2020 CIGNA COMPREHENSIVE DRUG LIST …...1 What is the Cigna Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna in consultation with a team of health

This drug list was updated in April 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 20085, Version Number 12 INT_20_76977_C_Final_1d

Plans coveredCigna-HealthSpring Alliance (HMO)Cigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Preferred (PPO)Cigna-HealthSpring Preferred GA (HMO)Cigna-HealthSpring Preferred Part B Savings (HMO)Cigna-HealthSpring Preferred Plus (HMO)Cigna-HealthSpring Premier (HMO-POS)Cigna-HealthSpring True Choice (PPO)Cigna-HealthSpring True Choice Plus (PPO)

Please read: This document contains information about all of the drugs we cover in this plan.

2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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

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

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and

you can also find information in the section entitled “How do I request an exception to the Cigna Drug List?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug or move it to a different cost-sharing tier.). Or we may make changes based on new clinical guidelines and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug. – If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Cigna’s Drug List?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Alliance (HMO), Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred (PPO), Cigna-HealthSpring Preferred GA (HMO), Cigna-HealthSpring Preferred Part B Savings (HMO), Cigna-HealthSpring PreferredPlus (HMO), Cigna-HealthSpring Premier (HMO-POS), Cigna-HealthSpring True Choice (PPO), and Cigna-HealthSpring True Choice Plus (PPO). This document includes a list of the drugs (formulary) for our plans, which is current as of April 2020. For an updated drug list, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

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drugs will remain available at the same cost-sharing and with no new restrictions for those customers taking them for the remainder of the coverage year. The enclosed drug list is current as of April 2020. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 20. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR, HYPERTENSION / LIPIDS”. If you know what your drug is used for, look for the category name in the list that begins on page 20. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index that begins on page 68. The Covered Drugs 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 Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill these prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for candesartan 32mg. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not opioid naïve) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 20. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for

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your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Some plans may offer a $0 copay for Tier 1 and 2 generic drugs filled at a preferred retail and/or mail-order pharmacies. Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered in the Cigna drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not on the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna.

• You can ask Cigna to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Cigna Drug List?You can ask Cigna to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not on our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna limits the

amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.

– If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

– If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

These exceptions would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.]

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug

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that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list that begins on page 20, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 68.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., candesartan).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 20 along with the amount dispensed per the days supplied. (For example: candesartan 32mg QL 30/30; this means the drug candesartan 32mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. If you need help finding a network pharmacy, please call Customer Service at 1-800-668-3813 (TTY 711), or you can visit www.CignaMedicare.com for the most current Pharmacy Directory.

For more information

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

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears on the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4, or Tier 5. Keep in mind that

the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.

Service Area: Alabama H7849-012 – Cigna-HealthSpring True Choice (PPO): Etowah and St. Clair, AlabamaH7849-013 – Cigna-HealthSpring True Choice (PPO): Autauga, Chilton, Cullman, Elmore, Jefferson, Montgomery, Shelby, Talladega and Walker, Alabama

Drug Tier

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Preferred Mail-Order Cost-Sharing

Standard Mail-Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $2 / $4 / $5 $7 / $14 / $21 $2 / $4 / $0 $7 / $14 / $21Tier 2: Generic Drugs $4 / $8 / $10 $9 / $18 / $27 $4 / $8 / $0 $9 / $18 / $27Tier 3: Preferred Brand Drugs $40 / $80 / $120 $45 / $90 / $135 $40 / $80 / $120 $45 / $90 / $135Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

Service Area: Arkansas H4513-038 – Cigna-HealthSpring Preferred (HMO): Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, ArkansasH4513-050 – Cigna-HealthSpring Preferred (HMO): Faulkner, Garland, Grant, Lonoke, Perry, Pulaski and Saline, ArkansasH4513-051 – Cigna-HealthSpring Preferred (HMO): Crawford and Sebastian, ArkansasH4513-052 – Cigna-HealthSpring Preferred (HMO): Benton, Madison and Washington, Arkansas

Drug Tier





30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $3 / $6 / $6 $10 / $20 / $30 $3 / $6 / $0 $10 / $20 / $30Tier 2: Generic Drugs $15 / $30 / $30 $20 / $40 / $60 $15 / $30 / $0 $20 / $40 / $60Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141Tier 4: Non-Preferred Drugs 50% 50% 50% 50%Tier 5: Specialty Tier 28% (30 days) 28% (30 days) 28% (30 days) 28% (30 days)

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Service Area: Denver H0672-001 – Cigna-HealthSpring Preferred (HMO): Adams, Arapahoe, Broomfield, Denver, Douglas and Jefferson, Colorado H0672-002 – Cigna-HealthSpring Preferred (HMO): Boulder, ColoradoH7849-001 – Cigna-HealthSpring True Choice (PPO): Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson, Colorado

Drug Tier





30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $12.50 $0 / $0 / $0 $5 / $10 / $12.50Tier 2: Generic Drugs $4 / $8 / $10 $9 / $18 / $22.50 $0 / $0 / $0 $9 / $18 / $22.50Tier 3: Preferred Brand Drugs $40 / $80 / $120 $45 / $90 / $135 $40 / $80 / $120 $45 / $90 / $135Tier 4: Non-Preferred Drugs $80 / $160 / $240 $85 / $170 / $255 $80 / $160 / $240 $85 / $170 / $255Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

Service Area: Florida H5410-018 – Cigna-HealthSpring Preferred (HMO): Bay, Escambia, Okaloosa, Santa Rosa and Walton, Florida

Drug Tier






Service Area: Florida H5410-024 – Cigna-HealthSpring Preferred (HMO): Lake, Orange, Osceola, Polk and Seminole, FloridaH5410-027 – Cigna-HealthSpring Preferred (HMO): Brevard and Volusia, FloridaH5410-029 – Cigna-HealthSpring Preferred (HMO): Hernando, Hillsborough, Pasco and Pinellas, Florida

Drug Tier






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Service Area: Florida H5410-026 – Cigna-HealthSpring Preferred Part B Savings (HMO): Lake, Orange, Osceola, Polk and Seminole, FloridaH5410-028 – Cigna-HealthSpring Preferred Part B Savings (HMO): Brevard and Volusia, FloridaH5410-030 – Cigna-HealthSpring Preferred Part B Savings (HMO): Hernando, Hillsborough, Pasco and Pinellas, Florida

Drug Tier






Service Area: GeorgiaH0439-003-001 – Cigna-HealthSpring Preferred GA (HMO): Barrow, Butts, Clarke, Clayton, DeKalb, Douglas, Franklin, Fulton, Greene, Gwinnett, Henry, Madison, Morgan, Newton, Oconee, Oglethorpe, Rockdale, Spalding and Walton, Georgia H0439-003-002 – Cigna-HealthSpring Preferred GA (HMO): Banks, Bartow, Chattooga, Cherokee, Cobb, Coweta, Dawson, Fayette, Floyd, Forsyth, Gordon, Habersham, Hall, Jackson, Lumpkin, Paulding, Pickens, Polk, Stephens and White, Georgia

Drug Tier






Service Area: GeorgiaH0439-006 – Cigna-HealthSpring Premier (HMO-POS): Barrow, Butts, Clarke, Clayton, DeKalb, Douglas, Franklin, Fulton, Greene, Gwinnett, Henry, Madison, Morgan, Newton, Oconee, Oglethorpe, Rockdale, Spalding and Walton, Georgia

Drug Tier






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Service Area: GeorgiaH0439-007 – Cigna-HealthSpring Preferred (HMO): Barrow, Butts, Cherokee, Clayton, Coweta, DeKalb, Fayette, Forsyth, Fulton, Gwinnett, Henry, Newton, Pickens, Rockdale and Spalding, GeorgiaH0439-009 – Cigna-HealthSpring Preferred (HMO): Clarke, Franklin, Greene, Madison, Morgan, Oconee, Oglethorpe and Walton, Georgia

Drug Tier






Service Area: GeorgiaH0439-008 – Cigna-HealthSpring Preferred (HMO): Cobb, Douglas and Paulding, Georgia

Drug Tier






Service Area: GeorgiaH0439-010 – Cigna-HealthSpring Preferred (HMO): Banks, Dawson, Habersham, Hall, Jackson, Lumpkin, Stephens and White, Georgia

Drug Tier






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Service Area: GeorgiaH0439-011 – Cigna-HealthSpring Preferred (HMO): Bartow, Chattooga, Floyd, Gordon and Polk, Georgia

Drug Tier






Service Area: GeorgiaH4513-030 – Cigna-HealthSpring Preferred (HMO): Catoosa, Dade and Walker, Georgia

Drug Tier






Service Area: GeorgiaH7849-003 – Cigna-HealthSpring True Choice (PPO): Butts, Newton, Rockdale and Spalding, Georgia

Drug Tier






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Service Area: Illinois H1415-021 – Cigna-HealthSpring Premier (HMO-POS): Cook, DuPage, Kane, Kankakee, Lake and Will, Illinois

Drug Tier






Service Area: Illinois H1415-024 – Cigna-HealthSpring Preferred (HMO): Cook, DuPage, Kane, Kankakee, Lake and Will, Illinois

Drug Tier






Service Area: Illinois H7849-002 – Cigna-HealthSpring True Choice (PPO): Cook, DuPage, Kane, Lake and Will, Illinois

Drug Tier






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Service Area: Kansas CityH9460-001 – Cigna-HealthSpring Preferred (HMO): Cass, Clay, Jackson, Platte and Ray, Missouri; Johnson, Miami and Wyandotte, Kansas

Drug Tier






Service Area: Maryland H2108-022 – Cigna-HealthSpring Preferred (HMO): Anne Arundel, Baltimore, Baltimore City and Harford, Maryland

Drug Tier






Service Area: Mid-Atlantic H2108-028 – Cigna-HealthSpring Preferred (HMO): District of Columbia; Kent, New Castle and Sussex, Delaware

Drug Tier






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Service Area: Mid-Atlantic H7849-008 – Cigna-HealthSpring True Choice (PPO): New Castle, DelawareH7849-009 – Cigna-HealthSpring True Choice Plus (PPO): New Castle, Delaware

Drug Tier






Service Area: MississippiH4407-026 – Cigna-HealthSpring Preferred (HMO): Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi

Drug Tier






Service Area: MississippiH4407-027 – Cigna-HealthSpring PreferredPlus (HMO): Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi

Drug Tier






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Service Area: New JerseyH3949-032 – Cigna-HealthSpring Preferred (HMO): Atlantic, Burlington, Camden, Gloucester and Mercer, New JerseyH3949-033 – Cigna-HealthSpring PreferredPlus (HMO): Atlantic, Burlington, Camden, Gloucester and Mercer, New Jersey

Drug Tier






Service Area: North CarolinaHH7849-011 – Cigna-HealthSpring True Choice (PPO): Davidson, Davie, Forsyth and Guilford, North Carolina

Drug Tier






Service Area: Pennsylvania H3949-030 – Cigna-HealthSpring Preferred (HMO): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, PennsylvaniaH3949-031 – Cigna-HealthSpring Alliance (HMO): Bucks, Delaware, Montgomery and Philadelphia, Pennsylvania

Drug Tier






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Service Area: Pennsylvania H3949-013 – Cigna-HealthSpring PreferredPlus (HMO): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania

Drug Tier






Service Area: Pennsylvania H7849-006 – Cigna-HealthSpring True Choice (PPO): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, PennsylvaniaH7849-007 – Cigna-HealthSpring True Choice Plus (PPO): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania

Drug Tier






Service Area: South CarolinaH7020-004 – Cigna-HealthSpring Preferred (HMO): Anderson, Cherokee, Chester, Greenville, Lancaster, Pickens, Spartanburg, Union and York, South Carolina

Drug Tier






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Service Area: South CarolinaH7020-006 – Cigna-HealthSpring PreferredPlus (HMO): Anderson, Cherokee, Chester, Greenville, Lancaster, Pickens, Spartanburg, Union and York, South Carolina

Drug Tier






Service Area: South CarolinaH7020-007 – Cigna-HealthSpring Preferred Part B Savings (HMO): Greenville, Spartanburg and York, South Carolina

Drug Tier






Service Area: Tennessee H4513-049-001 – Cigna-HealthSpring Preferred (HMO): Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Chester, Clay, Coffee, Crockett, Cumberland , Davidson, Decatur, DeKalb, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McNairy, Moore, Overton, Perry, Pickett, Polk, Putnam, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, TennesseeH4513-049-002 – Cigna-HealthSpring Preferred (HMO): Cheatham, Dickson, Hickman, Montgomery and Robertson, Tennessee

Drug Tier






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Service Area: TennesseeH4513-036 – Cigna-HealthSpring Premier (HMO-POS): Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland , Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McNairy, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee

Drug Tier






Service Area: TennesseeH4513-042 – Cigna-HealthSpring Alliance (HMO): Davidson, Sumner, Williamson and Wilson, Tennessee

Drug Tier






Service Area: TennesseeH4513-043 – Cigna-HealthSpring PreferredPlus (HMO): Davidson, Rutherford, Sumner, Williamson and Wilson, Tennessee

Drug Tier






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Service Area: TennesseeH4513-037 – Cigna-HealthSpring Preferred (HMO): Anderson, Blount, Cocke, Grainger, Hamblen, Jefferson, Knox, Loudon, Morgan, Sevier and Union, Tennessee

Drug Tier






Service Area: TennesseeH7849-010 – Cigna-HealthSpring True Choice (PPO): Davidson, Rutherford, Sumner, Williamson and Wilson, Tennessee

Drug Tier






Service Area: TexasH4513-025 – Cigna-HealthSpring Preferred (HMO): Angelina, Bexar, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563. 77565, 77568, 77573, 77574, 77590, 77591, and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, Texas

Drug Tier






18

Service Area: Texas H4513-026 – Cigna-HealthSpring Preferred (HMO): Henderson, Rusk, Smith, Upshur and Van Zandt, TexasH4513-028 – Cigna-HealthSpring Preferred (HMO): Bexar, Collin, Dallas, Denton, Hood, Johnson, Parker, Tarrant and Wise, Texas

Drug Tier





30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $3 / $6 / $7.50 $8 / $16 / $20 $0 / $0 / $0 $8 / $16 / $20Tier 2: Generic Drugs $8 / $16 / $20 $13 / $26 / $32.50 $0 / $0 / $0 $13 / $26 / $32.50Tier 3: Preferred Brand Drugs $35 / $70 / $105 $40 / $80 / $120 $35 / $70 / $105 $40 / $80 / $120Tier 4: Non-Preferred Drugs $70 / $140 / $210 $75 / $150 / $225 $70 / $140 / $210 $75 / $150 / $225Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

Service Area: TexasH7787-001 – Cigna-HealthSpring Preferred (PPO): Collin, Dallas, Denton, Johnson and Tarrant, Texas

Drug Tier






19

Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail-order, except when special circumstances or situations prohibit mailing a particular medication to your home.

My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.

My Medications Page Number in the Drug List Cost-Share through Cigna

20

Covered Drugs By Category

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 5 PA; NDSAMBISOME 5 PA; NDSamphotericin b 4 PAcaspofungin 5 PA; NDSclotrimazole mucous membrane

2

CRESEMBA ORAL 5 NDSfluconazole 2fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

4

flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 PA; QL (120/30)itraconazole oral solution 5 PA; NDSketoconazole oral 2MYCAMINE 5 NDSNOXAFIL ORAL SUSPENSION 5 PA; QL (600/30);

NDSNOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

nystatin oral suspension 2nystatin oral tablet 2POSACONAZOLE ORAL TABLET, DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

terbinafine hcl oral 2voriconazole intravenous 5 PA; NDSvoriconazole oral suspension for reconstitution

5 PA; QL (300/30); NDS

voriconazole oral tablet 4 PAANTIVIRALSabacavir oral solution 3 QL (960/30)abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acyclovir oral suspension 200 mg/5 ml

4

acyclovir oral tablet 2acyclovir sodium intravenous solution

4 B/D PA

adefovir 5 QL (30/30); NDSamantadine hcl 3APTIVUS 5 QL (120/30); NDSAPTIVUS (WITH VITAMIN E) 5 QL (285/28); NDSatazanavir oral capsule 150 mg 4 QL (30/30)atazanavir oral capsule 200 mg 5 QL (60/30); NDSatazanavir oral capsule 300 mg 5 QL (30/30); NDSATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 QL (30/30); NDSCIMDUO 5 QL (30/30); NDSCOMPLERA 5 QL (30/30); NDSCRIXIVAN ORAL CAPSULE 200 MG

4 QL (270/30)

CRIXIVAN ORAL CAPSULE 400 MG

4 QL (180/30)

DELSTRIGO 5 QL (30/30); NDSDESCOVY 5 QL (30/30); NDSdidanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 QL (30/30); NDSEDURANT 5 QL (30/30); NDSefavirenz oral capsule 200 mg 3 QL (120/30)efavirenz oral capsule 50 mg 3 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDSEMTRIVA ORAL CAPSULE 3 QL (30/30)EMTRIVA ORAL SOLUTION 3 QL (680/28)entecavir 4 QL (30/30)EPCLUSA 5 PA; QL (28/28);

NDSEPIVIR HBV ORAL SOLUTION 4EVOTAZ 5 QL (30/30); NDSfamciclovir 3 QL (60/30)fosamprenavir 5 QL (120/30); NDS

21


CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 19.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nevirapine oral tablet extended release 24 hr 400 mg

3 QL (30/30)

NORVIR ORAL POWDER IN PACKET

4 QL (360/30)

NORVIR ORAL SOLUTION 3 QL (480/30)NORVIR ORAL TABLET 4 QL (360/30)ODEFSEY 5 QL (30/30); NDSoseltamivir 3PIFELTRO 5 QL (30/30); NDSPREZCOBIX 5 QL (30/30); NDSPREZISTA ORAL SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (180/30)


5 QL (60/30); NDS


3 QL (210/30)


5 QL (30/30); NDS

RESCRIPTOR ORAL TABLET 4 QL (180/30)RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (180/30); NDS

ribavirin oral capsule 3 QL (168/28)ribavirin oral tablet 200 mg 3rimantadine 2ritonavir 3 QL (360/30)SELZENTRY ORAL SOLUTION

5 QL (1610/26); NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

4 QL (240/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

stavudine oral capsule 3 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FUZEON SUBCUTANEOUS RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDSHARVONI 5 PA; QL (28/28);

NDSINTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 5 QL (120/30); NDSISENTRESS HD 5 QL (60/30); NDSISENTRESS ORAL POWDER IN PACKET

4 QL (60/30)

ISENTRESS ORAL TABLET 5 QL (120/30); NDSISENTRESS ORAL TABLET,CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

3 QL (300/30)

KALETRA ORAL TABLET 200-50 MG

5 QL (120/30); NDS

lamivudine oral solution 3 QL (900/30)lamivudine oral tablet 100 mg, 300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)lamivudine-zidovudine 3 QL (60/30)LEXIVA ORAL SUSPENSION 4 QL (1575/28)lopinavir-ritonavir 3 QL (480/30)MAVYRET 5 PA; QL (84/28);

NDSnevirapine oral suspension 3 QL (1200/30)nevirapine oral tablet 3 QL (60/30)nevirapine oral tablet extended release 24 hr 100 mg

3 QL (90/30)

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3

cefadroxil oral tablet 3cefazolin 4cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4

cefdinir oral capsule 2cefdinir oral suspension for reconstitution

3

CEFEPIME IN DEXTROSE 5% 4cefepime in dextrose,iso-osm 4cefepime injection 4cefixime oral capsule 4 QL (30/30)cefixime oral suspension for reconstitution

4

cefotetan 4CEFOTETAN IN DEXTROSE, ISO-OSM

4

cefoxitin 4cefoxitin in dextrose, iso-osm 4cefpodoxime 2cefprozil 2ceftazidime 4CEFTAZIDIME IN D5W 4ceftriaxone in dextrose,iso-os 4ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

4

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous 4cefuroxime axetil oral tablet 2cefuroxime sodium injection recon soln 750 mg

4

cefuroxime sodium intravenous 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STRIBILD 5 QL (30/30); NDSSYMFI 5 QL (30/30); NDSSYMFI LO 5 QL (30/30); NDSSYMTUZA 5 QL (30/30); NDSSYNAGIS 5 PA; NDStenofovir disoproxil fumarate 4 QL (30/30)TIVICAY ORAL TABLET 10 MG 4 QL (60/30)TIVICAY ORAL TABLET 25 MG, 50 MG

5 QL (60/30); NDS

TRIUMEQ 5 QL (30/30); NDSTROGARZO 5 B/D PA; NDSTRUVADA 5 QL (30/30); NDSTYBOST 3 QL (30/30)valacyclovir oral tablet 1 gram 2 QL (120/30)valacyclovir oral tablet 500 mg 2 QL (60/30)valganciclovir 5 NDSVEMLIDY 5 NDSVIDEX 2 GRAM PEDIATRIC 4 QL (1200/30)VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG

4

VIRACEPT ORAL TABLET 250 MG

5 QL (270/30); NDS

VIRACEPT ORAL TABLET 625 MG

5 QL (120/30); NDS

VIREAD ORAL POWDER 5 QL (240/30); NDSVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (30/30); NDS

XOFLUZA 4zidovudine oral capsule 3 QL (180/30)zidovudine oral syrup 3 QL (1680/28)zidovudine oral tablet 3 QL (60/30)CEPHALOSPORINScefaclor oral capsule 2cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

3

cefaclor oral tablet extended release 12 hr

3

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

3

erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml

5 NDS

erythromycin ethylsuccinate oral tablet

3

erythromycin oral tablet 4erythromycin oral tablet,delayed release (dr/ec)

3

MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSALINIA ORAL SUSPENSION FOR RECONSTITUTION

5 QL (180/30); NDS

ALINIA ORAL TABLET 5 QL (20/10); NDSamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

4

ARIKAYCE 5 PA; NDSatovaquone 4atovaquone-proguanil 2aztreonam injection recon soln 1 gram

3

aztreonam injection recon soln 2 gram

5 NDS

bacitracin intramuscular 4CAPASTAT 4CAYSTON 5 PA; QL (84/56);

NDSchloramphenicol sod succinate 4chloroquine phosphate 2clindamycin hcl 2CLINDAMYCIN IN 0.9% SOD CHLOR

4

clindamycin in 5% dextrose 4clindamycin palmitate hcl 4clindamycin pediatric 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension for reconstitution

2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

4

tazicef 4TEFLARO 5 NDSERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4azithromycin oral packet 3azithromycin oral suspension for reconstitution

2

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack)

2

azithromycin oral tablet 600 mg 2 QL (60/30)clarithromycin oral suspension for reconstitution

3

clarithromycin oral tablet 2clarithromycin oral tablet extended release 24 hr

2

DIFICID 5 PA; QL (20/10); NDS

e.e.s. 400 oral tablet 3ERYPED 400 5 NDSery-tab oral tablet,delayed release (dr/ec) 250 mg

3

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG, 500 MG

3

erythrocin (as stearate) oral tablet 250 mg

3

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MEROPENEM-0.9% SODIUM CHLORIDE

4

metro i.v. 4metronidazole in nacl (iso-os) 4metronidazole oral tablet 1NEBUPENT 3 B/D PA; QL (1/28)neomycin 2ORBACTIV 5 QL (3/30); NDSparomomycin 4PASER 4PENTAM 3pentamidine inhalation 3 B/D PA; QL (1/28)pentamidine injection 3polymyxin b sulfate 4praziquantel 4PRIFTIN 4PRIMAQUINE 3pyrazinamide 3quinine sulfate 4 PA; QL (42/7)rifabutin 3rifampin intravenous 4rifampin oral 2RIFATER 4SIRTURO 4 PA; QL (188/365)SIVEXTRO INTRAVENOUS 5 B/D PA; QL (6/28);

NDSSIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 4SYNERCID 5 NDStigecycline 5 NDSTOBI PODHALER 5 QL (1568/365);

NDStobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDStobramycin sulfate 4TRECATOR 3VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate injection 4clindamycin phosphate intravenous solution 600 mg/4 ml

4

COARTEM 4 QL (24/30)colistin (colistimethate na) 4CYCLOSERINE 2dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 B/D PA; NDS

daptomycin intravenous recon soln 500 mg

5 B/D PA; NDS

DARAPRIM 5 QL (90/30); NDSEMVERM 5 NDSertapenem 4ethambutol 3FIRVANQ 4gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

4

gentamicin injection solution 40 mg/ml

4

gentamicin sulfate (ped) (pf) 4hydroxychloroquine 2imipenem-cilastatin 4isoniazid oral solution 3isoniazid oral tablet 2ivermectin oral 3lincomycin 4linezolid in dextrose 5% 4linezolid oral suspension for reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)linezolid-0.9% sodium chloride 4mefloquine 2meropenem 4

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dicloxacillin 2nafcillin 4nafcillin in dextrose iso-osm 4oxacillin injection 4penicillin g potassium 4penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet 250 mg

1

penicillin v potassium oral tablet 500 mg

2

pfizerpen-g 4PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4

ZOSYN IN DEXTROSE (ISO-OSM)

4

ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM

4

QUINOLONESBAXDELA 4 QL (28/14)ciprofloxacin 4ciprofloxacin hcl oral tablet 100 mg

3

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

2

ciprofloxacin in 5% dextrose 4levofloxacin in d5w 4levofloxacin intravenous 4levofloxacin oral solution 4levofloxacin oral tablet 2moxifloxacin oral 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK

4

VANCOMYCIN INJECTION 4vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

4

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM

4

vancomycin oral capsule 125 mg

3 QL (40/10)

vancomycin oral capsule 250 mg

3 QL (80/10)

vancomycin oral recon soln 2VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA; QL (90/30); NDS

PENICILLINSamoxicillin oral capsule 1amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet 2amoxicillin oral tablet,chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule 500 mg 2ampicillin sodium 4ampicillin-sulbactam 4BICILLIN L-A 4

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

URINARY TRACT AGENTSmethenamine hippurate 2MONUROL 4nitrofurantoin 4nitrofurantoin macrocrystal 2nitrofurantoin monohyd/m-cryst 2trimethoprim 2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection recon soln

4

leucovorin calcium injection solution 10 mg/ml

4

leucovorin calcium oral 3mesna 4 B/D PAMESNEX ORAL 5 NDSXGEVA 5 PA; QL (1.7/28);

NDSANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSabiraterone 5 PA; QL (120/30);

NDSABRAXANE 5 PA; NDSAFINITOR 5 PA; QL (28/28);

NDSAFINITOR DISPERZ 5 PA; QL (56/28);

NDSALECENSA 5 PA; QL (240/30);

NDSALIMTA 5 PA; NDSALIQOPA 5 PA; QL (3/28); NDSALKERAN 4ALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (180/30); NDS

ALUNBRIG ORAL TABLETS,DOSE PACK

5 PA; QL (60/365); NDS

anastrozole 2ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MOXIFLOXACIN-SOD.ACE,SUL-WATER

4

moxifloxacin-sod.chloride(iso) 4SULFAS / RELATED AGENTSsulfadiazine 3sulfamethoxazole-trimethoprim intravenous

4

sulfamethoxazole-trimethoprim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim 4TETRACYCLINESdemeclocycline 3doxy-100 4doxycycline hyclate intravenous 4doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg

1

doxycycline hyclate oral tablet 20 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

2

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

4

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2minocycline oral tablet 2mondoxyne nl oral capsule 100 mg, 75 mg

3

morgidox 1NUZYRA (7 DAY WITH LOAD DOSE)

4 QL (30/14)

NUZYRA (7 DAY) 4 QL (30/14)NUZYRA INTRAVENOUS 4 QL (15/14)NUZYRA ORAL 4 QL (30/14)tetracycline 2

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAPRELSA ORAL TABLET 300 MG

5 PA; QL (30/30); NDS

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

5 PA; QL (112/28); NDS

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28); NDS

COPIKTRA 5 PA; QL (60/30); NDS

COSMEGEN 5 B/D PA; NDSCOTELLIC 5 PA; QL (63/28);

NDScyclophosphamide intravenous 5 B/D PA; NDScyclophosphamide oral capsule 3 B/D PAcyclosporine intravenous 4 PAcyclosporine modified 4 PAcyclosporine oral capsule 4 PACYRAMZA 5 PA; NDSDARZALEX 5 PA; NDSdaunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

DAURISMO ORAL TABLET 25 MG

5 PA; QL (60/30); NDS

DROXIA 3ELIGARD 4 PA; QL (1/30)ELIGARD (3 MONTH) 4 PA; QL (1/90)ELIGARD (4 MONTH) 4 PA; QL (1/120)ELIGARD (6 MONTH) 4 PA; QL (1/180)ELZONRIS 5 B/D PA; NDSEMCYT 4ENHERTU 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

arsenic trioxide intravenous solution 2 mg/ml

4 B/D PA

ASTAGRAF XL 4 PAAVASTIN 5 PA; NDSAYVAKIT 5 PA; QL (30/30);

NDSAZASAN 3 PAazathioprine 2 PAazathioprine sodium 4 PABALVERSA ORAL TABLET 3 MG

5 PA; QL (90/30); NDS

BALVERSA ORAL TABLET 4 MG

5 PA; QL (60/30); NDS

BALVERSA ORAL TABLET 5 MG

5 PA; QL (30/30); NDS

BAVENCIO 5 PA; NDSBENDEKA 5 B/D PA; QL (8/21);

NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 2BORTEZOMIB 5 PA; QL (14/21);

NDSBOSULIF 5 PA; NDSBRAFTOVI 5 PA; QL (180/30);

NDSBRUKINSA 5 PA; NDSbusulfan 5 B/D PA; NDSBUSULFEX 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

5 PA; QL (30/30); NDS

CABOMETYX ORAL TABLET 40 MG

5 PA; QL (60/30); NDS

CALQUENCE 5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 100 MG

5 PA; QL (60/30); NDS

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gengraf oral solution 4 PAGILOTRIF 5 PA; QL (30/30);

NDSGLEOSTINE ORAL CAPSULE 10 MG, 40 MG

3

GLEOSTINE ORAL CAPSULE 100 MG

4

HALAVEN 5 PA; NDSHERCEPTIN HYLECTA 5 PA; NDSHERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA; NDS

hydroxyurea 2IBRANCE ORAL CAPSULE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

ICLUSIG ORAL TABLET 45 MG

5 PA; QL (30/30); NDS

IDHIFA 5 PA; QL (30/30); NDS

imatinib oral tablet 100 mg 5 PA; QL (180/30); NDS

imatinib oral tablet 400 mg 5 PA; QL (60/30); NDS

IMBRUVICA ORAL CAPSULE 140 MG

5 PA; QL (120/30); NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA; QL (30/30); NDS

IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS

IMFINZI 5 PA; NDSINFUGEM 5 B/D PA; NDSINLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDSINLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDSINREBIC 5 PA; QL (120/30);

NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAISTODAX 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG

4 PA

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 4 MG

5 PA; NDS

ERIVEDGE 5 PA; QL (28/28); NDS

ERLEADA 5 PA; NDSerlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30); NDS

etoposide intravenous 3 B/D PAeverolimus (antineoplastic) 5 PA; QL (28/28);

NDSEVOMELA 5 PA; NDSexemestane 2 QL (60/30)FARYDAK 5 PA; QL (6/21); NDSFASLODEX 5 B/D PA; QL (30/30);

NDSFIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

5 B/D PA; QL (4/365); NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 B/D PA; QL (1/28)

fludarabine 4 B/D PAflutamide 2FOLOTYN 5 B/D PA; NDSfulvestrant 5 B/D PA; QL (30/30);

NDSGAZYVA 5 PA; NDSgemcitabine intravenous recon soln

4 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA; NDS

gengraf oral capsule 100 mg, 25 mg

4 PA

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; QL (1/30); NDSLUPRON DEPOT (3 MONTH) 5 PA; QL (1/84); NDSLUPRON DEPOT (4 MONTH) 5 PA; QL (1/112);

NDSLUPRON DEPOT (6 MONTH) 5 PA; QL (1/168);

NDSLUPRON DEPOT-PED 5 PA; QL (1/30); NDSLUPRON DEPOT-PED (3 MONTH)

5 PA; QL (1/84); NDS

LYNPARZA ORAL TABLET 5 PA; QL (120/30); NDS

LYSODREN 5 NDSMATULANE 5 NDSmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

3 PA

megestrol oral tablet 3 PAMEKINIST ORAL TABLET 0.5 MG

5 PA; QL (90/30); NDS

MEKINIST ORAL TABLET 2 MG

5 PA; QL (30/30); NDS

MEKTOVI 5 PA; QL (180/30); NDS

melphalan 4melphalan hcl 5 B/D PA; NDSmercaptopurine 2methotrexate sodium (pf) 4methotrexate sodium injection 4methotrexate sodium oral 2MVASI 5 PA; NDSmycophenolate mofetil (hcl) 4 PAmycophenolate mofetil oral capsule

2 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JAKAFI 5 PA; QL (60/30); NDS

KADCYLA 5 PA; NDSKANJINTI 5 PA; NDSKEYTRUDA INTRAVENOUS SOLUTION

5 PA; NDS

KISQALI 5 PA; QL (63/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28); NDS


5 PA; QL (70/28); NDS


5 PA; QL (91/28); NDS

KYPROLIS 5 B/D PA; NDSLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30); NDS

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; QL (90/30); NDS

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)

5 PA; QL (60/30); NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 4 PALIBTAYO 5 PA; QL (7/21); NDSLONSURF ORAL TABLET 15-6.14 MG

5 PA; QL (100/28); NDS

LONSURF ORAL TABLET 20-8.19 MG

5 PA; QL (80/28); NDS

LORBRENA ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RAPAMUNE ORAL SOLUTION 5 PA; NDSREVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

5 PA; QL (28/28); NDS

REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG

5 PA; QL (21/28); NDS

RITUXAN 5 PA; NDSRITUXAN HYCELA 5 PA; NDSROMIDEPSIN 5 PA; NDSROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

RUBRACA 5 PA; QL (120/30); NDS

RUXIENCE 5 PA; NDSRYDAPT 5 PA; QL (224/28);

NDSSANDIMMUNE ORAL SOLUTION

4 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5 PA; NDS

SIGNIFOR 5 PA; QL (60/30); NDS

SIMULECT 5 B/D PA; NDSsirolimus oral solution 5 PA; NDSsirolimus oral tablet 4 PASOLTAMOX 5 NDSSOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML

5 PA; QL (0.5/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

5 PA; QL (0.2/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML

5 PA; QL (0.3/28); NDS

SPRYCEL 5 PA; QL (30/30); NDS

STIVARGA 5 PA; QL (120/28); NDS

SUTENT 5 PA; QL (28/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mycophenolate mofetil oral suspension for reconstitution

5 PA; NDS

mycophenolate mofetil oral tablet

2 PA

mycophenolate sodium 2 PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; QL (180/30);

NDSNEXAVAR 5 PA; QL (120/30);

NDSnilutamide 5 QL (60/30); NDSNINLARO 5 PA; QL (3/28); NDSNUBEQA 5 PA; QL (120/30);

NDSNULOJIX 5 PA; QL (26/28);

NDSoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

4 PA

octreotide acetate injection solution 50 mcg/ml

3 PA

ODOMZO 5 PA; QL (30/30); NDS

OPDIVO 5 PA; QL (80/28); NDS

paclitaxel 4 B/D PAPADCEV 5 PA; NDSPERJETA 5 PA; NDSPIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (28/28); NDS

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

5 PA; QL (56/28); NDS

POMALYST 5 PA; QL (21/28); NDS

POTELIGEO 5 PA; NDSPROGRAF INTRAVENOUS 4 PAPROGRAF ORAL GRANULES IN PACKET

4 PA

PURIXAN 5 PA; QL (300/30); NDS

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TREANDA INTRAVENOUS RECON SOLN 100 MG

5 B/D PA; NDS

TREANDA INTRAVENOUS RECON SOLN 25 MG

5 B/D PA; QL (8/21); NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG

5 PA; QL (1/84); NDS


5 PA; QL (1/168); NDS


5 PA; QL (1/28); NDS

tretinoin (chemotherapy) 5 NDSTRIPTODUR 5 PA; QL (1/168);

NDSTRISENOX INTRAVENOUS SOLUTION 2 MG/ML

4 B/D PA

TRUXIMA 5 PA; NDSTYKERB 5 PA; QL (180/30);

NDSUNITUXIN 5 PA; NDSVECTIBIX 5 PA; NDSVELCADE 5 PA; QL (14/21);

NDSVENCLEXTA ORAL TABLET 10 MG

3 PA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

5 PA; QL (120/30); NDS

VENCLEXTA ORAL TABLET 50 MG

3 PA; QL (30/30)

VENCLEXTA STARTING PACK 5 PA; QL (84/365); NDS

VERZENIO 5 PA; QL (60/30); NDS

vincasar pfs intravenous solution 1 mg/ml

4 B/D PA

vincristine 4 B/D PAvinorelbine 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNRIBO 5 PA; QL (28/28); NDS

TABLOID 4tacrolimus oral 2 PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; QL (30/30);

NDSTALZENNA 5 PA; QL (90/30);

NDStamoxifen 2TARGRETIN TOPICAL 5 PA; QL (60/30);

NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (420/30); NDS

TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

5 PA; QL (20/21); NDS

TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML)

5 PA; QL (28/28); NDS

temsirolimus 5 B/D PA; QL (4/28); NDS

THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG

5 PA; QL (28/28); NDS

THALOMID ORAL CAPSULE 200 MG

5 PA; QL (56/28); NDS

thiotepa 4 PATIBSOVO 5 PA; QL (60/30);

NDStoposar 3 B/D PAtopotecan intravenous recon soln

5 NDS

toremifene 5 QL (30/30); NDSTORISEL 5 B/D PA; QL (4/28);

NDS

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZORTRESS ORAL TABLET 0.75 MG, 1 MG

5 PA; QL (60/30); NDS

ZYDELIG 5 PA; QL (60/30); NDS

ZYKADIA ORAL TABLET 5 PA; QL (140/28); NDS

ZYTIGA ORAL TABLET 500 MG

5 PA; QL (60/30); NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

5 QL (180/30); NDS

APTIOM ORAL TABLET 400 MG

5 QL (90/30); NDS

APTIOM ORAL TABLET 600 MG, 800 MG

5 QL (60/30); NDS

BANZEL ORAL SUSPENSION 5 PA; QL (2400/30); NDS

BANZEL ORAL TABLET 5 PA; NDSBRIVIACT ORAL SOLUTION 4 QL (600/30)BRIVIACT ORAL TABLET 4 QL (60/30)carbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet 2carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet,chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 5 QL (480/30); NDSclobazam oral tablet 10 mg 4 QL (60/30)clobazam oral tablet 20 mg 5 QL (60/30); NDSclonazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

clonazepam oral tablet 2 mg 2 QL (300/30)clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg

2 QL (90/30)

clonazepam oral tablet,disintegrating 1 mg

2 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VITRAKVI ORAL CAPSULE 100 MG

5 PA; QL (60/30); NDS

VITRAKVI ORAL CAPSULE 25 MG

5 PA; QL (180/30); NDS

VITRAKVI ORAL SOLUTION 5 PA; QL (300/30); NDS

VIZIMPRO 5 PA; QL (30/30); NDS

VOTRIENT 5 PA; QL (120/30); NDS

VYXEOS 5 B/D PA; NDSXALKORI 5 PA; QL (60/30);

NDSXATMEP 4 PAXOSPATA 5 PA; QL (90/30);

NDSXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5)

5 PA; QL (20/28); NDS

XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8)

5 PA; QL (32/28); NDS


5 PA; QL (12/28); NDS


5 PA; QL (16/28); NDS

XTANDI 5 PA; QL (120/30); NDS

YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML)

5 PA; QL (80/21); NDS

YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML)

5 PA; NDS

YONDELIS 5 PA; NDSYONSA 5 PA; QL (120/30);

NDSZEJULA 5 PA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZOLINZA 5 QL (120/30); NDSZORTRESS ORAL TABLET 0.25 MG

4 PA; QL (60/30)

ZORTRESS ORAL TABLET 0.5 MG

5 PA; QL (120/30); NDS

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lamotrigine oral tablet,disintegrating

2

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 4levetiracetam oral 2LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG

3 QL (90/30)

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG

3 QL (60/30)

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

4 QL (90/30)

LYRICA ORAL CAPSULE 225 MG, 300 MG

4 QL (60/30)

LYRICA ORAL CAPSULE 75 MG

4 QL (120/30)

LYRICA ORAL SOLUTION 4 QL (900/30)NAYZILAM 5 PA; QL (10/30);

NDSoxcarbazepine 2PEGANONE 3phenobarbital oral elixir 3 QL (1500/30)phenobarbital oral tablet 3 QL (120/30)phenytoin oral suspension 2phenytoin oral tablet,chewable 2phenytoin sodium extended 2pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

3 QL (90/30)

pregabalin oral capsule 225 mg, 300 mg

3 QL (60/30)

pregabalin oral capsule 75 mg 3 QL (120/30)pregabalin oral solution 3 QL (900/30)primidone 2roweepra 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clonazepam oral tablet,disintegrating 2 mg

2 QL (300/30)

DIASTAT 4 QL (5/30)DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG

4 QL (40/30)

DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG

4 QL (20/30)

diazepam rectal kit 12.5-15-17.5-20 mg

4 QL (40/30)

diazepam rectal kit 2.5 mg 4 QL (5/30)diazepam rectal kit 5-7.5-10 mg 4 QL (20/30)DILANTIN 30 MG 3divalproex 2EPIDIOLEX 5 PA; NDSepitol 2ethosuximide 3felbamate oral suspension 5 NDSfelbamate oral tablet 4FYCOMPA ORAL SUSPENSION

4 QL (720/30)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

4 QL (30/30)

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG

4 QL (60/30)

gabapentin oral capsule 100 mg, 400 mg

2 QL (270/30)

gabapentin oral capsule 300 mg

2 QL (360/30)

gabapentin oral solution 2 QL (2160/30)gabapentin oral tablet 600 mg 2 QL (180/30)gabapentin oral tablet 800 mg 2lamotrigine oral tablet 2lamotrigine oral tablet extended release 24hr

2

lamotrigine oral tablet, chewable dispersible

2

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbidopa-levodopa oral tablet,disintegrating

2

carbidopa-levodopa-entacapone

3

entacapone 4 QL (240/30)NEUPRO 4pramipexole oral tablet 2pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg

4 QL (90/30)

pramipexole oral tablet extended release 24 hr 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

4 QL (30/30)

rasagiline 3ropinirole oral tablet 2RYTARY 4 STselegiline hcl 3tolcapone 5 NDStrihexyphenidyl 2 PAMIGRAINE / CLUSTER HEADACHE THERAPYdihydroergotamine nasal 4 PA; QL (8/30)ergotamine-caffeine 3 QL (40/28)migergot 5 QL (20/28); NDSnaratriptan 3 QL (18/28)rizatriptan 3 QL (36/28)sumatriptan 4 QL (18/28)sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

sumatriptan succinate subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate subcutaneous solution

4 QL (8/28)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG, 9 MG

5 PA; QL (120/30); NDS

AUSTEDO ORAL TABLET 6 MG

5 PA; QL (60/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

roweepra xr 2SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG

4 QL (60/30)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG

4 QL (120/30)

SYMPAZAN 5 PA; QL (60/30); NDS

tiagabine 4topiramate oral capsule, sprinkle

2

topiramate oral tablet 2TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG

4 QL (30/30)

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG

5 QL (60/30); NDS

valproic acid 2valproic acid (as sodium salt) oral solution

2

vigabatrin 5 PA; QL (180/30); NDS

vigadrone 5 PA; QL (180/30); NDS

VIMPAT INTRAVENOUS 4 QL (1200/30)VIMPAT ORAL SOLUTION 4 QL (1200/30)VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

4 QL (60/30)

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)zonisamide 2ANTIPARKINSONISM AGENTSAPOKYN 5 PA; QL (60/30);

NDSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 4carbidopa-levodopa oral tablet 2carbidopa-levodopa oral tablet extended release

3

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG

5 PA; QL (14/30); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

5 PA; QL (120/365); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 240 MG

5 PA; QL (60/30); NDS

tetrabenazine oral tablet 12.5 mg

5 PA; QL (90/30); NDS

tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS

TYSABRI 5 PA; QL (15/28); NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPYbaclofen oral tablet 10 mg, 5 mg

1

baclofen oral tablet 20 mg 2cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA

dantrolene oral 3methocarbamol oral 2 PApyridostigmine bromide oral syrup

5 NDS

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

3

regonol 4tizanidine oral capsule 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml

2 QL (270/30); NDS

acetaminophen-codeine oral solution 120-12 mg/5 ml

2 QL (2700/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

5 PA; QL (30/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

5 PA; QL (12/28); NDS

dalfampridine 3 PA; QL (60/30)donepezil oral tablet 10 mg 2 QL (60/30)donepezil oral tablet 23 mg 4 QL (30/30)donepezil oral tablet 5 mg 2 QL (30/30)donepezil oral tablet,disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet,disintegrating 5 mg

2 QL (30/30)

FIRDAPSE 5 PA; NDSgalantamine oral capsule,ext rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)galantamine oral tablet 4 QL (60/30)GILENYA ORAL CAPSULE 0.5 MG

5 PA; QL (30/30); NDS

memantine oral capsule,sprinkle,er 24hr

4 PA; QL (30/30)

memantine oral solution 2 PA; QL (300/30)memantine oral tablet 10 mg 2 PA; QL (60/30)memantine oral tablet 5 mg 2 PA; QL (90/30)memantine oral tablets,dose pack

3 PA; QL (98/365)

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

3 PA; QL (56/365)

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

3 PA

NUEDEXTA 4 PA; QL (60/30)OCREVUS 5 PA; NDSrivastigmine 4 QL (30/30)rivastigmine tartrate 4 QL (60/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

3 NDS

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

3 QL (2700/30); NDS

HYDROCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG

3 QL (180/30); NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg

3 QL (180/30); NDS

hydrocodone-acetaminophen oral tablet 5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

3 QL (150/30); NDS

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml

4 NDS

hydromorphone injection solution 2 mg/ml

4 NDS

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

4 NDS

hydromorphone oral liquid 3 QL (1200/30); NDShydromorphone oral tablet 2 mg, 4 mg

3 QL (180/30); NDS

hydromorphone oral tablet 8 mg

3 QL (120/30); NDS

ibuprofen-oxycodone 3 QL (28/30); NDSINFUMORPH P/F 4 B/D PA; QL

(200/30); NDSlorcet (hydrocodone) 3 QL (360/30); NDSlorcet hd 3 QL (180/30); NDSlorcet plus oral tablet 7.5-325 mg

3 QL (180/30); NDS

methadone injection solution 4 QL (150/30); NDSmethadone intensol 3 QL (500/30); NDSmethadone oral concentrate 3 QL (500/30); NDSmethadone oral solution 10 mg/5 ml

3 QL (450/30); NDS

methadone oral solution 5 mg/5 ml

3 QL (600/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (360/30); NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (180/30); NDS

ascomp with codeine 4 PA; QL (180/30)buprenorphine hcl injection solution

4 QL (150/30)

buprenorphine hcl injection syringe

4 QL (150/30); NDS

buprenorphine hcl sublingual 4 PA; QL (90/30)BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR

4 QL (4/28); NDS

buprenorphine transdermal patch weekly 7.5 mcg/hour

4 QL (4/28); NDS

butalbital compound w/codeine 4 PA; QL (180/30)butalbital-acetaminop-caf-cod 4 PA; QL (180/30)butalbital-acetaminophen-caff oral capsule

3 PA; QL (180/30)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

3 PA; QL (180/30)

butalbital-aspirin-caffeine oral capsule

4 PA; QL (180/30)

DURAMORPH (PF) 4 B/D PA; QL (180/30); NDS

endocet oral tablet 10-325 mg 3 QL (180/30); NDSendocet oral tablet 2.5-325 mg, 5-325 mg

3 QL (360/30); NDS

endocet oral tablet 7.5-325 mg 3 QL (240/30); NDSfentanyl 4 QL (10/30); NDSfentanyl citrate (pf) injection solution

4 B/D PA; NDS

fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)

4 B/D PA; NDS

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg

5 PA; QL (120/30); NDS

fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg

4 PA; QL (120/30); NDS

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

morphine intravenous syringe 4 mg/ml

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SYRINGE 8 MG/ML

4 B/D PA; QL (250/30); NDS

morphine oral solution 10 mg/5 ml

2 QL (700/30); NDS

morphine oral solution 20 mg/5 ml (4 mg/ml)

2 QL (900/30); NDS

MORPHINE ORAL TABLET 3 QL (120/30); NDSmorphine oral tablet extended release

3 QL (90/30); NDS

oxycodone oral concentrate 3 QL (120/30); NDSoxycodone oral solution 3 QL (1200/30); NDSoxycodone oral tablet 3 QL (180/30); NDSoxycodone-acetaminophen oral tablet 10-325 mg

3 QL (180/30); NDS

oxycodone-acetaminophen oral tablet 2.5-300 mg

3 NDS

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg

3 QL (360/30); NDS

oxycodone-acetaminophen oral tablet 7.5-325 mg

3 QL (240/30); NDS

oxycodone-aspirin 3 QL (180/30); NDSoxymorphone oral tablet extended release 12 hr

3 QL (90/30); NDS

XTAMPZA ER 3 QL (60/30); NDSzebutal oral capsule 50-325-40 mg

3 PA; QL (180/30)

NON-NARCOTIC ANALGESICSbuprenorphine-naloxone sublingual film 12-3 mg

4 QL (60/30)

buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg

4 QL (90/30)

buprenorphine-naloxone sublingual tablet

2 QL (90/30)

butorphanol tartrate injection solution 1 mg/ml

4 QL (480/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methadone oral tablet 10 mg 3 QL (120/30); NDSmethadone oral tablet 5 mg 3 QL (180/30); NDSMITIGO (PF) 4 QL (200/30); NDSmorphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

4 B/D PA; QL (180/30); NDS

morphine (pf) intravenous patient control.analgesia soln

4 B/D PA; NDS

morphine concentrate oral solution

2 QL (240/30); NDS

MORPHINE INJECTION SOLUTION 10 MG/ML

4 B/D PA; QL (240/30); NDS


4 B/D PA; NDS


4 B/D PA; QL (480/30); NDS


4 B/D PA; QL (700/30); NDS

morphine injection solution 8 mg/ml

4 B/D PA; QL (250/30); NDS

morphine injection syringe 10 mg/ml

4 B/D PA; QL (240/30); NDS


4 B/D PA; QL (1200/30); NDS


4 B/D PA; QL (480/30); NDS


4 B/D PA; NDS


4 B/D PA; QL (250/30); NDS

morphine intravenous solution 10 mg/ml

4 B/D PA; QL (240/30); NDS

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SOLUTION 8 MG/ML

4 B/D PA; QL (250/30); NDS

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML

4 B/D PA; QL (240/30); NDS

morphine intravenous syringe 2 mg/ml

4 B/D PA; QL (1200/30); NDS

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 3 QL (240/30); NDSVIVITROL 5 PA; NDSZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3 QL (90/30)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 5 QL (1/28); NDSalprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg

3 QL (90/30)

alprazolam oral tablet,disintegrating 2 mg

3 QL (150/30)

amitriptyline 3 PAamoxapine 3aripiprazole oral solution 3 QL (900/30)aripiprazole oral tablet 3 QL (30/30)aripiprazole oral tablet,disintegrating

5 QL (60/30); NDS

ARISTADA INITIO 5 QL (4.8/365); NDSARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

5 QL (3.9/56); NDS

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML

5 QL (1.6/28); NDS


5 QL (2.4/28); NDS


5 QL (3.2/28); NDS

armodafinil 4 PA; QL (30/30)atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

butorphanol tartrate injection solution 2 mg/ml

4 QL (240/30); NDS

butorphanol tartrate nasal 2 QL (5/30); NDScelecoxib 2 QL (60/30)diclofenac potassium 2diclofenac sodium oral 2diclofenac sodium topical drops 4 QL (450/28)diclofenac sodium topical gel 1%

3 QL (1000/30)

diflunisal 2ec-naproxen 2etodolac 4flurbiprofen 2ibu 1ibuprofen oral suspension 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

meloxicam oral tablet 1nabumetone 2nalbuphine injection solution 10 mg/ml

4 QL (180/30); NDS

nalbuphine injection solution 20 mg/ml

4 QL (90/30); NDS

naloxone injection solution 2naloxone injection syringe 1 mg/ml

2

naltrexone 2naproxen oral suspension 3naproxen oral tablet 1naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

4

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3 QL (4/30)

oxaprozin 4salsalate 2SUBOXONE SUBLINGUAL FILM 12-3 MG

3 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG

3 QL (90/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clozapine oral tablet,disintegrating 12.5 mg, 25 mg

4

clozapine oral tablet,disintegrating 150 mg

4 QL (180/30)

clozapine oral tablet,disintegrating 200 mg

5 QL (120/30); NDS

desipramine 3desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

4 QL (120/30)

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

4 QL (30/30)

dexmethylphenidate oral tablet 10 mg, 2.5 mg

3 QL (60/30)

dexmethylphenidate oral tablet 5 mg

3 QL (120/30)

dextroamphetamine oral capsule, extended release 10 mg

4 QL (180/30)


4 QL (120/30)


4 QL (60/30)

dextroamphetamine oral solution

4 QL (1800/30)

dextroamphetamine oral tablet 4 QL (180/30)dextroamphetamine-amphetamine oral capsule,extended release 24hr

4 QL (60/30)

dextroamphetamine-amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg

3 QL (60/30)


3 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

4 QL (30/30)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG

3 QL (30/30)

BELSOMRA ORAL TABLET 5 MG

3 QL (60/30)

bupropion hcl oral tablet 100 mg

3 QL (120/30)

bupropion hcl oral tablet 75 mg 3 QL (180/30)bupropion hcl oral tablet extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg

3 QL (60/30)

bupropion hcl oral tablet sustained-release 12 hr 150 mg

3 QL (90/30)

buspirone 2CAPLYTA 5 ST; QL (30/30);

NDSchlorpromazine injection 4chlorpromazine oral 2citalopram oral solution 3 QL (600/30)citalopram oral tablet 10 mg 1 QL (120/30)citalopram oral tablet 20 mg 1 QL (60/30)citalopram oral tablet 40 mg 1 QL (90/30)clomipramine 3 PAclonidine hcl oral tablet extended release 12 hr

4 QL (120/30)

clorazepate dipotassium oral tablet 15 mg, 3.75 mg

3 QL (180/30)

clorazepate dipotassium oral tablet 7.5 mg

3 QL (360/30)

clozapine oral tablet 3clozapine oral tablet,disintegrating 100 mg

4 QL (270/30)

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluoxetine oral capsule,delayed release(dr/ec)

3 QL (4/28)

fluoxetine oral solution 2 QL (600/30)fluoxetine oral tablet 10 mg, 20 mg

2

fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 2GEODON INTRAMUSCULAR 4 QL (6/30)GUANIDINE 3haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg

1

haloperidol oral tablet 10 mg, 20 mg

2

HETLIOZ 5 PA; QL (30/30); NDS

imipramine hcl 3 PAINVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

5 QL (0.75/28); NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML

5 QL (1/28); NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML

5 QL (1.5/28); NDS


4 QL (0.25/28)


5 QL (0.5/28); NDS

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML

5 QL (0.88/90); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


3 QL (90/30)


3 QL (360/30)

diazepam injection syringe 2diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3 PAdoxepin oral concentrate 3 PAdoxepin oral tablet 3 QL (30/30)DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG

4 QL (180/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG

4 QL (90/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG

4 QL (60/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg

2 QL (180/30)


2 QL (90/30)


2 QL (60/30)

EMSAM 5 QL (30/30); NDSescitalopram oxalate oral solution

3 QL (600/30)

escitalopram oxalate oral tablet 2FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG

4 ST; QL (60/30)

FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG

5 ST; QL (60/30); NDS

FANAPT ORAL TABLETS,DOSE PACK

4 ST; QL (16/365)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4 ST; QL (56/365)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine oral capsule 2

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mirtazapine oral tablet,disintegrating

2 QL (30/30)

molindone 2nefazodone 3nortriptyline 2NUPLAZID ORAL CAPSULE 5 PA; QL (30/30);

NDSNUPLAZID ORAL TABLET 10 MG

5 PA; QL (30/30); NDS

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 10 mg, 2.5 mg, 5 mg

2 QL (120/30)

olanzapine oral tablet 15 mg, 20 mg

2 QL (60/30)

olanzapine oral tablet 7.5 mg 2 QL (30/30)olanzapine oral tablet,disintegrating

3 QL (30/30)

olanzapine-fluoxetine 4 QL (30/30)oxazepam 2 QL (120/30)paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

4 ST; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 ST; QL (60/30)

paroxetine hcl oral tablet 10 mg 1 QL (60/30)paroxetine hcl oral tablet 20 mg 1 QL (90/30)paroxetine hcl oral tablet 30 mg, 40 mg

2 QL (60/30)

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

3 QL (30/30)

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

3 QL (60/30)

PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4perphenazine-amitriptyline 4 PAPERSERIS 5 QL (1/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


5 QL (1.32/90); NDS


5 QL (1.75/90); NDS


5 QL (2.63/90); NDS

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

5 QL (30/30); NDS

LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDSlithium carbonate 2lorazepam injection 4lorazepam intensol 3 QL (150/30)lorazepam oral concentrate 3 QL (150/30)lorazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

lorazepam oral tablet 2 mg 2 QL (150/30)loxapine succinate 2maprotiline 4MARPLAN 4 QL (180/30)metadate er 3 QL (90/30)methylphenidate hcl oral tablet 3 QL (90/30)methylphenidate hcl oral tablet extended release

3 QL (90/30)

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating)

3 QL (120/30)

methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating)

3 QL (30/30)

methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating)

3 QL (60/30)

mirtazapine oral tablet 2

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tranylcypromine 4trazodone 2trifluoperazine 3trimipramine 4 PATRINTELLIX 4 ST; QL (30/30)venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg

2 QL (60/30)

venlafaxine oral capsule,extended release 24hr 75 mg

2 QL (90/30)

venlafaxine oral tablet 2VERSACLOZ 4 QL (540/30)VIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (60/365)

VRAYLAR ORAL CAPSULE 5 ST; QL (30/30); NDS

VRAYLAR ORAL CAPSULE,DOSE PACK

4 ST; QL (14/365)

XYREM 5 PA; QL (540/30); NDS

zaleplon oral capsule 10 mg 3 QL (60/30)zaleplon oral capsule 5 mg 3 QL (30/30)ziprasidone hcl 3 QL (60/30)zolpidem oral tablet 3 QL (30/30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4 QL (2/28)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG

5 QL (2/28); NDS

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG

5 QL (1/28); NDS

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

phenelzine 3pimozide 3protriptyline 4quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 QL (90/30)

quetiapine oral tablet 300 mg, 400 mg

2 QL (60/30)

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg

3 QL (30/30)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg

3 QL (60/30)

ramelteon 3REXULTI 5 QL (30/30); NDSRISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML

4 QL (2/28)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 50 MG/2 ML

5 QL (2/28); NDS

risperidone oral solution 2 QL (240/30)risperidone oral tablet 2risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg

3 QL (60/30)

risperidone oral tablet,disintegrating 0.5 mg, 4 mg

3 QL (120/30)

SAPHRIS 4 QL (60/30)SECUADO 4 QL (30/30)sertraline oral concentrate 2 QL (300/30)sertraline oral tablet 100 mg, 25 mg

2 QL (60/30)

sertraline oral tablet 50 mg 2 QL (120/30)SILENOR 3 QL (30/30)temazepam oral capsule 15 mg, 30 mg

2 QL (60/365)

temazepam oral capsule 22.5 mg, 7.5 mg

3 QL (60/365)

thioridazine 3thiothixene 4

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bumetanide oral 2BYSTOLIC 3candesartan oral tablet 16 mg, 4 mg, 8 mg

1 QL (60/30)

candesartan oral tablet 32 mg 1 QL (30/30)candesartan-hydrochlorothiazid 1cartia xt 2carvedilol 1carvedilol phosphate 3chlorothiazide 2chlorothiazide sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

clonidine hcl oral tablet 0.1 mg, 0.2 mg

1

clonidine hcl oral tablet 0.3 mg 2clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr

3 QL (4/28)

clonidine transdermal patch weekly 0.3 mg/24 hr

3 QL (8/28)

DEMSER 5 PA; NDSdiltiazem hcl intravenous 4diltiazem hcl oral capsule,extended release 12 hr

2

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 2doxazosin 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amiodarone oral 2dofetilide 3flecainide 2lidocaine (pf) intravenous syringe

4

mexiletine 2MULTAQ 3 QL (60/30)pacerone oral tablet 100 mg, 200 mg, 400 mg

2

propafenone oral capsule,extended release 12 hr

4

propafenone oral tablet 2quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2aliskiren 4 QL (30/30)amiloride 2amiloride-hydrochlorothiazide 2amlodipine 1amlodipine-benazepril 1amlodipine-valsartan 1amlodipine-valsartan-hcthiazid 1atenolol 1atenolol-chlorthalidone 1benazepril 1benazepril-hydrochlorothiazide 1betaxolol oral 2BIDIL 3 QL (180/30)bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nicardipine intravenous solution 4nicardipine oral 2nifedipine oral tablet extended release

2 QL (60/30)

nifedipine oral tablet extended release 24hr

2 QL (60/30)

nimodipine 4nisoldipine 4olmesartan 1olmesartan-hydrochlorothiazide 1perindopril erbumine 1phenoxybenzamine 5 NDSpindolol 1prazosin 3propranolol oral capsule,extended release 24 hr

3

propranolol oral solution 2propranolol oral tablet 1propranolol-hydrochlorothiazid 2quinapril 1quinapril-hydrochlorothiazide 1ramipril 1REMODULIN 5 B/D PA; NDSspironolactone 1spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

2

TEKTURNA HCT 4 QL (30/30)telmisartan oral tablet 20 mg, 40 mg

1 QL (30/30)

telmisartan oral tablet 80 mg 1 QL (60/30)telmisartan-amlodipine 1 QL (30/30)telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg

1 QL (30/30)

telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg

1 QL (60/30)

terazosin 1timolol maleate oral 4torsemide oral 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EDARBI 4 ST; QL (30/30)EDARBYCLOR 4 STenalapril maleate 1enalapril-hydrochlorothiazide 1ethacrynate sodium 4felodipine 2fosinopril 1 QL (60/30)fosinopril-hydrochlorothiazide 1 QL (120/30)furosemide injection 2furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 1irbesartan oral tablet 150 mg 1 QL (60/30)irbesartan oral tablet 300 mg, 75 mg

1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)isradipine 3labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 2methyldopa 4metolazone 2metoprolol succinate 1metoprolol ta-hydrochlorothiaz 2metoprolol tartrate oral 1minoxidil oral 2moexipril 1nadolol 3nadolol-bendroflumethiazide oral tablet 80-5 mg

3

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enoxaparin subcutaneous syringe 100 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

3

enoxaparin subcutaneous syringe 120 mg/0.8 ml, 150 mg/ml

4

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

4

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4

HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML

4

jantoven 1pentoxifylline 2PRADAXA 4 QL (60/30)prasugrel 4 QL (30/30)PROMACTA ORAL POWDER IN PACKET

5 PA; QL (360/30); NDS

PROMACTA ORAL TABLET 5 PA; QL (30/30); NDS

warfarin 1XARELTO 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trandolapril 1treprostinil sodium 5 B/D PA; NDStriamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 5 PA; NDSvalsartan oral tablet 160 mg, 40 mg, 80 mg

1 QL (60/30)

valsartan oral tablet 320 mg 1 QL (30/30)valsartan-hydrochlorothiazide 1 QL (30/30)verapamil intravenous solution 4verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2

VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG

3

verapamil oral tablet 1verapamil oral tablet extended release

2

COAGULATION THERAPYaminocaproic acid oral 4aspirin-dipyridamole 4 QL (60/30)BRILINTA 3 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 2 QL (2/365)clopidogrel oral tablet 75 mg 2COUMADIN ORAL 4dipyridamole oral 3 PAELIQUIS 3ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin subcutaneous solution

3

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

simvastatin oral tablet 1 QL (30/30)VASCEPA ORAL CAPSULE 0.5 GRAM

3 QL (240/30)

VASCEPA ORAL CAPSULE 1 GRAM

3 QL (120/30)

MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PA; QL (60/30)digitek 2digox 2digoxin oral solution 50 mcg/ml (0.05 mg/ml)

3 QL (150/30)

digoxin oral tablet 2ENTRESTO 3 QL (60/30)ranolazine 4 QL (60/30)NITRATESisosorbide dinitrate oral tablet 3isosorbide mononitrate 2minitran 2nitroglycerin intravenous 4 B/D PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual spray,non-aerosol

4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3calcipotriene topical cream 4 QL (120/30)calcipotriene topical ointment 4 QL (120/30)calcitriol topical 4selenium sulfide topical lotion 2SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA; QL (2/28); NDS

STELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

atorvastatin oral tablet 40 mg 1 QL (60/30)cholestyramine (with sugar) 2cholestyramine light 2colesevelam 3colestipol 3ezetimibe 2 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 130 mg, 43 mg

4

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral capsule 4fenofibrate oral tablet 160 mg, 54 mg

2

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg

4 QL (30/30)

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg

4 QL (60/30)

gemfibrozil 2LIVALO 3 QL (30/30)lovastatin 1 QL (60/30)niacin oral tablet 500 mg 2niacin oral tablet extended release 24 hr

2

niacor 2omega-3 acid ethyl esters 4 QL (120/30)pravastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

pravastatin oral tablet 40 mg 1 QL (60/30)prevalite 2REPATHA 3 PA; QL (3/28)REPATHA PUSHTRONEX 3 PA; QL (3.5/28)REPATHA SURECLICK 3 PA; QL (3/28)rosuvastatin 1 QL (30/30)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REGRANEX 5 PA; NDSSANTYL 3silver sulfadiazine 3ssd 3tacrolimus topical 3 QL (100/90)TOLAK 4VALCHLOR 5 PA; QL (60/30);

NDSZTLIDO 4 PA; QL (90/30)THERAPY FOR ACNEamnesteem 4avita 4 PAclaravis 4clindacin etz topical swab 2clindacin p 2clindamycin phosphate topical gel

3

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

3

clindamycin phosphate topical lotion

4

clindamycin phosphate topical solution

3

clindamycin phosphate topical swab

2

ery pads 3erythromycin with ethanol topical gel

3

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4isotretinoin 4metronidazole topical 3myorisan 4rosadan topical cream 3rosadan topical gel 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MISCELLANEOUS DERMATOLOGICALSacyclovir topical cream 5 QL (5/30); NDSacyclovir topical ointment 4 QL (30/30)ammonium lactate 2DENAVIR 5 QL (5/30); NDSDUPIXENT 5 PA; NDSfluorouracil topical cream 0.5% 5 NDSfluorouracil topical cream 5% 3fluorouracil topical solution 2glydo 3 QL (60/30)imiquimod topical cream in metered-dose pump

5 NDS

imiquimod topical cream in packet

3

lidocaine (pf) injection solution 4lidocaine hcl injection solution 4lidocaine hcl laryngotracheal 2lidocaine hcl mucous membrane jelly

3 QL (60/30)

lidocaine hcl mucous membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

2

lidocaine topical adhesive patch,medicated 5%

4 PA; QL (90/30)

lidocaine topical ointment 4 QL (50/30)lidocaine viscous 1lidocaine-prilocaine topical cream

4 QL (30/30)

methoxsalen 4PANRETIN 5 NDSPICATO TOPICAL GEL 0.015% 4 QL (3/56)PICATO TOPICAL GEL 0.05% 4 QL (2/56)pimecrolimus 4 QL (100/90)podofilox 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TOPICAL CORTICOSTEROIDSala-cort topical cream 1% 1alclometasone 2betamethasone dipropionate 3betamethasone valerate topical cream

2

betamethasone valerate topical foam

3

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented 2clobetasol scalp 2 QL (100/28)clobetasol topical cream 2 QL (120/28)clobetasol topical foam 4 QL (100/28)clobetasol topical gel 2 QL (120/28)clobetasol topical ointment 2 QL (120/28)clobetasol topical shampoo 4 QL (236/28)clobetasol-emollient topical cream

2 QL (120/28)

clobetasol-emollient topical foam

4

CLOCORTOLONE PIVALATE 4clodan 4 QL (236/28)desonide 3desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone and shower cap 3fluocinolone topical cream 2fluocinolone topical oil 3fluocinolone topical ointment 2fluocinolone topical solution 2fluocinonide topical cream 0.05%

2

fluocinonide topical cream 0.1% 4fluocinonide topical gel 2 QL (120/30)fluocinonide topical ointment 3 QL (120/30)fluocinonide topical solution 3 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tazarotene 4TAZORAC TOPICAL CREAM 4TAZORAC TOPICAL GEL 4 QL (100/30)tretinoin microspheres 4 PAtretinoin topical cream 0.025%, 0.05%, 0.1%

4 PA

tretinoin topical topical gel 0.01%

3 PA

tretinoin topical topical gel 0.025%, 0.05%

4 PA

zenatane 4TOPICAL ANTIBACTERIALSgentamicin topical 3mupirocin 2mupirocin calcium 4sulfacetamide sodium (acne) 3TOPICAL ANTIFUNGALSciclodan topical solution 3ciclopirox topical cream 3 QL (90/28)ciclopirox topical shampoo 3 QL (120/28)ciclopirox topical solution 3ciclopirox topical suspension 3clotrimazole topical cream 2clotrimazole topical solution 2 QL (30/28)clotrimazole-betamethasone topical cream

2 QL (45/28)

clotrimazole-betamethasone topical lotion

2 QL (60/28)

econazole 3 QL (85/28)ketoconazole topical cream 2 QL (60/28)ketoconazole topical shampoo 2 QL (120/28)naftifine topical cream 3 QL (60/28)NAFTIN TOPICAL GEL 3nyamyc 2nystatin topical cream 2 QL (30/28)nystatin topical ointment 2 QL (30/28)nystatin topical powder 2nystatin-triamcinolone 4 QL (60/28)nystop 2

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4PHYSIOLYTE 4PHYSIOSOL IRRIGATION 4ringer’s irrigation 4tis-u-sol pentalyte 4MISCELLANEOUS AGENTSacamprosate 2alendronate oral tablet 40 mg 1 QL (30/30)anagrelide 2ARALAST NP 5 B/D PA; NDSAURYXIA 4 PA; QL (360/30)CARBAGLU 5 PA; NDSCARNITOR INTRAVENOUS 4 B/D PACHEMET 5 NDSCLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10%-0.45% sodium chloride 4 B/D PAd2.5%-0.45% sodium chloride 4 B/D PAd5% and 0.9% sodium chloride 4d5%-0.45% sodium chloride 4dextrose 10% and 0.2% nacl 4 B/D PADEXTROSE 10% IN WATER (D10W)

4 B/D PA

dextrose 20% in water (d20w) 4 B/D PAdextrose 25% in water (d25w) 4 B/D PAdextrose 30% in water (d30w) 4 B/D PAdextrose 40% in water (d40w) 4 B/D PADEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluticasone propionate topical cream

2

fluticasone propionate topical ointment

2

halobetasol propionate topical cream

3

halobetasol propionate topical ointment

3

hydrocortisone butyrate topical cream

4

hydrocortisone butyrate topical ointment

3

hydrocortisone butyrate topical solution

3

hydrocortisone butyr-emollient 4hydrocortisone topical cream 1%, 2.5%

1

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 3hydrocortisone-min oil-wht pet 2mometasone topical 2prednicarbate topical ointment 2triamcinolone acetonide topical cream 0.025%, 0.5%

2

triamcinolone acetonide topical cream 0.1%

1

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment

2

triderm topical cream 0.1% 1TOPICAL SCABICIDES / PEDICULICIDESlindane topical shampoo 3malathion 4permethrin topical cream 2

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sps (with sorbitol) 3trientine 5 QL (240/30); NDSVELPHORO 4 QL (180/30)VELTASSA 3water for irrigation, sterile 4XIAFLEX 5 PA; NDSZEMAIRA 5 B/D PA; NDSzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA; QL (100/365)

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (60/30)CHANTIX 3CHANTIX CONTINUING MONTH BOX

3

CHANTIX STARTING MONTH BOX

3

NICOTROL 4NICOTROL NS 4 QL (30/30)

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (30/25)chlorhexidine gluconate mucous membrane

1

ipratropium bromide nasal spray,non-aerosol 0.03%

2 QL (30/30)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06%)

2 QL (45/30)

oralone 3paroex oral rinse 1triamcinolone acetonide dental 3MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 2flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 2OTIC STEROID / ANTIBIOTICCIPRO HC 3CIPRODEX 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 5%-lactated ringers 4 B/D PAdextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4 B/D PAdextrose 70% in water (d70w) 4dextrose with sodium chloride 4disulfiram 2FERRIPROX 5 PA; NDSINCRELEX 4 PAJADENU 5 NDSJADENU SPRINKLE 5 NDSkionex (with sorbitol) 3levocarnitine (with sugar) 2levocarnitine oral solution 100 mg/ml

2

levocarnitine oral tablet 2LOKELMA 3midodrine 2nitisinone 5 NDSNORTHERA ORAL CAPSULE 100 MG

5 PA; QL (90/30); NDS

NORTHERA ORAL CAPSULE 200 MG, 300 MG

5 PA; QL (180/30); NDS

ORFADIN 5 NDSpilocarpine hcl oral 3PROLASTIN-C 5 B/D PA; NDSRENVELA ORAL POWDER IN PACKET

3 QL (180/30)

RENVELA ORAL TABLET 3 QL (540/30)riluzole 3SEVELAMER CARBONATE ORAL POWDER IN PACKET

4 QL (180/30)

SEVELAMER CARBONATE ORAL TABLET

4 QL (540/30)

sodium chloride 0.9% intravenous

4

sodium chloride irrigation 4sodium phenylbutyrate 5 PA; NDSsodium polystyrene (sorb free) 3sodium polystyrene sulfonate oral

3

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

3

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

1 B/D PA

prednisone oral tablet 50 mg 2 B/D PAprednisone oral tablets,dose pack

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection

2

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg, 25 mg

2 QL (90/30)

acarbose oral tablet 50 mg 2 QL (180/30)ALCOHOL PADS 2BAQSIMI 3BD PEN NEEDLE 2 QL(200/30)BYDUREON BCISE 4 QL (4/28)BYDUREON SUBCUTANEOUS PEN INJECTOR

4 QL (4/28)

CYCLOSET 4 QL (180/30)FARXIGA ORAL TABLET 10 MG

3 QL (30/30)

FARXIGA ORAL TABLET 5 MG 3 QL (60/30)GAUZE PADS 2 X 2 2glimepiride oral tablet 1 mg 1 QL (240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CORTISPORIN-TC 4neomycin-polymyxin-hc otic (ear)

3

ENDOCRINE/DIABETES

ADRENAL HORMONEScortisone 4DEPO-MEDROL 4dexamethasone intensol 4dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg

1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg

2

dexamethasone sodium phos (pf) injection solution

4

dexamethasone sodium phosphate injection solution

4

fludrocortisone 2hydrocortisone oral 3MEDROL ORAL TABLET 2 MG 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

4

methylprednisolone sodium succ intravenous recon soln 1,000 mg

4 QL (8/30)

methylprednisolone sodium succ intravenous recon soln 500 mg

4 QL (12/30)

prednisolone oral solution 15 mg/5 ml

3

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN R U-500 (CONC) INSULIN

3 B/D PA

HUMULIN R U-500 (CONC) KWIKPEN

3

INSULIN PEN NEEDLE 2 QL (200/30)INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

2 QL (200/30)

INVOKAMET 4 QL (60/30)INVOKAMET XR 4 QL (60/30)INVOKANA 4 QL (30/30)JANUMET 3 QL (60/30)JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)JARDIANCE 3 QL (30/30)JENTADUETO 3 QL (60/30)JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

3 QL (60/30)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG

3 QL (30/30)

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN 3LEVEMIR FLEXTOUCH U-100 INSULN

3

LEVEMIR U-100 INSULIN 3metformin oral tablet 1,000 mg 1 QL (75/30)metformin oral tablet 500 mg 1 QL (150/30)metformin oral tablet 850 mg 1 QL (90/30)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (120/30)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (60/30)

metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet)

1 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glimepiride oral tablet 2 mg 1 QL (120/30)glimepiride oral tablet 4 mg 1 QL (60/30)glipizide oral tablet 10 mg 1 QL (120/30)glipizide oral tablet 5 mg 1 QL (240/30)glipizide oral tablet extended release 24hr 10 mg

1 QL (60/30)

glipizide oral tablet extended release 24hr 2.5 mg

1 QL (240/30)

glipizide oral tablet extended release 24hr 5 mg

1 QL (120/30)

glipizide-metformin oral tablet 2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

GLYXAMBI 3 QL (30/30)GVOKE SYRINGE 3HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN INSULIN

3

HUMALOG MIX 50-50 INSULN U-100

3

HUMALOG MIX 50-50 KWIKPEN

3

HUMALOG MIX 75-25 KWIKPEN

3

HUMALOG MIX 75-25(U-100)INSULN

3

HUMALOG U-100 INSULIN 3HUMULIN 70/30 U-100 INSULIN

3

HUMULIN 70/30 U-100 KWIKPEN

3

HUMULIN N NPH INSULIN KWIKPEN

3

HUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRADJENTA 3 QL (30/30)TRESIBA FLEXTOUCH U-100 3TRESIBA FLEXTOUCH U-200 3TRESIBA U-100 INSULIN 3TRULICITY 3 QL (2/28)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 2-PAK 3 QL (9/30)VICTOZA 3-PAK 3 QL (9/30)XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG

3 QL (30/30)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

3 QL (60/30)

XULTOPHY 100/3.6 3 ST; QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDSANADROL-50 5 PA; NDScabergoline 3calcitonin (salmon) 3calcitriol intravenous solution 1 mcg/ml

4

calcitriol oral 2CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 B/D PA; NDS

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA

danazol 4desmopressin injection 4desmopressin nasal spray with pump

4

desmopressin nasal spray,non-aerosol

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

miglitol 4 QL (90/30)nateglinide oral tablet 120 mg 1 QL (90/30)nateglinide oral tablet 60 mg 1 QL (180/30)NEEDLES, INSULIN DISP.,SAFETY

2 QL (200/30)

NOVOFINE PEN NEEDLE 2 QL(200/30)NOVOTWIST PEN NEEDLE 2 QL(200/30)OMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC 3 QL (3/28)pioglitazone oral tablet 15 mg 1 QL (90/30)pioglitazone oral tablet 30 mg, 45 mg

1 QL (30/30)

pioglitazone-metformin 1 QL (90/30)PROGLYCEM 4repaglinide oral tablet 0.5 mg, 1 mg

1 QL (120/30)

repaglinide oral tablet 2 mg 1 QL (240/30)RIOMET 3 QL (750/30)SOLIQUA 100/33 3 ST; QL (18/30)SYMLINPEN 120 5 PA; QL (10.8/28);

NDSSYMLINPEN 60 5 PA; QL (6/30); NDSSYNJARDY 3 QL (60/30)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

3 QL (60/30)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG

3 QL (30/30)

TECHLITE PEN NEEDLE 2 QL(200/30)TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

testosterone enanthate 4testosterone transdermal gel 4 PA; QL (300/30)testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram)

4 PA; QL (300/30)

zoledronic acid intravenous solution

4 B/D PA; QL (15/21)

THYROID HORMONESlevothyroxine oral 1levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg

3

LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

liothyronine oral 2SYNTHROID 3THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

unithroid oral tablet 137 mcg 3

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICSatropine injection solution 0.4 mg/ml

4

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

4

dicyclomine oral capsule 1dicyclomine oral solution 3dicyclomine oral tablet 1diphenoxylate-atropine oral liquid

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

desmopressin oral 3doxercalciferol intravenous 4doxercalciferol oral capsule 0.5 mcg

4 QL (90/30)

doxercalciferol oral capsule 1 mcg

4 QL (240/30)

doxercalciferol oral capsule 2.5 mcg

4 QL (120/30)

ELAPRASE 5 PA; NDSFABRAZYME 5 B/D PA; NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSMIACALCIN INJECTION 5 NDSmiglustat 5 QL (90/30); NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; QL (2/28); NDSoxandrolone oral tablet 10 mg 4 PA; QL (60/30)oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30)pamidronate 4 B/D PAparicalcitol oral capsule 1 mcg, 2 mcg

2

paricalcitol oral capsule 4 mcg 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

SENSIPAR ORAL TABLET 30 MG, 60 MG

4 QL (60/30)

SENSIPAR ORAL TABLET 90 MG

4 QL (120/30)

SOMAVERT 5 PA; QL (30/30); NDS

STIMATE 5 NDSSYNAREL 5 PA; NDStestosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml)

3

TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML

3

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gavilyte-g 2gavilyte-n 2generlac 2granisetron (pf) intravenous solution 1 mg/ml (1 ml)

4 B/D PA

granisetron hcl intravenous 4 B/D PAgranisetron hcl oral 3 B/D PA; QL (30/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

1

lactulose oral solution 2LINZESS 3 QL (30/30)meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule,extended release 24hr

3 QL (120/30)

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4 QL (120/30)

mesalamine rectal enema 4mesalamine with cleansing wipe

4

metoclopramide hcl injection solution

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2OCALIVA 5 PA; QL (30/30);

NDSondansetron 1 B/D PAondansetron hcl (pf) 4ondansetron hcl intravenous 4ondansetron hcl oral solution 3 B/D PA; QL

(450/30)ondansetron hcl oral tablet 1 B/D PAOSMOPREP 4palonosetron intravenous solution 0.25 mg/5 ml

5 B/D PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diphenoxylate-atropine oral tablet

2

GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate injection 4glycopyrrolate oral 2loperamide oral capsule 2propantheline 4MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron oral tablet 0.5 mg 4 PA; QL (60/30)alosetron oral tablet 1 mg 5 PA; QL (60/30);

NDSAMITIZA 3 QL (60/30)aprepitant 4 B/D PAAPRISO 3 QL (120/30)balsalazide 4budesonide oral capsule,delayed,extend.release

4

budesonide oral tablet,delayed and ext.release

5 NDS

colocort 3compro 2constulose 2CREON 3cromolyn oral 3CYSTADANE 5 NDSdronabinol 4 PA; QL (60/30)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 2GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ULCER THERAPYCARAFATE ORAL SUSPENSION

4

esomeprazole magnesium 3 QL (60/30)famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

3 QL (60/30)

misoprostol 3nizatidine oral capsule 2omeprazole oral capsule,delayed release(dr/ec)

2 QL (60/30)

pantoprazole oral 1 QL (60/30)ranitidine hcl oral syrup 2ranitidine hcl oral tablet 150 mg, 300 mg

2

sucralfate oral suspension 4sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA; NDSARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML

5 PA; QL (4/28); NDS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML

4 PA; QL (4/28)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML

4 PA; QL (1.6/28)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML

5 PA; QL (2/28); NDS


5 PA; QL (1.2/28); NDS


5 PA; QL (1.6/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte 2PENTASA 3PLENVU 4prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 2procto-pak 2proctosol hc topical 2proctozone-hc 2RECTIV 4 QL (30/30)RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

RENFLEXIS 5 PA; NDSSANCUSO 5 QL (4/28); NDSscopolamine base 4 QL (10/30)sulfasalazine 2SUPREP BOWEL PREP KIT 3trilyte with flavor packets 2TRULANCE 4ursodiol 3VIBERZI 4 PA; QL (60/30)VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT

4

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT

5 NDS

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

3

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LEUKINE INJECTION RECON SOLN

5 PA; NDS

MOZOBIL 5 QL (9.6/30); NDSREBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDSREBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

5 PA; QL (6/28); NDS

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; QL (8.4/365); NDS

REBIF TITRATION PACK 5 PA; QL (8.4/365); NDS

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4 PA; QL (12/28)

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

5 PA; QL (6/28); NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5 PA; QL (4/28); NDS

ZARXIO 5 PA; NDSZIEXTENZO 5 PA; NDSVACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3 QL (0.5/365)

ATGAM 4 PABCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3 QL (0.5/365)BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (8/365)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


4 PA; QL (1.68/28)


5 PA; QL (2.4/28); NDS

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML

5 PA; QL (1/21); NDS


4 PA; QL (1.2/28)

ARCALYST 5 PA; NDSAVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA; QL (1/28); NDS

BETASERON SUBCUTANEOUS KIT

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA; NDS

INTRON A INJECTION RECON SOLN

5 NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STAMARIL (PF) 3 QL (1/999)TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 QL (0.5/28)

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3 QL (1/365)VARIZIG INTRAMUSCULAR SOLUTION

4 QL (12/30)

YF-VAX (PF) 3ZOSTAVAX (PF) 3 QL (1/999)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral capsule 3 QL (60/30)colchicine oral tablet 4 QL (120/30)FEBUXOSTAT 3 ST; QL (30/30)MITIGARE 3 QL (60/30)probenecid 2probenecid-colchicine 2OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

BINOSTO 4FORTEO 5 PA; QL (2.4/28);

NDSibandronate oral 1 QL (1/28)PROLIA 4 QL (1/180)raloxifene 2 QL (30/30)risedronate oral tablet 150 mg 3 QL (1/30)risedronate oral tablet 30 mg, 5 mg

3 QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

fomepizole 5 NDSGAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%)

5 B/D PA; NDS

GAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 3 QL (1.5/365)HAVRIX (PF) 3HIBERIX (PF) 3HIZENTRA 5 B/D PA; NDSIMOVAX RABIES VACCINE (PF)

3 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3IXIARO (PF) 3KINRIX (PF) 3MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3 QL (2/365)PEDIARIX (PF) 3PEDVAX HIB (PF) 3PROQUAD (PF) 3 QL (2/365)QUADRACEL (PF) 3RABAVERT (PF) 3 B/D PARECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

3 B/D PA; QL (3/365)

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

3 B/D PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

ROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 3 QL (2/999)

59



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML

5 PA; QL (2/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

leflunomide 2ORENCIA 5 PA; QL (4/28); NDSORENCIA CLICKJECT 5 PA; QL (4/28); NDSpenicillamine oral capsule 5 NDSRIDAURA 4RINVOQ 5 PA; QL (30/30);

NDSXELJANZ 5 PA; QL (60/30);

NDSXELJANZ XR 5 PA; QL (30/30);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINSALORA 3 PA; QL (8/28)camila 2deblitane 2DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

4

DEPO-ESTRADIOL 4DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

4 QL (10/28)

dotti 2 PA; QL (8/28)DUAVEE 4 PA; QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)

3 QL (4/28)

TYMLOS 5 PA; QL (1.56/30); NDS

OTHER RHEUMATOLOGICALSBENLYSTA INTRAVENOUS RECON SOLN 120 MG

5 PA; QL (30/28); NDS

BENLYSTA INTRAVENOUS RECON SOLN 400 MG

5 PA; QL (9/28); NDS

DEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

5 PA; QL (4.08/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDSHUMIRA PEN 5 PA; QL (4/28); NDSHUMIRA PEN CROHNS-UC-HS START

5 PA; QL (12/365); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (8/365); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML

5 PA; QL (2/28); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (6/365); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (4/365); NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (6/365); NDS

60


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vandazole 3ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 2alyacen 7/7/7 (28) 2amethia 2amethia lo 2amethyst (28) 2apri 2aranelle (28) 2ashlyna 2aubra 2aubra eq 2aurovela 1.5/30 (21) 2aurovela 1/20 (21) 2aurovela 24 fe 2aurovela fe 1.5/30 (28) 2aurovela fe 1-20 (28) 2aviane 2ayuna 2azurette (28) 2balziva (28) 2bekyree (28) 2blisovi 24 fe 2blisovi fe 1.5/30 (28) 2blisovi fe 1/20 (28) 2briellyn 2camrese 2camrese lo 2caziant (28) 2chateal (28) 2chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 2cyred 2cyred eq 2dasetta 1/35 (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

errin 2estradiol oral 2 PAestradiol transdermal patch semiweekly

2 PA; QL (8/28)

estradiol transdermal patch weekly

2 PA; QL (4/28)

estradiol vaginal cream 4estradiol vaginal tablet 4 QL (18/28)estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

ESTRING 4 QL (1/90)fyavolv 3 PAheather 2hydroxyprogesterone caproate 5 PA; NDSincassia 2jencycla 2lyza 2medroxyprogesterone intramuscular suspension

4

medroxyprogesterone intramuscular syringe

2

medroxyprogesterone oral 1MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3 PA

MENOSTAR 3 PA; QL (4/28)nora-be 2norethindrone (contraceptive) 2norethindrone acetate 2norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg

3 PA

PREMARIN INJECTION 4PREMARIN ORAL 3 PAPREMARIN VAGINAL 3progesterone micronized 2sharobel 2yuvafem 4 QL (18/28)MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 3metronidazole vaginal 3terconazole 3tranexamic acid oral 3

61



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

kurvelo (28) 2l norgest/e.estradiol-e.estrad 2larin 1.5/30 (21) 2larin 1/20 (21) 2larin 24 fe 2larin fe 1.5/30 (28) 2larin fe 1/20 (28) 2larissia 2layolis fe 2leena 28 2lessina 2levonest (28) 2levonorgestrel-ethinyl estrad 2levonorg-eth estrad triphasic 2levora-28 2lillow (28) 2loryna (28) 2low-ogestrel (28) 2lo-zumandimine (28) 2lutera (28) 2marlissa (28) 2melodetta 24 fe 2mibelas 24 fe 2microgestin 1.5/30 (21) 2microgestin 1/20 (21) 2microgestin fe 1.5/30 (28) 2microgestin fe 1/20 (28) 2mili 2mono-linyah 2necon 0.5/35 (28) 2nikki (28) 2noreth-ethinyl estradiol-iron 2norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dasetta 7/7/7 (28) 2daysee 2desog-e.estradiol/e.estradiol 2desogestrel-ethinyl estradiol 2drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 2ELLA 3emoquette 2enpresse 2enskyce 2estarylla 2ethynodiol diac-eth estradiol 2falmina (28) 2fayosim 2femynor 2gianvi (28) 2hailey 2hailey 24 fe 2introvale 2isibloom 2jasmiel (28) 2jolessa 2juleber 2junel 1.5/30 (21) 2junel 1/20 (21) 2junel fe 1.5/30 (28) 2junel fe 1/20 (28) 2junel fe 24 2kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 2

62


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-previfem (28) 2tri-sprintec (28) 2trivora (28) 2tri-vylibra 2tri-vylibra lo 2tydemy 2velivet triphasic regimen (28) 2vienva 2viorele (28) 2vyfemla (28) 2vylibra 2wera (28) 2wymzya fe 2zarah 2zovia 1/35e (28) 2zumandimine (28) 2

OPHTHALMOLOGY

ANTIBIOTICSak-poly-bac 2AZASITE 3bacitracin ophthalmic (eye) 2bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye)

2

erythromycin ophthalmic (eye) 2gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

2

moxifloxacin ophthalmic (eye) drops

3

NATACYN 3neomycin-bacitracin-polymyxin 2neomycin-polymyxin-gramicidin 2neo-polycin 2ofloxacin ophthalmic (eye) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

2

norethindrone-e.estradiol-iron oral tablet,chewable

2

norgestimate-ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 (21) 2nortrel 1/35 (28) 2nortrel 7/7/7 (28) 2ocella 2ogestrel (28) 3orsythia 2philith 2pimtrea (28) 2pirmella 2portia 28 2previfem 2reclipsen (28) 2rivelsa 2setlakin 2simliya (28) 2simpesse 2sprintec (28) 2sronyx 2syeda 2tarina 24 fe 2tarina fe 1/20 (28) 2tarina fe 1-20 eq (28) 2tilia fe 2tri femynor 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 2

63



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RESTASIS MULTIDOSE 3 QL (11/30)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2XIIDRA 3 QL (60/30)NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 3bimatoprost ophthalmic (eye) 2 QL (5/30)COMBIGAN 3dorzolamide 2dorzolamide-timolol 2latanoprost 2LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

3

RHOPRESSA 4 STROCKLATAN 4 STSIMBRINZA 4TRAVATAN Z 3travoprost 3ZIOPTAN (PF) 4 QL (30/30)STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 3neomycin-polymyxin b-dexameth

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ofloxacin otic (ear) 2polycin 2polymyxin b sulf-trimethoprim 2tobramycin 2TOBREX OPHTHALMIC (EYE) OINTMENT

4

ANTIVIRALStrifluridine 3ZIRGAN 3BETA-BLOCKERSbetaxolol ophthalmic (eye) 3carteolol 2levobunolol ophthalmic (eye) drops 0.5%

1

timolol maleate ophthalmic (eye) drops

1

TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION

4

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3azelastine ophthalmic (eye) 2BLEPHAMIDE 3BLEPHAMIDE S.O.P. 3cromolyn ophthalmic (eye) 2CYSTARAN 5 PA; QL (60/28);

NDSepinastine 3EYLEA 5 PA; NDSLACRISERT 4olopatadine ophthalmic (eye) 3PAZEO 3PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

3

RESTASIS 3 QL (60/30)

64


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levocetirizine oral tablet 2 QL (120/30)phenadoz rectal suppository 12.5 mg

4

promethazine oral 2 PApromethazine rectal suppository 12.5 mg, 25 mg

4

promethegan rectal suppository 25 mg, 50 mg

4

PULMONARY AGENTSacetylcysteine 3 B/D PAADEMPAS 5 PA; QL (90/30);

NDSADVAIR DISKUS 3 QL (60/30)ADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair)

4 QL (17/30)

ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL)

4 QL (13.4/30)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin)

4 QL (36/30)

albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 3albuterol sulfate oral tablet extended release 12 hr

2

ambrisentan 5 PA; QL (30/30); NDS

ANORO ELLIPTA 3 QL (60/30)ARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)bosentan 5 PA; QL (60/30);

NDSBREO ELLIPTA 3 QL (60/30)BROVANA 4 B/D PAbudesonide inhalation 4 B/D PACINRYZE 5 PA; QL (20/30);

NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

neomycin-polymyxin-hc ophthalmic (eye)

2

neo-polycin hc 3PRED-G 3PRED-G S.O.P. 3TOBRADEX OPHTHALMIC (EYE) OINTMENT

3

tobramycin-dexamethasone 3ZYLET 3STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

fluorometholone 3INVELTYS 4LOTEMAX 4LOTEMAX SM 4PRED MILD 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic (eye)

1

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

4

apraclonidine 3brimonidine ophthalmic (eye) drops 0.15%

3

brimonidine ophthalmic (eye) drops 0.2%

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 2diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector

2 QL (2/30)

EPIPEN 3 QL (2/30)EPIPEN 2-PAK 3 QL (2/30)EPIPEN JR 3 QL (2/30)EPIPEN JR 2-PAK 3 QL (2/30)hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4 QL (300/30)

65



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levalbuterol tartrate 3 QL (30/30)metaproterenol oral syrup 3mometasone nasal 3 QL (34/30)montelukast oral granules in packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)montelukast oral tablet,chewable

2 QL (30/30)

OFEV 5 PA; QL (60/30); NDS

OPSUMIT 5 PA; QL (30/30); NDS

ORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (120/30); NDS

PERFOROMIST 3 B/D PA; QL (120/30)

PROAIR HFA 3 QL (17/30)PROAIR RESPICLICK 3 QL (2/30)PULMICORT 4 B/D PAPULMOZYME 5 B/D PA; QL

(150/30); NDSRUCONEST 5 PA; QL (8/30); NDSSEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

terbutaline 4THEO-24 4theophylline oral tablet extended release 12 hr

3

theophylline oral tablet extended release 24 hr

3

TRACLEER ORAL TABLET FOR SUSPENSION

5 PA; NDS

TRELEGY ELLIPTA 3 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMBIVENT RESPIMAT 3 QL (8/30)cromolyn inhalation 2 B/D PA; QL

(240/30)DALIRESP 4 PA; QL (30/30)ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDSESBRIET ORAL TABLET 267 MG

5 PA; QL (270/30); NDS

ESBRIET ORAL TABLET 801 MG

5 PA; QL (90/30); NDS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL (60/30)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

3 QL (240/30)

FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION

3 QL (12/30)


3 QL (24/30)


3 QL (10.6/30)

flunisolide nasal spray,non-aerosol 25 mcg (0.025%)

3 QL (50/30)

fluticasone propionate nasal 2 QL (16/30)icatibant 5 PA; QL (18/30);

NDSINCRUSE ELLIPTA 3 QL (30/30)ipratropium bromide inhalation 2 B/D PAipratropium-albuterol 2 B/D PAKALYDECO 5 PA; QL (60/30);

NDSlevalbuterol hcl 4 B/D PA

66


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

K-PHOS ORIGINAL 4potassium citrate 4RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 2klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 1klor-con m20 1lactated ringers intravenous 4 B/D PAMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4 B/D PA

magnesium sulfate in water 4 B/D PAmagnesium sulfate injection 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN 5% DEXTROSE

4 B/D PA

PHOSLYRA 4POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4 B/D PA

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l

4 B/D PA

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4 B/D PA

potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride in lr-d5 4 B/D PApotassium chloride in water intravenous piggyback

4 B/D PA

potassium chloride intravenous 4 B/D PApotassium chloride oral capsule, extended release

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VENTAVIS 5 PA; QL (270/30); NDS

VENTOLIN HFA 4 QL (36/30)XHANCE 4 ST; QL (16/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; QL (6/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE

5 PA; QL (5/28); NDS

XOPENEX 4 B/D PAXOPENEX CONCENTRATE 4 B/D PAYUPELRI 4 B/D PAzafirlukast 3 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSdarifenacin 4flavoxate 2MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG

3 QL (60/30)

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

3 QL (30/30)

oxybutynin chloride oral syrup 1 QL (600/30)oxybutynin chloride oral tablet 1oxybutynin chloride oral tablet extended release 24hr

2 QL (60/30)

solifenacin 2 QL (30/30)tolterodine oral capsule,extended release 24hr

3 QL (30/30)

tolterodine oral tablet 3TOVIAZ 3 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2 QL (30/30)dutasteride 2 QL (30/30)dutasteride-tamsulosin 4 QL (30/30)finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)MISCELLANEOUS UROLOGICALSbethanechol chloride 2CYSTAGON 4ELMIRON 4

67



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15% 4 B/D PAelectrolyte-48 in d5w 4 B/D PAFREAMINE HBC 6.9% 4 B/D PAfreamine iii 10% 4 B/D PAHEPATAMINE 8% 4 B/D PAINTRALIPID INTRAVENOUS EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PANEPHRAMINE 5.4% 4 B/D PANORMOSOL-M IN 5% DEXTROSE

4 B/D PA

NORMOSOL-R PH 7.4 4 B/D PANUTRILIPID 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PAPREMASOL 10% 4 B/D PAPROCALAMINE 3% 4 B/D PAPROSOL 20% 4 B/D PATRAVASOL 10% 4 B/D PATROPHAMINE 10% 4 B/D PATROPHAMINE 6% 4 B/D PAVITAMINS / HEMATINICSfluoride (sodium) oral tablet 1fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

PRENATAL VITAMIN ORAL TABLET

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride oral liquid 4potassium chloride oral packet 2potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45% nacl 4 B/D PAPOTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4 B/D PA

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

4 B/D PA

POTASSIUM CHLORIDE-D5-0.9%NACL

4 B/D PA

ringer’s intravenous 4 B/D PAsodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml)

4

sodium chloride 0.45% intravenous parenteral solution

4

sodium chloride 3% 4sodium chloride 5% 4sodium chloride intravenous 4TPN ELECTROLYTES 4 B/D PAMISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 10% 4 B/D PAAMINOSYN II 15% 4 B/D PAAMINOSYN-PF 10% 4 B/D PAAMINOSYN-PF 7% (SULFITE-FREE)

4 B/D PA

68

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir-lamivudine . . . . . . . . . . . . . . . 20abacavir-lamivudine-zidovudine . . . . 20abacavir oral solution . . . . . . . . . . . . . . 20abacavir oral tablet . . . . . . . . . . . . . . . . 20ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 20ABILIFY MAINTENA . . . . . . . . . . . . . . . 38abiraterone . . . . . . . . . . . . . . . . . . . . . . . . 26ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 26acamprosate . . . . . . . . . . . . . . . . . . . . . . 49acarbose oral tablet 50 mg . . . . . . . . . 51acarbose oral tablet 100 mg, 25 mg . 51acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . 43acetaminophen-codeine oral solution 120-12 mg/5 ml . . . . . . . 35acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml . . . . . . 35acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . 36acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . 36acetazolamide . . . . . . . . . . . . . . . . . . . . . 63acetazolamide sodium . . . . . . . . . . . . . 63acetic acid otic (ear) . . . . . . . . . . . . . . . 50acetylcysteine . . . . . . . . . . . . . . . . . . . . . 64acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 57ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 56acyclovir oral capsule . . . . . . . . . . . . . . 20acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 20acyclovir oral tablet . . . . . . . . . . . . . . . . 20acyclovir sodium intravenous solution . . . . . . . . . . . . . . . 20acyclovir topical cream . . . . . . . . . . . . . 47acyclovir topical ointment . . . . . . . . . . 47ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 57adefovir . . . . . . . . . . . . . . . . . . . . . . . . . . . 20ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 64

ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 64ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 64AFINITOR . . . . . . . . . . . . . . . . . . . . . . . . 26AFINITOR DISPERZ . . . . . . . . . . . . . . . 26afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 60ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 62ala-cort topical cream 1% . . . . . . . . . . 48albendazole . . . . . . . . . . . . . . . . . . . . . . . 23albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair) . . . . . . . . . . . . . . . . . 64ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL) . . . . . 64albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin) . . . . . . . . . . . . . . . 64albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 64albuterol sulfate oral syrup . . . . . . . . . 64albuterol sulfate oral tablet . . . . . . . . . 64albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 64alclometasone . . . . . . . . . . . . . . . . . . . . . 48ALCOHOL PADS . . . . . . . . . . . . . . . . . . 51ALDURAZYME . . . . . . . . . . . . . . . . . . . . 53ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 26alendronate oral tablet 10 mg, 5 mg . 58alendronate oral tablet 35 mg, 70 mg . 58alendronate oral tablet 40 mg . . . . . . 49alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 66ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ALINIA ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 23ALINIA ORAL TABLET . . . . . . . . . . . . . 23ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 26aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ALKERAN . . . . . . . . . . . . . . . . . . . . . . . . 26allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 58ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 59alosetron oral tablet 0.5 mg . . . . . . . . 55

alosetron oral tablet 1 mg . . . . . . . . . . 55ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 64alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 38alprazolam oral tablet 2 mg . . . . . . . . 38alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 38alprazolam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 38altavera (28) . . . . . . . . . . . . . . . . . . . . . . 60ALUNBRIG ORAL TABLET 30 MG . 26ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 26ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 26alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 60alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 60amantadine hcl . . . . . . . . . . . . . . . . . . . . 20AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 20ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 64amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 60amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 60amethyst (28) . . . . . . . . . . . . . . . . . . . . . 60amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml . . . . . . . . 23amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 43amiloride-hydrochlorothiazide . . . . . . 43aminocaproic acid oral . . . . . . . . . . . . . 45AMINOSYN II 10% . . . . . . . . . . . . . . . . 67AMINOSYN II 15% . . . . . . . . . . . . . . . . 67AMINOSYN-PF 7% (SULFITE-FREE) 67AMINOSYN-PF 10% . . . . . . . . . . . . . . . 67amiodarone intravenous solution . . . 42amiodarone oral . . . . . . . . . . . . . . . . . . . 43AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 55amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 38amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 43amlodipine-benazepril . . . . . . . . . . . . . 43amlodipine-valsartan . . . . . . . . . . . . . . . 43amlodipine-valsartan-hcthiazid . . . . . 43

69


Covered Drugs Index

armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 38ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 64ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML . . . . . . . . . . . . . . 26arsenic trioxide intravenous solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 27ascomp with codeine . . . . . . . . . . . . . . 36ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 60aspirin-dipyridamole . . . . . . . . . . . . . . . 45ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 27atazanavir oral capsule 150 mg . . . . . 20atazanavir oral capsule 200 mg . . . . . 20atazanavir oral capsule 300 mg . . . . . 20atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 43atenolol-chlorthalidone . . . . . . . . . . . . . 43ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 57atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 38atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 39atorvastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 46atorvastatin oral tablet 40 mg . . . . . . . 46atovaquone . . . . . . . . . . . . . . . . . . . . . . . 23atovaquone-proguanil . . . . . . . . . . . . . . 23ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 20atropine injection solution 0.4 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . 54atropine injection syringe 0.05 mg/ml, 0.1 mg/ml . . . . . . . . . . . . . 54atropine ophthalmic (eye) drops . . . . 63ATROVENT HFA . . . . . . . . . . . . . . . . . . 64aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 60aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 60aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 60aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 60aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 60aurovela fe 1-20 (28) . . . . . . . . . . . . . . 60AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 49AUSTEDO ORAL TABLET 6 MG . . . 34

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML . . . . . . . . . 56ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML . . . 56ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML . . . . . . . . . . . . . . . . . . 57ARANESP (IN POLYSORBATE) INJECTION SYRINGE 60 MCG/0.3 ML . . . . . . . . . . . . . . . . . . . 57ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML . . . . . . . . . . . . . . . . . . 56ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML . . . . . . . . . . . . . . . . . . 56ARANESP (IN POLYSORBATE) INJECTION SYRINGE 200 MCG/0.4 ML . . . . . . . . . . . . . . . . . . 56ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML . . . . . . . . . . . . . . . . . . 57ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML . 57ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 57ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 23aripiprazole oral solution . . . . . . . . . . . 38aripiprazole oral tablet . . . . . . . . . . . . . 38aripiprazole oral tablet,disintegrating . 38ARISTADA INITIO . . . . . . . . . . . . . . . . . 38ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML . . . . . . . . . 38ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML . . . . . . . . . . . 38ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML . . . . . . . . . . . 38ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML . . . . . . . . . . . 38

ammonium lactate . . . . . . . . . . . . . . . . . 47amnesteem . . . . . . . . . . . . . . . . . . . . . . . 47amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 38amoxicillin oral capsule . . . . . . . . . . . . 25amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 25amoxicillin oral tablet . . . . . . . . . . . . . . 25amoxicillin oral tablet,chewable 125 mg, 250 mg . . . . . . . . . . . . . . . . . . . 25amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 25amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 25amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 25amoxicillin-pot clavulanate oral tablet extended release 12 hr . . 25amphotericin b . . . . . . . . . . . . . . . . . . . . 20ampicillin oral capsule 500 mg . . . . . . 25ampicillin sodium . . . . . . . . . . . . . . . . . . 25ampicillin-sulbactam . . . . . . . . . . . . . . . 25ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 53anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 49anastrozole . . . . . . . . . . . . . . . . . . . . . . . 26ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 64APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 34apraclonidine . . . . . . . . . . . . . . . . . . . . . . 64aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 55apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 55APTIOM ORAL TABLET 200 MG . . . 32APTIOM ORAL TABLET 400 MG . . . 32APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 32APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . 20APTIVUS (WITH VITAMIN E). . . . . . . 20ARALAST NP . . . . . . . . . . . . . . . . . . . . . 49aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 60ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML . . . . . . . . . . 56

70


Covered Drugs Index

BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 57bicalutamide . . . . . . . . . . . . . . . . . . . . . . 27BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 25BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 20bimatoprost ophthalmic (eye) . . . . . . . 63BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 58bisoprolol fumarate . . . . . . . . . . . . . . . . 43bisoprolol-hydrochlorothiazide . . . . . . 43BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 63BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 63blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 60blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 60blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 60BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 57BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 27bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 64BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . 27BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 57BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 27BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 64briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 45brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 64brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 64BRIVIACT ORAL SOLUTION . . . . . . . 32BRIVIACT ORAL TABLET . . . . . . . . . . 32bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 63bromocriptine . . . . . . . . . . . . . . . . . . . . . 34BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 64BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 27budesonide inhalation . . . . . . . . . . . . . . 64budesonide oral capsule, delayed,extend.release . . . . . . . . . . . . 55budesonide oral tablet, delayed and ext.release . . . . . . . . . . . . 55bumetanide injection . . . . . . . . . . . . . . . 43bumetanide oral . . . . . . . . . . . . . . . . . . . 43

BALVERSA ORAL TABLET 4 MG . . . 27BALVERSA ORAL TABLET 5 MG . . . 27balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 60BANZEL ORAL SUSPENSION . . . . . 32BANZEL ORAL TABLET . . . . . . . . . . . 32BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 51BARACLUDE ORAL SOLUTION . . . 20BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 27BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 25BCG VACCINE, LIVE (PF) . . . . . . . . . 57BD PEN NEEDLE . . . . . . . . . . . . . . . . . 51bekyree (28) . . . . . . . . . . . . . . . . . . . . . . 60BELSOMRA ORAL TABLET 5 MG . . 39BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG . . . . . . . . . . . . . 39benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 43benazepril-hydrochlorothiazide . . . . . 43BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 27BENLYSTA INTRAVENOUS RECON SOLN 120 MG . . . . . . . . . . . . 59BENLYSTA INTRAVENOUS RECON SOLN 400 MG . . . . . . . . . . . . 59benztropine injection . . . . . . . . . . . . . . . 34benztropine oral . . . . . . . . . . . . . . . . . . . 34BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 62BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 27betamethasone, augmented . . . . . . . . 48betamethasone dipropionate . . . . . . . 48betamethasone valerate topical cream . . . . . . . . . . . . . . . . . . . . . . 48betamethasone valerate topical foam . . . . . . . . . . . . . . . . . . . . . . . 48betamethasone valerate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 48betamethasone valerate topical ointment . . . . . . . . . . . . . . . . . . . 48BETASERON SUBCUTANEOUS KIT . 57betaxolol ophthalmic (eye) . . . . . . . . . 63betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 43bethanechol chloride . . . . . . . . . . . . . . . 66bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 27

AUSTEDO ORAL TABLET 12 MG, 9 MG . . . . . . . . . . . . . . . . . . . . . . 34AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 27aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47AVONEX INTRAMUSCULAR PEN INJECTOR KIT . . . . . . . . . . . . . . . 57AVONEX INTRAMUSCULAR SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 57ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 27AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 27AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 62azathioprine . . . . . . . . . . . . . . . . . . . . . . . 27azathioprine sodium . . . . . . . . . . . . . . . 27azelastine nasal . . . . . . . . . . . . . . . . . . . 50azelastine ophthalmic (eye) . . . . . . . . 63azithromycin intravenous . . . . . . . . . . . 23azithromycin oral packet . . . . . . . . . . . 23azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack) . . . . . . . . . . . 23azithromycin oral tablet 600 mg . . . . . 23AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 63aztreonam injection recon soln 1 gram . . . . . . . . . . . . . . . . . 23aztreonam injection recon soln 2 gram . . . . . . . . . . . . . . . . . 23azurette (28) . . . . . . . . . . . . . . . . . . . . . . 60

Bbacitracin intramuscular . . . . . . . . . . . . 23bacitracin ophthalmic (eye) . . . . . . . . . 62bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 62baclofen oral tablet 10 mg, 5 mg . . . . 35baclofen oral tablet 20 mg . . . . . . . . . . 35balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 55BALVERSA ORAL TABLET 3 MG . . . 27

71


Covered Drugs Index

carbidopa-levodopa-entacapone . . . . 34carbidopa-levodopa oral tablet . . . . . 34carbidopa-levodopa oral tablet,disintegrating . . . . . . . . . . . . . . . . 34carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . 34CARNITOR INTRAVENOUS . . . . . . . 49carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 63cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 43carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 43carvedilol phosphate . . . . . . . . . . . . . . . 43caspofungin . . . . . . . . . . . . . . . . . . . . . . . 20CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 23caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 60cefaclor oral capsule . . . . . . . . . . . . . . . 22cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . 22cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . 22cefadroxil oral capsule . . . . . . . . . . . . . 22cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 22cefadroxil oral tablet . . . . . . . . . . . . . . . 22cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 22cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . 22CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . 22cefdinir oral capsule . . . . . . . . . . . . . . . 22cefdinir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 22CEFEPIME IN DEXTROSE 5% . . . . . 22cefepime in dextrose,iso-osm . . . . . . 22cefepime injection . . . . . . . . . . . . . . . . . 22cefixime oral capsule . . . . . . . . . . . . . . 22cefixime oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 22cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 22

BYDUREON SUBCUTANEOUS PEN INJECTOR . . . . . . . . . . . . . . . . . . . 51BYSTOLIC . . . . . . . . . . . . . . . . . . . . . . . . 43

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 53CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . . . . . . . . . 27CABOMETYX ORAL TABLET 40 MG . 27calcipotriene scalp . . . . . . . . . . . . . . . . . 46calcipotriene topical cream . . . . . . . . . 46calcipotriene topical ointment . . . . . . . 46calcitonin (salmon) . . . . . . . . . . . . . . . . . 53calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 53calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 53calcitriol topical . . . . . . . . . . . . . . . . . . . . 46calcium acetate(phosphat bind) . . . . . 66CALQUENCE . . . . . . . . . . . . . . . . . . . . . 27camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 60camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 60candesartan-hydrochlorothiazid . . . . 43candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 43candesartan oral tablet 32 mg . . . . . . 43CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . 23CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 39CAPRELSA ORAL TABLET 100 MG . 27CAPRELSA ORAL TABLET 300 MG . 27CARAFATE ORAL SUSPENSION . . 56CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 49carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 32carbamazepine oral suspension 100 mg/5 ml . . . . . . . . . . . 32carbamazepine oral tablet . . . . . . . . . . 32carbamazepine oral tablet,chewable . 32carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 32carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 34

buprenorphine hcl injection solution . 36buprenorphine hcl injection syringe . 36buprenorphine hcl sublingual . . . . . . . 36buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg . . . . . . 37buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 37buprenorphine-naloxone sublingual tablet . . . . . . . . . . . . . . . . . . . 37buprenorphine transdermal patch weekly 7.5 mcg/hour . . . . . . . . . 36BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR . . . . . . . . . . . . . . . . . . . . . 36bupropion hcl oral tablet 75 mg . . . . . 39bupropion hcl oral tablet 100 mg . . . . 39bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . . . . . . . . . . 39bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . . . . . . . . . . 39bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg . . . . . . 39bupropion hcl oral tablet sustained-release 12 hr 150 mg . . . . . . . . . . . . . . 39bupropion hcl (smoking deter) . . . . . . 50buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 39busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 27BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 27butalbital-acetaminop-caf-cod . . . . . . 36butalbital-acetaminophen-caff oral capsule . . . . . . . . . . . . . . . . . . . . . . . 36butalbital-acetaminophen-caff oral tablet 50-325-40 mg . . . . . . . . . . . 36butalbital-aspirin-caffeine oral capsule . . . . . . . . . . . . . . . . . . . . . . . 36butalbital compound w/codeine . . . . . 36butorphanol tartrate injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 37butorphanol tartrate injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 38butorphanol tartrate nasal . . . . . . . . . . 38BYDUREON BCISE . . . . . . . . . . . . . . . 51

72


Covered Drugs Index

clindamycin palmitate hcl . . . . . . . . . . . 23clindamycin pediatric . . . . . . . . . . . . . . 23clindamycin phosphate injection . . . . 24clindamycin phosphate intravenous solution 600 mg/4 ml . . . . . . . . . . . . . . . 24clindamycin phosphate topical gel . . 47CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . . . . 47clindamycin phosphate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 47clindamycin phosphate topical solution . . . . . . . . . . . . . . . . . . . . 47clindamycin phosphate topical swab . . . . . . . . . . . . . . . . . . . . . . . 47clindamycin phosphate vaginal . . . . . 60CLINIMIX 4.25%/D5W SULFIT FREE 49CLINIMIX 4.25%/D10W SULF FREE . 67CLINIMIX 5%/D15W SULFITE FREE 67CLINIMIX 5%-D20W(SULFITE-FREE) 67CLINIMIX E 4.25%/D10W SUL FREE . 67CLINISOL SF 15% . . . . . . . . . . . . . . . . 67clobazam oral suspension . . . . . . . . . . 32clobazam oral tablet 10 mg . . . . . . . . . 32clobazam oral tablet 20 mg . . . . . . . . . 32clobetasol-emollient topical cream . . 48clobetasol-emollient topical foam . . . 48clobetasol scalp . . . . . . . . . . . . . . . . . . . 48clobetasol topical cream . . . . . . . . . . . 48clobetasol topical foam . . . . . . . . . . . . . 48clobetasol topical gel . . . . . . . . . . . . . . 48clobetasol topical ointment . . . . . . . . . 48clobetasol topical shampoo . . . . . . . . 48CLOCORTOLONE PIVALATE . . . . . . 48clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48clomipramine . . . . . . . . . . . . . . . . . . . . . . 39clonazepam oral tablet 0.5 mg, 1 mg . 32clonazepam oral tablet 2 mg . . . . . . . 32clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg . . . . . . . . . 32clonazepam oral tablet, disintegrating 1 mg . . . . . . . . . . . . . . . . 32

chlorpromazine oral . . . . . . . . . . . . . . . . 39chlorthalidone oral tablet 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 43cholestyramine light . . . . . . . . . . . . . . . 46cholestyramine (with sugar) . . . . . . . . 46CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR . . . . . . . 53ciclodan topical solution . . . . . . . . . . . . 48ciclopirox topical cream . . . . . . . . . . . . 48ciclopirox topical shampoo . . . . . . . . . 48ciclopirox topical solution . . . . . . . . . . . 48ciclopirox topical suspension . . . . . . . 48cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 45CILOXAN OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 62CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 20CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 64CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 50ciprofloxacin . . . . . . . . . . . . . . . . . . . . . . . 25ciprofloxacin hcl ophthalmic (eye) . . . 62ciprofloxacin hcl oral tablet 100 mg . 25ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 25ciprofloxacin in 5% dextrose . . . . . . . . 25CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 50citalopram oral solution . . . . . . . . . . . . 39citalopram oral tablet 10 mg . . . . . . . . 39citalopram oral tablet 20 mg . . . . . . . . 39citalopram oral tablet 40 mg . . . . . . . . 39claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 47clarithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23clarithromycin oral tablet . . . . . . . . . . . 23clarithromycin oral tablet extended release 24 hr . . . . . . . . . . . . 23clindacin etz topical swab . . . . . . . . . . 47clindacin p . . . . . . . . . . . . . . . . . . . . . . . . 47clindamycin hcl . . . . . . . . . . . . . . . . . . . . 23CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . 23clindamycin in 5% dextrose . . . . . . . . 23

CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . . . . . . . . . . . . . . 22cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . 22cefoxitin in dextrose, iso-osm . . . . . . . 22cefpodoxime . . . . . . . . . . . . . . . . . . . . . . 22cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 22ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 22CEFTAZIDIME IN D5W . . . . . . . . . . . . 22ceftriaxone in dextrose,iso-os . . . . . . 22ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . 22CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 22ceftriaxone intravenous . . . . . . . . . . . . 22cefuroxime axetil oral tablet . . . . . . . . 22cefuroxime sodium injection recon soln 750 mg . . . . . . . . . . . . . . . . . 22cefuroxime sodium intravenous . . . . . 22celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 38CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 32cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 23cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 53CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 50CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 50CHANTIX STARTING MONTH BOX . 50chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 60chateal eq (28) . . . . . . . . . . . . . . . . . . . . 60CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 49chloramphenicol sod succinate . . . . . 23chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 50chloroquine phosphate . . . . . . . . . . . . . 23chlorothiazide . . . . . . . . . . . . . . . . . . . . . 43chlorothiazide sodium . . . . . . . . . . . . . . 43chlorpromazine injection . . . . . . . . . . . 39

73


Covered Drugs Index

cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 60CYSTADANE . . . . . . . . . . . . . . . . . . . . . 55CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 66CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 63

Dd2.5%-0.45% sodium chloride . . . . . . 49d5%-0.45% sodium chloride . . . . . . . . 49d5% and 0.9% sodium chloride . . . . . 49d10%-0.45% sodium chloride . . . . . . 49dalfampridine . . . . . . . . . . . . . . . . . . . . . . 35DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 65danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 53dantrolene oral . . . . . . . . . . . . . . . . . . . . 35dapsone oral . . . . . . . . . . . . . . . . . . . . . . 24DAPTACEL (DTAP PEDIATRIC) (PF) . . . . . . . . . . . 57DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 24daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 24DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 24darifenacin . . . . . . . . . . . . . . . . . . . . . . . . 66DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 27dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 60dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 61daunorubicin intravenous solution . . 27DAURISMO ORAL TABLET 25 MG . 27DAURISMO ORAL TABLET 100 MG . 27daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 59DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML . . . . . . . . . . . . . . . . . . . . 59DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 20demeclocycline . . . . . . . . . . . . . . . . . . . . 26DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 43DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 47DEPEN TITRATABS . . . . . . . . . . . . . . . 59DEPO-ESTRADIOL . . . . . . . . . . . . . . . 59DEPO-MEDROL . . . . . . . . . . . . . . . . . . 51

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 27COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) 27COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) 27COMPLERA . . . . . . . . . . . . . . . . . . . . . . 20compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 55constulose . . . . . . . . . . . . . . . . . . . . . . . . 55COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML . . . . . . . . . . . . . . 35COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML . . . . . . . . . . . . . . 35COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 27CORLANOR ORAL TABLET . . . . . . . 46cortisone . . . . . . . . . . . . . . . . . . . . . . . . . . 51CORTISPORIN-TC . . . . . . . . . . . . . . . . 51COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 27COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 27COUMADIN ORAL . . . . . . . . . . . . . . . . 45CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 55CRESEMBA ORAL . . . . . . . . . . . . . . . . 20CRIXIVAN ORAL CAPSULE 200 MG . 20CRIXIVAN ORAL CAPSULE 400 MG . 20cromolyn inhalation . . . . . . . . . . . . . . . . 65cromolyn ophthalmic (eye) . . . . . . . . . 63cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 55cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 60cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 60cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 60cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 35cyclophosphamide intravenous . . . . . 27cyclophosphamide oral capsule . . . . 27CYCLOSERINE . . . . . . . . . . . . . . . . . . . 24CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 51cyclosporine intravenous . . . . . . . . . . . 27cyclosporine modified . . . . . . . . . . . . . . 27cyclosporine oral capsule . . . . . . . . . . 27CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 27cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 33clonidine hcl oral tablet 0.1 mg, 0.2 mg . . . . . . . . . . . . . . . . . . . . 43clonidine hcl oral tablet 0.3 mg . . . . . 43clonidine hcl oral tablet extended release 12 hr . . . . . . . . . . . . 39clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr . . 43clonidine transdermal patch weekly 0.3 mg/24 hr . . . . . . . . . . . . . . . 43clopidogrel oral tablet 75 mg . . . . . . . 45clopidogrel oral tablet 300 mg . . . . . . 45clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 39clorazepate dipotassium oral tablet 15 mg, 3.75 mg . . . . . . . . . 39clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 48clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 48clotrimazole mucous membrane . . . . 20clotrimazole topical cream . . . . . . . . . . 48clotrimazole topical solution . . . . . . . . 48clozapine oral tablet . . . . . . . . . . . . . . . 39clozapine oral tablet, disintegrating 12.5 mg, 25 mg . . . . . . 39clozapine oral tablet, disintegrating 100 mg . . . . . . . . . . . . . . 39clozapine oral tablet, disintegrating 150 mg . . . . . . . . . . . . . . 39clozapine oral tablet, disintegrating 200 mg . . . . . . . . . . . . . . 39COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 24colchicine oral capsule . . . . . . . . . . . . . 58colchicine oral tablet . . . . . . . . . . . . . . . 58colesevelam . . . . . . . . . . . . . . . . . . . . . . . 46colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 46colistin (colistimethate na) . . . . . . . . . . 24colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 55COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 63COMBIVENT RESPIMAT . . . . . . . . . . 65

74


Covered Drugs Index

diazepam rectal kit 2.5 mg . . . . . . . . . 33diazepam rectal kit 5-7.5-10 mg . . . . 33diazepam rectal kit 12.5-15-17.5-20 mg . . . . . . . . . . . . . . . . 33diclofenac potassium . . . . . . . . . . . . . . 38diclofenac sodium ophthalmic (eye) . 63diclofenac sodium oral . . . . . . . . . . . . . 38diclofenac sodium topical drops . . . . 38diclofenac sodium topical gel 1% . . . 38dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 25dicyclomine oral capsule . . . . . . . . . . . 54dicyclomine oral solution . . . . . . . . . . . 54dicyclomine oral tablet . . . . . . . . . . . . . 54didanosine oral capsule, delayed release(dr/ec) 200 mg, 250 mg, 400 mg . . . . . . . . . . . 20DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 23diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 38digitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46digox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46digoxin oral solution 50 mcg/ml (0.05 mg/ml) . . . . . . . . . . . . 46digoxin oral tablet . . . . . . . . . . . . . . . . . . 46dihydroergotamine nasal . . . . . . . . . . . 34DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 33diltiazem hcl intravenous . . . . . . . . . . . 43diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 43diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . 43diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg . . 43diltiazem hcl oral tablet . . . . . . . . . . . . . 43diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 43dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . 64diphenoxylate-atropine oral liquid . . . 54diphenoxylate-atropine oral tablet . . . 55

dextroamphetamine-amphetamine oral tablet 10 mg . . . . . . . . . . . . . . . . . . 39dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg . . 39dextroamphetamine-amphetamine oral tablet 15 mg . . . . . . . . . . . . . . . . . . 39dextroamphetamine-amphetamine oral tablet 20 mg . . . . . . . . . . . . . . . . . . 40dextroamphetamine oral capsule, extended release 5 mg . . . . . . . . . . . . . 39dextroamphetamine oral capsule, extended release 10 mg . . . . . . . . . . . 39dextroamphetamine oral capsule, extended release 15 mg . . . . . . . . . . . 39dextroamphetamine oral solution . . . 39dextroamphetamine oral tablet . . . . . 39dextrose 5%-0.2% sod chloride . . . . . 50dextrose 5%-0.3% sod.chloride . . . . . 50DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION . . . . . . . . . 49dextrose 5% in water (d5w) intravenous piggyback . . . . . . . . . . . . . 49dextrose 5%-lactated ringers . . . . . . . 50dextrose 10% and 0.2% nacl . . . . . . . 49DEXTROSE 10% IN WATER (D10W) . . . . . . . . . . . . . . . . 49dextrose 20% in water (d20w) . . . . . . 49dextrose 25% in water (d25w) . . . . . . 49dextrose 30% in water (d30w) . . . . . . 49dextrose 40% in water (d40w) . . . . . . 49dextrose 50% in water (d50w) . . . . . . 50dextrose 70% in water (d70w) . . . . . . 50dextrose with sodium chloride . . . . . . 50DIASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 33DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG . . . . . . . . . . 33DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG . . 33diazepam injection syringe . . . . . . . . . 40diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 40diazepam oral tablet . . . . . . . . . . . . . . . 40

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML. . . . . . . . . 59DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 20desipramine . . . . . . . . . . . . . . . . . . . . . . . 39desloratadine oral tablet . . . . . . . . . . . 64desmopressin injection . . . . . . . . . . . . . 53desmopressin nasal spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 53desmopressin nasal spray with pump . . . . . . . . . . . . . . . . . . . . . . . . . 53desmopressin oral . . . . . . . . . . . . . . . . . 54desog-e.estradiol/e.estradiol . . . . . . . 61desogestrel-ethinyl estradiol . . . . . . . . 61desonide . . . . . . . . . . . . . . . . . . . . . . . . . . 48desoximetasone topical cream . . . . . 48desoximetasone topical gel . . . . . . . . 48desoximetasone topical ointment . . . 48desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg . . . . . . . . . . . . . . . . 39desvenlafaxine succinate oral tablet extended release 24 hr 100 mg . . . . . 39dexamethasone intensol . . . . . . . . . . . 51dexamethasone oral elixir . . . . . . . . . . 51dexamethasone oral solution . . . . . . . 51dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg . . . . . . . . . . . . . 51dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg . . . . . . . . . . 51dexamethasone sodium phos (pf) injection solution . . . . . . . . . . . . . . . 51dexamethasone sodium phosphate injection solution . . . . . . . . 51dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 64dexmethylphenidate oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39dexmethylphenidate oral tablet 10 mg, 2.5 mg . . . . . . . . . . . . . . . . . . . . . 39dextroamphetamine-amphetamine oral capsule,extended release 24hr . 39dextroamphetamine-amphetamine oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 40

75


Covered Drugs Index

ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 66ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 27EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 27EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 55emoquette . . . . . . . . . . . . . . . . . . . . . . . . 61EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 40EMTRIVA ORAL CAPSULE . . . . . . . . 20EMTRIVA ORAL SOLUTION . . . . . . . 20EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 24enalapril-hydrochlorothiazide . . . . . . . 44enalapril maleate . . . . . . . . . . . . . . . . . . 44ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 59ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 59ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) . . . . . . 59ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) . . . . . . . 59ENBREL SURECLICK . . . . . . . . . . . . . 59endocet oral tablet 2.5-325 mg, 5-325 mg . . . . . . . . . . . . . 36endocet oral tablet 7.5-325 mg . . . . . 36endocet oral tablet 10-325 mg . . . . . . 36ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE . . . . . . 58ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 57ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 27enoxaparin subcutaneous solution . . 45enoxaparin subcutaneous syringe 100 mg/ml, 30 mg/0.3 ml, 40 mg/ 0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml . 45enoxaparin subcutaneous syringe 120 mg/0.8 ml, 150 mg/ml . . . . . . . . . . 45enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 61enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 61entacapone . . . . . . . . . . . . . . . . . . . . . . . 34entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 20ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 46enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG . . . . . . . . . 40DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG . . . . . . . . . . . . . . . . . 40dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 55drospirenone-e.estradiol-lm.fa . . . . . . 61drospirenone-ethinyl estradiol . . . . . . 61DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 27DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 59duloxetine oral capsule,delayed release(dr/ec) 20 mg . . . . . . . . . . . . . . . 40duloxetine oral capsule,delayed release(dr/ec) 30 mg . . . . . . . . . . . . . . . 40duloxetine oral capsule,delayed release(dr/ec) 60 mg . . . . . . . . . . . . . . . 40DUPIXENT . . . . . . . . . . . . . . . . . . . . . . . . 47DURAMORPH (PF) . . . . . . . . . . . . . . . . 36dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 66dutasteride-tamsulosin . . . . . . . . . . . . . 66

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 38econazole . . . . . . . . . . . . . . . . . . . . . . . . . 48EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 44EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 44EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 20e.e.s. 400 oral tablet . . . . . . . . . . . . . . . 23efavirenz oral capsule 50 mg . . . . . . . 20efavirenz oral capsule 200 mg . . . . . . 20efavirenz oral tablet . . . . . . . . . . . . . . . . 20ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 54electrolyte-48 in d5w . . . . . . . . . . . . . . . 67ELIGARD . . . . . . . . . . . . . . . . . . . . . . . . . 27ELIGARD (3 MONTH) . . . . . . . . . . . . . 27ELIGARD (4 MONTH) . . . . . . . . . . . . . 27ELIGARD (6 MONTH) . . . . . . . . . . . . . 27elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 45ELIQUIS DVT-PE TREAT 30D START 45

dipyridamole oral . . . . . . . . . . . . . . . . . . 45disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 50divalproex . . . . . . . . . . . . . . . . . . . . . . . . . 33dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 43donepezil oral tablet 5 mg . . . . . . . . . . 35donepezil oral tablet 10 mg . . . . . . . . . 35donepezil oral tablet 23 mg . . . . . . . . . 35donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 35donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 35dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 63dorzolamide-timolol . . . . . . . . . . . . . . . . 63dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 20doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 43doxepin oral capsule . . . . . . . . . . . . . . . 40doxepin oral concentrate . . . . . . . . . . . 40doxepin oral tablet . . . . . . . . . . . . . . . . . 40doxercalciferol intravenous . . . . . . . . . 54doxercalciferol oral capsule 0.5 mcg . . 54doxercalciferol oral capsule 1 mcg . . 54doxercalciferol oral capsule 2.5 mcg . . 54doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 26doxycycline hyclate intravenous . . . . 26doxycycline hyclate oral capsule . . . . 26doxycycline hyclate oral tablet 20 mg . . . . . . . . . . . . . . . . . . 26doxycycline hyclate oral tablet 100 mg . . . . . . . . . . . . . . . . . 26doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . 26DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE . . . . . . . . . . . . . . . . . . . . 26doxycycline monohydrate oral suspension for reconstitution . . . . . . . 26doxycycline monohydrate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 26DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG . . . . . . . . . . . . . . . . . 40

76


Covered Drugs Index

falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 61famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 20famotidine oral tablet 20 mg, 40 mg . . 56FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG . . . . . . . . . . . . . . . . 40FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG . . . . . . . 40FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 40FARXIGA ORAL TABLET 5 MG . . . . 51FARXIGA ORAL TABLET 10 MG . . . 51FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 28FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 28fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 61FEBUXOSTAT . . . . . . . . . . . . . . . . . . . . 58felbamate oral suspension . . . . . . . . . 33felbamate oral tablet . . . . . . . . . . . . . . . 33felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 44femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 61fenofibrate micronized oral capsule 130 mg, 43 mg . . . . . . . . 46fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 46fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 46fenofibrate oral capsule . . . . . . . . . . . . 46fenofibrate oral tablet 160 mg, 54 mg . 46fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg . . . . . . . . . . . . . . . 46fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg . . . . . . . . . . . . . 46fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 36fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg . . . . . . . . . . . . . . . 36fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg . . . . . . . . . . . . . . . . . 36fentanyl citrate (pf) injection solution . 36fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml) . . 36

erythromycin ophthalmic (eye) . . . . . . 62erythromycin oral tablet . . . . . . . . . . . . 23erythromycin oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 23erythromycin with ethanol topical gel . . . . . . . . . . . . . . . . . . . . . . . . . 47erythromycin with ethanol topical solution . . . . . . . . . . . . . . . . . . . . 47ESBRIET ORAL CAPSULE . . . . . . . . 65ESBRIET ORAL TABLET 267 MG . . 65ESBRIET ORAL TABLET 801 MG . . 65escitalopram oxalate oral solution . . 40escitalopram oxalate oral tablet . . . . . 40esomeprazole magnesium . . . . . . . . . 56estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 61estradiol oral . . . . . . . . . . . . . . . . . . . . . . 60estradiol transdermal patch semiweekly . . . . . . . . . . . . . . . . . . . . . . . 60estradiol transdermal patch weekly . 60estradiol vaginal cream . . . . . . . . . . . . 60estradiol vaginal tablet . . . . . . . . . . . . . 60estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml . . . . . . . . . . . . . 60ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 60ethacrynate sodium . . . . . . . . . . . . . . . . 44ethambutol . . . . . . . . . . . . . . . . . . . . . . . . 24ethosuximide . . . . . . . . . . . . . . . . . . . . . . 33ethynodiol diac-eth estradiol . . . . . . . . 61etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 38etoposide intravenous . . . . . . . . . . . . . 28everolimus (antineoplastic) . . . . . . . . . 28EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 28EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 20exemestane . . . . . . . . . . . . . . . . . . . . . . . 28EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 46ezetimibe-simvastatin . . . . . . . . . . . . . . 46

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 54

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG . . . . . . . . . . . . . 28ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 4 MG . . . . . . . . . . . . . . . . . . . . . . . 28EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 20EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 33epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 63epinephrine injection auto-injector . . 64EPIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 64EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 64EPIPEN JR . . . . . . . . . . . . . . . . . . . . . . . 64EPIPEN JR 2-PAK . . . . . . . . . . . . . . . . . 64epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33EPIVIR HBV ORAL SOLUTION . . . . 20ergotamine-caffeine . . . . . . . . . . . . . . . 34ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 28ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 28erlotinib oral tablet 25 mg . . . . . . . . . . 28erlotinib oral tablet 100 mg, 150 mg . . 28errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 24ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 47ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 23ery-tab oral tablet,delayed release (dr/ec) 250 mg . . . . . . . . . . . . . 23ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG, 500 MG . . . . . . . . . 23erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 23ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 23erythromycin-benzoyl peroxide . . . . . 47erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 23erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 23erythromycin ethylsuccinate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 23

77


Covered Drugs Index

fosinopril-hydrochlorothiazide . . . . . . 44FREAMINE HBC 6.9% . . . . . . . . . . . . . 67freamine iii 10% . . . . . . . . . . . . . . . . . . . 67fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 28furosemide injection . . . . . . . . . . . . . . . 44furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 44furosemide oral tablet . . . . . . . . . . . . . . 44FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 21fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60FYCOMPA ORAL SUSPENSION . . . 33FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 33FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 33

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 33gabapentin oral capsule 300 mg . . . . 33gabapentin oral solution . . . . . . . . . . . . 33gabapentin oral tablet 600 mg . . . . . . 33gabapentin oral tablet 800 mg . . . . . . 33galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 35galantamine oral solution . . . . . . . . . . . 35galantamine oral tablet . . . . . . . . . . . . . 35GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/ 100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%) . . . . . . 58GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 58GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 58GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 55GATTEX ONE-VIAL . . . . . . . . . . . . . . . 55GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 51gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 55gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 55gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 55GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 28

fluocinolone topical solution . . . . . . . . 48fluocinonide topical cream 0.1% . . . . 48fluocinonide topical cream 0.05% . . . 48fluocinonide topical gel . . . . . . . . . . . . . 48fluocinonide topical ointment . . . . . . . 48fluocinonide topical solution . . . . . . . . 48fluoride (sodium) oral tablet . . . . . . . . 67fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride) . . . . . . . . . 67fluorometholone . . . . . . . . . . . . . . . . . . . 64fluorouracil topical cream 0.5% . . . . . 47fluorouracil topical cream 5% . . . . . . . 47fluorouracil topical solution . . . . . . . . . 47fluoxetine oral capsule . . . . . . . . . . . . . 40fluoxetine oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 40fluoxetine oral solution . . . . . . . . . . . . . 40fluoxetine oral tablet 10 mg, 20 mg . 40fluphenazine decanoate . . . . . . . . . . . . 40fluphenazine hcl injection . . . . . . . . . . 40fluphenazine hcl oral concentrate . . . 40fluphenazine hcl oral elixir . . . . . . . . . . 40fluphenazine hcl oral tablet . . . . . . . . . 40flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 38flurbiprofen sodium . . . . . . . . . . . . . . . . 63flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 28fluticasone propionate nasal . . . . . . . . 65fluticasone propionate topical cream . 49fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 49fluvoxamine oral tablet . . . . . . . . . . . . . 40FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 28fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 58fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 45fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 45FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 58fosamprenavir . . . . . . . . . . . . . . . . . . . . . 20fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 44

FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 50FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 40FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK. . . . . . . 40finasteride oral tablet 5 mg . . . . . . . . . 66FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 35FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG . . . . . . . . . . . . . 28FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG . . . . . . . . . . . . 28FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 24flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 50flavoxate . . . . . . . . . . . . . . . . . . . . . . . . . . 66flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 43FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . 65FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION . . . . . . . . . . . . 65FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION . . . . 65FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION . . . 65FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION . . 65fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 20fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . 20flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 20fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 28fludrocortisone . . . . . . . . . . . . . . . . . . . . 51flunisolide nasal spray, non-aerosol 25 mcg (0.025%) . . . . . . 65fluocinolone acetonide oil . . . . . . . . . . 50fluocinolone and shower cap . . . . . . . 48fluocinolone topical cream . . . . . . . . . . 48fluocinolone topical oil . . . . . . . . . . . . . 48fluocinolone topical ointment . . . . . . . 48

78


Covered Drugs Index

halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 49halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 49haloperidol decanoate . . . . . . . . . . . . . 40haloperidol lactate injection . . . . . . . . 40haloperidol lactate oral . . . . . . . . . . . . . 40haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg . . . . . . . . . . 40haloperidol oral tablet 10 mg, 20 mg . 40HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 21HAVRIX (PF) . . . . . . . . . . . . . . . . . . . . . . 58heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 60heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml . . . . . . . . . . . . . . . . . 45heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) . . . . . 45heparin (porcine) injection solution . . 45heparin (porcine) in nacl (pf) . . . . . . . . 45heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml . . . . . . . . . . . 45HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML . . . . . . . . . . . . . . . . . . . . 45HEPATAMINE 8% . . . . . . . . . . . . . . . . . 67HERCEPTIN HYLECTA . . . . . . . . . . . . 28HERCEPTIN INTRAVENOUS RECON SOLN 150 MG . . . . . . . . . . . . 28HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 40HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 58HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . . 58HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 52HUMALOG KWIKPEN INSULIN . . . . 52HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 52HUMALOG MIX 50-50 KWIKPEN. . . 52HUMALOG MIX 75-25 KWIKPEN. . . 52

glimepiride oral tablet 1 mg . . . . . . . . . 51glimepiride oral tablet 2 mg . . . . . . . . . 52glimepiride oral tablet 4 mg . . . . . . . . . 52glipizide-metformin oral tablet 2.5-250 mg . . . . . . . . . . . . . . . . . . 52glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg . . . . . . . 52glipizide oral tablet 5 mg . . . . . . . . . . . 52glipizide oral tablet 10 mg . . . . . . . . . . 52glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 52glipizide oral tablet extended release 24hr 5 mg . . . . . . . . . . . . . . . . . 52glipizide oral tablet extended release 24hr 10 mg . . . . . . . . . . . . . . . . 52GLUCAGEN HYPOKIT . . . . . . . . . . . . 52GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 52GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 52glycopyrrolate injection . . . . . . . . . . . . . 55glycopyrrolate oral . . . . . . . . . . . . . . . . . 55GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 55glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . . . . . . . . . . . . . 55glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 52granisetron hcl intravenous . . . . . . . . . 55granisetron hcl oral . . . . . . . . . . . . . . . . 55granisetron (pf) intravenous solution 1 mg/ml (1 ml) . . . . . . . . . . . . . 55griseofulvin microsize . . . . . . . . . . . . . . 20griseofulvin ultramicrosize . . . . . . . . . . 20GUANIDINE . . . . . . . . . . . . . . . . . . . . . . . 40GVOKE SYRINGE . . . . . . . . . . . . . . . . . 52

Hhailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 61HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 28

gemcitabine intravenous recon soln . 28gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) . . . . . . . . . 28GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 28gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 46generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 55gengraf oral capsule 100 mg, 25 mg . 28gengraf oral solution . . . . . . . . . . . . . . . 28GENOTROPIN . . . . . . . . . . . . . . . . . . . . 57GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . 57GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . . 57gentak ophthalmic (eye) ointment . . . 62gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . 24GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 24gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 24gentamicin ophthalmic (eye) drops . . 62gentamicin sulfate (ped) (pf) . . . . . . . . 24gentamicin topical . . . . . . . . . . . . . . . . . 48GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 21GEODON INTRAMUSCULAR . . . . . . 40gianvi (28) . . . . . . . . . . . . . . . . . . . . . . . . 61GILENYA ORAL CAPSULE 0.5 MG . 35GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 28GLEOSTINE ORAL CAPSULE 10 MG, 40 MG . . . . . . . . . . 28GLEOSTINE ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 28

79


Covered Drugs Index

hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 28hydroxyzine hcl oral tablet . . . . . . . . . . 64

Iibandronate oral . . . . . . . . . . . . . . . . . . . 58IBRANCE ORAL CAPSULE . . . . . . . . 28ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ibuprofen oral suspension . . . . . . . . . . 38ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 38ibuprofen-oxycodone . . . . . . . . . . . . . . 36icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 65ICLUSIG ORAL TABLET 15 MG . . . . 28ICLUSIG ORAL TABLET 45 MG . . . . 28IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28imatinib oral tablet 100 mg . . . . . . . . . 28imatinib oral tablet 400 mg . . . . . . . . . 28IMBRUVICA ORAL CAPSULE 70 MG 28IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 28IMBRUVICA ORAL TABLET . . . . . . . . 28IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28imipenem-cilastatin . . . . . . . . . . . . . . . . 24imipramine hcl . . . . . . . . . . . . . . . . . . . . . 40imiquimod topical cream in metered-dose pump . . . . . . . . . . . . . 47imiquimod topical cream in packet . . 47IMOVAX RABIES VACCINE (PF) . . . 58incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 60INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 50INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 65indapamide . . . . . . . . . . . . . . . . . . . . . . . 44INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION . 58INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 28INFUMORPH P/F. . . . . . . . . . . . . . . . . . 36INLYTA ORAL TABLET 1 MG . . . . . . . 28INLYTA ORAL TABLET 5 MG . . . . . . . 28INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 28INSULIN PEN NEEDLE . . . . . . . . . . . . 52

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 36hydrocodone-acetaminophen oral tablet 5-325 mg . . . . . . . . . . . . . . . 36HYDROCODONE- ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG . . . . . . . . . . . 36hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg . . 36hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg . . 36hydrocortisone-acetic acid . . . . . . . . . 50hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 49hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 49hydrocortisone butyrate topical solution . . . . . . . . . . . . . . . . . . . . 49hydrocortisone butyr-emollient . . . . . . 49hydrocortisone-min oil-wht pet . . . . . . 49hydrocortisone oral . . . . . . . . . . . . . . . . 51hydrocortisone rectal . . . . . . . . . . . . . . 55hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 49hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 55hydrocortisone topical lotion 2.5% . . 49hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 49hydrocortisone valerate . . . . . . . . . . . . 49hydromorphone injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . . 36hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml . . . . . . . . . 36hydromorphone oral liquid . . . . . . . . . . 36hydromorphone oral tablet 2 mg, 4 mg . . . . . . . . . . . . . . . . . . . . . . . . 36hydromorphone oral tablet 8 mg . . . . 36hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml . . . . . . . . . . . . . . . . . 36hydroxychloroquine . . . . . . . . . . . . . . . . 24hydroxyprogesterone caproate . . . . . 60

HUMALOG MIX 75-25 (U-100)INSULN . . . . . . . . . . . . . . . . . . . 52HUMALOG U-100 INSULIN . . . . . . . . 52HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML . . . . . . . 59HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML- 40 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 59HUMIRA(CF) PEN CROHNS-UC-HS . 59HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 59HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . 59HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 59HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 59HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 59HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 59HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 59HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML . . 59HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 59HUMULIN 70/30 U-100 INSULIN . . . 52HUMULIN 70/30 U-100 KWIKPEN . . 52HUMULIN N NPH INSULIN KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . . . 52HUMULIN N NPH U-100 INSULIN . . 52HUMULIN R REGULAR U-100 INSULN . . . . . . . . . . . . . . . . . . . . 52HUMULIN R U-500 (CONC) INSULIN . 52HUMULIN R U-500 (CONC) KWIKPEN . . . . . . . . . . . . . . . . 52hydralazine injection . . . . . . . . . . . . . . . 44hydralazine oral . . . . . . . . . . . . . . . . . . . 44hydrochlorothiazide . . . . . . . . . . . . . . . . 44hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml . . . . . 36

80


Covered Drugs Index

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG . . 52JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 52JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 52jasmiel (28) . . . . . . . . . . . . . . . . . . . . . . . 61jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 60JENTADUETO . . . . . . . . . . . . . . . . . . . . 52JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG . 52JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG . . 52jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 21junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 61junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 61junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 61junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . 61junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 61

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 67KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 29kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 61KALETRA ORAL TABLET 100-25 MG 21KALETRA ORAL TABLET 200-50 MG 21kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 65KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 29kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 61kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 61kelnor 1-50 . . . . . . . . . . . . . . . . . . . . . . . . 61ketoconazole oral . . . . . . . . . . . . . . . . . . 20ketoconazole topical cream . . . . . . . . 48ketoconazole topical shampoo . . . . . 48ketorolac ophthalmic (eye) . . . . . . . . . 63KEYTRUDA INTRAVENOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 29KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . 58kionex (with sorbitol) . . . . . . . . . . . . . . . 50

ipratropium bromide inhalation . . . . . 65ipratropium bromide nasal spray, non-aerosol 0.03% . . . . . . . . . . . . . . . . 50ipratropium bromide nasal spray, non-aerosol 42 mcg (0.06%) . . . . . . . 50irbesartan-hydrochlorothiazide . . . . . 44irbesartan oral tablet 150 mg . . . . . . . 44irbesartan oral tablet 300 mg, 75 mg . . . . . . . . . . . . . . . . . . . . 44IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 28irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 28ISENTRESS HD . . . . . . . . . . . . . . . . . . . 21ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 21ISENTRESS ORAL TABLET . . . . . . . 21ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . 21ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . 21isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 61isoniazid oral solution . . . . . . . . . . . . . . 24isoniazid oral tablet . . . . . . . . . . . . . . . . 24isosorbide dinitrate oral tablet . . . . . . 46isosorbide mononitrate . . . . . . . . . . . . . 46isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 47isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 44ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . 28itraconazole oral capsule . . . . . . . . . . . 20itraconazole oral solution . . . . . . . . . . . 20ivermectin oral . . . . . . . . . . . . . . . . . . . . 24IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 58

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 50JADENU SPRINKLE . . . . . . . . . . . . . . . 50JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 29jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 45JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 52JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG . . . . . . . . . . 52

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 52INTELENCE ORAL TABLET 25 MG 21INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . . . . . . . . . . 21INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 67INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 57INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . 57INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . 57introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 61INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . 40INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . . 40INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML . . . . . . . . . . . . . . . . . . . 40INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML . . . . . . . . . . . . . . . . . . . . . . . 40INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML . . . . . . . . . . . . . . . . . . . . 40INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML . . . . . . . 40INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML . . . . . . . 41INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML . . . . . . . . 41INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML . . . . . . . 41INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 64INVIRASE ORAL TABLET . . . . . . . . . 21INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 52INVOKAMET XR . . . . . . . . . . . . . . . . . . 52INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 52IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ipratropium-albuterol . . . . . . . . . . . . . . . 65

81


Covered Drugs Index

levobunolol ophthalmic (eye) drops 0.5% . . . . . . . . . . . . . . . . . . 63levocarnitine oral solution 100 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . 50levocarnitine oral tablet . . . . . . . . . . . . 50levocarnitine (with sugar) . . . . . . . . . . . 50levocetirizine oral solution . . . . . . . . . . 64levocetirizine oral tablet . . . . . . . . . . . . 64levofloxacin in d5w . . . . . . . . . . . . . . . . 25levofloxacin intravenous . . . . . . . . . . . 25levofloxacin oral solution . . . . . . . . . . . 25levofloxacin oral tablet . . . . . . . . . . . . . 25levonest (28) . . . . . . . . . . . . . . . . . . . . . . 61levonorgestrel-ethinyl estrad . . . . . . . 61levonorg-eth estrad triphasic . . . . . . . 61levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 61levothyroxine oral . . . . . . . . . . . . . . . . . . 54levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg . . . . . . . 54LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 54LEXIVA ORAL SUSPENSION . . . . . . 21LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 29lidocaine hcl injection solution . . . . . . 47lidocaine hcl laryngotracheal . . . . . . . 47lidocaine hcl mucous membrane jelly . 47lidocaine hcl mucous membrane jelly in applicator . . . . . . . . 47lidocaine hcl mucous membrane solution 4% (40 mg/ml) . . 47lidocaine (pf) injection solution . . . . . . 47lidocaine (pf) intravenous syringe . . . 43lidocaine-prilocaine topical cream . . . 47lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 47lidocaine topical ointment . . . . . . . . . . 47lidocaine viscous . . . . . . . . . . . . . . . . . . 47lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 61lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 24lindane topical shampoo . . . . . . . . . . . 49

LANTUS U-100 INSULIN . . . . . . . . . . 52larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 61larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 61larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 61larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 61larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 61larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 63LATUDA ORAL TABLET 80 MG . . . . 41LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 41layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 61leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 61leflunomide . . . . . . . . . . . . . . . . . . . . . . . 59LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 29LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY (10 MG X 2-4 MG X 1) . . . . . . . . . . . . . 29LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) . . . . . . . . . . . . . 29lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 29leucovorin calcium injection recon soln . . . . . . . . . . . . . . . . . . . . . . . . . 26leucovorin calcium injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 26leucovorin calcium oral . . . . . . . . . . . . . 26LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 29LEUKINE INJECTION RECON SOLN 57leuprolide subcutaneous kit . . . . . . . . 29levalbuterol hcl . . . . . . . . . . . . . . . . . . . . 65levalbuterol tartrate . . . . . . . . . . . . . . . . 65LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 52LEVEMIR U-100 INSULIN . . . . . . . . . 52levetiracetam in nacl (iso-os) . . . . . . . 33levetiracetam intravenous . . . . . . . . . . 33levetiracetam oral . . . . . . . . . . . . . . . . . 33

KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 29KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 29KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 29KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 29klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 66KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 66KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 66klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 66klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 66KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 54K-PHOS ORIGINAL . . . . . . . . . . . . . . . 66kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 61KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 54KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 29

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 44LACRISERT . . . . . . . . . . . . . . . . . . . . . . 63lactated ringers intravenous . . . . . . . . 66lactated ringers irrigation . . . . . . . . . . . 49lactulose oral solution . . . . . . . . . . . . . . 55lamivudine oral solution . . . . . . . . . . . . 21lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . 21lamivudine oral tablet 150 mg . . . . . . 21lamivudine-zidovudine . . . . . . . . . . . . . 21lamotrigine oral tablet . . . . . . . . . . . . . . 33lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 33lamotrigine oral tablet,disintegrating 33lamotrigine oral tablet extended release 24hr . . . . . . . . . . . . . 33lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 56LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 52

82


Covered Drugs Index

MEDROL ORAL TABLET 2 MG . . . . . 51medroxyprogesterone intramuscular suspension . . . . . . . . . . 60medroxyprogesterone intramuscular syringe . . . . . . . . . . . . . . 60medroxyprogesterone oral . . . . . . . . . 60mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 24megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 29megestrol oral tablet . . . . . . . . . . . . . . . 29MEKINIST ORAL TABLET 0.5 MG . . 29MEKINIST ORAL TABLET 2 MG . . . . 29MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 29melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 61meloxicam oral tablet . . . . . . . . . . . . . . 38melphalan . . . . . . . . . . . . . . . . . . . . . . . . . 29melphalan hcl . . . . . . . . . . . . . . . . . . . . . 29memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 35memantine oral solution . . . . . . . . . . . . 35memantine oral tablet 5 mg . . . . . . . . 35memantine oral tablet 10 mg . . . . . . . 35memantine oral tablets,dose pack . . 35MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 58MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG . . . . . . . 60MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 60MENVEO A-C-Y-W-135-DIP (PF) . . . 58mercaptopurine . . . . . . . . . . . . . . . . . . . . 29meropenem . . . . . . . . . . . . . . . . . . . . . . . 24MEROPENEM-0.9% SODIUM CHLORIDE . . . . . . . . . . . . . . 24mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 55mesalamine oral tablet, delayed release (dr/ec) 1.2 gram . . . 55mesalamine rectal enema . . . . . . . . . . 55mesalamine with cleansing wipe . . . . 55mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26MESNEX ORAL . . . . . . . . . . . . . . . . . . . 26

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 63LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 54LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 29LUPRON DEPOT . . . . . . . . . . . . . . . . . 29LUPRON DEPOT (3 MONTH) . . . . . . 29LUPRON DEPOT (4 MONTH) . . . . . . 29LUPRON DEPOT (6 MONTH) . . . . . . 29LUPRON DEPOT-PED . . . . . . . . . . . . 29LUPRON DEPOT-PED (3 MONTH) . 29lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 61LYNPARZA ORAL TABLET . . . . . . . . . 29LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG . . . . . . . . . . . 33LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG . . . . . . . . . . . . . . . . . . . . 33LYRICA ORAL CAPSULE 75 MG . . . 33LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG . . . 33LYRICA ORAL CAPSULE 225 MG, 300 MG . . . . . . . . . . . . . . . . . . 33LYRICA ORAL SOLUTION . . . . . . . . . 33LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 29lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

MMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . 66magnesium sulfate injection . . . . . . . . 66magnesium sulfate in water . . . . . . . . 66malathion . . . . . . . . . . . . . . . . . . . . . . . . . 49maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 41marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 61MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 41MATULANE . . . . . . . . . . . . . . . . . . . . . . . 29matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 44MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . 21meclizine oral tablet 12.5 mg, 25 mg . . 55

linezolid-0.9% sodium chloride . . . . . 24linezolid in dextrose 5% . . . . . . . . . . . . 24linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 24linezolid oral tablet . . . . . . . . . . . . . . . . . 24LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 55liothyronine oral . . . . . . . . . . . . . . . . . . . 54lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 44lisinopril-hydrochlorothiazide . . . . . . . 44lithium carbonate . . . . . . . . . . . . . . . . . . 41LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 46l norgest/e.estradiol-e.estrad . . . . . . . 61LOKELMA . . . . . . . . . . . . . . . . . . . . . . . . 50LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . . . . . . . . . 29LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . . . . . . . . . 29loperamide oral capsule . . . . . . . . . . . . 55lopinavir-ritonavir . . . . . . . . . . . . . . . . . . 21lorazepam injection . . . . . . . . . . . . . . . . 41lorazepam intensol . . . . . . . . . . . . . . . . 41lorazepam oral concentrate . . . . . . . . 41lorazepam oral tablet 0.5 mg, 1 mg . 41lorazepam oral tablet 2 mg . . . . . . . . . 41LORBRENA ORAL TABLET 25 MG . 29LORBRENA ORAL TABLET 100 MG 29lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 36lorcet (hydrocodone) . . . . . . . . . . . . . . . 36lorcet plus oral tablet 7.5-325 mg . . . 36loryna (28) . . . . . . . . . . . . . . . . . . . . . . . . 61losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . 44losartan-hydrochlorothiazide oral tablet 50-12.5 mg . . . . . . . . . . . . . . . . . . 44losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg . . . . . 44LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 64LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 64lovastatin . . . . . . . . . . . . . . . . . . . . . . . . . 46low-ogestrel (28) . . . . . . . . . . . . . . . . . . 61loxapine succinate . . . . . . . . . . . . . . . . . 41lo-zumandimine (28) . . . . . . . . . . . . . . . 61

83


Covered Drugs Index

MITIGO (PF) . . . . . . . . . . . . . . . . . . . . . . 37M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 58moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 44molindone . . . . . . . . . . . . . . . . . . . . . . . . . 41mometasone nasal . . . . . . . . . . . . . . . . 65mometasone topical . . . . . . . . . . . . . . . 49mondoxyne nl oral capsule 100 mg, 75 mg . . . . . . . . . . . . . . . . . . . . 26mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 61montelukast oral granules in packet . . . . . . . . . . . . . . . . . . . . . . . . . . 65montelukast oral tablet . . . . . . . . . . . . . 65montelukast oral tablet,chewable . . . 65MONUROL . . . . . . . . . . . . . . . . . . . . . . . 26morgidox . . . . . . . . . . . . . . . . . . . . . . . . . . 26morphine concentrate oral solution . 37MORPHINE INJECTION SOLUTION 2 MG/ML . . . . . . . . . . . . . . 37MORPHINE INJECTION SOLUTION 4 MG/ML . . . . . . . . . . . . . . 37MORPHINE INJECTION SOLUTION 5 MG/ML . . . . . . . . . . . . . . 37morphine injection solution 8 mg/ml . 37MORPHINE INJECTION SOLUTION 10 MG/ML . . . . . . . . . . . . . 37morphine injection syringe 2 mg/ml . 37morphine injection syringe 4 mg/ml . 37morphine injection syringe 5 mg/ml . 37morphine injection syringe 8 mg/ml . 37morphine injection syringe 10 mg/ml . . 37MORPHINE INTRAVENOUS SOLUTION 4 MG/ML . . . . . . . . . . . . . . 37MORPHINE INTRAVENOUS SOLUTION 8 MG/ML . . . . . . . . . . . . . . 37morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . 37morphine intravenous syringe 2 mg/ml . . . . . . . . . . . . . . . . . . . 37morphine intravenous syringe 4 mg/ml . . . . . . . . . . . . . . . . . . . 37MORPHINE INTRAVENOUS SYRINGE 8 MG/ML . . . . . . . . . . . . . . . 37

methylprednisolone . . . . . . . . . . . . . . . . 51methylprednisolone acetate . . . . . . . . 51methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . 51methylprednisolone sodium succ intravenous recon soln 1,000 mg . . . 51methylprednisolone sodium succ intravenous recon soln 500 mg . . . . . 51metoclopramide hcl injection solution 55metoclopramide hcl oral solution . . . . 55metoclopramide hcl oral tablet . . . . . . 55metolazone . . . . . . . . . . . . . . . . . . . . . . . 44metoprolol succinate . . . . . . . . . . . . . . . 44metoprolol ta-hydrochlorothiaz . . . . . 44metoprolol tartrate oral . . . . . . . . . . . . . 44metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 24metronidazole in nacl (iso-os) . . . . . . 24metronidazole oral tablet . . . . . . . . . . . 24metronidazole topical . . . . . . . . . . . . . . 47metronidazole vaginal . . . . . . . . . . . . . . 60mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 43MIACALCIN INJECTION . . . . . . . . . . . 54mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 61microgestin 1.5/30 (21) . . . . . . . . . . . . 61microgestin 1/20 (21) . . . . . . . . . . . . . . 61microgestin fe 1.5/30 (28) . . . . . . . . . . 61microgestin fe 1/20 (28) . . . . . . . . . . . . 61midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 50migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 34miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 54mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 46minocycline oral capsule . . . . . . . . . . . 26minocycline oral tablet . . . . . . . . . . . . . 26minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 44mirtazapine oral tablet . . . . . . . . . . . . . 41mirtazapine oral tablet,disintegrating . 41misoprostol . . . . . . . . . . . . . . . . . . . . . . . 56MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 58

metadate er . . . . . . . . . . . . . . . . . . . . . . . 41metaproterenol oral syrup . . . . . . . . . . 65metformin oral tablet 1,000 mg . . . . . 52metformin oral tablet 500 mg . . . . . . . 52metformin oral tablet 850 mg . . . . . . . 52metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) . . . . . . . . . 52metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr) . . . . . . . . . 52metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet) . . . . . . . 52methadone injection solution . . . . . . . 36methadone intensol . . . . . . . . . . . . . . . . 36methadone oral concentrate . . . . . . . . 36methadone oral solution 5 mg/5 ml . 36methadone oral solution 10 mg/5 ml . 36methadone oral tablet 5 mg . . . . . . . . 37methadone oral tablet 10 mg . . . . . . . 37methazolamide . . . . . . . . . . . . . . . . . . . . 63methenamine hippurate . . . . . . . . . . . . 26methimazole oral tablet 10 mg, 5 mg . 51methocarbamol oral . . . . . . . . . . . . . . . 35methotrexate sodium injection . . . . . . 29methotrexate sodium oral . . . . . . . . . . 29methotrexate sodium (pf) . . . . . . . . . . . 29methoxsalen . . . . . . . . . . . . . . . . . . . . . . 47methyldopa . . . . . . . . . . . . . . . . . . . . . . . 44methylphenidate hcl oral tablet . . . . . 41methylphenidate hcl oral tablet extended release . . . . . . . . . . . . . . . . . . 41methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating) . . . . . . . . . . . 41methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . . . . . . . . 41methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating) . . . . . . . . . . . . . . . . . . 41

84


Covered Drugs Index

neomycin-polymyxin-gramicidin . . . . 62neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 64neomycin-polymyxin-hc otic (ear) . . . 51neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 62neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 64NEPHRAMINE 5.4% . . . . . . . . . . . . . . . 67NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 30NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 34nevirapine oral suspension . . . . . . . . . 21nevirapine oral tablet . . . . . . . . . . . . . . 21nevirapine oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . 21nevirapine oral tablet extended release 24 hr 400 mg . . . . . . . . . . . . . . 21NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 30niacin oral tablet 500 mg . . . . . . . . . . . 46niacin oral tablet extended release 24 hr . . . . . . . . . . . . . . . . . . . . . . 46niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46nicardipine intravenous solution . . . . 44nicardipine oral . . . . . . . . . . . . . . . . . . . . 44NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 50NICOTROL NS . . . . . . . . . . . . . . . . . . . . 50nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 44nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 44nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 61nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 30nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 44NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 30nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 44nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 50nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 26nitrofurantoin macrocrystal . . . . . . . . . 26nitrofurantoin monohyd/m-cryst . . . . . 26nitroglycerin intravenous . . . . . . . . . . . 46nitroglycerin sublingual . . . . . . . . . . . . . 46nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 46

nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 44nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . 25nafcillin in dextrose iso-osm . . . . . . . . 25naftifine topical cream . . . . . . . . . . . . . . 48NAFTIN TOPICAL GEL . . . . . . . . . . . . 48NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 54nalbuphine injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 38nalbuphine injection solution 20 mg/ml . . . . . . . . . . . . . . . . . . 38naloxone injection solution . . . . . . . . . 38naloxone injection syringe 1 mg/ml . 38naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 38NAMZARIC ORAL CAP, SPRINKLE,ER 24HR DOSE PACK . 35NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR . . . 35naproxen oral suspension . . . . . . . . . . 38naproxen oral tablet . . . . . . . . . . . . . . . 38naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 38naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . . . . . . . 38naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 34NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION . . . . . 38NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 62nateglinide oral tablet 60 mg . . . . . . . 53nateglinide oral tablet 120 mg . . . . . . 53NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 54NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 33NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 24necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 61NEEDLES, INSULIN DISP.,SAFETY . 53nefazodone . . . . . . . . . . . . . . . . . . . . . . . 41neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 24neomycin-bacitracin-poly-hc . . . . . . . . 63neomycin-bacitracin-polymyxin . . . . . 62neomycin-polymyxin b-dexameth . . . 63neomycin-polymyxin b gu . . . . . . . . . . 49

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML . . . . . . . . . . . . . . 37morphine oral solution 10 mg/5 ml . . 37morphine oral solution 20 mg/5 ml (4 mg/ml) . . . . . . . . . . . . . . 37MORPHINE ORAL TABLET . . . . . . . . 37morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 37morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . 37morphine (pf) intravenous patient control.analgesia soln . . . . . . . 37moxifloxacin ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 62moxifloxacin oral . . . . . . . . . . . . . . . . . . 25MOXIFLOXACIN-SOD.ACE, SUL-WATER . . . . . . . . . . . . . . . . . . . . . . 26moxifloxacin-sod.chloride(iso) . . . . . . 26MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 57MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 43mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 48mupirocin calcium . . . . . . . . . . . . . . . . . 48MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . 20mycophenolate mofetil (hcl) . . . . . . . . 29mycophenolate mofetil oral capsule . 29mycophenolate mofetil oral suspension for reconstitution . . . . . . . 30mycophenolate mofetil oral tablet . . . 30mycophenolate sodium . . . . . . . . . . . . 30MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 30myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 47MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG . . . . . . . . . . . . . . . . . . . . . 66MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG . . . . . . . . . . . . . . . . . . . . . 66

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 38nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

85


Covered Drugs Index

olopatadine ophthalmic (eye) . . . . . . . 63omega-3 acid ethyl esters . . . . . . . . . . 46omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 56OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 53OMNIPOD DASH 5 PACK. . . . . . . . . . 53OMNIPOD STARTER KIT . . . . . . . . . . 53ondansetron . . . . . . . . . . . . . . . . . . . . . . . 55ondansetron hcl intravenous . . . . . . . 55ondansetron hcl oral solution . . . . . . . 55ondansetron hcl oral tablet . . . . . . . . . 55ondansetron hcl (pf) . . . . . . . . . . . . . . . 55OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 30OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 65oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ORBACTIV . . . . . . . . . . . . . . . . . . . . . . . 24ORENCIA . . . . . . . . . . . . . . . . . . . . . . . . . 59ORENCIA CLICKJECT . . . . . . . . . . . . 59ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 50ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 65ORKAMBI ORAL TABLET . . . . . . . . . . 65orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 62oseltamivir . . . . . . . . . . . . . . . . . . . . . . . . 21OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 55oxacillin injection . . . . . . . . . . . . . . . . . . 25oxandrolone oral tablet 2.5 mg . . . . . 54oxandrolone oral tablet 10 mg . . . . . . 54oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 38oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 41oxcarbazepine . . . . . . . . . . . . . . . . . . . . 33oxybutynin chloride oral syrup . . . . . . 66oxybutynin chloride oral tablet . . . . . . 66oxybutynin chloride oral tablet extended release 24hr . . . . . . . . . . . . . 66oxycodone-acetaminophen oral tablet 2.5-300 mg . . . . . . . . . . . . . . 37oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg . . . 37oxycodone-acetaminophen oral tablet 7.5-325 mg . . . . . . . . . . . . . . 37

NUPLAZID ORAL TABLET 10 MG . . 41NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 67NUZYRA (7 DAY) . . . . . . . . . . . . . . . . . . 26NUZYRA (7 DAY WITH LOAD DOSE) . . . . . . . . 26NUZYRA INTRAVENOUS . . . . . . . . . . 26NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 26nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 48nystatin oral suspension . . . . . . . . . . . 20nystatin oral tablet . . . . . . . . . . . . . . . . . 20nystatin topical cream . . . . . . . . . . . . . . 48nystatin topical ointment . . . . . . . . . . . 48nystatin topical powder . . . . . . . . . . . . . 48nystatin-triamcinolone . . . . . . . . . . . . . . 48nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 55ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 35octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml . . . . . . . . . . . 30octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 30ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 21ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 30OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65ofloxacin ophthalmic (eye) . . . . . . . . . 62ofloxacin otic (ear) . . . . . . . . . . . . . . . . . 63ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . 62olanzapine-fluoxetine . . . . . . . . . . . . . . 41olanzapine intramuscular . . . . . . . . . . . 41olanzapine oral tablet 7.5 mg . . . . . . . 41olanzapine oral tablet 10 mg, 2.5 mg, 5 mg . . . . . . . . . . . . . . . 41olanzapine oral tablet 15 mg, 20 mg . 41olanzapine oral tablet,disintegrating . 41olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 44olmesartan-hydrochlorothiazide . . . . 44

nitroglycerin translingual spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 46nizatidine oral capsule . . . . . . . . . . . . . 56nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 60noreth-ethinyl estradiol-iron . . . . . . . . 61norethindrone acetate . . . . . . . . . . . . . . 60norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg . . . . . . . . . . . . . . 60norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg . 61norethindrone (contraceptive) . . . . . . 60norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) . . . . . . 62norethindrone-e.estradiol-iron oral tablet,chewable . . . . . . . . . . . . . . . 62norgestimate-ethinyl estradiol . . . . . . 62NORMOSOL-M IN 5% DEXTROSE 67NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 66NORMOSOL-R IN 5% DEXTROSE . 66NORMOSOL-R PH 7.4 . . . . . . . . . . . . 67NORTHERA ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 50NORTHERA ORAL CAPSULE 200 MG, 300 MG . . . . . . . . . . . . . . . . . . 50nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 62nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . 62nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . 62nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . 62nortriptyline . . . . . . . . . . . . . . . . . . . . . . . 41NORVIR ORAL POWDER IN PACKET 21NORVIR ORAL SOLUTION . . . . . . . . 21NORVIR ORAL TABLET . . . . . . . . . . . 21NOVOFINE PEN NEEDLE . . . . . . . . . 53NOVOTWIST PEN NEEDLE . . . . . . . 53NOXAFIL ORAL SUSPENSION . . . . 20NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC) . . . . . 20NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 30NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 35NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 30NUPLAZID ORAL CAPSULE . . . . . . . 41

86


Covered Drugs Index

PICATO TOPICAL GEL 0.05% . . . . . 47PICATO TOPICAL GEL 0.015% . . . . 47PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 21pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 63pilocarpine hcl oral . . . . . . . . . . . . . . . . . 50pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 47pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 42pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 62pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 44pioglitazone-metformin . . . . . . . . . . . . . 53pioglitazone oral tablet 15 mg . . . . . . 53pioglitazone oral tablet 30 mg, 45 mg . 53piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 25PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 25PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 30PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) . . . . . . . . 30pirmella . . . . . . . . . . . . . . . . . . . . . . . . . . . 62PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 67PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 56podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 47polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63polymyxin b sulfate . . . . . . . . . . . . . . . . 24polymyxin b sulf-trimethoprim . . . . . . 63POMALYST . . . . . . . . . . . . . . . . . . . . . . . 30portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 62POSACONAZOLE ORAL TABLET, DELAYED RELEASE (DR/EC) . . . . . 20POTASSIUM CHLORID-D5- 0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L . . . 66potassium chlorid-d5- 0.45%nacl intravenous parenteral solution 30 meq/l . . . . . . . . 66potassium chloride-0.45% nacl . . . . . 67

PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 58peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 56PEGANONE . . . . . . . . . . . . . . . . . . . . . . 33peg-electrolyte . . . . . . . . . . . . . . . . . . . . 56penicillamine oral capsule . . . . . . . . . . 59penicillin g potassium . . . . . . . . . . . . . . 25penicillin v potassium oral recon soln . . . . . . . . . . . . . . . . . . . . . . . . . 25penicillin v potassium oral tablet 250 mg . . . . . . . . . . . . . . . . . 25penicillin v potassium oral tablet 500 mg . . . . . . . . . . . . . . . . . 25PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 24pentamidine inhalation . . . . . . . . . . . . . 24pentamidine injection . . . . . . . . . . . . . . 24PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 56pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 45PERFOROMIST . . . . . . . . . . . . . . . . . . . 65PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 67perindopril erbumine . . . . . . . . . . . . . . . 44PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 30permethrin topical cream . . . . . . . . . . . 49perphenazine . . . . . . . . . . . . . . . . . . . . . 41perphenazine-amitriptyline . . . . . . . . . 41PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 41pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 25phenadoz rectal suppository 12.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . 64phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 42phenobarbital oral elixir . . . . . . . . . . . . 33phenobarbital oral tablet . . . . . . . . . . . 33phenoxybenzamine . . . . . . . . . . . . . . . . 44phenytoin oral suspension . . . . . . . . . 33phenytoin oral tablet,chewable . . . . . 33phenytoin sodium extended . . . . . . . . 33philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 66PHOSPHOLINE IODIDE . . . . . . . . . . . 63PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 49PHYSIOSOL IRRIGATION . . . . . . . . . 49

oxycodone-acetaminophen oral tablet 10-325 mg . . . . . . . . . . . . . . 37oxycodone-aspirin . . . . . . . . . . . . . . . . . 37oxycodone oral concentrate . . . . . . . . 37oxycodone oral solution . . . . . . . . . . . . 37oxycodone oral tablet . . . . . . . . . . . . . . 37oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 37OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 53

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 43paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 30PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 30paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 41paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . . . . . . . . . . 41palonosetron intravenous solution 0.25 mg/5 ml . . . . . . . . . . . . . . 55pamidronate . . . . . . . . . . . . . . . . . . . . . . . 54PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 47pantoprazole oral . . . . . . . . . . . . . . . . . . 56paricalcitol oral capsule 1 mcg, 2 mcg . . . . . . . . . . . . . . . . . . . . . . 54paricalcitol oral capsule 4 mcg . . . . . . 54paroex oral rinse . . . . . . . . . . . . . . . . . . 50paromomycin . . . . . . . . . . . . . . . . . . . . . . 24paroxetine hcl oral tablet 10 mg . . . . 41paroxetine hcl oral tablet 20 mg . . . . 41paroxetine hcl oral tablet 30 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 41paroxetine hcl oral tablet extended release 24 hr 12.5 mg . . . . . . . . . . . . . . 41paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg . . . . . . 41PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 24PAXIL ORAL SUSPENSION . . . . . . . 41PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 63PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 58

87


Covered Drugs Index

primidone . . . . . . . . . . . . . . . . . . . . . . . . . 33PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 65PROAIR RESPICLICK . . . . . . . . . . . . . 65probenecid . . . . . . . . . . . . . . . . . . . . . . . . 58probenecid-colchicine . . . . . . . . . . . . . . 58PROCALAMINE 3% . . . . . . . . . . . . . . . 67prochlorperazine . . . . . . . . . . . . . . . . . . 56prochlorperazine edisylate . . . . . . . . . 56prochlorperazine maleate oral . . . . . . 56procto-med hc . . . . . . . . . . . . . . . . . . . . . 56procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 56proctosol hc topical . . . . . . . . . . . . . . . . 56proctozone-hc . . . . . . . . . . . . . . . . . . . . . 56progesterone micronized . . . . . . . . . . . 60PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 53PROGRAF INTRAVENOUS . . . . . . . . 30PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 30PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 50PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 63PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 58PROMACTA ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 45PROMACTA ORAL TABLET . . . . . . . . 45promethazine oral . . . . . . . . . . . . . . . . . 64promethazine rectal suppository 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 64promethegan rectal suppository 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 64propafenone oral capsule, extended release 12 hr . . . . . . . . . . . . 43propafenone oral tablet . . . . . . . . . . . . 43propantheline . . . . . . . . . . . . . . . . . . . . . 55propranolol-hydrochlorothiazid . . . . . 44propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 44propranolol oral solution . . . . . . . . . . . 44propranolol oral tablet . . . . . . . . . . . . . . 44propylthiouracil . . . . . . . . . . . . . . . . . . . . 51PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 58PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 67

prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 44PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 64PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 64PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 64prednicarbate topical ointment . . . . . . 49prednisolone acetate . . . . . . . . . . . . . . 64prednisolone oral solution 15 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 51prednisolone sodium phosphate ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 64prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) . . . . . . . . . . . . . . . . . . . . . . 51prednisone intensol . . . . . . . . . . . . . . . . 51prednisone oral solution . . . . . . . . . . . . 51prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg . . . . . . . . 51prednisone oral tablet 50 mg . . . . . . . 51prednisone oral tablets,dose pack . . 51pregabalin oral capsule 75 mg . . . . . . 33pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg . . . . . 33pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 33pregabalin oral solution . . . . . . . . . . . . 33PREMARIN INJECTION . . . . . . . . . . . 60PREMARIN ORAL . . . . . . . . . . . . . . . . . 60PREMARIN VAGINAL . . . . . . . . . . . . . 60PREMASOL 10% . . . . . . . . . . . . . . . . . . 67PRENATAL VITAMIN ORAL TABLET . 67prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 46previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 62PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 21PREZISTA ORAL SUSPENSION . . . 21PREZISTA ORAL TABLET 75 MG . . 21PREZISTA ORAL TABLET 150 MG . 21PREZISTA ORAL TABLET 600 MG . 21PREZISTA ORAL TABLET 800 MG . 21PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 24PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 24

POTASSIUM CHLORIDE-D5-0.2% NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L . . . . . . . . . . . . . 67potassium chloride-d5-0.2% nacl intravenous parenteral solution 30 meq/l, 40 meq/l . . . . . . . . . 67potassium chloride-d5-0.3% nacl intravenous parenteral solution 20 meq/l . . . . . . . . . . . . . . . . . . 67POTASSIUM CHLORIDE- D5-0.9%NACL . . . . . . . . . . . . . . . . . . . . 67potassium chloride in 0.9% nacl intravenous parenteral solution 20 meq/l, 40 meq/l . . . . . . . . . 66potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l . . . . . . . 66potassium chloride in lr-d5 . . . . . . . . . 66potassium chloride intravenous . . . . . 66potassium chloride in water intravenous piggyback . . . . . . . . . . . . . 66potassium chloride oral capsule, extended release . . . . . . . . . . . . . . . . . . 66potassium chloride oral liquid . . . . . . . 67potassium chloride oral packet . . . . . 67potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 67potassium chloride oral tablet extended release . . . . . . . . . . . . . . . . . . 67potassium citrate . . . . . . . . . . . . . . . . . . 66POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 30PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 45pramipexole oral tablet . . . . . . . . . . . . . 34pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg . . . . . . . . . . . . . . . . . . . 34pramipexole oral tablet extended release 24 hr 2.25 mg, 3 mg, 3.75 mg, 4.5 mg . . . . . . . . . . . . . . . . . . . 34prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 45pravastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 46pravastatin oral tablet 40 mg . . . . . . . 46praziquantel . . . . . . . . . . . . . . . . . . . . . . . 24

88


Covered Drugs Index

REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG . . . . . . . . . . . . . 30REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG . . . . . . . . . . . . . 30REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 42REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 21RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 63ribavirin oral capsule . . . . . . . . . . . . . . . 21ribavirin oral tablet 200 mg . . . . . . . . . 21RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 59rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 24rifampin intravenous . . . . . . . . . . . . . . . 24rifampin oral . . . . . . . . . . . . . . . . . . . . . . . 24RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 24riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50rimantadine . . . . . . . . . . . . . . . . . . . . . . . 21ringer’s intravenous . . . . . . . . . . . . . . . . 67ringer’s irrigation . . . . . . . . . . . . . . . . . . . 49RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 59RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 53risedronate oral tablet 30 mg, 5 mg . 58risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) . . . 59risedronate oral tablet 150 mg . . . . . . 58RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML . . . . . . . . 42RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 50 MG/2 ML . . . . . . . . . . 42risperidone oral solution . . . . . . . . . . . . 42risperidone oral tablet . . . . . . . . . . . . . . 42risperidone oral tablet, disintegrating 0.5 mg, 4 mg . . . . . . . . 42risperidone oral tablet, disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . . . . . . . . . 42ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 21RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 30

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML . . . 57REBIF TITRATION PACK . . . . . . . . . . 57REBIF (WITH ALBUMIN) . . . . . . . . . . . 57reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 62RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML . . . . . . . . . . . . . . . . . . . . 58RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML . . . . . . . . . . 58RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE . . . . . . 58RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 56regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 35REGRANEX . . . . . . . . . . . . . . . . . . . . . . 47RELISTOR SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 56RELISTOR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 56REMODULIN . . . . . . . . . . . . . . . . . . . . . . 44RENACIDIN IRRIGATION SOLUTION 1980.6 MG- 59.4 MG-980.4MG/30ML . . . . . . . . . . . 66RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 56RENVELA ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 50RENVELA ORAL TABLET . . . . . . . . . . 50repaglinide oral tablet 0.5 mg, 1 mg . 53repaglinide oral tablet 2 mg . . . . . . . . 53REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 46REPATHA PUSHTRONEX . . . . . . . . . 46REPATHA SURECLICK . . . . . . . . . . . . 46RESCRIPTOR ORAL TABLET . . . . . 21RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 63RESTASIS MULTIDOSE . . . . . . . . . . . 63RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML . . . . 57RETACRIT INJECTION SOLUTION 40,000 UNIT/ML . . . . . . . 57RETROVIR INTRAVENOUS . . . . . . . 21

protriptyline . . . . . . . . . . . . . . . . . . . . . . . 42PULMICORT . . . . . . . . . . . . . . . . . . . . . . 65PULMOZYME . . . . . . . . . . . . . . . . . . . . . 65PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 30pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 24pyridostigmine bromide oral syrup . . 35pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . . . . . . 35pyridostigmine bromide oral tablet extended release . . . . . . . . . . . . 35

QQUADRACEL (PF) . . . . . . . . . . . . . . . . 58quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . . . . . . . . . 42quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 42quetiapine oral tablet extended release 24 hr 150 mg, 200 mg . . . . . . 42quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg . . . . . . . . . . . . . . . . . . . . 42quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 44quinapril-hydrochlorothiazide . . . . . . . 44quinidine sulfate oral tablet . . . . . . . . . 43quinine sulfate . . . . . . . . . . . . . . . . . . . . . 24

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 58raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 58ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 42ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ranitidine hcl oral syrup . . . . . . . . . . . . 56ranitidine hcl oral tablet 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . 56ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 46RAPAMUNE ORAL SOLUTION . . . . 30rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 34REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) . 57

89


Covered Drugs Index

sodium chloride 0.45% intravenous parenteral solution . . . . . 67sodium chloride 3% . . . . . . . . . . . . . . . . 67sodium chloride 5% . . . . . . . . . . . . . . . . 67sodium chloride intravenous . . . . . . . . 67sodium chloride irrigation . . . . . . . . . . . 50sodium phenylbutyrate . . . . . . . . . . . . . 50sodium polystyrene (sorb free) . . . . . 50sodium polystyrene sulfonate oral . . 50solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 66SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 53SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 30SOLU-CORTEF ACT-O-VIAL (PF) . . 51SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 30SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML . . . . . . . . . . . . . . . . . . . . . 30SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . 30SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 54sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 43sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 43SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 43spironolactone . . . . . . . . . . . . . . . . . . . . 44spironolacton-hydrochlorothiaz . . . . . 44sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 62SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG . . . . . . . . . . . . . . . . . . 34SPRITAM ORAL TABLET FOR SUSPENSION 750 MG . . . . . . . . . . . . 34SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 30sps (with sorbitol) . . . . . . . . . . . . . . . . . . 50sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 58stavudine oral capsule . . . . . . . . . . . . . 21

selenium sulfide topical lotion . . . . . . 46SELZENTRY ORAL SOLUTION . . . . 21SELZENTRY ORAL TABLET 25 MG . 21SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . . . . . . . . . 21SELZENTRY ORAL TABLET 300 MG . 21SENSIPAR ORAL TABLET 30 MG, 60 MG . . . . . . . . . . . . . . . . . . . . 54SENSIPAR ORAL TABLET 90 MG . . 54SEREVENT DISKUS . . . . . . . . . . . . . . 65sertraline oral concentrate . . . . . . . . . . 42sertraline oral tablet 50 mg . . . . . . . . . 42sertraline oral tablet 100 mg, 25 mg . 42setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 62SEVELAMER CARBONATE ORAL POWDER IN PACKET . . . . . . . 50SEVELAMER CARBONATE ORAL TABLET . . . . . . . . . . . . . . . . . . . . 50sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 60SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 58SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 30sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 65SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 42silver sulfadiazine . . . . . . . . . . . . . . . . . 47SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 63simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 62simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 62SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 30simvastatin oral tablet . . . . . . . . . . . . . . 46sirolimus oral solution . . . . . . . . . . . . . . 30sirolimus oral tablet . . . . . . . . . . . . . . . . 30SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 24SIVEXTRO INTRAVENOUS . . . . . . . . 24SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 24SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 46sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . . . 67sodium chloride 0.9% intravenous . . 50

RITUXAN HYCELA . . . . . . . . . . . . . . . . 30rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 35rivastigmine tartrate . . . . . . . . . . . . . . . . 35rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62rizatriptan . . . . . . . . . . . . . . . . . . . . . . . . . 34ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 63ROMIDEPSIN . . . . . . . . . . . . . . . . . . . . . 30ropinirole oral tablet . . . . . . . . . . . . . . . . 34rosadan topical cream . . . . . . . . . . . . . 47rosadan topical gel . . . . . . . . . . . . . . . . 47rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 46ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 58ROTATEQ VACCINE . . . . . . . . . . . . . . 58roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 33roweepra xr . . . . . . . . . . . . . . . . . . . . . . . 34ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 30ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 30RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 30RUCONEST . . . . . . . . . . . . . . . . . . . . . . 65RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 30RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 30RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Ssalsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 38SAMSCA ORAL TABLET 15 MG . . . . 54SAMSCA ORAL TABLET 30 MG . . . . 54SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 56SANDIMMUNE ORAL SOLUTION . . 30SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON . . . . . . . . . . . . . . . . . . . . . . 30SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 47SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 42scopolamine base . . . . . . . . . . . . . . . . . 56SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 42selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 34

90


Covered Drugs Index

TAZORAC TOPICAL CREAM . . . . . . 48TAZORAC TOPICAL GEL . . . . . . . . . . 48taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . . . . . . . . . 44TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 58TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 31TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 31TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG . . . . . . . . . . . . . . . . . . 35TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG (14)- 240 MG (46) 35TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 240 MG . . . . . . . . . . . . . . . . . . 35TECHLITE PEN NEEDLE . . . . . . . . . . 53TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 23TEKTURNA HCT . . . . . . . . . . . . . . . . . . 44telmisartan-amlodipine . . . . . . . . . . . . . 44telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg . . . 44telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg . . . . . . . . . . . . . . 44telmisartan oral tablet 20 mg, 40 mg . 44telmisartan oral tablet 80 mg . . . . . . . 44temazepam oral capsule 15 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . 42temazepam oral capsule 22.5 mg, 7.5 mg . . . . . . . . . . . . . . . . . . . 42temsirolimus . . . . . . . . . . . . . . . . . . . . . . 31TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 58tenofovir disoproxil fumarate . . . . . . . 22terazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 44terbinafine hcl oral . . . . . . . . . . . . . . . . . 20terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 65terconazole . . . . . . . . . . . . . . . . . . . . . . . 60

SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 30syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG . . . . . . . . . . . 57SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 22SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 53SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 53SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 34SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 22SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 22SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 54SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 24SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 53SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 53SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 53SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 31SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 54

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 31tacrolimus oral . . . . . . . . . . . . . . . . . . . . 31tacrolimus topical . . . . . . . . . . . . . . . . . . 47TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 31TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 31TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 31tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 31tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 66TARGRETIN TOPICAL . . . . . . . . . . . . 31tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 62tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 62tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 62TASIGNA ORAL CAPSULE 50 MG . 31TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 31tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 48tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 46STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 46STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 46STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 54STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 30streptomycin . . . . . . . . . . . . . . . . . . . . . . 24STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 22SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG . . . 38SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 38sucralfate oral suspension . . . . . . . . . 56sucralfate oral tablet . . . . . . . . . . . . . . . 56sulfacetamide-prednisolone . . . . . . . . 63sulfacetamide sodium (acne) . . . . . . . 48sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 63sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 26sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 26sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 26sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 26sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 56sulfatrim . . . . . . . . . . . . . . . . . . . . . . . . . . 26sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 34sumatriptan succinate oral . . . . . . . . . 34sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 34sumatriptan succinate subcutaneous pen injector . . . . . . . . . 34sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 34sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml . . 34SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML . . 23SUPREP BOWEL PREP KIT . . . . . . . 56

91


Covered Drugs Index

TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 63travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 63trazodone . . . . . . . . . . . . . . . . . . . . . . . . . 42TREANDA INTRAVENOUS RECON SOLN 25 MG . . . . . . . . . . . . . 31TREANDA INTRAVENOUS RECON SOLN 100 MG . . . . . . . . . . . . 31TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 24TRELEGY ELLIPTA . . . . . . . . . . . . . . . 65TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG . . . . . . 31TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG . . . . . 31TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG . . . . . . 31treprostinil sodium . . . . . . . . . . . . . . . . . 45TRESIBA FLEXTOUCH U-100 . . . . . 53TRESIBA FLEXTOUCH U-200 . . . . . 53TRESIBA U-100 INSULIN . . . . . . . . . . 53tretinoin (chemotherapy) . . . . . . . . . . . 31tretinoin microspheres . . . . . . . . . . . . . 48tretinoin topical cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . 48tretinoin topical topical gel 0.01% . . . 48tretinoin topical topical gel 0.025%, 0.05% . . . . . . . . . . . . . . . . . . . . 48triamcinolone acetonide dental . . . . . 50triamcinolone acetonide injection . . . 51triamcinolone acetonide topical cream 0.1% . . . . . . . . . . . . . . . . 49triamcinolone acetonide topical cream 0.025%, 0.5% . . . . . . . . 49triamcinolone acetonide topical lotion . . . . . . . . . . . . . . . . . . . . . . . 49triamcinolone acetonide topical ointment . . . . . . . . . . . . . . . . . . . 49triamterene-hydrochlorothiazid oral capsule 37.5-25 mg . . . . . . . . . . . 45triamterene-hydrochlorothiazid oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 45

tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 49TIVICAY ORAL TABLET 10 MG . . . . 22TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . 22tizanidine oral capsule . . . . . . . . . . . . . 35tizanidine oral tablet . . . . . . . . . . . . . . . 35TOBI PODHALER . . . . . . . . . . . . . . . . . 24TOBRADEX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 64tobramycin . . . . . . . . . . . . . . . . . . . . . . . . 63tobramycin-dexamethasone . . . . . . . . 64tobramycin in 0.225% nacl . . . . . . . . . 24tobramycin sulfate . . . . . . . . . . . . . . . . . 24TOBREX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 63TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 47tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 34tolterodine oral capsule, extended release 24hr . . . . . . . . . . . . . 66tolterodine oral tablet . . . . . . . . . . . . . . 66topiramate oral capsule, sprinkle . . . 34topiramate oral tablet . . . . . . . . . . . . . . 34toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 31topotecan intravenous recon soln . . . 31toremifene . . . . . . . . . . . . . . . . . . . . . . . . 31TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 31torsemide oral . . . . . . . . . . . . . . . . . . . . . 44TOUJEO MAX U-300 SOLOSTAR . . 53TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 53TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 66TPN ELECTROLYTES . . . . . . . . . . . . . 67TRACLEER ORAL TABLET FOR SUSPENSION . . . . . . . . . . . . . . . 65TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 53tramadol-acetaminophen . . . . . . . . . . . 38tramadol oral tablet 50 mg . . . . . . . . . 38trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 45tranexamic acid oral . . . . . . . . . . . . . . . 60tranylcypromine . . . . . . . . . . . . . . . . . . . 42TRAVASOL 10% . . . . . . . . . . . . . . . . . . 67

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml) . . . . 54TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML . 54testosterone enanthate . . . . . . . . . . . . 54testosterone transdermal gel . . . . . . . 54testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%) . . . . . . . . . . . 54testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) . . . . . . . . . . . . . . . . 54TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . . . . . . 58tetrabenazine oral tablet 12.5 mg . . . 35tetrabenazine oral tablet 25 mg . . . . . 35tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 26THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 31THALOMID ORAL CAPSULE 200 MG 31THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 65theophylline oral tablet extended release 12 hr . . . . . . . . . . . . 65theophylline oral tablet extended release 24 hr . . . . . . . . . . . . 65thioridazine . . . . . . . . . . . . . . . . . . . . . . . 42thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 31thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 42THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 54THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 54THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 54THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 54THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 54tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 34TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 31tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 24tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 63TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION. . 63timolol maleate oral . . . . . . . . . . . . . . . . 44

92


Covered Drugs Index

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 25vancomycin oral capsule 125 mg . . . 25vancomycin oral capsule 250 mg . . . 25vancomycin oral recon soln . . . . . . . . 25VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 25vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 60VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 58VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 58VARIZIG INTRAMUSCULAR SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 58VASCEPA ORAL CAPSULE 0.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 46VASCEPA ORAL CAPSULE 1 GRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 46VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 31VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 31velivet triphasic regimen (28) . . . . . . . 62VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 50VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 50VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . 22VENCLEXTA ORAL TABLET 10 MG . . . . . . . . . . . . . . . . . . . 31VENCLEXTA ORAL TABLET 50 MG . . . . . . . . . . . . . . . . . . . 31VENCLEXTA ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 31VENCLEXTA STARTING PACK . . . . 31venlafaxine oral capsule,extended release 24hr 75 mg . . . . . . . . . . . . . . . . 42venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg . . . . . . 42venlafaxine oral tablet . . . . . . . . . . . . . . 42VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 66VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 66verapamil intravenous solution . . . . . 45verapamil oral capsule, 24 hr er pellet ct . . . . . . . . . . . . . . . . . . . 45verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg . . . . . . . . . . . . . . . . . . . 45

TWINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 58TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 22tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 31TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 59TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 58TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 35

UUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 54unithroid oral tablet 137 mcg . . . . . . . 54UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 31UPTRAVI . . . . . . . . . . . . . . . . . . . . . . . . . 45ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Vvalacyclovir oral tablet 1 gram . . . . . . 22valacyclovir oral tablet 500 mg . . . . . 22VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 47valganciclovir . . . . . . . . . . . . . . . . . . . . . . 22valproic acid . . . . . . . . . . . . . . . . . . . . . . . 34valproic acid (as sodium salt) oral solution . . . . . . . . . . . . . . . . . . . . . . . 34valsartan-hydrochlorothiazide . . . . . . 45valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 45valsartan oral tablet 320 mg . . . . . . . . 45VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . 24VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . 25VANCOMYCIN INJECTION . . . . . . . . 25vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 25

triderm topical cream 0.1% . . . . . . . . . 49trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 62tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 62trifluoperazine . . . . . . . . . . . . . . . . . . . . . 42trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 63trihexyphenidyl . . . . . . . . . . . . . . . . . . . . 34tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 62tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 62tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 62tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 62tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 62tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 62trilyte with flavor packets . . . . . . . . . . . 56trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 26tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62trimipramine . . . . . . . . . . . . . . . . . . . . . . . 42TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 42tri-previfem (28) . . . . . . . . . . . . . . . . . . . 62TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 31TRISENOX INTRAVENOUS SOLUTION 2 MG/ML . . . . . . . . . . . . . . 31tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 62TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 22trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 62tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 62tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 62TROGARZO . . . . . . . . . . . . . . . . . . . . . . 22TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG . . . . . 34TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG . . . . . . . . . . . . . . . . . . . . . 34TROPHAMINE 6% . . . . . . . . . . . . . . . . 67TROPHAMINE 10% . . . . . . . . . . . . . . . 67TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 56TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 53TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 58TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 22TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 31

93


Covered Drugs Index

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG . . . . . . . . . . 53XIIDRA . . . . . . . . . . . . . . . . . . . . . . . . . . . 63XOFLUZA . . . . . . . . . . . . . . . . . . . . . . . . . 22XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 66XOLAIR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 66XOPENEX . . . . . . . . . . . . . . . . . . . . . . . . 66XOPENEX CONCENTRATE . . . . . . . 66XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 32XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3) . . . . . . . . . 32XPOVIO ORAL TABLET 80 MG/WEEK (20 MG X 4) . . . . . . . . . 32XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) . . . . . . . . 32XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8) . . . . . . . . 32XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 37XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 32XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 53XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

YYERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 32YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 32YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 58YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 32YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 32YUPELRI . . . . . . . . . . . . . . . . . . . . . . . . . 66yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 66zaleplon oral capsule 5 mg . . . . . . . . . 42

VITRAKVI ORAL CAPSULE 25 MG . . . . . . . . . . . . . . . . . 32VITRAKVI ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 32VITRAKVI ORAL SOLUTION . . . . . . . 32VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 38VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 32voriconazole intravenous . . . . . . . . . . . 20voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 20voriconazole oral tablet . . . . . . . . . . . . 20VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 22VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 32VRAYLAR ORAL CAPSULE . . . . . . . . 42VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 42vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 62vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 45water for irrigation, sterile . . . . . . . . . . 50wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 62wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 62

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 32XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 45XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 32XELJANZ . . . . . . . . . . . . . . . . . . . . . . . . . 59XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 59XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 26XHANCE . . . . . . . . . . . . . . . . . . . . . . . . . . 66XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 50XIFAXAN ORAL TABLET 550 MG . . 25XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG . . . . . . . . . . . . 53

VERAPAMIL ORAL CAPSULE, EXT REL. PELLETS 24 HR 360 MG . 45verapamil oral tablet . . . . . . . . . . . . . . . 45verapamil oral tablet extended release . . . . . . . . . . . . . . . . . . 45VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 42VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 31V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 53V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 53V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 53VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 56VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 53VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 53VIDEX 2 GRAM PEDIATRIC . . . . . . . 22VIDEX EC ORAL CAPSULE, DELAYED RELEASE (DR/EC) 125 MG . . . . . . . . . . . . . . . . . . 22vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 34vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 34VIIBRYD ORAL TABLET . . . . . . . . . . . 42VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 42VIMPAT INTRAVENOUS . . . . . . . . . . . 34VIMPAT ORAL SOLUTION . . . . . . . . . 34VIMPAT ORAL TABLET 50 MG . . . . . 34VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 34vincasar pfs intravenous solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 31vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 31vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 31VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT . . . . . . . 56VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT . . . . . . . 56viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 62VIRACEPT ORAL TABLET 250 MG . 22VIRACEPT ORAL TABLET 625 MG . 22VIREAD ORAL POWDER . . . . . . . . . . 22VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . 22

94


Covered Drugs Index

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG . . . . . . . . . 38ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG . . . . . . . . . . . . 38zumandimine (28) . . . . . . . . . . . . . . . . . 62ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYKADIA ORAL TABLET . . . . . . . . . . 32ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG . . 42ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG . . 42ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG . . 42ZYTIGA ORAL TABLET 500 MG . . . . 32

zaleplon oral capsule 10 mg . . . . . . . . 42zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 57zebutal oral capsule 50-325-40 mg . 37ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 32ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 50zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 48ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT . . . . . . . . 56zidovudine oral capsule . . . . . . . . . . . . 22zidovudine oral syrup . . . . . . . . . . . . . . 22zidovudine oral tablet . . . . . . . . . . . . . . 22ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 57ZIOPTAN (PF) . . . . . . . . . . . . . . . . . . . . . 63ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 42ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 63zoledronic acid intravenous solution . . . . . . . . . . . . . . . 54zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . 50ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 32zolpidem oral tablet . . . . . . . . . . . . . . . . 42zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 34ZORTRESS ORAL TABLET 0.5 MG . . . . . . . . . . . . . . . . . . . 32ZORTRESS ORAL TABLET 0.25 MG . . . . . . . . . . . . . . . . . . 32ZORTRESS ORAL TABLET 0.75 MG, 1 MG . . . . . . . . . . . 32ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 58ZOSYN IN DEXTROSE (ISO-OSM) 25ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM . . . 25zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 62ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

95

Notes

96

Notes

97

Notes

98

Notice of Nondiscrimination: Discrimination is Against the Law

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact Customer Service at 1-800-668-3813, 8 a.m.–8 p.m., 7 days a week.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Cigna Attn: Customer Grievances PO Box 2888 Houston, TX 77252-2888 Phone: 1-800-668-3813 (TTY 711) Fax: 1-888-586-9946.

You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m., 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m , 7 días de la semana. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.

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Notificación Contra la Discriminación: La Discriminación es Contra la Ley

Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Cigna no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Cigna: • Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Servicio al Cliente al 1-800-668-3813, 8 a.m. – 8 p.m., 7 días de la semana.

Si considera que Cigna no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Cigna Attn: Customer Grievances PO Box 2888 Houston, TX 77252-2888 Teléfono: 1-800-668-3813 (TTY 711) Fax: 1-888-586-9946.

Puede presentar el reclamo escrito por correo postal o fax. Si necesita ayuda para hacerlo, Servicio al Cliente está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal (Oficina de Derechos Civiles portal de quejas), disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m., 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m, 7 días de la semana. Cigna-HealthSpring tiene contrato con Medicare para planes PDP, planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción en Cigna-HealthSpring depende de la renovación de contrato.

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100Y0036_17_50169 ACCEPTED 17_MLI_MAPD

English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711).

Chinese – 1-800-668-3813 (TTY 711)

Vietnamese – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-668-3813 (TTY 711).

French Creole – ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-668-3813 (TTY 711).

Korean – 1-800-668-3813 (TTY 711)

Polish – UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-668-3813 (TTY 711).

French – ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-668-3813 (ATS 711).

Arabic – 1-800-668-3813 اتصل برقم. ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجاناللغة العربیةإذا كنت تتحدث : ملحوظة )TTY 711.(

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-668-3813 (телетайп 711).

Tagalog – PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-668-3813 (TTY 711).

Farsi/Persian – . توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد . تماس بگیرید (711 :TTY) 1-800-668-3813 با

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Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-668-3813 (TTY 711).

Italian – ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-668-3813 (TTY 711).

Japanese – 1-800-668-3813 (TTY 711)

Navajo – D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-668-3813 (TTY 711).

Gujarati – �યાન આપો: જો તમે �જુરાતી બોલતા હો તો િન:��ુક ભાષા સહાય સેવાઓ તમારા માટ� �પલ�� છે. ફોન કરો 1-800-668-3813 (TTY 711).

Urdu توجہ دیں: اگرآپ اردو زبان بولتے ہیں تو آپ کےلئے زبان معاون خدمات مفت میں دستیاب ہیں۔ کال کریں 1-800-668-3813 (TTY 711)

This drug list was updated in April 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc.© 2019 Cigna 929077 d

CignaMedicare.com

1-800-668-3813 (TTY 711) October 1 – March 31, 8:00 a.m. – 8:00 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday, 8:00 a.m. – 8:00 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

Documents

2020 CIGNA COMPREHENSIVE DRUG LIST …...1 What is the Cigna Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna in consultation with a team of health