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LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital/aspirin/caffeine 50-325-40 capsule 1 PTD PART DPRODUCTS
celecoxib (50 mg capsule, 100 mg capsule, 200 mgcapsule) 1
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
celecoxib 400 mg capsule 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75mg tablet dr, 100 mg tab er 24h) 1
C State PDL Class
PTD PART DPRODUCTS
diflunisal 1C State PDL Class
PTD PART DPRODUCTS
etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet,600 mg tab er 24h)
1C State PDL Class
PTD PART DPRODUCTS
fenoprofen calcium (400 mg capsule, 600 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
fenoprofen calcium 200 mg capsule 1 C State PDL Class
FENORTHO 1
flurbiprofen 1C State PDL Class
PTD PART DPRODUCTS
IBU 1C State PDL Class
PTD PART DPRODUCTS
PAGE 1 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mgtablet, 800 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
INDOCIN (25 MG/5 ML SUSPENSION, 50 MGSUPPOSITORY) 1
C State PDL Class
PTD PART DPRODUCTS
indomethacin (25 mg capsule, 50 mg capsule, 75 mgcapsule er) 1
C State PDL Class
PTD PART DPRODUCTS
indomethacin, submicronized 1 C State PDL Class
ketoprofen (50 mg capsule, 75 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
ketorolac tromethamine 10 mg tablet 1
QL 20 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
mefenamic acid 1 PTD PART DPRODUCTS
meloxicam 1C State PDL Class
PTD PART DPRODUCTS
nabumetone 1C State PDL Class
PTD PART DPRODUCTS
NALFON 400 MG CAPSULE 1 PTD PART DPRODUCTS
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mgtablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) 1
C State PDL Class
PTD PART DPRODUCTS
naproxen sodium (275 mg tablet, 550 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 2 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxaprozin 600 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
piroxicam 1C State PDL Class
PTD PART DPRODUCTS
salsalate 1C State PDL Class
PTD PART DPRODUCTS
sulindac 1C State PDL Class
PTD PART DPRODUCTS
TIVORBEX 1 PTD PART DPRODUCTS
OPIOID ANALGESICS, LONG-ACTING
BUTRANS 1
C State RebateClass
DC LONG ACTINGOPIOIDS
PA
PTD PART DPRODUCTS
fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72,50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hrpatch td72)
1
C State RebateClass
DC LONG ACTINGOPIOIDS
PA
PTD PART DPRODUCTS
morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mgtablet er, 100 mg tablet er, 200 mg tablet er) 1
C State RebateClass
DC LONG ACTINGOPIOIDS
PA
PTD PART DPRODUCTS
PAGE 3 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tramadol hcl (100 mg tab er 24h, 200 mg tab er 24h, 300mg tab er 24h) 1
C State RebateClass
DC LONG ACTINGOPIOIDS
PA
PTD PART DPRODUCTS
XTAMPZA ER 1
C State RebateClass
DC LONG ACTINGOPIOIDS
PA
PTD PART DPRODUCTS
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen with codeine phosphate (120-12mg/5solution, 300mg-15mg tablet, 300mg-30mg tablet,300mg-60mg tablet, 300mg/12.5 solution)
1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
ASCOMP WITH CODEINE 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
butalbital/acetaminophen/caffeine/codeine phosphate 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
codeine phosphate/butalbital/aspirin/caffeine 1C State PDL Class
PTD PART DPRODUCTS
ENDOCET 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
PAGE 4 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 2.5-108/5 solution,hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet,hydrocodone/acetaminophen 7.5-325 mg tablet,hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution,hydrocodone/acetaminophen 10mg-300mg tablet,hydrocodone/acetaminophen 10mg-325mg tablet)
1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
hydrocodone/ibuprofen 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mgsupp.rect, 4 mg tablet, 8 mg tablet) 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
ibuprofen/oxycodone hcl 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
meperidine hcl 50 mg tablet 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
PAGE 5 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10mg/5 ml solution, 15 mg tablet, 20 mg supp.rect, 20 mg/5ml solution, 30 mg supp.rect, 30 mg tablet, 100 mg/5mlsolution)
1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
morphine sulfate (4 mg/ml vial, 8 mg/ml vial, 10 mg/mlvial, 25 mg/ml vial, 50 mg/ml vial) 1
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
morphine sulfate/pf 30 mg/30ml pca vial 1DC SHORT ACTING
OPIOIDS
PTD PART DPRODUCTS
oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tablet, 15 mg tablet, 20 mg tablet, 20mg/ml oral conc, 30 mg tablet)
1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet, hcl/acetaminophen 5 mg-325mg tablet,hcl/acetaminophen 7.5-325 mg tablet,hcl/acetaminophen 10mg-325mg tablet)
1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
pentazocine hcl/naloxone hcl 1DC SHORT ACTING
OPIOIDS
PTD PART DPRODUCTS
PRIMLEV 1DC SHORT ACTING
OPIOIDS
PTD PART DPRODUCTS
tramadol hcl 50 mg tablet 1
C State PDL Class
DC SHORT ACTINGOPIOIDS
PTD PART DPRODUCTS
PAGE 6 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANESTHETICS
LOCAL ANESTHETICS
AGONEAZE 1
ANASTIA 1 PA
ANODYNE LPT 1 PTD PART DPRODUCTS
DERMACINRX EMPRICAINE 1 PTD PART DPRODUCTS
DERMACINRX PRIZOPAK 1 PTD PART DPRODUCTS
LEVA SET 1 PTD PART DPRODUCTS
LIDO-K 1C State PDL Class
PA
LIDO-PRILO CAINE PACK 1 PTD PART DPRODUCTS
LIDO-SORB 1C State PDL Class
PA
lidocaine (5 % adh. patch, 5 % oint. (g)) 1
C State PDL Class
PA
PTD PART DPRODUCTS
lidocaine hcl (2 % jel/pf app, 2 % jelly(ml)) 1
QL 60 / 30 days
C State PDL Class
PTD PART DPRODUCTS
lidocaine hcl 3 % lotion 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 7 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lidocaine hcl 2 % solution 1
QL 100 / 30 days
C State PDL Class
PTD PART DPRODUCTS
lidocaine hcl 4 % solution 1C State PDL Class
PTD PART DPRODUCTS
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g),lidocaine/prilocaine 2.5 kit) 1
QL 30 / 30 days
C State PDL Class
PTD PART DPRODUCTS
LIDOPRIL 1 PTD PART DPRODUCTS
LIDOPRIL XR 1 PTD PART DPRODUCTS
LIDOZION 1C State PDL Class
PA
LIPROZONEPAK 1 PTD PART DPRODUCTS
LIVIXIL PAK 1 PTD PART DPRODUCTS
MEDOLOR PAK 1 PTD PART DPRODUCTS
NUMBONEX 1 PA
PRILOLID 1 PTD PART DPRODUCTS
RELADOR PAK 1 PTD PART DPRODUCTS
RELADOR PAK PLUS 1 PTD PART DPRODUCTS
ZIONODIL 1C State PDL Class
PA
PAGE 8 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZIONODIL-100 1C State PDL Class
PA
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 1
QL 180 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
disulfiram 1C State PDL Class
PTD PART DPRODUCTS
naltrexone hcl 1C State Rebate
Class
PTD PART DPRODUCTS
VIVITROL 1C State Rebate
Class
PTD PART DPRODUCTS
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1
C State RebateClass
PA
PTD PART DPRODUCTS
buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mgtab subl, /naloxone 8 mg-2 mg tab subl) 1
C State RebateClass
PTD PART DPRODUCTS
SUBOXONE 1C State Rebate
Class
PTD PART DPRODUCTS
PAGE 9 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OPIOID REVERSAL AGENTS
naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1mg/ml syringe) 1
C State RebateClass
PTD PART DPRODUCTS
NARCAN 1C State Rebate
Class
PTD PART DPRODUCTS
SMOKING CESSATION AGENTS
bupropion hcl 150 mg tab er 12h 1
AL At least 18 yrsold
C State PDL Class
DC NicotineReplacement
QPD 2 per day
PTD PART DPRODUCTS
bupropion hcl 150 mg tab sr 12h 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1MG TABLET, STARTING MONTH BOX) 1
QL 360 / 180 DAYS
AL At least 18 yrsold
C State PDL Class
DC NicotineReplacement
PTD PART DPRODUCTS
famotidine 20 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
PAGE 10 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NICOTROL 1
AL At least 18 yrsold
C State PDL Class
DC NicotineReplacement
PTD PART DPRODUCTS
NICOTROL NS 1
AL At least 18 yrsold
C State PDL Class
DC NicotineReplacement
PTD PART DPRODUCTS
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate 1000mg/4ml vial 1 PTD PART DPRODUCTS
GENTAK 1C State PDL Class
PTD PART DPRODUCTS
gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 %drops) 1
C State PDL Class
PTD PART DPRODUCTS
gentamicin sulfate 40 mg/ml vial 1 PTD PART DPRODUCTS
neomycin sulfate 1C State PDL Class
PTD PART DPRODUCTS
tobramycin 0.3 % drops 1C State PDL Class
PTD PART DPRODUCTS
PAGE 11 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tobramycin sulfate (1.2 g vial, 40 mg/ml vial) 1 PTD PART DPRODUCTS
TOBREX 0.3% EYE OINTMENT 1
QL 3.5 / 7 DAYS
C State PDL Class
PTD PART DPRODUCTS
ANTIBACTERIALS, OTHER
bacitracin 500 unit/g oint. (g) 1
QL 3.5 / 7 days
C State PDL Class
PTD PART DPRODUCTS
CENTANY 1 PTD PART DPRODUCTS
CLEOCIN 100 MG VAGINAL OVULE 1C State PDL Class
PTD PART DPRODUCTS
CLEOCIN PHOS 150 MG/ML VIAL 1 PTD PART DPRODUCTS
CLINDACIN ETZ 1% PLEDGET 1 PTD PART DPRODUCTS
CLINDACIN P 1 PTD PART DPRODUCTS
clindamycin hcl 1 PTD PART DPRODUCTS
clindamycin palmitate hcl 1 PTD PART DPRODUCTS
clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 %med. swab, 1 % solution, 2 % cream/appl) 1
C State PDL Class
PTD PART DPRODUCTS
colistin (as colistimethate sodium) 1 PTD PART DPRODUCTS
PAGE 12 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lincomycin hcl 1 PTD PART DPRODUCTS
linezolid (100 mg/5ml susp recon, 600 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
metronidazole 0.75 % gel w/appl 1C State PDL Class
PTD PART DPRODUCTS
metronidazole (250 mg tablet, 500 mg tablet) 1 PTD PART DPRODUCTS
mupirocin 1C State PDL Class
PTD PART DPRODUCTS
mupirocin calcium 1C State PDL Class
PTD PART DPRODUCTS
nitrofurantoin 1 PTD PART DPRODUCTS
nitrofurantoin macrocrystal 1 PTD PART DPRODUCTS
nitrofurantoin monohydrate/macrocrystals 1 PTD PART DPRODUCTS
NUVESSA 1 PTD PART DPRODUCTS
ORBACTIV 1 PTD PART DPRODUCTS
trimethoprim 1 PTD PART DPRODUCTS
VANCOCIN HCL 1C Supplemental
PTD PART DPRODUCTS
PAGE 13 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vancomycin hcl (125 mg capsule, 250 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial,100 g bulkbaginj, 500 mg vial, 500 mg vial port, 750 mgvial, 750 mg vial port)
1C Supplemental
PTD PART DPRODUCTS
vancomycin hcl in water for injection (peg-400, nada)(vancomycin/water inj 1g/200ml piggyback,vancomycin/water inj 500mg/0.1l piggyback)
1 C Supplemental
vancomycin in 0.9 % sodium chloride (vancomycin/0.9 %1.25 g/250 plast. bag, vancomycin/0.9 % 1.5g/250mlplast. bag, vancomycin/0.9 % 1.5g/500ml plast. bag,vancomycin/0.9 % 1.75 g/500 plast. bag, vancomycin/0.9% 1.75g/250 plast. bag, vancomycin/0.9 % 1g/200mlfroz.piggy, vancomycin/0.9 % 1g/250ml plast. bag,vancomycin/0.9 % 2 g/500 ml plast. bag, vancomycin/0.9% 500mg/0.1l froz.piggy, vancomycin/0.9 % 750 mg/250plast. bag, vancomycin/0.9 % 750mg/.15l froz.piggy,vancomycin/0.9 % 750mg/.15l plast. bag)
1C Supplemental
PTD PART DPRODUCTS
vancomycin in 5 % dextrose in water (in 5 % 1 g/100 mlplast. bag, in 5 % 1.25 g/250 plast. bag, in 5 % 1.5g/250mlplast. bag, in 5 % 1.5g/500ml plast. bag, in 5 % 1g/200mlfroz.piggy, in 5 % 1g/250ml plast. bag, in 5 % 500mg/0.1lfroz.piggy, in 5 % 750mg/.15l froz.piggy)
1C Supplemental
PTD PART DPRODUCTS
VANDAZOLE 1C State PDL Class
PTD PART DPRODUCTS
ZYVOX 600 MG TABLET 1 PTD PART DPRODUCTS
BETA-LACTAM, CEPHALOSPORINS
cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250mg/5ml susp recon, 375 mg/5ml susp recon, 500 mgcapsule, 500 mg tab er 12h)
1C State PDL Class
PTD PART DPRODUCTS
PAGE 14 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mgcapsule, 500 mg/5ml susp recon) 1
C State PDL Class
PTD PART DPRODUCTS
cefazolin sodium in 0.9 % nacl 3 g/100 ml piggyback 1 PTD PART DPRODUCTS
cefazolin sodium/dextrose 5 % in water 1 PTD PART DPRODUCTS
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon,300 mg capsule) 1
C State PDL Class
PTD PART DPRODUCTS
cefixime 400 mg capsule 1
QL 1 / 30 days
C State PDL Class
PTD PART DPRODUCTS
cefixime (100 mg/5ml susp recon, 200 mg/5ml susprecon) 1
C State PDL Class
PTD PART DPRODUCTS
cefotaxime sodium 1 g vial 1 PTD PART DPRODUCTS
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mgtablet, 100 mg/5ml susp recon, 200 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250mg/5ml susp recon, 500 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
ceftriaxone sodium (250 mg vial, 500 mg vial) 1 PTD PART DPRODUCTS
cefuroxime axetil 1C State PDL Class
PTD PART DPRODUCTS
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500mg tablet, 750 mg capsule)
1C State PDL Class
PTD PART DPRODUCTS
PAGE 15 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLETCHEWABLE, 500 MG/5 ML SUSPENSION) 1
C State PDL Class
PTD PART DPRODUCTS
BETA-LACTAM, OTHER
VABOMERE 1 PTD PART DPRODUCTS
BETA-LACTAM, PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon,200 mg/5ml susp recon, 250 mg capsule, 250 mg tabchew, 250 mg/5ml susp recon, 400 mg/5ml susp recon,500 mg capsule, 500 mg tablet, 875 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
amoxicillin/potassium clavulanate (amoxicillin/potassium200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mgtab chew, amoxicillin/potassium 250-125 mg tablet,amoxicillin/potassium 250-62.5/5 susp recon,amoxicillin/potassium 400-57mg tab chew,amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet,amoxicillin/potassium 600-42.9/5 susp recon,amoxicillin/potassium 875-125 mg tablet,amoxicillin/potassium 1000-62.5 tab er 12h)
1C State PDL Class
PTD PART DPRODUCTS
ampicillin sodium 10 g vial 1 PTD PART DPRODUCTS
ampicillin trihydrate 1C State PDL Class
PTD PART DPRODUCTS
AUGMENTIN 125-31.25 MG/5 ML 1C State PDL Class
PTD PART DPRODUCTS
BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS) 1 PTD PART DPRODUCTS
dicloxacillin sodium 1C State PDL Class
PTD PART DPRODUCTS
PAGE 16 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
penicillin v potassium (125 mg/5ml soln recon, 250 mgtablet, 250 mg/5ml soln recon, 500 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
piperacillin sodium/tazobactam sodium(sodium/tazobactam 2.25 g vial, sodium/tazobactam3.375 g vial, sodium/tazobactam 4.5 g vial)
1 PTD PART DPRODUCTS
MACROLIDES
azithromycin (1 g packet, 100 mg/5ml susp recon, 200mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mgtablet)
1C State PDL Class
PTD PART DPRODUCTS
azithromycin 500 mg vial 1 PTD PART DPRODUCTS
clarithromycin (125 mg/5ml susp recon, 250 mg tablet,250 mg/5ml susp recon, 500 mg tab er 24h, 500 mgtablet)
1C State PDL Class
PTD PART DPRODUCTS
ERYTHROCIN LACT 500 MG VIAL 1 PTD PART DPRODUCTS
erythromycin base 5 mg/gram oint. (g) 1C State PDL Class
PTD PART DPRODUCTS
erythromycin base in ethanol 2 % solution 1C State PDL Class
PTD PART DPRODUCTS
ZITHROMAX 1 GM POWDER PACKET 1 PTD PART DPRODUCTS
QUINOLONES
CETRAXAL 1 PTD PART DPRODUCTS
CILOXAN 0.3% OINTMENT 1C State PDL Class
PTD PART DPRODUCTS
PAGE 17 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ciprofloxacin hcl (0.2 % droperette, 0.3 % drops, 100 mgtablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
levofloxacin (250 mg tablet, 250mg/10ml solution, 500mg tablet, 750 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
levofloxacin 25 mg/ml vial 1 PTD PART DPRODUCTS
MOXEZA 1 PTD PART DPRODUCTS
moxifloxacin hcl 0.5 % drops 1C State PDL Class
PTD PART DPRODUCTS
moxifloxacin hcl 0.5 % drops visc 1 C State PDL Class
ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
SULFONAMIDES
AVC 1C State Rebate
Class
PTD PART DPRODUCTS
silver sulfadiazine 1C State PDL Class
PTD PART DPRODUCTS
SSD 1C State PDL Class
PTD PART DPRODUCTS
sulfacetamide sodium (10 % drops, 10 % oint. (g)) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 18 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sulfadiazine 1C State PDL Class
PTD PART DPRODUCTS
sulfamethoxazole/trimethoprim(sulfamethoxazole/trimethoprim 200-40mg/5 oral susp,sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)
1C State PDL Class
PTD PART DPRODUCTS
SULFATRIM 1C State PDL Class
PTD PART DPRODUCTS
TETRACYCLINES
demeclocycline hcl 1
C State PDL Class
PA
PTD PART DPRODUCTS
doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mgcapsule, 100 mg tablet, 100 mg tablet dr) 1
C State PDL Class
PTD PART DPRODUCTS
doxycycline hyclate 200 mg tablet dr 1 PTD PART DPRODUCTS
doxycycline monohydrate (50 mg capsule, 100 mgcapsule) 1
C State PDL Class
PTD PART DPRODUCTS
doxycycline monohydrate 100 mg tablet 1 PTD PART DPRODUCTS
MINOCIN 100 MG VIAL 1 PTD PART DPRODUCTS
minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule) 1
C State PDL Class
PTD PART DPRODUCTS
MONDOXYNE NL 100 MG CAPSULE 1C State PDL Class
PTD PART DPRODUCTS
PAGE 19 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1C State PDL Class
PTD PART DPRODUCTS
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (100 mg/ml solution, 250 mg tablet, 500mg tab er 24h, 500 mg tablet, 500 mg/5ml solution, 750mg tab er 24h, 750 mg tablet, 1000 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
levetiracetam 500 mg/5ml vial 1 PTD PART DPRODUCTS
ROWEEPRA 1C State PDL Class
PTD PART DPRODUCTS
ROWEEPRA XR 1C State PDL Class
PTD PART DPRODUCTS
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide (250 mg capsule, 250 mg/5ml solution) 1C State PDL Class
PTD PART DPRODUCTS
zonisamide 1C State PDL Class
PTD PART DPRODUCTS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
clobazam (2.5 mg/ml oral susp, 10 mg tablet, 20 mgtablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1
QL 2 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
PAGE 20 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
divalproex sodium (125 mg cap dr spr, 125 mg tablet dr,250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h,500 mg tablet dr)
1C State PDL Class
PTD PART DPRODUCTS
gabapentin (100 mg capsule, 250 mg/5ml solution, 300mg capsule, 300 mg/6ml solution, 400 mg capsule, 600mg tablet, 800 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mgtablet, 97.2mg tablet, 100 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
primidone 1C State PDL Class
PTD PART DPRODUCTS
tiagabine hcl 1
C State PDL Class
PA
PTD PART DPRODUCTS
valproic acid 1C State PDL Class
PTD PART DPRODUCTS
valproic acid (as sodium salt) (valproate sodium) (250mg/5ml solution, 500mg/10ml solution) 1
C State PDL Class
PTD PART DPRODUCTS
valproic acid (as sodium salt) 500 mg/5ml vial 1 PTD PART DPRODUCTS
GLUTAMATE REDUCING AGENTS
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5mloral susp) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 21 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LAMICTAL XR (BLUE) 1 PTD PART DPRODUCTS
LAMICTAL XR (GREEN) 1 PTD PART DPRODUCTS
LAMICTAL XR (ORANGE) 1 PTD PART DPRODUCTS
lamotrigine (25(21)-50 tb rd dspk, 25(42)-100 tab ds pk,25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tabds pk, 50(42)-100 tb rd dspk)
1 PTD PART DPRODUCTS
lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tabrapdis, 25 mg tablet, 25 mg tb chw dsp, 50 mg tab er 24,50 mg tab rapdis, 100 mg tab er 24, 100 mg tab rapdis,100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mgtab rapdis, 200 mg tablet, 250 mg tab er 24, 300 mg taber 24)
1C State PDL Class
PTD PART DPRODUCTS
SUBVENITE 1C State PDL Class
PTD PART DPRODUCTS
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mgtablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
TROKENDI XR 1 PTD PART DPRODUCTS
SODIUM CHANNEL AGENTS
BANZEL 40 MG/ML SUSPENSION 1PA
PTD PART DPRODUCTS
BANZEL (200 MG TABLET, 400 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
carbamazepine 200mg/10ml oral susp 1 C State PDL Class
PAGE 22 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew,100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp12hr, 400 mg tab er 12h)
1C State PDL Class
PTD PART DPRODUCTS
DILANTIN 30 MG CAPSULE 1 PTD PART DPRODUCTS
EPITOL 1C State PDL Class
PTD PART DPRODUCTS
oxcarbazepine (150 mg tablet, 300 mg tablet, 300mg/5ml oral susp, 600 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
OXTELLAR XR 1 PTD PART DPRODUCTS
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125mg/5ml oral susp) 1
C State PDL Class
PTD PART DPRODUCTS
phenytoin sodium extended 1C State PDL Class
PTD PART DPRODUCTS
rufinamide 40 mg/ml oral susp 1
C State PDL Class
PA
PTD PART DPRODUCTS
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MGTABLET, 150 MG TABLET, 200 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
VIMPAT 200 MG/20 ML VIAL 1PA
PTD PART DPRODUCTS
PAGE 23 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1 PTD PART DPRODUCTS
CHOLINESTERASE INHIBITORS
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tabrapdis, 10 mg tablet, 23 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mgcap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel,24 mg cap24h pel)
1
C State PDL Class
PA
PTD PART DPRODUCTS
rivastigmine 1
C State PDL Class
PA
PTD PART DPRODUCTS
rivastigmine tartrate 1
C State PDL Class
PA
PTD PART DPRODUCTS
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (5 mg-10 mg tab ds pk, 7 mg cap spr 24,14 mg cap spr 24, 21 mg cap spr 24, 28 mg cap spr 24) 1
PA
PTD PART DPRODUCTS
memantine hcl (2 mg/ml solution, 5 mg tablet, 10 mgtablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
NAMENDA XR TITRATION PACK 1PA
PTD PART DPRODUCTS
PAGE 24 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
bupropion hcl (75 mg tablet, 100 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
bupropion hcl (100 mg tab sr 12h, 200 mg tab sr 12h) 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
mirtazapine (7.5 mg tablet, 15 mg tab rapdis, 15 mgtablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis,45 mg tablet)
1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
WELLBUTRIN XL 1 QPD 5.0 per day
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR
citalopram hydrobromide (10 mg/5 ml solution, 20mg/10ml solution) 1
AL 6.0 to 12.0 yrsold
C State PDL Class
QPD 20.0 per day
PTD PART DPRODUCTS
PAGE 25 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
citalopram hydrobromide (20 mg tablet, 40 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
citalopram hydrobromide 10 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
escitalopram oxalate (10 mg tablet, 20 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
escitalopram oxalate 5 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
fluoxetine hcl (10 mg capsule, 40 mg capsule) 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
fluoxetine hcl 20 mg capsule 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
PAGE 26 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluoxetine hcl 20 mg/5 ml solution 1
AL 6.0 to 12.0 yrsold
C State PDL Class
QPD 20.0 per day
PTD PART DPRODUCTS
fluvoxamine maleate 100 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 3.0 per day
PTD PART DPRODUCTS
fluvoxamine maleate 25 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
fluvoxamine maleate 50 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 6.0 per day
PTD PART DPRODUCTS
maprotiline hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
PAGE 27 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
paroxetine hcl 40 mg tablet 1
QL 45 / 30 days
AL At least 6 yrsold
C State PDL Class
QPD 1.5 per day
PTD PART DPRODUCTS
sertraline hcl 20 mg/ml oral conc 1
AL 6.0 to 12.0 yrsold
C State PDL Class
QPD 10.0 per day
PTD PART DPRODUCTS
sertraline hcl (25 mg tablet, 100 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 3.0 per day
PTD PART DPRODUCTS
sertraline hcl 50 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
trazodone hcl 100 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
trazodone hcl 150 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
PAGE 28 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
trazodone hcl 300 mg tablet 1
QL 30 / 30 DAYS
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
trazodone hcl 50 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 3.0 per day
PTD PART DPRODUCTS
venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tablet, 50mg tablet, 75 mg cap er 24h, 100 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 3.0 per day
PTD PART DPRODUCTS
venlafaxine hcl 150 mg cap er 24h 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
venlafaxine hcl 25 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
venlafaxine hcl 75 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 5.0 per day
PTD PART DPRODUCTS
PAGE 29 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRICYCLICS
amitriptyline hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
amoxapine 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
clomipramine hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
desipramine hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
doxepin hcl (10 mg capsule, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule) 1
QL 90 / 30 DAYS
AL At least 6 yrsold
C State PDL Class
QPD 3.0 per day
PTD PART DPRODUCTS
doxepin hcl 150 mg capsule 1
QL 90 / 30 DAYS
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
PAGE 30 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxepin hcl 10 mg/ml oral conc 1
QL 180 / 30 DAYS
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
imipramine hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
imipramine pamoate 1
AL At least 6 yrsold
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25mg capsule, 50 mg capsule, 75 mg capsule) 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
protriptyline hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
trimipramine maleate 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
PAGE 31 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIEMETICS
ANTIEMETICS, OTHER
COMPRO 1C State PDL Class
PTD PART DPRODUCTS
meclizine hcl 1 PTD PART DPRODUCTS
metoclopramide hcl (5 mg tab rapdis, 5 mg tablet, 5 mg/5ml solution, 10 mg tab rapdis, 10 mg tablet, 10 mg/10mlsolution)
1C State PDL Class
PTD PART DPRODUCTS
metoclopramide hcl (5 mg/ml vial, 10 mg/2 ml syringe) 1 PTD PART DPRODUCTS
perphenazine 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
PHENADOZ 1C State PDL Class
PTD PART DPRODUCTS
prochlorperazine 1C State PDL Class
PTD PART DPRODUCTS
prochlorperazine maleate 1C State PDL Class
PTD PART DPRODUCTS
promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50mg supp.rect) 1
C State PDL Class
PTD PART DPRODUCTS
PROMETHEGAN 1C State PDL Class
PTD PART DPRODUCTS
PAGE 32 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TIGAN 100 MG/ML VIAL 1 PTD PART DPRODUCTS
trimethobenzamide hcl 1 PTD PART DPRODUCTS
EMETOGENIC THERAPY ADJUNCTS
aprepitant 125mg-80mg cap ds pk 1
QL 6 / 21 DAYS
C State PDL Class
PTD PART DPRODUCTS
aprepitant (40 mg capsule, 80 mg capsule, 125 mgcapsule) 1
QL 6 / 21 days
C State PDL Class
PA
PTD PART DPRODUCTS
dronabinol 1 PTD PART DPRODUCTS
granisetron hcl (1 mg tablet, 1 mg/ml vial, 1 mg/ml(1)vial) 1
C State PDL Class
PA
PTD PART DPRODUCTS
granisetron hcl/pf 1PA
PTD PART DPRODUCTS
ondansetron 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
ondansetron hcl (2 mg/ml vial, 4 mg/5 ml solution) 1 PTD PART DPRODUCTS
ondansetron hcl (4 mg tablet, 8 mg tablet) 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
PAGE 33 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ondansetron hcl 24 mg tablet 1
C State PDL Class
PA
PTD PART DPRODUCTS
ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4mg/2 ml syringe, hcl/pf 4 mg/2 ml vial) 1 PTD PART D
PRODUCTS
ANTIFUNGALS
CICLODAN (0.77% CREAM, 8% SOLUTION) 1C State PDL Class
PTD PART DPRODUCTS
ciclopirox 8 % solution 1C State PDL Class
PTD PART DPRODUCTS
ciclopirox olamine 0.77 % cream (g) 1C State PDL Class
PTD PART DPRODUCTS
clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) 1C State PDL Class
PTD PART DPRODUCTS
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon) 1
C State PDL Class
QPD 20.0 per day
PTD PART DPRODUCTS
fluconazole (50 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet) 1
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
griseofulvin, microsize (125 mg/5ml oral susp, 500 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
ketoconazole (2 % cream (g), 2 % shampoo) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 34 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
miconazole nitrate 1C State PDL Class
PTD PART DPRODUCTS
NATACYN 1C State PDL Class
PTD PART DPRODUCTS
NYAMYC 1C State PDL Class
PTD PART DPRODUCTS
nystatin (500k unit tablet, 100000/g cream (g), 100000/goint. (g), 100000/g powder, 100000/ml oral susp) 1
C State PDL Class
PTD PART DPRODUCTS
NYSTOP 1C State PDL Class
PTD PART DPRODUCTS
terbinafine hcl 1
QL 90 / 365 Days
C State PDL Class
PTD PART DPRODUCTS
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mgsupp.vag) 1 PTD PART D
PRODUCTS
ANTIGOUT AGENTS
allopurinol 1C State PDL Class
PTD PART DPRODUCTS
colchicine 0.6 mg tablet 1
C State PDL Class
PA
PTD PART DPRODUCTS
febuxostat 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 35 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
probenecid 1C State PDL Class
PTD PART DPRODUCTS
probenecid/colchicine 1 PTD PART DPRODUCTS
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT 1PA
PTD PART DPRODUCTS
ergotamine tartrate/caffeine 1C State PDL Class
PTD PART DPRODUCTS
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 1
C State RebateClass
QPD 0.2 per day
PTD PART DPRODUCTS
naratriptan hcl 1
QL 9 / 30 days
C State RebateClass
PTD PART DPRODUCTS
rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mgtab rapdis, 10 mg tablet) 1
C State RebateClass
QPD 0.3 per day
PTD PART DPRODUCTS
sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5mlpen injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr) 1
C State RebateClass
QPD 0.067 per day
PTD PART DPRODUCTS
PAGE 36 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet) 1
C State RebateClass
QPD 0.3 per day
PTD PART DPRODUCTS
sumatriptan succinate 6 mg/0.5ml vial 1QPD 0.067 per day
PTD PART DPRODUCTS
zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tabrapdis, 5 mg tablet) 1
C State RebateClass
QPD 0.3 per day
PTD PART DPRODUCTS
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 1
ST
C State RebateClass
PA
QPD 0.2 per day
PTD PART DPRODUCTS
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1 PTD PART DPRODUCTS
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (25 mg tablet, 100 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 37 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTITUBERCULARS
ethambutol hcl 1C State PDL Class
PTD PART DPRODUCTS
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
pyrazinamide 1C State PDL Class
PTD PART DPRODUCTS
RIFAMATE 1 PTD PART DPRODUCTS
rifampin (150 mg capsule, 300 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLET 1
C State PDL Class
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PTD PART DPRODUCTS
GLEOSTINE 1 PTD PART DPRODUCTS
LEUKERAN 1 PTD PART DPRODUCTS
MATULANE 1C State PDL Class
PTD PART DPRODUCTS
PAGE 38 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
temozolomide 1
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
ANTIANDROGENS
bicalutamide 1 PTD PART DPRODUCTS
flutamide 1C State PDL Class
PTD PART DPRODUCTS
nilutamide 1 PTD PART DPRODUCTS
ZYTIGA 500 MG TABLET 1PA
PTD PART DPRODUCTS
ANTIANGIOGENIC AGENTS
REVLIMID 1
C State PDL Class
PA
PTD PART DPRODUCTS
THALOMID 1
C State PDL Class
PA
PTD PART DPRODUCTS
ANTIESTROGENS/MODIFIERS
SOLTAMOX 1 PTD PART DPRODUCTS
tamoxifen citrate 1C State PDL Class
PTD PART DPRODUCTS
PAGE 39 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
toremifene citrate 1
C State PDL Class
PA
PTD PART DPRODUCTS
ANTIMETABOLITES
fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1 PTD PART DPRODUCTS
hydroxyurea 1C State PDL Class
PTD PART DPRODUCTS
mercaptopurine 1C State PDL Class
PTD PART DPRODUCTS
TABLOID 1PA
PTD PART DPRODUCTS
ANTINEOPLASTICS, OTHER
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mgtablet, 25 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
SYLATRON 1
C State PDL Class
PA
PTD PART DPRODUCTS
ZOLINZA 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 40 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1
C State PDL Class
PA
PTD PART DPRODUCTS
exemestane 1
C State PDL Class
PA
PTD PART DPRODUCTS
letrozole 1 PTD PART DPRODUCTS
ENZYME INHIBITORS
etoposide 50 mg capsule 1
C State PDL Class
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
MOLECULAR TARGET INHIBITORS
AFINITOR 10 MG TABLET 1
C State PDL Class
PA
PTD PART DPRODUCTS
AFINITOR DISPERZ 1
C State PDL Class
PA
PTD PART DPRODUCTS
ALECENSA 1PA
PTD PART DPRODUCTS
PAGE 41 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CAPRELSA 1
C State PDL Class
PA
PTD PART DPRODUCTS
COTELLIC 1PA
PTD PART DPRODUCTS
ERIVEDGE 1PA
PTD PART DPRODUCTS
erlotinib hcl 1
C State PDL Class
PA
PTD PART DPRODUCTS
everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
GLEEVEC 1
C State PDL Class
PA
PTD PART DPRODUCTS
ICLUSIG (15 MG TABLET, 45 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
IMBRUVICA 140 MG CAPSULE 1
C State PDL Class
PA
PTD PART DPRODUCTS
INLYTA 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 42 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IRESSA 1
C State PDL Class
PA
PTD PART DPRODUCTS
JAKAFI 1
C State PDL Class
PA
PTD PART DPRODUCTS
lapatinib ditosylate 1
C State PDL Class
PA
PTD PART DPRODUCTS
NEXAVAR 1
C State PDL Class
PA
PTD PART DPRODUCTS
SUTENT 1
C State PDL Class
PA
PTD PART DPRODUCTS
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 1
C State PDL Class
PA
PTD PART DPRODUCTS
TYKERB 1PA
PTD PART DPRODUCTS
VOTRIENT 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 43 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XALKORI 1
C State PDL Class
PA
PTD PART DPRODUCTS
ZELBORAF 1
C State PDL Class
PA
PTD PART DPRODUCTS
MONOCLONAL ANTIBODIES
AVASTIN 1
C State RebateClass
PA
PTD PART DPRODUCTS
HERCEPTIN 1PA
PTD PART DPRODUCTS
RITUXAN 1
C State RebateClass
PA
PTD PART DPRODUCTS
RITUXAN HYCELA 1
C State RebateClass
PA
PTD PART DPRODUCTS
RETINOIDS
bexarotene 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 44 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tretinoin 10 mg capsule 1
AL Up to 26 yrs old
C State PDL Class
PTD PART DPRODUCTS
ANTIPARASITICS
ANTIHELMINTHICS
albendazole 1
C State PDL Class
PA
PTD PART DPRODUCTS
EMVERM 1 PTD PART DPRODUCTS
ivermectin (0.5 % lotion, 3 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
praziquantel 1C State PDL Class
PTD PART DPRODUCTS
SKLICE 1PA
PTD PART DPRODUCTS
ANTIPROTOZOALS
ALINIA 100 MG/5 ML SUSPENSION 1 PTD PART DPRODUCTS
atovaquone/proguanil hcl 1C State PDL Class
PTD PART DPRODUCTS
chloroquine phosphate 1C State PDL Class
PTD PART DPRODUCTS
PAGE 45 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COARTEM 1 PTD PART DPRODUCTS
hydroxychloroquine sulfate 200 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
primaquine phosphate 1C State PDL Class
PTD PART DPRODUCTS
quinine sulfate 1C State PDL Class
PTD PART DPRODUCTS
PEDICULICIDES/SCABICIDES
EURAX (CREAM, LOTION) 1C State PDL Class
PTD PART DPRODUCTS
lindane 1 PTD PART DPRODUCTS
malathion 1 PTD PART DPRODUCTS
permethrin 1C State PDL Class
PTD PART DPRODUCTS
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) 1 PTD PART DPRODUCTS
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml solution, 5 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 46 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (50 mg/5 ml solution, 100 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
entacapone 1C State PDL Class
PTD PART DPRODUCTS
STALEVO 125 1 PTD PART DPRODUCTS
STALEVO 50 1 PTD PART DPRODUCTS
STALEVO 75 1 PTD PART DPRODUCTS
DOPAMINE AGONISTS
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 4.5mg tab er 24h)
1C State PDL Class
PTD PART DPRODUCTS
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet,2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa/levodopa (carbidopa/levodopa 10mg-100mgtablet, carbidopa/levodopa 25mg-100mg tablet,carbidopa/levodopa 25mg-100mg tablet er,carbidopa/levodopa 25mg-250mg tablet,carbidopa/levodopa 50mg-200mg tablet er)
1C State PDL Class
PTD PART DPRODUCTS
PAGE 47 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25 mg/mlampul, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
fluphenazine decanoate 1
AL At least 18 yrsold
C State PDL Class
PTD PART DPRODUCTS
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5mlelixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
haloperidol 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
haloperidol decanoate (50 mg/ml ampul, 50 mg/ml vial,100 mg/ml ampul, 100 mg/ml vial) 1
AL At least 18 yrsold
C State PDL Class
PTD PART DPRODUCTS
haloperidol lactate 2 mg/ml oral conc 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
loxapine succinate 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
PAGE 48 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
molindone hcl 1 PTD PART DPRODUCTS
pimozide 1
AL At least 12 yrsold
C State PDL Class
PTD PART DPRODUCTS
thioridazine hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
thiothixene 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
trifluoperazine hcl 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
2ND GENERATION/ATYPICAL
ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER400 MG SYR, ER 400 MG VL) 1
QL 1 / 30 days
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15mg tablet, 20 mg tablet, 30 mg tablet) 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
PAGE 49 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARISTADA ER 1064 MG/3.9 ML SYR 1
QL 3.9 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
ARISTADA ER 441 MG/1.6 ML SYRN 1
QL 1.6 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
ARISTADA ER 662 MG/2.4 ML SYRN 1
QL 2.4 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
ARISTADA ER 882 MG/3.2 ML SYRN 1
QL 3.2 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA SUSTENNA 117 MG/0.75 ML 1
QL 0.75 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
PAGE 50 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVEGA SUSTENNA 156 MG/ML SYRG 1
QL 1 / 30 days
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA SUSTENNA 234 MG/1.5 ML 1
QL 1.5 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA SUSTENNA 39 MG/0.25 ML 1
QL 0.25 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA SUSTENNA 78 MG/0.5 ML 1
QL 0.5 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA TRINZA 273 MG/0.875 ML 1
QL 0.875 / 84DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
PAGE 51 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVEGA TRINZA 410 MG/1.315 ML 1
QL 1.315 / 84DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA TRINZA 546 MG/1.75 ML 1
QL 1.75 / 84 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
INVEGA TRINZA 819 MG/2.625 ML 1
QL 2.625 / 84DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
LATUDA 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tabrapdis, 20 mg tablet)
1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
PAGE 52 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olanzapine (5 mg tab rapdis, 10 mg tab rapdis) 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mgtablet, 200 mg tablet, 300 mg tablet, 400 mg tablet) 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
RISPERDAL CONSTA 1
QL 2 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
risperidone 1 mg/ml solution 1
AL At least 6 yrsold
C State RebateClass
QPD 8 per day
PTD PART DPRODUCTS
risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 2mg tab rapdis, 2 mg tablet, 3 mg tab rapdis, 3 mg tablet,4 mg tab rapdis, 4 mg tablet)
1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
PAGE 53 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ziprasidone hcl 1
AL At least 6 yrsold
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
TREATMENT-RESISTANT
clozapine 25 mg tablet 1
QL 150 / 30 DAYS
AL At least 18 yrsold
C State RebateClass
QPD 5.0 per day
PTD PART DPRODUCTS
clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 50 mgtablet, 100 mg tab rapdis, 100 mg tablet, 150 mg tabrapdis, 200 mg tab rapdis, 200 mg tablet)
1
AL At least 18 yrsold
C State RebateClass
QPD 5.0 per day
PTD PART DPRODUCTS
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir 1
C State PDL Class
PA
PTD PART DPRODUCTS
FOSCAVIR 6,000 MG/250 ML BTTL 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 54 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FOSCAVIR 6,000 MG/250 ML BAG 1C State PDL Class
PA
ganciclovir sodium 500 mg vial 1
C State PDL Class
PA
PTD PART DPRODUCTS
valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 1
C State RebateClass
PA
PTD PART DPRODUCTS
BARACLUDE 0.05 MG/ML SOLUTION 1
C State PDL Class
PA
PTD PART DPRODUCTS
entecavir 1
C State PDL Class
PA
PTD PART DPRODUCTS
EPIVIR HBV 25 MG/5 ML SOLN 1
C State PDL Class
PA
PTD PART DPRODUCTS
lamivudine 100 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
PAGE 55 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTI-HEPATITIS C (HCV) AGENTS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)
1
C State PDL Class
PA
PTD PART DPRODUCTS
MAVYRET 100-40 MG TABLET 1
C State RebateClass
PA
PTD PART DPRODUCTS
PEGASYS PROCLICK 1
C State RebateClass
PA
PTD PART DPRODUCTS
RIBASPHERE 200 MG CAPSULE 1 PTD PART DPRODUCTS
ribavirin (200 mg capsule, 200 mg tablet) 1
C State RebateClass
PA
PTD PART DPRODUCTS
sofosbuvir/velpatasvir 1
C State RebateClass
PA
PTD PART DPRODUCTS
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA 1C State PDL Class
PTD PART DPRODUCTS
ISENTRESS (25 MG TABLET CHEW, 100 MG POWDERPACKET, 100 MG TABLET CHEW, 400 MG TABLET) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 56 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISENTRESS HD 1C State PDL Class
PTD PART DPRODUCTS
STRIBILD 1C State PDL Class
PTD PART DPRODUCTS
TIVICAY 1C State PDL Class
PTD PART DPRODUCTS
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA 1C State PDL Class
PTD PART DPRODUCTS
COMPLERA 1C State PDL Class
PTD PART DPRODUCTS
EDURANT 1C State PDL Class
PTD PART DPRODUCTS
efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
INTELENCE 1C State PDL Class
PTD PART DPRODUCTS
nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200mg tablet, 400 mg tab er 24h) 1
C State PDL Class
PTD PART DPRODUCTS
ODEFSEY 1C State PDL Class
PTD PART DPRODUCTS
PAGE 57 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RESCRIPTOR 1C State PDL Class
PTD PART DPRODUCTS
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)
abacavir sulfate (20 mg/ml solution, 300 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
abacavir sulfate/lamivudine 1C State PDL Class
PTD PART DPRODUCTS
abacavir sulfate/lamivudine/zidovudine 1C State PDL Class
PTD PART DPRODUCTS
DESCOVY 1C State PDL Class
PTD PART DPRODUCTS
didanosine 1C State PDL Class
PTD PART DPRODUCTS
emtricitabine 1C State PDL Class
PTD PART DPRODUCTS
EMTRIVA 200 MG CAPSULE 1 PTD PART DPRODUCTS
EMTRIVA 10 MG/ML SOLUTION 1C State PDL Class
PTD PART DPRODUCTS
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 58 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lamivudine/zidovudine 1C State PDL Class
PTD PART DPRODUCTS
stavudine 1C State PDL Class
PTD PART DPRODUCTS
tenofovir disoproxil fumarate 1C State PDL Class
PTD PART DPRODUCTS
TRUVADA 1C State PDL Class
PTD PART DPRODUCTS
VIDEX 1C State PDL Class
PTD PART DPRODUCTS
VIDEX EC 125 MG CAPSULE 1C State PDL Class
PTD PART DPRODUCTS
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER) 1
C State PDL Class
PTD PART DPRODUCTS
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
ANTI-HIV AGENTS, OTHER
FUZEON 1
QL 1 / 30 DAYS
C State PDL Class
PA
PTD PART DPRODUCTS
PREZCOBIX 1C State PDL Class
PTD PART DPRODUCTS
PAGE 59 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MGTABLET, 300 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
TRIUMEQ 1C State PDL Class
PTD PART DPRODUCTS
TYBOST 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 1C State PDL Class
PTD PART DPRODUCTS
atazanavir sulfate 1C State PDL Class
PTD PART DPRODUCTS
CRIXIVAN 1C State PDL Class
PTD PART DPRODUCTS
EVOTAZ 1C State PDL Class
PTD PART DPRODUCTS
fosamprenavir calcium 1C State PDL Class
PTD PART DPRODUCTS
INVIRASE 1C State PDL Class
PTD PART DPRODUCTS
KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 60 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEXIVA 50 MG/ML SUSPENSION 1C State PDL Class
PTD PART DPRODUCTS
lopinavir/ritonavir 400-100/5 solution 1C State PDL Class
PTD PART DPRODUCTS
NORVIR 80 MG/ML SOLUTION 1C State PDL Class
PTD PART DPRODUCTS
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET) 1
C State PDL Class
PTD PART DPRODUCTS
REYATAZ 50 MG POWDER PACKET 1C State PDL Class
PTD PART DPRODUCTS
ritonavir 1C State PDL Class
PTD PART DPRODUCTS
VIRACEPT 1C State PDL Class
PTD PART DPRODUCTS
ANTI-INFLUENZA AGENTS
oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75mg capsule) 1
QL 20 / 270 DAYS
C State PDL Class
PTD PART DPRODUCTS
oseltamivir phosphate 6 mg/ml susp recon 1C State PDL Class
PTD PART DPRODUCTS
RELENZA 1
QL 40 / 270 DAYS
C State PDL Class
PTD PART DPRODUCTS
PAGE 61 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
rimantadine hcl 1C State PDL Class
PTD PART DPRODUCTS
ANTIHERPETIC AGENTS
acyclovir (5 % oint. (g), 200 mg capsule, 200 mg/5ml oralsusp, 400 mg tablet, 800 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
acyclovir sodium (50 mg/ml vial, 500 mg vial) 1 PTD PART DPRODUCTS
ALFERON N 1
C State PDL Class
PA
PTD PART DPRODUCTS
famciclovir 1
C State PDL Class
PA
PTD PART DPRODUCTS
SITAVIG 1 PTD PART DPRODUCTS
trifluridine 1C State PDL Class
PTD PART DPRODUCTS
valacyclovir hcl 1C State PDL Class
PTD PART DPRODUCTS
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl (10 mg tablet, 15 mg tablet) 1
QL 4 / DAY
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
PAGE 62 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
buspirone hcl (5 mg tablet, 7.5 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
buspirone hcl 30 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
BENZODIAZEPINES
alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h, 2 mg taber 24h, 3 mg tab er 24h) 1
AL At least 6 yrsold
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4 per day
PTD PART DPRODUCTS
alprazolam (2 mg tab rapdis, 2 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
ALPRAZOLAM INTENSOL 1
QL 60 / 15 DAYS
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
PAGE 63 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
chlordiazepoxide hcl 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
clonazepam (2 mg tab rapdis, 2 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mgtablet)
1
AL At least 6 yrsold
C State PDL Class
QPD 4 per day
PTD PART DPRODUCTS
clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4 per day
PTD PART DPRODUCTS
clorazepate dipotassium 15 mg tablet 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
diazepam 5 mg/ml oral conc 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
PAGE 64 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diazepam 5 mg/5 ml solution 1
QL 300 / 30 DAYS
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
diazepam (5 mg/ml cartridge, 5 mg/ml syringe, 5 mg/mlvial) 1 PTD PART D
PRODUCTS
diazepam (2 mg tablet, 5 mg tablet, 10 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4 per day
PTD PART DPRODUCTS
lorazepam (0.5 mg tablet, 1 mg tablet) 1
AL At least 6 yrsold
C State PDL Class
QPD 4 per day
PTD PART DPRODUCTS
lorazepam (2 mg tablet, 2 mg/ml oral conc) 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
LORAZEPAM INTENSOL 1
AL At least 6 yrsold
C State PDL Class
QPD 2 per day
PTD PART DPRODUCTS
oxazepam 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
PAGE 65 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETRO 1C State PDL Class
PTD PART DPRODUCTS
lithium carbonate (150 mg capsule, 300 mg capsule, 300mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mgcapsule)
1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
lithium citrate 1
AL At least 6 yrsold
C State PDL Class
PTD PART DPRODUCTS
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose 1C State PDL Class
PTD PART DPRODUCTS
ACTOPLUS MET XR 1C State Rebate
Class
PTD PART DPRODUCTS
BYDUREON PEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
BYETTA 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 66 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FARXIGA 1
C State RebateClass
PA
PTD PART DPRODUCTS
glimepiride 1C State PDL Class
PTD PART DPRODUCTS
glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10mg tab er 24, 10 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
glyburide 1C State PDL Class
PTD PART DPRODUCTS
glyburide,micronized 1C State PDL Class
PTD PART DPRODUCTS
glyburide/metformin hcl 1C State Rebate
Class
PTD PART DPRODUCTS
GLYXAMBI 1
C State RebateClass
PA
PTD PART DPRODUCTS
INVOKAMET 1
C State RebateClass
PA
PTD PART DPRODUCTS
INVOKANA 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 67 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JANUMET 1
C State RebateClass
PA
PTD PART DPRODUCTS
JANUMET XR 1
C State RebateClass
PA
PTD PART DPRODUCTS
JANUVIA 1
C State RebateClass
PA
PTD PART DPRODUCTS
JARDIANCE 1
C State RebateClass
PA
PTD PART DPRODUCTS
JENTADUETO 1
C State RebateClass
PA
PTD PART DPRODUCTS
JENTADUETO XR 1PA
PTD PART DPRODUCTS
KAZANO 1PA
PTD PART DPRODUCTS
KOMBIGLYZE XR 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 68 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mgtab er 24h, 850 mg tablet, 1000 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
nateglinide 1C State PDL Class
PTD PART DPRODUCTS
NESINA 1PA
PTD PART DPRODUCTS
ONGLYZA 1
C State RebateClass
PA
PTD PART DPRODUCTS
OSENI 1PA
PTD PART DPRODUCTS
pioglitazone hcl 1C State PDL Class
PTD PART DPRODUCTS
pioglitazone hcl/metformin hcl 1C State Rebate
Class
PTD PART DPRODUCTS
repaglinide 1C State PDL Class
PTD PART DPRODUCTS
SYMLINPEN 120 1
C State RebateClass
PA
PTD PART DPRODUCTS
SYMLINPEN 60 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 69 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYNJARDY 1
C State RebateClass
PA
PTD PART DPRODUCTS
TRADJENTA 1
C State RebateClass
PA
PTD PART DPRODUCTS
TRULICITY (0.75 MG/0.5 ML PEN, 1.5 MG/0.5 ML PEN) 1
C State RebateClass
PA
PTD PART DPRODUCTS
VICTOZA 2-PAK 1
C State RebateClass
PA
PTD PART DPRODUCTS
VICTOZA 3-PAK 1
C State RebateClass
PA
PTD PART DPRODUCTS
XIGDUO XR (5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET) 1
C State RebateClass
PA
PTD PART DPRODUCTS
GLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKIT 1C State PDL Class
PTD PART DPRODUCTS
PAGE 70 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLUCAGON 1 MG EMERGENCY KIT 1
QL 1 / 30 days
C State PDL Class
PTD PART DPRODUCTS
PROGLYCEM 1 PTD PART DPRODUCTS
INSULINS
HUMALOG 100 UNIT/ML CARTRIDGE 1C State Rebate
Class
PTD PART DPRODUCTS
HUMULIN R U-500 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMULIN R U-500 KWIKPEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
insulin aspart (100/ml (3) insuln pen, 100/ml cartridge,100/ml vial) 1 PTD PART D
PRODUCTS
insulin aspart protamine human/insulin aspart (artprot/insuln 70-30/ml insuln pen, art prot/insuln 70-30/mlvial)
1 PTD PART DPRODUCTS
insulin lispro (100/ml ins pen hf, 100/ml insuln pen,100/ml vial) 1 PTD PART D
PRODUCTS
insulin lispro protamine and insulin lispro 1 PTD PART DPRODUCTS
LANTUS 1C State Rebate
Class
PTD PART DPRODUCTS
PAGE 71 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LANTUS SOLOSTAR 1C State Rebate
Class
PTD PART DPRODUCTS
LEVEMIR 1C State Rebate
Class
PTD PART DPRODUCTS
LEVEMIR FLEXTOUCH 1C State Rebate
Class
PTD PART DPRODUCTS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 1
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4mlsyringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100mg/ml syringe, 120mg/.8ml syringe, 150 mg/ml syringe,300mg/3ml vial)
1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
heparin sodium,porcine 1C State Rebate
Class
PTD PART DPRODUCTS
heparin sod,pork in 0.45% nacl 12500/250 iv soln 1C State PDL Class
PTD PART DPRODUCTS
heparin sodium,porcine in 0.45 % sodium chloride (in25000/250 iv soln, in 25000/500 iv soln) 1
C State RebateClass
PTD PART DPRODUCTS
PAGE 72 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
heparin sodium,porcine in 0.9 % sodium chloride(sod,porcine/0.9 % 2500/250ml iv soln, sod,porcine/0.9 %2500/500ml iv soln, sod,porcine/0.9 % 30k/1000ml iv soln,sod,porcine/0.9 % 4k/1000 ml iv soln, sod,porcine/0.9 %5000/500ml iv soln, sod,porcine/0.9 % 5k/1000 ml iv soln)
1C State Rebate
Class
PTD PART DPRODUCTS
heparin sod,porcine/0.9 % nacl 100/ml kit 1 C State RebateClass
heparin sodium,porcine in 0.9 % sodium chloride/pf 1C State Rebate
Class
PTD PART DPRODUCTS
heparin sodium,porcine/dextrose 5 % in water 1C State Rebate
Class
PTD PART DPRODUCTS
heparin sodium,porcine/pf (sodium,porcine/pf 1 unit/mlsyringe, sodium,porcine/pf 10 unit/ml syringe,sodium,porcine/pf 200/2 ml syringe, sodium,porcine/pf300/3 ml syringe, sodium,porcine/pf 500/5 ml syringe,sodium,porcine/pf 5000/0.5ml cartridge,sodium,porcine/pf 5000/0.5ml vial)
1C State PDL Class
PTD PART DPRODUCTS
heparin sodium,porcine/pf (sodium,porcine/pf 10 unit/mlvial, sodium,porcine/pf 100/ml (1) syringe,sodium,porcine/pf 1000/10 ml syringe)
1 C State PDL Class
heparin sodium,porcine/pf (sodium,porcine/pf 1000/mlvial, sodium,porcine/pf 5000/0.5ml syringe,sodium,porcine/pf 5000/ml syringe)
1C State Rebate
Class
PTD PART DPRODUCTS
heparin sodium,porcine/pf 100/ml (1) vial 1 C State RebateClass
JANTOVEN 1C State Rebate
Class
PTD PART DPRODUCTS
PAGE 73 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRADAXA 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
warfarin sodium 1C State Rebate
Class
PTD PART DPRODUCTS
XARELTO DVT-PE TREAT START 30D 1
QL 51 / 30 days
C State RebateClass
PTD PART DPRODUCTS
XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
BLOOD FORMATION MODIFIERS
anagrelide hcl 1 PTD PART DPRODUCTS
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL,480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 1
C State RebateClass
PA
PTD PART DPRODUCTS
NPLATE (250 MCG VIAL, 500 MCG VIAL) 1
C State RebateClass
PA
PTD PART DPRODUCTS
PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET) 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 74 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COAGULANTS
aminocaproic acid (500 mg tablet, 1000 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
PLATELET MODIFYING AGENTS
BRILINTA 1
C State PDL Class
PA
PTD PART DPRODUCTS
cilostazol 1C State PDL Class
PTD PART DPRODUCTS
clopidogrel bisulfate 1C State PDL Class
PTD PART DPRODUCTS
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine 1
QL 4 / 28 DAYS
AL At least 6 yrsold
C State RebateClass
PTD PART DPRODUCTS
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1
AL At least 6 yrsold
C State RebateClass
PTD PART DPRODUCTS
PAGE 75 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
guanfacine hcl (1 mg tablet, 2 mg tablet) 1
AL At least 6 yrsold
C State RebateClass
PTD PART DPRODUCTS
methyldopa 1C State PDL Class
PTD PART DPRODUCTS
midodrine hcl 1 PTD PART DPRODUCTS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate 1C State Rebate
Class
PTD PART DPRODUCTS
prazosin hcl 1C State Rebate
Class
PTD PART DPRODUCTS
terazosin hcl 1C State Rebate
Class
PTD PART DPRODUCTS
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 1 PTD PART DPRODUCTS
irbesartan 1C State PDL Class
PTD PART DPRODUCTS
losartan potassium 1C State PDL Class
PTD PART DPRODUCTS
PAGE 76 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olmesartan medoxomil 1 PTD PART DPRODUCTS
valsartan 1C State PDL Class
PTD PART DPRODUCTS
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl 1C State PDL Class
PTD PART DPRODUCTS
captopril 1C State PDL Class
PTD PART DPRODUCTS
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mgtablet, 20 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
EPANED 1C State PDL Class
PTD PART DPRODUCTS
fosinopril sodium 1C State PDL Class
PTD PART DPRODUCTS
lisinopril 1C State PDL Class
PTD PART DPRODUCTS
moexipril hcl 1C State PDL Class
PTD PART DPRODUCTS
perindopril erbumine 1C State PDL Class
PTD PART DPRODUCTS
quinapril hcl 1C State PDL Class
PTD PART DPRODUCTS
PAGE 77 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ramipril 1C State PDL Class
PTD PART DPRODUCTS
trandolapril 1C State PDL Class
PTD PART DPRODUCTS
ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
disopyramide phosphate 1C State PDL Class
PTD PART DPRODUCTS
dofetilide 1
C State PDL Class
PA
PTD PART DPRODUCTS
flecainide acetate 1C State PDL Class
PTD PART DPRODUCTS
mexiletine hcl 1C State PDL Class
PTD PART DPRODUCTS
MULTAQ 1
C State PDL Class
PA
PTD PART DPRODUCTS
NORPACE CR 1C State PDL Class
PTD PART DPRODUCTS
PACERONE (100 MG TABLET, 200 MG TABLET) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 78 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225mg tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg caper 12h)
1C State PDL Class
PTD PART DPRODUCTS
quinidine gluconate 1C State PDL Class
PTD PART DPRODUCTS
quinidine sulfate 1C State PDL Class
PTD PART DPRODUCTS
SORINE 1C State PDL Class
PTD PART DPRODUCTS
SOTALOL AF 1C State PDL Class
PTD PART DPRODUCTS
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet,240 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
sotalol hcl 150mg/10ml vial 1 PTD PART DPRODUCTS
BETA-ADRENERGIC BLOCKING AGENTS
atenolol 1C State PDL Class
PTD PART DPRODUCTS
bisoprolol fumarate 1C State PDL Class
PTD PART DPRODUCTS
carvedilol 1C State PDL Class
PTD PART DPRODUCTS
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 79 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
metoprolol succinate 1C State PDL Class
PTD PART DPRODUCTS
metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mgtablet, 75 mg tablet, 100 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
nadolol 1C State PDL Class
PTD PART DPRODUCTS
propranolol hcl (120 mg cap sa 24h, 160 mg cap sa 24h) 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
propranolol hcl (60 mg cap sa 24h, 80 mg cap sa 24h) 1
QL 30 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsolution, 40 mg tablet, 40mg/5ml solution, 60 mg tablet,80 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
propranolol hcl 1 mg/ml vial 1 PTD PART DPRODUCTS
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
CARTIA XT (120 MG CAPSULE, 240 MG CAPSULE, 300 MGCAPSULE) 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
PAGE 80 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARTIA XT 180 MG CAPSULE 1C State PDL Class
PTD PART DPRODUCTS
DILT-XR 1C State PDL Class
PTD PART DPRODUCTS
diltiazem hcl (120 mg cap er 24h, 180 mg cap er 24h, 240mg cap er 24h, 300 mg cap er 24h, 360 mg cap er 24h) 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
diltiazem hcl (120 mg cap er deg, 180 mg cap er deg, 240mg cap er deg) 1 C State PDL Class
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mgtablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er12h, 120 mg cap sa 24h, 120 mg tablet, 180 mg cap sa24h, 240 mg cap sa 24h, 300 mg cap sa 24h, 360 mg capsa 24h, 420 mg cap sa 24h)
1C State PDL Class
PTD PART DPRODUCTS
felodipine 1C State PDL Class
PTD PART DPRODUCTS
nifedipine (10 mg capsule, 20 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tab er24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er) 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
TAZTIA XT 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
TIADYLT ER 1C State PDL Class
PTD PART DPRODUCTS
PAGE 81 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
verapamil hcl (120 mg cap24h pel, 120 mg tablet er, 180mg cap24h pel, 180 mg tablet er, 240 mg cap24h pel, 240mg tablet er)
1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
CARDIOVASCULAR AGENTS, OTHER
ALDACTAZIDE 50-50 TABLET 1C State PDL Class
PTD PART DPRODUCTS
atenolol/chlorthalidone 1C State PDL Class
PTD PART DPRODUCTS
benazepril/hydrochlorothiazide 5-6.25mg tablet 1 PTD PART DPRODUCTS
bisoprolol fumarate/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
captopril/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
DIGITEK 1C State PDL Class
PTD PART DPRODUCTS
DIGOX 1C State PDL Class
PTD PART DPRODUCTS
digoxin 250 mcg/ml ampul 1 PTD PART DPRODUCTS
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 82 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
enalapril maleate/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
ENTRESTO 1
C State PDL Class
PA
PTD PART DPRODUCTS
fosinopril sodium/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET) 1C State PDL Class
PTD PART DPRODUCTS
LANOXIN PEDIATRIC (100 MCG/ML AMPUL, 100 MCG/MLVIAL) 1 PTD PART D
PRODUCTS
lisinopril/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
losartan potassium/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
metoprolol tartrate/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
olmesartan medoxomil/hydrochlorothiazide 1 PTD PART DPRODUCTS
pentoxifylline 1 PTD PART DPRODUCTS
propranolol hcl/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
PAGE 83 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quinapril hcl/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
ranolazine 1
C State PDL Class
PA
PTD PART DPRODUCTS
spironolactone/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
triamterene/hydrochlorothiazide(triamterene/hydrochlorothiazid 37.5-25 mg capsule,triamterene/hydrochlorothiazid 37.5-25 mg tablet,triamterene/hydrochlorothiazid 75 mg-50mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
valsartan/hydrochlorothiazide 1C State PDL Class
PTD PART DPRODUCTS
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (125 mg tablet, 250 mg tablet, 500 mgcapsule er) 1
C State PDL Class
PTD PART DPRODUCTS
DIURETICS, LOOP
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40mg/5ml solution, 80 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
furosemide (10 mg/ml syringe, 10 mg/ml vial) 1 PTD PART DPRODUCTS
torsemide 1C State PDL Class
PTD PART DPRODUCTS
PAGE 84 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIURETICS, POTASSIUM-SPARING
amiloride hcl 1 PTD PART DPRODUCTS
eplerenone 1
C State PDL Class
PA
PTD PART DPRODUCTS
spironolactone 1C State PDL Class
PTD PART DPRODUCTS
DIURETICS, THIAZIDE
chlorthalidone 1C State PDL Class
PTD PART DPRODUCTS
DIURIL 1C State PDL Class
PTD PART DPRODUCTS
hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25mg tablet, 50 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
indapamide 1C State PDL Class
PTD PART DPRODUCTS
metolazone 1C State PDL Class
PTD PART DPRODUCTS
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate (54 mg tablet, 160 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 85 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fenofibrate nanocrystallized 1C State PDL Class
PTD PART DPRODUCTS
fenofibrate,micronized (67 mg capsule, 134 mg capsule,200 mg capsule) 1
C State PDL Class
PTD PART DPRODUCTS
fenofibric acid 1C State PDL Class
PTD PART DPRODUCTS
FIBRICOR 1 PTD PART DPRODUCTS
gemfibrozil 1C State PDL Class
PTD PART DPRODUCTS
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium 1
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
lovastatin 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
pravastatin sodium 1
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
rosuvastatin calcium 1
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
PAGE 86 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40mg tablet, 80 mg tablet) 1
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1C State PDL Class
PTD PART DPRODUCTS
cholestyramine/aspartame (cholestyramine/aspartame 4g powd pack, cholestyramine/aspartame 4 g powder) 1
C State PDL Class
PTD PART DPRODUCTS
colestipol hcl 1 g tablet 1C State PDL Class
PTD PART DPRODUCTS
ezetimibe 1C State Rebate
Class
PTD PART DPRODUCTS
NIACOR 1 PTD PART DPRODUCTS
PREVALITE (PACKET, POWDER) 1C State PDL Class
PTD PART DPRODUCTS
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
minoxidil 1C State PDL Class
PTD PART DPRODUCTS
PAGE 87 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
DILATRATE-SR 1C State PDL Class
PTD PART DPRODUCTS
isosorbide dinitrate 1C State PDL Class
PTD PART DPRODUCTS
isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1
C State PDL Class
PTD PART DPRODUCTS
MINITRAN 1C State PDL Class
PTD PART DPRODUCTS
NITRO-BID 1C State PDL Class
PTD PART DPRODUCTS
NITRO-DUR (0.3 MG/HR PATCH, 0.8 MG/HR PATCH) 1C State PDL Class
PTD PART DPRODUCTS
NITRO-TIME 1
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,0.3 mg tab subl, 0.4 mg tab subl, 0.4mg/hr patch td24,0.6 mg tab subl, 0.6mg/hr patch td24, 2.5 mg capsule er,6.5 mg capsule er, 9 mg capsule er)
1C State PDL Class
PTD PART DPRODUCTS
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADDERALL 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
PAGE 88 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ADDERALL XR 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mgtablet, dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)
1
AL At least 6 yrsold
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
dextroamphetamine sulfate (15 mg tablet, 20 mg tablet,30 mg tablet) 1
AL At least 6 yrsold
QPD 2.0 per day
dextroamphetamine sulfate (5 mg tablet, 10 mg tablet) 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)
1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
atomoxetine hcl 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
PAGE 89 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clonidine hcl 0.1 mg tab er 12h 1
AL At least 6 yrsold
C State RebateClass
QPD 4 per day
PTD PART DPRODUCTS
CONCERTA 1
AL At least 6 yrsold
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
DAYTRANA 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10mg tablet) 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
FOCALIN XR 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
PAGE 90 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mgtab er 24h, 4 mg tab er 24h) 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
METHYLIN 1
AL At least 6 yrsold
C State RebateClass
QPD 10 per day
PTD PART DPRODUCTS
methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 30 mg cpbp 30-70, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 60 mg cpbp 30-70)
1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet) 1
AL At least 6 yrsold
C State RebateClass
QPD 3 per day
PTD PART DPRODUCTS
RITALIN LA (20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE) 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
PAGE 91 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RITALIN LA 10 MG CAPSULE 1
AL At least 6 yrsold
C State RebateClass
QPD 1 per day
PTD PART DPRODUCTS
CENTRAL NERVOUS SYSTEM, OTHER
butalbital/acetaminophen/caffeine(butalb/acetaminophen/caffeine 50-300-40 capsule,butalb/acetaminophen/caffeine 50-325-40 capsule)
1 PTD PART DPRODUCTS
butalb/acetaminophen/caffeine 50-325-40 tablet 1C State PDL Class
PTD PART DPRODUCTS
ESGIC CAPSULE 1 PTD PART DPRODUCTS
HORIZANT 1
C State PDL Class
PA
PTD PART DPRODUCTS
OFIRMEV 1
ZEBUTAL 1 PTD PART DPRODUCTS
FIBROMYALGIA AGENTS
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) 1
AL At least 6 yrsold
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
duloxetine hcl 60 mg capsule dr 1
AL At least 6 yrsold
C State PDL Class
QPD 2.0 per day
PTD PART DPRODUCTS
PAGE 92 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pregabalin (20 mg/ml solution, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule,200 mg capsule, 225 mg capsule, 300 mg capsule)
1
C State PDL Class
PA
PTD PART DPRODUCTS
MULTIPLE SCLEROSIS AGENTS
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 1
C State RebateClass
PA
PTD PART DPRODUCTS
AVONEX PEN 30 MCG/0.5 ML KIT 1
C State RebateClass
PA
PTD PART DPRODUCTS
BETASERON 0.3 MG KIT 1
C State RebateClass
PA
PTD PART DPRODUCTS
COPAXONE 20 MG/ML SYRINGE 1
C State RebateClass
PA
PTD PART DPRODUCTS
EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 1PA
PTD PART DPRODUCTS
GILENYA 0.5 MG CAPSULE 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 93 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glatiramer acetate 40 mg/ml syringe 1PA
PTD PART DPRODUCTS
GLATOPA 40 MG/ML SYRINGE 1
C State RebateClass
PA
PTD PART DPRODUCTS
REBIF 1PA
PTD PART DPRODUCTS
REBIF REBIDOSE 1
C State RebateClass
PA
PTD PART DPRODUCTS
DENTAL AND ORAL AGENTS
BOCASAL 1
CAPHOSOL 1 PTD PART DPRODUCTS
chlorhexidine gluconate 1 PTD PART DPRODUCTS
NEUTRASAL 1 PTD PART DPRODUCTS
NUMOISYN LIQUID 1
ORALONE 1C State PDL Class
PTD PART DPRODUCTS
PAROEX 1 PTD PART DPRODUCTS
PERIOGARD 1 PTD PART DPRODUCTS
PAGE 94 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 PTD PART DPRODUCTS
PREVIDENT (0.2%, DENTAL) 1C State PDL Class
PTD PART DPRODUCTS
SALIVAMAX 1
triamcinolone acetonide 0.1 % paste (g) 1C State PDL Class
PTD PART DPRODUCTS
DERMATOLOGICAL AGENTS
acitretin 1 PTD PART DPRODUCTS
adapalene 0.1 % lotion 1
ammonium lactate (12 % cream (g), 12 % lotion) 1 PTD PART DPRODUCTS
AMNESTEEM 1PA
PTD PART DPRODUCTS
ANUSOL-HC 2.5% CREAM 1C State PDL Class
PTD PART DPRODUCTS
AVITA (CREAM, GEL) 1
AL Up to 26 yrs old
CState RebateClass - AHCCCStemp ok
PTD PART DPRODUCTS
BENZEPRO 7% CREAMY WASH 1
BENZEPRO 6% FOAMING CLOTHS 1 C State PDL Class
benzoyl peroxide 7 % cleanser 1C State PDL Class
PTD PART DPRODUCTS
PAGE 95 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
benzoyl peroxide 9.8 % foam 1
benzoyl peroxide microspheres 1
BPO 1 C State PDL Class
calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005% solution) 1 PTD PART D
PRODUCTS
CARAC 1 PTD PART DPRODUCTS
CLARAVIS 1PA
PTD PART DPRODUCTS
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1C State PDL Class
PTD PART DPRODUCTS
clotrimazole/betamethasone dip 1 %-0.05 % cream (g) 1C State PDL Class
PTD PART DPRODUCTS
CORTISPORIN OINTMENT 1C State PDL Class
PTD PART DPRODUCTS
DRITHOCREME HP 1 PTD PART DPRODUCTS
DRYSOL 1C State PDL Class
PTD PART DPRODUCTS
ELIDEL 1PA
PTD PART DPRODUCTS
EPIFOAM 1 PTD PART DPRODUCTS
fluocinonide 0.05 % cream (g) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 96 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUOROPLEX 1 PTD PART DPRODUCTS
fluorouracil 0.5 % cream (g) 1 PTD PART DPRODUCTS
imiquimod 5 % cream pack 1
AL At least 12 yrsold
C Supplemental
QPD 0.434 per day
PTD PART DPRODUCTS
isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule) 1
PA
PTD PART DPRODUCTS
KERALYT SCALP COMPLETE KIT 1
methoxsalen 10 mg cap lq rap 1 PTD PART DPRODUCTS
metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75% lotion) 1
C State PDL Class
PTD PART DPRODUCTS
MYORISAN 1PA
PTD PART DPRODUCTS
NATROBA 1
C State PDL Class
PA
PTD PART DPRODUCTS
NORITATE 1 PTD PART DPRODUCTS
PACNEX 1 C State PDL Class
PHARMABASE BARRIER 1 PTD PART DPRODUCTS
PAGE 97 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRAMOSONE (1% LOTION, 1%-1% CREAM, 2.5%-1%LOTION) 1 PTD PART D
PRODUCTS
REGRANEX 1 PTD PART DPRODUCTS
RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%CREAM, 0.1% CREAM) 1
AL Up to 26 yrs old
C State PDL Class
PTD PART DPRODUCTS
ROSADAN (CREAM, GEL) 1C State PDL Class
PTD PART DPRODUCTS
salicylic acid (6 % cream (g), 6 % foam, 28.5 % sol-filmer) 1 C State PDL Class
salicylic acid (6 % crm er (g), 6 % gel (gram), 6 % lotion, 6% lotion er, 6 % shampoo, 26 % liquid, 27.5 % liq-film) 1
C State PDL Class
PTD PART DPRODUCTS
SALIMEZ 1
SALIMEZ FORTE 1 PTD PART DPRODUCTS
selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1C State PDL Class
PTD PART DPRODUCTS
selenium sulfide 2.3 % shampoo 1 C State PDL Class
SORILUX 1 PTD PART DPRODUCTS
spinosad 1
C State PDL Class
PA
PTD PART DPRODUCTS
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 PTD PART DPRODUCTS
PAGE 98 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TOLAK 1 PTD PART DPRODUCTS
tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 %gel (gram), 0.05 % cream (g), 0.1 % cream (g)) 1
AL Up to 26 yrs old
CState RebateClass - AHCCCStemp ok
PTD PART DPRODUCTS
ZENATANE 1PA
PTD PART DPRODUCTS
zinc oxide 20 % oint. (g) 1
zinc oxide 25 % paste (g) 1 PTD PART DPRODUCTS
ENZYME REPLACEMENT/MODIFIERS
CERDELGA 1
C State PDL Class
PA
PTD PART DPRODUCTS
CEREZYME 1
C State PDL Class
PA
PTD PART DPRODUCTS
CREON 1
C State RebateClass
QPD 16 per day
PTD PART DPRODUCTS
ELAPRASE 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 99 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ELELYSO 1
C State PDL Class
PA
PTD PART DPRODUCTS
miglustat 1
C State RebateClass
PA
PTD PART DPRODUCTS
SUCRAID 1PA
PTD PART DPRODUCTS
VPRIV 1
C State PDL Class
PA
PTD PART DPRODUCTS
ZENPEP (DR 10,000 UNIT CAPSULE, DR 15,000 UNITCAPSULE, DR 20,000 UNIT CAPSULE, DR 25,000 UNITCAPSULE, DR 40,000 UNIT CAPSULE)
1
QL 500 / 30 days
C State RebateClass
QPD 16 per day
PTD PART DPRODUCTS
ZENPEP (DR 3,000 UNIT CAPSULE, DR 5,000 UNITCAPSULE) 1
C State RebateClass
QPD 16 per day
PTD PART DPRODUCTS
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
CUVPOSA 1C State PDL Class
PTD PART DPRODUCTS
PAGE 100 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dicyclomine hcl (10 mg/ml ampul, 10 mg/ml vial) 1 PTD PART DPRODUCTS
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
ED-SPAZ 1 C State PDL Class
glycopyrrolate (1 mg tablet, 2 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
glycopyrrolate 0.2 mg/ml vial 1 PTD PART DPRODUCTS
hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tabsubl, 0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er12h, 125mcg/5ml elixir)
1C State PDL Class
PTD PART DPRODUCTS
HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1 C State PDL Class
NULEV 1 C State PDL Class
OSCIMIN 1 C State PDL Class
OSCIMIN SL 1 C State PDL Class
OSCIMIN SR 1 C State PDL Class
propantheline bromide 1C State PDL Class
PTD PART DPRODUCTS
SYMAX DUOTAB 1
SYMAX-SR 1
GASTROINTESTINAL AGENTS, OTHER
cromolyn sodium 20 mg/ml oral conc 1 PTD PART DPRODUCTS
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine 2.5-.025mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 101 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
loperamide hcl 1C State PDL Class
PTD PART DPRODUCTS
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
famotidine (40 mg tablet, 40mg/5ml susp recon) 1C State PDL Class
PTD PART DPRODUCTS
nizatidine (150 mg capsule, 150mg/10ml solution, 300 mgcapsule) 1 PTD PART D
PRODUCTS
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 300 mgcapsule, 300 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
ranitidine hcl 150 mg tablet 1 C State PDL Class
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl 1 PTD PART DPRODUCTS
AMITIZA 1
C State PDL Class
PA
PTD PART DPRODUCTS
LINZESS 1
C State PDL Class
PA
PTD PART DPRODUCTS
lubiprostone 1PA
PTD PART DPRODUCTS
PAGE 102 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LAXATIVES
CONSTULOSE 1C State PDL Class
PTD PART DPRODUCTS
ENULOSE 1C State PDL Class
PTD PART DPRODUCTS
GAVILYTE-C 1 PTD PART DPRODUCTS
GAVILYTE-G 1C State PDL Class
PTD PART DPRODUCTS
GAVILYTE-N 1 PTD PART DPRODUCTS
GENERLAC 1C State PDL Class
PTD PART DPRODUCTS
KRISTALOSE 1 PTD PART DPRODUCTS
lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1C State PDL Class
PTD PART DPRODUCTS
peg 3350/sod sulf/sod bicarb/sod chloride/potassiumchloride 1
C State PDL Class
PTD PART DPRODUCTS
sodium chloride/sodium bicarbonate/potassiumchloride/peg 1 PTD PART D
PRODUCTS
TRILYTE WITH FLAVOR PACKETS 1 PTD PART DPRODUCTS
PAGE 103 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROTECTANTS
misoprostol 1 PTD PART DPRODUCTS
sucralfate 1 g tablet 1C State PDL Class
PTD PART DPRODUCTS
PROTON PUMP INHIBITORS
esomeprazole magnesium (20 mg capsule dr, 40 mgcapsule dr) 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
esomeprazole magnesium (10 mg suspdr pkt, 20 mgsuspdr pkt, 40 mg suspdr pkt) 1
AL Up to 18 yrs old
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
lansoprazole (15 mg capsule dr, 30 mg capsule dr) 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1
AL Up to 18 yrs old
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
omeprazole 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
PAGE 104 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1C State PDL Class
PTD PART DPRODUCTS
PROTONIX 40 MG SUSPENSION 1
AL Up to 18 yrs old
QPD 1.0 per day
PTD PART DPRODUCTS
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
DETROL 1C State Rebate
Class
PTD PART DPRODUCTS
DETROL LA 1C State Rebate
Class
PTD PART DPRODUCTS
oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5ml syrup, 10 mg tab er 24, 15 mg tab er 24) 1
C State RebateClass
PTD PART DPRODUCTS
TOVIAZ 1C State Rebate
Class
PTD PART DPRODUCTS
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 1C State PDL Class
PTD PART DPRODUCTS
dutasteride 1C State PDL Class
PTD PART DPRODUCTS
PAGE 105 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
finasteride 5 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
tamsulosin hcl 1C State PDL Class
PTD PART DPRODUCTS
GENITOURINARY AGENTS, OTHER
bethanechol chloride 1 PTD PART DPRODUCTS
citric acid/sodium citrate 1C Supplemental
PTD PART DPRODUCTS
ELMIRON 1
C State PDL Class
PA
PTD PART DPRODUCTS
K-PHOS NO.2 1 PTD PART DPRODUCTS
ORACIT 1 PTD PART DPRODUCTS
penicillamine 250 mg capsule 1C State PDL Class
PTD PART DPRODUCTS
phenazopyridine hcl 1C State PDL Class
PTD PART DPRODUCTS
potassium citrate 1 PTD PART DPRODUCTS
potassium citrate/citric acid 1 PTD PART DPRODUCTS
sodium/potassium/potassium citrate/sodium citrate/citac 1 PTD PART D
PRODUCTS
PAGE 106 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRICITRATES 1 PTD PART DPRODUCTS
VIRTRATE-2 1 PTD PART DPRODUCTS
VIRTRATE-3 1 PTD PART DPRODUCTS
VIRTRATE-K 1 PTD PART DPRODUCTS
PHOSPHATE BINDERS
calcium acetate 1C State Rebate
Class
PTD PART DPRODUCTS
sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack,800 mg tablet) 1
C State RebateClass
PTD PART DPRODUCTS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
A-HYDROCORT 1C State PDL Class
PTD PART DPRODUCTS
ADV ALLERGY COLLECTION KIT 1
ALA-CORT 1C State PDL Class
PTD PART DPRODUCTS
ALA-SCALP 1C State PDL Class
PTD PART DPRODUCTS
ARISTOSPAN 1C State PDL Class
PTD PART DPRODUCTS
PAGE 107 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
betamethasone dipropionate 0.05 % lotion 1C State PDL Class
PTD PART DPRODUCTS
betamethasone/propylene glyc 0.05 % cream (g) 1C State PDL Class
PTD PART DPRODUCTS
betamethasone valerate (0.1 % cream (g), 0.1 % lotion) 1C State PDL Class
PTD PART DPRODUCTS
betamethasone valerate 0.1 % oint. (g) 1 PTD PART DPRODUCTS
clobetasol propionate 0.05 % cream (g) 1
QL 100 / 30 days
C State PDL Class
PTD PART DPRODUCTS
clobetasol propionate 0.05 % gel (gram) 1
QL 118 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
clobetasol propionate (0.05 % oint. (g), 0.05 % solution) 1
QL 100 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
clobetasol propionate/emoll 0.05 % cream (g) 1
QL 100 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
CORMAX 1C State PDL Class
PTD PART DPRODUCTS
cortisone acetate 1 PTD PART DPRODUCTS
PAGE 108 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DECADRON 1 PTD PART DPRODUCTS
DEPO-MEDROL 20 MG/ML VIAL 1C State PDL Class
PTD PART DPRODUCTS
DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 1C State PDL Class
PTD PART DPRODUCTS
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mgtablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
DEXAMETHASONE INTENSOL 1C State PDL Class
PTD PART DPRODUCTS
DEXPAK 1 PTD PART DPRODUCTS
fludrocortisone acetate 1C State PDL Class
PTD PART DPRODUCTS
fluocinonide (0.05 % oint. (g), 0.05 % solution, 0.1 %cream (g)) 1
C State PDL Class
PTD PART DPRODUCTS
fluticasone propionate (0.005 % oint. (g), 0.05 % cream(g)) 1
C State PDL Class
PTD PART DPRODUCTS
halcinonide 1 PTD PART DPRODUCTS
halobetasol propionate 0.05 % cream (g) 1
QL 100 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
halobetasol propionate 0.05 % oint. (g) 1
QL 100 / 30 days
C State PDL Class
PTD PART DPRODUCTS
PAGE 109 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint.(g), 2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 %oint. (g))
1C State PDL Class
PTD PART DPRODUCTS
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 PTD PART DPRODUCTS
KENALOG-10 1C State PDL Class
PTD PART DPRODUCTS
KORLYM 1PA
PTD PART DPRODUCTS
MEDROL 2 MG TABLET 1 PTD PART DPRODUCTS
methylprednisolone (4 mg tab ds pk, 4 mg tablet, 8 mgtablet, 16 mg tablet, 32 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
methylprednisolone acetate (40 mg/ml vial, 80 mg/mlvial) 1
C State PDL Class
PTD PART DPRODUCTS
methylprednisolone sodium succinate 1C State PDL Class
PTD PART DPRODUCTS
MILLIPRED 1C State PDL Class
PTD PART DPRODUCTS
MILLIPRED DP 1C State PDL Class
PTD PART DPRODUCTS
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1% solution) 1
C State PDL Class
PTD PART DPRODUCTS
NOLIX 0.05% LOTION 1 PTD PART DPRODUCTS
PAGE 110 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prednisolone 1C State PDL Class
PTD PART DPRODUCTS
prednisolone sodium phosphate (5 mg/5 ml solution, 10mg tab rapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5 mlsolution, 30 mg tab rapdis)
1C State PDL Class
PTD PART DPRODUCTS
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mgtablet, 20 mg tablet, 50 mg tablet)
1C State PDL Class
PTD PART DPRODUCTS
PREDNISONE INTENSOL 1C State PDL Class
PTD PART DPRODUCTS
PROCTO-MED HC 1 PTD PART DPRODUCTS
PROCTO-PAK 1 PTD PART DPRODUCTS
PROCTOCORT 1% CREAM 1
PROCTOSOL-HC 1 PTD PART DPRODUCTS
PROCTOZONE-HC 1 PTD PART DPRODUCTS
RAYOS 1 PTD PART DPRODUCTS
SCALACORT 1C State PDL Class
PTD PART DPRODUCTS
SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O-VL)
1C State PDL Class
PTD PART DPRODUCTS
SOLU-MEDROL 2,000 MG VIAL 1C State PDL Class
PTD PART DPRODUCTS
PAGE 111 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAPERDEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 1 PTD PART DPRODUCTS
TOVET EMOLLIENT 1 PTD PART DPRODUCTS
triamcinolone acetonide (0.025 % cream (g), 0.025 %lotion, 0.025 % oint. (g), 0.05 % oint. (g), 0.1 % cream (g),0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint.(g), 10 mg/ml vial, 40 mg/ml vial)
1C State PDL Class
PTD PART DPRODUCTS
TRIANEX 1C State PDL Class
PTD PART DPRODUCTS
TRIDERM 1C State PDL Class
PTD PART DPRODUCTS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
DDAVP 10 MCG/0.1 ML SOLUTION 1C State PDL Class
PTD PART DPRODUCTS
desmopressin acetate (0.1 mg tablet, 0.2 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial,10/spray spray/pump) 1
C State PDL Class
PTD PART DPRODUCTS
desmopressin acetate (non-refrigerated) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 112 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG,MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MG CARTRIDGE)
1
C State RebateClass
PA
PTD PART DPRODUCTS
INCRELEX 1
C State PDL Class
PA
PTD PART DPRODUCTS
NORDITROPIN FLEXPRO 1
C State RebateClass
PA
PTD PART DPRODUCTS
STIMATE 1
C State PDL Class
PA
PTD PART DPRODUCTS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)
ANDROGENS
ANDRODERM 1
C State PDL Class
PA
PTD PART DPRODUCTS
ANDROGEL (1% (25 MG/2.5 G) PKT, 1% (50 MG/5 G) PKT,1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G)GEL PCKT)
1
C State PDL Class
PA
PTD PART DPRODUCTS
danazol 1C State PDL Class
PTD PART DPRODUCTS
PAGE 113 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NATESTO 1 PTD PART DPRODUCTS
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1
C State PDL Class
PA
PTD PART DPRODUCTS
testosterone enanthate 200 mg/ml vial 1
C State PDL Class
PA
PTD PART DPRODUCTS
ESTROGENS
AFIRMELLE 1 PTD PART DPRODUCTS
ALORA 1C State PDL Class
PTD PART DPRODUCTS
ALTAVERA 1 PTD PART DPRODUCTS
ALYACEN 1 PTD PART DPRODUCTS
AMABELZ 1 PTD PART DPRODUCTS
AMETHIA 1 PTD PART DPRODUCTS
AMETHIA LO 1 PTD PART DPRODUCTS
AMETHYST 1 PTD PART DPRODUCTS
APRI 1 PTD PART DPRODUCTS
ARANELLE 1 PTD PART DPRODUCTS
PAGE 114 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AUBRA 1 PTD PART DPRODUCTS
AUBRA EQ 1 PTD PART DPRODUCTS
AUROVELA 1C State PDL Class
PTD PART DPRODUCTS
AUROVELA 24 FE 1 PTD PART DPRODUCTS
AUROVELA FE 1 PTD PART DPRODUCTS
AVIANE 1 PTD PART DPRODUCTS
AYUNA 1 PTD PART DPRODUCTS
AZURETTE 1C State PDL Class
PTD PART DPRODUCTS
BALZIVA 1 PTD PART DPRODUCTS
BEKYREE 1 PTD PART DPRODUCTS
BLISOVI 24 FE 1 PTD PART DPRODUCTS
BLISOVI FE 1 PTD PART DPRODUCTS
BRIELLYN 1 PTD PART DPRODUCTS
CAMRESE 1 PTD PART DPRODUCTS
CAMRESE LO 1 PTD PART DPRODUCTS
PAGE 115 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CHATEAL 1 PTD PART DPRODUCTS
CHATEAL EQ 1 PTD PART DPRODUCTS
CLIMARA PRO 1 PTD PART DPRODUCTS
COMBIPATCH 1 PTD PART DPRODUCTS
CRYSELLE 1 PTD PART DPRODUCTS
CYCLAFEM 7-7-7-28 TABLET 1 PTD PART DPRODUCTS
CYRED 1 PTD PART DPRODUCTS
DASETTA 1 PTD PART DPRODUCTS
desogestrel-ethinyl estradiol 1C State PDL Class
PTD PART DPRODUCTS
desogestrel-ethinyl estradiol/ethinyl estradiol 1 PTD PART DPRODUCTS
ELINEST 1 PTD PART DPRODUCTS
ENPRESSE 1 PTD PART DPRODUCTS
ENSKYCE 1 PTD PART DPRODUCTS
ESTARYLLA 1 PTD PART DPRODUCTS
PAGE 116 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
estradiol (0.01 % cream/appl, .025mg/24h patch tdsw,.025mg/24h patch tdwk, .0375mg/24 patch tdsw,.0375mg/24 patch tdwk, 0.05mg/24h patch tdsw,0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk, 0.5 mgtablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet)
1C State PDL Class
PTD PART DPRODUCTS
estradiol/norethindrone acetate 1 PTD PART DPRODUCTS
ESTRING 1C State PDL Class
PTD PART DPRODUCTS
ethinyl estradiol/drospirenone 0.02-3(28) tablet 1 PTD PART DPRODUCTS
ethinyl estradiol/drospirenone 0.03mg-3mg tablet 1C State PDL Class
PTD PART DPRODUCTS
ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 1 PTD PART DPRODUCTS
ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 1C State PDL Class
PTD PART DPRODUCTS
FALMINA 1 PTD PART DPRODUCTS
FEMRING 1
C State PDL Class
PA
PTD PART DPRODUCTS
FEMYNOR 1 PTD PART DPRODUCTS
FYAVOLV 1C State PDL Class
PTD PART DPRODUCTS
PAGE 117 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GIANVI 1 PTD PART DPRODUCTS
HAILEY 1 PTD PART DPRODUCTS
HAILEY 24 FE 1 PTD PART DPRODUCTS
HAILEY FE 1 PTD PART DPRODUCTS
INTROVALE 1 PTD PART DPRODUCTS
ISIBLOOM 1 PTD PART DPRODUCTS
JAIMIESS 1 PTD PART DPRODUCTS
JASMIEL 1 PTD PART DPRODUCTS
JINTELI 1 PTD PART DPRODUCTS
JULEBER 1 PTD PART DPRODUCTS
JUNEL 1 PTD PART DPRODUCTS
JUNEL FE 1 PTD PART DPRODUCTS
JUNEL FE 24 1 PTD PART DPRODUCTS
KAITLIB FE 1C State PDL Class
PTD PART DPRODUCTS
KARIVA 1 PTD PART DPRODUCTS
KELNOR 1-35 1 PTD PART DPRODUCTS
PAGE 118 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KELNOR 1-50 1 PTD PART DPRODUCTS
KURVELO 1 PTD PART DPRODUCTS
LARIN 1 PTD PART DPRODUCTS
LARIN 24 FE 1 PTD PART DPRODUCTS
LARIN FE 1 PTD PART DPRODUCTS
LARISSIA 1 PTD PART DPRODUCTS
LESSINA 1 PTD PART DPRODUCTS
LEVONEST 1 PTD PART DPRODUCTS
levonorgestrel/ethinyl estradiol(levonorgestrel/ethin.estradiol 0.1-0.02mg tablet,levonorgestrel/ethin.estradiol 0.15-0.03 tablet,levonorgestrel/ethin.estradiol 0.15-0.03 tbdspk 3mo,levonorgestrel/ethin.estradiol 6-5-10 tablet,levonorgestrel/ethin.estradiol 90-20 mcg tablet)
1 PTD PART DPRODUCTS
LEVORA-28 1 PTD PART DPRODUCTS
LILLOW 1 PTD PART DPRODUCTS
LO-ZUMANDIMINE 1 PTD PART DPRODUCTS
LOPREEZA 1 PTD PART DPRODUCTS
LORYNA 1 PTD PART DPRODUCTS
LOW-OGESTREL 1 PTD PART DPRODUCTS
PAGE 119 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LUTERA 1 PTD PART DPRODUCTS
MARLISSA 1 PTD PART DPRODUCTS
MELODETTA 24 FE 1 PTD PART DPRODUCTS
MENEST 1C State PDL Class
PTD PART DPRODUCTS
MENOSTAR 1C State PDL Class
PTD PART DPRODUCTS
MICROGESTIN 1 PTD PART DPRODUCTS
MICROGESTIN FE 1 PTD PART DPRODUCTS
MILI 1 PTD PART DPRODUCTS
MIMVEY 1 PTD PART DPRODUCTS
NECON 1 PTD PART DPRODUCTS
NIKKI 1C State PDL Class
PTD PART DPRODUCTS
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet,1mg-20mcg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
norethindrone acetate-ethinyl estradiol (1mg-5mcgtablet, 1.5-0.03mg tablet) 1 PTD PART D
PRODUCTS
norethindrone-e.estradiol-iron 1mg-20(24) capsule 1C State PDL Class
PTD PART DPRODUCTS
PAGE 120 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
norethindrone acetate-ethinyl estradiol/ferrous fumarate(1mg-20(21) tablet, 1mg-20(24) tab chew, 1.5-30(21)tablet)
1 PTD PART DPRODUCTS
norethindrone-ethinyl estradiol/ferrous fumarate 1 PTD PART DPRODUCTS
norgestimate-ethinyl estradiol (0.25-0.035 tablet, 7daysx328 tablet, 7daysx3 lo tablet) 1 PTD PART D
PRODUCTS
NORTREL 1 PTD PART DPRODUCTS
NUVARING 1C State PDL Class
PTD PART DPRODUCTS
ORSYTHIA 1 PTD PART DPRODUCTS
PHILITH 1 PTD PART DPRODUCTS
PIMTREA 1 PTD PART DPRODUCTS
PIRMELLA 1-35 28 TABLET 1 PTD PART DPRODUCTS
PIRMELLA 7-7-7-28 TABLET 1C State PDL Class
PTD PART DPRODUCTS
PORTIA 1 PTD PART DPRODUCTS
PREMARIN VAGINAL CREAM-APPL 1
C State PDL Class
PA
PTD PART DPRODUCTS
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET) 1
C State PDL Class
PTD PART DPRODUCTS
PAGE 121 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREMPHASE 1 PTD PART DPRODUCTS
PREMPRO 1C State PDL Class
PTD PART DPRODUCTS
RECLIPSEN 1 PTD PART DPRODUCTS
SETLAKIN 1 PTD PART DPRODUCTS
SIMLIYA 1 PTD PART DPRODUCTS
SIMPESSE 1 PTD PART DPRODUCTS
SPRINTEC 1 PTD PART DPRODUCTS
SRONYX 1 PTD PART DPRODUCTS
SYEDA 1 PTD PART DPRODUCTS
TARINA 24 FE 1 PTD PART DPRODUCTS
TARINA FE 1 PTD PART DPRODUCTS
TARINA FE 1-20 EQ 1 PTD PART DPRODUCTS
TRI FEMYNOR 1 PTD PART DPRODUCTS
TRI-ESTARYLLA 1 PTD PART DPRODUCTS
TRI-LEGEST FE 1 PTD PART DPRODUCTS
TRI-LO-ESTARYLLA 1 PTD PART DPRODUCTS
PAGE 122 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRI-LO-MARZIA 1 PTD PART DPRODUCTS
TRI-LO-MILI 1 PTD PART DPRODUCTS
TRI-LO-SPRINTEC 1 PTD PART DPRODUCTS
TRI-MILI 1 PTD PART DPRODUCTS
TRI-PREVIFEM 1 PTD PART DPRODUCTS
TRI-SPRINTEC 1 PTD PART DPRODUCTS
TRI-VYLIBRA 1 PTD PART DPRODUCTS
TRI-VYLIBRA LO 1 PTD PART DPRODUCTS
TRIVORA-28 1 PTD PART DPRODUCTS
VELIVET 1 PTD PART DPRODUCTS
VIENVA 1 PTD PART DPRODUCTS
VIORELE 1 PTD PART DPRODUCTS
VOLNEA 1 PTD PART DPRODUCTS
VYFEMLA 1C State PDL Class
PTD PART DPRODUCTS
VYLIBRA 1 PTD PART DPRODUCTS
WERA 1 PTD PART DPRODUCTS
PAGE 123 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XULANE 1C State PDL Class
PTD PART DPRODUCTS
YUVAFEM 1C State PDL Class
PTD PART DPRODUCTS
ZARAH 1 PTD PART DPRODUCTS
ZOVIA 1-35 1 PTD PART DPRODUCTS
ZOVIA 1-35E 1 PTD PART DPRODUCTS
ZUMANDIMINE 1 PTD PART DPRODUCTS
PROGESTINS
CAMILA 1C State PDL Class
PTD PART DPRODUCTS
DEBLITANE 1 PTD PART DPRODUCTS
ERRIN 1 PTD PART DPRODUCTS
HEATHER 1 PTD PART DPRODUCTS
JENCYCLA 1 PTD PART DPRODUCTS
KYLEENA 1C Supplemental
PTD PART DPRODUCTS
LILETTA 1C Supplemental
PTD PART DPRODUCTS
PAGE 124 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAKENA 1,250 MG/5 ML VIAL 1
C State RebateClass
PA
PTD PART DPRODUCTS
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet,10 mg tablet, 150 mg/ml syringe, 150 mg/ml vial) 1
C State PDL Class
PTD PART DPRODUCTS
megestrol acetate (20 mg tablet, 40 mg tablet,400mg/10ml oral susp) 1 PTD PART D
PRODUCTS
MIRENA 1C Supplemental
PTD PART DPRODUCTS
NEXPLANON 1C Supplemental
PTD PART DPRODUCTS
norethindrone 1C State PDL Class
PTD PART DPRODUCTS
norethindrone acetate 1C State PDL Class
PTD PART DPRODUCTS
NORLYDA 1 PTD PART DPRODUCTS
progesterone, micronized 1C State PDL Class
PTD PART DPRODUCTS
SHAROBEL 1 PTD PART DPRODUCTS
SKYLA 1C Supplemental
PTD PART DPRODUCTS
PAGE 125 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 1C State PDL Class
PTD PART DPRODUCTS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (180 MG TABLET, 240 MG TABLET,300 MG TABLET) 1
C State PDL Class
PTD PART DPRODUCTS
LEVO-T 1
QL 30 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
levothyroxine sodium 50 mcg capsule 1C State PDL Class
PTD PART DPRODUCTS
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcgtablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,175 mcg tablet, 200 mcg tablet, 300 mcg tablet)
1
QL 30 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
LEVOXYL 1QL 30 / 30 DAYS
PTD PART DPRODUCTS
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcgtablet) 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
NATURE-THROID (16.25 MG TABLET, 48.75 MG TABLET,81.25 MG TABLET, 97.5 MG TABLET, 113.75 MG TABLET,146.25 MG TABLET, 162.5 MG TABLET, 195 MG TABLET,260 MG TABLET, 325 MG TABLET)
1
NATURE-THROID (32.5 MG TABLET, 65 MG TABLET, 130MG TABLET) 1 PTD PART D
PRODUCTS
PAGE 126 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NP THYROID 1C State PDL Class
PTD PART DPRODUCTS
THYROID 1C State PDL Class
PTD PART DPRODUCTS
thyroid,pork 1C State PDL Class
PTD PART DPRODUCTS
TIROSINT (13 MCG CAPSULE, 25 MCG CAPSULE, 50 MCGCAPSULE, 75 MCG CAPSULE, 88 MCG CAPSULE, 100 MCGCAPSULE, 112 MCG CAPSULE, 125 MCG CAPSULE, 137MCG CAPSULE, 150 MCG CAPSULE)
1 PTD PART DPRODUCTS
UNITHROID 1
QL 30 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
WESTHROID (32.5 MG TABLET, 65 MG TABLET, 130 MGTABLET) 1 PTD PART D
PRODUCTS
WESTHROID (97.5 MG TABLET, 195 MG TABLET) 1
WP THYROID (16.25 MG TABLET, 48.75 MG TABLET, 81.25MG TABLET, 97.5 MG TABLET, 113.75 MG TABLET) 1
WP THYROID (32.5 MG TABLET, 65 MG TABLET, 130 MGTABLET) 1 PTD PART D
PRODUCTS
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
cinacalcet hcl 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 127 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 1 PTD PART DPRODUCTS
ELIGARD 1PA
PTD PART DPRODUCTS
FIRMAGON (2 X 120 MG KIT, 80 MG KIT) 1PA
PTD PART DPRODUCTS
leuprolide acetate 1 mg/0.2ml kit 1
C State PDL Class
PA
PTD PART DPRODUCTS
LUPRON DEPOT (7.5 MG KIT, 11.25 MG 3MO KIT, 22.5 MG3MO KIT) 1
C State PDL Class
PA
PTD PART DPRODUCTS
LUPRON DEPOT (DEPOT 3.75 MG KIT, DEPOT-4 MONTHKIT, DEPOT 45 MG 6MO KIT) 1
PA
PTD PART DPRODUCTS
LUPRON DEPO 11.25MG (LUPANETA) 1
C State PDL Class
PA
PTD PART DPRODUCTS
LUPRON DEPOT 3.75MG (LUPANETA) 1PA
PTD PART DPRODUCTS
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25MG KIT, 15 MG KIT, 30 MG 3MO KIT) 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 128 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe,50 mcg/ml vial, 100 mcg/ml ampul, 100 mcg/ml syringe,100 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul,500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)
1PA
PTD PART DPRODUCTS
SANDOSTATIN LAR DEPOT 1PA
PTD PART DPRODUCTS
SOMATULINE DEPOT 1PA
PTD PART DPRODUCTS
SYNAREL 1PA
PTD PART DPRODUCTS
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 1C State PDL Class
PTD PART DPRODUCTS
propylthiouracil 1C State PDL Class
PTD PART DPRODUCTS
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
ASTAGRAF XL 1
C State PDL Class
PA
PTD PART DPRODUCTS
AZASAN 1 PTD PART DPRODUCTS
azathioprine 50 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
PAGE 129 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyclosporine 250 mg/5ml ampul 1 PTD PART DPRODUCTS
cyclosporine (25 mg capsule, 100 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
cyclosporine, modified (25 mg capsule, 50 mg capsule,100 mg capsule, 100 mg/ml solution) 1
C State PDL Class
PTD PART DPRODUCTS
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE) 1
C State RebateClass
PA
PTD PART DPRODUCTS
ENBREL MINI 1
C State RebateClass
PA
PTD PART DPRODUCTS
ENBREL SURECLICK 1
C State RebateClass
PA
PTD PART DPRODUCTS
everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 1
C State PDL Class
PA
PTD PART DPRODUCTS
GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION) 1
C State PDL Class
PTD PART DPRODUCTS
HUMIRA 40 MG/0.8 ML SYRINGE 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 130 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA PEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA PEN CROHN'S-UC-HS 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA PEN PSOR-UVEITS-ADOL HS 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) 20 MG/0.2 ML SYRING 1
C State RebateClass
PA
PTD PART DPRODUCTS
methotrexate sodium 2.5 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
mycophenolate mofetil (200 mg/ml susp recon, 250 mgcapsule, 500 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
SANDIMMUNE 100 MG/ML SOLN 1C State PDL Class
PTD PART DPRODUCTS
sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1C State PDL Class
PTD PART DPRODUCTS
PAGE 131 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TREXALL 1 PTD PART DPRODUCTS
XELJANZ 5 MG TABLET 1
C State RebateClass
PA
PTD PART DPRODUCTS
IMMUNIZING AGENTS, PASSIVE
FLEBOGAMMA DIF 1
C State RebateClass
PA
PTD PART DPRODUCTS
GAMMAGARD LIQUID 1
C State RebateClass
PA
PTD PART DPRODUCTS
GAMMAGARD S-D 1
C State RebateClass
PA
PTD PART DPRODUCTS
GAMMAKED 1
C State RebateClass
PA
PTD PART DPRODUCTS
GAMUNEX-C 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 132 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HIZENTRA (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL) 1
C State RebateClass
PA
PTD PART DPRODUCTS
PRIVIGEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
IMMUNOMODULATORS
ACTIMMUNE 1
C State PDL Class
PA
PTD PART DPRODUCTS
leflunomide 1C State PDL Class
PTD PART DPRODUCTS
OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 1
C State RebateClass
PA
PTD PART DPRODUCTS
SYNAGIS 1
C Supplemental
PA
PTD PART DPRODUCTS
VACCINES
ADACEL TDAP (SYRINGE, VIAL) 1C vaccine
PTD PART DPRODUCTS
BOOSTRIX TDAP (SYRINGE, VIAL) 1C vaccine
PTD PART DPRODUCTS
PAGE 133 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DAPTACEL DTAP 1C vaccine
PTD PART DPRODUCTS
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 1C vaccine
PTD PART DPRODUCTS
ENGERIX-B PEDIATRIC-ADOLESCENT 1C vaccine
PTD PART DPRODUCTS
HAVRIX 1C vaccine
PTD PART DPRODUCTS
INFANRIX DTAP (SYRINGE, VIAL) 1C vaccine
PTD PART DPRODUCTS
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
PREVNAR 13 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL,10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 1
C vaccine
PTD PART DPRODUCTS
SHINGRIX 1C vaccine
PTD PART DPRODUCTS
SHINGRIX ADJUVANT COMPONENT 1
AL At least 50 yrsold
C vaccine
PTD PART DPRODUCTS
PAGE 134 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SHINGRIX GE ANTIGEN COMPONENT 1C vaccine
PTD PART DPRODUCTS
VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 1 PTD PART D
PRODUCTS
ZOSTAVAX 1C vaccine
PTD PART DPRODUCTS
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
CANASA 1
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
DELZICOL 1
C State PDL Class
QPD 6.0 per day
PTD PART DPRODUCTS
LIALDA 1
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
PENTASA 1
C State PDL Class
QPD 9.0 per day
PTD PART DPRODUCTS
PAGE 135 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SFROWASA 1
C State PDL Class
QPD 60.0 per day
PTD PART DPRODUCTS
GLUCOCORTICOIDS
budesonide 3 mg capdr - er 1C State PDL Class
PTD PART DPRODUCTS
COLOCORT 1C State PDL Class
PTD PART DPRODUCTS
CORTIFOAM 1C State PDL Class
PTD PART DPRODUCTS
hydrocortisone 100mg/60ml enema 1C State PDL Class
PTD PART DPRODUCTS
SULFONAMIDES
sulfasalazine (500 mg tablet, 500 mg tablet dr) 1
C State PDL Class
QPD 8.0 per day
PTD PART DPRODUCTS
METABOLIC BONE DISEASE AGENTS
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mgtablet, 70 mg tablet, 70 mg/75ml solution) 1
C State PDL Class
PTD PART DPRODUCTS
calcitonin,salmon,synthetic 200/spray spray/pump 1C State PDL Class
PTD PART DPRODUCTS
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlampul, 1 mcg/ml solution) 1 PTD PART D
PRODUCTS
PAGE 136 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FORTEO 1
C State PDL Class
PA
PTD PART DPRODUCTS
ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial,150 mg tablet) 1
C State PDL Class
PTD PART DPRODUCTS
PROLIA 1
C State PDL Class
PA
PTD PART DPRODUCTS
teriparatide 1
C State PDL Class
PA
PTD PART DPRODUCTS
MISCELLANEOUS THERAPEUTIC AGENTS
compressor, for nebulizer 1
diaphragms, contoured 1 C State PDL Class
diaphragms, wide seal 1 C State PDL Class
DUROLANE 1 PA
EUFLEXXA 1
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
flash glucose scanning reader 1
AL At least 18 yrsold
C Supplemental
PA
PTBPART BELIGIBLEPRODUCTS
PAGE 137 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
flash glucose sensor 1
AL At least 18 yrsold
C Supplemental
PA
QPD 0.1 per day
PTBPART BELIGIBLEPRODUCTS
GELSYN-3 1
PA
PTBPART BELIGIBLEPRODUCTS
inhaler, assist devices 1QL 2 / 365 DAYS
C State PDL Class
inhaler,assist device,accesory each 1QL 2 / 365 DAYS
C State PDL Class
inhaler,assist device with large mask 1
QL 2 / 365 DAYS
C State PDL Class
PTD PART DPRODUCTS
inhaler,assist device with medium mask 1
QL 2 / 365 DAYS
C State PDL Class
PTD PART DPRODUCTS
inhaler,assist device with small mask 1
QL 2 / 365 DAYS
C State PDL Class
PTD PART DPRODUCTS
LIDO BDK 1
METHERGINE 1C State PDL Class
PTD PART DPRODUCTS
PAGE 138 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylergonovine maleate 0.2 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
mucus clearing device 1
nebulizer 1 PTD PART DPRODUCTS
nebulizer accessories each 1 C State PDL Class
nebulizer accessories kit 1
nebulizer and compressor 1
PARAGARD T 380-A 1C Supplemental
PTD PART DPRODUCTS
peak flow meter/inhaler, assist devices 1
pen needle, diabetic 1 PTD PART DPRODUCTS
spirometers and accessories 1
syringe with needle, insulin, safety, 0.3 ml (29 g x1/2" dispsyrin, 30 gx5/16" disp syrin) 1 PTD PART D
PRODUCTS
syringe with needle, insulin, safety, 0.5 ml (29 g x1/2" dispsyrin, 30 gx5/16" disp syrin) 1 PTD PART D
PRODUCTS
syringe with needle, insulin, safety, 1 ml 1 PTD PART DPRODUCTS
syringe with needle,disposable,insulin 1 ml (syringe dispsyrin, syringe 28gx1/2" disp syrin, syringe 29 g x1/2" dispsyrin, syringe 30 gx5/16" disp syrin)
1 PTD PART DPRODUCTS
syringe with needle,insulin,0.3 ml 1 PTD PART DPRODUCTS
syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin,ml 29 g x1/2" disp syrin, ml 30 gx5/16" disp syrin) 1 PTD PART D
PRODUCTS
syringe,safety with needle,1 ml (25gx1" syringe, 25gx5/8"disp syrin) 1 PTD PART D
PRODUCTS
PAGE 139 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AK-POLY-BAC 1C State PDL Class
PTD PART DPRODUCTS
atropine sulfate (1 % drops, 1 % oint. (g)) 1C State PDL Class
PTD PART DPRODUCTS
bacitracin/polymyxin b sulfate 1C State PDL Class
PTD PART DPRODUCTS
BLEPHAMIDE 1C State PDL Class
PTD PART DPRODUCTS
BLEPHAMIDE S.O.P. 1C State PDL Class
PTD PART DPRODUCTS
cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1C State PDL Class
PTD PART DPRODUCTS
HOMATROPAIRE 1C State PDL Class
PTD PART DPRODUCTS
homatropine hbr 1C State PDL Class
PTD PART DPRODUCTS
NEO-POLYCIN 1C State PDL Class
PTD PART DPRODUCTS
NEO-POLYCIN HC 1C State PDL Class
PTD PART DPRODUCTS
PAGE 140 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
neomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone 1
C State PDL Class
PTD PART DPRODUCTS
neomycin sulfate/bacitracin/polymyxin b 1C State PDL Class
PTD PART DPRODUCTS
neomycin sulfate/polymyxin b sulfate/gramicidin d 1C State PDL Class
PTD PART DPRODUCTS
neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1 PTD PART DPRODUCTS
neomycin/polymyxin b sulfate/dexamethasone(neomycin/polymyxin b/dexametha 0.1 % drops susp,neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g))
1C State PDL Class
PTD PART DPRODUCTS
phenylephrine hcl (2.5 % drops, 10 % drops) 1 PTD PART DPRODUCTS
POLYCIN 1C State PDL Class
PTD PART DPRODUCTS
polymyxin b sulfate/trimethoprim 1C State PDL Class
PTD PART DPRODUCTS
PRED-G (1% DROPS, S.O.P. OINTMENT) 1C State PDL Class
PTD PART DPRODUCTS
RESTASIS 1
C State PDL Class
PA
PTD PART DPRODUCTS
sulfacetamide sodium/prednisolone sodium phosphate 1C State PDL Class
PTD PART DPRODUCTS
PAGE 141 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TOBRADEX EYE OINTMENT 1C State PDL Class
PTD PART DPRODUCTS
TOBRADEX ST 1C State PDL Class
PTD PART DPRODUCTS
tobramycin/dexamethasone 1C State PDL Class
PTD PART DPRODUCTS
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOMIDE 1 PTD PART DPRODUCTS
azelastine hcl 0.05 % drops 1C State PDL Class
PTD PART DPRODUCTS
cromolyn sodium 4 % drops 1C State PDL Class
PTD PART DPRODUCTS
epinastine hcl 1 PTD PART DPRODUCTS
olopatadine hcl (0.1 % drops, 0.2 % drops) 1 PTD PART DPRODUCTS
PAZEO 1 PTD PART DPRODUCTS
OPHTHALMIC ANTI-INFLAMMATORIES
ACUVAIL 1 PTD PART DPRODUCTS
bromfenac sodium 1 PTD PART DPRODUCTS
BROMSITE 1 PTD PART DPRODUCTS
PAGE 142 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dexamethasone sodium phosphate 0.1 % drops 1C State PDL Class
PTD PART DPRODUCTS
diclofenac sodium 0.1 % drops 1C State PDL Class
PTD PART DPRODUCTS
fluorometholone 1C State PDL Class
PTD PART DPRODUCTS
flurbiprofen sodium 1C State PDL Class
PTD PART DPRODUCTS
FML FORTE 1 PTD PART DPRODUCTS
FML S.O.P. 1C State PDL Class
PTD PART DPRODUCTS
ketorolac tromethamine 0.4 % drops 1C State PDL Class
PTD PART DPRODUCTS
ketorolac tromethamine 0.5 % drops 1 PTD PART DPRODUCTS
MAXIDEX 1C State PDL Class
PTD PART DPRODUCTS
PRED MILD 1C State PDL Class
PTD PART DPRODUCTS
prednisolone acetate 1C State PDL Class
PTD PART DPRODUCTS
prednisolone sodium phosphate 1 % drops 1C State PDL Class
PTD PART DPRODUCTS
PAGE 143 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROLENSA 1 PTD PART DPRODUCTS
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 0.1% DROPS 1 PTD PART DPRODUCTS
apraclonidine hcl 1 PTD PART DPRODUCTS
AZOPT 1
C State PDL Class
PA
PTD PART DPRODUCTS
betaxolol hcl 0.5 % drops 1C State PDL Class
PTD PART DPRODUCTS
BETIMOL 1 PTD PART DPRODUCTS
BETOPTIC S 1C State PDL Class
PTD PART DPRODUCTS
brimonidine tartrate 1 PTD PART DPRODUCTS
carteolol hcl 1C State PDL Class
PTD PART DPRODUCTS
dorzolamide hcl 1C State PDL Class
PTD PART DPRODUCTS
dorzolamide hcl/timolol maleate 1C State PDL Class
PTD PART DPRODUCTS
IOPIDINE 1 PTD PART DPRODUCTS
PAGE 144 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levobunolol hcl 1C State PDL Class
PTD PART DPRODUCTS
methazolamide 1C State PDL Class
PTD PART DPRODUCTS
metipranolol 1C State PDL Class
PTD PART DPRODUCTS
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1C State PDL Class
PTD PART DPRODUCTS
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % dropdaily, 0.5 % drops, 0.5 % sol-gel) 1
C State PDL Class
PTD PART DPRODUCTS
TIMOPTIC OCUDOSE 1 PTD PART DPRODUCTS
TIMOPTIC-XE 1 PTD PART DPRODUCTS
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost 1
QL 2.5 / 30 days
C State PDL Class
PTD PART DPRODUCTS
travoprost 1
C State PDL Class
PA
PTD PART DPRODUCTS
ZIOPTAN 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 145 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OTIC AGENTS
acetic acid 2 % solution 1C State PDL Class
PTD PART DPRODUCTS
CIPRODEX 1C State Rebate
Class
PTD PART DPRODUCTS
fluocinolone acetonide oil 1 PTD PART DPRODUCTS
hydrocortisone/acetic acid 1C State PDL Class
PTD PART DPRODUCTS
neomycin sulfate/polymyxin b sulfate/hydrocortisone(neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp,neomycin/polymyxin b/hydrocort 3.5-10k-1 solution)
1C State PDL Class
PTD PART DPRODUCTS
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ASMANEX 1C State Rebate
Class
PTD PART DPRODUCTS
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb) 1
AL Up to 4 yrs old
C State RebateClass
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
FLOVENT DISKUS 1C State Rebate
Class
PTD PART DPRODUCTS
PAGE 146 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLOVENT HFA 1C State Rebate
Class
PTD PART DPRODUCTS
flunisolide 1C State PDL Class
PTD PART DPRODUCTS
fluticasone propionate 50 mcg spray susp 1C State PDL Class
PTD PART DPRODUCTS
OMNARIS 1 PTD PART DPRODUCTS
PULMICORT FLEXHALER 1C State Rebate
Class
PTD PART DPRODUCTS
QNASL 1 PTD PART DPRODUCTS
QNASL CHILDREN 1 PTD PART DPRODUCTS
triamcinolone acetonide 55 mcg spray 1 C State PDL Class
ZETONNA 1 PTD PART DPRODUCTS
ANTIHISTAMINES
azelastine hcl (137 mcg spray/pump, 205.5 mcgspray/pump) 1
C State PDL Class
PTD PART DPRODUCTS
cetirizine hcl 1 mg/ml solution 1
C State PDL Class
QPD 5 per day
PTD PART DPRODUCTS
clemastine fumarate 2.68 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
PAGE 147 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyproheptadine hcl 1C State PDL Class
PTD PART DPRODUCTS
DIPHEN 12.5 MG/5 ML ELIXIR 1C State PDL Class
PTD PART DPRODUCTS
DIPHEN 12.5 MG/5 ML SOLUTION 1 C State PDL Class
diphenhydramine hcl 12.5mg/5ml elixir 1 C State PDL Class
diphenhydramine hcl 50 mg/ml syringe 1 PTD PART DPRODUCTS
hydroxyzine hcl (10 mg/5 ml solution, 50 mg/25mlsolution) 1
QL 300 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
hydroxyzine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1
QL 240 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
hydroxyzine pamoate (50 mg capsule, 100 mg capsule) 1
QL 120 / 30 DAYS
C State PDL Class
PTD PART DPRODUCTS
hydroxyzine pamoate 25 mg capsule 1
QL 120 / 30 DAYS
C State PDL Class
QPD 4.0 per day
PTD PART DPRODUCTS
PHENERGAN (25 MG/ML VIAL, 50 MG/ML VIAL) 1 PTD PART DPRODUCTS
promethazine hcl (6.25mg/5ml syrup, 25 mg/ml ampul,50 mg/ml ampul) 1 PTD PART D
PRODUCTS
PAGE 148 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet) 1
C State PDL Class
PTD PART DPRODUCTS
ANTILEUKOTRIENES
montelukast sodium 4 mg gran pack 1
AL Up to 3 yrs old
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
montelukast sodium (4 mg tab chew, 5 mg tab chew, 10mg tablet) 1
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA 1C State Rebate
Class
PTD PART DPRODUCTS
ipratropium bromide 0.2 mg/ml solution 1
C State RebateClass
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
ipratropium bromide (21 mcg spray, 42 mcg spray) 1C State PDL Class
PTD PART DPRODUCTS
SPIRIVA 1C State Rebate
Class
PTD PART DPRODUCTS
PAGE 149 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TUDORZA PRESSAIR 1C State Rebate
Class
PTD PART DPRODUCTS
BRONCHODILATORS, SYMPATHOMIMETIC
albuterol sulfate 2 mg/5 ml syrup 1C State Rebate
Class
PTD PART DPRODUCTS
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 5 mg/mlsolution)
1
C State RebateClass
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
epinephrine (0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1
QL 2 / 30 DAYS
C State RebateClass
PTD PART DPRODUCTS
isoproterenol hcl 1 PTD PART DPRODUCTS
ISUPREL 1 MG/5 ML AMPUL 1 PTD PART DPRODUCTS
PROAIR HFA 1C State Rebate
Class
PTD PART DPRODUCTS
SEREVENT DISKUS 1
AL At least 4 yrsold
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 150 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CYSTIC FIBROSIS AGENTS
BETHKIS 1
C State RebateClass
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULESPACKET, 150 MG TABLET) 1
PA
PTD PART DPRODUCTS
KITABIS PAK 1
C State RebateClass
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
THEO-24 1 PTD PART DPRODUCTS
theophylline anhydrous (100 mg tab er 12h, 200 mg tab er12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)
1 PTD PART DPRODUCTS
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 1
C State RebateClass
PA
PTD PART DPRODUCTS
LETAIRIS 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 151 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REVATIO 10 MG/ML ORAL SUSP 1
AL Up to 12 yrs old
C State RebateClass
PTD PART DPRODUCTS
sildenafil citrate 20 mg tablet 1
C State RebateClass
PA
PTD PART DPRODUCTS
TRACLEER (62.5 MG TABLET, 125 MG TABLET) 1
C State RebateClass
PA
PTD PART DPRODUCTS
VELETRI 1PA
PTD PART DPRODUCTS
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine 1
C Supplemental
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
ADVAIR DISKUS 1
ST
C State RebateClass
PTD PART DPRODUCTS
ADVAIR HFA 1
ST
AL 4.0 to 12.0 yrsold
C State RebateClass
PTD PART DPRODUCTS
PAGE 152 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANORO ELLIPTA 1PA
PTD PART DPRODUCTS
ARALAST NP 1
C State PDL Class
PA
PTD PART DPRODUCTS
benzonatate (100 mg capsule, 150 mg capsule, 200 mgcapsule) 1
C State PDL Class
PTD PART DPRODUCTS
BROMFED DM 1C State PDL Class
PTD PART DPRODUCTS
brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 1
C State PDL Class
PTD PART DPRODUCTS
COMBIVENT RESPIMAT 1C State Rebate
Class
PTD PART DPRODUCTS
cromolyn sodium 20 mg/2 ml ampul-neb 1
C State PDL Class
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
DULERA (100 MCG INHALER, 200 MCG INHALER) 1C State Rebate
Class
PTD PART DPRODUCTS
hydrocodone bitartrate/homatropine methylbromide(bit/homatrop 5 mg-1.5mg tablet, bit/homatrop 5-1.5mg/5 syrup)
1
QL 240 / 12 DAYS
AL At least 18 yrsold
C State PDL Class
PTD PART DPRODUCTS
PAGE 153 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYDROMET 1
QL 240 / 12 DAYS
AL At least 18 yrsold
C State PDL Class
PTD PART DPRODUCTS
ipratropium bromide/albuterol sulfate 1
C State RebateClass
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
phenylephrine hcl/promethazine hcl 1C State PDL Class
PTD PART DPRODUCTS
PROLASTIN C 1,000 MG VIAL 1PA
PTD PART DPRODUCTS
promethazine hcl/codeine 6.25-10/5 syrup 1
AL At least 18 yrsold
C State PDL Class
QPD 20.0 per day
PTD PART DPRODUCTS
promethazine hcl/dextromethorphan hbr 1
C State PDL Class
QPD 16.0 per day
PTD PART DPRODUCTS
PULMOZYME 1
C State PDL Class
PA
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
PAGE 154 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
STIOLTO RESPIMAT 1
C State RebateClass
PA
PTD PART DPRODUCTS
SYMBICORT 1
ST
C State RebateClass
PTD PART DPRODUCTS
TUZISTRA XR 1
ZEMAIRA 1PA
PTD PART DPRODUCTS
SKELETAL MUSCLE RELAXANTS
baclofen (10 mg tablet, 20 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
dantrolene sodium (25 mg capsule, 50 mg capsule, 100mg capsule) 1
C State PDL Class
PTD PART DPRODUCTS
METAXALL 1 PTD PART DPRODUCTS
metaxalone 1 PTD PART DPRODUCTS
methocarbamol (500 mg tablet, 750 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
orphenadrine citrate 100 mg tablet er 1 PTD PART DPRODUCTS
PAGE 155 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tizanidine hcl (2 mg tablet, 4 mg tablet) 1C State PDL Class
PTD PART DPRODUCTS
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
eszopiclone 1
AL At least 6 yrsold
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
temazepam (15 mg capsule, 30 mg capsule) 1
AL At least 6 yrsold
C State PDL Class
QPD 1.0 per day
PTD PART DPRODUCTS
zolpidem tartrate 10 mg tablet 1
AL At least 6 yrsold
C State RebateClass
QPD 1.0 per day
PTD PART DPRODUCTS
zolpidem tartrate 5 mg tablet 1
AL At least 6 yrsold
C State RebateClass
QPD 2 per day
PTD PART DPRODUCTS
PAGE 156 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SLEEP DISORDERS, OTHER
ROZEREM 1
QL 30 / 30 Days
ST
AL At least 6 yrsold
C State RebateClass
PTD PART DPRODUCTS
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHROMAGEN 1
KIONEX 1C State PDL Class
PTD PART DPRODUCTS
NIFEREX 1
sodium polystyrene sulfonate (15 g/60 ml oral susp,powder) 1
C State PDL Class
PTD PART DPRODUCTS
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMASUSP) 1 PTD PART D
PRODUCTS
ELECTROLYTE/MINERAL REPLACEMENT
0.9 % sodium chloride (0.9 % 0.9 % cartridge, 0.9 % 0.9 %syringe) 1 PTD PART D
PRODUCTS
CORVITE 150 1
EFFER-K (20 TABLET EFF, 25 TABLET EFF) 1 PTD PART DPRODUCTS
EFFER-K 10 MEQ TABLET EFF 1
fluoride (sodium) 0.5 mg/ml drops 1 C State PDL Class
PAGE 157 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluoride (sodium) (0.25(0.55) tab chew, 0.5(1.1)mg tabchew, 1mg(2.2mg) tab chew) 1
C State PDL Class
PTD PART DPRODUCTS
FLUORITAB 1C State PDL Class
PTD PART DPRODUCTS
FLURA-DROPS 1 PTD PART DPRODUCTS
HEMATOGEN 1
HEMATOGEN FA 1
HEMATOGEN FORTE 1
K-TAB ER 8 MEQ TABLET 1 PTD PART DPRODUCTS
KLOR-CON 1 PTD PART DPRODUCTS
KLOR-CON 10 1 PTD PART DPRODUCTS
KLOR-CON 8 1 PTD PART DPRODUCTS
KLOR-CON M10 1 PTD PART DPRODUCTS
KLOR-CON M15 1 PTD PART DPRODUCTS
KLOR-CON M20 1 PTD PART DPRODUCTS
KLOR-CON-EF 1 PTD PART DPRODUCTS
LUDENT FLUORIDE 1C State PDL Class
PTD PART DPRODUCTS
NEPHRON FA 1
PAGE 158 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUFERA 1
potassium chloride (2 meq/ml ampul, 2 meq/ml vial, 8meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meqtab er prt, 20 meq tablet er, 20meq/15ml liquid,40meq/15ml liquid)
1 PTD PART DPRODUCTS
potassium chloride in water for injection, sterile (in10meq/0.1l piggyback, in 10meq/50ml piggyback, in20meq/0.1l piggyback, in 20meq/50ml piggyback, in40meq/0.1l piggyback)
1 PTD PART DPRODUCTS
TRICON 1 PTD PART DPRODUCTS
TRIGELS-F FORTE 1
BACMIN 1 PTD PART DPRODUCTS
BAL-CARE DHA 1 PTD PART DPRODUCTS
C-NATE DHA 1 PTD PART DPRODUCTS
CARNITOR 1 GM/5 ML VIAL 1 PTD PART DPRODUCTS
CITRANATAL B-CALM 1 PTD PART DPRODUCTS
COMPLETE NATAL DHA 1 PTD PART DPRODUCTS
CONCEPT DHA 1 PTD PART DPRODUCTS
CONCEPT OB 1 PTD PART DPRODUCTS
cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1C Supplemental
PTD PART DPRODUCTS
PAGE 159 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIALYVITE 1
DUET DHA 400 1 PTD PART DPRODUCTS
DUET DHA BALANCED 1 PTD PART DPRODUCTS
ELITE-OB 1 PTD PART DPRODUCTS
ergocalciferol (vitamin d2) 1 PTD PART DPRODUCTS
folic acid 1 mg tablet 1
FOLIVANE-OB 1 PTD PART DPRODUCTS
FORTAVIT 1 PTD PART DPRODUCTS
KOSHER PRENATAL PLUS IRON 1 PTD PART DPRODUCTS
levocarnitine 330 mg tablet 1 PTD PART DPRODUCTS
levocarnitine (with sugar) 1 PTD PART DPRODUCTS
MARNATAL-F 1 PTD PART DPRODUCTS
multivitamin combination no.51/ferrous fumarate/folicacid 1 PTD PART D
PRODUCTS
MVC-FLUORIDE 1 PTD PART DPRODUCTS
MYNATAL 1 PTD PART DPRODUCTS
MYNATAL PLUS 1 PTD PART DPRODUCTS
MYNATAL-Z 1 PTD PART DPRODUCTS
PAGE 160 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MYNEPHROCAPS 1
MYNEPHRON 1
NATACHEW 1 PTD PART DPRODUCTS
NEEVODHA 1 PTD PART DPRODUCTS
NESTABS 1 PTD PART DPRODUCTS
NESTABS ABC 1 PTD PART DPRODUCTS
NESTABS DHA 1 PTD PART DPRODUCTS
NEWGEN 1 PTD PART DPRODUCTS
NICADAN 1
NICAZEL 1 PTD PART DPRODUCTS
NICAZEL FORTE 1
NIVA-PLUS 1 PTD PART DPRODUCTS
O-CAL FA 1 PTD PART DPRODUCTS
O-CAL PRENATAL 1 PTD PART DPRODUCTS
OB COMPLETE 1 PTD PART DPRODUCTS
OB COMPLETE ONE 1 PTD PART DPRODUCTS
OB COMPLETE PETITE 1 PTD PART DPRODUCTS
OB COMPLETE PREMIER 1 PTD PART DPRODUCTS
PAGE 161 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OB COMPLETE WITH DHA 1 PTD PART DPRODUCTS
pediatric multivit with a,c,d3 no.21/sodium fluoride 1 PTD PART DPRODUCTS
pediatric multivitamin no.2/sodium fluoride 1
pediatric multivitamins no.17 with sodium fluoride 1 PTD PART DPRODUCTS
PNV 29-1 1 PTD PART DPRODUCTS
pnv no.72/ferrous fumarate/folic acid/omega-3/dha 1 PTD PART DPRODUCTS
PNV-OMEGA 1 PTD PART DPRODUCTS
PR NATAL 400 1 PTD PART DPRODUCTS
PR NATAL 400 EC 1 PTD PART DPRODUCTS
PR NATAL 430 1 PTD PART DPRODUCTS
PR NATAL 430 EC 1 PTD PART DPRODUCTS
PRENA1 CHEW 1 PTD PART DPRODUCTS
PRENA1 PEARL 1 PTD PART DPRODUCTS
PRENA1 TRUE 1 PTD PART DPRODUCTS
PRENATA 1 PTD PART DPRODUCTS
PRENATABS FA 1 PTD PART DPRODUCTS
PRENATABS RX 1 PTD PART DPRODUCTS
PAGE 162 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prenatal vits with calcium no.115/iron fumarate/folic acid 1
prenatal vits with calcium no.72/ferrous fumarate/folicacid 1 PTD PART D
PRODUCTS
prenatal vits with calcium no.72/iron,carbonyl/folic acid 1 PTD PART DPRODUCTS
PRENATE AM 1 PTD PART DPRODUCTS
PRENATE CHEWABLE 1 PTD PART DPRODUCTS
PRENATE DHA 1 PTD PART DPRODUCTS
PRENATE ELITE 1 PTD PART DPRODUCTS
PRENATE ENHANCE 1 PTD PART DPRODUCTS
PRENATE ESSENTIAL 1 PTD PART DPRODUCTS
PRENATE MINI 1 PTD PART DPRODUCTS
PRENATE PIXIE 1 PTD PART DPRODUCTS
PRENATE RESTORE 1 PTD PART DPRODUCTS
PRENATE STAR 1 PTD PART DPRODUCTS
PREPLUS 1 PTD PART DPRODUCTS
PRETAB 1 PTD PART DPRODUCTS
PRIMACARE 1 PTD PART DPRODUCTS
PROVIDA OB 1 PTD PART DPRODUCTS
PAGE 163 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PUREFE OB PLUS 1 PTD PART DPRODUCTS
pyridoxine hcl (vitamin b6) 1 PTD PART DPRODUCTS
QUFLORA (0.125 MG GUMMIES, PED 0.25 MG CHEW TAB,PED 0.25 MG/ML DROP, PED 0.5 MG CHEW TAB, PED 0.5MG/ML DROP, PED 1 MG CHEW TAB)
1 PTD PART DPRODUCTS
R-NATAL OB 1 PTD PART DPRODUCTS
RENA-VITE RX 1 PTD PART DPRODUCTS
RENAL CAPS 1
RENO CAPS 1
REQ49+ 1
SE-NATAL 19 1 PTD PART DPRODUCTS
SE-NATAL-19 1 PTD PART DPRODUCTS
SELECT-OB 1 PTD PART DPRODUCTS
SELECT-OB + DHA 1 PTD PART DPRODUCTS
STROVITE ONE 1 PTD PART DPRODUCTS
SUPERVITE 1
TARON-C DHA 1 PTD PART DPRODUCTS
thiamine hcl 1 PTD PART DPRODUCTS
THRIVITE RX 1 PTD PART DPRODUCTS
PAGE 164 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRICARE 1 PTD PART DPRODUCTS
TRINATAL RX 1 1 PTD PART DPRODUCTS
TRINATE 1 PTD PART DPRODUCTS
TRIPHROCAPS 1
TRISTART DHA 1 PTD PART DPRODUCTS
TRIVEEN-DUO DHA 1 PTD PART DPRODUCTS
VIC-FORTE 1 PTD PART DPRODUCTS
VIRT-C DHA 1 PTD PART DPRODUCTS
VIRT-CAPS 1 PTD PART DPRODUCTS
VIRT-NATE DHA 1 PTD PART DPRODUCTS
VIRT-PN DHA 1 PTD PART DPRODUCTS
VIRT-PN PLUS 1 PTD PART DPRODUCTS
VITAFOL GUMMIES 1 PTD PART DPRODUCTS
VITAFOL NANO 1 PTD PART DPRODUCTS
VITAFOL ULTRA 1 PTD PART DPRODUCTS
VITAFOL-OB 1 PTD PART DPRODUCTS
VITAFOL-OB+DHA 1 PTD PART DPRODUCTS
PAGE 165 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VITAFOL-ONE 1 PTD PART DPRODUCTS
VITAL-D RX 1
VITAMEDMD ONE RX 1 PTD PART DPRODUCTS
VITAMEDMD REDICHEW RX 1 PTD PART DPRODUCTS
VITAPEARL 1 PTD PART DPRODUCTS
VITATRUE 1 PTD PART DPRODUCTS
VP-PNV-DHA 1 PTD PART DPRODUCTS
VP-VITE RX 1
ZATEAN-PN DHA 1 PTD PART DPRODUCTS
ZATEAN-PN PLUS 1 PTD PART DPRODUCTS
Uncategorized
Unclassified
AFLURIA QUAD 2020-2021 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
AFLURIA QUAD 2020-21 (3YR UP) 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
PAGE 166 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AFLURIA QUAD 2020-21 (6-35MO) 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
AFLURIA QUAD 2021-2022 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
AFLURIA QUAD 2021-22 (3YR UP) 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
AFLURIA QUAD 2021-22 (6-35MO) 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
AIMOVIG AUTOINJECTOR 1PA
PTD PART DPRODUCTS
AJOVY AUTOINJECTOR 1
QL 1.5 / 30 days
C State RebateClass
PA
QPD 0.057 per day
PTD PART DPRODUCTS
AJOVY SYRINGE 1
C State RebateClass
PA
QPD 0.057 per day
PTD PART DPRODUCTS
PAGE 167 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARISTADA INITIO 1
QL 4.8 / 365 DAYS
AL At least 18 yrsold
C State RebateClass
PTD PART DPRODUCTS
AVSOLA 1
C State RebateClass
PA
PTD PART DPRODUCTS
baclofen 5 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
BIKTARVY 1
C State PDL Class
QPD 1 per day
PTD PART DPRODUCTS
butalbital/aspirin/caffeine 50-325-40 tablet 1C State PDL Class
PTD PART DPRODUCTS
CYCLOSPORINE IN KLARITY 1
DULERA 50 MCG-5 MCG INHALER 1C State Rebate
Class
PTD PART DPRODUCTS
ELIQUIS DVT-PE TREAT START 5MG 1
QL 80 / 365 days
C State RebateClass
PTD PART DPRODUCTS
EMGALITY PEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 168 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMGALITY 120 MG/ML SYRINGE 1
C State RebateClass
PA
PTD PART DPRODUCTS
ENBREL 25 MG/0.5 ML VIAL 1
C State RebateClass
PA
PTD PART DPRODUCTS
FLORIVA PLUS 1 PTD PART DPRODUCTS
FLUAD 2020-2021 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
FLUAD QUAD 2020-2021 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
FLUAD QUAD 2021-2022 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FLUARIX QUAD 2020-2021 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
FLUARIX QUAD 2021-2022 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FLUBLOK QUAD 2020-2021 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
PAGE 169 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUBLOK QUAD 2021-2022 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FLUCELVAX QUAD 2020-2021 (2020-2021 SYR, 2020-2021VIAL) 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
FLUCELVAX QUAD 2021-2022 (2021-2022 SYR, 2021-2022VIAL) 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FLULAVAL QUAD 2020-2021 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
FLULAVAL QUAD 2021-2022 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FLUMIST QUAD 2020-2021 1
C vaccine
PTBPART BELIGIBLEPRODUCTS
FLUZONE HIGH-DOSE QUAD 2020-21 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
FLUZONE HIGH-DOSE QUAD 2021-22 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
PAGE 170 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUZONE QUAD 2020-2021 (2020-2021 SYRINGE, 2020-2021 VIAL) 1
C vaccine
PTD PART DPRODUCTS
PTBPART BELIGIBLEPRODUCTS
FLUZONE QUAD 2021-2022 (2021-2022 SYRINGE, 2021-2022 VIAL) 1
C Vaccine
PTBPART BELIGIBLEPRODUCTS
FULPHILA 1
C State RebateClass
PA
PTD PART DPRODUCTS
ganciclovir sodium 500mg/10ml vial 1
C State PDL Class
PA
PTD PART DPRODUCTS
GILENYA 0.25 MG CAPSULE 1
C State RebateClass
PA
PTD PART DPRODUCTS
glycopyrrolate 1.5 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
heparin sodium,porcine in 0.9 % sodium chloride(sod,porcine/0.9 % 2500/5 ml syringe, sod,porcine/0.9 %6000/3 ml syringe)
1C State Rebate
Class
PTD PART DPRODUCTS
HIZENTRA (1 GRAM/5 ML SYRINGE, 2 GRAM/10 MLSYRINGE, 4 GRAM/20 ML SYRINGE) 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 171 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA(CF) (10 MG/0.1 ML SYRING, 40 MG/0.4 MLSYRING) 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) PEDIATRIC CROHN'S 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) PEN 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) PEN CROHN'S-UC-HS 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) PEN PEDIATRIC UC 1
C State RebateClass
PA
PTD PART DPRODUCTS
HUMIRA(CF) PEN PSOR-UV-ADOL HS 1
C State RebateClass
PA
PTD PART DPRODUCTS
ICLUSIG (10 MG TABLET, 30 MG TABLET) 1PA
PTD PART DPRODUCTS
IMBRUVICA (70 MG CAPSULE, 140 MG TABLET, 280 MGTABLET, 420 MG TABLET, 560 MG TABLET) 1
C State PDL Class
PA
PTD PART DPRODUCTS
PAGE 172 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JANSSEN COVID-19 VACCINE (EUA) 1
QLmax quantity 2fills per lifetimecovid vaccine
AL At least 18 yrsold
C vaccine
PTBPART BELIGIBLEPRODUCTS
KENALOG-80 1
C State PDL Class
PA
PTD PART DPRODUCTS
ketoprofen 25 mg capsule 1C State PDL Class
PTD PART DPRODUCTS
MAKENA 275 MG/1.1 ML AUTOINJCT 1
C State RebateClass
PA
PTD PART DPRODUCTS
MODERNA COVID-19 VACCINE (EUA) 1
QL max quantity 3per lifetime
AL At least 18 yrsold
C vaccine
PTBPART BELIGIBLEPRODUCTS
NESTABS ONE 1 PTD PART DPRODUCTS
NIVESTYM (300 MCG/0.5 ML SYRING, 480 MCG/0.8 MLSYRING) 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 173 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NPLATE 125 MCG VIAL 1
C State RebateClass
PA
PTD PART DPRODUCTS
NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE) 1
PA
PTD PART DPRODUCTS
NYVEPRIA 1
C State RebateClass
PA
PTD PART DPRODUCTS
oxycodone hcl/acetaminophen 2.5-300 mg tablet 1 C State PDL Class
PERSERIS (ER 90 MG SYRINGE KIT, ER 120 MG SYRINGEKIT) 1 PTD PART D
PRODUCTS
PERSERIS ER 90 MG POWDER SYRNG 1
PFIZER COVID (12Y UP) VAC(EUA) 1
QL max quantity 3per lifetime
AL At least 12 yrsold
PTBPART BELIGIBLEPRODUCTS
PFIZER COVID (5-11Y) VAC (EUA) 1
QLmax quantity 2fills per lifetimecovid vaccine
AL 5 to 11 yrs old
PTBPART BELIGIBLEPRODUCTS
PFIZER COVID-19 VACCINE (EUA) 1
QL max quantity 3per lifetime
AL At least 12 yrsold
C vaccine
PTBPART BELIGIBLEPRODUCTS
PAGE 174 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PIFELTRO 1C State PDL Class
PTD PART DPRODUCTS
prednisolone acetate/pf 1 C State PDL Class
PREVNAR 20 1
AL At least 19 yrsold
C Vaccine
PTBPART BELIGIBLEPRODUCTS
RETACRIT 1
C State RebateClass
PA
PTD PART DPRODUCTS
SPRAVATO 1
C State PDL Class
PA
PTD PART DPRODUCTS
SUBLOCADE 1
C State RebateClass
PA
PTD PART DPRODUCTS
syringe,safety with needle,1ml 23gx1" disp syrin 1 PTD PART DPRODUCTS
TASIGNA 50 MG CAPSULE 1
C State PDL Class
PA
PTD PART DPRODUCTS
testosterone cypionate 50 mg/ml vial 1C State PDL Class
PA
PAGE 175 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tramadol hcl 100 mg tablet 1C State PDL Class
PTD PART DPRODUCTS
triamcinolone diacetate in 0.9 % sodium chloride 1 C State PDL Class
triamcinolone diacetate in 0.9 % sodium chloride/pf 1 C State PDL Class
TRIJARDY XR 1
C State RebateClass
PA
PTD PART DPRODUCTS
TRULICITY (3 MG/0.5 ML PEN, 4.5 MG/0.5 ML PEN) 1
C State RebateClass
PA
PTD PART DPRODUCTS
UBRELVY 1PA
PTD PART DPRODUCTS
UDENYCA 1
C State RebateClass
PA
PTD PART DPRODUCTS
vancomycin hcl 50 mg/ml soln recon 1C State PDL Class
PTD PART DPRODUCTS
vancomycin hcl (1.25 g vial, 1.5 g vial, 250 mg vial) 1C Supplemental
PTD PART DPRODUCTS
vancomycin hcl in sterile water 1 C Supplemental
PAGE 176 LAST UPDATED 11/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vancomycin hcl in water for injection (peg-400, nada)(vancomycin/water inj 1.5g/300ml piggyback,vancomycin/water inj 2 g/400 ml piggyback)
1 C Supplemental
vancomycin/0.9 % sod chloride 1.5g/300ml plast. bag 1 C Supplemental
vancomycin hcl in 5 % dextrose 1.75 g/500 plast. bag 1 C Supplemental
XALIX 1
XARELTO 2.5 MG TABLET 1
C State RebateClass
QPD 2.0 per day
PTD PART DPRODUCTS
XELJANZ 10 MG TABLET 1
C State RebateClass
PA
PTD PART DPRODUCTS
XIGDUO XR 2.5 MG-1,000 MG TAB 1
C State RebateClass
PA
PTD PART DPRODUCTS
PAGE 177 LAST UPDATED 11/2021
Index of Covered Drugs
00.9 % sodium chloride 157
AA-HYDROCORT 107abacavir sulfate 58abacavir sulfate/lamivudine 58abacavir sulfate/lamivudine/zidovudine 58ABILIFY MAINTENA 49acamprosate calcium 9acarbose 66acetaminophen with codeine phosphate 4acetazolamide 84acetic acid 146acetylcysteine 152acitretin 95ACTIMMUNE 133ACTOPLUS MET XR 66ACUVAIL 142acyclovir 62acyclovir sodium 62ADACEL TDAP 133adapalene 95ADCIRCA 151ADDERALL 88ADDERALL XR 89adefovir dipivoxil 55ADV ALLERGY COLLECTION KIT 107ADVAIR DISKUS 152ADVAIR HFA 152AFINITOR 41AFINITOR DISPERZ 41AFIRMELLE 114AFLURIA QUAD 2020-2021 166AFLURIA QUAD 2020-21 (3YR UP) 166AFLURIA QUAD 2020-21 (6-35MO) 167AFLURIA QUAD 2021-2022 167AFLURIA QUAD 2021-22 (3YR UP) 167AFLURIA QUAD 2021-22 (6-35MO) 167AGONEAZE 7
AIMOVIG AUTOINJECTOR 167AJOVY AUTOINJECTOR 167AJOVY SYRINGE 167AK-POLY-BAC 140ALA-CORT 107ALA-SCALP 107albendazole 45albuterol sulfate 150ALDACTAZIDE 82ALECENSA 41alendronate sodium 136ALFERON N 62alfuzosin hcl 105ALINIA 45ALKERAN 38allopurinol 35ALOMIDE 142ALORA 114alosetron hcl 102ALPHAGAN P 144alprazolam 63ALPRAZOLAM INTENSOL 63ALTAVERA 114ALYACEN 114AMABELZ 114amantadine hcl 47AMETHIA 114AMETHIA LO 114AMETHYST 114amikacin sulfate 11amiloride hcl 85aminocaproic acid 75amiodarone hcl 78AMITIZA 102amitriptyline hcl 30amlodipine besylate 80ammonium lactate 95AMNESTEEM 95amoxapine 30amoxicillin 16amoxicillin/potassium clavulanate 16
ampicillin sodium 16ampicillin trihydrate 16anagrelide hcl 74ANASTIA 7anastrozole 41ANDRODERM 113ANDROGEL 113ANODYNE LPT 7ANORO ELLIPTA 153ANUSOL-HC 95apraclonidine hcl 144aprepitant 33APRI 114APRISO 135APTIVUS 60ARALAST NP 153ARANELLE 114aripiprazole 49ARISTADA 50ARISTADA INITIO 168ARISTOSPAN 107ARMOUR THYROID 126ASCOMP WITH CODEINE 4ASMANEX 146ASTAGRAF XL 129atazanavir sulfate 60atenolol 79atenolol/chlorthalidone 82atomoxetine hcl 89atorvastatin calcium 86atovaquone/proguanil hcl 45ATRIPLA 57atropine sulfate 140ATROVENT HFA 149AUBRA 115AUBRA EQ 115AUGMENTIN 16AUROVELA 115AUROVELA 24 FE 115AUROVELA FE 115AVASTIN 44
AVC 18AVIANE 115AVITA 95AVONEX 93AVONEX PEN 93AVSOLA 168AYUNA 115AZASAN 129azathioprine 129azelastine hcl 142,147azithromycin 17AZOPT 144AZURETTE 115
Bbacitracin 12bacitracin/polymyxin b sulfate 140baclofen 155,168BACMIN 159BAL-CARE DHA 159BALZIVA 115BANZEL 22BARACLUDE 55BEKYREE 115benazepril hcl 77benazepril hcl/hydrochlorothiazide 82BENZEPRO 95benzonatate 153benzoyl peroxide 95,96benzoyl peroxide microspheres 96benztropine mesylate 46betamethasone dipropionate 108betamethasone dipropionate/propyleneglycol 108betamethasone valerate 108BETASERON 93betaxolol hcl 144bethanechol chloride 106BETHKIS 151BETIMOL 144BETOPTIC S 144
bexarotene 44bicalutamide 39BICILLIN L-A 16BIKTARVY 168bisoprolol fumarate 79bisoprolol fumarate/hydrochlorothiazide 82BLEPHAMIDE 140BLEPHAMIDE S.O.P. 140BLISOVI 24 FE 115BLISOVI FE 115BOCASAL 94BOOSTRIX TDAP 133BPO 96BRIELLYN 115BRILINTA 75brimonidine tartrate 144BROMFED DM 153bromfenac sodium 142bromocriptine mesylate 47brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 153BROMSITE 142budesonide 136,146bumetanide 84buprenorphine hcl 9buprenorphine hcl/naloxone hcl 9bupropion hcl 10,25buspirone hcl 62,63butalbital/acetaminophen/caffeine 92butalbital/acetaminophen/caffeine/codeinephosphate 4butalbital/aspirin/caffeine 1,168BUTRANS 3BYDUREON PEN 66BYETTA 66
CC-NATE DHA 159cabergoline 128CAFERGOT 36calcipotriene 96
calcitonin,salmon,synthetic 136calcitriol 136calcium acetate 107CAMILA 124CAMRESE 115CAMRESE LO 115CANASA 135candesartan cilexetil 76CAPHOSOL 94CAPRELSA 42captopril 77captopril/hydrochlorothiazide 82CARAC 96carbamazepine 22,23carbidopa/levodopa 47CARNITOR 159carteolol hcl 144CARTIA XT 80,81carvedilol 79cefaclor 14cefadroxil 15cefazolin sodium in 0.9 % sodium chloride 15cefazolin sodium/dextrose 5 % in water 15cefdinir 15cefixime 15cefotaxime sodium 15cefpodoxime proxetil 15cefprozil 15ceftriaxone sodium 15cefuroxime axetil 15celecoxib 1CENTANY 12cephalexin 15CERDELGA 99CEREZYME 99cetirizine hcl 147CETRAXAL 17CHANTIX 10CHATEAL 116CHATEAL EQ 116chlordiazepoxide hcl 64
chlorhexidine gluconate 94chloroquine phosphate 45chlorpromazine hcl 48chlorthalidone 85cholestyramine (with sugar) 87cholestyramine/aspartame 87CHROMAGEN 157CICLODAN 34ciclopirox 34ciclopirox olamine 34cidofovir 54cilostazol 75CILOXAN 17cinacalcet hcl 127CIPRODEX 146ciprofloxacin hcl 18citalopram hydrobromide 25,26CITRANATAL B-CALM 159citric acid/sodium citrate 106CLARAVIS 96clarithromycin 17clemastine fumarate 147CLEOCIN 12CLEOCIN PHOSPHATE 12CLIMARA PRO 116CLINDACIN ETZ 12CLINDACIN P 12clindamycin hcl 12clindamycin palmitate hcl 12clindamycin phosphate 12clindamycin phosphate/benzoyl peroxide 96clobazam 20clobetasol propionate 108clobetasol propionate/emollient base 108clomipramine hcl 30clonazepam 64clonidine 75clonidine hcl 75,90clopidogrel bisulfate 75clorazepate dipotassium 64clotrimazole 34
clotrimazole/betamethasone dipropionate 96clozapine 54COARTEM 46codeine phosphate/butalbital/aspirin/caffeine 4colchicine 35colestipol hcl 87colistin (as colistimethate sodium) 12COLOCORT 136COMBIPATCH 116COMBIVENT RESPIMAT 153COMPLERA 57COMPLETE NATAL DHA 159compressor, for nebulizer 137COMPRO 32CONCEPT DHA 159CONCEPT OB 159CONCERTA 90CONSTULOSE 103COPAXONE 93CORMAX 108CORTIFOAM 136cortisone acetate 108CORTISPORIN 96CORVITE 150 157COTELLIC 42CREON 99CRIXIVAN 60cromolyn sodium 101,142,153CRYSELLE 116CUVPOSA 100cyanocobalamin (vitamin b-12) 159CYCLAFEM 116cyclobenzaprine hcl 155cyclopentolate hcl 140cyclophosphamide 38cyclosporine 130CYCLOSPORINE IN KLARITY 168cyclosporine, modified 130cyproheptadine hcl 148CYRED 116
Ddanazol 113dantrolene sodium 155dapsone 37DAPTACEL DTAP 134DASETTA 116DAYTRANA 90DDAVP 112DEBLITANE 124DECADRON 109DELZICOL 135demeclocycline hcl 19DEPO-MEDROL 109DERMA-SMOOTHE-FS 109DERMACINRX EMPRICAINE 7DERMACINRX PRIZOPAK 7DESCOVY 58desipramine hcl 30desmopressin acetate 112desmopressin acetate (non-refrigerated) 112desogestrel-ethinyl estradiol 116desogestrel-ethinyl estradiol/ethinyl estradiol 116DETROL 105DETROL LA 105dexamethasone 109DEXAMETHASONE INTENSOL 109dexamethasone sodium phosphate 143dexmethylphenidate hcl 90DEXPAK 109dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate 89dextroamphetamine sulfate 89DIALYVITE 160diaphragms, contoured 137diaphragms, wide seal 137diazepam 20,64,65diclofenac sodium 1,143dicloxacillin sodium 16dicyclomine hcl 101didanosine 58
diflunisal 1DIGITEK 82DIGOX 82digoxin 82DILANTIN 23DILATRATE-SR 88DILT-XR 81diltiazem hcl 81DIPHEN 148diphenhydramine hcl 148diphenoxylate hcl/atropine sulfate 101dipyridamole 75disopyramide phosphate 78disulfiram 9DIURIL 85divalproex sodium 21dofetilide 78donepezil hcl 24dorzolamide hcl 144dorzolamide hcl/timolol maleate 144doxazosin mesylate 76doxepin hcl 30,31doxycycline hyclate 19doxycycline monohydrate 19DRITHOCREME HP 96dronabinol 33DRYSOL 96DUET DHA 400 160DUET DHA BALANCED 160DULERA 153,168duloxetine hcl 92DUROLANE 137dutasteride 105
EED-SPAZ 101EDURANT 57efavirenz 57EFFER-K 157ELAPRASE 99ELELYSO 100
ELIDEL 96ELIGARD 128ELINEST 116ELIQUIS 72,168ELITE-OB 160ELMIRON 106EMGALITY PEN 168EMGALITY SYRINGE 169emtricitabine 58EMTRIVA 58EMVERM 45enalapril maleate 77enalapril maleate/hydrochlorothiazide 83ENBREL 130,169ENBREL MINI 130ENBREL SURECLICK 130ENDOCET 4ENGERIX-B ADULT 134ENGERIX-B PEDIATRIC-ADOLESCENT 134enoxaparin sodium 72ENPRESSE 116ENSKYCE 116entacapone 47entecavir 55ENTRESTO 83ENULOSE 103EPANED 77EPIFOAM 96epinastine hcl 142epinephrine 150EPITOL 23EPIVIR HBV 55eplerenone 85EQUETRO 66ergocalciferol (vitamin d2) 160ergoloid mesylates 24ergotamine tartrate/caffeine 36ERIVEDGE 42erlotinib hcl 42ERRIN 124ERYTHROCIN LACTOBIONATE 17
erythromycin base 17erythromycin base in ethanol 17escitalopram oxalate 26ESGIC 92esomeprazole magnesium 104ESTARYLLA 116estradiol 117estradiol/norethindrone acetate 117ESTRING 117eszopiclone 156ethambutol hcl 38ethinyl estradiol/drospirenone 117ethosuximide 20ethynodiol diacetate-ethinyl estradiol 117etodolac 1etoposide 41EUFLEXXA 137EURAX 46everolimus 42,130EVOTAZ 60exemestane 41EXTAVIA 93ezetimibe 87
FFALMINA 117famciclovir 62famotidine 10,102FARXIGA 67febuxostat 35felbamate 21felodipine 81FEMRING 117FEMYNOR 117fenofibrate 85fenofibrate nanocrystallized 86fenofibrate,micronized 86fenofibric acid 86fenoprofen calcium 1FENORTHO 1fentanyl 3
FIBRICOR 86finasteride 106FIRMAGON 128flash glucose scanning reader 137flash glucose sensor 138FLEBOGAMMA DIF 132flecainide acetate 78FLORIVA PLUS 169FLOVENT DISKUS 146FLOVENT HFA 147FLUAD 2020-2021 169FLUAD QUAD 2020-2021 169FLUAD QUAD 2021-2022 169FLUARIX QUAD 2020-2021 169FLUARIX QUAD 2021-2022 169FLUBLOK QUAD 2020-2021 169FLUBLOK QUAD 2021-2022 170FLUCELVAX QUAD 2020-2021 170FLUCELVAX QUAD 2021-2022 170fluconazole 34fludrocortisone acetate 109FLULAVAL QUAD 2020-2021 170FLULAVAL QUAD 2021-2022 170FLUMIST QUAD 2020-2021 170flunisolide 147fluocinolone acetonide oil 146fluocinonide 96,109fluoride (sodium) 157,158FLUORITAB 158fluorometholone 143FLUOROPLEX 97fluorouracil 40,97fluoxetine hcl 26,27fluphenazine decanoate 48fluphenazine hcl 48FLURA-DROPS 158flurbiprofen 1flurbiprofen sodium 143flutamide 39fluticasone propionate 109,147fluvoxamine maleate 27
FLUZONE HIGH-DOSE QUAD 2020-21 170FLUZONE HIGH-DOSE QUAD 2021-22 170FLUZONE QUAD 2020-2021 171FLUZONE QUAD 2021-2022 171FML FORTE 143FML S.O.P. 143FOCALIN XR 90folic acid 160FOLIVANE-OB 160FORTAVIT 160FORTEO 137fosamprenavir calcium 60FOSCAVIR 54,55fosinopril sodium 77fosinopril sodium/hydrochlorothiazide 83FULPHILA 171furosemide 84FUZEON 59FYAVOLV 117
Ggabapentin 21galantamine hbr 24GAMMAGARD LIQUID 132GAMMAGARD S-D 132GAMMAKED 132GAMUNEX-C 132ganciclovir sodium 55,171GAVILYTE-C 103GAVILYTE-G 103GAVILYTE-N 103GELSYN-3 138gemfibrozil 86GENERLAC 103GENGRAF 130GENOTROPIN 113GENTAK 11gentamicin sulfate 11GENVOYA 56GIANVI 118GILENYA 93,171
glatiramer acetate 94GLATOPA 94GLEEVEC 42GLEOSTINE 38glimepiride 67glipizide 67GLUCAGEN 70GLUCAGON EMERGENCY KIT 71glyburide 67glyburide,micronized 67glyburide/metformin hcl 67glycopyrrolate 101,171GLYXAMBI 67GRALISE 21granisetron hcl 33granisetron hcl/pf 33griseofulvin, microsize 34guanfacine hcl 76,91
HHAILEY 118HAILEY 24 FE 118HAILEY FE 118halcinonide 109halobetasol propionate 109haloperidol 48haloperidol decanoate 48haloperidol lactate 48HAVRIX 134HEATHER 124HEMATOGEN 158HEMATOGEN FA 158HEMATOGEN FORTE 158heparin sodium,porcine 72heparin sodium,porcine in 0.45 % sodiumchloride 72heparin sodium,porcine in 0.9 % sodiumchloride 73,171heparin sodium,porcine in 0.9 % sodiumchloride/pf 73heparin sodium,porcine/dextrose 5 % in water 73
heparin sodium,porcine/pf 73HERCEPTIN 44HIZENTRA 133,171HOMATROPAIRE 140homatropine hbr 140HORIZANT 92HUMALOG 71HUMIRA 130HUMIRA PEN 131HUMIRA PEN CROHN'S-UC-HS 131HUMIRA PEN PSOR-UVEITS-ADOL HS 131HUMIRA(CF) 131,172HUMIRA(CF) PEDIATRIC CROHN'S 172HUMIRA(CF) PEN 172HUMIRA(CF) PEN CROHN'S-UC-HS 172HUMIRA(CF) PEN PEDIATRIC UC 172HUMIRA(CF) PEN PSOR-UV-ADOL HS 172HUMULIN R U-500 71HUMULIN R U-500 KWIKPEN 71hydralazine hcl 87hydrochlorothiazide 85hydrocodone bitartrate/acetaminophen 5hydrocodone bitartrate/homatropinemethylbromide 153hydrocodone/ibuprofen 5hydrocortisone 110,136hydrocortisone/acetic acid 146HYDROMET 154hydromorphone hcl 5hydroxychloroquine sulfate 46hydroxyurea 40hydroxyzine hcl 148hydroxyzine pamoate 148hyoscyamine sulfate 101HYOSYNE 101
Iibandronate sodium 137IBU 1ibuprofen 2ibuprofen/oxycodone hcl 5
ICLUSIG 42,172IMBRUVICA 42,172imipramine hcl 31imipramine pamoate 31imiquimod 97IMITREX 36INCRELEX 113indapamide 85INDOCIN 2indomethacin 2indomethacin, submicronized 2INFANRIX DTAP 134inhaler, assist devices 138inhaler, assist devices, accessories 138inhaler,assist device with large mask 138inhaler,assist device with medium mask 138inhaler,assist device with small mask 138INLYTA 42insulin aspart 71insulin aspart protamine human/insulin aspart 71insulin lispro 71insulin lispro protamine and insulin lispro 71INTELENCE 57INTRON A 56INTROVALE 118INVEGA SUSTENNA 50,51INVEGA TRINZA 51,52INVIRASE 60INVOKAMET 67INVOKANA 67IOPIDINE 144ipratropium bromide 149ipratropium bromide/albuterol sulfate 154irbesartan 76IRESSA 43ISENTRESS 56ISENTRESS HD 57ISIBLOOM 118isoniazid 38isoproterenol hcl 150isosorbide dinitrate 88
isosorbide mononitrate 88isotretinoin 97ISUPREL 150ivermectin 45
JJAIMIESS 118JAKAFI 43JANSSEN COVID-19 VACCINE (EUA) 173JANTOVEN 73JANUMET 68JANUMET XR 68JANUVIA 68JARDIANCE 68JASMIEL 118JENCYCLA 124JENTADUETO 68JENTADUETO XR 68JINTELI 118JULEBER 118JUNEL 118JUNEL FE 118JUNEL FE 24 118
KK-PHOS NO.2 106K-TAB ER 158KAITLIB FE 118KALETRA 60KALYDECO 151KARIVA 118KAZANO 68KELNOR 1-35 118KELNOR 1-50 119KENALOG-10 110KENALOG-80 173KERALYT SCALP 97ketoconazole 34ketoprofen 2,173ketorolac tromethamine 2,143KIONEX 157
KITABIS PAK 151KLOR-CON 158KLOR-CON 10 158KLOR-CON 8 158KLOR-CON M10 158KLOR-CON M15 158KLOR-CON M20 158KLOR-CON-EF 158KOMBIGLYZE XR 68KORLYM 110KOSHER PRENATAL PLUS IRON 160KRISTALOSE 103KURVELO 119KYLEENA 124
Llabetalol hcl 79lactulose 103LAMICTAL XR (BLUE) 22LAMICTAL XR (GREEN) 22LAMICTAL XR (ORANGE) 22lamivudine 55,58lamivudine/zidovudine 59lamotrigine 22LANOXIN 83LANOXIN PEDIATRIC 83lansoprazole 104LANTUS 71LANTUS SOLOSTAR 72lapatinib ditosylate 43LARIN 119LARIN 24 FE 119LARIN FE 119LARISSIA 119latanoprost 145LATUDA 52leflunomide 133LESSINA 119LETAIRIS 151letrozole 41leucovorin calcium 40
LEUKERAN 38leuprolide acetate 128LEVA SET 7LEVEMIR 72LEVEMIR FLEXTOUCH 72levetiracetam 20LEVO-T 126levobunolol hcl 145levocarnitine 160levocarnitine (with sugar) 160levofloxacin 18LEVONEST 119levonorgestrel/ethinyl estradiol 119LEVORA-28 119levothyroxine sodium 126LEVOXYL 126LEXIVA 61LIALDA 135LIDO BDK 138LIDO-K 7LIDO-PRILO CAINE PACK 7LIDO-SORB 7lidocaine 7lidocaine hcl 7,8lidocaine/prilocaine 8LIDOPRIL 8LIDOPRIL XR 8LIDOZION 8LILETTA 124LILLOW 119lincomycin hcl 13lindane 46linezolid 13LINZESS 102liothyronine sodium 126LIPROZONEPAK 8lisinopril 77lisinopril/hydrochlorothiazide 83lithium carbonate 66lithium citrate 66LIVIXIL PAK 8
LO-ZUMANDIMINE 119loperamide hcl 102lopinavir/ritonavir 61LOPREEZA 119lorazepam 65LORAZEPAM INTENSOL 65LORYNA 119losartan potassium 76losartan potassium/hydrochlorothiazide 83lovastatin 86LOW-OGESTREL 119loxapine succinate 48lubiprostone 102LUDENT FLUORIDE 158LUPRON DEPOT 128LUPRON DEPOT (LUPANETA) 128LUPRON DEPOT-PED 128LUTERA 120
MMAKENA 125,173malathion 46maprotiline hcl 27MARLISSA 120MARNATAL-F 160MATULANE 38MAVYRET 56MAXIDEX 143meclizine hcl 32MEDOLOR PAK 8MEDROL 110medroxyprogesterone acetate 125mefenamic acid 2megestrol acetate 125MELODETTA 24 FE 120meloxicam 2memantine hcl 24MENEST 120MENOSTAR 120meperidine hcl 5mercaptopurine 40
METAXALL 155metaxalone 155metformin hcl 69methazolamide 145METHERGINE 138methimazole 129methocarbamol 155methotrexate sodium 131methoxsalen 97methyldopa 76methylergonovine maleate 139METHYLIN 91methylphenidate hcl 91methylprednisolone 110methylprednisolone acetate 110methylprednisolone sodium succinate 110metipranolol 145metoclopramide hcl 32metolazone 85metoprolol succinate 80metoprolol tartrate 80metoprolol tartrate/hydrochlorothiazide 83metronidazole 13,97mexiletine hcl 78miconazole nitrate 35MICROGESTIN 120MICROGESTIN FE 120midodrine hcl 76miglustat 100MILI 120MILLIPRED 110MILLIPRED DP 110MIMVEY 120MINITRAN 88MINOCIN 19minocycline hcl 19minoxidil 87MIRENA 125mirtazapine 25misoprostol 104MODERNA COVID-19 VACCINE (EUA) 173
moexipril hcl 77molindone hcl 49mometasone furoate 110MONDOXYNE NL 19montelukast sodium 149MORGIDOX 20morphine sulfate 3,6morphine sulfate/pf 6MOXEZA 18moxifloxacin hcl 18mucus clearing device 139MULTAQ 78multivitamin combination no.51/ferrousfumarate/folic acid 160mupirocin 13mupirocin calcium 13MVC-FLUORIDE 160mycophenolate mofetil 131MYNATAL 160MYNATAL PLUS 160MYNATAL-Z 160MYNEPHROCAPS 161MYNEPHRON 161MYORISAN 97
Nnabumetone 2nadolol 80NALFON 2naloxone hcl 10naltrexone hcl 9NAMENDA XR 24naproxen 2naproxen sodium 2naratriptan hcl 36NARCAN 10NATACHEW 161NATACYN 35nateglinide 69NATESTO 114NATROBA 97
NATURE-THROID 126nebulizer 139nebulizer accessories 139nebulizer and compressor 139NECON 120NEEVODHA 161NEO-POLYCIN 140NEO-POLYCIN HC 140neomycin sulfate 11neomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone 141neomycin sulfate/bacitracin/polymyxin b 141neomycin sulfate/polymyxin b sulfate/gramicidind 141neomycin sulfate/polymyxin bsulfate/hydrocortisone 141,146neomycin/polymyxin bsulfate/dexamethasone 141NEPHRON FA 158NESINA 69NESTABS 161NESTABS ABC 161NESTABS DHA 161NESTABS ONE 173NEUPOGEN 74NEUTRASAL 94nevirapine 57NEWGEN 161NEXAVAR 43NEXPLANON 125NIACOR 87NICADAN 161NICAZEL 161NICAZEL FORTE 161NICOTROL 11NICOTROL NS 11nifedipine 81NIFEREX 157NIKKI 120nilutamide 39NITRO-BID 88
NITRO-DUR 88NITRO-TIME 88nitrofurantoin 13nitrofurantoin macrocrystal 13nitrofurantoin monohydrate/macrocrystals 13nitroglycerin 88NIVA-PLUS 161NIVESTYM 173nizatidine 102NOLIX 110NORDITROPIN FLEXPRO 113norethindrone 125norethindrone acetate 125norethindrone acetate-ethinyl estradiol 120norethindrone acetate-ethinyl estradiol/ferrousfumarate 120,121norethindrone-ethinyl estradiol/ferrousfumarate 121norgestimate-ethinyl estradiol 121NORITATE 97NORLYDA 125NORPACE CR 78NORTREL 121nortriptyline hcl 31NORVIR 61NP THYROID 127NPLATE 74,174NUCALA 174NUFERA 159NULEV 101NUMBONEX 8NUMOISYN 94NUVARING 121NUVESSA 13NYAMYC 35nystatin 35NYSTOP 35NYVEPRIA 174
OO-CAL FA 161
O-CAL PRENATAL 161OB COMPLETE 161OB COMPLETE ONE 161OB COMPLETE PETITE 161OB COMPLETE PREMIER 161OB COMPLETE WITH DHA 162octreotide acetate 129ODEFSEY 57OFIRMEV 92ofloxacin 18olanzapine 52,53olmesartan medoxomil 77olmesartan medoxomil/hydrochlorothiazide 83olopatadine hcl 142omeprazole 104OMNARIS 147ondansetron 33ondansetron hcl 33,34ondansetron hcl/pf 34ONGLYZA 69ORACIT 106ORALONE 94ORBACTIV 13orphenadrine citrate 155ORSYTHIA 121OSCIMIN 101OSCIMIN SL 101OSCIMIN SR 101oseltamivir phosphate 61OSENI 69OTEZLA 133oxaprozin 3oxazepam 65oxcarbazepine 23OXTELLAR XR 23oxybutynin chloride 105oxycodone hcl 6oxycodone hcl/acetaminophen 6,174
PPACERONE 78
PACNEX 97pantoprazole sodium 105PARAGARD T 380-A 139PAROEX 94paroxetine hcl 27,28PAZEO 142peak flow meter/inhaler, assist devices 139pediatric multivit with a,c,d3 no.21/sodiumfluoride 162pediatric multivitamin no.2/sodium fluoride 162pediatric multivitamins no.17 with sodiumfluoride 162peg 3350/sod sulf/sod bicarb/sodchloride/potassium chloride 103PEGASYS PROCLICK 56pen needle, diabetic 139penicillamine 106penicillin v potassium 17PENTASA 135pentazocine hcl/naloxone hcl 6pentoxifylline 83perindopril erbumine 77PERIOGARD 94permethrin 46perphenazine 32PERSERIS 174PFIZER COVID (12Y UP) VAC(EUA) 174PFIZER COVID (5-11Y) VAC (EUA) 174PFIZER COVID-19 VACCINE (EUA) 174PHARMABASE BARRIER 97PHENADOZ 32phenazopyridine hcl 106PHENERGAN 148phenobarbital 21phenylephrine hcl 141phenylephrine hcl/promethazine hcl 154phenytoin 23phenytoin sodium extended 23PHILITH 121PIFELTRO 175pilocarpine hcl 95,145
pimozide 49PIMTREA 121pioglitazone hcl 69pioglitazone hcl/metformin hcl 69piperacillin sodium/tazobactam sodium 17PIRMELLA 121piroxicam 3PNEUMOVAX 23 134PNV 29-1 162pnv no.72/ferrous fumarate/folic acid/omega-3/dha 162PNV-OMEGA 162POLYCIN 141polymyxin b sulfate/trimethoprim 141PORTIA 121potassium chloride 159potassium chloride in water for injection,sterile 159potassium citrate 106potassium citrate/citric acid 106PR NATAL 400 162PR NATAL 400 EC 162PR NATAL 430 162PR NATAL 430 EC 162PRADAXA 74pramipexole di-hcl 47PRAMOSONE 98pravastatin sodium 86praziquantel 45prazosin hcl 76PRED MILD 143PRED-G 141prednisolone 111prednisolone acetate 143prednisolone acetate/pf 175prednisolone sodium phosphate 111,143prednisone 111PREDNISONE INTENSOL 111pregabalin 93PREMARIN 121PREMPHASE 122
PREMPRO 122PRENA1 CHEW 162PRENA1 PEARL 162PRENA1 TRUE 162PRENATA 162PRENATABS FA 162PRENATABS RX 162prenatal vits with calcium no.115/ironfumarate/folic acid 163prenatal vits with calcium no.72/ferrousfumarate/folic acid 163prenatal vits with calciumno.72/iron,carbonyl/folic acid 163PRENATE AM 163PRENATE CHEWABLE 163PRENATE DHA 163PRENATE ELITE 163PRENATE ENHANCE 163PRENATE ESSENTIAL 163PRENATE MINI 163PRENATE PIXIE 163PRENATE RESTORE 163PRENATE STAR 163PREPLUS 163PRETAB 163PREVALITE 87PREVIDENT 95PREVNAR 13 134PREVNAR 20 175PREZCOBIX 59PREZISTA 61PRILOLID 8PRIMACARE 163primaquine phosphate 46primidone 21PRIMLEV 6PRIVIGEN 133PROAIR HFA 150probenecid 36probenecid/colchicine 36prochlorperazine 32
prochlorperazine maleate 32PROCTO-MED HC 111PROCTO-PAK 111PROCTOCORT 111PROCTOSOL-HC 111PROCTOZONE-HC 111progesterone, micronized 125PROGLYCEM 71PROLASTIN C 154PROLENSA 144PROLIA 137PROMACTA 74promethazine hcl 32,148,149promethazine hcl/codeine 154promethazine hcl/dextromethorphan hbr 154PROMETHEGAN 32propafenone hcl 79propantheline bromide 101propranolol hcl 80propranolol hcl/hydrochlorothiazide 83propylthiouracil 129PROTONIX 105protriptyline hcl 31PROVIDA OB 163PULMICORT FLEXHALER 147PULMOZYME 154PUREFE OB PLUS 164pyrazinamide 38pyridostigmine bromide 37pyridoxine hcl (vitamin b6) 164
QQNASL 147QNASL CHILDREN 147quetiapine fumarate 53QUFLORA 164quinapril hcl 77quinapril hcl/hydrochlorothiazide 84quinidine gluconate 79quinidine sulfate 79quinine sulfate 46
RR-NATAL OB 164raloxifene hcl 126ramipril 78ranitidine hcl 102ranolazine 84RAYOS 111REBIF 94REBIF REBIDOSE 94RECLIPSEN 122RECOMBIVAX HB 134REGRANEX 98RELADOR PAK 8RELADOR PAK PLUS 8RELENZA 61RENA-VITE RX 164RENAL CAPS 164RENO CAPS 164repaglinide 69REQ49+ 164RESCRIPTOR 58RESTASIS 141RETACRIT 175RETIN-A 98REVATIO 152REVLIMID 39REYATAZ 61RIBASPHERE 56ribavirin 56RIFAMATE 38rifampin 38rimantadine hcl 62RISPERDAL CONSTA 53risperidone 53RITALIN LA 91,92ritonavir 61RITUXAN 44RITUXAN HYCELA 44rivastigmine 24rivastigmine tartrate 24
rizatriptan benzoate 36ropinirole hcl 47ROSADAN 98rosuvastatin calcium 86ROWEEPRA 20ROWEEPRA XR 20ROZEREM 157rufinamide 23
Ssalicylic acid 98SALIMEZ 98SALIMEZ FORTE 98SALIVAMAX 95salsalate 3SANDIMMUNE 131SANDOSTATIN LAR DEPOT 129SCALACORT 111SE-NATAL 19 164SE-NATAL-19 164SELECT-OB 164SELECT-OB + DHA 164selenium sulfide 98SELZENTRY 60SEREVENT DISKUS 150sertraline hcl 28SETLAKIN 122sevelamer carbonate 107SFROWASA 136SHAROBEL 125SHINGRIX 134SHINGRIX ADJUVANT COMPONENT 134SHINGRIX GE ANTIGEN COMPONENT 135sildenafil citrate 152silver sulfadiazine 18SIMLIYA 122SIMPESSE 122simvastatin 87sirolimus 131SITAVIG 62SKLICE 45
SKYLA 125sodium chloride/sodium bicarbonate/potassiumchloride/peg 103sodium polystyrene sulfonate 157sodium/potassium/potassium citrate/sodiumcitrate/cit ac 106sofosbuvir/velpatasvir 56SOLTAMOX 39SOLU-CORTEF 111SOLU-MEDROL 111SOMATULINE DEPOT 129SORILUX 98SORINE 79SOTALOL AF 79sotalol hcl 79spinosad 98SPIRIVA 149spirometers and accessories 139spironolactone 85spironolactone/hydrochlorothiazide 84SPRAVATO 175SPRINTEC 122SPS 157SRONYX 122SSD 18STALEVO 125 47STALEVO 50 47STALEVO 75 47stavudine 59STIMATE 113STIOLTO RESPIMAT 155STRIBILD 57STROVITE ONE 164SUBLOCADE 175SUBOXONE 9SUBVENITE 22SUCRAID 100sucralfate 104sulfacetamide sodium 18sulfacetamide sodium/prednisolone sodiumphosphate 141
sulfadiazine 19sulfamethoxazole/trimethoprim 19sulfasalazine 136SULFATRIM 19sulindac 3sumatriptan succinate 36,37SUPERVITE 164SUPRAX 16SUTENT 43SYEDA 122SYLATRON 40SYMAX DUOTAB 101SYMAX-SR 101SYMBICORT 155SYMLINPEN 120 69SYMLINPEN 60 69SYNAGIS 133SYNAREL 129SYNJARDY 70syringe with needle, insulin, safety, 0.3 ml 139syringe with needle, insulin, safety, 0.5 ml 139syringe with needle, insulin, safety, 1 ml 139syringe with needle,disposable,insulin 1 ml 139syringe with needle,insulin,0.3 ml 139syringe with needle,insulin,0.5 ml 139syringe,safety with needle,1 ml 139,175
TTABLOID 40tacrolimus 98,131tamoxifen citrate 39tamsulosin hcl 106TAPERDEX 112TARINA 24 FE 122TARINA FE 122TARINA FE 1-20 EQ 122TARON-C DHA 164TASIGNA 43,175TAZTIA XT 81temazepam 156temozolomide 39
tenofovir disoproxil fumarate 59terazosin hcl 76terbinafine hcl 35terconazole 35teriparatide 137testosterone cypionate 114,175testosterone enanthate 114THALOMID 39THEO-24 151theophylline anhydrous 151thiamine hcl 164thioridazine hcl 49thiothixene 49THRIVITE RX 164THYROID 127thyroid,pork 127TIADYLT ER 81tiagabine hcl 21TIGAN 33timolol maleate 145TIMOPTIC OCUDOSE 145TIMOPTIC-XE 145TIROSINT 127TIVICAY 57TIVORBEX 3tizanidine hcl 156TOBRADEX 142TOBRADEX ST 142tobramycin 11tobramycin sulfate 12tobramycin/dexamethasone 142TOBREX 12TOLAK 99topiramate 22toremifene citrate 40torsemide 84TOVET EMOLLIENT 112TOVIAZ 105TRACLEER 152TRADJENTA 70tramadol hcl 4,6,176
trandolapril 78travoprost 145trazodone hcl 28,29tretinoin 45,99TREXALL 132TRI FEMYNOR 122TRI-ESTARYLLA 122TRI-LEGEST FE 122TRI-LO-ESTARYLLA 122TRI-LO-MARZIA 123TRI-LO-MILI 123TRI-LO-SPRINTEC 123TRI-MILI 123TRI-PREVIFEM 123TRI-SPRINTEC 123TRI-VYLIBRA 123TRI-VYLIBRA LO 123triamcinolone acetonide 95,112,147triamcinolone diacetate in 0.9 % sodiumchloride 176triamcinolone diacetate in 0.9 % sodiumchloride/pf 176triamterene/hydrochlorothiazide 84TRIANEX 112TRICARE 165TRICITRATES 107TRICON 159TRIDERM 112trifluoperazine hcl 49trifluridine 62TRIGELS-F FORTE 159trihexyphenidyl hcl 46TRIJARDY XR 176TRILYTE WITH FLAVOR PACKETS 103trimethobenzamide hcl 33trimethoprim 13trimipramine maleate 31TRINATAL RX 1 165TRINATE 165TRIPHROCAPS 165TRISTART DHA 165
TRIUMEQ 60TRIVEEN-DUO DHA 165TRIVORA-28 123TROKENDI XR 22TRULICITY 70,176TRUVADA 59TUDORZA PRESSAIR 150TUZISTRA XR 155TYBOST 60TYKERB 43
UUBRELVY 176UDENYCA 176UNITHROID 127ursodiol 102
VVABOMERE 16valacyclovir hcl 62valganciclovir hcl 55valproic acid 21valproic acid (as sodium salt) (valproatesodium) 21valsartan 77valsartan/hydrochlorothiazide 84VANCOCIN HCL 13vancomycin hcl 14,176vancomycin hcl in sterile water 176vancomycin hcl in water for injection (peg-400,nada) 14,177vancomycin in 0.9 % sodium chloride 14,177vancomycin in 5 % dextrose in water 14,177VANDAZOLE 14VAQTA 135VELETRI 152VELIVET 123venlafaxine hcl 29verapamil hcl 82VIC-FORTE 165VICTOZA 2-PAK 70
VICTOZA 3-PAK 70VIDEX 59VIDEX EC 59VIENVA 123VIMPAT 23VIORELE 123VIRACEPT 61VIREAD 59VIRT-C DHA 165VIRT-CAPS 165VIRT-NATE DHA 165VIRT-PN DHA 165VIRT-PN PLUS 165VIRTRATE-2 107VIRTRATE-3 107VIRTRATE-K 107VITAFOL GUMMIES 165VITAFOL NANO 165VITAFOL ULTRA 165VITAFOL-OB 165VITAFOL-OB+DHA 165VITAFOL-ONE 166VITAL-D RX 166VITAMEDMD ONE RX 166VITAMEDMD REDICHEW RX 166VITAPEARL 166VITATRUE 166VIVITROL 9VOLNEA 123VOTRIENT 43VP-PNV-DHA 166VP-VITE RX 166VPRIV 100VYFEMLA 123VYLIBRA 123VYVANSE 89
Wwarfarin sodium 74WELLBUTRIN XL 25WERA 123
WESTHROID 127WP THYROID 127
XXALIX 177XALKORI 44XARELTO 74,177XELJANZ 132,177XIGDUO XR 70,177XTAMPZA ER 4XULANE 124
YYUVAFEM 124
ZZARAH 124ZATEAN-PN DHA 166ZATEAN-PN PLUS 166ZEBUTAL 92ZELBORAF 44ZEMAIRA 155ZENATANE 99ZENPEP 100ZETONNA 147zidovudine 59zinc oxide 99ZIONODIL 8ZIONODIL-100 9ZIOPTAN 145ziprasidone hcl 54ZITHROMAX 17ZOLINZA 40zolmitriptan 37zolpidem tartrate 156ZOMIG 37zonisamide 20ZOSTAVAX 135ZOVIA 1-35 124ZOVIA 1-35E 124ZUMANDIMINE 124
ZYTIGA 39ZYVOX 14
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