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2022 Formulary

(List of covered drugs)

For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.

Effective: July 1, 2022

©2022 HealthPartners

What’s the GenericsAdvantageRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a

team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety,

effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines are listed in alphabetical order by type of medicine starting on page 4.

Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand

medicines.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier is used to determine how much a medicine will cost you. For exact cost information,

• Find the tier status for your medicine.

• Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,

• Log on to your myHealthPartners account to check your pharmacy benefits.

o Tier 1 – Formulary Low Cost Generics o Tier 2 – Formulary High Cost Generics

o Tier 3 – Formulary Brands

o Tier 4 – Non-Formulary Generics & Brands

(Non-Formulary medicines are not listed in this document)

o Tier 5 – Specialty Generics & Brands

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.

These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.

Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than

non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan

tab to check your benefits for specialty medicines.

What do the abbreviations under Limits & Restrictions mean?

Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program

or rule for the medicine. Use this key to help you navigate the drug list:

• PA - Prior Authorization Required

• ST - Step Therapy Required

• AL1 - Age Limit

• AQ1 – Age Quantity Limit

• QL - Quantity Limit

• SC - Smoking Cessation Benefit

• WL - Weight Loss Benefit

• ONC - Oncology Benefit

• OH – Oncology Health

• TD - Trial Drug Program

• S – Specialty

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they

need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your

pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try

one or more other medicines first. HealthPartners

covers a medicine with step therapy, if you've already

tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners

before the medicine will be covered by your lowest

brand, generic or specialty copay or coinsurance.

What’s an Age Limit (AL1)? An age edit means some medicines are only covered if

you’re within a specific age range. If you're not in the

approved age range, you or your doctor will need to

request approval from HealthPartners for your

medicine to be covered.

What’s an Age Quantity Limit (AQ1)?

An age quantity limit means some medicines have a quantity limit that only applies to a specific age range. If

you're not in the approved age range, you or your

doctor will need to request approval from

HealthPartners for your medicine to be covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the

medicine you'll get each time you fill your prescription.

The quantity limit may be less than the day supply listed in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for

certain medicines that may not be well tolerated due

to:

• Side effects

• High cost

• High potential for waste

Your first 6 fills of a trial drug may be limited to less

than a month supply. If the medicine works well, you’ll

get the rest of your month supply. If a copay applies to

the medicine, you’ll pay no more than one copay for

each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount

you get or may not be covered under all plans. Log on to

your myHealthPartners account and click on My plan

benefits on the Medical Plan tab to check your benefits

for weight loss. Weight Loss medicines are listed on the

drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. ( 7/22) ©2022 HealthPartners

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

CAFERGOT 4 QL 40 TABS / 30 DAYS

D.H.E.45 4QL 24 MG (AMPS) / 28

DAYSPA

DIBENZYLINE 4 PA

dihydroergotamine 1 mg/ml amp 2QL 24 MG (AMPS) / 28

DAYSPA

dihydroergotamine 4 mg/ml spry 2QL 8 VIALS / 28 DAYS

PA

ergoloid mesylates 2 PA

ERGOMAR 4 QL 20 TABS / 30 DAYS

ergotamine-caffeine 2QL 40 TABS / 30 DAYS

PA

MIGERGOT 4QL 24 SUPP / 30 DAYS

PA

MIGRANAL 4QL 8 VIALS / 28 DAYS

PA

phenoxybenzamine hcl 2 PA

TRUDHESA 4QL 1 PKG / 28 DAYS

PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl er 2

FLOMAX 4

RAPAFLO 4

silodosin 2 PA

PAGE 1 LAST UPDATED 07/2022

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tamsulosin hcl 1

UROXATRAL 4 PA

ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.

ALLZITAL 4QL 8 TABS / 1 DAY

PA

BUPAP 4 PA

butalb-acetamin-caff 50-300-40 4 QL 6 CAPS / 1 DAY

butalb-acetamin-caff 50-325-40 2 QL 6 TABS / 1 DAY

butalbital-acetaminophn 25-325 4QL 8 TABS / 1 DAY

PA

butalbital-acetaminophn 50-300 4 PA

butalbital-acetaminophn 50-325 2 QL 6 TABS / 1 DAY

ESGIC 50-325-40 MG TABLET 4 QL 6 TABS / 1 DAY

ESGIC CAPSULE 4 QL 6 CAPS / 1 DAY

FIORICET 4 QL 6 CAPS / 1 DAY

GRALISE ER 300 MG TABLET 4QL 1 TAB / 1 DAY

PA

GRALISE ER 600 MG TABLET 4QL 3 TABS / 1 DAY

PA

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 4QL 1 TAB / 1 DAY

PA

LYRICA CR 330 MG TABLET 4QL 2 TABS / 1 DAY

PA

pregabalin er (er 82.5 mg tablet, er 165 mg tablet) 4QL 1 TAB / 1 DAY

PA

pregabalin er 330 mg tablet 4QL 2 TABS / 1 DAY

PA



TENCON 2 QL 6 TABS / 1 DAY

VANATOL LQ 4 PA

VANATOL S 4 PA

VTOL LQ 4 PA

ZEBUTAL 2 QL 6 CAPS / 1 DAY

OPIATE AGONISTS

acetamin-caf-dihydrocodein 325 2 PA

acetamin-codein 300-30 mg/12.5 2 AQ1 At least 12 yrs old;60 / 1 DAY

acetaminop-codeine 120-12 mg/5 1 AQ1 At least 12 yrs old;60 / 1 day(s)

acetaminophen-codeine (#2 tablet, #3 tablet, #4 tablet) 2 AQ1 At least 12 yrs old; 8/ 1 DAY

acetamn-caf-dihydrcodein 320.5 2PA

AQ1 At least 12 yrs old; 8/ 1 DAY(s)

ACTIQ 4 PA

APADAZ 4 PA

asa-butalb-caffeine-codeine 2QL 6 CAPS / 1 DAY

AL1 At least 12 yrs old

ASCOMP WITH CODEINE 2QL 6 CAPS / 1 DAY


belladonna-opium 4 QL 4 SUPP / 1 DAY

benzhydrocodone-acetaminophen 2 PA

butalb-acetamin-caf-cod 50-300 2

QL 6 CAPS / 1 DAY

PA


butalb-acetamin-caf-cod 50-325 2QL 6 TABS / 1 DAY




butalbital compound-codeine 2QL 6 CAPS / 1 DAY


codeine sulfate 2 AQ1 At least 12 yrs old; 8/ 1 DAY

CONZIP (200 MG CAPSULE, 300 MG CAPSULE) 4PA

AQ1 At least 12 yrs old; 1/ 1 DAY

CONZIP 100 MG CAPSULE 4PA


DILAUDID 2 MG TABLET 4 QL 8 TABS / 1 DAY


DILAUDID 5 MG/5 ML ORAL LIQUID 4 QL 20 ML / 1 DAY


DISKETS 4 PA

DURAGESIC 4 PA

DVORAH 4 PA

ENDOCET 10-325 MG TABLET 2 QL 5 TABS / 1 DAY

ENDOCET 2.5-325 MG TABLET 4 QL 8 TABS / 1 DAY

ENDOCET 5-325 MG TABLET 2 QL 8 TABS / 1 DAY

ENDOCET 7.5-325 MG TABLET 2 QL 7 TABS / 1 DAY

fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 100 mcg/hr patch)

2 PA

fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch, 87.5mcg/hr patch)

4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfentanyl citrate (cit 100 mcg buccal tb, cit 200 mcg buccaltb, cit 400 mcg buccal tb, cit 600 mcg buccal tb, cit 800mcg buccal tb, cit otfc 1,200 mcg, cit otfc 1,600 mcg,citrate otfc 200 mcg, citrate otfc 400 mcg, citrate otfc 600mcg, citrate otfc 800 mcg)

4 PA

FENTORA 4 PA

FIORICET WITH CODEINE 4

QL 6 CAPS / 1 DAY

PA


FIORINAL WITH CODEINE #3 4

QL 6 CAPS / 1 DAY

PA


hydrocodone bitartrate er (er 10 mg capsule, er 15 mgcapsule, er 20 mg capsule, er 30 mg capsule, er 40 mgcapsule, er 50 mg capsule)

2 PA

hydrocodone bitartrate er (er 20 mg tablet, er 30 mgtablet, er 40 mg tablet, er 60 mg tablet, er 80 mg tablet,er 100 mg tablet, er 120 mg tablet)

4 PA

hydrocodone-acetamin 10-325/15 4 PA

hydrocodone-acetaminophen (2.5-325, 5-300 mg, 7.5-300, 10-300 mg)

4 QL 8 TABS / 1 DAY

hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg)

2 QL 8 TABS / 1 DAY

hydrocodone-acetaminophen (hydrocodone-acetamin2.5-108/5, hydrocodone-acetamin 5-217/10,hydrocodone-acetamn 7.5-325/15)

2 QL 120 ML / 1 DAY

hydrocodone-ibuprofen (5-200 mg, 10-200) 4 QL 8 TABS / 1 DAY

hydrocodone-ibuprofen 7.5-200 2 QL 8 TABS / 1 DAY

hydromorphone 2 mg tablet 2 QL 8 TABS / 1 DAY

hydromorphone 3 mg suppos 2 QL 8 SUPP / 1 DAY





hydromorphone er 2 PA

hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 2 QL 20 ML / 1 DAY

HYSINGLA ER 4 PA

KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE, ER60 MG CAPSULE, ER 80 MG CAPSULE, ER 100 MGCAPSULE, ER 200 MG CAPSULE)

4 PA

LAZANDA 4 PA

levorphanol tartrate 2 PA

LORCET 2 QL 8 TABS / 1 DAY

LORCET HD 2 QL 8 TABS / 1 DAY

LORTAB 4 QL 120 ML / 1 DAY

meperidine 50 mg tablet 4 QL 8 TABS / 1 DAY

meperidine 50 mg/5 ml solution 4 QL 60 ML / 1 DAY

methadone hcl (5 mg/5 ml solution, hcl 5 mg tablet, 10mg/5 ml solution, 10 mg/ml oral conc, hcl 10 mg tablet,40 mg tablet dispr)

2 PA

METHADONE INTENSOL 2 PA

METHADOSE 10 MG/ML ORAL CONC 4 PA

METHADOSE 40 MG TABLET DISPR 2 PA

morphine sulf 10 mg/5 ml soln 2 QL 30 ML / 1 DAY

morphine sulf 100 mg/5 ml conc 2 QL 4 ML / 1 DAY

morphine sulf 20 mg/5 ml soln 2 QL 20 ML / 1 DAY

morphine sulfate (5 mg suppos, 10 mg suppos, 20 mgsuppos, 30 mg suppos)

2 QL 8 SUPP / 1 DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmorphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mgcap, er 40 mg cap, er 45 mg cap, er 50 mg cap, er 60 mgcap, er 75 mg cap, er 80 mg cap, er 90 mg cap, er 100 mgcap, er 120 mg cap)

4 PA

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet, er 200 mg tablet)

2 PA

morphine sulfate ir 15 mg tab 2 QL 5 TABS / 1 DAY

MORPHINE SULFATE IR 15 MG TAB (BRAND) 3 QL 5 TABS / 1 DAY

morphine sulfate ir 30 mg tab 2 QL 2 TABS / 1 DAY

MORPHINE SULFATE IR 30 MG TAB (BRAND) 3 QL 2 TABS / 1 DAY

MS CONTIN 4 PA

NALOCET 4 PA

NORCO 4 QL 8 TABS / 1 DAY

NUCYNTA 100 MG TABLET 3QL 2 TABS / 1 DAY

PA


PA


PA

NUCYNTA ER (ER 150 MG TABLET, ER 200 MG TABLET, ER250 MG TABLET)

4 PA

NUCYNTA ER 100 MG TABLET 4QL 2 TABS / 1 DAY

PA

NUCYNTA ER 50 MG TABLET 4QL 4 TABS / 1 DAY

PA

OXAYDO 4 PA

oxycodon-acetaminophen 7.5-300 4 QL 7 TABS / 1 DAY

oxycodone hcl (ir) 10 mg tab 2 QL 5 TABS / 1 DAY





oxycodone hcl (ir) 30 mg tab 2 PA

oxycodone hcl (ir) 5 mg cap 2 QL 8 CAPS / 1 DAY

oxycodone hcl (ir) 5 mg tablet 2 QL 8 TABS / 1 DAY

oxycodone hcl 100 mg/5 ml conc 2 QL 2 ML / 1 DAY

oxycodone hcl 5 mg/5 ml soln 1 QL 40 ML / 1 DAY

oxycodone hcl er (er 10 mg tablet, er 15 mg tablet, er 20mg tablet)

2 PA

oxycodone hcl er (er 30 mg tablet, er 40 mg tablet, er 60mg tablet, er 80 mg tablet)

1 PA

oxycodone hcl-aspirin 2 QL 8 TABS / 1 DAY

oxycodone-acetaminoph 10-300/5 4QL 20 ML / 1 DAY

PA

oxycodone-acetaminophen (oxycodone-acetaminophen 5-300, oxycodone-acetaminophn 2.5-325)

4 QL 8 TABS / 1 DAY

oxycodone-acetaminophen 10-300 4 QL 5 TABS / 1 DAY



oxycodone-acetaminophn 7.5-325 2 QL 7 TABS / 1 DAY

OXYCONTIN 3 PA

oxymorphone hcl 10 mg tablet 2QL 2 TABS / 1 DAY

PA

oxymorphone hcl 5 mg tablet 2QL 5 TABS / 1 DAY

PA

oxymorphone hcl er 2 PA

PERCOCET (2.5-325 MG TABLET, 5-325 MG TABLET) 4 QL 8 TABS / 1 DAY

PERCOCET 10-325 MG TABLET 4 QL 5 TABS / 1 DAY



PERCOCET 7.5-325 MG TABLET 4 QL 7 TABS / 1 DAY

PRIMLEV 10-300 MG TABLET 4 QL 5 TABS / 1 DAY

PRIMLEV 5-300 MG TABLET 4 QL 8 TABS / 1 DAY

PRIMLEV 7.5-300 MG TABLET 4 QL 7 TABS / 1 DAY

PROLATE 10 MG-300 MG/5 ML SOLN 4QL 20 ML / 1 DAY

PA

PROLATE 10-300 MG TABLET 4 QL 5 TABS / 1 DAY

PROLATE 5-300 MG TABLET 4 QL 8 TABS / 1 DAY

PROLATE 7.5-300 MG TABLET 4 QL 7 TABS / 1 DAY

QDOLO 4

QL 80 ML / 1 DAY

PA


ROXICODONE 15 MG TABLET 4 QL 3 TABS / 1 DAY

ROXICODONE 30 MG TABLET 4 PA

ROXICODONE 5 MG TABLET 4 QL 8 TABS / 1 DAY

ROXYBOND (15 MG TABLET, 30 MG TABLET) 4

ROXYBOND 5 MG TABLET 4 PA

SEGLENTIS 4

QL 4 TABS / 1 DAY

PA


SUBSYS 4 PA

tramadol er 100 mg tablet (generic for ryzolt) 2

QL 3 TABS / 1 DAY

PA



QL 1 TAB / 1 DAY

PA





QL 1 TAB / 1 DAY

PA


tramadol hcl 100 mg tablet 4PA

AQ1 At least 4 yrs old; 4 /1 day(s)

tramadol hcl 25 mg/5 ml cup 4

QL 80 ML / 1 DAY

PA


tramadol hcl 50 mg tablet 1 AQ1 At least 12 yrs old; 8/ 1 DAY

tramadol hcl er 100 mg capsule (generic for conzip) 2PA


tramadol hcl er 100 mg tablet (generic for ultram er) 2PA


tramadol hcl er 150 mg capsule 2PA

AQ1 At least 12 yrs old; 1/ 1 day(s)









tramadol hcl-acetaminophen 2PA




TREZIX 4 AQ1 At least 12 yrs old; 8/ 1 DAY

ULTRACET 4 AQ1 At least 12 yrs old; 8/ 1 DAY

ULTRAM 4 AQ1 At least 12 yrs old; 8/ 1 DAY

VICODIN HP 4 QL 8 TABS / 1 DAY

XTAMPZA ER 4 PA

ZOHYDRO ER 4 PA

OPIATE PARTIAL AGONISTS

BELBUCA (75 MCG FILM, 150 MCG FILM, 300 MCG FILM,450 MCG FILM)

4QL 4 FILMS / 1 DAY

PA

BELBUCA (750 MCG FILM, 900 MCG FILM) 4QL 2 FILMS / 1 DAY

PA

BELBUCA 600 MCG FILM 4QL 3 FILMS / 1 DAY

PA

BUNAVAIL 2.1-0.3 MG FILM 4 QL 6 FILMS / 1 DAY

BUNAVAIL 4.2-0.7 MG FILM 4 QL 3 FILMS / 1 DAY

BUNAVAIL 6.3-1 MG FILM 4 QL 2 FILMS / 1 DAY

buprenorphine 2 PA

buprenorphine 2 mg tablet sl 2 QL 12 TABS / 1 DAY

buprenorphine 600 mcg film 4QL 3 FILMS / 1 DAY

PA

buprenorphine 8 mg tablet sl 2 QL 3 TABS / 1 DAY

buprenorphine hcl (75 mcg film, 150 mcg film, 300 mcgfilm, 450 mcg film)

4QL 4 FILMS / 1 DAY

PA

buprenorphine hcl (750 mcg film, 900 mcg film) 4QL 2 FILMS / 1 DAY

PA



buprenorphine-nalox 12-3mg flm 2 QL 2 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg fm, 4-1mg film, 8-2mgfilm)

2 QL 3 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg tb, 8-2 mg tab) 2 QL 3 TABS / 1 DAY

butorphanol 10 mg/ml spray 4 QL 5 ML / 30 DAYS

BUTRANS 4 PA

pentazocine-naloxone hcl 2QL 8 TABS / 1 DAY

PA

SUBOXONE (2 MG-0.5 MG FILM, 4 MG-1 MG FILM, 8 MG-2 MG FILM)

4 QL 3 FILMS / 1 DAY

SUBOXONE 12 MG-3 MG SL FILM 4 QL 2 FILMS / 1 DAY

ZUBSOLV (0.7-0.18 MG TABLET, 1.4-0.36 MG TABLET) 4QL 12 TABS / 1 DAY

PA

ZUBSOLV 11.4-2.9 MG TABLET SL 4QL 1 TAB / 1 DAY

PA

ZUBSOLV 2.9-0.71 MG TABLET SL 4QL 4 TABS / 1 DAY

PA


PA


PA

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINES

ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET)

4 QL 3 TABS / 1 DAY

ADDERALL 30 MG TABLET 4 QL 2 TABS / 1 DAY

ADDERALL XR 2 QL 2 CAPS / 1 DAY

ADZENYS ER 4QL 15 ML / 1 DAY

PA



ADZENYS XR-ODT (12.5 MG TABLET, 15.7 MG TABLET,18.8 MG TABLET)

4QL 1 TAB / 1 DAY

PA

ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4MG TABLET)

4QL 2 TABS / 1 DAY

PA

amphetamine 4QL 15 ML / 1 DAY

PA

amphetamine sulfate 2QL 4 TABS / 1 DAY

PA

DESOXYN 4 QL 5 TABS / 1 DAY

DEXEDRINE 4QL 4 CAPS / 1 DAY

PA

dextroamp-amphetamin 15 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY

dextroamp-amphetamin 20 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY

dextroamp-amphetamin 30 mg tab 2 QL 2 TABS / 1 DAY

dextroamphetamine 5 mg/5 ml 4 QL 60 ML / 1 DAY

dextroamphetamine sulfate (5 mg tab, 10 mg tab) 2 QL 4 TABS / 1 DAY

dextroamphetamine sulfate er 2 QL 4 CAPS / 1 DAY

dextroamphetamine-amphet er 4QL 2 CAPS / 1 DAY

PA

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamine 5 mg tab)

2 QL 3 TABS / 1 DAY

DYANAVEL XR 2.5 MG/ML SUSP 4 QL 8 ML / 1 DAY

EVEKEO 4 QL 4 TABS / 1 DAY

EVEKEO ODT (ODT 15 MG, ODT 20 MG) 4 QL 2 TABS / 1 DAY

EVEKEO ODT (ODT 5 MG, ODT 10 MG) 4 QL 3 TABS / 1 DAY



methamphetamine hcl 4 QL 5 TABS / 1 DAY

MYDAYIS 4 QL 1 CAP / 1 DAY

PROCENTRA 4 QL 4 TABS / 1 DAY

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

3 QL 2 CAPS / 1 DAY

VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET) 3 QL 2 CHEW TABS / 1DAY

VYVANSE (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)

3 QL 1 CAP / 1 DAY

VYVANSE (40 MG TABLET, 50 MG TABLET, 60 MG TABLET) 3 QL 1 CHEW TAB / 1 DAY

ZENZEDI (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,10 MG TABLET, 15 MG TABLET, 20 MG TABLET)

4 QL 4 TABS / 1 DAY

ZENZEDI 30 MG TABLET 4 QL 2 TABS / 1 DAY

RESPIRATORY AND CNS STIMULANTS

ADHANSIA XR 4QL 1 CAP / 1 DAY

PA

APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 30 MG CAPSULE)

4 QL 2 CAPS / 1 DAY

APTENSIO XR (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE)

4 QL 1 CAP / 1 DAY

AZSTARYS 4QL 1 CAP / 1 DAY

PA

CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET)

2 QL 2 TABS / 1 DAY

CONCERTA ER 54 MG TABLET 2 QL 1 TAB / 1 DAY

COTEMPLA XR-ODT 4 QL 2 TABS / 1 DAY

DAYTRANA 4 QL 1 PATCH / 1 DAY

dexmethylphenidate hcl 2 QL 2 TABS / 1 DAY

dexmethylphenidate hcl er (er 25 mg cp, er 30 mg cp, er35 mg cp, er 40 mg cp)

2 QL 1 CAP / 1 DAY

dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 20 mg cp)

2 QL 2 CAPS / 1 DAY



FOCALIN 4 QL 2 TABS / 1 DAY

FOCALIN XR (25 MG CAPSULE, 30 MG CAPSULE, 35 MGCAPSULE, 40 MG CAPSULE)

4 QL 1 CAP / 1 DAY

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MGCAPSULE, 20 MG CAPSULE)

4 QL 2 CAPS / 1 DAY

JORNAY PM 4QL 1 CAP / 1 DAY

PA

METADATE ER 2 QL 3 TABS / 1 DAY

METHYLIN 10 MG/5 ML SOLUTION 4 QL 30 ML / 1 DAY

METHYLIN 5 MG/5 ML SOLUTION 4 QL 60 ML / 1 DAY

methylphenidate 4 QL 1 PATCH / 1 DAY

methylphenidate 10 mg/5 ml sol 4 QL 30 ML / 1 DAY

methylphenidate 5 mg/5 ml soln 4 QL 60 ML / 1 DAY

methylphenidate er (er 10 mg cap, er 15 mg cap, er 20 mgcap, er 30 mg cap)

2 QL 2 CAPS / 1 DAY

methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mgtab)

4QL 2 TABS / 1 DAY

PA

methylphenidate er (er 40 mg cap, er 50 mg cap, er 60 mgcap)

2 QL 1 CAP / 1 DAY

methylphenidate er (la) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY

methylphenidate er 10 mg cap (authorized generic) 2 QL 2 CAPS / 1 DAY

methylphenidate er 10 mg tab 2 QL 4 TABS / 1 DAY



methylphenidate er 20 mg tab 2 QL 3 TABS / 1 DAY


methylphenidate er 40 mg cap (authorized generic) 2 QL 1 CAP / 1 DAY




methylphenidate er 54 mg tab 4QL 1 TAB / 1 DAY

PA


methylphenidate er(la) 40mg cp 2 QL 1 CAP / 1 DAY

methylphenidate hcl (2.5 mg chew tb, 5 mg chew tab, 10mg chew tab)

4 QL 4 CHEW TABS / 1DAY

methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet)

2 QL 3 TABS / 1 DAY

methylphenidate hcl cd (10 mg cap, 20 mg cap, 30 mgcap)

2 QL 2 CAPS / 1 DAY

methylphenidate hcl cd (40 mg cap, 50 mg cap, 60 mgcap)

2 QL 1 CAP / 1 DAY

methylphenidate hcl er (cd) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY

methylphenidate hcl er (cd) (40mg cp, 50mg cp, 60mg cp) 2 QL 1 CAP / 1 DAY

methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap) 2 QL 2 CAPS / 1 DAY

methylphenidate la (40 mg cap, 60 mg cap) 2 QL 1 CAP / 1 DAY

QUILLICHEW ER 20 MG CHEW TAB 3 QL 3 CHEW TABS / 1DAY

QUILLICHEW ER 30 MG CHEW TAB 3 QL 2 CHEW TABS / 1DAY

QUILLICHEW ER 40 MG CHEW TAB 3 QL 1 CHEW TAB / 1 DAY

QUILLIVANT XR 3 QL 12 ML / 1 DAY

RITALIN 4 QL 3 TABS / 1 DAY

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

4 QL 2 CAPS / 1 DAY

RITALIN LA 40 MG CAPSULE 4 QL 1 CAP / 1 DAY

WAKEFULNESS-PROMOTING AGENTS

armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) 2 QL 1 TAB / 1 DAY



armodafinil 50 mg tablet 2 QL 2 TABS / 1 DAY

modafinil 2 QL 2 TABS / 1 DAY

NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MGTABLET)

4QL 1 TAB / 1 DAY

PA

NUVIGIL 50 MG TABLET 4QL 2 TABS / 1 DAY

PA

PROVIGIL 4QL 2 TABS / 1 DAY

PA

SUNOSI 3QL 1 TAB / 1 DAY

PA

WAKIX 5PA

S

ANTI-INFECTIVE AGENTSANTHELMINTICS

albendazole 2 PA

ALBENZA 4 PA

BILTRICIDE 4

EMVERM 4 PA

ivermectin 3 mg tablet 2

praziquantel 2

STROMECTOL 4

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 2 QL 1 PACKET / RX

FURADANTIN 4 AL1 Up to 12 yrs old

HIPREX 4

MACROBID 4

MACRODANTIN (50 MG CAPSULE, 100 MG CAPSULE) 4



MACRODANTIN 25 MG CAPSULE 4 AL1 Up to 12 yrs old

methenamine hippurate 2

methenamine mandelate 4

MONUROL 4 QL 1 PACKET / RX

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap) 2 AL1 Up to 12 yrs old

nitrofurantoin (50 mg cap, 100 mg cap) 2

nitrofurantoin mono-macro 2

phosphasal 4

PRIMSOL 4

trimethoprim 1

URELLE 4

URETRON D-S 4

URIBEL 4

uro-mp 4

UROQID-ACID NO.2 4

utira-c 4

ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)

AZASITE 3 PA

bacitracin 500 unit/gm ophth 2

bacitracin-polymyxin 2

BESIVANCE 3 PA

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 3

CETRAXAL 4

CILOXAN 0.3% EYE DROPS 4

CILOXAN 0.3% OINTMENT 3

CIPRO HC 3



CIPRODEX 4

ciprofloxacin 0.2% otic soln 2 PA

ciprofloxacin 0.3% eye drop 1

ciprofloxacin hcl-fluocinolone 2 PA

ciprofloxacin-dexamethasone 2

CORTISPORIN-TC 4

doxycycline hyclate 20 mg tab 1

erythromycin 0.5% eye ointment 2

gatifloxacin 2

GENTAK 2 PA

gentamicin 0.3% eye drop 2 PA

levofloxacin (0.5% drops, 1.5% drops) 2 PA

MAXITROL (DROPS, OINTMENT) 4

MOXEZA 4

moxifloxacin 0.5% eye drops 1

moxifloxacin 0.5% eye drops (generic for moxeza) 4

neomyc-polym-dexamet eye ointm 2

neomyc-polym-dexameth eye drop 4

neomycin-bacitracin-poly-hc 4

neomycin-bacitracin-polymyxin 2

neomycin-polymyxin-gramicidin 1

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort 2

OCUFLOX 4

ofloxacin (ear drops, eye drops) 2

OTIPRIO 4 PA

OTOVEL 4



polymyxin b sul-trimethoprim 2

POLYTRIM 4

PRED-G (1% DROPS, S.O.P. OINTMENT) 3 PA

sulfacetamide sodium (drops, ointment) 2

sulfacetamide-prednisolone 2

TOBRADEX EYE DROPS 4

TOBRADEX EYE OINTMENT 3

TOBRADEX ST 4

tobramycin 0.3% eye drop 2

tobramycin-dexamethasone 2

TOBREX 0.3% EYE DROP 4

TOBREX 0.3% EYE OINTMENT 3

VIGAMOX 4

ZYLET 3 PA

ZYMAXID 4

ANTIFUNGALS (EENT)

NATACYN 3 PA

ANTIVIRALS (EENT)trifluridine 2

ZIRGAN 3

EENT ANTI-INFECTIVES, MISCELLANEOUSacetic acid 2% ear solution 2

chlorhexidine gluconate 1

hydrocortisone-acetic acid 2

PAROEX 2

PERIDEX 4

PERIOGARD 2



ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ACANYA 4 PA

ALTABAX 3 ST

AMZEEQ 4 PA

BENZACLIN 4 PA

BENZAMYCIN 4

CENTANY 4 QL 44 GM / RX

CENTANY AT 4

CLEOCIN 100 MG VAGINAL OVULE 3

CLEOCIN 2% VAGINAL CREAM 4

CLEOCIN T (GEL, LOION) 4

CLEOCIN T 1% SOLUTION 4 QL 60 ML / 30 DAYS

clind ph-benzoyl pero 1.2-2.5% 4 PA

clind ph-benzoyl perox 1.2-5% 2

CLINDACIN ETZ (1% PLEDGET, KIT) 4 PA

CLINDACIN P 4 PA

CLINDACIN PAC 4 PA

CLINDAGEL 4 PA

clindamycin ph 1% gel (generic for cleocin t) 2

clindamycin ph 1% solution 2 QL 60 ML / 30 DAYS

clindamycin phos-tretinoin 4

clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream)

2

clindamycin phosphate 1% foam 4

clindamycin phosphate 1% gel (generic for clindagel) 4 PA

clindamycin-benzoyl peroxide 2



CLINDESSE 4

CORTISPORIN (CREAM, OINTMENT) 4

ERY 4

ERYGEL 4

erythromycin 2% gel 2

erythromycin 2% solution 1 QL 60 ML / 30 DAYS

erythromycin-benzoyl peroxide 2

EVOCLIN 4

gentamicin 0.1% cream 2 QL 30 GM / 30 DAYS

gentamicin 0.1% ointment 1

METROCREAM 4

METROGEL TOPICAL 1% GEL 4

METROGEL-VAGINAL 4

METROLOTION 4

metronidazole (0.75% cream, 0.75% lotion, topical 0.75%gl, topical 1% gel)

2

metronidazole vaginal 0.75% gl 1

mupirocin 2% cream 2QL 30 GM / 30 DAYS

PA

mupirocin 2% ointment 1 QL 44 GM / RX

NEO-SYNALAR (0.5%-0.025% CREAM, 0.5-0.025% CRMKIT)

4 PA

NEUAC (1.2-5% KIT, GEL) 4

NORITATE 4 PA

NUVESSA 4

ONEXTON GEL PUMP 4 PA

ROSADAN 0.75% CREAM 2

ROSADAN 0.75% CREAM KIT 4



VANDAZOLE 4

VELTIN 4 PA

XEPI 4

ZIANA 4 PA

ZILXI 4 PA

ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)

acyclovir 5% cream 2QL 5 GM / RX

PA

acyclovir 5% ointment 2 QL 15 GM / 1 FILL

DENAVIR 3 PA

XERESE 4 PA

ZOVIRAX 5% CREAM 4QL 5 GM / RX

PA

ZOVIRAX 5% OINTMENT 4QL 15 GM / 1 FILL

PA

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCORTIN A 4 PA

cleansing wash 4

FEM PH 4

hydrocortisone-iodoquinol 2

hydrocortisone-iodoquinol-aloe 4 PA

iodoquinol-hydrocortisone-aloe 4 PA

KLARON 4

mafenide acetate 2 PA

OVACE 4

OVACE PLUS (9.8% FOAM, 9.8% LOTION, 10% SHAMPOO,10% WASH)

4



ovace plus wash 4

QUINJA 4

selenium sulfide (2.25% shampoo, 2.3% shampoo) 4

selenium sulfide 2.5% lotion 2

SELRX 4

SILVADENE 4

silver sulfadiazine 2

sod sulface-sulfur 9-4.5% wash 4

sod sulfacetam 10% clnsng gel 4

sodium sulf-sulfur cleanser 2

SSD 2

sulfacetamide sodium (sod top susp, sodium lotn) 2

SULFAMYLON 8.5% CREAM 4

SULFAMYLON POWDER PACKET 4 PA

SUMADAN XLT 4 PA

VYTONE 4 PA

SCABICIDES AND PEDICULICIDESCROTAN 4

ELIMITE 4

EURAX 10% CREAM 3 PA

EURAX 10% LOTION 4

ivermectin 0.5% lotion 2 PA

lindane 2 PA

malathion 2

NATROBA 4

OVIDE 4

permethrin 2



SKLICE 4 PA

spinosad 2 PA

ULESFIA 3 PA

ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)

ALREX 3 PA

BECONASE AQ 4

DERMOTIC 4

dexamethasone 0.1% eye drop 2

difluprednate 2 PA

DUREZOL 4 PA

EYSUVIS 4 PA

FLAC OTIC OIL 4

FLAREX 4

flunisolide 2

fluocinolone acetonide oil 2

fluorometholone 2

fluticasone prop 50 mcg spray 1

FML 4

FML FORTE 4

FML S.O.P. 3

INVELTYS 4

LOTEMAX (EYE DROPS, OPHTHALMIC GEL) 4

LOTEMAX 0.5% EYE OINTMENT 3

LOTEMAX SM 3

loteprednol etabonate (etabonate drp, ophthalmc gel) 2

MAXIDEX 4



mometasone furoate 50 mcg spry 4

NASONEX 4

OMNARIS 4

PRED FORTE 4

PRED MILD 4

prednisolone ac 1% eye drop (generic pred forte) 2

prednisolone sod 1% eye drop 1

prednisolone-nepafenac 4

QNASL 4

QNASL CHILDREN 4

XHANCE 4 PA

ZETONNA 4

EENT ANTI-INFLAMMATORY AGENTS, MISC.

CEQUA 4 PA

cyclosporine 0.05% eye emuls 2

RESTASIS 4

RESTASIS MULTIDOSE 3

VERKAZIA 4 PA

XIIDRA 4 PA

EENT NONSTEROIDAL ANTI-INFLAM. AGENTSACULAR 4

ACULAR LS 4

ACUVAIL 4

bromfenac sodium 2

BROMSITE 4

diclofenac 0.1% eye drops 1

flurbiprofen sodium 1

ILEVRO 3 PA



ketorolac tromethamine (0.4% solution, 0.5% solution) 2

NEVANAC 4

PROLENSA 4

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTS

DUPIXENT 100 MG/0.67 ML SYRING 5PA

S

FASENRA PEN 5PA

S

NUCALA (40 MG/0.4 ML SYRINGE, 100 MG/ML AUTO-INJECTOR, 100 MG/ML SYRINGE)

5PA

S

SKYRIZI ON-BODY 5PA

S

LEUKOTRIENE MODIFIERSACCOLATE 4

montelukast sod 10 mg tablet 1

montelukast sodium (4 mg granules, 4 mg tab chew, 5 mgtab chew)

2

SINGULAIR 4

zafirlukast 2 PA

zileuton er 2QL 4 TABS / 1 DAY

PA

ZYFLO 4 PA

MAST-CELL STABILIZERS

ALOCRIL 3 PA

cromolyn 100 mg/5 ml oral conc 4 PA

cromolyn 20 mg/2 ml neb soln 2 PA

cromolyn 4% eye drops 2



GASTROCROM 4 PA

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA 3QL 60 GM / 30 DAYS

ST

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

ADV ALLERGY COLLECTION KIT 4 PA

ALA-CORT 1% CREAM 4

alclometasone dipropionate 2

amcinonide 0.1% cream 2 PA

amcinonide 0.1% lotion 4

ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1%LOTION)

4

anucort-hc 2

ANUSOL-HC (2.5% CREAM, 25 MG SUPPOSITORY) 4

APEXICON E 4 PA

betamethasone diprop augmented (gel, lot, oin) 2

betamethasone dipropionate (crm, lot, oint) 2

betamethasone dp aug 0.05% crm 1

betamethasone valer 0.12% foam 4 PA

betamethasone valerate (va cream, va lotion, valer ointm) 2

BRYHALI 4

CAPEX SHAMPOO 4 PA

clobetasol emollient 0.05% crm 2

clobetasol emollnt 0.05% foam 4 PA

clobetasol emulsion 4 PA

clobetasol propionate (cream, gel, ointment, solution) 2

clobetasol propionate (foam, spray) 4 PA



clobetasol propionate (shampoo, topical lotn) 4

CLOBEX 4 PA

clocortolone pivalate 4

CLODAN (KIT, SHAMPOO) 4

CLODERM 4

COLOCORT 4

CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION,0.05% OINTMENT)

4 PA

CORDRAN 4 MCG/SQ CM TAPE LARGE 3 PA

CORTENEMA 4

CORTIFOAM 4 PA

CUTIVATE 0.05% LOTION 4

DERMA-SMOOTHE-FS BODY OIL 4

DESONATE 4 PA

desonide (cream, lotion, ointment) 2

desonide 0.05% gel 4 PA

desoximetasone (0.05% cream, 0.05% gel, 0.25% cream,0.25% ointment)

2

desoximetasone 0.05% ointment 4

desoximetasone 0.25% spray 4 PA

diflorasone diacetate 2 PA

DIPROLENE 4

EPIFOAM 4

fluocinolone 0.01% solution 2 QL 60 ML / 30 DAYS

fluocinolone acetonide (0.01% body oil, 0.01% cream,0.01% scalp oil, 0.025% cream, 0.025% ointment)

2

fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment,0.05% solution, 0.1% cream)

2

fluocinonide-e 2



flurandrenolide (cream, lotion, ointment) 4 PA

fluticasone prop 0.05% lotion 4

fluticasone propionate (0.005% oint, 0.05% cream) 2

halcinonide 4 PA

halobetasol propionate 2 PA

HALOG (CREAM, OINTMENT, SOLUTION) 4 PA

hemmorex-hc 4

hydrocortisone (2.5% cream, 2.5% lotion, 100 mg/60 ml) 2

hydrocortisone 1% cream 4

hydrocortisone 2.5% ointment 1

hydrocortisone ac 25 mg supp 2

hydrocortisone butyrate (buty cream, butyr oint) 2

hydrocortisone butyrate (hydrocort buty lipid crm,hydrocort buty lipo cream, hydrocortisone butyr lotn,hydrocortisone butyr soln)

4

hydrocortisone valerate 2

hydrocortisone-1% ointment 4

hydrocortisone-pramoxine (1%-1% crm, 2.5-1% crm) 2

IMPEKLO 4 PA

IMPOYZ 4 PA

KENALOG 4 PA

LEXETTE 4 PA

lidocaine-hc 3-0.5% cream 4

LOCOID 4

LOCOID LIPOCREAM 4 PA

LUXIQ 4 PA

mometasone furoate (cream, oint, soln) 2



NOLIX (CREAM, LOTION) 4 PA

NOVACORT 4 PA

NOXIPAK 4 PA

NUTRIARX 4 PA

OLUX 4 PA

OLUX-E 4 PA

PANDEL 4

PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1%OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1%OINTMENT)

4

prednicarbate 4

PROCTO-MED HC 2

PROCTO-PAK 4

PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 4

PROCTOFOAM-HC 4

PROCTOSOL-HC 2

PROCTOZONE-HC 2

PSORCON 4 PA

SERNIVO 4 PA

SYNALAR (CREAM, CREAM KIT, OINTMENT, OINTMENTKIT)

4

SYNALAR 0.01% SOLUTION 4 QL 60 ML / 30 DAYS

SYNALAR TS 4

TEMOVATE 4

TEXACORT 4

TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT,0.25% CREAM, 0.25% OINTMENT)

4

TOPICORT 0.25% SPRAY 4 PA



TOVET EMOLLIENT 4 PA

triamcinolone 0.05% ointment 4

triamcinolone 0.1% paste 1

triamcinolone 0.147 mg/g spray 4 PA

triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment,0.5% cream, 0.5% ointment)

2

TRIDERM 2

VANOS 4

VANOXIDE-HC 4

VERDESO 4 PA

WHYTEDERM TDPAK 4 PA

WHYTEDERM TRILASIL PAK 4 PA

XILAPAK 4 PA

NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN)FROTEK 10% CREAM PACKET 4

ANTIANEMIA DRUGSIRON PREPARATIONS

ABATRON 4 PA

ACCRUFER 4 PA

folitab 500 4 PA

SIDEROL 4 PA

ANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICS

disopyramide phosphate 2

NORPACE 4

NORPACE CR 3

quinidine gluconate 4



quinidine sulfate 2

CLASS IB ANTIARRHYTHMICSmexiletine hcl 2

CLASS IC ANTIARRHYTHMICSflecainide acetate 2

propafenone hcl 2

propafenone hcl er 4 PA

RYTHMOL SR 4

CLASS III ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet)

2

dofetilide 2

MULTAQ 3 PA

PACERONE (100 MG TABLET, 400 MG TABLET) 2

TIKOSYN 4

ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICS

ARIKAYCE 5

QL 8.4 ML / 1 DAY

PA

S

BETHKIS 5PA

S

KITABIS PAK 5PA

S

neomycin sulfate 2

TOBI 5PA

S

TOBI PODHALER 5PA

S



tobramycin (300 mg/4 ml ampule, 300 mg/5 ml ampule,pak 300 mg/5 ml)

5PA

S

QUINOLONE ANTIBIOTICS

BAXDELA 450 MG TABLET 3 PA

CIPRO (250 MG TABLET, 500 MG TABLET) 4

CIPRO (5% SUSPENSION, 10% SUSPENSION) 3 AL1 Up to 12 yrs old

ciprofloxacin 2 AL1 Up to 12 yrs old

ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab,750 mg tab)

1

FACTIVE 3 PA

levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet)

1

levofloxacin 25 mg/ml solution 2 AL1 Up to 12 yrs old

moxifloxacin hcl 2

ofloxacin 400 mg tablet 4

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)BACTRIM 4

BACTRIM DS 4

sulfadiazine 2 PA

sulfamethoxazole-tmp susp 2

sulfamethoxazole-trimethoprim (ds tablet, ss tablet) 1

SULFATRIM 2

TETRACYCLINE ANTIBIOTICS

ACTICLATE 4 PA

AVIDOXY 4 PA

COREMINO 4 PA

demeclocycline hcl 2

DORYX 4 PA



DORYX MPC 4 PA

doxycycline 25 mg/5 ml susp 2 AL1 Up to 12 yrs old

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1

doxycycline hyclate (50 mg tablet, hyc dr 50 mg tab, hycdr 75 mg tab, hyc dr 80 mg tab, hyc dr 100 mg tab, hyc dr150 mg tab, hyc dr 200 mg tab, hyclate 75 mg tab,hyclate 150 mg tab)

4 PA

doxycycline ir-dr 4 PA

doxycycline monohydrate (50 mg cap, 50 mg tablet, 100mg cap, 100 mg tablet)

2

doxycycline monohydrate (75 mg capsule, 150 mg cap) 4 PA

doxycycline monohydrate (75 mg tablet, 150 mg tablet) 4

minocycline er 4 PA

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)

2

minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet)

4

minocycline hcl er 4 PA

MINOLIRA ER 4 PA

MONDOXYNE NL 4 PA

MONODOX 4 PA

MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 4 PA

ORACEA 4 PA

SOLODYN 4 PA

TARGADOX 4 PA

tetracycline hcl 2 PA

VIBRAMYCIN 100 MG CAPSULE 4 PA

VIBRAMYCIN 25 MG/5 ML SUSP 4PA

AL1 Up to 12 yrs old



VIBRAMYCIN 50 MG/5 ML SYRUP 4

XIMINO 4 PA

ANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICS

FIRVANQ 4

VANCOCIN HCL 4

vancomycin 250 mg/5 ml soln 4

vancomycin hcl 125 mg capsule 2

vancomycin hcl 250 mg capsule 1

LINCOMYCIN ANTIBIOTICSCLEOCIN HCL 4

CLEOCIN PEDIATRIC 4 AL1 Up to 12 yrs old

clindamycin (pediatric) 2 AL1 Up to 12 yrs old

clindamycin hcl (150 mg capsule, 300 mg capsule) 1

clindamycin hcl 75 mg capsule 2

OTHER MISC. ANTIBACTERIAL AGENTS

HELIDAC 4 PA

PYLERA 4

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5 ml susp 2 PA

linezolid 600 mg tablet 2 QL 28 TABS / RX

SIVEXTRO 200 MG TABLET 3 PA

ZYVOX 100 MG/5 ML SUSPENSION 4 PA

ZYVOX 600 MG TABLET 4QL 28 TABS / RX

PA

PLEUROMUTILINS

XENLETA 600 MG TABLET 3QL 10 TABS / RX

PA



RIFAMYCIN ANTIBIOTICS

AEMCOLO 4 PA

XIFAXAN 3 PA

ANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICS

ANASPAZ 4

ANORO ELLIPTA 3

ATROVENT HFA 3 QL 1 INHALER / 25 DAYS

belladonna-phenobarbital 4

BEVESPI AEROSPHERE 4 PA

chlordiazepoxide-clidinium 4

COMBIVENT RESPIMAT 3 QL 1 INHALER / 30 DAYS

CUVPOSA 4 PA

DARTISLA 4 PA

dicyclomine 10 mg capsule 2

dicyclomine hcl (10 mg/5 ml soln, 20 mg tablet) 1

DUAKLIR PRESSAIR 4 PA

ed-spaz 2

glycopyrrolate (1 mg tablet, 2 mg tablet) 2

glycopyrrolate 1 mg/5 ml soln 2 PA

glycopyrrolate 1.5 mg tablet 4 PA

hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab)

2

hyoscyamine sulfate er 2

hyoscyamine sulfate sr 2

hyosyne 2

INCRUSE ELLIPTA 3



ipratropium br 0.02% soln 2

ipratropium-albuterol 2

LEVBID 4

LEVSIN 0.125 MG TABLET 4

LEVSIN-SL 4

LIBRAX 4

LONHALA MAGNAIR REFILL 4 PA

LONHALA MAGNAIR STARTER 4 PA

methscopolamine bromide 2 PA

nulev 4

oscimin 2

oscimin sl 2

oscimin sr 2

phenobarb-hyosc-atrop-scop tab 4

phenohytro tablet 4

propantheline bromide 2

QBREXZA 5

QL 1 TOWELETTE / 1DAY

PA

S

ROBINUL 4 PA

ROBINUL FORTE 4 PA

SPIRIVA 4 PA

SPIRIVA RESPIMAT 4 PA

STIOLTO RESPIMAT 4 PA

symax 4

SYMAX DUOTAB 4



symax-sl 4

symax-sr 2

TUDORZA PRESSAIR 4 PA

YUPELRI 4 PA

ANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUS

ARIXTRA 4QL 1 SYRINGE / 1 DAY

PA

fondaparinux sodium 2QL 1 SYRINGE / 1 DAY

PA

COUMARIN DERIVATIVESjantoven 1

warfarin sodium 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 3 QL 2 TABS / 1 DAY

ELIQUIS DVT-PE TREAT START 5MG 3 QL 1 RX / 30 DAYS

SAVAYSA 4 PA

XARELTO (10 MG TABLET, 20 MG TABLET) 3 QL 1 TAB / 1 DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 3 QL 2 TABS / 1 DAY

XARELTO 1 MG/ML SUSPENSION 3 QL 20 ML / 1 DAY

XARELTO DVT-PE TREAT START 30D 3 QL 51 TABS / 30 DAYS

DIRECT THROMBIN INHIBITORS

dabigatran etexilate 2 PA

PRADAXA 3 PA

HEPARINS

enoxaparin 300 mg/3 ml vial 2 QL 2 VIALS / 1 DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSenoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)

2 QL 2 SYRINGES / 1 DAY

FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 MLSYR, 7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE,12,500 UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000UNIT/0.72 ML)

4 QL 1 SYRINGE / 1 DAY

FRAGMIN 95,000 UNIT/3.8 ML VL 4 QL 1 VIAL / 1 DAY

heparin sodium (sod 1,000 unit/ml vial, 5,000 unit/mlcarpujct, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000unit/ml vl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial,40,000 unit/4 ml vial, 50,000 unit/10 ml vial, 50,000unit/5 ml vial)

2

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 MLSYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE,150 MG/ML SYRINGE)

4 QL 2 SYRINGES / 1 DAY

LOVENOX 300 MG/3 ML VIAL 4 QL 2 VIALS / 1 DAY

ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS

ACTIVE-PAC 4 PA

APTIOM 3 PA

BANZEL 200 MG TABLET 4QL 16 TABS / 1 DAY

PA

BANZEL 40 MG/ML SUSPENSION 4QL 80 ML / 1 DAY

PA

BANZEL 400 MG TABLET 4QL 8 TABS / 1 DAY

PA

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MGTABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)

3 PA

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet)

2

carbamazepine er 2



CARBATROL 4

DEPAKOTE 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLE 4

DIACOMIT 250 MG CAPSULE 5

QL 12 CAPS / 1 DAY

PA

S

DIACOMIT 250 MG POWDER PACKET 5

QL 12 PACKETS / 1 DAY

PA

S

DIACOMIT 500 MG CAPSULE 5

QL 6 CAPS / 1 DAY

PA

S

DIACOMIT 500 MG POWDER PACKET 5

QL 6 PACKETS / 1 DAY

PA

S

divalproex sodium (dr 125 mg cap sprnk, dr 125 mgcp(sprnk))

1

divalproex sodium (dr 125 mg tab, dr 250 mg tab, dr 500mg tab)

2

divalproex sodium er 1

ELEPSIA XR 4 PA

EPIDIOLEX 5

QL 20 ML / 1 DAYS

PA

S

EPITOL 4

EPRONTIA 4 PA

EQUETRO 4

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5ML SUSP)

4

FINTEPLA 5PA

S

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MGTABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12MG TABLET)

3 PA

GABACAINE 4 PA

gabapentin (100 mg capsule, 300 mg capsule) 2 QL 12 CAPS / 1 DAY

gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 2 QL 72 ML / 1 DAY

gabapentin 400 mg capsule 2 QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet 2 QL 6 TABS / 1 DAY

gabapentin 800 mg tablet 2 QL 4 TABS / 1 DAY

GABITRIL 4

HORIZANT ER 300 MG TABLET 4QL 1 TAB / 1 DAY

PA

HORIZANT ER 600 MG TABLET 4QL 2 TABS / 1 DAY

PA

KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500MG TABLET, 750 MG TABLET, 1,000 MG TABLET)

4 PA

KEPPRA XR 4 PA

lacosamide (150 mg tablet, 200 mg tablet) 2 QL 2 TABS / 1 DAY

lacosamide 10 mg/ml solution 2 QL 40 ML / 1 DAY

lacosamide 100 mg tablet 2 QL 4 TABS / 1 DAY

lacosamide 50 mg tablet 2 QL 8 TABS / 1 DAY

LAMICTAL (25 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

4 PA

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET) 4

LAMICTAL (BLUE) 4 PA



LAMICTAL (GREEN) 4 PA

LAMICTAL (ORANGE) 4 PA

LAMICTAL ODT 4 PA

LAMICTAL ODT (BLUE) 4 PA

LAMICTAL ODT (GREEN) 4 PA

LAMICTAL ODT (ORANGE) 4 PA

LAMICTAL XR 4 PA

LAMICTAL XR (BLUE) 4 PA

LAMICTAL XR (GREEN) 4 PA

LAMICTAL XR (ORANGE) 4 PA

lamotrigine 2

lamotrigine (blue) 4 PA

lamotrigine (green) 4 PA

lamotrigine (orange) 4 PA

lamotrigine er 4

lamotrigine odt 4 PA

lamotrigine odt (blue) 4 PA

lamotrigine odt (green) 4 PA

lamotrigine odt (orange) 4 PA

levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet)

2

levetiracetam er 1

LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 4QL 2 CAPS / 1 DAY

PA

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)

4QL 3 CAPS / 1 DAY

PA



LYRICA 20 MG/ML ORAL SOLUTION 4QL 30 ML / 1 DAY

PA

NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE) 4QL 12 CAPS / 1 DAY

PA

NEURONTIN 250 MG/5 ML SOLUTION 4QL 72 ML / 1 DAY

PA

NEURONTIN 400 MG CAPSULE 4QL 9 CAPS / 1 DAY

PA

NEURONTIN 600 MG TABLET 4QL 6 TABS / 1 DAY

PA

NEURONTIN 800 MG TABLET 4QL 4 TABS / 1 DAY

PA

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet)

2

OXTELLAR XR 4 PA

pregabalin (225 mg capsule, 300 mg capsule) 2 QL 2 CAPS / 1 DAY

pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule)

2 QL 3 CAPS / 1 DAY

pregabalin 20 mg/ml solution 2 QL 30 ML / 1 DAY

QUDEXY XR 4 PA

ROWEEPRA 4 PA

ROWEEPRA XR 4 PA

rufinamide 200 mg tablet 2QL 16 TABS / 1 DAY

PA

rufinamide 40 mg/ml suspension 2QL 80 ML / 1 DAY

PA

rufinamide 400 mg tablet 2QL 8 TABS / 1 DAY

PA



SABRIL 5PA

S

SPRITAM 4 PA

SUBVENITE 2

SUBVENITE (BLUE) 4 PA

SUBVENITE (GREEN) 4 PA

SUBVENITE (ORANGE) 4 PA

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 4

TEGRETOL XR 4

tiagabine hcl 2

TOPAMAX 4 PA

topiramate 1

topiramate er 4 PA

TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5ML SUSP, 600 MG TABLET)

4 PA

TROKENDI XR 4 PA

valproic acid (250 mg capsule, 250 mg/5 ml soln, 500mg/10 ml sol)

2

vigabatrin 5PA

S

VIGADRONE 5PA

S

VIMPAT 10 MG/ML SOLUTION 3 QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET 3 QL 4 TABS / 1 DAY





PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSXCOPRI (12.5-25 MG TITRATION PK, 50 MG TABLET, 50-100 MG TITRATION PAK, 100 MG TABLET, 150-200 MGTITRATION PK)

4 QL 1 TAB / 1 DAY

XCOPRI (150 MG TABLET, 200 MG TABLET, 250 MG DAILYDOSE PACK, 350 MG DAILY DOSE PACK)

4 QL 2 TABS / 1 DAY

ZONEGRAN 4 PA

zonisamide 1

BARBITURATES (ANTICONVULSANTS)

MYSOLINE 4 PA

primidone 2

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 10 mg tablet 2 QL 4 TABS / 1 DAY

clobazam 2.5 mg/ml suspension 2 QL 16 ML / 1 DAY

clobazam 20 mg tablet 2 QL 2 TABS / 1 DAY

clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet)

1 QL 6 TABS / 1 DAY

clonazepam (1 mg dis tablet, 1 mg odt, 1 mg tablet) 1 QL 4 TABS / 1 DAY

clonazepam (2 mg odt, 2 mg tablet) 1 QL 2 TABS / 1 DAY

KLONOPIN 0.5 MG TABLET 4 QL 6 TABS / 1 DAY

KLONOPIN 1 MG TABLET 4 QL 4 TABS / 1 DAY

KLONOPIN 2 MG TABLET 4 QL 2 TABS / 1 DAY

NAYZILAM 3QL 2 BOTTLES / RX

PA

ONFI 10 MG TABLET 4QL 4 TABS / 1 DAY

PA

ONFI 2.5 MG/ML SUSPENSION 4QL 16 ML / 1 DAY

PA

ONFI 20 MG TABLET 4QL 2 TABS / 1 DAY

PA



SYMPAZAN 4

HYDANTOINSDILANTIN (50 MG INFATAB, 100 MG CAPSULE) 4

DILANTIN 30 MG CAPSULE 3

DILANTIN-125 4

PEGANONE 4

PHENYTEK 4

phenytoin (50 mg infatab chew, 50 mg tablet chew, 125mg/5 ml susp)

2

phenytoin sodium extended 2

SUCCINIMIDES

CELONTIN 3 PA

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 2

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 4

ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 4 PA

bupropion hcl 2

bupropion hcl sr 2

bupropion hcl xl 450 mg tablet 4 PA

bupropion xl (150 mg tablet, 300 mg tablet) 2

FORFIVO XL 4 PA

mirtazapine (15 mg odt, 30 mg odt, 45 mg odt) 4

mirtazapine (7.5 mg tablet, 15 mg tablet, 30 mg tablet, 45mg tablet)

2

REMERON 4

SPRAVATO 4 PA

WELLBUTRIN SR 4

WELLBUTRIN XL 4 PA



MONOAMINE OXIDASE INHIBITORSMARPLAN 4

NARDIL 4

PARNATE 4

phenelzine sulfate 2

tranylcypromine sulfate 2

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

CYMBALTA 4 PA

desvenlafaxine er 4

desvenlafaxine suc er 100 mg tablet (generic for pristiq) 1



DRIZALMA SPRINKLE 4 PA

duloxetine hcl (dr 20 mg cap, dr 30 mg cap, dr 60 mg cap) 2

duloxetine hcl dr 40 mg cap 4 PA

EFFEXOR XR 4 PA

FETZIMA 3 PA

PRISTIQ 4 PA

venlafaxine hcl 2

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150mg cap)

2

venlafaxine hcl er (er 37.5 mg tab, er 75 mg tab, er 150mg tab, er 225 mg tab)

4

SELECTIVE-SEROTONIN REUPTAKE INHIBITORSBRISDELLE 4

CELEXA 4 PA

citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1

citalopram hbr (10 mg/5 ml soln, 20 mg/10 ml sol) 2



citalopram hbr 30 mg capsule 4 PA

escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mgtablet)

1

escitalopram oxalate 5 mg/5 ml 2

fluoxetine 20 mg/5 ml solution 2

fluoxetine dr 4

fluoxetine hcl (10 mg capsule, 20 mg capsule, 40 mgcapsule)

1

fluoxetine hcl (10 mg tablet, 20 mg tablet, 60 mg tablet) 4

fluvoxamine maleate 2

fluvoxamine maleate er 4

LEXAPRO 4 PA

olanzapine-fluoxetine hcl 2PA


paroxetine cr 4

paroxetine er 4

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet,40 mg tablet)

1

paroxetine hcl 10 mg/5 ml susp 2

paroxetine mesylate 4

PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MGTABLET, 30 MG TABLET, 40 MG TABLET)

4

PAXIL CR 4

PEXEVA 4

PROZAC 4 PA

SARAFEM 4

sertraline hcl (150 mg capsule, 200 mg capsule) 4 PA

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50mg tablet, hcl 100 mg tablet)

1

SYMBYAX 4 AL1 At least 7 yrs old


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET)

4 PA

SEROTONIN MODULATORSnefazodone hcl 2

trazodone hcl 1

TRINTELLIX 3 PA

VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 4

VIIBRYD 10-20 MG STARTER PACK 3 PA

vilazodone hcl 2 PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl 2

amoxapine 2 PA

ANAFRANIL 4

chlordiazepoxide-amitriptyline 2PA

AQ1 Up to 64 yrs old; 4 /1 DAY

clomipramine hcl 2

desipramine hcl 2

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule,150 mg capsule)

2

doxepin hcl (3 mg tablet, 6 mg tablet) 2 PA

imipramine hcl 2

imipramine pamoate 4

maprotiline hcl 2 PA

NORPRAMIN 4

nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap)

2

PAMELOR 4

perphenazine-amitriptyline 2PA




protriptyline hcl 2 PA

SILENOR 4 PA

trimipramine maleate 2 PA

ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS

acarbose 1

GLYSET 4

miglitol 2

AMYLINOMIMETICSSYMLINPEN 60 4

ANTIDIABETIC AGENTS, MISCELLANEOUS

KORLYM 5PA

S

BIGUANIDES

FORTAMET 4 PA

GLUMETZA 4 PA

metformin er 1,000 mg gastr-tb (generic for glumetza er) 4 PA

metformin er 1,000 mg osm-tab (generic for fortamet er) 4 PA

metformin er 500 mg gastrc-tb (generic for glumetza er) 4 PA

metformin er 500 mg osmotic tb (generic for fortamet er) 4 PA

metformin hcl (500 mg/5 ml soln, 850 mg/8.5ml cup) 4

metformin hcl 1,000 mg tablet (generic for glucophage) 1

metformin hcl 500 mg tablet (generic for glucophage) 1

metformin hcl 625 mg tablet 4 PA

metformin hcl 850 mg tablet 1

metformin hcl er 1

RIOMET 4



RIOMET ER 4 PA

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

alogliptin 2 QL 1 TAB / 1 DAY

alogliptin-metformin 2 QL 2 TABS / 1 DAY

alogliptin-pioglitazone 2 QL 1 TAB / 1 DAY

JANUMET 4QL 2 TABS / 1 DAY

PA

JANUMET XR 4QL 2 TABS / 1 DAY

PA

JANUVIA 4QL 1 TAB / 1 DAY

PA

JENTADUETO 3 QL 2 TABS / 1 DAY

JENTADUETO XR 3 QL 2 TABS / 1 DAY

KAZANO 4QL 2 TABS / 1 DAY

PA

KOMBIGLYZE XR 4QL 2 TABS / 1 DAY

PA

NESINA 4QL 1 TAB / 1 DAY

PA

ONGLYZA 4QL 1 TAB / 1 DAY

PA

OSENI 4QL 1 TAB / 1 DAY

PA

TRADJENTA 3 QL 1 TAB / 1 DAY

INCRETIN MIMETICS

ADLYXIN 4QL 6 PENS / 28 DAYS

PA



BYDUREON BCISE 3 QL 3.4 ML / 28 DAYS

BYDUREON PEN 3 QL 4 PEN / 28 DAYS

BYETTA 10 MCG DOSE PEN INJ 3 QL 2.4 ML / 30 DAYS

BYETTA 5 MCG DOSE PEN INJ 3 QL 1.2 ML / 30 DAYS

MOUNJARO 4 PA

OZEMPIC (1 MG/DOSE (2 MG/1.5ML), 1 MG/DOSE (4MG/3 ML), 2 MG/DOSE (8 MG/3 ML))

3 QL 3 ML / 28 DAYS

OZEMPIC 0.25-0.5 MG/DOSE PEN 3 QL 1.5 ML / 28 DAYS

RYBELSUS 3 QL 1 TAB / 1 DAY

TRULICITY 3 QL 2 ML / 28 DAYS

VICTOZA 2-PAK 3 QL 9 ML / 30 DAYS

VICTOZA 3-PAK 3 QL 9 ML / 30 DAYS

MEGLITINIDESnateglinide 2

repaglinide 2

repaglinide-metformin hcl 4

STARLIX 4

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

FARXIGA 4QL 1 TAB / 1 DAY

PA

GLYXAMBI 3 QL 1 TAB / 1 DAY

INVOKAMET 4QL 2 TABS / 1 DAY

PA

INVOKAMET XR 4QL 2 TABS / 1 DAY

PA

INVOKANA 4QL 1 TAB / 1 DAY

PA



JARDIANCE 3 QL 1 TAB / 1 DAY

QTERN 4QL 1 TAB / 1 DAY

PA

SEGLUROMET 4QL 2 TABS / 1 DAY

PA

STEGLATRO 4QL 1 TAB / 1 DAY

PA

STEGLUJAN 4QL 1 TAB / 1 DAY

PA

SYNJARDY 3 QL 2 TABS / 1 DAY

SYNJARDY XR (10-1,000 MG TABLET, 25-1,000 MGTABLET)

3 QL 1 TAB / 1 DAY

SYNJARDY XR (5-1,000 MG TABLET, 12.5-1,000 MG TAB) 3 QL 2 TABS / 1 DAY

TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 3 QL 1 TAB / 1 DAY

TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 3 QL 2 TABS / 1 DAY

XIGDUO XR 4QL 1 TAB / 1 DAY

PA

SULFONYLUREASAMARYL 4

glimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glipizide-metformin 1

GLUCOTROL 4

GLUCOTROL XL 4

glyburide 2

glyburide micronized 2



glyburide-metformin hcl 2

GLYNASE 4 PA

THIAZOLIDINEDIONESACTOPLUS MET 4

ACTOPLUS MET XR 4

ACTOS 4

AVANDIA 4 PA

DUETACT 4

pioglitazone hcl 1

pioglitazone-glimepiride 2

pioglitazone-metformin 2

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

ANZEMET 4

granisetron hcl 1 mg tablet 2 PA

ondansetron 4 mg/5 ml solution 1

ondansetron hcl (4 mg tablet, 8 mg tablet) 2

ondansetron odt 2

SANCUSO 4 PA

ZOFRAN 4 PA

ZUPLENZ 4 PA

ANTIEMETICS, MISCELLANEOUSdronabinol (2.5 mg capsule, 5 mg capsule) 2

dronabinol 10 mg capsule 1

MARINOL 4

scopolamine 2

SYNDROS 4

TRANSDERM-SCOP 4



ANTIHISTAMINES (GI DRUGS)

ANTIVERT 50 MG TABLET 4 PA

BONJESTA 4 PA

DICLEGIS 4 PA

doxylamine succ-pyridoxine hcl 4 PA

meclizine 12.5 mg tablet 4

meclizine 25 mg tablet 2

prochlorperazine 2

prochlorperazine maleate 1

TIGAN 300 MG CAPSULE 4

trimethobenzamide hcl 2

NEUROKININ-1 RECEPTOR ANTAGONISTSAKYNZEO 300-0.5 MG CAPSULE 4

aprepitant 2

EMEND (40 MG CAPSULE, 80 MG CAPSULE, TRIPACK) 4

EMEND 125 MG POWDER PACKET 3

VARUBI 4

ANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALS

terbinafine hcl 1

ANTIFUNGALS, MISCELLANEOUS

BREXAFEMME 4 PA

griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 2

griseofulvin ultramicrosize 2

AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE 3 PA

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/MLSUSPENSION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

4



fluconazole (10 mg/ml susp, 40 mg/ml susp) 2

fluconazole (50 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet)

1

itraconazole (10 mg/ml solution, 100 mg/10 ml cup) 4 PA

itraconazole 100 mg capsule 2

ketoconazole 200 mg tablet 1

NOXAFIL 40 MG/ML SUSPENSION 3 PA

NOXAFIL DR 100 MG TABLET 4 PA

ONMEL 4 PA

posaconazole 2 PA

SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 4 PA

TOLSURA 4 PA

VFEND (40 MG/ML SUSPENSION, 50 MG TABLET, 200 MGTABLET)

4 PA

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)

2 PA

POLYENE ANTIFUNGALS

nystatin (100,000 unit/ml susp, 500,000 unit/5 ml cup) 2 QL 480 ML / RX

nystatin 500,000 unit oral tab 1

PYRIMIDINE ANTIFUNGALS

ANCOBON 4 PA

flucytosine 2 PA

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)

naftifine hcl (cream, gel) 2 PA

naftifine hcl 2% cream 2QL 60 GM / 30 DAYS

PA

NAFTIN (1% GEL, 2% GEL) 4 PA



NAFTIN 2% CREAM 4 QL 60 GM / 30 DAYS

AZOLES (SKIN AND MUCOUS MEMBRANE)clotrimazole 1% solution 4

clotrimazole 10 mg troche 2

clotrimazole-1% solution 4

clotrimazole-betamethasone crm 2

econazole nitrate 2 QL 85 GM / 30 DAYS

ECOZA 4

ERTACZO 3 PA

EXELDERM (CREAM, SOLUTION) 4 PA

EXTINA 4

GYNAZOLE 1 4

JUBLIA 4 PA

ketoconazole 2% cream 1 QL 60 GM / 30 DAYS

ketoconazole 2% foam 4

ketoconazole 2% shampoo 2

KETODAN 2% FOAM 4

luliconazole 2 PA

LUZU 4 PA

miconazole 3 200 mg vag supp 4

miconazole-zinc oxide-petroltm 4 PA

ORAVIG 4

oxiconazole nitrate 2QL 60 GM / 30 DAYS

PA

OXISTAT 1% CREAM 4 QL 60 GM / 30 DAYS

OXISTAT 1% LOTION 3 PA



sulconazole nitrate (cream, soln) 2 PA

terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 2

VUSION 4 PA

BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)MENTAX 4

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)CICLODAN (0.77% CREAM, 0.77% CREAM KIT, 8%SOLUTION)

4

ciclopirox (0.77% cream, 0.77% gel, 1% shampoo, 8%solution)

2

ciclopirox 0.77% topical susp 2 QL 60 ML / 30 DAYS

ciclopirox 8% treatment kit 4

LOPROX (0.77% CREAM, 0.77% SUSPENSION KIT, 1%SHAMPOO)

4

OXABOROLES

KERYDIN 4 PA

tavaborole 4 PA

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 4 QL 240 GM / RX

nystatin (unit/gm cream, unit/gm oint) 2

nystatin 100,000 unit/gm powd 2 QL 240 GM / RX

nystatin-triamcinolone 2

NYSTOP 4 QL 240 GM / RX

ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 3

ALPHAGAN P 0.15% EYE DROPS 4

brimonidine tartrate 2

brimonidine tartrate-timolol 2



COMBIGAN 4

BETA-ADRENERGIC BLOCKING AGENTS (EENT)betaxolol hcl 0.5% eye drop 2

BETIMOL 4

BETOPTIC S 4

carteolol hcl 1

ISTALOL 4

levobunolol hcl 1

metipranolol 2 PA

timolol 0.5% eye drop (generic for istalol) 4

timolol maleate (0.25%, 0.25% gfs, 0.5%, 0.5% gfs) 2

timolol maleate 0.25% eye drop (generic for timoptic) 1

timolol maleate 0.5% eye drops (generic for timoptic) 1

timolol maleate/pf 0.5% eye drop (generic for ocudose) 4 PA

TIMOPTIC 4

TIMOPTIC OCUDOSE (0.25% DROP, 0.5% DROP) 4 PA

TIMOPTIC-XE 4

CARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide 1

acetazolamide er 2

AZOPT 4

brinzolamide 2

COSOPT 4

COSOPT PF 4

dorzolamide hcl 2

dorzolamide-timolol (2%-0.5%, eye drops) 2

methazolamide 2

SIMBRINZA 3



TRUSOPT 4

MIOTICSISOPTO CARPINE 4

PHOSPHOLINE IODIDE 3

pilocarpine hcl (1% drops, 2% drops, 4% drops) 2

VUITY 4

PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops 2

latanoprost 2

LUMIGAN 3

TRAVATAN Z 4

travoprost 2

VYZULTA 4 PA

XALATAN 4

XELPROS 4

ZIOPTAN 3 PA

RHO KINASE INHIBITORSRHOPRESSA 3

ROCKLATAN 3

ANTIHEMORRHAGIC AGENTSHEMOSTATICS

ADVATE 5PA

S

ADYNOVATE 5PA

S

AFSTYLA 5PA

S

ALPHANATE 5PA

S



ALPHANINE SD 5PA

S

ALPROLIX 5PA

S

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET,1,000 MG TABLET)

4 PA

aminocaproic acid (0.25 gram/ml, 500 mg tab, 1,000 mgtab)

4 PA

BENEFIX 5PA

S

COAGADEX 5PA

S

CORIFACT 5PA

S

ELOCTATE 5PA

S

ESPEROCT 5PA

S

FEIBA NF 5PA

S

HEMLIBRA 5PA

S

HEMOFIL M 5PA

S

HUMATE-P 5PA

S

IDELVION 5PA

S

IXINITY 5PA

S



JIVI 5PA

S

KOATE 5PA

S

KOGENATE FS 5PA

S

KOVALTRY 5PA

S

LYSTEDA 4 QL 30 TABS / RX

MONONINE 5PA

S

NOVOEIGHT 5PA

S

NOVOSEVEN RT 5PA

S

NUWIQ 5PA

S

OBIZUR 5PA

S

PROFILNINE 5PA

S

REBINYN 5PA

S

RECOMBINATE 5PA

S

RIXUBIS 5PA

S

SEVENFACT 5PA

S



tranexamic acid 650 mg tablet 2 QL 30 TABS / RX

TRETTEN 5PA

S

VONVENDI 5PA

S

WILATE 5PA

S

XYNTHA 5PA

S

XYNTHA SOLOFUSE 5PA

S

ANTIHISTAMINE DRUGSSECOND GENERATION ANTIHISTAMINES

cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup, 5 mg/5 mlsoln)

4

CLARINEX 4 PA

CLARINEX-D 12 HOUR 4 PA

desloratadine (2.5 mg odt, 5 mg odt) 4

desloratadine 5 mg tablet 2 PA

levocetirizine 2.5 mg/5 ml sol 4

levocetirizine 5 mg tablet 2

SEMPREX-D 4

XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET) 4

ANTIHYPOGLYCEMIC AGENTSANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS

diazoxide 4

PROGLYCEM 4



GLYCOGENOLYTIC AGENTS

BAQSIMI 3 QL 4 BOTTLES / RX

GLUCAGEN 1 MG HYPOKIT (NOVO) 4 QL 4 VIALS / RX

GLUCAGEN DIAGNOSTIC 1 MG VIAL 4 QL 4 VIALS / RX

glucagon 1 mg emergency kit 2 QL 4 VIALS / RX

glucagon 1 mg emergency kit (generic glucagen) 2 QL 4 VIALS / RX

GLUCAGON 1 MG EMERGENCY KIT (LILLY) 4 QL 4 VIALS / RX

GLUCAGON 1 MG VIAL 4 QL 4 VIALS / RX

GVOKE 3 QL 0.8 ML / RX

GVOKE HYPOPEN 1-PK 1 MG/0.2 ML 3 QL 0.8 ML / RX

GVOKE HYPOPEN 1PK 0.5MG/0.1 ML 3 QL 0.4 ML / RX

GVOKE HYPOPEN 2-PK 1 MG/0.2 ML 3 QL 0.8 ML / RX

GVOKE HYPOPEN 2PK 0.5MG/0.1 ML 3 QL 0.4 ML / RX

GVOKE PFS 1-PK 1 MG/0.2 ML SYR 3 QL 0.8 ML / RX

GVOKE PFS 1PK 0.5MG/0.1 ML SYR 3 QL 0.4 ML / RX

GVOKE PFS 2-PK 1 MG/0.2 ML SYR 3 QL 0.8 ML / RX

GVOKE PFS 2PK 0.5MG/0.1 ML SYR 3 QL 0.4 ML / RX

ZEGALOGUE AUTOINJECTOR 3 QL 2.4 ML / RX

ZEGALOGUE SYRINGE 3 QL 2.4 ML / RX

ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl 2 PA

JUXTAPID 5PA

S

LOVAZA 4



NEXLETOL 4 PA

NEXLIZET 4 PA

niacin er 4

NIACOR 4

NIASPAN 4

omega-3 acid ethyl esters 1

VASCEPA 0.5 GM CAPSULE 3 PA

VASCEPA 1 GM CAPSULE 4 PA

BILE ACID SEQUESTRANTScholestyramine (packet, powder) 2

cholestyramine light (packet, powder) 2

colesevelam hcl 4 PA

COLESTID (1 GM TABLET, FLAVORED GRANULES,GRANULES, GRANULES PACKET)

4

colestipol hcl (granules, granules packet) 4

colestipol hcl 1 gm tablet 2

PREVALITE (PACKET, POWDER) 2

QUESTRAN (PACKET, POWDER) 4

QUESTRAN LIGHT 4

WELCHOL 4 PA

CHOLESTEROL ABSORPTION INHIBITORSezetimibe 1

ezetimibe-simvastatin 2

rosuvastatin-ezetimibe 4 PA

ROSZET 4 PA

VYTORIN 4

ZETIA 4



FIBRIC ACID DERIVATIVES

ANTARA 4 PA

fenofibrate (30 mg capsule, 40 mg tablet, 43 mg capsule,50 mg capsule, 90 mg capsule, 120 mg tablet, 130 mgcapsule, 150 mg capsule)

4

fenofibrate (48 mg tablet, 67 mg capsule, 134 mg capsule,145 mg tablet, 200 mg capsule)

1

fenofibrate (54 mg tablet, 160 mg tablet) 2

fenofibric acid (35 mg tablet, 105 mg tablet) 4

fenofibric acid (dr 45 mg cap, dr 135 mg cap) 2

FENOGLIDE 4 PA

FIBRICOR 4

gemfibrozil 1

LIPOFEN 4

LOPID 4

TRICOR 4

TRILIPIX 4

HMG-COA REDUCTASE INHIBITORSamlodipine-atorvastatin 4

atorvastatin calcium 1

CADUET 4

CRESTOR 4 PA

EZALLOR SPRINKLE 4 PA

FLOLIPID 20 MG/5 ML ORAL SUSP 4 PA

FLOLIPID 40 MG/5 ML ORAL SUSP 4

fluvastatin er 2 PA

fluvastatin sodium 2 PA

LESCOL 4

LESCOL XL 4



LIPITOR 4 PA

LIVALO 4

lovastatin 1

PRAVACHOL 4

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin 1

ZOCOR 4

ZYPITAMAG 4 PA

PCSK9 INHIBITORS

PRALUENT PEN 4 PA

REPATHA PUSHTRONEX 3 QL 1 PEN / 28 DAYS

REPATHA SURECLICK 3 QL 2 PENS / 28 DAYS

REPATHA SYRINGE 3 QL 2 PENS / 28 DAYS

ANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.

AIMOVIG AUTOINJECTOR 5

QL 1 ML / 30 DAYS

PA

S

AJOVY AUTOINJECTOR 5

QL 1.5 ML / 30 DAYS

PA

S

AJOVY SYRINGE 5

QL 1.5 ML / 30 DAYS

PA

S

EMGALITY 120 MG/ML SYRINGE 5

QL 1 ML / 30 DAYS

PA

S



EMGALITY PEN 5

QL 1 ML / 30 DAYS

PA

S

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))

5

QL 3 ML / 30 DAYS

PA

S

NURTEC ODT 3QL 8 TABS / 30 DAYS

PA

QULIPTA 5

QL 1 TAB / DAY

PA

S

UBRELVY 4QL 10 TABS / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS

almotriptan malate 2QL 12 TABS / 28 DAYS

PA

AMERGE 4QL 12 TABS / 30 DAYS

PA

eletriptan hbr 2QL 12 TABS / 28 DAYS

PA

FROVA 4QL 12 TABS / 28 DAYS

PA

frovatriptan succinate 2QL 12 TABS / 28 DAYS

PA

IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 4QL 12 TABS / 28 DAYS

PA

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PENINJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PENINJECT, 6 MG/0.5 ML VIAL)

4QL 5 ML / 30 DAYS

PA

IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 4QL 12 ML / 30 DAYS

PA



MAXALT 4QL 12 TABS / 28 DAYS

PA

MAXALT MLT 4QL 12 TABS / 28 DAYS

PA

MIGRANOW 4 PA

naratriptan hcl 1 QL 12 TABS / 30 DAYS

ONZETRA XSAIL 4QL 16 CAPS / 30 DAYS

PA

RELPAX 4QL 12 TABS / 28 DAYS

PA

REYVOW 3QL 8 TABS / 30 DAYS

PA

rizatriptan 2 QL 12 TABS / 28 DAYS

sumatriptan 2 QL 12 ML / 30 DAYS

sumatriptan succ-naproxen sod 2QL 18 TABS / 28 DAYS

PA

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet)

2 QL 12 TABS / 28 DAYS

sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)

2 QL 5 ML / 30 DAYS

TOSYMRA 4QL 6 DOSES / 30 DAYS

PA

TREXIMET 4QL 18 TABS / 28 DAYS

PA

ZEMBRACE SYMTOUCH 4QL 4 ML / 30 DAYS

PA

zolmitriptan (2.5 mg nasal spry, 5 mg nasal spray) 4 QL 12 ML / 30 DAYS

zolmitriptan (2.5 mg tablet, 5 mg tablet) 2 QL 12 TABS / 28 DAYS



zolmitriptan odt 2 QL 12 TABS / 28 DAYS

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 4QL 12 ML / 30 DAYS

PA

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 4QL 12 TABS / 28 DAYS

PA

ZOMIG ZMT 4QL 12 TABS / 28 DAYS

PA

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 2

ANTITUBERCULOSIS AGENTS

cycloserine 2 PA

ethambutol hcl 1

isoniazid (100 mg tablet, 300 mg tablet) 1

isoniazid 50 mg/5 ml solution 2

MYAMBUTOL 4

MYCOBUTIN 4

PASER 4

pretomanid 3 PA

PRIFTIN 3

pyrazinamide 2

rifabutin 2

rifampin (150 mg capsule, 300 mg capsule) 1

SIRTURO 3 PA

TRECATOR 3 PA

ANTINEOPLASTIC AGENTS

abiraterone acetate 2

PA

S

ONC Oncology

TD Trial Drug



AFINITOR 4

PA

S

ONC Oncology

TD Trial Drug

AFINITOR DISPERZ 3

PA

S

ONC Oncology

TD Trial Drug

ALECENSA 3

PA

S

ONC Oncology

ALKERAN 2 MG TABLET 4 PA

ALUNBRIG 4PA

S

anastrozole 1

ARIMIDEX 4 PA

AROMASIN 4 PA

AYVAKIT 3

PA

S

ONC Oncology

BALVERSA 3PA

S

BESREMI 3

PA

S

ONC Oncology

bexarotene 1% gel 5

PA

S

ONC Oncology

bexarotene 75 mg capsule 2

PA

S

TD Trial Drug



bicalutamide 1

BOSULIF 3

PA

S

ONC Oncology

TD Trial Drug

BRAFTOVI 3PA

S

BRUKINSA 3

PA

S

ONC Oncology

CABOMETYX 3

PA

S

ONC Oncology

TD Trial Drug

CALQUENCE 4PA

S

capecitabine 2S

ONC Oncology

CAPRELSA 3

PA

S

ONC Oncology

CARAC 4 PA

CASODEX 4 PA

COMETRIQ 3

PA

S

ONC Oncology

TD Trial Drug

COPIKTRA 3

PA

S

ONC Oncology

TD Trial Drug



COTELLIC 3

PA

S

ONC Oncology

cyclophosphamide (25 mg capsule, 25 mg tablet, 50 mgcapsule, 50 mg tablet)

2

DAURISMO 3

PA

S

TD Trial Drug

diclofenac sodium 3% gel 4

DROXIA 4

EFUDEX 4 PA

EMCYT 3

ERIVEDGE 3

PA

S

ONC Oncology

TD Trial Drug

ERLEADA 3

PA

S

ONC Oncology

erlotinib hcl 2

PA

S

ONC Oncology

TD Trial Drug

etoposide 50 mg capsule 2

everolimus (2 mg tab for susp, 2.5 mg tablet, 3 mg tab forsusp, 5 mg tab for susp, 5 mg tablet, 7.5 mg tablet, 10 mgtablet)

2

PA

S

ONC Oncology

TD Trial Drug

exemestane 1

EXKIVITY 3

PA

S

ONC Oncology



FARYDAK 4PA

S

FEMARA 4 PA

FLUOROPLEX 4

fluorouracil (2% topical soln, 5% cream, 5% topical soln) 2

fluorouracil 0.5% cream 4 PA

flutamide 2

FOTIVDA 3

PA

S

ONC Oncology

GAVRETO 3

PA

S

ONC Oncology

GILOTRIF 3

PA

S

ONC Oncology

GLEEVEC 4

PA

S

TD Trial Drug

GLEOSTINE 3

HYCAMTIN 3S

ONC Oncology

HYDREA 4 PA

hydroxyurea 2

IBRANCE 3

PA

S

ONC Oncology

ICLUSIG 3

PA

S

ONC Oncology

TD Trial Drug



IDHIFA 3

PA

S

ONC Oncology

imatinib mesylate 2

S

ONC Oncology

TD Trial Drug

IMBRUVICA (140 MG TABLET, 280 MG TABLET) 4

PA

S

ONC Oncology

IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 420 MGTABLET, 560 MG TABLET)

3

PA

S

ONC Oncology

INLYTA 3

PA

S

ONC Oncology

TD Trial Drug

INQOVI 3

PA

S

ONC Oncology

INREBIC 3

PA

S

ONC Oncology

IRESSA 3

PA

S

ONC Oncology

JAKAFI 3

PA

S

ONC Oncology

TD Trial Drug

KISQALI 3

PA

S

ONC Oncology



KISQALI FEMARA CO-PACK 3

PA

S

ONC Oncology

KOSELUGO 10 MG CAPSULE 3

QL 8 CAPS / 1 DAY

PA

S

ONC Oncology

KOSELUGO 25 MG CAPSULE 3

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

lapatinib 2

PA

S

ONC Oncology

lenalidomide 2S

ONC Oncology

LENVIMA 4

PA

S

TD Trial Drug

letrozole 1

LEUKERAN 3

LONSURF 3

PA

S

ONC Oncology

LORBRENA 3

PA

S

TD Trial Drug

LUMAKRAS 3

PA

S

ONC Oncology



LYNPARZA 3

PA

S

TD Trial Drug

LYSODREN 3PA

S

MATULANE 3

PA

S

ONC Oncology

MEKINIST 3

PA

S

ONC Oncology

MEKTOVI 3PA

S

melphalan 2

mercaptopurine 2

methotrexate (2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10ml vial)

2

methotrexate sodium 2

MYLERAN 3

NERLYNX 3

PA

S

ONC Oncology

TD Trial Drug

NEXAVAR 3

PA

S

ONC Oncology

TD Trial Drug

NILANDRON 4PA

S

nilutamide 2

PA

S

ONC Oncology



NINLARO 3

PA

S

ONC Oncology

NUBEQA 3PA

S

ODOMZO 3

PA

S

ONC Oncology

TD Trial Drug

ONUREG 3

PA

S

ONC Oncology

OTREXUP 4 PA

PANRETIN 4 PA

PEMAZYRE 3

PA

S

ONC Oncology

PICATO 3 PA

PIQRAY 4PA

S

POMALYST 3

PA

S

ONC Oncology

PURIXAN 4PA

S

QINLOCK 3

PA

S

ONC Oncology

RASUVO 3 PA



RETEVMO 3

PA

S

ONC Oncology

TD Trial Drug

REVLIMID 3S

ONC Oncology

ROZLYTREK 3

PA

S

ONC Oncology

RUBRACA 4

PA

S

TD Trial Drug

RYDAPT 3

PA

S

ONC Oncology

SCEMBLIX 3

PA

S

ONC Oncology

SIKLOS 1,000 MG TABLET 4

SIKLOS 100 MG TABLET 4QL 2 TABS / 1 DAY

PA

SOLARAZE 4 PA

sorafenib 2

PA

S

ONC Oncology

TD Trial Drug

SPRYCEL 3

PA

S

ONC Oncology

TD Trial Drug



STIVARGA 3

PA

S

ONC Oncology

sunitinib malate 2

PA

S

ONC Oncology

SUTENT 4

PA

S

ONC Oncology

SYNRIBO 4

PA

S

ONC Oncology

TABLOID 3

TABRECTA 3

PA

S

ONC Oncology

TAFINLAR 3

PA

S

ONC Oncology

TAGRISSO 3

PA

S

ONC Oncology

TD Trial Drug

TALZENNA 4

PA

S

TD Trial Drug

TARCEVA 4

PA

S

ONC Oncology

TD Trial Drug



TARGRETIN 1% GEL 5PA

S

TARGRETIN 75 MG CAPSULE 4

PA

S

TD Trial Drug

TASIGNA 3

PA

S

ONC Oncology

TD Trial Drug

TAZVERIK 3

PA

S

ONC Oncology

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MGCAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MGCAPSULE)

4PA

S

temozolomide 2S

ONC Oncology

TEPMETKO 3

PA

S

ONC Oncology

TIBSOVO 3

PA

S

ONC Oncology

TOLAK 4

tretinoin 10 mg capsule 2S

ONC Oncology

TREXALL 4 PA

TRUSELTIQ 3

PA

S

ONC Oncology



TUKYSA 4

PA

S

ONC Oncology

TURALIO 3PA

S

TYKERB 4

PA

S

ONC Oncology

UKONIQ 3

PA

S

ONC Oncology

VALCHLOR 5

PA

S

ONC Oncology

VENCLEXTA 4PA

S

VENCLEXTA STARTING PACK 4PA

S

VERZENIO 3

PA

S

ONC Oncology

VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100MG CAPSULE)

3

PA

S

TD Trial Drug

VIZIMPRO 3

PA

S

ONC Oncology

TD Trial Drug

VONJO 3

PA

S

ONC Oncology



VOTRIENT 3

PA

S

ONC Oncology

TD Trial Drug

WELIREG 3

PA

S

ONC Oncology

XALKORI 3

PA

S

ONC Oncology

TD Trial Drug

XATMEP 4 PA

XELODA 4PA

S

XOSPATA 3PA

S

XPOVIO 3

PA

S

ONC Oncology

XTANDI 3

PA

S

ONC Oncology

TD Trial Drug

YONSA 4

PA

S

TD Trial Drug

ZEJULA 3

PA

S

ONC Oncology

TD Trial Drug



ZELBORAF 3

PA

S

ONC Oncology

ZOLINZA 3

PA

S

ONC Oncology

TD Trial Drug

ZTALMY 5PA

S

ZYDELIG 4PA

S

ZYKADIA 3

PA

S

ONC Oncology

TD Trial Drug

ZYTIGA 4

PA

S

TD Trial Drug

ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)

amantadine (50 mg/5 ml solution, 100 mg tablet, 100mg/10 ml soln)

2

amantadine 100 mg capsule 1

GOCOVRI 4 PA

OSMOLEX ER 4 PA

ANTICHOLINERGIC AGENTS (CNS)benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)

2

trihexyphenidyl 2 mg/5 ml soln 2

trihexyphenidyl hcl (2 mg tablet, 5 mg tablet) 1



CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.COMTAN 4

entacapone 2

ONGENTYS 4 PA

TASMAR 4

tolcapone 4

DOPAMINE PRECURSORScarbidopa-levodopa 2

carbidopa-levodopa er 2

carbidopa-levodopa-entacapone 2

DHIVY 4

INBRIJA 5PA

S

RYTARY 3 ST

SINEMET 25-100 4

STALEVO 100 4

STALEVO 125 4

STALEVO 150 4

STALEVO 200 4

STALEVO 50 4

STALEVO 75 4

MONOAMINE OXIDASE B INHIBITORS

AZILECT 4 PA

EMSAM 3 PA

rasagiline mesylate 2 PA

selegiline hcl 2

XADAGO 4 PA



ZELAPAR 4

ANTIPROTOZOALSAMEBICIDES

paromomycin sulfate 4

ANTIMALARIALSARAKODA 4

atovaquone-proguanil hcl 2

chloroquine phosphate 2

COARTEM 4

DARAPRIM 4 PA

hydroxychloroquine 200 mg tab 2

hydroxychloroquine sulfate (100 mg tab, 300 mg tab, 400mg tab)

4 PA

KRINTAFEL 4

MALARONE 62.5-25 MG PED TAB 4

mefloquine hcl 1

PLAQUENIL 4

primaquine 4

pyrimethamine 4 PA

QUALAQUIN 4

quinine sulfate 2 PA

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA 100 MG/5 ML SUSPENSION 3 PA

ALINIA 500 MG TABLET 4 PA

atovaquone 2

benznidazole 2 PA

FLAGYL 4

IMPAVIDO 3 PA



LAMPIT 3 PA

MEPRON 4

metronidazole (250 mg tablet, 500 mg tablet) 2

metronidazole 375 mg capsule 4

NEBUPENT 4

nitazoxanide 2 PA

pentamidine 300 mg inhal powdr 4

SOLOSEC 4 PA

tinidazole 2

ANTIPSYCHOTIC AGENTSANTIPSYCHOTICS, MISCELLANEOUS

ADASUVE 4 PA

loxapine 2 AL1 At least 7 yrs old

molindone hcl 4 AL1 At least 7 yrs old

pimozide 2PA


ATYPICAL ANTIPSYCHOTICS

ABILIFY 4PA


ABILIFY MAINTENA 3

ABILIFY MYCITE 4PA


aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet,10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

2 AL1 At least 7 yrs old

aripiprazole odt 2PA


asenapine maleate 2PA




CAPLYTA 3QL 1 CAP / 1 DAY

PA

clozapine 2 AL1 At least 7 yrs old

clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt100 mg tablet, odt 150 mg tablet)

2PA


clozapine odt 200 mg tablet 1PA


CLOZARIL 4PA


FANAPT 3PA


GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE, 80 MG CAPSULE)

4PA


INVEGA 4PA


INVEGA SUSTENNA 3

LATUDA 3

QL 1 TAB / 1 DAY

PA


LYBALVI 3

QL 1 TAB / DAY

PA


NUPLAZID 5

PA

S

TD Trial Drug

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tablet, 20 mg tablet)


olanzapine odt 2 AL1 At least 7 yrs old

paliperidone er 1PA




quetiapine fumarate 2 AL1 At least 7 yrs old

quetiapine fumarate er 2 AL1 At least 7 yrs old

REXULTI 3PA


RISPERDAL (0.5 MG TABLET, 1 MG TABLET, 1 MG/MLSOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)

4PA


RISPERDAL CONSTA 3

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2mg tablet, 3 mg tablet, 4 mg tablet)


risperidone 1 mg/ml solution 2 AL1 At least 7 yrs old

risperidone odt 2PA


SAPHRIS 4PA


SECUADO 3 PA

SEROQUEL 4PA


SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MGTABLET, 300 MG TABLET, 400 MG TABLET, SAMPLE KIT)

4PA


VERSACLOZ 3PA


VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK) 3

QL 2 CAPS / 1 DAY

PA


VRAYLAR (3 MG CAPSULE, 4.5 MG CAPSULE, 6 MGCAPSULE)

3

QL 1 CAP / 1 DAY

PA


ziprasidone hcl 2 AL1 At least 7 yrs old



ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,10 MG TABLET, 15 MG TABLET, 20 MG TABLET)

4PA


ZYPREXA ZYDIS 4PA


BUTYROPHENONESHALDOL DECANOATE 100 3

HALDOL DECANOATE 50 3

haloperidol 2 AL1 At least 7 yrs old

haloperidol decanoate 2

haloperidol decanoate 100 2

haloperidol lactate (2 mg/ml conc, 10 mg/5 ml cup) 2 AL1 At least 7 yrs old

PHENOTHIAZINESchlorpromazine hcl (10 mg tablet, 25 mg tablet, 30 mg/mlconc, 50 mg tablet, 100 mg tablet, 100 mg/ml conc, 200mg tablet)

2 PA

fluphenazine decanoate 2

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 5 mg tablet,10 mg tablet)


fluphenazine hcl (2.5 mg/5 ml elix, 5 mg/ml conc) 1 AL1 At least 7 yrs old

perphenazine 1

thioridazine hcl 1 AL1 At least 7 yrs old

trifluoperazine hcl 2 AL1 At least 7 yrs old

THIOXANTHENES

thiothixene 1 AL1 At least 7 yrs old

ANTIRETROVIRALSHIV ENTRY AND FUSION INHIBITORS

FUZEON 5 S

maraviroc 2

RUKOBIA 3 PA



SELZENTRY (150 MG TABLET, 300 MG TABLET) 4

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET)

3

HIV INTEGRASE INHIBITOR ANTIRETROVIRALSDOVATO 4

ISENTRESS 3

ISENTRESS HD 3

JULUCA 3

TIVICAY 3

TIVICAY PD 3

VOCABRIA 3

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.DELSTRIGO 4

EDURANT 3

efavirenz (50 mg capsule, 600 mg tablet) 2

efavirenz 200 mg capsule 1

efavirenz-lamivu-tenofov disop 4

etravirine 2

INTELENCE (100 MG TABLET, 200 MG TABLET) 4

INTELENCE 25 MG TABLET 3

nevirapine (50 mg/5 ml susp, 200 mg tablet) 2

nevirapine er 2

PIFELTRO 4

SUSTIVA 4

SYMFI 4

SYMFI LO 4

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 4

VIRAMUNE XR 4



HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSabacavir (20 mg/ml solution, 300 mg tablet) 2

abacavir-lamivudine 1

abacavir-lamivudine-zidovudine 2

ATRIPLA 4

BIKTARVY 3

CIMDUO 4

COMBIVIR 4

COMPLERA 3

DESCOVY (120-15 MG TABLET, 200-25 MG TABLET) 3PA

ACA Affordable Care Act

didanosine 4

efavirenz-emtric-tenofov disop 2

emtricitabine 2

emtricitabine-tenofovir disop (100-150mg, 133-200mg,167-250mg)

2

emtricitabine-tenofv 200-300mg 2 ACA Affordable Care Act

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET)

4

EPIVIR HBV 100 MG TABLET 4

EPIVIR HBV 25 MG/5 ML SOLN 3

EPZICOM 4

GENVOYA 3

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mgtablet)

2

lamivudine hbv 2

lamivudine-zidovudine 2

ODEFSEY 3

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 4



stavudine 4

STRIBILD 3

TEMIXYS 4

tenofovir disoproxil fumarate 1

TRIUMEQ 3

TRIUMEQ PD 3

TRIZIVIR 4

TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MGTABLET)

4

TRUVADA 167 MG-250 MG TABLET 3

TRUVADA 200 MG-300 MG TABLET 4 PA

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)

3

VIREAD 300 MG TABLET 4

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 4

zidovudine (50 mg/5 ml syrup, 300 mg tablet) 2

zidovudine 100 mg capsule 1

HIV PROTEASE INHIBITOR ANTIRETROVIRALSAPTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3

atazanavir sulfate 2

CRIXIVAN 4

EVOTAZ 3

fosamprenavir calcium 2

INVIRASE 3

KALETRA (80 MG-20 MG/ML SOLN, 200-50 MG TABLET) 4

KALETRA 100-25 MG TABLET 3

LEXIVA 50 MG/ML SUSPENSION 3

LEXIVA 700 MG TABLET 4


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlopinavir-ritonavir (lopinavir-ritonavir 80-20mg/ml,lopinavir-ritonavr 100-25mg tb, lopinavir-ritonavr 200-50mg tb)

2

NORVIR (100 MG POWDER PACKET, 100 MG TABLET) 4

NORVIR 80 MG/ML SOLUTION 3

PREZCOBIX 3

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET)

3

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE)

4

REYATAZ 50 MG POWDER PACKET 3

ritonavir 2

SYMTUZA 3

VIRACEPT 4

ANTITHROMBOTIC AGENTSANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT 5PA

S

PLATELET-AGGREGATION INHIBITORSBRILINTA 3

cilostazol 2

clopidogrel 300 mg tablet 4

clopidogrel 75 mg tablet 1

EFFIENT 4

PLAVIX 4

prasugrel hcl 2

ZONTIVITY 3 PA

PLATELET-REDUCING AGENTSanagrelide hcl 2



ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK 3 PA

ODACTRA 3 PA

ORALAIR 4 PA

PALFORZIA 5PA

S

RAGWITEK 3 PA

TOXOIDSADACEL TDAP 3

BOOSTRIX TDAP 3

DAPTACEL DTAP 3

diphtheria-tetanus toxoids-ped 3

INFANRIX DTAP 3

tdvax 3

TENIVAC SYRINGE 3

VAXELIS 3

VACCINESACTHIB 3

adenovirus type 4 3

adenovirus type 4 and type 7 3

adenovirus type 7 3

AFLURIA QUAD 2020-2021 3 ACA Affordable Care Act

AFLURIA QUAD 2020-21 (3YR UP) 3 ACA Affordable Care Act

AFLURIA QUAD 2020-21 (6-35MO) 3 ACA Affordable Care Act





AFLURIA QUAD 2021-22 (6-35MO) 3 ACA Affordable Care Act



ASTRAZENECA COVID19 VAC(UNAPP) 3 QLC 5 DOSES / LIFETIME

BEXSERO 3

COMIRNATY (COVID-19 VACCINE VL, 30MCG/0.3ML VAC-GRAY)

3 QLC 5 DOSES / LIFETIME

DENGVAXIA 3

ENGERIX-B ADULT 3

ENGERIX-B PEDIATRIC-ADOLESCENT 3

FLUAD 2020-2021 3 ACA Affordable Care Act

FLUAD QUAD 2020-2021 3 ACA Affordable Care Act



FLUARIX QUAD 2020-2021 3 ACA Affordable Care Act



FLUBLOK QUAD 2020-2021 3 ACA Affordable Care Act



FLUCELVAX QUAD 2020-2021 (SYR, VIAL) 3 ACA Affordable Care Act



FLULAVAL QUAD 2020-2021 3 ACA Affordable Care Act





FLUMIST QUAD 2020-2021 3 ACA Affordable Care Act

FLUMIST QUAD 2021-2022 3 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2020-21 3 ACA Affordable Care Act



FLUZONE QUAD 2020-2021 3 ACA Affordable Care Act



FLUZONE QUAD SOUTHERN HEM 2020 (HEM2020 SYR,HEM 2020 VL)

3 ACA Affordable Care Act

FLUZONE QUAD SOUTHERN HEM 2021 (HEM2021 SYR,HEM 2021 VL)


GARDASIL 9 3

HAVRIX 3

HEPLISAV-B 3

HIBERIX 3

IPOL 3 ACA Affordable Care Act

JANSSEN COVID-19 VACCINE (EUA) 3 QLC 5 DOSES / LIFETIME

KINRIX 3

M-M-R II VACCINE 3 ACA Affordable Care Act

MENACTRA 3

MENQUADFI 3 ACA Affordable Care Act

MENVEO A-C-Y-W-135-DIP 3

MENVEO MENA COMPONENT 3 ACA Affordable Care Act

MENVEO MENCYW-135 COMPONENT 3 ACA Affordable Care Act



MODERNA COVID (12Y UP)VAC(EUA) 3 QLC 5 DOSES / LIFETIME

MODERNA COVID BIV BOOSTR(UNAP) 3 QLC 5 DOSES / LIFETIME

MODERNA COVID(6-11Y) VAC(EUA) 3 QLC 5 DOSES / LIFETIME

MODERNA COVID(6M-5Y) VACC(EUA) 3 QLC 5 DOSES / LIFETIME

MODERNA COVID-19 BOOSTER (EUA) 3 QLC 5 DOSES / LIFETIME

NOVAVAX COVID-19 VACC,ADJ(EUA) 3 QLC 5 DOSES / LIFETIME

PEDIARIX 3

PEDVAXHIB 3

PENTACEL 3

PENTACEL ACTHIB COMPONENT 3

PENTACEL DTAP-IPV COMPONENT 3

PFIZER COVID (12Y UP) VAC(EUA) 3 QLC 5 DOSES / LIFETIME

PFIZER COVID (5-11Y) VAC (EUA) 3 QLC 5 DOSES / LIFETIME

PFIZER COVID (6M-4Y) VACC(EUA) 3 QLC 5 DOSES / LIFETIME

PFIZER COVID-19 VACCINE (EUA) 3 QLC 5 DOSES / LIFETIME

PNEUMOVAX 23 3

PREHEVBRIO 3

PREVNAR 13 3

PREVNAR 20 3

PRIORIX 3

PROQUAD 3

QUADRACEL DTAP-IPV 3 ACA Affordable Care Act

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML SYR,40 MCG/ML VIAL)

3

RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL) 3 ACA Affordable Care Act

ROTARIX 3



ROTATEQ 3

SANOFI COVID BOOSTER-AG COMPNT 3 QLC 5 DOSES / LIFETIME

SHINGRIX 3 QL 1 KIT / RX

SHINGRIX GE ANTIGEN COMPONENT 3 QL 1 KIT / RX

SPIKEVAX COVID (18Y UP) VACC 3 QLC 5 DOSES / LIFETIME

TICOVAC 2.4 MCG/0.5 ML SYRINGE 3

TRUMENBA 3

TWINRIX 3

TYPHIM VI 4

VAQTA (25 UNITS/0.5 ML SYRINGE, 50 UNITS/MLSYRINGE, 50 UNITS/ML VIAL)

3

VAQTA 25 UNITS/0.5 ML VIAL 3 ACA Affordable Care Act

VARIVAX VACCINE 3

VAXCHORA ACTIVE COMPONENT 3

VAXCHORA VACCINE 3

VAXNEUVANCE 3

VIVOTIF 3

ZOSTAVAX 3

ANTIULCER AGENTS AND ACID SUPPRESSANTSANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA 3 PA

HISTAMINE H2-ANTAGONISTScimetidine (200 mg tablet, cvs 200 mg tablet, gnp 200 mgtablet)

4

cimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mgtablet, 400 mg/6.67 ml soln, 800 mg tablet)

2

cimetidine 200 mg tablet (prescription only) 4

famotidine (20 mg tablet, 40 mg tablet) 1

famotidine 40 mg/5 ml susp 2 AL1 Up to 12 yrs old


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnizatidine (15 mg/ml solution, 150 mg capsule, 300 mgcapsule)

2 PA

PEPCID 4

POTASSIUM-COMPETITIVE ACID BLOCKERS

VOQUEZNA DUAL PAK 4 PA

VOQUEZNA TRIPLE PAK 4 PA

PROSTAGLANDINSCYTOTEC 4

misoprostol 2

PROTECTANTSCARAFATE 1 GM TABLET 4

CARAFATE 1 GM/10 ML SUSP 4 PA

sucralfate 1 gm tablet 2

sucralfate 1 gm/10 ml susp 2 PA

PROTON-PUMP INHIBITORS

ACIPHEX 4 PA

ACIPHEX SPRINKLE (DR 5 MG CAP, DR 10 MG CAP) 4 PA

DEXILANT 4 PA

dexlansoprazole dr 4 PA

esomeprazole magnesium (cvs 20 mg cap, dr 20 mg cap,dr 40 mg cap, gnp dr 20 mg, gs dr 20 mg, hm dr 20 mg, qcdr 20 mg, ra dr 20 mg, sm dr 20 mg)

2

esomeprazole magnesium (dr 10 mg packet, dr 20 mgpacket, dr 40 mg packet, mag dr 20 mg tab)

4

esomeprazole strontium 4 PA

lansoprazol-amoxicil-clarithro 2 PA

lansoprazole (dr 15 mg capsule, dr 30 mg capsule) 2

lansoprazole (odt 15 mg tablet, odt 30 mg tablet) 2 AL1 Up to 9 yrs old

NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET)

4



NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 4 PA

NEXIUM 24HR 4

OMECLAMOX-PAK 4

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule)

2

omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680pkt, cvs 20-1,100, 40-1,100 cap, 40-1,680 pkt)

4 PA

pantoprazole 40 mg suspension 4

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1

PREVACID (15 MG, 30 MG) 4 AL1 Up to 9 yrs old

PREVACID (DR 15 MG CAPSULE, DR 30 MG CAPSULE) 4 PA

PREVACID 24HR DR 15 MG CAPSULE (OTC) 4 PA

PRILOSEC 4

PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 4 PA

PROTONIX 40 MG SUSPENSION 4

rabeprazole dr 10 mg sprnkl cp 4 PA

rabeprazole sod dr 20 mg tab 2

ZEGERID 4 PA

ANTIVIRALS (SYSTEMIC)ADAMANTANE ANTIVIRALS

FLUMADINE 4

rimantadine hcl 2

ANTIVIRALS, MISCELLANEOUS

LIVTENCITY 5PA

S

PAXLOVID 150-100 MG PACK (EUA) 3 QL 20 TABS / 5 DAYS

PAXLOVID 300-100 MG PACK (EUA) 3 QL 30 TABS / 5 DAYS

PREVYMIS (240 MG TABLET, 480 MG TABLET) 3



TPOXX (NATIONAL STOCKPILE) 3 PA

XOFLUZA 4

INTERFERON ANTIVIRALS

ALFERON N 5 S

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)

5 S

PEGASYS 5PA

S

PEGINTRON 5PA

S

SYLATRON 3S

ONC Oncology

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir 6 mg/ml suspension 2 QL 180 ML / 1 FILL

oseltamivir phos 30 mg capsule 2 QL 20 CAPS / 1 FILL

oseltamivir phosphate (45 mg capsule, 75 mg capsule) 2 QL 10 CAPS / 1 FILL

RELENZA 3 QL 20 CAPS / 1 FILL

TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE) 4 QL 10 CAPS / 1 FILL

TAMIFLU 30 MG CAPSULE 4 QL 20 CAPS / 1 FILL

TAMIFLU 6 MG/ML SUSPENSION 4 QL 180 ML / 1 FILL

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSacyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) 2

acyclovir 200 mg/5 ml susp 2 AL1 Up to 12 yrs old

adefovir dipivoxil 2

BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4

BARACLUDE 0.05 MG/ML SOLUTION 3

entecavir 1



famciclovir 2

HEPSERA 4

LAGEVRIO (EUA) 2 QL 40 CAPS / 5 DAYS

ribavirin (200 mg capsule, 200 mg tablet) 5 S

ribavirin 6 gm inhalation vial 5PA

S

SITAVIG 4

valacyclovir 2

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 4

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 2

VALTREX 4 PA

VEMLIDY 3

VIRAZOLE 5PA

S

ZOVIRAX 200 MG/5 ML SUSP 4PA

AL1 Up to 12 yrs old

ANXIOLYTICS, SEDATIVES AND HYPNOTICSANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

AMBIEN 4 PA

AMBIEN CR 4 PA

buspirone hcl 2

EDLUAR 4PA

AQ1 Up to 64 yrs old; 20 /1 FILL

eszopiclone 2

HETLIOZ 5PA

S

HETLIOZ LQ 5PA

S



hydroxyzine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, 50mg/25 ml syrup)

2

hydroxyzine pamoate 2

IGALMI 4QL 3 FILMS / 1 DAY

PA

INTERMEZZO 4 PA

LUNESTA 4

meprobamate 2QL 6 TABS / 1 DAY

PA

ramelteon 2 QL 1 TAB / 1 DAY

ROZEREM 4 QL 1 TAB / 1 DAY

VISTARIL 4

zaleplon 2

zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) 4 PA

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1

zolpidem tartrate er 2 ST

ZOLPIMIST 4 AQ1 Up to 64 yrs old; 7.7/ 1 FILL

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 30 mg/7.5 ml sol, 60mg tablet, 60 mg/15 ml soln, 100 mg tablet)

2

SECONAL SODIUM 4 QL 1 CAP / 1 DAY

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam 2 mg tablet 1 QL 3 TABS / 1 DAY

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam er 2 mg tablet 1 QL 3 TABS / 1 DAY



alprazolam er 3 mg tablet 1 QL 2 TABS / 1 DAY

ALPRAZOLAM INTENSOL 4 QL 6 ML / 1 DAY

alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1mg tab)

4 QL 6 TABS / 1 DAY

alprazolam odt 2 mg tab 4 QL 3 TABS / 1 DAY

alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam xr 2 mg tablet 1 QL 3 TABS / 1 DAY

alprazolam xr 3 mg tablet 1 QL 2 TABS / 1 DAY

ATIVAN (0.5 MG TABLET, 1 MG TABLET) 4QL 6 TABS / 1 DAY

PA

ATIVAN 2 MG TABLET 4QL 5 TABS / 1 DAY

PA

chlordiazepoxide 10 mg capsule 1 QL 6 CAPS / 1 DAY



clorazepate 15 mg tablet 2QL 4 TABS / 1 DAY

PA

clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet) 2QL 6 TABS / 1 DAY

PA

DIASTAT 4QL 4 KITS / 30 DAYS

PA

DIASTAT ACUDIAL 4QL 4 KITS / 30 DAYS

PA

diazepam (2 mg tablet, 5 mg tablet) 1 QL 6 TABS / 1 DAY

diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst)

2 QL 4 KITS / 30 DAYS

diazepam 10 mg tablet 1 QL 4 TABS / 1 DAY



diazepam 5 mg/5 ml solution 2 QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc 2 QL 8 ML / 1 DAY

DORAL 4 QL 2 TABS / 1 DAY

estazolam 1 mg tablet 2QL 2 TABS / 1 DAY

PA

estazolam 2 mg tablet 2QL 1 TAB / 1 DAY

PA

flurazepam 15 mg capsule 2QL 2 CAPS / 1 DAY

PA

flurazepam 30 mg capsule 2QL 1 CAP / 1 DAY

PA

HALCION 4 QL 2 TABS / 1 DAY

lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

lorazepam 2 mg tablet 1 QL 5 TABS / 1 DAY

lorazepam 2 mg/ml oral concent 2 QL 5 ML / 1 DAY

LORAZEPAM INTENSOL 2 QL 5 ML / 1 DAY

LOREEV XR 4 PA

midazolam hcl (2 mg/ml syrup, 5 mg/2.5 ml syrp) 4 QL 4 ML / 1 DAY

oxazepam (10 mg capsule, 15 mg capsule) 2QL 6 CAPS / 1 DAY

PA

oxazepam 30 mg capsule 2QL 4 CAPS / 1 DAY

PA

quazepam 2QL 2 TABS / 1 DAY

PA

RESTORIL (22.5 MG CAPSULE, 30 MG CAPSULE) 4QL 1 CAP / 1 DAY

PA



RESTORIL (7.5 MG CAPSULE, 15 MG CAPSULE) 4QL 2 CAPS / 1 DAY

PA

temazepam 15 mg capsule 1 QL 2 CAPS / 1 DAY

temazepam 22.5 mg capsule 4 QL 1 CAP / 1 DAY

temazepam 30 mg capsule 1 QL 1 CAP / 1 DAY

temazepam 7.5 mg capsule 4 QL 2 CAPS / 1 DAY

TRANXENE T-TAB 4QL 6 TABS / 1 DAY

PA

triazolam 0.125 mg tablet 2 QL 4 TABS / 1 DAY

triazolam 0.25 mg tablet 2 QL 2 TABS / 1 DAY

VALIUM (2 MG TABLET, 5 MG TABLET) 4 QL 6 TABS / 1 DAY

VALIUM 10 MG TABLET 4 QL 4 TABS / 1 DAY

VALTOCO 3QL 2 DOSES / RX

PA

XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 4 QL 6 TABS / 1 DAY

XANAX 2 MG TABLET 4 QL 3 TABS / 1 DAY

XANAX XR (0.5 MG TABLET, 1 MG TABLET) 4 QL 6 TABS / 1 DAY

XANAX XR 2 MG TABLET 4 QL 3 TABS / 1 DAY

XANAX XR 3 MG TABLET 4 QL 2 TABS / 1 DAY

OREXIN RECEPTOR ANTAGONISTS

BELSOMRA (15 MG TABLET, 20 MG TABLET) 4QL 1 TAB / 1 DAY

PA

BELSOMRA (5 MG TABLET, 10 MG TABLET) 4QL 2 TABS / 1 DAY

PA

DAYVIGO 4QL 1 TAB / 1 DAY

PA



QUVIVIQ 4QL 1 TAB / DAY

PA

AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS

apo-varenicline 0.5 mg tablet (apotex) 2

QL 2 TABS / 1 DAY


SC Smoking Cessation

apo-varenicline 1 mg tablet (apotex) 2

QL 2 TABS / 1 DAY



CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1MG TABLET)

4QL 2 TABS / 1 DAY

PA

CHANTIX STARTING MONTH BOX 4QL 53 TABS / 28 DAYS

PA

nicotine gum 2 SC Smoking Cessation

nicotine lozenge (2 mg lozenge, 2 mg mini lozenge, cvs 2mg lozenge, eq 2 mg lozenge, eql 2 mg lozenge, gnp 2 mglozenge, hm 2 mg lozenge, kro 2 mg lozenge, ra 2 mglozenge, sm 2 mg lozenge, sw 2 mg lozenge, 4 mglozenge, 4 mg mini lozenge, cvs 4 mg lozenge, eq 4 mglozenge, eql 4 mg lozenge, gnp 4 mg lozenge, gs 4 mglozenge, hm 4 mg lozenge, kro 4 mg lozenge, ra 4 mglozenge, sm 4 mg lozenge, sw 4 mg lozenge)

2 SC Smoking Cessation


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine patch (7 mg/24hr patch, cvs 7 mg/24hr patch, eq7 mg/24hr patch, hm 7 mg/24hr patch, kro 7 mg/24hrpatch, ra 7 mg/24hr patch, sm 7 mg/24hr patch, 14mg/24hr patch, cvs 14 mg/24hr patch, gnp 7 mg/24hrpatch, hm 14 mg/24hr patch, qc 14 mg/24hr patch, ra 14mg/24hr patch, 21 mg/24hr patch, cvs 21 mg/24hr patch,eq 14 mg/24hr patch, eq 21 mg/24hr patch, gnp 14mg/24hr patch, gnp 21 mg/24hr patch, hm 21 mg/24hrpatch, kro 14 mg/24hr patch, kro 21 mg/24hr patch, qc 21mg/24hr patch, ra 21 mg/24hr patch, sm 14 mg/24hrpatch, sm 21 mg/24hr patch)

2 SC Smoking Cessation

NICOTROL 3 SC Smoking Cessation

NICOTROL NS 3 SC Smoking Cessation

TYRVAYA 4QL 8.4 ML / 30 DAYS

PA

varenicline 2

QL 53 TABS / 28 DAYS



varenicline tartrate (0.5 mg tablet, 1 mg tablet) 2

QL 2 TABS / 1 DAY



PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

ADLARITY 4 PA

ARICEPT 4 PA

bethanechol chloride 2

cevimeline hcl 2

donepezil hcl (5 mg tablet, 10 mg tablet) 2

donepezil hcl 23 mg tablet 4

donepezil hcl odt 2

EVOXAC 4

EXELON 4

galantamine er 2



galantamine hbr 2

galantamine hydrobromide 2

guanidine hcl 3 PA

MESTINON (60 MG TABLET, 60 MG/5 ML SOLUTION, 180MG TIMESPAN)

4 PA

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 2

pyridostigmine 60 mg/5 ml soln 4 PA

pyridostigmine br 30 mg tablet 2 QL 1 TAB / 1 DAY

pyridostigmine br 60 mg tablet 2

pyridostigmine bromide er 2 PA

RAZADYNE 4

RAZADYNE ER 4

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)

2

SALAGEN 4

BETA-3-ADRENERGIC AGONISTSSELECTIVE BETA-3-ADRENERGIC AGONISTS

GEMTESA 4 PA

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 3

MYRBETRIQ ER 8 MG/ML SUSP 4 PA

BETA-ADRENERGIC AGONISTSSELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol sulfate (2 mg tab, 4 mg tab, er 4 mg tab, er 8mg tab)

4

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 mlsol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulf 2 mg/5ml syrup, 5 mg/ml solution, 100 mg/20 ml soln)

2

albuterol sulfate 90 mcg hfa aer ad (generic proair) 4 PA

albuterol sulfate 90 mcg hfa aer ad (generic proventil) 4 PA



albuterol sulfate 90 mcg hfa aer ad (generic ventolin) 4 PA

albuterol sulfate hfa 4 PA

arformoterol tartrate 2 PA

BROVANA 3 PA

formoterol fumarate 2 PA

levalbuterol concentrate 4

levalbuterol hcl 4

levalbuterol tartrate hfa 2

metaproterenol sulfate 4

PERFOROMIST 3 PA

PROAIR DIGIHALER 4 PA

PROAIR HFA 4 PA

PROAIR RESPICLICK 4 PA

PROVENTIL HFA 4 PA

SEREVENT DISKUS 3 PA

STRIVERDI RESPIMAT 3

terbutaline sulfate (2.5 mg tab, 5 mg tab) 2 PA

VENTOLIN HFA 2

XOPENEX 4

XOPENEX HFA 4

BLOOD FORMATION, COAGULATION, THROMBOSISBLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

OXBRYTA 5PA

S

PYRUKYND 5


PA

S



TAVALISSE 5PA

S

HEMATOPOIETIC AGENTS

ARANESP 5 S

DOPTELET 5PA

S

EPOGEN 5 S

FULPHILA 3 PA

GRANIX 5 S

LEUKINE 5PA

S

MIRCERA 5PA

S

MULPLETA 5PA

S

NEULASTA 5PA

S

NEULASTA ONPRO 5PA

S

NEUPOGEN 5PA

S

NIVESTYM 5PA

S

NYVEPRIA 3 PA

PROCRIT 5 S

PROMACTA 5PA

S



RELEUKO 5PA

S

RETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL,4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 20,000UNIT/ML VIAL, 40,000 UNIT/ML VIAL)

5 S

UDENYCA 3 PA

ZARXIO 5PA

S

ZIEXTENZO 3 PA

HEMORRHEOLOGIC AGENTSpentoxifylline 2

CALCIUM-CHANNEL BLOCKING AGENTSCALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CALAN SR 4

CARDIZEM 4

CARDIZEM CD 4 PA

CARDIZEM LA 4 PA

CARTIA XT 2

DILT-XR 1

diltiazem 12hr er 4

diltiazem 24h er(la) 360 mg tb (generic for cardizem la) 4

diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mgcap, 24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 420mg cap)

2

diltiazem 24hr er (cd) (24h 120 mg cp, 24h 180 mg cp, 24h240 mg cp, 24h 300 mg cp)

2

diltiazem 24hr er (la) (24h 180 mg tb, 24h 240 mg tb, 24h300 mg tb, 24h 420 mg tb)

4

diltiazem 24hr er (xr) 1

diltiazem 24hr er 360 mg cap 1

diltiazem 24hr er 360 mg cap (generic for cardizem cd) 4


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSdiltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet,120 mg tablet)

2

MATZIM LA (180 MG TABLET, 300 MG TABLET, 420 MGTABLET)

4

MATZIM LA 240 MG TABLET 1

MATZIM LA 360 MG TABLET (GENERIC FOR CARDIZEM LA) 4

TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MGCAPSULE, 300 MG CAPSULE)

2

TAZTIA XT 360 MG CAPSULE 1

TIADYLT ER (ER 180 MG CAPSULE, ER 420 MG CAPSULE) 2

TIAZAC 4 PA

verapamil er (er 120 mg capsule, er 180 mg capsule, er240 mg capsule)

1

verapamil er (er 120 mg tablet, er 180 mg tablet, er 240mg tablet)

2

verapamil er pm 4

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) 1

verapamil sr (sr 120 mg capsule, sr 180 mg capsule, sr 240mg capsule)

1

verapamil sr 360 mg capsule 2

VERELAN 4

VERELAN PM 4

DIHYDROPYRIDINESamlodipine besylate 1

amlodipine besylate-benazepril 2

amlodipine-olmesartan 2

amlodipine-valsartan 1

amlodipine-valsartan-hctz 2

AZOR 4 PA

CONJUPRI (2.5 MG TABLET, 5 MG TABLET) 4 PA

EXFORGE 4



EXFORGE HCT 4

felodipine er 2

isradipine 4

KATERZIA 4

levamlodipine maleate 4 PA

LOTREL 4

nicardipine hcl (20 mg capsule, 30 mg capsule) 4

nifedipine 2 AL1 Up to 45 yrs old

nifedipine er 2

nimodipine 2

nisoldipine 4

NORLIQVA 4

NORVASC 4 PA

NYMALIZE 4 PA

PROCARDIA 4 AL1 Up to 45 yrs old

PROCARDIA XL 4

SULAR 4

CARDIAC DRUGSCARDIAC DRUGS, MISCELLANEOUS

ASPRUZYO SPRINKLE 4 PA

CAMZYOS 5

QL 1 CAP / DAY

PA

S

CORLANOR (5 MG TABLET, 5 MG/5 ML ORAL SOLN, 7.5MG TABLET)

3 PA

RANEXA 4

ranolazine er 4



CARDIOTONIC AGENTSDIGITEK 125 MCG TABLET 2

DIGITEK 250 MCG TABLET 2 AL1 Up to 64 yrs old

DIGOX 125 MCG TABLET 2

DIGOX 250 MCG TABLET 2 AL1 Up to 64 yrs old

digoxin (0.125 mg tablet, 125 mcg tablet) 2

digoxin (0.25 mg tablet, 250 mcg tablet) 2 AL1 Up to 64 yrs old

digoxin 0.05 mg/ml solution 3

digoxin 62.5 mcg tablet 4

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET) 4

LANOXIN 250 MCG TABLET 4 AL1 Up to 64 yrs old

CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 4

CARDURA XL 4

doxazosin mesylate 2

MINIPRESS 4

prazosin hcl 2

terazosin hcl 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 2

atenolol 1

atenolol-chlorthalidone 2

BETAPACE 4

BETAPACE AF 4

betaxolol hcl (10 mg tablet, 20 mg tablet) 2

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide 1



BYSTOLIC 4 PA

carvedilol 1

carvedilol er 4

COREG CR 4 PA

CORGARD 4

DUTOPROL 4 PA

HEMANGEOL 4 PA

INDERAL LA 4 PA

INDERAL XL 4 PA

INNOPRAN XL 4 PA

KAPSPARGO SPRINKLE 4

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)

2

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 4

metoprolol succinate 2

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 1

metoprolol tartrate (37.5 mg tb, 75 mg tab) 4

metoprolol-hydrochlorothiazide 2

nadolol 1

nebivolol hcl 4 PA

pindolol 4

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)

2

propranolol hcl er 1

propranolol-hydrochlorothiazid 2

SORINE 4

sotalol 2



SOTALOL AF 2

SOTYLIZE 4

TENORMIN 4

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

TOPROL XL 4

CENTRAL NERVOUS SYSTEM AGENTSANTIMANIC AGENTS

lithium 2

lithium carbonate 2

lithium carbonate er 2

LITHOBID 4

CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium 2

atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mgcapsule, 40 mg capsule)

2 QL 2 CAPS / 1 DAY

atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mgcapsule)

2 QL 1 CAP / 1 DAY

carbidopa 4

guanfacine hcl er (er 3 mg tablet, er 4 mg tablet) 2 QL 1 TAB / 1 DAY

guanfacine hcl er 1 mg tablet 2 QL 3 TABS / 1 DAY

guanfacine hcl er 2 mg tablet 2 QL 2 TABS / 1 DAY

INTUNIV (ER 3 MG TABLET, ER 4 MG TABLET) 4 QL 1 TAB / 1 DAY

INTUNIV ER 1 MG TABLET 4 QL 3 TABS / 1 DAY

INTUNIV ER 2 MG TABLET 4 QL 2 TABS / 1 DAY

LODOSYN 4

memantine hcl (hcl 2 mg/ml solution, 5-10 mg titrationpk, hcl 5 mg tablet, hcl 10 mg tablet)

2

memantine hcl er 4 PA

NAMENDA 4 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE, TITRATION PACK)

4 PA

NAMZARIC 4

NOURIANZ 5PA

S

NUEDEXTA 4

QELBREE 4 PA

RADICAVA ORS 5

QL 70 ML / 28 DAYS

PA

S

RILUTEK 4

riluzole 2

STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MGCAPSULE, 40 MG CAPSULE)

4 QL 2 CAPS / 1 DAY

STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MGCAPSULE)

4 QL 1 CAP / 1 DAY

TIGLUTIK 4 PA

XYREM 5

QL 18 ML / 1 DAY

PA

S

XYWAV 5

QL 18 ML / 1 DAY

PA

S

FIBROMYALGIA AGENTS

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET)

3QL 2 TABS / 1 DAY

PA

SAVELLA TITRATION PACK 3QL 55 TABS / 28 DAYS

PA

OPIATE ANTAGONISTS

EVZIO 4 PA



KLOXXADO 3

LIFEMS NALOXONE 4 PA

nalmefene hcl 4

naloxone 2 mg auto-injector 4

naloxone hcl (2 mg/2 ml syringe, hcl 4 mg nasal spray) 2

naltrexone hcl 2

NARCAN 4

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO 5PA

S

AUSTEDO 12MG START TITR(WK1-4) 5PA

S

AUSTEDO TD TITRATN PK (WK 1-2) 5PA

S

INGREZZA 5PA

S

INGREZZA INITIATION PACK 5PA

S

tetrabenazine 5PA

S

XENAZINE 5PA

S

CEPHALOSPORIN ANTIBIOTICS1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg/5 mlsusp)

1

cefadroxil 500 mg capsule 2

cephalexin (125 mg/5 ml susp, 250 mg/5 ml susp) 2

cephalexin (250 mg capsule, 500 mg capsule) 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONScephalexin (250 mg tablet, 500 mg tablet, 750 mgcapsule)

4

KEFLEX 4

2ND GENERATION CEPHALOSPORIN ANTIBIOTICScefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 mlsusp, 375 mg/5 ml suspen)

4

cefaclor 500 mg capsule 2 PA

cefaclor er 4

cefprozil (125 mg/5 ml susp, 250 mg/5 ml susp) 1

cefprozil (250 mg tablet, 500 mg tablet) 2

cefuroxime 2

3RD GENERATION CEPHALOSPORIN ANTIBIOTICScefdinir (125 mg/5 ml susp, 250 mg/5 ml susp) 2

cefdinir 300 mg capsule 1

cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 4

cefixime 400 mg capsule 2 QL 1 CAP / 30 DAYS

cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 2 QL 14 TABS / RX

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)

2 QL 100 ML / RX

SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 MLSUSPENSION, 200 MG TABLET CHEWABLE, 200 MG/5 MLSUSPENSION, 500 MG/5 ML SUSPENSION)

4

SUPRAX 400 MG CAPSULE 4QL 1 CAP / 30 DAYS

PA

CORTICOSTEROIDS (RESPIRATORY TRACT)ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS 2

ADVAIR HFA 3

AIRDUO DIGIHALER 4 PA

AIRDUO RESPICLICK 4 PA



ALVESCO 4

ARMONAIR DIGIHALER 4 PA

ARNUITY ELLIPTA 3

ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220MCG #120)

3

ASMANEX HFA 3

BREO ELLIPTA 3

BREZTRI AEROSPHERE 3

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2ml inh susp)

2

budesonide-formoterol fumarate 2

DULERA 4 PA

FLOVENT DISKUS 3

FLOVENT HFA 3

fluticasone propionate hfa 4

fluticasone-salmeterol (100-50, 250-50, 500-50) 4

fluticasone-salmeterol 113-14 (generic for airduorespiclick)

2

fluticasone-salmeterol 232-14 (generic for airduorespiclick)

2

fluticasone-salmeterol 55-14 (generic for airduo respiclick) 2

fluticasone-vilanterol 4

PULMICORT 4 PA

PULMICORT FLEXHALER 3

QVAR REDIHALER 3

SYMBICORT 4 PA

TRELEGY ELLIPTA 3

WIXELA INHUB 4



CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 5PA

S

TRIKAFTA 5PA

S

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO 5PA

S

ORKAMBI 5PA

S

DEPIGMENTING AND PIGMENTING AGENTSPIGMENTING AGENTS

methoxsalen 4 PA

OXSORALEN-ULTRA 4 PA

DEVICES

astero 4 PA

ATOPICLAIR 4

BD INS SYRNG UF 0.3 ML 8MMX31G 3

BD VERITOR AT-HOME COVID19 TST 3QL 8 TESTS / MONTH


BINAXNOW COVD AG CARD HOME TST 3QL 8 TESTS / MONTH


BINAXNOW COVID-19 AG SELF TEST 3QL 8 TESTS / MONTH


CAPHOSOL 4

CARESTART COVID-19 AG HOME TST 3QL 8 TESTS / MONTH




CELLTRION DIATRUST COV-19 HOME 3QL 8 TESTS / MONTH


CLINITEST COVID-19 HOME TEST 3QL 8 TESTS / MONTH


COVID-19 AT-HOME TEST 3QL 8 TESTS / MONTH


CUE COVID-19 HOME TEST 3QL 8 TESTS / MONTH


ELETONE 4

ELLUME COVID-19 HOME TEST 3QL 8 TESTS / MONTH


emulsion sb 4

ENTTY 4 PA

EPICYN 4

EPISIL 4

FLOWFLEX COVID-19 AG HOME TEST 3QL 8 TESTS / MONTH


HYLATOPICPLUS (EMOLLIENT FOAM, LOTION) 4

IHEALTH COVID-19 AG HOME TEST 3QL 8 TESTS / MONTH


INDICAID COVID-19 AG HOME TEST 3QL 8 TESTS / MONTH


INTELISWAB COVID-19 HOME TEST 3QL 8 TESTS / MONTH


ldo plus 4 PA

LEVICYN (ANTIPRURITIC GEL, DERMAL SPRAY) 4

LIDOTREX 2%-1.2%-1% WOUND GEL 4 PA

LOUTREX 4



LUCIRA CHECK-IT COVID HOME TST 3QL 8 TESTS / MONTH


mb hydrogel 4 PA

MICROCYN HYDROGEL 4 PA

MIDASPOT COVID19 ANTIBODY TEST 3 ACA Affordable Care Act

NEOSALUS FOAM 4 PA

ON-GO COVID-19 AG AT HOME TEST 3QL 8 TESTS / MONTH


PIXEL COVID-19 HOME COLLECT KT 3QL 8 TESTS / MONTH


QUICKVUE AT-HOME COVID-19 TEST 3QL 8 TESTS / MONTH


SALIVAMAX 4 PA

SCARCARE 4 PA

SILIPAC 4 PA

SILVRSTAT 4 PA

SYNERDERM 4

VASHE WOUND 4

VASHE WOUND THERAPY 4

VEXASYN 4

DIAGNOSTIC AGENTSADRENOCORTICAL INSUFFICIENCY

ACTHAR 5PA

S

CORTROPHIN 5PA

S



PITUITARY FUNCTION

MACRILEN 5PA

S

METOPIRONE 4 PA

RESPIRATORY FUNCTION

methacholine chloride 4 PA

ROENTGENOGRAPHY AND OTHER IMAGING AGENTSOMNIPAQUE 12 MG/ML ORAL SOLN 4

DIURETICSLOOP DIURETICS

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 2

EDECRIN 4 PA

ethacrynic acid 2 PA

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)

1

LASIX 4

SOAANZ 4 PA

torsemide 2

POTASSIUM-SPARING DIURETICSamiloride hcl 2

amiloride-hydrochlorothiazide 2

DYAZIDE 4

DYRENIUM 4

MAXZIDE 4

MAXZIDE-25 MG 4

triamterene 4

triamterene-hydrochlorothiazid 1



THIAZIDE DIURETICSDIURIL 3

hydrochlorothiazide 1

THIAZIDE-LIKE DIURETICSchlorthalidone 2

indapamide 2

metolazone 2

THALITONE 4

VASOPRESSIN ANTAGONISTS

JYNARQUE 5PA

S

SAMSCA 5PA

S

tolvaptan 5PA

S

DOPAMINE RECEPTOR AGONISTSERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate 2

cabergoline 2

CYCLOSET 3 PA

PARLODEL 2.5 MG TABLET 4

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

APOKYN 5PA

S

apomorphine hcl 5PA

S

KYNMOBI 5PA

S

MIRAPEX 4 PA



MIRAPEX ER 4 PA

NEUPRO 3 PA

pramipexole dihydrochloride 2

pramipexole er 2

REQUIP XL 4 PA

ropinirole er 2

ropinirole hcl 2

ELECTROLYTIC, CALORIC, AND WATER BALANCEACIDIFYING AGENTS

K-PHOS NO.2 4

K-PHOS ORIGINAL 4

ALKALINIZING AGENTSpotassium citrate er 2

UROCIT-K 4

AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 5PA

S

CARBAGLU 5PA

S

carglumic acid 5PA

S

ENULOSE 2

GENERLAC 2

KRISTALOSE (10 GM PACKET, 20 GM PACKET) 4 PA

lactulose 10 gm packet 4 PA

lactulose 10 gm/15 ml solution 2

LITHOSTAT 4

RAVICTI 5PA

S



sodium phenylbutyrate 500mg tb 5PA

S

sodium phenylbutyrate powder 2 PA

CALORIC AGENTS

DOJOLVI 5PA

S

levocarnitine 330 mg tablet 1

REPLACEMENT PREPARATIONS

CALTRATE 600-D3 PLUS MINERALS 4 PA

EFFER-K (10 TABLET EFF, 20 TABLET EFF, 25 TABLET EFF) 4

k-tab er 4

KLOR-CON 4

KLOR-CON 10 4

KLOR-CON 8 4

KLOR-CON M10 2

KLOR-CON M15 2

KLOR-CON M20 2

klor-con-ef 4

potassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20 meq packet, 20% (40meq/15ml), er 20 meq tablet)

2

URICOSURIC AGENTS

DUZALLO 4 PA

probenecid 2

probenecid-colchicine 2



EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS

ammonium lactate 12% lotion 2

BASIC OILS AND OTHER SOLVENTS

CERACADE 4 PA

BASIC OINTMENTS AND PROTECTANTSammonium lactate 12% cream 2

DEXERYL 4 PA

NUTRASEB 4 PA

TETRIX 4 PA

ENZYMES

PALYNZIQ 5PA

S

REVCOVI 5PA

S

STRENSIQ 5PA

S

SUCRAID 5PA

S

ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS

EVISTA 4

FARESTON 4 PA

raloxifene hcl 2

SOLTAMOX 3

tamoxifen citrate 2

toremifene citrate 2 PA



ESTROGENSACTIVELLA 4

ALORA 4

AMABELZ 0.5 MG-0.1 MG TABLET 2

AMABELZ 1 MG-0.5 MG TABLET 4

ANGELIQ 4

CLIMARA 4

CLIMARA PRO 3

COMBIPATCH 3

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75MG GEL PACKET, 1 MG GEL PACKET, 1.25 MG GELPACKET)

4

DOTTI 2

DUAVEE 4

ELESTRIN 4

ESTRACE (0.01% CREAM, 0.5 MG TABLET, 1 MG TABLET, 2MG TABLET)

4

estradiol (0.01% cream, 10 mcg vaginal insrt) 2

estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

estradiol (once weekly) 2

estradiol (twice weekly) 2

estradiol-noreth 0.5-0.1 mg tb 2

estradiol-noreth 1-0.5 mg tab 4

ESTRING 3

ESTROGEL 4

EVAMIST 4

FEMHRT 4

FEMRING 4

FYAVOLV 2

JINTELI 2



LOPREEZA 4

MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MGTABLET)

4

MENOSTAR 4

MIMVEY 4

MINIVELLE 4

norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5)

2

PREFEST 4

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINALCREAM-APPL)

3

PREMPHASE 3

PREMPRO 3

VAGIFEM 4

VIVELLE-DOT 4

YUVAFEM 2

EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS

ALOMIDE 3 PA

azelastine hcl 2

azelastine-fluticasone 4

bepotastine besilate 4 PA

BEPREVE 4 PA

DYMISTA 4

epinastine hcl 2

LASTACAFT 3 PA

olopatadine 665 mcg nasal spry 2 PA

olopatadine hcl 0.1% eye drops 2



olopatadine hcl 0.2% eye drop 4

PATANASE 4

PAZEO 4 PA

TICALAST 4 PA

ZERVIATE 3 PA

EENT DRUGS, MISCELLANEOUS

apraclonidine hcl 2 PA

CYSTADROPS 5

QL 5 ML / RX

PA

S

CYSTARAN 5

QL 15 ML / RX

PA

S

IOPIDINE 4

ipratropium bromide (0.03% spray, 0.06% spray) 2

LACRISERT 4 PA

OXERVATE 5

QL 1 ML / 1 DAY

PA

S

PHOTREXA 4

PHOTREXA VISCOUS 4

LOCAL ANESTHETICS (EENT)

ADVANCED DNA MEDICATED COLLECT 4 PA

fluorescein-benoxinate 4

lidocaine hcl (2% jel urojet ac, 2% jelly, 2% jelly uro-jet, 4%solution)

2

lidocaine hcl viscous 2

pro dna collection 4 PA



PRO DNA MEDICATED COLLECTION 4 PA

proparacaine hcl 4

MYDRIATICSatropine sulfate (drops, ointment) 2

CYCLOGYL 4

CYCLOMYDRIL 4

cyclopentolate hcl (0.5% eye drops, hcl 2% drops) 4

cyclopentolate hcl (drop, drops) 2

homatropaire 2

MYDRIACYL 4

tropicamide 4

VASOCONSTRICTORSADRENALIN CHLORIDE 4

phenylephrine hcl (2.5% drop, 10% drops) 2

UPNEEQ 4 PA

FIRST GENERATION ANTIHISTAMINESETHANOLAMINE DERIVATIVES

carbinoxamine maleate 4 mg tab 2 PA

carbinoxamine maleate 6 mg tab 4 PA

clemastine 0.5 mg/5 ml syrup 4 PA

clemastine fum 2.68 mg tab 4

diphenhydramine hcl (12.5 mg/5 ml, 25 mg capsule, 25mg/10 ml, 50 mg capsule)

4

KARBINAL ER 4

RYVENT 4

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp)

2



PHENOTHIAZINE DERIVATIVESpromethazine hcl (12.5 mg suppos, 25 mg suppository, 50mg suppository)

2

promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet)

2 AQ1 Up to 64 yrs old; 30 /1 FILL

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp) 1 AQ1 Up to 64 yrs old; 300/ 1 FILL

promethazine vc 1

promethazine-phenylephrine 1

PROMETHEGAN 2

PROPYLAMINE DERIVATIVESdexchlorpheniramine maleate 4

RYCLORA 4

GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 2 PA

APRISO 4

ASACOL HD 4

balsalazide disodium 2

CANASA 4

COLAZAL 4 PA

DELZICOL 4

DIPENTUM 3 PA

LIALDA 4

LOTRONEX 4 PA

mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 800mg dr tablet, 1,000 mg supp)

2

mesalamine 4 gm/60 ml kit 4 QL 4 KITS / 28 DAYS

mesalamine dr 2

mesalamine er 0.375 gram cap 2



mesalamine er 500 mg capsule 4

PENTASA 4

ROWASA 4 GM/60 ML ENEMA KIT 4 QL 4 KITS / 28 DAYS

ANTIDIARRHEA AGENTS

diphenoxylat-atrop 2.5-0.025/5 2 QL 40 ML / 1 DAY

diphenoxylate-atrop 2.5-0.025 2 QL 8 TABS / 1 DAY

LOMOTIL 4QL 8 TABS / 1 DAY

PA

loperamide 2 mg capsule 4

MOTOFEN 4 PA

opium tincture 4 QL 2.4 ML / 1 DAY

XERMELO 5PA

S

CATHARTICS AND LAXATIVES

AMITIZA 4QL 2 CAPS / 1 DAY

PA

CLENPIQ 4

GAVILYTE-C 1 ACA Affordable Care Act

GAVILYTE-G 1 ACA Affordable Care Act

GAVILYTE-N 2

GOLYTELY 4

lubiprostone 2 QL 2 CAPS / 1 DAY

MOVIPREP 4

NULYTELY WITH FLAVOR PACKS 4

OSMOPREP 4

peg 3350-electrolyte 1 ACA Affordable Care Act

peg-3350 and electrolytes 1 ACA Affordable Care Act



PEG-PREP 4

peg3350-sod sul-nacl-kcl-asb-c 4

PLENVU 4

polyethylene glycol 3350 4

SUPREP 3 ACA Affordable Care Act

SUTAB 4 PA

TRILYTE WITH FLAVOR PACKETS 4

CHOLELITHOLYTIC AGENTS

ACTIGALL 4 PA

CHENODAL 5PA

S

RELTONE 4 PA

URSO 4

URSO FORTE 4

ursodiol (200 mg capsule, 400 mg capsule) 4 PA

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 2

DIGESTANTSCREON 3

PANCREAZE 4 PA

PERTZYE 4 PA

VIOKACE 4 PA

ZENPEP 4 PA

GI DRUGS, MISCELLANEOUSalvimopan 4

BYLVAY 5PA

S

CHOLBAM 5PA

S



ENDARI 5PA

S

ENTEREG 4

GATTEX 5PA

S

HUMIRA(CF) PEDI CROHN 80-40 MG 5

QL 2 SYRINGES / 28DAYS

PA

S

IBSRELA 4 PA

LINZESS 3 QL 1 CAP / 1 DAY

LIVMARLI 5PA

S

MOVANTIK 3QL 1 TAB / 1 DAY

PA

OCALIVA 5PA

S

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL, 150 MG TABLET)

4 PA

SYMPROIC 3 PA

TRULANCE 4 PA

VIBERZI 4 PA

PROKINETIC AGENTS

GIMOTI 3 PA

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol)

1

metoclopramide hcl odt 2 PA

MOTEGRITY 4 PA

REGLAN 4



ZELNORM 4 PA

GENITOURINARY SMOOTH MUSCLE RELAXANTSANTIMUSCARINICS

darifenacin er 2 PA

DETROL 4

DETROL LA 4

DITROPAN XL 4

fesoterodine fumarate er 4

flavoxate hcl 2 PA

GELNIQUE 4

oxybutynin 5 mg tablet 1

oxybutynin 5 mg/5 ml syrup 2

oxybutynin chloride er 2

OXYTROL 4 PA

solifenacin succinate 2

tolterodine tartrate 2

tolterodine tartrate er 2

TOVIAZ 4

trospium chloride 1

trospium chloride er 4

VESICARE 4

VESICARE LS 4 PA

GOLD COMPOUNDSRIDAURA 3

GONADOTROPINS AND ANTIGONADOTROPINSANTIGONADTROPINS

FYREMADEL 2

MYFEMBREE 5


PA

S



ORGOVYX 3PA

S

ORIAHNN 5

QL 2 CAPS / 1 DAY

PA

S

ORILISSA 150 MG TABLET 5

QL 1 TAB / 1 DAY

PA

S

ORILISSA 200 MG TABLET 5


PA

S

GONADOTROPINS

LUPANETA PACK 4 PA

SYNAREL 4

HCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 5PA

S

HARVONI 5PA

S

ledipasvir-sofosbuvir 5PA

S

sofosbuvir-velpatasvir 5PA

S

SOVALDI 5PA

S

VOSEVI 5PA

S



HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET 5PA

S

HCV REPLICATION COMPLEX INHIBITORS

VIEKIRA PAK 5PA

S

ZEPATIER 5PA

S

HEAVY METAL ANTAGONISTSCHEMET 3

CUPRIMINE 5PA

S

D-PENAMINE 2 PA

deferasirox (90 mg granule pkt, 90 mg tablet, 125 mg tbfor susp, 180 mg granule pkt, 180 mg tablet, 250 mg tbfor susp, 360 mg granule pkt, 360 mg tablet, 500 mg tbfor susp)

5

PA

S

TD Trial Drug

deferiprone 5PA

S

deferiprone (3 times a day) 5PA

S

DEPEN 5PA

S

EXJADE 5

PA

S

TD Trial Drug

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET,1,000 MG TABLET)

5PA

S

FERRIPROX (2 TIMES A DAY) 5PA

S



FERRIPROX (3 TIMES A DAY) 5PA

S

JADENU 5

PA

S

TD Trial Drug

JADENU SPRINKLE 5

PA

S

TD Trial Drug

penicillamine (250 mg capsule, 250 mg tablet) 5PA

S

SYPRINE 5PA

S

trientine hcl 5PA

S

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS

ALKINDI SPRINKLE 4 PA

BETALOAN SUIK 4 PA

budesonide dr 2

budesonide ec 2

budesonide er 4

CORTEF 4

dexamethasone (0.5 mg tablet, 0.75 mg tablet, 1 mgtablet, 1.5 mg tablet, 4 mg tablet, 6 mg tablet)

1

dexamethasone (0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 2 mgtablet)

2

dexamethasone 6 day 1.5 mg tab 4 PA

DEXAMETHASONE INTENSOL 3

dexamethasone sodium phosphate (10 mg/ml syring, 10mg/ml vial, 100 mg/10 ml vl)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSdexamethasone sodium phosphate (4 mg/ml vial, 20mg/5 ml vial, 120 mg/30 ml vl)

1

DMT SUIK 4 PA

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET, 36 MG TABLET)

5PA

S

ENTOCORT EC 4

fludrocortisone acetate 2

HEMADY 4 PA

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET,16 MG TABLET, 32 MG TABLET)

4

MEDROL 2 MG TABLET 3

MEDROLOAN II SUIK 4 PA

MEDROLOAN SUIK 4 PA

methylprednisolone 2

MILLIPRED 3

ORAPRED ODT 4

ORTIKOS 4 PA

prednisolone 1

prednisolone sodium phos odt 4

prednisolone sodium phosphate (10 mg/5 ml soln, 20mg/5 ml soln)

4

prednisolone sodium phosphate (5 mg/5 ml soln, 15 mg/5ml soln, sod ph 25 mg/5 ml)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 10 mg tab dose pack, 10 mg tablet, 20mg tablet, 50 mg tablet)

1

prednisone 5 mg/5 ml solution 2

PREDNISONE INTENSOL 3

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL)

3



TAPERDEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 4 PA

TARPEYO 4QL 4 CAPS / 1 DAY

PA

TRILOAN SUIK 4 PA

UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 4

ZCORT 4 PA

ANDROGENS

ANADROL-50 3 PA

ANDRODERM 4 PA

ANDROGEL 4 PA

ANDROID 4QL 5 CAPS / 1 DAY

PA

covaryx 4 QL 1 TAB / 1 DAY

covaryx h.s. 4 QL 1 TAB / 1 DAY

danazol 2

DEPO-TESTOSTERONE 4 PA

eemt 4 QL 1 TAB / 1 DAY

eemt h.s. 4 QL 1 TAB / 1 DAY

estrogen-methyltestosterone 4 QL 1 TAB / 1 DAY

FORTESTA 4 PA

JATENZO 4 PA

METHITEST 4QL 5 TABS / 1 DAY

PA

methyltestosterone 2QL 5 CAPS / 1 DAY

PA

NATESTO 4 PA



OXANDRIN 10 MG TABLET 4QL 2 TABS / 1 DAY

PA

OXANDRIN 2.5 MG TABLET 4QL 4 TABS / 1 DAY

PA

oxandrolone 10 mg tablet 2QL 2 TABS / 1 DAY

PA

oxandrolone 2.5 mg tablet 2QL 4 TABS / 1 DAY

PA

TESTIM 4 PA

testosterone (1% (25mg/2.5g) pk, 1% (50 mg/5 g) pk,1.62% (2.5 g) pkt, 1.62% gel pump, 1.62%(1.25 g) pkt, 10mg gel pump, 12.5 mg/1.25 gram, 50 mg/5 gram gel, 50mg/5 gram pkt)

2 PA

testosterone 30 mg/1.5 ml pump 4 PA

testosterone cypionate 2 PA

testosterone enanthate 2 PA

TESTRED 4QL 5 CAPS / 1 DAY

PA

TLANDO 4 PA

VOGELXO 4 PA

XYOSTED 4 PA

CONTRACEPTIVES

AFIRMELLE 2 ACA Affordable Care Act

AFTER PILL 2 ACA Affordable Care Act

ALTAVERA 2 ACA Affordable Care Act

ALYACEN 2 ACA Affordable Care Act

AMETHIA 2 ACA Affordable Care Act



AMETHIA LO 2 ACA Affordable Care Act

AMETHYST 2 ACA Affordable Care Act

ANNOVERA 4QL 1 RING / 365 DAYS

PA

APRI 2 ACA Affordable Care Act

ARANELLE 2 ACA Affordable Care Act

ASHLYNA 2 ACA Affordable Care Act

AUBRA 2 ACA Affordable Care Act

AUBRA EQ 2 ACA Affordable Care Act

AUROVELA 2 ACA Affordable Care Act

AUROVELA 24 FE 2 ACA Affordable Care Act

AUROVELA FE 2 ACA Affordable Care Act

AVIANE 2 ACA Affordable Care Act

AYUNA 2 ACA Affordable Care Act

AZURETTE 2 ACA Affordable Care Act

BALCOLTRA 4 PA

BALZIVA 2 ACA Affordable Care Act

BEKYREE 2 ACA Affordable Care Act

BEYAZ 4 PA

BLISOVI 24 FE 2 ACA Affordable Care Act

BLISOVI FE 2 ACA Affordable Care Act

BRIELLYN 2 ACA Affordable Care Act

CAMILA 2 ACA Affordable Care Act

CAMRESE 2 ACA Affordable Care Act



CAMRESE LO 2 ACA Affordable Care Act

CAZIANT 2 ACA Affordable Care Act

CHARLOTTE 24 FE 4 PA

CHATEAL 2 ACA Affordable Care Act

CHATEAL EQ 2 ACA Affordable Care Act

CRYSELLE 2 ACA Affordable Care Act

CYCLAFEM 2 ACA Affordable Care Act

CYRED 2 ACA Affordable Care Act

CYRED EQ 2 ACA Affordable Care Act

DASETTA 2 ACA Affordable Care Act

DAYSEE 2 ACA Affordable Care Act

DEBLITANE 2 ACA Affordable Care Act

desogestr-eth estrad eth estra 2 ACA Affordable Care Act

desogestrel-ethinyl estradiol 2 ACA Affordable Care Act

DOLISHALE 2 ACA Affordable Care Act

drospirenone-eth estra-levomef 4 PA

drospirenone-ethinyl estradiol 2 ACA Affordable Care Act

ECONTRA ONE-STEP 2 ACA Affordable Care Act

ELINEST 2 ACA Affordable Care Act

ELLA 3 ACA Affordable Care Act

ELURYNG 2 ACA Affordable Care Act

EMOQUETTE 2 ACA Affordable Care Act

ENPRESSE 2 ACA Affordable Care Act

ENSKYCE 2 ACA Affordable Care Act



ERRIN 2 ACA Affordable Care Act

ESTARYLLA 2 ACA Affordable Care Act

ESTROSTEP FE 4 PA

ethynodiol-ethinyl estradiol 2 ACA Affordable Care Act

etonogestrel-ethinyl estradiol 2 ACA Affordable Care Act

FALMINA 2 ACA Affordable Care Act

FAYOSIM 2 ACA Affordable Care Act

FEMYNOR 2 ACA Affordable Care Act

GEMMILY 4 PA

GENERESS FE 4 PA

GIANVI 2 ACA Affordable Care Act

HAILEY 2 ACA Affordable Care Act

HAILEY 24 FE 2 ACA Affordable Care Act

HAILEY FE 2 ACA Affordable Care Act

HEATHER 2 ACA Affordable Care Act

ICLEVIA 2 ACA Affordable Care Act

INCASSIA 2 ACA Affordable Care Act

INTROVALE 2 ACA Affordable Care Act

ISIBLOOM 2 ACA Affordable Care Act

JAIMIESS 2 ACA Affordable Care Act

JASMIEL 2 ACA Affordable Care Act

JENCYCLA 2 ACA Affordable Care Act

JOLESSA 2 ACA Affordable Care Act

JULEBER 2 ACA Affordable Care Act



JUNEL 2 ACA Affordable Care Act

JUNEL FE 2 ACA Affordable Care Act

JUNEL FE 24 2 ACA Affordable Care Act

KAITLIB FE 4 PA

KALLIGA 2 ACA Affordable Care Act

KARIVA 2 ACA Affordable Care Act

KELNOR 1-35 2 ACA Affordable Care Act

KELNOR 1-50 2 ACA Affordable Care Act

KURVELO 2 ACA Affordable Care Act

LARIN 2 ACA Affordable Care Act

LARIN 24 FE 2 ACA Affordable Care Act

LARIN FE 2 ACA Affordable Care Act

LARISSIA 2 ACA Affordable Care Act

LAYOLIS FE 4 PA

LEENA 2 ACA Affordable Care Act

LESSINA 2 ACA Affordable Care Act

LEVONEST 2 ACA Affordable Care Act

levonorg-eth estrad eth estrad 2 ACA Affordable Care Act

levonorgestrel 2 ACA Affordable Care Act

levonorgestrel-eth estradiol 2 ACA Affordable Care Act

LEVORA-28 2 ACA Affordable Care Act

LILLOW 2 ACA Affordable Care Act

LO LOESTRIN FE 4 PA

LO-ZUMANDIMINE 2 ACA Affordable Care Act



LOESTRIN 4 PA

LOESTRIN FE 4 PA

LOJAIMIESS 2 ACA Affordable Care Act

LORYNA 2 ACA Affordable Care Act

LOSEASONIQUE 4 PA

LOW-OGESTREL 2 ACA Affordable Care Act

LUTERA 2 ACA Affordable Care Act

LYLEQ 2 ACA Affordable Care Act

LYZA 2 ACA Affordable Care Act

MARLISSA 2 ACA Affordable Care Act

MELODETTA 24 FE 4 PA

MERZEE 4 PA

MIBELAS 24 FE 4 PA

MICROGESTIN 2 ACA Affordable Care Act

MICROGESTIN 24 FE 2

MICROGESTIN FE 2 ACA Affordable Care Act

MILI 2 ACA Affordable Care Act

MINASTRIN 24 FE 4 PA

MIRCETTE 4 PA

MONO-LINYAH 2 ACA Affordable Care Act

MY WAY 2 ACA Affordable Care Act

NATAZIA 4 PA

NECON 2 ACA Affordable Care Act

NEXTSTELLIS 4 PA



NIKKI 2 ACA Affordable Care Act

NORA-BE 2 ACA Affordable Care Act

norethin-eth estra-ferrous fum 4 PA

norethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)


norethindrone 2 ACA Affordable Care Act

norethindrone-e.estradiol-iron (1-0.02(21)-75 tab, 1.5-0.03mg(21)-75)


norethindrone-e.estradiol-iron (cap, chw) 4 PA

norgestimate-ethinyl estradiol 2 ACA Affordable Care Act

NORLYDA 2 ACA Affordable Care Act

NORTREL 2 ACA Affordable Care Act

NUVARING 4 PA

NYLIA 2 ACA Affordable Care Act

NYMYO 2 ACA Affordable Care Act

OCELLA 2 ACA Affordable Care Act

ORSYTHIA 2 ACA Affordable Care Act

ORTHO MICRONOR 4 PA

ORTHO TRI-CYCLEN 4 PA

ORTHO-NOVUM 4 PA

PHILITH 2 ACA Affordable Care Act

PIMTREA 2 ACA Affordable Care Act

PIRMELLA 2 ACA Affordable Care Act

PLAN B ONE-STEP 4 PA

PORTIA 2 ACA Affordable Care Act



PREVIFEM 2 ACA Affordable Care Act

QUARTETTE 4 PA

RECLIPSEN 2 ACA Affordable Care Act

RIVELSA 2 ACA Affordable Care Act

SAFYRAL 4 PA

SEASONIQUE 4 PA

SETLAKIN 2 ACA Affordable Care Act

SHAROBEL 2 ACA Affordable Care Act

SIMLIYA 2 ACA Affordable Care Act

SIMPESSE 2 ACA Affordable Care Act

SLYND 4 PA

SPRINTEC 2 ACA Affordable Care Act

SRONYX 2 ACA Affordable Care Act

SYEDA 2 ACA Affordable Care Act

TARINA 24 FE 2 ACA Affordable Care Act

TARINA FE 2 ACA Affordable Care Act

TARINA FE 1-20 EQ 2 ACA Affordable Care Act

TAYSOFY 4 PA

TAYTULLA 4 PA

TILIA FE 2 ACA Affordable Care Act

TRI FEMYNOR 2 ACA Affordable Care Act

TRI-ESTARYLLA 2 ACA Affordable Care Act

TRI-LEGEST FE 2 ACA Affordable Care Act

TRI-LINYAH 2 ACA Affordable Care Act



TRI-LO-ESTARYLLA 2 ACA Affordable Care Act

TRI-LO-MARZIA 2 ACA Affordable Care Act

TRI-LO-MILI 2 ACA Affordable Care Act

TRI-LO-SPRINTEC 2 ACA Affordable Care Act

TRI-MILI 2 ACA Affordable Care Act

TRI-NYMYO 2 ACA Affordable Care Act

TRI-PREVIFEM 2 ACA Affordable Care Act

TRI-SPRINTEC 2 ACA Affordable Care Act

TRI-VYLIBRA 2 ACA Affordable Care Act

TRI-VYLIBRA LO 2 ACA Affordable Care Act

TRIVORA-28 2 ACA Affordable Care Act

TULANA 2 ACA Affordable Care Act

TWIRLA 4 PA

TYBLUME 2 ACA Affordable Care Act

TYDEMY 4 PA

VELIVET 2 ACA Affordable Care Act

VESTURA 2 ACA Affordable Care Act

VIENVA 2 ACA Affordable Care Act

VIORELE 2 ACA Affordable Care Act

VOLNEA 2 ACA Affordable Care Act

VYFEMLA 2 ACA Affordable Care Act

VYLIBRA 2 ACA Affordable Care Act

WERA 2 ACA Affordable Care Act

WYMZYA FE 4 PA



XULANE 2 ACA Affordable Care Act

YASMIN 28 4 PA

YAZ 4 PA

ZAFEMY 2 ACA Affordable Care Act

ZARAH 2 ACA Affordable Care Act

ZOVIA 1-35 2 ACA Affordable Care Act

ZOVIA 1-35E 2 ACA Affordable Care Act

ZUMANDIMINE 2 ACA Affordable Care Act

LEPTINS

MYALEPT 5PA

S

PITUITARY

DDAVP (0.01% NASAL SPRAY, 10 MCG/0.1 ML SOLUTION) 4 PA

DDAVP (0.1 MG TABLET, 0.2 MG TABLET) 4 AL1 At least 8 yrs old

desmopressin acetate (0.01% solution, 1.5 mg/ml spray,10 mcg/0.1 ml spr)

2 PA

desmopressin acetate (0.1 mg tb, 0.2 mg tb) 2 AL1 At least 8 yrs old

NOCDURNA 4

NOCTIVA 4

SEROSTIM 5PA

S

STIMATE 4 PA

PROGESTINSAYGESTIN 4

CRINONE 4% GEL 4

medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab)

1



megestrol 625 mg/5 ml susp 4

megestrol acetate (20 mg tablet, 40 mg tablet, acet 40mg/ml susp)

2

norethindrone ac (lupaneta) 2

norethindrone acetate 2

progesterone (100 mg capsule, 200 mg capsule) 2

PROMETRIUM 4

PROVERA 4

HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS

CATAPRES 4

CATAPRES-TTS 1 4

CATAPRES-TTS 2 4

CATAPRES-TTS 3 4

clonidine 2

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1

clonidine hcl er 2QL 4 TABS / 1 DAY

PA

guanfacine hcl 1

KAPVAY 4QL 4 TABS / 1 DAY

PA

methyldopa 2

methyldopa-hydrochlorothiazide 4

NEXICLON XR 4 PA

DIRECT VASODILATORSBIDIL 4

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet)

2

isosorbide dinit-hydralazine 4



minoxidil (2.5 mg tablet, 10 mg tablet) 2

INSULINSINTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

NOVOLIN 70-30 100 UNIT/ML VIAL 4 PA

NOVOLIN 70-30 FLEXPEN 4 PA

NOVOLIN N 100 UNIT/ML FLEXPEN 4 PA

NOVOLIN N 100 UNIT/ML VIAL 4 PA

relion novolin 70-30 flexpen 3

relion novolin 70-30 vial 3

relion novolin n 100 unit/ml 3

relion novolin n u-100 flexpen 3

LONG-ACTING INSULINS

BASAGLAR KWIKPEN U-100 4 PA

insulin glargine 4 PA

insulin glargine solostar 4 PA

insulin glargine-yfgn 4 PA

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 3 PA

LEVEMIR FLEXTOUCH 3 PA

SEMGLEE 4 PA

SEMGLEE (YFGN) 4 PA



SEMGLEE (YFGN) PEN 4 PA

SEMGLEE PEN 4 PA

SOLIQUA 100-33 3

TOUJEO MAX SOLOSTAR 3

TOUJEO SOLOSTAR 3

TRESIBA 4 PA

TRESIBA FLEXTOUCH U-100 4 PA

TRESIBA FLEXTOUCH U-200 4 PA

XULTOPHY 100-3.6 3

RAPID-ACTING INSULINS

ADMELOG 4 PA

ADMELOG SOLOSTAR 4 PA

AFREZZA 4 PA

APIDRA 4 PA

APIDRA SOLOSTAR 4 PA

FIASP 4 PA

FIASP FLEXTOUCH 4 PA

FIASP PENFILL 4 PA

HUMALOG 3

HUMALOG JUNIOR KWIKPEN 3

HUMALOG KWIKPEN U-100 3

HUMALOG KWIKPEN U-200 3

HUMALOG MIX 50-50 3

HUMALOG MIX 50-50 KWIKPEN 3

HUMALOG MIX 75-25 3

HUMALOG MIX 75-25 KWIKPEN 3



insulin aspart 2 PA

insulin aspart flexpen 2 PA

insulin aspart penfill 2 PA

insulin aspart prot mix 70-30 4 PA

insulin lispro 2

insulin lispro junior kwikpen 2

insulin lispro kwikpen u-100 2

insulin lispro protamine mix 2

LYUMJEV 4 PA

LYUMJEV KWIKPEN U-100 4 PA

LYUMJEV KWIKPEN U-200 4 PA

NOVOLOG (100 UNIT/ML VIAL, RELION 100 UNIT/ML VL) 4 PA

novolog flexpen (100 unit/ml, relion u-100) 4 PA

NOVOLOG MIX 70-30 (RELION VIAL, VIAL) 4 PA

NOVOLOG MIX 70-30 FLEXPEN (FLEXPEN, RELION FLXPN) 4 PA

NOVOLOG PENFILL 4 PA

SHORT-ACTING INSULINSHUMULIN R 3

HUMULIN R U-500 3

HUMULIN R U-500 KWIKPEN 3

NOVOLIN R 100 UNIT/ML FLEXPEN 4 PA

NOVOLIN R 100 UNIT/ML VIAL 4 PA

relion novolin r 100 unit/ml 3

relion novolin r u-100 flexpen 3



ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS

AURYXIA 4

calcium acetate (667 mg capsule, 667 mg gelcap) 2

calcium acetate 667 mg tablet 4

FOSRENOL 4

lanthanum carbonate 2 PA

PHOSLYRA 3

RENAGEL 4

RENVELA 4

sevelamer carbonate 2

sevelamer hcl 4

VELPHORO 4

POTASSIUM-REMOVING AGENTSLOKELMA 3

sodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)

2

VELTASSA 4

KALLIKREIN-KININ SYSTEM INHIBITORSBRADYKININ RECEPTOR ANTAGONISTS

FIRAZYR 5

QL 9 ML / 1 FILL

PA

S

icatibant 5

QL 9 ML / 1 FILL

PA

S

SAJAZIR 5

QL 9 ML / 1 FILL

PA

S



COMPLEMENT INHIBITORS

BERINERT 5PA

S

CINRYZE 5PA

S

HAEGARDA 5PA

S

RUCONEST 5PA

S

KALLIKREIN INHIBITORS

KALBITOR 5PA

S

ORLADEYO 5

QL 1 CAP / 1 DAY

PA

S

TAKHZYRO 5

QL 4 ML / 28 DAYS

PA

S

LOCAL ANESTHETICS (PARENTERAL)

ACCUCAINE 4 PA

MARVONA SUIK 4 PA

MACROLIDE ANTIBIOTICSERYTHROMYCIN ANTIBIOTICS

E.E.S. 200 4

E.E.S. 400 4

ERY-TAB 4

ERYPED 200 4

ERYPED 400 4

ERYTHROCIN STEARATE 4


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSerythromycin (250 mg tablet, dr 250 mg cap, dr 333 mgtablet)

4

erythromycin 500 mg tablet 2 PA

erythromycin ethylsuccinate (200 mg/5 ml susp, es 400mg tab)

4

OTHER MACROLIDE ANTIBIOTICSazithromycin (100 mg/5 ml susp, 200 mg/5 ml susp) 2

azithromycin (250 mg tablet, 500 mg tablet, 600 mgtablet)

1

clarithromycin (125 mg/5 ml sus, 250 mg/5 ml sus) 2 AL1 Up to 12 yrs old

clarithromycin (250 mg tablet, 500 mg tablet) 2

clarithromycin er 4

DIFICID (40 MG/ML SUSPENSION, 200 MG TABLET) 3 PA

ZITHROMAX (250 MG TABLET, 250 MG Z-PAK TABLET) 4 PA

MISC. BETA-LACTAM ANTIBIOTICSMONOBACTAM ANTIBIOTICS

CAYSTON 5PA

S

MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORS

AVODART 4 PA

dutasteride 2

dutasteride-tamsulosin 2 PA

finasteride 5 mg tablet 1

JALYN 4

PROSCAR 4

ALCOHOL DETERRENTSANTABUSE 4

disulfiram 2



ANTIDOTESleucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab)

2

VISTOGARD 5PA

S

ANTIGOUT AGENTSallopurinol 1

colchicine 2

COLCRYS 4

febuxostat 2 ST

GLOPERBA 4 PA

MITIGARE 4 PA

ULORIC 4 PA

ANTISENSE OLIGONUCLEOTIDES

TEGSEDI 5PA

S

BONE RESORPTION INHIBITORS

ACTONEL 4 PA

alendronate sod 70 mg/75 ml 2 PA

alendronate sodium (5 mg tablet, 10 mg tab, 35 mg tab,70 mg tab)

1

ATELVIA 4

BINOSTO 4 PA

BONIVA 4

FOSAMAX PLUS D 4

ibandronate sodium 150 mg tab 2

risedronate sodium 2

risedronate sodium dr 4



CARBONIC ANHYDRASE INHIBITORS (MISC.)

KEVEYIS 5PA

S

CARIOSTATIC AGENTSCLINPRO 5000 4

denta 5000 plus 1

dentagel 1

fluoride 1AL1 Up to 5 yrs old


fluoridex 4

FLUORIDEX SENSITIVITY RELIEF 4

fluoritab (0.5 mg tablet chew, 1 mg tablet chew) 3AL1 Up to 5 yrs old


GEL-KAM 4 PA

ludent fluoride 3AL1 Up to 5 yrs old


PERIOMED 4

PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS,DENTAL RINSE)

4

PREVIDENT 5000 DRY MOUTH 4

PREVIDENT 5000 ENAMEL PROTECT 4

PREVIDENT 5000 PLUS 4

PREVIDENT 5000 SENSITIVE 4

sf 1

sf 5000 plus 1

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))

1AL1 Up to 5 yrs old


sodium fluoride 5000 dry mouth 4

sodium fluoride 5000 ppm paste 4



sodium fluoride enamel protect 4

sodium fluoride sensitive 4

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 5


PA

S

ACTEMRA ACTPEN 5PA

S

ARAVA 4

AZULFIDINE 4

CIBINQO 5

QL 1 TAB / DAY

PA

S

CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 5

QL 1 KIT = 2 SYRINGES /28 DAYS

PA

S

COSENTYX (2 SYRINGES) 5PA

S

COSENTYX PEN 5PA

S

COSENTYX PEN (2 PENS) 5PA

S

COSENTYX SYRINGE 5PA

S

ENBREL (25 MG/0.5 ML SYRINGE, 25 MG/0.5 ML VIAL) 5

QL 4 ML (8 DOSES) / 28DAYS

PA

S

ENBREL 25 MG KIT 5

QL 8 VIALS (8 ML) / 28DAYS

PA

S



ENBREL 50 MG/ML SYRINGE 5


PA

S

ENBREL MINI 5


PA

S

ENBREL SURECLICK 5


PA

S

HUMIRA 5


PA

S

HUMIRA PEN 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN CROHN'S-UC-HS 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN PSOR-UVEITS-ADOL HS 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) 5


PA

S

HUMIRA(CF) PEDI CROHN 80MG/0.8 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 40 MG/0.4 ML 5

QL 2 PENS / 28 DAYS

PA

S



HUMIRA(CF) PEN 80 MG/0.8 ML 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN CROHN'S-UC-HS 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PEDIATRIC UC 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PSOR-UV-ADOL HS 5

QL 2 PENS / 28 DAYS

PA

S

KEVZARA (150 MG/1.14 ML PEN INJ, 200 MG/1.14 MLPEN INJ)

5

QL 2 PENS / 28 DAYS

PA

S

KEVZARA (150 MG/1.14 ML SYRINGE, 200 MG/1.14 MLSYRINGE)

5


PA

S

KINERET 5


PA

S

leflunomide 2

OLUMIANT (1 MG TABLET, 2 MG TABLET) 5

QL 1 TAB / 1 DAY

PA

S

OLUMIANT 4 MG TABLET 5

QL 1 TAB / DAY

PA

S

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE)

5


PA

S



ORENCIA CLICKJECT 5

QL 4 ML / 28 DAYS

PA

S

OTEZLA 28 DAY STARTER PACK 5


PA

S

OTEZLA 30 MG TABLET 5

QL 2 TABS / 1 DAY

PA

S

OTEZLA STARTER PACK 5

QL 2 PACKS / 28 DAYS

PA

S

RINVOQ 5

QL 1 TAB / 1 DAY

PA

S

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR)

5

QL 1 SYRINGE / 28 DAYS

PA

S

SIMPONI 100 MG/ML SYRINGE 5

QL 1 ML / 28 DAYS

PA

S

sulfasalazine 2

sulfasalazine dr 2

XELJANZ (5 MG TABLET, 10 MG TABLET) 5

QL 2 TABS / 1 DAY

PA

S

XELJANZ 1 MG/ML SOLUTION 5

QL 10 ML / 1 DAY

PA

S

XELJANZ XR 5

QL 1 TAB / 1 DAY

PA

S



IMMUNOMODULATORY AGENTS

ACTIMMUNE 5PA

S

AUBAGIO 5QL 1 TAB / 1 DAY

S

AVONEX 30 MCG/0.5 ML SYRINGE 5QL 4 SYRINGES / 28

DAYSS

AVONEX PEN 5QL 1 KIT / 28 DAYS

S

AVONEX PREFILLED SYR 30 MCG KT 5QL 1 KIT / 28 DAYS

S

BAFIERTAM 5

QL 4 CAPS / 1 DAY

PA

S

BETASERON 0.3 MG KIT 5QL 15 ML / 28 DAYS

S

BETASERON 0.3 MG VIAL 5QL 15 ML / 30 DAYS

S

COPAXONE 20 MG/ML SYRINGE 5

QL 30 ML / 30 DAYS

PA

S

COPAXONE 40 MG/ML SYRINGE 5

QL 12 ML / 28 DAYS

PA

S

dimethyl fumarate 5QL 2 CAPS / 1 DAY

S

ENSPRYNG 5PA

S



EXTAVIA 0.3 MG KIT 5

QL 15 ML / 28 DAYS

PA

S

EXTAVIA 0.3 MG VIAL 5

QL 15 ML / 30 DAYS

PA

S

GILENYA 5QL 1 CAP / 1 DAY

S

glatiramer 20 mg/ml syringe 5QL 30 ML / 30 DAYS

S

glatiramer 40 mg/ml syringe 5QL 12 ML / 28 DAYS

S

GLATOPA 20 MG/ML SYRINGE 5QL 30 ML / 30 DAYS

S

GLATOPA 40 MG/ML SYRINGE 5QL 12 ML / 28 DAYS

S

KESIMPTA PEN 5QL 1 PEN / 28 DAYS

S

MAYZENT (1 MG TABLET, 2 MG TABLET) 5QL 1 TAB / 1 DAY

S

MAYZENT 0.25 MG TABLET 5QL 4 TABS / 1 DAY

S

MAYZENT 0.25MG START-1MG MAINT 5QL 7 TABS / 4 DAYS

S

MAYZENT 0.25MG START-2MG MAINT 5QL 12 TABS / 4 DAYS

S

PLEGRIDY 5QL 1 ML / 28 DAYS

S

PLEGRIDY PEN 5QL 1 ML / 28 DAYS

S



PONVORY 14-DAY STARTER PACK 5


PA

S

PONVORY 20 MG TABLET 5

QL 1 TAB / 1 DAY

PA

S

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE)

5

QL 6 ML / 28 DAYS

PA

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 5

QL 6 ML / 28 DAYS

PA

S

REBIF REBIDOSE TITRATION PACK 5

QL 4.2 ML / 28 DAYS

PA

S

REBIF TITRATION PACK 5

QL 4.2 ML / 28 DAYS

PA

S

REDITREX 3 PA

TECFIDERA 5

QL 2 CAPS / 1 DAY

PA

S

THALOMID 3S

ONC Oncology

VUMERITY 5QL 4 CAPS / 1 DAY

S

ZEPOSIA 0.23-0.46 MG START PCK 5

QL 7 CAPS / 180 DAYS

PA

S



ZEPOSIA 0.23-0.46-0.92 MG KIT 5


PA

S

ZEPOSIA 0.92 MG CAPSULE 5

QL 1 CAP / DAY

PA

S

IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL 4 PA

AZASAN 4

azathioprine (75 mg tablet, 100 mg tablet) 4

azathioprine 50 mg tablet 2

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/MLSYRINGE)

5PA

S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500MG TABLET)

4 PA

cyclosporine (25 mg capsule, 100 mg capsule) 2

cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 2

ENVARSUS XR 4 PA

everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet,1 mg tablet)

2 PA

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)

2

LUPKYNIS 5

QL 6 CAPS / 1 DAY

PA

S

MAVENCLAD 5PA

S

mycophenolate mofetil (200 mg/ml susp, 250 mg capsule,500 mg tablet)

2

mycophenolic acid 2



MYFORTIC 4 PA

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATINCAPSULE, 100 MG/ML SOLUTION)

4

PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULEPACKET)

4 PA

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MGCAPSULE)

4

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/MLORAL SOLN, 2 MG TABLET)

4

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLN)

4

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet)

2

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 2

ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MGTABLET)

4

ZORTRESS 1 MG TABLET 3 PA

KALLIKREIN-KININ SYSTEM INHIBITORS

TAVNEOS 5PA

S

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

AMPYRA 5

QL 2 TABS / 1 DAY

PA

S

ARCALYST 5PA

S

betaine anhydrous 4

CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 4

CARNITOR SF 4

CERDELGA 5PA

S

CYSTADANE 4



CYSTAGON 3

dalfampridine er 5

QL 2 TABS / 1 DAY

PA

S

DEMSER 4 PA

EVRYSDI 5PA

S

FIRDAPSE 5

QL 8 TABS / 30 DAYS

PA

S

GALAFOLD 5


PA

S

ILARIS 5

QL 2 ML / 28 DAYS

PA

S

ISTURISA 5PA

S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500MG POWDER PACKET)

5PA

S

levocarnitine 1 g/10 ml soln 2

levocarnitine sf 2

metyrosine 4 PA

miglustat 5PA

S

nitisinone 5PA

S

NITYR 5PA

S



ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE)

5PA

S

POTABA 4 PA

PROCYSBI 5PA

S

RECORLEV 5PA

S

RETAINE OM3 4 PA

RETAINE VISION 4 PA

REZUROCK 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

RUZURGI 5

QL 10 TABS / 1 DAY

PA

S

sapropterin dihydrochloride 5PA

S

THIOLA 5PA

S

THIOLA EC 5PA

S

tiopronin 5PA

S

TYBOST 3

VIJOICE 5PA

S

VOXZOGO 5PA

S



VYNDAMAX 5PA

S

VYNDAQEL 5PA

S

wrestone 4 PA

XURIDEN 5PA

S

ZAVESCA 5PA

S

ZOKINVY 5PA

S

PROTECTIVE AGENTSELMIRON 3

MESNEX 400 MG TABLET 4

NONHORMONAL CONTRACEPTIVES

gynol ii 4 PA

PHEXXI 4 PA

TODAY CONTRACEPTIVE SPONGE 3 ACA Affordable Care Act

vcf 1 ACA Affordable Care Act

NONSTEROIDAL ANTI-INFLAMMATORY AGENTSCYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX 4 PA

celecoxib 2

ELYXYB 4QL 4.8 ML / 1 DAY

PA

NUDROXIPAK 4 PA



OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSANAPROX DS 4

ARTHROTEC 50 4

ARTHROTEC 75 4

CAMBIA 4 PA

DAYPRO 4

diclo gel 4 PA

DICLO GEL-XRYLIX SHEET 4 PA

diclofenac 4 PA

diclofenac epolamine 4 PA

diclofenac pot 50 mg tablet 2

diclofenac potassium (pot 25 mg tablet, potassium 25 mgcap)

4 PA

diclofenac sodium (1.5% topical soln, 2% solution pump) 4 PA

diclofenac sodium (sod dr 25 mg tab, sod dr 50 mg tab,sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sodec 75 mg tab, sodium 1% gel)

2

diclofenac sodium er 2

diclofenac sodium-misoprostol 2 PA

DICLOFONO 4

DICLOPR 4 PA

DICLOZOR 4 PA

diflunisal 2 PA

DITHOL 4 PA

DUEXIS 4 PA

EC-NAPROSYN 4

ec-naproxen 4



etodolac (200 mg capsule, 300 mg capsule) 1

etodolac (400 mg tablet, 500 mg tablet) 2

etodolac er 2

FELDENE 4

fenoprofen calcium 2 PA

FLECTOR 4 PA

flurbiprofen 2

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1

ibuprofen-famotidine 2 PA

INDOCIN 25 MG/5 ML SUSPENSION 4PA

AQ1 Up to 64 yrs old; 150/ 1 FILL

INDOCIN 50 MG SUPPOSITORY 4 PA

indomethacin (25 mg capsule, 50 mg capsule) 1

indomethacin 20 mg capsule 4PA

AQ1 Up to 64 yrs old; 20 /fill(s)

indomethacin er 4 AQ1 Up to 64 yrs old; 20 /1 FILL

INFLAMMA-K 4 PA

ketoprofen (25 mg capsule, 50 mg capsule, 75 mgcapsule)

2 PA

ketoprofen er 200 mg capsule 4

ketorolac 10 mg tablet 2 QL 20 TABS / RX

ketorolac 15.75 mg nasal spray 4 PA

ketorolac tromethamine (15 mg/ml carpuject, 15 mg/mlisecure syr, 15 mg/ml vial, 30 mg/ml carpuject, 30 mg/mlvial, 60 mg/2 ml vial)

4 QL 20 ML / 30 DAYS

LICART 4 PA

meclofenamate sodium 2 PA



mefenamic acid 2 PA

meloxicam (5 mg capsule, 10 mg capsule) 4 PA

meloxicam (7.5 mg tablet, 7.5 mg/5 ml susp, 15 mgtablet)

1

MOBIC 4

nabumetone 2

NALFON 400 MG CAPSULE 4

NAPRELAN 4 PA

NAPROSYN 500 MG TABLET 4

naproxen (250 mg tablet, 375 mg tablet, 500 mg kit, 500mg tablet)

1

naproxen (dr 375 mg tablet, dr 500 mg tablet) 2

naproxen sodium (275 mg tab, 550 mg tab) 4

naproxen sodium cr 4 PA

naproxen sodium er 4 PA

naproxen-esomeprazole mag 2 PA

NUDROXIPAK DSDR-50 4 PA

NUDROXIPAK DSDR-75 4 PA

NUDROXIPAK E-400 4 PA

NUDROXIPAK I-800 4 PA

NUDROXIPAK N-500 4 PA

oxaprozin 2 PA

PENNSAID 2% PUMP 4 PA

piroxicam 1

RELAFEN DS 4 PA

SPRIX 4 PA



sulindac 2

TIVORBEX 4PA

AQ1 Up to 64 yrs old; 20 /fill(s)

tolmetin sodium 2 PA

TORONOVA II SUIK 4 PA

TORONOVA SUIK 4 PA

TRIXYLITRAL 4 PA

VENNGEL ONE 4 PA

VIMOVO 4 PA

VIVLODEX (5 MG CAPSULE, 10 MG CAPSULE) 4 PA

VOLTAREN 4

VOLTAREN-XR 4

ZIPSOR 4 PA

ZORVOLEX (18 MG CAPSULE, 35 MG CAPSULE) 4 PA



SALICYLATESaspirin (81 mg chewable tablet, 325 mg tablet, bayer 325mg tablet, cvs 81 mg chewable tab, cvs 325 mg caplet, cvs325 mg tablet, eq 81 mg chewable tab, eq 325 mg tablet,eql 81 mg chewable tab, eql 325 mg tablet, gnp 81 mgchewable tab, gnp 325 mg tablet, gs 81 mg chewable tab,gs 325 mg tablet, hm 81 mg chewable tab, hm 325 mgtablet, kro 81 mg chewable tab, kro 325 mg tablet, pub 81mg chewable tab, pub 325 mg tablet, qc 81 mg chewabletab, qc 325 mg tablet, ra 81 mg chewable tab, ra 325 mgtablet, sm 81 mg chewable tab, sm 325 mg tablet)


aspirin ec (bayer ec 325 mg tablet, cvs ec 81 mg tablet,cvs ec 325 mg tablet, ec 81 mg tablet, ec 325 mg caplet,ec 325 mg tablet, eq ec 81 mg tablet, eq ec 325 mg tablet,eql ec 81 mg tablet, eql ec 325 mg tablet, gnp ec 81 mgtablet, gnp ec 325 mg tablet, gs ec 81 mg tablet, gs ec 325mg tablet, hm ec 81 mg tablet, hm ec 325 mg tablet, kroec 81 mg tablet, qc ec 81 mg tablet, qc ec 325 mg tablet,ra ec 81 mg tablet, ra ec 325 mg tablet, sm ec 81 mgtablet, sm ec 325 mg tablet)


aspirin-omeprazole 2 PA

BAYER CHEWABLE ASPIRIN 3 ACA Affordable Care Act

butalbital-aspirin-caffeine cp 1 QL 6 CAPS / 1 DAY

choline mag trisalicylate 4

DURLAZA 4 PA

FIORINAL 4 QL 6 CAPS / 1 DAY

salsalate 2

st. joseph aspirin 1 ACA Affordable Care Act

st. joseph aspirin ec 1 ACA Affordable Care Act

tru-micin 4

YOSPRALA 4 PA

OXYTOCICSMETHERGINE 4



methylergonovine 0.2 mg tablet 2

MIFEPREX 4

PARATHYROID AND ANTIPARATHYROID AGENTSANTIPARATHYROID AGENTS

calcitonin-salmon 200 units sp 2

cinacalcet hcl 2

SENSIPAR 3

PARATHYROID AGENTS

FORTEO 5PA

S

NATPARA 5PA

S

teriparatide 5PA

S

TYMLOS 5PA

S

PENICILLIN ANTIBIOTICSAMINOPENICILLIN ANTIBIOTICS

amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250mg/5 ml susp, 400 mg/5 ml susp, 500 mg capsule, 500 mgtablet, 875 mg tablet)

1

amoxicillin-clavulanate pot er 4

amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

2

ampicillin trihydrate 1

AUGMENTIN 125-31.25 MG/5 ML 4

AUGMENTIN XR 4

MOXATAG 4



NATURAL PENICILLIN ANTIBIOTICSpenicillin v potassium (125 mg/5 ml soln, 250 mg/5 mlsoln)

2

penicillin v potassium (250 mg tablet, 500 mg tablet) 1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 2

PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT 3 QL 1 KIT / RX

VAXCHORA BUFFER COMPONENT 3

RADIOACTIVE AGENTS

HICON 4 PA

sodium iodide i-123 4PA

S

sodium iodide i-131 4PA

S

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 4

ATACAND HCT 4

AVALIDE 4

AVAPRO 4

BENICAR 4 PA

BENICAR HCT 4 PA

candesartan cilexetil 2

candesartan-hydrochlorothiazid 4

COZAAR 4

DIOVAN 4

DIOVAN HCT 4

EDARBI 4 PA



EDARBYCLOR 4 PA

ENTRESTO 3

eprosartan mesylate 4

HYZAAR 4

irbesartan 1

irbesartan-hydrochlorothiazide 2

losartan potassium 1

losartan-hydrochlorothiazide 1

MICARDIS 4

MICARDIS HCT 4

olmesartan medoxomil 2

olmesartan-amlodipine-hctz 4

olmesartan-hydrochlorothiazide 2

telmisartan 2

telmisartan-amlodipine 4

telmisartan-hydrochlorothiazid 2

TRIBENZOR 4 PA

TWYNSTA 4

valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet, 320mg tablet)

2

valsartan 4 mg/ml solution 4 PA

valsartan-hydrochlorothiazide 2

ANGIOTENSIN-CONVERTING ENZYME INHIBITORSACCUPRIL 4

ACCURETIC 4

ALTACE 4

benazepril hcl 1

benazepril-hydrochlorothiazide 2



captopril 2

captopril-hydrochlorothiazide 2

enalapril 1 mg/ml oral soln 4

enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20mg tab)

2

enalapril-hydrochlorothiazide 1

EPANED 4

fosinopril sodium 1

fosinopril-hydrochlorothiazide 2

lisinopril 1

lisinopril-hydrochlorothiazide 1

LOTENSIN 10 MG TABLET 4

moexipril hcl 2

perindopril erbumine 2

PRESTALIA 4

PRINIVIL 4

QBRELIS 4

quinapril hcl 1

quinapril-hydrochlorothiazide 2

ramipril 1

TARKA 4

trandolapril 2

trandolapril-verapamil er 4

VASERETIC 4

VASOTEC 4 PA

ZESTORETIC 4

ZESTRIL 4



MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSALDACTAZIDE 4

ALDACTONE 4

CAROSPIR 4 PA

eplerenone 2

INSPRA 4 PA

KERENDIA 4QL 1 TAB / 1 DAY

PA

spironolactone 2

spironolactone-hctz 2

RENIN INHIBITORSaliskiren 150 mg tablet 4

TEKTURNA 4

TEKTURNA HCT 4

RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MGTABLET)

5PA

S

OFEV 5PA

S

pirfenidone 5PA

S

ANTITUSSIVESbenzonatate (100 mg capsule, perle 100 mg cap, 200 mgcapsule)

2

benzonatate 150 mg capsule 4

CAPCOF 4 AQ1 At least 6 yrs old; 60/ 1 DAY

codeine-guaifenesin 2 AQ1 At least 18 yrs old;60 / 1 day(s)



guaifenesin dac 4 AQ1 At least 6 yrs old; 40/ 1 DAY

guaifenesin-codeine 2 AQ1 At least 18 yrs old;60 / 1 day(s)

HISTEX-AC 4 AQ1 At least 6 yrs old; 20/ 1 DAY

hydrocodone-chlorpheniramne er 2PA

AQ1 At least 18 yrs old;10 / 1 DAY

hydrocodone-homatropine mbr 4 AQ1 At least 18 yrs old;30 / 1 DAY

ninjacof-xg 4 AQ1 At least 6 yrs old; 60/ 1 DAY

OBREDON 4 QL 60 ML / 1 DAY

promethazine vc-codeine 4 AQ1 At least 6 yrs old; 30/ 1 DAY

promethazine-codeine 4PA

AQ1 At least 18 yrs old;30 / 1 DAY

promethazine-dm 1

promethazine-phenyleph-codeine 4 AQ1 At least 6 yrs old; 30/ 1 DAY(s)

rydex 4 AQ1 At least 6 yrs old; 60/ 1 DAY

TUSNEL PEDIATRIC LIQUID 4

TUSSICAPS 4 QL 2 CAPS / 1 DAY

TUZISTRA XR 4 AQ1 At least 18 yrs old;20 / 1 DAY

MUCOLYTIC AGENTSacetylcysteine (10% vial, 20% vial) 2

PULMOZYME 5

QL 150 ML / 30 DAYS

PA

S



PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP 3 PA

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

BRONCHITOL 5


PA

S

XOLAIR (75 MG/0.5 ML SYRINGE, 150 MG/ML SYRINGE) 5PA

S

VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS 5PA

S

ambrisentan 5PA

S

bosentan 5PA

S

epoprostenol sodium 5PA

S

FLOLAN 1.5 MG VIAL 5PA

S

LETAIRIS 5PA

S

OPSUMIT 5PA

S

ORENITRAM ER 5PA

S

REMODULIN 5PA

S

TRACLEER 5PA

S



treprostinil 5PA

S

TYVASO 5PA

S

TYVASO DPI 5PA

S

TYVASO REFILL KIT 5PA

S

TYVASO STARTER KIT 5PA

S

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK,400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)

5PA

S

VELETRI 5PA

S

VENTAVIS 5PA

S

SKELETAL MUSCLE RELAXANTSCENTRALLY ACTING SKELETAL MUSCLE RELAXNT

AMRIX 4 PA

carisoprodol 250 mg tablet 2QL 4 TABS / 1 DAY

PA

carisoprodol 350 mg tablet 2 QL 4 TABS / 1 DAY

carisoprodol-aspirin 4 QL 8 TABS / 1 DAY

carisoprodol-aspirin-codeine 2QL 8 TABS / 1 DAY

PA

chlorzoxazone (375 mg tablet, 750 mg tablet) 4

chlorzoxazone 250 mg tablet 4 PA



chlorzoxazone 500 mg tablet 2

cyclobenzaprine 7.5 mg tablet 4 PA

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2

cyclobenzaprine hcl er (er 15 mg cap, er 30 mg cap) 4 PA

CYCLOTENS (REFILL, STARTER) 4 PA

FEXMID 4 PA

LORZONE 4 PA

METAXALL 4

metaxalone 400 mg tablet 4

metaxalone 800 mg tablet 2 PA

methocarbamol (500 mg tablet, 750 mg tablet) 2

ROBAXIN-750 4

SKELAXIN 4

SOMA 4 QL 4 TABS / 1 DAY

tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg capsule) 4

tizanidine hcl (2 mg tablet, 4 mg tablet) 2

ZANAFLEX 4

DIRECT-ACTING SKELETAL MUSCLE RELAXANTSDANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 4

dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 2

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTbaclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

baclofen 5 mg/5 ml solution 4 PA

FLEQSUVY 4 PA

LYVISPAH 4 PA

OZOBAX 4 PA



SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

NORGESIC FORTE 4 PA

orphenadrine citrate er 4

orphenadrine-aspirin-caffeine 4 PA

ORPHENGESIC FORTE 4 PA

SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

ADAZIN 4

ANACAINE 4

ANASTIA 4

CETACAINE 4

DOLOTRANZ 4 PA

doxepin 5% cream 2QL 45 GM / 1 FILL

PA

lido-k 4 PA

lidocaine 3% cream 4

lidocaine 5% ointment 4

lidocaine 5% patch 2QL 1 PATCH / 1 DAY

PA

lidocaine hcl 3% lotion 4 PA

lidocaine-hydrocortisone (2.8-0.55% gel, 3-0.5% cream kit,3-1% cream kit, 3-2.5% gel kit)

4

lidocaine-prilocaine 2 QL 60 GM / 1 FILL

lidocaine-tetracaine 2 PA

LIDODERM 4QL 1 PATCH / 1 DAY

PA

lidopin (3% cream, 3.25% cream) 4

LIDOTRAL 4 PA



LIDOTRANS 5 PAK 4 PA

LIDOVEX 4 PA

MENTHO-CAINE 4 PA

NUMBONEX 4

PAINGO KFT 4 PA

phenazopyridine hcl 1

PLIAGLIS 4 PA

PONTOCAINE 4

PRUDOXIN 4 QL 45 GM / 1 FILL

SOLUPAK 4 PA

SYNERA 4

SYNVEXIA TC 4 PA

TRANZAREL 4 PA

WPR PLUS 4 PA

XRYLIDERM 4 PA

ZONALON 4 QL 45 GM / 1 FILL

ASTRINGENTSDRYSOL 3

CELL STIMULANTS AND PROLIFERANTSATRALIN 4

AVITA 2

REGRANEX 4

RETIN-A 4

RETIN-A MICRO 4 PA

RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.06%GEL, PUMP 0.08% GEL, PUMP 0.1% GEL)

4 PA

TRETIN-X 0.075% CREAM 4


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONStretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream)

2

tretinoin 0.05% gel 4

tretinoin microsphere 4 PA

TWYNEO 4 PA

EMOLLIENTS, DEMULCENTS, AND PROTECTANTSLEVICYN ANTIPRURITIC SG 4

KERATOLYTIC AGENTS

AVAR 9.5-5% CLEANSING PADS 4 PA

avar cleanser 4QL 12 ML / 1 DAY

PA

AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS,CLEANSER)

4 PA

avar-e 4 PA

avar-e green 4 PA

AVAR-E LS 4 PA

bensal hp 4

benzepro (5.3% emollient foam, 6% foaming cloths, 9.8%foam)

4 PA

bp 10-1 4 PA

bpo (6% foaming cloths, 8% gel) 4 PA

HYDRO 35 4

HYDRO 40 4

KERAFOAM 30% FOAM 4

KERALAC 4

PACNEX 4 PA

RIAX (5.5% FOAM, 9.5% FOAM) 4

ROSULA 10%-4.5% WASH 4



SALEX 4

salicylic acid (3% ointment, 6% cream, 6% lotion, 6%shampoo)

4

sod sulfacet-sulfur 10-5% clsr 2 QL 12 ML / 1 DAY

sodium sulfacetamide-sulfur (crm, lot) 2

sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8%crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sulfacetamide-sulfur 9-4% clsr,sulfacetamide-sulfur 10-5% sus)

4

sss 10-5 cream 2

sulfacetamide-sulfur 8-4% susp 4 PA

sulfacleanse 8-4 4 PA

SUMADAN 9%-4.5% WASH 4 PA

SUMAXIN 9%-4% WASH 4

SUMAXIN CLEANSING PADS 4 PA

SUMAXIN TS 4 PA

ULTRASAL-ER 4

URAMAXIN 45% UREA CREAM 4

urea (41% cream, 45% cream, 45% nail gel, 47% cream,50% nail stick)

4

urea (cream, lotion) 2

UREVAZ 4

XALIX 4

KERATOPLASTIC AGENTSDRITHOCREME HP 4

ZITHRANOL 4

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.ABSORICA (10 MG CAPSULE, 20 MG CAPSULE, 25 MGCAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MGCAPSULE)

4 PA



ABSORICA LD 4 PA

acitretin 2

ACZONE 4 PA

adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 2 PA

adapalene (solution, swab) 4 PA

adapalene 0.1% gel 2

adapalene 0.1% gel (rx only) 4 PA

adapalene 0.1% lotion 4

adapalene-bnzyl perox 0.1-2.5% 4

adapalene-bnzyl perox 0.3-2.5% 4 PA

ADBRY 5PA

S

AKLIEF 4 PA

ALDARA 4 PA

AMELUZ 4

AMNESTEEM 2

azelaic acid 2

AZELEX 4 PA

calcipotriene (cream, ointment, solution) 2 QL 120 GM / 30 DAYS

calcipotriene 0.005% foam 4 PA

calcipotriene-betamethasone 4 PA

calcipotriene-betamethasone dp 4

calcitriol 3 mcg/g ointment 2 PA

CLARAVIS 2

CONDYLOX 4 PA

dapsone 5% gel 2



dapsone 7.5% gel pump 4 PA

DIFFERIN (0.1% CREAM, 0.1% LOTION, 0.3% GEL PUMP) 4 PA

DIFFERIN 0.1% GEL 3

DOVONEX 4 QL 120 GM / 30 DAYS

DUPIXENT PEN 5PA

S

DUPIXENT SYRINGE (200 MG/1.14 ML SYRING, 300 MG/2ML SYRINGE)

5PA

S

ELIDEL 4 QL 100 GM / 30 DAYS

ENSTILAR 4 PA

EPIDUO 4

EPIDUO FORTE 4 PA

EPSOLAY 4 PA

FABIOR 4QL 50 GM / 30 DAYS

PA

FINACEA 15% FOAM 4 PA

FINACEA 15% GEL 4

HYFTOR 5PA

S

imiquimod (cream, cream pump) 4 PA

imiquimod 5% cream packet 2

isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

2

isotretinoin (25 mg capsule, 35 mg capsule) 4 PA

ivermectin 1% cream 4 PA

KLISYRI 4 PA



MYORISAN 2

NEURAPTINE 10% CREAM PACKET 4

OPZELURA 4QL 60 GM / 30 DAYS

PA

pimecrolimus 2 QL 100 GM / 30 DAYS

podofilox 2

PROTOPIC 4QL 100 GM / 30 DAYS

PA

RECTIV 4

SANTYL 4

SILIQ 5


PA

S

SKYRIZI (2 SYRINGES) KIT 5PA

S

SKYRIZI (75 MG/0.83 ML SYRINGE, 150 MG/ML SYRINGE) 5PA

S

SKYRIZI PEN 5PA

S

SOOLANTRA 4 PA

SORIATANE 4

SORILUX 4 PA

STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90MG/ML SYRINGE)

5PA

S

TACLONEX 4 PA

tacrolimus (0.03% ointment, 0.1% ointment) 2 QL 100 GM / 30 DAYS

TALTZ AUTOINJECTOR 5

QL 1 PACKAGE / 28DAYS

PA

S



TALTZ AUTOINJECTOR (2 PACK) 5


PA

S

TALTZ AUTOINJECTOR (3 PACK) 5


PA

S

TALTZ SYRINGE 5


PA

S

tazarotene 0.1% cream 2 QL 30 GM / 30 DAYS

tazarotene 0.1% foam 4QL 50 GM / 30 DAYS

PA

TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL) 3QL 30 GM / 30 DAYS

PA

TAZORAC 0.1% CREAM 4 QL 30 GM / 30 DAYS

TREMFYA 100 MG/ML INJECTOR 5

QL 1 ML / 28 DAYS

PA

S

TREMFYA 100 MG/ML SYRINGE 5


PA

S

VECTICAL 4 PA

VTAMA 4 PA

WHYTEDERM SURGIPAK 4 PA

WINLEVI 4 PA

WYNZORA 4 PA

ZENATANE 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75%CREAM PUMP)

4 PA

SMOOTH MUSCLE RELAXANTSRESPIRATORY SMOOTH MUSCLE RELAXANTS

ELIXOPHYLLIN 4

THEO-24 4

theophylline (er 400 mg tablet, er 600 mg tablet) 2

theophylline 80 mg/15 ml soln 4

theophylline anhydrous 2

theophylline er 2

SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS

BYNFEZIA 5PA

S

lanreotide acetate 5PA

S

MYCAPSSA 5PA

S

octreotide acetate 5 S

SANDOSTATIN 5PA

S

SANDOSTATIN LAR DEPOT 5 S

SIGNIFOR 5PA

S

SIGNIFOR LAR 5PA

S

SOMATULINE DEPOT 5PA

S



SOMATOTROPIN AGONISTS AND ANTAGONISTSSOMATOTROPIN AGONISTS

EGRIFTA 5PA

S

EGRIFTA SV 5PA

S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 5PA

S

SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS

AUVI-Q (0.1 MG, 0.15 MG, 0.3 MG) 4 PA

droxidopa 5PA

S

epinephrine 0.15 mg auto-injct (teva) 2

epinephrine 0.15 mg auto-inject (generic for adrenaclick) 4 PA

epinephrine 0.15 mg auto-inject (generic for epi-pen jr /mylan)

2

epinephrine 0.3 mg auto-inject (generic for adrenaclick) 2

epinephrine 0.3 mg auto-inject (generic for epi-pen /mylan)

2

epinephrine 0.3 mg auto-inject (teva) 2

EPIPEN 4

EPIPEN 2-PAK 4

EPIPEN JR 4

EPIPEN JR 2-PAK 4

NORTHERA 5PA

S

SYMJEPI 3



ALPHA-ADRENERGIC AGONISTSmidodrine hcl 2

TETRACYCLINE ANTIBIOTICSAMINOMETHYLCYCLINES

NUZYRA 150 MG TABLET 3 PA

SEYSARA 4 PA

THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS

methimazole 1

propylthiouracil 2

SSKI 4

TAPAZOLE 4

THYROID AGENTSARMOUR THYROID 4

CYTOMEL 4

euthyrox 2

LEVO-T 4

levothyroxine 4

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)

2

LEVOXYL 4

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 2

NATURE-THROID 4

np thyroid 4

SYNTHROID 3

THYQUIDITY 4 PA

TIROSINT 4

TIROSINT-SOL 4



UNITHROID 4

WESTHROID 4

WP THYROID 4

UncategorizedUnclassified

amcinonide 0.1% ointment 2 PA

meperidine 100 mg tablet 4 QL 8 TABS / 1 DAY

ondansetron hcl 24 mg tablet 2

VASODILATING AGENTSNITRATES AND NITRITES

DILATRATE-SR 4

GONITRO 4

ISORDIL 4

ISORDIL TITRADOSE 4

isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30mg tab)

2

isosorbide dinitrate 40 mg tab 4

isosorbide mononitrate 2

isosorbide mononitrate er 2

MINITRAN 4

NITRO-BID 3

NITRO-DUR 4

NITRO-TIME ER 9 MG CAPSULE 4

nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 2

nitroglycerin 400 mcg spray 4

nitroglycerin patch 2

NITROLINGUAL 4

NITROMIST 4

NITROSTAT 4



PHOSPHODIESTERASE TYPE 5 INHIBITORS

ADCIRCA 5

QL 2 TABS / 1 DAY

PA

S

ALYQ 5

QL 2 TABS / 1 DAY

PA

S

CIALIS (2.5 MG TABLET, 5 MG TABLET) 4QL 1 TAB / 1 DAY

PA

REVATIO 10 MG/ML ORAL SUSP 5PA

S

REVATIO 20 MG TABLET 5

QL 1 TAB / 1 DAY

PA

S

sildenafil 10 mg/ml oral susp 5PA

S

sildenafil 20 mg tablet (generic for revatio) 2 QL 1 TAB / 1 DAY

tadalafil (2.5 mg tablet, 5 mg tablet) 2 QL 1 TAB / 1 DAY

tadalafil 20 mg tablet (generic for adcirca) 2QL 2 TABS / 1 DAY

PA

VASODILATING AGENTS, MISCELLANEOUSAGGRENOX 4

aspirin-dipyridamole er 2

dipyridamole 2

isoxsuprine hcl 4

VERQUVO 3 PA



VITAMINSMULTIVITAMIN PREPARATIONS

AZESCO 4 PA

bal-care dha 4 PA

BAL-CARE DHA ESSENTIAL 4 PA

c-nate dha 4 PA

CADEAU DHA 4 PA

CITRANATAL HARMONY 4 PA

complete natal dha 4 PA

completenate 2

CONCEPT DHA 4 PA

CONCEPT OB 4 PA

DUET DHA 400 4 PA

DUET DHA BALANCED 4 PA

ENBRACE HR 4 PA

folivane-ob 4 PA

KOSHER PRENATAL PLUS IRON 4 PA

m-natal plus 1

M.V.I. ADULT 4 PA

M.V.I.-12 4 PA

MARNATAL-F 4 PA

multi-vitamin daily 4 PA

MVW COMPLETE FORMLTN PEDIATRIC 4 PA

MVW COMPLETE FORMULATION D3000 4 PA

MYNATAL 4 PA



mynatal plus 1

mynatal-z 1

NATACHEW 4 PA

NEEVODHA 4 PA

NESTABS 4 PA

NESTABS ABC 4 PA

NESTABS DHA 4 PA

NESTABS ONE 4 PA

newgen 4 PA

O-CAL PRENATAL 1

OB COMPLETE 4 PA

OB COMPLETE ONE 4 PA

OB COMPLETE PETITE 4 PA

OB COMPLETE PREMIER 4 PA

OB COMPLETE WITH DHA 4 PA

OCUVEL 4 PA

pnv 29-1 2

pnv-dha 4 PA

pnv-omega 4 PA

pnv-select 4 PA

pr natal 400 4 PA

pr natal 400 ec 4 PA

pr natal 430 4 PA

pr natal 430 ec 4 PA

PRENA1 CHEW 4 PA



prena1 pearl 4 PA

prena1 true 4

PRENATA 3

PRENATABS FA 1

PRENATABS RX 2

prenatal 19 4 PA

prenatal plus (iron tablet, pnv multivit tab) 1

prenatal plus-dha 4 PA

prenatal vitamin plus low iron 1

prenatal-u 2 PA

PRENATE AM 4 PA

PRENATE CHEWABLE 4 PA

PRENATE DHA 4 PA

PRENATE ELITE 3

PRENATE ENHANCE 4 PA

PRENATE ESSENTIAL 4 PA

PRENATE MINI 4 PA

PRENATE PIXIE 4 PA

PRENATE RESTORE 4 PA

PRENATE STAR 4 PA

preplus 1

pretab 1

PRIMACARE 4 PA

PROVIDA OB 4 PA

PUREFE OB PLUS 1



r-natal ob 4 PA

se-natal 19 1

SELECT-OB 4 PA

SELECT-OB + DHA 4 PA

taron-c dha 4 PA

thrivite rx 3

TRICARE 4 PA

trinatal rx 1 3

TRINATE 2

triveen-duo dha 4 PA

VINATE CARE 1

vinate one 1

vinate-m 1

virt-c dha 4 PA

virt-nate dha 4 PA

virt-pn dha 4 PA

virt-pn plus 4 PA

VITAFOL GUMMIES 4 PA

VITAFOL NANO 4 PA

VITAFOL ULTRA 4 PA

VITAFOL-OB 4 PA

VITAFOL-OB+DHA 4 PA

VITAFOL-ONE 4 PA

VITAMEDMD ONE RX 4 PA

VITAMEDMD REDICHEW RX 4 PA



VITAPEARL 4 PA

VITATRUE 4

VP-PNV-DHA 4 PA

westab plus 1

zalvit 4 PA

zatean-pn dha 4 PA

zatean-pn plus 4 PA

zingiber 4 PA

VITAMIN A

AQUASOL A 4 PA

VITAMIN B COMPLEXcyanocobalamin injection 1

dodex (1,000 mcg/ml vial, 10,000 mcg/10 ml vial, 30,000mcg/30 ml vial)

1

ELIGEN B12 4 PA

folic acid (0.4 mg tablet, 0.8 mg tablet, 400 mcg tablet,800 mcg tablet, cvs 800 mcg tablet, gnp 400 mcg tablet,ra 0.4 mg tablet, ra 800 mcg tablet, sm 400 mcg tablet, sv800 mcg tablet)


folic acid (1 mg tablet, 1,000 mcg tablet) 1

hydroxocobalamin 4 PA

NEPHRONEX-SL 4 PA

SUPPORT-500 4 PA

vitamin b-12 5,000 mcg tab sl 4 PA

VITAMIN C

ascorbic acid 4 PA

VITAMIN Dcalcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution)

2



doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 4

DRISDOL 4 PA

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 4

RAYALDEE 4 PA

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1MCG/ML ORAL SOLN)

4 PA

vitamin d2 1.25mg(50,000 unit) 1

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4

VITAMIN K ACTIVITY

MEPHYTON 4QL 3 TABS / 1 FILL

PA

phytonadione 5 mg tablet 2 QL 3 TABS / 1 FILL


Index of Covered Drugs

Aabacavir 93abacavir-lamivudine 93abacavir-lamivudine-zidovudine 93ABATRON 32ABILIFY 88ABILIFY MAINTENA 88ABILIFY MYCITE 88abiraterone acetate 71ABSORICA 194ABSORICA LD 195acamprosate calcium 119ACANYA 21acarbose 51ACCOLATE 27ACCRUFER 32ACCUCAINE 161ACCUPRIL 184ACCURETIC 184acebutolol hcl 117acetamin-caff-dihydrocodeine 3acetaminophen-codeine 3acetazolamide 60acetazolamide er 60acetic acid 20acetylcysteine 187ACIPHEX 101ACIPHEX SPRINKLE 101acitretin 195ACTEMRA 165ACTEMRA ACTPEN 165ACTHAR 126ACTHIB 96ACTICLATE 34ACTIGALL 138ACTIMMUNE 169ACTIQ 3ACTIVE-PAC 40ACTIVELLA 132ACTONEL 163

ACTOPLUS MET 55ACTOPLUS MET XR 55ACTOS 55ACULAR 26ACULAR LS 26ACUVAIL 26acyclovir 23,103ACZONE 195ADACEL TDAP 96adapalene 195adapalene 0.1% gel (rx only) 195adapalene-benzoyl peroxide 195ADASUVE 88ADAZIN 191ADBRY 195ADCIRCA 203ADDERALL 12ADDERALL XR 12adefovir dipivoxil 103ADEMPAS 188adenovirus type 4 96adenovirus type 4 and type 7 96adenovirus type 7 96ADHANSIA XR 14ADLARITY 110ADLYXIN 52ADMELOG 158ADMELOG SOLOSTAR 158ADRENALIN CHLORIDE 135ADV ALLERGY COLLECTION KIT 28ADVAIR DISKUS 122ADVAIR HFA 122ADVANCED DNA MEDICATED COLLECT 134ADVATE 61ADYNOVATE 61ADZENYS ER 12ADZENYS XR-ODT 13AEMCOLO 37AFINITOR 72AFINITOR DISPERZ 72AFIRMELLE 146

AFLURIA QUAD 2020-2021 96AFLURIA QUAD 2020-21 (3YR UP) 96AFLURIA QUAD 2020-21 (6-35MO) 96AFLURIA QUAD 2021-2022 96AFLURIA QUAD 2021-22 (3YR UP) 96AFLURIA QUAD 2021-22 (6-35MO) 97AFLURIA QUAD 2022-2023 97AFLURIA QUAD 2022-23 (3YR UP) 97AFREZZA 158AFSTYLA 61AFTER PILL 146AGGRENOX 203AIMOVIG AUTOINJECTOR 68AIRDUO DIGIHALER 122AIRDUO RESPICLICK 122AJOVY AUTOINJECTOR 68AJOVY SYRINGE 68AKLIEF 195AKYNZEO 56ALA-CORT 28albendazole 17ALBENZA 17albuterol sulfate 111albuterol sulfate 90 mcg hfa aer ad (genericproair) 111albuterol sulfate 90 mcg hfa aer ad (genericproventil) 111albuterol sulfate 90 mcg hfa aer ad (genericventolin) 112albuterol sulfate hfa 112alclometasone dipropionate 28ALCORTIN A 23ALDACTAZIDE 186ALDACTONE 186ALDARA 195ALECENSA 72alendronate sodium 163ALFERON N 103alfuzosin hcl er 1ALINIA 87aliskiren 186

ALKERAN 72ALKINDI SPRINKLE 143allopurinol 163ALLZITAL 2almotriptan malate 69ALOCRIL 27alogliptin 52alogliptin-metformin 52alogliptin-pioglitazone 52ALOMIDE 133ALORA 132alosetron hcl 136ALPHAGAN P 59ALPHANATE 61ALPHANINE SD 62alprazolam 105alprazolam er 105,106ALPRAZOLAM INTENSOL 106alprazolam odt 106alprazolam xr 106ALPROLIX 62ALREX 25ALTABAX 21ALTACE 184ALTAVERA 146ALUNBRIG 72ALVESCO 123alvimopan 138ALYACEN 146ALYQ 203AMABELZ 132amantadine 85AMARYL 54AMBIEN 104AMBIEN CR 104ambrisentan 188amcinonide 28,202AMELUZ 195AMERGE 69AMETHIA 146AMETHIA LO 147

AMETHYST 147AMICAR 62amiloride hcl 127amiloride-hydrochlorothiazide 127aminocaproic acid 62amiodarone hcl 33AMITIZA 137amitriptyline hcl 50amlodipine besylate 115amlodipine besylate-benazepril 115amlodipine-atorvastatin 67amlodipine-olmesartan 115amlodipine-valsartan 115amlodipine-valsartan-hctz 115ammonium lactate 131AMNESTEEM 195amoxapine 50amoxicillin 182amoxicillin-clavulanate pot er 182amoxicillin-clavulanate potass 182amphetamine 13amphetamine sulfate 13ampicillin trihydrate 182AMPYRA 173AMRIX 189AMZEEQ 21ANACAINE 191ANADROL-50 145ANAFRANIL 50anagrelide hcl 95ANALPRAM HC 28ANAPROX DS 177ANASPAZ 37ANASTIA 191anastrozole 72ANCOBON 57ANDRODERM 145ANDROGEL 145ANDROID 145ANGELIQ 132ANNOVERA 147

ANORO ELLIPTA 37ANTABUSE 162ANTARA 67ANTIVERT 56anucort-hc 28ANUSOL-HC 28ANZEMET 55APADAZ 3APEXICON E 28APIDRA 158APIDRA SOLOSTAR 158APLENZIN 47apo-varenicline 0.5 mg tablet (apotex) 109apo-varenicline 1 mg tablet (apotex) 109APOKYN 128apomorphine hcl 128apraclonidine hcl 134aprepitant 56APRI 147APRISO 136APTENSIO XR 14APTIOM 40APTIVUS 94AQUASOL A 208ARAKODA 87ARANELLE 147ARANESP 113ARAVA 165ARCALYST 173arformoterol tartrate 112ARICEPT 110ARIKAYCE 33ARIMIDEX 72aripiprazole 88aripiprazole odt 88ARIXTRA 39armodafinil 16,17ARMONAIR DIGIHALER 123ARMOUR THYROID 201ARNUITY ELLIPTA 123AROMASIN 72

ARTHROTEC 50 177ARTHROTEC 75 177asa-butalb-caffeine-codeine 3ASACOL HD 136ASCOMP WITH CODEINE 3ascorbic acid 208asenapine maleate 88ASHLYNA 147ASMANEX 123ASMANEX HFA 123aspirin 181aspirin ec 181aspirin-dipyridamole er 203aspirin-omeprazole 181ASPRUZYO SPRINKLE 116ASTAGRAF XL 172astero 124ASTRAZENECA COVID19 VAC(UNAPP) 97ATACAND 183ATACAND HCT 183atazanavir sulfate 94ATELVIA 163atenolol 117atenolol-chlorthalidone 117ATIVAN 106atomoxetine hcl 119ATOPICLAIR 124atorvastatin calcium 67atovaquone 87atovaquone-proguanil hcl 87ATRALIN 192ATRIPLA 93atropine sulfate 135ATROVENT HFA 37AUBAGIO 169AUBRA 147AUBRA EQ 147AUGMENTIN 182AUGMENTIN XR 182AUROVELA 147AUROVELA 24 FE 147

AUROVELA FE 147AURYXIA 160AUSTEDO 121AUSTEDO 12MG START TITR(WK1-4) 121AUSTEDO TD TITRATN PK (WK 1-2) 121AUVI-Q 200AVALIDE 183AVANDIA 55AVAPRO 183AVAR 193avar 193AVAR LS 193avar-e 193avar-e green 193AVAR-E LS 193AVIANE 147AVIDOXY 34AVITA 192AVODART 162AVONEX 169AVONEX PEN 169AYGESTIN 155AYUNA 147AYVAKIT 72AZASAN 172AZASITE 18azathioprine 172azelaic acid 195azelastine hcl 133azelastine-fluticasone 133AZELEX 195AZESCO 204AZILECT 86azithromycin 162AZOPT 60AZOR 115AZSTARYS 14AZULFIDINE 165AZURETTE 147

Bbacitracin 18bacitracin-polymyxin 18baclofen 190BACTRIM 34BACTRIM DS 34BAFIERTAM 169bal-care dha 204BAL-CARE DHA ESSENTIAL 204BALCOLTRA 147balsalazide disodium 136BALVERSA 72BALZIVA 147BANZEL 40BAQSIMI 65BARACLUDE 103BASAGLAR KWIKPEN U-100 157BAXDELA 34BAYER CHEWABLE ASPIRIN 181bd veritor at-home covid19 tst 124BECONASE AQ 25BEKYREE 147BELBUCA 11belladonna-opium 3belladonna-phenobarbital 37BELSOMRA 108benazepril hcl 184benazepril-hydrochlorothiazide 184BENEFIX 62BENICAR 183BENICAR HCT 183BENLYSTA 172bensal hp 193BENZACLIN 21BENZAMYCIN 21benzepro 193benzhydrocodone-acetaminophen 3benznidazole 87benzonatate 186benztropine mesylate 85

bepotastine besilate 133BEPREVE 133BERINERT 161BESIVANCE 18BESREMI 72betaine anhydrous 173BETALOAN SUIK 143betamethasone diprop augmented 28betamethasone dipropionate 28betamethasone valerate 28BETAPACE 117BETAPACE AF 117BETASERON 169betaxolol hcl 60,117bethanechol chloride 110BETHKIS 33BETIMOL 60BETOPTIC S 60BEVESPI AEROSPHERE 37bexarotene 72BEXSERO 97BEYAZ 147bicalutamide 73BIDIL 156BIKTARVY 93BILTRICIDE 17bimatoprost 61binaxnow covd ag card home tst 124binaxnow covid-19 ag self test 124BINOSTO 163bisoprolol fumarate 117bisoprolol-hydrochlorothiazide 117BLEPHAMIDE 18BLEPHAMIDE S.O.P. 18BLISOVI 24 FE 147BLISOVI FE 147BONIVA 163BONJESTA 56BOOSTRIX TDAP 96bosentan 188BOSULIF 73

bp 10-1 193bpo 193BRAFTOVI 73BREO ELLIPTA 123BREXAFEMME 56BREZTRI AEROSPHERE 123BRIELLYN 147BRILINTA 95brimonidine tartrate 59brimonidine tartrate-timolol 59brinzolamide 60BRISDELLE 48BRIVIACT 40bromfenac sodium 26bromocriptine mesylate 128BROMSITE 26BRONCHITOL 188BROVANA 112BRUKINSA 73BRYHALI 28budesonide 123budesonide dr 143budesonide ec 143budesonide er 143budesonide-formoterol fumarate 123bumetanide 127BUNAVAIL 11BUPAP 2BUPHENYL 129buprenorphine 11buprenorphine hcl 11buprenorphine-naloxone 12bupropion hcl 47bupropion hcl sr 47bupropion xl 47buspirone hcl 104butalb-acetaminoph-caff-codein 3butalbital compound-codeine 4butalbital-acetaminophen 2butalbital-acetaminophen-caffe 2butalbital-aspirin-caffeine 181

butorphanol tartrate 12BUTRANS 12BYDUREON BCISE 53BYDUREON PEN 53BYETTA 53BYLVAY 138BYNFEZIA 199BYSTOLIC 118

Cc-nate dha 204cabergoline 128CABLIVI 95CABOMETYX 73CADEAU DHA 204CADUET 67CAFERGOT 1CALAN SR 114calcipotriene 195calcipotriene-betamethasone 195calcipotriene-betamethasone dp 195calcitonin-salmon 182calcitriol 195,208calcium acetate 160CALQUENCE 73CALTRATE 600-D3 PLUS MINERALS 130CAMBIA 177CAMILA 147CAMRESE 147CAMRESE LO 148CAMZYOS 116CANASA 136candesartan cilexetil 183candesartan-hydrochlorothiazid 183CAPCOF 186capecitabine 73CAPEX SHAMPOO 28CAPHOSOL 124CAPLYTA 89CAPRELSA 73captopril 185

captopril-hydrochlorothiazide 185CARAC 73CARAFATE 101CARBAGLU 129carbamazepine 40carbamazepine er 40CARBATROL 41carbidopa 119carbidopa-levodopa 86carbidopa-levodopa er 86carbidopa-levodopa-entacapone 86carbinoxamine maleate 135CARDIZEM 114CARDIZEM CD 114CARDIZEM LA 114CARDURA 117CARDURA XL 117carestart covid-19 ag home tst 124carglumic acid 129carisoprodol 189carisoprodol-aspirin 189carisoprodol-aspirin-codeine 189CARNITOR 173CARNITOR SF 173CAROSPIR 186carteolol hcl 60CARTIA XT 114carvedilol 118carvedilol er 118CASODEX 73CATAPRES 156CATAPRES-TTS 1 156CATAPRES-TTS 2 156CATAPRES-TTS 3 156CAYSTON 162CAZIANT 148cefaclor 122cefaclor er 122cefadroxil 121cefdinir 122cefixime 122

cefpodoxime proxetil 122cefprozil 122cefuroxime 122CELEBREX 176celecoxib 176CELEXA 48CELLCEPT 172celltrion diatrust cov-19 home 125CELONTIN 47CENTANY 21CENTANY AT 21cephalexin 121,122CEQUA 26CERACADE 131CERDELGA 173CETACAINE 191cetirizine hcl 64CETRAXAL 18cevimeline hcl 110CHANTIX 109CHARLOTTE 24 FE 148CHATEAL 148CHATEAL EQ 148CHEMET 142CHENODAL 138chlordiazepoxide hcl 106chlordiazepoxide-amitriptyline 50chlordiazepoxide-clidinium 37chlorhexidine gluconate 20chloroquine phosphate 87chlorpromazine hcl 91chlorthalidone 128chlorzoxazone 189,190CHOLBAM 138cholestyramine 66cholestyramine light 66choline mag trisalicylate 181CIALIS 203CIBINQO 165CICLODAN 59ciclopirox 59

cilostazol 95CILOXAN 18CIMDUO 93cimetidine 100cimetidine 200 mg tablet (prescription only) 100CIMZIA 165cinacalcet hcl 182CINRYZE 161CIPRO 34CIPRO HC 18CIPRODEX 19ciprofloxacin 34ciprofloxacin hcl 19,34ciprofloxacin hcl-fluocinolone 19ciprofloxacin-dexamethasone 19citalopram hbr 48,49CITRANATAL HARMONY 204CLARAVIS 195CLARINEX 64CLARINEX-D 12 HOUR 64clarithromycin 162clarithromycin er 162cleansing wash 23clemastine fumarate 135CLENPIQ 137CLEOCIN 21CLEOCIN HCL 36CLEOCIN PEDIATRIC 36CLEOCIN T 21CLIMARA 132CLIMARA PRO 132CLINDACIN ETZ 21CLINDACIN P 21CLINDACIN PAC 21CLINDAGEL 21clindamycin (pediatric) 36clindamycin hcl 36clindamycin ph 1% gel (generic for cleocin t) 21clindamycin phos-benzoyl perox 21clindamycin phos-tretinoin 21clindamycin phosphate 21

clindamycin phosphate 1% gel (generic forclindagel) 21clindamycin-benzoyl peroxide 21CLINDESSE 22clinitest covid-19 home test 125CLINPRO 5000 164clobazam 46clobetasol emollient 28clobetasol emulsion 28clobetasol propionate 28,29CLOBEX 29clocortolone pivalate 29CLODAN 29CLODERM 29clomipramine hcl 50clonazepam 46clonidine 156clonidine hcl 156clonidine hcl er 156clopidogrel 95clorazepate dipotassium 106clotrimazole 58clotrimazole-1% solution 58clotrimazole-betamethasone 58clozapine 89clozapine odt 89CLOZARIL 89COAGADEX 62COARTEM 87codeine sulfate 4codeine-guaifenesin 186COLAZAL 136colchicine 163COLCRYS 163colesevelam hcl 66COLESTID 66colestipol hcl 66COLOCORT 29COMBIGAN 60COMBIPATCH 132COMBIVENT RESPIMAT 37

COMBIVIR 93COMETRIQ 73COMIRNATY 97COMPLERA 93complete natal dha 204completenate 204COMTAN 86CONCEPT DHA 204CONCEPT OB 204CONCERTA 14CONDYLOX 195CONJUPRI 115CONZIP 4COPAXONE 169COPIKTRA 73CORDRAN 29COREG CR 118COREMINO 34CORGARD 118CORIFACT 62CORLANOR 116CORTEF 143CORTENEMA 29CORTIFOAM 29CORTISPORIN 22CORTISPORIN-TC 19CORTROPHIN 126COSENTYX (2 SYRINGES) 165COSENTYX PEN 165COSENTYX PEN (2 PENS) 165COSENTYX SYRINGE 165COSOPT 60COSOPT PF 60COTELLIC 74COTEMPLA XR-ODT 14covaryx 145covaryx h.s. 145covid-19 at-home test 125COZAAR 183CREON 138CRESEMBA 56

CRESTOR 67CRINONE 155CRIXIVAN 94cromolyn sodium 27CROTAN 24CRYSELLE 148cue covid-19 home test 125CUPRIMINE 142CUTIVATE 29CUVPOSA 37cyanocobalamin injection 208CYCLAFEM 148cyclobenzaprine hcl 190cyclobenzaprine hcl er 190CYCLOGYL 135CYCLOMYDRIL 135cyclopentolate hcl 135cyclophosphamide 74cycloserine 71CYCLOSET 128cyclosporine 26,172cyclosporine modified 172CYCLOTENS 190CYMBALTA 48cyproheptadine hcl 135CYRED 148CYRED EQ 148CYSTADANE 173CYSTADROPS 134CYSTAGON 174CYSTARAN 134CYTOMEL 201CYTOTEC 101

DD-PENAMINE 142D.H.E.45 1dabigatran etexilate 39dalfampridine er 174DALIRESP 188danazol 145

DANTRIUM 190dantrolene sodium 190dapsone 71,195,196DAPTACEL DTAP 96DARAPRIM 87darifenacin er 140DARTISLA 37DASETTA 148DAURISMO 74DAYPRO 177DAYSEE 148DAYTRANA 14DAYVIGO 108DDAVP 155DEBLITANE 148deferasirox 142deferiprone 142deferiprone (3 times a day) 142DELSTRIGO 92DELZICOL 136demeclocycline hcl 34DEMSER 174DENAVIR 23DENGVAXIA 97denta 5000 plus 164dentagel 164DEPAKOTE 41DEPAKOTE ER 41DEPAKOTE SPRINKLE 41DEPEN 142DEPO-TESTOSTERONE 145DERMA-SMOOTHE-FS 29DERMOTIC 25DESCOVY 93desipramine hcl 50desloratadine 64desmopressin acetate 155desogestr-eth estrad eth estra 148desogestrel-ethinyl estradiol 148DESONATE 29desonide 29

desoximetasone 29DESOXYN 13desvenlafaxine er 48desvenlafaxine suc er 100 mg tablet (generic forpristiq) 48desvenlafaxine suc er 25 mg tablet (generic forpristiq) 48desvenlafaxine suc er 50 mg tablet (generic forpristiq) 48DETROL 140DETROL LA 140dexamethasone 143DEXAMETHASONE INTENSOL 143dexamethasone sodium phosphate 25,143,144dexchlorpheniramine maleate 136DEXEDRINE 13DEXERYL 131DEXILANT 101dexlansoprazole dr 101dexmethylphenidate hcl 14dexmethylphenidate hcl er 14dextroamp-amphetamin 15 mg tab (genericadderall) 13dextroamp-amphetamin 20 mg tab (genericadderall) 13dextroamphetamine sulfate 13dextroamphetamine sulfate er 13dextroamphetamine-amphet er 13dextroamphetamine-amphetamine 13DHIVY 86DIACOMIT 41DIASTAT 106DIASTAT ACUDIAL 106diazepam 106,107diazoxide 64DIBENZYLINE 1DICLEGIS 56diclo gel 177DICLO GEL-XRYLIX SHEET 177diclofenac 177diclofenac epolamine 177

diclofenac potassium 177diclofenac sodium 26,74,177diclofenac sodium er 177diclofenac sodium-misoprostol 177DICLOFONO 177DICLOPR 177dicloxacillin sodium 183DICLOZOR 177dicyclomine hcl 37didanosine 93DIFFERIN 196DIFICID 162diflorasone diacetate 29DIFLUCAN 56diflunisal 177difluprednate 25DIGITEK 117DIGOX 117digoxin 117dihydroergotamine mesylate 1DILANTIN 47DILANTIN-125 47DILATRATE-SR 202DILAUDID 4DILT-XR 114diltiazem 12hr er 114diltiazem 24h er(la) 360 mg tb (generic forcardizem la) 114diltiazem 24hr er 114diltiazem 24hr er (cd) 114diltiazem 24hr er (la) 114diltiazem 24hr er (xr) 114diltiazem 24hr er 360 mg cap (generic forcardizem cd) 114diltiazem hcl 115dimethyl fumarate 169DIOVAN 183DIOVAN HCT 183DIPENTUM 136diphenhydramine hcl 135diphenoxylate-atropine 137

diphtheria-tetanus toxoids-ped 96DIPROLENE 29dipyridamole 203DISKETS 4disopyramide phosphate 32disulfiram 162DITHOL 177DITROPAN XL 140DIURIL 128divalproex sodium 41divalproex sodium er 41DIVIGEL 132DMT SUIK 144dodex 208dofetilide 33DOJOLVI 130DOLISHALE 148DOLOTRANZ 191donepezil hcl 110donepezil hcl odt 110DOPTELET 113DORAL 107DORYX 34DORYX MPC 35dorzolamide hcl 60dorzolamide-timolol 60DOTTI 132DOVATO 92DOVONEX 196doxazosin mesylate 117doxepin hcl 50,191doxercalciferol 209doxycycline hyclate 19,35doxycycline ir-dr 35doxycycline monohydrate 35doxylamine succ-pyridoxine hcl 56DRISDOL 209DRITHOCREME HP 194DRIZALMA SPRINKLE 48dronabinol 55drospirenone-eth estra-levomef 148

drospirenone-ethinyl estradiol 148DROXIA 74droxidopa 200DRYSOL 192DUAKLIR PRESSAIR 37DUAVEE 132DUET DHA 400 204DUET DHA BALANCED 204DUETACT 55DUEXIS 177DULERA 123duloxetine hcl 48DUPIXENT PEN 196DUPIXENT SYRINGE 27,196DURAGESIC 4DUREZOL 25DURLAZA 181dutasteride 162dutasteride-tamsulosin 162DUTOPROL 118DUZALLO 130DVORAH 4DYANAVEL XR 13DYAZIDE 127DYMISTA 133DYRENIUM 127

EE.E.S. 200 161E.E.S. 400 161EC-NAPROSYN 177ec-naproxen 177econazole nitrate 58ECONTRA ONE-STEP 148ECOZA 58ed-spaz 37EDARBI 183EDARBYCLOR 184EDECRIN 127EDLUAR 104EDURANT 92

eemt 145eemt h.s. 145efavirenz 92efavirenz-emtric-tenofov disop 93efavirenz-lamivu-tenofov disop 92EFFER-K 130EFFEXOR XR 48EFFIENT 95EFUDEX 74EGRIFTA 200EGRIFTA SV 200ELEPSIA XR 41ELESTRIN 132ELETONE 125eletriptan hbr 69ELIDEL 196ELIGEN B12 208ELIMITE 24ELINEST 148ELIQUIS 39ELIXOPHYLLIN 199ELLA 148ellume covid-19 home test 125ELMIRON 176ELOCTATE 62ELURYNG 148ELYXYB 176EMCYT 74EMEND 56EMFLAZA 144EMGALITY PEN 69EMGALITY SYRINGE 68,69EMOQUETTE 148EMSAM 86emtricitabine 93emtricitabine-tenofovir disop 93EMTRIVA 93emulsion sb 125EMVERM 17enalapril maleate 185enalapril-hydrochlorothiazide 185

ENBRACE HR 204ENBREL 165,166ENBREL MINI 166ENBREL SURECLICK 166ENDARI 139ENDOCET 4ENGERIX-B ADULT 97ENGERIX-B PEDIATRIC-ADOLESCENT 97enoxaparin sodium 39,40ENPRESSE 148ENSKYCE 148ENSPRYNG 169ENSTILAR 196entacapone 86entecavir 103ENTEREG 139ENTOCORT EC 144ENTRESTO 184ENTTY 125ENULOSE 129ENVARSUS XR 172EPANED 185EPCLUSA 141EPICYN 125EPIDIOLEX 41EPIDUO 196EPIDUO FORTE 196EPIFOAM 29epinastine hcl 133epinephrine 0.15 mg auto-injct (teva) 200epinephrine 0.15 mg auto-inject (generic foradrenaclick) 200epinephrine 0.15 mg auto-inject (generic for epi-pen jr / mylan) 200epinephrine 0.3 mg auto-inject (generic foradrenaclick) 200epinephrine 0.3 mg auto-inject (generic for epi-pen / mylan) 200epinephrine 0.3 mg auto-inject (teva) 200EPIPEN 200EPIPEN 2-PAK 200

EPIPEN JR 200EPIPEN JR 2-PAK 200EPISIL 125EPITOL 41EPIVIR 93EPIVIR HBV 93eplerenone 186EPOGEN 113epoprostenol sodium 188EPRONTIA 41eprosartan mesylate 184EPSOLAY 196EPZICOM 93EQUETRO 41ergoloid mesylates 1ERGOMAR 1ergotamine-caffeine 1ERIVEDGE 74ERLEADA 74erlotinib hcl 74ERRIN 149ERTACZO 58ERY 22ERY-TAB 161ERYGEL 22ERYPED 200 161ERYPED 400 161ERYTHROCIN STEARATE 161erythromycin 19,22,162erythromycin ethylsuccinate 162erythromycin-benzoyl peroxide 22ESBRIET 186escitalopram oxalate 49ESGIC 2esomeprazole magnesium 101esomeprazole strontium 101ESPEROCT 62ESTARYLLA 149estazolam 107ESTRACE 132estradiol 132

estradiol (once weekly) 132estradiol (twice weekly) 132estradiol-norethindrone acetat 132ESTRING 132ESTROGEL 132estrogen-methyltestosterone 145ESTROSTEP FE 149eszopiclone 104ethacrynic acid 127ethambutol hcl 71ethosuximide 47ethynodiol-ethinyl estradiol 149etodolac 178etodolac er 178etonogestrel-ethinyl estradiol 149etoposide 74etravirine 92EUCRISA 28EURAX 24euthyrox 201EVAMIST 132EVEKEO 13EVEKEO ODT 13everolimus 74,172EVISTA 131EVOCLIN 22EVOTAZ 94EVOXAC 110EVRYSDI 174EVZIO 120EXELDERM 58EXELON 110exemestane 74EXFORGE 115EXFORGE HCT 116EXJADE 142EXKIVITY 74EXTAVIA 170EXTINA 58EYSUVIS 25EZALLOR SPRINKLE 67

ezetimibe 66ezetimibe-simvastatin 66

FFABIOR 196FACTIVE 34FALMINA 149famciclovir 104famotidine 100FANAPT 89FARESTON 131FARXIGA 53FARYDAK 75FASENRA PEN 27FAYOSIM 149febuxostat 163FEIBA NF 62felbamate 41FELBATOL 42FELDENE 178felodipine er 116FEM PH 23FEMARA 75FEMHRT 132FEMRING 132FEMYNOR 149fenofibrate 67fenofibric acid 67FENOGLIDE 67fenoprofen calcium 178fentanyl 4fentanyl citrate 5FENTORA 5FERRIPROX 142FERRIPROX (2 TIMES A DAY) 142FERRIPROX (3 TIMES A DAY) 143fesoterodine fumarate er 140FETZIMA 48FEXMID 190FIASP 158FIASP FLEXTOUCH 158

FIASP PENFILL 158FIBRICOR 67FINACEA 196finasteride 162FINTEPLA 42FIORICET 2FIORICET WITH CODEINE 5FIORINAL 181FIORINAL WITH CODEINE #3 5FIRAZYR 160FIRDAPSE 174FIRVANQ 36FLAC OTIC OIL 25FLAGYL 87FLAREX 25flavoxate hcl 140flecainide acetate 33FLECTOR 178FLEQSUVY 190FLOLAN 188FLOLIPID 67FLOMAX 1FLOVENT DISKUS 123FLOVENT HFA 123flowflex covid-19 ag home test 125FLUAD 2020-2021 97FLUAD QUAD 2020-2021 97FLUAD QUAD 2021-2022 97FLUAD QUAD 2022-2023 97FLUARIX QUAD 2020-2021 97FLUARIX QUAD 2021-2022 97FLUARIX QUAD 2022-2023 97FLUBLOK QUAD 2020-2021 97FLUBLOK QUAD 2021-2022 97FLUBLOK QUAD 2022-2023 97FLUCELVAX QUAD 2020-2021 97FLUCELVAX QUAD 2021-2022 97FLUCELVAX QUAD 2022-2023 97fluconazole 57flucytosine 57fludrocortisone acetate 144

FLULAVAL QUAD 2020-2021 97FLULAVAL QUAD 2021-2022 97FLULAVAL QUAD 2022-2023 98FLUMADINE 102FLUMIST QUAD 2020-2021 98FLUMIST QUAD 2021-2022 98flunisolide 25fluocinolone acetonide 29fluocinolone acetonide oil 25fluocinonide 29fluocinonide-e 29fluorescein-benoxinate 134fluoride 164fluoridex 164FLUORIDEX SENSITIVITY RELIEF 164fluoritab 164fluorometholone 25FLUOROPLEX 75fluorouracil 75fluoxetine dr 49fluoxetine hcl 49fluphenazine decanoate 91fluphenazine hcl 91flurandrenolide 30flurazepam hcl 107flurbiprofen 178flurbiprofen sodium 26flutamide 75fluticasone propionate 25,30fluticasone propionate hfa 123fluticasone-salmeterol 123fluticasone-salmeterol 113-14 (generic for airduorespiclick) 123fluticasone-salmeterol 232-14 (generic for airduorespiclick) 123fluticasone-salmeterol 55-14 (generic for airduorespiclick) 123fluticasone-vilanterol 123fluvastatin er 67fluvastatin sodium 67fluvoxamine maleate 49

fluvoxamine maleate er 49FLUZONE HIGH-DOSE QUAD 2020-21 98FLUZONE HIGH-DOSE QUAD 2021-22 98FLUZONE HIGH-DOSE QUAD 2022-23 98FLUZONE QUAD 2020-2021 98FLUZONE QUAD 2021-2022 98FLUZONE QUAD 2022-2023 98FLUZONE QUAD SOUTHERN HEM 2020 98FLUZONE QUAD SOUTHERN HEM 2021 98FML 25FML FORTE 25FML S.O.P. 25FOCALIN 15FOCALIN XR 15folic acid 208folitab 500 32folivane-ob 204fondaparinux sodium 39FORFIVO XL 47formoterol fumarate 112FORTAMET 51FORTEO 182FORTESTA 145FOSAMAX PLUS D 163fosamprenavir calcium 94fosfomycin tromethamine 17fosinopril sodium 185fosinopril-hydrochlorothiazide 185FOSRENOL 160FOTIVDA 75FRAGMIN 40FROTEK 32FROVA 69frovatriptan succinate 69FULPHILA 113FURADANTIN 17furosemide 127FUZEON 91FYAVOLV 132FYCOMPA 42FYREMADEL 140

GGABACAINE 42gabapentin 42GABITRIL 42GALAFOLD 174galantamine er 110galantamine hbr 111galantamine hydrobromide 111GARDASIL 9 98GASTROCROM 28gatifloxacin 19GATTEX 139GAVILYTE-C 137GAVILYTE-G 137GAVILYTE-N 137GAVRETO 75GEL-KAM 164GELNIQUE 140gemfibrozil 67GEMMILY 149GEMTESA 111GENERESS FE 149GENERLAC 129GENGRAF 172GENTAK 19gentamicin sulfate 19,22GENVOYA 93GEODON 89GIANVI 149GILENYA 170GILOTRIF 75GIMOTI 139glatiramer acetate 170GLATOPA 170GLEEVEC 75GLEOSTINE 75glimepiride 54glipizide 54glipizide er 54glipizide xl 54

glipizide-metformin 54GLOPERBA 163GLUCAGEN 65GLUCAGEN 1 MG HYPOKIT (NOVO) 65glucagon 1 mg emergency kit 65glucagon 1 mg emergency kit (genericglucagen) 65glucagon 1 mg emergency kit (Lilly) 65GLUCAGON EMERGENCY KIT 65GLUCOTROL 54GLUCOTROL XL 54GLUMETZA 51glyburide 54glyburide micronized 54glyburide-metformin hcl 55glycopyrrolate 37GLYNASE 55GLYSET 51GLYXAMBI 53GOCOVRI 85GOLYTELY 137GONITRO 202GRALISE 2granisetron hcl 55GRANIX 113GRASTEK 96griseofulvin 56griseofulvin ultramicrosize 56guaifenesin dac 187guaifenesin-codeine 187guanfacine hcl 156guanfacine hcl er 119guanidine hcl 111GVOKE 65GVOKE HYPOPEN 1-PACK 65GVOKE HYPOPEN 2-PACK 65GVOKE PFS 1-PACK SYRINGE 65GVOKE PFS 2-PACK SYRINGE 65GYNAZOLE 1 58gynol ii 176

HHAEGARDA 161HAILEY 149HAILEY 24 FE 149HAILEY FE 149halcinonide 30HALCION 107HALDOL DECANOATE 100 91HALDOL DECANOATE 50 91halobetasol propionate 30HALOG 30haloperidol 91haloperidol decanoate 91haloperidol decanoate 100 91haloperidol lactate 91HARVONI 141HAVRIX 98HEATHER 149HELIDAC 36HEMADY 144HEMANGEOL 118HEMLIBRA 62hemmorex-hc 30HEMOFIL M 62heparin sodium 40HEPLISAV-B 98HEPSERA 104HETLIOZ 104HETLIOZ LQ 104HIBERIX 98HICON 183HIPREX 17HISTEX-AC 187homatropaire 135HORIZANT 42HUMALOG 158HUMALOG JUNIOR KWIKPEN 158HUMALOG KWIKPEN U-100 158HUMALOG KWIKPEN U-200 158HUMALOG MIX 50-50 158

HUMALOG MIX 50-50 KWIKPEN 158HUMALOG MIX 75-25 158HUMALOG MIX 75-25 KWIKPEN 158HUMATE-P 62HUMIRA 166HUMIRA PEN 166HUMIRA PEN CROHN'S-UC-HS 166HUMIRA PEN PSOR-UVEITS-ADOL HS 166HUMIRA(CF) 166HUMIRA(CF) PEDIATRIC CROHN'S 139,166HUMIRA(CF) PEN 166,167HUMIRA(CF) PEN CROHN'S-UC-HS 167HUMIRA(CF) PEN PEDIATRIC UC 167HUMIRA(CF) PEN PSOR-UV-ADOL HS 167HUMULIN 70-30 157HUMULIN 70/30 KWIKPEN 157HUMULIN N 157HUMULIN N KWIKPEN 157HUMULIN R 159HUMULIN R U-500 159HUMULIN R U-500 KWIKPEN 159HYCAMTIN 75hydralazine hcl 156HYDREA 75HYDRO 35 193HYDRO 40 193hydrochlorothiazide 128hydrocodone bitartrate er 5hydrocodone-acetaminophen 5hydrocodone-chlorpheniramne er 187hydrocodone-homatropine mbr 187hydrocodone-ibuprofen 5hydrocortisone 30,144hydrocortisone acetate 30hydrocortisone butyrate 30hydrocortisone valerate 30hydrocortisone-1% ointment 30hydrocortisone-acetic acid 20hydrocortisone-iodoquinol 23hydrocortisone-iodoquinol-aloe 23hydrocortisone-pramoxine 30

hydromorphone er 6hydromorphone hcl 5,6hydroxocobalamin 208hydroxychloroquine sulfate 87hydroxyurea 75hydroxyzine hcl 105hydroxyzine pamoate 105HYFTOR 196HYLATOPICPLUS 125hyoscyamine sulfate 37hyoscyamine sulfate er 37hyoscyamine sulfate sr 37hyosyne 37HYSINGLA ER 6HYZAAR 184

Iibandronate sodium 163IBRANCE 75IBSRELA 139ibuprofen 178ibuprofen-famotidine 178icatibant 160ICLEVIA 149ICLUSIG 75icosapent ethyl 65IDELVION 62IDHIFA 76IGALMI 105ihealth covid-19 ag home test 125ILARIS 174ILEVRO 26imatinib mesylate 76IMBRUVICA 76imipramine hcl 50imipramine pamoate 50imiquimod 196IMITREX 69IMPAVIDO 87IMPEKLO 30IMPOYZ 30

INBRIJA 86INCASSIA 149INCRUSE ELLIPTA 37indapamide 128INDERAL LA 118INDERAL XL 118indicaid covid-19 ag home test 125INDOCIN 178indomethacin 178indomethacin er 178INFANRIX DTAP 96INFLAMMA-K 178INGREZZA 121INGREZZA INITIATION PACK 121INLYTA 76INNOPRAN XL 118INQOVI 76INREBIC 76INSPRA 186insulin aspart 159insulin aspart flexpen 159insulin aspart penfill 159insulin aspart prot mix 70-30 159insulin glargine 157insulin glargine solostar 157insulin glargine-yfgn 157insulin lispro 159insulin lispro junior kwikpen 159insulin lispro kwikpen u-100 159insulin lispro protamine mix 159insulin syringe 124INTELENCE 92inteliswab covid-19 home test 125INTERMEZZO 105INTRON A 103INTROVALE 149INTUNIV 119INVEGA 89INVEGA SUSTENNA 89INVELTYS 25INVIRASE 94

INVOKAMET 53INVOKAMET XR 53INVOKANA 53iodoquinol-hydrocortisone-aloe 23IOPIDINE 134IPOL 98ipratropium bromide 38,134ipratropium-albuterol 38irbesartan 184irbesartan-hydrochlorothiazide 184IRESSA 76ISENTRESS 92ISENTRESS HD 92ISIBLOOM 149isoniazid 71ISOPTO CARPINE 61ISORDIL 202ISORDIL TITRADOSE 202isosorbide dinit-hydralazine 156isosorbide dinitrate 202isosorbide mononitrate 202isosorbide mononitrate er 202isotretinoin 196isoxsuprine hcl 203isradipine 116ISTALOL 60ISTURISA 174itraconazole 57ivermectin 17,24,196IXINITY 62

JJADENU 143JADENU SPRINKLE 143JAIMIESS 149JAKAFI 76JALYN 162JANSSEN COVID-19 VACCINE (EUA) 98jantoven 39JANUMET 52JANUMET XR 52

JANUVIA 52JARDIANCE 54JASMIEL 149JATENZO 145JENCYCLA 149JENTADUETO 52JENTADUETO XR 52JINTELI 132JIVI 63JOLESSA 149JORNAY PM 15JUBLIA 58JULEBER 149JULUCA 92JUNEL 150JUNEL FE 150JUNEL FE 24 150JUXTAPID 65JYNARQUE 128

KK-PHOS NO.2 129K-PHOS ORIGINAL 129k-tab er 130KADIAN 6KAITLIB FE 150KALBITOR 161KALETRA 94KALLIGA 150KALYDECO 124KAPSPARGO SPRINKLE 118KAPVAY 156KARBINAL ER 135KARIVA 150KATERZIA 116KAZANO 52KEFLEX 122KELNOR 1-35 150KELNOR 1-50 150KENALOG 30KEPPRA 42

KEPPRA XR 42KERAFOAM 193KERALAC 193KERENDIA 186KERYDIN 59KESIMPTA PEN 170ketoconazole 57,58KETODAN 58ketoprofen 178ketorolac tromethamine 27,178KEVEYIS 164KEVZARA 167KINERET 167KINRIX 98KISQALI 76KISQALI FEMARA CO-PACK 77KITABIS PAK 33KLARON 23KLISYRI 196KLONOPIN 46KLOR-CON 130KLOR-CON 10 130KLOR-CON 8 130KLOR-CON M10 130KLOR-CON M15 130KLOR-CON M20 130klor-con-ef 130KLOXXADO 121KOATE 63KOGENATE FS 63KOMBIGLYZE XR 52KORLYM 51KOSELUGO 77KOSHER PRENATAL PLUS IRON 204KOVALTRY 63KRINTAFEL 87KRISTALOSE 129KURVELO 150KUVAN 174KYNMOBI 128

Llabetalol hcl 118lacosamide 42LACRISERT 134lactulose 129LAGEVRIO (EUA) 104LAMICTAL 42LAMICTAL (BLUE) 42LAMICTAL (GREEN) 43LAMICTAL (ORANGE) 43LAMICTAL ODT 43LAMICTAL ODT (BLUE) 43LAMICTAL ODT (GREEN) 43LAMICTAL ODT (ORANGE) 43LAMICTAL XR 43LAMICTAL XR (BLUE) 43LAMICTAL XR (GREEN) 43LAMICTAL XR (ORANGE) 43lamivudine 93lamivudine hbv 93lamivudine-zidovudine 93lamotrigine 43lamotrigine (blue) 43lamotrigine (green) 43lamotrigine (orange) 43lamotrigine er 43lamotrigine odt 43lamotrigine odt (blue) 43lamotrigine odt (green) 43lamotrigine odt (orange) 43LAMPIT 88LANOXIN 117lanreotide acetate 199lansoprazol-amoxicil-clarithro 101lansoprazole 101lanthanum carbonate 160LANTUS 157LANTUS SOLOSTAR 157lapatinib 77LARIN 150

LARIN 24 FE 150LARIN FE 150LARISSIA 150LASIX 127LASTACAFT 133latanoprost 61LATUDA 89LAYOLIS FE 150LAZANDA 6ldo plus 125ledipasvir-sofosbuvir 141LEENA 150leflunomide 167lenalidomide 77LENVIMA 77LESCOL 67LESCOL XL 67LESSINA 150LETAIRIS 188letrozole 77leucovorin calcium 163LEUKERAN 77LEUKINE 113levalbuterol concentrate 112levalbuterol hcl 112levalbuterol tartrate hfa 112levamlodipine maleate 116LEVBID 38LEVEMIR 157LEVEMIR FLEXTOUCH 157levetiracetam 43levetiracetam er 43LEVICYN 125LEVICYN ANTIPRURITIC SG 193LEVO-T 201levobunolol hcl 60levocarnitine 130,174levocarnitine sf 174levocetirizine dihydrochloride 64levofloxacin 19,34LEVONEST 150

levonorg-eth estrad eth estrad 150levonorgestrel 150levonorgestrel-eth estradiol 150LEVORA-28 150levorphanol tartrate 6levothyroxine 201levothyroxine sodium 201LEVOXYL 201LEVSIN 38LEVSIN-SL 38LEXAPRO 49LEXETTE 30LEXIVA 94LIALDA 136LIBRAX 38LICART 178lido-k 191lidocaine 191lidocaine hcl 134,191lidocaine hcl viscous 134lidocaine-hydrocortisone 30,191lidocaine-prilocaine 191lidocaine-tetracaine 191LIDODERM 191lidopin 191LIDOTRAL 191LIDOTRANS 5 PAK 192LIDOTREX 125LIDOVEX 192LIFEMS NALOXONE 121LILLOW 150lindane 24linezolid 36LINZESS 139liothyronine sodium 201LIPITOR 68LIPOFEN 67lisinopril 185lisinopril-hydrochlorothiazide 185lithium 119lithium carbonate 119

lithium carbonate er 119LITHOBID 119LITHOSTAT 129LIVALO 68LIVMARLI 139LIVTENCITY 102LO LOESTRIN FE 150LO-ZUMANDIMINE 150LOCOID 30LOCOID LIPOCREAM 30LODOSYN 119LOESTRIN 151LOESTRIN FE 151LOJAIMIESS 151LOKELMA 160LOMOTIL 137LONHALA MAGNAIR REFILL 38LONHALA MAGNAIR STARTER 38LONSURF 77loperamide 137LOPID 67lopinavir-ritonavir 95LOPREEZA 133LOPRESSOR 118LOPROX 59lorazepam 107LORAZEPAM INTENSOL 107LORBRENA 77LORCET 6LORCET HD 6LOREEV XR 107LORTAB 6LORYNA 151LORZONE 190losartan potassium 184losartan-hydrochlorothiazide 184LOSEASONIQUE 151LOTEMAX 25LOTEMAX SM 25LOTENSIN 185loteprednol etabonate 25

LOTREL 116LOTRONEX 136LOUTREX 125lovastatin 68LOVAZA 65LOVENOX 40LOW-OGESTREL 151loxapine 88lubiprostone 137lucira check-it covid home tst 126ludent fluoride 164luliconazole 58LUMAKRAS 77LUMIGAN 61LUNESTA 105LUPANETA PACK 141LUPKYNIS 172LUTERA 151LUXIQ 30LUZU 58LYBALVI 89LYLEQ 151LYNPARZA 78LYRICA 43,44LYRICA CR 2LYSODREN 78LYSTEDA 63LYUMJEV 159LYUMJEV KWIKPEN U-100 159LYUMJEV KWIKPEN U-200 159LYVISPAH 190LYZA 151

MM-M-R II VACCINE 98m-natal plus 204M.V.I. ADULT 204M.V.I.-12 204MACRILEN 127MACROBID 17MACRODANTIN 17,18

mafenide acetate 23MALARONE 87malathion 24maprotiline hcl 50maraviroc 91MARINOL 55MARLISSA 151MARNATAL-F 204MARPLAN 48MARVONA SUIK 161MATULANE 78MATZIM LA 115MATZIM LA 360 MG TABLET (generic forCARDIZEM LA) 115MAVENCLAD 172MAVYRET 142MAXALT 70MAXALT MLT 70MAXIDEX 25MAXITROL 19MAXZIDE 127MAXZIDE-25 MG 127MAYZENT 170mb hydrogel 126meclizine hcl 56meclofenamate sodium 178MEDROL 144MEDROLOAN II SUIK 144MEDROLOAN SUIK 144medroxyprogesterone acetate 155mefenamic acid 179mefloquine hcl 87megestrol acetate 156MEKINIST 78MEKTOVI 78MELODETTA 24 FE 151meloxicam 179melphalan 78memantine hcl 119memantine hcl er 119MENACTRA 98

MENEST 133MENOSTAR 133MENQUADFI 98MENTAX 59MENTHO-CAINE 192MENVEO A-C-Y-W-135-DIP 98MENVEO MENA COMPONENT 98MENVEO MENCYW-135 COMPONENT 98meperidine hcl 6,202MEPHYTON 209meprobamate 105MEPRON 88mercaptopurine 78MERZEE 151mesalamine 136mesalamine dr 136mesalamine er 136,137MESNEX 176MESTINON 111METADATE ER 15metaproterenol sulfate 112METAXALL 190metaxalone 190metformin er 1,000 mg gastr-tb (generic forglumetza er) 51metformin er 1,000 mg osm-tab (generic forfortamet er) 51metformin er 500 mg gastrc-tb (generic forglumetza er) 51metformin er 500 mg osmotic tb (generic forfortamet er) 51metformin hcl 51metformin hcl 1,000 mg tablet (generic forglucophage) 51metformin hcl 500 mg tablet (generic forglucophage) 51metformin hcl er 51methacholine chloride 127methadone hcl 6METHADONE INTENSOL 6METHADOSE 6

methamphetamine hcl 14methazolamide 60methenamine hippurate 18methenamine mandelate 18METHERGINE 181methimazole 201METHITEST 145methocarbamol 190methotrexate 78methotrexate sodium 78methoxsalen 124methscopolamine bromide 38methyldopa 156methyldopa-hydrochlorothiazide 156methylergonovine maleate 182METHYLIN 15methylphenidate 15methylphenidate er 15,16methylphenidate er (la) 15,16methylphenidate er 10 mg cap (authorizedgeneric) 15methylphenidate er 15 mg cap (authorizedgeneric) 15methylphenidate er 20 mg cap (authorizedgeneric) 15methylphenidate er 30 mg cap (authorizedgeneric) 15methylphenidate er 40 mg cap (authorizedgeneric) 15methylphenidate er 50 mg cap (authorizedgeneric) 16methylphenidate er 60 mg cap (authorizedgeneric) 16methylphenidate hcl 15,16methylphenidate hcl cd 16methylphenidate hcl er (cd) 16methylphenidate la 16methylprednisolone 144methyltestosterone 145metipranolol 60metoclopramide hcl 139

metoclopramide hcl odt 139metolazone 128METOPIRONE 127metoprolol succinate 118metoprolol tartrate 118metoprolol-hydrochlorothiazide 118METROCREAM 22METROGEL 22METROGEL-VAGINAL 22METROLOTION 22metronidazole 22,88metyrosine 174mexiletine hcl 33MIBELAS 24 FE 151MICARDIS 184MICARDIS HCT 184miconazole 3 58miconazole-zinc oxide-petroltm 58MICROCYN HYDROGEL 126MICROGESTIN 151MICROGESTIN 24 FE 151MICROGESTIN FE 151midaspot covid19 antibody test 126midazolam hcl 107midodrine hcl 201MIFEPREX 182MIGERGOT 1miglitol 51miglustat 174MIGRANAL 1MIGRANOW 70MILI 151MILLIPRED 144MIMVEY 133MINASTRIN 24 FE 151MINIPRESS 117MINITRAN 202MINIVELLE 133minocycline er 35minocycline hcl 35minocycline hcl er 35

MINOLIRA ER 35minoxidil 157MIRAPEX 128MIRAPEX ER 129MIRCERA 113MIRCETTE 151mirtazapine 47misoprostol 101MITIGARE 163MOBIC 179modafinil 17MODERNA COVID (12Y UP)VAC(EUA) 99MODERNA COVID BIV BOOSTR(UNAP) 99MODERNA COVID(6-11Y) VAC(EUA) 99MODERNA COVID(6M-5Y) VACC(EUA) 99MODERNA COVID-19 BOOSTER (EUA) 99moexipril hcl 185molindone hcl 88mometasone furoate 26,30MONDOXYNE NL 35MONO-LINYAH 151MONODOX 35MONONINE 63montelukast sodium 27MONUROL 18MORGIDOX 35morphine sulfate 6,7morphine sulfate er 7MORPHINE SULFATE IR 15 MG TAB (BRAND) 7MORPHINE SULFATE IR 30 MG TAB (BRAND) 7MOTEGRITY 139MOTOFEN 137MOUNJARO 53MOVANTIK 139MOVIPREP 137MOXATAG 182MOXEZA 19moxifloxacin 19moxifloxacin 0.5% eye drops (generic formoxeza) 19moxifloxacin hcl 34

MS CONTIN 7MULPLETA 113MULTAQ 33multi-vitamin daily 204mupirocin 22MVW COMPLETE FORMLTN PEDIATRIC 204MVW COMPLETE FORMULATION D3000 204MY WAY 151MYALEPT 155MYAMBUTOL 71MYCAPSSA 199MYCOBUTIN 71mycophenolate mofetil 172mycophenolic acid 172MYDAYIS 14MYDRIACYL 135MYFEMBREE 140MYFORTIC 173MYLERAN 78MYNATAL 204mynatal plus 205mynatal-z 205MYORISAN 197MYRBETRIQ 111MYSOLINE 46

Nnabumetone 179nadolol 118naftifine hcl 57NAFTIN 57,58NALFON 179nalmefene hcl 121NALOCET 7naloxone hcl 121naltrexone hcl 121NAMENDA 119NAMENDA XR 120NAMZARIC 120NAPRELAN 179NAPROSYN 179

naproxen 179naproxen sodium 179naproxen sodium cr 179naproxen sodium er 179naproxen-esomeprazole mag 179naratriptan hcl 70NARCAN 121NARDIL 48NASONEX 26NATACHEW 205NATACYN 20NATAZIA 151nateglinide 53NATESTO 145NATPARA 182NATROBA 24NATURE-THROID 201NAYZILAM 46nebivolol hcl 118NEBUPENT 88NECON 151NEEVODHA 205nefazodone hcl 50NEO-SYNALAR 22neomycin sulfate 33neomycin-bacitracin-poly-hc 19neomycin-bacitracin-polymyxin 19neomycin-polymyxin-dexameth 19neomycin-polymyxin-gramicidin 19neomycin-polymyxin-hc 19neomycin-polymyxin-hydrocort 19NEORAL 173NEOSALUS 126NEPHRONEX-SL 208NERLYNX 78NESINA 52NESTABS 205NESTABS ABC 205NESTABS DHA 205NESTABS ONE 205NEUAC 22

NEULASTA 113NEULASTA ONPRO 113NEUPOGEN 113NEUPRO 129NEURAPTINE 197NEURONTIN 44NEVANAC 27nevirapine 92nevirapine er 92newgen 205NEXAVAR 78NEXICLON XR 156NEXIUM 101,102NEXIUM 24HR 102NEXLETOL 66NEXLIZET 66NEXTSTELLIS 151niacin er 66NIACOR 66NIASPAN 66nicardipine hcl 116nicotine gum 109nicotine lozenge 109nicotine patch 110NICOTROL 110NICOTROL NS 110nifedipine 116nifedipine er 116NIKKI 152NILANDRON 78nilutamide 78nimodipine 116ninjacof-xg 187NINLARO 79nisoldipine 116nitazoxanide 88nitisinone 174NITRO-BID 202NITRO-DUR 202NITRO-TIME 202nitrofurantoin 18

nitrofurantoin mono-macro 18nitroglycerin 202nitroglycerin patch 202NITROLINGUAL 202NITROMIST 202NITROSTAT 202NITYR 174NIVESTYM 113nizatidine 101NOCDURNA 155NOCTIVA 155NOLIX 31NORA-BE 152NORCO 7norethin-eth estra-ferrous fum 152norethindron-ethinyl estradiol 133,152norethindrone 152norethindrone ac (lupaneta) 156norethindrone acetate 156norethindrone-e.estradiol-iron 152NORGESIC FORTE 191norgestimate-ethinyl estradiol 152NORITATE 22NORLIQVA 116NORLYDA 152NORPACE 32NORPACE CR 32NORPRAMIN 50NORTHERA 200NORTREL 152nortriptyline hcl 50NORVASC 116NORVIR 95NOURIANZ 120NOVACORT 31NOVAVAX COVID-19 VACC,ADJ(EUA) 99NOVOEIGHT 63NOVOLIN 70-30 157NOVOLIN 70-30 FLEXPEN 157novolin 70-30 flexpen 157NOVOLIN N 157

NOVOLIN N FLEXPEN 157NOVOLIN R 159NOVOLIN R FLEXPEN 159NOVOLOG 159novolog flexpen 159NOVOLOG MIX 70-30 159NOVOLOG MIX 70-30 FLEXPEN 159NOVOLOG PENFILL 159NOVOSEVEN RT 63NOXAFIL 57NOXIPAK 31np thyroid 201NUBEQA 79NUCALA 27NUCYNTA 7NUCYNTA ER 7NUDROXIPAK 176NUDROXIPAK DSDR-50 179NUDROXIPAK DSDR-75 179NUDROXIPAK E-400 179NUDROXIPAK I-800 179NUDROXIPAK N-500 179NUEDEXTA 120nulev 38NULYTELY WITH FLAVOR PACKS 137NUMBONEX 192NUPLAZID 89NURTEC ODT 69NUTRASEB 131NUTRIARX 31NUVARING 152NUVESSA 22NUVIGIL 17NUWIQ 63NUZYRA 201NYAMYC 59NYLIA 152NYMALIZE 116NYMYO 152nystatin 57,59nystatin-triamcinolone 59

NYSTOP 59NYVEPRIA 113

OO-CAL PRENATAL 205OB COMPLETE 205OB COMPLETE ONE 205OB COMPLETE PETITE 205OB COMPLETE PREMIER 205OB COMPLETE WITH DHA 205OBIZUR 63OBREDON 187OCALIVA 139OCELLA 152octreotide acetate 199OCUFLOX 19OCUVEL 205ODACTRA 96ODEFSEY 93ODOMZO 79OFEV 186ofloxacin 19,34olanzapine 89olanzapine odt 89olanzapine-fluoxetine hcl 49olmesartan medoxomil 184olmesartan-amlodipine-hctz 184olmesartan-hydrochlorothiazide 184olopatadine hcl 133,134OLUMIANT 167OLUX 31OLUX-E 31OMECLAMOX-PAK 102omega-3 acid ethyl esters 66omeprazole 102omeprazole-sodium bicarbonate 102OMNARIS 26OMNIPAQUE 127on-go covid-19 ag at home test 126ondansetron hcl 55,202ondansetron odt 55

ONEXTON 22ONFI 46ONGENTYS 86ONGLYZA 52ONMEL 57ONUREG 79ONZETRA XSAIL 70opium tincture 137OPSUMIT 188OPZELURA 197ORACEA 35ORALAIR 96ORAPRED ODT 144ORAVIG 58ORENCIA 167ORENCIA CLICKJECT 168ORENITRAM ER 188ORFADIN 175ORGOVYX 141ORIAHNN 141ORILISSA 141ORKAMBI 124ORLADEYO 161orphenadrine citrate er 191orphenadrine-aspirin-caffeine 191ORPHENGESIC FORTE 191ORSYTHIA 152ORTHO MICRONOR 152ORTHO TRI-CYCLEN 152ORTHO-NOVUM 152ORTIKOS 144oscimin 38oscimin sl 38oscimin sr 38oseltamivir phosphate 103OSENI 52OSMOLEX ER 85OSMOPREP 137OTEZLA 168OTIPRIO 19OTOVEL 19

OTREXUP 79OVACE 23OVACE PLUS 23ovace plus wash 24OVIDE 24OXANDRIN 146oxandrolone 146oxaprozin 179OXAYDO 7oxazepam 107OXBRYTA 112oxcarbazepine 44OXERVATE 134oxiconazole nitrate 58OXISTAT 58OXSORALEN-ULTRA 124OXTELLAR XR 44oxybutynin chloride 140oxybutynin chloride er 140oxycodone hcl 7,8oxycodone hcl er 8oxycodone hcl-aspirin 8oxycodone-acetaminophen 7,8OXYCONTIN 8oxymorphone hcl 8oxymorphone hcl er 8OXYTROL 140OZEMPIC 53OZOBAX 190

PPACERONE 33PACNEX 193PAINGO KFT 192PALFORZIA 96paliperidone er 89PALYNZIQ 131PAMELOR 50PANCREAZE 138PANDEL 31PANRETIN 79

pantoprazole sodium 102paricalcitol 209PARLODEL 128PARNATE 48PAROEX 20paromomycin sulfate 87paroxetine cr 49paroxetine er 49paroxetine hcl 49paroxetine mesylate 49PASER 71PATANASE 134PAXIL 49PAXIL CR 49PAXLOVID (EUA) 102PAZEO 134PEDIARIX 99PEDVAXHIB 99peg 3350-electrolyte 137peg-3350 and electrolytes 137PEG-PREP 138peg3350-sod sul-nacl-kcl-asb-c 138PEGANONE 47PEGASYS 103PEGINTRON 103PEMAZYRE 79penicillamine 143penicillin v potassium 183PENNSAID 179PENTACEL 99PENTACEL ACTHIB COMPONENT 99PENTACEL DTAP-IPV COMPONENT 99pentamidine isethionate 88PENTASA 137pentazocine-naloxone hcl 12pentoxifylline 114PEPCID 101PERCOCET 8,9PERFOROMIST 112PERIDEX 20perindopril erbumine 185

PERIOGARD 20PERIOMED 164permethrin 24perphenazine 91perphenazine-amitriptyline 50PERTZYE 138PEXEVA 49PFIZER COVID (12Y UP) VAC(EUA) 99PFIZER COVID (5-11Y) VAC (EUA) 99PFIZER COVID (6M-4Y) VACC(EUA) 99PFIZER COVID-19 VACCINE (EUA) 99phenazopyridine hcl 192phenelzine sulfate 48phenobarbital 105phenobarbital-hyosc-atrop-scop 38phenohytro 38phenoxybenzamine hcl 1phenylephrine hcl 135PHENYTEK 47phenytoin 47phenytoin sodium extended 47PHEXXI 176PHILITH 152PHOSLYRA 160phosphasal 18PHOSPHOLINE IODIDE 61PHOTREXA 134PHOTREXA VISCOUS 134phytonadione 209PICATO 79PIFELTRO 92pilocarpine hcl 61,111pimecrolimus 197pimozide 88PIMTREA 152pindolol 118pioglitazone hcl 55pioglitazone-glimepiride 55pioglitazone-metformin 55PIQRAY 79pirfenidone 186

PIRMELLA 152piroxicam 179pixel covid-19 home collect kt 126PLAN B ONE-STEP 152PLAQUENIL 87PLAVIX 95PLEGRIDY 170PLEGRIDY PEN 170PLENVU 138PLIAGLIS 192PNEUMOVAX 23 99pnv 29-1 205pnv-dha 205pnv-omega 205pnv-select 205podofilox 197polyethylene glycol 3350 138polymyxin b sul-trimethoprim 20POLYTRIM 20POMALYST 79PONTOCAINE 192PONVORY 171PORTIA 152posaconazole 57POTABA 175potassium chloride 130potassium citrate er 129pr natal 400 205pr natal 400 ec 205pr natal 430 205pr natal 430 ec 205PRADAXA 39PRALUENT PEN 68pramipexole dihydrochloride 129pramipexole er 129PRAMOSONE 31prasugrel hcl 95PRAVACHOL 68pravastatin sodium 68praziquantel 17prazosin hcl 117

PRED FORTE 26PRED MILD 26PRED-G 20prednicarbate 31prednisolone 144prednisolone ac 1% eye drop (generic predforte) 26prednisolone sodium phos odt 144prednisolone sodium phosphate 26,144prednisolone-nepafenac 26prednisone 144PREDNISONE INTENSOL 144PREFEST 133pregabalin 44pregabalin er 2PREHEVBRIO 99PREMARIN 133PREMPHASE 133PREMPRO 133PRENA1 CHEW 205prena1 pearl 206prena1 true 206PRENATA 206PRENATABS FA 206PRENATABS RX 206prenatal 19 206prenatal plus 206prenatal plus-dha 206prenatal vitamin plus low iron 206prenatal-u 206PRENATE AM 206PRENATE CHEWABLE 206PRENATE DHA 206PRENATE ELITE 206PRENATE ENHANCE 206PRENATE ESSENTIAL 206PRENATE MINI 206PRENATE PIXIE 206PRENATE RESTORE 206PRENATE STAR 206preplus 206

PRESTALIA 185pretab 206pretomanid 71PREVACID 102PREVACID 24HR DR 15 MG CAPSULE (OTC) 102PREVALITE 66PREVIDENT 164PREVIDENT 5000 DRY MOUTH 164PREVIDENT 5000 ENAMEL PROTECT 164PREVIDENT 5000 PLUS 164PREVIDENT 5000 SENSITIVE 164PREVIFEM 153PREVNAR 13 99PREVNAR 20 99PREVYMIS 102PREZCOBIX 95PREZISTA 95PRIFTIN 71PRILOSEC 102PRIMACARE 206primaquine 87primidone 46PRIMLEV 9PRIMSOL 18PRINIVIL 185PRIORIX 99PRISTIQ 48pro dna collection 134PRO DNA MEDICATED COLLECTION 135PROAIR DIGIHALER 112PROAIR HFA 112PROAIR RESPICLICK 112probenecid 130probenecid-colchicine 130PROCARDIA 116PROCARDIA XL 116PROCENTRA 14prochlorperazine 56prochlorperazine maleate 56PROCRIT 113PROCTO-MED HC 31

PROCTO-PAK 31PROCTOCORT 31PROCTOFOAM-HC 31PROCTOSOL-HC 31PROCTOZONE-HC 31PROCYSBI 175PROFILNINE 63progesterone 156PROGLYCEM 64PROGRAF 173PROLATE 9PROLENSA 27PROMACTA 113promethazine hcl 136promethazine vc 136promethazine vc-codeine 187promethazine-codeine 187promethazine-dm 187promethazine-phenyleph-codeine 187promethazine-phenylephrine 136PROMETHEGAN 136PROMETRIUM 156propafenone hcl 33propafenone hcl er 33propantheline bromide 38proparacaine hcl 135propranolol hcl 118propranolol hcl er 118propranolol-hydrochlorothiazid 118propylthiouracil 201PROQUAD 99PROSCAR 162PROTONIX 102PROTOPIC 197protriptyline hcl 51PROVENTIL HFA 112PROVERA 156PROVIDA OB 206PROVIGIL 17PROZAC 49PRUDOXIN 192

PSORCON 31PULMICORT 123PULMICORT FLEXHALER 123PULMOZYME 187PUREFE OB PLUS 206PURIXAN 79PYLERA 36pyrazinamide 71pyridostigmine bromide 111pyridostigmine bromide er 111pyrimethamine 87PYRUKYND 112

QQBRELIS 185QBREXZA 38QDOLO 9QELBREE 120QINLOCK 79QNASL 26QNASL CHILDREN 26QTERN 54QUADRACEL DTAP-IPV 99QUALAQUIN 87QUARTETTE 153quazepam 107QUDEXY XR 44QUESTRAN 66QUESTRAN LIGHT 66quetiapine fumarate 90quetiapine fumarate er 90quickvue at-home covid-19 test 126QUILLICHEW ER 16QUILLIVANT XR 16quinapril hcl 185quinapril-hydrochlorothiazide 185quinidine gluconate 32quinidine sulfate 33quinine sulfate 87QUINJA 24QULIPTA 69

QUVIVIQ 109QVAR REDIHALER 123

Rr-natal ob 207rabeprazole sodium 102RADICAVA ORS 120RAGWITEK 96raloxifene hcl 131ramelteon 105ramipril 185RANEXA 116ranolazine er 116RAPAFLO 1RAPAMUNE 173rasagiline mesylate 86RASUVO 79RAVICTI 129RAYALDEE 209RAZADYNE 111RAZADYNE ER 111REBIF 171REBIF REBIDOSE 171REBINYN 63RECLIPSEN 153RECOMBINATE 63RECOMBIVAX HB 99RECORLEV 175RECTIV 197REDITREX 171REGLAN 139REGRANEX 192RELAFEN DS 179RELENZA 103RELEUKO 114relion novolin 70-30 vial 157relion novolin n 100 unit/ml 157relion novolin n u-100 flexpen 157relion novolin r 100 unit/ml 159relion novolin r u-100 flexpen 159RELISTOR 139

RELPAX 70RELTONE 138REMERON 47REMODULIN 188RENAGEL 160RENVELA 160repaglinide 53repaglinide-metformin hcl 53REPATHA PUSHTRONEX 68REPATHA SURECLICK 68REPATHA SYRINGE 68REQUIP XL 129RESTASIS 26RESTASIS MULTIDOSE 26RESTORIL 107,108RETACRIT 114RETAINE OM3 175RETAINE VISION 175RETEVMO 80RETIN-A 192RETIN-A MICRO 192RETIN-A MICRO PUMP 192RETROVIR 93REVATIO 203REVCOVI 131REVLIMID 80REXULTI 90REYATAZ 95REYVOW 70REZUROCK 175RHOPRESSA 61RIAX 193ribavirin 104RIDAURA 140rifabutin 71rifampin 71RILUTEK 120riluzole 120rimantadine hcl 102RINVOQ 168RIOMET 51

RIOMET ER 52risedronate sodium 163risedronate sodium dr 163RISPERDAL 90RISPERDAL CONSTA 90risperidone 90risperidone odt 90RITALIN 16RITALIN LA 16ritonavir 95rivastigmine 111RIVELSA 153RIXUBIS 63rizatriptan 70ROBAXIN-750 190ROBINUL 38ROBINUL FORTE 38ROCALTROL 209ROCKLATAN 61ropinirole er 129ropinirole hcl 129ROSADAN 22ROSULA 193rosuvastatin calcium 68rosuvastatin-ezetimibe 66ROSZET 66ROTARIX 99ROTATEQ 100ROWASA 137ROWEEPRA 44ROWEEPRA XR 44ROXICODONE 9ROXYBOND 9ROZEREM 105ROZLYTREK 80RUBRACA 80RUCONEST 161rufinamide 44RUKOBIA 91RUZURGI 175RYBELSUS 53

RYCLORA 136RYDAPT 80rydex 187RYTARY 86RYTHMOL SR 33RYVENT 135

SSABRIL 45SAFYRAL 153SAJAZIR 160SALAGEN 111SALEX 194salicylic acid 194SALIVAMAX 126salsalate 181SAMSCA 128SANCUSO 55SANDIMMUNE 173SANDOSTATIN 199SANDOSTATIN LAR DEPOT 199SANOFI COVID BOOSTER-AG COMPNT 100SANTYL 197SAPHRIS 90sapropterin dihydrochloride 175SARAFEM 49SAVAYSA 39SAVELLA 120SCARCARE 126SCEMBLIX 80scopolamine 55se-natal 19 207SEASONIQUE 153SECONAL SODIUM 105SECUADO 90SEGLENTIS 9SEGLUROMET 54SELECT-OB 207SELECT-OB + DHA 207selegiline hcl 86selenium sulfide 24

SELRX 24SELZENTRY 92SEMGLEE 157SEMGLEE (YFGN) 157SEMGLEE (YFGN) PEN 158SEMGLEE PEN 158SEMPREX-D 64SENSIPAR 182SEREVENT DISKUS 112SERNIVO 31SEROQUEL 90SEROQUEL XR 90SEROSTIM 155sertraline hcl 49SETLAKIN 153sevelamer carbonate 160sevelamer hcl 160SEVENFACT 63SEYSARA 201sf 164sf 5000 plus 164SHAROBEL 153SHINGRIX 100SHINGRIX ADJUVANT COMPONENT 183SHINGRIX GE ANTIGEN COMPONENT 100SIDEROL 32SIGNIFOR 199SIGNIFOR LAR 199SIKLOS 80sildenafil 20 mg tablet (generic for revatio) 203sildenafil citrate 203SILENOR 51SILIPAC 126SILIQ 197silodosin 1SILVADENE 24silver sulfadiazine 24SILVRSTAT 126SIMBRINZA 60SIMLIYA 153SIMPESSE 153

SIMPONI 168simvastatin 68SINEMET 25-100 86SINGULAIR 27sirolimus 173SIRTURO 71SITAVIG 104SIVEXTRO 36SKELAXIN 190SKLICE 25SKYRIZI 197SKYRIZI (2 SYRINGES) KIT 197SKYRIZI ON-BODY 27SKYRIZI PEN 197SLYND 153SOAANZ 127sodium fluoride 164sodium fluoride 5000 dry mouth 164sodium fluoride enamel protect 165sodium fluoride sensitive 165sodium iodide i-123 183sodium iodide i-131 183sodium phenylbutyrate 130sodium polystyrene sulfonate 160sodium sulfacetamide 24sodium sulfacetamide-sulfur 24,194sofosbuvir-velpatasvir 141SOLARAZE 80solifenacin succinate 140SOLIQUA 100-33 158SOLODYN 35SOLOSEC 88SOLTAMOX 131SOLU-CORTEF 144SOLUPAK 192SOMA 190SOMATULINE DEPOT 199SOMAVERT 200SOOLANTRA 197sorafenib 80SORIATANE 197

SORILUX 197SORINE 118sotalol 118SOTALOL AF 119SOTYLIZE 119SOVALDI 141SPIKEVAX COVID (18Y UP) VACC 100spinosad 25SPIRIVA 38SPIRIVA RESPIMAT 38spironolactone 186spironolactone-hctz 186SPORANOX 57SPRAVATO 47SPRINTEC 153SPRITAM 45SPRIX 179SPRYCEL 80SRONYX 153SSD 24SSKI 201sss 10-5 194st. joseph aspirin 181st. joseph aspirin ec 181STALEVO 100 86STALEVO 125 86STALEVO 150 86STALEVO 200 86STALEVO 50 86STALEVO 75 86STARLIX 53stavudine 94STEGLATRO 54STEGLUJAN 54STELARA 197STIMATE 155STIOLTO RESPIMAT 38STIVARGA 81STRATTERA 120STRENSIQ 131STRIBILD 94

STRIVERDI RESPIMAT 112STROMECTOL 17SUBOXONE 12SUBSYS 9SUBVENITE 45SUBVENITE (BLUE) 45SUBVENITE (GREEN) 45SUBVENITE (ORANGE) 45SUCRAID 131sucralfate 101SULAR 116sulconazole nitrate 59sulfacetamide sodium 20,24sulfacetamide-prednisolone 20sulfacleanse 8-4 194sulfadiazine 34sulfamethoxazole-trimethoprim 34SULFAMYLON 24sulfasalazine 168sulfasalazine dr 168SULFATRIM 34sulindac 180SUMADAN 194SUMADAN XLT 24sumatriptan 70sumatriptan succ-naproxen sod 70sumatriptan succinate 70SUMAXIN 194SUMAXIN TS 194sunitinib malate 81SUNOSI 17SUPPORT-500 208SUPRAX 122SUPREP 138SUSTIVA 92SUTAB 138SUTENT 81SYEDA 153SYLATRON 103symax 38SYMAX DUOTAB 38

symax-sl 39symax-sr 39SYMBICORT 123SYMBYAX 49SYMDEKO 124SYMFI 92SYMFI LO 92SYMJEPI 200SYMLINPEN 60 51SYMPAZAN 47SYMPROIC 139SYMTUZA 95SYNALAR 31SYNALAR TS 31SYNAREL 141SYNDROS 55SYNERA 192SYNERDERM 126SYNJARDY 54SYNJARDY XR 54SYNRIBO 81SYNTHROID 201SYNVEXIA TC 192SYPRINE 143

TTABLOID 81TABRECTA 81TACLONEX 197tacrolimus 173,197tadalafil 203tadalafil 20 mg tablet (generic for adcirca) 203TAFINLAR 81TAGRISSO 81TAKHZYRO 161TALICIA 100TALTZ AUTOINJECTOR 197TALTZ AUTOINJECTOR (2 PACK) 198TALTZ AUTOINJECTOR (3 PACK) 198TALTZ SYRINGE 198TALZENNA 81

TAMIFLU 103tamoxifen citrate 131tamsulosin hcl 2TAPAZOLE 201TAPERDEX 145TARCEVA 81TARGADOX 35TARGRETIN 82TARINA 24 FE 153TARINA FE 153TARINA FE 1-20 EQ 153TARKA 185taron-c dha 207TARPEYO 145TASIGNA 82TASMAR 86tavaborole 59TAVALISSE 113TAVNEOS 173TAYSOFY 153TAYTULLA 153tazarotene 198TAZORAC 198TAZTIA XT 115TAZVERIK 82tdvax 96TECFIDERA 171TEGRETOL 45TEGRETOL XR 45TEGSEDI 163TEKTURNA 186TEKTURNA HCT 186telmisartan 184telmisartan-amlodipine 184telmisartan-hydrochlorothiazid 184temazepam 108TEMIXYS 94TEMODAR 82TEMOVATE 31temozolomide 82TENCON 3

TENIVAC 96tenofovir disoproxil fumarate 94TENORMIN 119TEPMETKO 82terazosin hcl 117terbinafine hcl 56terbutaline sulfate 112terconazole 59teriparatide 182TESTIM 146testosterone 146testosterone cypionate 146testosterone enanthate 146TESTRED 146tetrabenazine 121tetracycline hcl 35TETRIX 131TEXACORT 31THALITONE 128THALOMID 171THEO-24 199theophylline 199theophylline anhydrous 199theophylline er 199THIOLA 175THIOLA EC 175thioridazine hcl 91thiothixene 91thrivite rx 207THYQUIDITY 201TIADYLT ER 115tiagabine hcl 45TIAZAC 115TIBSOVO 82TICALAST 134TICOVAC 100TIGAN 56TIGLUTIK 120TIKOSYN 33TILIA FE 153timolol 0.5% eye drop (generic for istalol) 60

timolol maleate 60,119timolol maleate 0.25% eye drop (generic fortimoptic) 60timolol maleate 0.5% eye drops (generic fortimoptic) 60timolol maleate/pf 0.5% eye drop (generic forocudose) 60TIMOPTIC 60TIMOPTIC OCUDOSE 60TIMOPTIC-XE 60tinidazole 88tiopronin 175TIROSINT 201TIROSINT-SOL 201TIVICAY 92TIVICAY PD 92TIVORBEX 180tizanidine hcl 190TLANDO 146TOBI 33TOBI PODHALER 33TOBRADEX 20TOBRADEX ST 20tobramycin 20,34tobramycin-dexamethasone 20TOBREX 20TODAY CONTRACEPTIVE SPONGE 176TOLAK 82tolcapone 86tolmetin sodium 180TOLSURA 57tolterodine tartrate 140tolterodine tartrate er 140tolvaptan 128TOPAMAX 45TOPICORT 31topiramate 45topiramate er 45TOPROL XL 119toremifene citrate 131TORONOVA II SUIK 180

TORONOVA SUIK 180torsemide 127TOSYMRA 70TOUJEO MAX SOLOSTAR 158TOUJEO SOLOSTAR 158TOVET EMOLLIENT 32TOVIAZ 140TPOXX (NATIONAL STOCKPILE) 103TRACLEER 188TRADJENTA 52tramadol er 100 mg tablet (generic for ryzolt) 9tramadol er 200 mg tablet (generic for ryzolt) 9tramadol er 300 mg tablet (generic for ryzolt) 10tramadol hcl 10tramadol hcl er 10tramadol hcl er 100 mg capsule (generic forconzip) 10tramadol hcl er 100 mg tablet (generic for ultramer) 10tramadol hcl er 200 mg capsule (generic forconzip) 10tramadol hcl er 200 mg tablet (generic for ultramer) 10tramadol hcl er 300 mg capsule (generic forconzip) 10tramadol hcl er 300 mg tablet (generic for ultramer) 10tramadol hcl-acetaminophen 10trandolapril 185trandolapril-verapamil er 185tranexamic acid 64TRANSDERM-SCOP 55TRANXENE T-TAB 108tranylcypromine sulfate 48TRANZAREL 192TRAVATAN Z 61travoprost 61trazodone hcl 50TRECATOR 71TRELEGY ELLIPTA 123TREMFYA 198

treprostinil 189TRESIBA 158TRESIBA FLEXTOUCH U-100 158TRESIBA FLEXTOUCH U-200 158TRETIN-X 192tretinoin 82,193tretinoin microsphere 193TRETTEN 64TREXALL 82TREXIMET 70TREZIX 11TRI FEMYNOR 153TRI-ESTARYLLA 153TRI-LEGEST FE 153TRI-LINYAH 153TRI-LO-ESTARYLLA 154TRI-LO-MARZIA 154TRI-LO-MILI 154TRI-LO-SPRINTEC 154TRI-MILI 154TRI-NYMYO 154TRI-PREVIFEM 154TRI-SPRINTEC 154TRI-VYLIBRA 154TRI-VYLIBRA LO 154triamcinolone acetonide 32triamterene 127triamterene-hydrochlorothiazid 127triazolam 108TRIBENZOR 184TRICARE 207TRICOR 67TRIDERM 32trientine hcl 143trifluoperazine hcl 91trifluridine 20trihexyphenidyl hcl 85TRIJARDY XR 54TRIKAFTA 124TRILEPTAL 45TRILIPIX 67

TRILOAN SUIK 145TRILYTE WITH FLAVOR PACKETS 138trimethobenzamide hcl 56trimethoprim 18trimipramine maleate 51trinatal rx 1 207TRINATE 207TRINTELLIX 50TRIUMEQ 94TRIUMEQ PD 94triveen-duo dha 207TRIVORA-28 154TRIXYLITRAL 180TRIZIVIR 94TROKENDI XR 45tropicamide 135trospium chloride 140trospium chloride er 140tru-micin 181TRUDHESA 1TRULANCE 139TRULICITY 53TRUMENBA 100TRUSELTIQ 82TRUSOPT 61TRUVADA 94TUDORZA PRESSAIR 39TUKYSA 83TULANA 154TURALIO 83TUSNEL PEDIATRIC 187TUSSICAPS 187TUZISTRA XR 187TWINRIX 100TWIRLA 154TWYNEO 193TWYNSTA 184TYBLUME 154TYBOST 175TYDEMY 154TYKERB 83

TYMLOS 182TYPHIM VI 100TYRVAYA 110TYVASO 189TYVASO DPI 189TYVASO REFILL KIT 189TYVASO STARTER KIT 189

UUBRELVY 69UCERIS 145UDENYCA 114UKONIQ 83ULESFIA 25ULORIC 163ULTRACET 11ULTRAM 11ULTRASAL-ER 194UNITHROID 202UPNEEQ 135UPTRAVI 189URAMAXIN 194urea 194URELLE 18URETRON D-S 18UREVAZ 194URIBEL 18uro-mp 18UROCIT-K 129UROQID-ACID NO.2 18UROXATRAL 2URSO 138URSO FORTE 138ursodiol 138utira-c 18

VVAGIFEM 133valacyclovir 104VALCHLOR 83VALCYTE 104

valganciclovir hcl 104VALIUM 108valproic acid 45valsartan 184valsartan-hydrochlorothiazide 184VALTOCO 108VALTREX 104VANATOL LQ 3VANATOL S 3VANCOCIN HCL 36vancomycin hcl 36VANDAZOLE 23VANOS 32VANOXIDE-HC 32VAQTA 100varenicline 110varenicline tartrate 110VARIVAX VACCINE 100VARUBI 56VASCEPA 66VASERETIC 185VASHE WOUND 126VASHE WOUND THERAPY 126VASOTEC 185VAXCHORA ACTIVE COMPONENT 100VAXCHORA BUFFER COMPONENT 183VAXCHORA VACCINE 100VAXELIS 96VAXNEUVANCE 100vcf 176VECTICAL 198VELETRI 189VELIVET 154VELPHORO 160VELTASSA 160VELTIN 23VEMLIDY 104VENCLEXTA 83VENCLEXTA STARTING PACK 83venlafaxine hcl 48venlafaxine hcl er 48

VENNGEL ONE 180VENTAVIS 189VENTOLIN HFA 112verapamil er 115verapamil er pm 115verapamil hcl 115verapamil sr 115VERDESO 32VERELAN 115VERELAN PM 115VERKAZIA 26VERQUVO 203VERSACLOZ 90VERZENIO 83VESICARE 140VESICARE LS 140VESTURA 154VEXASYN 126VFEND 57VIBERZI 139VIBRAMYCIN 35,36VICODIN HP 11VICTOZA 2-PAK 53VICTOZA 3-PAK 53VIEKIRA PAK 142VIENVA 154vigabatrin 45VIGADRONE 45VIGAMOX 20VIIBRYD 50VIJOICE 175vilazodone hcl 50VIMOVO 180VIMPAT 45VINATE CARE 207vinate one 207vinate-m 207VIOKACE 138VIORELE 154VIRACEPT 95VIRAMUNE 92

VIRAMUNE XR 92VIRAZOLE 104VIREAD 94virt-c dha 207virt-nate dha 207virt-pn dha 207virt-pn plus 207VISTARIL 105VISTOGARD 163VITAFOL GUMMIES 207VITAFOL NANO 207VITAFOL ULTRA 207VITAFOL-OB 207VITAFOL-OB+DHA 207VITAFOL-ONE 207VITAMEDMD ONE RX 207VITAMEDMD REDICHEW RX 207vitamin b-12 208vitamin d2 209VITAPEARL 208VITATRUE 208VITRAKVI 83VIVELLE-DOT 133VIVLODEX 180VIVOTIF 100VIZIMPRO 83VOCABRIA 92VOGELXO 146VOLNEA 154VOLTAREN 180VOLTAREN-XR 180VONJO 83VONVENDI 64VOQUEZNA DUAL PAK 101VOQUEZNA TRIPLE PAK 101voriconazole 57VOSEVI 141VOTRIENT 84VOXZOGO 175VP-PNV-DHA 208VRAYLAR 90

VTAMA 198VTOL LQ 3VUITY 61VUMERITY 171VUSION 59VYFEMLA 154VYLIBRA 154VYNDAMAX 176VYNDAQEL 176VYTONE 24VYTORIN 66VYVANSE 14VYZULTA 61

WWAKIX 17warfarin sodium 39WELCHOL 66WELIREG 84WELLBUTRIN SR 47WELLBUTRIN XL 47WERA 154westab plus 208WESTHROID 202WHYTEDERM SURGIPAK 198WHYTEDERM TDPAK 32WHYTEDERM TRILASIL PAK 32WILATE 64WINLEVI 198WIXELA INHUB 123WP THYROID 202WPR PLUS 192wrestone 176WYMZYA FE 154WYNZORA 198

XXADAGO 86XALATAN 61XALIX 194XALKORI 84

XANAX 108XANAX XR 108XARELTO 39XATMEP 84XCOPRI 46XELJANZ 168XELJANZ XR 168XELODA 84XELPROS 61XENAZINE 121XENLETA 36XEPI 23XERESE 23XERMELO 137XHANCE 26XIFAXAN 37XIGDUO XR 54XIIDRA 26XILAPAK 32XIMINO 36XOFLUZA 103XOLAIR 188XOPENEX 112XOPENEX HFA 112XOSPATA 84XPOVIO 84XRYLIDERM 192XTAMPZA ER 11XTANDI 84XULANE 155XULTOPHY 100-3.6 158XURIDEN 176XYNTHA 64XYNTHA SOLOFUSE 64XYOSTED 146XYREM 120XYWAV 120XYZAL 64

YYASMIN 28 155

YAZ 155YONSA 84YOSPRALA 181YUPELRI 39YUVAFEM 133

ZZAFEMY 155zafirlukast 27zaleplon 105zalvit 208ZANAFLEX 190ZARAH 155ZARONTIN 47ZARXIO 114zatean-pn dha 208zatean-pn plus 208ZAVESCA 176ZCORT 145ZEBUTAL 3ZEGALOGUE AUTOINJECTOR 65ZEGALOGUE SYRINGE 65ZEGERID 102ZEJULA 84ZELAPAR 87ZELBORAF 85ZELNORM 140ZEMBRACE SYMTOUCH 70ZEMPLAR 209ZENATANE 198ZENPEP 138ZENZEDI 14ZEPATIER 142ZEPOSIA 171,172ZERVIATE 134ZESTORETIC 185ZESTRIL 185ZETIA 66ZETONNA 26ZIAGEN 94ZIANA 23

zidovudine 94ZIEXTENZO 114zileuton er 27ZILXI 23zingiber 208ZIOPTAN 61ziprasidone hcl 90ZIPSOR 180ZIRGAN 20ZITHRANOL 194ZITHROMAX 162ZOCOR 68ZOFRAN 55ZOHYDRO ER 11ZOKINVY 176ZOLINZA 85zolmitriptan 70zolmitriptan odt 71ZOLOFT 50zolpidem tartrate 105zolpidem tartrate er 105ZOLPIMIST 105ZOMIG 71ZOMIG ZMT 71ZONALON 192ZONEGRAN 46zonisamide 46ZONTIVITY 95ZORTRESS 173ZORVOLEX 180ZOSTAVAX 100ZOVIA 1-35 155ZOVIA 1-35E 155ZOVIRAX 23,104ZTALMY 85ZUBSOLV 12ZUMANDIMINE 155ZUPLENZ 55ZYCLARA 199ZYDELIG 85ZYFLO 27

ZYKADIA 85ZYLET 20ZYMAXID 20ZYPITAMAG 68ZYPREXA 91ZYPREXA ZYDIS 91ZYTIGA 85ZYVOX 36

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