Name Drug Tier Requirements/Limitsdiclofenac sodium (actinic keratoses) gel 3% 4diflorasone diacetate oint 0.05% 4 QL (120 grams/30 days)ELIDEL - pimecrolimus cream 1% 4 PAfluocinolone acetonide cream 0.01% 2 QL (120 grams/30 days)fluocinonide cream 0.05% 2 QL (120 grams/30 days)fluocinonide emulsified base cream 0.05% 2 QL (120 grams/30 days)fluocinonide gel 0.05% 2 QL (120 grams/30 days)fluocinonide oint 0.05% 2 QL (120 grams/30 days)fluocinonide soln 0.05% 2 QL (120 mls/30 days)FLUOROURACIL - fluorouracil cream 0.5% 5FLUOROURACIL - fluorouracil soln 2% 2FLUOROURACIL - fluorouracil soln 5% 2fluorouracil cream 5% 3fluticasone propionate cream 0.05% 2 QL (120 grams/30 days)fluticasone propionate oint 0.005% 2 QL (120 grams/30 days)gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2halobetasol propionate cream 0.05% 3 QL (200 grams/28 days)halobetasol propionate oint 0.05% 3 QL (200 grams/28 days)hydrocortisone butyrate cream 0.1% 3 QL (135 grams/30 days)hydrocortisone butyrate hydrophilic lipo base cream 0.1% 3 QL (120 grams/30 days)hydrocortisone butyrate oint 0.1% 3 QL (135 grams/30 days)hydrocortisone butyrate soln 0.1% 3 QL (120 mls/30 days)hydrocortisone cream 1% 2 QL (454 grams/30 days)hydrocortisone cream 2.5% 2 QL (454 grams/30 days)hydrocortisone lotion 2.5% 2 QL (118 mls/30 days)hydrocortisone oint 1% 2 QL (453.6 grams/30 days)hydrocortisone oint 2.5% 2 QL (454 grams/30 days)hydrocortisone valerate cream 0.2% 3 QL (120 grams/30 days)hydrocortisone valerate oint 0.2% 3 QL (120 grams/30 days)imiquimod cream 5% 2 PAisotretinoin cap 10 mg 3isotretinoin cap 20 mg 3isotretinoin cap 30 mg 3isotretinoin cap 40 mg 3lactic acid (ammonium lactate) cream 12% 2lactic acid (ammonium lactate) lotion 12% 2methoxsalen rapid cap 10 mg 5

2020


Drug Name Drug Tier Requirements/Limitsmetronidazole cream 0.75% 2metronidazole gel 0.75% 2metronidazole gel 1% 2metronidazole lotion 0.75% 2mometasone furoate cream 0.1% 2 QL (135 grams/28 days)mometasone furoate oint 0.1% 2 QL (135 grams/28 days)mometasone furoate solution 0.1% (lotion) 2 QL (120 mls/30 days)mupirocin calcium cream 2% 3mupirocin oint 2% 2nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)pimecrolimus cream 1% 4 PApodofilox soln 0.5% 2PREDNICARBATE - prednicarbate cream 0.1% 2 QL (120 grams/30 days)PREDNICARBATE - prednicarbate oint 0.1% 2 QL (120 grams/30 days)REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 3tacrolimus oint 0.03% 2 PAtacrolimus oint 0.1% 2 PAtazarotene cream 0.1% 3 PATAZORAC - tazarotene cream 0.05% 4 PATAZORAC - tazarotene gel 0.05% 4 PATAZORAC - tazarotene gel 0.1% 4 PAtretinoin cream 0.025% 3 PAtretinoin cream 0.05% 3 PAtretinoin cream 0.1% 3 PAtretinoin gel 0.01% 3 PAtretinoin gel 0.025% 3 PAtriamcinolone acetonide cream 0.025% 2 QL (454 grams/30 days)triamcinolone acetonide cream 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide cream 0.5% 2 QL (454 grams/30 days)triamcinolone acetonide lotion 0.025% 2 QL (120 mls/30 days)triamcinolone acetonide lotion 0.1% 2 QL (120 mls/30 days)

2020


81

Drug Name Drug Tier Requirements/Limitstriamcinolone acetonide oint 0.025% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.5% 2 QL (120 grams/30 days)Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 15% 3 BDAMINOSYN II - amino acid infusion 10% 4 BDAMINOSYN-PF - amino acid infusion 10% 4 BDAMINOSYN-PF 7% - amino acid infusion 7% 4 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PA, QL (360 tablets/30 days)calcium acetate cap 667 mg 2calcium acetate tab 667 mg 2CARBAGLU - carglumic acid tab 200 mg* 5 PACHEMET - succimer cap 100 mg 5CLINIMIX E 2.75%/DEXTROSE 5% - amino acid electrolyte w/cal

infusion 2.75% in d5w4 BD

CLINIMIX E 4.25%/DEXTROSE 10% - amino acid electrolyte w/calinfusion 4.25% in d10w

4 BD

CLINIMIX E 4.25%/DEXTROSE 5% - amino acid electrolyte w/calinfusion 4.25% in d5w

4 BD

CLINIMIX E 5%/DEXTROSE 15% - amino acid electrolyte w/calinfusion 5% in d15w

4 BD

CLINIMIX E 5%/DEXTROSE 20% - amino acid electrolyte w/calinfusion 5% in d20w

4 BD

CLINIMIX 4.25%/DEXTROSE 10% - amino acid infusion 4.25% ind10w

4 BD

CLINIMIX 4.25%/DEXTROSE 5% - amino acid infusion 4.25% ind5w

4 BD

CLINIMIX 5%/DEXTROSE 15% - amino acid infusion 5% in d15w 4 BDCLINIMIX 5%/DEXTROSE 20% - amino acid infusion 5% in d20w 4 BDdeferasirox tab for oral susp 125 mg 5 PAdeferasirox tab for oral susp 250 mg 5 PAdeferasirox tab for oral susp 500 mg 5 PAdeferasirox tab 90 mg 5 PAdeferasirox tab 360 mg 5 PAdextrose inj 5% 3dextrose inj 10% 3DEXTROSE 2.5%/NACL 0.45% - dextrose 2.5% w/ sodium chloride

0.45%3

dextrose 5% in lactated ringers 3dextrose 5% w/ sodium chloride 0.2% 3dextrose 5% w/ sodium chloride 0.33% 3

2020


Drug Name Drug Tier Requirements/Limitsdextrose 5% w/ sodium chloride 0.45% 3dextrose 5% w/ sodium chloride 0.9% 3fomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)FREAMINE HBC 6.9% - amino acid infusion 6.9% 4 BDFREAMINE III - amino acid infusion 10% 4 BDHEPATAMINE - amino acid infusion 8% 4 BDINTRALIPID - fat emulsion plant based iv emulsion 20% 4 BDJADENU - deferasirox tab 90 mg* 5 PAJADENU - deferasirox tab 180 mg* 5 PAJADENU - deferasirox tab 360 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg* 5 PAK-TAB - potassium chloride tab er 20 meq (1500 mg) 3kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 3kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 3kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 3lactated ringer's solution 4lanthanum carbonate chew tab 500 mg 5 QL (90 tablets/30 days)lanthanum carbonate chew tab 750 mg 5 QL (180 tablets/30 days)lanthanum carbonate chew tab 1000 mg 5 QL (120 tablets/30 days)levocarnitine oral soln 1 gm/10ml (10%) 3levocarnitine tab 330 mg 3magnesium sulfate inj 50% 3NEPHRAMINE - amino acid infusion 5.4% 4 BDNORMOSOL-M IN D5W - electrolyte-m in d5w soln 4NUTRILIPID - fat emulsion plant based iv emulsion 20% 4 BDPHOSLYRA - calcium acetate oral soln 667 mg/5ml 4potassium chloride cap er 8 meq 2potassium chloride cap er 10 meq 2potassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq 2potassium chloride microencapsulated crys er tab 20 meq 2

2020


83

Drug Name Drug Tier Requirements/Limitspotassium chloride oral soln 10% (20 meq/15ml) 3potassium chloride tab er 8 meq (600 mg) 3potassium chloride tab er 10 meq 2potassium chloride tab er 20 meq (1500 mg) 3potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 3POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

3

potassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2PREMASOL - amino acid infusion 10% 4 BDPROCALAMINE - amino acid electrolyte infusion 3% 4 BDPROSOL - amino acid infusion 20% 4 BDSAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5 QL (270 packets/30 days)sevelamer carbonate packet 2.4 gm 5 QL (90 packets/30 days)sevelamer carbonate tab 800 mg 3 QL (270 tablets/30 days)sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.45% 3sodium chloride iv soln 0.9% 3sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2TRAVASOL - amino acid infusion 10% 4 BDtrientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)TROPHAMINE - amino acid infusion 10% 4 BDVELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5 QL (180 tablets/30 days)VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 5water for irrigation, sterile irrigation soln 3Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5 PA, QL (60 tablets/30 days)alosetron hcl tab 1 mg 5 PA, QL (60 tablets/30 days)AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PA

2020


Drug Name Drug Tier Requirements/LimitsCARAFATE - sucralfate susp 1 gm/10ml 4CHENODAL - chenodiol tab 250 mg* 5 PACIMETIDINE HCL - cimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2cimetidine tab 400 mg 2cimetidine tab 800 mg 2COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 240 gm4

cromolyn sodium oral conc 100 mg/5ml 3dicyclomine hcl tab 20 mg# 3 PAesomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)esomeprazole sodium for intravenous soln 40 mg 3famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg 2famotidine tab 40 mg 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for soln

236 gm4

lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 3metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 3metoclopramide hcl tab 5 mg 2metoclopramide hcl tab 10 mg 2misoprostol tab 100 mcg 2

2020


85

Drug Name Drug Tier Requirements/Limitsmisoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppack 2.5 mg


nizatidine cap 150 mg 2nizatidine cap 300 mg 2NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for

soln 420 gm4

omeprazole cap delayed release 10 mg 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 2 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 2 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 3peg 3350-kcl-sod bicarb-nacl for soln 420 gm 3peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 3peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg5

ranitidine hcl cap 150 mg 2ranitidine hcl cap 300 mg 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2ranitidine hcl tab 150 mg 2ranitidine hcl tab 300 mg 2RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate susp 1 gm/10ml 4sucralfate tab 1 gm 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

2020


Drug Name Drug Tier Requirements/Limitsursodiol cap 300 mg 3ursodiol tab 250 mg 3ursodiol tab 500 mg 3XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

CEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CRYSVITA - burosumab-twza inj 10 mg/ml 5 PACRYSVITA - burosumab-twza inj 20 mg/ml 5 PACRYSVITA - burosumab-twza inj 30 mg/ml 5 PACYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4 PACYSTAGON - cysteamine bitartrate cap 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml) 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg* 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5nitisinone cap 2 mg* 5nitisinone cap 5 mg* 5nitisinone cap 10 mg* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5

2020


87

Drug Name Drug Tier Requirements/LimitsORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVPRIV - velaglucerase alfa for inj 400 unit 5 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2DEPEN TITRATABS - penicillamine tab 250 mg 5

2020


Drug Name Drug Tier Requirements/Limitsdutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 2 QL (30 tablets/30 days)FLOMAX - tamsulosin hcl cap 0.4 mg 4 QL (60 capsules/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)penicillamine tab 250 mg 5PROSCAR - finasteride tab 5 mg 4 QL (30 tablets/30 days)silodosin cap 4 mg 3 QL (30 capsules/30 days)silodosin cap 8 mg 3 QL (30 capsules/30 days)tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone tab 1 mg 2DEXAMETHASONE - dexamethasone tab 2 mg 2dexamethasone elixir 0.5 mg/5ml 3dexamethasone sodium phosphate inj 4 mg/ml 3dexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab 0.5 mg 2dexamethasone tab 0.75 mg 2dexamethasone tab 1.5 mg 2dexamethasone tab 4 mg 2dexamethasone tab 6 mg 2

2020


89

Drug Name Drug Tier Requirements/Limitsfludrocortisone acetate tab 0.1 mg 2hydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 500 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21) 3methylprednisolone tab 4 mg 3methylprednisolone tab 8 mg 3methylprednisolone tab 16 mg 3methylprednisolone tab 32 mg 3prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 3prednisolone sod phosphate oral soln 15 mg/5ml 3prednisolone sod phosphate oral soln 10 mg/5ml 3prednisolone sod phosphate oral soln 20 mg/5ml 3prednisolone syrup 15 mg/5ml 3PREDNISONE - prednisone oral soln 5 mg/5ml 3prednisone tab therapy pack 5 mg (21) 2prednisone tab therapy pack 5 mg (48) 2prednisone tab therapy pack 10 mg (21) 2prednisone tab therapy pack 10 mg (48) 2prednisone tab 1 mg 2prednisone tab 2.5 mg 2prednisone tab 5 mg 2prednisone tab 10 mg 2prednisone tab 20 mg 2prednisone tab 50 mg 2Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit4 PA

desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal spray soln 0.01% 3desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA SV - tesamorelin acetate for inj 2 mg* 5 PA

2020


Drug Name Drug Tier Requirements/LimitsINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit4 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day#4

COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.25 mg/day#

4

danazol cap 50 mg 3 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 3 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 3desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 3desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4DIVIGEL - estradiol td gel 1.25 mg/1.25gm (0.1%)# 4drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg 3drospirenone-ethinyl estradiol tab 3-0.02 mg 3drospirenone-ethinyl estradiol tab 3-0.03 mg 3DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 0.5-0.1 mg# 4estradiol & norethindrone acetate tab 1-0.5 mg# 4estradiol tab 0.5 mg# 3estradiol tab 1 mg# 3estradiol tab 2 mg# 3estradiol td patch twice weekly 0.025 mg/24hr# 4

2020


91

Drug Name Drug Tier Requirements/Limitsestradiol td patch twice weekly 0.0375 mg/24hr# 4estradiol td patch twice weekly 0.05 mg/24hr# 4estradiol td patch twice weekly 0.075 mg/24hr# 4estradiol td patch twice weekly 0.1 mg/24hr# 4estradiol td patch weekly 0.025 mg/24hr# 4estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4estradiol td patch weekly 0.05 mg/24hr# 4estradiol td patch weekly 0.06 mg/24hr# 4estradiol td patch weekly 0.075 mg/24hr# 4estradiol td patch weekly 0.1 mg/24hr# 4estradiol vaginal cream 0.1 mg/gm 3estradiol vaginal tab 10 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 3HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 3levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 3levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 3levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 3levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 3medroxyprogesterone acetate im susp 150 mg/ml 3medroxyprogesterone acetate tab 2.5 mg 2medroxyprogesterone acetate tab 5 mg 2medroxyprogesterone acetate tab 10 mg 2megestrol acetate susp 40 mg/ml# 3 PAmegestrol acetate tab 20 mg# 3 PAmegestrol acetate tab 40 mg# 3 PAMETHYLTESTOSTERONE - methyltestosterone cap 10 mg 5 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3

2020


Drug Name Drug Tier Requirements/Limitsnorethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 3norethindrone acetate tab 5 mg 2norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg# 4norethindrone tab 0.35 mg 3norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 3norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 3norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 3norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 3norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 3norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 3oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4


4


4

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4

progesterone micronized cap 100 mg 3progesterone micronized cap 200 mg 3raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 12.5 mg/act (1%) 3 PA, QL (4 pump bottles/30 days)testosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 units/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)

2020


93

Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (euthyrox, levo-t, levoxyl,

unithroid)2

levothyroxine sodium tab 50 mcg (euthyrox, levo-t, levoxyl,unithroid)

2


2


2


2


2


2


2


2


2


2

levothyroxine sodium tab 300 mcg (levo-t, unithroid) 2liothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2liothyronine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3

2020


Drug Name Drug Tier Requirements/LimitsHormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 5LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 3 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 3 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 3 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 3 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PA

2020


95

Drug Name Drug Tier Requirements/LimitsSIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 2methimazole tab 10 mg 2propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

2020


Drug Name Drug Tier Requirements/LimitsBENLYSTA - belimumab subcutaneous solution prefilled syringe

200 mg/ml5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

4

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)*5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneousauto-inj 150 mg/ml (300 mg dose)*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

CUVITRU - immune globulin (human) subcutaneous inj 1 gm/5ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 2 gm/10ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 4 gm/20ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 8 gm/40ml 5 BD, PACUVITRU - immune globulin (human) subcutaneous inj 10 gm/50ml 5 BD, PAcyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 3 BDcyclosporine iv soln 50 mg/ml 3 BDcyclosporine modified cap 25 mg 3 BDcyclosporine modified cap 50 mg 3 BDcyclosporine modified cap 100 mg 3 BDcyclosporine modified oral soln 100 mg/ml 3 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

2020


97

Drug Name Drug Tier Requirements/LimitsENBREL SURECLICK - etanercept subcutaneous solution auto-

injector 50 mg/ml5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDGARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im

susp4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit*

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit*

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 80 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 4 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4INFLECTRA - infliximab-dyyb for iv inj 100 mg 5 PAIPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4

2020


Drug Name Drug Tier Requirements/LimitsIXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles-mumps-rubella virus vaccines for inj soln 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)2

methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 3 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 3 BDmycophenolate sodium tab dr 360 mg 3 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector125 mg/ml

5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg*

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 4PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

2020


99

Drug Name Drug Tier Requirements/LimitsPENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for

im susp4

PRIVIGEN - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAPRIVIGEN - immune globulin (human) iv soln 40 gm/400ml 5 BD, PAPROGRAF - tacrolimus inj 5 mg/ml 4 BDPROGRAF - tacrolimus packet for susp 0.2 mg 4 BDPROGRAF - tacrolimus packet for susp 1 mg 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp4

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

4

RABAVERT - rabies vaccine, pcec for inj 4 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5RINVOQ - upadacitinib tab er 24hr 15 mg 5 PAROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus oral soln 1 mg/ml 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 3 BDsirolimus tab 2 mg 5 BDSKYRIZI - risankizumab-rzaa sol prefilled syringe 2 x 75 mg/0.83ml

kit5 PA

STAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PA

2020


Drug Name Drug Tier Requirements/LimitsSTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 3 BDtacrolimus cap 1 mg 3 BDtacrolimus cap 5 mg 3 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 4 BDTHYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TREMFYA - guselkumab soln pen-injector 100 mg/ml 5 PATREMFYA - guselkumab soln prefilled syringe 100 mg/ml 5 PATRUMENBA - meningococcal group b vac (recomb) im susp

prefilled syr4

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 4TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml4

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

VARIZIG - varicella-zoster immune glob (human) im inj 125unit/1.2ml

4

XATMEP - methotrexate oral soln 2.5 mg/ml 4 BDXELJANZ - tofacitinib citrate tab 5 mg 5 PAXELJANZ - tofacitinib citrate tab 10 mg 5 PAXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe 150 mg/ml*

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

2020


101

Drug Name Drug Tier Requirements/LimitsInflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 4 QL (90 capsules/30 days)CANASA - mesalamine suppos 1000 mg 5hydrocortisone enema 100 mg/60ml 3hydrocortisone rectal cream 1% 2hydrocortisone rectal cream 2.5% 2mesalamine cap dr 400 mg 3 QL (180 capsules/30 days)mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)mesalamine enema 4 gm 3mesalamine rectal enema 4 gm & cleanser wipe kit 3mesalamine suppos 1000 mg 5mesalamine tab delayed release 800 mg 3 QL (180 tablets/30 days)mesalamine tab delayed release 1.2 gm 3 QL (120 tablets/30 days)PENTASA - mesalamine cap er 250 mg 4 QL (480 capsules/30 days)PENTASA - mesalamine cap er 500 mg 4 QL (240 capsules/30 days)sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg^ 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg^ 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg^ 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg^ 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2CALCITRIOL - calcitriol inj 1 mcg/ml 4calcitriol cap 0.25 mcg 2calcitriol cap 0.5 mcg 2calcitriol oral soln 1 mcg/ml 3cinacalcet hcl tab 30 mg 5 PAcinacalcet hcl tab 60 mg 5 PAcinacalcet hcl tab 90 mg 5 PAFORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 3ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

2020


Drug Name Drug Tier Requirements/LimitsNATPARA - parathyroid hormone (recombinant) for inj cartridge

50 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge75 mcg*

5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge100 mcg*

5 PA, QL (2 cartridges/28 days)

paricalcitol cap 1 mcg 3paricalcitol cap 2 mcg 3paricalcitol cap 4 mcg 3paricalcitol iv soln 2 mcg/ml 3paricalcitol iv soln 5 mcg/ml 3PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)TYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4Ophthalmic AgentsACULAR - ketorolac tromethamine ophth soln 0.5% 4ACULAR LS - ketorolac tromethamine ophth soln 0.4% 4ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03% 2brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 2bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 2CILOXAN - ciprofloxacin hcl ophth soln 0.3% 4

2020


103

Drug Name Drug Tier Requirements/Limitsciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 2CYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PADEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 3FLURBIPROFEN SODIUM - flurbiprofen sodium ophth soln 0.03% 3FML LIQUIFILM - fluorometholone ophth susp 0.1% 4gatifloxacin ophth soln 0.5% 3GENTAK - gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 2levofloxacin ophth soln 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MAXITROL - neomycin-polymyxin-dexamethasone ophth oint 0.1% 4MAXITROL - neomycin-polymyxin-dexamethasone ophth susp

0.1%4

MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5% (generic for Vigamox) 2moxifloxacin hcl ophth soln 0.5% (2 times daily) (generic for

Moxeza)4

NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml2

2020


Drug Name Drug Tier Requirements/LimitsOCUFLOX - ofloxacin ophth soln 0.3% 4ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2olopatadine hcl ophth soln 0.2% 2PATANOL - olopatadine hcl ophth soln 0.1% 4PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 3pilocarpine hcl ophth soln 2% 3pilocarpine hcl ophth soln 4% 3polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 2POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%4

PRED FORTE - prednisolone acetate ophth susp 1% 4PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 STSIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth soln 0.25% 2timolol maleate ophth soln 0.5% 2timolol maleate ophth soln 0.5% (once-daily) 2TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timolol

maleate ophth gel forming soln 0.25%2

TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timololmaleate ophth gel forming soln 0.5%

2

TIMOPTIC - timolol maleate ophth soln 0.25% 4TIMOPTIC - timolol maleate ophth soln 0.5% 4TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25% 4TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4TOBRADEX - tobramycin-dexamethasone ophth susp 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TOBREX - tobramycin ophth soln 0.3% 4TRAVATAN Z - travoprost ophth soln 0.004% 3

2020


105

Drug Name Drug Tier Requirements/Limitstravoprost ophth soln 0.004% 3TRIFLURIDINE - trifluridine ophth soln 1% 3Otic Agentsacetic acid otic soln 2% 2fluocinolone acetonide (otic) oil 0.01% 3hydrocortisone w/ acetic acid otic soln 1-2% 3neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 3Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADEMPAS - riociguat tab 0.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg* 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 4 mg 3ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 8 mg 3albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BDalbuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab 2 mg 3albuterol sulfate tab 4 mg 3ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

2020


Drug Name Drug Tier Requirements/LimitsARNUITY ELLIPTA - fluticasone furoate aerosol powder breath

activ 50 mcg/act3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 100 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 200 mcg/act


ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh












ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 3 BDbudesonide inhalation susp 0.5 mg/2ml 3 BDbudesonide inhalation susp 1 mg/2ml 3 BDcaffeine citrate oral soln 60 mg/3ml 2CAYSTON - aztreonam lysine for inhal soln 75 mg* 5CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 250 mcg 4 PA, QL (30 tablets/30 days)DALIRESP - roflumilast tab 500 mcg 4 PA, QL (30 tablets/30 days)

2020


107

Drug Name Drug Tier Requirements/Limitsdiphenhydramine hcl inj 50 mg/ml 3DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(generic for

EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)


fluticasone propionate nasal susp 50 mcg/act 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act


INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh


ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 25 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)levocetirizine dihydrochloride tab 5 mg^ 1mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 2

2020


Drug Name Drug Tier Requirements/Limitsmontelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 3montelukast sodium tab 10 mg 2OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer80 mcg/act


REMODULIN - treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tabtbpk


2020


109

Drug Name Drug Tier Requirements/LimitsSYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg

tab tbpk5 PA, QL (60 tablets/30 days)

tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 3terbutaline sulfate tab 5 mg 3theophylline tab er 12hr 300 mg 2theophylline tab er 12hr 450 mg 2theophylline tab er 24hr 400 mg 2theophylline tab er 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDtreprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDtreprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDtreprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDTRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor

150 mg tbpk5 PA, QL (90 tablets/30 days)

UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg(60)*

5 PA, QL (1 pack (200tablets)/28 days)

UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 3zafirlukast tab 20 mg 3Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PA

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Drug Name Drug Tier Requirements/LimitsSleep Disorder Agentsarmodafinil tab 50 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 3 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)doxepin hcl (sleep) tab 3 mg 3 QL (30 tablets/30 days)doxepin hcl (sleep) tab 6 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 3 PA, QL (30 tablets/30 days)modafinil tab 200 mg 3 PA, QL (30 tablets/30 days)ramelteon tab 8 mg 2 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4zaleplon cap 10 mg# 4zolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA


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INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................44abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................44abacavir sulfate soln 20 mg/ml.................................. 44abacavir sulfate tab 300 mg.......................................44abiraterone acetate tab 250 mg.................................26ABRAXANE...................................................................26acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 50acarbose tab 25 mg.................................................... 50acarbose tab 50 mg.................................................... 50ACCUPRIL.................................................................... 60ACCUPRIL.................................................................... 60ACCUPRIL.................................................................... 60ACCUPRIL.................................................................... 60ACCURETIC................................................................. 60ACCURETIC................................................................. 60ACCURETIC................................................................. 60acebutolol hcl cap 200 mg..........................................60acebutolol hcl cap 400 mg..........................................60acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

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

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................60acetazolamide tab 125 mg......................................... 61acetazolamide tab 250 mg......................................... 61acetic acid otic soln 2%............................................ 105acetylcysteine inhal soln 10%..................................105acetylcysteine inhal soln 20%..................................105acitretin cap 10 mg......................................................78acitretin cap 17.5 mg...................................................78acitretin cap 25 mg......................................................78ACTHIB..........................................................................95ACTIMMUNE................................................................ 95ACTOS...........................................................................50ACTOS...........................................................................50ACTOS...........................................................................50ACULAR......................................................................102ACULAR LS................................................................102acyclovir cap 200 mg.................................................. 44acyclovir oint 5%..........................................................44

acyclovir sodium iv soln 50 mg/ml.............................44acyclovir susp 200 mg/5ml......................................... 44acyclovir tab 400 mg................................................... 44acyclovir tab 800 mg................................................... 44ADACEL........................................................................ 95ADALAT CC..................................................................61ADALAT CC..................................................................61ADALAT CC..................................................................61ADASUVE..................................................................... 39adefovir dipivoxil tab 10 mg........................................44ADEMPAS...................................................................105ADEMPAS...................................................................105ADEMPAS...................................................................105ADEMPAS...................................................................105ADEMPAS...................................................................105ADRIAMYCIN............................................................... 26ADRIAMYCIN............................................................... 26ADVAIR DISKUS....................................................... 105ADVAIR DISKUS....................................................... 105ADVAIR DISKUS....................................................... 105ADVAIR HFA.............................................................. 105ADVAIR HFA.............................................................. 105ADVAIR HFA.............................................................. 105AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AIMOVIG....................................................................... 24AIMOVIG....................................................................... 24albendazole tab 200 mg............................................. 37ALBUTEROL SULFATE ER..................................... 105ALBUTEROL SULFATE ER..................................... 105albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................105albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................. 105albuterol sulfate soln nebu 0.63

mg/3ml......................................................................105albuterol sulfate soln nebu 1.25

mg/3ml......................................................................105albuterol sulfate syrup 2 mg/5ml..............................105albuterol sulfate tab 2 mg.........................................105albuterol sulfate tab 4 mg.........................................105alclometasone dipropionate cream

0.05%..........................................................................78alclometasone dipropionate oint

0.05%..........................................................................78ALCOHOL SWABS......................................................50ALDACTONE................................................................ 61

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ALDACTONE................................................................ 61ALDACTONE................................................................ 61ALDURAZYME............................................................. 86ALECENSA................................................................... 26alendronate sodium tab 10 mg................................ 101alendronate sodium tab 35 mg................................ 101alendronate sodium tab 5 mg.................................. 101alendronate sodium tab 70 mg................................ 101alfuzosin hcl tab er 24hr 10 mg................................. 87ALIMTA.......................................................................... 26ALIMTA.......................................................................... 26ALINIA............................................................................37ALINIA............................................................................37ALIQOPA....................................................................... 26aliskiren fumarate tab 150 mg....................................61aliskiren fumarate tab 300 mg....................................61allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24alosetron hcl tab 0.5 mg............................................. 83alosetron hcl tab 1 mg................................................ 83ALPHAGAN P............................................................ 102alprazolam tab 0.25 mg.............................................. 49alprazolam tab 0.5 mg................................................ 49alprazolam tab 1 mg....................................................49alprazolam tab 2 mg....................................................49ALTACE......................................................................... 61ALTACE......................................................................... 61ALTACE......................................................................... 61ALTACE......................................................................... 61ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26amantadine hcl cap 100 mg.......................................38amantadine hcl syrup 50 mg/5ml...............................38amantadine hcl tab 100 mg........................................38AMARYL........................................................................ 50AMARYL........................................................................ 50AMARYL........................................................................ 50AMBISOME...................................................................23ambrisentan tab 10 mg.............................................105ambrisentan tab 5 mg............................................... 105amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................4amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................4amiloride & hydrochlorothiazide tab 5-50

mg................................................................................61amiloride hcl tab 5 mg.................................................61amino acid infusion 15%.............................................81AMINOSYN II............................................................... 81

AMINOSYN-PF.............................................................81AMINOSYN-PF 7%......................................................81amiodarone hcl tab 100 mg........................................61amiodarone hcl tab 200 mg........................................61amiodarone hcl tab 400 mg........................................61AMITIZA.........................................................................83AMITIZA.........................................................................83amitriptyline hcl tab 100 mg....................................... 17amitriptyline hcl tab 10 mg..........................................17amitriptyline hcl tab 150 mg....................................... 17amitriptyline hcl tab 25 mg..........................................17amitriptyline hcl tab 50 mg..........................................17amitriptyline hcl tab 75 mg..........................................17amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................61amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................61amlodipine besylate-atorvastatin calcium tab 2.5-10







mg................................................................................61amlodipine besylate-benazepril hcl cap 10-20


mg................................................................................62amlodipine besylate-benazepril hcl cap 2.5-10




mg................................................................................61amlodipine besylate-olmesartan medoxomil tab

10-20 mg....................................................................62amlodipine besylate-olmesartan medoxomil tab

10-40 mg....................................................................62

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amlodipine besylate-olmesartan medoxomil tab 5-20mg................................................................................62

amlodipine besylate-olmesartan medoxomil tab 5-40mg................................................................................62

amlodipine besylate tab 10 mg..................................61amlodipine besylate tab 2.5 mg.................................61amlodipine besylate tab 5 mg.................................... 61amlodipine besylate-valsartan tab 10-160

mg................................................................................62amlodipine besylate-valsartan tab 10-320



mg................................................................................62amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................62amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................62amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................62amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................62amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 62AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXICILLIN................................................................. 5AMOXICILLIN................................................................. 5AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5AMOXICILLIN/CLAVULANATE POTASSIUM

ER..................................................................................5amoxicillin (trihydrate) cap 250 mg..............................5amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 5amoxicillin (trihydrate) tab 500 mg...............................5amoxicillin (trihydrate) tab 875 mg...............................5amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 5

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

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

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

amoxicillin & k clavulanate tab 250-125mg..................................................................................5



amphetamine-dextroamphetamine cap er 24hr 10mg................................................................................75






amphetamine-dextroamphetamine tab 10mg................................................................................76

amphetamine-dextroamphetamine tab 12.5mg................................................................................76





amphetamine-dextroamphetamine tab 7.5mg................................................................................76

AMPHOTERICIN B......................................................23AMPICILLIN.................................................................... 5ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................5AMPICILLIN SODIUM................................................... 5ampicillin sodium for inj 1 gm.......................................5ampicillin sodium for inj 250 mg...................................5ampicillin sodium for inj 2 gm.......................................5ampicillin sodium for inj 500 mg...................................5ampicillin sodium for iv soln 10 gm..............................5ampicillin sodium for iv soln 2 gm................................5AMPICILLIN-SULBACTAM........................................... 5ANADROL-50............................................................... 90anagrelide hcl cap 0.5 mg.......................................... 57

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anagrelide hcl cap 1 mg............................................. 57anastrozole tab 1 mg...................................................26ANDRODERM.............................................................. 90ANDRODERM.............................................................. 90ANORO ELLIPTA.......................................................105APOKYN........................................................................38aprepitant capsule 125 mg.........................................22aprepitant capsule 40 mg........................................... 21aprepitant capsule 80 mg........................................... 21aprepitant capsule therapy pack 80 & 125

mg................................................................................21APRISO....................................................................... 101APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 44APTIVUS....................................................................... 45ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARCALYST....................................................................95aripiprazole orally disintegrating tab 10

mg................................................................................39aripiprazole orally disintegrating tab 15

mg................................................................................39aripiprazole oral solution 1 mg/ml..............................39aripiprazole tab 10 mg................................................ 40aripiprazole tab 15 mg................................................ 40aripiprazole tab 20 mg................................................ 40aripiprazole tab 2 mg...................................................39aripiprazole tab 30 mg................................................ 40aripiprazole tab 5 mg...................................................40ARISTADA.....................................................................40ARISTADA.....................................................................40ARISTADA.....................................................................40ARISTADA.....................................................................40ARISTADA INITIO........................................................40armodafinil tab 150 mg............................................. 110armodafinil tab 200 mg............................................. 110

armodafinil tab 250 mg............................................. 110armodafinil tab 50 mg............................................... 110ARNUITY ELLIPTA....................................................106ARNUITY ELLIPTA....................................................106ARNUITY ELLIPTA....................................................106ARRANON.................................................................... 26arsenic trioxide iv soln 10 mg/10ml (1 mg/

ml)................................................................................26arsenic trioxide iv soln 12 mg/6ml (2 mg/

ml)................................................................................26ARZERRA..................................................................... 26ARZERRA..................................................................... 26ASMANEX HFA..........................................................106ASMANEX HFA..........................................................106ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................106ASMANEX TWISTHALER 14 METERED





DOSES.....................................................................106aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................57ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"......................................... 50ASSURE ID INSULIN SAFETY SYRINGE/

U-100/1ML/29G X 1/2".............................................50ASSURE ID SAFETY PEN NEEDLES 31G X 5MM

(1/5" OR 3/16")..........................................................50ATACAND......................................................................62ATACAND......................................................................62ATACAND......................................................................62ATACAND......................................................................62ATACAND HCT............................................................ 62ATACAND HCT............................................................ 62ATACAND HCT............................................................ 62atazanavir sulfate cap 150 mg...................................45atazanavir sulfate cap 200 mg...................................45atazanavir sulfate cap 300 mg...................................45atenolol & chlorthalidone tab 100-25

mg................................................................................62atenolol & chlorthalidone tab 50-25 mg.................... 62atenolol tab 100 mg.....................................................62atenolol tab 25 mg.......................................................62atenolol tab 50 mg.......................................................62ATGAM.......................................................................... 95atomoxetine hcl cap 100 mg...................................... 76

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atomoxetine hcl cap 10 mg........................................ 76atomoxetine hcl cap 18 mg........................................ 76atomoxetine hcl cap 25 mg........................................ 76atomoxetine hcl cap 40 mg........................................ 76atomoxetine hcl cap 60 mg........................................ 76atomoxetine hcl cap 80 mg........................................ 76atorvastatin calcium tab 10 mg.................................. 62atorvastatin calcium tab 20 mg.................................. 62atorvastatin calcium tab 40 mg.................................. 62atorvastatin calcium tab 80 mg.................................. 62atovaquone-proguanil hcl tab 250-100

mg................................................................................37atovaquone-proguanil hcl tab 62.5-25

mg................................................................................37atovaquone susp 750 mg/5ml....................................37ATRIPLA........................................................................ 45ATROVENT HFA........................................................106AUGMENTED BETAMETHASONE

DIPROPIONATE....................................................... 78AURYXIA.......................................................................81AUTOPEN..................................................................... 50AVALIDE........................................................................ 62AVALIDE........................................................................ 62AVAPRO........................................................................ 62AVAPRO........................................................................ 62AVAPRO........................................................................ 62AVASTIN........................................................................27AVASTIN........................................................................27AVONEX........................................................................ 76AVONEX PEN.............................................................. 76azacitidine for inj 100 mg............................................58AZACTAM........................................................................5AZACTAM........................................................................5AZASAN........................................................................ 95AZASAN........................................................................ 95AZATHIOPRINE........................................................... 95azathioprine tab 50 mg............................................... 95azelaic acid gel 15%................................................... 78azelastine hcl nasal spray 0.1% (137 mcg/

spray)........................................................................106azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)........................................................................106azelastine hcl ophth soln 0.05%..............................102AZELEX......................................................................... 78AZITHROMYCIN............................................................ 5azithromycin for susp 100 mg/5ml...............................5azithromycin for susp 200 mg/5ml...............................5azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT.........................................................................102

AZOR............................................................................. 62AZOR............................................................................. 63AZOR............................................................................. 63AZOR............................................................................. 63aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN.............................................................. 102bacitracin-polymyxin b ophth oint............................ 102bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................. 102baclofen tab 10 mg......................................................44baclofen tab 20 mg......................................................44balsalazide disodium cap 750 mg........................... 101BALVERSA....................................................................27BALVERSA....................................................................27BALVERSA....................................................................27BANZEL.........................................................................13BANZEL.........................................................................13BANZEL.........................................................................13BAQSIMI ONE PACK..................................................50BAQSIMI TWO PACK................................................. 50BARACLUDE................................................................ 45BAVENCIO.................................................................... 27BCG VACCINE.............................................................95BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G

X 15/64"......................................................................50BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G

X 15/64"......................................................................50BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X

15/64"..........................................................................50BELEODAQ.................................................................. 27BELSOMRA................................................................ 110BELSOMRA................................................................ 110BELSOMRA................................................................ 110BELSOMRA................................................................ 110benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................63benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................63benazepril & hydrochlorothiazide tab 20-25

mg................................................................................63benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................63benazepril hcl tab 10 mg............................................ 63benazepril hcl tab 20 mg............................................ 63benazepril hcl tab 40 mg............................................ 63benazepril hcl tab 5 mg.............................................. 63BENDEKA..................................................................... 27BENICAR.......................................................................63BENICAR.......................................................................63BENICAR.......................................................................63

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BENICAR HCT............................................................. 63BENICAR HCT............................................................. 63BENICAR HCT............................................................. 63BENLYSTA.................................................................... 95BENLYSTA.................................................................... 95BENLYSTA.................................................................... 95BENLYSTA.................................................................... 96BENZNIDAZOLE..........................................................37BENZNIDAZOLE..........................................................37benzoyl peroxide-erythromycin gel

5-3%............................................................................78benztropine mesylate tab 0.5 mg.............................. 38benztropine mesylate tab 1 mg..................................38benztropine mesylate tab 2 mg..................................38BESIVANCE................................................................102BESPONSA.................................................................. 27betamethasone dipropionate augmented cream

0.05%..........................................................................78betamethasone dipropionate augmented lotion

0.05%..........................................................................78betamethasone dipropionate augmented oint

0.05%..........................................................................78betamethasone dipropionate cream

0.05%..........................................................................78betamethasone dipropionate lotion

0.05%..........................................................................78betamethasone dipropionate oint

0.05%..........................................................................78betamethasone valerate cream 0.1%....................... 78betamethasone valerate lotion 0.1%.........................78betamethasone valerate oint 0.1%............................78BETASERON................................................................ 76betaxolol hcl ophth soln 0.5%..................................102betaxolol hcl tab 10 mg...............................................63betaxolol hcl tab 20 mg...............................................63bethanechol chloride tab 10 mg.................................87bethanechol chloride tab 25 mg.................................87bethanechol chloride tab 50 mg.................................87bethanechol chloride tab 5 mg...................................87BETOPTIC-S.............................................................. 102BEVYXXA......................................................................58BEVYXXA......................................................................58bexarotene cap 75 mg................................................ 27BEXSERO..................................................................... 96bicalutamide tab 50 mg...............................................27BICILLIN C-R..................................................................6BICILLIN C-R..................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BIKTARVY..................................................................... 45bimatoprost ophth soln 0.03%................................. 102

bisoprolol & hydrochlorothiazide tab 10-6.25mg................................................................................63

bisoprolol & hydrochlorothiazide tab 2.5-6.25mg................................................................................63

bisoprolol & hydrochlorothiazide tab 5-6.25mg................................................................................63

bisoprolol fumarate tab 10 mg................................... 63bisoprolol fumarate tab 5 mg..................................... 63bleomycin sulfate for inj 15 unit................................. 27bleomycin sulfate for inj 30 unit................................. 27BLINCYTO.....................................................................27BOOSTRIX....................................................................96bosentan tab 125 mg................................................ 106bosentan tab 62.5 mg............................................... 106BOSULIF....................................................................... 27BOSULIF....................................................................... 27BOSULIF....................................................................... 27BRAFTOVI.....................................................................27BREO ELLIPTA..........................................................106BREO ELLIPTA..........................................................106BRILINTA.......................................................................58BRILINTA.......................................................................58brimonidine tartrate ophth soln 0.15%.................... 102brimonidine tartrate ophth soln 0.2%...................... 102BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13bromfenac sodium ophth soln 0.09% (once-

daily)......................................................................... 102bromocriptine mesylate cap 5 mg..............................38bromocriptine mesylate tab 2.5 mg........................... 38BRUKINSA....................................................................27budesonide delayed release particles cap 3

mg............................................................................. 101budesonide inhalation susp 0.25

mg/2ml......................................................................106budesonide inhalation susp 0.5

mg/2ml......................................................................106budesonide inhalation susp 1 mg/2ml.....................106bumetanide inj 0.25 mg/ml......................................... 63bumetanide tab 0.5 mg............................................... 63bumetanide tab 1 mg.................................................. 63bumetanide tab 2 mg.................................................. 63buprenorphine hcl-naloxone hcl sl film 12-3

mg..................................................................................4buprenorphine hcl-naloxone hcl sl film 2-0.5

mg..................................................................................4

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buprenorphine hcl-naloxone hcl sl film 4-1mg..................................................................................4

buprenorphine hcl-naloxone hcl sl film 8-2mg..................................................................................4

buprenorphine hcl-naloxone hcl sl tab 2-0.5mg..................................................................................4

buprenorphine hcl-naloxone hcl sl tab 8-2mg..................................................................................4

buprenorphine hcl sl tab 2 mg......................................4buprenorphine hcl sl tab 8 mg......................................4bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................4bupropion hcl tab 100 mg...........................................18bupropion hcl tab 75 mg.............................................18bupropion hcl tab er 12hr 100 mg............................. 17bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 18bupropion hcl tab er 24hr 150 mg............................. 18bupropion hcl tab er 24hr 300 mg............................. 18buspirone hcl tab 10 mg............................................. 49buspirone hcl tab 15 mg............................................. 49buspirone hcl tab 30 mg............................................. 49buspirone hcl tab 5 mg............................................... 49buspirone hcl tab 7.5 mg............................................ 49busulfan inj 6 mg/ml.................................................... 27butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg.........................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON BCISE.....................................................50BYDUREON PEN........................................................ 50BYSTOLIC.....................................................................63BYSTOLIC.....................................................................63BYSTOLIC.....................................................................63BYSTOLIC.....................................................................63Ccabergoline tab 0.5 mg............................................... 94CABLIVI......................................................................... 96CABOMETYX............................................................... 27

CABOMETYX............................................................... 27CABOMETYX............................................................... 27caffeine citrate oral soln 60 mg/3ml........................ 106CALAN SR.................................................................... 63CALAN SR.................................................................... 63calcipotriene cream 0.005%.......................................78calcipotriene oint 0.005%............................................78calcipotriene soln 0.005% (50 mcg/ml).....................78calcitonin (salmon) nasal soln 200 unit/

act..............................................................................101CALCITRIOL...............................................................101calcitriol cap 0.25 mcg.............................................. 101calcitriol cap 0.5 mcg................................................ 101calcitriol oral soln 1 mcg/ml......................................101calcium acetate cap 667 mg...................................... 81calcium acetate tab 667 mg....................................... 81CALQUENCE................................................................27CANASA......................................................................101candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................64candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................64candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................64candesartan cilexetil tab 16 mg................................. 64candesartan cilexetil tab 32 mg................................. 64candesartan cilexetil tab 4 mg................................... 63candesartan cilexetil tab 8 mg................................... 63CAPASTAT SULFATE..................................................25CAPRELSA................................................................... 27CAPRELSA................................................................... 27captopril tab 100 mg....................................................64captopril tab 12.5 mg...................................................64captopril tab 25 mg......................................................64captopril tab 50 mg......................................................64CARAFATE....................................................................84CARBAGLU.................................................................. 81carbamazepine cap er 12hr 100 mg......................... 13carbamazepine cap er 12hr 200 mg......................... 13carbamazepine cap er 12hr 300 mg......................... 13carbamazepine chew tab 100 mg..............................13carbamazepine susp 100 mg/5ml..............................13carbamazepine tab 200 mg........................................13carbamazepine tab er 12hr 100 mg.......................... 13carbamazepine tab er 12hr 200 mg.......................... 13carbamazepine tab er 12hr 400 mg.......................... 13CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................39CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................39

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CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................39



carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................38



carbidopa & levodopa tab 10-100 mg....................... 38carbidopa & levodopa tab 25-100 mg....................... 38carbidopa & levodopa tab 25-250 mg....................... 38carbidopa & levodopa tab er 25-100

mg................................................................................38carbidopa & levodopa tab er 50-200

mg................................................................................38carbidopa tab 25 mg................................................... 38carboplatin iv soln 150 mg/15ml................................ 27carboplatin iv soln 450 mg/45ml................................ 27carboplatin iv soln 50 mg/5ml.................................... 27carboplatin iv soln 600 mg/60ml................................ 27CARDIZEM....................................................................64CARDIZEM....................................................................64CARDIZEM....................................................................64CARDIZEM CD............................................................ 64CARDIZEM CD............................................................ 64CARDIZEM CD............................................................ 64CARDIZEM CD............................................................ 64CARDIZEM CD............................................................ 64carmustine for inj 100 mg...........................................27carteolol hcl ophth soln 1%...................................... 102carvedilol tab 12.5 mg.................................................64carvedilol tab 25 mg....................................................64carvedilol tab 3.125 mg...............................................64carvedilol tab 6.25 mg.................................................64caspofungin acetate for iv soln 50 mg...................... 23caspofungin acetate for iv soln 70 mg...................... 23CAYSTON................................................................... 106cefaclor cap 250 mg......................................................6cefaclor cap 500 mg......................................................6cefadroxil cap 500 mg...................................................6cefadroxil for susp 250 mg/5ml....................................6cefadroxil for susp 500 mg/5ml....................................6cefadroxil tab 1 gm........................................................ 6cefazolin sodium for inj 10 gm..................................... 6cefazolin sodium for inj 1 gm....................................... 6cefazolin sodium for inj 500 mg................................... 6cefdinir cap 300 mg....................................................... 6cefdinir for susp 125 mg/5ml........................................6

cefdinir for susp 250 mg/5ml........................................6cefepime hcl for inj 1 gm.............................................. 6cefepime hcl for inj 2 gm.............................................. 6cefixime cap 400 mg..................................................... 6cefixime for susp 100 mg/5ml...................................... 6cefixime for susp 200 mg/5ml...................................... 6CEFOTAXIME SODIUM................................................6cefotaxime sodium for inj 1 gm.................................... 6cefoxitin sodium for inj 10 gm...................................... 6cefoxitin sodium for iv soln 1 gm................................. 6cefoxitin sodium for iv soln 2 gm................................. 6cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 6cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 6cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................7cefprozil tab 500 mg......................................................7ceftazidime for inj 1 gm.................................................7ceftazidime for inj 2 gm.................................................7ceftazidime for inj 6 gm.................................................7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7ceftriaxone sodium for inj 10 gm..................................7ceftriaxone sodium for inj 1 gm....................................7ceftriaxone sodium for inj 250 mg................................7ceftriaxone sodium for inj 2 gm....................................7ceftriaxone sodium for inj 500 mg................................7ceftriaxone sodium for iv soln 1 gm.............................7ceftriaxone sodium for iv soln 2 gm.............................7cefuroxime axetil tab 250 mg....................................... 7cefuroxime axetil tab 500 mg....................................... 7cefuroxime sodium for inj 7.5 gm.................................7cefuroxime sodium for inj 750 mg................................7cefuroxime sodium for iv soln 1.5 gm..........................7celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELEXA.........................................................................18CELEXA.........................................................................18CELEXA.........................................................................18CELONTIN.................................................................... 13cephalexin cap 250 mg.................................................7cephalexin cap 500 mg.................................................7

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cephalexin cap 750 mg.................................................7cephalexin for susp 125 mg/5ml..................................7cephalexin for susp 250 mg/5ml..................................7CEREZYME.................................................................. 86cevimeline hcl cap 30 mg...........................................77CHANTIX......................................................................... 4CHANTIX......................................................................... 4CHANTIX CONTINUING MONTH

PACK.............................................................................4CHANTIX STARTING MONTH PACK.........................4CHEMET........................................................................81CHENODAL.................................................................. 84CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................7chlordiazepoxide hcl cap 10 mg................................ 49chlordiazepoxide hcl cap 25 mg................................ 49chlordiazepoxide hcl cap 5 mg.................................. 49chlorhexidine gluconate soln 0.12%..........................77CHLOROQUINE PHOSPHATE................................. 38chloroquine phosphate tab 500 mg...........................38CHLOROTHIAZIDE..................................................... 64chlorothiazide tab 500 mg.......................................... 64CHLORPROMAZINE HCL..........................................22CHLORPROMAZINE HCL..........................................22chlorpromazine hcl tab 100 mg..................................22chlorpromazine hcl tab 10 mg....................................22chlorpromazine hcl tab 200 mg..................................22chlorpromazine hcl tab 25 mg....................................22chlorpromazine hcl tab 50 mg....................................22chlorthalidone tab 25 mg............................................ 64chlorthalidone tab 50 mg............................................ 64cholestyramine light powder 4 gm/

dose............................................................................ 64cholestyramine light powder packets 4

gm................................................................................64cholestyramine powder 4 gm/dose............................64cholestyramine powder packets 4 gm.......................64choline fenofibrate cap dr 135 mg............................. 64choline fenofibrate cap dr 45 mg............................... 64CHORIONIC GONADOTROPIN................................89ciclopirox gel 0.77%.................................................... 23ciclopirox olamine cream 0.77%................................23ciclopirox olamine susp 0.77%...................................23ciclopirox shampoo 1%............................................... 23ciclopirox solution 8%..................................................23cidofovir iv inj 75 mg/ml.............................................. 45cilostazol tab 100 mg.................................................. 58cilostazol tab 50 mg.................................................... 58CILOXAN.....................................................................102CIMDUO........................................................................ 45CIMETIDINE HCL........................................................ 84cimetidine tab 200 mg.................................................84

cimetidine tab 300 mg.................................................84cimetidine tab 400 mg.................................................84cimetidine tab 800 mg.................................................84cinacalcet hcl tab 30 mg...........................................101cinacalcet hcl tab 60 mg...........................................101cinacalcet hcl tab 90 mg...........................................101CINRYZE.......................................................................96ciprofloxacin 200 mg/100ml in d5w............................. 8ciprofloxacin 400 mg/200ml in d5w............................. 8CIPROFLOXACIN HCL.................................................7ciprofloxacin hcl ophth soln 0.3%............................ 103ciprofloxacin hcl tab 250 mg.........................................7ciprofloxacin hcl tab 500 mg.........................................7ciprofloxacin hcl tab 750 mg.........................................7CISPLATIN.................................................................... 27cisplatin inj 100 mg/100ml (1 mg/ml).........................27cisplatin inj 50 mg/50ml (1 mg/ml).............................27citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 18citalopram hydrobromide tab 10 mg..........................18citalopram hydrobromide tab 20 mg..........................18citalopram hydrobromide tab 40 mg..........................18cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................27CLARITHROMYCIN.......................................................8CLARITHROMYCIN.......................................................8clarithromycin tab 250 mg............................................ 8clarithromycin tab 500 mg............................................ 8clarithromycin tab er 24hr 500 mg...............................8CLEMASTINE FUMARATE......................................106CLEOCIN.........................................................................8clindamycin hcl cap 150 mg......................................... 8clindamycin hcl cap 300 mg......................................... 8clindamycin hcl cap 75 mg........................................... 8clindamycin palmitate hcl for soln 75

mg/5ml.......................................................................... 8clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................78clindamycin phosphate gel 1%.................................... 8clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 8clindamycin phosphate inj 300 mg/2ml....................... 8clindamycin phosphate inj 600 mg/4ml....................... 8clindamycin phosphate inj 900 mg/6ml....................... 8clindamycin phosphate inj 9 gm/60ml......................... 8clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 8

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clindamycin phosphate iv soln 600mg/4ml.......................................................................... 8

clindamycin phosphate iv soln 900mg/6ml.......................................................................... 8

clindamycin phosphate lotion 1%................................ 8clindamycin phosphate soln 1%...................................8clindamycin phosphate swab 1%.................................8clindamycin phosphate vaginal cream

2%..................................................................................8clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5%......................................................................... 78CLINIMIX 4.25%/DEXTROSE 10%...........................81CLINIMIX 4.25%/DEXTROSE 5%.............................81CLINIMIX 5%/DEXTROSE 15%................................ 81CLINIMIX 5%/DEXTROSE 20%................................ 81CLINIMIX E 2.75%/DEXTROSE 5%......................... 81CLINIMIX E 4.25%/DEXTROSE 10%.......................81CLINIMIX E 4.25%/DEXTROSE 5%......................... 81CLINIMIX E 5%/DEXTROSE 15%............................ 81CLINIMIX E 5%/DEXTROSE 20%............................ 81clobazam suspension 2.5 mg/ml............................... 13clobazam tab 10 mg....................................................13clobazam tab 20 mg....................................................13clobetasol propionate cream 0.05%..........................78clobetasol propionate emollient base cream

0.05%..........................................................................78clobetasol propionate gel 0.05%................................78clobetasol propionate oint 0.05%.............................. 78clobetasol propionate soln 0.05%..............................78clofarabine iv soln 1 mg/ml.........................................27clomipramine hcl cap 25 mg...................................... 18clomipramine hcl cap 50 mg...................................... 18clomipramine hcl cap 75 mg...................................... 18clonazepam orally disintegrating tab 0.125

mg................................................................................49clonazepam orally disintegrating tab 0.25

mg................................................................................49clonazepam orally disintegrating tab 0.5

mg................................................................................49clonazepam orally disintegrating tab 1

mg................................................................................49clonazepam orally disintegrating tab 2

mg................................................................................49clonazepam tab 0.5 mg.............................................. 49clonazepam tab 1 mg..................................................49clonazepam tab 2 mg..................................................49clonidine hcl tab 0.1 mg..............................................64clonidine hcl tab 0.2 mg..............................................64clonidine hcl tab 0.3 mg..............................................64clonidine hcl tab er 12hr 0.1 mg................................ 76clonidine td patch weekly 0.1 mg/24hr......................64clonidine td patch weekly 0.2 mg/24hr......................64

clonidine td patch weekly 0.3 mg/24hr......................64clopidogrel bisulfate tab 300 mg................................58clopidogrel bisulfate tab 75 mg..................................58clorazepate dipotassium tab 15 mg...........................49clorazepate dipotassium tab 3.75 mg....................... 49clorazepate dipotassium tab 7.5 mg......................... 49clotrimazole cream 1%................................................23clotrimazole troche 10 mg.......................................... 23clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 78clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 78clozapine orally disintegrating tab 100

mg................................................................................40clozapine orally disintegrating tab 12.5

mg................................................................................40clozapine orally disintegrating tab 25

mg................................................................................40clozapine tab 100 mg..................................................40clozapine tab 200 mg..................................................40clozapine tab 25 mg....................................................40clozapine tab 50 mg....................................................40COARTEM.....................................................................38codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24colestipol hcl granule packets 5 gm.......................... 64colestipol hcl granules 5 gm.......................................65colestipol hcl tab 1 gm................................................ 65colistimethate sod for inj 150 mg................................. 8COLYTE-FLAVOR PACKS......................................... 84COMBIGAN................................................................ 103COMBIPATCH.............................................................. 90COMBIPATCH.............................................................. 90COMBIVENT RESPIMAT......................................... 106COMETRIQ...................................................................27COMETRIQ...................................................................28COMETRIQ...................................................................28COMPLERA.................................................................. 45COPIKTRA....................................................................28COPIKTRA....................................................................28COREG..........................................................................65COREG..........................................................................65COREG..........................................................................65COREG..........................................................................65CORLANOR..................................................................65CORLANOR..................................................................65CORLANOR..................................................................65CORTISONE ACETATE..............................................88COSENTYX.................................................................. 96COSENTYX.................................................................. 96

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COSENTYX SENSOREADY PEN............................ 96COSENTYX SENSOREADY PEN............................ 96COTELLIC.....................................................................28COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COZAAR........................................................................65COZAAR........................................................................65COZAAR........................................................................65CREON..........................................................................86CREON..........................................................................86CREON..........................................................................86CREON..........................................................................86CREON..........................................................................86CRESEMBA.................................................................. 23CRESEMBA.................................................................. 23CRIXIVAN......................................................................45CRIXIVAN......................................................................45cromolyn sodium ophth soln 4%..............................103cromolyn sodium oral conc 100

mg/5ml........................................................................ 84cromolyn sodium soln nebu 20

mg/2ml......................................................................106CRYSVITA.....................................................................86CRYSVITA.....................................................................86CRYSVITA.....................................................................86CUVITRU.......................................................................96CUVITRU.......................................................................96CUVITRU.......................................................................96CUVITRU.......................................................................96CUVITRU.......................................................................96cyclobenzaprine hcl tab 10 mg................................ 109cyclobenzaprine hcl tab 5 mg.................................. 109cyclophosphamide cap 25 mg................................... 28cyclophosphamide cap 50 mg................................... 28cyclophosphamide for inj 1 gm.................................. 28cyclophosphamide for inj 2 gm.................................. 28cyclophosphamide for inj 500 mg..............................28cycloserine cap 250 mg..............................................25CYCLOSET...................................................................50cyclosporine cap 100 mg............................................96cyclosporine cap 25 mg..............................................96cyclosporine iv soln 50 mg/ml....................................96cyclosporine modified cap 100 mg............................ 96cyclosporine modified cap 25 mg.............................. 96cyclosporine modified cap 50 mg.............................. 96

cyclosporine modified oral soln 100 mg/ml.................................................................................96

CYRAMZA.....................................................................28CYRAMZA.....................................................................28CYSTADANE................................................................ 86CYSTAGON.................................................................. 86CYSTAGON.................................................................. 86CYSTARAN.................................................................103CYTARABINE............................................................... 28cytarabine inj pf 100 mg/ml........................................ 28cytarabine inj pf 20 mg/ml.......................................... 28DDACARBAZINE............................................................ 28dacarbazine for inj 200 mg.........................................28dactinomycin for inj 0.5 mg........................................ 28dalfampridine tab er 12hr 10 mg................................76DALIRESP.................................................................. 106DALIRESP.................................................................. 106DALVANCE......................................................................8danazol cap 100 mg....................................................90danazol cap 200 mg....................................................90danazol cap 50 mg......................................................90dantrolene sodium cap 100 mg................................. 44dantrolene sodium cap 25 mg....................................44dantrolene sodium cap 50 mg....................................44dapsone tab 100 mg................................................... 25dapsone tab 25 mg......................................................25DAPTACEL....................................................................96daptomycin for iv soln 500 mg..................................... 8DARAPRIM................................................................... 38DARZALEX................................................................... 28DARZALEX................................................................... 28daunorubicin hcl iv soln 20 mg/4ml........................... 28DAUNORUBICIN HYDROCHLORIDE......................28DAURISMO...................................................................28DAURISMO...................................................................28decitabine for inj 50 mg.............................................. 28deferasirox tab 360 mg............................................... 81deferasirox tab 90 mg................................................. 81deferasirox tab for oral susp 125 mg.........................81deferasirox tab for oral susp 250 mg.........................81deferasirox tab for oral susp 500 mg.........................81DELSTRIGO................................................................. 45demeclocycline hcl tab 150 mg....................................8demeclocycline hcl tab 300 mg....................................8DEMSER....................................................................... 65DENAVIR.......................................................................45DEPEN TITRATABS.................................................... 87DEPO-PROVERA........................................................ 90DESCOVY.....................................................................45desipramine hcl tab 100 mg.......................................18

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desipramine hcl tab 10 mg......................................... 18desipramine hcl tab 150 mg.......................................18desipramine hcl tab 25 mg......................................... 18desipramine hcl tab 50 mg......................................... 18desipramine hcl tab 75 mg......................................... 18desmopressin acetate inj 4 mcg/ml...........................89desmopressin acetate nasal spray soln

0.01%..........................................................................89desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 89desmopressin acetate tab 0.1 mg............................. 89desmopressin acetate tab 0.2 mg............................. 89desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 90desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................90

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................90

desonide cream 0.05%............................................... 78desonide lotion 0.05%.................................................78desonide oint 0.05%....................................................78desoximetasone cream 0.05%...................................78desoximetasone cream 0.25%...................................78desoximetasone gel 0.05%........................................ 78desoximetasone oint 0.25%....................................... 78desvenlafaxine succinate tab er 24hr 100

mg................................................................................18desvenlafaxine succinate tab er 24hr 25

mg................................................................................18desvenlafaxine succinate tab er 24hr 50

mg................................................................................18DEXAMETHASONE.................................................... 88DEXAMETHASONE.................................................... 88dexamethasone elixir 0.5 mg/5ml..............................88DEXAMETHASONE SODIUM

PHOSPHATE...........................................................103dexamethasone sodium phosphate inj 120

mg/30ml......................................................................88dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 88dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................88dexamethasone tab 0.5 mg........................................88dexamethasone tab 0.75 mg......................................88dexamethasone tab 1.5 mg........................................88dexamethasone tab 4 mg...........................................88dexamethasone tab 6 mg...........................................88dexmethylphenidate hcl tab 10 mg............................76dexmethylphenidate hcl tab 2.5 mg...........................76dexmethylphenidate hcl tab 5 mg..............................76dexrazoxane hcl for inj 250 mg..................................28

dexrazoxane hcl for inj 500 mg..................................28dextroamphetamine sulfate cap er 24hr 10

mg................................................................................76dextroamphetamine sulfate cap er 24hr 15

mg................................................................................76dextroamphetamine sulfate cap er 24hr 5

mg................................................................................76dextroamphetamine sulfate tab 10 mg......................76dextroamphetamine sulfate tab 5 mg........................76DEXTROSE 2.5%/NACL 0.45%................................ 81dextrose 5% in lactated ringers................................. 81dextrose 5% w/ sodium chloride 0.2%...................... 81dextrose 5% w/ sodium chloride

0.33%..........................................................................81dextrose 5% w/ sodium chloride

0.45%..........................................................................82dextrose 5% w/ sodium chloride 0.9%...................... 82dextrose inj 10%.......................................................... 81dextrose inj 5%.............................................................81DIASTAT ACUDIAL......................................................13DIASTAT ACUDIAL......................................................13DIASTAT PEDIATRIC..................................................14DIAZEPAM.................................................................... 49diazepam conc 5 mg/ml..............................................49DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................49diazepam tab 2 mg......................................................49diazepam tab 5 mg......................................................49diclofenac potassium tab 50 mg.................................. 1diclofenac sodium (actinic keratoses) gel

3%............................................................................... 79diclofenac sodium gel 1%.............................................1diclofenac sodium ophth soln 0.1%.........................103diclofenac sodium soln 1.5%........................................1diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1dicloxacillin sodium cap 250 mg.................................. 8dicloxacillin sodium cap 500 mg.................................. 8dicyclomine hcl tab 20 mg..........................................84didanosine delayed release capsule 200

mg................................................................................45

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didanosine delayed release capsule 250mg................................................................................45

didanosine delayed release capsule 400mg................................................................................45

DIFICID............................................................................ 8diflorasone diacetate oint 0.05%................................79diflunisal tab 500 mg..................................................... 1digoxin oral soln 0.05 mg/ml...................................... 65digoxin tab 125 mcg (0.125 mg)................................65digoxin tab 250 mcg (0.25 mg).................................. 65DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 65diltiazem hcl cap er 12hr 60 mg.................................65diltiazem hcl cap er 12hr 90 mg.................................65diltiazem hcl cap er 24hr 120 mg.............................. 65diltiazem hcl cap er 24hr 180 mg.............................. 65diltiazem hcl cap er 24hr 240 mg.............................. 65diltiazem hcl coated beads cap er 24hr 120

mg................................................................................65diltiazem hcl coated beads cap er 24hr 180




mg................................................................................65diltiazem hcl coated beads tab er 24hr 180





mg................................................................................65diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 65diltiazem hcl extended release beads cap er 24hr





420 mg....................................................................... 65diltiazem hcl tab 120 mg.............................................66diltiazem hcl tab 30 mg...............................................66diltiazem hcl tab 60 mg...............................................66

diltiazem hcl tab 90 mg...............................................66DIOVAN......................................................................... 66DIOVAN......................................................................... 66DIOVAN......................................................................... 66DIOVAN......................................................................... 66DIOVAN HCT................................................................66DIOVAN HCT................................................................66DIOVAN HCT................................................................66DIOVAN HCT................................................................66DIOVAN HCT................................................................66diphenhydramine hcl inj 50 mg/ml...........................107DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................96dipyridamole tab 25 mg.............................................. 58dipyridamole tab 50 mg.............................................. 58dipyridamole tab 75 mg.............................................. 58disulfiram tab 250 mg....................................................4disulfiram tab 500 mg....................................................4divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium tab delayed release 125



mg................................................................................14divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................14DIVIGEL.........................................................................90DIVIGEL.........................................................................90DIVIGEL.........................................................................90DIVIGEL.........................................................................90DIVIGEL.........................................................................90DOCETAXEL.................................................................28docetaxel for inj conc 160 mg/8ml (20 mg/

ml)................................................................................28docetaxel for inj conc 20 mg/ml................................. 28docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................28docetaxel soln for iv infusion 160

mg/16ml......................................................................28docetaxel soln for iv infusion 20

mg/2ml........................................................................ 28docetaxel soln for iv infusion 80

mg/8ml........................................................................ 28dofetilide cap 125 mcg (0.125 mg)............................66dofetilide cap 250 mcg (0.25 mg).............................. 66dofetilide cap 500 mcg (0.5 mg)................................ 66donepezil hydrochloride orally disintegrating tab 10

mg................................................................................17donepezil hydrochloride orally disintegrating tab 5

mg................................................................................17

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donepezil hydrochloride tab 10 mg........................... 17donepezil hydrochloride tab 23 mg........................... 17donepezil hydrochloride tab 5 mg..............................17dorzolamide hcl ophth soln 2%................................103dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 103DOVATO........................................................................ 45doxazosin mesylate tab 1 mg.................................... 66doxazosin mesylate tab 2 mg.................................... 66doxazosin mesylate tab 4 mg.................................... 66doxazosin mesylate tab 8 mg.................................... 66DOXEPIN HCL............................................................. 18doxepin hcl (sleep) tab 3 mg....................................110doxepin hcl (sleep) tab 6 mg....................................110doxepin hcl cap 100 mg..............................................18doxepin hcl cap 10 mg................................................18doxepin hcl cap 25 mg................................................18doxepin hcl cap 50 mg................................................18doxepin hcl cap 75 mg................................................18doxepin hcl conc 10 mg/ml.........................................18doxorubicin hcl for inj 10 mg...................................... 28doxorubicin hcl for inj 50 mg...................................... 28doxorubicin hcl inj 2 mg/ml.........................................29doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................29doxycycline hyclate cap 100 mg..................................8doxycycline hyclate cap 50 mg.................................... 8doxycycline hyclate for inj 100 mg...............................8doxycycline hyclate tab 100 mg...................................9doxycycline hyclate tab 20 mg.....................................9doxycycline monohydrate cap 100 mg........................9doxycycline monohydrate cap 150 mg........................9doxycycline monohydrate cap 50 mg..........................9doxycycline monohydrate cap 75 mg..........................9doxycycline monohydrate tab 100 mg.........................9doxycycline monohydrate tab 150 mg.........................9doxycycline monohydrate tab 50 mg...........................9doxycycline monohydrate tab 75 mg...........................9DRIZALMA SPRINKLE............................................... 18DRIZALMA SPRINKLE............................................... 18DRIZALMA SPRINKLE............................................... 18DRIZALMA SPRINKLE............................................... 19dronabinol cap 10 mg................................................. 22dronabinol cap 2.5 mg................................................ 22dronabinol cap 5 mg....................................................22drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................90drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................90drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................90

drospirenone-ethinyl estrad-levomefolate tab3-0.03-0.451 mg........................................................90

DUAVEE........................................................................ 90DULERA......................................................................107DULERA......................................................................107duloxetine hcl enteric coated pellets cap 20

mg................................................................................19duloxetine hcl enteric coated pellets cap 30

mg................................................................................19duloxetine hcl enteric coated pellets cap 60

mg................................................................................19DUPIXENT.................................................................... 96DUPIXENT.................................................................... 96DUREZOL................................................................... 103dutasteride cap 0.5 mg............................................... 88dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................88EEASY TOUCH FLIPLOCK SAFETY INSULIN

SYRINGE 1ML/30G X 1/2"......................................50EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/0.5ML/29G X 1/2"......................................... 50EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/1ML/30G X 1/2".............................................50EASY TOUCH SHEATHLOCK SAFETY INSULIN

SYRINGE 1ML/29G X 1/2"......................................50EASY TOUCH SHEATHLOCK SAFETY SYRINGE

1ML/30G X 1/2"........................................................ 50EC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1econazole nitrate cream 1%.......................................23EDURANT..................................................................... 45efavirenz cap 200 mg..................................................45efavirenz cap 50 mg....................................................45efavirenz tab 600 mg...................................................45EGRIFTA....................................................................... 89EGRIFTA SV.................................................................89ELAPRASE................................................................... 86ELELYSO.......................................................................86ELIDEL...........................................................................79ELIGARD.......................................................................94ELIGARD.......................................................................94ELIGARD.......................................................................94ELIGARD.......................................................................94ELIQUIS.........................................................................58ELIQUIS.........................................................................58ELIQUIS STARTER PACK......................................... 58ELITEK...........................................................................29ELITEK...........................................................................29ELLA...............................................................................90EMCYT.......................................................................... 29EMEND..........................................................................22

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EMGALITY.................................................................... 24EMGALITY.................................................................... 25EMGALITY.................................................................... 25EMPLICITI.....................................................................29EMPLICITI.....................................................................29EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................45EMTRIVA.......................................................................45enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................66enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................66enalapril maleate tab 10 mg.......................................66enalapril maleate tab 2.5 mg......................................66enalapril maleate tab 20 mg.......................................66enalapril maleate tab 5 mg.........................................66ENBREL........................................................................ 96ENBREL........................................................................ 96ENBREL........................................................................ 96ENBREL MINI...............................................................96ENBREL SURECLICK................................................ 97ENGERIX-B.................................................................. 97ENGERIX-B.................................................................. 97ENHERTU..................................................................... 29enoxaparin sodium inj 100 mg/ml..............................58enoxaparin sodium inj 120 mg/0.8ml........................ 58enoxaparin sodium inj 150 mg/ml..............................58enoxaparin sodium inj 300 mg/3ml............................58enoxaparin sodium inj 30 mg/0.3ml...........................58enoxaparin sodium inj 40 mg/0.4ml...........................58enoxaparin sodium inj 60 mg/0.6ml...........................58enoxaparin sodium inj 80 mg/0.8ml...........................58entacapone tab 200 mg..............................................39entecavir tab 0.5 mg....................................................45entecavir tab 1 mg.......................................................45ENTRESTO...................................................................66ENTRESTO...................................................................66ENTRESTO...................................................................66EPCLUSA......................................................................45EPIDIOLEX................................................................... 14epinastine hcl ophth soln 0.05%..............................103epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).................................................................... 107epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak).................... 107epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................29epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................29EPIVIR HBV..................................................................45

eplerenone tab 25 mg.................................................66eplerenone tab 50 mg.................................................66EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58ERBITUX....................................................................... 29ERBITUX....................................................................... 29ERGOLOID MESYLATES...........................................17ergotamine w/ caffeine tab 1-100 mg........................25ERIVEDGE....................................................................29ERLEADA......................................................................29erlotinib hcl tab 100 mg.............................................. 29erlotinib hcl tab 150 mg.............................................. 29erlotinib hcl tab 25 mg.................................................29ertapenem sodium for inj 1 gm.................................... 9ERWINAZE................................................................... 29ERYTHROCIN LACTOBIONATE.................................9ERYTHROCIN STEARATE.......................................... 9erythromycin ethylsuccinate for susp 200

mg/5ml.......................................................................... 9erythromycin ethylsuccinate for susp 400

mg/5ml.......................................................................... 9erythromycin ophth oint 5 mg/gm............................ 103erythromycin pads 2%...................................................9erythromycin soln 2%.................................................... 9erythromycin tab 250 mg.............................................. 9erythromycin tab 500 mg.............................................. 9erythromycin tab delayed release 250

mg..................................................................................9erythromycin tab delayed release 333

mg..................................................................................9erythromycin tab delayed release 500

mg..................................................................................9erythromycin w/ delayed release particles cap 250

mg..................................................................................9ESBRIET..................................................................... 107ESBRIET..................................................................... 107ESBRIET..................................................................... 107escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 5 mg...................................19esomeprazole magnesium cap delayed release 20

mg................................................................................84esomeprazole magnesium cap delayed release 40

mg................................................................................84esomeprazole sodium for intravenous soln 40

mg................................................................................84estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................90

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126

estradiol & norethindrone acetate tab 1-0.5mg................................................................................90

estradiol tab 0.5 mg.....................................................90estradiol tab 1 mg........................................................90estradiol tab 2 mg........................................................90estradiol td patch twice weekly 0.025

mg/24hr...................................................................... 90estradiol td patch twice weekly 0.0375




mg/24hr...................................................................... 91estradiol td patch weekly 0.025

mg/24hr...................................................................... 91estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 91estradiol td patch weekly 0.05 mg/24hr.................... 91estradiol td patch weekly 0.06 mg/24hr.................... 91estradiol td patch weekly 0.075

mg/24hr...................................................................... 91estradiol td patch weekly 0.1 mg/24hr...................... 91estradiol vaginal cream 0.1 mg/gm........................... 91estradiol vaginal tab 10 mcg...................................... 91ethambutol hcl tab 100 mg.........................................25ethambutol hcl tab 400 mg.........................................25ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................91ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................91ETHYOL........................................................................ 29etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................1etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 600 mg........................................ 1ETOPOPHOS............................................................... 29etoposide inj 100 mg/5ml (20 mg/ml)........................29etoposide inj 1 gm/50ml (20 mg/ml).......................... 29etoposide inj 500 mg/25ml (20 mg/ml)......................29everolimus tab 2.5 mg.................................................29everolimus tab 5 mg....................................................29everolimus tab 7.5 mg.................................................29EVOMELA..................................................................... 29EVOTAZ.........................................................................45exemestane tab 25 mg............................................... 29

EXFORGE.....................................................................66EXFORGE.....................................................................66EXFORGE.....................................................................66EXFORGE.....................................................................66EXFORGE HCT........................................................... 66EXFORGE HCT........................................................... 66EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67ezetimibe-simvastatin tab 10-10 mg..........................67ezetimibe-simvastatin tab 10-20 mg..........................67ezetimibe-simvastatin tab 10-40 mg..........................67ezetimibe-simvastatin tab 10-80 mg..........................67ezetimibe tab 10 mg....................................................67FFABRAZYME................................................................ 86FABRAZYME................................................................ 86famciclovir tab 125 mg................................................45famciclovir tab 250 mg................................................45famciclovir tab 500 mg................................................45famotidine inj 200 mg/20ml........................................ 84famotidine inj 20 mg/2ml.............................................84famotidine inj 40 mg/4ml.............................................84famotidine tab 20 mg...................................................84famotidine tab 40 mg...................................................84FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT TITRATION PACK....................................... 40FARYDAK......................................................................29FARYDAK......................................................................29FARYDAK......................................................................29FASLODEX................................................................... 29felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 67felodipine tab er 24hr 2.5 mg..................................... 67felodipine tab er 24hr 5 mg........................................ 67fenofibrate micronized cap 134 mg........................... 67fenofibrate micronized cap 200 mg........................... 67fenofibrate micronized cap 67 mg............................. 67fenofibrate tab 145 mg................................................67fenofibrate tab 160 mg................................................67fenofibrate tab 48 mg.................................................. 67fenofibrate tab 54 mg.................................................. 67

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127

fentanyl citrate lozenge on a handle 1200mcg................................................................................2






fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA TITRATION PACK......................................19finasteride tab 5 mg.....................................................88FIRMAGON...................................................................94FIRMAGON...................................................................94flecainide acetate tab 100 mg....................................67flecainide acetate tab 150 mg....................................67flecainide acetate tab 50 mg...................................... 67FLOMAX........................................................................88FLOVENT DISKUS....................................................107FLOVENT DISKUS....................................................107FLOVENT DISKUS....................................................107FLOVENT HFA...........................................................107FLOVENT HFA...........................................................107FLOVENT HFA...........................................................107fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................23fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................23fluconazole tab 200 mg...............................................23fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 23flucytosine cap 500 mg............................................... 23fludarabine phosphate for inj 50 mg..........................29

fludarabine phosphate inj 25 mg/ml.......................... 29fludrocortisone acetate tab 0.1 mg............................ 89fluocinolone acetonide (otic) oil

0.01%........................................................................105fluocinolone acetonide cream 0.01%........................ 79fluocinonide cream 0.05%.......................................... 79fluocinonide emulsified base cream

0.05%..........................................................................79fluocinonide gel 0.05%................................................79fluocinonide oint 0.05%...............................................79fluocinonide soln 0.05%..............................................79fluorometholone ophth susp 0.1%...........................103FLUOROURACIL......................................................... 79FLUOROURACIL......................................................... 79FLUOROURACIL......................................................... 79fluorouracil cream 5%................................................. 79fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................29fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................29fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................29fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................29FLUOXETINE DR........................................................ 19fluoxetine hcl cap 10 mg.............................................19fluoxetine hcl cap 20 mg.............................................19fluoxetine hcl cap 40 mg.............................................19fluoxetine hcl solution 20 mg/5ml.............................. 19fluoxetine hcl tab 10 mg..............................................19fluoxetine hcl tab 20 mg..............................................19fluphenazine decanoate inj 25 mg/ml........................40FLUPHENAZINE HCL.................................................40FLUPHENAZINE HCL.................................................40fluphenazine hcl tab 10 mg........................................ 40fluphenazine hcl tab 1 mg.......................................... 40fluphenazine hcl tab 2.5 mg....................................... 40fluphenazine hcl tab 5 mg.......................................... 40FLUPHENAZINE HYDROCHLORIDE...................... 40FLURBIPROFEN SODIUM...................................... 103flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................30FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 107FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 107FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 107fluticasone propionate cream 0.05%.........................79fluticasone propionate nasal susp 50 mcg/

act..............................................................................107

2020

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fluticasone propionate oint 0.005%........................... 79fluvastatin sodium cap 20 mg.................................... 67fluvastatin sodium cap 40 mg.................................... 67fluvastatin sodium tab er 24 hr 80 mg.......................67fluvoxamine maleate tab 100 mg...............................19fluvoxamine maleate tab 25 mg.................................19fluvoxamine maleate tab 50 mg.................................19FML LIQUIFILM......................................................... 103FOLOTYN......................................................................30FOLOTYN......................................................................30fomepizole inj 1 gm/ml (for iv infusion)......................82fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................59fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................58fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................59fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................59FORTEO......................................................................101fosamprenavir calcium tab 700 mg........................... 45fosaprepitant dimeglumine for iv infusion 150

mg................................................................................22fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................67fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................67fosinopril sodium tab 10 mg....................................... 67fosinopril sodium tab 20 mg....................................... 67fosinopril sodium tab 40 mg....................................... 67fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................14FOSRENOL.................................................................. 82FOSRENOL.................................................................. 82FREAMINE HBC 6.9%................................................82FREAMINE III............................................................... 82frovatriptan succinate tab 2.5 mg.............................. 25FULPHILA..................................................................... 59fulvestrant inj 250 mg/5ml...........................................30furosemide inj 10 mg/ml..............................................67furosemide oral soln 10 mg/ml...................................67furosemide tab 20 mg................................................. 67furosemide tab 40 mg................................................. 67furosemide tab 80 mg................................................. 67FUZEON........................................................................45FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14

Ggabapentin cap 100 mg.............................................. 14gabapentin cap 300 mg.............................................. 14gabapentin cap 400 mg.............................................. 14gabapentin oral soln 250 mg/5ml.............................. 14gabapentin tab 600 mg............................................... 14gabapentin tab 800 mg............................................... 14GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

mg................................................................................17galantamine hydrobromide cap er 24hr 24

mg................................................................................17galantamine hydrobromide cap er 24hr 8

mg................................................................................17galantamine hydrobromide tab 12 mg...................... 17galantamine hydrobromide tab 4 mg.........................17galantamine hydrobromide tab 8 mg.........................17ganciclovir sodium for inj 500 mg.............................. 45GARDASIL 9.................................................................97GARDASIL 9.................................................................97gatifloxacin ophth soln 0.5%.................................... 103GATTEX.........................................................................84GAUZE PADS 2" X 2".................................................50GAZYVA.........................................................................30gemcitabine hcl for inj 1 gm....................................... 30gemcitabine hcl for inj 200 mg...................................30gemcitabine hcl for inj 2 gm....................................... 30gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................30gemfibrozil tab 600 mg............................................... 67GENTAK...................................................................... 103gentamicin in saline inj 1.2 mg/ml................................9GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE...................................................................9GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE...................................................................9gentamicin sulfate cream 0.1%..................................79gentamicin sulfate inj 10 mg/ml....................................9gentamicin sulfate inj 40 mg/ml....................................9gentamicin sulfate oint 0.1%...................................... 79gentamicin sulfate ophth soln 0.3%........................ 103GENVOYA.....................................................................46GEODON.......................................................................41GILENYA....................................................................... 76GILOTRIF......................................................................30GILOTRIF......................................................................30GILOTRIF......................................................................30

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129

glatiramer acetate soln prefilled syringe 20 mg/ml.................................................................................76

glatiramer acetate soln prefilled syringe 40 mg/ml.................................................................................76

GLEOSTINE..................................................................30GLEOSTINE..................................................................30GLEOSTINE..................................................................30glimepiride tab 1 mg....................................................51glimepiride tab 2 mg....................................................51glimepiride tab 4 mg....................................................51glipizide-metformin hcl tab 2.5-250 mg.....................51glipizide-metformin hcl tab 2.5-500 mg.....................51glipizide-metformin hcl tab 5-500 mg........................ 51glipizide tab 10 mg...................................................... 51glipizide tab 5 mg.........................................................51glipizide tab er 24hr 10 mg.........................................51glipizide tab er 24hr 2.5 mg........................................51glipizide tab er 24hr 5 mg...........................................51GLUCAGEN HYPOKIT............................................... 51GLUCAGON EMERGENCY KIT............................... 51GLUCOPHAGE............................................................ 51GLUCOPHAGE............................................................ 51GLUCOPHAGE............................................................ 51GLUCOPHAGE XR..................................................... 51GLUCOPHAGE XR..................................................... 51GLUCOTROL................................................................51GLUCOTROL................................................................51GLUCOTROL XL......................................................... 51GLUCOTROL XL......................................................... 51GLUCOTROL XL......................................................... 51glycopyrrolate tab 1 mg.............................................. 84glycopyrrolate tab 2 mg.............................................. 84GLYXAMBI.................................................................... 51GLYXAMBI.................................................................... 51GOLYTELY....................................................................84granisetron hcl inj 1 mg/ml......................................... 22granisetron hcl inj 4 mg/4ml (1 mg/ml)......................22granisetron hcl tab 1 mg.............................................22GRANIX......................................................................... 59GRANIX......................................................................... 59GRANIX......................................................................... 59GRANIX......................................................................... 59griseofulvin microsize susp 125

mg/5ml........................................................................ 23griseofulvin microsize tab 500 mg............................. 23griseofulvin ultramicrosize tab 125 mg......................23griseofulvin ultramicrosize tab 250 mg......................24GUANIDINE HCL.........................................................25HHAEGARDA.................................................................. 97HAEGARDA.................................................................. 97

HALAVEN...................................................................... 30halobetasol propionate cream 0.05%........................79halobetasol propionate oint 0.05%............................ 79haloperidol decanoate im soln 100 mg/

ml.................................................................................41haloperidol decanoate im soln 50 mg/

ml.................................................................................41haloperidol lactate inj 5 mg/ml................................... 41haloperidol lactate oral conc 2 mg/ml........................41haloperidol tab 0.5 mg................................................ 41haloperidol tab 10 mg................................................. 41haloperidol tab 1 mg....................................................41haloperidol tab 20 mg................................................. 41haloperidol tab 2 mg....................................................41haloperidol tab 5 mg....................................................41HARVONI...................................................................... 46HARVONI...................................................................... 46HAVRIX..........................................................................97HAVRIX..........................................................................97HEPARIN SODIUM......................................................59HEPARIN SODIUM......................................................59HEPARIN SODIUM/D5W............................................59heparin sodium (porcine) inj 10000 unit/

ml.................................................................................59heparin sodium (porcine) inj 1000 unit/



ml.................................................................................59heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................59HEPATAMINE............................................................... 82HERCEPTIN................................................................. 30HERCEPTIN HYLECTA.............................................. 30HETLIOZ..................................................................... 110HIBERIX........................................................................ 97HUMALOG.................................................................... 51HUMALOG.................................................................... 51HUMALOG JUNIOR KWIKPEN.................................51HUMALOG KWIKPEN.................................................51HUMALOG KWIKPEN.................................................51HUMALOG MIX 50/50.................................................51HUMALOG MIX 50/50 KWIKPEN............................. 51HUMALOG MIX 75/25.................................................51HUMALOG MIX 75/25 KWIKPEN............................. 51HUMIRA.........................................................................97HUMIRA.........................................................................97HUMIRA.........................................................................97HUMIRA.........................................................................97HUMIRA.........................................................................97HUMIRA.........................................................................97

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HUMIRA PEDIATRIC CROHNS DISEASESTARTER PACK.......................................................97

HUMIRA PEDIATRIC CROHNS DISEASESTARTER PACK.......................................................97

HUMIRA PEN............................................................... 97HUMIRA PEN............................................................... 97HUMIRA PEN-CD/UC/HS STARTER........................97HUMIRA PEN-CD/UC/HS STARTER........................97HUMIRA PEN-PS/UV STARTER...............................97HUMIRA PEN-PS/UV STARTER...............................97HUMULIN 70/30...........................................................52HUMULIN 70/30 KWIKPEN....................................... 52HUMULIN N..................................................................52HUMULIN N KWIKPEN.............................................. 52HUMULIN R..................................................................52HUMULIN R U-500 (CONCENTRATE).....................52HUMULIN R U-500 KWIKPEN...................................52hydralazine hcl tab 100 mg........................................ 68hydralazine hcl tab 10 mg.......................................... 67hydralazine hcl tab 25 mg.......................................... 68hydralazine hcl tab 50 mg.......................................... 68hydrochlorothiazide cap 12.5 mg...............................68hydrochlorothiazide tab 12.5 mg................................68hydrochlorothiazide tab 25 mg...................................68hydrochlorothiazide tab 50 mg...................................68hydrocodone-acetaminophen tab 10-325

mg..................................................................................2hydrocodone-acetaminophen tab 5-325

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocortisone butyrate cream 0.1%........................ 79hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................79hydrocortisone butyrate oint 0.1%.............................79hydrocortisone butyrate soln 0.1%............................ 79hydrocortisone cream 1%...........................................79hydrocortisone cream 2.5%........................................79hydrocortisone enema 100 mg/60ml.......................101hydrocortisone lotion 2.5%......................................... 79hydrocortisone oint 1%............................................... 79hydrocortisone oint 2.5%............................................ 79hydrocortisone rectal cream 1%.............................. 101hydrocortisone rectal cream 2.5%...........................101hydrocortisone tab 10 mg...........................................89hydrocortisone tab 20 mg...........................................89hydrocortisone tab 5 mg............................................. 89hydrocortisone valerate cream 0.2%.........................79hydrocortisone valerate oint 0.2%............................. 79hydrocortisone w/ acetic acid otic soln

1-2%..........................................................................105hydromorphone hcl inj 2 mg/ml....................................2

hydromorphone hcl preservative free inj 2 mg/ml................................................................................... 2

hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 38HYDROXYPROGESTERONE

CAPROATE................................................................91hydroxyurea cap 500 mg............................................ 30hydroxyzine hcl syrup 10 mg/5ml.............................. 49hydroxyzine hcl tab 10 mg..........................................49hydroxyzine hcl tab 25 mg..........................................49hydroxyzine hcl tab 50 mg..........................................49HYZAAR........................................................................ 68HYZAAR........................................................................ 68HYZAAR........................................................................ 68Iibandronate sodium iv soln 3 mg/3ml..................... 101ibandronate sodium tab 150 mg..............................101IBRANCE.......................................................................30IBRANCE.......................................................................30IBRANCE.......................................................................30ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen tab 400 mg.................................................... 2ibuprofen tab 600 mg.................................................... 2ibuprofen tab 800 mg.................................................... 2icatibant acetate inj 30 mg/3ml.................................. 97ICLUSIG........................................................................ 30ICLUSIG........................................................................ 30idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................30IDHIFA............................................................................30IDHIFA............................................................................30IFEX............................................................................... 30IFOSFAMIDE................................................................ 30ifosfamide for inj 1 gm.................................................30ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 30ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 30ILARIS............................................................................97ILEVRO........................................................................103imatinib mesylate tab 100 mg.................................... 30imatinib mesylate tab 400 mg.................................... 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31

2020

131

IMFINZI..........................................................................31IMFINZI..........................................................................31imipenem-cilastatin intravenous for soln 250

mg..................................................................................9imipenem-cilastatin intravenous for soln 500

mg..................................................................................9imipramine hcl tab 10 mg........................................... 19imipramine hcl tab 25 mg........................................... 19imipramine hcl tab 50 mg........................................... 19imiquimod cream 5%...................................................79IMLYGIC........................................................................ 31IMLYGIC........................................................................ 31IMOVAX RABIES (H.D.C.V.)...................................... 97IMPAVIDO........................................................................9INBRIJA......................................................................... 39INCRELEX.................................................................... 90INCRUSE ELLIPTA................................................... 107indapamide tab 1.25 mg............................................. 68indapamide tab 2.5 mg............................................... 68INFANRIX......................................................................97INFLECTRA.................................................................. 97INLYTA...........................................................................31INLYTA...........................................................................31INREBIC........................................................................ 31INSULIN PEN NEEDLE 29G X 12.7MM

(1/2")........................................................................... 52INSULIN PEN NEEDLE 29G X 5MM (1/5" OR

3/16")...........................................................................52INSULIN PEN NEEDLE 29G X 8MM (1/3" OR








15/64")........................................................................ 52INSULIN PEN NEEDLE 33G X 8MM (1/3" OR

5/16")...........................................................................52INSULIN PEN NEEDLE 34G X 3.5MM

(9/64")......................................................................... 52INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X

1/2".............................................................................. 52INSULIN SYRINGE/NEEDLE

U-100/0.3ML/29G......................................................52

INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X1"................................................................................. 52

INSULIN SYRINGE/NEEDLEU-100/0.3ML/30G......................................................52

INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X1/4" (6MM)..................................................................52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X1/2".............................................................................. 52

INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X5/16"............................................................................52


INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X5/16"............................................................................53


INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X3/16" (5MM)............................................................... 53

INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X3/8".............................................................................. 53

INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X1/4" (6MM)..................................................................53

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X1"................................................................................. 53

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X5/8".............................................................................. 53




INSULIN SYRINGE/NEEDLE U-100/1ML/28G X5/16"............................................................................53

INSULIN SYRINGE/NEEDLE U-100/1ML/29G X5/16"............................................................................53

INSULIN SYRINGE/NEEDLEU-100/1ML/30G.........................................................53

INSULIN SYRINGE/NEEDLE U-100/1ML/30G X3/16" (5MM)............................................................... 53

INSULIN SYRINGE/NEEDLE U-100/1ML/31G X1/4" (6MM)..................................................................53

INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X5/8".............................................................................. 53

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X15/64"..........................................................................52

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X15/64"..........................................................................52

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X5/16"............................................................................52

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X15/64"..........................................................................52

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INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X5/16"............................................................................52

INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X6MM (15/64").............................................................53

INSULIN SYRINGE (DISP)U-100/0.3ML.............................................................. 52

INSULIN SYRINGE (DISP)U-100/0.5ML.............................................................. 52

INSULIN SYRINGE (DISP)U-100/1ML................................................................. 52

INTELENCE.................................................................. 46INTELENCE.................................................................. 46INTELENCE.................................................................. 46INTRALIPID.................................................................. 82INTRON A.....................................................................46INTRON A.....................................................................46INTRON A.....................................................................46INTRON A.....................................................................46INTRON A.....................................................................46INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVIRASE......................................................................46INVOKAMET.................................................................53INVOKAMET.................................................................53INVOKAMET.................................................................53INVOKAMET.................................................................53INVOKAMET XR..........................................................53INVOKAMET XR..........................................................53INVOKAMET XR..........................................................53INVOKAMET XR..........................................................53INVOKANA....................................................................53INVOKANA....................................................................53IPOL INACTIVATED IPV.............................................97ipratropium bromide inhal soln 0.02%.....................107ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................107ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................107irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................68irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................68irbesartan tab 150 mg.................................................68irbesartan tab 300 mg.................................................68irbesartan tab 75 mg................................................... 68

IRESSA..........................................................................31IRINOTECAN................................................................31irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................31irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 31ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS HD...........................................................46ISONIAZID.................................................................... 26isoniazid tab 100 mg................................................... 26isoniazid tab 300 mg................................................... 26isosorbide dinitrate tab 10 mg....................................68isosorbide dinitrate tab 20 mg....................................68isosorbide dinitrate tab 30 mg....................................68isosorbide dinitrate tab 5 mg......................................68isosorbide mononitrate tab 10 mg............................. 68isosorbide mononitrate tab 20 mg............................. 68isosorbide mononitrate tab er 24hr 120

mg................................................................................68isosorbide mononitrate tab er 24hr 30

mg................................................................................68isosorbide mononitrate tab er 24hr 60

mg................................................................................68ISOTONIC GENTAMICIN............................................. 9isotretinoin cap 10 mg.................................................79isotretinoin cap 20 mg.................................................79isotretinoin cap 30 mg.................................................79isotretinoin cap 40 mg.................................................79isradipine cap 2.5 mg..................................................68isradipine cap 5 mg..................................................... 68ISTODAX (OVERFILL)................................................31itraconazole cap 100 mg............................................ 24ivermectin tab 3 mg.....................................................38IXEMPRA KIT...............................................................31IXEMPRA KIT...............................................................31IXIARO...........................................................................98JJADENU........................................................................ 82JADENU........................................................................ 82JADENU........................................................................ 82JADENU SPRINKLE................................................... 82JADENU SPRINKLE................................................... 82JADENU SPRINKLE................................................... 82JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JANUMET......................................................................53

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JANUMET......................................................................53JANUMET XR...............................................................53JANUMET XR...............................................................53JANUMET XR...............................................................53JANUVIA........................................................................53JANUVIA........................................................................53JANUVIA........................................................................53JARDIANCE..................................................................54JARDIANCE..................................................................54JENTADUETO.............................................................. 54JENTADUETO.............................................................. 54JENTADUETO.............................................................. 54JENTADUETO XR....................................................... 54JENTADUETO XR....................................................... 54JEVTANA.......................................................................31JULUCA.........................................................................46KKADCYLA......................................................................31KADCYLA......................................................................31KALETRA...................................................................... 46KALETRA...................................................................... 46KALYDECO.................................................................107KALYDECO.................................................................107KALYDECO.................................................................107KALYDECO.................................................................107KANJINTI.......................................................................31KANJINTI.......................................................................31kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 82kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%


inj................................................................................. 82kcl 20 meq/l (0.15%) in nacl 0.45% inj......................82kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 82KEPIVANCE..................................................................77ketoconazole cream 2%..............................................24ketoconazole shampoo 2%........................................ 24ketoconazole tab 200 mg........................................... 24ketorolac tromethamine ophth soln

0.4%..........................................................................103ketorolac tromethamine ophth soln

0.5%..........................................................................103KEYTRUDA...................................................................31KINERET....................................................................... 98KINRIX........................................................................... 98KISQALI.........................................................................31KISQALI.........................................................................31KISQALI.........................................................................31

KISQALI FEMARA 200 DOSE...................................32KISQALI FEMARA 400 DOSE...................................32KISQALI FEMARA 600 DOSE...................................32KOMBIGLYZE XR........................................................54KOMBIGLYZE XR........................................................54KOMBIGLYZE XR........................................................54KORLYM........................................................................93K-TAB.............................................................................82KUVAN...........................................................................86KUVAN...........................................................................86KUVAN...........................................................................86KYPROLIS.................................................................... 32KYPROLIS.................................................................... 32KYPROLIS.................................................................... 32Llabetalol hcl tab 100 mg..............................................68labetalol hcl tab 200 mg..............................................68labetalol hcl tab 300 mg..............................................68LACRISERT................................................................103lactated ringer's solution............................................. 82lactic acid (ammonium lactate) cream

12%............................................................................. 79lactic acid (ammonium lactate) lotion

12%............................................................................. 79lactulose (encephalopathy) solution 10

gm/15ml......................................................................84lactulose solution 10 gm/15ml....................................84lamivudine oral soln 10 mg/ml................................... 46lamivudine tab 100 mg (hbv)......................................46lamivudine tab 150 mg................................................46lamivudine tab 300 mg................................................46lamivudine-zidovudine tab 150-300 mg.................... 46lamotrigine tab 100 mg............................................... 14lamotrigine tab 150 mg............................................... 15lamotrigine tab 200 mg............................................... 15lamotrigine tab 25 mg................................................. 14lamotrigine tab chewable dispersible 25

mg................................................................................14lamotrigine tab chewable dispersible 5

mg................................................................................14lansoprazole cap delayed release 15

mg................................................................................84lansoprazole cap delayed release 30

mg................................................................................84lanthanum carbonate chew tab 1000



mg................................................................................82LANTUS.........................................................................54

2020

134

LANTUS SOLOSTAR..................................................54LARTRUVO...................................................................32LARTRUVO...................................................................32LASIX............................................................................. 68LASIX............................................................................. 68LASIX............................................................................. 68latanoprost ophth soln 0.005%................................ 103LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LEDIPASVIR/SOFOSBUVIR...................................... 46leflunomide tab 10 mg.................................................98leflunomide tab 20 mg.................................................98LENVIMA 10 MG DAILY DOSE.................................32LENVIMA 12MG DAILY DOSE..................................32LENVIMA 14 MG DAILY DOSE.................................32LENVIMA 18 MG DAILY DOSE.................................32LENVIMA 20 MG DAILY DOSE.................................32LENVIMA 24 MG DAILY DOSE.................................32LENVIMA 4 MG DAILY DOSE...................................32LENVIMA 8 MG DAILY DOSE...................................32letrozole tab 2.5 mg.....................................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32leucovorin calcium for inj 100 mg.............................. 32leucovorin calcium for inj 200 mg.............................. 32leucovorin calcium for inj 350 mg.............................. 32leucovorin calcium for inj 500 mg.............................. 32leucovorin calcium for inj 50 mg................................ 32leucovorin calcium inj 500 mg/50ml (10 mg/

ml)................................................................................32leucovorin calcium tab 25 mg.................................... 32leucovorin calcium tab 5 mg.......................................32LEUKERAN...................................................................32LEUKINE....................................................................... 59leuprolide acetate inj kit 5 mg/ml............................... 94LEVEMIR.......................................................................54LEVEMIR FLEXTOUCH..............................................54levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................15levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15

levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levetiracetam tab er 24hr 500 mg..............................15levetiracetam tab er 24hr 750 mg..............................15levobunolol hcl ophth soln 0.5%..............................103levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 82levocarnitine tab 330 mg............................................ 82levocetirizine dihydrochloride tab 5

mg............................................................................. 107levofloxacin in d5w iv soln 250 mg/50ml.....................9levofloxacin in d5w iv soln 500

mg/100ml......................................................................9levofloxacin in d5w iv soln 750

mg/150ml......................................................................9levofloxacin iv soln 25 mg/ml....................................... 9levofloxacin ophth soln 0.5%................................... 103levofloxacin oral soln 25 mg/ml..................................10levofloxacin tab 250 mg..............................................10levofloxacin tab 500 mg..............................................10levofloxacin tab 750 mg..............................................10levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 91levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................91levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................91levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................91levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................91levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................91levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................91LEVORPHANOL TARTRATE....................................... 2levorphanol tartrate tab 2 mg....................................... 2levothyroxine sodium tab 100 mcg (euthyrox, levo-t,

levoxyl, unithroid)......................................................93levothyroxine sodium tab 112 mcg (euthyrox, levo-t,






levoxyl, unithroid)......................................................93

2020

135

levothyroxine sodium tab 25 mcg (euthyrox, levo-t,levoxyl, unithroid)......................................................93

levothyroxine sodium tab 300 mcg (levo-t,unithroid).....................................................................93




LEXAPRO......................................................................19LEXAPRO......................................................................19LEXAPRO......................................................................19LEXIVA...........................................................................46LIBTAYO........................................................................ 33LIDOCAINE HCL..........................................................68LIDOCAINE HCL..........................................................69lidocaine hcl soln 4%.....................................................4lidocaine hcl urethral/mucosal gel 2%.........................4lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4LINDANE....................................................................... 38LINEZOLID....................................................................10linezolid for susp 100 mg/5ml.................................... 10linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................10linezolid tab 600 mg.................................................... 10LINZESS........................................................................84LINZESS........................................................................84LINZESS........................................................................84liothyronine sodium tab 25 mcg.................................93liothyronine sodium tab 50 mcg.................................93liothyronine sodium tab 5 mcg................................... 93lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................69lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................69lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................69lisinopril tab 10 mg...................................................... 69lisinopril tab 2.5 mg..................................................... 69lisinopril tab 20 mg...................................................... 69lisinopril tab 30 mg...................................................... 69lisinopril tab 40 mg...................................................... 69lisinopril tab 5 mg.........................................................69LITHIUM........................................................................ 49lithium carbonate cap 150 mg....................................49lithium carbonate cap 300 mg....................................50

lithium carbonate cap 600 mg....................................50lithium carbonate tab 300 mg.....................................50lithium carbonate tab er 300 mg................................50lithium carbonate tab er 450 mg................................50LONSURF..................................................................... 33LONSURF..................................................................... 33loperamide hcl cap 2 mg............................................ 84lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................46LOPRESSOR................................................................69LOPRESSOR................................................................69lorazepam tab 0.5 mg................................................. 49lorazepam tab 1 mg.................................................... 49lorazepam tab 2 mg.................................................... 49LORBRENA.................................................................. 33LORBRENA.................................................................. 33losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 69losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................69losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................69losartan potassium tab 100 mg..................................69losartan potassium tab 25 mg....................................69losartan potassium tab 50 mg....................................69LOTENSIN.................................................................... 69LOTENSIN.................................................................... 69LOTENSIN.................................................................... 69lovastatin tab 10 mg....................................................69lovastatin tab 20 mg....................................................69lovastatin tab 40 mg....................................................69loxapine succinate cap 10 mg....................................41loxapine succinate cap 25 mg....................................41loxapine succinate cap 50 mg....................................41loxapine succinate cap 5 mg......................................41LUMIGAN....................................................................103LUMIZYME....................................................................86LUMOXITI......................................................................33LUPRON DEPOT (1-MONTH)...................................94LUPRON DEPOT (1-MONTH)...................................94LUPRON DEPOT (3-MONTH)...................................94LUPRON DEPOT (3-MONTH)...................................94LUPRON DEPOT (4-MONTH)...................................94LUPRON DEPOT (6-MONTH)...................................94LUPRON DEPOT-PED (1-MONTH)..........................94LUPRON DEPOT-PED (1-MONTH)..........................94LUPRON DEPOT-PED (1-MONTH)..........................94LUPRON DEPOT-PED (3-MONTH)..........................94LUPRON DEPOT-PED (3-MONTH)..........................94LYNPARZA....................................................................33LYNPARZA....................................................................33LYSODREN...................................................................93

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Mmagnesium sulfate inj 50%........................................ 82malathion lotion 0.5%..................................................38MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MARPLAN..................................................................... 19MARQIBO......................................................................33MATULANE...................................................................33MAVENCLAD................................................................76MAVENCLAD................................................................76MAVENCLAD................................................................76MAVENCLAD................................................................76MAVENCLAD................................................................76MAVENCLAD................................................................76MAVENCLAD................................................................76MAXITROL..................................................................103MAXITROL..................................................................103MAYZENT......................................................................77MAYZENT......................................................................77meclizine hcl tab 12.5 mg...........................................22medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................91medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 91medroxyprogesterone acetate tab 10

mg................................................................................91medroxyprogesterone acetate tab 2.5

mg................................................................................91medroxyprogesterone acetate tab 5

mg................................................................................91MEFLOQUINE HCL.....................................................38megestrol acetate susp 40 mg/ml..............................91megestrol acetate tab 20 mg..................................... 91megestrol acetate tab 40 mg..................................... 91MEKINIST......................................................................33MEKINIST......................................................................33MEKTOVI.......................................................................33meloxicam tab 15 mg....................................................2meloxicam tab 7.5 mg...................................................2melphalan hcl for inj 50 mg........................................ 33memantine hcl oral solution 2 mg/ml.........................17memantine hcl tab 10 mg...........................................17memantine hcl tab 5 mg............................................. 17memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................17MENACTRA.................................................................. 98MENVEO....................................................................... 98mercaptopurine tab 50 mg......................................... 33meropenem iv for soln 1 gm...................................... 10meropenem iv for soln 500 mg.................................. 10

mesalamine cap dr 400 mg......................................101mesalamine cap er 24hr 0.375 gm..........................101mesalamine enema 4 gm.........................................101mesalamine rectal enema 4 gm & cleanser wipe

kit...............................................................................101mesalamine suppos 1000 mg..................................101mesalamine tab delayed release 1.2

gm............................................................................. 101mesalamine tab delayed release 800

mg............................................................................. 101mesna inj 100 mg/ml...................................................33MESNEX........................................................................33metformin hcl tab 1000 mg.........................................54metformin hcl tab 500 mg...........................................54metformin hcl tab 850 mg...........................................54metformin hcl tab er 24hr 500 mg............................. 54metformin hcl tab er 24hr 750 mg............................. 54methadone hcl tab 10 mg.............................................2methadone hcl tab 5 mg............................................... 2methazolamide tab 25 mg.......................................... 69methazolamide tab 50 mg.......................................... 69methenamine hippurate tab 1 gm..............................10methimazole tab 10 mg.............................................. 95methimazole tab 5 mg.................................................95methocarbamol tab 500 mg..................................... 109methocarbamol tab 750 mg..................................... 109METHOTREXATE SODIUM.......................................98methotrexate sodium for inj 1 gm.............................. 98methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................98methotrexate sodium inj pf 1000 mg/40ml (25 mg/



ml)................................................................................98methotrexate sodium tab 2.5 mg............................... 98methoxsalen rapid cap 10 mg....................................79methscopolamine bromide tab 2.5 mg......................84methscopolamine bromide tab 5 mg......................... 84methylergonovine maleate tab 0.2 mg......................88methylphenidate hcl tab 10 mg..................................77methylphenidate hcl tab 20 mg..................................77methylphenidate hcl tab 5 mg....................................77methylphenidate hcl tab er 20 mg............................. 77methylprednisolone sod succ for inj 1000

mg................................................................................89methylprednisolone sod succ for inj 125

mg................................................................................89methylprednisolone sod succ for inj 40

mg................................................................................89

2020

137

methylprednisolone sod succ for inj 500mg................................................................................89

methylprednisolone tab 16 mg...................................89methylprednisolone tab 32 mg...................................89methylprednisolone tab 4 mg.....................................89methylprednisolone tab 8 mg.....................................89methylprednisolone tab therapy pack 4 mg

(21)..............................................................................89METHYLTESTOSTERONE........................................ 91metoclopramide hcl inj 5 mg/ml................................. 84metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................84metoclopramide hcl tab 10 mg...................................84metoclopramide hcl tab 5 mg.....................................84metolazone tab 10 mg................................................ 69metolazone tab 2.5 mg............................................... 69metolazone tab 5 mg...................................................69metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................69metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................69metoprolol succinate tab er 24hr 100




mg................................................................................69metoprolol tartrate tab 100 mg...................................69metoprolol tartrate tab 25 mg.....................................69metoprolol tartrate tab 50 mg.....................................69METRONIDAZOLE...................................................... 10metronidazole cap 375 mg.........................................10metronidazole cream 0.75%.......................................80metronidazole gel 0.75%............................................ 80metronidazole gel 1%..................................................80metronidazole in nacl 0.74% iv soln 500

mg/100ml....................................................................10metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................10metronidazole lotion 0.75%........................................ 80metronidazole tab 250 mg..........................................10metronidazole tab 500 mg..........................................10metronidazole vaginal gel 0.75%...............................10MEXILETINE HCL....................................................... 70MEXILETINE HCL....................................................... 70MEXILETINE HCL....................................................... 70MIACALCIN................................................................ 101MICARDIS.....................................................................70MICARDIS.....................................................................70MICARDIS.....................................................................70

MICARDIS HCT........................................................... 70MICARDIS HCT........................................................... 70MICARDIS HCT........................................................... 70midodrine hcl tab 10 mg............................................. 70midodrine hcl tab 2.5 mg............................................ 70midodrine hcl tab 5 mg............................................... 70MIGERGOT...................................................................25miglitol tab 100 mg...................................................... 54miglitol tab 25 mg........................................................ 54miglitol tab 50 mg........................................................ 54miglustat cap 100 mg..................................................86MIGRANAL....................................................................25minocycline hcl cap 100 mg.......................................10minocycline hcl cap 50 mg......................................... 10minocycline hcl cap 75 mg......................................... 10minocycline hcl tab 100 mg........................................10minocycline hcl tab 50 mg..........................................10minocycline hcl tab 75 mg..........................................10minoxidil tab 10 mg..................................................... 70minoxidil tab 2.5 mg.................................................... 70mirtazapine orally disintegrating tab 15

mg................................................................................19mirtazapine orally disintegrating tab 30

mg................................................................................20mirtazapine orally disintegrating tab 45

mg................................................................................20mirtazapine tab 15 mg................................................ 20mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 20misoprostol tab 100 mcg............................................ 84misoprostol tab 200 mcg............................................ 85MITIGARE..................................................................... 24mitomycin for iv soln 20 mg....................................... 33mitomycin for iv soln 40 mg....................................... 33mitomycin for iv soln 5 mg..........................................33mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................33mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................33mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................33M-M-R II........................................................................ 98modafinil tab 100 mg.................................................110modafinil tab 200 mg.................................................110moexipril hcl tab 15 mg...............................................70moexipril hcl tab 7.5 mg..............................................70MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41mometasone furoate cream 0.1%............................. 80

2020

138

mometasone furoate nasal susp 50 mcg/act..............................................................................107

mometasone furoate oint 0.1%..................................80mometasone furoate solution 0.1%

(lotion).........................................................................80MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2".................................... 54MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.5ML/29G X 1/2".................................... 54MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/1ML/29G X 1/2"........................................54montelukast sodium chew tab 4 mg........................107montelukast sodium chew tab 5 mg........................108montelukast sodium oral granules packet 4

mg............................................................................. 108montelukast sodium tab 10 mg................................108morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................2morphine sulfate oral soln 10 mg/5ml......................... 2morphine sulfate oral soln 20 mg/5ml......................... 2morphine sulfate tab 15 mg..........................................3morphine sulfate tab 30 mg..........................................3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 2morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 2morphine sulfate tab er 60 mg..................................... 2MOVIPREP................................................................... 85MOXEZA..................................................................... 103moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................10moxifloxacin hcl ophth soln 0.5% (2 times daily)

(generic for Moxeza).............................................. 103moxifloxacin hcl ophth soln 0.5% (generic for

Vigamox).................................................................. 103moxifloxacin hcl tab 400 mg.......................................10MOXIFLOXACIN HYDROCHLORIDE...................... 10MOZOBIL...................................................................... 59MULTAQ........................................................................ 70mupirocin calcium cream 2%..................................... 80mupirocin oint 2%........................................................ 80MVASI............................................................................ 33MVASI............................................................................ 33MYALEPT...................................................................... 85MYCAMINE...................................................................24MYCAMINE...................................................................24mycophenolate mofetil cap 250 mg...........................98mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................98mycophenolate mofetil hcl for iv soln 500

mg................................................................................98mycophenolate mofetil tab 500 mg........................... 98

mycophenolate sodium tab dr 180 mg......................98mycophenolate sodium tab dr 360 mg......................98MYLOTARG.................................................................. 33MYRBETRIQ.................................................................88MYRBETRIQ.................................................................88Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................70nadolol tab 40 mg........................................................70nadolol tab 80 mg........................................................70NAFCILLIN SODIUM...................................................10NAFCILLIN SODIUM...................................................10NAFCILLIN SODIUM...................................................10nafcillin sodium for inj 1 gm........................................10nafcillin sodium for inj 2 gm........................................10nafcillin sodium for iv soln 10 gm.............................. 10NAGLAZYME................................................................86NALOXONE HCL........................................................... 4NALOXONE HCL........................................................... 4naloxone hcl inj 0.4 mg/ml............................................4naloxone hcl inj 4 mg/10ml...........................................4naltrexone hcl tab 50 mg.............................................. 4naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen sodium tab er 24hr 375 mg......................... 3naproxen sodium tab er 24hr 500 mg......................... 3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................25naratriptan hcl tab 2.5 mg...........................................25NARCAN..........................................................................4NARDIL..........................................................................20NATACYN....................................................................103nateglinide tab 120 mg............................................... 54nateglinide tab 60 mg..................................................54NATPARA....................................................................101NATPARA....................................................................102NATPARA....................................................................102NATPARA....................................................................102NAYZILAM.....................................................................15NEBUPENT...................................................................38NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20NEFAZODONE HYDROCHLORIDE.........................20

2020

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NEOMYCIN/POLYMYXIN/GRAMICIDIN........................................................... 103

NEOMYCIN/POLYMYXIN BSULFATES................................................................. 10

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin........................103

neomycin-polymyxin-dexamethasone ophth oint0.1%..........................................................................103

neomycin-polymyxin-dexamethasone ophth susp0.1%..........................................................................103

neomycin-polymyxin-hc otic soln 1%...................... 105neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 105neomycin sulfate tab 500 mg.....................................10NEPHRAMINE..............................................................82NERLYNX......................................................................33nevirapine susp 50 mg/5ml........................................ 46nevirapine tab 200 mg................................................ 46nevirapine tab er 24hr 100 mg...................................46nevirapine tab er 24hr 400 mg...................................46NEXAVAR......................................................................33NEXIUM.........................................................................85NEXIUM.........................................................................85NEXIUM.........................................................................85NEXIUM.........................................................................85NEXIUM.........................................................................85niacin tab er 1000 mg................................................. 70niacin tab er 500 mg................................................... 70niacin tab er 750 mg................................................... 70nicardipine hcl cap 20 mg...........................................70nicardipine hcl cap 30 mg...........................................70NICOTROL INHALER................................................... 4NICOTROL NS............................................................... 4nifedipine tab er 24hr 30 mg...................................... 70nifedipine tab er 24hr 60 mg...................................... 70nifedipine tab er 24hr 90 mg...................................... 70nifedipine tab er 24hr osmotic release 30

mg................................................................................70nifedipine tab er 24hr osmotic release 60

mg................................................................................70nifedipine tab er 24hr osmotic release 90

mg................................................................................70nilutamide tab 150 mg.................................................33nimodipine cap 30 mg.................................................70NINLARO.......................................................................33NINLARO.......................................................................33NINLARO.......................................................................33NIPENT..........................................................................33NISOLDIPINE ER........................................................ 70nisoldipine tab er 24hr 17 mg.................................... 70nisoldipine tab er 24hr 34 mg.................................... 70nisoldipine tab er 24hr 8.5 mg................................... 70

nitisinone cap 10 mg................................................... 86nitisinone cap 2 mg..................................................... 86nitisinone cap 5 mg..................................................... 86NITRO-BID....................................................................70nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................10nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11nitroglycerin sl tab 0.3 mg.......................................... 70nitroglycerin sl tab 0.4 mg.......................................... 71nitroglycerin sl tab 0.6 mg.......................................... 71nitroglycerin td patch 24hr 0.1 mg/hr.........................71nitroglycerin td patch 24hr 0.2 mg/hr.........................71nitroglycerin td patch 24hr 0.4 mg/hr.........................71nitroglycerin td patch 24hr 0.6 mg/hr.........................71nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................71NIVESTYM....................................................................59NIVESTYM....................................................................59NIVESTYM....................................................................59NIVESTYM....................................................................59nizatidine cap 150 mg.................................................85nizatidine cap 300 mg.................................................85norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................91norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................91norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................91norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................91norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................91norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................92norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................92norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................92norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................91norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................92norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg..............................................................................92norethindrone acetate tab 5 mg.................................92norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................91

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norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35mg-mcg.......................................................................92

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35mg-mcg.......................................................................92

norethindrone tab 0.35 mg......................................... 92norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................92norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................92norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................92norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................92NORMOSOL-M IN D5W............................................. 82NORTHERA.................................................................. 71NORTHERA.................................................................. 71NORTHERA.................................................................. 71NORTRIPTYLINE HCL............................................... 20nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 20NORVASC..................................................................... 71NORVASC..................................................................... 71NORVASC..................................................................... 71NORVIR.........................................................................46NORVIR.........................................................................46NOXAFIL....................................................................... 24NOXAFIL....................................................................... 24NOXAFIL....................................................................... 24NUBEQA........................................................................33NUEDEXTA...................................................................77NULOJIX........................................................................98NULYTELY/FLAVOR PACKS..................................... 85NUPLAZID.....................................................................42NUPLAZID.....................................................................42NUTRILIPID.................................................................. 82nystatin cream 100000 unit/gm..................................24nystatin oint 100000 unit/gm...................................... 24nystatin susp 100000 unit/ml......................................24nystatin tab 500000 unit..............................................24nystatin topical powder 100000 unit/

gm................................................................................24nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................80nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................80OOCALIVA....................................................................... 86OCALIVA....................................................................... 86

octreotide acetate inj 1000 mcg/ml (1 mg/ml)................................................................................94

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)................................................................................94




OCUFLOX...................................................................104ODEFSEY..................................................................... 46ODOMZO...................................................................... 33OFEV........................................................................... 108OFEV........................................................................... 108ofloxacin ophth soln 0.3%........................................ 104ofloxacin otic soln 0.3%............................................ 105ofloxacin tab 400 mg...................................................11OGIVRI.......................................................................... 33OGIVRI.......................................................................... 33olanzapine for im inj 10 mg........................................ 42olanzapine orally disintegrating tab 10

mg................................................................................42olanzapine orally disintegrating tab 15



mg................................................................................42olanzapine tab 10 mg..................................................42olanzapine tab 15 mg..................................................42olanzapine tab 2.5 mg.................................................42olanzapine tab 20 mg..................................................42olanzapine tab 5 mg....................................................42olanzapine tab 7.5 mg.................................................42olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg............................................................. 71olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg...........................................................71olmesartan-amlodipine-hydrochlorothiazide tab

40-10-25 mg.............................................................. 71olmesartan-amlodipine-hydrochlorothiazide tab

40-5-12.5 mg............................................................. 71olmesartan-amlodipine-hydrochlorothiazide tab

40-5-25 mg................................................................ 71olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................71olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................71olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................71olmesartan medoxomil tab 20 mg............................. 71

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olmesartan medoxomil tab 40 mg............................. 71olmesartan medoxomil tab 5 mg............................... 71olopatadine hcl nasal soln 0.6%..............................108olopatadine hcl ophth soln 0.1%..............................104olopatadine hcl ophth soln 0.2%..............................104omega-3-acid ethyl esters cap 1 gm.........................71omeprazole cap delayed release 10

mg................................................................................85omeprazole cap delayed release 20

mg................................................................................85omeprazole cap delayed release 40

mg................................................................................85OMNITROPE................................................................ 90OMNITROPE................................................................ 90OMNITROPE................................................................ 90ONCASPAR.................................................................. 33ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................22ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22ondansetron orally disintegrating tab 8

mg................................................................................22ONGLYZA......................................................................54ONGLYZA......................................................................54ONIVYDE...................................................................... 34OPDIVO.........................................................................34OPDIVO.........................................................................34OPDIVO.........................................................................34OPSUMIT....................................................................108ORACEA........................................................................80ORENCIA...................................................................... 98ORENCIA...................................................................... 98ORENCIA...................................................................... 98ORENCIA...................................................................... 98ORENCIA CLICKJECT............................................... 98ORFADIN.......................................................................86ORFADIN.......................................................................86ORFADIN.......................................................................87ORFADIN.......................................................................87ORFADIN.......................................................................87ORKAMBI....................................................................108ORKAMBI....................................................................108ORKAMBI....................................................................108ORKAMBI....................................................................108oseltamivir phosphate cap 30 mg..............................46oseltamivir phosphate cap 45 mg..............................46

oseltamivir phosphate cap 75 mg..............................46oseltamivir phosphate for susp 6 mg/

ml.................................................................................47OTEZLA.........................................................................98OTEZLA.........................................................................98OXACILLIN SODIUM.................................................. 11OXACILLIN SODIUM.................................................. 11oxaliplatin for iv inj 100 mg.........................................34oxaliplatin for iv inj 50 mg...........................................34oxaliplatin iv soln 100 mg/20ml..................................34oxaliplatin iv soln 50 mg/10ml....................................34oxandrolone tab 10 mg............................................... 92oxandrolone tab 2.5 mg..............................................92oxaprozin tab 600 mg....................................................3oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................15oxcarbazepine tab 150 mg.........................................15oxcarbazepine tab 300 mg.........................................15oxcarbazepine tab 600 mg.........................................15oxybutynin chloride syrup 5 mg/5ml..........................88oxybutynin chloride tab 5 mg..................................... 88oxybutynin chloride tab er 24hr 10 mg......................88oxybutynin chloride tab er 24hr 15 mg......................88oxybutynin chloride tab er 24hr 5 mg........................88oxycodone-aspirin tab 4.8355-325 mg........................3oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................3oxycodone hcl tab 20 mg..............................................3oxycodone hcl tab 30 mg..............................................3oxycodone hcl tab 5 mg................................................3oxycodone w/ acetaminophen tab 10-325

mg..................................................................................3oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................3oxycodone w/ acetaminophen tab 5-325

mg..................................................................................3oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................3OZEMPIC...................................................................... 54OZEMPIC...................................................................... 54Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................34paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................34paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................34PADCEV........................................................................ 34PADCEV........................................................................ 34paliperidone tab er 24hr 1.5 mg.................................42paliperidone tab er 24hr 3 mg....................................42paliperidone tab er 24hr 6 mg....................................42

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paliperidone tab er 24hr 9 mg....................................42palonosetron hcl iv soln 0.25 mg/5ml........................22palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 22PALONOSETRON

HYDROCHLORIDE.................................................. 22PALYNZIQ..................................................................... 87PALYNZIQ..................................................................... 87PALYNZIQ..................................................................... 87PANRETIN.....................................................................34pantoprazole sodium ec tab 20 mg........................... 85pantoprazole sodium ec tab 40 mg........................... 85pantoprazole sodium for iv soln 40 mg..................... 85paricalcitol cap 1 mcg............................................... 102paricalcitol cap 2 mcg............................................... 102paricalcitol cap 4 mcg............................................... 102paricalcitol iv soln 2 mcg/ml..................................... 102paricalcitol iv soln 5 mcg/ml..................................... 102PARNATE...................................................................... 20paromomycin sulfate cap 250 mg..............................11paroxetine hcl tab 10 mg............................................ 20paroxetine hcl tab 20 mg............................................ 20paroxetine hcl tab 30 mg............................................ 20paroxetine hcl tab 40 mg............................................ 20PASER........................................................................... 26PATANOL.................................................................... 104PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAXIL............................................................................. 20PAZEO.........................................................................104PEDIARIX......................................................................98PEDVAX HIB................................................................ 98peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................85peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................85peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................85PEGANONE..................................................................15PEGASYS..................................................................... 47PEGASYS..................................................................... 47PEGASYS PROCLICK................................................47penicillamine tab 250 mg............................................88penicillin g potassium for inj 20000000

unit...............................................................................11penicillin g potassium for inj 5000000

unit...............................................................................11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 11

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 11

PENICILLIN G SODIUM............................................. 11PENICILLIN V POTASSIUM...................................... 11PENICILLIN V POTASSIUM...................................... 11penicillin v potassium tab 250 mg............................. 11penicillin v potassium tab 500 mg............................. 11PENTACEL....................................................................99PENTAM 300................................................................38pentamidine isethionate for nebulization soln 300

mg................................................................................38pentamidine isethionate for soln 300

mg................................................................................38PENTASA....................................................................101PENTASA....................................................................101pentoxifylline tab er 400 mg....................................... 71perindopril erbumine tab 2 mg................................... 71perindopril erbumine tab 4 mg................................... 71perindopril erbumine tab 8 mg................................... 71PERJETA.......................................................................34permethrin cream 5%..................................................38perphenazine tab 16 mg.............................................22perphenazine tab 2 mg............................................... 22perphenazine tab 4 mg............................................... 22perphenazine tab 8 mg............................................... 22PERSERIS.................................................................... 42PERSERIS.................................................................... 42phenelzine sulfate tab 15 mg.....................................20phenobarbital elixir 20 mg/5ml...................................15phenobarbital sodium inj 130 mg/ml......................... 15phenobarbital sodium inj 65 mg/ml............................15phenobarbital tab 100 mg...........................................15phenobarbital tab 15 mg.............................................15phenobarbital tab 16.2 mg..........................................15phenobarbital tab 30 mg.............................................15phenobarbital tab 32.4 mg..........................................15phenobarbital tab 60 mg.............................................15phenobarbital tab 64.8 mg..........................................15phenobarbital tab 97.2 mg..........................................15phenoxybenzamine hcl cap 10 mg............................71phenytoin chew tab 50 mg......................................... 15phenytoin sodium extended cap 100

mg................................................................................15phenytoin sodium extended cap 200

mg................................................................................15phenytoin sodium extended cap 300

mg................................................................................15phenytoin susp 125 mg/5ml....................................... 15PHOSLYRA...................................................................82PHOSPHOLINE IODIDE.......................................... 104

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PICATO..........................................................................80PICATO..........................................................................80PIFELTRO..................................................................... 47pilocarpine hcl ophth soln 1%..................................104pilocarpine hcl ophth soln 2%..................................104pilocarpine hcl ophth soln 4%..................................104pilocarpine hcl tab 5 mg..............................................77pilocarpine hcl tab 7.5 mg.......................................... 77pimecrolimus cream 1%..............................................80PIMOZIDE..................................................................... 42PIMOZIDE..................................................................... 42pindolol tab 10 mg....................................................... 71pindolol tab 5 mg......................................................... 71pioglitazone hcl-glimepiride tab 30-2

mg................................................................................55pioglitazone hcl-glimepiride tab 30-4

mg................................................................................55pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................55pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................55pioglitazone hcl tab 15 mg..........................................54pioglitazone hcl tab 30 mg..........................................54pioglitazone hcl tab 45 mg..........................................55piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................11piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 11piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 11PIQRAY 200MG DAILY DOSE...................................34PIQRAY 250MG DAILY DOSE...................................34PIQRAY 300MG DAILY DOSE...................................34piroxicam cap 10 mg..................................................... 3piroxicam cap 20 mg..................................................... 3PLEGRIDY.................................................................... 77PLEGRIDY.................................................................... 77PLEGRIDY STARTER PACK..................................... 77PLEGRIDY STARTER PACK..................................... 77podofilox soln 0.5%..................................................... 80POLIVY..........................................................................34polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 104POLYTRIM.................................................................. 104POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34PORTRAZZA................................................................ 34posaconazole tab delayed release 100

mg................................................................................24POTASSIUM CHLORIDE/DEXTROSE.....................83

POTASSIUM CHLORIDE/DEXTROSE/LACTATEDRINGERS...................................................................83

potassium chloride 20 meq/l (0.15%) in dextrose 5%inj................................................................................. 83

potassium chloride cap er 10 meq............................ 82potassium chloride cap er 8 meq...............................82potassium chloride inj 2 meq/ml................................ 82potassium chloride microencapsulated crys er tab 10

meq............................................................................. 82potassium chloride microencapsulated crys er tab 20

meq............................................................................. 82potassium chloride oral soln 10% (20

meq/15ml).................................................................. 83potassium chloride tab er 10 meq............................. 83potassium chloride tab er 20 meq (1500

mg).............................................................................. 83potassium chloride tab er 8 meq (600

mg).............................................................................. 83potassium citrate tab er 10 meq (1080



mg).............................................................................. 83POTELIGEO................................................................. 34PRADAXA..................................................................... 59PRADAXA..................................................................... 59PRADAXA..................................................................... 59pramipexole dihydrochloride tab 0.125

mg................................................................................39pramipexole dihydrochloride tab 0.25




mg................................................................................39pramipexole dihydrochloride tab 1 mg...................... 39prasugrel hcl tab 10 mg..............................................59prasugrel hcl tab 5 mg................................................ 59pravastatin sodium tab 10 mg....................................71pravastatin sodium tab 20 mg....................................71pravastatin sodium tab 40 mg....................................71pravastatin sodium tab 80 mg....................................71praziquantel tab 600 mg............................................. 38prazosin hcl cap 1 mg.................................................71prazosin hcl cap 2 mg.................................................71prazosin hcl cap 5 mg.................................................72PRECOSE.....................................................................55PRECOSE.....................................................................55PRECOSE.....................................................................55

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PRED FORTE............................................................ 104PREDNICARBATE.......................................................80PREDNICARBATE.......................................................80PREDNISOLONE ACETATE....................................104prednisolone sod phosphate oral soln 10

mg/5ml........................................................................ 89prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 89prednisolone sod phosphate oral soln 20

mg/5ml........................................................................ 89prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................89prednisolone syrup 15 mg/5ml...................................89PREDNISONE.............................................................. 89prednisone tab 10 mg................................................. 89prednisone tab 1 mg................................................... 89prednisone tab 2.5 mg................................................ 89prednisone tab 20 mg................................................. 89prednisone tab 50 mg................................................. 89prednisone tab 5 mg................................................... 89prednisone tab therapy pack 10 mg

(21)..............................................................................89prednisone tab therapy pack 10 mg

(48)..............................................................................89prednisone tab therapy pack 5 mg (21).................... 89prednisone tab therapy pack 5 mg (48).................... 89pregabalin cap 100 mg............................................... 16pregabalin cap 150 mg............................................... 16pregabalin cap 200 mg............................................... 16pregabalin cap 225 mg............................................... 16pregabalin cap 25 mg................................................. 15pregabalin cap 300 mg............................................... 16pregabalin cap 50 mg................................................. 15pregabalin cap 75 mg................................................. 15pregabalin soln 20 mg/ml........................................... 16PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 90PREMARIN................................................................... 92PREMASOL.................................................................. 83PREMPHASE............................................................... 92PREMPRO.................................................................... 92PREMPRO.................................................................... 92PREMPRO.................................................................... 92PREMPRO.................................................................... 92PREVENT SAFETY PEN NEEDLES 31G X

1/4".............................................................................. 55PREVENT SAFETY PEN NEEDLES 31G X

5/16"............................................................................55PREVYMIS....................................................................47PREVYMIS....................................................................47PREZCOBIX................................................................. 47PREZISTA..................................................................... 47

PREZISTA..................................................................... 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PRIFTIN.........................................................................26primaquine phosphate tab 26.3 mg...........................38primidone tab 250 mg................................................. 16primidone tab 50 mg................................................... 16PRINIVIL........................................................................72PRINIVIL........................................................................72PRINIVIL........................................................................72PRIVIGEN..................................................................... 99PRIVIGEN..................................................................... 99PRIVIGEN..................................................................... 99PRIVIGEN..................................................................... 99PROAIR HFA..............................................................108PROAIR RESPICLICK..............................................108probenecid tab 500 mg............................................... 24PROCALAMINE........................................................... 83PROCARDIA XL.......................................................... 72PROCARDIA XL.......................................................... 72PROCARDIA XL.......................................................... 72PROCHLORPERAZINE EDISYLATE....................... 22prochlorperazine edisylate inj 10

mg/2ml........................................................................ 22prochlorperazine maleate tab 10 mg.........................22prochlorperazine maleate tab 5 mg...........................22prochlorperazine suppos 25 mg................................ 22PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59progesterone micronized cap 100 mg.......................92progesterone micronized cap 200 mg.......................92PROGLYCEM............................................................... 55PROGRAF.....................................................................99PROGRAF.....................................................................99PROGRAF.....................................................................99PROLASTIN-C..............................................................87PROLASTIN-C..............................................................87PROLENSA................................................................ 104PROLEUKIN................................................................. 34PROLIA........................................................................102PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 60PROMACTA.................................................................. 60promethazine hcl suppos 12.5 mg............................ 23promethazine hcl suppos 25 mg................................23

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promethazine hcl syrup 6.25 mg/5ml........................ 23promethazine hcl tab 12.5 mg....................................23promethazine hcl tab 25 mg.......................................23promethazine hcl tab 50 mg.......................................23propafenone hcl cap er 12hr 225 mg........................ 72propafenone hcl cap er 12hr 325 mg........................ 72propafenone hcl cap er 12hr 425 mg........................ 72propafenone hcl tab 150 mg...................................... 72propafenone hcl tab 225 mg...................................... 72propafenone hcl tab 300 mg...................................... 72propranolol hcl cap er 24hr 120 mg.......................... 72propranolol hcl cap er 24hr 160 mg.......................... 72propranolol hcl cap er 24hr 60 mg.............................72propranolol hcl cap er 24hr 80 mg.............................72propranolol hcl inj 1 mg/ml......................................... 72propranolol hcl tab 10 mg...........................................72propranolol hcl tab 20 mg...........................................72propranolol hcl tab 40 mg...........................................72propranolol hcl tab 60 mg...........................................72propranolol hcl tab 80 mg...........................................72propylthiouracil tab 50 mg.......................................... 95PROQUAD.................................................................... 99PROSCAR.....................................................................88PROSOL........................................................................83protriptyline hcl tab 10 mg.......................................... 20protriptyline hcl tab 5 mg............................................ 20PROZAC........................................................................20PROZAC........................................................................20PROZAC........................................................................20PULMOZYME.............................................................108PURIXAN.......................................................................34PYLERA.........................................................................85pyrazinamide tab 500 mg........................................... 26pyridostigmine bromide oral soln 60

mg/5ml........................................................................ 25pyridostigmine bromide tab 60 mg............................ 25pyridostigmine bromide tab er 180 mg......................25QQUADRACEL................................................................99quetiapine fumarate tab 100 mg................................42quetiapine fumarate tab 200 mg................................42quetiapine fumarate tab 25 mg..................................42quetiapine fumarate tab 300 mg................................42quetiapine fumarate tab 400 mg................................42quetiapine fumarate tab 50 mg..................................42quetiapine fumarate tab er 24hr 150

mg................................................................................42quetiapine fumarate tab er 24hr 200

mg................................................................................42quetiapine fumarate tab er 24hr 300

mg................................................................................42

quetiapine fumarate tab er 24hr 400mg................................................................................42

quetiapine fumarate tab er 24hr 50 mg.....................42quinapril hcl tab 10 mg............................................... 72quinapril hcl tab 20 mg............................................... 72quinapril hcl tab 40 mg............................................... 72quinapril hcl tab 5 mg..................................................72quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................72quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................72quinapril-hydrochlorothiazide tab 20-25

mg................................................................................72quinidine gluconate tab er 324 mg............................ 72QUINIDINE SULFATE................................................. 72QUINIDINE SULFATE................................................. 72QVAR REDIHALER................................................... 108QVAR REDIHALER................................................... 108RRABAVERT................................................................... 99raloxifene hcl tab 60 mg............................................. 92ramelteon tab 8 mg................................................... 110ramipril cap 1.25 mg....................................................72ramipril cap 10 mg.......................................................72ramipril cap 2.5 mg......................................................72ramipril cap 5 mg.........................................................72ranitidine hcl cap 150 mg........................................... 85ranitidine hcl cap 300 mg........................................... 85ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................85ranitidine hcl tab 150 mg............................................ 85ranitidine hcl tab 300 mg............................................ 85ranolazine tab er 12hr 1000 mg.................................73ranolazine tab er 12hr 500 mg...................................72rasagiline mesylate tab 0.5 mg.................................. 39rasagiline mesylate tab 1 mg..................................... 39REBIF.............................................................................77REBIF.............................................................................77REBIF REBIDOSE.......................................................77REBIF REBIDOSE.......................................................77REBIF REBIDOSE TITRATION PACK......................77REBIF TITRATION PACK...........................................77RECOMBIVAX HB....................................................... 99RECOMBIVAX HB....................................................... 99RECOMBIVAX HB....................................................... 99RECTIV..........................................................................73REGRANEX.................................................................. 80RELENZA DISKHALER.............................................. 47RELISTOR.....................................................................85RELISTOR.....................................................................85RELISTOR.....................................................................85

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REMERON....................................................................20REMERON....................................................................20REMERON SOLTAB....................................................20REMERON SOLTAB....................................................20REMERON SOLTAB....................................................20REMODULIN.............................................................. 108REMODULIN.............................................................. 108REMODULIN.............................................................. 108REMODULIN.............................................................. 108RENFLEXIS.................................................................. 99repaglinide tab 0.5 mg................................................ 55repaglinide tab 1 mg....................................................55repaglinide tab 2 mg....................................................55REPATHA...................................................................... 73REPATHA PUSHTRONEX SYSTEM........................73REPATHA SURECLICK.............................................. 73RESCRIPTOR.............................................................. 47RESTASIS...................................................................104RESTASIS MULTIDOSE...........................................104RETACRIT.....................................................................60RETACRIT.....................................................................60RETACRIT.....................................................................60RETACRIT.....................................................................60RETACRIT.....................................................................60RETROVIR IV INFUSION...........................................47REVCOVI...................................................................... 87REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................43REYATAZ.......................................................................47RHOPRESSA............................................................. 104ribavirin cap 200 mg....................................................47ribavirin for inhal soln 6 gm......................................108ribavirin tab 200 mg.....................................................47RIDAURA...................................................................... 99rifabutin cap 150 mg....................................................26rifampin cap 150 mg....................................................26rifampin cap 300 mg....................................................26rifampin for inj 600 mg................................................ 26riluzole tab 50 mg........................................................ 77RINVOQ.........................................................................99risedronate sodium tab 150 mg...............................102risedronate sodium tab 30 mg................................. 102

risedronate sodium tab 35 mg................................. 102risedronate sodium tab 5 mg................................... 102risedronate sodium tab delayed release 35

mg............................................................................. 102RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERIDONE ODT................................................... 43risperidone orally disintegrating tab 0.5

mg................................................................................43risperidone orally disintegrating tab 1




mg................................................................................43risperidone soln 1 mg/ml............................................ 43risperidone tab 0.25 mg..............................................43risperidone tab 0.5 mg................................................ 43risperidone tab 1 mg................................................... 43risperidone tab 2 mg................................................... 43risperidone tab 3 mg................................................... 43risperidone tab 4 mg................................................... 43ritonavir tab 100 mg.................................................... 47RITUXAN.......................................................................34RITUXAN.......................................................................34RITUXAN HYCELA......................................................35RITUXAN HYCELA......................................................35rivastigmine tartrate cap 1.5 mg................................ 17rivastigmine tartrate cap 3 mg....................................17rivastigmine tartrate cap 4.5 mg................................ 17rivastigmine tartrate cap 6 mg....................................17rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 17rivastigmine td patch 24hr 4.6 mg/24hr.....................17rivastigmine td patch 24hr 9.5 mg/24hr.....................17rizatriptan benzoate oral disintegrating tab 10

mg................................................................................25rizatriptan benzoate oral disintegrating tab 5

mg................................................................................25rizatriptan benzoate tab 10 mg.................................. 25rizatriptan benzoate tab 5 mg.................................... 25ropinirole hydrochloride tab 0.25 mg.........................39ropinirole hydrochloride tab 0.5 mg...........................39ropinirole hydrochloride tab 1 mg.............................. 39ropinirole hydrochloride tab 2 mg.............................. 39ropinirole hydrochloride tab 3 mg.............................. 39ropinirole hydrochloride tab 4 mg.............................. 39ropinirole hydrochloride tab 5 mg.............................. 39

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rosuvastatin calcium tab 10 mg................................. 73rosuvastatin calcium tab 20 mg................................. 73rosuvastatin calcium tab 40 mg................................. 73rosuvastatin calcium tab 5 mg................................... 73ROTARIX.......................................................................99ROTATEQ......................................................................99ROZLYTREK.................................................................35ROZLYTREK.................................................................35RUBRACA.....................................................................35RUBRACA.....................................................................35RUBRACA.....................................................................35RYDAPT........................................................................ 35RYTARY.........................................................................39RYTARY.........................................................................39RYTARY.........................................................................39RYTARY.........................................................................39SSAFETY INSULIN SYRINGES 1ML/30G X

1/2".............................................................................. 55SAMSCA........................................................................83SAMSCA........................................................................83SANDIMMUNE............................................................. 99SANTYL.........................................................................80SAPHRIS.......................................................................43SAPHRIS.......................................................................43SAPHRIS.......................................................................43scopolamine td patch 72hr 1 mg/3days.................... 23SECUADO.....................................................................43SECUADO.....................................................................43SECUADO.....................................................................43selegiline hcl cap 5 mg............................................... 39selegiline hcl tab 5 mg................................................ 39selenium sulfide lotion 2.5%.......................................80SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SEREVENT DISKUS.................................................108sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................21sertraline hcl tab 100 mg............................................ 21sertraline hcl tab 25 mg.............................................. 21sertraline hcl tab 50 mg.............................................. 21sevelamer carbonate packet 0.8 gm......................... 83sevelamer carbonate packet 2.4 gm......................... 83sevelamer carbonate tab 800 mg..............................83SHINGRIX..................................................................... 99SIGNIFOR..................................................................... 94SIGNIFOR..................................................................... 94SIGNIFOR..................................................................... 94SIGNIFOR LAR............................................................94

SIGNIFOR LAR............................................................95SIGNIFOR LAR............................................................95SIGNIFOR LAR............................................................95SIGNIFOR LAR............................................................95sildenafil citrate tab 20 mg....................................... 108SILENOR.....................................................................110SILENOR.....................................................................110silodosin cap 4 mg.......................................................88silodosin cap 8 mg.......................................................88silver sulfadiazine cream 1%......................................80SIMBRINZA................................................................ 104SIMULECT.................................................................... 99SIMULECT.................................................................... 99simvastatin tab 10 mg.................................................73simvastatin tab 20 mg.................................................73simvastatin tab 40 mg.................................................73simvastatin tab 5 mg................................................... 73simvastatin tab 80 mg.................................................73sirolimus oral soln 1 mg/ml.........................................99sirolimus tab 0.5 mg.................................................... 99sirolimus tab 1 mg....................................................... 99sirolimus tab 2 mg....................................................... 99SIRTURO.......................................................................26SIVEXTRO.................................................................... 11SIVEXTRO.................................................................... 11SKYRIZI.........................................................................99sodium chloride irrigation soln 0.9%......................... 83sodium chloride iv soln 0.45%................................... 83sodium chloride iv soln 0.9%..................................... 83sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................87sodium phenylbutyrate tab 500 mg........................... 87sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................83sodium polystyrene sulfonate powder.......................83sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................83SOFOSBUVIR/VELPATASVIR...................................47SOLTAMOX...................................................................35SOMATULINE DEPOT................................................95SOMATULINE DEPOT................................................95SOMATULINE DEPOT................................................95SOMAVERT.................................................................. 95SOMAVERT.................................................................. 95SOMAVERT.................................................................. 95SOMAVERT.................................................................. 95SOMAVERT.................................................................. 95sotalol hcl (afib/afl) tab 120 mg..................................73sotalol hcl (afib/afl) tab 160 mg..................................73sotalol hcl (afib/afl) tab 80 mg....................................73sotalol hcl tab 120 mg.................................................73sotalol hcl tab 160 mg.................................................73

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sotalol hcl tab 240 mg.................................................73sotalol hcl tab 80 mg...................................................73SPIRIVA HANDIHALER............................................108SPIRIVA RESPIMAT................................................. 108SPIRIVA RESPIMAT................................................. 108spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................73spironolactone tab 100 mg.........................................73spironolactone tab 25 mg........................................... 73spironolactone tab 50 mg........................................... 73SPRAVATO 56MG DOSE........................................... 21SPRAVATO 84MG DOSE........................................... 21SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35STAMARIL.....................................................................99STARLIX........................................................................ 55STARLIX........................................................................ 55stavudine cap 15 mg...................................................47stavudine cap 20 mg...................................................47stavudine cap 30 mg...................................................47stavudine cap 40 mg...................................................47STELARA...................................................................... 99STELARA...................................................................... 99STELARA...................................................................... 99STELARA....................................................................100STIMATE....................................................................... 90STIOLTO RESPIMAT................................................ 108STIVARGA.....................................................................35STRENSIQ....................................................................87STRENSIQ....................................................................87STRENSIQ....................................................................87STRENSIQ....................................................................87STREPTOMYCIN SULFATE...................................... 11STRIBILD...................................................................... 47sucralfate susp 1 gm/10ml......................................... 85sucralfate tab 1 gm......................................................85sulfacetamide sodium lotion 10%.............................. 11sulfacetamide sodium ophth soln

10%...........................................................................104sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 104SULFADIAZINE............................................................ 11sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 11

sulfamethoxazole-trimethoprim susp 200-40mg/5ml........................................................................ 11

sulfamethoxazole-trimethoprim tab 400-80mg................................................................................11

sulfamethoxazole-trimethoprim tab 800-160mg................................................................................11

sulfasalazine tab 500 mg..........................................101sulfasalazine tab delayed release 500

mg............................................................................. 101sulindac tab 150 mg...................................................... 3sulindac tab 200 mg...................................................... 3sumatriptan nasal spray 20 mg/act........................... 25sumatriptan nasal spray 5 mg/act..............................25SUMATRIPTAN SUCCINATE.....................................25sumatriptan succinate inj 6 mg/0.5ml........................25sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................25sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................25sumatriptan succinate tab 100 mg............................ 25sumatriptan succinate tab 25 mg...............................25sumatriptan succinate tab 50 mg...............................25SUPRAX........................................................................11SUPRAX........................................................................11SUPREP BOWEL PREP KIT.....................................85SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SYLATRON................................................................... 47SYLATRON................................................................... 47SYLATRON................................................................... 47SYLVANT.....................................................................100SYLVANT.....................................................................100SYMBICORT...............................................................108SYMBICORT...............................................................108SYMDEKO.................................................................. 108SYMDEKO.................................................................. 109SYMFI............................................................................ 47SYMFI LO..................................................................... 47SYMLINPEN 120......................................................... 55SYMLINPEN 60............................................................55SYMPAZAN...................................................................16SYMPAZAN...................................................................16SYMPAZAN...................................................................16SYMTUZA..................................................................... 48SYNAGIS.................................................................... 100SYNAGIS.................................................................... 100

2020

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SYNAREL......................................................................95SYNERCID....................................................................11SYNJARDY................................................................... 55SYNJARDY................................................................... 55SYNJARDY................................................................... 55SYNJARDY................................................................... 55SYNJARDY XR............................................................ 55SYNJARDY XR............................................................ 55SYNJARDY XR............................................................ 55SYNJARDY XR............................................................ 55SYNRIBO...................................................................... 35SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93SYNTHROID.................................................................93TTABLOID........................................................................35tacrolimus cap 0.5 mg...............................................100tacrolimus cap 1 mg..................................................100tacrolimus cap 5 mg..................................................100tacrolimus oint 0.03%..................................................80tacrolimus oint 0.1%.................................................... 80tadalafil tab 20 mg (pah)...........................................109TAFINLAR..................................................................... 35TAFINLAR..................................................................... 35TAGRISSO.................................................................... 35TAGRISSO.................................................................... 35TALZENNA....................................................................35TALZENNA....................................................................35tamoxifen citrate tab 10 mg........................................35tamoxifen citrate tab 20 mg........................................35tamsulosin hcl cap 0.4 mg..........................................88TARGRETIN..................................................................35TASIGNA....................................................................... 35TASIGNA....................................................................... 35TASIGNA....................................................................... 35tazarotene cream 0.1%...............................................80TAZICEF........................................................................ 11TAZICEF........................................................................ 11TAZORAC......................................................................80TAZORAC......................................................................80TAZORAC......................................................................80TDVAX......................................................................... 100TECENTRIQ................................................................. 35

TECENTRIQ................................................................. 35TECFIDERA..................................................................77TECFIDERA..................................................................77TECFIDERA STARTER PACK...................................77TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X

1/2".............................................................................. 55TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X


5/16"............................................................................55TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X

15/64"..........................................................................55TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X





15/64"..........................................................................56TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X

5/16"............................................................................56TECHLITE INSULIN SYRINGE U-100/1ML/29G X

1/2".............................................................................. 56TECHLITE INSULIN SYRINGE U-100/1ML/30G X

1/2".............................................................................. 56TECHLITE INSULIN SYRINGE U-100/1ML/30G X

5/16"............................................................................56TECHLITE INSULIN SYRINGE U-100/1ML/31G X

15/64"..........................................................................56TECHLITE INSULIN SYRINGE U-100/1ML/31G X

5/16"............................................................................56TECHLITE PEN NEEDLES/31G X

6MM............................................................................ 56TECHLITE PEN NEEDLES/31G X




8MM............................................................................ 56TECHLITE PEN NEEDLES 29G X

10MM..........................................................................56TECHLITE PEN NEEDLES 29G X

12MM..........................................................................56TECHLITE PEN NEEDLES 31G X

5MM............................................................................ 56TEFLARO......................................................................11TEFLARO......................................................................12

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150

TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................73telmisartan tab 20 mg................................................. 73telmisartan tab 40 mg................................................. 73telmisartan tab 80 mg................................................. 73temazepam cap 15 mg............................................. 110temazepam cap 30 mg............................................. 110TEMIXYS.......................................................................48TEMODAR.................................................................... 35temsirolimus soln for iv infusion 25 mg/

ml.................................................................................36TENCON..........................................................................3TENIVAC..................................................................... 100tenofovir disoproxil fumarate tab 300

mg................................................................................48terazosin hcl cap 10 mg..............................................74terazosin hcl cap 1 mg................................................73terazosin hcl cap 2 mg................................................74terazosin hcl cap 5 mg................................................74terbinafine hcl tab 250 mg..........................................24terbutaline sulfate tab 2.5 mg.................................. 109terbutaline sulfate tab 5 mg......................................109TERCONAZOLE...........................................................24terconazole vaginal cream 0.4%................................24terconazole vaginal suppos 80 mg............................24testosterone cypionate im inj in oil 100 mg/

ml.................................................................................92testosterone cypionate im inj in oil 200 mg/

ml.................................................................................92testosterone enanthate im inj in oil 200 mg/

ml.................................................................................92testosterone td gel 12.5 mg/act (1%)........................ 92testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 92testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 92testosterone td gel 25 mg/2.5gm (1%)......................92testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 92testosterone td gel 50 mg/5gm (1%).........................92testosterone td soln 30 mg/act...................................92tetrabenazine tab 12.5 mg..........................................77tetrabenazine tab 25 mg.............................................77tetracycline hcl cap 250 mg........................................12

tetracycline hcl cap 500 mg........................................12THALOMID....................................................................36THALOMID....................................................................36THALOMID....................................................................36THALOMID....................................................................36theophylline tab er 12hr 300 mg..............................109theophylline tab er 12hr 450 mg..............................109theophylline tab er 24hr 400 mg..............................109theophylline tab er 24hr 600 mg..............................109thioridazine hcl tab 100 mg........................................ 43thioridazine hcl tab 10 mg.......................................... 43thioridazine hcl tab 25 mg.......................................... 43thioridazine hcl tab 50 mg.......................................... 43thiotepa for inj 15 mg.................................................. 36thiothixene cap 10 mg.................................................43thiothixene cap 1 mg...................................................43thiothixene cap 2 mg...................................................43thiothixene cap 5 mg...................................................43THYMOGLOBULIN....................................................100tiagabine hcl tab 12 mg.............................................. 16tiagabine hcl tab 16 mg.............................................. 16tiagabine hcl tab 2 mg.................................................16tiagabine hcl tab 4 mg.................................................16TIAZAC.......................................................................... 74TIAZAC.......................................................................... 74TIAZAC.......................................................................... 74TIAZAC.......................................................................... 74TIAZAC.......................................................................... 74TIAZAC.......................................................................... 74TIBSOVO.......................................................................36tigecycline for iv soln 50 mg.......................................12TIMOLOL MALEATE................................................... 74TIMOLOL MALEATE................................................... 74TIMOLOL MALEATE OPHTHALMIC GEL

FORMING................................................................ 104TIMOLOL MALEATE OPHTHALMIC GEL

FORMING................................................................ 104timolol maleate ophth soln 0.25%........................... 104timolol maleate ophth soln 0.5%..............................104timolol maleate ophth soln 0.5% (once-

daily)......................................................................... 104timolol maleate tab 5 mg............................................ 74TIMOPTIC................................................................... 104TIMOPTIC................................................................... 104TIMOPTIC-XE.............................................................104tinidazole tab 250 mg..................................................12tinidazole tab 500 mg..................................................12TIVICAY......................................................................... 48TIVICAY......................................................................... 48TIVICAY......................................................................... 48tizanidine hcl cap 2 mg............................................... 44tizanidine hcl cap 4 mg............................................... 44

2020

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tizanidine hcl cap 6 mg............................................... 44tizanidine hcl tab 2 mg................................................44tizanidine hcl tab 4 mg................................................44TOBRADEX................................................................ 104TOBRADEX................................................................ 104tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................104tobramycin nebu soln 300 mg/5ml.......................... 109tobramycin ophth soln 0.3%.....................................104TOBRAMYCIN SULFATE........................................... 12TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................12tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................12TOBREX......................................................................104tolcapone tab 100 mg................................................. 39TOLMETIN SODIUM..................................................... 3tolterodine tartrate cap er 24hr 2 mg.........................88tolterodine tartrate cap er 24hr 4 mg.........................88tolterodine tartrate tab 1 mg.......................................88tolterodine tartrate tab 2 mg.......................................88topiramate sprinkle cap 15 mg...................................16topiramate sprinkle cap 25 mg...................................16topiramate tab 100 mg................................................16topiramate tab 200 mg................................................16topiramate tab 25 mg.................................................. 16topiramate tab 50 mg.................................................. 16topotecan hcl for inj 4 mg........................................... 36topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 36toremifene citrate tab 60 mg...................................... 36torsemide tab 100 mg................................................. 74torsemide tab 10 mg................................................... 74torsemide tab 20 mg................................................... 74torsemide tab 5 mg......................................................74TOUJEO MAX SOLOSTAR........................................56TOUJEO SOLOSTAR..................................................56TOVIAZ.......................................................................... 88TOVIAZ.......................................................................... 88TRACLEER.................................................................109TRADJENTA................................................................. 56tramadol-acetaminophen tab 37.5-325

mg..................................................................................3tramadol hcl tab 50 mg................................................. 3tramadol hcl tab er 24hr 100 mg..................................3tramadol hcl tab er 24hr 200 mg..................................3tramadol hcl tab er 24hr 300 mg..................................3trandolapril tab 1 mg................................................... 74trandolapril tab 2 mg................................................... 74trandolapril tab 4 mg................................................... 74

tranexamic acid iv soln 1000 mg/10ml (100 mg/ml)................................................................................60

tranexamic acid tab 650 mg.......................................60tranylcypromine sulfate tab 10 mg............................ 21TRAVASOL....................................................................83TRAVATAN Z.............................................................. 104travoprost ophth soln 0.004%.................................. 105trazodone hcl tab 100 mg...........................................21trazodone hcl tab 150 mg...........................................21trazodone hcl tab 300 mg...........................................21trazodone hcl tab 50 mg.............................................21TREANDA..................................................................... 36TREANDA..................................................................... 36TRECATOR...................................................................26TRELEGY ELLIPTA...................................................109TRELSTAR MIXJECT..................................................95TRELSTAR MIXJECT..................................................95TRELSTAR MIXJECT..................................................95TREMFYA................................................................... 100TREMFYA................................................................... 100treprostinil inj soln 100 mg/20ml (5 mg/

ml)............................................................................. 109treprostinil inj soln 200 mg/20ml (10 mg/

ml)............................................................................. 109treprostinil inj soln 20 mg/20ml (1 mg/

ml)............................................................................. 109treprostinil inj soln 50 mg/20ml (2.5 mg/

ml)............................................................................. 109TRESIBA....................................................................... 56TRESIBA FLEXTOUCH.............................................. 56TRESIBA FLEXTOUCH.............................................. 56tretinoin cap 10 mg......................................................36tretinoin cream 0.025%............................................... 80tretinoin cream 0.05%................................................. 80tretinoin cream 0.1%................................................... 80tretinoin gel 0.01%.......................................................80tretinoin gel 0.025%.....................................................80triamcinolone acetonide cream

0.025%........................................................................80triamcinolone acetonide cream 0.1%........................80triamcinolone acetonide cream 0.5%........................80triamcinolone acetonide dental paste

0.1%............................................................................77triamcinolone acetonide lotion 0.025%..................... 80triamcinolone acetonide lotion 0.1%..........................80triamcinolone acetonide oint 0.025%........................ 81triamcinolone acetonide oint 0.1%.............................81triamcinolone acetonide oint 0.5%.............................81triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................74triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................74

2020

152

triamterene & hydrochlorothiazide tab 75-50mg................................................................................74

TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74trientine hcl cap 250 mg............................................. 83trifluoperazine hcl tab 10 mg......................................44trifluoperazine hcl tab 1 mg........................................43trifluoperazine hcl tab 2 mg........................................43trifluoperazine hcl tab 5 mg........................................43TRIFLURIDINE...........................................................105TRIKAFTA................................................................... 109trimethobenzamide hcl cap 300 mg.......................... 23trimethoprim tab 100 mg.............................................12trimipramine maleate cap 100 mg............................. 21trimipramine maleate cap 25 mg............................... 21trimipramine maleate cap 50 mg............................... 21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRISENOX....................................................................36TRIUMEQ......................................................................48TROGARZO..................................................................48TROPHAMINE..............................................................83trospium chloride cap er 24hr 60 mg.........................88trospium chloride tab 20 mg.......................................88TRUEPLUS 5-BEVEL PEN NEEDLES

31GX5MM.................................................................. 57TRUEPLUS 5-BEVEL PEN NEEDLES



32GX4MM.................................................................. 57TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G

X 1/2"..........................................................................56TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G

X 5/16"........................................................................56TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G





X 5/16"........................................................................56TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X

1/2".............................................................................. 56

TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2".............................................................................. 56

TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16"............................................................................56

TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16"............................................................................56

TRUEPLUS PEN NEEDLES 29G X12MM..........................................................................56

TRUEPLUS PEN NEEDLES 31G X5MM............................................................................ 56




TRULICITY....................................................................57TRULICITY....................................................................57TRUMENBA................................................................100TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TRUXIMA...................................................................... 36TRUXIMA...................................................................... 36TURALIO....................................................................... 36TWINRIX..................................................................... 100TYBOST........................................................................ 48TYKERB........................................................................ 36TYMLOS......................................................................102TYPHIM VI..................................................................100TYSABRI....................................................................... 77UUDENYCA.....................................................................60ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G

X 1/2"..........................................................................57ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X

1/2".............................................................................. 57UNITUXIN......................................................................36UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109UPTRAVI..................................................................... 109ursodiol cap 300 mg....................................................86ursodiol tab 250 mg.....................................................86ursodiol tab 500 mg.....................................................86

2020

153

Vvalacyclovir hcl tab 1 gm............................................ 48valacyclovir hcl tab 500 mg........................................48VALCHLOR................................................................... 36valganciclovir hcl for soln 50 mg/ml.......................... 48valganciclovir hcl tab 450 mg.....................................48valproate sodium inj 100 mg/ml.................................16valproate sodium oral soln 250 mg/5ml.................... 16valproic acid cap 250 mg............................................16valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................74valsartan-hydrochlorothiazide tab 160-25

mg................................................................................74valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................74valsartan-hydrochlorothiazide tab 320-25

mg................................................................................75valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................74valsartan tab 160 mg...................................................74valsartan tab 320 mg...................................................74valsartan tab 40 mg.....................................................74valsartan tab 80 mg.....................................................74VANCOMYCIN..............................................................12VANCOMYCIN..............................................................12VANCOMYCIN HCL.................................................... 12VANCOMYCIN HCL.................................................... 12vancomycin hcl cap 125 mg.......................................12vancomycin hcl cap 250 mg.......................................12vancomycin hcl for iv soln 10 gm.............................. 12vancomycin hcl for iv soln 1 gm.................................12vancomycin hcl for iv soln 500 mg............................ 12vancomycin hcl for iv soln 5 gm.................................12vancomycin hcl for iv soln 750 mg............................ 12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE..........................12VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 12VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 13VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 13VANISHPOINT INSULIN SYRINGE/0.5ML/30G X

1/2".............................................................................. 57VAQTA......................................................................... 100VAQTA......................................................................... 100VARIVAX..................................................................... 100

VARIZIG.......................................................................100VASCEPA...................................................................... 75VASCEPA...................................................................... 75VASERETIC.................................................................. 75VASOTEC......................................................................75VASOTEC......................................................................75VASOTEC......................................................................75VASOTEC......................................................................75VECTIBIX...................................................................... 36VECTIBIX...................................................................... 36VELCADE......................................................................36VELPHORO.................................................................. 83VELTASSA.................................................................... 83VELTASSA.................................................................... 83VELTASSA.................................................................... 83VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA STARTING PACK................................ 36venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 75 mg...........................................21VENTAVIS................................................................... 109VENTAVIS................................................................... 109VENTOLIN HFA......................................................... 109verapamil hcl cap er 24hr 120 mg.............................75verapamil hcl cap er 24hr 180 mg.............................75verapamil hcl cap er 24hr 200 mg.............................75verapamil hcl cap er 24hr 240 mg.............................75verapamil hcl cap er 24hr 300 mg.............................75VERAPAMIL HCL ER..................................................75VERAPAMIL HCL SR..................................................75verapamil hcl tab 120 mg........................................... 75verapamil hcl tab 40 mg............................................. 75verapamil hcl tab 80 mg............................................. 75verapamil hcl tab er 120 mg.......................................75verapamil hcl tab er 180 mg.......................................75verapamil hcl tab er 240 mg.......................................75VERSACLOZ................................................................ 44VERZENIO....................................................................36VERZENIO....................................................................36VERZENIO....................................................................36VERZENIO....................................................................36VICTOZA....................................................................... 57VIDEX............................................................................ 48VIDEX............................................................................ 48VIDEX EC..................................................................... 48

2020

154

VIDEX EC..................................................................... 48VIDEX EC..................................................................... 48vigabatrin powd pack 500 mg.................................... 16vigabatrin tab 500 mg................................................. 16VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD STARTER PACK......................................... 21VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VINBLASTINE SULFATE............................................36vincristine sulfate iv soln 1 mg/ml..............................36vinorelbine tartrate inj 10 mg/ml.................................36vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................36VIRACEPT.................................................................... 48VIRACEPT.................................................................... 48VIREAD..........................................................................48VIREAD..........................................................................48VIREAD..........................................................................48VIREAD..........................................................................48VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VIVITROL........................................................................ 4VIZIMPRO..................................................................... 37VIZIMPRO..................................................................... 37VIZIMPRO..................................................................... 37voriconazole for inj 200 mg........................................ 24voriconazole for susp 40 mg/ml.................................24voriconazole tab 200 mg............................................ 24voriconazole tab 50 mg...............................................24VOTRIENT.................................................................... 37VPRIV............................................................................ 87VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VYNDAMAX.................................................................. 75VYNDAQEL...................................................................75VYXEOS........................................................................37Wwarfarin sodium tab 10 mg.........................................60warfarin sodium tab 1 mg...........................................60warfarin sodium tab 2.5 mg........................................60warfarin sodium tab 2 mg...........................................60warfarin sodium tab 3 mg...........................................60warfarin sodium tab 4 mg...........................................60

warfarin sodium tab 5 mg...........................................60warfarin sodium tab 6 mg...........................................60warfarin sodium tab 7.5 mg........................................60water for irrigation, sterile irrigation

soln..............................................................................83XXALKORI....................................................................... 37XALKORI....................................................................... 37XARELTO...................................................................... 60XARELTO...................................................................... 60XARELTO...................................................................... 60XARELTO...................................................................... 60XARELTO STARTER PACK.......................................60XATMEP...................................................................... 100XELJANZ.....................................................................100XELJANZ.....................................................................100XGEVA.........................................................................102XIFAXAN........................................................................86XOFLUZA......................................................................48XOFLUZA......................................................................48XOLAIR........................................................................100XOLAIR........................................................................100XOLAIR........................................................................100XOPENEX HFA..........................................................109XOSPATA...................................................................... 37XPOVIO 100 MG ONCE WEEKLY............................37XPOVIO 60 MG ONCE WEEKLY..............................37XPOVIO 80 MG ONCE WEEKLY..............................37XPOVIO 80 MG TWICE WEEKLY.............................37XTANDI.......................................................................... 37XYREM........................................................................110YYERVOY........................................................................37YERVOY........................................................................37YF-VAX........................................................................ 100YONDELIS.................................................................... 37YONSA.......................................................................... 37Zzafirlukast tab 10 mg.................................................109zafirlukast tab 20 mg.................................................109zaleplon cap 10 mg...................................................110zaleplon cap 5 mg..................................................... 110ZALTRAP.......................................................................37ZALTRAP.......................................................................37ZANOSAR..................................................................... 37ZARXIO..........................................................................60ZARXIO..........................................................................60ZEJULA..........................................................................37ZELBORAF................................................................... 37ZENPEP........................................................................ 87

2020

155

ZENPEP........................................................................ 87ZENPEP........................................................................ 87ZENPEP........................................................................ 87ZENPEP........................................................................ 87ZENPEP........................................................................ 87ZENPEP........................................................................ 87ZESTORETIC............................................................... 75ZESTORETIC............................................................... 75ZESTORETIC............................................................... 75ZESTRIL........................................................................75ZESTRIL........................................................................75ZESTRIL........................................................................75ZESTRIL........................................................................75ZESTRIL........................................................................75ZESTRIL........................................................................75zidovudine cap 100 mg...............................................48zidovudine syrup 10 mg/ml.........................................48zidovudine tab 300 mg................................................48ziprasidone hcl cap 20 mg..........................................44ziprasidone hcl cap 40 mg..........................................44ziprasidone hcl cap 60 mg..........................................44ziprasidone hcl cap 80 mg..........................................44zoledronic acid inj conc for iv infusion 4

mg/5ml......................................................................102zoledronic acid iv soln 5 mg/100ml......................... 102ZOLINZA........................................................................37ZOLOFT.........................................................................21ZOLOFT.........................................................................21ZOLOFT.........................................................................21zolpidem tartrate tab 10 mg..................................... 110zolpidem tartrate tab 5 mg....................................... 110zonisamide cap 100 mg..............................................17zonisamide cap 25 mg................................................16zonisamide cap 50 mg................................................16ZONTIVITY....................................................................60ZORTRESS.................................................................100ZORTRESS.................................................................100ZORTRESS.................................................................100ZORTRESS.................................................................100ZOSTAVAX..................................................................100ZOSYN...........................................................................13ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 37ZYDELIG....................................................................... 37ZYKADIA....................................................................... 37ZYLOPRIM....................................................................24ZYLOPRIM....................................................................24ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 44ZYTIGA..........................................................................37

Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Illinois:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact Civil Rights Coordinator

If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.Call <1-877-774-8592> (TTY: <711>).

Call <1-877-774-8592> (TTY: <711>).

Llame al <1-877-774-8592> (TTY: <711>).

pod numer <1-877-774-8592> (TTY: <711>).

<1-877-774-8592> (TTY: <711>)

walang bayad. Tumawag sa <1-877-774-8592> (TTY: <711>).

<1-877-774-8592>

8592> (телетайп: <711>).

(TTY: <711>).

<1-877-774-8592>

<1-877-774-8592>

<1-877-774-8592> (TTY: <711>).

Chiamare il numero <1-877-774-8592> (TTY: <711>).

<1-877-774-8592> (TTY: <711>)

Appelez le <1-877-774-8592> (ATS : <711>).

<1-877-774-8592> (TTY: <711>).

. Rufnummer: <1-877-774-8592> (TTY: <711>).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń

注意：如果您使用繁體中文 ,您可以免費獲得語言援助服務。請致電 <1-877-774-8592> (TTY: <711>)。

주의: 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 .

번으로 전화해 주십시오 .

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang

بالمجان :مل حوظ تتوافر لك فإن خدمات المساعدة اللغوية تتحدث اللغة العربية، رقم . إذا كنت اتصل

والبكم ) الصم هاتف (.<711>: رقم

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <1-877-774-

کريںل کا۔ ں ہیب دستياں میت مفت خدمای کد مدی کن زب او کپ آو ت، ہي ںے ب ولتو ارد پ آ ر اگ :خبردار. (TTY: <711>)

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

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti.

ध्यान दें: यदद आप दहदी बोलत हैं तो आपक ललए मफ्त म भाषा सहायता सेवाएिं उपलब्ध हैं। पर कॉल कर।

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711)

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711).

1-877-774-8592

1-877-774-8592 711).

(TTY: 711)

1-877-774-8592

1-877-774-8592

.(711

.(TTY: 711)

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711)

1-877-774-8592 (ATS: 711).

1-877-774-8592 (TTY: 711).

1-877-774-8592 (TTY: 711).

[GUJARATI PLACEHOLDER]<8592-774-877-1>کريںلکا۔ںہیبدستياںمیتمفتخدمایکدمدیکنزباوکپآوت،ہيںےبولتواردپآراگ:خبردار

. (TTY: <711>)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số <1-877-774-8592> (TTY: <711>).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti.Chiamare il numero <1-877-774-8592> (TTY: <711>).

ध्यान दें: यदद आप दहिंदी बोलत ेहैं तो आपके ललए मफु्त में भाषा सहायता सेवाएिं उपलब्ध हैं।<1-877-774-8592> (TTY: <711>) पर कॉल करें।ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.Appelez le <1-877-774-8592> (ATS : <711>).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίεςπαρέχονται δωρεάν. Καλέστε <1-877-774-8592> (TTY: <711>).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: <1-877-774-8592> (TTY: <711>).


ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al <1-877-774-8592> (TTY: <711>).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.Zadzwoń pod numer <1-877-774-8592> (TTY: <711>).

注意：如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 <1-877-774-8592> (TTY: <711>)。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

<1-877-774-8592> (TTY: <711>) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa <1-877-774-8592> (TTY: <711>).

<8592-774-877-1>اتصل رقم. إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان: ملحوظهاتف الصم والبكم) .(<711>: رقم

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <1-877-774-8592> (телетайп: <711>).

[GUJARATI PLACEHOLDER]


ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al <1-877-774-8592> (TTY: <711>).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.Zadzwoń pod numer <1-877-774-8592> (TTY: <711>).

注意：如果您使用繁體中文, 您可以免費獲得語言援助服務。請致電 <1-877-774-8592> (TTY: <711>)。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. <1-877-774-8592>(TTY: <711>) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nangwalang bayad. Tumawag sa <1-877-774-8592> (TTY: <711>).

مقرب لصتا .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم.(<711> :مكبلاو مصلا فتاه مقر) <1-877-774-8592>

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.Звоните <1-877-774-8592> (телетайп: <711>).

ںیرک لاک ۔ ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںیہ ےتلوب ودرا پآ رگا :رادربخ<1-877-774-8592> (TTY: <711>).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số <1-877-774-8592> (TTY: <711>).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti.Chiamare il numero <1-877-774-8592> (TTY: <711>).

ध्यान दंे: यदि आप हिंदी बोलते हंै तो आपके लिए मुफ्त मंे भाषा सहायता सेवाएं उपलब्ध हंै। <1-877-774-8592>(TTY: <711>) पर कॉल करंे।

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.Appelez le <1-877-774-8592> (ATS : <711>).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίεςπαρέχονται δωρεάν. Καλέστε <1-877-774-8592> (TTY: <711>).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: <1-877-774-8592> (TTY: <711>).

िं े े ु ेंें

This formulary was updated on 03/16/2020. For more recent information or other questions, please contact Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/mapd/druglist.

HMO and HMO-POS plans provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract. Enrollment in HCSC’s plans depends on contract renewal.

http://www.getblueil.com/mapd/druglist

Documents

(List of Covered Drugs) - Blue Cross Blue Shield …...Blue Cross Medicare Advantage 2020 Formulary (List of Covered Drugs) Note to existing members: This formulary has changed since