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Formulary for NDPERS Dakota Plan Members
For the most current list of covered medications or if you have questions: Call Pharmacy Management Team at (877) 658-9194
Visit sanfordhealthplan.com/members and link to the OptumRx website to:• Locate a participating retail pharmacy by ZIP code• Look up possible lower-cost medication alternatives• Compare medication pricing and options
HP-2175 04-15-2020
2
What is a formulary?
A formulary is a list of prescribed medications chosen by health care providers on Sanford Health Plan’s Pharmacy and Therapeutics Committee. Selection criteria includes clinical efficacy, safety, and cost. Medications on this list are approved by the U.S. Food and Drug Administration for use in the United States.
How do I use my formulary?
You and your provider can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed here, please visit sanfordhealthplan.com, log in to your Member Portal at sanfordhealthplan.com/memberlogin or call the toll-free member phone number on your ID card.
About this formularyWhere differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details.
Understanding your formulary
3
The formulary gives you choices so you and your provider can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).
Drug Category Information
The drug category determines the cost levels you pay for a medication. This is how much you will pay when you fill a prescription. Using generic or formulary brand medications can help you pay your lowest out-of-pocket cost. Consult your Summary of Benefits and Coverage (SBC) to determine your cost for each of the drug categories listed below.
Drug Category
Includes Helpful Tips
Generic $ Lower-cost generic medications
Use generic drugs for the lowest out-of-pocket costs.
Formulary Brand
$$ Mid-range cost preferred brand-name
Use Formulary Brand drugs if a generic alternative is not available.
Non-Formulary Brand
$$$ Higher-cost non-preferred
Non-Formulary Brand drugs are not listed and have lower-cost options in Generic or Formulary Brand categories. Ask your provider if they could work for you.
Reading your formulary
4
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.
PA
Prior Authorization – You or your provider must get pre-approval for the medicine with Sanford Health Plan before you can get the prescription filled. NOTE: The Member is ultimately responsible for obtaining pre-approval from the Plan, but your provider may also request approval.
QL Quantity Limit / Amount Allowed – Medication may be limited to a certain quantity.
SP
Specialty Medication – Medication is designated as specialty. Specialty medications are typically used to treat complex medical conditions. These medications may require frequent dosing adjustments, close monitoring, special training, or compliance assistance. In addition, specialty medications may need special handling and/or administration, and may have limited or exclusive product availability and distribution.
STStep Therapy – Trial of a lower-cost medication(s) is required before a higher-cost medication can be covered.
Table of Contents
Analgesics - Drugs for Pain......................................................................................................................7Analgesics - Drugs for Pain and Inflammation......................................................................................... 9Anesthetics.............................................................................................................................................10Anti-Addiction / Substance Abuse Treatment Agents............................................................................ 11Antibacterials..........................................................................................................................................11Anticoagulants........................................................................................................................................14Anticonvulsants - Drugs for Seizures..................................................................................................... 14Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................... 16Antidepressants......................................................................................................................................16Antiemetics - Drugs for Nausea and Vomiting........................................................................................17Antifungals..............................................................................................................................................18Antigout Agents...................................................................................................................................... 19Anti-inflammatory Agents....................................................................................................................... 19Antimigraine Agents............................................................................................................................... 19Antimyasthenic Agents...........................................................................................................................20Antimycobacterials................................................................................................................................. 20Antineoplastics - Drugs for Cancer.........................................................................................................21Antiparasitics.......................................................................................................................................... 21Antiparkinson Agents............................................................................................................................. 22Antiplatelets............................................................................................................................................22Antipsychotics - Drugs for Mood Disorders............................................................................................ 23Antivirals.................................................................................................................................................24Anxiolytics - Drugs for Anxiety................................................................................................................26Bipolar Agents - Drugs for Mood Disorders............................................................................................27Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders...................................27Cardiovascular Agents - Drugs for Heart and Circulation Conditions.....................................................27Central Nervous System Agents - Drugs for Attention Deficit Disorder.................................................33Central Nervous System Agents - Drugs for Multiple Sclerosis............................................................. 34Central Nervous System Agents - Miscellaneous.................................................................................. 35Dental and Oral Agents - Drugs for Mouth and Throat Conditions.........................................................35Dermatological Agents - Drugs for Skin Conditions............................................................................... 36Diabetes - Antidiabetic Agents............................................................................................................... 41Diabetes - Glucose Monitoring............................................................................................................... 42Diabetes - Glycemic Agents................................................................................................................... 42Diabetes - Insulins..................................................................................................................................42Electrolytes / Minerals / Metals / Vitamins..............................................................................................43Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer.....................................................................46Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions......................................47Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment...................................49Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions............................................49Genitourinary Agents - Drugs for Prostate Conditions........................................................................... 51Hormonal Agents - Adrenal.................................................................................................................... 51Hormonal Agents - Men's Health............................................................................................................51Hormonal Agents - Osteoporosis........................................................................................................... 52Hormonal Agents - Pituitary................................................................................................................... 52Hormonal Agents - Prostaglandins.........................................................................................................53Hormonal Agents - Sex Hormones and Birth Control.............................................................................53
5
Hormonal Agents - Thyroid.................................................................................................................... 54Immunological Agents - Drugs for Immune System Stimulation or Suppression................................... 55Inflammatory Bowel Disease Agents......................................................................................................57Metabolic Bone Disease Agents - Drugs for Osteoporosis.................................................................... 58Metabolic Bone Disease Agents - Other................................................................................................ 58Miscellaneous Therapeutic Agents........................................................................................................ 58Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation................................................59Ophthalmic Agents - Drugs for Glaucoma..............................................................................................61Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions.............................................................. 61Otic Agents - Drugs for Ear Conditions.................................................................................................. 63Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold.............................................63Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions........................ 64Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis......................................................... 67Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension......................................... 67Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm............................................................68Sleep Disorder Agents........................................................................................................................... 68
6
Drug Name Limits/ Required
Analgesics - Drugs for Pain
ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 400 MCG, 600 MCG, 800 MCG
acetaminophen-codeine QL
acetaminophen-codeine #2 QL
acetaminophen-codeine #3 QL
acetaminophen-codeine #4 QL
apap-caff-dihydrocodeine oral tablet 325-30-16 mg QL
ascomp-codeine
BELBUCA QL
buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr
QL
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
QL
butalbital-acetaminophen capsule 50-300 mg oral
butalbital-acetaminophen oral tablet
butalbital-apap-caff-cod
butalbital-apap-caffeine oral capsule
butalbital-apap-caffeine oral tablet 50-325-40 mg
butalbital-asa-caff-codeine
butalbital-aspirin-caffeine
butorphanol tartrate nasal QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR QL
carisoprodol-aspirin-codeine
codeine sulfate oral tablet QL
duraxin
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
QL
fentanyl QL
fentanyl citrate buccal lozenge on a handle
FENTANYL CITRATE BUCCAL TABLET
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
hydrocodone bitartrate er QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/20207
Drug Name Limits/ Required
hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
QL
hydromorphone hcl er QL
hydromorphone hcl oral QL
HYSINGLA ER QL
levorphanol tartrate oral tablet 2 mg QL
levorphanol tartrate oral tablet 3 mg
lorcet QL
lorcet hd QL
lorcet plus oral tablet 7.5-325 mg QL
LORTAB ORAL ELIXIR 10-300 MG/15ML QL
meperidine hcl oral QL
methadone hcl intensol
methadone hcl oral
methadose oral concentrate 10 mg/ml
methadose oral tablet soluble
methadose sugar-free
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
QL
morphine sulfate er beads QL
morphine sulfate er oral capsule extended release 24 hour QL
morphine sulfate er oral tablet extended release QL
morphine sulfate oral QL
NUCYNTA QL
OXYCODONE HCL
oxycodone hcl oral capsule QL
oxycodone hcl oral concentrate 100 mg/5ml QL
oxycodone hcl oral solution QL
oxycodone hcl oral tablet QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/20208
Drug Name Limits/ Required
oxycodone-aspirin oral tablet 4.8355-325 mg QL
oxycodone-ibuprofen QL
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT
QL
oxymorphone hcl QL
oxymorphone hcl er QL
pentazocine-naloxone hcl QL
SUBSYS
tencon oral tablet 50-325 mg
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg
tramadol hcl er oral tablet extended release 24 hour
tramadol hcl oral tablet 100 mg
tramadol hcl oral tablet 50 mg QL
tramadol-acetaminophen QL
vicodin hp oral tablet 10-300 mg QL
VTOL LQ PA
Analgesics - Drugs for Pain and Inflammation
celecoxib oral
DICLOFENAC EPOLAMINE QL
diclofenac potassium
diclofenac sodium er
diclofenac sodium oral
diclofenac sodium transdermal gel 1 % QL
diclofenac sodium transdermal solution
diclofenac-misoprostol oral tablet delayed release
diflunisal oral
ec-naproxen
etodolac er
etodolac oral
fenoprofen calcium oral
fenortho oral capsule 200 mg
FLECTOR QL
flurbiprofen oral
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/20209
Drug Name Limits/ Required
ibu
ibuprofen oral suspension
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
INDOCIN ORAL
INDOCIN RECTAL
indomethacin er
indomethacin oral capsule 25 mg, 50 mg
ketoprofen er
ketoprofen oral
ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml
ketorolac tromethamine oral QL
ketorolac tromethamine solution 60 mg/2ml intramuscular
meclofenamate sodium oral
mefenamic acid oral
meloxicam oral tablet
nabumetone oral
naproxen dr
naproxen oral
naproxen sodium er
naproxen sodium oral tablet 275 mg, 550 mg
naproxen-esomeprazole
oxaprozin
piroxicam oral
sulindac oral
tolmetin sodium oral capsule
tolmetin sodium oral tablet 600 mg
ZORVOLEX
Anesthetics
ethyl chloride
GEBAUERS PAIN EASE
GEBAUERS SPRAY AND STRETCH
glydo external prefilled syringe
lidocaine external patch 5 %
lidocaine hcl external solution
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202010
Drug Name Limits/ Required
lidocaine hcl urethral/mucosal
lidocaine ointment 5 % external
lidocaine-prilocaine external cream
Anti-Addiction / Substance Abuse Treatment Agents
acamprosate calcium
BUNAVAIL QL
buprenorphine hcl sublingual QL
buprenorphine hcl-naloxone hcl QL
disulfiram oral
LUCEMYRA QL
NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR
naltrexone hcl oral
NARCAN QL
ZUBSOLV QL
Antibacterials
amoxicillin oral capsule
amoxicillin oral suspension reconstituted
amoxicillin oral tablet
amoxicillin oral tablet chewable 125 mg, 250 mg
amoxicillin-potassium clavulanate er
amoxicillin-potassium clavulanate oral
ampicillin oral capsule 500 mg
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
avidoxy
azithromycin oral packet
azithromycin oral suspension reconstituted
azithromycin oral tablet 250 mg, 500 mg, 600 mg
BAXDELA ORAL PA
benzalkonium chloride external solution , 50 %
cefaclor
cefaclor er
cefadroxil
cefdinir
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202011
Drug Name Limits/ Required
cefditoren pivoxil
cefixime
cefpodoxime proxetil
cefprozil
cefuroxime axetil oral tablet
cephalexin
ciprofloxacin hcl oral
clarithromycin er
clarithromycin oral
CLEOCIN VAGINAL SUPPOSITORY
clindamycin hcl oral
clindamycin palmitate hcl
clindamycin phosphate vaginal
CLINDESSE
demeclocycline hcl oral
dicloxacillin sodium
DIFICID
doxycycline hyclate oral capsule
doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 50 mg, 75 mg
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg
doxycycline monohydrate oral
E.E.S. 400 ORAL TABLET
ERYTHROCIN STEARATE ORAL TABLET 250 MG
erythromycin base oral
erythromycin ethylsuccinate oral
erythromycin oral
FIRVANQ
gentamicin sulfate external
hydrogen peroxide solution 30 %
levofloxacin oral
linezolid oral
mafenide acetate external
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202012
Drug Name Limits/ Required
methenamine hippurate
metronidazole oral
metronidazole vaginal
minocycline hcl oral
mondoxyne nl oral capsule 100 mg, 75 mg
MONUROL
morgidox oral capsule 100 mg
moxifloxacin hcl oral
mupirocin external
neomycin sulfate oral
nitrofurantoin macrocrystal oral
nitrofurantoin monohydrate macrocrystals
nitrofurantoin oral suspension
ofloxacin oral tablet 300 mg, 400 mg
okebo oral capsule 75 mg
paromomycin sulfate oral
penicillin v potassium
silver sulfadiazine external
ssd
sulfadiazine oral
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
sulfamethoxazole-trimethoprim oral tablet
sulfatrim pediatric
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML
SUPRAX ORAL TABLET CHEWABLE
tetracycline hcl oral
tinidazole oral
trimethoprim oral
vancomycin hcl oral
vandazole
VIBRAMYCIN ORAL SYRUP
XENLETA ORAL
XEPI
XIFAXAN ORAL TABLET 550 MG
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202013
Drug Name Limits/ Required
Anticoagulants
BEVYXXA QL
ELIQUIS
ELIQUIS DVT/PE STARTER PACK
enoxaparin sodium
fondaparinux sodium
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
heparin sodium (porcine) pf injection solution 5000 unit/0.5ml
jantoven
warfarin sodium oral
XARELTO
XARELTO STARTER PACK
Anticonvulsants - Drugs for Seizures
BANZEL
BRIVIACT ORAL
carbamazepine er
carbamazepine oral
CELONTIN
clobazam
DIACOMIT PA; SP
diazepam rectal QL
DILANTIN ORAL CAPSULE 30 MG
divalproex sodium er oral tablet extended release 24 hour
divalproex sodium oral capsule delayed release sprinkle
divalproex sodium oral tablet delayed release
EPIDIOLEX PA; SP
epitol
EQUETRO
ethosuximide oral
felbamate
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202014
Drug Name Limits/ Required
FYCOMPA
gabapentin oral
LAMICTAL XR ORAL KIT
lamotrigine er
lamotrigine oral tablet
lamotrigine oral tablet chewable
lamotrigine oral tablet dispersible
lamotrigine starter kit-blue
lamotrigine starter kit-green
lamotrigine starter kit-orange
levetiracetam er
levetiracetam oral
NAYZILAM QL
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital oral
phenytoin infatabs
phenytoin oral suspension 125 mg/5ml
phenytoin oral tablet chewable
phenytoin sodium extended
primidone oral
roweepra
roweepra xr
subvenite
subvenite starter kit-blue
subvenite starter kit-green
subvenite starter kit-orange
tiagabine hcl
topiramate er
topiramate oral
TROKENDI XR
valproic acid oral capsule
valproic acid oral solution
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202015
Drug Name Limits/ Required
vigabatrin SP
vigadrone SP
VIMPAT ORAL
zonisamide oral
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia
donepezil hcl
galantamine hydrobromide
galantamine hydrobromide er
memantine hcl er
memantine hcl oral
NAMENDA XR TITRATION PACK
NAMZARIC
rivastigmine
rivastigmine tartrate
Antidepressants
amitriptyline hcl oral
amoxapine
bupropion hcl er (sr)
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
bupropion hcl oral
chlordiazepoxide-amitriptyline
citalopram hydrobromide QL
clomipramine hcl oral
desipramine hcl oral
desvenlafaxine succinate er
doxepin hcl oral capsule
doxepin hcl oral concentrate
duloxetine hcl oral
escitalopram oxalate
fluoxetine hcl (pmdd) oral tablet
fluoxetine hcl oral
fluvoxamine maleate
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202016
Drug Name Limits/ Required
fluvoxamine maleate er
imipramine hcl oral
imipramine pamoate
maprotiline hcl
MARPLAN
mirtazapine oral
nefazodone hcl
nortriptyline hcl oral
olanzapine-fluoxetine hcl
paroxetine hcl er QL
paroxetine hcl oral tablet QL
paroxetine mesylate QL
perphenazine-amitriptyline
phenelzine sulfate oral
protriptyline hcl
sertraline hcl oral
tranylcypromine sulfate
trazodone hcl oral
trimipramine maleate oral
TRINTELLIX ST; QL
venlafaxine hcl
venlafaxine hcl er
Antiemetics - Drugs for Nausea and Vomiting
AKYNZEO ORAL QL
ANZEMET ORAL QL
aprepitant QL
compro
dronabinol
EMEND ORAL SUSPENSION RECONSTITUTED QL
granisetron hcl oral QL
meclizine hcl oral tablet
metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml
metoclopramide hcl oral tablet
metoclopramide hcl oral tablet dispersible
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202017
Drug Name Limits/ Required
ondansetron hcl oral
ondansetron odt
perphenazine oral
prochlorperazine
prochlorperazine maleate oral
scopolamine
trimethobenzamide hcl oral
Antifungals
BIO-STATIN ORAL CAPSULE
ciclodan external solution
ciclopirox
CICLOPIROX OLAMINE
ciclopirox olamine external
clotrimazole cream 1 % external (rx)
clotrimazole mouth/throat
CLOTRIMAZOLE POWDER
clotrimazole solution 1 % external (rx)
clotrimazole-betamethasone
CRESEMBA ORAL
econazole nitrate external
exoderm external lotion
fluconazole oral
flucytosine oral
griseofulvin microsize oral
griseofulvin ultramicrosize
GYNAZOLE-1
itraconazole oral QL
ketoconazole external cream
ketoconazole external foam
ketoconazole external shampoo 2 %
ketoconazole oral
ketodan external foam
miconazole 3 vaginal suppository
naftifine hcl
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202018
Drug Name Limits/ Required
NAFTIN EXTERNAL GEL 2 %
NOXAFIL ORAL SUSPENSION
nyamyc
nystatin external
nystatin mouth/throat
nystatin oral tablet
nystatin-triamcinolone
nystop
oxiconazole nitrate
posaconazole
terbinafine hcl oral
terconazole QL
TOLNAFTATE
voriconazole oral
Antigout Agents
allopurinol oral
COLCHICINE ORAL CAPSULE ST
colchicine tablet 0.6 mg oral
COLCHICINE TABLET 0.6 MG ORAL ST
colchicine-probenecid
COLCRYS
febuxostat ST
MITIGARE ST
probenecid oral
Anti-inflammatory Agents
EMFLAZA PA; SP
Antimigraine Agents
AIMOVIG PA; QL
almotriptan malate QL
dihydroergotamine mesylate injection QL
dihydroergotamine mesylate nasal QL
eletriptan hydrobromide QL
EMGALITY PA; QL
EMGALITY (300 MG DOSE) PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202019
Drug Name Limits/ Required
ERGOMAR
ergotamine-caffeine
frovatriptan succinate QL
MIGERGOT
naratriptan hcl QL
ONZETRA XSAIL
rizatriptan benzoate QL
sumatriptan nasal QL
sumatriptan succinate oral QL
sumatriptan succinate refill subcutaneous solution cartridge QL
sumatriptan succinate subcutaneous solution 6 mg/0.5ml QL
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
QL
sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml
QL
UBRELVY PA; QL
zolmitriptan oral QL
ZOMIG NASAL QL
Antimyasthenic Agents
pyridostigmine bromide er
pyridostigmine bromide oral solution
pyridostigmine bromide oral tablet
Antimycobacterials
cycloserine oral
dapsone oral
ethambutol hcl oral
isoniazid oral
PASER
PRETOMANID
PRIFTIN
pyrazinamide oral
rifabutin QL
RIFAMATE
rifampin oral
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202020
Drug Name Limits/ Required
RIFATER
SIRTURO
TRECATOR
Antineoplastics - Drugs for Cancer
anastrozole oral
DROXIA
exemestane
hydroxyurea oral
letrozole oral
leucovorin calcium oral
mercaptopurine oral
MESNEX ORAL
PANRETIN
PURIXAN
SOLTAMOX
tamoxifen citrate oral
TARGRETIN EXTERNAL SP
Antiparasitics
albendazole oral
ALINIA
atovaquone oral
atovaquone-proguanil hcl
BENZNIDAZOLE QL
chloroquine phosphate oral
COARTEM
crotan
EMVERM
hydroxychloroquine sulfate oral
IMPAVIDO
ivermectin oral
KRINTAFEL QL
lindane external shampoo
malathion external
mefloquine hcl
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202021
Drug Name Limits/ Required
pentamidine isethionate inhalation
permethrin external cream
praziquantel oral
primaquine phosphate oral
pyrimethamine oral PA; SP
quinine sulfate oral
SKLICE
spinosad
sulfurated lime
ULESFIA
Antiparkinson Agents
amantadine hcl oral
APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE SP
benztropine mesylate oral
bromocriptine mesylate oral
carbidopa oral
carbidopa-levodopa
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
carbidopa-levodopa-entacapone
entacapone
NEUPRO
pramipexole dihydrochloride
pramipexole dihydrochloride er
rasagiline mesylate oral
ropinirole hcl
ropinirole hcl er
RYTARY ST
selegiline hcl oral
tolcapone
trihexyphenidyl hcl
ZELAPAR
Antiplatelets
aspirin-dipyridamole er
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202022
Drug Name Limits/ Required
BRILINTA
CABLIVI PA; SP; QL
cilostazol
clopidogrel bisulfate oral
dipyridamole oral
prasugrel hcl
ZONTIVITY
Antipsychotics - Drugs for Mood Disorders
ADASUVE
aripiprazole oral solution
aripiprazole oral tablet QL
aripiprazole oral tablet dispersible QL
chlorpromazine hcl oral
clozapine
fluphenazine hcl oral
haloperidol lactate oral
haloperidol oral
LATUDA ST; QL
loxapine succinate oral
molindone hcl
NUPLAZID ORAL CAPSULE ST; QL
NUPLAZID ORAL TABLET 10 MG ST; QL
olanzapine oral
paliperidone er
pimozide
quetiapine fumarate QL
quetiapine fumarate er QL
risperidone
thioridazine hcl oral
thiothixene oral
trifluoperazine hcl oral
VERSACLOZ
ziprasidone hcl
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202023
Drug Name Limits/ Required
Antivirals
abacavir sulfate
abacavir sulfate-lamivudine
abacavir-lamivudine-zidovudine
acyclovir external
acyclovir oral
adefovir dipivoxil
APTIVUS
atazanavir sulfate
ATRIPLA
BARACLUDE ORAL SOLUTION
BIKTARVY
CIMDUO
COMPLERA
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
DELSTRIGO
DESCOVY
didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg
DOVATO
EDURANT
efavirenz
EMTRIVA
entecavir
EPCLUSA PA; SP; QL
EPIVIR HBV ORAL SOLUTION
EVOTAZ
famciclovir oral QL
fosamprenavir calcium
GENVOYA
HARVONI PA; SP; QL
INTELENCE
INVIRASE ORAL TABLET
ISENTRESS
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202024
Drug Name Limits/ Required
ISENTRESS HD
JULUCA
KALETRA ORAL TABLET
lamivudine oral solution
lamivudine oral tablet 100 mg, 300 mg
lamivudine oral tablet 150 mg QL
lamivudine-zidovudine
LEDIPASVIR-SOFOSBUVIR PA; SP; QL
LEXIVA ORAL SUSPENSION
lopinavir-ritonavir
MAVYRET PA; SP; QL
nevirapine
nevirapine er
NORVIR ORAL PACKET
NORVIR ORAL SOLUTION
ODEFSEY
oseltamivir phosphate oral QL
PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML
SP
PEGASYS SUBCUTANEOUS SOLUTION SP
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML SP
PIFELTRO
PREVYMIS ORAL SP; QL
PREZCOBIX
PREZISTA ORAL SUSPENSION
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
RELENZA DISKHALER QL
REYATAZ ORAL PACKET
ribavirin inhalation
ribavirin oral capsule
ribavirin oral tablet 200 mg
rimantadine hcl
ritonavir
SELZENTRY
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202025
Drug Name Limits/ Required
SITAVIG
SOFOSBUVIR-VELPATASVIR PA; SP; QL
stavudine oral capsule
STRIBILD
SYMFI
SYMFI LO
SYMTUZA
TEMIXYS
tenofovir disoproxil fumarate
TIVICAY
TRIUMEQ
TRUVADA
TYBOST
valacyclovir hcl oral
valganciclovir hcl
VEMLIDY
VIRACEPT ORAL TABLET
VIREAD ORAL POWDER
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
VOSEVI PA; SP; QL
XOFLUZA (40 MG DOSE) QL
XOFLUZA (80 MG DOSE) QL
zidovudine
Anxiolytics - Drugs for Anxiety
alprazolam er
alprazolam intensol
alprazolam oral tablet
alprazolam xr
buspirone hcl oral
chlordiazepoxide hcl
clonazepam oral
clorazepate dipotassium
diazepam intensol
diazepam oral concentrate
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202026
Drug Name Limits/ Required
diazepam oral solution 5 mg/5ml
diazepam oral tablet
estazolam
hydroxyzine hcl oral syrup
hydroxyzine hcl oral tablet
hydroxyzine pamoate oral
lorazepam intensol
lorazepam oral concentrate 2 mg/ml
lorazepam oral tablet
meprobamate
midazolam hcl oral
oxazepam
triazolam
Bipolar Agents - Drugs for Mood Disorders
lithium
lithium carbonate er
lithium carbonate oral
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders
aminocaproic acid oral solution
aminocaproic acid oral tablet
anagrelide hcl
MULPLETA PA; SP; QL
PROMACTA ORAL PACKET 12.5 MG PA; SP; QL
PROMACTA ORAL TABLET PA; SP; QL
TAVALISSE PA; SP; QL
tranexamic acid oral QL
Cardiovascular Agents - Drugs for Heart and Circulation Conditions
acebutolol hcl oral
ALDACTAZIDE ORAL TABLET 50-50 MG
aliskiren fumarate
amiloride hcl oral
amiloride-hydrochlorothiazide
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202027
Drug Name Limits/ Required
amiodarone hcl oral
amlodipine besylate oral
amlodipine besylate-benazepril hcl
amlodipine besylate-valsartan
amlodipine-atorvastatin QL
amlodipine-olmesartan
amlodipine-valsartan-hctz
atenolol oral
atenolol-chlorthalidone
atorvastatin calcium oral QL
benazepril hcl oral
benazepril-hydrochlorothiazide
betaxolol hcl oral
BIDIL
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
bumetanide oral
BYSTOLIC
candesartan cilexetil
candesartan cilexetil-hctz
captopril oral
captopril-hydrochlorothiazide
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG
cartia xt
carvedilol
carvedilol phosphate er
chlorothiazide oral
chlorthalidone oral tablet 25 mg, 50 mg
cholestyramine light QL
cholestyramine oral QL
clonidine
clonidine hcl oral
colesevelam hcl
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202028
Drug Name Limits/ Required
colestipol hcl
CORLANOR
DEMSER
digitek
digox
digoxin oral
DILATRATE-SR
diltiazem hcl er beads
diltiazem hcl er coated beads
diltiazem hcl er oral capsule extended release 12 hour
diltiazem hcl oral
dilt-xr
disopyramide phosphate oral
DIURIL
dofetilide
doxazosin mesylate oral QL
enalapril maleate oral
enalapril-hydrochlorothiazide
ENTRESTO
eplerenone
ethacrynic acid oral
ezetimibe QL
ezetimibe-simvastatin QL
felodipine er
fenofibrate micronized
fenofibrate oral capsule 134 mg, 200 mg, 67 mg
fenofibrate oral tablet
fenofibric acid oral capsule delayed release
fenofibric acid oral tablet 105 mg
flecainide acetate
fluvastatin sodium QL
fluvastatin sodium er QL
fosinopril sodium
fosinopril sodium-hctz
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202029
Drug Name Limits/ Required
furosemide oral solution 10 mg/ml, 8 mg/ml
furosemide oral tablet
gemfibrozil oral
GONITRO
guanfacine hcl oral
HEMANGEOL SP
hydralazine hcl oral
hydrochlorothiazide oral
indapamide oral
irbesartan
irbesartan-hydrochlorothiazide
isosorbide dinitrate oral
isosorbide mononitrate
isosorbide mononitrate er
isradipine
KATERZIA
labetalol hcl oral
LANOXIN ORAL TABLET 62.5 MCG
lisinopril oral
lisinopril-hydrochlorothiazide
losartan potassium
losartan potassium-hctz
lovastatin QL
matzim la
methyldopa oral
methyldopa-hydrochlorothiazide
metolazone
metoprolol succinate er
metoprolol tartrate oral
metoprolol-hydrochlorothiazide
mexiletine hcl oral
midodrine hcl
minitran
minoxidil oral
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202030
Drug Name Limits/ Required
moexipril hcl
MULTAQ
nadolol oral tablet 20 mg, 40 mg, 80 mg
niacin (antihyperlipidemic)
niacin er (antihyperlipidemic)
niacor
nicardipine hcl oral
nifedipine er
nifedipine er osmotic release
nifedipine oral
nimodipine oral
nisoldipine er
NITRO-BID
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR
nitroglycerin sublingual
nitroglycerin transdermal patch 24 hour
nitroglycerin translingual solution
NORPACE CR
NORTHERA SP
olmesartan medoxomil oral
olmesartan medoxomil-hctz
olmesartan-amlodipine-hctz
omega-3-acid ethyl esters
pacerone oral tablet 200 mg
pentoxifylline er
perindopril erbumine
phenoxybenzamine hcl oral
pindolol
PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL
pravastatin sodium QL
prazosin hcl oral
PRESTALIA
prevalite QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202031
Drug Name Limits/ Required
propafenone hcl
propafenone hcl er
propranolol hcl er
propranolol hcl oral
propranolol-hctz
quinapril hcl
quinapril-hydrochlorothiazide
quinidine gluconate er
quinidine sulfate oral
ramipril
ranolazine er
RECTIV
REPATHA PA; QL
REPATHA PUSHTRONEX SYSTEM PA; QL
REPATHA SURECLICK PA; QL
rosuvastatin calcium QL
simvastatin oral tablet QL
sorine
sotalol hcl (af)
sotalol hcl oral
SOTYLIZE
spironolactone oral
spironolactone-hctz
taztia xt
TEKTURNA HCT
telmisartan
telmisartan-amlodipine
telmisartan-hctz
tiadylt er
timolol maleate oral
torsemide oral
trandolapril
trandolapril-verapamil hcl er
triamterene oral
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202032
Drug Name Limits/ Required
triamterene-hctz oral capsule 37.5-25 mg
triamterene-hctz oral tablet
valsartan
valsartan-hydrochlorothiazide
VASCEPA
VECAMYL
verapamil hcl er oral capsule extended release 24 hour
verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg
verapamil hcl oral
VYNDAMAX PA; SP; QL
VYNDAQEL PA; SP; QL
Central Nervous System Agents - Drugs for Attention Deficit Disorder
ADZENYS ER
ADZENYS XR-ODT
AMPHETAMINE ER
amphetamine sulfate
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine er
atomoxetine hcl QL
clonidine hcl er
DAYTRANA
dexmethylphenidate hcl
dexmethylphenidate hcl er
dextroamphetamine sulfate er
dextroamphetamine sulfate oral
guanfacine hcl er
metadate er oral tablet extended release 20 mg
methamphetamine hcl
methylphenidate hcl er (cd)
methylphenidate hcl er (la)
methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg
methylphenidate hcl er oral tablet extended release 24 hour
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202033
Drug Name Limits/ Required
methylphenidate hcl oral
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER
VYVANSE
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
Central Nervous System Agents - Drugs for Multiple Sclerosis
AUBAGIO PA; SP; QL
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT PA; SP; QL
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT
PA; SP; QL
AVONEX VIAL INTRAMUSCULAR KIT PA; SP; QL
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA; SP; QL
dalfampridine er PA; SP; QL
EXTAVIA SUBCUTANEOUS KIT PA; SP; QL
GILENYA ORAL CAPSULE 0.25 MG PA; SP
GILENYA ORAL CAPSULE 0.5 MG PA; SP; QL
MAVENCLAD (10 TABS) PA; SP; QL
MAVENCLAD (4 TABS) PA; SP; QL
MAVENCLAD (5 TABS) PA; SP; QL
MAVENCLAD (6 TABS) PA; SP; QL
MAVENCLAD (7 TABS) PA; SP; QL
MAVENCLAD (8 TABS) PA; SP; QL
MAVENCLAD (9 TABS) PA; SP; QL
MAYZENT PA; SP; QL
MAYZENT STARTER PACK PA; SP; QL
PLEGRIDY PA; SP; QL
PLEGRIDY STARTER PACK PA; SP; QL
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PA; SP; QL
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PA; SP; QL
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202034
Drug Name Limits/ Required
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA; SP; QL
TECFIDERA PA; SP; QL
Central Nervous System Agents - Miscellaneous
benzphetamine hcl PA
caffeine citrate oral
diethylpropion hcl er PA
diethylpropion hcl oral PA
GRALISE
GRALISE STARTER
HORIZANT ORAL TABLET EXTENDED RELEASE
LOMAIRA PA
NUEDEXTA QL
phendimetrazine tartrate PA
phendimetrazine tartrate er PA
phentermine hcl oral PA
pregabalin oral QL
riluzole
SAVELLA ST; QL
SAVELLA TITRATION PACK ST; QL
TEGSEDI PA; SP; QL
tetrabenazine PA; SP
Dental and Oral Agents - Drugs for Mouth and Throat Conditions
cavarest
cevimeline hcl
chlorhexidine gluconate mouth/throat
clinpro 5000 paste 1.1 % dental
DEBACTEROL SOLUTION 30-50 % MOUTH/THROAT
denta 5000 plus
dentagel
fluoridex
fluoridex enhanced whitening dental paste
fluoridex sensitivity relief dental paste
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202035
Drug Name Limits/ Required
lidocaine hcl mouth/throat
lidocaine viscous hcl
MI PASTE
MI PASTE PLUS
NAFRINSE DAILY ACIDULATED
NAFRINSE DAILY/NEUTRAL
NAFRINSE WEEKLY
neutral sodium fluoride
oralone
paroex
periogard
pilocarpine hcl oral
PREVIDENT 5000 BOOSTER PLUS
PREVIDENT 5000 DRY MOUTH DENTAL GEL
PREVIDENT 5000 ENAMEL PROTECT
PREVIDENT 5000 ORTHO DEFENSE
PREVIDENT 5000 PLUS
PREVIDENT 5000 SENSITIVE
PREVIDENT DENTAL
prevident mouth/throat
REMESENSE
sf
sf 5000 plus
sodium fluoride 5000 plus
sodium fluoride 5000 ppm
sodium fluoride dental cream
sodium fluoride dental gel 1.1 %
TOPEX TOPICAL ANESTHETIC MOUTH/THROAT AEROSOL
triamcinolone acetonide mouth/throat
Dermatological Agents - Drugs for Skin Conditions
acitretin
ACZONE EXTERNAL GEL 7.5 %
adapalene external cream
adapalene external gel
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202036
Drug Name Limits/ Required
ADAPALENE EXTERNAL SOLUTION
adapalene-benzoyl peroxide
ala-cort external cream
alclometasone dipropionate
ALTRENO
ALUMINUM CHLORIDE ANHYDROUS
ALUMINUM CHLORIDE HEXAHYDRATE POWDER
amcinonide external lotion
amcinonide external ointment
ammonium lactate cream 12 % external (rx)
ammonium lactate lotion 12 % external (rx)
amnesteem
avita external cream
azelaic acid external
AZELEX
balsam peru-castor oil
benzoyl peroxide-erythromycin
beser external lotion
betamethasone dipropionate aug
betamethasone dipropionate external
betamethasone valerate external
BPCO
CALAMINE
calcipotriene external cream
calcipotriene external ointment
calcipotriene external solution
calcipotriene-betameth diprop external ointment QL
CALCIPOTRIENE-BETAMETH DIPROP EXTERNAL SUSPENSION
QL
calcitriol external
CARAC
claravis
clindacin etz external swab
clindacin-p
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202037
Drug Name Limits/ Required
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 %
clindamycin phosphate external foam
clindamycin phosphate external lotion
clindamycin phosphate external solution
clindamycin phosphate external swab
clindamycin phosphate gel 1 % external
clindamycin-tretinoin
clobetasol prop emollient base
clobetasol propionate e
clobetasol propionate emulsion
clobetasol propionate external
clocortolone pivalate
clodan external shampoo
coal tar external solution
CONDYLOX EXTERNAL GEL
CORDRAN EXTERNAL TAPE
CORTISPORIN EXTERNAL
dapsone external gel 5 %
dapsone gel 7.5 % external
DAPSONE GEL 7.5 % EXTERNAL
DERMULCERA
desonide external
desoximetasone external cream 0.25 %
desoximetasone external gel
desoximetasone external liquid
desoximetasone external ointment 0.25 %
diclofenac sodium gel 3 % transdermal
diflorasone diacetate external
doxepin hcl external
DRYSOL
DUPIXENT PA; SP; QL
EPIDUO FORTE
EPIFOAM
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202038
Drug Name Limits/ Required
ery
erythromycin external gel
erythromycin external solution
EUCRISA PA; QL
FINACEA EXTERNAL FOAM
fluocinolone acetonide body
fluocinolone acetonide external
fluocinolone acetonide scalp
fluocinonide emulsified base
fluocinonide external
FLUOROPLEX
FLUOROURACIL EXTERNAL CREAM 0.5 %
fluorouracil external cream 5 %
fluorouracil external solution
flurandrenolide
fluticasone propionate external
halcinonide
halobetasol propionate external cream
halobetasol propionate external ointment
hydrocortisone butyr lipo base
hydrocortisone butyrate external lotion
hydrocortisone butyrate external ointment
hydrocortisone butyrate external solution
hydrocortisone cream 1 % external (rx)
hydrocortisone external cream 2.5 %
hydrocortisone external lotion 2.5 %
hydrocortisone external ointment 2.5 %
hydrocortisone ointment 1 % external (rx)
hydrocortisone valerate
imiquimod external QL
IMIQUIMOD PUMP QL
isotretinoin oral
ivermectin external
lactic acid e
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202039
Drug Name Limits/ Required
lactic acid external lotion
LEVULAN KERASTICK
methoxsalen rapid
metronidazole external
mometasone furoate external
myorisan
NEO-SYNALAR EXTERNAL CREAM
neuac external gel
nolix
ONEXTON
PICATO
pimecrolimus
podofilox external
prednicarbate
PROMISEB CREAM EXTERNAL
PYROGALLIC ACID
QBREXZA ST; QL
REGRANEX QL
rosadan external cream
rosadan external gel
SANTYL
selenium sulfide external lotion
sulfacetamide sodium (acne)
TACLONEX EXTERNAL SUSPENSION QL
tacrolimus external ointment
tazarotene external
TAZORAC EXTERNAL CREAM 0.05 %
TAZORAC EXTERNAL GEL
TEXACORT
TOLAK
tovet external foam
tretinoin external
tretinoin microsphere
tretinoin microsphere pump
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202040
Drug Name Limits/ Required
triamcinolone acetonide external
trianex
triderm external cream
trivix
VENELEX
zenatane
ZYCLARA QL
ZYCLARA PUMP QL
Diabetes - Antidiabetic Agents
acarbose oral
AVANDIA ORAL TABLET 2 MG, 4 MG
BYDUREON BCISE AUTOINJECTOR ST; QL
BYDUREON PEN ST; QL
BYDUREON VIAL ST; QL
BYETTA 10 MCG PEN ST; QL
BYETTA 5 MCG PEN ST; QL
CYCLOSET
FARXIGA QL
glimepiride
glipizide er
glipizide ir
glipizide xl
glipizide-metformin hcl
glyburide micronized
glyburide oral
glyburide-metformin
GLYXAMBI QL
JANUMET QL
JANUMET XR QL
JANUVIA QL
JARDIANCE QL
KOMBIGLYZE XR QL
metformin hcl er
metformin hcl oral tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202041
Drug Name Limits/ Required
miglitol
nateglinide
ONGLYZA QL
OZEMPIC ST; QL
pioglitazone hcl QL
pioglitazone hcl-glimepiride
pioglitazone hcl-metformin hcl
QTERN QL
repaglinide
RYBELSUS ST; QL
SOLIQUA ST; QL
SYMLINPEN 120 PA
SYMLINPEN 60 PA
SYNJARDY QL
SYNJARDY XR QL
tolbutamide
TRULICITY ST; QL
VICTOZA ST; QL
XIGDUO XR QL
XULTOPHY ST; QL
Diabetes - Glucose Monitoring
ONETOUCH ULTRA BLUE TEST STRIPS QL
ONETOUCH VERIO TEST STRIPS QL
Diabetes - Glycemic Agents
BAQSIMI ONE PACK QL
BAQSIMI TWO PACK QL
diazoxide oral
GLUCAGON EMERGENCY KIT QL
GVOKE PFS QL
PROGLYCEM
Diabetes - Insulins
AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT
FIASP
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202042
Drug Name Limits/ Required
FIASP FLEXTOUCH
FIASP PENFILL
HUMULIN R U-500 KWIKPEN
HUMULIN R U-500 VIAL (CONCENTRATED)
LANTUS U-100 SOLOSTAR
LANTUS U-100 VIAL
LEVEMIR U-100 FLEXTOUCH
LEVEMIR U-100 VIAL
NOVOLIN 70/30 FLEXPEN
NOVOLIN 70/30 FLEXPEN RELION
NOVOLIN 70/30 RELION
NOVOLIN 70/30 VIAL
NOVOLIN N RELION
NOVOLIN N VIAL
NOVOLIN R FLEXPEN
NOVOLIN R FLEXPEN RELION
NOVOLIN R RELION
NOVOLIN R VIAL
NOVOLOG U-100 FLEXPEN
NOVOLOG MIX 70/30 FLEXPEN
NOVOLOG MIX 70/30 VIAL
NOVOLOG U-100 PENFILL
NOVOLOG U-100 VIAL
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
TRESIBA
TRESIBA FLEXTOUCH
Electrolytes / Minerals / Metals / Vitamins
ALANINE
CALCIFOL
CALCIUM CHLORIDE DIHYDRATE POWDER
CALCIUM GLUCONATE
CALCIUM GLUCONATE ANHYDROUS
CALCIUM GLUCONATE MONOHYDRATE
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202043
Drug Name Limits/ Required
CALCIUM LACTATE PENTAHYDRATE
CALCIUM PHOSPHATE DIBASIC
CALCIUM PHOSPHATE TRIBASIC
CARBAGLU SP
CHEMET
CHOLINE BITARTRATE POWDER
clovique SP
cyanocobalamin injection solution 1000 mcg/ml
deferasirox oral tablet 360 mg, 90 mg SP
deferasirox oral tablet soluble SP
DL-ALANINE
DL-LEUCINE
DL-METHIONINE POWDER (RX)
DL-PHENYLALANINE
effer-k oral tablet effervescent 25 meq
FERRIPROX SP
GALZIN
iodine strong oral
JADENU ORAL TABLET 180 MG SP
JADENU SPRINKLE SP
JYNARQUE ORAL TABLET SP
JYNARQUE ORAL TABLET THERAPY PACK PA; SP; QL
kionex oral suspension
klor-con 10
klor-con m10
KLOR-CON M15
klor-con m20
klor-con oral packet 20 meq
klor-con oral tablet extended release
klor-con sprinkle
klor-con/ef tablet effervescent 25 meq oral
K-PHOS TABLET 500 MG ORAL
k-prime
L-ALANINE
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202044
Drug Name Limits/ Required
L-ARGININE
L-CYSTINE
levocarnitine oral solution
levocarnitine oral tablet
levocarnitine sf
L-GLUTAMIC ACID
L-HISTIDINE MONOHYDROCHLORIDE POWDER
L-ISOLEUCINE POWDER (RX)
L-LEUCINE
L-METHIONINE POWDER (RX)
LOKELMA QL
L-PHENYLALANINE
L-PROLINE
L-TYROSINE
L-VALINE POWDER
MAGNEBIND 400
MAGNESIUM CARBONATE HEAVY
MAGNESIUM CARBONATE POWDER
METHIONINE POWDER (RX)
M-NATAL PLUS
NEONATAL COMPLETE
NEONATAL PLUS
NESTABS
ORACIT SOLUTION 490-640 MG/5ML ORAL
phosphorous
phytonadione oral
pnv prenatal plus multivit+dha
pot bicarb-pot chloride
potassium chloride crys er
potassium chloride er
potassium chloride oral packet
potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)
potassium citrate er
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202045
Drug Name Limits/ Required
prenatal oral tablet 27-1 mg
prenatal plus iron
RELNATE DHA
SAMSCA SP
sod citrate-citric acid solution 500-334 mg/5ml oral
SODIUM ASCORBATE POWDER
sodium polystyrene sulfonate oral
sodium polystyrene sulfonate rectal
sps
TAURINE POWDER
THREONINE
trientine hcl SP
trinate
VALINE
VELTASSA
virt-phos 250 neutral
vp-pnv-dha
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
cimetidine hcl oral
cimetidine oral
esomeprazole magnesium capsule delayed release 20 mg oral (rx)
QL
esomeprazole magnesium oral capsule delayed release 40 mg QL
esomeprazole magnesium oral packet QL
famotidine oral suspension reconstituted
famotidine oral tablet 40 mg
famotidine tablet 20 mg oral (rx)
lansoprazole oral capsule delayed release QL
misoprostol oral
NEXIUM ORAL PACKET 2.5 MG, 5 MG QL
nizatidine
omeprazole oral capsule delayed release QL
omeprazole-sodium bicarbonate QL
pantoprazole sodium oral QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202046
Drug Name Limits/ Required
PRILOSEC ORAL PACKET
rabeprazole sodium oral tablet delayed release QL
ranitidine hcl oral capsule
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions
alosetron hcl
AMITIZA QL
amoxicill-clarithro-lansopraz QL
BISACODYL
cascara sagrada oral fluid extract
CHENODAL PA; SP
chlordiazepoxide-clidinium capsule 5-2.5 mg oral
CLENPIQ
constulose
cromolyn sodium oral
CUVPOSA
dicyclomine hcl oral
diphenoxylate-atropine
ed-spaz
ENTEREG
enulose
GATTEX PA; SP
gavilyte-c
gavilyte-g
gavilyte-h
gavilyte-n with flavor pack
generlac
glycopyrrolate oral tablet 1 mg, 2 mg
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
hyoscyamine sulfate oral elixir
hyoscyamine sulfate oral solution
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202047
Drug Name Limits/ Required
hyoscyamine sulfate sl
hyoscyamine sulfate tablet 0.125 mg oral
hyoscyamine sulfate tablet dispersible 0.125 mg oral
hyoscyamine sulfate tablet sublingual 0.125 mg sublingual
lactulose encephalopathy
lactulose oral solution
LINZESS QL
loperamide hcl oral capsule
methscopolamine bromide oral
mineral oil heavy oral
MOTEGRITY ST; QL
MOVANTIK QL
MOVIPREP
MYTESI
nulev
oscimin oral tablet
oscimin sublingual
OSMOPREP
peg 3350-kcl-na bicarb-nacl
peg-3350/electrolytes
peg-prep
phenobarbital-belladonna alk elixir 16.2 mg/5ml oral
PLENVU
PREPOPIK
propantheline bromide oral
RESTORA RX
sodium bicarbonate oral powder
SUPREP BOWEL PREP KIT
SYMPROIC QL
trilyte
ursodiol oral
VIBERZI
XERMELO PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202048
Drug Name Limits/ Required
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment
CERDELGA PA; SP
CHOLBAM PA; SP
CREON
CYSTADANE POWDER ORAL SP
CYSTAGON SP
GALAFOLD PA; SP; QL
KUVAN PA; SP
L-GLUTAMIC ACID HCL
miglustat PA; SP
MYALEPT PA; SP
nitisinone SP
NITYR SP
ORFADIN ORAL CAPSULE 20 MG SP
ORFADIN ORAL SUSPENSION SP
PALYNZIQ PA; SP; QL
PANCREAZE
PERTZYE
RAVICTI PA; SP
sodium phenylbutyrate oral powder 3 gm/tsp SP
sodium phenylbutyrate oral tablet SP
STRENSIQ PA; SP
SUCRAID PA; SP
VIOKACE
XURIDEN SP
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions
AURYXIA
bethanechol chloride oral
calcium acetate (phos binder)
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202049
Drug Name Limits/ Required
calcium acetate oral tablet 667 mg
darifenacin hydrobromide er
ELMIRON
flavoxate hcl
FOSRENOL ORAL PACKET
INTRAROSA QL
lanthanum carbonate
LITHOSTAT
MYRBETRIQ ST
oxybutynin chloride er
oxybutynin chloride oral
penicillamine oral capsule
penicillamine oral tablet SP
phenazo oral tablet 200 mg
phenazopyridine hcl oral tablet 100 mg
phenazopyridine hcl tablet 200 mg oral
PHOSLYRA
sevelamer carbonate
sevelamer hcl
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg QL
solifenacin succinate
tadalafil oral tablet 10 mg, 2.5 mg, 20 mg QL
THIOLA SP
THIOLA EC SP
tolterodine tartrate
tolterodine tartrate er
TOVIAZ ST
trospium chloride
trospium chloride er
uretron d/s
urin ds
utrona-c
vardenafil hcl oral QL
VELPHORO
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202050
Drug Name Limits/ Required
Genitourinary Agents - Drugs for Prostate Conditions
alfuzosin hcl er
dutasteride oral
dutasteride-tamsulosin hcl
finasteride oral tablet 5 mg
silodosin
tamsulosin hcl
terazosin hcl oral
Hormonal Agents - Adrenal
cortisone acetate oral
dexamethasone intensol
dexamethasone oral
fludrocortisone acetate oral
hydrocortisone oral
MEDROL ORAL TABLET 2 MG
methylprednisolone oral
MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK
MILLIPRED DP ORAL TABLET THERAPY PACK
MILLIPRED ORAL TABLET
prednisolone oral solution
prednisolone oral syrup 15 mg/5ml
prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
prednisolone sodium phosphate oral tablet dispersible
prednisone intensol
prednisone oral
Hormonal Agents - Men's Health
ANADROL-50
ANDRODERM TRANSDERMAL PATCH 24 HOUR PA
danazol oral
FORTESTA PA
METHITEST
METHYLTESTOSTERONE
methyltestosterone oral
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202051
Drug Name Limits/ Required
oxandrolone oral
STRIANT PA
testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml
PA
testosterone enanthate intramuscular solution PA
testosterone gel 50 mg/5gm (1%) transdermal PA
testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%)
PA
testosterone transdermal solution PA
Hormonal Agents - Osteoporosis
OSPHENA
raloxifene hcl
Hormonal Agents - Pituitary
ACTHAR PA; SP
cabergoline QL
CETROTIDE SUBCUTANEOUS KIT 0.25 MG
chorionic gonadotropin intramuscular QL
clomiphene citrate oral
DDAVP RHINAL TUBE
desmopressin ace spray refrig
desmopressin acetate oral
desmopressin acetate spray
FOLLISTIM AQ SUBCUTANEOUS
ganirelix acetate subcutaneous solution prefilled syringe
GONAL-F
GONAL-F RFF
GONAL-F RFF REDIJECT
HUMATROPE PA; SP
INCRELEX PA; SP
leuprolide acetate injection
MENOPUR
novarel intramuscular solution reconstituted 10000 unit QL
NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT
QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202052
Drug Name Limits/ Required
NUTROPIN AQ NUSPIN 10 PA; SP
NUTROPIN AQ NUSPIN 20 PA; SP
NUTROPIN AQ NUSPIN 5 PA; SP
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
SP
ORILISSA PA; QL
OVIDREL
pregnyl QL
SIGNIFOR SP
STIMATE SP
SYNAREL
Hormonal Agents - Prostaglandins
KORLYM PA; SP
Hormonal Agents - Sex Hormones and Birth Control
amabelz
COMBIPATCH QL
CRINONE
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML
DEPO-ESTRADIOL
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
DIVIGEL
dotti QL
DUAVEE
ELESTRIN
ENDOMETRIN
estradiol oral
estradiol transdermal QL
estradiol vaginal
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet
ESTRING QL
ESTROGEL
EVAMIST
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202053
Drug Name Limits/ Required
FEMRING QL
fyavolv
hydroxyprogesterone caproate intramuscular
IMVEXXY MAINTENANCE PACK
IMVEXXY STARTER PACK
jinteli
lopreeza oral tablet 1-0.5 mg
medroxyprogesterone acetate oral
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml
megestrol acetate oral tablet
mimvey
norethindrone acetate oral
norethindrone-eth estradiol
PREFEST
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
progesterone intramuscular
progesterone micronized oral
yuvafem
Hormonal Agents - Thyroid
ARMOUR THYROID
euthyrox
levo-t
levothyroxine sodium oral
levoxyl
liothyronine sodium oral
methimazole oral
NATURE-THROID
np thyroid
propylthiouracil oral
SYNTHROID
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202054
Drug Name Limits/ Required
thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg
TIROSINT
TIROSINT-SOL
unithroid
WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG
WP THYROID ORAL TABLET 113.75 MG, 130 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
Immunological Agents - Drugs for Immune System Stimulation or Suppression
ACTEMRA ACTPEN PA; SP; QL
ACTEMRA SUBCUTANEOUS PA; SP; QL
ACTIMMUNE PA; SP
ARCALYST PA; SP
ASTAGRAF XL
AZASAN
azathioprine oral
BENLYSTA SUBCUTANEOUS PA; SP; QL
CIMZIA PREFILLED KIT PA; SP; QL
CIMZIA STARTER KIT PA; SP; QL
COSENTYX (300 MG DOSE) PA; SP; QL
COSENTYX 150 MG/ML PA; SP; QL
COSENTYX SENSOREADY (300 MG) PA; SP; QL
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
PA; SP; QL
cyclosporine modified
cyclosporine oral capsule
ENBREL MINI PA; SP; QL
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PA; SP; QL
ENVARSUS XR
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg
gengraf oral capsule 100 mg, 25 mg
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202055
Drug Name Limits/ Required
gengraf oral solution
HAEGARDA PA; SP
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
PA; SP; QL
HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.4ML SUBCUTANEOUS
PA; SP
HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.4ML SUBCUTANEOUS
PA; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML
PA; SP; QL
HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 80 MG/0.8ML SUBCUTANEOUS
PA; SP
HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 80 MG/0.8ML SUBCUTANEOUS
PA; SP; QL
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML
PA; SP; QL
HUMIRA PEN-PS/UV/ADOL HS START PA; SP; QL
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QL
icatibant acetate PA; SP
KEVZARA PA; SP; QL
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA; SP; QL
leflunomide oral QL
methotrexate oral
methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml
methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml
methotrexate sodium injection solution reconstituted
methotrexate sodium oral
mycophenolate mofetil
mycophenolate sodium
OLUMIANT PA; SP; QL
ORENCIA CLICKJECT PA; SP; QL
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202056
Drug Name Limits/ Required
OTEZLA ORAL TABLET PA; SP; QL
OTEZLA ORAL TABLET THERAPY PACK PA; SP; QL
PROGRAF ORAL PACKET
RIDAURA SP
RINVOQ PA; SP; QL
SANDIMMUNE ORAL SOLUTION
SILIQ PA; SP; QL
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL
sirolimus oral
SKYRIZI (150 MG DOSE) PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA; SP; QL
tacrolimus oral
TAKHZYRO PA; SP; QL
TALTZ PA; SP; QL
TREMFYA PA; SP; QL
TREXALL
VARIZIG INTRAMUSCULAR SOLUTION
XELJANZ PA; SP; QL
XELJANZ XR PA; SP; QL
ZORTRESS ORAL TABLET 1 MG
Inflammatory Bowel Disease Agents
balsalazide disodium
budesonide er oral tablet extended release 24 hour QL
budesonide oral QL
colocort
CORTIFOAM EXTERNAL
hydrocortisone (perianal)
hydrocortisone rectal enema
mesalamine er
mesalamine oral
mesalamine rectal
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202057
Drug Name Limits/ Required
mesalamine-cleanser
PENTASA
PROCTOFOAM HC EXTERNAL
procto-med hc external
procto-pak external
proctosol hc external
proctozone-hc external
sulfasalazine oral
UCERIS RECTAL
Metabolic Bone Disease Agents - Drugs for Osteoporosis
alendronate sodium oral solution
alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg
calcitonin (salmon)
ibandronate sodium oral
MIACALCIN INJECTION
RAYALDEE
risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg
risedronate sodium oral tablet delayed release
TYMLOS PA; SP; QL
Metabolic Bone Disease Agents - Other
calcitriol oral
cinacalcet hcl
doxercalciferol oral
NATPARA PA; SP
paricalcitol oral
Miscellaneous Therapeutic Agents
ASPARTAME
aspartame (nutrasweet)
BREATHE EASE LARGE
BREATHE EASE MEDIUM
BREATHE EASE SMALL
BREATHERITE
BROMELAIN
CETYLCIDE-G
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202058
Drug Name Limits/ Required
CHARCOAL ACTIVATED
COMPACT SPACE CHAMBER/LG MASK
COMPACT SPACE CHAMBER/MED MASK
COMPACT SPACE CHAMBER/SM MASK
EASIVENT
ENDARI
ergoloid mesylates oral
formaldehyde solution 37 % external (rx)
glutaraldehyde external
GRASTEK
methergine oral
methylergonovine maleate oral
MICROCHAMBER DEVICE
ODACTRA QL
ORALAIR
ORALAIR ADULT SAMPLE KIT
ORALAIR ADULT STARTER PACK
ORALAIR CHILDRENS STARTER PACK
pocket spacer
RADIOGARDASE
RAGWITEK
RUZURGI PA; SP; QL
SACCHARIN
sodium saccharin powder
VISTOGARD SP
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation
AZASITE
azelastine hcl ophthalmic
bacitracin ophthalmic
BETADINE OPHTHALMIC PREP
bromfenac sodium (once-daily)
CILOXAN OPHTHALMIC OINTMENT
ciprofloxacin hcl ophthalmic
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202059
Drug Name Limits/ Required
cromolyn sodium ophthalmic
dexamethasone sodium phosphate ophthalmic
diclofenac sodium ophthalmic
epinastine hcl
erythromycin ophthalmic
FLAREX
fluorometholone ophthalmic
flurbiprofen sodium
FML
FML FORTE ST
gatifloxacin ophthalmic
gentak ophthalmic ointment
gentamicin sulfate ophthalmic solution
ILEVRO
INVELTYS
ketorolac tromethamine ophthalmic
levofloxacin ophthalmic
LOTEMAX SM
MAXIDEX
MITOSOL
moxifloxacin hcl (2x day)
moxifloxacin hcl ophthalmic
NATACYN
ofloxacin ophthalmic
olopatadine hcl ophthalmic
POVIDONE-IODINE OPHTHALMIC
PRED MILD ST
prednisolone acetate ophthalmic
prednisolone sodium phosphate ophthalmic
sulfacetamide sodium ophthalmic
tobramycin ophthalmic
TOBREX OPHTHALMIC OINTMENT
trifluridine ophthalmic
ZIRGAN
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202060
Drug Name Limits/ Required
Ophthalmic Agents - Drugs for Glaucoma
acetazolamide er
acetazolamide oral
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
apraclonidine hcl
AZOPT
betaxolol hcl ophthalmic
BETIMOL
BETOPTIC-S
bimatoprost ophthalmic
brimonidine tartrate ophthalmic
carteolol hcl
COMBIGAN
dorzolamide hcl solution 2 % ophthalmic
dorzolamide hcl-timolol mal
dorzolamide hcl-timolol mal pf
IOPIDINE OPHTHALMIC SOLUTION 1 %
KEVEYIS SP
latanoprost ophthalmic
levobunolol hcl ophthalmic solution 0.5 %
LUMIGAN OPHTHALMIC SOLUTION 0.01 % ST
methazolamide oral
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
RHOPRESSA
ROCKLATAN ST
SIMBRINZA
timolol maleate ophthalmic
TIMOPTIC OCUDOSE
travoprost (bak free)
XELPROS
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
ak-poly-bac
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202061
Drug Name Limits/ Required
altafrin ophthalmic solution 10 %, 2.5 %
atropine sulfate ophthalmic ointment
atropine sulfate ophthalmic solution 1 %
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
bacitra-neomycin-polymyxin-hc
BLEPHAMIDE
BLEPHAMIDE S.O.P.
CEQUA QL
cyclopentolate hcl ophthalmic
CYSTARAN SP
homatropaire
ISOPTO ATROPINE
LACRISERT
neomycin-bacitracin zn-polymyx
neomycin-polymyxin-dexameth ophthalmic ointment
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1
neo-polycin
neo-polycin hc
OXERVATE PA; SP; QL
phenylephrine hcl ophthalmic solution 10 %, 2.5 %
polycin
polymyxin b-trimethoprim
PRED-G
PRED-G S.O.P.
proparacaine hcl ophthalmic
RESTASIS QL
RESTASIS MULTIDOSE EMULSION 0.05 % OPHTHALMIC QL
RESTASIS MULTIDOSE EMULSION 0.05 % OPHTHALMIC
sulfacetamide-prednisolone ophthalmic solution
TOBRADEX OPHTHALMIC OINTMENT
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202062
Drug Name Limits/ Required
TOBRADEX ST
tobramycin-dexamethasone
XIIDRA QL
ZYLET
Otic Agents - Drugs for Ear Conditions
acetic acid otic
CIPRODEX
ciprofloxacin hcl otic
COLY-MYCIN S
flac
fluocinolone acetonide otic
hydrocortisone-acetic acid
neomycin-polymyxin-hc otic
ofloxacin otic
PRAMOTIC
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold
azelastine hcl nasal
benzonatate
bromfed dm
brompheniramine tannate oral tablet chewable
carbinoxamine maleate oral solution
carbinoxamine maleate oral tablet
cetirizine hcl oral solution
clemastine fumarate oral tablet 2.68 mg
cyproheptadine hcl oral
desloratadine
diphen oral elixir
diphenhydramine hcl oral elixir
FASENRA PEN PA; SP; QL
flunisolide nasal solution 25 mcg/act (0.025%)
fluticasone propionate suspension 50 mcg/act nasal (rx) QL
guaiatussin ac QL
guaifenesin ac QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202063
Drug Name Limits/ Required
hydrocodone polst-cpm polst er oral suspension extended release
QL
hydrocodone-homatropine QL
hydromet QL
HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %
ipratropium bromide nasal
levocetirizine dihydrochloride oral solution
levocetirizine dihydrochloride tablet 5 mg oral (rx)
mometasone furoate nasal QL
nebusal inhalation nebulization solution 3 %
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL
olopatadine hcl nasal
phenadoz
promethazine hcl oral
promethazine hcl rectal suppository 12.5 mg, 25 mg
promethazine-codeine QL
promethazine-dm oral syrup
promethazine-phenyleph-codeine QL
promethazine-phenylephrine
promethegan
pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml
pulmosal
sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %
virtussin ac w/alc QL
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
acetylcysteine inhalation
ADVAIR DISKUS QL
ADVAIR HFA QL
albuterol sulfate er
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202064
Drug Name Limits/ Required
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION
QL
albuterol sulfate inhalation
albuterol sulfate oral
ANORO ELLIPTA QL
ARCAPTA NEOHALER QL
ARNUITY ELLIPTA QL
ASMANEX (120 METERED DOSES) QL
ASMANEX (14 METERED DOSES) QL
ASMANEX (30 METERED DOSES) QL
ASMANEX (60 METERED DOSES) QL
ASMANEX (7 METERED DOSES) QL
ASMANEX HFA QL
ATROVENT HFA QL
BEVESPI AEROSPHERE QL
BREO ELLIPTA QL
budesonide inhalation QL
COMBIVENT RESPIMAT QL
cromolyn sodium inhalation
DALIRESP
difil-g forte
ELIXOPHYLLIN
epinephrine injection solution auto-injector QL
ESBRIET PA; SP; QL
FLOVENT DISKUS QL
FLOVENT HFA QL
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
QL
INCRUSE ELLIPTA QL
ipratropium bromide inhalation
ipratropium-albuterol
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202065
Drug Name Limits/ Required
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT QL
LONHALA MAGNAIR REFILL KIT ST; QL
LONHALA MAGNAIR STARTER KIT ST; QL
metaproterenol sulfate oral syrup
montelukast sodium oral
OFEV PA; SP; QL
PERFOROMIST QL
PROAIR HFA QL
PROAIR RESPICLICK QL
PROVENTIL HFA QL
PULMICORT FLEXHALER QL
QVAR REDIHALER QL
SEEBRI NEOHALER
SEREVENT DISKUS QL
SPIRIVA HANDIHALER QL
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
QL
STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT
QL
STRIVERDI RESPIMAT QL
SYMBICORT QL
SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML
QL
terbutaline sulfate oral
THEO-24
theophylline
theophylline er oral tablet extended release 12 hour 300 mg, 450 mg
theophylline er oral tablet extended release 24 hour
TRELEGY ELLIPTA QL
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT
QL
UTIBRON NEOHALER QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202066
Drug Name Limits/ Required
VENTOLIN HFA QL
wixela inhub
XOPENEX HFA QL
YUPELRI ST; QL
zafirlukast
zileuton er
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis
BETHKIS SP; QL
CAYSTON SP
KALYDECO PA; SP; QL
KITABIS PAK SP; QL
ORKAMBI PA; SP; QL
PULMOZYME SP
SYMDEKO PA; SP; QL
TOBI PODHALER SP; QL
tobramycin nebulization solution 300 mg/5ml inhalation SP; QL
TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION
SP; QL
TRIKAFTA PA; SP; QL
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension
ADEMPAS PA; SP; QL
alyq PA; SP; QL
ambrisentan PA; SP; QL
bosentan PA; SP; QL
OPSUMIT PA; SP; QL
ORENITRAM PA; SP
sildenafil citrate oral suspension reconstituted PA; QL
sildenafil citrate oral tablet 20 mg PA; QL
tadalafil (pah) PA; SP; QL
TRACLEER 32 MG PA; SP; QL
TYVASO PA; SP
TYVASO REFILL PA; SP
TYVASO STARTER PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202067
Drug Name Limits/ Required
UPTRAVI PA; SP; QL
VENTAVIS PA; SP; QL
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
baclofen oral
carisoprodol oral
carisoprodol-aspirin
chlorzoxazone oral
cyclobenzaprine hcl oral tablet 5 mg, 7.5 mg
cyclobenzaprine hcl tablet 10 mg oral
dantrolene sodium oral
metaxalone
methocarbamol oral
orphenadrine citrate er
orphenadrine-aspirin-caffeine oral tablet 50-770-60 mg
tizanidine hcl oral
Sleep Disorder Agents
armodafinil QL
doxepin hcl oral tablet QL
eszopiclone QL
flurazepam hcl
modafinil QL
ramelteon
SECONAL
temazepam
XYREM PA; SP; QL
zaleplon QL
zolpidem tartrate QL
zolpidem tartrate er QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
Created on 4/15/202068
Index of Drugs
abacavir sulfate..................... 24abacavir sulfate-lamivudine... 24abacavir-lamivudine-zidovudine............................. 24ABSTRAL................................ 7acamprosate calcium.............11acarbose................................41acebutolol hcl.........................27acetaminophen-codeine.......... 7acetaminophen-codeine #2..... 7acetaminophen-codeine #3..... 7acetaminophen-codeine #4..... 7acetazolamide....................... 61acetazolamide er................... 61acetic acid..............................63acetylcysteine........................ 64acitretin.................................. 36ACTEMRA............................. 55ACTEMRA ACTPEN............. 55ACTHAR................................52ACTIMMUNE.........................55acyclovir.................................24ACZONE................................36adapalene..............................36ADAPALENE......................... 37adapalene-benzoyl peroxide. 37ADASUVE............................. 23adefovir dipivoxil.................... 24ADEMPAS............................. 67ADVAIR DISKUS...................64ADVAIR HFA......................... 64ADZENYS ER........................33ADZENYS XR-ODT...............33AFREZZA.............................. 42AIMOVIG............................... 19ak-poly-bac............................ 61AKYNZEO............................. 17ala-cort...................................37ALANINE............................... 43albendazole........................... 21albuterol sulfate..................... 65albuterol sulfate er................. 64albuterol sulfate hfa............... 64ALBUTEROL SULFATE HFA....................................... 65alclometasone dipropionate...37ALDACTAZIDE......................27alendronate sodium............... 58alfuzosin hcl er.......................51
ALINIA................................... 21aliskiren fumarate.................. 27allopurinol.............................. 19almotriptan malate................. 19alosetron hcl.......................... 47ALPHAGAN P........................61alprazolam............................. 26alprazolam er.........................26alprazolam intensol................26alprazolam xr......................... 26altafrin....................................62ALTRENO..............................37ALUMINUM CHLORIDE ANHYDROUS........................37ALUMINUM CHLORIDE HEXAHYDRATE....................37alyq........................................ 67amabelz................................. 53amantadine hcl...................... 22ambrisentan...........................67amcinonide............................ 37amiloride hcl.......................... 27amiloride-hydrochlorothiazide............... 27aminocaproic acid..................27amiodarone hcl...................... 28AMITIZA................................ 47amitriptyline hcl......................16amlodipine besylate...............28amlodipine besylate-benazepril hcl........................ 28amlodipine besylate-valsartan................................ 28amlodipine-atorvastatin......... 28amlodipine-olmesartan.......... 28amlodipine-valsartan-hctz......28ammonium lactate................. 37amnesteem............................37amoxapine............................. 16amoxicill-clarithro-lansopraz.. 47amoxicillin.............................. 11amoxicillin-potassium clavulanate............................ 11amoxicillin-potassium clavulanate er........................ 11AMPHETAMINE ER.............. 33amphetamine sulfate............. 33amphetamine-dextroamphetamine...............33
amphetamine-dextroamphetamine er...........33ampicillin................................11ANADROL-50........................ 51anagrelide hcl........................ 27anastrozole............................ 21ANDRODERM....................... 51ANORO ELLIPTA.................. 65ANZEMET............................. 17apap-caff-dihydrocodeine........ 7APOKYN................................22apraclonidine hcl....................61aprepitant...............................17APTIVUS............................... 24ARCALYST............................55ARCAPTA NEOHALER.........65aripiprazole............................ 23armodafinil ............................. 68ARMOUR THYROID............. 54ARNUITY ELLIPTA............... 65ascomp-codeine...................... 7ASMANEX (120 METERED DOSES).................................65ASMANEX (14 METERED DOSES).................................65ASMANEX (30 METERED DOSES).................................65ASMANEX (60 METERED DOSES).................................65ASMANEX (7 METERED DOSES).................................65ASMANEX HFA.....................65ASPARTAME........................ 58aspartame (nutrasweet).........58aspirin-dipyridamole er.......... 22ASTAGRAF XL......................55atazanavir sulfate.................. 24atenolol.................................. 28atenolol-chlorthalidone.......... 28atomoxetine hcl..................... 33atorvastatin calcium...............28atovaquone............................21atovaquone-proguanil hcl...... 21ATRIPLA................................24atropine sulfate...................... 62ATROVENT HFA...................65AUBAGIO.............................. 34AUGMENTIN......................... 11AURYXIA...............................49
69
AVANDIA...............................41avidoxy.................................. 11avita....................................... 37AVONEX PEN....................... 34AVONEX PREFILLED........... 34AVONEX VIAL INTRAMUSCULAR KIT........ 34AZASAN................................ 55AZASITE................................59azathioprine........................... 55azelaic acid............................37azelastine hcl...................59, 63AZELEX.................................37azithromycin.......................... 11AZOPT...................................61bacitracin............................... 59bacitracin-polymyxin b........... 62bacitra-neomycin-polymyxin-hc...........................................62baclofen................................. 68balsalazide disodium............. 57balsam peru-castor oil........... 37BANZEL.................................14BAQSIMI ONE PACK............ 42BAQSIMI TWO PACK........... 42BARACLUDE.........................24BAXDELA.............................. 11BELBUCA................................7benazepril hcl........................ 28benazepril-hydrochlorothiazide............... 28BENLYSTA............................55benzalkonium chloride...........11BENZNIDAZOLE................... 21benzonatate...........................63benzoyl peroxide-erythromycin.......................... 37benzphetamine hcl................ 35benztropine mesylate............ 22beser......................................37BETADINE OPHTHALMIC PREP.....................................59betamethasone dipropionate.37betamethasone dipropionate aug.........................................37betamethasone valerate........ 37betaxolol hcl.....................28, 61bethanechol chloride............. 49BETHKIS............................... 67BETIMOL...............................61
BETOPTIC-S......................... 61BEVESPI AEROSPHERE..... 65BEVYXXA..............................14BIDIL......................................28BIKTARVY.............................24bimatoprost............................61BIO-STATIN.......................... 18BISACODYL.......................... 47bisoprolol fumarate................ 28bisoprolol-hydrochlorothiazide............... 28BLEPHAMIDE....................... 62BLEPHAMIDE S.O.P.............62bosentan................................67BPCO.................................... 37BREATHE EASE LARGE......58BREATHE EASE MEDIUM... 58BREATHE EASE SMALL...... 58BREATHERITE..................... 58BREO ELLIPTA..................... 65BRILINTA.............................. 23brimonidine tartrate................61BRIVIACT.............................. 14BROMELAIN......................... 58bromfed dm........................... 63bromfenac sodium (once-daily)...................................... 59bromocriptine mesylate......... 22brompheniramine tannate......63budesonide...................... 57, 65budesonide er........................57bumetanide............................28BUNAVAIL.............................11buprenorphine......................... 7BUPRENORPHINE................. 7buprenorphine hcl..................11buprenorphine hcl-naloxone hcl.......................................... 11bupropion hcl......................... 16bupropion hcl er (sr).............. 16bupropion hcl er (xl)...............16buspirone hcl......................... 26butalbital-acetaminophen........ 7butalbital-apap-caff-cod........... 7butalbital-apap-caffeine........... 7butalbital-asa-caff-codeine...... 7butalbital-aspirin-caffeine.........7butorphanol tartrate................. 7BUTRANS............................... 7BYDUREON.......................... 41
BYDUREON BCISE AUTOINJECTOR...................41BYETTA 10 MCG PEN..........41BYETTA 5 MCG PEN............41BYSTOLIC.............................28cabergoline............................ 52CABLIVI.................................23caffeine citrate....................... 35CALAMINE............................ 37CALCIFOL............................. 43calcipotriene.......................... 37calcipotriene-betameth diprop.....................................37CALCIPOTRIENE-BETAMETH DIPROP............ 37calcitonin (salmon).................58calcitriol............................37, 58calcium acetate......................50calcium acetate (phos binder)................................... 49CALCIUM CHLORIDE DIHYDRATE..........................43CALCIUM GLUCONATE....... 43CALCIUM GLUCONATE ANHYDROUS........................43CALCIUM GLUCONATE MONOHYDRATE.................. 43CALCIUM LACTATE PENTAHYDRATE................. 44CALCIUM PHOSPHATE DIBASIC................................ 44CALCIUM PHOSPHATE TRIBASIC.............................. 44candesartan cilexetil .............. 28candesartan cilexetil-hctz...... 28captopril ................................. 28captopril-hydrochlorothiazide.28CARAC.................................. 37CARBAGLU...........................44carbamazepine...................... 14carbamazepine er..................14carbidopa...............................22carbidopa-levodopa............... 22carbidopa-levodopa er...........22carbidopa-levodopa-entacapone............................22carbinoxamine maleate......... 63CARDIZEM LA...................... 28carisoprodol........................... 68carisoprodol-aspirin............... 68
70
carisoprodol-aspirin-codeine... 7carteolol hcl........................... 61cartia xt.................................. 28carvedilol............................... 28carvedilol phosphate er......... 28cascara sagrada.................... 47cavarest................................. 35CAYSTON............................. 67cefaclor.................................. 11cefaclor er..............................11cefadroxil............................... 11cefdinir................................... 11cefditoren pivoxil....................12cefixime................................. 12cefpodoxime proxetil ..............12cefprozil................................. 12cefuroxime axetil ....................12celecoxib..................................9CELONTIN............................ 14cephalexin............................. 12CEQUA..................................62CERDELGA...........................49cetirizine hcl...........................63CETROTIDE..........................52CETYLCIDE-G...................... 58cevimeline hcl........................ 35CHARCOAL ACTIVATED..... 59CHEMET............................... 44CHENODAL...........................47chlordiazepoxide hcl.............. 26chlordiazepoxide-amitriptyline........................... 16chlordiazepoxide-clidinium.... 47chlorhexidine gluconate.........35chloroquine phosphate.......... 21chlorothiazide........................ 28chlorpromazine hcl................ 23chlorthalidone........................ 28chlorzoxazone....................... 68CHOLBAM.............................49cholestyramine...................... 28cholestyramine light...............28CHOLINE BITARTRATE....... 44chorionic gonadotropin.......... 52ciclodan................................. 18ciclopirox................................18CICLOPIROX OLAMINE....... 18ciclopirox olamine.................. 18cilostazol................................23CILOXAN...............................59
CIMDUO................................ 24cimetidine.............................. 46cimetidine hcl.........................46CIMZIA PREFILLED KIT....... 55CIMZIA STARTER KIT.......... 55cinacalcet hcl......................... 58CIPRODEX............................63ciprofloxacin hcl......... 12, 59, 63citalopram hydrobromide....... 16claravis.................................. 37clarithromycin........................ 12clarithromycin er.................... 12clemastine fumarate.............. 63CLENPIQ...............................47CLEOCIN...............................12clindacin etz...........................37clindacin-p............................. 37clindamycin hcl...................... 12clindamycin palmitate hcl.......12clindamycin phosphate.... 12, 38clindamycin phosphate-benzoyl peroxide................... 38clindamycin-tretinoin..............38CLINDESSE.......................... 12clinpro 5000........................... 35clobazam............................... 14clobetasol prop emollient base.......................................38clobetasol propionate............ 38clobetasol propionate e......... 38clobetasol propionate emulsion................................ 38clocortolone pivalate..............38clodan.................................... 38clomiphene citrate................. 52clomipramine hcl....................16clonazepam........................... 26clonidine................................ 28clonidine hcl...........................28clonidine hcl er.......................33clopidogrel bisulfate...............23clorazepate dipotassium........26clotrimazole........................... 18CLOTRIMAZOLE...................18clotrimazole-betamethasone. 18clovique................................. 44clozapine............................... 23coal tar...................................38COARTEM.............................21codeine sulfate........................ 7
COLCHICINE........................ 19colchicine...............................19colchicine-probenecid............19COLCRYS............................. 19colesevelam hcl..................... 28colestipol hcl.......................... 29colocort.................................. 57COLY-MYCIN S.....................63COMBIGAN........................... 61COMBIPATCH.......................53COMBIVENT RESPIMAT......65COMPACT SPACE CHAMBER/LG MASK............59COMPACT SPACE CHAMBER/MED MASK........ 59COMPACT SPACE CHAMBER/SM MASK........... 59COMPLERA.......................... 24compro...................................17CONDYLOX.......................... 38constulose............................. 47COPAXONE.......................... 34CORDRAN............................ 38CORLANOR.......................... 29CORTIFOAM......................... 57cortisone acetate................... 51CORTISPORIN......................38COSENTYX (300 MG DOSE)................................... 55COSENTYX 150 MG/ML....... 55COSENTYX SENSOREADY (300 MG)............................... 55COSENTYX SENSOREADY PEN....................................... 55CREON..................................49CRESEMBA.......................... 18CRINONE.............................. 53CRIXIVAN..............................24cromolyn sodium....... 47, 60, 65crotan.....................................21CUVPOSA............................. 47cyanocobalamin.....................44cyclobenzaprine hcl............... 68cyclopentolate hcl.................. 62cycloserine.............................20CYCLOSET........................... 41cyclosporine...........................55cyclosporine modified............ 55cyproheptadine hcl................ 63CYSTADANE.........................49
71
CYSTAGON.......................... 49CYSTARAN........................... 62dalfampridine er.....................34DALIRESP.............................65danazol.................................. 51dantrolene sodium................. 68dapsone...........................20, 38DAPSONE............................. 38darifenacin hydrobromide er..50DAYTRANA........................... 33DDAVP RHINAL TUBE......... 52DEBACTEROL...................... 35deferasirox.............................44DELESTROGEN................... 53DELSTRIGO..........................24demeclocycline hcl................ 12DEMSER............................... 29denta 5000 plus..................... 35dentagel.................................35DEPO-ESTRADIOL...............53DEPO-PROVERA..................53DERMULCERA..................... 38DESCOVY............................. 24desipramine hcl..................... 16desloratadine......................... 63desmopressin ace spray refrig...................................... 52desmopressin acetate........... 52desmopressin acetate spray..52desonide................................ 38desoximetasone.................... 38desvenlafaxine succinate er.. 16dexamethasone..................... 51dexamethasone intensol........51dexamethasone sodium phosphate..............................60dexmethylphenidate hcl.........33dexmethylphenidate hcl er.....33dextroamphetamine sulfate... 33dextroamphetamine sulfate er........................................... 33DIACOMIT............................. 14diazepam................... 14, 26, 27diazepam intensol..................26diazoxide............................... 42DICLOFENAC EPOLAMINE... 9diclofenac potassium............... 9diclofenac sodium........9, 38, 60diclofenac sodium er................9diclofenac-misoprostol.............9
dicloxacillin sodium................12dicyclomine hcl...................... 47didanosine............................. 24diethylpropion hcl...................35diethylpropion hcl er.............. 35DIFICID..................................12difil-g forte..............................65diflorasone diacetate............. 38diflunisal...................................9digitek.................................... 29digox...................................... 29digoxin................................... 29dihydroergotamine mesylate. 19DILANTIN.............................. 14DILATRATE-SR.....................29diltiazem hcl...........................29diltiazem hcl er.......................29diltiazem hcl er beads............29diltiazem hcl er coated beads.....................................29dilt-xr......................................29diphen....................................63diphenhydramine hcl............. 63diphenoxylate-atropine.......... 47dipyridamole.......................... 23disopyramide phosphate....... 29disulfiram............................... 11DIURIL...................................29divalproex sodium..................14divalproex sodium er............. 14DIVIGEL................................ 53DL-ALANINE......................... 44DL-LEUCINE......................... 44DL-METHIONINE.................. 44DL-PHENYLALANINE........... 44dofetilide................................ 29donepezil hcl..........................16dorzolamide hcl..................... 61dorzolamide hcl-timolol mal... 61dorzolamide hcl-timolol mal pf............................................61dotti........................................53DOVATO............................... 24doxazosin mesylate............... 29doxepin hcl................ 16, 38, 68doxercalciferol....................... 58doxycycline hyclate................12doxycycline monohydrate...... 12dronabinol..............................17DROXIA.................................21
DRYSOL................................38DUAVEE................................53duloxetine hcl.........................16DUPIXENT............................ 38duraxin.....................................7dutasteride.............................51dutasteride-tamsulosin hcl.....51E.E.S. 400............................. 12EASIVENT.............................59ec-naproxen.............................9econazole nitrate................... 18ed-spaz..................................47EDURANT............................. 24efavirenz................................ 24effer-k.................................... 44ELESTRIN............................. 53eletriptan hydrobromide.........19ELIQUIS................................ 14ELIQUIS DVT/PE STARTER PACK.....................................14ELIXOPHYLLIN..................... 65ELMIRON.............................. 50EMEND..................................17EMFLAZA.............................. 19EMGALITY............................ 19EMGALITY (300 MG DOSE).19EMTRIVA...............................24EMVERM...............................21enalapril maleate................... 29enalapril-hydrochlorothiazide.29ENBREL................................ 55ENBREL MINI........................55ENBREL SURECLICK...........55ENDARI................................. 59endocet....................................7ENDOMETRIN...................... 53enoxaparin sodium................ 14entacapone............................22entecavir................................ 24ENTEREG............................. 47ENTRESTO........................... 29enulose.................................. 47ENVARSUS XR.....................55EPCLUSA..............................24EPIDIOLEX............................14EPIDUO FORTE....................38EPIFOAM.............................. 38epinastine hcl.........................60epinephrine............................65epitol...................................... 14
72
EPIVIR HBV.......................... 24eplerenone.............................29EQUETRO.............................14ergoloid mesylates.................59ERGOMAR............................ 20ergotamine-caffeine...............20ery..........................................39ERYTHROCIN STEARATE...12erythromycin.............. 12, 39, 60erythromycin base................. 12erythromycin ethylsuccinate.. 12ESBRIET............................... 65escitalopram oxalate..............16esomeprazole magnesium.... 46estazolam.............................. 27estradiol................................. 53estradiol valerate................... 53estradiol-norethindrone acet..53ESTRING...............................53ESTROGEL........................... 53eszopiclone............................68ethacrynic acid.......................29ethambutol hcl....................... 20ethosuximide......................... 14ethyl chloride......................... 10etodolac................................... 9etodolac er...............................9EUCRISA...............................39euthyrox.................................54EVAMIST...............................53everolimus............................. 55EVOTAZ................................ 24exemestane........................... 21exoderm.................................18EXTAVIA............................... 34ezetimibe............................... 29ezetimibe-simvastatin............ 29famciclovir..............................24famotidine.............................. 46FARXIGA...............................41FASENRA PEN..................... 63febuxostat.............................. 19felbamate...............................14felodipine er........................... 29FEMRING.............................. 54fenofibrate..............................29fenofibrate micronized........... 29fenofibric acid........................ 29fenoprofen calcium.................. 9fenortho................................... 9
fentanyl.................................... 7fentanyl citrate......................... 7FENTANYL CITRATE............. 7FENTORA............................... 7FERRIPROX..........................44FIASP.................................... 42FIASP FLEXTOUCH............. 43FIASP PENFILL.....................43FINACEA............................... 39finasteride.............................. 51FIRVANQ...............................12flac......................................... 63FLAREX.................................60flavoxate hcl...........................50flecainide acetate...................29FLECTOR................................9FLOVENT DISKUS................65FLOVENT HFA......................65fluconazole............................ 18flucytosine..............................18fludrocortisone acetate.......... 51flunisolide...............................63fluocinolone acetonide.....39, 63fluocinolone acetonide body..39fluocinolone acetonide scalp. 39fluocinonide........................... 39fluocinonide emulsified base. 39fluoridex................................. 35fluoridex enhanced whitening............................... 35fluoridex sensitivity relief........35fluorometholone.....................60FLUOROPLEX...................... 39FLUOROURACIL.................. 39fluorouracil............................. 39fluoxetine hcl..........................16fluoxetine hcl (pmdd)............. 16fluphenazine hcl.....................23flurandrenolide.......................39flurazepam hcl....................... 68flurbiprofen...............................9flurbiprofen sodium................ 60fluticasone propionate..... 39, 63fluticasone-salmeterol............65FLUTICASONE-SALMETEROL...................... 65fluvastatin sodium..................29fluvastatin sodium er..............29fluvoxamine maleate..............16fluvoxamine maleate er......... 17
FML....................................... 60FML FORTE.......................... 60FOLLISTIM AQ......................52fondaparinux sodium............. 14formaldehyde.........................59FORTESTA........................... 51fosamprenavir calcium...........24fosinopril sodium....................29fosinopril sodium-hctz............29FOSRENOL...........................50FRAGMIN.............................. 14frovatriptan succinate............ 20furosemide.............................30fyavolv................................... 54FYCOMPA.............................15gabapentin.............................15GALAFOLD........................... 49galantamine hydrobromide.... 16galantamine hydrobromide er........................................... 16GALZIN..................................44ganirelix acetate.................... 52gatifloxacin.............................60GATTEX................................ 47gavilyte-c............................... 47gavilyte-g............................... 47gavilyte-h............................... 47gavilyte-n with flavor pack..... 47GEBAUERS PAIN EASE.......10GEBAUERS SPRAY AND STRETCH..............................10gemfibrozil............................. 30generlac.................................47gengraf............................ 55, 56gentak....................................60gentamicin sulfate............12, 60GENVOYA.............................24GILENYA............................... 34glimepiride............................. 41glipizide er............................. 41glipizide ir...............................41glipizide xl.............................. 41glipizide-metformin hcl...........41GLUCAGON EMERGENCY KIT......................................... 42glutaraldehyde....................... 59glyburide................................ 41glyburide micronized..............41glyburide-metformin...............41glycopyrrolate........................ 47
73
glydo...................................... 10GLYXAMBI............................ 41GOLYTELY............................47GONAL-F...............................52GONAL-F RFF.......................52GONAL-F RFF REDIJECT.... 52GONITRO..............................30GRALISE............................... 35GRALISE STARTER............. 35granisetron hcl....................... 17GRASTEK............................. 59griseofulvin microsize............ 18griseofulvin ultramicrosize..... 18guaiatussin ac........................63guaifenesin ac....................... 63guanfacine hcl....................... 30guanfacine hcl er................... 33GVOKE PFS..........................42GYNAZOLE-1........................18HAEGARDA.......................... 56halcinonide............................ 39halobetasol propionate.......... 39haloperidol............................. 23haloperidol lactate................. 23HARVONI.............................. 24HEMANGEOL........................30heparin sodium (porcine).......14heparin sodium (porcine) pf...14homatropaire......................... 62HORIZANT............................ 35HUMATROPE........................52HUMIRA................................ 56HUMIRA PEDIATRIC CROHNS START.................. 56HUMIRA PEN........................ 56HUMIRA PEN-CD/UC/HS STARTER..............................56HUMIRA PEN-PS/UV/ADOL HS START.............................56HUMULIN R U-500 KWIKPEN.............................. 43HUMULIN R U-500 VIAL (CONCENTRATED).............. 43hydralazine hcl.......................30hydrochlorothiazide............... 30hydrocodone bitartrate er........ 7hydrocodone polst-cpm polst er........................................... 64hydrocodone-acetaminophen........................ 8
hydrocodone-homatropine.....64hydrocodone-ibuprofen............8hydrocortisone........... 39, 51, 57hydrocortisone (perianal).......57hydrocortisone butyr lipo base.......................................39hydrocortisone butyrate......... 39hydrocortisone valerate......... 39hydrocortisone-acetic acid.....63hydrogen peroxide.................12hydromet................................64hydromorphone hcl..................8hydromorphone hcl er..............8hydroxychloroquine sulfate....21hydroxyprogesterone caproate.................................54hydroxyurea...........................21hydroxyzine hcl......................27hydroxyzine pamoate............ 27hyoscyamine sulfate........ 47, 48hyoscyamine sulfate sl.......... 48HYPERSAL........................... 64HYSINGLA ER........................ 8ibandronate sodium............... 58ibu..........................................10ibuprofen................................10icatibant acetate.................... 56ILEVRO................................. 60imipramine hcl....................... 17imipramine pamoate.............. 17imiquimod.............................. 39IMIQUIMOD PUMP............... 39IMPAVIDO............................. 21IMVEXXY MAINTENANCE PACK.....................................54IMVEXXY STARTER PACK..54INCRELEX.............................52INCRUSE ELLIPTA............... 65indapamide............................ 30INDOCIN............................... 10indomethacin......................... 10indomethacin er..................... 10INTELENCE.......................... 24INTRAROSA..........................50INVELTYS............................. 60INVIRASE..............................24iodine strong.......................... 44IOPIDINE...............................61ipratropium bromide.........64, 65ipratropium-albuterol..............65
irbesartan...............................30irbesartan-hydrochlorothiazide............... 30ISENTRESS.......................... 24ISENTRESS HD.................... 25isoniazid.................................20ISOPTO ATROPINE..............62isosorbide dinitrate................ 30isosorbide mononitrate.......... 30isosorbide mononitrate er...... 30isotretinoin............................. 39isradipine............................... 30itraconazole........................... 18ivermectin........................ 21, 39JADENU................................ 44JADENU SPRINKLE............. 44jantoven................................. 14JANUMET..............................41JANUMET XR........................41JANUVIA............................... 41JARDIANCE.......................... 41jinteli ...................................... 54JULUCA.................................25JYNARQUE........................... 44KALETRA.............................. 25KALYDECO........................... 67KATERZIA............................. 30ketoconazole......................... 18ketodan..................................18ketoprofen..............................10ketoprofen er......................... 10ketorolac tromethamine... 10, 60KEVEYIS............................... 61KEVZARA..............................56KINERET............................... 56kionex.................................... 44KITABIS PAK.........................67klor-con..................................44klor-con 10.............................44klor-con m10..........................44KLOR-CON M15....................44klor-con m20..........................44klor-con sprinkle.................... 44klor-con/ef..............................44KOMBIGLYZE XR................. 41KORLYM............................... 53K-PHOS.................................44k-prime...................................44KRINTAFEL...........................21KUVAN.................................. 49
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labetalol hcl............................30LACRISERT.......................... 62lactic acid...............................40lactic acid e............................39lactulose................................ 48lactulose encephalopathy...... 48L-ALANINE............................ 44LAMICTAL XR....................... 15lamivudine............................. 25lamivudine-zidovudine........... 25lamotrigine............................. 15lamotrigine er.........................15lamotrigine starter kit-blue..... 15lamotrigine starter kit-green...15lamotrigine starter kit-orange.15LANOXIN...............................30lansoprazole.......................... 46lanthanum carbonate.............50LANTUS SOLOSTAR............43LANTUS U-100 VIAL.............43L-ARGININE.......................... 45latanoprost.............................61LATUDA................................ 23L-CYSTINE............................45LEDIPASVIR-SOFOSBUVIR.25leflunomide............................ 56letrozole................................. 21leucovorin calcium................. 21leuprolide acetate.................. 52levalbuterol hcl.......................66LEVALBUTEROL HFA.......... 66LEVEMIR U-100 FLEXTOUCH.........................43LEVEMIR U-100 VIAL........... 43levetiracetam......................... 15levetiracetam er..................... 15levobunolol hcl.......................61levocarnitine.......................... 45levocarnitine sf.......................45levocetirizine dihydrochloride 64levofloxacin......................12, 60levorphanol tartrate..................8levo-t......................................54levothyroxine sodium.............54levoxyl....................................54LEVULAN KERASTICK.........40LEXIVA.................................. 25L-GLUTAMIC ACID............... 45L-GLUTAMIC ACID HCL....... 49
L-HISTIDINE MONOHYDROCHLORIDE....45lidocaine.......................... 10, 11lidocaine hcl.....................10, 36lidocaine hcl urethral/mucosal.................... 11lidocaine viscous hcl..............36lidocaine-prilocaine................11lindane................................... 21linezolid..................................12LINZESS................................48liothyronine sodium................54lisinopril ..................................30lisinopril-hydrochlorothiazide. 30L-ISOLEUCINE......................45lithium.................................... 27lithium carbonate................... 27lithium carbonate er............... 27LITHOSTAT...........................50L-LEUCINE............................45L-METHIONINE.....................45LOKELMA..............................45LOMAIRA.............................. 35LONHALA MAGNAIR REFILL KIT............................66LONHALA MAGNAIR STARTER KIT....................... 66loperamide hcl....................... 48lopinavir-ritonavir................... 25lopreeza.................................54lorazepam..............................27lorazepam intensol................ 27lorcet........................................8lorcet hd...................................8lorcet plus................................ 8LORTAB.................................. 8losartan potassium................ 30losartan potassium-hctz.........30LOTEMAX SM....................... 60lovastatin............................... 30loxapine succinate................. 23L-PHENYLALANINE..............45L-PROLINE............................45L-TYROSINE......................... 45LUCEMYRA...........................11LUMIGAN.............................. 61L-VALINE...............................45mafenide acetate................... 12MAGNEBIND 400..................45MAGNESIUM CARBONATE.45
MAGNESIUM CARBONATE HEAVY.................................. 45malathion............................... 21maprotiline hcl....................... 17MARPLAN............................. 17matzim la............................... 30MAVENCLAD (10 TABS)...... 34MAVENCLAD (4 TABS)........ 34MAVENCLAD (5 TABS)........ 34MAVENCLAD (6 TABS)........ 34MAVENCLAD (7 TABS)........ 34MAVENCLAD (8 TABS)........ 34MAVENCLAD (9 TABS)........ 34MAVYRET............................. 25MAXIDEX.............................. 60MAYZENT............................. 34MAYZENT STARTER PACK.34meclizine hcl.......................... 17meclofenamate sodium......... 10MEDROL............................... 51medroxyprogesterone acetate...................................54mefenamic acid..................... 10mefloquine hcl....................... 21megestrol acetate.................. 54meloxicam............................. 10memantine hcl....................... 16memantine hcl er................... 16MENOPUR............................ 52meperidine hcl......................... 8meprobamate........................ 27mercaptopurine......................21mesalamine........................... 57mesalamine er....................... 57mesalamine-cleanser............ 58MESNEX............................... 21metadate er........................... 33metaproterenol sulfate...........66metaxalone............................ 68metformin hcl er.....................41metformin hcl ir...................... 41methadone hcl......................... 8methadone hcl intensol............8methadose...............................8methadose sugar-free............. 8methamphetamine hcl........... 33methazolamide...................... 61methenamine hippurate.........13methergine.............................59methimazole.......................... 54
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METHIONINE........................ 45METHITEST.......................... 51methocarbamol......................68methotrexate..........................56methotrexate sodium............. 56methotrexate sodium (pf).......56methoxsalen rapid................. 40methscopolamine bromide.... 48methyldopa............................ 30methyldopa-hydrochlorothiazide............... 30methylergonovine maleate.... 59methylphenidate hcl...............34methylphenidate hcl er.......... 33methylphenidate hcl er (cd)... 33methylphenidate hcl er (la).... 33methylprednisolone............... 51METHYLTESTOSTERONE...51methyltestosterone................ 51metoclopramide hcl............... 17metolazone............................ 30metoprolol succinate er......... 30metoprolol tartrate................. 30metoprolol-hydrochlorothiazide............... 30metronidazole.................. 13, 40mexiletine hcl.........................30MI PASTE..............................36MI PASTE PLUS................... 36MIACALCIN........................... 58miconazole 3......................... 18MICROCHAMBER.................59midazolam hcl........................27midodrine hcl......................... 30MIGERGOT........................... 20miglitol................................... 42miglustat................................ 49MILLIPRED............................51MILLIPRED DP......................51MILLIPRED DP 12-DAY........ 51mimvey.................................. 54mineral oil heavy....................48minitran..................................30minocycline hcl...................... 13minoxidil.................................30mirtazapine............................ 17misoprostol............................ 46MITIGARE............................. 19MITOSOL.............................. 60M-NATAL PLUS.................... 45
modafinil ................................ 68moexipril hcl...........................31molindone hcl........................ 23mometasone furoate........40, 64mondoxyne nl........................ 13montelukast sodium...............66MONUROL............................ 13morgidox................................13morphine sulfate...................... 8morphine sulfate (concentrate)........................... 8morphine sulfate er..................8morphine sulfate er beads....... 8MOTEGRITY......................... 48MOVANTIK............................48MOVIPREP............................48moxifloxacin hcl............... 13, 60moxifloxacin hcl (2x day)....... 60MULPLETA............................27MULTAQ................................31mupirocin............................... 13MYALEPT..............................49mycophenolate mofetil ...........56mycophenolate sodium..........56myorisan................................ 40MYRBETRIQ......................... 50MYTESI................................. 48nabumetone...........................10nadolol................................... 31NAFRINSE DAILY ACIDULATED........................36NAFRINSE DAILY/NEUTRAL.................. 36NAFRINSE WEEKLY............ 36naftifine hcl............................ 18NAFTIN..................................19NALOXONE HCL.................. 11naltrexone hcl........................ 11NAMENDA XR TITRATION PACK.....................................16NAMZARIC............................16naproxen................................10naproxen dr........................... 10naproxen sodium................... 10naproxen sodium er...............10naproxen-esomeprazole........10naratriptan hcl........................20NARCAN............................... 11NATACYN............................. 60nateglinide............................. 42
NATPARA..............................58NATURE-THROID.................54NAYZILAM.............................15nebusal.................................. 64NEBUSAL..............................64nefazodone hcl...................... 17neomycin sulfate....................13neomycin-bacitracin zn-polymyx................................. 62neomycin-polymyxin-dexameth...............................62neomycin-polymyxin-gramicidin.............................. 62neomycin-polymyxin-hc... 62, 63NEONATAL COMPLETE...... 45NEONATAL PLUS.................45neo-polycin............................ 62neo-polycin hc....................... 62NEO-SYNALAR.....................40NESTABS..............................45neuac.....................................40NEUPRO............................... 22neutral sodium fluoride.......... 36nevirapine.............................. 25nevirapine er..........................25NEXIUM.................................46niacin (antihyperlipidemic)..... 31niacin er (antihyperlipidemic).31niacor.....................................31nicardipine hcl........................31nifedipine............................... 31nifedipine er........................... 31nifedipine er osmotic release.31nimodipine............................. 31nisoldipine er......................... 31nitisinone............................... 49NITRO-BID............................ 31NITRO-DUR.......................... 31nitrofurantoin..........................13nitrofurantoin macrocrystal.... 13nitrofurantoin monohydrate macrocrystals........................ 13nitroglycerin........................... 31NITYR....................................49nizatidine............................... 46nolix....................................... 40norethindrone acetate............54norethindrone-eth estradiol....54NORPACE CR.......................31NORTHERA.......................... 31
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nortriptyline hcl...................... 17NORVIR.................................25novarel...................................52NOVAREL............................. 52NOVOLIN 70/30 FLEXPEN...43NOVOLIN 70/30 FLEXPEN RELION................................. 43NOVOLIN 70/30 RELION...... 43NOVOLIN 70/30 VIAL............43NOVOLIN N RELION............ 43NOVOLIN N VIAL.................. 43NOVOLIN R FLEXPEN......... 43NOVOLIN R FLEXPEN RELION................................. 43NOVOLIN R RELION............ 43NOVOLIN R VIAL.................. 43NOVOLOG FLEXPEN........... 43NOVOLOG MIX 70/30 FLEXPEN.............................. 43NOVOLOG MIX 70/30 VIAL.. 43NOVOLOG PENFILL.............43NOVOLOG U-100 VIAL.........43NOXAFIL............................... 19np thyroid...............................54NUCALA................................ 64NUCYNTA............................... 8NUEDEXTA........................... 35nulev...................................... 48NUPLAZID.............................23NUTROPIN AQ NUSPIN 10.. 53NUTROPIN AQ NUSPIN 20.. 53NUTROPIN AQ NUSPIN 5.... 53nyamyc.................................. 19nystatin.................................. 19nystatin-triamcinolone............19nystop.................................... 19octreotide acetate.................. 53ODACTRA............................. 59ODEFSEY............................. 25OFEV.....................................66ofloxacin.................... 13, 60, 63okebo.....................................13olanzapine............................. 23olanzapine-fluoxetine hcl....... 17olmesartan medoxomil.......... 31olmesartan medoxomil-hctz...31olmesartan-amlodipine-hctz.. 31olopatadine hcl................ 60, 64OLUMIANT............................ 56omega-3-acid ethyl esters..... 31
omeprazole............................46omeprazole-sodium bicarbonate............................46ondansetron hcl..................... 18ondansetron odt.....................18ONETOUCH ULTRA BLUE TEST STRIPS....................... 42ONETOUCH VERIO KIT W/DEVICE.............................42ONEXTON.............................40ONGLYZA............................. 42ONZETRA XSAIL.................. 20OPSUMIT.............................. 67ORACIT................................. 45ORALAIR...............................59ORALAIR ADULT SAMPLE KIT......................................... 59ORALAIR ADULT STARTER PACK................... 59ORALAIR CHILDRENS STARTER PACK................... 59oralone...................................36ORENCIA.............................. 56ORENCIA CLICKJECT..........56ORENITRAM......................... 67ORFADIN.............................. 49ORILISSA.............................. 53ORKAMBI.............................. 67orphenadrine citrate er.......... 68orphenadrine-aspirin-caffeine.................................. 68oscimin.................................. 48oseltamivir phosphate............25OSMOPREP..........................48OSPHENA............................. 52OTEZLA.................................57OVIDREL...............................53oxandrolone...........................52oxaprozin............................... 10oxazepam.............................. 27oxcarbazepine....................... 15OXERVATE........................... 62oxiconazole nitrate.................19OXTELLAR XR......................15oxybutynin chloride................50oxybutynin chloride er............50OXYCODONE HCL................. 8oxycodone hcl..........................8oxycodone-acetaminophen..... 8oxycodone-aspirin................... 9
oxycodone-ibuprofen............... 9OXYCONTIN........................... 9oxymorphone hcl..................... 9oxymorphone hcl er................. 9OZEMPIC.............................. 42pacerone................................31paliperidone er.......................23PALYNZIQ.............................49PANCREAZE.........................49PANRETIN............................ 21pantoprazole sodium............. 46paricalcitol..............................58paroex....................................36paromomycin sulfate............. 13paroxetine hcl........................ 17paroxetine hcl er.................... 17paroxetine mesylate.............. 17PASER.................................. 20peg 3350-kcl-na bicarb-nacl.. 48peg-3350/electrolytes............ 48PEGANONE.......................... 15PEGASYS............................. 25PEGASYS PROCLICK.......... 25PEGINTRON......................... 25peg-prep................................ 48penicillamine..........................50penicillin v potassium.............13pentamidine isethionate.........22PENTASA..............................58pentazocine-naloxone hcl........9pentoxifylline er......................31PERFOROMIST.................... 66perindopril erbumine..............31periogard............................... 36permethrin............................. 22perphenazine.........................18perphenazine-amitriptyline.... 17PERTZYE.............................. 49phenadoz...............................64phenazo.................................50phenazopyridine hcl...............50phendimetrazine tartrate........35phendimetrazine tartrate er... 35phenelzine sulfate..................17phenobarbital.........................15phenobarbital-belladonna alk 48phenoxybenzamine hcl..........31phentermine hcl..................... 35phenylephrine hcl.................. 62phenytoin............................... 15
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phenytoin infatabs................. 15phenytoin sodium extended...15PHOSLYRA........................... 50PHOSPHOLINE IODIDE....... 61phosphorous..........................45phytonadione......................... 45PICATO................................. 40PIFELTRO............................. 25pilocarpine hcl..................36, 61pimecrolimus......................... 40pimozide................................ 23pindolol.................................. 31pioglitazone hcl......................42pioglitazone hcl-glimepiride... 42pioglitazone hcl-metformin hcl.......................................... 42piroxicam............................... 10PLEGRIDY............................ 34PLEGRIDY STARTER PACK.....................................34PLENVU................................ 48pnv prenatal plus multivit+dha........................... 45pocket spacer........................ 59podofilox................................ 40polycin................................... 62polymyxin b-trimethoprim...... 62posaconazole........................ 19pot bicarb-pot chloride........... 45potassium chloride.................45potassium chloride crys er.....45potassium chloride er............ 45potassium citrate er............... 45POVIDONE-IODINE.............. 60PRALUENT........................... 31pramipexole dihydrochloride..22pramipexole dihydrochloride er........................................... 22PRAMOTIC............................63prasugrel hcl.......................... 23pravastatin sodium................ 31praziquantel........................... 22prazosin hcl........................... 31PRED MILD........................... 60PRED-G.................................62PRED-G S.O.P...................... 62prednicarbate.........................40prednisolone.......................... 51prednisolone acetate............. 60
prednisolone sodium phosphate........................51, 60prednisone.............................51prednisone intensol............... 51PREFEST.............................. 54pregabalin..............................35pregnyl...................................53PREMARIN............................54PREMPHASE........................ 54PREMPRO............................ 54prenatal..................................46prenatal plus iron................... 46PREPOPIK............................ 48PRESTALIA...........................31PRETOMANID.......................20prevalite................................. 31PREVIDENT.......................... 36prevident................................36PREVIDENT 5000 BOOSTER PLUS...................36PREVIDENT 5000 DRY MOUTH................................. 36PREVIDENT 5000 ENAMEL PROTECT............................. 36PREVIDENT 5000 ORTHO DEFENSE..............................36PREVIDENT 5000 PLUS.......36PREVIDENT 5000 SENSITIVE............................36PREVYMIS............................ 25PREZCOBIX..........................25PREZISTA............................. 25PRIFTIN.................................20PRILOSEC............................ 47primaquine phosphate........... 22primidone...............................15PROAIR HFA.........................66PROAIR RESPICLICK.......... 66probenecid.............................19prochlorperazine....................18prochlorperazine maleate...... 18PROCTOFOAM HC...............58procto-med hc........................58procto-pak..............................58proctosol hc........................... 58proctozone-hc........................58progesterone......................... 54progesterone micronized....... 54PROGLYCEM........................42PROGRAF.............................57
PROMACTA.......................... 27promethazine hcl................... 64promethazine-codeine........... 64promethazine-dm...................64promethazine-phenyleph-codeine.................................. 64promethazine-phenylephrine.64promethegan......................... 64PROMISEB............................40propafenone hcl.....................32propafenone hcl er.................32propantheline bromide...........48proparacaine hcl.................... 62propranolol hcl....................... 32propranolol hcl er...................32propranolol-hctz.....................32propylthiouracil...................... 54protriptyline hcl...................... 17PROVENTIL HFA.................. 66pseudoephedrine-bromphen-dm........................ 64PULMICORT FLEXHALER... 66pulmosal................................ 64PULMOZYME........................67PURIXAN...............................21pyrazinamide......................... 20pyridostigmine bromide......... 20pyridostigmine bromide er..... 20pyrimethamine....................... 22PYROGALLIC ACID.............. 40QBREXZA............................. 40QTERN.................................. 42quetiapine fumarate...............23quetiapine fumarate er...........23QUILLIVANT XR....................34quinapril hcl........................... 32quinapril-hydrochlorothiazide.32quinidine gluconate er........... 32quinidine sulfate.....................32quinine sulfate....................... 22QVAR REDIHALER...............66rabeprazole sodium............... 47RADIOGARDASE..................59RAGWITEK........................... 59raloxifene hcl......................... 52ramelteon...............................68ramipril ...................................32ranitidine hcl.......................... 47ranolazine er..........................32rasagiline mesylate................22
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RAVICTI................................ 49RAYALDEE........................... 58REBIF.................................... 34REBIF REBIDOSE................ 34REBIF REBIDOSE TITRATION PACK.................34REBIF TITRATION PACK..... 35RECTIV................................. 32REGRANEX.......................... 40RELENZA DISKHALER.........25RELNATE DHA..................... 46REMESENSE........................ 36repaglinide............................. 42REPATHA..............................32REPATHA PUSHTRONEX SYSTEM................................32REPATHA SURECLICK........ 32RESTASIS.............................62RESTASIS MULTIDOSE.......62RESTORA RX....................... 48REYATAZ.............................. 25RHOPRESSA........................ 61ribavirin.................................. 25RIDAURA.............................. 57rifabutin..................................20RIFAMATE............................ 20rifampin..................................20RIFATER............................... 21riluzole................................... 35rimantadine hcl...................... 25RINVOQ................................ 57risedronate sodium................ 58risperidone.............................23ritonavir..................................25rivastigmine........................... 16rivastigmine tartrate............... 16rizatriptan benzoate............... 20ROCKLATAN.........................61ropinirole hcl.......................... 22ropinirole hcl er...................... 22rosadan..................................40rosuvastatin calcium.............. 32roweepra................................15roweepra xr............................15RUZURGI.............................. 59RYBELSUS........................... 42RYTARY................................ 22SACCHARIN......................... 59SAMSCA............................... 46SANDIMMUNE...................... 57
SANTYL.................................40SAVELLA...............................35SAVELLA TITRATION PACK.....................................35scopolamine.......................... 18SECONAL............................. 68SEEBRI NEOHALER.............66selegiline hcl.......................... 22selenium sulfide.....................40SELZENTRY......................... 25SEREVENT DISKUS.............66sertraline hcl.......................... 17sevelamer carbonate............. 50sevelamer hcl........................ 50sf............................................36sf 5000 plus........................... 36SIGNIFOR............................. 53sildenafil citrate................50, 67SILIQ..................................... 57silodosin.................................51silver sulfadiazine.................. 13SIMBRINZA........................... 61SIMPONI............................... 57simvastatin.............................32sirolimus................................ 57SIRTURO.............................. 21SITAVIG................................ 26SKLICE..................................22SKYRIZI (150 MG DOSE)..... 57sod citrate-citric acid..............46SODIUM ASCORBATE......... 46sodium bicarbonate............... 48sodium chloride..................... 64sodium fluoride...................... 36sodium fluoride 5000 plus......36sodium fluoride 5000 ppm..... 36sodium phenylbutyrate.......... 49sodium polystyrene sulfonate................................ 46sodium saccharin...................59SOFOSBUVIR-VELPATASVIR...................... 26solifenacin succinate............. 50SOLIQUA...............................42SOLTAMOX...........................21sorine.....................................32sotalol hcl...............................32sotalol hcl (af)........................ 32SOTYLIZE............................. 32spinosad................................ 22
SPIRIVA HANDIHALER........ 66SPIRIVA RESPIMAT............. 66spironolactone....................... 32spironolactone-hctz............... 32sps......................................... 46ssd......................................... 13stavudine............................... 26STELARA.............................. 57STIMATE............................... 53STIOLTO RESPIMAT............66STRENSIQ............................ 49STRIANT............................... 52STRIBILD.............................. 26STRIVERDI RESPIMAT........ 66SUBSYS.................................. 9subvenite............................... 15subvenite starter kit-blue....... 15subvenite starter kit-green..... 15subvenite starter kit-orange... 15SUCRAID.............................. 49sucralfate............................... 47sulfacetamide sodium............60sulfacetamide sodium (acne).40sulfacetamide-prednisolone...62sulfadiazine............................13sulfamethoxazole-trimethoprim...........................13sulfasalazine..........................58sulfatrim pediatric.................. 13sulfurated lime....................... 22sulindac................................. 10sumatriptan............................20sumatriptan succinate............20sumatriptan succinate refill .... 20SUPRAX................................13SUPREP BOWEL PREP KIT 48SYMBICORT......................... 66SYMDEKO.............................67SYMFI....................................26SYMFI LO..............................26SYMJEPI............................... 66SYMLINPEN 120...................42SYMLINPEN 60.....................42SYMPROIC........................... 48SYMTUZA............................. 26SYNAREL..............................53SYNJARDY........................... 42SYNJARDY XR..................... 42SYNTHROID......................... 54TACLONEX........................... 40
79
tacrolimus........................ 40, 57tadalafil .................................. 50tadalafil (pah).........................67TAKHZYRO........................... 57TALTZ....................................57tamoxifen citrate.................... 21tamsulosin hcl........................51TARGRETIN..........................21TAURINE...............................46TAVALISSE........................... 27tazarotene..............................40TAZORAC............................. 40taztia xt.................................. 32TECFIDERA.......................... 35TEGSEDI...............................35TEKTURNA HCT...................32telmisartan............................. 32telmisartan-amlodipine.......... 32telmisartan-hctz..................... 32temazepam............................68TEMIXYS...............................26tencon......................................9tenofovir disoproxil fumarate. 26terazosin hcl.......................... 51terbinafine hcl........................ 19terbutaline sulfate.................. 66terconazole............................ 19testosterone...........................52testosterone cypionate.......... 52testosterone enanthate..........52tetrabenazine.........................35tetracycline hcl.......................13TEXACORT........................... 40THEO-24............................... 66theophylline........................... 66theophylline er....................... 66THIOLA..................................50THIOLA EC............................50thioridazine hcl.......................23thiothixene............................. 23THREONINE......................... 46thyroid....................................55tiadylt er................................. 32tiagabine hcl.......................... 15timolol maleate................ 32, 61TIMOPTIC OCUDOSE.......... 61tinidazole............................... 13TIROSINT..............................55TIROSINT-SOL..................... 55TIVICAY.................................26
tizanidine hcl..........................68TOBI PODHALER................. 67TOBRADEX...........................62TOBRADEX ST..................... 63tobramycin....................... 60, 67TOBRAMYCIN.......................67tobramycin-dexamethasone.. 63TOBREX................................60TOLAK...................................40tolbutamide............................ 42tolcapone............................... 22tolmetin sodium..................... 10TOLNAFTATE....................... 19tolterodine tartrate................. 50tolterodine tartrate er............. 50TOPEX TOPICAL ANESTHETIC........................36topiramate..............................15topiramate er......................... 15torsemide...............................32TOUJEO MAX SOLOSTAR...43TOUJEO SOLOSTAR........... 43tovet.......................................40TOVIAZ..................................50TRACLEER........................... 67tramadol hcl er.........................9tramadol hcl er (biphasic)........ 9tramadol hcl ir.......................... 9tramadol-acetaminophen.........9trandolapril .............................32trandolapril-verapamil hcl er.. 32tranexamic acid..................... 27tranylcypromine sulfate..........17travoprost (bak free).............. 61trazodone hcl......................... 17TRECATOR...........................21TRELEGY ELLIPTA.............. 66TREMFYA............................. 57TRESIBA............................... 43TRESIBA FLEXTOUCH........ 43tretinoin..................................40tretinoin microsphere............. 40tretinoin microsphere pump... 40TREXALL...............................57triamcinolone acetonide...36, 41triamterene............................ 32triamterene-hctz.....................33trianex....................................41triazolam................................ 27triderm................................... 41
trientine hcl............................ 46trifluoperazine hcl.................. 23trifluridine............................... 60trihexyphenidyl hcl................. 22TRIKAFTA............................. 67trilyte...................................... 48trimethobenzamide hcl.......... 18trimethoprim...........................13trimipramine maleate............. 17trinate.....................................46TRINTELLIX.......................... 17TRIUMEQ.............................. 26trivix....................................... 41TROKENDI XR...................... 15trospium chloride................... 50trospium chloride er............... 50TRULICITY............................ 42TRUVADA............................. 26TUDORZA PRESSAIR.......... 66TYBOST................................ 26TYMLOS................................58TYVASO................................ 67TYVASO REFILL...................67TYVASO STARTER.............. 67UBRELVY..............................20UCERIS................................. 58ULESFIA................................22unithroid.................................55UPTRAVI............................... 68uretron d/s............................. 50urin ds....................................50ursodiol.................................. 48UTIBRON NEOHALER..........66utrona-c................................. 50valacyclovir hcl...................... 26valganciclovir hcl................... 26VALINE..................................46valproic acid...........................15valsartan................................ 33valsartan-hydrochlorothiazide............... 33vancomycin hcl...................... 13vandazole.............................. 13vardenafil hcl......................... 50VARIZIG................................ 57VASCEPA..............................33VECAMYL............................. 33VELPHORO...........................50VELTASSA............................ 46VEMLIDY...............................26
80
VENELEX.............................. 41venlafaxine hcl.......................17venlafaxine hcl er...................17VENTAVIS.............................68VENTOLIN HFA.................... 67verapamil hcl......................... 33verapamil hcl er..................... 33VERSACLOZ.........................23VIBERZI.................................48VIBRAMYCIN........................ 13vicodin hp................................ 9VICTOZA............................... 42vigabatrin............................... 16vigadrone...............................16VIMPAT................................. 16VIOKACE...............................49VIRACEPT.............................26VIREAD................................. 26virt-phos 250 neutral..............46virtussin ac w/alc................... 64VISTOGARD......................... 59voriconazole.......................... 19VOSEVI................................. 26vp-pnv-dha.............................46VTOL LQ................................. 9VYNDAMAX.......................... 33VYNDAQEL........................... 33VYVANSE..............................34warfarin sodium..................... 14WESTHROID.........................55wixela inhub...........................67WP THYROID........................55XARELTO..............................14XARELTO STARTER PACK. 14XELJANZ...............................57XELJANZ XR.........................57XELPROS..............................61XENLETA.............................. 13XEPI...................................... 13XERMELO............................. 48XIFAXAN............................... 13XIGDUO XR.......................... 42XIIDRA...................................63XOFLUZA (40 MG DOSE).....26XOFLUZA (80 MG DOSE).....26XOPENEX HFA..................... 67XULTOPHY........................... 42XURIDEN.............................. 49XYREM..................................68YUPELRI............................... 67
yuvafem................................. 54zafirlukast.............................. 67zaleplon................................. 68ZELAPAR.............................. 22zenatane................................41ZENPEP................................ 49ZENZEDI............................... 34zidovudine............................. 26zileuton er.............................. 67ziprasidone hcl.......................23ZIRGAN................................. 60zolmitriptan............................ 20zolpidem tartrate....................68zolpidem tartrate er................68ZOMIG...................................20zonisamide............................ 16ZONTIVITY............................23ZORTRESS........................... 57ZORVOLEX........................... 10ZUBSOLV..............................11ZYCLARA.............................. 41ZYCLARA PUMP...................41ZYLET................................... 63
81
Non-discrimination notice
Sanford Health Plan does not discriminate against any future, current, or past Member on the basis of race; ethnicity; color; national origin; disability; sex; gender; sexual orientation; gender identity; religion; spiritual beliefs; medical condition, including a current or past history of mental health and substance use disorders; sources of payment for care; or age, in its coverage, treatment, or benefit decisions.
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formats)
Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, contact our Civil Rights Coordinator, 300 Cherapa Place #201, Sioux Falls, SD 57103, (800) 752-5863, TTY/TDD (877) 652-1844, fax (605) 328-6812, [email protected].
If you believe that Sanford Health Plan has failed to provide these services or discriminated in any way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator (contact information listed above.) You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the US Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: US Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, (800) 368-1019, TTY/TDD (800) 537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
For help in a language other than English, please call toll-free (800) 892-0675. Free oral and written translation services are available in at least 150 languages. If you have any questions, for example, about your benefits, this document, or how Sanford Health Plan pays for your care, please call us.
ế ạ ế ệ ị ụ ỗ ợ ữ ễ ạ
ọ ố
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電
This Notice has Important Information. This notice
has important information about your application or
coverage through Sanford Health Plan. Look for key
dates in this notice. You may need to take action by certain
deadlines to keep your health coverage or help with costs.
You have the right to get this information and help in your
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Este Aviso contiene información importante. Este
aviso contiene información importante acerca de su
solicitud o cobertura a través de Sanford Health Plan.
Preste atención a las fechas clave que contiene este aviso.
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Llame al 1-800-892-0675.
Hmong
Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem
ceeb. Tsab ntawv tshaj xo no muaj cov ntsiab lus tseem
ceeb txog koj daim ntawv thov kev pab los yog koj qhov
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caij nyoog los yog tej hnub tseem ceeb uas sau rau hauv
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hom lus pub dawb rau koj. Hu rau 1-800-892-
0675.
Cushite
Beeksisni kun odeeffannoo
barbaachisaa qaba. Beeksisti kun
sagantaa yookan karaa Sanford Health
Plan tiin tajaajila keessan ilaalchisee
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ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር
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HP-1186 Combined Use 6-2018