2021 Northwest Commercial Formulary (List of Covered Drugs)
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2021 Northwest Commercial Formulary
(List of Covered Drugs)
Please Read: This document contains information about the drugs we
cover when you participate in a Kaiser Permanente Commercial
(non-Medicare) plan.
What is the Kaiser Permanente Northwest Commercial Formulary? A
formulary is a list of covered drugs chosen by a group of Kaiser
Permanente physicians and pharmacists known as the Formulary and
Therapeutics Committee. This committee meets regularly to evaluate
and select the safest, most effective medications for our members.
What is a generic drug? Our plan 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. What is a brand-name drug?
Brand-name drugs are manufactured and sold by the pharmaceutical
company that originally researched and developed the drug. When the
patent on a brand-name drug expires, other pharmaceutical companies
may manufacture and sell an FDA-approved generic version of the
drug with the same active ingredient(s) at lower prices. What are
specialty-tier drugs? Specialty-tier drugs are very high-cost
drugs. Kaiser Permanente Formulary The formulary list that begins
on the next page provides coverage information about some of the
drugs covered by our plan.
The first column of the chart lists the drug name. Brand-name drugs
are capitalized (e.g. ALBENZA) and generic drugs are listed in
lower-case italics (e.g. amoxicillin).
The second column will indicate what tier the drug is in. Drugs on
our formulary are categorized as Generic, Preferred Brand or
Specialty.
The third column of the chart will indicate any requirements or
limits for that drug.
DS = A drug that is limited to no more than a 30-day supply per
dispense.
PA = A drug that requires specific medical criteria be met and
requires approval by the plan prior to being dispensed for
benefit.
QL = A drug that is limited to no more than a specific quantity
within a certain period of days.
Last Updated 09/25/2021 Effective 10/21/2021
Drug Name Drug Tier Requirements/Limits Analgesics No USP Class
(Combination Product) acetaminophen-codeine #2 tabs 300-15 mg
Generic acetaminophen-codeine #3 tabs 300-30 mg Generic
acetaminophen-codeine soln 120-12 mg/5ml Generic
hydrocodone-acetaminophen soln 7.5-325 mg/15ml Generic DS
hydrocodone-acetaminophen tabs 10-325 mg Generic DS
hydrocodone-acetaminophen tabs 5-325 mg Generic DS
oxycodone-acetaminophen tabs 5-325 mg Generic DS Nonsteroidal
Anti-Inflammatory Drugs etodolac caps 300 mg Generic etodolac tabs
400 mg Generic ibuprofen tabs 800 mg Generic indomethacin caps 25
mg Generic indomethacin caps 50 mg Generic indomethacin er cpcr 75
mg Generic ketorolac tromethamine soln 30 mg/ml Generic meloxicam
tabs 15 mg Generic meloxicam tabs 7.5 mg Generic nabumetone tabs
500 mg Generic nabumetone tabs 750 mg Generic naproxen tabs 250 mg
Generic naproxen tabs 375 mg Generic naproxen tabs 500 mg Generic
sulindac tabs 150 mg Generic sulindac tabs 200 mg Generic Opioid
Analgesics, Long-Acting fentanyl pt72 100 mcg/hr Generic DS
fentanyl pt72 12 mcg/hr Generic DS fentanyl pt72 25 mcg/hr Generic
DS fentanyl pt72 50 mcg/hr Generic DS fentanyl pt72 75 mcg/hr
Generic DS methadone hcl conc 10 mg/ml Generic DS methadone hcl
tabs 10 mg Generic DS methadone hcl tabs 5 mg Generic DS morphine
sulfate (concentrate) soln 100 mg/5ml Generic DS morphine sulfate
er tbcr 100 mg Generic DS morphine sulfate er tbcr 15 mg Generic DS
morphine sulfate er tbcr 200 mg Generic DS morphine sulfate er tbcr
30 mg Generic DS morphine sulfate er tbcr 60 mg Generic DS morphine
sulfate soln 10 mg/5ml Generic DS MORPHINE SULFATE TABS 15 MG
Preferred Brand DS MORPHINE SULFATE TABS 30 MG Preferred Brand DS
Opioid Analgesics, Short-Acting codeine sulfate tabs 30 mg Generic
DS
Last Updated 09/25/2021 Effective 10/21/2021
codeine sulfate tabs 60 mg Generic DS hydromorphone hcl tabs 2 mg
Generic DS hydromorphone hcl tabs 4 mg Generic DS morphine sulfate
supp 10 mg Generic DS morphine sulfate supp 20 mg Generic DS
morphine sulfate supp 30 mg Generic DS oxycodone hcl soln 5 mg/5 ml
Generic DS oxycodone hcl tabs 5 mg Generic DS oxycodone hcl tabs 10
mg Generic PA, DS oxycodone hcl tabs 15 mg Generic PA, DS tramadol
hcl tabs 50 mg Generic Anesthetics Local Anesthetics lidocaine hcl
gel 2 % Generic lidocaine hcl soln 4 % Generic lidocaine hcl
urethral/mucosal prsy 2 % Generic lidocaine viscous soln 2 %
Generic Anti-Addiction/Substance Abuse Treatment Agents Alcohol
Deterrents/Anti-Craving acamprosate calcium tbec 333 mg Generic
disulfiram tabs 250 mg Generic No USP Class (Combination Product)
buprenorphine hcl-naloxone hcl subl 2-0.5 mg Generic DS
buprenorphine hcl-naloxone hcl subl 8-2 mg Generic DS Opioid
Antagonists buprenorphine hcl subl 2 mg Generic DS buprenorphine
hcl subl 8 mg Generic DS naloxone hcl sosy 2 mg/2ml Generic
naltrexone hcl tabs 50 mg Generic NARCAN LIQD 4 MG/0.1ML Preferred
Brand Smoking Cessation Agents bupropion hcl er (smoking det) tb12
150 mg Generic CHANTIX STARTING MONTH PAK TABS 0.5 MG X 11 & 1
MG X 42 Preferred Brand PA
CHANTIX TABS 0.5 MG Preferred Brand PA CHANTIX TABS 1 MG Preferred
Brand PA gnp nicotine polacrilex lozg 2 mg Generic gnp nicotine
polacrilex lozg 4 mg Generic nicotine kit 21-14-7 mg/24hr Generic
nicotine polacrilex gum 2 mg Generic nicotine polacrilex gum 4 mg
Generic nicotine pt24 14 mg/24hr Generic nicotine pt24 21 mg/24hr
Generic nicotine pt24 7 mg/24hr Generic Antibacterials
Aminoglycosides gentak oint 0.3 % Generic gentamicin sulfate crea
0.1 % Generic
Last Updated 09/25/2021 Effective 10/21/2021
gentamicin sulfate oint 0.1 % Generic gentamicin sulfate soln 0.3 %
Generic neomycin sulfate tabs 500 mg Generic paromomycin sulfate
caps 250 mg Generic TOBI PODHALER CAPS 28 MG Specialty tobramycin
nebu 300 mg/5ml Generic tobramycin soln 0.3 % Generic
Antibacterials, Other acetic acid soln 2 % Generic bacitracin oint
500 unit/gm Generic clindamycin hcl caps 150 mg Generic clindamycin
hcl caps 300 mg Generic clindamycin palmitate hcl solr 75 mg/5ml
Generic clindamycin phosphate gel 1 % Generic clindamycin phosphate
lotn 1 % Generic clindamycin phosphate soln 1 % Generic fosfomycin
tromethamine pack 3 gm Generic linezolid susr 100 mg/5ml Generic
linezolid tabs 600 mg Generic metronidazole crea 0.75 % Generic
metronidazole gel 0.75 % Generic metronidazole tabs 250 mg Generic
metronidazole tabs 500 mg Generic mupirocin oint 2 % Generic
nitrofurantoin macrocrystal caps 25 mg Generic nitrofurantoin
macrocrystal caps 50 mg Generic nitrofurantoin macrocrystal caps
100 mg Generic nitrofurantoin monohyd macro caps 100 mg Generic
trimethoprim tabs 100 mg Generic vancomycin hcl caps 125 mg Generic
vancomycin hcl caps 250 mg Generic vancomycin hcl solr 250 mg/5ml
Generic Beta-Lactam, Cephalosporins cefadroxil caps 500 mg Generic
cefdinir caps 300 mg Generic cefdinir susr 125 mg/5ml Generic
cefdinir susr 250 mg/5ml Generic cefixime caps 400 mg Generic
cefpodoxime proxetil susr 100 mg/5ml Generic cefpodoxime proxetil
tabs 200 mg Generic cefuroxime axetil tabs 250 mg Generic
cefuroxime axetil tabs 500 mg Generic cephalexin caps 250 mg
Generic cephalexin caps 500 mg Generic cephalexin susr 125 mg/5ml
Generic cephalexin susr 250 mg/5ml Generic Beta-Lactam, Other
CAYSTON SOLR 75 MG Specialty DS
Last Updated 09/25/2021 Effective 10/21/2021
Beta-Lactam, Penicillins amoxicillin caps 250 mg Generic
amoxicillin caps 500 mg Generic amoxicillin susr 125 mg/5ml Generic
amoxicillin susr 250 mg/5ml Generic amoxicillin susr 400 mg/5ml
Generic amoxicillin-pot clavulanate chew 200-28.5 mg Generic
amoxicillin-pot clavulanate chew 400-57 mg Generic amoxicillin-pot
clavulanate susr 200-28.5 mg/5ml Generic amoxicillin-pot
clavulanate susr 400-57 mg/5ml Generic amoxicillin-pot clavulanate
susr 600-42.9 mg/5ml Generic amoxicillin-pot clavulanate tabs
500-125 mg Generic amoxicillin-pot clavulanate tabs 875-125 mg
Generic dicloxacillin sodium caps 250 mg Generic dicloxacillin
sodium caps 500 mg Generic penicillin v potassium solr 125 mg/5ml
Generic penicillin v potassium solr 250 mg/5ml Generic penicillin v
potassium tabs 250 mg Generic penicillin v potassium tabs 500 mg
Generic Macrolides azithromycin susr 100 mg/5ml Generic
azithromycin susr 200 mg/5ml Generic azithromycin tabs 250 mg
Generic azithromycin tabs 600 mg Generic clarithromycin tabs 500 mg
Generic ery-tab tbec 250 mg Generic erythromycin ethylsuccinate
susr 400 mg/5ml Generic erythromycin oint 5 mg/gm Generic
erythromycin soln 2 % Generic Quinolones ciprofloxacin hcl soln 0.3
% Generic ciprofloxacin hcl tabs 250 mg Generic ciprofloxacin hcl
tabs 500 mg Generic ciprofloxacin hcl tabs 750 mg Generic
levofloxacin soln 25 mg/ml Generic levofloxacin tabs 250 mg Generic
levofloxacin tabs 500 mg Generic levofloxacin tabs 750 mg Generic
moxifloxacin hcl soln 0.5 % Generic ofloxacin soln 0.3 % Generic
Sulfonamides silver sulfadiazine crea 1 % Generic sulfacetamide
sodium soln 10 % Generic sulfadiazine tabs 500 mg Generic
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml Generic
sulfamethoxazole-trimethoprim tabs 400-80 mg Generic
sulfamethoxazole-trimethoprim tabs 800-160 mg Generic
Tetracyclines
Last Updated 09/25/2021 Effective 10/21/2021
doxycycline hyclate caps 100 mg Generic doxycycline hyclate caps 50
mg Generic doxycycline hyclate tabs 20 mg Generic doxycycline
monohydrate tabs 100 mg Generic doxycycline monohydrate tabs 50 mg
Generic minocycline hcl caps 100 mg Generic minocycline hcl caps 50
mg Generic Anticonvulsants Anticonvulsants, Other diazepam gel 2.5
mg Generic diazepam gel 10 mg Generic diazepam gel 20 mg Generic
levetiracetam er tb24 500 mg Generic levetiracetam er tb24 750 mg
Generic levetiracetam soln 100 mg/ml Generic levetiracetam tabs
1000 mg Generic levetiracetam tabs 250 mg Generic levetiracetam
tabs 500 mg Generic levetiracetam tabs 750 mg Generic Calcium
Channel Modifying Agents CELONTIN CAPS 300 MG Preferred Brand
ethosuximide caps 250 mg Generic ethosuximide soln 250 mg/5ml
Generic pregabalin caps 25 mg Generic pregabalin caps 50 mg Generic
pregabalin caps 75 mg Generic pregabalin caps 100 mg Generic
pregabalin caps 150 mg Generic pregabalin caps 200 mg Generic
pregabalin caps 225 mg Generic pregabalin caps 300 mg Generic
pregabalin soln 20 mg/ml Generic zonisamide caps 100 mg Generic
zonisamide caps 25 mg Generic zonisamide caps 50 mg Generic
Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam tabs
0.5 mg Generic clonazepam tabs 1 mg Generic clonazepam tabs 2 mg
Generic divalproex sodium csdr 125 mg Generic divalproex sodium er
tb24 250 mg Generic divalproex sodium er tb24 500 mg Generic
divalproex sodium tbec 125 mg Generic divalproex sodium tbec 250 mg
Generic divalproex sodium tbec 500 mg Generic gabapentin caps 100
mg Generic gabapentin caps 300 mg Generic gabapentin caps 400 mg
Generic
Last Updated 09/25/2021 Effective 10/21/2021
gabapentin tabs 600 mg Generic gabapentin tabs 800 mg Generic
phenobarbital elix 20 mg/5ml Generic phenobarbital tabs 16.2 mg
Generic phenobarbital tabs 32.4 mg Generic phenobarbital tabs 64.8
mg Generic phenobarbital tabs 97.2 mg Generic primidone tabs 250 mg
Generic primidone tabs 50 mg Generic tiagabine hcl tabs 2 mg
Generic tiagabine hcl tabs 4 mg Generic tiagabine hcl tabs 12 mg
Generic tiagabine hcl tabs 16 mg Generic valproic acid caps 250 mg
Generic valproic acid soln 250 mg/5ml Generic Glutamate Reducing
Agents lamotrigine chew 25 mg Generic lamotrigine chew 5 mg Generic
lamotrigine tabs 100 mg Generic lamotrigine tabs 150 mg Generic
lamotrigine tabs 200 mg Generic lamotrigine tabs 25 mg Generic
topiramate cpsp 15 mg Generic topiramate cpsp 25 mg Generic
topiramate tabs 100 mg Generic topiramate tabs 200 mg Generic
topiramate tabs 25 mg Generic topiramate tabs 50 mg Generic Sodium
Channel Agents carbamazepine chew 100 mg Generic carbamazepine er
cp12 100 mg Generic carbamazepine er cp12 200 mg Generic
carbamazepine er cp12 300 mg Generic carbamazepine er tb12 100 mg
Generic carbamazepine er tb12 200 mg Generic carbamazepine er tb12
400 mg Generic carbamazepine susp 100 mg/5ml Generic carbamazepine
tabs 200 mg Generic dilantin caps 30 mg Generic oxcarbazepine susp
300 mg/5ml Generic oxcarbazepine tabs 150 mg Generic oxcarbazepine
tabs 300 mg Generic oxcarbazepine tabs 600 mg Generic phenytoin
chew 50 mg Generic phenytoin sodium extended caps 100 mg Generic
phenytoin susp 125 mg/5ml Generic Antidementia Agents
Cholinesterase Inhibitors
Last Updated 09/25/2021 Effective 10/21/2021
donepezil hcl tabs 10 mg Generic donepezil hcl tabs 5 mg Generic
galantamine hydrobromide er cp24 16 mg Generic galantamine
hydrobromide er cp24 24 mg Generic galantamine hydrobromide er cp24
8 mg Generic galantamine hydrobromide tabs 12 mg Generic
galantamine hydrobromide tabs 4 mg Generic galantamine hydrobromide
tabs 8 mg Generic N-Methyl-D-Aspartate (NMDA) Receptor Antagonists
memantine hcl tabs 10 mg Generic memantine hcl tabs 5 mg Generic
Antidepressants Antidepressants, Other aripiprazole tabs 10 mg
Generic aripiprazole tabs 15 mg Generic aripiprazole tabs 2 mg
Generic aripiprazole tabs 20 mg Generic aripiprazole tabs 30 mg
Generic aripiprazole tabs 5 mg Generic bupropion hcl er (sr) tb12
100 mg Generic bupropion hcl er (sr) tb12 150 mg Generic bupropion
hcl er (sr) tb12 200 mg Generic bupropion hcl er (xl) tb24 150 mg
Generic bupropion hcl er (xl) tb24 300 mg Generic bupropion hcl
tabs 100 mg Generic bupropion hcl tabs 75 mg Generic mirtazapine
tabs 15 mg Generic mirtazapine tabs 30 mg Generic mirtazapine tabs
45 mg Generic trazodone hcl tabs 50 mg Generic trazodone hcl tabs
100 mg Generic trazodone hcl tabs 150 mg Generic Monoamine Oxidase
Inhibitors phenelzine sulfate tabs 15 mg Generic tranylcypromine
sulfate tabs 10 mg Generic Serotonin/Norepinephrine Reuptake
Inhibitors citalopram hydrobromide soln 10 mg/5ml Generic
citalopram hydrobromide tabs 10 mg Generic citalopram hydrobromide
tabs 20 mg Generic citalopram hydrobromide tabs 40 mg Generic
desvenlafaxine succinate er tb24 25 mg Generic desvenlafaxine
succinate er tb24 50 mg Generic desvenlafaxine succinate er tb24
100 mg Generic duloxetine hcl cpep 20 mg Generic duloxetine hcl
cpep 30 mg Generic duloxetine hcl cpep 60 mg Generic escitalopram
oxalate tabs 10 mg Generic escitalopram oxalate tabs 20 mg
Generic
Last Updated 09/25/2021 Effective 10/21/2021
escitalopram oxalate tabs 5 mg Generic fluoxetine hcl caps 10 mg
Generic fluoxetine hcl caps 20 mg Generic fluoxetine hcl caps 40 mg
Generic fluoxetine hcl soln 20 mg/5ml Generic fluvoxamine maleate
tabs 100 mg Generic fluvoxamine maleate tabs 25 mg Generic
fluvoxamine maleate tabs 50 mg Generic paroxetine hcl tabs 10 mg
Generic paroxetine hcl tabs 20 mg Generic paroxetine hcl tabs 30 mg
Generic paroxetine hcl tabs 40 mg Generic sertraline hcl tabs 100
mg Generic sertraline hcl tabs 25 mg Generic sertraline hcl tabs 50
mg Generic venlafaxine hcl er cp24 150 mg Generic venlafaxine hcl
er cp24 37.5 mg Generic venlafaxine hcl er cp24 75 mg Generic
venlafaxine hcl tabs 100 mg Generic venlafaxine hcl tabs 25 mg
Generic venlafaxine hcl tabs 37.5 mg Generic venlafaxine hcl tabs
50 mg Generic venlafaxine hcl tabs 75 mg Generic Tricyclics
amitriptyline hcl tabs 10 mg Generic amitriptyline hcl tabs 100 mg
Generic amitriptyline hcl tabs 150 mg Generic amitriptyline hcl
tabs 25 mg Generic amitriptyline hcl tabs 50 mg Generic
amitriptyline hcl tabs 75 mg Generic desipramine hcl tabs 10 mg
Generic desipramine hcl tabs 25 mg Generic desipramine hcl tabs 50
mg Generic desipramine hcl tabs 75 mg Generic desipramine hcl tabs
100 mg Generic desipramine hcl tabs 150 mg Generic doxepin hcl caps
10 mg Generic doxepin hcl caps 25 mg Generic doxepin hcl caps 50 mg
Generic doxepin hcl conc 10 mg/ml Generic nortriptyline hcl caps 10
mg Generic nortriptyline hcl caps 25 mg Generic nortriptyline hcl
caps 50 mg Generic nortriptyline hcl caps 75 mg Generic
protriptyline hcl tabs 10 mg Generic protriptyline hcl tabs 5 mg
Generic Antiemetics Antiemetics, Other
Last Updated 09/25/2021 Effective 10/21/2021
chlorpromazine hcl tabs 10 mg Generic chlorpromazine hcl tabs 100
mg Generic chlorpromazine hcl tabs 200 mg Generic chlorpromazine
hcl tabs 25 mg Generic chlorpromazine hcl tabs 50 mg Generic
hydroxyzine hcl soln 10 mg/5ml Generic hydroxyzine hcl soln 50
mg/ml Generic hydroxyzine hcl tabs 10 mg Generic hydroxyzine hcl
tabs 25 mg Generic hydroxyzine hcl tabs 50 mg Generic hydroxyzine
pamoate caps 25 mg Generic hydroxyzine pamoate caps 50 mg Generic
metoclopramide hcl soln 5 mg/5ml Generic metoclopramide hcl tabs 10
mg Generic metoclopramide hcl tabs 5 mg Generic perphenazine tabs
16 mg Generic perphenazine tabs 2 mg Generic perphenazine tabs 4 mg
Generic perphenazine tabs 8 mg Generic prochlorperazine maleate
tabs 10 mg Generic prochlorperazine maleate tabs 5 mg Generic
prochlorperazine supp 25 mg Generic promethazine hcl syrp 6.25
mg/5ml Generic promethazine hcl tabs 25 mg Generic promethegan supp
12.5 mg Generic promethegan supp 25 mg Generic scopolamine pt72 1
mg/3days Generic Emetogenic Therapy Adjuncts ondansetron hcl tabs 4
mg Generic ondansetron hcl tabs 8 mg Generic ondansetron tbdp 4 mg
Generic ondansetron tbdp 8 mg Generic Antifungals clotrimazole troc
10 mg Generic fluconazole tabs 100 mg Generic fluconazole tabs 150
mg Generic fluconazole tabs 200 mg Generic fluconazole tabs 50 mg
Generic FLUCYTOSINE CAPS 250 MG Specialty FLUCYTOSINE CAPS 500 MG
Specialty griseofulvin microsize susp 125 mg/5ml Generic
griseofulvin ultramicrosize tabs 125 mg Generic griseofulvin
ultramicrosize tabs 250 mg Generic ketoconazole crea 2 % Generic
ketoconazole sham 2 % Generic ketoconazole tabs 200 mg Generic
NATACYN SUSP 5 % Preferred Brand NOXAFIL SUSP 40 MG/ML
Specialty
Last Updated 09/25/2021 Effective 10/21/2021
nystatin crea 100000 unit/gm Generic nystatin oint 100000 unit/gm
Generic nystatin susp 100000 unit/ml Generic nystop powd 100000
unit/gm Generic posaconazole tbec 100 mg Specialty terbinafine hcl
tabs 250 mg Generic voriconazole tabs 200 mg Generic voriconazole
tabs 50 mg Generic Antigout Agents allopurinol tabs 100 mg Generic
allopurinol tabs 300 mg Generic probenecid tabs 500 mg Generic
colchicine tabs 0.6 mg Generic colchicine-probenecid tabs 0.5-500
mg Generic Antimigraine Agents Ergot Alkaloids dihydroergotamine
mesylate soln 1 mg/ml Generic DS dihydroergotamine mesylate soln 4
mg/ml Generic No USP Class (Combination Product) MIGERGOT SUPP
2-100 MG Preferred Brand Serotonin (5-HT) 1B/1D Receptor Agonists
naratriptan hcl tabs 1 mg Generic naratriptan hcl tabs 2.5 mg
Generic rizatriptan benzoate tabs 10 mg Generic rizatriptan
benzoate tabs 5 mg Generic rizatriptan benzoate tbdp 10 mg Generic
rizatriptan benzoate tbdp 5 mg Generic sumatriptan soln 20 mg/act
Generic sumatriptan succinate refill soct 6 mg/0.5ml Generic
sumatriptan succinate soaj 6 mg/0.5ml Generic sumatriptan succinate
soln 6 mg/0.5ml Generic sumatriptan succinate tabs 100 mg Generic
sumatriptan succinate tabs 25 mg Generic sumatriptan succinate tabs
50 mg Generic Antimyasthenic Agents Parasympathomimetics
pyridostigmine bromide er tbcr 180 mg Generic pyridostigmine
bromide tabs 60 mg Generic Antimycobacterials Antimycobacterials,
Other dapsone tabs 100 mg Generic dapsone tabs 25 mg Generic
rifabutin caps 150 mg Generic Antituberculars ethambutol hcl tabs
100 mg Generic ethambutol hcl tabs 400 mg Generic isoniazid syrp 50
mg/5ml Generic isoniazid tabs 100 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
isoniazid tabs 300 mg Generic PRETOMANID TABS 200 MG Preferred
Brand pyrazinamide tabs 500 mg Generic rifamate caps 150-300 mg
Generic rifampin caps 150 mg Generic rifampin caps 300 mg Generic
TRECATOR TABS 250 MG Preferred Brand Antineoplastics Alkylating
Agents cyclophosphamide caps 25 mg Generic cyclophosphamide caps 50
mg Generic GLEOSTINE CAPS 10 MG Preferred Brand GLEOSTINE CAPS 40
MG Specialty GLEOSTINE CAPS 100 MG Specialty LEUKERAN TABS 2 MG
Preferred Brand LOMUSTINE CAPS 100 MG Preferred Brand MATULANE CAPS
50 MG Specialty DS melphalan tabs 2 mg Generic MYLERAN TABS 2 MG
Preferred Brand temozolomide caps 100 mg Generic temozolomide caps
140 mg Generic temozolomide caps 180 mg Generic temozolomide caps
20 mg Generic temozolomide caps 250 mg Generic temozolomide caps 5
mg Generic Antiangiogenic Agents
REVLIMID CAPS 2.5 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 5 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 10 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 15 MG Specialty DS, QL (21 PER 28 DAYS)
REVLIMID CAPS 20 MG Specialty DS, QL (21 PER 28 DAYS)
REVLIMID CAPS 25 MG Specialty DS, QL (21 PER 28 DAYS)
Antiestrogens/Modifiers tamoxifen citrate tabs 10 mg Generic
tamoxifen citrate tabs 20 mg Generic Antimetabolites capecitabine
tabs 150 mg Generic DS capecitabine tabs 500 mg Generic DS
hydroxyurea caps 500 mg Generic LONSURF TABS 15-6.14 MG Specialty
DS LONSURF TABS 20-8.19 MG Specialty DS PURIXAN SUSP 2000 MG/100ML
Specialty DS
Last Updated 09/25/2021 Effective 10/21/2021
TABLOID TABS 40 MG Preferred Brand Antineoplastics, Other etoposide
caps 50 mg Generic
JAKAFI TABS 10 MG Specialty DS, QL (30 PER 30 DAYS)
JAKAFI TABS 15 MG Specialty DS, QL (60 PER 30 DAYS)
JAKAFI TABS 20 MG Specialty DS, QL (60 PER 30 DAYS)
JAKAFI TABS 25 MG Specialty DS, QL (60 PER 30 DAYS)
JAKAFI TABS 5 MG Specialty DS, QL (30 PER 30 DAYS)
leucovorin calcium tabs 25 mg Generic leucovorin calcium tabs 5 mg
Generic
ODOMZO CAPS 200 MG Specialty PA, DS, QL (30 PER 30 DAYS)
POMALYST CAPS 1 MG Specialty PA, DS, QL (21 PER 28 DAYS)
POMALYST CAPS 2 MG Specialty PA, DS, QL (21 PER 28 DAYS)
POMALYST CAPS 3 MG Specialty PA, DS, QL (21 PER 28 DAYS)
POMALYST CAPS 4 MG Specialty PA, DS, QL (21 PER 28 DAYS)
XTANDI CAPS 40 MG Specialty PA, DS, QL (120 PER 30 DAYS)
XTANDI TABS 40 MG Specialty PA, DS, QL (120 PER 30 DAYS)
XTANDI TABS 80 MG Specialty PA, DS, QL (60 PER 30 DAYS)
Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 mg Generic
letrozole tabs 2.5 mg Generic Enzyme Inhibitors ALECENSA CAPS 150
MG Specialty DS
BRUKINSA CAPS 80 MG Specialty PA, DS, QL (120 PER 30 DAYS)
CALQUENCE CAPS 100 MG Preferred Brand PA, DS, QL (60 PER 30
DAYS)
COPIKTRA CAPS 15 MG Specialty PA, DS COPIKTRA CAPS 25 MG Specialty
PA, DS
COTELLIC TABS 20 MG Specialty DS, QL (63 PER 28 DAYS)
IBRANCE TABS 75 MG Specialty DS, QL (21 PER 28 DAYS)
IBRANCE TABS 100 MG Specialty DS, QL (21 PER 28 DAYS)
Last Updated 09/25/2021 Effective 10/21/2021
IBRANCE TABS 125 MG Specialty DS, QL (21 PER 28 DAYS)
IRESSA TABS 250 MG Specialty DS LENVIMA 4 MG DAILY DOSE CPPK 4 MG
Specialty PA, DS LENVIMA 10 MG DAILY DOSE CPPK 10 MG Specialty PA,
DS LENVIMA 12 MG DAILY DOSE CPPK 3 X 4 MG Specialty PA, DS LENVIMA
14 MG DAILY DOSE CPPK 10 & 4 MG Specialty PA, DS LENVIMA 18 MG
DAILY DOSE CPPK 10 MG & 2 X 4 MG Specialty PA, DS LENVIMA 20 MG
DAILY DOSE CPPK 10 (2) MG Specialty PA, DS LENVIMA 24 MG DAILY DOSE
CPPK 10 (2) & 4 MG Specialty PA, DS LORBRENA TABS 25 MG
Specialty PA, DS LORBRENA TABS 100 MG Specialty PA, DS LYNPARZA
TABS 100 MG Specialty DS LYNPARZA TABS 150 MG Specialty DS MEKINIST
TABS 0.5 MG Specialty DS MEKINIST TABS 2 MG Specialty DS ROZLYTREK
CAPS 100 MG Specialty DS ROZLYTREK CAPS 200 MG Specialty DS RYDAPT
CAPS 25 MG Specialty DS
TAFINLAR CAPS 50 MG Specialty DS, QL (120 PER 30 DAYS)
TAFINLAR CAPS 75 MG Specialty DS, QL (120 PER 30 DAYS)
TAGRISSO TABS 40 MG Specialty DS TAGRISSO TABS 80 MG Specialty DS
VELCADE SOLR 3.5 MG Preferred Brand ZEJULA CAPS 100 MG Specialty DS
Molecular Target Inhibitors AFINITOR TABS 10 MG Specialty DS
erlotinib hcl tabs 25 mg Generic DS, QL (90 PER 30 DAYS)
erlotinib hcl tabs 100 mg Generic DS, QL (30 PER 30 DAYS)
erlotinib hcl tabs 150 mg Generic DS, QL (30 PER 30 DAYS)
everolimus tabs 2.5 mg Specialty DS everolimus tabs 5 mg Specialty
DS everolimus tabs 7.5 mg Specialty DS imatinib mesylate tabs 100
mg Generic imatinib mesylate tabs 400 mg Generic
IMBRUVICA CAPS 140 MG Specialty PA, DS, QL (60 PER 30 DAYS)
IMBRUVICA TABS 420 MG Specialty PA, DS, QL (30 PER 30 DAYS)
IMBRUVICA TABS 560 MG Specialty PA, DS, QL (30 PER 30 DAYS)
NEXAVAR TABS 200 MG Specialty DS, QL (30 PER 30 DAYS)
Last Updated 09/25/2021 Effective 10/21/2021
SPRYCEL TABS 100 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 140 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 20 MG Specialty DS, QL (60 PER 30 DAYS)
SPRYCEL TABS 50 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 70 MG Specialty DS, QL (30 PER 30 DAYS)
SUTENT CAPS 12.5 MG Specialty DS SUTENT CAPS 25 MG Specialty DS
SUTENT CAPS 50 MG Specialty DS TUKYSA TABS 50 MG Specialty PA, DS
TUKYSA TABS 150 MG Specialty PA, DS
TYKERB TABS 250 MG Specialty DS, QL (180 PER 30 DAYS)
VENCLEXTA STARTING PACK TBPK 10 & 50 & 100 MG Specialty PA,
DS VENCLEXTA TABS 10 MG Preferred Brand PA, DS VENCLEXTA TABS 50 MG
Preferred Brand PA, DS VENCLEXTA TABS 100 MG Specialty PA, DS
VOTRIENT TABS 200 MG Specialty DS XALKORI CAPS 200 MG Specialty DS
XALKORI CAPS 250 MG Specialty DS ZELBORAF TABS 240 MG Specialty DS
Monoclonal Antibodies HERCEPTIN SOLR 440 MG Preferred Brand No USP
Class MESNEX TABS 400 MG Preferred Brand DS Retinoids RETIN-A CREA
0.025 % Preferred Brand RETIN-A CREA 0.05 % Preferred Brand RETIN-A
CREA 0.1 % Preferred Brand RETIN-A GEL 0.01 % Preferred Brand
RETIN-A GEL 0.025 % Preferred Brand RETIN-A MICRO GEL 0.1 %
Preferred Brand tretinoin caps 10 mg Generic DS Antiparasitics
Anthelmintics albendazole tabs 200 mg Generic DS ivermectin tabs 3
mg Generic praziquantel tabs 600 mg Generic Antiprotozoals ALINIA
SUSR 100 MG/5ML Preferred Brand atovaquone susp 750 mg/5ml Generic
atovaquone-proguanil hcl tabs 250-100 mg Generic
atovaquone-proguanil hcl tabs 62.5-25 mg Generic chloroquine
phosphate tabs 500 mg Generic PA
Last Updated 09/25/2021 Effective 10/21/2021
COARTEM TABS 20-120 MG Preferred Brand DARAPRIM TABS 25 MG
Preferred Brand DS hydroxychloroquine sulfate tabs 200 mg Generic
KRINTAFEL TABS 150 MG Preferred Brand mefloquine hcl tabs 250 mg
Generic primaquine phosphate tabs 26.3 mg Generic YODOXIN TABS 650
MG Preferred Brand Pediculicides/Scabicides permethrin crea 5 %
Generic Antiparkinson Agents Anticholinergics benztropine mesylate
tabs 0.5 mg Generic benztropine mesylate tabs 1 mg Generic
benztropine mesylate tabs 2 mg Generic trihexyphenidyl hcl tabs 2
mg Generic trihexyphenidyl hcl tabs 5 mg Generic Antiparkinson
Agents, Other amantadine hcl caps 100 mg Generic amantadine hcl
syrp 50 mg/5ml Generic amantadine hcl tabs 100 mg Generic
entacapone tabs 200 mg Generic Dopamine Agonists bromocriptine
mesylate tabs 2.5 mg Generic pramipexole dihydrochloride tabs 0.125
mg Generic pramipexole dihydrochloride tabs 0.25 mg Generic
pramipexole dihydrochloride tabs 0.5 mg Generic pramipexole
dihydrochloride tabs 0.75 mg Generic pramipexole dihydrochloride
tabs 1 mg Generic pramipexole dihydrochloride tabs 1.5 mg Generic
ropinirole hcl tabs 0.25 mg Generic ropinirole hcl tabs 0.5 mg
Generic ropinirole hcl tabs 1 mg Generic ropinirole hcl tabs 2 mg
Generic ropinirole hcl tabs 3 mg Generic ropinirole hcl tabs 4 mg
Generic ropinirole hcl tabs 5 mg Generic Dopamine
Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa tabs 25
mg Generic carbidopa-levodopa er tbcr 25-100 mg Generic
carbidopa-levodopa er tbcr 50-200 mg Generic carbidopa-levodopa
tabs 10-100 mg Generic carbidopa-levodopa tabs 25-100 mg Generic
carbidopa-levodopa tabs 25-250 mg Generic Monoamine Oxidase B
(MAO-B) Inhibitors selegiline hcl caps 5 mg Generic No USP Class
(Combination Product) carbidopa-levodopa-entacapone tabs
12.5-50-200 mg Generic carbidopa-levodopa-entacapone tabs
18.75-75-200 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
carbidopa-levodopa-entacapone tabs 25-100-200 mg Generic
carbidopa-levodopa-entacapone tabs 31.25-125-200 mg Generic
carbidopa-levodopa-entacapone tabs 37.5-150-200 mg Generic
carbidopa-levodopa-entacapone tabs 50-200-200 mg Generic
Antipsychotics 1st Generation/Typical fluphenazine hcl tabs 1 mg
Generic fluphenazine hcl tabs 10 mg Generic fluphenazine hcl tabs
2.5 mg Generic fluphenazine hcl tabs 5 mg Generic haloperidol
lactate conc 2 mg/ml Generic haloperidol tabs 0.5 mg Generic
haloperidol tabs 1 mg Generic haloperidol tabs 10 mg Generic
haloperidol tabs 2 mg Generic haloperidol tabs 5 mg Generic
loxapine succinate caps 10 mg Generic loxapine succinate caps 25 mg
Generic loxapine succinate caps 5 mg Generic loxapine succinate
caps 50 mg Generic molindone hcl tabs 25 mg Generic thiothixene
caps 1 mg Generic thiothixene caps 10 mg Generic thiothixene caps 2
mg Generic thiothixene caps 5 mg Generic trifluoperazine hcl tabs 1
mg Generic trifluoperazine hcl tabs 10 mg Generic trifluoperazine
hcl tabs 2 mg Generic trifluoperazine hcl tabs 5 mg Generic 2nd
Generation/Atypical
LATUDA TABS 20 MG Specialty PA, QL (15 PER 30 DAYS)
LATUDA TABS 40 MG Specialty PA, QL (15 PER 30 DAYS)
LATUDA TABS 60 MG Specialty PA, QL (15 PER 30 DAYS)
LATUDA TABS 80 MG Specialty PA, QL (30 PER 30 DAYS)
LATUDA TABS 120 MG Specialty PA, QL (30 PER 30 DAYS)
olanzapine tabs 10 mg Generic olanzapine tabs 15 mg Generic
olanzapine tabs 2.5 mg Generic olanzapine tabs 20 mg Generic
olanzapine tabs 5 mg Generic olanzapine tabs 7.5 mg Generic
quetiapine fumarate er tb24 50 mg Generic quetiapine fumarate er
tb24 200 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
quetiapine fumarate er tb24 300 mg Generic quetiapine fumarate er
tb24 400 mg Generic quetiapine fumarate tabs 100 mg Generic
quetiapine fumarate tabs 200 mg Generic quetiapine fumarate tabs 25
mg Generic quetiapine fumarate tabs 300 mg Generic quetiapine
fumarate tabs 400 mg Generic quetiapine fumarate tabs 50 mg Generic
risperidone soln 1 mg/ml Generic risperidone tabs 0.25 mg Generic
risperidone tabs 0.5 mg Generic risperidone tabs 1 mg Generic
risperidone tabs 2 mg Generic risperidone tabs 3 mg Generic
risperidone tabs 4 mg Generic ziprasidone hcl caps 20 mg Generic
ziprasidone hcl caps 40 mg Generic ziprasidone hcl caps 60 mg
Generic ziprasidone hcl caps 80 mg Generic Treatment-Resistant
clozapine tabs 100 mg Generic clozapine tabs 200 mg Generic
clozapine tabs 25 mg Generic clozapine tabs 50 mg Generic
Antispasticity Agents baclofen tabs 10 mg Generic baclofen tabs 20
mg Generic dantrolene sodium caps 100 mg Generic dantrolene sodium
caps 25 mg Generic dantrolene sodium caps 50 mg Generic tizanidine
hcl tabs 2 mg Generic tizanidine hcl tabs 4 mg Generic Antivirals
Anti-Cytomegalovirus (CMV) Agents
PREVYMIS TABS 240 MG Preferred Brand PA, DS, QL (30 PER 30
DAYS)
PREVYMIS TABS 480 MG Preferred Brand PA, DS, QL (30 PER 30
DAYS)
valganciclovir hcl solr 50 mg/ml Generic valganciclovir hcl tabs
450 mg Generic Antihepatitis Agents adefovir dipivoxil tabs 10 mg
Generic entecavir tabs 0.5 mg Generic entecavir tabs 1 mg
Generic
EPCLUSA TABS 400-100 MG Preferred Brand DS, QL (28 PER 28
DAYS)
HARVONI TABS 45-200 MG Preferred Brand DS
Last Updated 09/25/2021 Effective 10/21/2021
HARVONI TABS 90-400 MG Preferred Brand DS, QL (28 PER 28
DAYS)
INTRON A SOLN 10000000 UNIT/ML Preferred Brand DS PEGASYS PROCLICK
SOLN 180 MCG/0.5ML Preferred Brand DS PEGASYS SOLN 180 MCG/0.5ML
Preferred Brand DS PEGINTRON KIT 50 MCG/0.5ML Specialty PEGINTRON
KIT 80 MCG Preferred Brand PEG-INTRON REDIPEN PAK 4 KIT 80 MCG RP
Preferred Brand PEG-INTRON REDIPEN KIT 120 MCG/0.5ML Preferred
Brand ribavirin caps 200 mg Generic ribavirin tabs 200 mg Generic
SOVALDI TABS 400 MG Preferred Brand DS
VOSEVI TABS 400-100-100 MG Preferred Brand DS, QL (28 PER 28
DAYS)
Antiherpetic Agents acyclovir caps 200 mg Generic acyclovir susp
200 mg/5ml Generic acyclovir tabs 400 mg Generic acyclovir tabs 800
mg Generic trifluridine soln 1 % Generic valacyclovir hcl tabs 1 gm
Generic valacyclovir hcl tabs 500 mg Generic Anti-HIV Agents,
Non-Nucleoside Reverse Transcriptase Inhibitors EDURANT TABS 25 MG
Preferred Brand efavirenz caps 50 mg Generic efavirenz caps 200 mg
Generic efavirenz tabs 600 mg Generic INTELENCE TABS 100 MG
Preferred Brand INTELENCE TABS 200 MG Preferred Brand nevirapine
tabs 200 mg Generic PIFELTRO TABS 100 MG Preferred Brand RESCRIPTOR
TABS 100 MG Preferred Brand RESCRIPTOR TABS 200 MG Preferred Brand
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase
Inhibitors abacavir sulfate soln 20 mg/ml Generic abacavir sulfate
tabs 300 mg Generic abacavir sulfate-lamivudine tabs 600-300 mg
Generic abacavir-lamivudine-zidovudine tabs 300-150-300 mg Generic
didanosine cpdr 200 mg Generic didanosine cpdr 250 mg Generic
didanosine cpdr 400 mg Generic emtricitabine-tenofovir df tabs
200-300 mg Generic EMTRIVA SOLN 10 MG/ML Preferred Brand lamivudine
soln 10 mg/ml Generic lamivudine tabs 100 mg Generic lamivudine
tabs 150 mg Generic lamivudine tabs 300 mg Generic
lamivudine-zidovudine tabs 150-300 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
tenofovir disoproxil fumarate tabs 300 mg Generic VIREAD POWD 40
MG/GM Preferred Brand VIREAD TABS 150 MG Preferred Brand zidovudine
caps 100 mg Generic zidovudine syrp 50 mg/5ml Generic zidovudine
tabs 300 mg Generic Anti-HIV Agents, Other FUZEON SOLR 90 MG
Preferred Brand DS ISENTRESS CHEW 100 MG Preferred Brand ISENTRESS
CHEW 25 MG Preferred Brand ISENTRESS PACK 100 MG Preferred Brand
ISENTRESS TABS 400 MG Preferred Brand ISENTRESS HD TABS 600 MG
Preferred Brand JULUCA TABS 50-25 MG Preferred Brand SELZENTRY TABS
25 MG Preferred Brand SELZENTRY TABS 75 MG Preferred Brand
SELZENTRY TABS 150 MG Preferred Brand SELZENTRY TABS 300 MG
Preferred Brand SYMTUZA TABS 800-150-200-10 MG Preferred Brand
TIVICAY TABS 50 MG Preferred Brand Anti-HIV Agents, Protease
Inhibitors atazanavir sulfate caps 150 mg Generic atazanavir
sulfate caps 200 mg Generic atazanavir sulfate caps 300 mg Generic
EVOTAZ TABS 300-150 MG Preferred Brand lopinavir-ritonavir soln
400-100 mg/5ml Generic lopinavir-ritonavir tabs 100-25 mg Generic
lopinavir-ritonavir tabs 200-50 mg Generic NORVIR SOLN 80 MG/ML
Preferred Brand PREZCOBIX TABS 800-150 MG Preferred Brand PREZISTA
TABS 150 MG Preferred Brand PREZISTA TABS 600 MG Preferred Brand
PREZISTA TABS 75 MG Preferred Brand PREZISTA TABS 800 MG Preferred
Brand ritonavir tabs 100 mg Generic VIRACEPT TABS 250 MG Preferred
Brand VIRACEPT TABS 625 MG Preferred Brand Anti-Influenza Agents
oseltamivir phosphate caps 30 mg Generic oseltamivir phosphate caps
75 mg Generic oseltamivir phosphate susr 6 mg/ml Generic RELENZA
DISKHALER AEPB 5 MG/BLISTER Preferred Brand rimantadine hcl tabs
100 mg Generic No USP Class (Combination Product) BIKTARVY TABS
50-200-25 MG Preferred Brand COMPLERA TABS 200-25-300 MG Preferred
Brand PA DESCOVY TABS 200-25 MG Preferred Brand PA DOVATO TABS
50-300 MG Preferred Brand
Last Updated 09/25/2021 Effective 10/21/2021
efavirenz-emtricitab-tenofovir tabs 600-200-300 mg Generic GENVOYA
TABS 150-150-200-10 MG Preferred Brand ODEFSEY TABS 200-25-25 MG
Preferred Brand STRIBILD TABS 150-150-200-300 MG Preferred Brand PA
SYMFI TABS 600-300-300 MG Preferred Brand TRIUMEQ TABS 600-50-300
MG Preferred Brand Anxiolytics Anxiolytics, Other alprazolam tabs
0.25 mg Generic alprazolam tabs 0.5 mg Generic alprazolam tabs 1 mg
Generic alprazolam tabs 2 mg Generic buspirone hcl tabs 5 mg
Generic buspirone hcl tabs 7.5 mg Generic buspirone hcl tabs 10 mg
Generic buspirone hcl tabs 15 mg Generic buspirone hcl tabs 30 mg
Generic chlordiazepoxide hcl caps 10 mg Generic chlordiazepoxide
hcl caps 25 mg Generic chlordiazepoxide hcl caps 5 mg Generic
clorazepate dipotassium tabs 15 mg Generic clorazepate dipotassium
tabs 3.75 mg Generic clorazepate dipotassium tabs 7.5 mg Generic
diazepam intensol conc 5 mg/ml Generic diazepam tabs 10 mg Generic
diazepam tabs 2 mg Generic diazepam tabs 5 mg Generic lorazepam
tabs 0.5 mg Generic lorazepam tabs 1 mg Generic lorazepam tabs 2 mg
Generic midazolam hcl soln 10 mg/2ml Generic midazolam hcl syrp 2
mg/ml Generic oxazepam caps 10 mg Generic oxazepam caps 15 mg
Generic oxazepam caps 30 mg Generic Bipolar Agents Mood Stabilizers
lithium carbonate caps 150 mg Generic lithium carbonate caps 300 mg
Generic lithium carbonate caps 600 mg Generic lithium carbonate er
tbcr 300 mg Generic lithium carbonate er tbcr 450 mg Generic Blood
Glucose Regulators Antidiabetic Agents acarbose tabs 100 mg Generic
acarbose tabs 50 mg Generic glimepiride tabs 1 mg Generic
glimepiride tabs 2 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
glimepiride tabs 4 mg Generic glipizide tabs 5 mg Generic glipizide
tabs 10 mg Generic glyburide tabs 1.25 mg Generic glyburide tabs
2.5 mg Generic glyburide tabs 5 mg Generic
JARDIANCE TABS 25 MG Preferred Brand PA, QL (15 PER 30 DAYS)
metformin hcl er tb24 500 mg Generic metformin hcl er tb24 750 mg
Generic metformin hcl tabs 1000 mg Generic metformin hcl tabs 500
mg Generic metformin hcl tabs 850 mg Generic
OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML Preferred Brand PA,
QL (1.5 PER 30 DAYS)
OZEMPIC (1 MG/DOSE) SOPN 2 MG/1.5ML Preferred Brand PA, QL (1.5 PER
30 DAYS)
OZEMPIC (1 MG/DOSE) SOPN 4 MG/3ML Preferred Brand PA, QL (3 PER 30
DAYS)
pioglitazone hcl tabs 15 mg Generic pioglitazone hcl tabs 30 mg
Generic pioglitazone hcl tabs 45 mg Generic repaglinide tabs 0.5 mg
Generic repaglinide tabs 1 mg Generic repaglinide tabs 2 mg Generic
tolazamide tabs 250 mg Generic tolazamide tabs 500 mg Generic
VICTOZA SOPN 18 MG/3ML Preferred Brand PA, QL (9 PER 30 DAYS)
Glycemic Agents BAQSIMI ONE PACK POWD 3 MG/DOSE Preferred Brand
glucagon emergency kit 1 mg Generic GVOKE PFS SOSY 0.5 MG/0.1ML
Preferred Brand Insulins HUMALOG JUNIOR KWIKPEN SOPN 100 UNIT/ML
Preferred Brand PA HUMALOG KWIKPEN SOPN 100 UNIT/ML Preferred Brand
PA HUMALOG SOLN 100 UNIT/ML Preferred Brand PA HUMULIN 70/30
KWIKPEN SUPN (70-30) 100 UNIT/ML Preferred Brand PA HUMULIN 70/30
SUSP (70-30) 100 UNIT/ML Preferred Brand HUMULIN N KWIKPEN SUPN 100
UNIT/ML Preferred Brand PA HUMULIN N SUSP 100 UNIT/ML Preferred
Brand HUMULIN R SOLN 100 UNIT/ML Preferred Brand HUMULIN R U-500
KWIKPEN SOPN 500 UNIT/ML Preferred Brand PA HUMULIN R U-500
(CONCENTRATED) SOLN 500 UNIT/ML Preferred Brand PA LANTUS SOLN 100
UNIT/ML Preferred Brand PA LANTUS SOLOSTAR SOPN 100 UNIT/ML
Preferred Brand PA Blood Products/Modifiers/Volume Expanders
Anticoagulants
Last Updated 09/25/2021 Effective 10/21/2021
enoxaparin sodium soln 100 mg/ml Generic DS enoxaparin sodium soln
120 mg/0.8ml Generic DS enoxaparin sodium soln 150 mg/ml Generic DS
enoxaparin sodium soln 30 mg/0.3ml Generic DS enoxaparin sodium
soln 300 mg/3ml Generic DS enoxaparin sodium soln 40 mg/0.4ml
Generic DS enoxaparin sodium soln 60 mg/0.6ml Generic DS enoxaparin
sodium soln 80 mg/0.8ml Generic DS
PRADAXA CAPS 75 MG Preferred Brand QL (60 PER 30 DAYS
PRADAXA CAPS 110 MG Preferred Brand QL (60 PER 30 DAYS)
PRADAXA CAPS 150 MG Preferred Brand QL (60 PER 30 DAYS)
warfarin sodium tabs 1 mg Generic warfarin sodium tabs 10 mg
Generic warfarin sodium tabs 2 mg Generic warfarin sodium tabs 2.5
mg Generic warfarin sodium tabs 3 mg Generic warfarin sodium tabs 4
mg Generic warfarin sodium tabs 5 mg Generic warfarin sodium tabs 6
mg Generic warfarin sodium tabs 7.5 mg Generic
XARELTO TABS 2.5 MG Preferred Brand PA, QL (60 PER 30 DAYS)
XARELTO TABS 10 MG Preferred Brand PA, QL (30 PER 30 DAYS)
XARELTO TABS 15 MG Preferred Brand PA, QL (60 PER 30 DAYS)
XARELTO TABS 20 MG Preferred Brand PA, QL (30 PER 30 DAYS)
Blood Formation Modifiers anagrelide hcl caps 0.5 mg Generic
NIVESTYM SOLN 300 MCG/ML Specialty DS NIVESTYM SOLN 480 MCG/1.6ML
Specialty DS NIVESTYM SOSY 300 MCG/0.5ML Specialty DS NIVESTYM SOSY
480 MCG/0.8ML Specialty DS PROCRIT SOLN 2000 UNIT/ML Preferred
Brand DS PROCRIT SOLN 3000 UNIT/ML Preferred Brand DS PROCRIT SOLN
4000 UNIT/ML Preferred Brand DS PROCRIT SOLN 10000 UNIT/ML
Preferred Brand DS PROCRIT SOLN 20000 UNIT/ML Preferred Brand DS
PROCRIT SOLN 40000 UNIT/ML Preferred Brand DS
PROMACTA TABS 25 MG Specialty PA, DS, QL (60 PER 30 DAYS)
PROMACTA TABS 50 MG Specialty PA, DS, QL (90 PER 30 DAYS)
Last Updated 09/25/2021 Effective 10/21/2021
PROMACTA TABS 75 MG Specialty PA, DS, QL (60 PER 30 DAYS)
VENOFER SOLN 20 MG/ML Preferred Brand ZARXIO SOSY 300 MCG/0.5ML
Specialty DS ZARXIO SOSY 480 MCG/0.8ML Specialty DS Coagulants
aminocaproic acid tabs 500 mg Generic BENEFIX KIT 250 UNIT
Preferred Brand PA BENEFIX KIT 500 UNIT Preferred Brand PA BENEFIX
KIT 1000 UNIT Preferred Brand PA BENEFIX KIT 2000 UNIT Preferred
Brand PA BENEFIX KIT 3000 UNIT Preferred Brand PA HEMLIBRA SOLN 30
MG/ML Preferred Brand DS HEMLIBRA SOLN 60 MG/0.4ML Preferred Brand
DS HEMLIBRA SOLN 105 MG/0.7ML Preferred Brand DS HEMLIBRA SOLN 150
MG/ML Preferred Brand DS HUMATE-P SOLR 1000-2400 UNIT Preferred
Brand PA, DS HUMATE-P SOLR 250-600 UNIT Preferred Brand PA, DS
HUMATE-P SOLR 500-1200 UNIT Preferred Brand PA, DS KOVALTRY SOLR
250 UNIT Preferred Brand DS KOVALTRY SOLR 500 UNIT Preferred Brand
DS KOVALTRY SOLR 1000 UNIT Preferred Brand DS KOVALTRY SOLR 2000
UNIT Preferred Brand DS KOVALTRY SOLR 3000 UNIT Preferred Brand DS
phytonadione tabs 5 mg Generic RIXUBIS SOLR 250 UNIT Preferred
Brand PA RIXUBIS SOLR 500 UNIT Preferred Brand PA RIXUBIS SOLR 1000
UNIT Preferred Brand PA RIXUBIS SOLR 2000 UNIT Preferred Brand PA
RIXUBIS SOLR 3000 UNIT Preferred Brand PA Platelet Modifying Agents
aspirin-dipyridamole er cp 12 25-200 mg Generic BRILINTA TABS 60 MG
Preferred Brand PA BRILINTA TABS 90 MG Preferred Brand PA
cilostazol tabs 100 mg Generic cilostazol tabs 50 mg Generic
clopidogrel bisulfate tabs 75 mg Generic dipyridamole tabs 25 mg
Generic dipyridamole tabs 50 mg Generic dipyridamole tabs 75 mg
Generic prasugrel hcl tabs 5 mg Generic prasugrel hcl tabs 10 mg
Generic Cardiovascular Agents Alpha-Adrenergic Agonists clonidine
hcl tabs 0.1 mg Generic clonidine hcl tabs 0.2 mg Generic clonidine
hcl tabs 0.3 mg Generic guanfacine hcl tabs 1 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
guanfacine hcl tabs 2 mg Generic methyldopa tabs 250 mg Generic
methyldopa tabs 500 mg Generic midodrine hcl tabs 2.5 mg Generic
midodrine hcl tabs 5 mg Generic midodrine hcl tabs 10 mg Generic
Alpha-Adrenergic Blocking Agents doxazosin mesylate tabs 1 mg
Generic doxazosin mesylate tabs 2 mg Generic doxazosin mesylate
tabs 4 mg Generic doxazosin mesylate tabs 8 mg Generic prazosin hcl
caps 1 mg Generic prazosin hcl caps 2 mg Generic prazosin hcl caps
5 mg Generic terazosin hcl caps 1 mg Generic terazosin hcl caps 10
mg Generic terazosin hcl caps 2 mg Generic terazosin hcl caps 5 mg
Generic Angiotensin II Receptor Antagonists losartan potassium tabs
100 mg Generic losartan potassium tabs 25 mg Generic losartan
potassium tabs 50 mg Generic valsartan tabs 160 mg Generic
valsartan tabs 320 mg Generic valsartan tabs 40 mg Generic
valsartan tabs 80 mg Generic Angiotensin-Converting Enzyme (ACE)
Inhibitors benazepril hcl tabs 10 mg Generic benazepril hcl tabs 20
mg Generic benazepril hcl tabs 40 mg Generic benazepril hcl tabs 5
mg Generic EPANED SOLR 1 MG/ML Preferred Brand lisinopril tabs 10
mg Generic lisinopril tabs 2.5 mg Generic lisinopril tabs 20 mg
Generic lisinopril tabs 30 mg Generic lisinopril tabs 40 mg Generic
lisinopril tabs 5 mg Generic Antiarrhythmics amiodarone hcl tabs
200 mg Generic disopyramide phosphate caps 100 mg Generic
disopyramide phosphate caps 150 mg Generic dofetilide caps 125 mcg
Generic dofetilide caps 250 mcg Generic dofetilide caps 500 mcg
Generic flecainide acetate tabs 100 mg Generic flecainide acetate
tabs 150 mg Generic flecainide acetate tabs 50 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
mexiletine hcl caps 150 mg Generic mexiletine hcl caps 200 mg
Generic mexiletine hcl caps 250 mg Generic NORPACE CR CP12 100 MG
Preferred Brand NORPACE CR CP12 150 MG Preferred Brand propafenone
hcl tabs 150 mg Generic propafenone hcl tabs 225 mg Generic
propafenone hcl tabs 300 mg Generic quinidine gluconate er tbcr 324
mg Generic quinidine sulfate tabs 200 mg Generic Beta-Adrenergic
Blocking Agents acebutolol hcl caps 200 mg Generic acebutolol hcl
caps 400 mg Generic atenolol tabs 100 mg Generic atenolol tabs 25
mg Generic atenolol tabs 50 mg Generic bisoprolol fumarate tabs 10
mg Generic bisoprolol fumarate tabs 5 mg Generic carvedilol tabs
12.5 mg Generic carvedilol tabs 25 mg Generic carvedilol tabs 3.125
mg Generic carvedilol tabs 6.25 mg Generic labetalol hcl tabs 100
mg Generic labetalol hcl tabs 200 mg Generic labetalol hcl tabs 300
mg Generic metoprolol succinate er tb24 25 mg Generic metoprolol
succinate er tb24 50 mg Generic metoprolol succinate er tb24 100 mg
Generic metoprolol succinate er tb24 200 mg Generic metoprolol
tartrate tabs 100 mg Generic metoprolol tartrate tabs 25 mg Generic
metoprolol tartrate tabs 50 mg Generic nadolol tabs 20 mg Generic
nadolol tabs 40 mg Generic nadolol tabs 80 mg Generic propranolol
hcl soln 20 mg/5ml Generic propranolol hcl tabs 10 mg Generic
propranolol hcl tabs 20 mg Generic propranolol hcl tabs 40 mg
Generic propranolol hcl tabs 60 mg Generic propranolol hcl tabs 80
mg Generic propranolol hcl er cp24 60 mg Generic propranolol hcl er
cp24 80 mg Generic propranolol hcl er cp24 120 mg Generic
propranolol hcl er cp24 160 mg Generic sotalol hcl (af) tabs 120 mg
Generic sotalol hcl (af) tabs 160 mg Generic sotalol hcl (af) tabs
80 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
sotalol hcl tabs 120 mg Generic sotalol hcl tabs 160 mg Generic
sotalol hcl tabs 80 mg Generic SOTYLIZE SOLN 5 MG/ML Preferred
Brand Calcium Channel Blocking Agents amlodipine besylate tabs 10
mg Generic amlodipine besylate tabs 2.5 mg Generic amlodipine
besylate tabs 5 mg Generic diltiazem hcl er coated beads cp24 120
mg Generic diltiazem hcl er coated beads cp24 180 mg Generic
diltiazem hcl er coated beads cp24 240 mg Generic diltiazem hcl er
coated beads cp24 300 mg Generic diltiazem hcl er coated beads cp24
360 mg Generic diltiazem hcl tabs 120 mg Generic diltiazem hcl tabs
30 mg Generic diltiazem hcl tabs 60 mg Generic diltiazem hcl tabs
90 mg Generic dilt-xr cp24 120 mg Generic dilt-xr cp24 180 mg
Generic dilt-xr cp24 240 mg Generic KATERZIA SUSP 1 MG/ML Brand PA
nifedipine er osmotic release tb24 30 mg Generic nifedipine er
osmotic release tb24 60 mg Generic nifedipine er osmotic release
tb24 90 mg Generic nifedipine er tb24 90 mg Generic nimodipine caps
30 mg Generic verapamil hcl er tbcr 180 mg Generic verapamil hcl er
tbcr 240 mg Generic verapamil hcl tabs 40 mg Generic verapamil hcl
tabs 80 mg Generic verapamil hcl tabs 120 mg Generic Cardiovascular
Agents, Other DIGOXIN SOLN 0.05 MG/ML Preferred Brand digoxin tabs
125 mcg Generic digoxin tabs 250 mcg Generic pentoxifylline er tbcr
400 mg Generic Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide er cp12 500 mg Generic acetazolamide tabs 125 mg
Generic acetazolamide tabs 250 mg Generic methazolamide tabs 50 mg
Generic Diuretics, Loop bumetanide tabs 0.5 mg Generic bumetanide
tabs 1 mg Generic bumetanide tabs 2 mg Generic ethacrynic acid tabs
25 mg Generic PA furosemide soln 10 mg/ml Generic furosemide tabs
20 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
furosemide tabs 40 mg Generic furosemide tabs 80 mg Generic
torsemide tabs 10 mg Generic torsemide tabs 100 mg Generic
torsemide tabs 20 mg Generic Diuretics, Potassium-Sparing amiloride
hcl tabs 5 mg Generic CAROSPIR SUSP 25 MG/5ML Preferred Brand
spironolactone tabs 100 mg Generic spironolactone tabs 25 mg
Generic spironolactone tabs 50 mg Generic Diuretics, Thiazide
chlorthalidone tabs 25 mg Generic chlorthalidone tabs 50 mg Generic
DIURIL SUSP 250 MG/5ML Preferred Brand hydrochlorothiazide tabs
12.5 mg Generic hydrochlorothiazide tabs 25 mg Generic
hydrochlorothiazide tabs 50 mg Generic indapamide tabs 1.25 mg
Generic indapamide tabs 2.5 mg Generic metolazone tabs 2.5 mg
Generic metolazone tabs 5 mg Generic metolazone tab 10 mg Generic
Dyslipidemics, Fibric Acid Derivatives fenofibrate tabs 160 mg
Generic fenofibrate tabs 54 mg Generic gemfibrozil tabs 600 mg
Generic Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin
calcium tabs 10 mg Generic atorvastatin calcium tabs 20 mg Generic
atorvastatin calcium tabs 40 mg Generic atorvastatin calcium tabs
80 mg Generic lovastatin tabs 10 mg Generic lovastatin tabs 20 mg
Generic lovastatin tabs 40 mg Generic pravastatin sodium tabs 10 mg
Generic pravastatin sodium tabs 20 mg Generic pravastatin sodium
tabs 40 mg Generic pravastatin sodium tabs 80 mg Generic
rosuvastatin calcium tabs 5 mg Generic rosuvastatin calcium tabs 10
mg Generic rosuvastatin calcium tabs 20 mg Generic rosuvastatin
calcium tabs 40 mg Generic simvastatin tabs 10 mg Generic
simvastatin tabs 20 mg Generic simvastatin tabs 40 mg Generic
simvastatin tabs 80 mg Generic Dyslipidemics, Other
Last Updated 09/25/2021 Effective 10/21/2021
cholestyramine pack 4 gm Generic cholestyramine powd 4 gm/dose
Generic colestipol hcl gran 5 gm Generic colestipol hcl tabs 1 gm
Generic ezetimibe tabs 10 mg Generic niacin tabs 100 mg Generic
niacin tabs 500 mg Generic niacin er (antihyperlipidemic) tbcr 500
mg Generic prevalite powd 4 gm/dose Generic No USP Class
(Combination Product) atenolol-chlorthalidone tabs 100-25 mg
Generic atenolol-chlorthalidone tabs 50-25 mg Generic
bisoprolol-hydrochlorothiazide tabs 10-6.25 mg Generic
bisoprolol-hydrochlorothiazide tabs 2.5-6.25 mg Generic
bisoprolol-hydrochlorothiazide tabs 5-6.25 mg Generic
lisinopril-hydrochlorothiazide tabs 10-12.5 mg Generic
lisinopril-hydrochlorothiazide tabs 20-12.5 mg Generic
lisinopril-hydrochlorothiazide tabs 20-25 mg Generic losartan
potassium-hctz tabs 100-12.5 mg Generic losartan potassium-hctz
tabs 100-25 mg Generic losartan potassium-hctz tabs 50-12.5 mg
Generic spironolactone-hctz tabs 25-25 mg Generic triamterene-hctz
tabs 37.5-25 mg Generic triamterene-hctz tabs 75-50 mg Generic
valsartan-hydrochlorothiazide tabs 80-12.5 mg Generic
valsartan-hydrochlorothiazide tabs 160-12.5 mg Generic
valsartan-hydrochlorothiazide tabs 160-25 mg Generic
valsartan-hydrochlorothiazide tabs 320-12.5 mg Generic
valsartan-hydrochlorothiazide tabs 320-25 mg Generic Vasodilators,
Direct-Acting Arterial hydralazine hcl tabs 10 mg Generic
hydralazine hcl tabs 100 mg Generic hydralazine hcl tabs 25 mg
Generic hydralazine hcl tabs 50 mg Generic Vasodilators,
Direct-Acting Arterial/Venous isosorbide dinitrate er tbcr 40 mg
Generic isosorbide dinitrate tabs 10 mg Generic isosorbide
dinitrate tabs 20 mg Generic isosorbide dinitrate tabs 40 mg
Generic isosorbide dinitrate tabs 5 mg Generic isosorbide
mononitrate er tb24 120 mg Generic isosorbide mononitrate er tb24
30 mg Generic isosorbide mononitrate er tb24 60 mg Generic
nitro-bid oint 2 % Generic nitroglycerin pt24 0.1 mg/hr Generic
nitroglycerin pt24 0.2 mg/hr Generic nitroglycerin pt24 0.4 mg/hr
Generic nitroglycerin pt24 0.6 mg/hr Generic
Last Updated 09/25/2021 Effective 10/21/2021
nitroglycerin subl 0.3 mg Generic nitroglycerin subl 0.4 mg Generic
nitroglycerin subl 0.6 mg Generic Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine-dextroamphetamine tabs 5 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 7.5 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 10 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 12.5 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 15 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 20 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphetamine tabs 30 mg Generic QL (90 PER 30
DAYS)
amphetamine-dextroamphet er cp24 5 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphet er cp24 10 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphet er cp24 15 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphet er cp24 20 mg Generic QL (120 PER 30
DAYS)
amphetamine-dextroamphet er cp24 25 mg Generic QL (90 PER 30
DAYS)
amphetamine-dextroamphet er cp24 30 mg Generic QL (90 PER 30
DAYS)
dextroamphetamine sulfate er cp24 5 mg Generic PA dextroamphetamine
sulfate er cp24 10 mg Generic PA dextroamphetamine sulfate er cp24
15 mg Generic PA dextroamphetamine sulfate tabs 5 mg Generic
dextroamphetamine sulfate tabs 10 mg Generic Attention Deficit
Hyperactivity Disorder Agents, Non-Amphetamines atomoxetine hcl
caps 10 mg Generic atomoxetine hcl caps 18 mg Generic atomoxetine
hcl caps 25 mg Generic atomoxetine hcl caps 40 mg Generic
atomoxetine hcl caps 60 mg Generic atomoxetine hcl caps 80 mg
Generic atomoxetine hcl caps 100 mg Generic dexmethylphenidate hcl
er cp24 10 mg Generic dexmethylphenidate hcl er cp24 15 mg Generic
dexmethylphenidate hcl er cp24 20 mg Generic dexmethylphenidate hcl
er cp24 25 mg Generic dexmethylphenidate hcl er cp24 30 mg
Generic
Last Updated 09/25/2021 Effective 10/21/2021
dexmethylphenidate hcl er cp24 35 mg Generic dexmethylphenidate hcl
er cp24 40 mg Generic dexmethylphenidate hcl er cp24 5 mg Generic
dexmethylphenidate hcl tabs 10 mg Generic dexmethylphenidate hcl
tabs 2.5 mg Generic dexmethylphenidate hcl tabs 5 mg Generic
guanfacine hcl er tb24 1 mg Generic guanfacine hcl er tb24 2 mg
Generic guanfacine hcl er tb24 3 mg Generic guanfacine hcl er tb24
4 mg Generic methylphenidate hcl er (cd) cpcr 10 mg Generic
methylphenidate hcl er (cd) cpcr 20 mg Generic methylphenidate hcl
er (cd) cpcr 30 mg Generic methylphenidate hcl er (cd) cpcr 40 mg
Generic methylphenidate hcl er (cd) cpcr 50 mg Generic
methylphenidate hcl er (cd) cpcr 60 mg Generic methylphenidate hcl
er tbcr 10 mg Generic methylphenidate hcl er tbcr 20 mg Generic
methylphenidate hcl er tbcr 18 mg Generic methylphenidate hcl er
tbcr 27 mg Generic methylphenidate hcl er tbcr 36 mg Generic
methylphenidate hcl er tbcr 54 mg Generic methylphenidate hcl tabs
10 mg Generic methylphenidate hcl tabs 20 mg Generic
methylphenidate hcl tabs 5 mg Generic Central Nervous System
Agents, Other riluzole tabs 50 mg Generic Ergot Alkaloids CAFERGOT
TABS 1-100 MG Preferred Brand Multiple Sclerosis Agents AVONEX KIT
30 MCG Specialty PA, DS AVONEX PEN AJKT 30 MCG/0.5ML Specialty PA,
DS AVONEX PREFILLED PSKT 30 MCG/0.5ML Specialty PA, DS
dalfampridine er tb12 10 mg Generic EXTAVIA KIT 0.3 MG Preferred
Brand DS glatopa sosy 20 mg/ml Generic DS No USP Class ketorolac
tromethamine soln 60 mg/2ml Generic Dental and Oral Agents
chlorhexidine gluconate soln 0.12 % Generic denta 5000 plus crea
1.1 % Generic pilocarpine hcl tabs 5 mg Generic PREVIDENT GEL 1.1 %
Preferred Brand Dermatological Agents
acitretin caps 10 mg Generic DS, QL (30 PER 30 DAYS)
acitretin caps 17.5 mg Generic DS, QL (30 PER 30 DAYS)
Last Updated 09/25/2021 Effective 10/21/2021
acitretin caps 25 mg Generic DS, QL (60 PER 30 DAYS)
adapalene gel 0.1 % Generic adapalene gel 0.3 % Generic azelaic
acid gel 15 % Generic AZELEX CREA 20 % Preferred Brand
calcipotriene soln 0.005 % Generic claravis caps 10 mg Generic DS
claravis caps 20 mg Generic DS claravis caps 30 mg Generic DS
claravis caps 40 mg Generic DS
COSENTYX SENSOREADY PEN SOAJ 150 MG/ML Specialty PA, QL (2 PER 28
DAYS)
COSENTYX SOSY 150 MG/ML Specialty PA, QL (2 PER 28 DAYS)
DIFFERIN CREA 0.1 % Preferred Brand DRITHO-CRÈME HP CREA 1 %
Preferred Brand DRYSOL SOLN 20 % Preferred Brand fluocinolone
acetonide scalp oil 0.01% Generic fluorouracil crea 5 % Generic
fluorouracil soln 2 % Generic fluorouracil soln 5 % Generic
hydrocortisone lotn 2.5 % Generic imiquimod crea 5 % Generic
methoxsalen rapid caps 10 mg Generic nystatin-triamcinolone crea
100000-0.1 unit/gm-% Generic nystatin-triamcinolone oint 100000-0.1
unit/gm-% Generic pimecrolimus crea 1 % Generic podofilox soln 0.5
% Generic RECTIV OINT 0.4 % Preferred Brand SANTYL OINT 250 UNIT/GM
Preferred Brand selenium sulfide lotn 2.5 % Generic STELARA SOLN
130 MG/26ML Specialty PA
STELARA SOSY 45 MG/0.5ML Specialty PA, QL (0.5 PER 84 DAYS)
STELARA SOSY 90 MG/ML Specialty PA, QL (1 PER 56 DAYS)
sulfacetamide sodium-sulfur emul 10-5 % Generic tacrolimus oint
0.03 % Generic tacrolimus oint 0.1 % Generic tazarotene crea 0.1 %
Generic TAZORAC CREA 0.05 % Preferred Brand TAZORAC GEL 0.05 %
Preferred Brand TAZORAC GEL 0.1 % Preferred Brand VECTICAL OINT 3
MCG/GM Preferred Brand XERAC AC SOLN 6.25 % Preferred Brand Enzyme
Replacement/Modifiers CERDELGA CAPS 84 MG Specialty DS
Last Updated 09/25/2021 Effective 10/21/2021
CREON CPEP 3000-9500 UNIT Preferred Brand CREON CPEP 6000-19000
UNIT Preferred Brand CREON CPEP 12000-38000 UNIT Preferred Brand
CREON CPEP 24000-76000 UNIT Preferred Brand CREON CPEP 36000-114000
UNIT Preferred Brand ZENPEP CPEP 5000-24000 UNIT Preferred Brand
ZENPEP CPEP 10000-32000 UNIT Preferred Brand ZENPEP CPEP
15000-47000 UNIT Preferred Brand ZENPEP CPEP 20000-63000 UNIT
Preferred Brand ZENPEP CPEP 25000-79000 UNIT Preferred Brand ZENPEP
CPEP 40000-126000 UNIT Preferred Brand Gastrointestinal Agents
Antispasmodics, Gastrointestinal dicyclomine hcl caps 10 mg Generic
dicyclomine hcl soln 10 mg/5ml Generic dicyclomine hcl tabs 20 mg
Generic glycopyrrolate tabs 1 mg Generic glycopyrrolate tabs 2 mg
Generic Gastrointestinal Agents, Other diphenoxylate-atropine liqd
2.5-0.025 mg/5ml Generic diphenoxylate-atropine tabs 2.5-0.025 mg
Generic propantheline bromide tabs 15 mg Generic READI-CAT 2 SUSP 2
% Preferred Brand ursodiol caps 300 mg Generic ursodiol tabs 250 mg
Generic ursodiol tabs 500 mg Generic Histamine-2 (H2) Receptor
Antagonists cimetidine hcl soln 300 mg/5ml Generic famotidine susr
40 mg/5ml Generic ranitidine hcl tabs 300 mg Generic Irritable
Bowel Syndrome Agents mesalamine enem 4 gm Generic salsalate tabs
500 mg Generic salsalate tabs 750 mg Generic Laxatives gavilyte-c
solr 240 gm Generic gavilyte-g solr 236 gm Generic gavilyte-n with
flavor pack solr 420 gm Generic lactulose soln 10 gm/15ml Generic
Protectants misoprostol tabs 100 mcg Generic misoprostol tabs 200
mcg Generic sucralfate tabs 1 gm Generic Proton Pump Inhibitors
pantoprazole sodium tbec 20 mg Generic pantoprazole sodium tbec 40
mg Generic Genitourinary Agents Antispasmodics, Urinary
Last Updated 09/25/2021 Effective 10/21/2021
MYRBETRIQ TB24 25 MG Preferred Brand PA, QL (30 PER 30 DAYS)
MYRBETRIQ TB24 50 MG Preferred Brand PA, QL (30 PER 30 DAYS)
oxybutynin chloride er tb24 10 mg Generic oxybutynin chloride er
tb24 15 mg Generic oxybutynin chloride er tb24 5 mg Generic
oxybutynin chloride syrp 5 mg/5ml Generic oxybutynin chloride tabs
5 mg Generic solifenacin succinate tabs 5 mg Generic solifenacin
succinate tabs 10 mg Generic tolterodine tartrate tabs 1 mg Generic
tolterodine tartrate tabs 2 mg Generic trospium chloride tabs 20 mg
Generic Benign Prostatic Hypertrophy Agents finasteride tabs 5 mg
Generic tamsulosin hcl caps 0.4 mg Generic Genitourinary Agents,
Other bethanechol chloride tabs 5 mg Generic bethanechol chloride
tabs 10 mg Generic bethanechol chloride tabs 25 mg Generic DEPEN
TITRATABS TABS 250 MG Preferred Brand ELMIRON CAPS 100 MG Preferred
Brand No USP Class methylergonovine maleate tabs 0.2 mg Generic
Phosphate Binders calcium acetate (phos binder) caps 667 mg Generic
PHOSLYRA SOLN 667 MG/5ML Preferred Brand sevelamer carbonate pack
0.8 gm Generic sevelamer carbonate pack 2.4 gm Generic sevelamer
carbonate tabs 800 mg Generic sevelamer hcl tabs 800 mg Generic
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids betamethasone dipropionate aug
crea 0.05 % Generic betamethasone dipropionate aug lotn 0.05 %
Generic betamethasone dipropionate aug oint 0.05 % Generic
betamethasone dipropionate lotn 0.05 % Generic budesonide cpep 3 mg
Generic clobetasol propionate crea 0.05 % Generic clobetasol
propionate gel 0.05 % Generic clobetasol propionate lotn 0.05 %
Generic clobetasol propionate oint 0.05 % Generic clobetasol
propionate soln 0.05 % Generic CLOBEX SHAM 0.05 % Preferred Brand
CLOBEX SPRAY LIQD 0.05 % Preferred Brand colocort enem 100 mg/60ml
Generic desonide lotn 0.05 % Generic
Last Updated 09/25/2021 Effective 10/21/2021
desonide oint 0.05 % Generic dexamethasone elix 0.5 mg/5ml Generic
dexamethasone intensol conc 1 mg/ml Generic dexamethasone soln 0.5
mg/5ml Generic dexamethasone tabs 0.5 mg Generic dexamethasone tabs
0.75 mg Generic dexamethasone tabs 1.5 mg Generic dexamethasone
tabs 4 mg Generic fludrocortisone acetate tabs 0.1 mg Generic
fluocinolone acetonide soln 0.01 % Generic fluocinonide gel 0.05 %
Generic fluocinonide oint 0.05 % Generic fluocinonide soln 0.05 %
Generic fluticasone propionate crea 0.05 % Generic fluticasone
propionate oint 0.005 % Generic hydrocortisone crea 2.5 % Generic
hydrocortisone enem 100 mg/60ml Generic hydrocortisone oint 2.5 %
Generic hydrocortisone tabs 10 mg Generic hydrocortisone tabs 20 mg
Generic hydrocortisone tabs 5 mg Generic hydrocortisone valerate
crea 0.2 % Generic methylprednisolone tbpk 4 mg Generic mometasone
furoate crea 0.1 % Generic mometasone furoate soln 0.1 % Generic
prednicarbate crea 0.1 % Generic prednisolone sodium phosphate soln
15 mg/5ml Generic prednisone tabs 1 mg Generic prednisone tabs 10
mg Generic prednisone tabs 2.5 mg Generic prednisone tabs 20 mg
Generic prednisone tabs 5 mg Generic prednisone tabs 50 mg Generic
SOLU-CORTEF SOLR 100 MG Preferred Brand triamcinolone acetonide
crea 0.025 % Generic triamcinolone acetonide crea 0.1 % Generic
triamcinolone acetonide crea 0.5 % Generic triamcinolone acetonide
oint 0.025 % Generic triamcinolone acetonide oint 0.1 % Generic
triamcinolone acetonide oint 0.5 % Generic triamcinolone acetonide
pste 0.1 % Generic Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary) chorionic gonadotropin solr 10000 unit Generic
desmopressin acetate spray soln 0.01 % Generic desmopressin acetate
tabs 0.1 mg Generic desmopressin acetate tabs 0.2 mg Generic
OMNITROPE SOLN 10 MG/1.5ML Preferred Brand DS OMNITROPE SOLN 5
MG/1.5ML Preferred Brand DS
Last Updated 09/25/2021 Effective 10/21/2021
OMNITROPE SOLR 5.8 MG Preferred Brand DS Hormonal Agents,
Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens
danazol caps 100 mg Generic danazol caps 200 mg Generic danazol
caps 50 mg Generic DEPO-TESTOSTERONE SOLN 100 MG/ML Preferred Brand
PA DEPO-TESTOSTERONE SOLN 200 MG/ML Preferred Brand PA methitest
tabs 10 mg Generic testosterone enanthate soln 200 mg/ml Generic PA
testosterone gel 20.25 mg/act (1.62%) Generic PA testosterone gel
25 mg/2.5gm (1%) Generic PA testosterone gel 50 mg/5gm (1%) Generic
PA Estrogens CLIMARA PTWK 0.025 MG/24HR Preferred Brand CLIMARA
PTWK 0.0375 MG/24HR Preferred Brand CLIMARA PTWK 0.05 MG/24HR
Preferred Brand CLIMARA PTWK 0.06 MG/24HR Preferred Brand CLIMARA
PTWK 0.075 MG/24HR Preferred Brand CLIMARA PTWK 0.1 MG/24HR
Preferred Brand depo-estradiol oil 5 mg/ml Generic dotti pttw
0.0375 mg/24hr Generic ESTRACE CREA 0.1 MG/GM Preferred Brand
estradiol pttw 0.025 mg/24hr Generic estradiol pttw 0.05 mg/24hr
Generic estradiol pttw 0.075 mg/24hr Generic estradiol pttw 0.1
mg/24hr Generic estradiol tabs 0.5 mg Generic estradiol tabs 1 mg
Generic estradiol tabs 2 mg Generic ESTRING RING 2 MG Preferred
Brand yuvafem tabs 10 mcg Generic No USP Class (Combination
Product) apri tabs 0.15-30 mg/mcg Generic aranelle tabs
0.5/1/0.5-35 mg-mcg Generic balziva tabs 0.4-35 mg-mcg Generic
cryselle-28 tabs 0.3-30 mg-mcg Generic drospirenone-ethinyl
estradiol tabs 3-0.02 mg Generic drospirenone-ethinyl estradiol
tabs 3-0.03 mg Generic eluryng ring 0.12-0.015 mg/24hr Generic est
estrogens-methyltest hs tabs 0.625-1.25 mg Generic est
estrogens-methyltest tabs 1.25-2.5 mg Generic kelnor 1/50 tabs 1-50
mg-mcg Generic levora 0.15/30 (28) tabs 0.15-30 mg-mcg Generic
lutera tabs 0.1-20 mg-mcg Generic microgestin fe 1.5/30 tabs 1.5-30
mg-mcg Generic microgestin fe 1/20 tabs 1-20 mg-mcg Generic necon
0.5/35 (28) tabs 0.5-35 mg-mcg Generic
Last Updated 09/25/2021 Effective 10/21/2021
norethin ace-eth estrad-fe chew 1-20 mg-mcg(24) Generic nortrel
1/35 (28) tabs 1-35 mg-mcg Generic nortrel 7/7/7 tabs 0.5/0.75/1-35
mg-mcg Generic sprintec 28 tabs 0.25-35 mg-mcg Generic
tri-lo-sprintec tabs 0.18/0.215/0.25 mg-25 mcg Generic tri-sprintec
tabs 0.18/0.215/0.25 mg-35 mcg Generic trivora (28) tabs Generic
XULANE PTWK 150 35 MCG/24HR Preferred Brand zovia 1/35e (28) tabs
1-35 mg-mcg Generic Progestins DEPO-SUBQ PROVERA 104 SUSY 104
MG/0.65ML Preferred Brand econtra ez tabs 1.5 mg Generic ELLA TABS
30 MG Preferred Brand hydroxyprogesterone caproate oil 250 mg/ml
Generic DS medroxyprogesterone acetate susp 150 mg/ml Generic
medroxyprogesterone acetate tabs 10 mg Generic medroxyprogesterone
acetate tabs 2.5 mg Generic medroxyprogesterone acetate tabs 5 mg
Generic megestrol acetate susp 40 mg/ml Generic megestrol acetate
tabs 20 mg Generic megestrol acetate tabs 40 mg Generic MIRENA (52
MG) IUD 20 MCG/24HR Preferred Brand NEXPLANON IMPL 68 MG Preferred
Brand nora-be tabs 0.35 mg Generic norethindrone acetate tabs 5 mg
Generic progesterone micronized caps 100 mg Generic progesterone
micronized caps 200 mg Generic Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs
100 mcg Generic levothyroxine sodium tabs 112 mcg Generic
levothyroxine sodium tabs 125 mcg Generic levothyroxine sodium tabs
137 mcg Generic levothyroxine sodium tabs 150 mcg Generic
levothyroxine sodium tabs 175 mcg Generic levothyroxine sodium tabs
200 mcg Generic levothyroxine sodium tabs 25 mcg Generic
levothyroxine sodium tabs 300 mcg Generic levothyroxine sodium tabs
50 mcg Generic levothyroxine sodium tabs 75 mcg Generic
levothyroxine sodium tabs 88 mcg Generic liothyronine sodium tabs
25 mcg Generic liothyronine sodium tabs 5 mcg Generic liothyronine
sodium tabs 50 mcg Generic Hormonal Agents, Suppressant (Adrenal)
LYSODREN TABS 500 MG Preferred Brand DS Hormonal Agents,
Suppressant (Pituitary) cabergoline tabs 0.5 mg Generic octreotide
acetate soln 100 mcg/ml Generic
Last Updated 09/25/2021 Effective 10/21/2021
octreotide acetate soln 1000 mcg/ml Generic octreotide acetate soln
200 mcg/ml Generic octreotide acetate soln 500 mcg/ml Generic
SYNAREL SOLN 2 MG/ML Preferred Brand Hormonal Agents, Suppressant
(Sex Hormones/Modifiers) Antiandrogens
abiraterone acetate tabs 250 mg Specialty DS, QL (120 PER 30
DAYS)
bicalutamide tabs 50 mg Generic flutamide caps 125 mg Generic
ZYTIGA TABS 500 MG Specialty DS Hormonal Agents, Suppressant
(Thyroid) Antithyroid Agents methimazole tabs 10 mg Generic
methimazole tabs 5 mg Generic propylthiouracil tabs 50 mg Generic
Immunological Agents Immune Suppressants azathioprine tabs 50 mg
Generic everolimus tabs 0.25 mg Generic everolimus tabs 0.5 mg
Specialty everolimus tabs 0.75 mg Specialty gengraf caps 100 mg
Generic gengraf caps 25 mg Generic
HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML Specialty PA, DS, QL
(3 PER 365 DAYS)
HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4ML
Specialty PA, DS, QL (2 PER
365 DAYS)
HUMIRA PEN PNKT 40 MG/0.4ML Specialty PA, DS, QL (2 PER 28
DAYS)
HUMIRA PEN PNKT 40 MG/0.8ML Specialty PA, DS, QL (2 PER 28
DAYS)
HUMIRA PSKT 10 MG/0.1ML Specialty PA, DS, QL (2 PER 28 DAYS)
HUMIRA PSKT 20 MG/0.2ML Specialty PA, DS, QL (2 PER 28 DAYS)
HUMIRA PSKT 20 MG/0.4ML Specialty DS, QL (2 PER 28 DAYS)
HUMIRA PSKT 40 MG/0.4ML Specialty PA, DS, QL (2 PER 28 DAYS)
HUMIRA PSKT 40 MG/0.8ML Specialty PA, DS, QL (2 PER 28 DAYS)
mercaptopurine tabs 50 mg Generic methotrexate sodium (pf) soln 50
mg/2ml Generic methotrexate sodium soln 50 mg/2ml Generic
methotrexate tabs 2.5 mg Generic mycophenolate mofetil caps 250 mg
Generic mycophenolate mofetil tabs 500 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
NEORAL SOLN 100 MG/ML Preferred Brand RASUVO SOAJ 10 MG/0.2ML
Preferred Brand RASUVO SOAJ 12.5 MG/0.25ML Preferred Brand RASUVO
SOAJ 15 MG/0.3ML Preferred Brand RASUVO SOAJ 17.5 MG/0.35ML
Preferred Brand RASUVO SOAJ 20 MG/0.4ML Preferred Brand RASUVO SOAJ
22.5 MG/0.45ML Preferred Brand RASUVO SOAJ 25 MG/0.5ML Preferred
Brand RASUVO SOAJ 27.5 MG/0.55ML Preferred Brand RASUVO SOAJ 30
MG/0.6ML Preferred Brand RASUVO SOAJ 7.5 MG/0.15ML Preferred Brand
SANDIMMUNE CAPS 100 MG Preferred Brand SANDIMMUNE CAPS 25 MG
Preferred Brand sirolimus tabs 0.5 mg Generic sirolimus tabs 1 mg
Generic sirolimus tabs 2 mg Generic sirolimus soln 1 mg/ml
Generic
SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83ML Specialty PA, QL (2 PER 84
DAYS)
tacrolimus caps 0.5 mg Generic tacrolimus caps 1 mg Generic
tacrolimus caps 5 mg Generic
TREMFYA SOPN 100 MG/ML Specialty PA, QL (1 PER 56 DAYS)
TREMFYA SOSY 100 MG/ML Specialty PA, QL (1 PER 56 DAYS)
XELJANZ TABS 10 MG Preferred Brand PA, DS, QL (60 PER 30
DAYS)
Immunizing Agents, Passive GAMMAGARD SOLN 1 GM/10ML Preferred Brand
GAMMAGARD SOLN 2.5 GM/25ML Preferred Brand GAMMAGARD SOLN 5 GM/50ML
Preferred Brand GAMMAGARD SOLN 10 GM/100ML Preferred Brand
GAMMAGARD SOLN 20 GM/200ML Preferred Brand GAMMAGARD SOLN 30
GM/300ML Preferred Brand HIZENTRA SOLN 1 GM/5ML Preferred Brand DS
HIZENTRA SOLN 2 GM/10ML Preferred Brand DS HIZENTRA SOLN 4 GM/20ML
Preferred Brand DS HIZENTRA SOLN 10 GM/50ML Preferred Brand DS
HIZENTRA SOSY 1 GM/5ML Preferred Brand HIZENTRA SOSY 2 GM/10ML
Preferred Brand HIZENTRA SOSY 4 GM/20ML Preferred Brand VIVOTIF
CPDR Preferred Brand Immunomodulators leflunomide tabs 10 mg
Generic leflunomide tabs 20 mg Generic
OTEZLA TABS 30 MG Specialty PA, DS, QL (60 PER 30 DAYS)
Last Updated 09/25/2021 Effective 10/21/2021
OTEZLA TBPK 10 & 20 & 30 MG Specialty PA, DS, QL (55 PER
365 DAYS)
RIDAURA CAPS 3 MG Preferred Brand No USP Class HAEGARDA SOLR 2000
UNIT Specialty DS HAEGARDA SOLR 3000 UNIT Specialty DS TAKHZYRO
SOLN 300 MG/2ML Specialty PA, DS Inflammatory Bowel Disease Agents
Aminosalicylates ASACOL TBEC 400 MG Preferred Brand balsalazide
disodium caps 750 mg Generic mesalamine-cleanser kit 4 gm Generic
mesalamine supp 1000 mg Generic mesalamine tbec 1.2 gm Generic
Sulfonamides sulfasalazine tabs 500 mg Generic sulfasalazine tbec
500 mg Generic Metabolic Bone Disease Agents alendronate sodium
tabs 10 mg Generic alendronate sodium tabs 70 mg Generic calcitonin
(salmon) soln 200 unit/act Generic calcitonin (salmon) soln 200
unit/ml Generic calcitriol caps 0.25 mcg Generic calcitriol caps
0.5 mcg Generic calcitriol soln 1 mcg/ml Generic etidronate
disodium tabs 200 mg Generic etidronate disodium tabs 400 mg
Generic No Designated Placement on USP Model Guidelines V5.0 acetic
acid soln 0.25 % Generic BD INSULIN SYRINGE ULTRAFINE MISC 31G X
15/64" 0.3 ML Preferred Brand
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.5 ML Preferred
Brand
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML Preferred
Brand
BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML Preferred Brand bd
magni-guide magnifier misc Generic bd pen needle mini u/f misc 31g
x 5 mm Generic bd safetyglide insulin syringe misc 29g x 1/2" 0.5
ml Generic CAYA DPRH Preferred Brand fluoridex pste 1.1 % Generic
KETOSTIX STRP Preferred Brand ONETOUCH ULTRA BLUE STRP Preferred
Brand PARAGARD INTRAUTERINE COPPER IUD Preferred Brand PRECISION
XTRA KETONE STRP Preferred Brand proctozone-hc crea 2.5 % Generic
sodium benzoate powd Generic WIDE-SEAL DIAPHRAGM 60 DPRH 2 %
Preferred Brand
Last Updated 09/25/2021 Effective 10/21/2021
WIDE-SEAL DIAPHRAGM 65 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM
70 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 75 DPRH 2 %
Preferred Brand WIDE-SEAL DIAPHRAGM 80 DPRH 2 % Preferred Brand
WIDE-SEAL DIAPHRAGM 85 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM
90 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 95 DPRH 2 %
Preferred Brand Ophthalmic Agents No USP Class (Combination
Product) bacitracin-polymyxin b oint 500-10000 unit/gm Generic
bacitra-neomycin-polymyxin-hc oint 1 % Generic blephamide s.o.p.
oint 10-0.2 % Generic neomycin-bacitracin zn-polymyx oint
5-400-10000 Generic neomycin-polymyxin-dexameth oint 3.5-10000-0.1
Generic neomycin-polymyxin-dexameth susp 3.5-10000-0.1 Generic
polymyxin b-trimethoprim soln 10000-0.1 unit/ml-% Generic PRED-G
SUSP 0.3-1 % Preferred Brand sulfacetamide-prednisolone soln
10-0.23 % Generic Ophthalmic Agents, Other ATROPINE SULFATE OINT 1
% Preferred Brand ATROPINE SULFATE SOLN 1 % Preferred Brand
cyclopentolate hcl soln 0.5 % Generic cyclopentolate hcl soln 1 %
Generic cyclopentolate hcl soln 2 % Generic homatropaire soln 5 %
Generic ISOPTO CARBACHOL SOLN 1.5 % Preferred Brand ISOPTO
CARBACHOL SOLN 3 % Preferred Brand tropicamide soln 0.5 % Generic
tropicamide soln 1 % Generic VISUDYNE SOLR 15 MG Preferred Brand
Ophthalmic Anti-Allergy Agents cromolyn sodium soln 4 % Generic
olopatadine hcl soln 0.1 % Generic Ophthalmic Antiglaucoma Agents
betaxolol hcl soln 0.5 % Generic brimonidine tartrate soln 0.2 %
Generic dorzolamide hcl soln 2 % Generic dorzolamide hcl-timolol
mal soln 22.3-6.8 mg/ml Generic levobunolol hcl soln 0.5 % Generic
phenylephrine hcl soln 2.5 % Generic PHOSPHOLINE IODIDE SOLR 0.125
% Preferred Brand timolol maleate soln 0.25 % Generic timolol
maleate soln 0.5 % Generic Ophthalmic Anti-Inflammatories
dexamethasone sodium phosphate soln 0.1 % Generic diclofenac sodium
soln 0.1 % Generic fluorometholone susp 0.1 % Generic flurbiprofen
sodium soln 0.03 % Generic
Last Updated 09/25/2021 Effective 10/21/2021
FML OINT 0.1 % Preferred Brand LOTEMAX OINT 0.5 % Preferred Brand
PRED MILD SUSP 0.12 % Preferred Brand prednisolone acetate susp 1 %
Generic Ophthalmic Prostaglandin and Prostamide Analogs latanoprost
soln 0.005 % Generic Otic Agents borofair sol 2% otic Generic
ciprofloxacin-dexamethasone susp 0.3-0.1 % Generic
neomycin-polymyxin-hc soln 1 % Generic Respiratory Tract Agents
Antihistamines azelastine hcl soln 0.1 % Generic cyproheptadine hcl
syrp 2 mg/5ml Generic cyproheptadine hcl tabs 4 mg Generic
Anti-Inflammatories, Inhaled Corticosteroids ALVESCO AERS 80
MCG/ACT Preferred Brand ALVESCO AERS 160 MCG/ACT Preferred Brand
ASMANEX 120 METERED DOSES AEPB 220 MCG/INH Preferred Brand ASMANEX
30 METERED DOSES AEPB 110 MCG/INH Preferred Brand ASMANEX 60
METERED DOSES AEPB 220 MCG/INH Preferred Brand ASMANEX HFA AERO 100
MCG/ACT Preferred Brand ASMANEX HFA AERO 200 MCG/ACT Preferred
Brand FLOVENT HFA AERO 44 MCG/ACT Preferred Brand DS mometasone
furoate susp 50 mcg/act Generic SYMBICORT AERO 80-4.5 MCG/ACT
Preferred Brand SYMBICORT AERO 160-4.5 MCG/ACT Preferred Brand
Antileukotrienes montelukast sodium chew 4 mg Generic montelukast
sodium chew 5 mg Generic montelukast sodium tabs 10 mg Generic
Bronchodilators, Anticholinergic ATROVENT HFA AERS 17 MCG/ACT
Preferred Brand ipratropium bromide soln 0.02 % Generic ipratropium
bromide soln 0.03 % Generic ipratropium bromide soln 0.06 % Generic
SPIRIVA RESPIMAT AERS 2.5 MCG/ACT Preferred Brand Bronchodilators,
Phosphodiesterase Inhibitors (Xanthines) theophylline er tb12 300
mg Generic theophylline er tb24 400 mg Generic Bronchodilators,
Sympathomimetic albuterol sulfate hfa aers 108 (90 base) mcg/act
Generic albuterol sulfate nebu (2.5 mg/3ml) 0.083% Generic
albuterol sulfate nebu (5 mg/ml) 0.5% Generic epinephrine soaj 0.15
mg/0.15ml Generic epinephrine soaj 0.3 mg/0.3ml Generic SEREVENT
DISKUS AEPB 50 MCG/DOSE Preferred Brand STRIVERDI RESPIMAT AERS 2.5
MCG/ACT Preferred Brand
Last Updated 09/25/2021 Effective 10/21/2021
terbutaline sulfate tabs 2.5 mg Generic terbutaline sulfate tabs 5
mg Generic VENTOLIN HFA AERS 108 (90 Base) MCG/ACT Preferred Brand
No USP Class benzonatate caps 100 mg Generic HYPERSAL NEBU 7 %
Preferred Brand PULMOZYME SOLN 1 MG/ML Specialty sodium chloride
nebu 0.9 % Generic sodium chloride nebu 10 % Generic No USP Class
(Combination Product) ADVAIR HFA AERO 45-21 MCG/ACT Preferred Brand
PA ADVAIR HFA AERO 115-21 MCG/ACT Preferred Brand PA ADVAIR HFA
AERO 230-21 MCG/ACT Preferred Brand PA COMBIVENT RESPIMAT AERS
20-100 MCG/ACT Preferred Brand fluticasone-salmeterol aepb 55-14
mcg/act Generic fluticasone-salmeterol aepb 113-14 mcg/act Generic
fluticasone-salmeterol aepb 232-14 mcg/act Generic
hydrocodone-homatropine syrp 5-1.5 mg/5ml Generic DS
ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml Generic promethazine
vc plain syrp 6.25-5 mg/5ml Generic promethazine vc/codeine syrp
6.25-5-10 mg/5ml Generic promethazine-codeine syrp 6.25-10 mg/5ml
Generic promethazine-dm syrp 6.25-15 mg/5ml Generic STIOLTO
RESPIMAT AERS 2.5-2.5 MCG/ACT Preferred Brand wixela inhub aepb
100-50 mcg/dose Generic wixela inhub aepb 250-50 mcg/dose Generic
wixela inhub aepb 500-50 mcg/dose Generic Pulmonary
Antihypertensives
ambrisentan tabs 5 mg Generic PA, DS, QL (30 PER 30 DAYS)
ambrisentan tabs 10 mg Generic PA, DS, QL (30 PER 30 DAYS)
bosentan tabs 62.5 mg Generic PA, DS bosentan tabs 125 mg Generic
PA, DS VELETRI SOLR 1.5 MG Preferred Brand Respiratory Tract
Agents, Other acetylcysteine soln 10 % Generic acetylcysteine soln
20 % Generic cheratussin dac soln 30-10-100 mg/5ml Generic FASENRA
PEN SOAJ 30 MG/ML Specialty PA FASENRA SOSY 30 MG/ML Specialty PA
guaifenesin-codeine soln 100-10 mg/5ml Generic TRIKAFTA TBPK
50-25-37.5 & 75 MG Specialty PA, DS TRIKAFTA TBPK 100-50-75
& 150 MG Specialty PA, DS Skeletal Muscle Relaxants
cyclobenzaprine hcl tabs 10 mg Generic cyclobenzaprine hcl tabs 5
mg Generic methocarbamol tabs 500 mg Generic
Last Updated 09/25/2021 Effective 10/21/2021
methocarbamol tabs 750 mg Generic Sleep Disorder Agents GABA
Receptor Modulators eszopiclone tabs 1 mg Generic eszopiclone tabs
2 mg Generic eszopiclone tabs 3 mg Generic zolpidem tartrate tabs
10 mg Generic zolpidem tartrate tabs 5 mg Generic Sleep Disorders,
Other armodafinil tabs 50 mg Generic armodafinil tabs 150 mg
Generic armodafinil tabs 200 mg Generic armodafinil tabs 250 mg
Generic modafinil tabs 100 mg Generic modafinil tabs 200 mg Generic
temazepam caps 15 mg Generic temazepam caps 30 mg Generic
Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral
Modifiers deferasirox tabs 90 mg Specialty deferasirox tabs 180 mg
Specialty deferasirox tabs 360 mg Specialty deferoxamine mesylate
solr 500 mg Generic deferoxamine mesylate solr 2 gm Generic JADENU
TABS 180 MG Specialty DS kionex susp 15 gm/60ml Generic LOKELMA
PACK 5 GM Preferred Brand LOKELMA PACK 10 GM Preferred Brand sodium
polystyrene sulfonate powd Generic sodium polystyrene sulfonate
susp 15 gm/60ml Generic sps susp 15 gm/60ml Generic SSKI SOLN 1
GM/ML Preferred Brand Electrolyte/Mineral Replacement citric
acid-sodium citrate soln 334-500 mg/5ml Generic klor-con m20 tbcr
20 meq Generic K-PHOS TABS 500 MG Preferred Brand K-TAB TBCR 10 MEQ
Preferred Brand PHOSPHA 250 NEUTRAL TABS 155-852-130 MG Preferred
Brand potassium chloride soln 20 meq/15ml (10%) Generic PA
potassium citrate er tbcr 5 meq (540 mg) Generic potassium citrate
er tbcr 10 meq (1080 mg) Generic potassium citrate er tbcr 15 meq
(1620 mg) Generic potassium citrate-citric acid soln 1100-334
mg/5ml Generic sodium fluoride chew 0.55 (0.25 f) mg Generic sodium
fluoride chew 1.1 (0.5 f) mg Generic sodium fluoride chew 2.2 (1 f)
mg Generic sodium fluoride soln 1.1 (0.5 f) mg/ml Generic No USP
Class
Last Updated 09/25/2021 Effective 10/21/2021
cyanocobalamin soln 1000 mcg/ml Generic multi-vit/fluoride soln
0.25 mg/ml Generic multi-vit/fluoride soln 0.5 mg/ml Generic
multi-vit/fluoride/iron soln 0.25-10 mg/ml Generic
multivitamin/fluoride chew 0.25 mg Generic multivitamin/fluoride
chew 1 mg Generic polyvitamin/fluoride dro 0.5mg/ml Generic
poly-vit drops w/fluoride dro 0.25mg Generic
poly-vitamin/iron/fluoride dro /fl 0.25 Generic PRENATAL/IRON TABS
28-0.8 MG Preferred Brand tri-vit/fluoride soln 0.25 mg/ml Generic
tri-vit/fluoride soln 0.5 mg/ml Generic tri-vit/fluoride/iron soln
0.25-10 mg/ml Generic vitamin d (ergocalciferol) caps 50000 unit
Generic
Last Updated 09/25/2021 Effective 10/21/2021
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civil rights laws and does not discriminate on the basis of race,
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Information written in other languages
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assistance services, free of charge, are available to you. Call
1-800-813-2000 (TTY: 711).
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