2 02 2 List of Cover ed Drugs (Formulary)

Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)

2022 List of Covered Drugs (Formulary) Counties Los Angeles amp San Diego

This formulary was updated on 08192021 For more recent information or other questions please contact Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free or visit wwwblueshieldcacompromisecalmediconnect

Formulary ID 22440 Version 8

H0148_22_156_C_Approved08052021

06212022

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is freeFor more information visit wwwblueshieldcacompromisecalmediconnect

Blue Shield Promise Cal MediConnect Plan | 2022 List of Covered Drugs (Formulary)

Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and over-the-counter drugs and items are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook You can request a copy by calling Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free

Table of Contents

A Disclaimers iii

B Frequently Asked Questions (FAQ) vi

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) vi

B2 Does the Drug List ever change vii

B3 What happens when there is a change to the Drug List viii

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs ix

B5 How will I know if the drug I want has limits or if there are required actions to take to get the drug ix

B6 What happens if Blue Shield Promise Cal MediConnect Plan changes their rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) x

B7 How can I find a drug on the Drug List x

B8 What if the drug I want to take is not on the Drug List x

B9 What if I am a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find my drug on the Drug List or have a problem getting my drug xi

B10 Can I ask for an exception to cover my drug xii

B11 How can I ask for an exception xii

B12 How long does it take to get an exception xii

B13 What are generic drugs xii

B14 What are OTC drugs xiii

B15 Does Blue Shield Promise Cal MediConnect Plan cover OTC non-drug products xiii

B16 What is my copay xiii

B17 What are drug tiers xiv

C Overview of the List of Covered Drugs xiv

C1 Drugs Grouped by Medical Condition xvi

D Index of Covered Drugs 120 125

A Disclaimers

This is a list of drugs that members can get in Blue Shield Promise Cal MediConnect

Blue Shield Promise Cal MediConnect is a health plan that contracts with bothMedicare and Medi-Cal to provide benefits of both programs to enrollees

The List of Covered Drugs andor pharmacy and provider networks maychange throughout the year We will send you a notice before we make achange that affects you

Benefits andor copays may change on January 1 of each year

You can always check Blue Shield Promise Cal MediConnectrsquos up-to-date Listof Covered Drugs online at wwwblueshieldcacompromisecalmediconnector by calling 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days aweek The call is free

Limits copays and restrictions may apply For more information call BlueShield Promise Cal MediConnect Customer Care or read the Blue ShieldPromise Cal MediConnect Member Handbook

Copays for prescription drugs may vary based on the level of Extra Help youget Please contact the plan for more details

ATTENTION If you speak English language assistance services free of chargeare available to you Call 1-855-905-3825 (TTY 711) 800 am to 800 pmseven days a week The call is free

中文 (Chinese)请留意如果您说中文可以免费获得语言协助服务请拨打 1-855-905-3825（听障

和语障专线711）每周七天办公早上 800 至晚上 800此电话为免付费专线

한국어(Korean)주 귀하가 한국어를 사용하시는 경우 무료로 언어 지원 서비스를 이용하실 수있습니다 1-855-905-3825(TTY 711)번으로 주 7일 오전 8시부터 오후 8시까지전화하실 수 있습니다 이 전화는 무료입니다

Русский (Russian)ОБРАТИТЕ ВНИМАНИЕ Если Вы говорите по-русски мы можем предложитьВам бесплатные услуги языковой поддержки Звоните по телефону 1-855-905-3825 (TTY 711) с 800 до 2000 без выходных Звонок бесплатный

) فارسیFarsi ( توجھ اگر بھ زبان فارسی صحبت می کنید خدمات امداد زبانی بدون اخذ ھزینھ در اختیار شما می باشد با شماره

1-855-905-3825 (TTY711) شب در ھفت روز ھفتھ تماس بگیرید این تماس 800صبح تا 800 از ساعت رایگان است

भाषा (Hindi)धयान यद आप भाषा बोलत ह तो आपक लए भाषा सहायता सवाए नःशलक उपलबध ह फ़ोन करना1-855-905-3825 (TTY 711) सबह 800 बज स शाम 800 बज तक सपताह क सात दन फ़ोनकरना फर ह

Lus Hmoob (Hmong)LUS CEEV Yog koj hais Lus Hmoob muaj kev pab txhais lus pub dawb raukojHu rau 1-855-905-3825 (TTY 711) 800 teev sawv ntxov txog 800 teev tsausntuj xya hnub hauv ib lub as thivQhov hu xov tooj no yog hu dawb xwb

Espantildeol (Spanish)ATENCIOacuteN Si usted habla espantildeol hay a su disposicioacuten servicios de asistenciade idiomas sin costo Llame al 1-855-905-3825 (TTY 711) de 800 am a 800pm los siete diacuteas de la semana La llamada es gratuita

Tiếng Việt (Vietnamese)LƯU Yacute Nếu quyacute vị noacutei tiếng Việt chuacuteng tocirci sẽ cung cấp miễn phiacute dịch vụ hỗ trợngocircn ngữ cho quyacute vị Goi socirc 1-855-905-3825 (TTY 711) 8 giơ sang đến 8 giơ tocirciba y nga y trong tuacircn Cuocircc goi na y miecircn phi

Tagalog (Tagalog)PAUNAWA Kung nagsasalita kayo ng Tagalog may mga available na librengserbisyo ng tulong sa wika para sa inyo Tumawag sa 1-855-905-3825 (TTY 711)800 am hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

) العربیةArabic( 3825-905-855-1اتصل على الرقم كنت تتحدث اللغة العربیة یتوفر لك خدمات المساعدة اللغویة المجانیة إذا تنبیھ

(TTY 711) علما بأن ھذه المكالمة مجانیة مساء طوال أیام الأسبوع 800صباحا إلى 800 من الساعة

ພາສາລາວ (Laotian)ສງສາຄນ ຖາທານເວາພາສາລາວແມນມບລການຊວຍເຫອທາງດານພາສາບເສຍຄາໃຫທານ ໂທຫາເບ1-855-905-3825 (TTY 711) 800 ໂມງເຊາ ຫາ 800 ໂມງແລງ ເຈດວນຕອາທດການໂທແມນບເສຍຄາ

日本語 (Japanese)注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825 (TTY 711）までお電話にてご連絡ください毎日午前 8 時から午後 8 時

まで受け付けています通話は無料です

ภาษาไทย (Thai)เรยน หากคณพดภาษา ภาษาไทยเรามบรการความช วยเหลอด านภาษาให แก คณโดยไม มค าใช จ ายโทร 1-855-905-3825 (TTY 711) 800 น ถง 2000 น ได ตลอดเจดวนต อสปดาห โทรฟรไม มค าใช จ าย

ਪ ਜਾਬੀ (Punjabi)ਸਾਵਧਾਨ ਜ ਤਸ [ਪਜਾਬੀ] ਬਲਦ ਹ ਤ ਤਹਾਡ ਲਈ ਮਫਤ ਭਾਸ ਸਹਾਇਤਾ ਸਵਾਵ ਉਪਲਬਧ ਹਨ | ਕਾਲ ਕਰ1-855-905-3825 (TTY 711) ਸਵਰ 800 ਵਜ ਤ ਸ 800 ਵਜ ਤ ਕ ਹਫ਼ਤ ਦ ਸ ਤ ਿਦਨ |711) ਸਵਰ ਦ 8ਵਜ ਤ ਲ ਕ ਰਾਤ ਦ 8 ਵਜ ਤਕ ਹਫ਼ਤ ਦ ਸ ਤ ਿਦਨ ਕਾਲ ਫੀ ਹ |

ែខរ (Khmer)បរមណ េបើសនអកនយែខរ េសជនយ គនសបអក

េយឥតគតៃថ េ 1-855-905-3825 (TTY 711) េង 800 រពក ដល 800 យប

រពរៃថមយទតយ េគឥតគតៃថេទ

Հայերեն (Armenian)ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն Ձեզ տրամադրելի են անվճարլեզվական օգնության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY 711)համարով 800-ից 2000 շաբաթը յոթ օր Հեռախոսազանգն անվճար է

Українська (Ukrainian)ЗВЕРНІТЬ УВАГУ Якщо Ви розмовляєте українською ми можемо запропонуватиВам безкоштовні послуги мовної підтримки Телефонуйте 1-855-905-3825 (TTY711) з 800 до 2000 без вихідних Дзвінок безкоштовний

Mienh (Mien)TOV JANGX LONGX OC Beiv taix meih gorngv Mienh waac nor ninh mbuogorn zangc duqv mbenc nzoih wang-henh nzie weih faan waac bun meihmuangx maiv zuqc feix liuc cuotv zinh nyaanh Douc waac lorx taux 1-855-905-3825 (TTY 711) 800 diemv ziangh hoc lungh ndorm mingh taux 800 zianghhoc lungh muonz yietc norm liv baaiz se koi nzoih siec hnoi Naaiv norm doucwaac gorn se wang-henh longc maiv zuqc feix liuc cuotv zinh nyaanh

You can get this document for free in other formats such as large printbraille or audio Call Customer Care at 1-855-905-3825 (TTY 711) 800am ndash 800 pm seven days a week The call is free

Blue Shield of California Promise Health Plan is an independent licenseeof the Blue Shield Association

This is not a complete list The benefit information is a summary not acomplete description of benefits For more information call the plan orread the Blue Shield Promise Cal MediConnect Plan Member Handbook

You can make a standing request to get materials in a language other thanEnglish or in an alternate format now and in the future To make a requestplease contact Blue Shield Promise Cal MediConnect Plan Customer Care

B Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs You can read all of the FAQ to learn more or look for a question and answer

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short)

The drugs on the Drug List are the drugs covered by Blue Shield Promise Cal MediConnect Plan The drugs are available at pharmacies within our network A pharmacy is in our network if we have an agreement with them to work with us and provide you services We refer to these pharmacies as ldquonetwork pharmaciesrdquo

bull Blue Shield Promise Cal MediConnect Plan will cover all medicallynecessary drugs on the Drug List if

o your doctor or other prescriber says you need them to get betteror stay healthy and

o you fill the prescription at a Blue Shield Promise Cal MediConnectPlan network pharmacy

bull In some cases you have to do something before you can get a drug(refer toquestion B4 below)

You can also find an up-to-date list of drugs that we cover on our website at wwwblueshieldcacompromisecalmediconnect or call Customer Care at 1-855-905-3825 (TTY711) 800 am to 800 pm seven days a week

B2 Does the Drug List ever change Yes and Blue Shield Promise Cal MediConnect Plan must follow Medicare and Medicaid rules when making changes We may add or remove drugs on the Drug List during the year

We may also change our rules about drugs For example we could

bull Decide to require or not require prior approval for a drug (Priorapproval is permission from Blue Shield Promise Cal MediConnectPlan before you can get a drug)

bull Add or change the amount of a drug you can get (called quantitylimits)

bull Add or change step therapy restrictions on a drug (Step therapymeans you must try one drug before we will cover another drug)

For more information on these drug rules refer to question B4

If you are taking a drug that was covered at the beginning of the year we will generally not remove or change coverage of that drug during the rest of the year unless

bull a new cheaper drug comes on the market that works as well as adrug on the Drug List now or

bull we learn that a drug is not safe or

bull a drug is removed from the market

Questions B3 and B6 below have more information on what happens when the Drug List changes

bull You can always check Blue Shield Promise Cal MediConnect Planrsquos up todate Drug List online at wwwblueshieldcacompromisecalmediconnect

bull You can also call Customer Care to check the current Drug List at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week

B3 What happens when there is a change to the Drug List Some changes to the Drug List will happen immediately For example

bull A new generic drug becomes available Sometimes a new genericdrug comes on the market that works as well as a brand name drugon the Drug List now When that happens we may remove the brandname drug and add the new generic drug but your cost for the newdrug will stay the same or will be lower When we add the newgeneric drug we may also decide to keep the brand name drug onthe list but change its coverage rules or limits

o We may not tell you before we make this change but we willsend you information about the specific change we made once ithappens

o You or your provider can ask for an exception from thesechanges We will send you a notice with the steps you can take toask for an exception Please see question B10 for more informationon exceptions

bull A drug is taken off the market If the Food and Drug Administration(FDA) says a drug you are taking is not safe or the drugrsquosmanufacturer takes a drug off the market we will take it off the DrugList If you are taking the drug we will let you know that the drug hasbeen taken off the Drug List and instruct you on what to do next

We may make other changes that affect the drugs you take We will tell you in advance about these other changes to the Drug List These changes might happen if

bull The FDA provides new guidance or there are new clinical guidelinesabout a drug

bull We add a generic drug that is not new to the market and

o Replace a brand name drug currently on the Drug List or

o Change the coverage rules or limits for the brand name drug

When these changes happen we will

bull Tell you at least 30 days before we make the change to the Drug List or

bull Let you know and give you a 30-day supply of the drug after you ask for arefill

This will give you time to talk to your doctor or other prescriber He or she can help you decide

bull If there is a similar drug on the Drug List you can take instead or

bull Whether to ask for an exception from these changes To learn more aboutexceptions refer to question B10

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs

Yes some drugs have coverage rules or have limits on the amount you can get In some cases you or your doctor or other prescriber must do something before you can get the drug For example

bull Prior approval (or prior authorization) For some drugs you or your doctor orother prescriber must get approval from Blue Shield Promise CalMediConnect Plan before you fill your prescription Blue Shield Promise CalMediConnect Plan may not cover the drug if you do not get approval

bull Quantity limits Sometimes Blue Shield Promise Cal MediConnect Planlimits the amount of a drug you can get

bull Step therapy Sometimes Blue Shield Promise Cal MediConnect Planrequires you to do step therapy This means you will have to try drugsin a certain order for your medical condition You might have to tryone drug before we will cover another drug If your doctor thinks thefirst drug doesnrsquot work for you then we will cover the second

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 ndash 119 You can also get more information by visiting our website at wwwblueshieldcacompromisecalmediconnect We have posted online documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy

You can ask for an exception from these limits This will give you time to talk to your doctor or other prescriber They can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception Please refer to questions B10-B12 for more information about exceptions

B5 How will I know if the drug I want has limits or if there are required actions to take to get the drug

1 - 124

The table of drugs on page 1 ndash 119 has a column labeled ldquoNecessary actions restrictions or limits on userdquo

B6 What happens if Blue Shield Promise Health Plan changes their rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions)

In some cases we will tell you in advance if we add or change prior approval quantity limits andor step therapy restrictions on a drug Refer to question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change

B7 How can I find a drug on the Drug List There are two ways to find a drug

bull You can search alphabetically (by the drug) drugrsquos name or

bull You can search by medical condition

To search alphabetically refer to the Index of Covered Drugs section You can find it in the index that begins on page 120 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

To search by medical condition find the section labeled ldquoDrugs Grouped by Medical Conditionrdquo on page xvi The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat For example if you have a heart condition you should look in the category Cardiovascular agents That is where you will find drugs that treat heart conditions

B8 What if the drug I want to take is not on the Drug List If you donrsquot find your drug on the Drug List call Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week and ask about it the call is free If you learn that Blue Shield Promise Cal MediConnect Plan will not cover the drug you can do one of these things

bull Ask Customer Care for a list of drugs like the one you want to takeThen show the list to your doctor or other prescriber They canprescribe a drug on the Drug List that is like the one you want to takeOr

1 - 124

bull You can ask the health plan to make an exception to cover yourdrug Please refer to questions B10-B12 for more information aboutexceptions

B9 What if I am a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find my drug on the Drug List or have a problem getting my drug

We can help We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Blue Shield Promise Cal MediConnect Plan This will give you time to talk to your doctor or other prescriber He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception

If your prescription is written for fewer days we will allow multiple refills to provide up to a maximum of 30 days of medication

We will cover a 30 day supply of your drug if

bull you are taking a drug that is not on our Drug List or

bull health plan rules do not let you get the amount ordered by yourprescriber or

bull the drug requires prior approval by Blue Shield Promise CalMediConnect Plan or

bull you are taking a drug that is part of a step therapy restriction

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need we can help If you have been in the plan for more than 90 days live in a long-term care facility and need a supply right away

bull We will cover one 31 day supply of the drug you need (unless youhave a prescription for fewer days) whether or not you are a newBlue Shield Promise Cal MediConnect Plan member

bull This is in addition to the temporary supply during the first 90 days youare a member of Blue Shield Promise Cal MediConnect Plan

Transition Policy In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield Promise Cal MediConnect Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy Examples of level of care changes are beneficiaries who are discharged from

a hospital to a home beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary beneficiaries who end a long-term care facility stay and return to the community and beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized

B10 Can I ask for an exception to cover my drug Yes You can ask Blue Shield Promise Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List

You can also ask us to change the rules on your drug

bull For example Blue Shield Promise Cal MediConnect Plan may limit theamount of a drug we will cover If your drug has a limit you can askus to change the limit and cover more

bull Other examples You can ask us to drop step therapy restrictions orprior approval requirements

B11 How can I ask for an exception To ask for an exception call Customer Care 1-855-905-3825 (TTY711) 800 am to 800 pm seven days a week Customer Care will work with you and your provider to help you ask for an exception You can also read Chapter 9 of the Member Handbook to learn more about exceptions

B12 How long does it take to get an exception After we get a statement from your prescriber supporting your request for an exception we will give you a decision within 72 hours Your prescriber can send this statement electronically (online or fax) or by mail They can also call Blue Shield Promise Pharmacy Department and give us the statement verbally and then send us a written statement if needed

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision you can ask for an expedited exception This is a faster decision If your prescriber supports your request we will give you a decision within 24 hours of getting your prescriberrsquos supporting statement

B13 What are generic drugs Generic drugs are made up of the same ingredients as brand name drugs They usually cost less than the brand name drug and their names are less commonly known Generic drugs are approved by the Food and Drug Administration (FDA)

Blue Shield Promise Cal MediConnect Plan covers both brand name drugs and generic drugs

B14 What are OTC drugs OTC stands for ldquoover-the-counterrdquo Blue Shield Promise Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to find out what OTC drugs are covered

B15 Does Blue Shield Promise Cal MediConnect Plan cover non-drug OTC products

Blue Shield Promise Cal MediConnect Plan covers some non-drug OTC products when they are written as prescriptions by your provider

Examples of non-drug OTC products include Vortex Adult Mask or Microchamber

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to find out what non-drug OTC products are covered

B16 What is my copay You can read the Blue Shield Promise Cal MediConnect Plan Drug List to learn about the copay for each drug Blue Shield Promise Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no copays Some members getting long-term care in the community will also have no copays

Copays are listed by tiers Tiers are groups of drugs with the same copay Co-pay amount will vary depending on your level of Medi-Cal eligibility

Tier Description Co-payment 30-day supply 90-day supply 100-day

supplyTier 1 Preferred Generic

Drugs $0 $0 $0

Tier 2 Generic Drugs $0 to $395 copay

$0 to $395 copay

Not available

Tier 3 Brand Drugs $0 to $985 copay

$0 to $985 copay

Not available

Tier 4 Non-Medicare Rx Over-the-counter (OTC) drugs

$0 copay $0 copay Not available

Tiers are groups of drugs on our Drug List bull Tier 1 drugs are Preferred Generic Drugs (lowest co-payment)

bull Tier 2 drugs are Generic Drugs (medium co-payment)bull Tier 3 drugs are Brand Drugs (highest co-payment)bull Tier 4 drugs are Non-Medicare RX drugs and Over-the-Counter (OTC) drugs

(no copayment)

B17 What are drug tiers Tiers are groups of drugs on our Drug List

bull Tier 1 drugs are Preferred Generic Drugsbull Tier 2 drugs are Generic Drugsbull Tier 3 drugs are Brand Drugsbull Tier 4 drugs are Non-Medicare RX drugs and Over-the-Counter (OTC) drugs

C Overview of the List of Covered Drugs

The following list of covered drugs gives you information about the drugs covered by Blue Shield Promise Cal MediConnect Plan If you have trouble finding your drug in the list turn to the Index of Covered Drugs that begins on page 120 The Index alphabetically lists all drugs covered by Blue Shield Promise Cal MediConnect Plan

The first column of the chart lists the name of the drug Brand name drugs are capitalized (eg ELIQUIS) and generic drugs are listed in lower-case italics (eg simvastatin)

The information in the ldquoNecessary actions restrictions or limits on userdquo column tells you if Blue Shield Promise Cal MediConnect Plan has any rules for covering your drug

LEGEND

TIER NAME

1 Preferred Generic Drugs

2 Generic Drugs

3 Brand Drugs

4 Non-Medicare RxOTC Drugs

SYMBOL NAME DESCRIPTION

LA Limited Access This prescription may be available only at certain pharmacies For more information call Blue Shield Promise Cal MediConnect Plan Customer Care

PA Prior Authorization

You (or your physician) are required to get prior authorization from Blue Shield Promise Cal MediConnect Plan before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

QL Quantity Limit Blue Shield Promise Cal MediConnect Plan limits the quantity to be covered within a specific time frame for this drug

ST Step Therapy

Before Blue Shield Promise Cal MediConnect Plan will provide coverage for this drug you must first try another drug(s) on the formulary to treat your medical condition This drug may only be covered if the other drug(s) does not work for you

BvD Part B vs Part D

This drug may be eligible for payment under Medicare Part B or Part D You (or your physician) are required to get prior authorization from Blue Shield Promise Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

NPD Non-Part D Drug

This drug is covered by Medi-Cal and is not a ldquoPart D drugrdquo If you have questions call Blue Shield Promise Cal MediConnect Plan Customer Care

NDS Non-Extended Day Supply

Medication is NOT available for long-term supply

Note The NPD next to a drug means the drug is not a ldquoPart D drugrdquo You will not be required to pay a copay for these drugs These drugs also have different rules for appeals

bull An appeal is a formal way of asking us to review a decision we madeabout your coverage and to change it if you think we made amistake For example we might decide that a drug that you want isnot covered or is no longer covered by Medicare or Medi-Cal

bull If you or your doctor disagrees with our decision you can appeal Ifyou ever have a question call Customer Care at 1-855-905-3825 (TTY711) 800 am to 800 pm seven days a week You can also readChapter 9 of the Member Handbook to learn how to appeal adecision

C1 Drugs Grouped by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat For example if you have a heart condition you should look in the category Cardiovascular Agents That is where you will find drugs that treat heart conditions

Drugs Grouped by Medical ConditionANALGESICS 1

ANESTHETICS 4

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEMENTIA AGENTS 16

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTIMIGRAINE AGENTS 23

ANTIMYASTHENIC AGENTS 24

ANTIMYCOBACTERIALS 24

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPARKINSON AGENTS 36

ANTIPSYCHOTICS 37

ANTISPASTICITY AGENTS 41

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

BLOOD GLUCOSE REGULATORS 49

BLOOD PRODUCTS AND MODIFIERS 53

CARDIOVASCULAR AGENTS 55

CENTRAL NERVOUS SYSTEM AGENTS 66

DENTAL AND ORAL AGENTS 69

DERMATOLOGICAL AGENTS 70

ELECTROLYTESMINERALSMETALSVITAMINS 73

GASTROINTESTINAL AGENTS 76

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERS TREATMENT 79

GENITOURINARY AGENTS 80

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) 81

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) 83

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) 83

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) 87

HORMONAL AGENTS SUPPRESSANT (PITUITARY) 87

HORMONAL AGENTS SUPPRESSANT (THYROID) 88

IMMUNOLOGICAL AGENTS 89

INFLAMMATORY BOWEL DISEASE AGENTS 95

METABOLIC BONE DISEASE AGENTS 96

MISCELLANEOUS THERAPEUTIC AGENTS 97

Non-Part D Drugs 112

OPHTHALMIC AGENTS 101

OTIC AGENTS 105

RESPIRATORY TRACTPULMONARY AGENTS 106

SKELETAL MUSCLE RELAXANTS 110

SLEEP DISORDER AGENTS 111

ANALGESICS

Name of drug What the drug will costyou(tier level)

Necessary actionsrestrictions or limits onuse

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib (cap 100 mg cap 200mg cap 50 mg)

Tier 2 QL (2 PER 1 DAYS)

celecoxib cap 400 mg Tier 2 QL (1 PER 1 DAYS)

diclofenac potassium tab 50 mg Tier 2

diclofenac sodium (tab delayedrelease 25 mg tab delayed release50 mg tab delayed release 75 mgtab er 24hr 100 mg)

Tier 2

diclofenac sodium gel 1 Tier 2

diflunisal tab 500 mg Tier 2

etodolac (tab 400 mg tab 500 mgtab er 24hr 400 mg tab er 24hr 500mg tab er 24hr 600 mg)

Tier 2

flurbiprofen tab 100 mg Tier 2

ibuprofen (tab 400 mg tab 600 mgtab 800 mg)

Tier 2

indomethacin (cap 25 mg cap 50mg)

Tier 2 PA

meloxicam (tab 15 mg tab 75 mg) Tier 2

nabumetone (tab 500 mg tab 750mg)

Tier 2

naproxen (tab 250 mg tab 375 mgtab 500 mg tab ec 375 mg tab ec500 mg)

Tier 2

piroxicam (cap 10 mg cap 20 mg) Tier 2

sulindac (tab 150 mg tab 200 mg) Tier 2

OPIOID ANALGESICS LONG-ACTINGfentanyl (patch 72hr 100 mcghrpatch 72hr 12 mcghr patch 72hr 25mcghr patch 72hr 50 mcghrpatch 72hr 75 mcghr)

Tier 2 PA QL (10 PER 30 OVERTIME) NDS

methadone hcl (10 mg5ml solutionsoln 10 mg5ml)

methadone hcl (10 mgml solutioninj 10 mgml)

Tier 2 PA NDS

You can find information on what the symbols and abbreviations in this table meanby going to pages xiv - xv and reading the explanation provided in the legends

ANALGESICS

methadone hcl tab 10 mg Tier 2 PA QL (90 PER 30 OVERTIME) NDS

morphine sulfate (tab er 100 mgtab er 200 mg tab er 60 mg)

Tier 2 QL (60 PER 30 OVER TIME)NDS

morphine sulfate tab er 15 mg Tier 2 QL (180 PER 30 OVERTIME) NDS

morphine sulfate tab er 30 mg Tier 2 QL (90 PER 30 OVER TIME)NDS

OPIOID ANALGESICS SHORT-ACTINGacetaminophen w codeine (tab300-15 mg tab 300-30 mg)

Tier 2 QL (12 PER 1 DAYS) NDS

acetaminophen w codeine soln120-12 mg5ml

Tier 2 QL (1800 PER 30 OVERTIME) NDS

acetaminophen w codeine tab300-60 mg

butalbital-acetaminophen-caff wcod cap 50-325-40-30 mg

codeine sulfate (30 mg tab tab 30mg)

CODEINE SULFATE 15 MG TAB Tier 2 QL (336 PER 30 OVERTIME) NDS

fentanyl citrate (100 mcg tab 200mcg tab 400 mcg tab 600 mcgtab 800 mcg tab lozenge on ahandle 1200 mcg lozenge on ahandle 1600 mcg lozenge on ahandle 200 mcg lozenge on ahandle 400 mcg lozenge on ahandle 600 mcg lozenge on ahandle 800 mcg)

hydrocodone-acetaminophen (tab10-325 mg tab 75-325 mg)

ANALGESICS

hydrocodone-acetaminophen soln75-325 mg15ml

hydrocodone-acetaminophen tab5-325 mg

hydromorphone hcl liqd 1 mgml Tier 2 QL (675 PER 30 OVERTIME) NDS

hydromorphone hcl tab 2 mg Tier 2 QL (154 PER 30 OVERTIME) NDS

hydromorphone hcl tab 4 mg Tier 2 QL (84 PER 30 OVER TIME)NDS

morphine sulfate (15 mg tab 30 mgtab tab 15 mg tab 30 mg)

morphine sulfate (20 mg5mlsolution oral soln 20 mg5ml)

morphine sulfate oral soln 10mg5ml

morphine sulfate oral soln 100mg5ml (20 mgml)

oxycodone hcl (tab 15 mg tab 30mg)

oxycodone hcl soln 5 mg5ml Tier 2 QL (840 PER 30 OVERTIME) NDS

oxycodone hcl tab 10 mg Tier 2 QL (84 PER 30 OVER TIME)NDS

oxycodone hcl tab 20 mg Tier 2 QL (120 PER 30 OVERTIME) NDS

oxycodone w acetaminophen (tab25-325 mg tab 5-325 mg)

oxycodone w acetaminophen tab10-325 mg

ANALGESICS

tramadol hcl tab 50 mg Tier 2 QL (8 PER 1 DAYS) NDS

tramadol-acetaminophen tab 375-325 mg

ANESTHETICS

LOCAL ANESTHETICSlidocaine hcl (4 solution soln 4) Tier 2

lidocaine hcl viscous soln 2 Tier 2

lidocaine oint 5 Tier 2 QL (50 PER 30 OVER TIME)

lidocaine patch 5 Tier 2 PA QL (3 PER 1 DAYS)

lidocaine-prilocaine cream 25-25 Tier 2 QL (30 PER 30 OVER TIME)

NAYZILAM 5 MG01ML SOLUTION Tier 3 QL (10 PER 30 OVER TIME)

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTSANTI-CRAVINGacamprosate calcium tab delayedrelease 333 mg

Tier 2

disulfiram (tab 250 mg tab 500 mg) Tier 2

OPIOID DEPENDENCEbuprenorphine hcl sl tab 2 mg (baseequiv)

Tier 2 QL (84 PER 90 OVER TIME)

buprenorphine hcl sl tab 8 mg (baseequiv)

buprenorphine hcl-naloxone hcldihydrate (-naloxone sl film 2-05 mg(base equiv) -naloxone sl film 4-1mg (base equiv))

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

buprenorphine hcl-naloxone hcl slfilm 12-3 mg (base equiv)

buprenorphine hcl-naloxone hcl sltab 2-05 mg (base equiv)

ZUBSOLV (07-018 MG SL TAB 14-036 MG SL TAB 57-14 MG SL TAB)

ZUBSOLV (114-29 MG SL TAB 29-071 MG SL TAB)

ZUBSOLV 86-21 MG SL TAB Tier 3 QL (2 PER 1 DAYS)

OPIOID REVERSAL AGENTSnaloxone hcl (04 mgml soln cartnasal spray 4 mg01ml)

naloxone hcl (inj 04 mgml inj 4mg10ml soln prefilled syringe 2mg2ml)

Tier 2

naltrexone hcl tab 50 mg Tier 2

NARCAN 4 MG01ML LIQUID Tier 3 QL (2 PER 30 OVER TIME)

SMOKING CESSATION AGENTSbupropion hcl (smoking deterrent)tab er 12hr 150 mg

NICOTROL 10 MG INHALER Tier 3

NICOTROL NS 10 MGML SOLUTION Tier 3

VARENICLINE TARTRATE (05 MG TAB1 MG TAB)

VARENICLINE TARTRATE 05 MG X 11amp 1 MG X 42 MISC

ANTIBACTERIALS

AMINOGLYCOSIDESamikacin sulfate inj 500 mg2ml (250mgml)

Tier 2

gentamicin sulfate (topical) (cream01 oint 01)

Tier 2

gentamicin sulfate inj 40 mgml Tier 2

neomycin sulfate tab 500 mg Tier 2

paromomycin sulfate cap 250 mg Tier 2

STREPTOMYCIN SULFATE 1 GMRECON SOLN

Tier 2

tobramycin sulfate (10 mgmlsolution 2 gm50ml solution for inj12 gm inj 12 gm30ml (40 mgml)(base equiv) inj 80 mg2ml (40mgml) (base equiv))

Tier 2

ANTIBACTERIALS OTHERacetic acid otic soln 2 Tier 2

aztreonam (inj 1 gm inj 2 gm) Tier 2

clindamycin hcl (cap 150 mg cap300 mg cap 75 mg)

Tier 2

clindamycin palmitate hcl for soln75 mg5ml (base equiv)

Tier 2

clindamycin phosphate (inj 300mg2ml inj 600 mg4ml inj 9gm60ml inj 900 mg6ml iv soln 300mg2ml iv soln 600 mg4ml iv soln900 mg6ml)

Tier 2

clindamycin phosphate in d5w (soln300 mg50ml soln 600 mg50ml soln900 mg50ml)

Tier 2

CLINDAMYCIN PHOSPHATE IN NACL(300-09 MG50ML- SOLUTION 600-09 MG50ML- SOLUTION 900-09MG50ML- SOLUTION)

Tier 2

clindamycin phosphate swab 1 Tier 2

clindamycin phosphate vaginalcream 2

Tier 2

ANTIBACTERIALS

colistimethate sod for inj 150 mg(colistin base activity)

Tier 2

daptomycin (350 mg recon soln foriv soln 350 mg for iv soln 500 mg)

Tier 2

fosfomycin tromethamine powdpack 3 gm (base equivalent)

linezolid (for susp 100 mg5ml tab600 mg)

Tier 2 PA

LINEZOLID IN SODIUM CHLORIDE 600-09 MG300ML- SOLUTION

Tier 2

linezolid iv soln 600 mg300ml (2mgml)

Tier 2

methenamine hippurate tab 1 gm Tier 2

metronidazole (5 mgml solution ivsoln 500 mg100ml tab 250 mg tab500 mg)

Tier 2

metronidazole (topical) (cream075 gel 075 gel 1 lotion075)

Tier 2

metronidazole vaginal gel 075 Tier 2

nitrofurantoin macrocrystal (cap 100mg cap 25 mg cap 50 mg)

Tier 2

nitrofurantoin monohydratemacrocrystalline cap 100 mg

Tier 2

ORBACTIV 400 MG RECON SOLN Tier 3 PA QL (9 PER 30 OVERTIME)

SYNERCID 150-350 MG RECON SOLN Tier 3

tigecycline (50 mg recon soln for ivsoln 50 mg)

Tier 2

trimethoprim (100 mg tab tab 100mg)

Tier 2

ANTIBACTERIALS

vancomycin hcl (125 gm reconsoln 15 gm recon soln 100 gmrecon soln 250 mg recon soln 750mg recon soln cap 125 mg (baseequivalent) cap 250 mg (baseequivalent) for iv soln 1 gm (baseequivalent) for iv soln 10 gm (baseequivalent) for iv soln 500 mg (baseequivalent) for iv soln 750 mg (baseequivalent))

Tier 2

VANDAZOLE 075 GEL Tier 3

XIFAXAN 200 MG TAB Tier 3 PA QL (9 PER 30 OVERTIME)

XIFAXAN 550 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

BETA-LACTAM CEPHALOSPORINScefaclor (125 mg5ml recon susp250 mg cap 250 mg5ml reconsusp 375 mg5ml recon susp 500mg cap cap 250 mg cap 500 mg)

Tier 2

cefadroxil (1 gm tab cap 500 mgfor susp 250 mg5ml for susp 500mg5ml tab 1 gm)

Tier 2

cefazolin sodium (1 gm recon soln100 gm recon soln 2 gm recon soln20 gm recon soln 300 gm reconsoln for inj 1 gm for inj 10 gm for inj500 mg)

Tier 2

cefdinir (cap 300 mg for susp 125mg5ml for susp 250 mg5ml)

Tier 2

cefepime hcl (2 gm recon soln forinj 1 gm for inj 2 gm)

Tier 2

cefixime (cap 400 mg for susp 100mg5ml for susp 200 mg5ml)

Tier 2

cefotaxime sodium (1 gm reconsoln for inj 1 gm)

Tier 2

cefotetan disodium (1 gm reconsoln 2 gm recon soln for inj 1 gmfor inj 2 gm)

Tier 2

cefoxitin sodium (soln 1 gm soln 10gm soln 2 gm)

Tier 2

ANTIBACTERIALS

cefpodoxime proxetil (for susp 100mg5ml for susp 50 mg5ml tab 100mg tab 200 mg)

Tier 2

cefprozil (for susp 125 mg5ml forsusp 250 mg5ml tab 250 mg tab500 mg)

Tier 2

ceftazidime (inj 1 gm inj 6 gm ivsoln 2 gm)

Tier 2

ceftriaxone sodium (inj 1 gm inj 10gm inj 2 gm inj 250 mg inj 500 mgiv soln 1 gm iv soln 2 gm)

Tier 2

cefuroxime axetil (tab 250 mg tab500 mg)

Tier 2

cefuroxime sodium (inj 75 gm inj750 mg iv soln 15 gm)

Tier 2

cephalexin (cap 250 mg cap 500mg for susp 125 mg5ml for susp250 mg5ml)

Tier 2

TAZICEF (1 GM RECON SOLN 6 GMRECON SOLN)

Tier 2

TEFLARO (400 MG RECON SOLN 600MG RECON SOLN)

Tier 3

BETA-LACTAM PENICILLINSamoxicillin amp pot clavulanate (forsusp 200-285 mg5ml for susp 250-625 mg5ml for susp 400-57mg5ml for susp 600-429 mg5mltab 250-125 mg tab 500-125 mgtab 875-125 mg)

Tier 2

AMOXICILLIN ((TRIHYDRATE) CAP 250MG (TRIHYDRATE) CAP 500 MG(TRIHYDRATE) FOR SUSP 125MG5ML (TRIHYDRATE) FOR SUSP200 MG5ML (TRIHYDRATE) FORSUSP 250 MG5ML (TRIHYDRATE)FOR SUSP 400 MG5ML(TRIHYDRATE) TAB 500 MG(TRIHYDRATE) TAB 875 MG 125 MGCHEW TAB 250 MG CHEW TAB)

Tier 2

AMOXICILLIN-POT CLAVULANATE(200-285 MG CHEW TAB 400-57 MGCHEW TAB)

Tier 2

ANTIBACTERIALS

ampicillin amp sulbactam sodium (inj15 (1-05) gm inj 3 (2-1) gm iv soln15 (10-5) gm)

Tier 2

AMPICILLIN 500 MG CAP Tier 2

ampicillin sodium (1 gm recon soln125 mg recon soln 2 gm recon solnfor inj 1 gm for inj 2 gm for inj 250mg for inj 500 mg for iv soln 10 gmfor iv soln 2 gm)

Tier 2

AMPICILLIN-SULBACTAM SODIUM(15 (1-05) GM RECON SOLN 3 (2-1)GM RECON SOLN)

Tier 2

BICILLIN L-A (1200000 UNIT2ML SUSPPRSYR 2400000 UNIT4MLSUSPENSION 600000 UNITML SUSPPRSYR)

Tier 3

dicloxacillin sodium (cap 250 mgcap 500 mg)

Tier 2

nafcillin sodium (1 gm recon soln 2gm recon soln for inj 1 gm for inj 2gm for iv soln 10 gm)

Tier 2

penicillin g potassium (inj 20000000unit inj 5000000 unit)

Tier 2

PENICILLIN G SODIUM 5000000 UNITRECON SOLN

Tier 2

penicillin v potassium (125 mg5mlrecon soln 250 mg5ml recon solntab 250 mg tab 500 mg)

Tier 2

PFIZERPEN (20000000 UNIT RECONSOLN 5000000 UNIT RECON SOLN)

Tier 2

piperacillin sodium-tazobactamsodium (na for inj 3375 gm (3-0375gm) sod for inj 135 gm (12-15 gm)sod for inj 225 gm (2-025 gm) sodfor inj 45 gm (4-05 gm) sod for inj405 gm (36-45 gm))

Tier 2

CARBAPENEMSertapenem sodium for inj 1 gm(base equivalent)

Tier 2

ANTIBACTERIALS

imipenem-cilastatin (250 mg reconsoln intravenous for soln 250 mgintravenous for soln 500 mg)

Tier 2

meropenem (soln 1 gm soln 500mg)

Tier 2

MACROLIDESazithromycin (1 gm packet for susp100 mg5ml for susp 200 mg5ml ivfor soln 500 mg tab 250 mg tab 500mg tab 600 mg)

Tier 2

clarithromycin (125 mg5ml reconsusp 250 mg5ml recon susp tab250 mg tab 500 mg tab er 24hr 500mg)

Tier 2

EES 400 400 MG TAB Tier 2

ERYTHROCIN LACTOBIONATE 500MG RECON SOLN

Tier 3

erythromycin base (base 250 mg cpdr part tab 250 mg tab 500 mg wdelayed release particles cap 250mg)

Tier 2

ERYTHROMYCIN ETHYLSUCCINATE400 MG TAB

Tier 2

erythromycin lactobionate for inj 500mg

Tier 3

QUINOLONESBESIVANCE 06 SUSPENSION Tier 3

CILOXAN 03 OINTMENT Tier 3

ciprofloxacin 200 mg100ml in d5w Tier 2

ciprofloxacin for oral susp 500mg5ml (10) (10 gm100ml)

Tier 2

ciprofloxacin hcl (100 mg tab tab250 mg (base equiv) tab 500 mg(base equiv) tab 750 mg (baseequiv))

Tier 2

ciprofloxacin hcl ophth soln 03(base equivalent)

Tier 2

ANTIBACTERIALS

levofloxacin (iv soln 25 mgml oralsoln 25 mgml tab 250 mg tab 500mg tab 750 mg)

Tier 2

levofloxacin in d5w (soln 500mg100ml soln 750 mg150ml)

Tier 2

moxifloxacin hcl tab 400 mg (baseequiv)

Tier 2

ofloxacin (300 mg tab tab 400 mg) Tier 2

SULFONAMIDESsulfacetamide sodium lotion 10(acne)

Tier 2

sulfadiazine (500 mg tab tab 500mg)

Tier 2

sulfamethoxazole-trimethoprim (ivsoln 400-80 mg5ml susp 200-40mg5ml tab 400-80 mg tab 800-160mg)

Tier 2

TETRACYCLINESdoxycycline (monohydrate) (cap100 mg cap 50 mg tab 100 mgtab 50 mg tab 75 mg)

Tier 2

doxycycline hyclate (cap 100 mgcap 50 mg for inj 100 mg tab 100mg tab 20 mg)

Tier 2

minocycline hcl (cap 100 mg cap50 mg cap 75 mg tab 100 mg tab50 mg tab 75 mg)

Tier 2

tetracycline hcl (cap 250 mg cap500 mg)

Tier 2

ANTICONVULSANTS

ANTICONVULSANTS OTHERBRIVIACT (10 MG TAB 100 MG TAB25 MG TAB 50 MG TAB 75 MG TAB)

Tier 3 ST QL (2 PER 1 DAYS)

ANTICONVULSANTS

BRIVIACT 10 MGML SOLUTION Tier 3 ST QL (20 PER 1 DAYS)

DIACOMIT (250 MG CAP 250 MGPACKET)

Tier 3 PA LA QL (3 PER 1 DAYS)

divalproex sodium (cap delayedrelease sprinkle 125 mg tabdelayed release 125 mg tabdelayed release 250 mg tabdelayed release 500 mg tab er 24hr 250 mg tab er 24 hr 500 mg)

Tier 2

EPIDIOLEX 100 MGML SOLUTION Tier 3 PA LA

EPRONTIA 25 MGML SOLUTION Tier 3 PA QL (16 PER 1 DAYS)

felbamate (susp 600 mg5ml tab400 mg tab 600 mg)

Tier 2

FINTEPLA 22 MGML SOLUTION Tier 3 PA LA QL (12 PER 1 DAYS)

FYCOMPA (10 MG TAB 12 MG TAB 4MG TAB 6 MG TAB 8 MG TAB)

FYCOMPA 05 MGML SUSPENSION Tier 3 QL (24 PER 1 DAYS)

FYCOMPA 2 MG TAB Tier 3 QL (3 PER 1 DAYS)

lamotrigine (tab 100 mg tab 150mg tab 200 mg tab 25 mg tabchewable dispersible 25 mg tabchewable dispersible 5 mg)

Tier 2

levetiracetam (oral soln 100 mgmltab 1000 mg tab 250 mg tab 500mg tab 750 mg)

Tier 2

levetiracetam tab er 24hr 500 mg Tier 2 QL (6 PER 1 DAYS)

SPRITAM (250 MG TAB 500 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

SPRITAM 1000 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

topiramate (sprinkle cap 15 mgsprinkle cap 25 mg tab 100 mg tab200 mg tab 25 mg tab 50 mg)

Tier 2

valproate sodium (inj 100 mgmloral soln 250 mg5ml (base equiv))

Tier 2

ANTICONVULSANTS

valproic acid cap 250 mg Tier 2

XCOPRI (100 MG TAB 50 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)

XCOPRI (250 MG DAILY DOSE) (MGDAILY DOSE) 100 amp 150 MG TABTHPK MG DAILY DOSE) 50 amp 200 MGTAB THPK)

Tier 3 PA QL (2 PER 1 DAYS)

XCOPRI (350 MG DAILY DOSE) 150 amp200 MG TAB THPK

XCOPRI (COPRI 14 125 MG amp 14 25MG TAB THPK COPRI 14 150 MG amp14 200 MG TAB THPK COPRI 14 50MG amp 14 100 MG TAB THPK)

Tier 3 PA QL (28 PER 28 OVERTIME)

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG CAP Tier 3

ethosuximide (cap 250 mg soln 250mg5ml)

Tier 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam suspension 25 mgml Tier 2 PA QL (16 PER 1 DAYS)

clobazam tab 10 mg Tier 2 PA QL (4 PER 1 DAYS)

DIAZEPAM 10 MG GEL Tier 2 QL (20 PER 30 OVER TIME)

gabapentin (tab 600 mg tab 800mg)

gabapentin cap 100 mg Tier 2 QL (12 PER 1 DAYS)

gabapentin oral soln 250 mg5ml Tier 2 QL (72 PER 1 DAYS)

phenobarbital (elixir 20 mg5ml tab100 mg tab 15 mg tab 162 mg tab30 mg tab 324 mg tab 60 mg tab648 mg tab 972 mg)

Tier 2 PA

ANTICONVULSANTS

primidone (tab 250 mg tab 50 mg) Tier 2

SYMPAZAN (10 MG FILM 20 MGFILM 5 MG FILM)

tiagabine hcl (tab 12 mg tab 16mg tab 2 mg tab 4 mg)

Tier 2 PA

VALTOCO 10 MG DOSE 10MG01ML LIQUID

VALTOCO 15 MG DOSE 75MG01ML LIQD THPK

VALTOCO 5 MG DOSE 5 MG01MLLIQUID

vigabatrin (powd pack 500 mg tab500 mg)

SODIUM CHANNEL AGENTSAPTIOM (200 MG TAB 400 MG TAB) Tier 3 QL (1 PER 1 DAYS)

APTIOM (600 MG TAB 800 MG TAB) Tier 3 QL (2 PER 1 DAYS)

carbamazepine (cap er 12hr 100mg cap er 12hr 200 mg cap er 12hr300 mg chew tab 100 mg susp 100mg5ml tab 200 mg tab er 12hr 100mg tab er 12hr 200 mg tab er 12hr400 mg)

Tier 2

DILANTIN (100 MG CAP 30 MG CAP) Tier 3

DILANTIN INFATABS 50 MG CHEWTAB

Tier 3

lacosamide (tab 100 mg tab 150mg tab 200 mg tab 50 mg)

lacosamide iv inj 200 mg20ml (10mgml)

Tier 2 BvD

lacosamide oral solution 10 mgml Tier 2 QL (40 PER 1 DAYS)

oxcarbazepine (susp 300 mg5ml(60 mgml) tab 150 mg tab 300mg tab 600 mg)

Tier 2

PEGANONE 250 MG TAB Tier 3

ANTICONVULSANTS

PHENYTEK (200 MG CAP 300 MGCAP)

Tier 3

phenytoin (chew tab 50 mg susp125 mg5ml)

Tier 2

phenytoin sodium extended (cap100 mg cap 200 mg cap 300 mg)

Tier 2

rufinamide susp 40 mgml Tier 2 ST QL (80 PER 1 DAYS)

rufinamide tab 200 mg Tier 2 ST QL (16 PER 1 DAYS)

VIMPAT 10 MGML SOLUTION Tier 3 QL (40 PER 1 DAYS)

zonisamide (cap 100 mg cap 25mg cap 50 mg)

Tier 2

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS OTHERERGOLOID MESYLATES 1 MG TAB Tier 2 PA

CHOLINESTERASE INHIBITORSdonepezil hydrochloride (orallydisintegrating tab 10 mg orallydisintegrating tab 5 mg tab 10 mgtab 5 mg)

Tier 2

rivastigmine (patch 24hr 133mg24hr patch 24hr 46 mg24hrpatch 24hr 95 mg24hr)

rivastigmine tartrate (cap 15 mg(base equivalent) cap 3 mg (baseequivalent) cap 45 mg (baseequivalent) cap 6 mg (baseequivalent))

Tier 2

ANTIDEMENTIA AGENTS

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (cap er 24hr 14 mgcap er 24hr 21 mg cap er 24hr 28mg cap er 24hr 7 mg oral solution 2mgml tab 10 mg tab 28 x 5 mg amp21 x 10 mg titration pack tab 5 mg)

Tier 2

ANTIDEPRESSANTS

ANTIDEPRESSANTS OTHERbupropion hcl (tab 100 mg tab er12hr 100 mg)

bupropion hcl (tab er 12hr 150 mgtab er 24hr 150 mg)

bupropion hcl tab 75 mg Tier 2 QL (6 PER 1 DAYS)

bupropion hcl tab er 12hr 200 mg Tier 2 QL (2 PER 1 DAYS)

LYBALVI (10-10 MG TAB 15-10 MGTAB 20-10 MG TAB 5-10 MG TAB)

MAPROTILINE HCL (25 MG TAB 50MG TAB 75 MG TAB)

Tier 2

mirtazapine (orally disintegratingtab 15 mg orally disintegrating tab30 mg orally disintegrating tab 45mg tab 15 mg tab 30 mg tab 45mg tab 75 mg)

Tier 2

MONOAMINE OXIDASE INHIBITORSEMSAM (12 MG24HR PATCH 24HR 6MG24HR PATCH 24HR 9 MG24HRPATCH 24HR)

Tier 3 PA

MARPLAN 10 MG TAB Tier 3

phenelzine sulfate tab 15 mg Tier 2

tranylcypromine sulfate tab 10 mg Tier 2

ANTIDEPRESSANTS

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORSEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR)citalopram hydrobromide (oral soln10 mg5ml tab 10 mg (base equiv)tab 20 mg (base equiv) tab 40 mg(base equiv))

Tier 2

desvenlafaxine succinate (tab er24hr 25 mg (base equiv) tab er 24hr50 mg (base equiv))

desvenlafaxine succinate tab er24hr 100 mg (base equiv)

escitalopram oxalate (soln 5 mg5ml(base equiv) tab 10 mg (baseequiv) tab 20 mg (base equiv) tab5 mg (base equiv))

Tier 2

FETZIMA (120 MG CAP ER 24H 20MG CAP ER 24H 40 MG CAP ER 24H80 MG CAP ER 24H)

FETZIMA TITRATION 20 amp 40 MG CP24THPK

fluoxetine hcl (cap 10 mg cap 20mg cap 40 mg solution 20 mg5ml)

Tier 2

FLUOXETINE HCL (PMDD) (10 MGCAP 20 MG CAP)

Tier 2

FLUOXETINE HCL 90 MG CAP DR Tier 2 QL (4 PER 28 OVER TIME)

fluvoxamine maleate (tab 100 mgtab 25 mg tab 50 mg)

Tier 2

nefazodone hcl (100 mg tab 150mg tab 200 mg tab 250 mg tab 50mg tab tab 250 mg tab 50 mg)

Tier 2

paroxetine hcl (tab 10 mg tab 20mg tab 30 mg tab 40 mg)

Tier 2

paroxetine hcl oral susp 10 mg5ml(base equiv)

sertraline hcl (oral concentrate forsolution 20 mgml tab 100 mg tab25 mg tab 50 mg)

Tier 2

trazodone hcl (tab 100 mg tab 150mg tab 300 mg tab 50 mg)

Tier 2

ANTIDEPRESSANTS

TRINTELLIX (10 MG TAB 20 MG TAB 5MG TAB)

venlafaxine hcl (cap er 24hr 150 mg(base equivalent) cap er 24hr 375mg (base equivalent))

venlafaxine hcl (tab 100 mg (baseequivalent) tab 25 mg (baseequivalent) tab 375 mg (baseequivalent) tab 50 mg (baseequivalent) tab 75 mg (baseequivalent))

Tier 2

venlafaxine hcl cap er 24hr 75 mg(base equivalent)

VIIBRYD (10 MG TAB 20 MG TAB 40MG TAB)

VIIBRYD STARTER PACK 10 amp 20 MGKIT

Tier 3 ST QL (30 PER 30 OVERTIME)

vilazodone hcl (tab 10 mg tab 20mg tab 40 mg)

TRICYCLICSamitriptyline hcl (tab 10 mg tab 100mg tab 150 mg tab 25 mg tab 50mg tab 75 mg)

Tier 2 PA

AMOXAPINE (100 MG TAB 150 MGTAB 25 MG TAB 50 MG TAB)

Tier 2

clomipramine hcl (cap 25 mg cap50 mg cap 75 mg)

Tier 2 PA

desipramine hcl (tab 10 mg tab 100mg tab 150 mg tab 25 mg tab 50mg tab 75 mg)

Tier 2

doxepin hcl (cap 10 mg cap 100mg cap 150 mg cap 25 mg cap50 mg cap 75 mg conc 10 mgml)

Tier 2 PA

imipramine hcl (tab 10 mg tab 25mg tab 50 mg)

Tier 2 PA

nortriptyline hcl (10 mg5ml solutioncap 10 mg cap 25 mg cap 50 mgcap 75 mg soln 10 mg5ml)

Tier 2

ANTIDEPRESSANTS

nortriptyline oral solution (unit dose) Tier 2

protriptyline hcl (tab 10 mg tab 5mg)

Tier 2

trimipramine maleate (cap 100 mgcap 25 mg cap 50 mg)

Tier 2 PA

ANTIEMETICS

ANTIEMETICS OTHERmeclizine hcl (tab 125 mg tab 25mg)

Tier 2

metoclopramide hcl (inj 5 mgml(base equivalent) soln 5 mg5ml (10mg10ml) (base equiv) tab 10 mg(base equivalent) tab 5 mg (baseequivalent))

Tier 2

perphenazine (tab 16 mg tab 2 mgtab 4 mg tab 8 mg)

Tier 2

prochlorperazine maleate (tab 10mg (base equivalent) tab 5 mg(base equivalent))

Tier 2

prochlorperazine suppos 25 mg Tier 2

promethazine hcl (tab 125 mg tab25 mg tab 50 mg)

Tier 2 PA

scopolamine td patch 72hr 1mg3days

Tier 2 PA

EMETOGENIC THERAPY ADJUNCTSaprepitant (capsule 125 mgcapsule 80 mg capsule therapypack 80 amp 125 mg)

Tier 2 BvD

aprepitant capsule 40 mg Tier 2 PA QL (1 PER 30 OVERTIME)

dronabinol (cap 10 mg cap 25 mgcap 5 mg)

ANTIEMETICS

granisetron hcl (01 mgml solutioninj 1 mgml inj 4 mg4ml (1 mgml))

Tier 2 BvD

granisetron hcl tab 1 mg Tier 2 QL (2 PER 1 DAYS) BvD

ondansetron (tab 4 mg tab 8 mg) Tier 2 QL (3 PER 1 DAYS) BvD

ondansetron hcl (24 mg tab tab 24mg)

Tier 2 QL (15 PER 30 OVER TIME)BvD

ondansetron hcl (tab 4 mg tab 8mg)

Tier 2 QL (3 PER 1 DAYS) BvD

ondansetron hcl oral soln 4 mg5ml Tier 2 QL (30 PER 1 DAYS) BvD

ANTIFUNGALS

ANTIFUNGALSABELCET 5 MGML SUSPENSION Tier 3 BvD

AMBISOME 50 MG RECON SUSP Tier 3 BvD

AMPHOTERICIN B 50 MG RECONSOLN

Tier 2 BvD

amphotericin b liposome iv for susp50 mg

Tier 2 BvD

caspofungin acetate (50 mg reconsoln 70 mg recon soln for iv soln 50mg for iv soln 70 mg)

Tier 2 PA

ciclopirox olamine (cream 077(base equiv) susp 077 (baseequiv))

Tier 2

clotrimazole (topical) (cream 1soln 1)

Tier 2

clotrimazole troche 10 mg Tier 2

CRESEMBA (186 MG CAP 372 MGRECON SOLN)

Tier 3 PA

econazole nitrate cream 1 Tier 2

fluconazole (for susp 10 mgml forsusp 40 mgml tab 100 mg tab 150mg tab 200 mg tab 50 mg)

Tier 2

ANTIFUNGALS

fluconazole in dextrose (j 200mg100ml j 400 mg200ml)

Tier 2

fluconazole in nacl (j 200 mg100mlj 400 mg200ml)

Tier 2

flucytosine (cap 250 mg cap 500mg)

Tier 2

griseofulvin microsize (susp 125mg5ml tab 500 mg)

Tier 2

griseofulvin ultramicrosize (tab 125mg tab 250 mg)

Tier 2

itraconazole cap 100 mg Tier 2 PA

ketoconazole (topical) (cream 2shampoo 2)

Tier 2

ketoconazole tab 200 mg Tier 2

micafungin sodium (soln 100 mgsoln 50 mg)

Tier 2

MICONAZOLE 3 200 MG SUPPOS Tier 2

NOXAFIL 40 MGML SUSPENSION Tier 3 PA

nystatin (topical) (cream 100000unitgm oint 100000 unitgmtopical powder 100000 unitgm)

Tier 2

nystatin susp 100000 unitml Tier 2

nystatin tab 500000 unit Tier 2

posaconazole tab delayed release100 mg

terbinafine hcl tab 250 mg Tier 2 QL (1 PER 1 DAYS)

terconazole vaginal (cream 04cream 08 suppos 80 mg)

Tier 2

voriconazole (for susp 40 mgml tab200 mg tab 50 mg)

Tier 2 PA

voriconazole for inj 200 mg Tier 2 BvD

ANTIGOUT AGENTS

ANTIGOUT AGENTSallopurinol (tab 100 mg tab 300 mg) Tier 2

colchicine (06 mg cap tab 06 mg) Tier 2 QL (4 PER 1 DAYS)

colchicine w probenecid tab 05-500 mg

Tier 2

COLCRYS 06 MG TAB Tier 3 QL (4 PER 1 DAYS)

KRYSTEXXA 8 MGML SOLUTION Tier 3 PA LA

probenecid tab 500 mg Tier 2

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS OTHERUBRELVY (100 MG TAB 50 MG TAB) Tier 3 PA QL (16 PER 30 OVER

ERGOT ALKALOIDSdihydroergotamine mesylate inj 1mgml

Tier 2 PA

dihydroergotamine mesylate nasalspray 4 mgml

MIGERGOT 2-100 MG SUPPOS Tier 3 QL (20 PER 30 OVER TIME)

PROPHYLACTICAIMOVIG (140 MG DOSE) 70 MGMLSOLN A-INJ

AIMOVIG (140 MGML SOLN A-INJ70 MGML SOLN A-INJ)

timolol maleate (tab 10 mg tab 20mg tab 5 mg)

Tier 2

SEROTONIN (5-HT) RECEPTOR AGONISTnaratriptan hcl (tab 1 mg (baseequiv) tab 25 mg (base equiv))

ANTIMIGRAINE AGENTS

rizatriptan benzoate (oraldisintegrating tab 10 mg (base eq)oral disintegrating tab 5 mg (baseeq) tab 10 mg (base equivalent)tab 5 mg (base equivalent))

sumatriptan (20 mgact 5 mgact) Tier 2 QL (18 PER 30 OVER TIME)

sumatriptan succinate (6 mg05mlsoln prsyr inj 6 mg05ml solutionauto-injector 4 mg05ml solutionauto-injector 6 mg05ml solutioncartridge 4 mg05ml solutioncartridge 6 mg05ml)

sumatriptan succinate (tab 100 mgtab 25 mg tab 50 mg)

SUMATRIPTAN SUCCINATE REFILL (4MG05ML SOLN CART 6 MG05MLSOLN CART)

zolmitriptan (orally disintegrating tab25 mg orally disintegrating tab 5mg tab 25 mg tab 5 mg)

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICSGUANIDINE HCL 125 MG TAB Tier 2

pyridostigmine bromide tab 60 mg Tier 2 QL (25 PER 1 DAYS)

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS OTHERdapsone (tab 100 mg tab 25 mg) Tier 2

rifabutin cap 150 mg Tier 2

ANTIMYCOBACTERIALS

ANTITUBERCULARSCAPASTAT SULFATE 1 GM RECONSOLN

Tier 3

ethambutol hcl (tab 100 mg tab400 mg)

Tier 2

isoniazid (100 mg tab 100 mgmlsolution 50 mg5ml syrup tab 100mg tab 300 mg)

Tier 2

PASER 4 GM PACKET Tier 3

PRIFTIN 150 MG TAB Tier 3

pyrazinamide tab 500 mg Tier 2

rifampin (cap 150 mg cap 300 mgfor inj 600 mg)

Tier 2

RIFATER 50-120-300 MG TAB Tier 3

SIRTURO 100 MG TAB Tier 3 PA QL (24 PER 28 OVERTIME)

TRECATOR 250 MG TAB Tier 3

ANTINEOPLASTICS

ALKYLATING AGENTScyclophosphamide (25 mg cap 25mg tab 50 mg cap 50 mg tab cap25 mg cap 50 mg)

Tier 3 BvD

GLEOSTINE (10 MG CAP 100 MGCAP 40 MG CAP 5 MG CAP)

Tier 3

LEUKERAN 2 MG TAB Tier 3

MATULANE 50 MG CAP Tier 3 LA

thiotepa (inj 100 mg inj 15 mg) Tier 2 BvD

ANTINEOPLASTICS

VALCHLOR 0016 GEL Tier 3 PA LA QL (60 PER 30OVER TIME)

ANTIANDROGENSabiraterone acetate tab 250 mg Tier 2 PA QL (4 PER 1 DAYS)

abiraterone acetate tab 500 mg Tier 2 PA QL (2 PER 1 DAYS)

bicalutamide tab 50 mg Tier 2

ERLEADA 60 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

flutamide (125 mg cap cap 125mg)

Tier 2

nilutamide tab 150 mg Tier 2 QL (1 PER 1 DAYS)

NUBEQA 300 MG TAB Tier 3 PA QL (4 PER 1 DAYS)

XTANDI (40 MG CAP 40 MG TAB) Tier 3 PA LA QL (4 PER 1 DAYS)

XTANDI 80 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

ANTIANGIOGENIC AGENTSlenalidomide (cap 10 mg cap 15mg cap 25 mg cap 5 mg)

POMALYST (1 MG CAP 2 MG CAP 3MG CAP 4 MG CAP)

REVLIMID (25 MG CAP 20 MG CAP) Tier 3 PA LA QL (1 PER 1 DAYS)

THALOMID (100 MG CAP 50 MGCAP)

ANTIESTROGENSMODIFIERSEMCYT 140 MG CAP Tier 3

fulvestrant (250 mg5ml solution inj250 mg5ml)

Tier 2

SOLTAMOX 10 MG5ML SOLUTION Tier 3 PA

tamoxifen citrate (tab 10 mg (baseequivalent) tab 20 mg (baseequivalent))

Tier 2

toremifene citrate tab 60 mg (baseequivalent)

Tier 2

ANTINEOPLASTICS

ANTIMETABOLITESDROXIA (200 MG CAP 300 MG CAP400 MG CAP)

Tier 3

hydroxyurea cap 500 mg Tier 2

INQOVI 35-100 MG TAB Tier 3 PA LA QL (5 PER 28 OVERTIME)

mercaptopurine tab 50 mg Tier 2

PURIXAN 2000 MG100MLSUSPENSION

Tier 3 PA LA

TABLOID 40 MG TAB Tier 3

ANTINEOPLASTICS OTHERAYVAKIT (100 MG TAB 200 MG TAB25 MG TAB 300 MG TAB 50 MG TAB)

BESREMI 500 MCGML SOLN PRSYR Tier 3 PA LA QL (2 PER 28 OVERTIME)

BRUKINSA 80 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

EXKIVITY 40 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

FOTIVDA (089 MG CAP 134 MGCAP)

Tier 3 PA LA QL (21 PER 28OVER TIME)

IDHIFA (100 MG TAB 50 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

INREBIC 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)

KISQALI FEMARA (400 MG DOSE) 200amp 25 MG TAB THPK

KISQALI FEMARA(200 MG DOSE) 200amp 25 MG TAB THPK

KOSELUGO 10 MG CAP Tier 3 PA LA QL (8 PER 1 DAYS)

leucovorin calcium (for inj 100 mgfor inj 350 mg tab 10 mg tab 15 mgtab 25 mg tab 5 mg)

Tier 2

LONSURF 15-614 MG TAB Tier 3 PA LA QL (100 PER 28OVER TIME)

ANTINEOPLASTICS

LUMAKRAS 120 MG TAB Tier 3 PA QL (8 PER 1 DAYS)

LYSODREN 500 MG TAB Tier 3

NINLARO (23 MG CAP 3 MG CAP 4MG CAP)

ONUREG (200 MG TAB 300 MG TAB) Tier 3 PA QL (14 PER 28 OVERTIME)

QINLOCK 50 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

RETEVMO 40 MG CAP Tier 3 PA QL (6 PER 1 DAYS)

ROZLYTREK 100 MG CAP Tier 3 PA QL (5 PER 1 DAYS)

SYNRIBO 35 MG RECON SOLN Tier 3 BvD

TABRECTA (150 MG TAB 200 MGTAB)

TAZVERIK 200 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

WELIREG 40 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

XPOVIO (100 MG ONCE WEEKLY) 20MG TAB THPK

Tier 3 PA LA QL (8 PER 28 OVERTIME)

XPOVIO (40 MG TWICE WEEKLY) 20MG TAB THPK

ANTINEOPLASTICS

ZOLINZA 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)

AROMATASE INHIBITORS 3RD GENERATIONanastrozole tab 1 mg Tier 2

exemestane tab 25 mg Tier 2

letrozole tab 25 mg Tier 2

MOLECULAR TARGET INHIBITORSALECENSA 150 MG CAP Tier 3 PA LA QL (8 PER 1 DAYS)

ALUNBRIG (180 MG TAB 90 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

ALUNBRIG 30 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

ALUNBRIG 90 amp 180 MG TAB THPK Tier 3 PA LA QL (30 PER 30OVER TIME)

BALVERSA 3 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

BOSULIF (400 MG TAB 500 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)

BOSULIF 100 MG TAB Tier 3 PA QL (4 PER 1 DAYS)

BRAFTOVI 50 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

CABOMETYX (20 MG TAB 40 MGTAB 60 MG TAB)

CALQUENCE 100 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

CAPRELSA 100 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

ANTINEOPLASTICS

COMETRIQ (100 MG DAILY DOSE) 80amp 20 MG KIT

COMETRIQ (140 MG DAILY DOSE) 3 X20 MG amp 80 MG KIT

COMETRIQ (60 MG DAILY DOSE) 20MG KIT

COPIKTRA (15 MG CAP 25 MG CAP) Tier 3 PA LA QL (56 PER 28OVER TIME)

COTELLIC 20 MG TAB Tier 3 PA LA QL (63 PER 28OVER TIME)

DAURISMO 100 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

ERIVEDGE 150 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

erlotinib hcl (tab 100 mg (baseequivalent) tab 150 mg (baseequivalent))

erlotinib hcl tab 25 mg (baseequivalent)

everolimus (tab 10 mg tab 75 mg) Tier 2 PA QL (2 PER 1 DAYS)

everolimus (tab for oral susp 2 mgtab for oral susp 3 mg tab for oralsusp 5 mg)

Tier 2 PA

FARYDAK (10 MG CAP 15 MG CAP20 MG CAP)

GAVRETO 100 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

GILOTRIF (20 MG TAB 30 MG TAB 40MG TAB)

IBRANCE (100 MG CAP 100 MG TAB125 MG CAP 125 MG TAB 75 MGCAP 75 MG TAB)

ICLUSIG (10 MG TAB 15 MG TAB 30MG TAB 45 MG TAB)

imatinib mesylate tab 100 mg (baseequivalent)

ANTINEOPLASTICS

IMBRUVICA (280 MG TAB 420 MGTAB 560 MG TAB 70 MG CAP)

IMBRUVICA 140 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

INLYTA 1 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)

IRESSA 250 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

JAKAFI (10 MG TAB 15 MG TAB 20MG TAB 25 MG TAB 5 MG TAB)

KISQALI (200 MG DOSE) 200 MG TABTHPK

lapatinib ditosylate tab 250 mg(base equiv)

LENVIMA (10 MG DAILY DOSE) 10MG CAP THPK

LENVIMA (12 MG DAILY DOSE) 3 X 4MG CAP THPK

LENVIMA (14 MG DAILY DOSE) 10 amp4 MG CAP THPK

LENVIMA (18 MG DAILY DOSE) 10MG amp 2 X 4 MG CAP THPK

LENVIMA (24 MG DAILY DOSE) 2 X 10MG amp 4 MG CAP THPK

LENVIMA (4 MG DAILY DOSE) 4 MGCAP THPK

LORBRENA 100 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

LYNPARZA (100 MG TAB 150 MGTAB)

ANTINEOPLASTICS

MEKINIST 05 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

MEKTOVI 15 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)

NERLYNX 40 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)

NEXAVAR 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

ODOMZO 200 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

PEMAZYRE (135 MG TAB 45 MGTAB 9 MG TAB)

PIQRAY (200 MG DAILY DOSE) 200MG TAB THPK

PIQRAY (250 MG DAILY DOSE) 200 amp50 MG TAB THPK

PIQRAY (300 MG DAILY DOSE) 2 X150 MG TAB THPK

RUBRACA (200 MG TAB 250 MG TAB300 MG TAB)

RYDAPT 25 MG CAP Tier 3 PA QL (8 PER 1 DAYS)

SCEMBLIX 20 MG TAB Tier 3 PA QL (20 PER 1 DAYS)

sorafenib tosylate tab 200 mg (baseequivalent)

SPRYCEL (100 MG TAB 140 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)

SPRYCEL 20 MG TAB Tier 3 PA QL (6 PER 1 DAYS)

STIVARGA 40 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

sunitinib malate (cap 375 mg (baseequivalent) cap 50 mg (baseequivalent))

sunitinib malate cap 125 mg (baseequivalent)

ANTINEOPLASTICS

TAFINLAR (50 MG CAP 75 MG CAP) Tier 3 PA LA QL (4 PER 1 DAYS)

TAGRISSO (40 MG TAB 80 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

TALZENNA (05 MG CAP 075 MGCAP 1 MG CAP)

TALZENNA 025 MG CAP Tier 3 PA LA QL (3 PER 1 DAYS)

TASIGNA (150 MG CAP 200 MGCAP 50 MG CAP)

TEPMETKO 225 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

TIBSOVO 250 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

TRUSELTIQ (100MG DAILY DOSE) 100MG CAP THPK

TRUSELTIQ (125MG DAILY DOSE) 100amp 25 MG CAP THPK

TUKYSA (150 MG TAB 50 MG TAB) Tier 3 PA LA QL (4 PER 1 DAYS)

TURALIO 200 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

UKONIQ 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

VENCLEXTA 10 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

VENCLEXTA STARTING PACK 10 amp 50amp 100 MG TAB THPK

VERZENIO (100 MG TAB 150 MG TAB200 MG TAB 50 MG TAB)

VITRAKVI 100 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

VITRAKVI 20 MGML SOLUTION Tier 3 PA LA QL (10 PER 1 DAYS)

VIZIMPRO (15 MG TAB 30 MG TAB45 MG TAB)

VOTRIENT 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

ANTINEOPLASTICS

XALKORI (200 MG CAP 250 MGCAP)

XOSPATA 40 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

ZEJULA 100 MG CAP Tier 3 PA LA QL (3 PER 1 DAYS)

ZELBORAF 240 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

ZYDELIG (100 MG TAB 150 MG TAB) Tier 3 PA LA QL (2 PER 1 DAYS)

ZYKADIA (150 MG CAP 150 MG TAB) Tier 3 PA LA QL (3 PER 1 DAYS)

RETINOIDSbexarotene cap 75 mg Tier 2 PA QL (10 PER 1 DAYS)

bexarotene gel 1 Tier 2 PA QL (60 PER 30 OVERTIME)

PANRETIN 01 GEL Tier 3 PA

TARGRETIN 1 GEL Tier 3 PA QL (60 PER 30 OVERTIME)

tretinoin cap 10 mg Tier 2

TREATMENT ADJUNCTSmesna inj 100 mgml Tier 2

MESNEX 400 MG TAB Tier 3

VONJO 100 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

ANTIPARASITICS

ANTHELMINTHICSalbendazole tab 200 mg Tier 2

ivermectin tab 3 mg Tier 2 QL (16 PER 365 OVER TIME)

praziquantel tab 600 mg Tier 2

ANTIPROTOZOALSALINIA 100 MG5ML RECON SUSP Tier 3 PA QL (180 PER 3 OVER

ANTIPARASITICS

atovaquone susp 750 mg5ml Tier 2 PA

atovaquone-proguanil hcl (tab 250-100 mg tab 625-25 mg)

Tier 2

BENZNIDAZOLE 100 MG TAB Tier 3 QL (240 PER 365 OVERTIME)

chloroquine phosphate (500 mgtab tab 500 mg)

chloroquine phosphate tab 250 mg Tier 2 QL (50 PER 30 OVER TIME)

COARTEM 20-120 MG TAB Tier 3 QL (24 PER 2 OVER TIME)

HYDROXYCHLOROQUINE SULFATE100 MG TAB

hydroxychloroquine sulfate tab 200mg

mefloquine hcl tab 250 mg Tier 2

nitazoxanide tab 500 mg Tier 2 PA QL (6 PER 3 OVERTIME)

pentamidine isethionate fornebulization soln 300 mg

Tier 2 BvD

pentamidine isethionate for soln 300mg

Tier 2

primaquine phosphate (263 (15base) mg tab tab 263 mg (15 mgbase))

Tier 3

pyrimethamine tab 25 mg Tier 2 PA

quinine sulfate cap 324 mg Tier 2 PA QL (6 PER 1 DAYS)

ANTIPARKINSON AGENTS

ANTICHOLINERGICSbenztropine mesylate (inj 1 mgmltab 05 mg tab 1 mg tab 2 mg)

Tier 2

trihexyphenidyl hcl (04 mgmlsolution oral soln 04 mgml tab 2mg tab 5 mg)

Tier 2

ANTIPARKINSON AGENTS OTHERamantadine hcl (cap 100 mg soln50 mg5ml syrup 50 mg5ml tab100 mg)

Tier 2

carbidopa-levodopa-entacapone(125-50-200 mg tab 1875-75-200mg tab 375-150-200 mg tab tabs125-50-200 mg tabs 1875-75-200mg tabs 25-100-200 mg tabs 3125-125-200 mg tabs 375-150-200 mgtabs 50-200-200 mg)

Tier 2

entacapone tab 200 mg Tier 2 QL (8 PER 1 DAYS)

DOPAMINE AGONISTSapomorphine hcl soln cartridge 30mg3ml

Tier 2 PA

bromocriptine mesylate (cap 5 mg(base equivalent) tab 25 mg (baseequivalent))

Tier 2

pramipexole dihydrochloride (tab0125 mg tab 025 mg tab 05 mgtab 075 mg tab 1 mg tab 15 mg)

Tier 2

ropinirole hydrochloride (tab 025mg tab 05 mg tab 1 mg tab 2 mgtab 3 mg tab 4 mg tab 5 mg)

Tier 2

DOPAMINE PRECURSORS ANDOR L-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa tab 25 mg Tier 2

CARBIDOPA-LEVODOPA(CARBIDOPA amp LEVODOPA ORALLYDISINTEGRATING TAB 10-100 MGCARBIDOPA amp LEVODOPA ORALLYDISINTEGRATING TAB 25-100 MGCARBIDOPA amp LEVODOPA ORALLYDISINTEGRATING TAB 25-250 MGCARBIDOPA amp LEVODOPA TAB 10-100 MG CARBIDOPA amp LEVODOPATAB 25-100 MG CARBIDOPA ampLEVODOPA TAB 25-250 MGCARBIDOPA amp LEVODOPA TAB ER25-100 MG CARBIDOPA ampLEVODOPA TAB ER 50-200 MGCARBIDOPA-LEVODOPA 10-100 MGTAB DISP CARBIDOPA-LEVODOPA25-100 MG TAB DISP CARBIDOPA-LEVODOPA 25-250 MG TAB DISP)

Tier 2

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate (tab 05 mg(base equiv) tab 1 mg (baseequiv))

selegiline hcl (cap 5 mg tab 5 mg) Tier 2

ANTIPSYCHOTICS

1ST GENERATIONTYPICALchlorpromazine hcl (100 mgmlconc 30 mgml conc 50 mg2mlsolution inj 25 mgml tab 10 mgtab 100 mg tab 200 mg tab 25 mgtab 50 mg)

Tier 2

fluphenazine decanoate inj 25mgml

Tier 2

fluphenazine hcl (25 mg5ml elixir25 mgml solution 5 mgml conctab 1 mg tab 10 mg tab 25 mgtab 5 mg)

Tier 2

ANTIPSYCHOTICS

haloperidol (tab 05 mg tab 1 mgtab 10 mg tab 2 mg tab 20 mgtab 5 mg)

Tier 2

haloperidol decanoate (soln 100mgml soln 50 mgml)

Tier 2

haloperidol lactate (inj 5 mgml oralconc 2 mgml)

Tier 2

loxapine succinate (cap 10 mg cap25 mg cap 5 mg cap 50 mg)

Tier 2

MOLINDONE HCL 10 MG TAB Tier 2 QL (8 PER 1 DAYS)

PIMOZIDE (1 MG TAB 2 MG TAB) Tier 2

thioridazine hcl (tab 10 mg tab 100mg tab 25 mg tab 50 mg)

Tier 2 PA

thiothixene (cap 1 mg cap 10 mgcap 2 mg cap 5 mg)

Tier 2

trifluoperazine hcl (tab 1 mg (baseequivalent) tab 10 mg (baseequivalent) tab 2 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 2

2ND GENERATIONATYPICALABILIFY MAINTENA (300 MG PRSYR300 MG SRER 400 MG PRSYR 400MG SRER)

Tier 3 PA

aripiprazole (orally disintegrating tab10 mg orally disintegrating tab 15mg tab 5 mg)

aripiprazole (tab 10 mg tab 15 mgtab 20 mg tab 30 mg)

aripiprazole oral solution 1 mgml Tier 2 QL (25 PER 1 DAYS)

aripiprazole tab 2 mg Tier 2 QL (4 PER 1 DAYS)

ARISTADA (1064 MG39ML PRSYR441 MG16ML PRSYR 662 MG24MLPRSYR 882 MG32ML PRSYR)

Tier 3 PA

ANTIPSYCHOTICS

ARISTADA INITIO 675 MG24MLPRSYR

asenapine maleate (sl tab 10 mg(base equiv) sl tab 25 mg (baseequiv) sl tab 5 mg (base equiv))

CAPLYTA 42 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

FANAPT (1 MG TAB 10 MG TAB 12MG TAB 2 MG TAB 4 MG TAB 6 MGTAB 8 MG TAB)

FANAPT TITRATION PACK 1 amp 2 amp 4 amp6 MG TAB

INVEGA HAFYERA 1092 MG35MLSUSP PRSYR

INVEGA SUSTENNA 117 MG075MLSUSP PRSYR

INVEGA SUSTENNA 156 MGML SUSPPRSYR

INVEGA TRINZA 273 MG088ML SUSPPRSYR

LATUDA (120 MG TAB 80 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

LATUDA (20 MG TAB 40 MG TAB 60MG TAB)

ANTIPSYCHOTICS

NUPLAZID (10 MG TAB 34 MG CAP) Tier 3 PA LA QL (1 PER 1 DAYS)

NUPLAZID 17 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

olanzapine (for im inj 10 mg orallydisintegrating tab 10 mg orallydisintegrating tab 15 mg orallydisintegrating tab 20 mg orallydisintegrating tab 5 mg tab 10 mgtab 15 mg tab 25 mg tab 20 mgtab 5 mg tab 75 mg)

Tier 2

paliperidone (tab er 24hr 15 mgtab er 24hr 3 mg tab er 24hr 9 mg)

paliperidone tab er 24hr 6 mg Tier 2 PA QL (2 PER 1 DAYS)

PERSERIS (120 MG PRSYR 90 MGPRSYR)

quetiapine fumarate (tab 100 mgtab 200 mg tab 25 mg tab 300 mgtab 400 mg tab 50 mg tab er 24hr150 mg tab er 24hr 200 mg tab er24hr 300 mg tab er 24hr 400 mg taber 24hr 50 mg)

Tier 2

REXULTI (025 MG TAB 05 MG TAB 1MG TAB 2 MG TAB 3 MG TAB 4 MGTAB)

RISPERDAL CONSTA (125 MG SRER25 MG SRER 375 MG SRER 50 MGSRER)

Tier 3

risperidone (025 mg tab disp orallydisintegrating tab 05 mg orallydisintegrating tab 1 mg orallydisintegrating tab 2 mg orallydisintegrating tab 3 mg orallydisintegrating tab 4 mg soln 1mgml tab 025 mg tab 05 mg tab1 mg tab 2 mg tab 3 mg tab 4mg)

Tier 2

SECUADO (38 MG24HR PATCH24HR 57 MG24HR PATCH 24HR 76MG24HR PATCH 24HR)

VRAYLAR (15 MG CAP 3 MG CAP45 MG CAP 6 MG CAP)

VRAYLAR 15 amp 3 MG CAP THPK Tier 3 PA QL (7 PER 30 OVERTIME)

ANTIPSYCHOTICS

ziprasidone hcl (cap 20 mg cap 40mg cap 60 mg cap 80 mg)

Tier 2

ziprasidone mesylate for inj 20 mg(base equivalent)

Tier 2

ZYPREXA RELPREVV (210 MG RECONSUSP 300 MG RECON SUSP 405 MGRECON SUSP)

Tier 3 PA

TREATMENT-RESISTANTclozapine (125 mg tab disp 150 mgtab disp 200 mg tab disp orallydisintegrating tab 100 mg orallydisintegrating tab 25 mg tab 100mg tab 200 mg tab 25 mg tab 50mg)

Tier 2

VERSACLOZ 50 MGML SUSPENSION Tier 3 PA QL (18 PER 1 DAYS)

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTSbaclofen tab 10 mg Tier 2 QL (8 PER 1 DAYS)

baclofen tab 20 mg Tier 2 QL (4 PER 1 DAYS)

dantrolene sodium (cap 100 mgcap 25 mg cap 50 mg)

Tier 2

tizanidine hcl (tab 2 mg (baseequivalent) tab 4 mg (baseequivalent))

Tier 2

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTSPREVYMIS 240 MG TAB Tier 3 QL (200 PER 365 OVER

PREVYMIS 480 MG TAB Tier 3 QL (100 PER 365 OVERTIME)

valganciclovir hcl for soln 50 mgml(base equiv)

valganciclovir hcl tab 450 mg (baseequivalent)

ZIRGAN 015 GEL Tier 3 QL (5 PER 30 OVER TIME)

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil tab 10 mg Tier 2 QL (1 PER 1 DAYS)

BARACLUDE 005 MGML SOLUTION Tier 3 QL (21 PER 1 DAYS)

entecavir (tab 05 mg tab 1 mg) Tier 2 QL (1 PER 1 DAYS)

EPIVIR HBV 5 MGML SOLUTION Tier 3

lamivudine tab 100 mg (hbv) Tier 2

VEMLIDY 25 MG TAB Tier 3 QL (1 PER 1 DAYS)

ANTI-HEPATITIS C (HCV) AGENTSEPCLUSA (150-375 MG PACKET 200-50 MG TAB 400-100 MG TAB)

EPCLUSA 200-50 MG PACKET Tier 3 PA QL (2 PER 1 DAYS)

HARVONI (3375-150 MG PACKET45-200 MG TAB 90-400 MG TAB)

HARVONI 45-200 MG PACKET Tier 3 PA QL (2 PER 1 DAYS)

LEDIPASVIR-SOFOSBUVIR 90-400 MGTAB

MAVYRET 100-40 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

MAVYRET 50-20 MG PACKET Tier 3 PA QL (6 PER 1 DAYS)

ribavirin (hepatitis c) (cap 200 mgtab 200 mg)

Tier 2

SOFOSBUVIR-VELPATASVIR 400-100MG TAB

ANTIVIRALS

VOSEVI 400-100-100 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)APRETUDE 600 MG3ML SUSP Tier 3 QL (21 PER 365 OVER

TIME) BvD

BIKTARVY (30-120-15 MG TAB 50-200-25 MG TAB)

DOVATO 50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

GENVOYA 150-150-200-10 MG TAB Tier 3 QL (1 PER 1 DAYS)

ISENTRESS (100 MG CHEW TAB 25MG CHEW TAB)

ISENTRESS 100 MG PACKET Tier 3 QL (2 PER 1 DAYS)

ISENTRESS 400 MG TAB Tier 3 QL (4 PER 1 DAYS)

ISENTRESS HD 600 MG TAB Tier 3 QL (2 PER 1 DAYS)

JULUCA 50-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

STRIBILD 150-150-200-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

TIVICAY (10 MG TAB 25 MG TAB 50MG TAB)

TIVICAY PD 5 MG TAB SOL Tier 3 QL (6 PER 1 DAYS)

ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)COMPLERA 200-25-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

DELSTRIGO 100-300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

EDURANT 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

efavirenz cap 200 mg Tier 2 QL (3 PER 1 DAYS)

efavirenz tab 600 mg Tier 2 QL (1 PER 1 DAYS)

efavirenz-emtricitabine-tenofovir dftab 600-200-300 mg

efavirenz-lamivudine-tenofovirdisoproxil fumarate (tab 400-300-300mg tab 600-300-300 mg)

etravirine tab 100 mg Tier 2 QL (4 PER 1 DAYS)

ANTIVIRALS

INTELENCE 25 MG TAB Tier 3 QL (12 PER 1 DAYS)

NEVIRAPINE 50 MG5ML SUSPENSION Tier 2 QL (40 PER 1 DAYS)

NEVIRAPINE ER 100 MG TAB ER 24H Tier 2 QL (3 PER 1 DAYS)

nevirapine tab 200 mg Tier 2 QL (2 PER 1 DAYS)

nevirapine tab er 24hr 100 mg Tier 2 QL (3 PER 1 DAYS)

ODEFSEY 200-25-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

PIFELTRO 100 MG TAB Tier 3 QL (2 PER 1 DAYS)

RESCRIPTOR 100 MG TAB Tier 3 QL (12 PER 1 DAYS)

ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS(NRTI)abacavir sulfate soln 20 mgml(base equiv)

abacavir sulfate tab 300 mg (baseequiv)

abacavir sulfate-lamivudine tab600-300 mg

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

CIMDUO 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

DESCOVY (120-15 MG TAB 200-25MG TAB)

DIDANOSINE (200 MG CAP DR 250MG CAP DR 400 MG CAP DR)

emtricitabine caps 200 mg Tier 2 QL (1 PER 1 DAYS)

emtricitabine-tenofovir disoproxilfumarate (tab 100-150 mg tab 133-200 mg tab 167-250 mg tab 200-300 mg)

EMTRIVA 10 MGML SOLUTION Tier 3 QL (24 PER 1 DAYS)

lamivudine oral soln 10 mgml Tier 2 QL (30 PER 1 DAYS)

ANTIVIRALS

lamivudine tab 150 mg Tier 2 QL (2 PER 1 DAYS)

lamivudine-zidovudine tab 150-300mg

stavudine (15 mg cap 20 mg cap30 mg cap 40 mg cap cap 15 mgcap 20 mg cap 30 mg cap 40 mg)

TEMIXYS 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

tenofovir disoproxil fumarate tab 300mg

TRIUMEQ 600-50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

TRIUMEQ PD 60-5-30 MG TAB SOL Tier 3 QL (6 PER 1 DAYS)

VIDEX 2 GM RECON SOLN Tier 3

VIDEX EC 125 MG CAP DR Tier 3 QL (1 PER 1 DAYS)

VIREAD (200 MG TAB 250 MG TAB) Tier 3 QL (1 PER 1 DAYS)

VIREAD 150 MG TAB Tier 3 QL (2 PER 1 DAYS)

VIREAD 40 MGGM POWDER Tier 3 QL (240 PER 30 OVER TIME)

ZERIT 1 MGML RECON SOLN Tier 3 QL (80 PER 1 DAYS)

zidovudine cap 100 mg Tier 2 QL (6 PER 1 DAYS)

zidovudine syrup 10 mgml Tier 2 QL (60 PER 1 DAYS)

zidovudine tab 300 mg Tier 2 QL (2 PER 1 DAYS)

ANTI-HIV AGENTS OTHERCABENUVA 400 amp 600 MG2ML SUSP Tier 3 QL (4 PER 30 OVER TIME)

CABENUVA 600 amp 900 MG3ML SUSP Tier 3 QL (6 PER 30 OVER TIME)BvD

FUZEON 90 MG RECON SOLN Tier 3 QL (60 PER 30 OVER TIME)

maraviroc tab 150 mg Tier 2 QL (2 PER 1 DAYS)

RUKOBIA 600 MG TAB ER 12H Tier 3 QL (2 PER 1 DAYS)

SELZENTRY 20 MGML SOLUTION Tier 3 QL (60 PER 1 DAYS)

ANTIVIRALS

SELZENTRY 25 MG TAB Tier 3 QL (8 PER 1 DAYS)

TYBOST 150 MG TAB Tier 3 QL (1 PER 1 DAYS)

ANTI-HIV AGENTS PROTEASE INHIBITORS (PI)APTIVUS 100 MGML SOLUTION Tier 3 QL (10 PER 1 DAYS)

APTIVUS 250 MG CAP Tier 3 QL (4 PER 1 DAYS)

atazanavir sulfate (cap 150 mg(base equiv) cap 200 mg (baseequiv))

atazanavir sulfate cap 300 mg(base equiv)

CRIXIVAN 200 MG CAP Tier 3 QL (9 PER 1 DAYS)

EVOTAZ 300-150 MG TAB Tier 3 QL (1 PER 1 DAYS)

fosamprenavir calcium tab 700 mg(base equiv)

INVIRASE 200 MG CAP Tier 3 QL (10 PER 1 DAYS)

INVIRASE 500 MG TAB Tier 3 QL (4 PER 1 DAYS)

LEXIVA 50 MGML SUSPENSION Tier 3 QL (56 PER 1 DAYS)

lopinavir-ritonavir soln 400-100mg5ml (80-20 mgml)

lopinavir-ritonavir tab 100-25 mg Tier 2 QL (10 PER 1 DAYS)

NORVIR (100 MG CAP 100 MGPACKET)

NORVIR 80 MGML SOLUTION Tier 3 QL (15 PER 1 DAYS)

PREZCOBIX 800-150 MG TAB Tier 3 QL (1 PER 1 DAYS)

PREZISTA 100 MGML SUSPENSION Tier 3 QL (12 PER 1 DAYS)

PREZISTA 150 MG TAB Tier 3 QL (8 PER 1 DAYS)

ANTIVIRALS

REYATAZ 50 MG PACKET Tier 3 QL (8 PER 1 DAYS)

ritonavir tab 100 mg Tier 2 QL (12 PER 1 DAYS)

SYMTUZA 800-150-200-10 MG TAB Tier 3 QL (1 PER 1 DAYS)

VIRACEPT 250 MG TAB Tier 3 QL (9 PER 1 DAYS)

ANTI-INFLUENZA AGENTSoseltamivir phosphate cap 30 mg(base equiv)

Tier 2 QL (120 PER 180 OVERTIME)

oseltamivir phosphate cap 45 mg(base equiv)

oseltamivir phosphate for susp 6mgml (base equiv)

RELENZA DISKHALER 5 MGBLISTERAER POW BA

RIMANTADINE HCL 100 MG TAB Tier 2

XOFLUZA (40 MG DOSE) (MG DOSE)1 X 40 MG TAB THPK MG DOSE) 2 X20 MG TAB THPK)

XOFLUZA (80 MG DOSE) 1 X 80 MGTAB THPK

ANTIHERPETIC AGENTSacyclovir (cap 200 mg susp 200mg5ml tab 400 mg tab 800 mg)

Tier 2

acyclovir sodium iv soln 50 mgml Tier 2 BvD

famciclovir (tab 125 mg tab 250mg tab 500 mg)

Tier 2

TRIFLURIDINE 1 SOLUTION Tier 2

valacyclovir hcl (tab 1 gm tab 500mg)

Tier 2

ANXIOLYTICS

ANXIOLYTICS OTHERbuspirone hcl (tab 10 mg tab 15mg tab 30 mg tab 5 mg tab 75mg)

Tier 2

meprobamate (tab 200 mg tab 400mg)

Tier 2 PA

BENZODIAZEPINESalprazolam (tab 025 mg tab 05mg tab 1 mg)

alprazolam tab 2 mg Tier 2 QL (5 PER 1 DAYS)

chlordiazepoxide hcl cap 10 mg Tier 2 PA QL (30 PER 1 DAYS)

clonazepam (orally disintegratingtab 0125 mg orally disintegratingtab 025 mg orally disintegratingtab 05 mg tab 05 mg)

clonazepam (orally disintegratingtab 1 mg tab 1 mg)

clorazepate dipotassium tab 15 mg Tier 2 QL (6 PER 1 DAYS)

clorazepate dipotassium tab 375mg

diazepam (conc 5 mgml tab 5mg)

diazepam oral soln 1 mgml Tier 2 QL (60 PER 1 DAYS)

diazepam tab 10 mg Tier 2 QL (6 PER 1 DAYS)

lorazepam (conc 2 mgml tab 2mg)

lorazepam tab 05 mg Tier 2 QL (20 PER 1 DAYS)

BIPOLAR AGENTS

MOOD STABILIZERSLITHIUM 8 MEQ5ML SOLUTION Tier 2

lithium carbonate (150 mg cap 300mg cap 600 mg cap cap 150 mgcap 300 mg cap 600 mg tab 300mg tab er 300 mg tab er 450 mg)

Tier 2

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTSacarbose (tab 100 mg tab 25 mgtab 50 mg)

Tier 2

FARXIGA (10 MG TAB 5 MG TAB) Tier 3 QL (1 PER 1 DAYS)

glimepiride (tab 1 mg tab 2 mg tab4 mg)

Tier 1

glipizide (tab 10 mg tab 5 mg taber 24hr 10 mg tab er 24hr 25 mgtab er 24hr 5 mg)

Tier 1

glipizide-metformin hcl (tab 25-250mg tab 25-500 mg tab 5-500 mg)

Tier 1

glyburide (tab 125 mg tab 25 mgtab 5 mg)

Tier 1 PA

glyburide micronized (tab 15 mgtab 3 mg tab 6 mg)

Tier 1 PA

glyburide-metformin (tab 125-250mg tab 25-500 mg tab 5-500 mg)

Tier 1 PA

GLYXAMBI (10-5 MG TAB 25-5 MGTAB)

JANUMET (50-1000 MG TAB 50-500MG TAB)

JANUMET XR (100-1000 MG TAB ER24H 50-500 MG TAB ER 24H)

JANUMET XR 50-1000 MG TAB ER 24H Tier 3 QL (2 PER 1 DAYS)

JANUVIA (100 MG TAB 25 MG TAB50 MG TAB)

JARDIANCE (10 MG TAB 25 MG TAB) Tier 3 QL (1 PER 1 DAYS)

JENTADUETO (25-1000 MG TAB 25-500 MG TAB 25-850 MG TAB)

JENTADUETO XR 25-1000 MG TAB ER24H

metformin hcl (tab 1000 mg tab 500mg tab 850 mg tab er 24hr 500 mgtab er 24hr 750 mg)

Tier 1

miglitol (tab 100 mg tab 25 mg tab50 mg)

nateglinide (tab 120 mg tab 60 mg) Tier 2

OZEMPIC (025 OR 05 MGDOSE) 2MG15ML SOLN PEN

OZEMPIC (1 MGDOSE) (2 MG15MLSOLN PEN 4 MG3ML SOLN PEN)

OZEMPIC (2 MGDOSE) 8 MG3MLSOLN PEN

pioglitazone hcl (tab 15 mg (baseequiv) tab 30 mg (base equiv) tab45 mg (base equiv))

Tier 2

repaglinide (tab 05 mg tab 1 mgtab 2 mg)

Tier 2

RYBELSUS (14 MG TAB 3 MG TAB 7MG TAB)

SYNJARDY (125-1000 MG TAB 125-500 MG TAB 5-1000 MG TAB 5-500MG TAB)

SYNJARDY XR (10-1000 MG TAB ER24H 125-1000 MG TAB ER 24H 5-1000 MG TAB ER 24H)

SYNJARDY XR 25-1000 MG TAB ER24H

TRADJENTA 5 MG TAB Tier 3 QL (1 PER 1 DAYS)

TRULICITY (075 MG05ML SOLN PEN15 MG05ML SOLN PEN 3MG05ML SOLN PEN 45 MG05MLSOLN PEN)

VICTOZA 18 MG3ML SOLN PEN Tier 3 QL (9 PER 30 OVER TIME)

XIGDUO XR (10-1000 MG TAB ER 24H25-1000 MG TAB ER 24H 5-1000 MGTAB ER 24H)

XIGDUO XR (10-500 MG TAB ER 24H5-500 MG TAB ER 24H)

GLYCEMIC AGENTSBAQSIMI ONE PACK 3 MGDOSEPOWDER

BAQSIMI TWO PACK 3 MGDOSEPOWDER

diazoxide susp 50 mgml Tier 2

GLUCAGEN HYPOKIT 1 MG RECONSOLN

glucagon (rdna) for inj kit 1 mg Tier 3 QL (2 PER 2 OVER TIME)

GLUCAGON EMERGENCY (1 MG KIT1 MGML RECON SOLN)

INSULINSHUMALOG (100 UNITML SOLN CART100 UNITML SOLUTION)

Tier 3

HUMALOG JUNIOR KWIKPEN 100UNITML SOLN PEN

Tier 3

HUMALOG KWIKPEN (100 UNITMLSOLN PEN 200 UNITML SOLN PEN)

Tier 3

HUMALOG MIX 5050 (50-50) 100UNITML SUSPENSION

Tier 3

HUMALOG MIX 5050 KWIKPEN (50-50) 100 UNITML SUSP PEN

Tier 3

HUMULIN 7030 (70-30) 100 UNITMLSUSPENSION

Tier 3

HUMULIN 7030 KWIKPEN (70-30) 100UNITML SUSP PEN

Tier 3

HUMULIN N 100 UNITML SUSPENSION Tier 3

HUMULIN N KWIKPEN 100 UNITMLSUSP PEN

Tier 3

HUMULIN R 100 UNITML SOLUTION Tier 3

HUMULIN R U-500 (CONCENTRATED)500 UNITML SOLUTION

Tier 3

HUMULIN R U-500 KWIKPEN 500UNITML SOLN PEN

Tier 3

INSULIN LISPRO (1 UNIT DIAL) 100UNITML SOLN PEN

Tier 3

INSULIN LISPRO 100 UNITMLSOLUTION

Tier 3

INSULIN LISPRO JUNIOR KWIKPEN 100UNITML SOLN PEN

Tier 3

INSULIN LISPRO PROT amp LISPRO (75-25) 100 UNITML SUSP PEN

Tier 3

LANTUS 100 UNITML SOLUTION Tier 3 QL (40 PER 30 OVER TIME)

LANTUS SOLOSTAR 100 UNITML SOLNPEN

LYUMJEV 100 UNITML SOLUTION Tier 3

LYUMJEV KWIKPEN (100 UNITMLSOLN PEN 200 UNITML SOLN PEN)

Tier 3

NOVOLIN 7030 (70-30) 100 UNITMLSUSPENSION

Tier 3

NOVOLIN 7030 RELION (70-30) 100UNITML SUSPENSION

Tier 3

NOVOLIN N 100 UNITMLSUSPENSION

Tier 3

NOVOLIN N RELION 100 UNITMLSUSPENSION

Tier 3

NOVOLIN R 100 UNITML SOLUTION Tier 3

NOVOLIN R RELION 100 UNITMLSOLUTION

Tier 3

TOUJEO MAX SOLOSTAR 300 UNITMLSOLN PEN

TOUJEO SOLOSTAR 300 UNITMLSOLN PEN

BLOOD PRODUCTS AND MODIFIERS

ANTICOAGULANTSELIQUIS (25 MG TAB 5 MG TAB) Tier 3 QL (2 PER 1 DAYS)

ELIQUIS DVTPE STARTER PACK 5 MGTAB THPK

enoxaparin sodium (inj 300 mg3mlinj soln pref syr 100 mgml inj solnpref syr 150 mgml)

enoxaparin sodium (inj soln pref syr120 mg08ml inj soln pref syr 80mg08ml)

enoxaparin sodium inj soln pref syr30 mg03ml

fondaparinux sodium subcutaneousinj 10 mg08ml

heparin sodium (porcine) (inj 1000unitml inj 10000 unitml inj 20000unitml inj 5000 unitml)

Tier 2 BvD

PRADAXA (110 MG CAP 150 MGCAP 75 MG CAP)

warfarin sodium (tab 1 mg tab 10mg tab 2 mg tab 25 mg tab 3 mgtab 4 mg tab 5 mg tab 6 mg tab75 mg)

Tier 2

XARELTO (10 MG TAB 15 MG TAB 20MG TAB)

XARELTO 1 MGML RECON SUSP Tier 3 QL (20 PER 1 DAYS)

XARELTO 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

XARELTO STARTER PACK 15 amp 20 MGTAB THPK

ZONTIVITY 208 MG TAB Tier 3 QL (1 PER 1 DAYS)

BLOOD PRODUCTS AND MODIFIERS OTHERanagrelide hcl (cap 05 mg cap 1mg)

Tier 2

ARANESP (ALBUMIN FREE) (10MCG04ML SOLN PRSYR 100MCG05ML SOLN PRSYR 100MCGML SOLUTION 150MCG03ML SOLN PRSYR 200MCG04ML SOLN PRSYR 200MCGML SOLUTION 25MCG042ML SOLN PRSYR 25MCGML SOLUTION 300MCG06ML SOLN PRSYR 300MCGML SOLUTION 40 MCG04MLSOLN PRSYR 40 MCGML SOLUTION500 MCGML SOLN PRSYR 60MCG03ML SOLN PRSYR 60MCGML SOLUTION)

Tier 3 PA

MOZOBIL 24 MG12ML SOLUTION Tier 3 PA LA

PROMACTA (125 MG PACKET 125MG TAB)

PROMACTA (25 MG TAB 50 MG TAB) Tier 3 PA LA QL (3 PER 1 DAYS)

PROMACTA 25 MG PACKET Tier 3 PA LA QL (6 PER 1 DAYS)

PROMACTA 75 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

RETACRIT (10000 UNITML SOLUTION2000 UNITML SOLUTION 20000UNITML SOLUTION 3000 UNITMLSOLUTION 4000 UNITML SOLUTION40000 UNITML SOLUTION)

Tier 3 PA

ZARXIO (300 MCG05ML SOLNPRSYR 480 MCG08ML SOLN PRSYR)

Tier 3 PA

HEMOSTASIS AGENTStranexamic acid iv soln 1000mg10ml (100 mgml)

Tier 2

tranexamic acid tab 650 mg Tier 2 QL (1 PER 1 DAYS)

PLATELET MODIFYING AGENTSaspirin-dipyridamole cap er 12hr 25-200 mg

Tier 2

BRILINTA (60 MG TAB 90 MG TAB) Tier 3 QL (2 PER 1 DAYS)

CABLIVI 11 MG KIT Tier 3 PA LA QL (1 PER 1 DAYS)

cilostazol (tab 100 mg tab 50 mg) Tier 2

clopidogrel bisulfate tab 75 mg(base equiv)

dipyridamole (tab 25 mg tab 50mg tab 75 mg)

Tier 2 PA

OXBRYTA (300 MG TAB SOL 500 MGTAB)

prasugrel hcl (tab 10 mg (baseequiv) tab 5 mg (base equiv))

TAVALISSE (100 MG TAB 150 MGTAB)

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTSclonidine (patch weekly 01mg24hr patch weekly 02 mg24hrpatch weekly 03 mg24hr)

Tier 2

clonidine hcl (tab 01 mg tab 02mg tab 03 mg)

Tier 2

droxidopa cap 100 mg Tier 2 PA QL (252 PER 90 OVERTIME)

guanfacine hcl (tab 1 mg tab 2mg)

Tier 2

methyldopa (250 mg tab 500 mgtab tab 250 mg tab 500 mg)

Tier 2

midodrine hcl (tab 10 mg tab 25mg tab 5 mg)

Tier 2

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate (tab 1 mg tab 2mg tab 4 mg tab 8 mg)

Tier 2

prazosin hcl (cap 1 mg cap 2 mgcap 5 mg)

Tier 2

terazosin hcl (cap 1 mg (baseequivalent) cap 10 mg (baseequivalent) cap 2 mg (baseequivalent) cap 5 mg (baseequivalent))

Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil (tab 16 mgtab 32 mg tab 4 mg tab 8 mg)

Tier 2

EPROSARTAN MESYLATE 600 MG TAB Tier 1 QL (1 PER 1 DAYS)

irbesartan (tab 150 mg tab 300 mgtab 75 mg)

Tier 1

losartan potassium (tab 100 mg tab25 mg tab 50 mg)

Tier 1

olmesartan medoxomil (tab 20 mgtab 40 mg tab 5 mg)

Tier 2

telmisartan (tab 20 mg tab 40 mgtab 80 mg)

Tier 1

valsartan (tab 160 mg tab 320 mgtab 40 mg tab 80 mg)

Tier 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl (tab 10 mg tab 20mg tab 40 mg tab 5 mg)

Tier 1

captopril (tab 100 mg tab 125 mgtab 25 mg tab 50 mg)

Tier 1

enalapril maleate (tab 10 mg tab25 mg tab 20 mg tab 5 mg)

Tier 1

fosinopril sodium (tab 10 mg tab 20mg tab 40 mg)

Tier 1

lisinopril (tab 10 mg tab 25 mg tab20 mg tab 30 mg tab 40 mg tab 5mg)

Tier 1

moexipril hcl (tab 15 mg tab 75mg)

Tier 1

perindopril erbumine (tab 2 mg tab4 mg tab 8 mg)

Tier 1

quinapril hcl (tab 10 mg tab 20 mgtab 40 mg tab 5 mg)

Tier 1

ramipril (cap 125 mg cap 10 mgcap 25 mg cap 5 mg)

Tier 1

trandolapril (tab 1 mg tab 2 mgtab 4 mg)

Tier 1

ANTIARRHYTHMICSamiodarone hcl (tab 100 mg tab200 mg tab 400 mg)

Tier 2

disopyramide phosphate (cap 100mg cap 150 mg)

Tier 2

dofetilide (cap 125 mcg (0125 mg)cap 250 mcg (025 mg) cap 500mcg (05 mg))

Tier 2

flecainide acetate (tab 100 mg tab150 mg tab 50 mg)

Tier 2

mexiletine hcl (cap 150 mg cap 200mg cap 250 mg)

Tier 2

MULTAQ 400 MG TAB Tier 3 QL (2 PER 1 DAYS)

propafenone hcl (tab 150 mg tab225 mg tab 300 mg)

Tier 2

quinidine sulfate (200 mg tab 300mg tab tab 200 mg tab 300 mg)

Tier 2

sotalol hcl (afibafl) (tab 120 mgtab 160 mg tab 80 mg)

Tier 2

sotalol hcl (tab 120 mg tab 160 mgtab 240 mg tab 80 mg)

Tier 2

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl (cap 200 mg cap400 mg)

Tier 2

atenolol (tab 100 mg tab 25 mgtab 50 mg)

Tier 1

betaxolol hcl (tab 10 mg tab 20mg)

Tier 2

bisoprolol fumarate (tab 10 mg tab5 mg)

Tier 2

carvedilol (tab 125 mg tab 25 mgtab 3125 mg tab 625 mg)

Tier 1

labetalol hcl (tab 100 mg tab 200mg tab 300 mg)

Tier 2

metoprolol succinate (tab er 24hr100 mg (tartrate equiv) tab er 24hr200 mg (tartrate equiv) tab er 24hr25 mg (tartrate equiv) tab er 24hr50 mg (tartrate equiv))

Tier 2

metoprolol tartrate (tab 100 mg tab25 mg tab 50 mg)

Tier 1

nadolol (tab 20 mg tab 40 mg tab80 mg)

Tier 2

nebivolol hcl (tab 10 mg (baseequivalent) tab 25 mg (baseequivalent) tab 20 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 2

pindolol (tab 10 mg tab 5 mg) Tier 2

propranolol hcl (40 mg5ml solutioncap er 24hr 120 mg cap er 24hr 160mg cap er 24hr 60 mg cap er 24hr80 mg oral soln 20 mg5ml tab 10mg tab 20 mg tab 40 mg tab 60mg tab 80 mg)

Tier 2

CALCIUM CHANNEL BLOCKING AGENTS DIHYDROPYRIDINESamlodipine besylate (tab 10 mg(base equivalent) tab 25 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 1

felodipine (tab er 24hr 10 mg tab er24hr 25 mg tab er 24hr 5 mg)

Tier 2

nicardipine hcl (cap 20 mg cap 30mg)

Tier 2

nifedipine (cap 10 mg cap 20 mgtab er 24hr 30 mg tab er 24hr 60mg tab er 24hr 90 mg tab er 24hrosmotic release 30 mg tab er 24hrosmotic release 60 mg tab er 24hrosmotic release 90 mg)

Tier 2

nimodipine cap 30 mg Tier 2

NYMALIZE 6 MGML SOLUTION Tier 3 QL (1260 PER 21 OVERTIME)

CALCIUM CHANNEL BLOCKING AGENTS NONDIHYDROPYRIDINESdiltiazem hcl (cap er 12hr 120 mgcap er 12hr 60 mg cap er 12hr 90mg cap er 24hr 120 mg cap er 24hr180 mg cap er 24hr 240 mg tab 120mg tab 30 mg tab 60 mg tab 90mg)

Tier 2

diltiazem hcl coated beads (beadscap er 24hr 120 mg beads cap er24hr 180 mg beads cap er 24hr 240mg beads cap er 24hr 300 mgbeads cap er 24hr 360 mg beadstab er 24hr 180 mg beads tab er24hr 240 mg beads tab er 24hr 300mg beads tab er 24hr 360 mgbeads tab er 24hr 420 mg)

Tier 2

diltiazem hcl extended releasebeads (beads cap er 24hr 120 mgbeads cap er 24hr 180 mg beadscap er 24hr 240 mg beads cap er24hr 300 mg beads cap er 24hr 360mg beads cap er 24hr 420 mg)

Tier 2

verapamil hcl (cap er 24hr 100 mgcap er 24hr 120 mg cap er 24hr 180mg cap er 24hr 200 mg cap er 24hr240 mg cap er 24hr 300 mg tab 120mg tab 40 mg tab 80 mg tab er120 mg tab er 180 mg tab er 240mg)

Tier 2

VERAPAMIL HCL ER (ER 100 MG CAPER 24H ER 200 MG CAP ER 24H ER300 MG CAP ER 24H ER 360 MGCAP ER 24H)

Tier 2

CARDIOVASCULAR AGENTS OTHERacetazolamide (tab 125 mg tab250 mg)

Tier 2

aliskiren fumarate (tab 150 mg(base equivalent) tab 300 mg(base equivalent))

Tier 2 PA

amiloride amp hydrochlorothiazide tab5-50 mg

Tier 2

amlodipine besylate-benazepril hcl(cap 10-20 mg cap 10-40 mg cap25-10 mg cap 5-10 mg cap 5-20mg cap 5-40 mg)

Tier 1

amlodipine besylate-olmesartanmedoxomil (tab 10-20 mg tab 10-40mg tab 5-20 mg tab 5-40 mg)

Tier 2

amlodipine besylate-valsartan (tab10-160 mg tab 10-320 mg tab 5-160mg tab 5-320 mg)

Tier 1

amlodipine-valsartan-hydrochlorothiazide (tab 10-160-125mg tab 10-160-25 mg tab 10-320-25mg tab 5-160-125 mg tab 5-160-25mg)

Tier 2

atenolol amp chlorthalidone (tab 100-25 mg tab 50-25 mg)

Tier 1

benazepril amp hydrochlorothiazide(tab 10-125 mg tab 20-125 mg tab20-25 mg tab 5-625 mg)

Tier 1

BENAZEPRIL-HYDROCHLOROTHIAZIDE5-625 MG TAB

Tier 1

bisoprolol amp hydrochlorothiazide(tab 10-625 mg tab 25-625 mgtab 5-625 mg)

Tier 2

candesartan cilexetil-hydrochlorothiazide (tab 16-125mg tab 32-125 mg tab 32-25 mg)

Tier 2

CAPTOPRIL-HYDROCHLOROTHIAZIDE(25-15 MG TAB 25-25 MG TAB 50-15MG TAB 50-25 MG TAB)

Tier 1

CORLANOR (5 MG TAB 75 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

CORLANOR 5 MG5ML SOLUTION Tier 3 PA QL (20 PER 1 DAYS)

digoxin (005 mgml solution oralsoln 005 mgml)

Tier 3

digoxin tab 125 mcg (0125 mg) Tier 2 QL (1 PER 1 DAYS)

digoxin tab 250 mcg (025 mg) Tier 2 PA QL (1 PER 1 DAYS)

enalapril maleate amphydrochlorothiazide (tab 10-25 mgtab 5-125 mg)

Tier 1

ENTRESTO (24-26 MG TAB 49-51 MGTAB 97-103 MG TAB)

fosinopril sodium amphydrochlorothiazide (tab 10-125mg tab 20-125 mg)

Tier 1

irbesartan-hydrochlorothiazide (tab150-125 mg tab 300-125 mg)

Tier 1

lisinopril amp hydrochlorothiazide (tab10-125 mg tab 20-125 mg tab 20-25 mg)

Tier 1

losartan potassium amphydrochlorothiazide (tab 100-125mg tab 100-25 mg tab 50-125 mg)

Tier 1

metoprolol amp hydrochlorothiazide(tab 100-25 mg tab 50-25 mg)

Tier 2

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MGTAB

Tier 2

metyrosine cap 250 mg Tier 2

olmesartan medoxomil-amlodipine-hydrochlorothiazide (tab 20-5-125mg tab 40-10-125 mg tab 40-10-25mg tab 40-5-125 mg tab 40-5-25mg)

Tier 2

olmesartan medoxomil-hydrochlorothiazide (tab 20-125mg tab 40-125 mg tab 40-25 mg)

Tier 2

pentoxifylline tab er 400 mg Tier 2

PROPRANOLOL-HCTZ (40-25 MG TAB80-25 MG TAB)

Tier 2

quinapril-hydrochlorothiazide (tab10-125 mg tab 20-125 mg tab 20-25 mg)

Tier 1

ranolazine (tab er 12hr 1000 mg taber 12hr 500 mg)

spironolactone amphydrochlorothiazide tab 25-25 mg

Tier 2

TEKTURNA HCT (150-125 MG TAB150-25 MG TAB 300-125 MG TAB300-25 MG TAB)

Tier 3 PA

telmisartan-hydrochlorothiazide (tab40-125 mg tab 80-125 mg tab 80-25 mg)

Tier 1

triamterene amp hydrochlorothiazide(cap 375-25 mg tab 375-25 mgtab 75-50 mg)

Tier 2

valsartan-hydrochlorothiazide (tab160-125 mg tab 160-25 mg tab320-125 mg tab 320-25 mg tab 80-125 mg)

Tier 1

VYNDAMAX 61 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

DIURETICS LOOPbumetanide (inj 025 mgml tab 05mg tab 1 mg tab 2 mg)

Tier 2

furosemide (8 mgml solution inj 10mgml oral soln 10 mgml)

Tier 2

furosemide (tab 20 mg tab 40 mgtab 80 mg)

Tier 1

torsemide (tab 10 mg tab 100 mgtab 20 mg tab 5 mg)

Tier 2

DIURETICS POTASSIUM-SPARINGamiloride hcl tab 5 mg Tier 2

eplerenone (tab 25 mg tab 50 mg) Tier 2

spironolactone (tab 100 mg tab 25mg tab 50 mg)

Tier 2

DIURETICS THIAZIDEchlorothiazide (500 mg tab tab 500mg)

Tier 2

chlorthalidone (tab 25 mg tab 50mg)

Tier 2

hydrochlorothiazide (cap 125 mgtab 125 mg tab 25 mg tab 50 mg)

Tier 1

indapamide (tab 125 mg tab 25mg)

Tier 2

metolazone (tab 10 mg tab 25 mgtab 5 mg)

Tier 2

DYSLIPIDEMICS FIBRIC ACID DERIVATIVEScholine fenofibrate (cap dr 135 mg(fenofibric acid equiv) cap dr 45mg (fenofibric acid equiv))

Tier 2

fenofibrate (tab 145 mg tab 160mg tab 48 mg tab 54 mg)

Tier 2

fenofibrate micronized (cap 130mg cap 134 mg cap 200 mg cap43 mg cap 67 mg)

Tier 2

gemfibrozil tab 600 mg Tier 2

DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORSatorvastatin calcium (tab 10 mg(base equivalent) tab 20 mg (baseequivalent) tab 40 mg (baseequivalent) tab 80 mg (baseequivalent))

Tier 1

fluvastatin sodium (cap 20 mg (baseequivalent) cap 40 mg (baseequivalent))

Tier 1

fluvastatin sodium tab er 24 hr 80 mg(base equivalent)

Tier 2

lovastatin (tab 10 mg tab 20 mgtab 40 mg)

Tier 1

pravastatin sodium (tab 10 mg tab20 mg tab 40 mg tab 80 mg)

Tier 1

rosuvastatin calcium (tab 10 mgtab 20 mg tab 40 mg tab 5 mg)

Tier 1

simvastatin (tab 10 mg tab 20 mgtab 40 mg tab 5 mg tab 80 mg)

Tier 1

DYSLIPIDEMICS OTHERcholestyramine (powder 4 gmdosepowder packets 4 gm)

Tier 2

cholestyramine light (powder 4gmdose powder packets 4 gm)

Tier 2

colesevelam hcl (packet for susp375 gm tab 625 mg)

Tier 2

colestipol hcl (granule packets 5gm granules 5 gm tab 1 gm)

Tier 2

ezetimibe tab 10 mg Tier 2

ezetimibe-simvastatin (tab 10-10mg tab 10-20 mg tab 10-40 mgtab 10-80 mg)

Tier 2

icosapent ethyl cap 1 gm Tier 2 QL (4 PER 1 DAYS)

JUXTAPID (40 MG CAP 60 MG CAP) Tier 3 PA LA QL (1 PER 1 DAYS)

JUXTAPID 10 MG CAP Tier 3 PA LA QL (6 PER 1 DAYS)

niacin (antihyperlipidemic) (tab er1000 mg (antihyperlipidemic) tab er750 mg (antihyperlipidemic))

NIACIN (ANTIHYPERLIPIDEMIC) 500MG TAB

Tier 2

niacin tab er 500 mg(antihyperlipidemic)

NIACOR 500 MG TAB Tier 2

omega-3-acid ethyl esters cap 1 gm Tier 2 QL (4 PER 1 DAYS)

REPATHA 140 MGML SOLN PRSYR Tier 3 PA QL (2 PER 28 OVERTIME)

REPATHA PUSHTRONEX SYSTEM 420MG35ML SOLN CART

REPATHA SURECLICK 140 MGMLSOLN A-INJ

VASCEPA 05 GM CAP Tier 3 QL (8 PER 1 DAYS)

VASODILATORS DIRECT-ACTING ARTERIALhydralazine hcl (tab 10 mg tab 100mg tab 25 mg tab 50 mg)

Tier 2

minoxidil (tab 10 mg tab 25 mg) Tier 2

VASODILATORS DIRECT-ACTING ARTERIALVENOUSisosorbide dinitrate (tab 10 mg tab20 mg tab 30 mg tab 5 mg)

Tier 2

ISOSORBIDE DINITRATE ER 40 MG TABER

Tier 2

isosorbide mononitrate (tab 10 mgtab 20 mg tab er 24hr 120 mg taber 24hr 30 mg tab er 24hr 60 mg)

Tier 2

NITRO-BID 2 OINTMENT Tier 3

nitroglycerin (sl tab 03 mg sl tab 04mg sl tab 06 mg td patch 24hr 01mghr td patch 24hr 02 mghr tdpatch 24hr 04 mghr td patch 24hr06 mghr)

Tier 2

NITROSTAT (03 MG SL TAB 04 MG SLTAB 06 MG SL TAB)

Tier 3

RECTIV 04 OINTMENT Tier 3 QL (30 PER 30 OVER TIME)

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS AMPHETAMINESamphetamine-dextroamphetamine(cap er 24hr 10 mg cap er 24hr 15mg cap er 24hr 20 mg cap er 24hr25 mg cap er 24hr 30 mg cap er24hr 5 mg tab 30 mg)

amphetamine-dextroamphetamine(tab 10 mg tab 15 mg tab 5 mgtab 75 mg)

amphetamine-dextroamphetaminetab 125 mg

dextroamphetamine sulfate (cap er24hr 10 mg tab 10 mg tab 5 mg)

dextroamphetamine sulfate (cap er24hr 15 mg tab 15 mg)

dextroamphetamine sulfate cap er24hr 5 mg

dextroamphetamine sulfate tab 20mg

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINESatomoxetine hcl (cap 10 mg (baseequiv) cap 18 mg (base equiv)cap 25 mg (base equiv))

atomoxetine hcl (cap 100 mg (baseequiv) cap 60 mg (base equiv)cap 80 mg (base equiv))

atomoxetine hcl cap 40 mg (baseequiv)

clonidine hcl tab er 12hr 01 mg Tier 2

dexmethylphenidate hcl (tab 10mg tab 25 mg tab 5 mg)

guanfacine hcl (adhd) (tab er 24hr1 mg (base equiv) tab er 24hr 2 mg(base equiv) tab er 24hr 3 mg (baseequiv) tab er 24hr 4 mg (baseequiv))

methylphenidate hcl (tab 10 mgtab er 10 mg)

methylphenidate hcl tab 5 mg Tier 2 QL (12 PER 1 DAYS)

CENTRAL NERVOUS SYSTEM OTHERAUSTEDO (12 MG TAB 9 MG TAB) Tier 3 PA QL (4 PER 1 DAYS)

AUSTEDO 6 MG TAB Tier 3 PA QL (8 PER 1 DAYS)

butalbital-acetaminophen-caffeinetab 50-325-40 mg

FIRDAPSE 10 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

INGREZZA (60 MG CAP 80 MG CAP) Tier 3 PA LA QL (1 PER 1 DAYS)

INGREZZA 40 amp 80 MG CAP THPK Tier 3 PA LA QL (28 PER 28OVER TIME)

INGREZZA 40 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

riluzole tab 50 mg Tier 2

tetrabenazine tab 125 mg Tier 2 PA LA QL (8 PER 1 DAYS)

FIBROMYALGIA AGENTSDRIZALMA SPRINKLE (20 MG CAP DR30 MG CAP DR)

DRIZALMA SPRINKLE (40 MG CAP DR60 MG CAP DR)

duloxetine hcl (cap 20 mg (baseeq) cap 60 mg (base eq))

duloxetine hcl enteric coatedpellets cap 30 mg (base eq)

pregabalin (cap 100 mg cap 150mg cap 25 mg cap 50 mg cap 75mg)

pregabalin (cap 200 mg cap 225mg cap 300 mg)

pregabalin soln 20 mgml Tier 2 QL (30 PER 1 DAYS)

SAVELLA (100 MG TAB 125 MG TAB25 MG TAB 50 MG TAB)

SAVELLA TITRATION PACK 125 amp 25amp 50 MG MISC

MULTIPLE SCLEROSIS AGENTSAUBAGIO (14 MG TAB 7 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

AVONEX 30 MCG KIT Tier 3 PA QL (4 PER 28 OVERTIME)

AVONEX PEN 30 MCG05ML AUT-IJKIT

AVONEX PREFILLED 30 MCG05MLPREF SY KT

BETASERON 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

dalfampridine tab er 12hr 10 mg Tier 2 PA QL (2 PER 1 DAYS)

dimethyl fumarate (capsuledelayed release 120 mg capsuledelayed release 240 mg capsule drstarter pack 120 mg amp 240 mg)

EXTAVIA 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

GILENYA 05 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

glatiramer acetate soln prefilledsyringe 20 mgml

PLEGRIDY (125 MCG05ML SOLNPEN 125 MCG05ML SOLN PRSYR)

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PEN

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PRSYR

REBIF (22 MCG05ML SOLN PRSYR44 MCG05ML SOLN PRSYR)

REBIF REBIDOSE (22 MCG05MLSOLN A-INJ 44 MCG05ML SOLN A-INJ)

REBIF REBIDOSE TITRATION PACK6X88 amp 6X22 MCG SOLN A-INJ

REBIF TITRATION PACK 6X88 amp 6X22MCG SOLN PRSYR

TYSABRI 300 MG15ML CONC Tier 3 PA LA

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTSchlorhexidine gluconate soln 012 Tier 2

KEPIVANCE 625 MG RECON SOLN Tier 3 BvD

pilocarpine hcl (oral) (tab 5 mg tab75 mg)

Tier 2

triamcinolone acetonide dentalpaste 01

Tier 2

DERMATOLOGICAL AGENTS

ACNE AND ROSACEA AGENTSacitretin (cap 10 mg cap 175 mgcap 25 mg)

Tier 2

adapalene gel 01 Tier 2 PA

isotretinoin (cap 10 mg cap 20 mgcap 30 mg cap 40 mg)

Tier 2

tazarotene cream 01 Tier 2

TAZORAC 005 CREAM Tier 3

tretinoin (cream 0025 cream005 cream 01 gel 001 gel0025)

Tier 2 PA

DERMATITIS AND PRURITUS AGENTSalclometasone dipropionate oint005

Tier 2

betamethasone dipropionate(topical) (cream 005 lotion 005)

Tier 2

BETAMETHASONE DIPROPIONATEAUG 005 GEL

Tier 2

betamethasone dipropionateaugmented oint 005

Tier 2

betamethasone valerate (cream01 (base equivalent) lotion 01(base equivalent) oint 01 (baseequivalent))

Tier 2

clobetasol propionate (cream005 gel 005 oint 005 soln005)

Tier 2

clobetasol propionate emollientbase cream 005

Tier 2

desonide (cream 005 oint 005) Tier 2

desoximetasone (cream 025 oint025)

Tier 2

fluocinolone acetonide (cream001 cream 0025 oil 001(body oil) oil 001 (scalp oil) oint0025 soln 001)

Tier 2

fluocinonide (cream 005 gel005 oint 005 soln 005)

Tier 2

fluocinonide emulsified base cream005

Tier 2

fluticasone propionate (cream005 oint 0005)

Tier 2

halobetasol propionate (cream005 oint 005)

hydrocortisone (rectal) (cream 1cream 25)

Tier 2

hydrocortisone (topical) (cream25 lotion 25 oint 1 oint 25)

Tier 2

hydrocortisone butyrate (01 solution soln 01)

Tier 2 ST

hydrocortisone valerate cream 02 Tier 2 ST

lactic acid (ammonium lactate)(cream 12 lotion 12)

Tier 2

mometasone furoate solution 01(lotion)

Tier 2

selenium sulfide lotion 25 Tier 2

tacrolimus (topical) (oint 003 oint01)

triamcinolone acetonide (topical)(cream 0025 cream 01 cream05 lotion 0025 lotion 01 oint0025 oint 01 oint 05)

Tier 2

DERMATOLOGICAL AGENTS OTHERcalcipotriene (cream 0005 oint0005 soln 0005 (50 mcgml))

Tier 2

clotrimazole w betamethasone(cream 1-005 lotion 1-005)

Tier 2

diclofenac sodium (actinickeratoses) gel 3

FLUOROURACIL (2 SOLUTION 5 SOLUTION)

Tier 2

fluorouracil cream 5 Tier 2

imiquimod cream 5 Tier 2 QL (24 PER 30 OVER TIME)

nystatin-triamcinolone (cream100000-01 unitgm- oint 100000-01 unitgm-)

Tier 2

OTEZLA 30 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

podofilox soln 05 Tier 2

REGRANEX 001 GEL Tier 3 PA QL (15 PER 2 OVERTIME)

SANTYL 250 UNITGM OINTMENT Tier 3 QL (180 PER 30 OVER TIME)

silver sulfadiazine cream 1 Tier 2

TOLAK 4 CREAM Tier 3

PEDICULICIDESSCABICIDESLINDANE 1 SHAMPOO Tier 2

malathion lotion 05 Tier 3

permethrin cream 5 Tier 2

TOPICAL ANTI-INFECTIVESacyclovir oint 5 Tier 2 PA QL (30 PER 30 OVER

ciclopirox solution 8 Tier 2

clindamycin phosphate (topical)(gel 1 lotion 1 soln 1)

Tier 2

ERY 2 PAD Tier 2

erythromycin (acne aid) (gel 2soln 2)

Tier 2

mupirocin oint 2 Tier 2

SULFAMYLON 85 MGGM CREAM Tier 3

ELECTROLYTESMINERALSMETALSVITAMINS

ELECTROLYTEMINERAL REPLACEMENTamino acid electrolyte infusion85

Tier 2 BvD

amino acid infusion 15 Tier 2 BvD

AMINO ACID 10 SOLUTION Tier 2 BvD

AMINOSYN (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II 15 SOLUTION Tier 3 BvD

AMINOSYN-HBC 7 SOLUTION Tier 3 BvD

AMINOSYN-PF 10 SOLUTION Tier 2 BvD

AMINOSYN-RF 52 SOLUTION Tier 2 BvD

AMINOSYNELECTROLYTES (7 SOLUTION 85 SOLUTION)

Tier 2 BvD

carglumic acid soluble tab 200 mg Tier 2 PA LA

CRYSVITA 10 MGML SOLUTION Tier 3 PA LA QL (2 PER 28 OVERTIME)

FREAMINE III 10 SOLUTION Tier 2 BvD

HEPATAMINE 8 SOLUTION Tier 3 BvD

INTRALIPID (20 EMULSION 30 EMULSION)

Tier 3 BvD

KCL IN DEXTROSE-NACL (20-5-0225MEQL-- SOLUTION 20-5-033MEQL-- SOLUTION 40-5-09MEQL-- SOLUTION)

Tier 2

NORMOSOL-M IN D5W SOLUTION Tier 2

NUTRILIPID 20 EMULSION Tier 3 BvD

potassium chloride (10 meq100mlsolution 20 meq100ml solution 40meq100ml solution cap er 10 meqcap er 8 meq inj 10 meq100ml inj2 meqml inj 20 meq100ml inj 40meq100ml oral soln 10 (20meq15ml) oral soln 20 (40meq15ml) tab er 10 meq tab er 20meq (1500 mg) tab er 8 meq (600mg))

Tier 2

POTASSIUM CHLORIDE ER 8 MEQ TABER

Tier 2

potassium chloride in dextrose ampsodium chloride (20 meql (015) indextrose 5 amp nacl 02 inj 20meql (015) in dextrose 5 amp nacl033 inj 20 meql (015) indextrose 5 amp nacl 045 inj 20meql (015) in dextrose 5 amp nacl09 inj)

Tier 2

POTASSIUM CHLORIDE IN NACL (KCL20 MEQL (015) 09 J KCL 40MEQL (03) 09 J POTASSIUMCHLORIDE 40-09 MEQL-SOLUTION)

Tier 2

potassium chloridemicroencapsulated crystals er (cryser tab 10 meq crys er tab 15 meqcrys er tab 20 meq)

Tier 2

potassium citrate (alkalinizer) (tab er10 meq (1080 mg) tab er 15 meq(1620 mg) tab er 5 meq (540 mg))

Tier 2

PREMASOL 10 SOLUTION Tier 2 BvD

sodium chloride (09 solution inj25 meqml (146) iv soln 045 ivsoln 09 iv soln 3 iv soln 5preservative free (pf) inj 09)

Tier 2

SYNTHAMIN 17 10 SOLUTION Tier 2 BvD

TRAVASOL 10 SOLUTION Tier 2 BvD

TROPHAMINE 10 SOLUTION Tier 2 BvD

ELECTROLYTEMINERALMETAL MODIFIERSdeferasirox (tab 180 mg tab 360mg tab 90 mg tab for oral susp 125mg tab for oral susp 250 mg tab fororal susp 500 mg)

Tier 2

deferiprone tab 1000 mg Tier 2 PA

deferiprone tab 500 mg Tier 2 PA LA

FERRIPROX 100 MGML SOLUTION Tier 3 PA LA

trientine hcl cap 250 mg Tier 2 PA QL (8 PER 1 DAYS)

PHOSPHATE BINDERSAURYXIA 1 GM 210 MG(FE) TAB Tier 3 PA QL (12 PER 1 DAYS)

calcium acetate (phosphatebinder) (cap 667 mg (169 mg ca)tab 667 mg)

Tier 2

sevelamer carbonate tab 800 mg Tier 2

POTASSIUM BINDERSsodium polystyrene sulfonate(sodium powder sodium oral susp15 gm60ml)

Tier 2

SPS 15 GM60ML SUSPENSION Tier 2

VELTASSA (168 GM PACKET 252GM PACKET 84 GM PACKET)

Tier 3

VITAMINSdextrose (inj 10 inj 5) Tier 2

dextrose 5 in lactated ringers Tier 2

dextrose w sodium chloride (25w sodium chloride 045 5 wsodium chloride 02 5 w sodiumchloride 0225 5 w sodiumchloride 03 5 w sodiumchloride 033 5 w sodiumchloride 045 5 w sodiumchloride 09)

Tier 2

DEXTROSE-NACL (10-02 SOLUTION 10-045 SOLUTION 25-045 SOLUTION 5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

DEXTROSE-SODIUM CHLORIDE (5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

KCL-LACTATED RINGERS-D5W 20MEQL SOLUTION

Tier 2

lactated ringers for irrigation Tier 2

lactated ringers solution Tier 2

LACTATED RINGERS SOLUTION Tier 2

levocarnitine tab 330 mg Tier 2

NEONATAL PLUS 27-1 MG TAB Tier 3

POTASSIUM CHLORIDE IN DEXTROSE(20 MEQL (015) 5 J 40-5 MEQL- SOLUTION)

Tier 2

PRENATAL PLUS 27-1 MG TAB Tier 3

PRENATAL PLUS VITAMINMINERAL27-1 MG TAB

Tier 3

prenatal vitamins Tier 3

ringers solution Tier 2

ringers solution for irrigation Tier 2

SMOFLIPID 20 EMULSION Tier 3 BvD

sodium fluoride (chew tab 025 mg f(from 055 mg naf) chew tab 05mg f (from 11 mg naf) chew tab 1mg f (from 22 mg naf) soln 05mgml f (from 11 mgml naf))

Tier 2

TPN ELECTROLYTES CONC Tier 3 BvD

GASTROINTESTINAL AGENTS

ANTI-CONSTIPATION AGENTSAMITIZA (24 MCG CAP 8 MCG CAP) Tier 3 QL (2 PER 1 DAYS)

lactulose (encephalopathy) solution10 gm15ml

Tier 2

lactulose solution 10 gm15ml Tier 2

LINZESS (145 MCG CAP 290 MCGCAP 72 MCG CAP)

LUBIPROSTONE (24 MCG CAP 8MCG CAP)

MOVANTIK (125 MG TAB 25 MGTAB)

peg 3350-kcl-sod bicarb-nacl forsoln 420 gm

Tier 2

RELISTOR (12 MG06ML SOLUTION 8MG04ML SOLUTION)

Tier 3 PA

SUPREP BOWEL PREP KIT 175-313-16GM177ML SOLUTION

Tier 3

ANTI-DIARRHEAL AGENTSalosetron hcl (tab 05 mg (baseequiv) tab 1 mg (base equiv))

Tier 2 PA

diphenoxylate w atropine tab 25-0025 mg

Tier 2

DIPHENOXYLATE-ATROPINE 25-0025MG5ML LIQUID

Tier 2

loperamide hcl cap 2 mg Tier 2

XERMELO 250 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

ANTISPASMODICS GASTROINTESTINALdicyclomine hcl (cap 10 mg tab 20mg)

Tier 2 PA

glycopyrrolate (tab 1 mg tab 2 mg) Tier 2

GASTROINTESTINAL AGENTS OTHERGATTEX 5 MG KIT Tier 3 PA LA

GAVILYTE-C 240 GM RECON SOLN Tier 2

MYALEPT 113 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

peg 3350-kcl-sod bicarb-sodchloride-sod sulfate (soln 236 gmsoln 240 gm)

Tier 2

ursodiol (cap 300 mg tab 250 mgtab 500 mg)

Tier 2

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (tab 200 mg tab 300 mgtab 400 mg tab 800 mg)

Tier 2

cimetidine hcl (300 mg5ml solutionsoln 300 mg5ml)

Tier 2

famotidine (tab 20 mg tab 40 mg) Tier 2

nizatidine (150 mg cap 300 mgcap cap 150 mg cap 300 mg)

Tier 2

PROTECTANTSmisoprostol (tab 100 mcg tab 200mcg)

Tier 2

sucralfate tab 1 gm Tier 2

PROTON PUMP INHIBITORSlansoprazole cap delayed release15 mg

Tier 2

lansoprazole cap delayed release30 mg

omeprazole (cap delayed release10 mg cap delayed release 20 mg)

Tier 2

omeprazole cap delayed release 40mg

pantoprazole sodium ec tab 20 mg(base equiv)

Tier 2

rabeprazole sodium ec tab 20 mg Tier 2

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERSTREATMENT

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERS TREATMENTbetaine powder for oral solution Tier 2

ALDURAZYME 29 MG5ML SOLUTION Tier 3 LA BvD

ARALAST NP (1000 MG RECON SOLN500 MG RECON SOLN)

Tier 3 LA BvD

BYLVAY (PELLETS) 200 MCG CAPSPRINK

BYLVAY 1200 MCG CAP Tier 3 PA LA QL (5 PER 1 DAYS)

CERDELGA 84 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

CEREZYME 400 UNIT RECON SOLN Tier 3 PA LA

CHOLBAM 250 MG CAP Tier 3 PA QL (5 PER 1 DAYS)

CREON (12000 UNIT CP DR PART24000-76000 UNIT CP DR PART 3000-9500 UNIT CP DR PART 36000 UNITCP DR PART 6000 UNIT CP DR PART)

Tier 3

cromolyn sodium oral conc 100mg5ml

Tier 2

CYSTAGON (150 MG CAP 50 MGCAP)

Tier 3 PA LA

CYSTARAN 044 SOLUTION Tier 3 PA LA QL (60 PER 28OVER TIME)

FABRAZYME 35 MG RECON SOLN Tier 3 LA BvD

miglustat cap 100 mg Tier 2 PA LA QL (3 PER 1 DAYS)

NAGLAZYME 1 MGML SOLUTION Tier 3 LA BvD

nitisinone (cap 10 mg cap 2 mgcap 5 mg)

Tier 2 PA

NITYR (10 MG TAB 2 MG TAB 5 MGTAB)

Tier 3 PA LA

PROCYSBI (25 MG CAP DR 300 MGPACKET 75 MG CAP DR 75 MGPACKET)

Tier 3 PA LA

PROLASTIN-C (1000 MG RECONSOLN 1000 MG20ML SOLUTION)

Tier 3 LA BvD

RAVICTI 11 GMML LIQUID Tier 3 PA LA QL (525 PER 30OVER TIME)

sapropterin dihydrochloride(powder packet 100 mg powderpacket 500 mg tab 100 mg)

Tier 2 PA

sodium phenylbutyrate (oralpowder 3 gmteaspoonful tab 500mg)

Tier 2 PA

STRENSIQ (18 MG045ML SOLUTION28 MG07ML SOLUTION 40 MGMLSOLUTION)

Tier 3 PA LA

STRENSIQ 80 MG08ML SOLUTION Tier 3 PA LA QL (384 PER 28OVER TIME)

VYNDAQEL 20 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

ZENPEP (10000-32000 UNIT CP DRPART 15000-47000 UNIT CP DR PART20000-63000 UNIT CP DR PART25000-79000 UNIT CP DR PART 3000-10000 UNIT CP DR PART 3000-14000UNIT CP DR PART 40000-126000 UNITCP DR PART 5000-24000 UNIT CP DRPART)

Tier 3

GENITOURINARY AGENTS

ANTISPASMODICS URINARYMYRBETRIQ (25 MG TAB ER 24H 50MG TAB ER 24H)

Tier 3

oxybutynin chloride (syrup 5mg5ml tab 5 mg tab er 24hr 10mg tab er 24hr 15 mg tab er 24hr 5mg)

Tier 2

solifenacin succinate (tab 10 mgtab 5 mg)

tolterodine tartrate (cap er 24hr 2mg cap er 24hr 4 mg tab 1 mg tab2 mg)

Tier 2 ST

trospium chloride tab 20 mg Tier 2

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl tab er 24hr 10 mg Tier 2

dutasteride cap 05 mg Tier 2 QL (1 PER 1 DAYS)

finasteride tab 5 mg Tier 2

silodosin (cap 4 mg cap 8 mg) Tier 2 QL (1 PER 1 DAYS)

tamsulosin hcl cap 04 mg Tier 2

GENITOURINARY AGENTS OTHERbethanechol chloride (tab 10 mgtab 25 mg tab 5 mg tab 50 mg)

Tier 2

penicillamine tab 250 mg Tier 2 PA

THIOLA EC (EC 100 MG TAB DR EC300 MG TAB DR)

Tier 3 PA LA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)ACTHAR 80 UNITML GEL Tier 3 PA LA

alclometasone dipropionate cream005

Tier 2

betamethasone dipropionateaugmented (cream 005 lotion005)

Tier 2

betamethasone dipropionate oint005

Tier 2

CORTISONE ACETATE 25 MG TAB Tier 2

CORTROPHIN 80 UNITML GEL Tier 3 PA LA

dexamethasone (05 mg tab 05mg5ml solution 075 mg tab 1 mgtab 2 mg tab elixir 05 mg5ml tab05 mg tab 075 mg tab 15 mg tab4 mg tab 6 mg)

Tier 2

dexamethasone sodium phosphate(inj 120 mg30ml inj 20 mg5ml inj 4mgml)

Tier 2

dexamethasone sodium phosphate(sod phosphate preservative free inj10 mgml sodium phosphate inj 10mgml sodium phosphate inj 100mg10ml)

Tier 2 BvD

fludrocortisone acetate tab 01 mg Tier 2

HEMADY 20 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

hydrocortisone butyrate oint 01 Tier 2 ST

hydrocortisone valerate oint 02 Tier 2

KORLYM 300 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

methylprednisolone (tab 16 mg tab32 mg tab 4 mg tab 8 mg tabtherapy pack 4 mg (21))

Tier 2

methylprednisolone acetate (40mgml suspension inj susp 40 mgmlinj susp 80 mgml)

Tier 2

methylprednisolone sod succ (inj 125mg (base equiv) inj 40 mg (baseequiv))

Tier 2

mometasone furoate (cream 01oint 01)

Tier 2

PREDNISOLONE 15 MG5MLSOLUTION

Tier 2

PREDNISOLONE SODIUM PHOSPHATE(SOD PHOSPH ORAL SOLN 67MG5ML (5 MG5ML BASE) SODIUMPHOSPHATE 25 MG5ML SOLUTION)

Tier 2

prednisone (5 mg5ml solution tab 1mg tab 10 mg tab 25 mg tab 20mg tab 5 mg tab 50 mg)

Tier 2

PREDNISONE INTENSOL 5 MGMLCONC

Tier 2

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)desmopressin acetate (inj 4 mcgmlpreservative free (pf) inj 4 mcgmltab 01 mg tab 02 mg)

Tier 2

desmopressin acetate nasal spraysoln 001

Tier 2

desmopressin acetate nasal spraysoln 001 (refrigerated)

Tier 2

EGRIFTA 1 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

EGRIFTA SV 2 MG RECON SOLN Tier 3 PA LA QL (30 PER 30OVER TIME)

INCRELEX 40 MG4ML SOLUTION Tier 3 PA LA

NORDITROPIN FLEXPRO (10MG15ML SOLN PEN 15 MG15MLSOLN PEN 30 MG3ML SOLN PEN 5MG15ML SOLN PEN)

Tier 3 PA

SEROSTIM (4 MG RECON SOLN 5 MGRECON SOLN 6 MG RECON SOLN)

Tier 3 PA LA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS)

ANABOLIC STEROIDSANADROL-50 50 MG TAB Tier 3

oxandrolone (tab 10 mg tab 25mg)

Tier 2 PA

ANDROGENSANDRODERM (2 MG24HR PATCH24HR 4 MG24HR PATCH 24HR)

danazol (cap 100 mg cap 200 mgcap 50 mg)

Tier 2

testosterone (125 mgact (1) gel25 mg25gm (1) gel 50 mg5gm(1) gel td gel 125 mgact (1) tdgel 25 mg25gm (1) td gel 50mg5gm (1))

testosterone cypionate (100 mgmlsolution 200 mgml solution im inj inoil 100 mgml im inj in oil 200 mgml)

Tier 2

testosterone enanthate (200 mgmlsolution im inj in oil 200 mgml)

ESTROGENSDEPO-ESTRADIOL 5 MGML OIL Tier 3

desogest-eth estrad amp eth estradtab 015-002001 mg(215)

Tier 2

desogest-ethin est tab 01-00250125-0025015-0025mg-mg

Tier 2

desogestrel amp ethinyl estradiol tab015 mg-30 mcg

Tier 2

drospirenone-ethinyl estradiol (tab3-002 mg tab 3-003 mg)

Tier 2

estradiol (patch twice weekly 0025mg24hr patch twice weekly 00375mg24hr patch twice weekly 005mg24hr patch twice weekly 0075mg24hr patch twice weekly 01mg24hr)

estradiol (patch weekly 0025mg24hr patch weekly 00375mg24hr (375 mcg24hr) patchweekly 005 mg24hr patch weekly006 mg24hr patch weekly 0075mg24hr patch weekly 01 mg24hr)

estradiol (tab 05 mg tab 1 mg tab2 mg)

Tier 2 PA

estradiol vaginal (cream 01 mggmtab 10 mcg)

Tier 2

ESTRING 2 MG RING Tier 3 QL (1 PER 84 OVER TIME)

ethynodiol diacet amp eth estrad (tab1 mg-35 mcg tab 1 mg-50 mcg)

Tier 2

etonogestrel-ethinyl estradiol va ring0120-0015 mg24hr

levonorgestrel amp eth estradiol (tab01 mg-20 mcg tab 015 mg-30mcg)

Tier 2

levonorgestrel amp ethinyl estradiol(91-day) tab 015-003 mg

Tier 2

levonorgestrel-eth estra tab 005-300075-400125-30mg-mcg

Tier 2

MENEST (03 MG TAB 0625 MG TAB125 MG TAB 25 MG TAB)

Tier 3 PA

norethin acet amp estrad-fe (tab 1 mg-20 mcg tab 15 mg-30 mcg)

Tier 2

norethindrone amp eth estradiol (tab04 mg-35 mcg tab 05 mg-35 mcgtab 1 mg-35 mcg)

Tier 2

norethindrone amp ethinyl estradiol-fechew tab 04 mg-35 mcg

Tier 2

norethindrone acet amp eth estra (tab1 mg-20 mcg tab 15 mg-30 mcg)

Tier 2

norethindrone acetate-ethinylestradiol (tab 05 mg-25 mcg tab 1mg-5 mcg)

Tier 2 PA

norethindrone-eth estradiol(triphasic) (tab 05-35075-351-35mg-mcg tab 05-351-3505-35 mg-mcg)

Tier 2

norgestimate amp ethinyl estradiol tab025 mg-35 mcg

Tier 2

norgestimate-eth estrad tab 018-350215-35025-35 mg-mcg

Tier 2

norgestrel amp ethinyl estradiol tab 03mg-30 mcg

Tier 2

PREMARIN (03 MG TAB 045 MGTAB 0625 MG TAB 09 MG TAB 125MG TAB)

Tier 3 PA

PREMARIN 0625 MGGM CREAM Tier 3

PREMPHASE 0625-5 MG TAB Tier 3 PA

PREMPRO (03-15 MG TAB 045-15MG TAB 0625-25 MG TAB 0625-5MG TAB)

PROGESTINSDEPO-PROVERA 400 MGMLSUSPENSION

Tier 3

HYDROXYPROGESTERONECAPROATE 125 GM5ML SOLUTION

Tier 2

medroxyprogesterone acetate(contraceptive) (susp 150 mgmlsusp prefilled syr 150 mgml)

Tier 2

medroxyprogesterone acetate (tab10 mg tab 25 mg tab 5 mg)

Tier 2

megestrol acetate (susp 40 mgmltab 20 mg tab 40 mg)

Tier 2 PA

megestrol acetate susp 625 mg5ml Tier 2 PA

norethindrone acetate tab 5 mg Tier 2

norethindrone tab 035 mg Tier 2

progesterone (cap 100 mg cap 200mg)

Tier 2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSOSPHENA 60 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

raloxifene hcl tab 60 mg Tier 2 QL (1 PER 1 DAYS)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)levothyroxine sodium (tab 100 mcgtab 112 mcg tab 125 mcg tab 137mcg tab 150 mcg tab 175 mcgtab 200 mcg tab 25 mcg tab 300mcg tab 50 mcg tab 75 mcg tab88 mcg)

Tier 2

liothyronine sodium (tab 25 mcgtab 5 mcg tab 50 mcg)

Tier 2

SYNTHROID (100 MCG TAB 112 MCGTAB 125 MCG TAB 137 MCG TAB150 MCG TAB 175 MCG TAB 200MCG TAB 25 MCG TAB 300 MCGTAB 50 MCG TAB 75 MCG TAB 88MCG TAB)

Tier 3

HORMONAL AGENTS SUPPRESSANT (PITUITARY)

HORMONAL AGENTS SUPPRESSANT (PITUITARY)cabergoline tab 05 mg Tier 2 QL (16 PER 30 OVER TIME)

FIRMAGON (240 MG DOSE) 120MGVIAL RECON SOLN

Tier 3

FIRMAGON 80 MG RECON SOLN Tier 3

LANREOTIDE ACETATE 120 MG05MLSOLUTION

Tier 3 PA

leuprolide acetate inj kit 5 mgml Tier 2

LUPRON DEPOT (1-MONTH) (375 MGKIT 75 MG KIT)

Tier 3

LUPRON DEPOT (3-MONTH) (1125MG KIT 225 MG KIT)

Tier 3

LUPRON DEPOT (4-MONTH) 30 MGKIT

Tier 3

LUPRON DEPOT-PED (1-MONTH)(1125 MG KIT 15 MG KIT 75 MG KIT)

Tier 3

LUPRON DEPOT-PED (3-MONTH)(1125 MG (PED) KIT 30 MG (PED)KIT)

Tier 3

octreotide acetate (100 mcgmlsoln prsyr 1000 mcgml solution 200mcgml solution 50 mcgml solnprsyr 500 mcgml soln prsyr inj 100mcgml (01 mgml) inj 1000mcgml (1 mgml) inj 200 mcgml(02 mgml) inj 50 mcgml (005mgml) inj 500 mcgml (05 mgml))

Tier 2 PA

ORGOVYX 120 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

SANDOSTATIN LAR DEPOT (10 MGKIT 20 MG KIT 30 MG KIT)

Tier 3 PA

SIGNIFOR (03 MGML SOLUTION 06MGML SOLUTION 09 MGMLSOLUTION)

SOMATULINE DEPOT (60 MG02MLSOLUTION 90 MG03ML SOLUTION)

Tier 3 PA

SOMAVERT (10 MG RECON SOLN 15MG RECON SOLN 20 MG RECONSOLN 25 MG RECON SOLN 30 MGRECON SOLN)

SYNAREL 2 MGML SOLUTION Tier 3

TRELSTAR MIXJECT (1125 MG RECONSUSP 225 MG RECON SUSP 375 MGRECON SUSP)

Tier 3 BvD

HORMONAL AGENTS SUPPRESSANT (THYROID)

ANTITHYROID AGENTSmethimazole (tab 10 mg tab 5 mg) Tier 2

propylthiouracil tab 50 mg Tier 2

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTSBERINERT 500 UNIT KIT Tier 3 PA LA

CINRYZE 500 UNIT RECON SOLN Tier 3 PA LA

HAEGARDA (2000 UNIT RECONSOLN 3000 UNIT RECON SOLN)

Tier 3 PA LA

icatibant acetate inj 30 mg3ml(base equivalent)

RUCONEST 2100 UNIT RECON SOLN Tier 3 PA LA

IMMUNOGLOBULINSBIVIGAM (10 GM100ML SOLUTION 5GM50ML SOLUTION)

Tier 3 PA LA

FLEBOGAMMA DIF (05 GM10MLSOLUTION 10 GM100ML SOLUTION10 GM200ML SOLUTION 25GM50ML SOLUTION 20 GM200MLSOLUTION 20 GM400ML SOLUTION5 GM100ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

GAMMAGARD (1 GM10MLSOLUTION 10 GM100ML SOLUTION25 GM25ML SOLUTION 20GM200ML SOLUTION 30 GM300MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

GAMMAGARD SD LESS IGA (10 GMRECON SOLN 5 GM RECON SOLN)

Tier 3 PA

GAMMAKED (1 GM10ML SOLUTION10 GM100ML SOLUTION 20GM200ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

GAMMAPLEX (10 GM100MLSOLUTION 20 GM200ML SOLUTION20 GM400ML SOLUTION 5GM100ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA LA

GAMMAPLEX 10 GM200MLSOLUTION

Tier 3 PA

GAMUNEX-C (1 GM10ML SOLUTION10 GM100ML SOLUTION 25GM25ML SOLUTION 20 GM200MLSOLUTION 40 GM400ML SOLUTION5 GM50ML SOLUTION)

Tier 3 PA

HIZENTRA (1 GM5ML SOLN PRSYR 1GM5ML SOLUTION 10 GM50MLSOLUTION 2 GM10ML SOLN PRSYR2 GM10ML SOLUTION 4 GM20MLSOLN PRSYR 4 GM20ML SOLUTION)

Tier 3 PA LA

PRIVIGEN (10 GM100ML SOLUTION20 GM200ML SOLUTION 40GM400ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

VARIZIG 125 UNIT12ML SOLUTION Tier 3

IMMUNOLOGICAL AGENTS OTHERARCALYST 220 MG RECON SOLN Tier 3 PA LA

BENLYSTA (200 MGML SOLN A-INJ200 MGML SOLN PRSYR)

ILARIS 150 MGML SOLUTION Tier 3 PA LA

OTEZLA 10 amp 20 amp 30 MG TAB THPK Tier 3 PA QL (55 PER 28 OVERTIME)

SKYRIZI (150 MG DOSE) 75MG083ML PREF SY KT

Tier 3 PA

SKYRIZI 150 MGML SOLN PRSYR Tier 3 PA

SKYRIZI PEN 150 MGML SOLN A-INJ Tier 3 PA

STELARA (45 MG05ML SOLN PRSYR45 MG05ML SOLUTION 90 MGMLSOLN PRSYR)

Tier 3 PA

TALTZ (80 MGML SOLN A-INJ 80MGML SOLN PRSYR)

XELJANZ (10 MG TAB 5 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

XELJANZ 1 MGML SOLUTION Tier 3 PA QL (10 PER 1 DAYS)

XOLAIR (150 MG RECON SOLN 150MGML SOLN PRSYR 75 MG05MLSOLN PRSYR)

Tier 3 PA LA

IMMUNOSTIMULANTSACTIMMUNE 2000000 UNIT05MLSOLUTION

Tier 3 PA LA

INTRON A (10000000 UNIT RECONSOLN 10000000 UNITML SOLUTION18000000 UNIT RECON SOLN50000000 UNIT RECON SOLN6000000 UNITML SOLUTION)

Tier 3 LA

PEGASYS 180 MCG05ML SOLNPRSYR

PEGASYS 180 MCGML SOLUTION Tier 3 PA QL (4 PER 30 OVERTIME)

PEGASYS PROCLICK 180 MCG05MLSOLN A-INJ

SYLATRON (200 MCG KIT 300 MCGKIT 600 MCG KIT)

Tier 3 LA

IMMUNOSUPPRESSANTSAZATHIOPRINE SODIUM 100 MGRECON SOLN

Tier 2 BvD

azathioprine tab 50 mg Tier 2 BvD

cyclosporine (cap 100 mg cap 25mg iv soln 50 mgml)

Tier 2 BvD

cyclosporine modified (formicroemulsion) (cap 100 mg cap25 mg cap 50 mg oral soln 100mgml)

Tier 2 BvD

ENBREL (25 MG RECON SOLN 25MG05ML SOLN PRSYR 25MG05ML SOLUTION 50 MGMLSOLN PRSYR)

Tier 3 PA

ENBREL SURECLICK 50 MGML SOLNA-INJ

Tier 3 PA

ENVARSUS XR (075 MG TAB ER 24H1 MG TAB ER 24H 4 MG TAB ER 24H)

Tier 3 PA

everolimus (immunosuppressant)(tab 025 mg tab 05 mg tab 075mg tab 1 mg)

Tier 2 PA

HUMIRA (10 MG01ML PREF SY KT 10MG02ML PREF SY KT 20 MG02MLPREF SY KT 20 MG04ML PREF SY KT40 MG04ML PREF SY KT 40MG08ML PREF SY KT)

Tier 3 PA

HUMIRA PEDIATRIC CROHNS START(40 MG08ML PREF SY KT 80MG08ML amp 40MG04ML PREF SYKT 80 MG08ML PREF SY KT)

Tier 3 PA

HUMIRA PEN (PEN 40 MG04ML PENKIT PEN 40 MG08ML PEN KIT PEN80 MG08ML PEN KIT)

Tier 3 PA

HUMIRA PEN-CDUCHS STARTER (40MG08ML PEN KIT 80 MG08MLPEN KIT)

Tier 3 PA

HUMIRA PEN-PEDIATRIC UC START 80MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSUVADOL HS START40 MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSORUVEIT STARTER 80MG08ML amp 40MG04ML PEN KIT

Tier 3 PA

leflunomide (tab 10 mg tab 20 mg) Tier 2

methotrexate sodium (250 mg10mlsolution for inj 1 gm inj 50 mg2ml(25 mgml) inj pf 1000 mg40ml (25mgml) inj pf 250 mg10ml (25mgml) inj pf 50 mg2ml (25mgml))

Tier 2 BvD

methotrexate sodium tab 25 mg(base equiv)

Tier 2

mycophenolate mofetil (cap 250mg for oral susp 200 mgml tab 500mg)

Tier 2 BvD

mycophenolate mofetil hcl for ivsoln 500 mg (base equiv)

Tier 2 BvD

mycophenolate sodium (tab dr 180mg (mycophenolic acid equiv) tabdr 360 mg (mycophenolic acidequiv))

Tier 2 BvD

PROGRAF (02 MG PACKET 1 MGPACKET)

Tier 3 PA

REZUROCK 200 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

RINVOQ (15 MG TAB ER 24H 30 MGTAB ER 24H)

RINVOQ 45 MG TAB ER 24H Tier 3 PA QL (56 PER 365 OVERTIME)

SANDIMMUNE 100 MGML SOLUTION Tier 3 BvD

sirolimus (oral soln 1 mgml tab 05mg tab 1 mg tab 2 mg)

Tier 2 BvD

tacrolimus (cap 05 mg cap 1 mgcap 5 mg)

Tier 2 BvD

XATMEP 25 MGML SOLUTION Tier 3 PA

XELJANZ XR (11 MG TAB ER 24H 22MG TAB ER 24H)

VACCINESACTHIB RECON SOLN Tier 3

ADACEL 5-2-155 LF-MCG05SUSPENSION

Tier 3

BCG VACCINE 50 MG RECON SOLN Tier 3

BEXSERO SUSP PRSYR Tier 3

BOOSTRIX (SUSP PRSYR SUSPENSION) Tier 3

DAPTACEL 23-15-5 SUSPENSION Tier 3

DENGVAXIA RECON SUSP Tier 3

DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU05ML SUSPENSION

Tier 3

ENGERIX-B (10 MCG05MLINJECTABLE 10 MCG05MLSUSPENSION 20 MCGMLINJECTABLE 20 MCGMLSUSPENSION)

Tier 3 BvD

GARDASIL 9 (9 SUSP PRSYR 9SUSPENSION)

Tier 3

HAVRIX (1440 EL UML SUSPENSION720 EL U05ML SUSPENSION)

Tier 3

HIBERIX 10 MCG RECON SOLN Tier 3

IMOVAX RABIES 25 UNITMLINJECTABLE

Tier 3

INFANRIX 25-58-10 SUSPENSION Tier 3

IPOL INJECTABLE Tier 3

IXIARO SUSPENSION Tier 3

KINRIX (05 ML SUSP PRSYRSUSPENSION)

Tier 3

M-M-R II RECON SOLN Tier 3

MENACTRA SOLUTION Tier 3

MENQUADFI SOLUTION Tier 3

MENVEO RECON SOLN Tier 3

PEDIARIX SUSP PRSYR Tier 3

PEDVAX HIB 75 MCG05MLSUSPENSION

Tier 3

PENTACEL RECON SUSP Tier 3

PREHEVBRIO 10 MCGMLSUSPENSION

Tier 3 BvD

PROQUAD RECON SUSP Tier 3

QUADRACEL (05 ML SUSP PRSYRSUSPENSION)

Tier 3

RABAVERT RECON SUSP Tier 3

RECOMBIVAX HB (10 MCGMLSUSPENSION 40 MCGMLSUSPENSION 5 MCG05MLSUSPENSION)

Tier 3 BvD

ROTARIX RECON SUSP Tier 3

ROTATEQ SOLUTION Tier 3

SHINGRIX 50 MCG05ML RECONSUSP

TDVAX 2-2 LF05ML SUSPENSION Tier 3

TENIVAC 5-2 LFU INJECTABLE Tier 3

TICOVAC 24 MCG05ML SUSPPRSYR

Tier 3

TRUMENBA SUSP PRSYR Tier 3

TWINRIX 720-20 ELU-MCGML SUSPPRSYR

Tier 3 BvD

TYPHIM VI (25 MCG05ML SOLNPRSYR 25 MCG05ML SOLUTION)

Tier 3

VAQTA (25 UNIT05ML SUSPENSION50 UNITML SUSPENSION)

Tier 3

VARIVAX 1350 PFU05MLINJECTABLE

Tier 3

YF-VAX INJECTABLE Tier 3

ZOSTAVAX 19400 UNT065MLRECON SUSP

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATESbalsalazide disodium cap 750 mg Tier 2

mesalamine (cap er 24hr 0375 gmtab delayed release 12 gm)

mesalamine (enema 4 gm suppos1000 mg)

Tier 2

sulfasalazine (tab 500 mg tabdelayed release 500 mg)

Tier 2

GLUCOCORTICOIDSbudesonide delayed releaseparticles cap 3 mg

budesonide tab er 24hr 9 mg Tier 2 PA QL (1 PER 1 DAYS)

hydrocortisone (tab 10 mg tab 20mg tab 5 mg)

Tier 2

hydrocortisone enema 100 mg60ml Tier 2

METABOLIC BONE DISEASE AGENTS

METABOLIC BONE DISEASE AGENTSalendronate sodium (40 mg tab 5mg tab tab 10 mg tab 35 mg tab5 mg tab 70 mg)

Tier 1

calcitonin (salmon) nasal soln 200unitact

calcitriol (1 mcgml solution cap025 mcg cap 05 mcg oral soln 1mcgml)

Tier 2 BvD

cinacalcet hcl (tab 30 mg (baseequiv) tab 60 mg (base equiv) tab90 mg (base equiv))

Tier 2 BvD

doxercalciferol (cap 05 mcg cap 1mcg cap 25 mcg inj 4 mcg2ml (2mcgml))

Tier 2 BvD

ETIDRONATE DISODIUM 200 MG TAB Tier 2

FORTEO 600 MCG24ML SOLN PEN Tier 3 PA

ibandronate sodium iv soln 3mg3ml (base equivalent)

Tier 2 PA

ibandronate sodium tab 150 mg(base equivalent)

Tier 2

NATPARA (100 MCG CARTRIDGE 25MCG CARTRIDGE 50 MCGCARTRIDGE 75 MCG CARTRIDGE)

paricalcitol (cap 1 mcg cap 2 mcgcap 4 mcg iv soln 2 mcgml iv soln5 mcgml)

Tier 2 BvD

PROLIA 60 MGML SOLN PRSYR Tier 3 PA

risedronate sodium (tab 150 mg tab35 mg tab 5 mg)

Tier 2

TYMLOS 3120 MCG156ML SOLNPEN

XGEVA 120 MG17ML SOLUTION Tier 3 PA QL (17 PER 28 OVERTIME)

zoledronic acid (4 mg recon soln 4mg100ml solution inj conc for ivinfusion 4 mg5ml iv soln 5mg100ml)

Tier 2 BvD

MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTSADVOCATE ALCOHOL PREP PADS 70 PAD

Tier 2

ALCOHOL 70 PADS Tier 2

ALCOHOL PREP (70 PAD PAD) Tier 2

ALCOHOL PREP PADS 70 PAD Tier 2

ALCOHOL WIPES 70 MISC Tier 2

AUM MINI INSULIN PEN NEEDLE (PENNEEDLE 32G X 4 MM MISC PENNEEDLE 32G X 5 MM MISC PENNEEDLE 32G X 6 MM MISC PENNEEDLE 32G X 8 MM MISC PENNEEDLE 33G X 4 MM MISC PENNEEDLE 33G X 5 MM MISC PENNEEDLE 33G X 6 MM MISC)

Tier 2

AUM READYGARD DUO PEN NEEDLE32G X 4 MM MISC

Tier 2

BD ECLIPSE SYRINGE 30G X 12 1 MLMISC

Tier 2

BD INSULIN SYRINGE 275G X 58 2ML MISC

Tier 2

BD Pen Needle Mini UF 31G X 5 MMMISC

Tier 2

BD Pen Needle Nano UF 32G X 4MM MISC

Tier 2

BD Pen Needle Original UF 29G X127MM MISC

Tier 2

BD Pen Needle Short UF 31G X 8MM MISC

Tier 2

BIOGUARD GAUZE SPONGES 2X2PAD

Tier 2

CAREONE UNIFINE PENTIPS PLUS 33GX 4 MM MISC

Tier 2

CARETOUCH INSULIN SYRINGE (05ML MISC 1 ML MISC)

Tier 2

CARETOUCH PEN NEEDLES 29G X12MM MISC

Tier 2

COMFORT TOUCH ALCOHOL PREP70 PAD

Tier 2

COMFORT TOUCH INSULIN PEN NEED(PEN NEED 31G X 4 MM MISC PENNEED 31G X 5 MM MISC PEN NEED31G X 6 MM MISC PEN NEED 31G X8 MM MISC PEN NEED 32G X 4 MMMISC PEN NEED 32G X 5 MM MISCPEN NEED 32G X 6 MM MISC PENNEED 32G X 8 MM MISC)

Tier 2

CVS ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

DROPSAFE ALCOHOL PREP 70 PAD Tier 2

DROPSAFE SAFETY PEN NEEDLES 31GX 5 MM MISC

Tier 2

EASY TOUCH INSULIN SYRINGE (27GX 12 05 ML MISC 27G X 12 1 MLMISC 28G X 12 05 ML MISC 28G X12 1 ML MISC 29G X 12 05 MLMISC 29G X 12 1 ML MISC)

Tier 2

EASY TOUCH PEN NEEDLES 30G X 6MM MISC

Tier 2

gauze pads 2x2 Tier 2

GNP ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

GNP STERILE GAUZE 2X2 PAD Tier 2

GNP ULTIGUARD SAFEPACK NEEDLE(31G X 5 MM MISC 31G X 8 MMMISC 32G X 4 MM MISC 32G X 6MM MISC)

Tier 2

H-E-B INCONTROL PEN NEEDLES 31GX 5 MM MISC

Tier 2

H-E-B INCONTROL UNIFINE PENTIP(31G X 5 MM MISC 31G X 6 MMMISC 31G X 8 MM MISC 32G X 4MM MISC 33G X 4 MM MISC)

Tier 2

HM ULTICARE MINI PEN NEEDLES 31GX 5 MM MISC

Tier 2

INSULIN PEN NEEDLES Tier 2

INSULIN SYRINGE 03 ML Tier 2

INSULIN SYRINGE-NEEDLE U-100 30GX 516 1 ML MISC

Tier 2

ISOPROPYL ALCOHOL 70 MISC Tier 2

ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

MEDPURA ALCOHOL PADS 70 MISC

Tier 2

methylergonovine maleate tab 02mg

Tier 2

novofine 32g x 6 mm misc Tier 2

novotwist 32g x 5 mm misc Tier 2

PENTIPS (29G X 12MM MISC 31G X 5MM MISC 31G X 6 MM MISC 31G X8 MM MISC 32G X 4 MM MISC)

Tier 2

PREVENT DROPSAFE PEN NEEDLES(PEN NEEDLES 31G X 6 MM MISCPEN NEEDLES 31G X 8 MM MISC)

Tier 2

QC UNIFINE PENTIPS 32G X 4 MMMISC

Tier 2

RA ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

RELION PEN NEEDLES (PEN NEEDLES31G X 6 MM MISC PEN NEEDLES31G X 8 MM MISC PEN NEEDLES32G X 4 MM MISC)

Tier 2

RUZURGI 10 MG TAB Tier 3 PA LA QL (10 PER 1 DAYS)

TRUE COMFORT PEN NEEDLES (PENNEEDLES 31G X 8 MM MISC PENNEEDLES 32G X 5 MM MISC PENNEEDLES 32G X 6 MM MISC PENNEEDLES 33G X 4 MM MISC PENNEEDLES 33G X 5 MM MISC PENNEEDLES 33G X 6 MM MISC)

Tier 2

TRUE COMFORT PRO ALCOHOL PREP70 PAD

Tier 2

TRUE COMFORT PRO INSULIN SYR(30G X 12 05 ML MISC 30G X 121 ML MISC 30G X 516 05 ML MISC30G X 516 1 ML MISC 31G X 51605 ML MISC 31G X 516 1 ML MISC32G X 516 05 ML MISC 32G X 5161 ML MISC)

Tier 2

TRUE COMFORT PRO PEN NEEDLES(PEN NEEDLES 31G X 5 MM MISCPEN NEEDLES 31G X 6 MM MISC PENNEEDLES 32G X 4 MM MISC)

Tier 2

ULTICARE MINI PEN NEEDLES 30G X 5MM MISC

Tier 2

ULTICARE SHORT PEN NEEDLES 30G X8 MM MISC

Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE(PEN NEEDLE 29G X 127MM MISCPEN NEEDLE 31G X 5 MM MISC PENNEEDLE 31G X 6 MM MISC PENNEEDLE 31G X 8 MM MISC PENNEEDLE 32G X 4 MM MISC PENNEEDLE 32G X 6 MM MISC)

Tier 2

ULTIGUARD SAFEPACK SYRNEEDLE(30G X 12 03 ML MISC 30G X 1205 ML MISC 30G X 12 1 ML MISC31G X 516 03 ML MISC 31G X 51605 ML MISC 31G X 516 1 ML MISC)

Tier 2

ULTRA FLO INSULIN PEN NEEDLES(PEN NEEDLES 31G X 5 MM MISCPEN NEEDLES 31G X 8 MM MISC PENNEEDLES 32G X 4 MM MISC PENNEEDLES 33G X 4 MM MISC)

Tier 2

ULTRA FLO INSULIN SYR 12 UNIT (30GX 03 ML MISC 30G X 516 03 MLMISC 31G X 516 03 ML MISC)

Tier 2

ULTRA FLO INSULIN SYRINGE (29G X12 05 ML MISC 29G X 12 1 MLMISC 30G X 12 03 ML MISC 30G X12 05 ML MISC 30G X 12 1 MLMISC 30G X 516 03 ML MISC 30GX 516 05 ML MISC 30G X 516 1ML MISC 31G X 516 03 ML MISC31G X 516 05 ML MISC 31G X 5161 ML MISC)

Tier 2

UNIFINE PEN NEEDLES 32G X 4 MMMISC

Tier 2

UNIFINE PENTIPS (31G X 5 MM MISC31G X 6 MM MISC 31G X 8 MMMISC 32G X 4 MM MISC)

Tier 2

UNIFINE ULTRA PEN NEEDLE (PENNEEDLE 31G X 5 MM MISC PENNEEDLE 31G X 6 MM MISC PENNEEDLE 31G X 8 MM MISC PENNEEDLE 32G X 4 MM MISC)

Tier 2

water for irrigation sterile irrigationsoln

Tier 2

ZEVRX INSULIN SYRINGE (12 05 MLMISC 12 1 ML MISC 516 05 MLMISC 516 1 ML MISC)

Tier 2

ZEVRX PEN NEEDLES (PEN NEEDLES31G X 5 MM MISC PEN NEEDLES31G X 6 MM MISC PEN NEEDLES31G X 8 MM MISC PEN NEEDLES32G X 4 MM MISC)

Tier 2

ZEVRX STERILE ALCOHOL PREP PAD70 PAD

Tier 2

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS OTHERATROPINE SULFATE 1 SOLUTION Tier 2

atropine sulfate ophth soln 1 Tier 2

OPHTHALMIC AGENTS

bacitracin-polymyxin b ophth oint Tier 2

bacitracin-polymyxin-neomycin-hcophth oint 1

Tier 2

brimonidine tartrate-timolol maleateophth soln 02-05

Tier 2

COMBIGAN 02-05 SOLUTION Tier 3

DORZOLAMIDE HCL-TIMOLOL MAL223-68 MGML SOLUTION

Tier 2

dorzolamide hcl-timolol maleateophth soln 223-68 mgml

Tier 2

neomycin-bacitrac zn-polymyx5(35)mg-400unt-10000unt op oin

Tier 2

neomycin-polymy-dexameth (oint01 susp 01)

Tier 2

NEOMYCIN-POLYMYXIN-GRAMICIDIN 175-10000-025SOLUTION

Tier 2

RESTASIS 005 EMULSION Tier 3 QL (60 PER 30 OVER TIME)

RESTASIS MULTIDOSE 005 EMULSION

ROCKLATAN 002-0005 SOLUTION Tier 3 QL (25 PER 25 OVER TIME)

sulfacetamide sodium-prednisoloneophth soln 10-023(025)

Tier 2

SULFACETAMIDE-PREDNISOLONE 10-023 SOLUTION

Tier 2

tobramycin-dexamethasone ophthsusp 03-01

Tier 2

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine hcl ophth soln 005 Tier 2

cromolyn sodium ophth soln 4 Tier 2

olopatadine hcl (soln 01 (baseequivalent) soln 02 (baseequivalent))

Tier 2

OPHTHALMIC AGENTS

OPHTHALMIC ANTI-INFECTIVESBACITRACIN 500 UNITGM OINTMENT Tier 2

erythromycin ophth oint 5 mggm Tier 2

GENTAK 03 OINTMENT Tier 2

gentamicin sulfate ophth soln 03 Tier 2

levofloxacin ophth soln 05 Tier 2

MOXIFLOXACIN HCL (2X DAY) 05 SOLUTION

Tier 2

moxifloxacin hcl ophth soln 05(base equiv)

Tier 2

NATACYN 5 SUSPENSION Tier 3

ofloxacin ophth soln 03 Tier 2

polymyxin b-trimethoprim ophth soln10000 unitml-01

Tier 2

SULFACETAMIDE SODIUM 10 OINTMENT

Tier 2

sulfacetamide sodium ophth soln10

Tier 2

tobramycin ophth soln 03 Tier 2

OPHTHALMIC ANTI-INFLAMMATORIESALREX 02 SUSPENSION Tier 3

DEXAMETHASONE SODIUMPHOSPHATE 01 SOLUTION

Tier 2

diclofenac sodium ophth soln 01 Tier 2

fluorometholone ophth susp 01 Tier 2

flurbiprofen sodium (003 solutionophth soln 003)

Tier 2

ILEVRO 03 SUSPENSION Tier 3 QL (17 PER 30 OVER TIME)

ketorolac tromethamine (ophth)(soln 04 soln 05)

Tier 2

loteprednol etabonate ophth susp05

Tier 2

OPHTHALMIC AGENTS

PREDNISOLONE ACETATE 1 SUSPENSION

Tier 2

PREDNISOLONE SODIUM PHOSPHATE1 SOLUTION

Tier 2

PROLENSA 007 SOLUTION Tier 3

OPHTHALMIC BETA-ADRENERGIC BLOCKING AGENTSbetaxolol hcl ophth soln 05 Tier 2

CARTEOLOL HCL 1 SOLUTION Tier 2

levobunolol hcl (05 solutionophth soln 05)

Tier 2

METIPRANOLOL 03 SOLUTION Tier 2

TIMOLOL MALEATE (025 GEL FSOLN 05 GEL F SOLN)

Tier 2

timolol maleate (ophth) (gel formingsoln 025 gel forming soln 05soln 025 soln 05)

Tier 2

OPHTHALMIC INTRAOCULAR PRESSURE LOWERING AGENTS OTHERacetazolamide cap er 12hr 500 mg Tier 2

ALPHAGAN P 01 SOLUTION Tier 3

apraclonidine hcl ophth soln 05(base equivalent)

Tier 2

AZOPT 1 SUSPENSION Tier 3

brimonidine tartrate (soln 015 soln02)

Tier 2

brinzolamide ophth susp 1 Tier 2

dorzolamide hcl ophth soln 2 Tier 2

methazolamide (tab 25 mg tab 50mg)

Tier 2

PHOSPHOLINE IODIDE 0125 RECON SOLN

Tier 3

pilocarpine hcl (soln 1 soln 2soln 4)

Tier 2

RHOPRESSA 002 SOLUTION Tier 3 QL (25 PER 25 OVER TIME)

OPHTHALMIC AGENTS

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost ophth soln 003 Tier 2 ST QL (5 PER 30 OVER

latanoprost (0005 solution ophthsoln 0005)

Tier 2

LUMIGAN 001 SOLUTION Tier 3 QL (5 PER 30 OVER TIME)

travoprost ophth soln 0004(benzalkonium free) (bak free)

OTIC AGENTS

OTIC AGENTSCIPROFLOXACIN HCL 02 SOLUTION

Tier 2

ciprofloxacin-dexamethasone oticsusp 03-01

Tier 2

COLY-MYCIN S 33-3-10-05 MGMLSUSPENSION

Tier 3

CORTISPORIN-TC 33-3-10-05 MGMLSUSPENSION

Tier 3

DERMOTIC 001 OIL Tier 3

hydrocortisone w acetic acid oticsoln 1-2

Tier 2

neomycin-polymyxin-hc (otic) (soln1 susp 35 mgml-10000 unitml-1)

Tier 2

ofloxacin otic soln 03 Tier 2

RESPIRATORY TRACTPULMONARY AGENTS

ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSbudesonide (inhalation) (susp 025mg2ml susp 05 mg2ml susp 1mg2ml)

Tier 2 BvD

FLOVENT DISKUS (100 MCGBLIST AERPOW BA 50 MCGBLIST AER POWBA)

FLOVENT DISKUS 250 MCGBLIST AERPOW BA

FLOVENT HFA (110 MCGACTAEROSOL 220 MCGACT AEROSOL)

FLOVENT HFA 44 MCGACTAEROSOL

FLUNISOLIDE 25 MCGACT (0025)SOLUTION

fluticasone propionate nasal susp 50mcgact

PULMICORT FLEXHALER (180MCGACT AER POW BA 90MCGACT AER POW BA)

QVAR REDIHALER (40 MCGACTAERO BA 80 MCGACT AERO BA)

ANTIHISTAMINESazelastine hcl (01 (137 mcg)015 (2055 mcg))

cyproheptadine hcl tab 4 mg Tier 2 PA

hydroxyzine hcl (tab 10 mg tab 25mg tab 50 mg)

Tier 2 PA

levocetirizine dihydrochloride tab 5mg

Tier 2

promethazine hcl (inj 25 mgml inj50 mgml syrup 625 mg5ml)

Tier 2 PA

ANTILEUKOTRIENESmontelukast sodium (chew tab 4mg (base equiv) chew tab 5 mg(base equiv) oral granules packet 4mg (base equiv) tab 10 mg (baseequiv))

zafirlukast (tab 10 mg tab 20 mg) Tier 2 QL (2 PER 1 DAYS)

BRONCHODILATORS ANTICHOLINERGICATROVENT HFA 17 MCGACT AEROSOLN

INCRUSE ELLIPTA 625 MCGINH AERPOW BA

ipratropium bromide inhal soln 002 Tier 2 BvD

ipratropium bromide nasal soln003 (21 mcgspray)

SPIRIVA HANDIHALER 18 MCG CAP Tier 3 QL (30 PER 30 OVER TIME)

SPIRIVA RESPIMAT (125 MCGACTAERO SOLN 25 MCGACT AEROSOLN)

BRONCHODILATORS SYMPATHOMIMETICalbuterol 90mcg hfa inhaler(generic proair)

albuterol 90mg hfa inhaler (genericproair)

albuterol 90mg hfa inhaler (genericproventil)

albuterol 90mg hfa inhaler (genericventolin)

albuterol sulfate (soln nebu 0083(25 mg3ml) soln nebu 05 (5mgml) soln nebu 063 mg3ml(base equiv) soln nebu 125 mg3ml(base equiv))

Tier 2 BvD

albuterol sulfate (tab 2 mg tab 4mg)

Tier 2

epinephrine (anaphylaxis) (solutionauto-injector 015 mg03ml (12000)solution auto-injector 03 mg03ml(11000))

EPINEPHRINE 03 MG03ML SOLN A-INJ

EPINEPHRINE AUTOINJECTOR(GENERIC ADRENACLICK)

levalbuterol hcl (soln nebu 031mg3ml (base equiv) soln nebu 063mg3ml (base equiv) soln nebu 125mg3ml (base equiv) soln nebuconc 125 mg05ml (base equiv))

Tier 2 PA

LEVALBUTEROL TARTRATE 45MCGACT AEROSOL

SEREVENT DISKUS 50 MCGDOSE AERPOW BA

STRIVERDI RESPIMAT 25 MCGACTAERO SOLN

CYSTIC FIBROSIS AGENTSCAYSTON 75 MG RECON SOLN Tier 3 PA LA QL (84 PER 28

OVER TIME)

KALYDECO (150 MG TAB 25 MGPACKET 50 MG PACKET 75 MGPACKET)

PULMOZYME 25 MG25MLSOLUTION

Tier 3 QL (150 PER 30 OVERTIME) BvD

SYMDEKO (100-150 amp 150 MG TABTHPK 50-75 amp 75 MG TAB THPK)

TOBI PODHALER 28 MG CAP Tier 3 PA LA QL (224 PER 28OVER TIME)

tobramycin nebu soln 300 mg4ml Tier 2 PA QL (224 PER 28 OVERTIME)

TRIKAFTA (100-50-75 amp 150 MG TABTHPK 50-25-375 amp 75 MG TAB THPK)

MAST CELL STABILIZERScromolyn sodium soln nebu 20mg2ml

Tier 2 BvD

PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASEDALIRESP 250 MCG TAB Tier 3 PA QL (28 PER 180 OVER

DALIRESP 500 MCG TAB Tier 3 PA QL (1 PER 1 DAYS)

theophylline (soln 80 mg15ml taber 12hr 100 mg tab er 12hr 200 mgtab er 12hr 300 mg tab er 12hr 450mg tab er 24hr 400 mg tab er 24hr600 mg)

Tier 2

THEOPHYLLINE ER (ER 300 MG TAB ER12H ER 450 MG TAB ER 12H)

Tier 2

PULMONARY ANTIHYPERTENSIVESADEMPAS (05 MG TAB 1 MG TAB15 MG TAB 2 MG TAB 25 MG TAB)

ambrisentan (tab 10 mg tab 5 mg) Tier 2 PA LA QL (1 PER 1 DAYS)

bosentan tab 125 mg Tier 2 PA LA QL (2 PER 1 DAYS)

OPSUMIT 10 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

sildenafil citrate for suspension 10mgml

sildenafil citrate tab 20 mg Tier 3 PA QL (3 PER 1 DAYS)

tadalafil tab 20 mg (pah) Tier 2 PA QL (2 PER 1 DAYS)

TRACLEER 32 MG TAB SOL Tier 3 PA LA QL (4 PER 1 DAYS)

VENTAVIS 10 MCGML SOLUTION Tier 3 LA QL (270 PER 30 OVERTIME) BvD

PULMONARY FIBROSIS AGENTSESBRIET (267 MG CAP 267 MG TAB) Tier 3 PA LA QL (9 PER 1 DAYS)

ESBRIET 801 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

OFEV (100 MG CAP 150 MG CAP) Tier 3 PA LA QL (2 PER 1 DAYS)

pirfenidone tab 267 mg Tier 2 PA LA QL (9 PER 1 DAYS)

RESPIRATORY TRACT AGENTS OTHERacetylcysteine (soln 10 soln 20) Tier 2 BvD

ANORO ELLIPTA 625-25 MCGINHAER POW BA

BEVESPI AEROSPHERE 9-48MCGACT AEROSOL

COMBIVENT RESPIMAT 20-100MCGACT AERO SOLN

FLUTICASONE-SALMETEROL (113-14MCGACT AER POW BA 232-14MCGACT AER POW BA 55-14MCGACT AER POW BA)

fluticasone-salmeterol (aer powderba 100-50 mcgact aer powder ba250-50 mcgact aer powder ba500-50 mcgact)

ipratropium-albuterol nebu soln 05-25(3) mg3ml

Tier 2 BvD

NUCALA (100 MG RECON SOLN 100MGML SOLN A-INJ 100 MGMLSOLN PRSYR)

NUCALA 40 MG04ML SOLN PRSYR Tier 3 PA LA QL (04 PER 28OVER TIME)

ribavirin for inhal soln 6 gm Tier 2 BvD

TRELEGY ELLIPTA (100-625-25MCGINH AER POW BA 200-625-25MCGINH AER POW BA)

SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTScarisoprodol tab 350 mg Tier 2 PA QL (4 PER 1 DAYS)

cyclobenzaprine hcl (tab 10 mgtab 5 mg)

Tier 2 PA

methocarbamol (tab 500 mg tab750 mg)

Tier 2 PA

SLEEP DISORDER AGENTS

SLEEP PROMOTING AGENTSestazolam (tab 1 mg tab 2 mg) Tier 2 QL (1 PER 1 DAYS)

eszopiclone (tab 1 mg tab 2 mgtab 3 mg)

HETLIOZ 20 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

ramelteon tab 8 mg Tier 2 QL (1 PER 1 DAYS)

temazepam cap 15 mg Tier 2 QL (2 PER 1 DAYS)

triazolam tab 0125 mg Tier 2 QL (4 PER 1 DAYS)

zaleplon cap 10 mg Tier 2 QL (2 PER 1 DAYS)

zolpidem tartrate tab 10 mg Tier 2 QL (1 PER 1 DAYS)

WAKEFULNESS PROMOTING AGENTSmodafinil tab 100 mg Tier 2 QL (3 PER 1 DAYS)

modafinil tab 200 mg Tier 2 QL (2 PER 1 DAYS)

XYREM 500 MGML SOLUTION Tier 3 PA LA QL (540 PER 30OVER TIME)

Non-Part D Drugs

acetaminophen ((tab 325 mg tab500 mg) tab 325 mg)

Tier 4 NPD

AEROCHAMBER MINI CHAMBERDEVICE

Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER MV MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER PLUS FLO-VU MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER PLUS FLO-VU LARGEMISC

AEROCHAMBER PLUS FLO-VUMEDIUM MISC

AEROCHAMBER PLUS FLO-VU SMALLMISC

AEROCHAMBER PLUS FLO-VUWMASK MISC

AEROCHAMBER PLUS FLOW VUMISC

AEROCHAMBER WFLOWSIGNALMISC

AEROCHAMBER Z-STAT PLUS MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER Z-STAT PLUSCHAMBR MISC

AEROCHAMBER Z-STAT PLUSLARGEMISC

AEROCHAMBER Z-STAT PLUSMEDIUMMISC

AEROCHAMBER Z-STAT PLUSSMALLMISC

AEROVENT PLUS DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

ALLI 60 MG CAP Tier 4 PA NPD

alum amp mag hydrox-simethicone(hydrox-simethicone (susp 200-200-20 mg5ml susp 400-400-40mg5ml) hydroxide-simethiconesusp 200-200-20 mg5ml)

Tier 4 NPD

Non-Part D Drugs

ALUMINUM HYDROXIDE GEL 320MG5ML SUSPENSION

Tier 4 NPD

aluminum hydroxide-magnesiumcarbonate chew tab 160-105 mg

Tier 4 NPD

aluminum hydroxide-magnesiumtrisilicate chew tab 80-20 mg

Tier 4 NPD

ANTI-DIARRHEAL 1 MG5ML LIQUID Tier 4 NPD

ARIAL CHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

ascorbic acid ((tab 1000 mg tab250 mg) tab 1000 mg)

Tier 4 NPD

aspirin ((300 mg suppos 600 mgsuppos chew tab 81 mg tab 325mg tab delayed release 325 mgtab delayed release 81 mg) 300 mgsuppos 600 mg suppos chew tab81 mg tab 325 mg tab delayedrelease 325 mg)

Tier 4 NPD

aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg

Tier 4 NPD

B-12 5000 MCG TAB DISP Tier 4 NPD

B-12 DOTS 500 MCG TAB DISP Tier 4 NPD

bacitracin oint 500 unitgm Tier 4 NPD

bacitracin zinc oint 500 unitgm Tier 4 NPD

bacitracin-polymyxin b oint Tier 4 NPD

BAYER PLUS 500 MG TAB Tier 4 NPD

benzonatate ((cap 100 mg cap 200mg) cap 100 mg)

Tier 4 NPD

benzoyl peroxide ((cream 10 gel10 liq 10) cream 10 gel 10)

Tier 4 NPD

bisacodyl ((suppos 10 mg tabdelayed release 5 mg) suppos 10mg)

Tier 4 NPD

bismuth subsalicylate ((chew tab262 mg susp 525 mg15ml tab 262mg) chew tab 262 mg susp 525mg15ml)

Tier 4 NPD

Non-Part D Drugs

BREATHE EASE LARGE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHE EASE MEDIUM DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHE EASE SMALL DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITE COLL SPACER ADULTMISC

BREATHERITE COLL SPACER CHILDMISC

BREATHERITE COLL SPACER INFANTMISC

BREATHERITE RIGID SPACERMASKMISC

BREATHERITE SPACER NEONATEMISC

BREATHERITE SPACER SMALL CHILDMISC

BREATHERITELARGE MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITEMEDIUM MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITESMALL MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

CALAMINE LOTION Tier 4 NPD

CALAMINE-ZINC OXIDE 8-8 SUSPENSION

Tier 4 NPD

CALCI-CHEW 1250 (500 CA) MGCHEW TAB

Tier 4 NPD

calcium ascorbate tab 500 mg Tier 4 NPD

Non-Part D Drugs

calcium carbonate ((1250 (500 ca)mg chew tab tab 1250 mg (500 mgelemental ca) tab 1500 mg (600mg elemental ca) tab 600 mg)1250 (500 ca) mg chew tab tab1250 mg (500 mg elemental ca)tab 1500 mg (600 mg elementalca))

Tier 4 NPD

calcium carbonate (antacid)((chew tab 500 mg chew tab 750mg) chew tab 500 mg)

Tier 4 NPD

CALCIUM CARBONATE ANTACID 648MG TAB

Tier 4 NPD

calcium carbonate-cholecalciferol((tab 250 mg-125 unit tab 500 mg-125 unit tab 500 mg-200 unit tab500 mg-400 unit tab 500 mg-600unit) tab 250 mg-125 unit tab 500mg-125 unit tab 500 mg-200 unittab 500 mg-400 unit)

Tier 4 NPD

calcium carbonate-ergocalciferoltab 500mg-200 unit

Tier 4 NPD

calcium carbonate-vitamin d ((tab250 mg-125 unit tab 500 mg-125unit tab 500 mg-200 unit) tab 250mg-125 unit tab 500 mg-125 unit)

Tier 4 NPD

CALCIUM GLUCONATE ((50 MG TAB500 MG TAB) 50 MG TAB)

Tier 4 NPD

calcium tab 600 mg Tier 4 NPD

CALCIUMCD 500-10-250 MG-MG-UNIT CHEW TAB

Tier 4 NPD

carbamide peroxide 65 otic soln Tier 4 NPD

cetirizine hcl ((tab 10 mg tab 5 mg)tab 10 mg)

Tier 4 NPD

CHEWABLE CALCIUMD3 500-15 MG-MCG WAFER

Tier 4 NPD

chlorpheniramine maleate syrup 2mg5ml

Tier 4 NPD

CLEVER CHOICE HOLDINGCHAMBER DEVICE

Non-Part D Drugs

clotrimazole vaginal cream 1 Tier 4 NPD

COMPACT SPACE CHAMBERDEVICE

COMPACT SPACE CHAMBERLGMASK DEVICE

COMPACT SPACE CHAMBERMEDMASK DEVICE

COMPACT SPACE CHAMBERSMMASK DEVICE

CONDOMS LATEX LUBRICATED Tier 4 NPD

cromolyn sodium nasal aerosol soln52 mgact (4)

Tier 4 NPD

CVS LICE SOLUTION 3-STEP KIT Tier 4 NPD

diphenhydramine hcl ((cap 25 mgelixir 125 mg5ml liquid 125mg5ml tab 25 mg) cap 25 mgelixir 125 mg5ml liquid 125mg5ml)

Tier 4 NPD

docosanol cream 10 Tier 4 NPD

docusate sodium ((cap 100 mgcap 250 mg liquid 150 mg15ml)cap 100 mg cap 250 mg)

Tier 4 NPD

EASIVENT MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK LARGE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK MEDIUM MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK SMALL MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EQ CALAMINE 8-8 SUSPENSION Tier 4 NPD

EQ SPACE CHAMBER ANTI-STATICDEVICE

EQ SPACE CHAMBER ANTI-STATIC LDEVICE

EQ SPACE CHAMBER ANTI-STATIC MDEVICE

Non-Part D Drugs

EQ SPACE CHAMBER ANTI-STATIC SDEVICE

ergocalciferol ((cap 125 mg (50000unit) soln 200 mcgml (8000unitml)) cap 125 mg (50000 unit))

Tier 4 NPD

eye wash Tier 4 NPD

famotidine tab 10 mg Tier 4 NPD

ferrous sulfate ((220 (44 fe) liquidelixir 220 (44 fe) soln 75 mgml (15mgml fe) syrup 300 (60 fe) tab ec325 mg (65 mg fe equivalent)) 220(44 fe) liquid elixir 220 (44 fe) soln 75mgml (15 mgml fe) syrup 300 (60fe))

Tier 4 NPD

ferrous sulfate ((tab 27 mg(elemental fe) tab 325 mg (65 mgelemental fe)) tab 27 mg(elemental fe))

Tier 4 NPD

ferrous sulfate dried tab 200 mg (65mg elemental fe)

Tier 4 NPD

fexofenadine hcl ((tab 180 mg tab60 mg) tab 180 mg)

Tier 4 NPD

FLEXICHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

folic acid ((cap 08 mg tab 1 mgtab 400 mcg tab 800 mcg) cap 08mg tab 1 mg tab 400 mcg)

Tier 4 NPD

GLUCOSE CHEW TAB 4 GM Tier 4 NPD

GLUCOSE-VITAMIN C CHEW TAB 4-6GM-MG

Tier 4 NPD

glycerin (laxative) ((laxative)(suppos 1 gm suppos 12 gmsuppos 2 gm suppos 21 gm suppos807) suppos 1 gm suppos 12 gmsuppos 2 gm suppos 21 gm)

Tier 4 NPD

GOODSENSE CALAMINE 8-8 SUSPENSION

Tier 4 NPD

guaifenesin liquid 100 mg5ml Tier 4 NPD

Non-Part D Drugs

guaifenesin-codeine soln 100-10mg5ml

Tier 4 QL (420 PER 30 OVERTIME) NDS NPD

HYCODAN 5-15 MG5ML SOLUTION Tier 4 QL (210 PER 30 OVERTIME) NDS NPD

hydrocodone bitart-homatropinemethylbrom soln 5-15 mg5ml

hydrocortisone (topical) ((topical)(cream 05 cream 1 oint 05)cream 05 cream 1)

Tier 4 NPD

HYDROCORTISONE-ALOE 05 CREAM

Tier 4 NPD

hydrocortisone-aloe vera ((cream05 cream 1) cream 05)

Tier 4 NPD

ibuprofen ((cap 200 mg chew tab100 mg susp 40 mgml tab 100 mgtab 200 mg) cap 200 mg chew tab100 mg susp 40 mgml tab 100 mg)

Tier 4 NPD

INSPIRACHAMBERLARGE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIRACHAMBERMEDIUM DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIRACHAMBERMOUTHPIECEDEVICE

INSPIRACHAMBERSMALL DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIREASE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

ketotifen fumarate ophth soln0025 (base equiv)

Tier 4 NPD

levonorgestrel tab 15 mg Tier 4 NPD

LITEAIRE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

loperamide hcl ((liq 1 mg5ml (02mgml) liq 1 mg75ml tab 2 mg)liq 1 mg5ml (02 mgml) liq 1mg75ml)

Tier 4 NPD

loratadine ((rapidly-disintegratingtab 10 mg tab 10 mg) rapidly-disintegrating tab 10 mg)

Tier 4 NPD

Non-Part D Drugs

MAG-G 500 (27 MG) MG TAB Tier 4 NPD

magnesium citrate soln Tier 4 NPD

magnesium gluconate tab 500 mg(27 mg elemental mg)

Tier 4 NPD

meclizine hcl chew tab 25 mg Tier 4 NPD

miconazole nitrate vaginal ((cream2 suppos 100 mg) cream 2)

Tier 4 NPD

MICROCHAMBER ((DEVICE MISC)DEVICE)

MICROSPACER MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

MURO 128 2 SOLUTION Tier 4 NPD

naphazoline w pheniramine ophthsoln 0027-0315

Tier 4 NPD

NASACORT ALLERGY 24HR 55MCGACT AEROSOL

Tier 4 NPD

NASACORT ALLERGY 24HRCHILDREN 55 MCGACT AEROSOL

Tier 4 NPD

NASAL DECONGESTANT ((30MG5ML LIQUID 30 MG5ML SYRUP)30 MG5ML LIQUID)

Tier 4 NPD

neomycin-bacitracin-polymyxin oint Tier 4 NPD

neomycin-polymyxin w pramoxinecream 1

Tier 4 NPD

niacin ((cap er 250 mg cap er 500mg tab 100 mg tab 250 mg tab 50mg tab 500 mg tab er 250 mg taber 500 mg tab er 750 mg) cap er250 mg cap er 500 mg tab 100 mgtab 250 mg tab 50 mg tab 500 mgtab er 250 mg tab er 500 mg)

Tier 4 NPD

NIACIN ER 1000 MG TAB ER Tier 4 NPD

niacinamide tab 500 mg Tier 4 NPD

nicotine ((patch 24hr 14 mg24hrpatch 24hr 21 mg24hr patch 24hr 7mg24hr) td patch 24hr 14 mg24hrtd patch 24hr 21 mg24hr)

Tier 4 NPD

Non-Part D Drugs

nicotine polacrilex ((gum 2 mg gum4 mg lozenge 2 mg lozenge 4 mg)gum 2 mg gum 4 mg lozenge 2mg)

Tier 4 NPD

NIX COMPLETE LICE TREATMENT 1 amp025 KIT

Tier 4 NPD

omega-3 fatty acids cap 1000 mg Tier 4 NPD

omeprazole delayed release tab 20mg

Tier 4 NPD

OPTICHAMBER ADVANTAGE-LGMASK MISC

OPTICHAMBER ADVANTAGE-MEDMASK MISC

OPTICHAMBER ADVANTAGE-SMMASK MISC

OPTICHAMBER DIAMOND ((DEVICEMISC) DEVICE)

OPTICHAMBER DIAMOND-LG MASKDEVICE

OPTICHAMBER DIAMOND-MD MASKMISC

OPTICHAMBER DIAMOND-SM MASKMISC

OPTICHAMBER FACE MASK-LARGEMISC

OPTICHAMBER FACE MASK-MEDIUMMISC

OPTICHAMBER FACE MASK-SMALLMISC

OPTIHALER ((DEVICE MISC) DEVICE) Tier 4 QL (2 PER 365 OVER TIME)NPD

OPTIONS GYNOL II CONTRACEPTIVE3 GEL

Tier 4 NPD

oral electrolyte solution Tier 4 NPD

OYSTER SHELL CALCIUM 500 + D 500-125 MG-UNIT TAB

Tier 4 NPD

Non-Part D Drugs

oyster shell calcium tab 500 mg Tier 4 NPD

OYSTER SHELL CALCIUMD 500-200MG-UNIT TAB

Tier 4 NPD

permethrin ((creme rinse 1 lotion1) creme rinse 1)

Tier 4 NPD

phentermine hcl ((cap 15 mg cap30 mg) cap 15 mg)

Tier 4 PA NPD

phytonadione tab 100 mcg Tier 4 NPD

phytonadione tab 5 mg Tier 4 QL (5 PER 7 OVER TIME)NPD

POCKET CHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

POCKET SPACER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

polyethylene glycol 3350 (3350 (3350oral packet 17 gm 3350 oralpowder 17 gmscoop) 3350 oralpacket 17 gm)

Tier 4 NPD

polyvinyl alcohol ophth soln 14 Tier 4 NPD

PRE-NATAL FORMULA TAB Tier 4 NPD

PRENATAL (WIRON amp FA) 27-08 MGTAB

Tier 4 NPD

PRENATAL FORTE TAB Tier 4 NPD

PRENATAL VITAMIN WITH IRON TAB27-08 MG

Tier 4 NPD

PRENATALIRON TAB Tier 4 NPD

PRO COMFORT SPACER ADULTMISC

PRO COMFORT SPACER CHILDMISC

PRO COMFORT SPACER INFANTDEVICE

PROCARE SPACERADULT MASKDEVICE

Non-Part D Drugs

PROCARE SPACERCHILD MASKDEVICE

promethazine w codeine syrup625-10 mg5ml

Tier 4 PA QL (240 PER 30 OVERTIME) NDS NPD

promethazine-dm ((solution syrup )solution)

Tier 4 PA NPD

promethazine-phenylephrine-codeine syrup 625-5-10 mg5ml

pseudoephedrine hcl ((tab 30 mgtab 60 mg) tab 30 mg)

Tier 4 NPD

pyrantel pamoate susp 144 mgml(50 mgml base equiv)

Tier 4 NPD

pyreth-piperonyl butox sham-permeth aero-nit remover gel kit

Tier 4 NPD

pyrethrins-piperonyl butoxide ((liq033-4 shampoo 033-4) liq 033-4)

Tier 4 NPD

pyridoxine hcl ((tab 100 mg tab 50mg) tab 100 mg)

Tier 4 NPD

QSYMIA ((1125-69 MG CAP ER 24H15-92 MG CAP ER 24H 375-23 MGCAP ER 24H 75-46 MG CAP ER 24H)1125-69 MG CAP ER 24H 15-92 MGCAP ER 24H 375-23 MG CAP ER24H)

Tier 4 PA NPD

RA CALAMINE 8-8 SUSPENSION Tier 4 NPD

RA DAYLOGIC ACNE FOAMINGWASH 10 FOAM

Tier 4 NPD

RA OYSTER SHELL CALCIUMD2 500-200 MG-UNIT TAB

Tier 4 NPD

riboflavin ((tab 100 mg tab 50 mg)tab 100 mg)

Tier 4 NPD

RID 033-4 LIQUID Tier 4 NPD

RID COMPLETE LICE ELIMINATIONKIT

Tier 4 NPD

RITEFLO DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

Non-Part D Drugs

saline nasal spray 065 Tier 4 NPD

SAXENDA 18 MG3ML SOLN PEN Tier 4 PA NPD

selenium sulfide lotion 1 Tier 4 NPD

sennosides tab 86 mg Tier 4 NPD

simethicone ((cap 125 mg chewtab 80 mg susp 40 mg06ml) cap125 mg chew tab 80 mg)

Tier 4 NPD

SM FOAMING ANTACID 80-20 MGCHEW TAB

Tier 4 NPD

sodium bicarbonate tab 325 mg Tier 4 NPD

sodium chloride hypertonic ophthsoln 5

Tier 4 NPD

thiamine hcl tab 100 mg Tier 4 NPD

thiamine mononitrate tab 100 mg Tier 4 NPD

tioconazole vaginal oint 65 Tier 4 NPD

tolnaftate cream 1 Tier 4 NPD

triamcinolone acetonide nasalaerosol suspension 55 mcgact

Tier 4 NPD

triprolidine amp pseudoephedrine tab25-60 mg

Tier 4 NPD

VALVED HOLDING CHAMBERDEVICE

VCF VAGINAL CONTRACEPTIVE((125 FOAM 4 GEL) 125 FOAM)

Tier 4 NPD

vitamin a cap 3 mg (10000 unit) Tier 4 NPD

VITAMIN D2 10 MCG (400 UNIT) TAB Tier 4 NPD

vitamin e ((cap 180 mg (400 unit)cap 268 mg (400 unit) cap 400unit) cap 180 mg (400 unit) cap268 mg (400 unit))

Tier 4 NPD

VITAMIN K 100 MCG TAB Tier 4 NPD

VORTEX VALVED HOLDINGCHAMBER DEVICE

Non-Part D Drugs

WATCHHALER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

Index of Covered Drugs

Aabacavir sulfate 44abacavir sulfate-lamivudine 44abacavir sulfate-lamivudine-zidovudine 44ABELCET 21ABILIFY MAINTENA 38abiraterone acetate 26acamprosate calcium 4acarbose 49acebutolol hcl 58acetaminophen 112acetaminophen w codeine 2acetazolamide 60104acetic acid (otic) 6acetylcysteine 110acitretin 70ACTHAR 81ACTHIB 93ACTIMMUNE 90acyclovir 47acyclovir sodium 47acyclovir topical 72ADACEL 93adapalene 70adefovir dipivoxil 42ADEMPAS 109ADVOCATE ALCOHOL PREP PADS 97AEROCHAMBER MINI CHAMBER 112AEROCHAMBER MV 112AEROCHAMBER PLUS FLO-VU 112AEROCHAMBER PLUS FLO-VU LARGE 112AEROCHAMBER PLUS FLO-VU MEDIUM 112AEROCHAMBER PLUS FLO-VU SMALL 112AEROCHAMBER PLUS FLO-VU WMASK 112AEROCHAMBER PLUS FLOW VU 112AEROCHAMBER WFLOWSIGNAL 112AEROCHAMBER Z-STAT PLUS 112AEROCHAMBER Z-STAT PLUS CHAMBR 112AEROCHAMBER Z-STAT PLUSLARGE 112AEROCHAMBER Z-STAT PLUSMEDIUM 112

AEROCHAMBER Z-STAT PLUSSMALL 112AEROVENT PLUS 112AIMOVIG 23AIMOVIG (140 MG DOSE) 23albendazole 34albuterol 90mcg hfa inhaler (genericproair) 107albuterol 90mg hfa inhaler (generic proair)107albuterol 90mg hfa inhaler (genericproventil) 107Albuterol 90mg HFA inhaler (GenericVentolin) 107albuterol sulfate 107alclometasone dipropionate 7081ALCOHOL 70 PADS 97ALCOHOL PREP 97ALCOHOL PREP PADS 97ALCOHOL WIPES 97ALDURAZYME 79ALECENSA 29alendronate sodium 96alfuzosin hcl 81ALINIA 34aliskiren fumarate 60ALLI 112allopurinol 23alosetron hcl 77ALPHAGAN P 104alprazolam 48ALREX 103alum amp mag hydrox-simethicone 112ALUMINUM HYDROXIDE GEL 113aluminum hydroxide-mag carb 113aluminum hydroxide-mag trisil 113ALUNBRIG 29amantadine hcl 36AMBISOME 21ambrisentan 109amikacin sulfate 6amiloride amp hydrochlorothiazide 60amiloride hcl 63

AMINO ACID 73amino acid electrolyte infusion 73amino acid infusion 73AMINOSYN 73AMINOSYN II 73AMINOSYN-HBC 73AMINOSYN-PF 73AMINOSYN-RF 73AMINOSYNELECTROLYTES 73amiodarone hcl 57AMITIZA 76amitriptyline hcl 19amlodipine besylate 59amlodipine besylate-benazepril hcl 60amlodipine besylate-olmesartanmedoxomil 60amlodipine besylate-valsartan 60amlodipine-valsartan-hydrochlorothiazide 60AMOXAPINE 19AMOXICILLIN 9amoxicillin amp pot clavulanate 9AMOXICILLIN-POT CLAVULANATE 9amphetamine-dextroamphetamine 66AMPHOTERICIN B 21amphotericin b liposome 21AMPICILLIN 10ampicillin amp sulbactam sodium 10ampicillin sodium 10AMPICILLIN-SULBACTAM SODIUM 10ANADROL-50 83anagrelide hcl 54anastrozole 29ANDRODERM 84ANORO ELLIPTA 110ANTI-DIARRHEAL 113apomorphine hydrochloride 36apraclonidine hcl 104aprepitant 20APRETUDE 43APTIOM 15APTIVUS 46

ARALAST NP 79ARANESP (ALBUMIN FREE) 54ARCALYST 90ARIAL CHAMBER 113aripiprazole 38ARISTADA 38ARISTADA INITIO 39ascorbic acid 113asenapine maleate 39aspirin 113aspirin buffered (cal carb-mag carb-magoxide) 113aspirin-dipyridamole 55atazanavir sulfate 46atenolol 58atenolol amp chlorthalidone 60atomoxetine hcl 67atorvastatin calcium 64atovaquone 35atovaquone-proguanil hcl 35ATROPINE SULFATE 101atropine sulfate (ophthalmic) 101ATROVENT HFA 107AUBAGIO 68AUM MINI INSULIN PEN NEEDLE 97AUM READYGARD DUO PEN NEEDLE 97AURYXIA 75AUSTEDO 67AVONEX 68AVONEX PEN 68AVONEX PREFILLED 68AYVAKIT 27azathioprine 91AZATHIOPRINE SODIUM 91azelastine hcl 106azelastine hcl (ophth) 102azithromycin 11AZOPT 104aztreonam 6

BB-12 113B-12 DOTS 113BACITRACIN 103bacitracin (topical) 113bacitracin zinc 113bacitracin-poly-neomycin-hc 102bacitracin-polymyxin b (ophth) 102bacitracin-polymyxin b oint 113baclofen 41balsalazide disodium 95BALVERSA 29BAQSIMI ONE PACK 51BAQSIMI TWO PACK 51BARACLUDE 42BAYER PLUS 113BCG VACCINE 93BD ECLIPSE SYRINGE 97BD INSULIN SYRINGE 97BD Pen Needle Mini UF 31G X 5 MM MISC 97BD Pen Needle Nano UF 32G X 4 MMMISC 97BD Pen Needle Original UF 29G X 127MMMISC 97BD Pen Needle Short UF 31G X 8 MM MISC 97benazepril amp hydrochlorothiazide 61benazepril hcl 57BENAZEPRIL-HYDROCHLOROTHIAZIDE 61BENLYSTA 90BENZNIDAZOLE 35benzonatate 113benzoyl peroxide 113benztropine mesylate 36BERINERT 89BESIVANCE 11BESREMI 27betaine 79betamethasone dipropionate (topical) 7081BETAMETHASONE DIPROPIONATE AUG 70

betamethasone dipropionateaugmented 7081betamethasone valerate 70BETASERON 68betaxolol hcl 58betaxolol hcl (ophth) 104bethanechol chloride 81BEVESPI AEROSPHERE 110bexarotene 34bexarotene (topical) 34BEXSERO 93bicalutamide 26BICILLIN L-A 10BIKTARVY 43bimatoprost 105BIOGUARD GAUZE SPONGES 97bisacodyl 113bismuth subsalicylate 113bisoprolol amp hydrochlorothiazide 61bisoprolol fumarate 58BIVIGAM 89BOOSTRIX 93bosentan 109BOSULIF 29BRAFTOVI 29BREATHE EASE LARGE 114BREATHE EASE MEDIUM 114BREATHE EASE SMALL 114BREATHERITE 114BREATHERITE COLL SPACER ADULT 114BREATHERITE COLL SPACER CHILD 114BREATHERITE COLL SPACER INFANT 114BREATHERITE RIGID SPACERMASK 114BREATHERITE SPACER NEONATE 114BREATHERITE SPACER SMALL CHILD 114BREATHERITELARGE MASK 114BREATHERITEMEDIUM MASK 114BREATHERITESMALL MASK 114BRILINTA 55brimonidine tartrate 104brimonidine tartrate-timolol maleate 102

brinzolamide 104BRIVIACT 1213bromocriptine mesylate 36BRUKINSA 27budesonide 95budesonide (inhalation) 106bumetanide 63buprenorphine hcl 4buprenorphine hcl-naloxone hcl dihydrate 45bupropion hcl 17bupropion hcl (smoking deterrent) 5buspirone hcl 48butalbital-acetaminophen-caffeine 67butalbital-acetaminophen-caffeine wcodeine 2BYLVAY 79BYLVAY (PELLETS) 79

CCABENUVA 45cabergoline 87CABLIVI 55CABOMETYX 29CALAMINE LOTION 114CALAMINE-ZINC OXIDE 114CALCI-CHEW 114calcipotriene 71calcitonin (salmon) 96calcitriol 96calcium 115calcium acetate (phosphate binder) 75calcium ascorbate 114calcium carbonate 115calcium carbonate (antacid) 115CALCIUM CARBONATE ANTACID 115calcium carbonate-cholecalciferol 115calcium carbonate-ergocalciferol 115calcium carbonate-vitamin d 115CALCIUM GLUCONATE 115CALCIUMCD 115CALQUENCE 29

candesartan cilexetil 56candesartan cilexetil-hydrochlorothiazide 61CAPASTAT SULFATE 25CAPLYTA 39CAPRELSA 29captopril 57CAPTOPRIL-HYDROCHLOROTHIAZIDE 61carbamazepine 15carbamide peroxide (otic) 115carbidopa 36CARBIDOPA-LEVODOPA 37carbidopa-levodopa-entacapone 36CAREONE UNIFINE PENTIPS PLUS 97CARETOUCH INSULIN SYRINGE 97CARETOUCH PEN NEEDLES 97carglumic acid 73carisoprodol 110CARTEOLOL HCL 104carvedilol 58caspofungin acetate 21CAYSTON 108cefaclor 8cefadroxil 8cefazolin sodium 8cefdinir 8cefepime hcl 8cefixime 8cefotaxime sodium 8cefotetan disodium 8cefoxitin sodium 8cefpodoxime proxetil 9cefprozil 9ceftazidime 9ceftriaxone sodium 9cefuroxime axetil 9cefuroxime sodium 9celecoxib 1CELONTIN 14cephalexin 9CERDELGA 79CEREZYME 79

cetirizine hcl 115CHEWABLE CALCIUMD3 115chlordiazepoxide hcl 48chlorhexidine gluconate (mouth-throat) 69chloroquine phosphate 35chlorothiazide 63chlorpheniramine maleate 115chlorpromazine hcl 37chlorthalidone 63CHOLBAM 79cholestyramine 64cholestyramine light 64choline fenofibrate 63ciclopirox 72ciclopirox olamine 21cilostazol 55CILOXAN 11CIMDUO 44cimetidine 78cimetidine hcl 78cinacalcet hcl 96CINRYZE 89ciprofloxacin 11ciprofloxacin hcl 11CIPROFLOXACIN HCL 105ciprofloxacin hcl (ophth) 11ciprofloxacin in d5w 11ciprofloxacin-dexamethasone 105citalopram hydrobromide 18clarithromycin 11CLEVER CHOICE HOLDING CHAMBER 115clindamycin hcl 6clindamycin palmitate hydrochloride 6clindamycin phosphate 6clindamycin phosphate (topical) 672clindamycin phosphate in d5w 6CLINDAMYCIN PHOSPHATE IN NACL 6clindamycin phosphate vaginal 6clobazam 14clobetasol propionate 70clobetasol propionate emollient base 7081

clomipramine hcl 19clonazepam 48clonidine 55clonidine hcl 56clonidine hcl (adhd) 67clopidogrel bisulfate 55clorazepate dipotassium 48clotrimazole 21clotrimazole (topical) 21clotrimazole vaginal 116clotrimazole w betamethasone 71clozapine 41COARTEM 35codeine sulfate 2CODEINE SULFATE 2colchicine 23colchicine w probenecid 23COLCRYS 23colesevelam hcl 64colestipol hcl 64colistimethate sodium 7COLY-MYCIN S 105COMBIGAN 102COMBIVENT RESPIMAT 110COMETRIQ (100 MG DAILY DOSE) 30COMETRIQ (140 MG DAILY DOSE) 30COMETRIQ (60 MG DAILY DOSE) 30COMFORT TOUCH ALCOHOL PREP 98COMFORT TOUCH INSULIN PEN NEED 98COMPACT SPACE CHAMBER 116COMPACT SPACE CHAMBERLG MASK 116COMPACT SPACE CHAMBERMED MASK 116COMPACT SPACE CHAMBERSM MASK 116COMPLERA 43CONDOMS LATEX LUBRICATED 116COPIKTRA 30CORLANOR 61CORTISONE ACETATE 81CORTISPORIN-TC 105CORTROPHIN 82COTELLIC 30

CREON 79CRESEMBA 21CRIXIVAN 46cromolyn sodium 109cromolyn sodium (mastocytosis) 79cromolyn sodium (nasal) 116cromolyn sodium (ophth) 102CRYSVITA 73CVS ISOPROPYL ALCOHOL WIPES 98CVS LICE SOLUTION 3-STEP 116cyclobenzaprine hcl 111cyclophosphamide 25cyclosporine 91cyclosporine modified (for microemulsion) 91cyproheptadine hcl 106CYSTAGON 79CYSTARAN 79

Ddalfampridine 68DALIRESP 109danazol 84dantrolene sodium 41dapsone 24DAPTACEL 93daptomycin 7DAURISMO 30deferasirox 75deferiprone 75DELSTRIGO 43DENGVAXIA 93DEPO-ESTRADIOL 84DEPO-PROVERA 86DERMOTIC 105DESCOVY 44desipramine hcl 19desmopressin acetate 83desmopressin acetate spray 83desmopressin acetate spray refrigerated 83desogestrel amp ethinyl estradiol 84desogestrel-ethinyl estradiol (biphasic) 84

desogestrel-ethinyl estradiol (triphasic) 84desonide 70desoximetasone 70desvenlafaxine succinate 18dexamethasone 82dexamethasone sodium phosphate 82DEXAMETHASONE SODIUM PHOSPHATE 103dexmethylphenidate hcl 67dextroamphetamine sulfate 66dextrose 75dextrose in lactated ringers 75dextrose w sodium chloride 75DEXTROSE-NACL 75DEXTROSE-SODIUM CHLORIDE 76DIACOMIT 13DIAZEPAM 14diazepam 48diazoxide 51diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic keratoses) 71diclofenac sodium (ophth) 103diclofenac sodium (topical) 1dicloxacillin sodium 10dicyclomine hcl 77DIDANOSINE 44diflunisal 1digoxin 61dihydroergotamine mesylate 23DILANTIN 15DILANTIN INFATABS 15diltiazem hcl 59diltiazem hcl coated beads 59diltiazem hcl extended release beads 60dimethyl fumarate 68diphenhydramine hcl 116diphenoxylate w atropine 77DIPHENOXYLATE-ATROPINE 77DIPHTHERIA-TETANUS TOXOIDS DT 93dipyridamole 55disopyramide phosphate 57

disulfiram 4divalproex sodium 13docosanol 116docusate sodium 116dofetilide 57donepezil hydrochloride 16dorzolamide hcl 104DORZOLAMIDE HCL-TIMOLOL MAL 102dorzolamide hcl-timolol maleate 102DOVATO 43doxazosin mesylate 56doxepin hcl 19doxercalciferol 96doxycycline (monohydrate) 12doxycycline hyclate 12DRIZALMA SPRINKLE 68dronabinol 20DROPSAFE ALCOHOL PREP 98DROPSAFE SAFETY PEN NEEDLES 98drospirenone-ethinyl estradiol 84DROXIA 27droxidopa 56duloxetine hcl 68dutasteride 81

EEES 400 11EASIVENT 116EASIVENT MASK LARGE 116EASIVENT MASK MEDIUM 116EASIVENT MASK SMALL 116EASY TOUCH INSULIN SYRINGE 98EASY TOUCH PEN NEEDLES 98econazole nitrate 21EDURANT 43efavirenz 43efavirenz-emtricitabine-tenofovir disoproxilfumarate 43efavirenz-lamivudine-tenofovir disoproxilfumarate 43EGRIFTA 83

EGRIFTA SV 83ELIQUIS 53ELIQUIS DVTPE STARTER PACK 53EMCYT 26EMSAM 17emtricitabine 44emtricitabine-tenofovir disoproxil fumarate 44EMTRIVA 44enalapril maleate 57enalapril maleate amp hydrochlorothiazide 61ENBREL 91ENBREL SURECLICK 91ENGERIX-B 93enoxaparin sodium 53entacapone 36entecavir 42ENTRESTO 61ENVARSUS XR 91EPCLUSA 42EPIDIOLEX 13EPINEPHRINE 108epinephrine (anaphylaxis) 108EPINEPHRINE AUTOINJECTOR (GENERICADRENACLICK) 108EPIVIR HBV 42eplerenone 63EPRONTIA 13EPROSARTAN MESYLATE 56EQ CALAMINE 116EQ SPACE CHAMBER ANTI-STATIC 116EQ SPACE CHAMBER ANTI-STATIC L 116EQ SPACE CHAMBER ANTI-STATIC M 116EQ SPACE CHAMBER ANTI-STATIC S 117ergocalciferol 117ERGOLOID MESYLATES 16ERIVEDGE 30ERLEADA 26erlotinib hcl 30ertapenem sodium 10ERY 72ERYTHROCIN LACTOBIONATE 11

erythromycin (acne aid) 72erythromycin (ophth) 103erythromycin base 11ERYTHROMYCIN ETHYLSUCCINATE 11erythromycin lactobionate 11ESBRIET 109escitalopram oxalate 18estazolam 111estradiol 8485estradiol vaginal 85ESTRING 85eszopiclone 111ethambutol hcl 25ethosuximide 14ethynodiol diacet amp eth estrad 85ETIDRONATE DISODIUM 96etodolac 1etonogestrel-ethinyl estradiol 85etravirine 4344everolimus 30everolimus (immunosuppressant) 91EVOTAZ 46exemestane 29EXKIVITY 27EXTAVIA 69eye wash 117ezetimibe 64ezetimibe-simvastatin 64

FFABRAZYME 79famciclovir 47famotidine 78117FANAPT 39FANAPT TITRATION PACK 39FARXIGA 49FARYDAK 30felbamate 13felodipine 59fenofibrate 63fenofibrate micronized 63

fentanyl 1fentanyl citrate 2FERRIPROX 75ferrous sulfate 117ferrous sulfate dried 117FETZIMA 18FETZIMA TITRATION 18fexofenadine hcl 117finasteride 81FINTEPLA 13FIRDAPSE 67FIRMAGON 87FIRMAGON (240 MG DOSE) 87FLEBOGAMMA DIF 89flecainide acetate 57FLEXICHAMBER 117FLOVENT DISKUS 106FLOVENT HFA 106fluconazole 21fluconazole in dextrose 22fluconazole in nacl 22flucytosine 22fludrocortisone acetate 82FLUNISOLIDE 106fluocinolone acetonide 70fluocinonide 71fluocinonide emulsified base 71fluorometholone (ophth) 103FLUOROURACIL 71fluorouracil (topical) 71fluoxetine hcl 18FLUOXETINE HCL 18FLUOXETINE HCL (PMDD) 18fluphenazine decanoate 37fluphenazine hcl 37flurbiprofen 1flurbiprofen sodium 103flutamide 26fluticasone propionate 71fluticasone propionate (nasal) 106FLUTICASONE-SALMETEROL 110

fluticasone-salmeterol 110fluvastatin sodium 64fluvoxamine maleate 18folic acid 117fondaparinux sodium 53FORTEO 96fosamprenavir calcium 46fosfomycin tromethamine 7fosinopril sodium 57fosinopril sodium amp hydrochlorothiazide 61FOTIVDA 27FREAMINE III 73fulvestrant 26furosemide 63FUZEON 45FYCOMPA 13

Ggabapentin 14GAMMAGARD 89GAMMAGARD SD LESS IGA 89GAMMAKED 89GAMMAPLEX 89GAMUNEX-C 89GARDASIL 9 93GATTEX 77gauze pads 2x2 98GAVILYTE-C 77GAVRETO 30gemfibrozil 64GENTAK 103gentamicin sulfate 6gentamicin sulfate (ophth) 103gentamicin sulfate (topical) 6GENVOYA 43GILENYA 69GILOTRIF 30glatiramer acetate 69GLEOSTINE 25glimepiride 49glipizide 49

glipizide-metformin hcl 49GLUCAGEN HYPOKIT 51glucagon (rdna) 51GLUCAGON EMERGENCY 51GLUCOSE CHEW TAB 4 GM 117GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 117glyburide 49glyburide micronized 49glyburide-metformin 49glycerin (laxative) 117glycopyrrolate 77GLYXAMBI 49GNP ISOPROPYL ALCOHOL WIPES 98GNP STERILE GAUZE 98GNP ULTIGUARD SAFEPACK NEEDLE 98GOODSENSE CALAMINE 117granisetron hcl 21griseofulvin microsize 22griseofulvin ultramicrosize 22guaifenesin 117guaifenesin-codeine 118guanfacine hcl 56guanfacine hcl (adhd) 67GUANIDINE HCL 24

HH-E-B INCONTROL PEN NEEDLES 98H-E-B INCONTROL UNIFINE PENTIP 98HAEGARDA 89halobetasol propionate 71haloperidol 38haloperidol decanoate 38haloperidol lactate 38HARVONI 42HAVRIX 93HEMADY 82heparin sodium (porcine) 53HEPATAMINE 73HETLIOZ 111HIBERIX 93

HIZENTRA 90HM ULTICARE MINI PEN NEEDLES 98HUMALOG 51HUMALOG JUNIOR KWIKPEN 51HUMALOG KWIKPEN 51HUMALOG MIX 5050 51HUMALOG MIX 5050 KWIKPEN 51HUMALOG MIX 7525 51HUMALOG MIX 7525 KWIKPEN 51HUMIRA 91HUMIRA PEDIATRIC CROHNS START 92HUMIRA PEN 92HUMIRA PEN-CDUCHS STARTER 92HUMIRA PEN-PEDIATRIC UC START 92HUMIRA PEN-PSUVADOL HS START 92HUMIRA PEN-PSORUVEIT STARTER 92HUMULIN 7030 52HUMULIN 7030 KWIKPEN 52HUMULIN N 52HUMULIN N KWIKPEN 52HUMULIN R 52HUMULIN R U-500 (CONCENTRATED) 52HUMULIN R U-500 KWIKPEN 52HYCODAN 118hydralazine hcl 65hydrochlorothiazide 63hydrocodone bitartrate-homatropinemethylbromide 118hydrocodone-acetaminophen 23hydrocortisone 95hydrocortisone (intrarectal) 95hydrocortisone (rectal) 71hydrocortisone (topical) 71118hydrocortisone butyrate 7182hydrocortisone valerate 7182hydrocortisone wacetic acid 105HYDROCORTISONE-ALOE 118hydrocortisone-aloe vera 118hydromorphone hcl 3HYDROXYCHLOROQUINE SULFATE 35hydroxychloroquine sulfate 35

HYDROXYPROGESTERONE CAPROATE 86hydroxyurea 27hydroxyzine hcl 106

Iibandronate sodium 96IBRANCE 30ibuprofen 1118icatibant acetate 89ICLUSIG 30icosapent ethyl 64IDHIFA 27ILARIS 90ILEVRO 103imatinib mesylate 30IMBRUVICA 31imipenem-cilastatin 11imipramine hcl 19imiquimod 72IMOVAX RABIES 93INCRELEX 83INCRUSE ELLIPTA 107indapamide 63indomethacin 1INFANRIX 93INGREZZA 67INLYTA 31INQOVI 27INREBIC 27INSPIRACHAMBERLARGE 118INSPIRACHAMBERMEDIUM 118INSPIRACHAMBERMOUTHPIECE 118INSPIRACHAMBERSMALL 118INSPIREASE 118INSULIN LISPRO 52INSULIN LISPRO (1 UNIT DIAL) 52INSULIN LISPRO JUNIOR KWIKPEN 52INSULIN LISPRO PROT amp LISPRO 52INSULIN PEN NEEDLES 98INSULIN SYRINGE 03 ML 99INSULIN SYRINGE 05 ML 99

INSULIN SYRINGE 1 ML 99INSULIN SYRINGE-NEEDLE U-100 99INTELENCE 44INTRALIPID 73INTRON A 91INVEGA HAFYERA 39INVEGA SUSTENNA 39INVEGA TRINZA 39INVIRASE 46IPOL 94ipratropium bromide 107ipratropium bromide (nasal) 107ipratropium-albuterol 110irbesartan 56irbesartan-hydrochlorothiazide 61IRESSA 31ISENTRESS 43ISENTRESS HD 43isoniazid 25ISOPROPYL ALCOHOL 99ISOPROPYL ALCOHOL WIPES 99isosorbide dinitrate 65ISOSORBIDE DINITRATE ER 65isosorbide mononitrate 65isotretinoin 70itraconazole 22ivermectin 34IXIARO 94

JJAKAFI 31JANUMET 49JANUMET XR 49JANUVIA 50JARDIANCE 50JENTADUETO 50JENTADUETO XR 50JULUCA 43JUXTAPID 6465

KKALYDECO 108KCL IN DEXTROSE-NACL 73KCL-LACTATED RINGERS-D5W 76KEPIVANCE 69ketoconazole 22ketoconazole (topical) 22ketorolac tromethamine (ophth) 103ketotifen fumarate (ophth) 118KINRIX 94KISQALI (200 MG DOSE) 31KISQALI (400 MG DOSE) 31KISQALI (600 MG DOSE) 31KISQALI FEMARA (400 MG DOSE) 27KISQALI FEMARA (600 MG DOSE) 27KISQALI FEMARA(200 MG DOSE) 27KORLYM 82KOSELUGO 27KRYSTEXXA 23

Llabetalol hcl 58lacosamide 15lactated ringers 76lactated ringers (irrigation) 76LACTATED RINGERS 76lactic acid (ammonium lactate) 71lactulose 77lactulose (encephalopathy) 77lamivudine 4445lamivudine (hbv) 42lamivudine-zidovudine 45lamotrigine 13LANREOTIDE ACETATE 87lansoprazole 78LANTUS 52LANTUS SOLOSTAR 52lapatinib ditosylate 31latanoprost 105LATUDA 39

LEDIPASVIR-SOFOSBUVIR 42leflunomide 92lenalidomide 26LENVIMA (10 MG DAILY DOSE) 31LENVIMA (12 MG DAILY DOSE) 31LENVIMA (14 MG DAILY DOSE) 31LENVIMA (18 MG DAILY DOSE) 31LENVIMA (20 MG DAILY DOSE) 31LENVIMA (24 MG DAILY DOSE) 31LENVIMA (4 MG DAILY DOSE) 31LENVIMA (8 MG DAILY DOSE) 31letrozole 29leucovorin calcium 27LEUKERAN 25leuprolide acetate 87levalbuterol hcl 108LEVALBUTEROL TARTRATE 108levetiracetam 13levobunolol hcl 104levocarnitine (metabolic modifiers) 76levocetirizine dihydrochloride 106levofloxacin 12levofloxacin (ophth) 103levofloxacin in d5w 12levonorgestrel amp eth estradiol 85levonorgestrel (emergency oc) 118levonorgestrel-eth estradiol (triphasic) 85levonorgestrel-ethinyl estradiol (91-day) 85levothyroxine sodium 87LEXIVA 46lidocaine 4lidocaine hcl 4lidocaine hcl (mouth-throat) 4lidocaine-prilocaine 4LINDANE 72linezolid 7LINEZOLID IN SODIUM CHLORIDE 7LINZESS 77liothyronine sodium 87lisinopril 57lisinopril amp hydrochlorothiazide 61

LITEAIRE 118LITHIUM 49lithium carbonate 49LONSURF 2728loperamide hcl 77118lopinavir-ritonavir 46loratadine 118lorazepam 48LORBRENA 31losartan potassium 56losartan potassium amp hydrochlorothiazide 61loteprednol etabonate 103lovastatin 64loxapine succinate 38LUBIPROSTONE 77LUMAKRAS 28LUMIGAN 105LUPRON DEPOT (1-MONTH) 87LUPRON DEPOT (3-MONTH) 87LUPRON DEPOT (4-MONTH) 87LUPRON DEPOT (6-MONTH) 87LUPRON DEPOT-PED (1-MONTH) 88LUPRON DEPOT-PED (3-MONTH) 88LYBALVI 17LYNPARZA 31LYSODREN 28LYUMJEV 52LYUMJEV KWIKPEN 52

MM-M-R II 94MAG-G 119magnesium citrate 119magnesium gluconate 119malathion 72MAPROTILINE HCL 17maraviroc 45MARPLAN 17MATULANE 25MAVYRET 42meclizine hcl 20119

MEDPURA ALCOHOL PADS 99medroxyprogesterone acetate 86medroxyprogesterone acetate(contraceptive) 86mefloquine hcl 35megestrol acetate 86megestrol acetate (appetite) 86MEKINIST 32MEKTOVI 32meloxicam 1memantine hcl 17MENACTRA 94MENEST 85MENQUADFI 94MENVEO 94meprobamate 48mercaptopurine 27meropenem 11mesalamine 95mesna 34MESNEX 34metformin hcl 50methadone hcl 12methazolamide 104methenamine hippurate 7methimazole 88methocarbamol 111methotrexate sodium 92methyldopa 56methylergonovine maleate 99methylphenidate hcl 67methylprednisolone 82methylprednisolone acetate 82methylprednisolone sod succ 82METIPRANOLOL 104metoclopramide hcl 20metolazone 63metoprolol amp hydrochlorothiazide 61metoprolol succinate 58metoprolol tartrate 58METOPROLOL-HYDROCHLOROTHIAZIDE 62

metronidazole 7metronidazole (topical) 7metronidazole vaginal 7metyrosine 62mexiletine hcl 57micafungin sodium 22MICONAZOLE 3 22miconazole nitrate vaginal 119MICROCHAMBER 119MICROSPACER 119midodrine hcl 56MIGERGOT 23miglitol 50miglustat 79minocycline hcl 12minoxidil 65mirtazapine 17misoprostol 78modafinil 111moexipril hcl 57MOLINDONE HCL 38mometasone furoate 7182montelukast sodium 107morphine sulfate 23MOVANTIK 77moxifloxacin hcl 12MOXIFLOXACIN HCL (2X DAY) 103moxifloxacin hcl (ophth) 103MOZOBIL 54MULTAQ 58mupirocin 72MURO 128 119MYALEPT 77mycophenolate mofetil 92mycophenolate mofetil hcl 92mycophenolate sodium 92MYRBETRIQ 80

Nnabumetone 1nadolol 58

nafcillin sodium 10NAGLAZYME 79naloxone hcl 5naltrexone hcl 5naphazoline w pheniramine 119naproxen 1naratriptan hcl 23NARCAN 5NASACORT ALLERGY 24HR 119NASACORT ALLERGY 24HR CHILDREN 119NASAL DECONGESTANT 119NATACYN 103nateglinide 50NATPARA 96NAYZILAM 4nebivolol hcl 58nefazodone hcl 18neomycin sulfate 6neomycin-bacitracin zn-polymyxin 102neomycin-bacitracin-polymyxin oint 119neomycin-polymy-dexameth 102neomycin-polymyxin w pramoxine 119NEOMYCIN-POLYMYXIN-GRAMICIDIN 102neomycin-polymyxin-hc (otic) 105NEONATAL PLUS 76NERLYNX 32NEVIRAPINE 44nevirapine 44NEVIRAPINE ER 44NEXAVAR 32niacin 119niacin (antihyperlipidemic) 65NIACIN (ANTIHYPERLIPIDEMIC) 65NIACIN ER 119niacinamide 119NIACOR 65nicardipine hcl 59nicotine 119nicotine polacrilex 120NICOTROL 5NICOTROL NS 5

nifedipine 59nilutamide 26nimodipine 59NINLARO 28nitazoxanide 35nitisinone 79NITRO-BID 65nitrofurantoin macrocrystal 7nitrofurantoin monohyd macro 7nitroglycerin 66NITROSTAT 66NITYR 79NIX COMPLETE LICE TREATMENT 120nizatidine 78NORDITROPIN FLEXPRO 83norethin acet amp estrad-fe 85norethindrone amp eth estradiol 85norethindrone amp ethinyl estradiol-fe 85norethindrone (contraceptive) 86norethindrone acet amp eth estra 85norethindrone acetate 86norethindrone acetate-ethinyl estradiol 85norethindrone-eth estradiol (triphasic) 85norgestimate-ethinyl estradiol 85norgestimate-ethinyl estradiol (triphasic) 86norgestrel amp ethinyl estradiol 86NORMOSOL-M IN D5W 73nortriptyline hcl 19nortriptyline oral solution (unit dose) 20NORVIR 46NovoFine 32G X 6 MM MISC 99NOVOLIN 7030 52NOVOLIN 7030 RELION 52NOVOLIN N 52NOVOLIN N RELION 52NOVOLIN R 52NOVOLIN R RELION 53NovoTwist 32G X 5 MM MISC 99NOXAFIL 22NUBEQA 26NUCALA 110

NUPLAZID 40NUTRILIPID 73NYMALIZE 59nystatin 22nystatin (mouth-throat) 22nystatin (topical) 22nystatin-triamcinolone 72

Ooctreotide acetate 88ODEFSEY 44ODOMZO 32OFEV 110ofloxacin 12ofloxacin (ophth) 103ofloxacin (otic) 105olanzapine 40olmesartan medoxomil 56olmesartan medoxomil-amlodipine-hydrochlorothiazide 62olmesartan medoxomil-hydrochlorothiazide62olopatadine hcl 102omega-3 fatty acids cap 1000 mg 120omega-3-acid ethyl esters 65omeprazole 78120ondansetron 21ondansetron hcl 21ONUREG 28OPSUMIT 109OPTICHAMBER ADVANTAGE-LG MASK 120OPTICHAMBER ADVANTAGE-MED MASK 120OPTICHAMBER ADVANTAGE-SM MASK 120OPTICHAMBER DIAMOND 120OPTICHAMBER DIAMOND-LG MASK 120OPTICHAMBER DIAMOND-MD MASK 120OPTICHAMBER DIAMOND-SM MASK 120OPTICHAMBER FACE MASK-LARGE 120OPTICHAMBER FACE MASK-MEDIUM 120OPTICHAMBER FACE MASK-SMALL 120OPTIHALER 120OPTIONS GYNOL II CONTRACEPTIVE 120

oral electrolyte solution 120ORBACTIV 7ORGOVYX 88oseltamivir phosphate 47OSPHENA 86OTEZLA 7290oxandrolone 83OXBRYTA 55oxcarbazepine 15oxybutynin chloride 80oxycodone hcl 3oxycodone w acetaminophen 3oyster shell 121OYSTER SHELL CALCIUM 500 + D 120OYSTER SHELL CALCIUMD 121OZEMPIC (025 OR 05 MGDOSE) 50OZEMPIC (1 MGDOSE) 50OZEMPIC (2 MGDOSE) 50

Ppaliperidone 40PANRETIN 34pantoprazole sodium 78paricalcitol 96paromomycin sulfate 6paroxetine hcl 18PASER 25PEDIARIX 94PEDVAX HIB 94peg 3350-kcl-sod bicarb-sod chloride-sodsulfate 78peg 3350-potassium chloride-sodbicarbonate-sod chloride 77PEGANONE 15PEGASYS 91PEGASYS PROCLICK 91PEMAZYRE 32penicillamine 81penicillin g potassium 10PENICILLIN G SODIUM 10penicillin v potassium 10

PENTACEL 94pentamidine isethionate 35PENTIPS 99pentoxifylline 62perindopril erbumine 57permethrin 72121perphenazine 20PERSERIS 40PFIZERPEN 10phenelzine sulfate 17phenobarbital 14phentermine hcl 121PHENYTEK 16phenytoin 16phenytoin sodium extended 16PHOSPHOLINE IODIDE 104phytonadione 121PIFELTRO 44pilocarpine hcl 104pilocarpine hcl (oral) 69PIMOZIDE 38pindolol 58pioglitazone hcl 50piperacillin sodium-tazobactam sodium 10PIQRAY (200 MG DAILY DOSE) 32PIQRAY (250 MG DAILY DOSE) 32PIQRAY (300 MG DAILY DOSE) 32pirfenidone 110piroxicam 1PLEGRIDY 69PLEGRIDY STARTER PACK 69POCKET CHAMBER 121POCKET SPACER 121podofilox 72polyethylene glycol 3350 121polymyxin b-trimethoprim 103polyvinyl alcohol 121POMALYST 26posaconazole 22potassium chloride 74POTASSIUM CHLORIDE ER 74

POTASSIUM CHLORIDE IN DEXTROSE 76potassium chloride in dextrose amp sodiumchloride 74POTASSIUM CHLORIDE IN NACL 74potassium chloride microencapsulatedcrystals er 74potassium citrate (alkalinizer) 74PRADAXA 54pramipexole dihydrochloride 36prasugrel hcl 55pravastatin sodium 64praziquantel 34prazosin hcl 56PRE-NATAL FORMULA 121PREDNISOLONE 82PREDNISOLONE ACETATE 104PREDNISOLONE SODIUM PHOSPHATE 82104prednisone 82PREDNISONE INTENSOL 83pregabalin 68PREHEVBRIO 94PREMARIN 86PREMASOL 74PREMPHASE 86PREMPRO 86PRENATAL (WIRON amp FA) 121PRENATAL FORTE 121PRENATAL PLUS 76PRENATAL PLUS VITAMINMINERAL 76PRENATAL VITAMIN WITH IRON TAB 27-08MG 121PRENATAL VITAMIN WITH IRON TAB 28-08MG 121prenatal vitamins 76PRENATALIRON 121PREVENT DROPSAFE PEN NEEDLES 99PREVYMIS 42PREZCOBIX 46PREZISTA 4647PRIFTIN 25primaquine phosphate 35

primidone 15PRIVIGEN 90PRO COMFORT SPACER ADULT 121PRO COMFORT SPACER CHILD 121PRO COMFORT SPACER INFANT 121probenecid 23PROCARE SPACERADULT MASK 121PROCARE SPACERCHILD MASK 122prochlorperazine 20prochlorperazine maleate 20PROCYSBI 79progesterone 86PROGRAF 92PROLASTIN-C 80PROLENSA 104PROLIA 96PROMACTA 54promethazine hcl 20106promethazine wcodeine 122promethazine-dm 122promethazine-phenylephrine-codeine 122propafenone hcl 58propranolol hcl 59PROPRANOLOL-HCTZ 62propylthiouracil 88PROQUAD 94protriptyline hcl 20pseudoephedrine hcl 122PULMICORT FLEXHALER 106PULMOZYME 108PURIXAN 27pyrantel pamoate 122pyrazinamide 25pyrethrins-piperonyl butoxide 122pyrethrins-piperonyl butoxide-permethrin-nitremover 122pyridostigmine bromide 24pyridoxine hcl 122pyrimethamine 35

QQC UNIFINE PENTIPS 99QINLOCK 28QSYMIA 122QUADRACEL 94quetiapine fumarate 40quinapril hcl 57quinapril-hydrochlorothiazide 62quinidine sulfate 58quinine sulfate 35QVAR REDIHALER 106

RRA CALAMINE 122RA DAYLOGIC ACNE FOAMING WASH 122RA ISOPROPYL ALCOHOL WIPES 99RA OYSTER SHELL CALCIUMD2 122RABAVERT 94rabeprazole sodium 78raloxifene hcl 86ramelteon 111ramipril 57ranolazine 62rasagiline mesylate 37RAVICTI 80REBIF 69REBIF REBIDOSE 69REBIF REBIDOSE TITRATION PACK 69REBIF TITRATION PACK 69RECOMBIVAX HB 94RECTIV 66REGRANEX 72RELENZA DISKHALER 47RELION PEN NEEDLES 99RELISTOR 77repaglinide 50REPATHA 65REPATHA PUSHTRONEX SYSTEM 65REPATHA SURECLICK 65RESCRIPTOR 44

RESTASIS 102RESTASIS MULTIDOSE 102RETACRIT 55RETEVMO 28REVLIMID 26REXULTI 40REYATAZ 47REZUROCK 92RHOPRESSA 104ribavirin 110ribavirin (hepatitis c) 42riboflavin 122RID 122RID COMPLETE LICE ELIMINATION 122rifabutin 24rifampin 25RIFATER 25riluzole 67RIMANTADINE HCL 47ringers 76ringers irrigation 76RINVOQ 9293risedronate sodium 96RISPERDAL CONSTA 40risperidone 40RITEFLO 122ritonavir 47rivastigmine 16rivastigmine tartrate 16rizatriptan benzoate 24ROCKLATAN 102ropinirole hydrochloride 36rosuvastatin calcium 64ROTARIX 94ROTATEQ 94ROZLYTREK 28RUBRACA 32RUCONEST 89rufinamide 16RUKOBIA 45RUZURGI 99

RYBELSUS 50RYDAPT 32

Ssaline 123SANDIMMUNE 93SANDOSTATIN LAR DEPOT 88SANTYL 72sapropterin dihydrochloride 80SAVELLA 68SAVELLA TITRATION PACK 68SAXENDA 123SCEMBLIX 32scopolamine 20SECUADO 40selegiline hcl 37selenium sulfide 71123SELZENTRY 4546sennosides 123SEREVENT DISKUS 108SEROSTIM 83sertraline hcl 18sevelamer carbonate 75SHINGRIX 94SIGNIFOR 88sildenafil citrate (pulmonary hypertension) 109silodosin 81silver sulfadiazine 72simethicone 123simvastatin 64sirolimus 93SIRTURO 25SKYRIZI 90SKYRIZI (150 MG DOSE) 90SKYRIZI PEN 90SM FOAMING ANTACID 123SMOFLIPID 76sodium bicarbonate (antacid) 123sodium chloride 74sodium chloride hypertonic 123sodium fluoride 76

sodium phenylbutyrate 80sodium polystyrene sulfonate 75SOFOSBUVIR-VELPATASVIR 42solifenacin succinate 80SOLTAMOX 26SOMATULINE DEPOT 88SOMAVERT 88sorafenib tosylate 32sotalol hcl 58sotalol hcl (afibafl) 58SPIRIVA HANDIHALER 107SPIRIVA RESPIMAT 107spironolactone 63spironolactone amp hydrochlorothiazide 62SPRITAM 13SPRYCEL 32SPS 75stavudine 45STELARA 90STIVARGA 32STRENSIQ 80STREPTOMYCIN SULFATE 6STRIBILD 43STRIVERDI RESPIMAT 108sucralfate 78sulfacetamide sod-prednisolone 102SULFACETAMIDE SODIUM 103sulfacetamide sodium (acne) 12sulfacetamide sodium (ophth) 103SULFACETAMIDE-PREDNISOLONE 102sulfadiazine 12sulfamethoxazole-trimethoprim 12SULFAMYLON 72sulfasalazine 95sulindac 1sumatriptan 24sumatriptan succinate 24SUMATRIPTAN SUCCINATE REFILL 24sunitinib malate 32SUPREP BOWEL PREP KIT 77SYLATRON 91

SYMDEKO 108SYMPAZAN 15SYMTUZA 47SYNAREL 88SYNERCID 7SYNJARDY 50SYNJARDY XR 50SYNRIBO 28SYNTHAMIN 17 74SYNTHROID 87

TTABLOID 27TABRECTA 28tacrolimus 93tacrolimus (topical) 71tadalafil (pulmonary hypertension) 109TAFINLAR 33TAGRISSO 33TALTZ 90TALZENNA 33tamoxifen citrate 26tamsulosin hcl 81TARGRETIN 34TASIGNA 33TAVALISSE 55tazarotene 70TAZICEF 9TAZORAC 70TAZVERIK 28TDVAX 94TEFLARO 9TEKTURNA HCT 62telmisartan 56telmisartan-hydrochlorothiazide 62temazepam 111TEMIXYS 45TENIVAC 94tenofovir disoproxil fumarate 45TEPMETKO 33terazosin hcl 56

terbinafine hcl 22terconazole vaginal 22testosterone 84testosterone cypionate 84testosterone enanthate 84tetrabenazine 6768tetracycline hcl 12THALOMID 26theophylline 109THEOPHYLLINE ER 109thiamine hcl 123thiamine mononitrate 123THIOLA EC 81thioridazine hcl 38thiotepa 25thiothixene 38tiagabine hcl 15TIBSOVO 33TICOVAC 94tigecycline 7timolol maleate 23TIMOLOL MALEATE 104timolol maleate (ophth) 104tioconazole vaginal 123TIVICAY 43TIVICAY PD 43tizanidine hcl 41TOBI PODHALER 108tobramycin 108tobramycin (ophth) 103tobramycin sulfate 6tobramycin-dexamethasone 102TOLAK 72tolnaftate 123tolterodine tartrate 81topiramate 13toremifene citrate 26torsemide 63TOUJEO MAX SOLOSTAR 53TOUJEO SOLOSTAR 53TPN ELECTROLYTES 76

TRACLEER 109TRADJENTA 50tramadol hcl 4tramadol-acetaminophen 4trandolapril 57tranexamic acid 55tranylcypromine sulfate 17TRAVASOL 74travoprost 105trazodone hcl 18TRECATOR 25TRELEGY ELLIPTA 110TRELSTAR MIXJECT 88tretinoin 70tretinoin (chemotherapy) 34triamcinolone acetonide (mouth) 69triamcinolone acetonide (nasal) 123triamcinolone acetonide (topical) 71triamterene amp hydrochlorothiazide 62triazolam 111trientine hcl 75trifluoperazine hcl 38TRIFLURIDINE 47trihexyphenidyl hcl 36TRIKAFTA 108trimethoprim 7trimipramine maleate 20TRINTELLIX 19triprolidine amp pseudoephedrine 123TRIUMEQ 45TRIUMEQ PD 45TROPHAMINE 74trospium chloride 81TRUE COMFORT PEN NEEDLES 99TRUE COMFORT PRO ALCOHOL PREP 99TRUE COMFORT PRO INSULIN SYR 100TRUE COMFORT PRO PEN NEEDLES 100TRULICITY 51TRUMENBA 94TRUSELTIQ (100MG DAILY DOSE) 33TRUSELTIQ (125MG DAILY DOSE) 33

TRUSELTIQ (50MG DAILY DOSE) 33TRUSELTIQ (75MG DAILY DOSE) 33TUKYSA 33TURALIO 33TWINRIX 94TYBOST 46TYMLOS 96TYPHIM VI 95TYSABRI 69

UUBRELVY 23UKONIQ 33ULTICARE MINI PEN NEEDLES 100ULTICARE SHORT PEN NEEDLES 100ULTIGUARD SAFEPACK PEN NEEDLE 100ULTIGUARD SAFEPACK SYRNEEDLE 100ULTRA FLO INSULIN PEN NEEDLES 100ULTRA FLO INSULIN SYR 12 UNIT 100ULTRA FLO INSULIN SYRINGE 101UNIFINE PEN NEEDLES 101UNIFINE PENTIPS 101UNIFINE ULTRA PEN NEEDLE 101ursodiol 78

Vvalacyclovir hcl 47VALCHLOR 26valganciclovir hcl 42valproate sodium 13valproic acid 14valsartan 57valsartan-hydrochlorothiazide 62VALTOCO 10 MG DOSE 15VALTOCO 15 MG DOSE 15VALTOCO 20 MG DOSE 15VALTOCO 5 MG DOSE 15VALVED HOLDING CHAMBER 123vancomycin hcl 8VANDAZOLE 8VAQTA 95

VARENICLINE TARTRATE 5VARIVAX 95VARIZIG 90VASCEPA 65VCF VAGINAL CONTRACEPTIVE 123VELTASSA 75VEMLIDY 42VENCLEXTA 33VENCLEXTA STARTING PACK 33venlafaxine hcl 19VENTAVIS 109verapamil hcl 60VERAPAMIL HCL ER 60VERSACLOZ 41VERZENIO 33VICTOZA 51VIDEX 45VIDEX EC 45vigabatrin 15VIIBRYD 19VIIBRYD STARTER PACK 19vilazodone hcl 19VIMPAT 16VIRACEPT 47VIREAD 45vitamin a 123VITAMIN D2 123vitamin e 123VITAMIN K 123VITRAKVI 33VIZIMPRO 33VONJO 34voriconazole 22VORTEX VALVED HOLDING CHAMBER 123VOSEVI 43VOTRIENT 33VRAYLAR 40VYNDAMAX 62VYNDAQEL 80

Wwarfarin sodium 54WATCHHALER 124water for irrigation sterile 101WELIREG 28

XXALKORI 34XARELTO 54XARELTO STARTER PACK 54XATMEP 93XCOPRI 14XCOPRI (250 MG DAILY DOSE) 14XCOPRI (350 MG DAILY DOSE) 14XELJANZ 90XELJANZ XR 93XERMELO 77XGEVA 96XIFAXAN 8XIGDUO XR 51XOFLUZA (40 MG DOSE) 47XOFLUZA (80 MG DOSE) 47XOLAIR 90XOSPATA 34XPOVIO (100 MG ONCE WEEKLY) 28XPOVIO (40 MG ONCE WEEKLY) 28XPOVIO (40 MG TWICE WEEKLY) 28XPOVIO (60 MG ONCE WEEKLY) 28XPOVIO (60 MG TWICE WEEKLY) 29XPOVIO (80 MG ONCE WEEKLY) 29XPOVIO (80 MG TWICE WEEKLY) 29XTANDI 26XYREM 111

YYF-VAX 95

Zzafirlukast 107zaleplon 111

ZARXIO 55ZEJULA 34ZELBORAF 34ZENPEP 80ZERIT 45ZEVRX INSULIN SYRINGE 101ZEVRX PEN NEEDLES 101ZEVRX STERILE ALCOHOL PREP PAD 101zidovudine 45ziprasidone hcl 41ziprasidone mesylate 41ZIRGAN 42zoledronic acid 96ZOLINZA 29zolmitriptan 24zolpidem tartrate 111zonisamide 16ZONTIVITY 54ZOSTAVAX 95ZUBSOLV 5ZYDELIG 34ZYKADIA 34ZYPREXA RELPREVV 41

Blue Shield of California Promise Health Plan

601 Potrero Grande Drive Monterey Park CA 91755

H0148_20_503

A51247-C

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hanggang 800 pm pitong araw sa isang linggo Libre ang tawag

(Arabicالعربية )

3825-905-855-1اتصل على الرقم یتوفر لك خدمات المساعدة اللغویة المجانیةإذا كنت تتحدث اللغة العربیة تنبیه (TTY 711) علما بأن هذه المكالمة مجانیة مساء طوال أیام الأسبوع 800صباحا إلى 800 من الساعة

ພາສາລາວ (Laotian)

ສ ງສ ຳຄນ ຖຳທ ຳນເວ ຳພຳສຳລຳວແມ ນມບ ລ ກຳນຊວຍເຫ ອທຳງດຳນພຳສຳບ ເສຍຄຳໃຫທ ຳນ ໂທຫຳເບ 1-855-905-3825 (TTY 711) 800 ໂມງເຊ ຳ ຫຳ 800 ໂມງແລງ ເຈດວນຕ ອຳທ ດ ກຳນໂທແມ ນບ ເສຍຄຳ

日本語 (Japanese)

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825

(TTY 711）までお電話にてご連絡ください毎日午前 8時から午後 8時まで受け付けてい

ます通話は無料です

ภาษาไทย (Thai) เรยน หากคณพดภาษา ภาษาไทย เรามบรการความชวยเหลอดานภาษาใหแกคณโดยไมมคาใชจาย โทร 1-855-905-3825 (TTY 711) 800 น ถง 2000 น ไดตลอดเจดวนตอสปดาห โทรฟร ไมมคาใชจาย

ਪਜਾਬੀ (Punjabi)

ਸਾਵਧਾਨ ਜ ਤਸੀ [ਪਜਾਬੀ] ਬਲਦ ਹ ਤਾ ਤਹਾਡ ਲਈ ਮਫਤ ਭਾਸਾ ਸਹਾਇਤਾ ਸਵਾਵਾ ਉਪਲਬਧ ਹਨ | ਕਾਲ ਕਰ 1-855-905-3825 (TTY 711) ਸਵਰ 800 ਵਜ ਤ ਸਾਮ 800 ਵਜ ਤਕ ਹਫਤ ਦ ਸਤ ਦਦਨ |711) ਸਵਰ ਦ 8 ਵਜ ਤ ਲ ਕ ਰਾਤ ਦ 8 ਵਜ ਤਕ ਹਫਤ ਦ ਸਤ ਦਦਨ ਕਾਲ ਫਰੀ ਹ |

ខមែរ (Khmer)

ចាបអារមមណ បបើសនអនកនយាយភាសាខមមរ បសវាជនយភាសា គមានសរាបអនក បោយឥតគតថលៃ បៅ

1-855-905-3825 (TTY 711) បមាោ ង 800 ពរក ដល 800 យប ពរររថលៃមយអាទតយ

បៅគឥតគតថលៃបទ

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն Ձեզ տրամադրելի են անվճար լեզվական

օգնության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY 711) համարով 800-ից

2000 շաբաթը յոթ օր Հեռախոսազանգն անվճար է

Українська (Ukrainian) ЗВЕРНІТЬ УВАГУ Якщо Ви розмовляєте українською ми можемо запропонувати Вам безкоштовні послуги мовної підтримки Телефонуйте 1-855-905-3825 (TTY 711) з 800 до 2000 без вихідних Дзвінок безкоштовний

Mienh (Mien)

TOV JANGX LONGX OC Beiv taix meih gorngv Mienh waac nor ninh mbuo gorn

zangc duqv mbenc nzoih wang-henh nzie weih faan waac bun meih muangx maiv

zuqc feix liuc cuotv zinh nyaanh Douc waac lorx taux 1-855-905-3825 (TTY 711)

800 diemv ziangh hoc lungh ndorm mingh taux 800 ziangh hoc lungh muonz yietc

norm liv baaiz se koi nzoih siec hnoi Naaiv norm douc waac gorn se wang-henh longc

maiv zuqc feix liuc cuotv zinh nyaanh

H0148_21_166

08172021

This formulary was updated on 08192021 For more recent information or other questions please contact Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week or visit wwwblueshieldcacompromisecalmediconnect

06212022

Blue Shield Promise Cal MediConnect Plan(Medicare-Medicaid Plan)2022 List of Covered Drugs (Formulary)


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)

Русский (Russian)

(Farsi) فارس


Lus Hmoob (Hmong)


Tiếng Việt (Vietnamese)

Tagalog (Tagalog)

(Arabic) العرب



ภาษาไทย (Thai)


ែខ1048951រ (Khmer)


Українська (Ukrainian)

Mienh (Mien)



B2 Does the Drug List ever change

B3 What happens when there is a change to the Drug List




B7 How can I find a drug on the Drug List

To search alphabetically refer to the Index of Covered Drugs section You can find it in the index that begins on page 120 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic

B8 What if the drug I want to take is not on the Drug List


Transition Policy In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield Promise Cal MediConnect Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to f

B10 Can I ask for an exception to cover my drug

B11 How can I ask for an exception

B12 How long does it take to get an exception

B13 What are generic drugs

B14 What are OTC drugs


B16 What is my copay


B17 What are drug tiers


C1 Drugs Grouped by Medical Condition

List of Covered Drugs


Alphabetical Listing

Category Listing



Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and over-the-counter drugs and items are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook You can request a copy by calling Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free

Table of Contents

A Disclaimers iii

B Frequently Asked Questions (FAQ) vi

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) vi

B2 Does the Drug List ever change vii

B3 What happens when there is a change to the Drug List viii

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs ix

B5 How will I know if the drug I want has limits or if there are required actions to take to get the drug ix

B6 What happens if Blue Shield Promise Cal MediConnect Plan changes their rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) x

B7 How can I find a drug on the Drug List x

B8 What if the drug I want to take is not on the Drug List x

B9 What if I am a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find my drug on the Drug List or have a problem getting my drug xi

B10 Can I ask for an exception to cover my drug xii

A Disclaimers

1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



A Disclaimers

1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



A Disclaimers

1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



1 - 124

Drugs $0 $0 $0

$0 to $395 copay

Not available

$0 to $985 copay

Not available

(no copayment)

LEGEND

TIER NAME

2 Generic Drugs

3 Brand Drugs

ST Step Therapy

NPD Non-Part D Drug

ANESTHETICS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 12

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPSYCHOTICS 37

ANTIVIRALS 42

ANXIOLYTICS 48

BIPOLAR AGENTS 49

OTIC AGENTS 105

ANALGESICS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA NDS

ANALGESICS

ANESTHETICS

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 2 PA

Tier 2

ANTIBACTERIALS

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

ANTIBACTERIALS

Tier 2

ANTICONVULSANTS

Tier 2

ANTICONVULSANTS

Tier 2

Tier 2 PA

ANTICONVULSANTS

Tier 2 PA

Tier 2

Tier 3

Tier 2 BvD

Tier 2

ANTICONVULSANTS

Tier 3

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEMENTIA AGENTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 3 PA

ANTIDEPRESSANTS

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

ANTIDEPRESSANTS

Tier 2

Tier 2 PA

ANTIEMETICS

Tier 2

Tier 2 PA

Tier 2 BvD

ANTIEMETICS

Tier 2 BvD

ANTIFUNGALS

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

ANTIFUNGALS

Tier 2

Tier 2 PA

ANTIGOUT AGENTS

Tier 2

ANTIMIGRAINE AGENTS

Tier 2 PA

Tier 2

ANTIMIGRAINE AGENTS

ANTIMYCOBACTERIALS

Tier 3

Tier 2

ANTINEOPLASTICS

Tier 3 BvD

Tier 3

ANTINEOPLASTICS

Tier 2

ANTINEOPLASTICS

Tier 3

Tier 3 PA LA

Tier 2

ANTINEOPLASTICS

Tier 2 PA

ANTINEOPLASTICS

ANTIPARASITICS

Tier 2

Tier 2 BvD

Tier 2

Tier 3

Tier 2

Tier 2 PA

Tier 2

ANTIPSYCHOTICS

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

ANTIPSYCHOTICS

Tier 2

Tier 3

Tier 2

ANTIPSYCHOTICS

Tier 2

Tier 3 PA

Tier 2

ANTIVIRALS

Tier 2

ANTIVIRALS

TIME) BvD

ANTIVIRALS

Tier 2

ANXIOLYTICS

Tier 2

Tier 2 PA

BIPOLAR AGENTS

Tier 2

Tier 1

Tier 1 PA

Tier 1

Tier 2

Tier 3

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 2 PA

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 3

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3 PA

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 1

Tier 2

Tier 3

Tier 3 PA LA

Tier 2

Tier 2 PA

Tier 2

Tier 2 ST

Tier 2

ERY 2 PAD Tier 2

Tier 2

Tier 2 BvD

Tier 3 BvD

Tier 2

Tier 3

Tier 2

Tier 3

Tier 2

Tier 3 PA

Tier 3

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 LA BvD

Tier 3

Tier 2

Tier 3 PA LA

Tier 2 PA

Tier 3 PA LA

Tier 3 LA BvD

Tier 2 PA

Tier 3 PA LA

Tier 3

Tier 2

Tier 2 ST

Tier 2

Tier 3 PA LA

Tier 2

Tier 2 BvD

Tier 2

Tier 3 PA

Tier 3 PA LA

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 2

Tier 2 PA

Tier 2

Tier 3 PA

Tier 3

Tier 2

Tier 2 PA

Tier 2

Tier 3

Tier 3 PA

Tier 3

Tier 2 PA

Tier 3 PA

Tier 3 BvD

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 PA

Tier 3 PA LA

Tier 3 LA

Tier 2 BvD

Tier 3 PA

Tier 2 PA

Tier 3 PA

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 3 PA

Tier 2 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 3 BvD

Tier 3

Tier 2

Tier 1

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

OPHTHALMIC AGENTS

Tier 2

Tier 3

Tier 2

OPHTHALMIC AGENTS

Tier 2

OTIC AGENTS

Tier 2

Tier 3

Tier 2

Tier 2 BvD

Tier 2 PA

Tier 2

Tier 2 PA

Tier 2 BvD

Tier 2

Tier 2 PA

OVER TIME)

Tier 2 BvD

Tier 2

Tier 2 BvD

Tier 2 PA

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

eye wash Tier 4 NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 PA NPD

Tier 4 NPD

Tier 4 PA NPD

Tier 4 NPD

Non-Part D Drugs

Tier 4 NPD

Non-Part D Drugs

YYF-VAX 95

H0148_20_503

A51247-C

Coordinator

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

English

中文 (Chinese)

한국어(Korean)

( Farsiفارسی )

Lus Hmoob (Hmong)

Tagalog (Tagalog)

Mienh (Mien)

H0148_21_166

08172021

06212022


Introduction

Table of Contents

A Disclaimers

中文 (Chinese)

한국어(Korean)


(Farsi) فارس


Lus Hmoob (Hmong)



Tagalog (Tagalog)

(Arabic) العرب








Mienh (Mien)



























Category Listing



Documents

2 02 2 List of Cover ed Drugs (Formulary)