CareSource Healthy Indiana Plan (HIP) Basic, HIP State

CareSource Indiana Medica id Effective 1/1/2022

1

CareSource Healthy Indiana Plan (HIP) Basic, HIP State Plan Basic and Hoosier Healthwise Preferred Drug List

ANTI - INFECTIVES ANTINEOPLASTIC / IMMUNOSUPAUTONOMIC / CNS DRUGS, NEURCARDIOVASCULAR, HYPERTENSDERMATOLOGICALS/TOPICAL TDIAGNOSTICS / MISCELLANEOUSEAR, NOSE / THROAT MEDICATIENDOCRINE/DIABETESGASTROENTEROLOGY IMMUNOLOGY, VACCINES / BIOMUSCULOSKELETAL / RHEUMAOBSTETRICS / GYNECOLOGY OPHTHALMOLOGY RESPIRATORY AND ALLERGY . UROLOGICALSVITAMINS, HEMATINICS / ELECTIndex

Table of Contents

PRESSANT DRUGSOLOGY / PSYCH ION / LIPIDS HERAPY AGENTS

ONS

TECHNOLOGY TOLOGY

ROLYTES

3 6 8

18 23 27 28 28 32 34 37 37 42 44

47 48 49

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CareSource Indiana Medicaid Effective 1/1/2022 List of Abbreviations

1: Generic

2: Brand

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

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Drug Name Tier / Limits Drug Requirements

ANTI - INFECTIVES ANTIFUNGAL AGENTS clotrimazole mucous membrane

1

fluconazole 1

griseofulvin microsize

1

griseofulvin ultramicrosize

1

itraconazole oral capsule

1 QL

ketoconazole oral 1

nystatin oral suspension

1

nystatin oral tablet 1

terbinaf ine hcl oral 1 QL

ANTIVIRALS acyclovir oral capsule

1

acyclovir oral suspension 200 mg/5 ml

1

acyclovir oral tablet 1

adefovir 1 PA

amantadine hcl 1

atazanav ir 1

BARACLUDE ORAL SOLUTION

2 PA

BIKTARVY 2 QL

DESCOVY 2 PA

EDURANT 2

entecavir 1 PA

EPIVIR HBV ORAL SOLUTION

2 PA

famciclovir 1

FUZEON SUBCUTANEOUS RECON SOLN

2

GENVOYA 2

ISENTRESS 2

ISENTRESS HD 2

lamivudine oral solution

1

lamivudine oral tablet 100 mg

1 PA

lamivudine oral tablet 150 mg, 300 mg

1

NORVIR ORAL POWDER IN PACKET

2 QL

NORVIR ORAL SOLUTION

2

ODEFSEY 2

oseltamivir 1 QL

RELENZA DISKHALER

2 QL

rimantadine 1

ritonavir 1

SYMFI LO 2 QL

SYNAGIS 2 PA; QL

tenofovir disoproxil fumarate

1

TRIUMEQ 2 PA

TRUVADA 2

valacyclovir 1




4

valganc iclovir 1

VIREAD 2

zidovudine 1

CEPHALOSPORINS cefaclor oral capsule 1

cefaclor oral tablet extended release 12 hr

1

cefadroxil oral capsule

1

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

1

cefadroxil oral tablet 1

cefdinir 1

cefprozil 1

cefuroxime axetil oral tablet

1

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension for reconstitution

1

cephalexin oral tablet

1

ERYTHROMYCINS / OTHER MACROLIDES azithromycin oral 1

clarithromycin 1

e.e.s. 400 oral tablet 1

Drug Name Drug Tier

Requirements / Limits

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate) oral tablet 250 mg

1

erythromycin ethylsuccinate oral suspension for reconstitution

1

erythromycin ethylsuccinate oral tablet

1

erythromycin oral 1

MISCELLANEOUS ANTIINFECTIVES atovaquone 1

atovaquone-proguani l

1 QL

benznidazole 1

CAYSTON 2 PA, QL

chloroquine phosphate

1 PA; QL

clindamycin hcl 1

clindamycin palmitate hcl

1

clindamycin pediatric

1

COARTEM 2 QL

dapsone oral 1

EMVERM 2

Drug Name Drug Tier




5

ethambutol 1

FLAGYL 2

hydroxychloroquine 1 QL

isoniazid oral 1

ivermectin oral 1

KRINTAFEL 1

mefloquine 1 QL

metronidazole oral 1

neomycin 1

nitazoxanide 1 PA, QL

praziquantel 1

PRIFTIN 2

primaquine 1 QL

pyrazinamide 1

pyrimethamine 1

rifabutin 1

rifampin oral 1

SIRTURO ORAL TABLET 100 MG

2 PA

SIRTURO ORAL TABLET 20 MG

2

tobramycin in 0.225 % nacl

1

TOBRAMYCIN WITH NEBULIZER

2 QL

TRECATOR 2 PA

XIFAXAN 2 PA; QL

PENICILLINS amoxicillin oral capsule

1


amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

amoxicillin-pot clavulanate

1

ampicillin oral capsule

1

dicloxacillin 1

penicillin v potassium

1

pretomanid 1

QUINOLONES CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON

2

ciprofloxacin 1

ciprofloxacin hcl oral

1

levofloxacin oral 1

ofloxacin oral tablet 300 mg, 400 mg

1 QL

SULFA'S / RELATED A GENTS sulfadiazine 1

sulfamethoxazole-trimethopr im oral

1

sulfatrim 1

TETRACYCLINES doxycycl ine hyclate 1 oral capsule




6

doxycycl ine hyclate oral tablet 100 mg, 20 mg

1

doxycycl ine monohy drate oral capsule 100 mg, 50 mg

1

doxycycl ine monohy drate oral suspension for reconstitution

1

doxycycl ine monohy drate oral tablet 50 mg, 75 mg

1

minocycline oral capsule

1

minocycline oral tablet

1

mondox yne nl oral capsule 100 mg

1

MONODOX ORAL CAPSULE 100 MG, 50 MG

2

morgidox 1

tetracycline 1

VIBRAMYCIN ORAL CAPSULE 100 MG

2

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N

2

URINARY TRACT AGENTS methenamine hippurate

1

methenamine 1 mande late

Drug Name Drug Tier


nitrofurantoin 1

nitrofurantoin macrocrystal

1

nitrofurantoin monohy d/m-cryst

1

trimethoprim 1

VANCOMYCIN FIRVANQ 2 PA

vancomycin oral recon soln

1 PA

Drug Name Drug Tier


ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral

1

MESNEX ORAL 2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS abiraterone 1 PA

AFINITOR DISPERZ

2 PA

AFINITOR ORAL TABLET 10 MG

2 PA

anas trozole 1

azathioprine 1

bexarotene 1 PA

bicalutamide 1

capecitabine 1 PA

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

2 PA



7

cyclosporine modified

1

cyclosporine oral capsule

1

DROXIA 2 PA

EMCYT 2 PA

EMPAVELI 2 PA; QL

ERIVEDGE 2 PA

erlotinib 1 PA

etopos ide oral 1

everolimus (immunosuppressive )

1

exemestane 1

FARYDAK 2 PA

flutamide 1

gengraf oral capsule 100 mg, 25 mg

1

gengraf oral solution 1

GILOTRIF 2 PA

HYCAMTIN ORAL 2 PA

hydroxyurea 1

IBRANCE 2 PA

ICLUSIG 2 PA

imatinib 1 PA

IMBRUVICA 2 PA; QL

INLYTA 2 PA

JAKAFI 2 PA; QL

LENVIMA 2 PA

letrozole 1 PA

LEUKERAN 2 PA

LYSODREN 2


MATULANE 2

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

1

megestrol oral suspension 625 mg/5 ml (125 mg/ml)

1 PA

megestrol oral tablet 1

MEKINIST 2 PA

melphalan 1 PA

mercaptopur ine 1

methotrexate sodium 1

methotrexate sodium (pf) injection solution

1

mycophenolate mofetil

1

mycophenolate sodium

1

MYLERAN 2 PA

NEXAVAR 2 PA

octreotide acetate 1 PA

POMALYST 2 PA

REVLIMID 2 PA

RITUXAN 2 PA

SANDIMMUNE ORAL SOLUTION

2

sirolimus 1

SPRYCEL 2 PA

SUTENT 2 PA

TABLOID 2 PA

tacrolimus oral 1




8

TAFINLAR 2 PA

tamoxifen 1

TARGRETIN TOPICAL

2 PA; QL

TASIGNA 2 PA

temozolomide 1 PA

THALOMID 2 PA

toremifene 1

tretinoin (antineoplastic)

1

TREXALL 2

TYKERB 2 PA

VOTRIENT 2 PA

XALKORI 2 PA

XTANDI 2 PA

ZELBORAF 2 PA

ZOLADEX 2

ZOLINZA 2 PA

ZORTRESS ORAL TABLET 1 MG

2

Drug Name Drug Tier


AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL ORAL SUSPENSION

2 PA

BANZEL ORAL TABLET

2 ST

carbamazepine oral capsule, er multiphase 12 hr

1

carbamazepine oral suspension 100 mg/5 ml

1

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr

1

carbamazepine oral tablet,chewable

1

CELONTIN ORAL CAPSULE 300 MG

2

clobazam 1 QL

clonazepam 1 QL

diazepam rectal 1

DILANTIN 2

DILANTIN EXTENDED

2

divalproex 1

epitol 1

EQUETRO 2 QL

ethosuximide 1

felbamate 1

FYCOMPA ORAL SUSPENSION

2 ST

FYCOMPA ORAL TABLET

2 ST; QL

gabape ntin oral capsule

1 QL

gabape ntin oral solution

1 QL

gabape ntin oral tablet 600 mg, 800 mg

1 QL

LAMICTAL XR STARTER (BLUE)

2

LAMICTAL XR STARTER

2

(GREEN)

Drug Name Drug Tier




9

LAMICTAL XR STARTER (ORANGE)

2

lamotrigine 1

levetiracetam oral 1 QL

oxcarbazepine 1

OXTELLAR XR 2

PEGANONE 2

phenobarbital 1

phenobarbital sodium injection solution

1

phenytoin oral suspension

1

phenytoin oral tablet,chewable

1

phenytoin sodium extended

1

pregabal in oral capsule 100 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

1 PA; QL

pregabal in oral capsule 150 mg, 200 mg

1 QL

pregabal in oral solution

1 PA; QL

primidone 1

QUDEXY XR 2 QL

roweepra 1 QL

roweepra xr 1 QL

subvenite 1

subvenite starter (blue) kit

1


subvenite starter (green) kit

1

subvenite starter (orange ) kit

1

SYMPAZAN 2 QL

tiagabine 1

topiramate oral capsule, sprinkle

1

TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR

2 QL

topiramate oral tablet

1

TROKENDI XR 2 QL

valproate sodium 1

valproic acid 1

valproic acid (as sodium salt) oral solution

1

VIMPAT ORAL TABLET

2 ST

zonisamide

ALZHEIMER’S THERAPY

1 QL

ADUHELM 2 PA

ANTIPARKINSONISM A GENTS benztropine oral 1

bromocriptine 1

carbidopa -levodopa 1

carbidopa -levodopa-entacapone

1

entacapone 1

pramipexole oral 1 tablet




10

ropinirole oral tablet 1

selegiline hcl 1

SELEGILINE H CL (BULK)

2

trihexyphenidyl 1

ZELAPAR 2

MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate 1 QL

dihydroergotamine injection

1

EMGALITY 2 PA

ergotamine-caffeine 1

IMITREX ORAL 2 QL

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML

2

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML

2 QL

IMITREX SUBCUTANEOUS

2

migergot 1

naratriptan 1 QL

REYVOW 2 PA

rizatriptan 1 QL

sumatriptan 1 QL

sumatriptan succinate oral

1 QL

Drug Name Drug Tier


sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml

1

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml

1

sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous solution

1

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

1 QL

MISCELLANEOUS NEUROLOGICAL THERAPY AUBAGIO 2 PA, QL

AUSTEDO 2 PA, QL

dalfampridine 1 PA

donepezil 1 QL

EXELON TRANSDERMAL

2 QL

galantamine 1 QL

GILENYA ORAL CAPSULE 0.5 MG

2 PA; QL

glatiramer 1

Drug Name Drug Tier




11

glatopa 1

memantine oral capsule,sprinkle,er 24hr

1 QL

memantine oral solution

1 QL

memantine oral tablet

1 QL

MEMANTINE ORAL TABLETS,DOSE PACK

2 QL

NAMENDA TITRATION PAK

2 QL

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

2 QL

NAMZARIC 2 QL

NUEDEXTA 2 PA

rivastigmine 1 QL

rivastigmine tartrate 1 QL

TECFIDERA 2 PA; QL

tetrabenazine 1 PA

VUMERITY 2 PA; QL

ZEPOSIA 2 PA, QL

MUSCLE R ELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 20 mg

1

BACLOFEN ORAL TABLET 5 MG

2

carisoprodol oral tablet 350 mg

1 QL

carisoprodol-aspirin 1 PA; QL


chlorzoxazone oral tablet 500 mg

1

cyclobenzaprine oral tablet 10 mg, 5 mg

1

dantrolene oral 1

meprobamate 1 QL

MESTINON ORAL TABLET

2

MESTINON TIMESPAN

2

methocarbamol oral 1

orphenadrine citrate oral

1

pyridostigmine bromide oral syrup

1

pyridostigmine bromide oral tablet 60 mg

1

pyridostigmine bromide oral tablet extended release

1

tizanidine oral tablet 1

NARCOTIC AN ALGESICS acetaminophe n-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

1

acetaminophe n-codeine oral tablet

1

ascomp with codeine 1

buprenorphine hcl sublingual

1 QL

butalbital compound 1 w/codeine




12

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg

1

butalbital-acetaminophe n oral tablet 50-325 mg

1 QL

butalbital-acetaminophe n-caff oral capsule 50-325-40 mg

1 QL

butalbital-acetaminophe n-caff oral tablet 50-325-40 mg

1 QL

butalbital-aspirin-caffeine oral capsule

1 QL

codeine sulfate oral tablet

1

codeine-butalbital-asa-caff

1

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

ESGIC 2 QL

fentanyl 1 PA; QL

fentanyl citrate buccal lozenge on a handle

1 PA; QL

FENTANYL CITRATE BUCCAL TABLET, EFFERVESCENT

2 PA; QL

FENTORA 2 PA; QL

hydrocodone-acetaminophe n oral solution 7.5-325

1

mg/15 ml

Drug Name Drug Tier


hydrocodone-acetaminophe n oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1

hydrocodone-ibuprofen oral tablet 7.5-200 mg

1

hydromorphone oral liquid

1

hydromorphone oral tablet

1

hydromorphone rectal

1

lorcet (hydrocodone) 1

lorcet hd 1

meperidine oral 1

methadone intensol 1 PA; QL

methadone oral concentrate

1 PA; QL

methadone oral solution

1 PA; QL

methadone oral tablet

1 PA; QL

morphine concentrate oral solution

1

morphine oral solution

1

morphine oral tablet 1

morphine oral tablet extended release

1 PA; QL

morphine rectal 1

NORCO 2

oxycodone oral capsule

1

Drug Name Drug Tier




13

oxycodone oral concentrate

1

oxycodone oral solution

1

oxycodone oral tablet

1

oxycodone-acetaminophe n oral tablet 10-325 mg, 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

oxycodone-aspirin 1

oxymorphone oral tablet extended release 12 hr

1 PA; QL

tencon oral tablet 50-325 mg

1 QL

zebutal oral capsule 50-325-40 mg

1 QL

NON-NARCOTIC AN ALGESICS buprenorphine-naloxone sublingual tablet

1 QL

butorphanol nasal 1 QL

celecoxib 1 ST

diclofenac potassium 1

diclofenac sodium oral

1

diclofenac sodium topical gel 1 %

1 QL

diclofenac-misoprostol

1

diflunisal 1

ec-naproxen 1


etodolac 1

flurbiprofen oral tablet 100 mg

1

ibu 1

ibuprofen oral suspension

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN 2

indomethacin oral 1

ketoprofen oral capsule 50 mg, 75 mg

1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

1

ketorolac oral 1 QL

KLOXXADO 2 QL

meclofenamate 1

meloxicam oral tablet

1

nabumetone 1

naloxone injection solution

1 QL

naltrexone 1

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet 275 mg, 550 mg

1

naproxen- 1 esomeprazole




14

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

2 QL

oxaprozin 1

pentazocine-naloxone

1

piroxicam 1

SPRIX 2 PA; QL

sulindac 1

tramadol oral tablet 50 mg

1

tramadol-acetaminophe n

1

VIVITROL 2 QL

PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA

2 QL

ABILIFY MYCITE 2 QL;

ABILIFY MYCITE STARTER PAK

2 QL;

ABILIFY MYCITE MAINTENANCE PAK

2 QL;

ADHANSIA XR 2 PA; QL

ADZENYS ER 2 QL

ADZENYS XR-ODT

2 QL

alprazolam 1 QL

alprazolam intensol 1 QL

amitriptyline 1 QL

amitriptyline-chlordiazepoxide

1

amoxapine 1 QL

AMPHETAMINE 2 QL

Drug Name Drug Tier


amphetamine sulfate 1 QL

AMYTAL 2

APLENZIN 2 QL

aripiprazole 1 QL

ARISTADA 2 QL

ARISTADA INITIO 2 QL

armodaf inil 1 PA; QL

asenapine 1 QL

atomoxetine 1 QL

AZSTARYS 2 QL

BELSOMRA 2 QL

bupropion hcl oral tablet

1 QL

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

1 QL

BUPROPION HCL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG

2 QL

bupropion hcl oral tablet sustained-release 12 hr

1 QL

buspirone 1 QL

CAPLYTA 2 QL

CHLORAL HYDRATE (BULK)

2

chlordiazepoxide hcl 1 QL

chlorpromazine 1 QL

citalopram 1 QL

clomipramine 1 QL

Drug Name Drug Tier




15

clonidine hcl oral tablet extended release 12 hr

1 ST; QL

clorazepate dipotassium

1 QL

clozapine oral tablet 1 QL

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

1 QL

CLOZAPINE ORAL TABLET,DISINTE GRATING 150 MG, 200 MG

2 QL

COTEMPLA XR-ODT

2 QL

DAYTRANA 2 QL

DAYVIGO 2 QL

desipramine 1 QL

DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR

2 QL

desvenlafaxine succinate

1 QL

dexmethylphenidate 1 QL

dextroamphetamine 1 QL

dextroamphetamine-amphetamine

1 QL

diazepam injection 1

diazepam intensol 1 QL

diazepam oral concentrate

1 QL


diazepam oral solution 5 mg/5 ml (1 mg/ml)

1 QL

diazepam oral tablet 1 QL

DORAL 2 QL

doxepin oral 1 QL

DRIZALMA SPRINKLE

2 QL

duloxetine 1 QL

DYANAVEL XR 2 QL

EDLUAR 2 QL

EMSAM 2 QL

ergoloid 1 QL

escitalopram oxalate 1 QL

estazolam 1 QL

eszopiclone 1 QL

EVEKEO ODT 2 QL

FANAPT 2 QL

FETZIMA 2 QL

fluoxetine 1 QL

fluphenazine decanoate

1

FLUPHENAZINE DECANOATE (BULK)

2

fluphenazine hcl 1 QL

flurazepam 1 QL

fluvoxamine 1 QL

FORFIVO XL 2 QL

GEODON INTRAMUSCULA R

2




16

guanf acine oral tablet extended release 24 hr

1 ST; QL

haloperidol 1 QL

haloperidol decanoate

1

haloperidol lactate 1

HETLIOZ 2 QL;

imipramine hcl 1 QL

imipramine pamoate 1 QL

INVEGA SUSTENNA

2 QL

INVEGA TRINZA 2 QL

INVEGA HAFYERA

2 QL

JORNAY PM 2 QL

LATUDA 2 QL

lithium carbonate 1

lithium citrate oral solution 8 meq/5 ml

1

lorazepam injection 1

lorazepam intensol 1

lorazepam oral concentrate

1

lorazepam oral tablet

1 QL

LOREEV XR 2 QL

loxapine succinate 1 QL

maprotiline 1 QL

MARPLAN 2 QL

metadate er 1 QL

methamphetamine 1

Drug Name Drug Tier


methylphenidate hcl oral capsule, er biphas ic 30-70

1 QL

methylphenidate hcl oral capsule,er biphas ic 50-50

1 QL

methylphenidate hcl oral solution

1 QL

methylphenidate hcl oral tablet

1 QL

methylphenidate hcl oral tablet extended release

1 QL

methylphenidate hcl oral capsule extended release 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1 QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

1 QL

METHYLPHENID ATE HCL ORAL TABLET EXTENDED RELEASE 24HR 72 MG

2 QL

methylphenidate hcl oral tablet,chewable

1 QL

midazolam (pf) injection

1

midazolam injection 1

MIDAZOLAM INTRAVENOUS SYRINGE 150 MG/30 ML (5 MG/ML)

2

Drug Name Drug Tier




17

midazolam oral syrup 2 mg/ml

1

mirtazapine 1 QL

modaf inil 1 PA; QL

molindone 1 QL

MYDAYIS 2 QL

nefazodone 1 QL

NEMBUTAL SODIUM

2

nortriptyline 1 QL

NORTRIPTYLINE (BULK)

2

NUPLAZID ORAL CAPSULE

2 QL

NUPLAZID ORAL TABLET 10 MG

2 QL

olanzapine 1 QL

olanzapine-fluoxetine

1 QL

LYBALVI 2 QL

oxazepam 1 QL

paliperidone 1 QL

paroxetine hcl oral tablet

1 QL

paroxetine hcl oral tablet extended release 24 hr

1 QL

paroxetine hcl oral suspension

2 QL

pentobarbital sodium injection solution

1

perphenazine 1 QL


perphenazine-amitriptyline

1

PERSERIS 2 QL

PEXEVA 2 QL

phenelzine 1 QL

pimozide 1 QL

procentra 1 QL

protriptyline 1 QL

quazepam 1 QL

QELBREE 2 QL

quetiapine 1 QL

QUILLICHEW ER 2 QL

QUILLIVANT XR 2 QL

ramelteon 1 QL

RELEXXII 2 QL

REXULTI 2 QL

RISPERDAL CONSTA

2 QL

risperidone oral solution

1 QL

risperidone oral tablet

1 QL

risperidone oral tablet,disintegrating

1 QL

ROZEREM 2 QL

seconal sodium 1

SECUADO 2 QL

sertraline 1 QL




18

SPRAVATO NASAL SPRAY,NON-AEROSOL 56 MG (28 MG X 2), 84 MG (28 MG X 3)

2 QL

SUNOSI 2 PA; QL

temazepam 1 QL

thioridazine 1 QL

thiothixene 1 QL

tranylcypromine 1 QL

trazodone 1 QL

triazolam oral tablet 0.125 mg

1 PA; QL

triazolam oral tablet 0.25 mg

1 QL

trifluoperazine 1 QL

trimipramine 1 QL

TRINTELLIX 2 QL

venlafaxine 1 QL

VERSACLOZ 2 QL

VIIBRYD ORAL TABLET

2 QL

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

2

VRAYLAR 2 QL

VYVANSE 2 QL

WAKIX 2 PA; QL

XYREM 2 PA; QL

XYWAV 2 PA; QL

zaleplon 1 QL

zenzedi oral tablet 1 QL 10 mg, 5 mg

Drug Name Drug Tier


ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

2 QL

ziprasidone hcl 1 QL

zolpidem 1 QL

ZOLPIMIST 2 QL

ZYPREXA RELPREVV

2 QL

Drug Name Drug Tier


CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 200 mg, 400 mg

1

disopyramide phosphate oral capsule

1

dofetilide 1

flecainide 1

NORPACE CR 2

pacerone oral tablet 200 mg, 400 mg

1

propaf enone 1

sorine 1

sotalol af 1

sotalol oral 1

ANTIHYPERTENSIVE THERAPY acebutolol 1 QL

ALDACTAZIDE 2

aliskiren 1

amiloride 1

amiloride- 1 hydrochlorothiazide



19

amlodipine 1

amlodipine-benazepril

1

amlodipine-olmesartan

1

amlodipine-valsartan

1

amlodipine-valsartan-hcthiazid

1

atenolol 1

atenolol-chlorthalidone

1

benazepril 1

benazepril-hydrochlorothiazide

1

betaxolol oral 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

candesartan 1

candesartan-hydrochlorothiazid

1

captopril 1

captopril-hydrochlorothiazide

1

CARDIZEM LA 2

cartia xt 1

carvedilol 1

chlorothiazide oral tablet 500 mg

1

chlorthalidone oral tablet 25 mg, 50 mg

1

clonidine 1 ST; QL


clonidine hcl oral tablet

1 ST; QL

DEMSER 2 PA

diltiazem hcl oral capsule,ext.rel 24h degradable 180 mg, 240 mg

1

diltiazem hcl oral capsule,extended release 12 hr

1

diltiazem hcl oral capsule,extended release 24 hr

1

diltiazem hcl oral capsule,extended release 24hr

1

diltiazem hcl oral tablet

1

diltiazem hcl oral tablet extended release 24 hr

1

dilt-xr 1

DIURIL 2

doxazosin 1

enalapril maleate 1

enalapril-hydrochlorothiazide

1

EPANED ORAL SOLUTION

2

eplerenone 1

felodipine 1

fosinopr il 1

fosinopr il-hydrochlorothiazide

1




20

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

furosemide oral tablet

1

guanf acine oral tablet

1 ST

HEMANGEOL 2

hydralazine oral 1

hydrochlorothiazide 1

indapamide 1

INDERAL XL 2

INNOPRAN XL 2

irbesartan 1

irbesartan-hydrochlorothiazide

1

labetalol oral 1

lisinopril 1

lisinopril-hydrochlorothiazide

1

losartan 1

losartan-hydrochlorothiazide

1

matzim la 1

methyldopa 1

methyldopa -hydrochlorothiazide

1

metolazone 1

metoprolol succinate 1

metoprolol ta-hydrochlorothiaz

1

metoprolol tartrate oral tablet 100 mg,

1

25 mg, 50 mg

Drug Name Drug Tier


metyrosine 1 PA

minoxidil oral 1

moexipril 1

nadolol 1

nadolol-bendroflumethiazide oral tablet 80-5 mg

1

nicardipine oral 1 QL

nifedipine 1

olmesartan 1

olmesartan-amlodipin-hcthiazid

1

olmesartan-hydrochlorothiazide

1

perindopr il erbumine

1

pindolol 1 QL

prazosin 1

propranolol 1

propranolol-hydrochlorothiazid

1

quinapr il 1

quinapr il-hydrochlorothiazide

1

ramipril 1

REMODULIN 2 PA

spironolactone 1

spironolacton-hydrochlorothiaz

1

taztia xt 1

TEKTURNA 2

telmisartan 1

telmisartan- 1 amlodipine

Drug Name Drug Tier




21

telmisartan-hydrochlorothiazid

1

terazosin 1

timolol maleate oral 1 QL

torsemide oral 1

trandolapril 1

treprostinil sodium 1 PA

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg

1 QL

triamterene-hydrochlorothiazid oral tablet 75-50 mg

1

valsartan 1

valsartan-hydrochlorothiazide

1

veletri 1 PA

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet 120 mg, 80 mg

1

verapamil oral tablet 40 mg

1 QL

verapamil oral tablet extended release

1

CARDIAC GLYCOSIDES digitek 1

digox 1


digoxin oral solution 50 mcg/ml (0.05 mg/ml)

1

digoxin oral tablet 1

COAGULATION THERAPY aminocaproic acid oral

1

BRILINTA 2 ST

cilostazol 1

clopidogrel 1

dipyridamole oral 1

ELIQUIS 2

ELIQUIS DVT-PE TREAT 30D START

2

enoxapar in 1

fondapa rinux 1 QL

FRAGMIN SUBCUTANEOUS SOLUTION

2 PA

FRAGMIN SUBCUTANEOUS SYRINGE

2 PA

hep flush-10 (pf) 1

heparin (porcine) injection cartridge

1

heparin (porcine) injection solution

1

heparin (porcine) injection syringe 5,000 uni t/ml

1

heparin lock flush 1

heparin lock flush (porcine)

1

intravenous solution




22

heparin lockflush(porcine)(pf )

1

heparin, porcine (pf) injection solution

1

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

1

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

2

heparin, porcine (pf) intravenous solution 100 uni t/ml (1 ml)

1

heparin, porcine (pf) intravenous syringe

1

HEPARIN, PORCINE (PF) SUBCUTANEOUS

2

jantoven 1

pentoxifylline 1

phytonadione (vitamin k1) oral tablet 5 mg

1 PA; QL

prasugrel 1

PROMACTA ORAL TABLET

2 PA; QL

warfarin 1

XARELTO DVT-PE TREAT 30D START

2

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

2

XARELTO ORAL 2 ST TABLET 2.5 MG

Drug Name Drug Tier


LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin 1

cholestyramine (with sugar)

1

cholestyramine light 1

colestipol oral granules

1

colestipol oral tablet 1

ezetimibe 1 QL

fenof ibrate micronized oral capsule 134 mg, 200 mg, 67 mg

1

fenof ibrate nanoc rystallized oral tablet 145 mg, 48 mg

1

fenof ibrate oral tablet

1

gemfibrozil 1

JUXTAPID 2 PA

lovastatin 1

omega-3 acid ethyl esters

1

pravastatin 1

prevalite 1

rosuvastatin 1 ST

REPATHA 2 PA

simvastatin oral tablet

1

TRIGLIDE ORAL TABLET 160 MG

2

MISCELLANEOUS CARDIOVASCULAR AGENTS

Drug Name Drug Tier




23

ENTRESTO 2 PA

ranolazine 1

VYNDAMAX 2 PA

VYNDAQEL 2 PA

NITRATES ISORDIL TITRADOSE ORAL TABLET 5 MG

2

isosorbide dinitrate oral

1

isosorbide mononi trate

1

MINITRAN 2

nitro-bid 1

NITRO-DUR 2

nitroglycerin oral 1

nitroglycerin sublingual

1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual spray,non-aerosol

1

nitro-time 1


DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 2 PA

calcipotriene scalp 1 QL

calcipotriene topical 1 QL cream

CALCIPOTRIENE TOPICAL FOAM

2 QL

calcipotriene topical ointment

1 QL

SORILUX 2 QL

BURN THERAPY silver sulfadiazine 1

ssd 1

MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical lotion

1

diclofenac 3% gel 1 PA

EFUDEX TOPICAL CREAM

2

fluorouracil topical cream 5 %

1

fluorouracil topical solution

1

PANRETIN 2 PA

pimecrolimus 1 ST; QL

podof ilox 1 QL

REGRANEX 2 PA; QL

tacrolimus topical 1

tri-chlor 1

urea topical cream 39 %, 40 %, 41 %, 45 %, 47 %, 50 %

1

UREA TOPICAL LOTION 40 %

2

VALCHLOR 2 PA; QL

VEREGEN 2 PA

THERAPY FOR ACNE




24

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

2 PA

adapal ene topical cream

1 PA

amnesteem 1 PA

avar topical cleanser 1

AVAR-E 2

AVAR-E GREEN 2

AVAR-E LS 2

avita topical cream 1 PA; QL

AVITA TOPICAL GEL

2 PA; QL

claravis 1 PA

clindamycin phosphate topical foam

1

clindamycin phosphate topical gel

1

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

2

clindamycin phosphate topical lotion

1

clindamycin phosphate topical solution

1

ery pads 1

erythromycin with ethanol topical gel

1

erythromycin with ethanol topical

1

solution

Drug Name Drug Tier


isotretinoin 1 PA

METROCREAM 2

METROLOTION 2

metronidazole topical cream

1

metronidazole topical gel

1

metronidazole topical lotion

1

myorisan 1 PA

rosadan topical cream

1

rosadan topical gel 1

ROSANIL 2

sss 10-5 1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

1

sulfacetamide sodium-sulfur topical cleanser 9-4 %

1 ST

sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)

1

sulfacetamide sodium-sulfur topical lotion

1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

1 ST

Drug Name Drug Tier




25

sulfacetamide sodium-sulfur topical suspension 10-5 %

1

sulfacetamide sodium-sulfur topical suspension 8-4 %

1 ST

sulfacleanse 8-4 1 ST

SUMAXIN TOPICAL PADS, MEDICATED

2 ST

SUMAXIN TS 2 ST

tretinoin 1 PA; QL

tretinoin microspheres

1

TRETIN-X TOPICAL CREAM 0.075 %

2 QL

zenatane 1 PA

TOPICAL A NESTHETICS glydo 1 QL

lidocaine hcl mucous membrane jelly

1 QL

lidocaine hcl mucous membrane jelly in applicator

1 QL

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

1 PA; QL

lidocaine hcl topical cream 3 %

1 QL

lidocaine hcl-hydrocortison ac topical

1 PA; QL

lidocaine viscous 1 QL


lidocaine-prilocaine topical cream

1 QL

TOPICAL A NTIBACTERIALS CENTANY 2 QL

gentamicin topical 1

mupirocin 1 QL

sulfacetamide sodium (acne)

1

TOPICAL ANTIFUNGALS ciclodan 1

ciclopirox 1

clotrimazole topical cream

1

clotrimazole-betamethasone topical cream

1 QL

ketoconazole topical cream

1 QL

ketoconazole topical shampoo

1 QL

nyamyc 1 QL

nystatin topical cream

1

nystatin topical ointment

1

nystatin topical powder

1 QL

nystop 1 QL

TOPICAL ANTIVIRALS acyclovir topical 1 ST; QL

DENAVIR 2 ST; QL

TOPICAL C ORTICOSTEROIDS




26

ala-cort topical cream 1 %

1

alclometasone topical cream

1

alclometasone topical ointment

1 QL

betamethasone dipropionate topical cream

1

betamethasone dipropionate topical lotion

1

betamethasone dipropionate topical ointment

1 PA

betamethasone valerate topical cream

1

betamethasone valerate topical lotion

1

betamethasone valerate topical ointment

1

betamethasone, augmented topical cream

1

betamethasone, augmented topical lotion

1

betamethasone, augmented topical ointment

1

clobetasol scalp 1 PA

clobetasol topical cream

1 PA

clobetasol topical 1 PA gel

Drug Name Drug Tier


clobetasol topical ointment

1

clobetasol topical shampoo

1 PA; QL

clobetasol-emollient topical cream

1

clodan 1 PA; QL

desonide topical cream

1

desonide topical ointment

1

desoximetasone topical cream 0.25 %

1

desoximetasone topical ointment 0.05 %

1 QL

diflorasone 1 PA; QL

fluocinolone and shower cap

1 QL

fluocinolone topical cream

1 QL

fluocinolone topical oil

1

fluocinolone topical ointment

1 QL

fluocinolone topical solution

1 QL

fluocinonide topical cream

1 PA

fluocinonide topical gel

1 PA; QL

fluocinonide topical ointment

1 PA; QL

fluocinonide topical solution

1 QL

fluocinonide-e 1

Drug Name Drug Tier




27

fluocinonide-emollient

1

fluticasone propionate topical cream

1 QL

fluticasone propionate topical ointment

1 QL

hydrocortisone butyrate topical ointment

1

hydrocortisone butyrate topical solution

1 QL

hydrocortisone butyr-emollient

1

hydrocortisone topical cream 1 %, 2.5 %

1

hydrocortisone topical lotion 2.5 %

1

hydrocortisone topical ointment 1 %, 2.5 %

1

hydrocortisone valerate topical cream

1

mometasone topical 1

prednicarbate topical ointment

1

triamcinolone acetonide topical cream

1 QL

triamcinolone acetonide topical lotion

1


triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

1 QL

triderm topical cream

1 QL

TOPICAL ENZYMES SANTYL 2 QL

TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo

1

malathion 1 QL

NATROBA 2

permethrin topical cream

1

spinosad 1

ULESFIA 2 ST; QL


DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS acamprosate 1

anagr elide 1

caffeine citrate oral 1

CARBAGLU 2 PA

CHEMET 2

deferasirox oral tablet, dispersible

1 PA

disulfiram 1

etidronate disodium oral tablet 200 mg

1

kionex (with 1 sorbitol)



28

lanthanum 1

levocarnitine (with sugar)

1

levocarnitine oral solution 100 mg/ml

1

levocarnitine oral tablet

1 PA; QL

LITHOSTAT 2 PA

midodr ine 1

nitisinone 1 PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

2 PA

pilocarpine hcl oral 1

riluzole 1 PA

sodium phenylbutyrate oral tablet

1 PA

sodium polystyrene (sorb free)

1

sodium polystyrene sulfonate oral powder

1

sps (with sorbitol) 1

SMOKING DETERRENTS bupropion hcl (smok ing deter)

1

CHANTIX 2

CHANTIX CONTINUING MONTH BOX

2

CHANTIX STARTING MONTH BOX

2

Drug Name Drug Tier


Drug Name Drug Tier


EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal 1 QL

chlorhexidine gluconate mucous membrane

1

denta 5000 plus 1

fluoride (sodium) dental cream

1

ipratropium bromide nasal

1 QL

oralone 1

paroex oral rinse 1

periogard 1

sf 5000 plus 1

sodium fluoride 5000 plus

1

triamcinolone acetonide dental

1

MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) 1

ciprofloxacin hcl otic (ear)

1

hydrocortisone-acetic acid

1 QL

ofloxacin otic (ear) 1

OTIC STEROID / ANTIBIOTIC neomycin-polymyxin-hc otic (ear)

1

ENDOCRINE/DIABETES ADRENAL HORMONES



29

cortisone 1

decadron oral tablet 1

dexamethasone intensol

1

dexamethasone oral elixir

1

dexamethasone oral solution

1

dexamethasone oral tablet

1

DEXONTO 2

EMFLAZA 2 PA

fludrocortisone 1

hydrocortisone oral 1

MEDROL (PAK) 2

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

2

methylprednisolone 1

PEDIAPRED 2

prednisolone oral solution 15 mg/5 ml

1

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

1

prednisone 1

prednisone intensol 1

ANTITHYROID A GENTS methimazole oral tablet 10 mg, 5 mg

1

propylthiouracil 1


SSKI 2

DIABETES THERAPY acarbose 1

ACCU-CHEK AVIVA PLUS TEST STRP

2 OTC; QL

ACCU-CHEK GUIDE TEST STRIPS

2 OTC; QL

ACCU-CHEK SMARTVIEW TEST STRIP

2 OTC; QL

ADMELOG SOLOSTAR U-100 INSULIN

2 QL

ADMELOG U-100 2

ALOGLIPTIN 2

ALOGLIPTIN-METFORMIN

2

ALOGLIPTIN-PIOGLITAZONE

2

ALTERA NEBULIZER

2 ST

ALTERA NEBULIZER SYSTEM

2 ST; QL

BAQSIMI 2 ST; QL

FREESTYLE INSULINX STRIP

2 OTC; QL

FREESTYLE INSULINX TEST STRIPS

2 OTC; QL

FREESTYLE LITE STRIPS

2 OTC; QL

FREESTYLE TEST 2 OTC; QL




30

glimepiride 1

glipizide 1

glipizide-metformin 1

GLUCAGEN DIAGNOSTIC KIT

2

GLUCAGEN HYPOKIT

2 QL

GLUCAGON EMERGENCY KIT (HUMAN)

2 QL

glyburide 1 QL

glyburide micronized oral tablet 1.5 mg, 6 mg

1 QL

glyburide micronized oral tablet 3 mg

1

glyburide-metformin 1 QL

HUMULIN 70/30 U-100 INSULIN

2 QL

HUMULIN 70/30 U-100 KWIKPEN

2 QL

HUMULIN N NPH INSULIN KWIKPEN

2 QL

HUMULIN N NPH U-100 INSULIN

2 QL

HUMULIN R REGULAR U-100 INSULN

2 QL

HUMULIN R U-500 (CONC) INSULIN

2

HUMULIN R U-500 (CONC) KWIKPEN

2 QL

LANCETS 2 OTC; QL

metformin oral 1 solution

Drug Name Drug Tier


metformin oral tablet

1

metformin oral tablet extended release 24 hr

1

miglitol 1

nateglinide 1

NOVOLIN 70/30 U-100 INSULIN

2 QL

NOVOLIN 70-30 FLEXPEN U-100

2 QL

NOVOLIN N NPH U-100 INSULIN

2 QL

NOVOLIN R REGULAR U-100 INSULN

2 QL

pioglitazone 1

pioglitazone-glimepiride

1 ST

pioglitazone-metformin

1

repaglinide 1

RYBELSUS 2 ST; QL

SEGLUROMET 2 ST

SOLIQUA 100/33 2 ST; QL

SEMGLEE 100 UNIT/ML VIAL

1 QL

SEMGLEE 100 UNIT/ML PEN

1 QL

STEGLATRO 2 ST

SYMLINPEN 120 2 ST

SYMLINPEN 60 2 ST

TRUE METRIX GLUCOSE TEST STRIP

2 OTC; QL

Drug Name Drug Tier




31

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML

2 ST; QL

MISCELLANEOUS HORMONES ANADROL-50 2 PA

ANDROGEL TRANSDERMAL GEL IN PACKET

2 PA; QL

cabergoline 1

calcitonin (salmon) 1

calcitriol oral 1

cinacalcet 1

danaz ol 1

DDAVP NASAL SOLUTION

2

DEPO-TESTOSTERONE

2 PA

desmopressin nasal spray with pump

1

desmopressin oral 1

FORTESTA 2 PA; QL

KUVAN 2 PA

MIACALCIN INJECTION

2

miglustat 1 PA

ORILISSA 2 PA; QL

ORIAHNN 2 PA

oxandrolone 1 PA

paricalcitol oral capsule 4 mcg

1 ST

SAMSCA ORAL 2 PA TABLET 15 MG


SENSIPAR 2

SOMAVERT 2 PA

SYNAREL 2

TESTIM 2 PA; QL

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

1 PA

testosterone enanthate

1 PA

testosterone transdermal gel

1 PA; QL

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 20.25 mg/1.25 gram (1.62 %)

1 PA; QL

testosterone transdermal gel in packet

1 PA; QL

VOGELXO TRANSDERMAL GEL

2 PA; QL

VOGELXO TRANSDERMAL GEL IN PACKET

2 PA; QL

THYROID HOR MONES ARMOUR THYROID

2

euthyrox 2

levothyroxine oral 1




32

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine oral 1

np thyroid 1

thyroid (pork) 1

THYROLAR-1 2 QL

THYROLAR-1/2 2 QL

THYROLAR-1/4 2 QL

THYROLAR-2 2 QL

THYROLAR-3 2 QL

unithroid 1

Drug Name Drug Tier


GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS belladonna alkaloids-opium

1

chlordiazepoxide-clidinium

1

CUVPOSA 2 PA

dicyclomine oral capsule

1

dicyclomine oral solution

1

dicyclomine oral tablet

1

diphenoxylate-atropine

1

ed-spaz 1

glycopyrrolate oral 1

hyoscyamine sulfate 1 oral

hyoscyamine sulfate sublingual

1

hyosyne 1

loperamide oral capsule

1 QL

methscopolamine 1

MYTESI 2 PA

NULEV 2

oscimin oral tablet 1

oscimin sl 1

oscimin sr 1

symax-sl 1

symax-sr 1

MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO (NETUPITANT)

2 PA; QL

alosetron 1 PA

ANALPRAM-HC RECTAL CREAM

2

ANALPRAM-HC SINGLES RECTAL CREAM 2.5-1 % (4G)

2

aprepitant 1 PA; QL

APRISO 2

balsalazide 1

budesonide oral capsule,delayed,exte nd.release

1

CHOLBAM 2 PA

COMPAZINE RECTAL

2

compro 1

Drug Name Drug Tier




33

constulose 1

CORTIFOAM 2

CREON 2

cromolyn oral 1 PA

DIPENTUM 2 ST

dronabinol 1 PA

droperidol injection solution

1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n 1

generlac 1

GOLYTELY ORAL POWDER IN PACKET

2

granisetron hcl oral 1 QL

hydrocortisone rectal

1

hydrocortisone topical cream with perineal applicator

1

hydrocortisone-pramoxine rectal

1

KRISTALOSE 2

lactulose 1

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1 PA; QL

lubiprostone capsule 1 ST; QL

meclizine oral tablet 12.5 mg, 25 mg

1


mesalamine oral capsule (with del rel tablets)

1

mesalamine oral capsule,extended release 24hr

1

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

1 ST

mesalamine oral tablet,delayed release (dr/ec) 800 mg

1

mesalamine rectal 1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

ondans etron 1

ondans etron hcl oral 1

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

1

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

1

peg-electrolyte soln 1

peg-prep 1

PENTASA 2 ST

polyethylene glycol 3350 or al powder

1

prochlorperazine 1

prochlorperazine 1 edisylate




34

prochlorperazine maleate

1

procto-med hc 1

procto-pak 1

proctosol hc topical 1

proctozone-hc 1

SUCRAID 2 PA

sulfasalazine 1

trilyte with flavor packets

1

trimethobenzamide oral

1

ursodiol 1

VIOKACE 2

ULCER THERAPY amoxicil-clarithromy-lansopraz

1

CARAFATE ORAL SUSPENSION

2

cimetidine 1

cimetidine hcl oral 1

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

1

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

1 QL

esomeprazole magnesium oral granules dr for susp in packet

1

famotidine oral 1 suspension

Drug Name Drug Tier


famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule,delayed release(dr/ec)

1 PA; QL

misoprostol 1

NEXIUM 24HR ORAL CAPSULE,DELAY ED RELEASE(DR/EC)

2 OTC

nizatidine 1

omeprazole oral capsule,delayed release(dr/ec)

1 QL

pantoprazole oral tablet,delayed release (dr/ec)

1 QL

PEPCID ORAL TABLET

2

PREVACID 2 PA; QL

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

2 QL

PRILOSEC OTC 2 OTC; QL

ranitidine hcl oral syrup

1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate 1

Drug Name Drug Tier


IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 2 PA



35

ARANESP (IN POLYSORBATE)

2 PA

ARCALYST 2 PA

AVONEX INTRAMUSCULA R PEN INJECTOR KIT

2 PA, QL

AVONEX INTRAMUSCULA R SYRINGE KIT

2 PA, QL

BETASERON SUBCUTANEOUS KIT

2 PA, QL

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

2 PA

EXTAVIA 2 PA; QL

INTRON A INJECTION RECON SOLN

2 PA

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

2 PA

NEULASTA 2 QL

OMNITROPE SUBCUTANEOUS RECON SOLN

2 PA

PEGASYS 2 PA; QL

PROCRIT 2 PA; QL


REBIF (WITH ALBUMIN)

2 PA; QL

REBIF REBIDOSE 2 PA; QL

REBIF TITRATION PACK

2 PA; QL

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

2 PA

ZARXIO 2 QL

VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) 2

ADACEL(TDAP ADOLESN/ADULT )(PF)

2

AFLURIA QD 2020-21(3YR UP)(PF)

2

AFLURIA QD 2020-21(6-35MO)(PF)

2

AFLURIA QUAD 2020-2021(6MO UP)

2

BEXSERO 2

BOOSTRIX TDAP 2

DAPTACEL (DTAP PEDIATRIC) (PF)

2

ENGERIX-B (P F) 2

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE

2

FLUAD 2020-2021 2 (65 YR UP)(PF)




36

FLUAD QUAD 2020-21(65Y UP)(PF)

2

FLUARIX QUAD 2020-2021 ( PF)

2

FLUBLOK QUAD 2020-2021 ( PF)

2

FLUCELVAX QUAD 2020-2021

2

FLUCELVAX QUAD 2020-2021 (PF)

2

FLULAVAL QUAD 2020-2021 ( PF)

2

FLUMIST QUAD 2020-2021

2

FLUZONE HIGHDOSE QUAD 20-21 P F

2

FLUZONE QUAD 2020-2021

2

FLUZONE QUAD 2020-2021 ( PF)

2

GARDASIL 9 (PF) 2

GRASTEK 2 PA

HAVRIX (PF) INTRAMUSCULA R SUSPENSION 1,440 ELISA UNIT/ML

2

HAVRIX (PF) INTRAMUSCULA R SYRINGE

2

HEPLISAV-B (PF) INTRAMUSCULA R SYRINGE

2

HIBERIX (P F) 2

Drug Name Drug Tier


INFANRIX (DTAP) (PF)

2

IPOL 2

KINRIX (PF) 2

MENACTRA (PF) INTRAMUSCULA R SOLUTION

2

MENVEO A-C-Y-W-135-DIP (P F)

2

M-M-R II (PF) 2

PEDIARIX (PF) 2

PEDVAX HIB (PF) 2

PENTACEL (PF) 2

PENTACEL ACTHIB COMPONENT (PF)

2

PNEUMOVAX-23 2

PREVNAR 13 (PF) 2

PROQUAD (PF) 2

QUADRACEL (PF) 2

RAGWITEK 2 PA

RECOMBIVAX HB (PF)

2

ROTARIX 2

ROTATEQ VACCINE

2

SHINGRIX (P F) 2

TDVAX 2

TENIVAC (PF) 2

TETANUS,DIPHTH ERIA TOX PED(PF)

2

TRUMENBA 2

Drug Name Drug Tier




37

TWINRIX (P F) INTRAMUSCULA R SYRINGE

2

VAQTA (PF) 2

VARIVAX (PF) 2

VARIZIG INTRAMUSCULA R SOLUTION

2

ZOSTAVAX (PF) 2


MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopur inol 1

colchicine oral tablet

1 QL

febuxostat 1 ST

probenecid 1

ULORIC 2 ST

OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1

ibandr onate oral 1

raloxifene 1

OTHER R HEUMATOLOGICALS ENBREL MINI 2 PA; QL

ENBREL SUBCUTANEOUS RECON SOLN

2 PA; QL

ENBREL SUBCUTANEOUS SYRINGE

2 PA; QL

ENBREL 2 PA; QL SURECLICK

KINERET 2 PA

leflunomide 1

penicillamine oral capsule

1

SAVELLA 2


OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS ALORA 2 PA; QL

amabelz 1

camila 1

CLIMARA 2

CLIMARA PRO 2 ST

COMBIPATCH 2

covaryx 1

covaryx h.s. 1

CRINONE VAGINAL GEL 4 %

2

deblitane 1

DEPO-ESTRADIOL 2

DEPO-PROVERA INTRAMUSCULA R SUSPENSION 150 MG/ML

2

DUAVEE 2 ST

eemt 1

eemt hs 1

errin 1

ESTRACE 2

estradiol oral 1



38

estradiol transdermal patch semiweek ly 0.025 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

1 PA; QL

estradiol transdermal patch week ly

1

estradiol vaginal 1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

1

estradiol-norethindrone acet

1

estrogens-methyltestosterone

1

fyavolv 1

heather 1

incassia 1

jencycla 1

jinteli 1

lopreeza oral tablet 1-0.5 mg

1

lyza 1

medroxyprogesteron e

1

MENEST 2

mimvey 1

nora-be 1

norethindrone (contraceptive)

1

norethindrone acetate

1

Drug Name Drug Tier


norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

norlyda 1

PREFEST 2

PREMARIN ORAL 2

PREMARIN VAGINAL

2

PREMPHASE 2

PREMPRO 2

progesterone 1

progesterone micronized

1

sharobel 1

tulana 1

VAGIFEM 2

yuvafem 1

MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin phosphate vaginal

1

eluryng 1

etonoge strel-ethinyl estradiol

1

isoxsuprine 1

KYLEENA 2

LILETTA 2

metronidazole vaginal

1 QL

MIRENA 2

NEXPLANON 2

Drug Name Drug Tier




39

SKYLA 2

terconazole 1

tranexamic acid oral 1 ST

vandaz ole 1 QL

xulane 1 ST

zafemy 1 ST

ORAL CONTRACEPTIVES / RELATED A GENTS afirmelle 1

altavera (28) 1

alyacen 1/35 (28) 1

alyacen 7/7/7 (28) 1

amethia 1 QL

amethia lo 1 QL

amethyst (28) 1

apri 1

aranelle (28) 1

ashlyna 1 QL

aubra 1

aubra eq 1

aurovela 1.5/30 (21) 1

aurovela 1/20 (21) 1

aurovela 24 fe 1

aurovela fe 1.5/30 (28)

1

aurovela fe 1-20 (28)

1

aviane 1

ayuna 1

azurette (28) 1

balziva (28) 1


bekyree (28) 1

BEYAZ 2 PA

blisovi 24 fe 1

blisovi fe 1.5/30 (28) 1

blisovi fe 1/20 (28) 1

briellyn 1

camrese 1 QL

camrese lo 1 QL

caziant (28) 1

chateal (28) 1

chateal eq (28) 1

cryselle (28) 1

cyclafem 1/35 (28) 1

cyclafem 7/7/7 (28) 1

cyred 1

cyred eq 1

dasetta 1/35 (28) 1

dasetta 7/7/7 (28) 1

daysee 1 QL

desog-e.estradiol/e.estradio l

1

desogestrel-ethinyl estradiol

1

drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg (24) (4)

1 PA

drospirenone-ethinyl estradiol

1

elinest 1

ELLA 2 QL




40

emoque tte 1

enpresse 1

enskyce 1

estarylla 1

ethynodiol diac-eth estradiol

1

falmina (28) 1

femynor 1

gianvi (28) 1

hailey 1

hailey 24 fe 1

hailey fe 1.5/30 (28) 1

hailey fe 1/20 (28) 1

introvale 1 QL

isibloom 1

jasmiel (28) 1

jolessa 1 QL

juleber 1

junel 1.5/30 (21) 1

junel 1/20 (21) 1

junel fe 1.5/30 (28) 1

junel fe 1/20 (28) 1

junel fe 24 1

kaitlib fe 1

kalliga 1

kariva (28) 1

kelnor 1/35 (28) 1

kelnor 1-50 1

kurvelo (28) 1

Drug Name Drug Tier


l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

1 QL

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

1

larin 1.5/30 (21) 1

larin 1/20 (21) 1

larin 24 fe 1

larin fe 1.5/30 (28) 1

larin fe 1/20 (28) 1

larissia 1

layolis fe 1

leena 28 1

lessina 1

levonest (28) 1

levonorgestrel-ethinyl estrad oral tablet

1

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1 QL

levonorg-eth estrad triphasic

1

levora-28 1

lillow (28) 1

loryna (28) 1

LOSEASONIQUE 2 QL

Drug Name Drug Tier




41

low-ogestrel (28) 1

lo-zumandimine (28) 1

lutera (28) 1

marlissa (28) 1

microgestin 1.5/30 (21)

1

microgestin 1/20 (21)

1

microgestin fe 1.5/30 (28)

1

microgestin fe 1/20 (28)

1

mili 1

mono-linyah 1

necon 0.5/35 (28) 1

nikki (28) 1

noreth-ethinyl estradiol-iron

1

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

1

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

1

norgestimate-ethinyl estradiol

1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 (28) 1

ocella 1


orsythia 1

philith 1

pimtrea (28) 1

pirmella 1

portia 28 1

previfem 1

reclipsen (28) 1

SEASONIQUE 2 QL

setlakin 1 QL

simliya (28) 1

simpesse 1 QL

sprintec (28) 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1/20 (28) 1

tarina fe 1-20 eq (28)

1

tilia fe 1

tri femynor 1

tri-estarylla 1

tri-legest fe 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem (28) 1

tri-sprintec (28) 1




42

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

velivet triphasic regimen (28)

1

vienva 1

viorele (28) 1

vyfemla (28) 1

vylibra 1

wera (28) 1

wymzya fe 1

zarah 1

zovia 1/35e (28) 1

zumandimine (28) 1

OXYTOCICS methergine 1

methylergonov ine oral

1

Drug Name Drug Tier


OPHTHALMOLOGY ANTIBIOTICS ak -poly-bac 1

bacitracin ophthalmic (eye)

1

bacitracin-polymyxin b ophthalmic (eye)

1

ciprofloxacin hcl ophthalmic (eye)

1

erythromycin ophthalmic (eye)

1

gentak ophthalmic (eye) ointment

1

gentamicin ophthalmic (eye) drops

1

moxifloxacin ophthalmic (eye) drops

1 ST

moxifloxacin ophthalmic (eye) drops, viscous

1

NATACYN 2 QL

neomycin-bacitracin-polymyxin

1

neomycin-polymyxin-gramicidin

1

neo-polycin 1

ofloxacin ophthalmic (eye)

1 QL

polycin 1

polymyxin b sulf-trimethoprim

1

tobramycin ophthalmic (eye)

1

TOBREX OPHTHALMIC (EYE) OINTMENT

2

ANTIVIRALS trifluridine 1

ZIRGAN 2 PA

BETA-BLOCKERS betaxolol ophthalmic (eye)

1

carteolol 1

Drug Name Drug Tier




43

levobunol ol ophthalmic (eye) drops 0.5 %

1

metipranolol 1

timolol maleate ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) gel forming solution

1

TIMOPTIC OCUDOSE (PF)

2

CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE

2

CYCLOPLEGIC MYDRIATICS atropine ophthalmic (eye) drops

1

atropine ophthalmic (eye) ointment

1

CYCLOGYL OPHTHALMIC (EYE) DROPS 1 %, 2 %

2

cyclopentolate ophthalmic (eye) drops 1 %, 2 %

1

homatropaire 1

ISOPTO ATROPINE

2

tropicamide 1

DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic (eye)

1

drops 1 %, 2 %, 4 %


MISCELLANEOUS OPHTHALMOLOGICS altacaine 1 PA

azelastine ophthalmic (eye)

1

cromolyn ophthalmic (eye)

1

OXERVATE 2 PA

tetracaine hcl 1 PA

TETRACAINE HCL (PF) OPHTHALMIC (EYE)

2 PA

XIIDRA 2 PA; QL

NON-STEROIDAL A NTI-INFLAMMATORY AGENTS diclofenac sodium ophthalmic (eye)

1

flurbiprofen sodium 1

ketorolac ophthalmic (eye) drops 0.4 %

1 QL

ketorolac ophthalmic (eye) drops 0.5 %

1

ORAL DRUGS FOR GLAUCOMA acetazolamide 1

methazolamide 1

OTHER GLAUCOMA DRUGS dorzolamide 1

DORZOLAMIDE (PF)

2

dorzolamide-timolol 1




44

DORZOLAMIDE-TIMOLOL (PF) OPHTHALMIC (EYE) DROPS

2

latanopr ost 1

LATANOPROST (PF)

2

STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc

1

neomycin-polymyxin b-dexameth

1

neomycin-polymyxin-hc ophthalmic (eye)

1

neo-polycin hc 1

PRED-G 2

PRED-G S.O.P. 2

TOBRADEX OPHTHALMIC (EYE) OINTMENT

2

TOBRADEX ST 2

tobramycin-dexamethasone

1

STEROIDS dexamethasone sodium phosphate ophthalmic (eye)

1

fluorometholone 1

FML S.O.P. 2 QL

PRED MILD 2

prednisolone acetate 1

PREDNISOLONE ACETATE (PF)

2

Drug Name Drug Tier


prednisolone sodium phosphate ophthalmic (eye)

1

STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE 2

BLEPHAMIDE S.O.P.

2

sulfacetamide-prednisolone

1

SULFONAMIDES sulfacetamide sodium ophthalmic (eye) drops

1

SYMPATHOMIMETICS brimonidine 1

VASOCONSTRICTOR DECONGESTANTS phenylephrine hcl ophthalmic (eye)

1

Drug Name Drug Tier


RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS benzonatate oral capsule 100 mg, 200 mg

1 QL

BROMFED DM 2

brompheniramine-pseudoeph-dm oral syrup

1

CAPCOF 2

cetirizine oral solution 1 mg/ml

1



45

clemastine oral tablet 2.68 mg

1

codeine-guaifenesin 1

cyproheptadine 1

diphenhydramine hcl oral capsule 50 mg

1

diphenhydramine hcl oral elixir

1

EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML

2 QL

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml

1 QL

g tussin ac 1

guaiatussin ac 1

guaifenesin ac 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

1 QL

HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML)

2 QL

hydromet 1 QL

hydroxyzine hcl intramuscular

1

hydroxyzine hcl oral solution 10 mg/5 ml

1 QL

hydroxyzine hcl oral tablet

1 QL

hydroxyzine 1 QL pamoate


levocetirizine oral tablet

1

PALFORZIA 2 PA

promethazine oral 1

promethazine rectal 1

promethazine vc 1

promethazine-dm 1

promethazine-phenylephrine

1

promethegan 1

SEMPREX-D 2 QL

virtussin ac 1

PULMONARY A GENTS ADEMPAS 2 PA

albuterol sulfate inhalation

1 QL

albuterol sulfate oral 1

ambrisentan 1 PA

ARCAPTA NEOHALER

2 QL

ARNUITY ELLIPTA

2 QL

ATROVENT HFA 2 QL

azelastine-fluticasone

1

bosentan 1 PA

budesonide inhalation

1 QL

budesonide nasal 1 QL

COMBIVENT RESPIMAT

2 QL

cromolyn inhalation 1 QL




46

DALIRESP ORAL TABLET 250 MCG

2 ST

DALIRESP ORAL TABLET 500 MCG

2 ST; QL

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION , 200-5 MCG/ACTUATION

2 QL

DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION

2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

2

ESBRIET ORAL CAPSULE

2 PA

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

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

1 QL

fluticasone propionate nasal

1 QL

FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED

2 QL

fluticasone propion-salmeterol inhalation blister with device

1 QL

Drug Name Drug Tier


HYPER-SAL 2

ipratropium bromide inhalation

1 QL

ipratropium-albuterol

1 QL

LETAIRIS 2 PA

LEVALBUTEROL TARTRATE

2 QL

metaproterenol oral syrup

1

montelukast 1

nebusal inhalation solution for nebulization 3 %

1

OFEV 2 PA

OPSUMIT 2 PA

PROAIR DIGIHALER

2 QL

PROAIR HFA 2 QL

PROAIR RESPICLICK

2 QL

PROVENTIL HFA 2 QL

pulmosal 1

PULMOZYME 2 PA; QL

QVAR REDIHALER

2 QL

SEREVENT DISKUS

2 QL

sildenafil (pulm.hypertension) oral tablet

1 PA; QL

sodium chloride inhalation solution for nebulization 0.9 %, 3 %, 7 %

1

Drug Name Drug Tier




47

sodium chloride inhalation solution for nebulization 10 %

1 QL

SPIRIVA RESPIMAT

2 QL

STIOLTO RESPIMAT

2 QL

STRIVERDI RESPIMAT

2 QL

tadalafil 20 mg 1

terbutaline oral 1

THEO-24 2

theochron oral tablet extended release 12 hr 100 mg, 200 mg

1

theophy lline oral elixir

1

theophy lline oral solution

1

theophy lline oral tablet extended release 12 hr 300 mg, 450 mg

1

theophy lline oral tablet extended release 24 hr

1

TRACLEER ORAL TABLET

2 PA

TRELEGY ELLIPTA

2 ST; QL

VENTAVIS 2 PA

VENTOLIN HFA 2 QL

zafirlukast 1


UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS flavoxate 1

oxybutynin chloride 1

OXYTROL 2

trospium oral capsule,extended release 24hr

1

trospium oral tablet 1 ST

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin 1

finasteride oral tablet 5 mg

1

tamsulosin 1

CHOLINERGIC STIMULANTS bethanechol chloride 1

MISCELLANEOUS UROLOGICALS ELMIRON 2

methen-sod phos -meth blue-hyos

1

phosphasal 1

potassium citrate 1

URELLE 2

uretron d-s oral tablet 81.6-10.8-40.8 mg

1

urin ds 1

uro-458 1

uryl 1

ustell 1

utira-c 1




48

vilevev mb 1

URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg

1

Drug Name Drug Tier


VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate(phosphat bind) oral capsule

1

effer-k oral tablet, effervescent 25 meq

1

GALZIN 2 PA

klor-con 10 1

klor-con 8 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con/ef 1

potassium chloride oral

1

VITAMINS / HEMATINICS cyanocobalamin (vitamin b-12) injection

1

DRISDOL ORAL CAPSULE

2

ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 uni t)

1

folic acid oral tablet 1 mg

1

KOSHER PRENATAL PLUS IRON

2

m-natal plus 1

mynatal advance 1

mynatal oral tablet 1

OBTREX DHA 2

pnv 29-1 1

prenaissance plus 1

prenatabs fa 1

prenatabs rx 1

PRENATAL 19 2

prenatal plus 1

prenatal plus (calcium carb)

1

prenatal vitamin plus low iron

1

preplus 1

pretab 1

se-natal 19 chewable 1

THRIVITE RX 2

TRICARE 2

trinatal rx 1 1

vitamin d2 1

SICKLE CEL ANEMIA ENDARI 2 PA

Drug Name Drug Tier




49

Index

A ABILIFY MAINTENA ....... 14 ABILIFY MYCITE............. 14 abiraterone ............................ 6 ABSORICA........................ 24 acamprosate ........................ 27 acarbose.............................. 29 ACCU-CHEK AVIVA PLUS

TEST STRP .................... 29 ACCU-CHEK GUIDE TEST

STRIPS........................... 29 ACCU-CHEK SMARTVIEW

TEST STRIP ................... 29 acebutolol ........................... 18 acetaminophen-codeine ....... 11 acetazolamide ..................... 43 acetic acid........................... 28 ACTHIB (PF) ..................... 35 ACTIMMUNE.................... 34 acyclovir .......................... 3, 25 ADACEL(TDAP

ADOLESN/ADULT)(PF) 35 adapalene ............................ 24 adefovir ................................ 3 ADEMPAS......................... 45 ADHANSIA XR ................. 14 ADMELOG SOLOSTAR U-

100 INSULIN.................. 29 ADMELOG U-100 INSULIN

LISPRO .......................... 29 ADZENYS ER.................... 14 ADZENYS XR-ODT .......... 14 AFINITOR ........................... 6 AFINITOR DISPERZ........... 6 afirmelle ............................. 39 AFLURIA QD 2020-21(3YR

UP)(PF) .......................... 35 AFLURIA QD 2020-21(6-

35MO)(PF) ..................... 35 AFLURIA QUAD 2020-

2021(6MO UP) ............... 35 ak-poly-bac ......................... 42 AKYNZEO (NETUPITANT)

....................................... 32

ala-cort ............................... 26 albuterol sulfate................... 45 alclometasone ..................... 26 ALDACTAZIDE ................ 18 alendronate ......................... 37 alfuzosin ............................. 47 allopurinol .......................... 37 almotriptan malate............... 10 ALOGLIPTIN..................... 29 ALOGLIPTIN-METFORMIN

....................................... 29 ALOGLIPTIN-

PIOGLITAZONE............ 29 ALORA.............................. 37 alosetron ............................. 32 alprazolam .......................... 14 alprazolam intensol ............. 14 altacaine.............................. 43 altavera (28) ........................ 39 ALTERA NEBULIZER ...... 29 ALTERA NEBULIZER

SYSTEM ........................ 29 alyacen 1/35 (28)................. 39 alyacen 7/7/7 (28)................ 39 amabelz .............................. 37 amantadine hcl ...................... 3 ambrisentan......................... 45 amethia ............................... 39 amethia lo ........................... 39 amethyst (28) ...................... 39 amiloride............................. 18 amiloride-hydrochlorothiazide

....................................... 18 aminocaproic acid ............... 21 amiodarone ......................... 18 amitriptyline........................ 14 amitriptyline-chlordiazepoxide

....................................... 14 amlodipine .......................... 19 amlodipine-benazepril ......... 19 amlodipine-olmesartan ........ 19 amlodipine-valsartan ........... 19 amlodipine-valsartan-hcthiazid

....................................... 19

ammonium lactate ............... 23 amnesteem .......................... 24 amoxapine .......................... 14 amoxicil-clarithromy-lansopraz

....................................... 34 amoxicillin............................ 5 amoxicillin-pot c lavulanate.... 5 AMPHETAMINE ............... 14 amphetamine sulfate............ 14 ampicillin.............................. 5 AMYTAL........................... 14 ANADROL-50.................... 31 anagrelide ........................... 27 ANALPRAM-HC ............... 32 ANALPRAM-HC SINGLES32 anastrozole ............................ 6 ANDROGEL ...................... 31 APLENZIN......................... 14 aprepitant............................ 32 apri ..................................... 39 APRISO.............................. 32 aranelle (28) ........................ 39 ARANESP (IN

POLYSORBATE)........... 35 ARCALYST....................... 35 ARCAPTA NEOHALER .... 45 aripiprazole ......................... 14 ARISTADA........................ 14 ARISTADA INITIO............ 14 armodafinil ......................... 14 ARMOUR THYROID......... 31 ARNUITY ELLIPTA.......... 45 ascomp with codeine ........... 11 ashlyna ............................... 39 atazanavir ............................. 3 atenolol............................... 19 atenolol-chlorthalidone........ 19 atomoxetine ........................ 14 atorvastatin ......................... 22 atovaquone............................ 4 atovaquone-proguanil ............ 4 atropine............................... 43 ATROVENT HFA .............. 45 AUBAGIO.......................... 10

CareSource Indiana Medica id aubra................................... 39 BEYAZ .............................. 39

Effective 1/1/2022 camrese............................... 39


50

aubra eq .............................. 39 aurovela 1.5/30 (21) ............ 39 aurovela 1/20 (21) ............... 39 aurovela 24 fe ..................... 39 aurovela fe 1.5/30 (28)......... 39 aurovela fe 1-20 (28) ........... 39 AUSTEDO ......................... 10 avar .................................... 24 AVAR-E............................. 24 AVAR-E GREEN ............... 24 AVAR-E LS ....................... 24 aviane ................................ . 39 avita.................................... 24 AVITA ............................... 24 AVONEX........................... 35 ayuna .................................. 39 azathioprine .......................... 6 azelastine ....................... 28, 43azelastine-fluticasone .......... 45 azithromycin ......................... 4 azurette (28) ........................ 39 B bacitrac in ............................ 42 bacitrac in-polymyxin b........ 42 baclofen.............................. 11 BACLOFEN ....................... 11 balsalazide .......................... 32 balziva (28) ......................... 39 BANZEL.............................. 8 BAQSIMI ........................... 29 BARACLUDE...................... 3 bekyree (28) ........................ 39 belladonna alkaloids-opium . 32 BELSOMRA ...................... 14 benazepril ........................... 19 benazepril-hydrochlorothiazide

....................................... 19 benzonatate ......................... 44 benztropine ........................... 9 betamethasone dipropionate. 26 betamethasone valerate........ 26 betamethasone, augmented .. 26 BETASERON..................... 35 betaxolol........................ 19, 42bethanechol chloride............ 47 bexarotene ............................ 6 BEXSERO.......................... 35

bicalutamide.......................... 6 BIKTARVY.......................... 3 bisoprolol fumarate ............. 19 bisoprolol-hydrochlorothiazide

....................................... 19 BLEPHAMIDE................... 44 BLEPHAMIDE S.O.P......... 44 blisovi 24 fe ........................ 39 blisovi fe 1.5/30 (28) ........... 39 blisovi fe 1/20 (28) .............. 39 BOOSTRIX TDAP ............. 35 bosentan.............................. 45 briellyn ............................... 39 BRILINTA ......................... 21 brimonidine......................... 44 BROMFED DM.................. 44 bromocriptine........................ 9 brompheniramine-pseudoeph-

dm .................................. 44 budesonide..................... 32, 45bumetanide ......................... 19 buprenorphine hcl ............... 11 buprenorphine-naloxone ...... 13 bupropion hcl...................... 14 BUPROPION HCL............. 14 bupropion hc l (smoking de ter)

....................................... 28 buspirone ............................ 14 butalbital compound w/codeine

....................................... 11 butalbital-acetaminop-caf-cod

....................................... 12 butalbital-acetaminophen ..... 12 butalbital-acetaminophen-caff

....................................... 12 butalbital-aspirin-caffeine .... 12 butorphanol......................... 13 C cabergoline ......................... 31 caffeine citrate .................... 27 calcipotriene........................ 23 CALCIPOTRIENE.............. 23 calcitonin (salmon).............. 31 calcitriol.............................. 31 calcium acetate(phosphat bind)

....................................... 48 camila ................................ . 37

camrese lo........................... 39 candesartan ......................... 19 candesartan-hydrochlorothiazid

....................................... 19 CAPCOF............................ 44 capecitabine .......................... 6 CAPLYTA.......................... 14 captopril.............................. 19 captopril-hydrochlorothiazide

....................................... 19 CARAFATE....................... 34 CARBAGLU ...................... 27 carbamazepine ...................... 8 carbidopa-levodopa ............... 9 carbidopa-levodopa-

entacapone ........................ 9 CARDIZEM LA ................. 19 carisoprodol ........................ 11 carisoprodol-aspirin............. 11 carteolol.............................. 42 cartia xt............................... 19 carvedilol............................ 19 CAYSTON ........................... 4 caziant (28) ......................... 39 cefaclor................................ . 4 cefadroxil.............................. 4 cefdinir ................................ . 4 cefprozil................................ 4 cefuroxime axetil................... 4 celecoxib............................. 13 CELONTIN .......................... 8 CENTANY......................... 25 cephalexin............................. 4 cetirizine ............................. 44 CHANTIX.......................... 28 CHANTIX CONTINUING

MONTH BOX................. 28 CHANTIX STARTING

MONTH BOX................. 28 chateal (28) ......................... 39 chateal eq (28)..................... 39 CHEMET ........................... 27 CHLORAL HYDRATE

(BULK) .......................... 14 chlordiazepoxide hcl............ 14 chlordiazepoxide-clidinium . 32 chlorhexidine gluconate....... 28



51

chloroquine phosphate........... 4 chlorothiazide ..................... 19 chlorpromazine ................... 14 chlorthalidone ..................... 19 chlorzoxazone ..................... 11 CHOLBAM........................ 32 cholestyramine (with sugar). 22 cholestyramine light ............ 22 ciclodan .............................. 25 ciclopirox............................ 25 cilostazol............................. 21 cimetidine ........................... 34 cimetidine hcl...................... 34 cinacalcet ............................ 31 CIPRO.................................. 5 ciprofloxacin......................... 5 ciprofloxacin hcl ........ 5, 28, 42 citalopram........................... 14 claravis ............................... 24 clarithromycin....................... 4 clemastine ........................... 45 CLEOCIN........................... 38 CLIMARA.......................... 37 CLIMARA PRO ................. 37 clindamycin hcl..................... 4 clindamycin palmitate hcl...... 4 clindamycin pediatric ............ 4 clindamycin phosphate ...24, 38 CLINDAMYCIN

PHOSPHATE ................. 24 clobazam............................... 8 clobetasol............................ 26 clobetasol-emollient ............ 26 clodan ................................ . 26 clomipramine ...................... 14 clonazepam........................... 8 clonidine ............................. 19 clonidine hcl .................. 15, 19clopidogrel.......................... 21 clorazepate dipotassium....... 15 clotrimazole ..................... 3, 25 clotrimazole-betamethasone. 25 clozapine............................. 15 CLOZAPINE...................... 15 COARTEM........................... 4 codeine sulfate .................... 12 codeine-butalbital-asa-caff... 12

codeine-guaifenesin............. 45 colchicine ........................... 37 colestipol ............................ 22 COMBIPATCH .................. 37 COMBIVENT RESPIMAT. 45 COMETRIQ ......................... 6 COMPAZINE..................... 32 compro ............................... 32 constulose ........................... 33 CORTIFOAM..................... 33 cortisone ............................. 29 COTEMPLA XR-ODT........ 15 covaryx............................... 37 covaryx h.s.......................... 37 CREON .............................. 33 CRINONE.......................... 37 cromolyn.................. 33, 43, 45 cryselle (28) ........................ 39 CUVPOSA ......................... 32 cyanocobalamin ( vitamin b -12)

....................................... 48 cyclafem 1/35 (28) .............. 39 cyclafem 7/7/7 (28) ............. 39 cyclobenzaprine .................. 11 CYCLOGYL ...................... 43 cyclopentolate ..................... 43 cyclosporine.......................... 7 cyclosporine modified ........... 7 cyproheptadine.................... 45 cyred................................... 39 cyred eq .............................. 39 D dalfampridine ...................... 10 DALIRESP......................... 46 danazol ............................... 31 dantrolene ........................... 11 dapsone................................ . 4 DAPTACEL (DTAP

PEDIATRIC) (PF)........... 35 dasetta 1/35 (28).................. 39 dasetta 7/7/7 (28)................. 39 daysee................................ . 39 DAYTRANA...................... 15 DAYVIGO ......................... 15 DDAVP.............................. 31 deblitane ............................. 37 decadron ............................. 29

deferasirox .......................... 27 DEMSER............................ 19 DENAVIR.......................... 25 denta 5000 plus ................... 28 DEPO-ESTRADIOL........... 37 DEPO-PROVERA .............. 37 DEPO-TESTOSTERONE ... 31 DESCOVY ........................... 3 desipramine......................... 15 desmopressin ...................... 31 desog-e.estradiol/e.estradiol. 39desogestrel-ethinyl estradiol 39 desonide.............................. 26 desoximetasone ................... 26 DESVENLAFAXINE ......... 15 desvenlafaxine succ inate ..... 15 dexamethasone.................... 29 dexamethasone intensol....... 29 dexamethasone sodium

phosphate ........................ 44 dexmethylphenidate ............ 15 DEXONTO......................... 29 dextroamphetamine ............. 15 dextroamphetamine-

amphetamine ................... 15 diazepam.......................... 8, 15 diazepam intensol................ 15 diclofenac potassium ........... 13 diclofenac sodium .......... 13, 43 diclofenac-misoprostol ........ 13 dicloxacillin .......................... 5 dicyclomine ........................ 32 diflorasone .......................... 26 diflunisal............................. 13 digitek ................................ 21 digox .................................. 21 digoxin ............................... 21 dihydroergotamine .............. 10 DILANTIN........................... 8 DILANTIN EXTENDED ...... 8 diltiazem hcl ....................... 19 dilt-xr.................................. 19 DIPENTUM........................ 33 diphenhydramine hcl ........... 45 diphenoxylate-atropine ........ 32 dipyridamole....................... 21 disopyramide phosphate ...... 18

CareSource Indiana Medica id disulfiram ........................... 27 EMSAM ............................. 15

Effective 1/1/2022 estradiol valerate ................. 38


52

DIURIL .............................. 19 divalproex............................. 8 dofetilide............................. 18 donepezil ............................ 10 DORAL.............................. 15 dorzolamide ........................ 43 DORZOLAMIDE (PF)........ 43 dorzolamide-timolol ............ 43 DORZOLAMIDE-TIMOLOL

(PF) ................................ 44 doxazosin............................ 19 doxepin............................... 15 doxycycline hyclate........... 5, 6 doxycycline monohydrate...... 6 DRISDOL........................... 48 DRIZALMA SPRINKLE.... 15 dronabinol........................... 33 droperidol ........................... 33 drospirenone-e.estradiol-lm.fa

....................................... 39 drospirenone-ethinyl e stradiol

....................................... 39 DROXIA .............................. 7 DUAVEE ........................... 37 DULERA............................ 46 duloxetine ........................... 15 DYANAVEL XR................ 15 E e.e.s. 400............................... 4 ec-naproxen ........................ 13 EDLUAR............................ 15 ed-spaz ............................... 32 EDURANT........................... 3 eemt.................................... 37 eemt hs ............................... 37 effer-k................................ . 48 EFUDEX ............................ 23 elinest ................................ . 39 ELIQUIS ............................ 21 ELIQUIS DVT-PE TREAT

30D START.................... 21 ELIXOPHYLLIN................ 46 ELLA ................................ . 39 ELMIRON.......................... 47 eluryng ............................... 38 EMCYT................................ 7 emoquette ........................... 40

EMVERM ............................ 4 enalapril maleate ................. 19 enalapril-hydrochlorothiazide

....................................... 19 ENBREL ............................ 37 ENBREL MINI................... 37 ENBREL SURECLICK....... 37 endocet ............................... 12 ENGERIX-B (PF) ............... 35 ENGERIX-B P EDIATRIC

(PF) ................................ 35 enoxaparin .......................... 21 enpresse.............................. 40 enskyce............................... 40 entacapone ............................ 9 entecavir ............................... 3 ENTRESTO........................ 23 enulose ............................... 33 EPANED............................ 19 epinephrine ......................... 45 EPINEPHRINE................... 45 epitol .................................... 8 EPIVIR HBV........................ 3 eplerenone .......................... 19 EPOGEN ............................ 35 EQUETRO ........................... 8 ergocalciferol (vitamin d2) .. 48 ergoloid .............................. 15 ergotamine-caffeine............. 10 ERIVEDGE .......................... 7 erlotinib ................................ 7 errin .................................... 37 ery pads .............................. 24 ery-tab .................................. 4 ERY-TAB............................. 4 erythrocin (as stearate)........... 4 erythromycin.................... 4, 42 erythromycin ethylsuccinate .. 4 erythromycin with ethanol ... 24 ESBRIET............................ 46 escitalopram oxalate ............ 15 ESGIC ................................ 12 esomeprazole magnesium .... 34 estarylla .............................. 40 estazolam............................ 15 ESTRACE .......................... 37 estradiol ......................... 37, 38

estradiol-norethindrone acet. 38 estrogens-methyltestosterone 38 eszopiclone ......................... 15 ethambutol ............................ 5 ethosuximide......................... 8 ethynodiol diac-eth estradiol 40 etidronate disodium............. 27 etodolac .............................. 13 etonogestrel-ethinyl estradiol38 etoposide............................... 7 euthyrox.............................. 31 EVEKEO ODT ................... 15 everolimus

(immunosuppressive)......... 7 EXELON ............................ 10 exemestane ........................... 7 EXTAVIA .......................... 35 ezetimibe ............................ 22 F falmina (28) ........................ 40 famciclovir............................ 3 famotidine........................... 34 FANAPT............................ 15 FARYDAK........................... 7 febuxostat ........................... 37 felbamate .............................. 8 felodipine............................ 19 femynor .............................. 40 fenofibrate .......................... 22 fenofibrate micronized......... 22 fenofibrate nanocrystallized. 22 fentanyl............................... 12 fentanyl c itrate .................... 12 FENTANYL CITRATE ...... 12 FENTORA.......................... 12 FETZIMA........................... 15 finasteride ........................... 47 FIRVANQ ............................ 6 FLAGYL .............................. 5 flavoxate ............................. 47 flecainide ............................ 18 FLOVENT DISKUS ........... 46 FLOVENT HFA ................. 46 FLUAD 2020-2021 (65 YR

UP)(PF) .......................... 35 FLUAD QUAD 2020-21(65Y

UP)(PF) .......................... 36



53

FLUARIX QUAD 2020-2021 (PF) ................................ 36

FLUBLOK QUAD 2020-2021 (PF) ................................ 36

FLUCELVAX QUAD 2020-2021................................ 36

FLUCELVAX QUAD 2020-2021 (PF) ........................ 36

fluconazole ........................... 3 fludrocortisone .................... 29 FLULAVAL QUAD 2020-

2021 (PF) ........................ 36 FLUMIST QUAD 2020-2021

....................................... 36 flunisolide........................... 46 fluocinolone........................ 26 fluocinolone and shower cap 26 fluocinonide ........................ 26 fluocinonide-e ..................... 26 fluocinonide-emollient......... 27 fluoride (sodium)................. 28 fluorometholone.................. 44 fluorouracil ......................... 23 fluoxetine............................ 15 fluphenazine decanoate........ 15 FLUPHENAZINE

DECANOATE (BULK)... 15 fluphenazine hcl.................. 15 flurazepam .......................... 15 flurbiprofen......................... 13 flurbiprofen sodium............. 43 flutamide............................... 7 fluticasone propionate ....27, 46 fluticasone pr opion-salmeterol

....................................... 46 FLUTICASONE PROPION-

SALMETEROL .............. 46 fluvoxamine ........................ 15 FLUZONE HIGHDOSE

QUAD 20-21 PF ............. 36 FLUZONE QUAD 2020-2021

....................................... 36 FLUZONE QUAD 2020-2021

(PF) ................................ 36 FML S.O.P.......................... 44 folic acid............................. 48 fondaparinux....................... 21

FORFIVO XL..................... 15 FORTESTA ........................ 31 fosinopril ............................ 19 fosinopril-hydrochlorothiazide

....................................... 19 FRAGMIN.......................... 21 FREESTYLE INSULINX ... 29 FREESTYLE INSULINX

TEST STRIPS................. 29 FREESTYLE LITE STRIPS 29 FREESTYLE TEST ............ 29 furosemide .......................... 20 FUZEON .............................. 3 fyavolv ............................... 38 FYCOMPA........................... 8 G g tussin ac ........................... 45gabapentin ............................ 8 galantamine......................... 10 GALZIN ............................. 48 GARDASIL 9 (PF) ............. 36 gavilyte-c............................ 33 gavilyte-g............................ 33 gavilyte-n............................ 33 gemfibrozil ......................... 22 generlac .............................. 33 gengraf ................................ . 7 gentak................................ . 42 gentamicin ..................... 25, 42 GENVOYA .......................... 3 GEODON ........................... 15 gianvi (28) .......................... 40 GILENYA .......................... 10 GILOTRIF............................ 7 glatiramer ........................... 10 glatopa ................................ 11 glimepiride.......................... 30 glipizide.............................. 30 glipizide-metformin............. 30 GLUCAGEN DIAGNOSTIC

KIT................................ . 30 GLUCAGEN HYPOKIT..... 30 GLUCAGON EMERGENCY

KIT (HUMAN) ............... 30 glyburide............................. 30 glyburide micronized........... 30 glyburide-metformin ........... 30

glycopyrrolate ..................... 32 glydo .................................. 25 GOLYTELY ....................... 33 granisetron hcl .................... 33 GRASTEK.......................... 36 griseofulvin microsize ........... 3 griseofulvin u ltramicrosize .... 3 guaiatussin ac...................... 45 guaifenesin ac ..................... 45 guanfacine ..................... 16, 20 H hailey.................................. 40 hailey 24 fe ......................... 40 hailey fe 1.5/30 (28) ............ 40 hailey fe 1/20 (28) ............... 40 haloperidol.......................... 16 haloperidol decanoate.......... 16 haloperidol lactate ............... 16 HAVRIX (PF)..................... 36 heather................................ 38 HEMANGEOL ................... 20 hep flush-10 (pf) ................. 21 heparin (porcine) ................. 21 heparin lock flush................ 21 heparin lock flush (porcine) . 21 heparin lockflush(porcine)(pf)

....................................... 22 heparin, porcine (pf) ............ 22 HEPARIN, PORCINE (PF). 22 HEPLISAV-B (PF) ............. 36 HETLIOZ........................... 16 HIBERIX (PF) .................... 36 homatropaire ....................... 43 HUMULIN 70/30 U-100

INSULIN ........................ 30 HUMULIN 70/30 U-100

KWIKPEN...................... 30 HUMULIN N NPH INSULIN

KWIKPEN...................... 30 HUMULIN N NPH U-100

INSULIN ........................ 30 HUMULIN R REGULAR U-

100 INSULN................... 30 HUMULIN R U-500 (CONC)

INSULIN ........................ 30 HUMULIN R U-500 (CONC)

KWIKPEN...................... 30

CareSource Indiana Medica id HYCAMTIN......................... 7 IPOL................................... 36

Effective 1/1/2022 klor-con m15....................... 48


54

hydralazine ......................... 20 hydrochlorothiazide............. 20 hydrocodone-acetaminophen 12 hydrocodone-homatropine ... 45 HYDROCODONE-

HOMATROPINE............ 45 hydrocodone-ibuprofen ....... 12 hydrocortisone ......... 27, 29, 33 hydrocortisone butyrate ....... 27 hydrocortisone but yr-emollient

....................................... 27 hydrocortisone valerate........ 27 hydrocortisone-acetic acid ... 28 hydrocortisone-pramoxine ... 33 hydromet............................. 45 hydromorphone................... 12 hydroxychloroquine .............. 5 hydroxyurea .......................... 7 hydroxyzine hcl................... 45 hydroxyzine pamoate .......... 45 hyoscyamine sulfate ............ 32 hyosyne .............................. 32 HYPER-SAL...................... 46 I ibandronate ......................... 37 IBRANCE ............................ 7 ibu ...................................... 13 ibuprofen ............................ 13 ICLUSIG .............................. 7 imatinib ................................ 7 IMBRUVICA ....................... 7 imipramine hcl .................... 16 imipramine pamoate ............ 16 IMITREX ........................... 10 IMITREX STATDOSE PEN10 incassia ............................... 38 indapamide ......................... 20 INDERAL XL .................... 20 INDOCIN........................... 13 indomethacin ...................... 13 INFANRIX (DTAP) (PF).... 36 INLYTA............................... 7 INNOPRAN XL.................. 20 INTRON A......................... 35 introvale.............................. 40 INVEGA SUSTENNA ........ 16 INVEGA TRINZA.............. 16

ipratropium bromide....... 28, 46 ipratropium-albuterol........... 46 irbesartan ............................ 20 irbesartan-hydrochlorothiazide

....................................... 20 ISENTRESS ......................... 3 ISENTRESS HD ................... 3 isibloom.............................. 40 isoniazid ............................... 5 ISOPTO ATROPINE .......... 43 ISORDIL TITRADOSE ...... 23 isosorbide dinitrate .............. 23 isosorbide mononitrate ........ 23 isotretinoin.......................... 24 isoxsuprine.......................... 38 itraconazole........................... 3 ivermect in ............................. 5 J JAKAFI................................ 7 jantoven.............................. 22 jasmiel (28) ......................... 40 jencycla .............................. 38 jinteli .................................. 38 jolessa................................ . 40 JORNAY PM...................... 16 juleber ................................ 40 junel 1.5/30 (21).................. 40 junel 1/20 (21)..................... 40 junel fe 1.5/30 (28).............. 40 junel fe 1/20 (28)................. 40 junel fe 24........................... 40 JUXTAPID......................... 22 K kaitlib fe ............................. 40 kalliga................................ . 40 kariva (28) .......................... 40 kelnor 1/35 (28)................... 40 kelnor 1-50 ......................... 40 ketoconazole .................... 3, 25ketoprofen........................... 13 ketorolac ........................ 13, 43 KINERET........................... 37 KINRIX (PF) ...................... 36 kionex (with sorbitol) .......... 27 klor-con 10 ......................... 48 klor-con 8 ........................... 48 klor-con m10....................... 48

klor-con m20....................... 48 klor-con/ef .......................... 48 KOSHER PRENATAL PLUS

IRON.............................. 48 KRISTALOSE.................... 33 kurvelo (28) ........................ 40 KUVAN ............................. 31 KYLEENA ......................... 38 L l norgest/e.estradiol-e.estrad 40 labetalol .............................. 20 lactulose.............................. 33 LAMICTAL XR STARTER

(BLUE)............................. 8 LAMICTAL XR STARTER

(GREEN) .......................... 8 LAMICTAL XR STARTER

(ORANGE) ....................... 9 lamivudine ............................ 3 lamotrigine............................ 9 LANCETS.......................... 30 lansoprazole ........................ 34 lanthanum........................... 28 larin 1.5/30 (21) .................. 40 larin 1/20 (21) ..................... 40 larin 24 fe ........................... 40 larin fe 1.5/30 (28)............... 40 larin fe 1/20 (28) ................. 40 larissia ................................ 40 latanoprost .......................... 44 LATANOPROST (PF) ........ 44 LATUDA ........................... 16 layolis fe ............................. 40 leena 28 .............................. 40 leflunomide......................... 37 LENVIMA............................ 7 lessina................................ . 40 LETAIRIS .......................... 46 letrozole................................ 7 leucovorin calcium................ 6 LEUKERAN......................... 7 LEVALBUTEROL

TARTRATE.................... 46 levetiracetam......................... 9 levobunolol ......................... 43 levocarnitine ....................... 28 levocarnitine (with sugar) .... 28



55

levocetirizine ...................... 45 levofloxacin .......................... 5 levonest (28) ....................... 40 levonorgestrel-ethinyl estrad 40 levonorg-eth estrad triphasic 40 levora-28............................. 40 levothyroxine ...................... 31 levoxyl................................ 32 lidocaine hcl........................ 25 lidocaine hc l-hydrocortison a c

.................................. 25, 33 lidocaine viscous ................. 25 lidocaine-prilocaine ............. 25 LILETTA ........................... 38 lillow (28) ........................... 40 lindane ................................ 27 liothyronine......................... 32 lisinopril ............................. 20 lisinopril-hydrochlorothiazide

....................................... 20 lithium carbonate................. 16 lithium citrate...................... 16 LITHOSTAT ...................... 28 loperamide .......................... 32 lopreeza .............................. 38 lorazepam ........................... 16 lorazepam intensol .............. 16 lorcet (hydrocodone) ........... 12 lorcet hd.............................. 12 loryna (28) .......................... 40 losartan............................... 20 losartan-hydrochlorothiazide 20 LOSEASONIQUE .............. 40 lovastatin ............................ 22 low-ogestrel (28) ................. 41 loxapine succinate ............... 16 lo-zumandimine (28) ........... 41 lutera (28) ........................... 41 LYSODREN......................... 7 lyza..................................... 38 M malathion............................ 27 maprotiline.......................... 16 marlissa (28) ....................... 41 MARPLAN......................... 16 MATULANE........................ 7 matzim la ............................ 20

meclizine ............................ 33 meclofenamate .................... 13 MEDROL ........................... 29 MEDROL (PAK)................ 29 medroxyprogesterone .......... 38 mefloquine............................ 5 megestrol .............................. 7 MEKINIST ........................... 7 meloxicam .......................... 13 melphalan ............................. 7 memantine .......................... 11 MEMANTINE .................... 11 MENACTRA (PF) .............. 36 MENEST............................ 38 MENVEO A-C-Y-W-135-DIP

(PF) ................................ 36 meperidine .......................... 12 meprobamate ...................... 11 mercaptopurine ..................... 7 mesalamine ......................... 33 MESNEX ............................. 6 MESTINON........................ 11 MESTINON TIMESPAN.... 11 metadate er ......................... 16 metaproterenol .................... 46 metformin........................... 30 methadone .......................... 12 methadone intensol.............. 12 methamphetamine ............... 16 methazolamide .................... 43 methenamine hippurate.......... 6 methenamine mandelate ........ 6 methen-sod phos-meth blue-

hyos ................................ 47 methergine .......................... 42 methimazole........................ 29 methocarbamol.................... 11 methotrexate sodium ............. 7 methotrexate sodium (pf) ....... 7 methscopolamine ................ 32 methyldopa ......................... 20 methyldopa-

hydrochlorothiazide ......... 20 methylergonovine................ 42 methylphenidate hcl ............ 16 METHYLPHENIDATE HCL

....................................... 16

methylprednisolone ............. 29 metipranolol........................ 43 metoclopramide hcl............. 33 metolazone.......................... 20 metoprolol succinate............ 20 metoprolol t a-hydrochlorothiaz

....................................... 20 metoprolol tartrate............... 20 METROCREAM ................ 24 METROLOTION................ 24 metronidazole ............ 5, 24, 38metyrosine .......................... 20 MIACALCIN...................... 31 microgestin 1.5/30 (21)........ 41 microgestin 1/20 (21) .......... 41 microgestin fe 1.5/30 (28).... 41 microgestin fe 1/20 (28)....... 41 midazolam ..................... 16, 17MIDAZOLAM.................... 16 midazolam (pf).................... 16 midodrine ........................... 28 migergot ............................. 10 miglitol ............................... 30 miglustat ............................. 31 mili..................................... 41 mimvey............................... 38 MINITRAN ........................ 23 minocycline .......................... 6 minoxidil ............................ 20 MIRENA ............................ 38 mirtazapine ......................... 17 misoprostol ......................... 34 M-M-R II (PF) .................... 36 m-natal plus ........................ 48 modafinil ............................ 17 moexipril ............................ 20 molindone........................... 17 mometasone ........................ 27 mondoxyne nl ....................... 6 MONODOX ......................... 6 mono-linyah........................ 41 montelukast......................... 46 morgidox .............................. 6 morphine............................. 12 morphine concentrate .......... 12 moxifloxacin....................... 42 mupirocin ........................... 25

CareSource Indiana Medica id mycophenolate mofetil .......... 7 nitisinone ............................ 28

Effective 1/1/2022 ocella .................................. 41


56

mycophenolate sodium.......... 7 MYDAYIS ......................... 17 MYLERAN .......................... 7 mynatal............................... 48 mynatal advance.................. 48 myorisan............................. 24 MYTESI ............................. 32 N nabumetone......................... 13 nadolol................................ 20 nadolol-bendroflumethiazide 20 naloxone ............................. 13 naltrexone ........................... 13 NAMENDA TITRATION

PAK................................ 11 NAMENDA XR.................. 11 NAMZARIC....................... 11 naproxen............................. 13 naproxen sodium................. 13 naproxen-esomeprazole ....... 13 naratriptan........................... 10 NARCAN........................... 14 NATACYN......................... 42 nateglinide .......................... 30 NATROBA......................... 27 nebusal ............................... 46 necon 0.5/35 (28) ................ 41 nefazodone.......................... 17 NEMBUTAL SODIUM ...... 17 neomycin .............................. 5 neomycin-bacitrac in-poly-hc 44 neomycin-bacitracin-

polymyxin....................... 42 neomycin-polymyxin b-

dexameth......................... 44 neomycin-polymyxin-

gramicidin....................... 42 neomycin-polymyxin-hc.28, 44neo-polycin......................... 42 neo-polycin hc .................... 44 NEULASTA ....................... 35 NEXAVAR........................... 7 NEXIUM 24HR .................. 34 NEXPLANON.................... 38 nicardipine .......................... 20 nifedipine............................ 20 nikki (28) ............................ 41

nitro-bid.............................. 23 NITRO-DUR ...................... 23 nitrofurantoin ........................ 6 nitrofurantoin macrocrystal.... 6 nitrofurantoin m onohyd/m-

cryst.................................. 6 nitroglycerin........................ 23 nitro-time ............................ 23 nizatidine ............................ 34 nora-be ............................... 38 NORCO.............................. 12 noreth-ethinyl estradiol-iron 41 norethindrone ( contraceptive)

....................................... 38 norethindrone acetate .......... 38 norethindrone a c-eth estradiol

.................................. 38, 41 norethindrone-e.estradiol-iron

....................................... 41 norgestimate-ethinyl e stradiol

....................................... 41 norlyda ............................... 38 NORPACE CR ................... 18 nortrel 0.5/35 (28) ............... 41 nortrel 1/35 (21) .................. 41 nortrel 1/35 (28) .................. 41 nortrel 7/7/7 (28) ................. 41 nortriptyline ........................ 17 NORTRIPTYLINE (BULK) 17 NORVIR .............................. 3 NOVOLIN 70/30 U-100

INSULIN ........................ 30 NOVOLIN 70-30 F LEXPEN

U-100.............................. 30 NOVOLIN N NPH U-100

INSULIN ........................ 30 NOVOLIN R REGULAR U-

100 INSULN................... 30 np thyroid ........................... 32 NUEDEXTA ...................... 11 NULEV .............................. 32 NUPLAZID........................ 17 nyamyc ............................... 25 nystatin ............................ 3, 25 nystop................................ . 25 O OBTREX DHA................... 48

octreotide acetate................... 7 ODEFSEY ............................ 3 OFEV ................................ . 46 ofloxacin.................... 5, 28, 42olanzapine........................... 17 olanzapine-fluoxetine .......... 17 olmesartan .......................... 20 olmesartan-amlodipin-

hcthiazid ......................... 20 olmesartan-

hydrochlorothiazide ......... 20 omega-3 ac id ethyl esters..... 22 omeprazole ......................... 34 OMNITROPE..................... 35 ondansetron......................... 33 ondansetron hcl ................... 33 OPSUMIT .......................... 46 oralone................................ 28 ORFADIN .......................... 28 ORILISSA .......................... 31 orphenadrine c itrate............. 11 orsythia............................... 41 oscimin ............................... 32 oscimin sl............................ 32 oscimin sr ........................... 32 oseltamivir ............................ 3 oxandrolone ........................ 31 oxaprozin............................ 14 oxazepam............................ 17 oxcarbazepine ....................... 9 OXTELLAR XR ................... 9 oxybutynin chloride............. 47 oxycodone ..................... 12, 13 oxycodone-acetaminophen .. 13 oxycodone-aspirin ............... 13 oxymorphone ...................... 13 OXYTROL ......................... 47 P pacerone ............................. 18 paliperidone ........................ 17 PANRETIN ........................ 23 pantoprazole........................ 34 paricalcitol .......................... 31 paroex oral rinse.................. 28 paroxetine hcl...................... 17 PAXIL................................ . 17 PEDIAPRED...................... 29



57

PEDIARIX (PF).................. 36 PEDVAX HIB (PF)............. 36 peg 3350-electrolytes .......... 33 peg3350-sod sul-nacl-kcl-asb-c

....................................... 33 PEGANONE......................... 9 PEGASYS .......................... 35 peg-electrolyte soln ............. 33 peg-prep.............................. 33 penicillamine ...................... 37 penicillin v potassium............ 5 PENTACEL (PF)................ 36 PENTACEL ACTHIB

COMPONENT (PF) ........ 36 PENTASA.......................... 33 pentazocine-naloxone .......... 14 pentobarbital sodium ........... 17 pentoxifylline ...................... 22 PEPCID.............................. 34 perindopril erbumine ........... 20 periogard............................. 28 permethrin .......................... 27 perphenazine ....................... 17 perphenazine-amitriptyline .. 17 PERSERIS.......................... 17 PEXEVA ............................ 17 phenazopyridine .................. 48 phenelzine........................... 17 phenobarbital ........................ 9 phenobarbital sodium ............ 9 phenylephrine hcl................ 44 phenytoin.............................. 9 phenytoin sodium extended ... 9 philith ................................ . 41 phosphasal .......................... 47 PHOSPHOLINE IODIDE ... 43 phytonadione (vitamin k1) ... 22 pilocarpine hcl ............... 28, 43 pimecrolimus ...................... 23 pimozide ............................. 17 pimtrea (28) ........................ 41 pindolol .............................. 20 pioglitazone ........................ 30 pioglitazone-glimepiride...... 30 pioglitazone-metformin ....... 30 pirmella .............................. 41 piroxicam............................ 14

PNEUMOVAX-23.............. 36 pnv 29-1 ............................. 48 podofilox ............................ 23 polycin................................ 42 polyethylene glycol 3350..... 33 polymyxin b sulf-trimethoprim

....................................... 42 POMALYST......................... 7 portia 28 ............................. 41 potassium chloride .............. 48 potassium citrate ................. 47 pramipexole .......................... 9 prasugrel............................. 22 pravastatin .......................... 22 praziquantel .......................... 5 prazosin .............................. 20 PRED MILD....................... 44 PRED-G ............................. 44 PRED-G S.O.P.................... 44 prednicarbate ...................... 27 prednisolone........................ 29 prednisolone acetate............ 44 PREDNISOLONE ACETATE

(PF) ................................ 44 prednisolone sodium phos phate

.................................. 29, 44 prednisone .......................... 29 prednisone intensol.............. 29 PREFEST ........................... 38 pregabalin ............................. 9 PREMARIN ....................... 38 PREMPHASE..................... 38 PREMPRO ......................... 38 prenaissance plus................. 48 prenatabs fa......................... 48 prenatabs rx ........................ 48 PRENATAL 19................... 48 prenatal p lus........................ 48 prenatal plus (calcium carb) . 48 prenatal vitamin plus low iron

....................................... 48 preplus ................................ 48 pretab.................................. 48 PREVACID........................ 34 prevalite.............................. 22 previfem ............................. 41 PREVNAR 13 (PF)............. 36

PRIFTIN............................... 5 PRILOSEC ......................... 34 PRILOSEC OTC................. 34 primaquine............................ 5 primidone ............................. 9 PROAIR DIGIHALER........ 46 PROAIR HFA..................... 46 PROAIR RESPICLICK....... 46 probenecid .......................... 37 procentra............................. 17 prochlorperazine ................. 33 prochlorperazine edisylate ... 33 prochlorperazine maleate..... 34 PROCRIT........................... 35 procto-med hc ..................... 34 procto-pak........................... 34 proctosol hc ........................ 34 proctozone-hc ..................... 34 progesterone........................ 38 progesterone micronized...... 38 PROMACTA...................... 22 promethazine ...................... 45 promethazine vc .................. 45 promethazine-dm ................ 45 promethazine-phenylephrine 45 promethegan ....................... 45 propafenone ........................ 18 propranolol ......................... 20 propranolol-hydrochlorothiazid

....................................... 20 propylthiouracil................... 29 PROQUAD (PF)................. 36 protriptyline ........................ 17 PROVENTIL HFA.............. 46 pulmosal ............................. 46 PULMOZYME................... 46 pyrazinamide ........................ 5 pyridostigmine bromide....... 11 pyrimethamine ...................... 5 Q QUADRACEL (PF)............ 36 quazepam............................ 17 QUDEXY XR ....................... 9 quetiapine ........................... 17 QUILLICHEW ER.............. 17 QUILLIVANT XR.............. 17 quinapril ............................. 20

CareSource Indiana Medica id quinapril-hydrochlorothiazide SEASONIQUE ................... 41

Effective 1/1/2022 ssd ...................................... 23


58

....................................... 20 QVAR REDIHALER.......... 46 R RAGWITEK ....................... 36 raloxifene............................ 37 ramelteon............................ 17 ramipril............................... 20 ranitidine hcl....................... 34 ranolazine ........................... 23 REBIF (WITH ALBUMIN). 35 REBIF REBIDOSE............. 35 REBIF TITRATION PACK 35 reclipsen (28) ...................... 41 RECOMBIVAX HB (PF).... 36 REGRANEX ...................... 23 RELENZA DISKHALER...... 3 RELEXXII.......................... 17 REMODULIN .................... 20 repaglinide .......................... 30 REVLIMID........................... 7 REXULTI ........................... 17 rifabutin ................................ 5 rifampin................................ 5 riluzole ............................... 28 rimantadine ........................... 3 RISPERDAL CONSTA....... 17 risperidone .......................... 17 ritonavir ................................ 3 RITUXAN ............................ 7 rivastigmine ........................ 11 rivastigmine tartrate............. 11 rizatriptan ........................... 10 ropinirole ............................ 10 rosadan ............................... 24 ROSANIL........................... 24 rosuvastatin ......................... 22 ROTARIX .......................... 36 ROTATEQ VACCINE........ 36 roweepra............................... 9 roweepra xr........................... 9 ROZEREM......................... 17 RYBELSUS........................ 30 S SAMSCA ........................... 31 SANDIMMUNE ................... 7 SANTYL ............................ 27 SAVELLA.......................... 37

seconal sodium.................... 17 SECUADO ......................... 17 SEGLUROMET.................. 30 selegiline hcl....................... 10 SELEGILINE HCL (BULK) 10 SEMPREX-D...................... 45 se-natal 19 chewable ........... 48 SENSIPAR ......................... 31 SEREVENT DISKUS ......... 46 sertraline ............................. 17 setlakin ............................... 41 sf 5000 plus......................... 28 sharobel .............................. 38 SHINGRIX (PF) ................. 36 sildenafil ( pulm.hypertension)

....................................... 46 silver sulfadiazine ............... 23 simliya (28)......................... 41 simpesse ............................. 41 simvastatin .......................... 22 sirolimus ............................... 7 SIRTURO............................. 5 SKYLA .............................. 39 sodium chloride.............. 46, 47sodium fluoride 5000 plus ... 28 sodium phenylbutyrate ........ 28 sodium polystyrene ( sorb free)

....................................... 28 sodium polystyrene s ulfonate

....................................... 28 SOLIQUA 100/33 ............... 30 SOMAVERT ...................... 31 SORILUX........................... 23 sorine.................................. 18 sotalol................................ . 18 sotalol af ............................. 18 spinosad.............................. 27 SPIRIVA RESPIMAT......... 47 spironolactone..................... 20 spironolacton-hydrochlorothiaz

....................................... 20 SPRAVATO....................... 18 sprintec (28)........................ 41 SPRIX ................................ 14 SPRYCEL ............................ 7 sps (with sorbitol)................ 28 sronyx................................ . 41

SSKI................................... 29 sss 10-5............................... 24 STEGLATRO ..................... 30 STIOLTO RESPIMAT........ 47 STRIVERDI RESPIMAT.... 47 subvenite............................... 9 subvenite starter (blue) kit ..... 9 subvenite starter (green) kit.... 9 subvenite starter (orange) kit.. 9 SUCRAID .......................... 34 sucralfate ............................ 34 sulfacetamide sodium .......... 44 sulfacetamide sodium (acne) 25 sulfacetamide sodium-sulfur 24,

25 sulfacetamide-prednisolone . 44 sulfacleanse 8-4................... 25 sulfadiazine........................... 5 sulfamethoxazole-trimethoprim

......................................... 5 sulfasalazine........................ 34 sulfatrim ............................... 5 sulindac .............................. 14 sumatriptan ......................... 10 sumatriptan succinate .......... 10 SUMAXIN ......................... 25 SUMAXIN TS .................... 25 SUNOSI ............................. 18 SUTENT............................... 7 syeda .................................. 41 SYLATRON....................... 35 symax-sl ............................. 32 symax-sr ............................. 32 SYMFI LO ........................... 3 SYMLINPEN 120............... 30 SYMLINPEN 60................. 30 SYMPAZAN ........................ 9 SYNAGIS............................. 3 SYNAREL.......................... 31 T TABLOID ............................ 7 tacrolimus ........................ 7, 23TAFINLAR .......................... 8 tamoxifen.............................. 8 tamsulosin........................... 47 TARGRETIN........................ 8 tarina 24 fe.......................... 41



59

tarina fe 1/20 (28)................ 41 tarina fe 1-20 eq (28) ........... 41 TASIGNA ............................ 8 taztia xt ............................... 20 TDVAX.............................. 36 TECFIDERA ...................... 11 telmisartan .......................... 20 telmisartan-amlodipine ........ 20 telmisartan-hydrochlorothiazid

....................................... 21 temazepam.......................... 18 temozolomide ....................... 8 tencon................................ . 13 TENIVAC (PF)................... 36 tenofovir disoproxil fumarate. 3 terazosin ............................. 21 terbinafine hcl ....................... 3 terbutaline ........................... 47 terconazole.......................... 39 TESTIM ............................. 31 testosterone ......................... 31 testosterone cypionate ......... 31 testosterone enanthate.......... 31 TETANUS,DIPHTHERIA

TOX PED(PF)................. 36 tetrabenazine ....................... 11 tetracaine hcl....................... 43 TETRACAINE HCL (PF) ... 43 tetracycline ........................... 6 THALOMID......................... 8 THEO-24............................ 47 theochron............................ 47 theophylline ........................ 47 thioridazine ......................... 18 thiothixene .......................... 18 THRIVITE RX ................... 48 thyroid (pork)...................... 32 THYROLAR-1 ................... 32 THYROLAR-1/2 ................ 32 THYROLAR-1/4 ................ 32 THYROLAR-2 ................... 32 THYROLAR-3 ................... 32 tiagabine ............................... 9 tilia fe ................................ . 41 timolol maleate .............. 21, 43 TIMOPTIC OCUDOSE (PF)

....................................... 43

tizanidine ............................ 11 TOBRADEX ...................... 44 TOBRADEX ST ................. 44 tobramycin.......................... 42 tobramycin in 0.225 % nacl ... 5 TOBRAMYCIN WITH

NEBULIZER .................... 5 tobramycin-dexamethasone . 44 TOBREX............................ 42 topiramate............................. 9 TOPIRAMATE..................... 9 toremifene............................. 8 torsemide ............................ 21 TRACLEER........................ 47 tramadol.............................. 14 tramadol-acetaminophen...... 14 trandolapril ......................... 21 tranexamic acid ................... 39 tranylcypromine .................. 18 trazodone ............................ 18 TRECATOR ......................... 5 TRELEGY ELLIPTA.......... 47 treprostinil sodium .............. 21 tretinoin .............................. 25 tretinoin (antineoplastic) ........ 8 tretinoin microspheres ......... 25 TRETIN-X.......................... 25 TREXALL............................ 8 tri femynor .......................... 41 triamcinolone acetonide..27, 28 triamterene-hydrochlorothiazid

....................................... 21 triazolam............................. 18 TRICARE........................... 48 tri-chlor............................... 23 triderm................................ 27 tri-estarylla.......................... 41 trifluoperazine..................... 18 trifluridine........................... 42 TRIGLIDE.......................... 22 trihexyphenidyl ................... 10 tri-legest fe.......................... 41 tri-linyah............................. 41 tri-lo-estarylla ..................... 41 tri-lo-marzia ........................ 41 tri-lo-mili ............................ 41 tri-lo-sprintec ...................... 41

trilyte with flavor packets .... 34 trimethobenzamide .............. 34 trimethoprim ......................... 6 tri-mili ................................ 41 trimipramine ....................... 18 trinatal rx 1 ......................... 48 TRINTELLIX ..................... 18 tri-previfem (28).................. 41 tri-sprintec (28) ................... 41 TRIUMEQ............................ 3 trivora (28).......................... 42 tri-vylibra............................ 42 tri-vylibra lo ........................ 42 TROKENDI XR.................... 9 tropicamide ......................... 43 trospium.............................. 47 TRUE METRIX GLUCOSE

TEST STRIP ................... 30 TRULICITY ....................... 31 TRUMENBA...................... 36 TRUVADA........................... 3 tulana.................................. 38 TWINRIX (PF) ................... 37 TYKERB.............................. 8 U ULESFIA ........................... 27 ULORIC ............................. 37 unithroid ............................. 32 urea .................................... 23 UREA................................ . 23 URELLE............................. 47 uretron d-s........................... 47 urin ds................................ . 47 uro-458 ............................... 47 ursodiol............................... 34 uryl..................................... 47 ustell................................... 47 utira-c ................................ . 47 V VAGIFEM.......................... 38 valacyclovir .......................... 3 VALCHLOR ...................... 23 valganciclovir ....................... 4 valproate sodium................... 9 valproic acid ......................... 9 valproic acid (as sodium salt). 9 valsartan ............................. 21

CareSource Indiana Medica id valsartan-hydrochlorothiazide VIVITROL......................... 14

Effective 1/1/2022 Z


60

....................................... 21 vancomycin........................... 6 vandazole............................ 39 VAQTA (PF)...................... 37 VARIVAX (PF).................. 37 VARIZIG ........................... 37 veletri ................................ . 21 velivet triphasic r egimen (28)

....................................... 42 venlafaxine ......................... 18 VENTAVIS........................ 47 VENTOLIN HFA ............... 47 verapamil............................ 21 VEREGEN ......................... 23 VERSACLOZ..................... 18 VIBRAMYCIN..................... 6 vienva ................................ . 42 VIIBRYD ........................... 18 vilevev mb .......................... 48 VIMPAT .............................. 9 VIOKACE.......................... 34 viorele (28) ......................... 42 VIREAD............................... 4 virtussin ac.......................... 45 vitamin d2........................... 48

IN-MMED-3126a-V.9; First Use: 12/30/2019

VOGELXO......................... 31 VOTRIENT .......................... 8 VRAYLAR......................... 18 VUMERITY ....................... 11 vyfemla (28) ....................... 42 vylibra ................................ 42 VYVANSE......................... 18 W WAKIX.............................. 18 warfarin .............................. 22 wera (28) ............................ 42 wymzya fe .......................... 42 X XALKORI ............................ 8 XARELTO ......................... 22 XARELTO DVT-PE TREAT

30D START.................... 22 XIFAXAN ............................ 5 XIIDRA.............................. 43 XTANDI............................... 8 xulane ................................ . 39 XYREM ............................. 18 Y yuvafem.............................. 38

OM

zafirlukast ........................... 47 zaleplon .............................. 18 zarah................................... 42 ZARXIO............................. 35 zebutal ................................ 13 ZELAPAR.......................... 10 ZELBORAF ......................... 8 zenatane.............................. 25 zenzedi ............................... 18 ZENZEDI ........................... 18 zidovudine ............................ 4 ziprasidone hcl .................... 18 ZIRGAN............................. 42 ZOLADEX ........................... 8 ZOLINZA............................. 8 zolpidem............................. 18 ZOLPIMIST ....................... 18 zonisamide............................ 9 ZORTRESS .......................... 8 ZOSTAVAX (PF) ............... 37 zovia 1/35e (28) .................. 42 zumandimine (28) ............... 42 ZYPREXA RELPREVV ..... 18

PP Approved: 12/30/2019

Documents

CareSource Healthy Indiana Plan (HIP) Basic, HIP State