Medicaid List of Covered Drugs (Formulary) 2019Medicaid List of Covered Drugs (Formulary) 2019 UCare Connect (SNBC) Families and Children (Prepaid Medical Assistance Program (PMAP))

UCare, 500 Stinson Blvd, Minneapolis, MN 55413

UCare Customer Service: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit ucare.org.

Medicaid List of Covered Drugs (Formulary) 2019

UCare Connect (SNBC) Families and Children (Prepaid Medical Assistance Program (PMAP))

MinnesotaCare Minnesota Senior Care Plus (MSC Plus)

DHS Approved Date 10/04/2019

UCare Connect counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Faribault, Fillmore, Hennepin, Houston, Isanti, Itasca, Jackson, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Washington, Watonwan, Wilkin, Winona, Wright and Yellow Medicine.

Families and Children (PMAP) counties: Anoka, Blue Earth, Carver, Chippewa, Cottonwood, Dakota, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, Martin, Mower, Murray, Nicollet, Nobles, Olmsted, Ramsey, Redwood, Rice, Rock, St. Louis, Scott, Sibley, Swift, Washington, Watonwan, Winona, Wright, Yellow Medicine.

MinnesotaCare counties: Anoka, Big Stone, Blue Earth, Carver, Chippewa, Cottonwood, Dakota,

Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Isanti, Jackson, Kanabec, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, McLeod, Martin, Meeker, Morrison, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Ramsey, Redwood, Renville, Rice, Rock, St. Louis, Scott, Sibley, Steele, Stevens, Swift, Todd, Traverse, Wadena, Waseca, Washington, Watonwan, Winona, Wright, Yellow Medicine.

Minnesota Senior Care Plus counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Todd, Wabasha, Wadena, Washington, Watonwan, Winona, Wright, Yellow Medicine.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. MEMBERS MUST USE NETWORK

PHARMACIES TO RECEIVE PRESCRIPTION DRUG BENEFITS.

This list is subject to change and is not all-inclusive. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. Note to existing members: This list of covered drugs has changed since last year. Please review this document to make sure that it still has the drugs you take. Please contact UCare Customer Service with questions: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit ucare.org.

Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services.

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your heath plan Primary Care Provider (PCP) prior to the referral.

Table of Contents

What is a List of Covered Drugs? .......................................................................................... ii

Does the List of Covered Drugs ever change? .................................................................... ii

How are drugs listed in the List of Covered Drugs? ........................................................... ii

What is a Preferred Drug List? .............................................................................................. ii

What are generic or biosimilar drugs? .................................................................................iii

What are over-the-counter (OTC) drugs? ............................................................................iii

What if a drug is not on the list of covered drugs? ............................................................iv

Are there any restrictions on my coverage? ......................................................................iv

Can I request an exception to the coverage restrictions? ................................................. v

What will a prescription cost? ............................................................................................... v

Drug List (formulary) Key ...................................................................................................... v

Drug List ................................................................................................................................. 1

Drug Index ..........................................................................................................................119

Over-the-counter ...............................................................................................................139

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What is a List of Covered Drugs?A list of covered drugs includes the prescription drugs covered by UCare.The drugs on the list are selected by UCare with the help of a team of doctors and pharmacists. UCare will generally cover the drugs listed in the list of covered drugs as long as the drug is medically necessary, the prescription is filled at a UCare network pharmacy and other requirements related to the drug are followed.

Does the List of Covered Drugs ever change?The UCare list of covered drugs can change during the course of a calendar year. If changes occur which will impact the coverage of a medication you are taking, UCare will make reasonable efforts to contact you and your prescriber to inform you and your prescriber about the change and possible alternative medications which will be covered.

Examples of some changes that may occur are:

• A drug you are taking is no longer preferred.

• A drug is removed from the list of covered drugs due to safety reasons.

• Changes in prior authorization requirements.

How are drugs listed in the List of Covered Drugs?There are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing.

Search by Medical ConditionDrugs listed by medical condition begin on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page 1. Then look under the category name for your drug.

Search by Alphabetical ListingIf you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary.

What is a Preferred Drug List?In Minnesota, all managed care organizations are required to follow the Department of Human Services’ Preferred Drug List (PDL). The PDL is created by the Department of Human Services, in consultation with the Drug Formulary Committee, to let prescribers and members know about drugs or drug classes that are more or less cost effective. Generally, drugs that are listed on the PDL as preferred are more cost effective; and drugs that are listed as non-preferred on PDL are less cost effective. Preferred drugs are available to members with fewer restrictions. Non-preferred drugs will require a prior authorization. To receive a non-preferred drug, your doctor or health care provider must get prior authorization.

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The Preferred Drug List is a portion of UCare’s list of covered drugs. UCare’s list of covered drugs is a complete list of all covered drugs. The Preferred Drug List is available on the department’s website: Minnesota Fee-for-Service Medicaid Preferred Drug List (mn.gov/dhs/mhcp/ffs-preferred-drug-list).

What are generic or biosimilar drugs?A generic drug is approved by the Food and Drug Administration (FDA) and has the same active ingredient as the brand-name drug and produces the same clinical effect as the brand-name drug.

A biosimilar drug is an FDA-approved biologic drug (most often an injectable prescription drug) that is highly similar to and has no clinically meaningful differences in terms of safety and effectiveness from an already-approved biological product. Biosimilar drugs are not the same as generic drugs, but like generics, biosimilar drugs may offer more affordable treatment options for you.

Generic or biosimilar substitution means a generic version or biosimilar version of a drug is given instead of the brand-name or non-biosimilar version of the drug.

UCare will cover the brand name or non-biosimilar version of the drug only when:

1. Your prescriber informs UCare in writing that the brand name or non-biosimilar version of the drug is medically necessary; OR

2. UCare may prefer the dispensing of the brand-name version over the generic version or non-biosimilar version over the biosimilar version of the drug; OR

3. Minnesota Law requires the dispensing of the brand-name or non-biosimilar version of the drug.

Within the list of covered drugs, brand-name drugs are capitalized (e.g. EPIPEN) and generic drugs are listed in lower-case italics (e.g. maprotiline tablet).

What are over-the-counter (OTC) drugs?Drugs and products that are available for purchase without a prescription are referred to as over-the-counter (OTC). Although an OTC product is available without a prescription, if a doctor writes a prescription for an OTC product, UCare may cover it.

What are specialty drugs?Specialty drugs are used by people with complex or chronic diseases. These drugs often require special handling, dispensing, or monitoring by a specially-trained pharmacist.

If you are prescribed a drug that is on the UCare Specialty Drug List, your prescriber will need to send the prescription of that specialty drug to UCare’s Specialty Pharmacy.

Name of Specialty Pharmacy: Fairview Specialty Pharmacy

Phone and TTY: 612-672-5260 or 1-800-595-7140 (toll free) TTY call the National Relay Center at 711 and ask for 1-800-595-7140.

Fax: 1-866-347-4939

Hours of Operation: 24 hours a day, seven days a week

www.fairviewspecialtyrx.org

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You will also need to call the Specialty Pharmacy at 612-672-5260 or 1-800-595-7140 toll free to set up an account. You will need to have your UCare Member Identification (ID) card when you call the Specialty Pharmacy.

What if a drug is not on the list of covered drugs?Not all drugs are covered. If a drug is not listed in the list of covered drugs, you should contact UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free and ask if the drug is covered. If not, it is considered a non-formulary drug. If you need a drug that is not included in the list of covered drugs,

• You can ask your health care provider if there is another covered drug that will work for you.

• You and/or your health care provider can ask UCare to make an “exception” and cover the drug for you or remove the restrictions or limits. If your exception request is approved, the drug will be covered at the appropriate generic or brand name copay level.

Generally, UCare will only approve your health care provider’s request for a formulary exception if the alternative drug included on UCare’s list of covered drugs would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If your healthcare provider prescribes a drug that is not on our list of covered drugs or a drug that requires prior authorization, your provider should call Express Scripts or visit our provider website to complete a request form. Members may also find more information on ucare.org. Please call UCare Customer Service at the number listed on the front cover for help.

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

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

• Quantity Limits: For certain drugs, UCare limits the amount of the drug that UCare will cover.

• Age requirements: In some cases, there are age requirements for you to try certain drugs. A prior authorization is needed depending on your age and the specific drug prescribed.

You can find out if your drug requires prior authorization, has quantity limits, or has an age requirement by looking in this list of covered drugs. A drug restriction or limit can be removed if your doctor submits a statement or documentation supporting the request. Refer to your Member Handbook for more information. You can also get more information about the restrictions applied to specific covered drugs by contacting UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free or by visiting our website at ucare.org.

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• Excluded Drugs: Some drugs are excluded from the list of covered drugs. Excluded drugs include the following:

- Drugs used to treat sexual or erectile dysfunction

- Drugs used to enhance fertility

- Drugs used for cosmetic purposes, including drugs to treat hair loss

- Drugs or products to promote weight loss

- Drugs not clinically proven to be effective

- Investigational or experimental drugs

- Medical cannabis

Can I request an exception to the coverage restrictions?Yes. Your healthcare provider can obtain the Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions from ucare.org or by contacting, UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Your provider must return this form to the fax number or address listed on the document. To facilitate a thorough review and to ensure that your healthcare provider receives a response within 24 hours, UCare asks that all information requested in the form be provided, including documentation of which medications have been tried and failed, including the dosages used, and the identified reason for failure (e.g. side effects).

What will a prescription cost?All copay information for prescriptions is listed in the Member Handbook. If you have additional questions, contact UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free or by visiting our website at ucare.org.

Drug List (formulary) Key

Explanation of Coverage Status

P Preferred Drug Preferred drugs are covered without Prior Authorization

NP Non-Preferred Drug Non-preferred drugs require Prior Authorization from UCare

AD Additional Drugs Additional drugs covered by UCare

Explanation of Requirements

PA Prior Authorization Drugs that require approval from UCare before you fill your prescription

QL Quantity Limit There are limits to the quantity of the drug covered per month

SP Specialty Drug Specialty drugs are used for complex conditions and require Fairview Specialty Pharmacy to fill your prescription.

Drug Tier Limits or RestrictionsANTIHISTAMINE DRUGSALL DAY ALLERGY (CETIRIZINE) ORAL TABLET P

ALL DAY ALLERGY-D ORAL PALLERGY AND CONGESTION RELIEF ORAL PALLERGY COMPLETE-D ORAL PALLERGY RELIEF (LORATADINE) ORAL PALLERGY RELIEF D-24HR ORAL PALLERGY RELIEF,NASAL DECONGEST ORAL PALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR P

ALLER-TEC ORAL Pcarbinoxamine maleate oral liquid ADcarbinoxamine maleate oral tablet 4 mg ADcetirizine oral solution 1 mg/ml Pcetirizine oral tablet Pcetirizine oral tablet,chewable Pcetirizine-pseudoephedrine oral PCHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION P

CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE P

CHILD'S ALL DAY ALLERGY(CETIR) ORAL PCLARINEX ORAL SYRUP NP PACLARINEX ORAL TABLET NP PACLARINEX-D 12 HOUR ORAL NP PAclemastine oral tablet 2.68 mg ADcyproheptadine oral ADdesloratadine oral NP PAdimenhydrinate injection solution ADdiphenhydramine hcl injection solution 50 mg/ml AD

diphenhydramine hcl injection syringe ADhydroxyzine hcl intramuscular ADhydroxyzine hcl oral solution 10 mg/5 ml ADhydroxyzine hcl oral tablet ADhydroxyzine pamoate oral ADlevocetirizine oral PLORATA-DINE D ORAL P

UCare Comprehensive FormularyEffective: November 1, 2019

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Drug Tier Limits or Restrictionsloratadine oral solution Ploratadine oral tablet PLORATADINE-D ORAL Pmeclizine oral tablet 12.5 mg, 25 mg ADmeclizine oral tablet,chewable ADNON-DROWSY ALLERGY ORAL Ppromethazine injection solution ADpromethazine oral ADpromethazine rectal suppository 12.5 mg, 25 mg AD

SEMPREX-D ORAL NP PAWAL-ZYR (CETIRIZINE) ORAL TABLET PANTI-INFECTIVE AGENTSabacavir oral ADabacavir-lamivudine oral ADabacavir-lamivudine-zidovudine oral ADacyclovir oral capsule Pacyclovir oral suspension 200 mg/5 ml Pacyclovir oral tablet Pacyclovir sodium intravenous ADadefovir oral P SPAEMCOLO ORAL ADalbendazole oral ADamantadine hcl oral ADamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml AD

amoxicillin oral capsule ADamoxicillin oral suspension for reconstitution AD

amoxicillin oral tablet ADamoxicillin oral tablet,chewable 125 mg, 250 mg AD

amoxicillin-pot clavulanate oral suspension for reconstitution P

amoxicillin-pot clavulanate oral tablet Pamoxicillin-pot clavulanate oral tablet extended release 12 hr NP PA

amoxicillin-pot clavulanate oral tablet,chewable NP PA


Drug Tier Limits or Restrictionsamphotericin b injection ADampicillin oral capsule ADampicillin sodium injection ADampicillin sodium intravenous ADampicillin-sulbactam injection ADampicillin-sulbactam intravenous ADANCOBON ORAL NP PAAPTIVUS ORAL ADARIKAYCE INHALATION AD PA; SPatazanavir oral ADatovaquone oral ADatovaquone-proguanil oral ADATRIPLA ORAL ADAUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

NP PA

AUGMENTIN XR ORAL NP PAAVELOX ORAL NP PAazithromycin intravenous ADazithromycin oral PAZULFIDINE EN-TABS ORAL NP PAAZULFIDINE ORAL NP PABACIIM INTRAMUSCULAR ADbacitracin intramuscular ADBARACLUDE ORAL P SPBAXDELA ORAL NP PABENZNIDAZOLE ORAL AD SPBETHKIS INHALATION P SPBIKTARVY ORAL ADCAYSTON INHALATION NP SP; PA; QL (84 per 30 days)cefaclor oral capsule Pcefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml P

cefaclor oral tablet extended release 12 hr NP PAcefadroxil oral capsule Pcefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml P

cefadroxil oral tablet NP PA


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Drug Tier Limits or Restrictionscefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml AD

cefazolin injection ADcefazolin intravenous ADcefdinir oral Pcefditoren pivoxil oral tablet 200 mg ADcefepime in dextrose,iso-osm intravenous ADcefepime injection ADcefixime oral NP PAcefotaxime injection recon soln 1 gram ADcefotetan injection ADcefotetan intravenous ADcefoxitin in dextrose, iso-osm intravenous ADcefoxitin intravenous ADcefpodoxime oral NP PAcefprozil oral Pceftazidime injection ADceftriaxone in dextrose,iso-os intravenous ADceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg AD

ceftriaxone intravenous ADcefuroxime axetil oral tablet Pcefuroxime sodium injection recon soln 750 mg AD

cefuroxime sodium intravenous ADcephalexin oral capsule Pcephalexin oral suspension for reconstitution P

cephalexin oral tablet ADchloramphenicol sod succinate intravenous ADchloroquine phosphate oral ADCIMDUO ORAL ADCIPRO ORAL SUSPENSION,MICROCAPSULE RECON NP PA

CIPRO ORAL TABLET 250 MG, 500 MG NP PACIPRO XR ORAL NP PAciprofloxacin (mixture) oral NP PAciprofloxacin hcl oral Pciprofloxacin in 5 % dextrose intravenous AD


Drug Tier Limits or Restrictionsciprofloxacin oral NP PAclarithromycin oral suspension for reconstitution NP PA

clarithromycin oral tablet Pclarithromycin oral tablet extended release 24 hr NP PA

clindamycin hcl oral capsule 150 mg, 300 mg AD

clindamycin palmitate hcl oral ADCLINDAMYCIN PEDIATRIC ORAL ADclindamycin phosphate injection ADclindamycin phosphate intravenous ADCOARTEM ORAL ADcolistin (colistimethate na) injection ADCOMBIVIR ORAL NP PACOMPLERA ORAL ADCRESEMBA ORAL NP PACRIXIVAN ORAL CAPSULE 200 MG, 400 MG ADDAKLINZA ORAL NP PA; SPdapsone oral ADdaptomycin intravenous recon soln 500 mg ADDARAPRIM ORAL AD PADAXBIA ORAL NP PADELSTRIGO ORAL ADDESCOVY ORAL ADdicloxacillin oral ADdidanosine oral ADDIFLUCAN ORAL NP PADOVATO ORAL ADdoxycycline hyclate oral capsule ADdoxycycline hyclate oral tablet 100 mg ADdoxycycline monohydrate oral capsule 100 mg, 50 mg AD

E.E.S. 400 ORAL TABLET PE.E.S. GRANULES ORAL NP PAEDURANT ORAL ADefavirenz oral capsule ADEMTRIVA ORAL ADentecavir oral P SPUCare Comprehensive FormularyEffective: November 1, 2019

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Drug Tier Limits or RestrictionsEPCLUSA ORAL NP PA; SPEPIVIR HBV ORAL PEPIVIR ORAL Pertapenem injection ADERYPED 200 ORAL NP PAERYPED 400 ORAL NP PAERY-TAB ORAL NP PAERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG NP PA

erythromycin ethylsuccinate oral suspension for reconstitution NP PA

erythromycin ethylsuccinate oral tablet NP PAerythromycin oral capsule,delayed release(dr/ec) P

erythromycin oral tablet NP PAethambutol oral ADEVOTAZ ORAL ADfamciclovir oral tablet 125 mg, 500 mg NP PA; QL (21 per 30 days)famciclovir oral tablet 250 mg NP PA; QL (60 per 30 days)fluconazole in dextrose(iso-o) intravenous ADfluconazole in nacl (iso-osm) intravenous ADfluconazole oral suspension for reconstitution P

fluconazole oral tablet 100 mg, 200 mg, 50 mg P

fluconazole oral tablet 150 mg P QL (2 Max Qty Per Fill Retail)flucytosine oral NP PAfosamprenavir oral ADFUZEON SUBCUTANEOUS RECON SOLN AD SPgentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

AD

gentamicin injection ADgentamicin sulfate (ped) (pf) injection ADgentamicin sulfate (pf) intravenous solution 100 mg/10 ml AD

GENVOYA ORAL ADGOCOVRI ORAL NP PAgriseofulvin microsize oral NP PA


Drug Tier Limits or Restrictionsgriseofulvin ultramicrosize oral NP PAGRIS-PEG (ULTRAMICROSIZE) ORAL NP PAHARVONI ORAL TABLET 90-400 MG NP PA; SPHEPSERA ORAL P SPhydroxychloroquine oral ADHYOPHEN ORAL ADINTELENCE ORAL ADINTRON A INJECTION AD SPINVIRASE ORAL TABLET ADISENTRESS HD ORAL ADISENTRESS ORAL TABLET ADISENTRESS ORAL TABLET,CHEWABLE ADisoniazid injection ADisoniazid oral ADitraconazole oral capsule NP PA; QL (30 per 30 days)itraconazole oral solution NP PAivermectin oral ADJULUCA ORAL ADKALETRA ORAL TABLET ADKEFLEX ORAL CAPSULE NP PAketoconazole oral NP PAKITABIS PAK INHALATION P SPlamivudine oral Plamivudine-zidovudine oral ADledipasvir-sofosbuvir oral NP PA; SPLEVAQUIN ORAL TABLET 500 MG, 750 MG NP PAlevofloxacin oral PLEXIVA ORAL SUSPENSION ADlinezolid in dextrose 5% intravenous ADlinezolid oral ADlinezolid-0.9% sodium chloride intravenous ADlopinavir-ritonavir oral ADLUGOLS ORAL ADMAVYRET ORAL P PA; SPmefloquine oral ADmeropenem intravenous ADmethenamine hippurate oral ADmethenamine mandelate oral ADUCare Comprehensive FormularyEffective: November 1, 2019

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Drug Tier Limits or Restrictionsmetronidazole in nacl (iso-os) intravenous ADmetronidazole oral ADminocycline oral capsule ADMODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 400 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7), 600-600 MG (28)-MG (28)

NP SP; PA

moxifloxacin oral NP PAMYCAMINE INTRAVENOUS ADnafcillin in dextrose iso-osm intravenous ADnafcillin injection ADnafcillin intravenous ADNEBUPENT INHALATION AD SPneomycin oral ADnevirapine oral suspension ADnevirapine oral tablet ADnitrofurantoin macrocrystal oral capsule 100 mg, 50 mg AD

nitrofurantoin monohyd/m-cryst oral ADnitrofurantoin oral ADNORVIR ORAL CAPSULE ADNORVIR ORAL SOLUTION ADNOXAFIL ORAL NP PANUZYRA ORAL NP PAnystatin oral powder 150 million unit, 500 million unit AD

nystatin oral suspension Pnystatin oral tablet NP PAODEFSEY ORAL ADofloxacin oral tablet 300 mg, 400 mg NP PAONMEL ORAL NP PAoseltamivir oral capsule 30 mg AD QL (40 per 30 days)oseltamivir oral capsule 45 mg, 75 mg AD QL (30 per 30 days)oseltamivir oral suspension for reconstitution AD QL (360 per 273 days)

oxacillin in dextrose(iso-osm) intravenous ADoxacillin injection ADoxacillin intravenous ADparomomycin oral AD


Drug Tier Limits or RestrictionsPCE ORAL NP PAPEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML AD SP; QL (4 per 30 days)

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML P SP; QL (4 per 30 days)

PEGASYS SUBCUTANEOUS P SP; QL (4 per 30 days)PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML NP SP; PA

penicillin g potassium injection ADpenicillin g procaine intramuscular ADpenicillin g sodium injection ADpenicillin v potassium oral ADPIFELTRO ORAL ADpiperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

AD

polymyxin b sulfate injection ADpraziquantel oral ADPREVYMIS INTRAVENOUS AD SPPREVYMIS ORAL AD SPPREZCOBIX ORAL ADPREZISTA ORAL SUSPENSION ADPREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG AD

PRIFTIN ORAL ADPYLERA ORAL ADpyrazinamide oral ADquinidine gluconate injection ADquinidine gluconate oral ADquinidine sulfate oral tablet ADquinine sulfate oral ADREBETOL ORAL SOLUTION NP SP; PARELENZA DISKHALER INHALATION AD QL (40 per 273 days)RESCRIPTOR ORAL ADRETROVIR INTRAVENOUS ADRIBASPHERE ORAL TABLET 400 MG, 600 MG NP SP; PA


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Drug Tier Limits or RestrictionsRIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

NP SP; PA

ribavirin oral capsule P SPribavirin oral tablet 200 mg P SPrifabutin oral ADrifampin intravenous ADrifampin oral ADRIFATER ORAL ADrimantadine oral ADritonavir oral ADSELZENTRY ORAL SOLUTION ADSELZENTRY ORAL TABLET 150 MG, 300 MG ADSIRTURO ORAL ADSITAVIG BUCCAL NP PAsofosbuvir-velpatasvir oral NP PA; SPSOLOSEC ORAL NP PASOVALDI ORAL TABLET 400 MG NP PA; SPSPORANOX ORAL NP PAstavudine oral capsule ADSTRIBILD ORAL ADSTRONG IODINE ORAL ADsulfadiazine oral ADsulfamethoxazole-trimethoprim intravenous AD

sulfamethoxazole-trimethoprim oral ADsulfasalazine oral PSUPRAX ORAL CAPSULE PSUPRAX ORAL SUSPENSION FOR RECONSTITUTION P

SUPRAX ORAL TABLET,CHEWABLE NP PASYLATRON SUBCUTANEOUS AD SPSYMFI LO ORAL ADSYMFI ORAL ADSYMTUZA ORAL ADSYNAGIS INTRAMUSCULAR AD PA; SPTAMIFLU ORAL SUSPENSION FOR RECONSTITUTION AD QL (360 per 273 days)


Drug Tier Limits or RestrictionsTECHNIVIE ORAL NP PA; SPtenofovir disoproxil fumarate oral ADterbinafine hcl oral Ptetracycline oral ADtinidazole oral ADTIVICAY ORAL ADTOBI INHALATION NP SP; PATOBI PODHALER INHALATION NP SP; PAtobramycin in 0.225 % nacl inhalation NP SP; PA; QL (280 per 30 days)tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml AD

tobramycin sulfate injection ADTOLSURA ORAL NP PAtrimethoprim oral ADTRIUMEQ ORAL ADTROGARZO INTRAVENOUS ADTRUVADA ORAL TABLET 200-300 MG ADUR N-C ORAL ADURIMAR-T ORAL ADUROGESIC-BLUE ORAL ADvalacyclovir oral P QL (30 per 30 days)valganciclovir oral ADVALTREX ORAL NP PAVANCOCIN ORAL NP PAvancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 500 mg/100 ml AD

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg AD

vancomycin oral capsule PVEMLIDY ORAL NP SP; PAVFEND ORAL SUSPENSION FOR RECONSTITUTION NP PA

VIDEX 2 GRAM PEDIATRIC ORAL ADVIEKIRA PAK ORAL NP PA; SPVIRACEPT ORAL TABLET ADVIREAD ORAL POWDER AD SPVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG AD SP

voriconazole intravenous AD


11

Drug Tier Limits or Restrictionsvoriconazole oral suspension for reconstitution NP PA

voriconazole oral tablet ADVOSEVI ORAL P PA; SPXIFAXAN ORAL ADXOFLUZA ORAL ADZEPATIER ORAL NP PA; SPzidovudine oral ADZITHROMAX ORAL PACKET NP PAZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION NP PA

ZITHROMAX ORAL TABLET 250 MG, 500 MG NP PA

ZITHROMAX TRI-PAK ORAL NP PAZOVIRAX ORAL NP PAANTINEOPLASTIC AGENTSabiraterone oral AD PA; SPADRUCIL INTRAVENOUS ADAFINITOR DISPERZ ORAL AD PA; SPAFINITOR ORAL AD PA; SPALECENSA ORAL AD PA; SP; QL (240 per 30 days)ALIQOPA INTRAVENOUS AD SPALUNBRIG ORAL TABLET 180 MG, 90 MG AD PA; SPALUNBRIG ORAL TABLET 30 MG AD PA; SP; QL (180 per 30 days)ALUNBRIG ORAL TABLETS,DOSE PACK AD PA; SPanastrozole oral ADazacitidine injection AD SPBALVERSA ORAL AD PABAVENCIO INTRAVENOUS ADBELEODAQ INTRAVENOUS ADBESPONSA INTRAVENOUS AD SPbexarotene oral ADbicalutamide oral ADbleomycin injection ADBLINCYTO INTRAVENOUS KIT ADBORTEZOMIB INTRAVENOUS ADBOSULIF ORAL AD PA; SPBRAFTOVI ORAL AD PA; SP


Drug Tier Limits or RestrictionsCABOMETYX ORAL AD PA; SPCALQUENCE ORAL AD PA; SPcapecitabine oral AD SPCAPRELSA ORAL AD PA; SPcarboplatin intravenous ADcisplatin intravenous solution ADcladribine intravenous ADCOMETRIQ ORAL AD PA; SPCOPIKTRA ORAL AD PA; SPCOTELLIC ORAL AD PA; SP; QL (63 per 30 days)cyclophosphamide intravenous ADCYCLOPHOSPHAMIDE ORAL CAPSULE ADCYRAMZA INTRAVENOUS AD SPcytarabine (pf) injection solution ADcytarabine injection ADdacarbazine intravenous ADdaunorubicin intravenous ADDAURISMO ORAL AD PA; SPdiclofenac sodium topical gel 3 % NP PADOCETAXEL INTRAVENOUS SOLUTION 160 MG/16 ML (10 MG/ML), 160 MG/8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML), 20 MG/ML, 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML), 80 MG/8 ML (10 MG/ML)

AD

doxorubicin intravenous ADDROXIA ORAL ADEMCYT ORAL ADepirubicin intravenous recon soln ADepirubicin intravenous solution 50 mg/25 ml AD

ERIVEDGE ORAL AD PA; SPERLEADA ORAL AD PA; SPerlotinib oral AD PA; SPetoposide intravenous ADetoposide oral ADexemestane oral ADFARYDAK ORAL AD PA; SPfloxuridine injection AD SPFLUOROPLEX TOPICAL AD


13

Drug Tier Limits or Restrictionsfluorouracil intravenous ADfluorouracil topical cream 5 % ADfluorouracil topical solution ADflutamide oral ADfulvestrant intramuscular AD SPGILOTRIF ORAL AD PA; SP; QL (30 per 30 days)GLEOSTINE ORAL ADhydroxyurea oral ADIBRANCE ORAL AD PA; SPICLUSIG ORAL TABLET 15 MG AD PA; SP; QL (60 per 30 days)ICLUSIG ORAL TABLET 45 MG AD PA; SP; QL (30 per 30 days)idarubicin intravenous ADIDHIFA ORAL AD PA; SPifosfamide intravenous ADifosfamide-mesna intravenous kit 1-1 gram ADimatinib oral tablet 100 mg AD PA; SPimatinib oral tablet 400 mg AD PA; SP; QL (60 per 30 days)IMBRUVICA ORAL CAPSULE 140 MG AD PA; SP; QL (120 per 30 days)IMBRUVICA ORAL CAPSULE 70 MG AD PA; SPIMBRUVICA ORAL TABLET 140 MG AD PA; SP; QL (120 per 30 days)IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG AD PA; SP

IMFINZI INTRAVENOUS AD SPINLYTA ORAL AD PA; SPINTRON A INJECTION AD SPIRESSA ORAL AD PA; SPirinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml AD

JAKAFI ORAL AD PA; SPKADCYLA INTRAVENOUS AD PA; SPKISQALI FEMARA CO-PACK ORAL AD PA; SPKISQALI ORAL AD PA; SPLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)

AD PA

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 4 MG AD PA; SP


Drug Tier Limits or Restrictionsletrozole oral ADLEUKERAN ORAL ADleuprolide subcutaneous kit AD SPLONSURF ORAL AD PA; SPLORBRENA ORAL AD PA; SPLUPRON DEPOT (3 MONTH) INTRAMUSCULAR AD PA; SP

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR AD PA; SP


LUPRON DEPOT INTRAMUSCULAR AD PA; SPLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR AD PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR AD PA; SPLYNPARZA ORAL TABLET AD PA; SPMATULANE ORAL AD SPMEGACE ES ORAL NP PAmegestrol oral suspension 400 mg/10 ml (10 ml), 625 mg/5 ml NP PA

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) P PA

megestrol oral tablet P PAMEKINIST ORAL AD PA; SPMEKTOVI ORAL AD PA; SPmelphalan hcl intravenous ADmercaptopurine oral ADmethotrexate sodium (pf) injection ADmethotrexate sodium injection ADmethotrexate sodium oral ADmitomycin intravenous ADmitoxantrone intravenous AD SPMYLERAN ORAL ADNERLYNX ORAL AD PA; SPNEXAVAR ORAL AD PA; SPnilutamide oral ADNINLARO ORAL AD PA; SP; QL (3 per 30 days)OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 MG/0.4 ML NP PA


15

Drug Tier Limits or Restrictionsoxaliplatin intravenous ADpaclitaxel intravenous ADPICATO TOPICAL ADPIQRAY ORAL AD PAPOMALYST ORAL AD SPPOTELIGEO INTRAVENOUS AD PA; SPPROLEUKIN INTRAVENOUS AD SPREVLIMID ORAL AD PA; SPRITUXAN HYCELA SUBCUTANEOUS AD PARUBRACA ORAL AD PA; SPRYDAPT ORAL AD PA; SPSIKLOS ORAL ADSPRYCEL ORAL AD PA; SPSTIVARGA ORAL AD PA; SPSUTENT ORAL AD PA; SPSYLATRON SUBCUTANEOUS AD SPSYLVANT INTRAVENOUS AD SPTABLOID ORAL ADTAFINLAR ORAL AD PA; SP; QL (120 per 30 days)TAGRISSO ORAL AD PA; SP; QL (30 per 30 days)TALZENNA ORAL AD PA; SPtamoxifen oral ADTARGRETIN TOPICAL ADTASIGNA ORAL AD PA; SPTECENTRIQ INTRAVENOUS AD SPTEMODAR INTRAVENOUS AD SPtemozolomide oral AD SPTIBSOVO ORAL AD PA; SPTICE BCG INTRAVESICAL AD SPTOPOSAR INTRAVENOUS ADtoremifene oral ADtretinoin (chemotherapy) oral ADTYKERB ORAL AD PA; SPUNITUXIN INTRAVENOUS ADVALCHLOR TOPICAL AD SPVECTIBIX INTRAVENOUS AD SPVELCADE INJECTION AD SPVENCLEXTA ORAL AD PA; SPUCare Comprehensive FormularyEffective: November 1, 201916

Drug Tier Limits or RestrictionsVENCLEXTA STARTING PACK ORAL AD PA; SPVERZENIO ORAL AD PA; SPvinblastine intravenous solution ADVINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML AD

vincristine intravenous ADvinorelbine intravenous ADVITRAKVI ORAL AD PA; SPVIZIMPRO ORAL AD PA; SPVOTRIENT ORAL AD PA; SPXALKORI ORAL AD PA; SPXOSPATA ORAL AD PA; SPXPOVIO ORAL AD PAXTANDI ORAL AD PA; SPYONDELIS INTRAVENOUS AD PAZEJULA ORAL AD PA; QL (90 per 30 days)ZELBORAF ORAL AD PA; SPZOLINZA ORAL AD SPZYDELIG ORAL AD PAZYKADIA ORAL CAPSULE AD PA; SPZYTIGA ORAL TABLET 500 MG AD PA; SPANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESACTHIB (PF) INTRAMUSCULAR ADADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR AD

AFLURIA QD 2019-20(3YR UP)(PF) INTRAMUSCULAR AD

AFLURIA QD 2019-20(6-35MO)(PF) INTRAMUSCULAR AD

AFLURIA QUAD 2019-20(6MO UP) INTRAMUSCULAR AD

BEXSERO INTRAMUSCULAR ADBOOSTRIX TDAP INTRAMUSCULAR ADDAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR AD

ENGERIX-B (PF) INTRAMUSCULAR ADENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE AD


17

Drug Tier Limits or RestrictionsFLUAD 2019-2020 (65 YR UP)(PF) INTRAMUSCULAR AD

FLUARIX QUAD 2019-2020 (PF) INTRAMUSCULAR AD

FLUBLOK QUAD 2019-2020 (PF) INTRAMUSCULAR AD

FLUCELVAX QUAD 2019-2020 (PF) INTRAMUSCULAR AD

FLUCELVAX QUAD 2019-2020 INTRAMUSCULAR AD

FLULAVAL QUAD 2019-2020 (PF) INTRAMUSCULAR AD

FLULAVAL QUAD 2019-2020 INTRAMUSCULAR AD

FLUMIST QUAD 2019-2020 NASAL ADFLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR AD

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR AD

FLUZONE QUAD 2018-2019 INTRAMUSCULAR AD

FLUZONE QUAD PEDI 2019-20 (PF) INTRAMUSCULAR AD

GAMASTAN S/D INTRAMUSCULAR AD SPGAMMAGARD LIQUID INJECTION AD SPGAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS AD SP

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)

AD SP

GARDASIL 9 (PF) INTRAMUSCULAR ADHAVRIX (PF) INTRAMUSCULAR ADHEPLISAV-B (PF) INTRAMUSCULAR SOLUTION AD

HIBERIX (PF) INTRAMUSCULAR ADHIZENTRA SUBCUTANEOUS AD SPHYPERHEP B S/D INTRAMUSCULAR AD SPHYPERHEP B S-D NEONATAL INTRAMUSCULAR AD SP

HYPERRAB S/D (PF) INTRAMUSCULAR AD SP


Drug Tier Limits or RestrictionsHYPERRHO S/D INTRAMUSCULAR AD SPIMOVAX RABIES VACCINE (PF) INTRAMUSCULAR AD

INFANRIX (DTAP) (PF) INTRAMUSCULAR ADIPOL INJECTION ADIXIARO (PF) INTRAMUSCULAR ADKINRIX (PF) INTRAMUSCULAR ADMENACTRA (PF) INTRAMUSCULAR SOLUTION AD

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

MENVEO MENA COMPONENT (PF) INTRAMUSCULAR AD

MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR AD

M-M-R II (PF) SUBCUTANEOUS ADPEDIARIX (PF) INTRAMUSCULAR ADPEDVAX HIB (PF) INTRAMUSCULAR ADPENTACEL (PF) INTRAMUSCULAR ADPENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR AD

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR AD

PNEUMOVAX 23 INJECTION ADPREVNAR 13 (PF) INTRAMUSCULAR ADPRIVIGEN INTRAVENOUS AD SPPROQUAD (PF) SUBCUTANEOUS ADQUADRACEL (PF) INTRAMUSCULAR ADRABAVERT (PF) INTRAMUSCULAR ADRECOMBIVAX HB (PF) INTRAMUSCULAR ADROTARIX ORAL ADROTATEQ VACCINE ORAL ADSHINGRIX (PF) INTRAMUSCULAR ADSHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR AD

STAMARIL (PF) SUBCUTANEOUS ADTENIVAC (PF) INTRAMUSCULAR ADtetanus,diphtheria tox ped(pf) intramuscular AD


19

Drug Tier Limits or Restrictionstetanus-diphtheria toxoids-td intramuscular AD

TICE BCG INTRAVESICAL AD SPTRUMENBA INTRAMUSCULAR ADTWINRIX (PF) INTRAMUSCULAR SYRINGE ADVAQTA (PF) INTRAMUSCULAR ADVARIVAX (PF) SUBCUTANEOUS ADVARIZIG INTRAMUSCULAR SOLUTION NP PAVAXCHORA VACCINE ORAL ADVIVOTIF ORAL ADWINRHO SDF INJECTION AD SPYF-VAX (PF) SUBCUTANEOUS ADZOSTAVAX (PF) SUBCUTANEOUS ADAUTONOMIC DRUGSacebutolol oral NP PAADVAIR DISKUS INHALATION NP PAADVAIR HFA INHALATION P QL (12 per 30 days)AIRDUO RESPICLICK INHALATION NP PAalbuterol hfa 90 mcg inhaler NP PA; Tevaalbuterol hfa 90 mcg inhaler NP PA; Paralbuterol hfa 90 mcg inhaler P Prasco; QL (36 per 30 days)albuterol sulfate inhalation solution for nebulization P

albuterol sulfate oral syrup Palbuterol sulfate oral tablet NP PAalbuterol sulfate oral tablet extended release 12 hr NP PA

alfuzosin oral PALL DAY ALLERGY-D ORAL PALLERGY AND CONGESTION RELIEF ORAL PALLERGY COMPLETE-D ORAL PALLERGY RELIEF D-24HR ORAL PALLERGY RELIEF,NASAL DECONGEST ORAL PALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR P

ANORO ELLIPTA INHALATION NP PAARCAPTA NEOHALER INHALATION NP PAARICEPT ORAL NP PAatenolol oral PUCare Comprehensive FormularyEffective: November 1, 201920

Drug Tier Limits or Restrictionsatenolol-chlorthalidone oral ADatropine injection solution ADatropine injection syringe 0.05 mg/ml, 0.1 mg/ml AD

baclofen oral tablet 10 mg, 20 mg ADbenztropine injection ADbenztropine oral ADBETAPACE AF ORAL NP PABETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

betaxolol oral NP PAbethanechol chloride oral ADBEVESPI AEROSPHERE INHALATION NP PAbisoprolol fumarate oral Pbisoprolol-hydrochlorothiazide oral ADBREO ELLIPTA INHALATION NP PAbrompheniramine-pseudoeph-dm oral syrup AD

BROVANA INHALATION NP PAbupivacaine-epinephrine (pf) injection ADbupivacaine-epinephrine injection ADBYSTOLIC ORAL NP PABYVALSON ORAL NP PACARDURA ORAL NP PACARDURA XL ORAL NP PAcarisoprodol-asa-codeine oral NP PAcarvedilol oral Pcarvedilol phosphate oral NP PAcetirizine-pseudoephedrine oral Pcevimeline oral ADCHANTIX CONTINUING MONTH BOX ORAL PCHANTIX ORAL TABLET 0.5 MG PCHANTIX ORAL TABLET 1 MG ADCHANTIX STARTING MONTH BOX ORAL Pchlorzoxazone oral tablet 500 mg ADCLARINEX-D 12 HOUR ORAL NP PAclonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml) AD

clonidine hcl oral tablet ADUCare Comprehensive FormularyEffective: November 1, 2019

21

Drug Tier Limits or Restrictionsclonidine transdermal AD QL (4 per 30 days)COMBIVENT RESPIMAT INHALATION P QL (8 per 30 days)COREG CR ORAL NP PACOREG ORAL NP PACORGARD ORAL NP PACORZIDE ORAL NP PAcyclobenzaprine oral tablet 10 mg, 5 mg ADdantrolene oral ADdicyclomine oral capsule ADdicyclomine oral solution ADdicyclomine oral tablet ADdihydroergotamine injection ADdiphenoxylate-atropine oral ADdobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

AD

dobutamine intravenous ADdonepezil oral tablet 10 mg, 5 mg Pdonepezil oral tablet 23 mg NP PAdonepezil oral tablet,disintegrating Pdopamine in 5 % dextrose intravenous ADdopamine intravenous solution ADdoxazosin oral tablet 1 mg, 2 mg, 4 mg P QL (30 per 30 days)doxazosin oral tablet 8 mg P QL (60 per 30 days)DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION P QL (13 per 30 days)

DULERA INHALATION HFA AEROSOL INHALER 200-5 MCG/ACTUATION P QL

ED-SPAZ ORAL ADephedrine sulfate injection solution ADepinephrine injection auto-injector 0.15 mg/0.15 ml NP PA; Non-Mylan

epinephrine injection auto-injector 0.15 mg/0.3 ml P Mylan; QL (2 per 30 days)

epinephrine injection auto-injector 0.3 mg/0.3 ml NP PA; Non-Mylan


epinephrine injection solution AD


Drug Tier Limits or Restrictionsepinephrine injection syringe 0.1 mg/ml ADEPIPEN 2-PAK INJECTION NP PA; QL (2 per 30 days)EPIPEN INJECTION NP PA; QL (2 per 30 days)EPIPEN JR 2-PAK INJECTION NP PA; QL (2 per 30 days)EPIPEN JR INJECTION NP PA; QL (2 per 30 days)ergoloid oral ADEXELON TRANSDERMAL NP PAFLOMAX ORAL NP PAfluticasone propion-salmeterol inhalation NP PAgalantamine oral NP PAglycopyrrolate injection ADglycopyrrolate oral tablet 1 mg, 2 mg ADguanidine oral ADHEMANGEOL ORAL NP PAhyoscyamine sulfate oral elixir ADhyoscyamine sulfate oral tablet ADhyoscyamine sulfate oral tablet extended release 12 hr AD

hyoscyamine sulfate oral tablet,disintegrating AD

hyoscyamine sulfate sublingual ADINCRUSE ELLIPTA INHALATION NP PAINDERAL LA ORAL NP PAINDERAL XL ORAL NP PAINNOPRAN XL ORAL NP PAipratropium bromide inhalation Pipratropium-albuterol inhalation PJALYN ORAL NP PAlabetalol intravenous solution ADlabetalol intravenous syringe 20 mg/4 ml (5 mg/ml) AD

labetalol oral Plevalbuterol hcl inhalation NP PAlevalbuterol tartrate inhalation NP PAlidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

AD

LONHALA MAGNAIR REFILL INHALATION NP PALONHALA MAGNAIR STARTER INHALATION NP PA


23

Drug Tier Limits or RestrictionsLOPRESSOR ORAL NP PALORATA-DINE D ORAL PLORATADINE-D ORAL Pmetaproterenol oral syrup ADmetaproterenol oral tablet NP PAmetaxalone oral tablet 800 mg ADmethocarbamol oral ADmethscopolamine oral ADmethyldopa oral ADmethyldopa-hydrochlorothiazide oral ADmethyldopate intravenous ADmetoprolol succinate oral Pmetoprolol ta-hydrochlorothiaz oral ADmetoprolol tartrate intravenous ADmetoprolol tartrate oral Pmidodrine oral ADnadolol oral Pnadolol-bendroflumethiazide oral ADNAMZARIC ORAL NP PANICODERM CQ TRANSDERMAL NP PANICORELIEF BUCCAL PNICORETTE BUCCAL NP PAnicotine (polacrilex) buccal Pnicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr P

NICOTROL INHALATION NP PANICOTROL NS NASAL NP PAnorepinephrine bitartrate intravenous ADorphenadrine citrate injection ADorphenadrine citrate oral ADPERFOROMIST INHALATION NP PAphenylephrine hcl injection ADphysostigmine salicylate injection ADpilocarpine hcl oral ADpindolol oral Pprazosin oral ADPROAIR HFA INHALATION P QL (17 per 30 days)PROAIR RESPICLICK INHALATION NP PA


Drug Tier Limits or Restrictionspropantheline oral ADpropranolol intravenous ADpropranolol oral capsule,extended release 24 hr 120 mg, 160 mg NP PA

propranolol oral capsule,extended release 24 hr 60 mg, 80 mg P

propranolol oral solution Ppropranolol oral tablet Ppropranolol-hydrochlorothiazid oral ADPROVENTIL HFA INHALATION Ppyridostigmine bromide oral tablet 60 mg ADRAPAFLO ORAL NP PARAZADYNE ER ORAL NP PARAZADYNE ORAL TABLET NP PAREVONTO INTRAVENOUS ADrivastigmine tartrate oral NP PArivastigmine transdermal NP PASEEBRI NEOHALER INHALATION NP PASEMPREX-D ORAL NP PASEREVENT DISKUS INHALATION Psilodosin oral NP PASORINE ORAL ADSOTALOL AF ORAL Psotalol oral PSOTYLIZE ORAL NP PASPIRIVA RESPIMAT INHALATION PSPIRIVA WITH HANDIHALER INHALATION P QL (90 per 30 days)STIOLTO RESPIMAT INHALATION PSTRIVERDI RESPIMAT INHALATION NP PASYMBICORT INHALATION P QLSYMJEPI INJECTION P QL (2 per 30 days)tamsulosin oral PTENORETIC 100 ORAL NP PATENORETIC 50 ORAL NP PATENORMIN ORAL NP PAterazosin oral capsule 1 mg, 2 mg, 5 mg P QL (30 per 30 days)terazosin oral capsule 10 mg P QL (60 per 30 days)terbutaline oral AD


25

Drug Tier Limits or Restrictionsterbutaline subcutaneous ADtimolol maleate oral NP PAtizanidine oral ADTOPROL XL ORAL NP PATRELEGY ELLIPTA INHALATION NP PAtrihexyphenidyl oral ADUTIBRON NEOHALER INHALATION NP PAVENTOLIN HFA INHALATION NP PA; QL (36 per 30 days)WIXELA INHUB INHALATION P QL (60 per 30 days)XOPENEX CONCENTRATE INHALATION NP PAXOPENEX HFA INHALATION NP PAXOPENEX INHALATION NP PAYUPELRI INHALATION NP PAZIAC ORAL NP PABLOOD DERIVATIVESalbumin, human 25 % intravenous ADALBURX (HUMAN) 25 % INTRAVENOUS ADALBUTEIN 25 % INTRAVENOUS ADALBUTEIN 5 % INTRAVENOUS ADBLOOD FORMATION, COAGULATION, THROMBOSISADVATE INTRAVENOUS AD SPADYNOVATE INTRAVENOUS ADAFSTYLA INTRAVENOUS AD SPAGGRENOX ORAL PALPHANATE INTRAVENOUS AD SPALPHANINE SD INTRAVENOUS AD SPALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT

AD

ALPROLIX INTRAVENOUS RECON SOLN 250 UNIT AD SP

aminocaproic acid intravenous ADanagrelide oral ADARANESP (IN POLYSORBATE) INJECTION P SPARIXTRA SUBCUTANEOUS P SPaspirin-dipyridamole oral NP PABAL-CARE DHA ORAL ADBENEFIX INTRAVENOUS AD SPUCare Comprehensive FormularyEffective: November 1, 201926

Drug Tier Limits or RestrictionsBRILINTA ORAL NP PAbutalbital-aspirin-caffeine oral ADCABLIVI INJECTION AD PA; SPCATHFLO ACTIVASE INTRA-CATHETER ADcilostazol oral ADclopidogrel oral PCOAGADEX INTRAVENOUS ADCORIFACT INTRAVENOUS AD SPdesmopressin injection AD PAdesmopressin nasal spray,non-aerosol ADdesmopressin oral ADdipyridamole intravenous ADdipyridamole oral PEFFIENT ORAL NP PAELIQUIS ORAL NP PAELITE-OB 400 ORAL ADELOCTATE INTRAVENOUS AD SPenoxaparin subcutaneous P SPEPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

NP SP; PA

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT

AD SP

FOLIVANE-OB ORAL ADfondaparinux subcutaneous NP PAFRAGMIN SUBCUTANEOUS SYRINGE P SPFULPHILA SUBCUTANEOUS AD PA; SPGRANIX SUBCUTANEOUS AD SPHELIXATE FS INTRAVENOUS AD SPHEMLIBRA SUBCUTANEOUS AD PA; SPHEMOFIL M HIGH INTRAVENOUS AD SPHEMOFIL M LOW INTRAVENOUS AD SPHEMOFIL M MID INTRAVENOUS AD SPHEMOFIL M SUPER HIGH INTRAVENOUS AD SPHEP FLUSH-10 (PF) INTRAVENOUS AD


27

Drug Tier Limits or Restrictionsheparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

AD

heparin (porcine) in nacl (pf) intravenous ADheparin (porcine) injection cartridge ADheparin (porcine) injection solution ADheparin flush(porcine)-0.9nacl intravenous ADheparin lock flush (porcine) intravenous syringe 100 unit/ml AD

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE AD

HEPARIN LOCK INTRAVENOUS ADHEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS AD

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

AD

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

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml AD

HUMATE-P INTRAVENOUS AD SPIDELVION INTRAVENOUS AD SPINFED INJECTION ADIXINITY INTRAVENOUS AD SPJANTOVEN ORAL PJIVI INTRAVENOUS AD SPKOATE INTRAVENOUS AD SPKOGENATE FS INTRAVENOUS AD SPKOVALTRY INTRAVENOUS AD SPLEUKINE INJECTION RECON SOLN AD SPLOVENOX SUBCUTANEOUS NP SP; PAMONOCLATE-P INTRAVENOUS AD SPMONONINE INTRAVENOUS AD SPMOZOBIL SUBCUTANEOUS AD SPMYNATAL ADVANCE ORAL ADMYNATAL ORAL CAPSULE ADMYNATAL PLUS ORAL AD


Drug Tier Limits or RestrictionsMYNATAL-Z ORAL ADNEULASTA SUBCUTANEOUS AD PA; SP; QL (2 per 30 days)NEUPOGEN INJECTION AD PA; SPNIVESTYM INJECTION AD PA; SPNIVESTYM SUBCUTANEOUS AD PA; SPNOVOEIGHT INTRAVENOUS ADNOVOSEVEN RT INTRAVENOUS AD SPNUWIQ INTRAVENOUS AD SPOBIZUR INTRAVENOUS ADpentoxifylline oral ADPLAVIX ORAL NP PAPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA + DOCUSATE ORAL ADPNV-DHA ORAL ADPNV-OMEGA ORAL ADPNV-SELECT ORAL ADPR NATAL 400 EC ORAL ADPR NATAL 400 ORAL ADPR NATAL 430 EC ORAL ADPR NATAL 430 ORAL ADPRADAXA ORAL Pprasugrel oral NP PAPRENAISSANCE ORAL ADPRENAISSANCE PLUS ORAL ADPRENATABS FA ORAL ADPRENATABS RX ORAL ADPRENATAL LOW IRON ORAL ADPRENATAL PLUS (CALCIUM CARB) ORAL ADPRENATAL PLUS ORAL ADPROCRIT INJECTION P PA; SPPROFILNINE INTRAVENOUS AD SPPROMACTA ORAL AD PA; SPREBINYN INTRAVENOUS AD SPRECOMBINATE INTRAVENOUS AD SPRETACRIT INJECTION AD PA; SPRIXUBIS INTRAVENOUS AD SPSAVAYSA ORAL NP PA


29

Drug Tier Limits or RestrictionsSE-NATAL 19 (WITH DOCUSATE) ORAL ADSE-NATAL 19 ORAL ADTARON-C DHA ORAL ADTARON-PREX PRENATAL-DHA ORAL ADTL-SELECT ORAL ADtranexamic acid oral ADTRETTEN INTRAVENOUS AD SPTRIADVANCE ORAL ADTRINATAL RX 1 ORAL ADTRINATE ORAL ADTRIVEEN-DUO DHA ORAL ADTRIVEEN-ONE ORAL ADTRIVEEN-PRX RNF ORAL ADUDENYCA SUBCUTANEOUS AD PA; SP; QL (2 per 30 days)VENA-BAL DHA ORAL ADVENOFER INTRAVENOUS ADVINACAL ORAL ADVINATE CARE ORAL ADVINATE GT ORAL ADVINATE M ORAL ADVINATE ONE ORAL ADVINATE ULTRA ORAL ADVIRT-PN DHA ORAL ADVIRT-PN ORAL ADVIRT-PN PLUS ORAL ADVIRT-SELECT ORAL ADVITAFOL-OB ORAL ADVOL-NATE ORAL ADVOL-TAB RX ORAL ADVONVENDI INTRAVENOUS ADwarfarin oral ADWILATE INTRAVENOUS AD SPXARELTO ORAL TABLET 10 MG, 15 MG, 20 MG P

XARELTO ORAL TABLET 2.5 MG NP PAXARELTO ORAL TABLETS,DOSE PACK NP PAXYNTHA INTRAVENOUS AD SPXYNTHA SOLOFUSE INTRAVENOUS AD SP


Drug Tier Limits or RestrictionsYOSPRALA ORAL NP PAZARXIO INJECTION AD PA; SPZATEAN-PN DHA ORAL ADZATEAN-PN PLUS ORAL ADZONTIVITY ORAL NP PACARDIOVASCULAR DRUGSACCUPRIL ORAL NP PAACCURETIC ORAL NP PAacebutolol oral NP PAacetazolamide oral ADacetazolamide sodium injection ADADALAT CC ORAL NP PAADCIRCA ORAL NP PA; SPADEMPAS ORAL NP PAadenosine (diagnostic) intravenous ADadenosine intravenous solution ADAGGRENOX ORAL Paliskiren oral NP PAalprostadil injection ADALTACE ORAL NP PAALTOPREV ORAL NP PAALYQ ORAL NP PAambrisentan oral NP PAamiloride-hydrochlorothiazide oral ADamiodarone intravenous solution ADamiodarone oral ADamlodipine oral Pamlodipine-atorvastatin oral NP PAamlodipine-benazepril oral Pamlodipine-olmesartan oral NP PAamlodipine-valsartan oral Pamlodipine-valsartan-hcthiazid oral PANTARA ORAL CAPSULE 30 MG, 90 MG NP PAaspirin-dipyridamole oral NP PAATACAND HCT ORAL NP PAATACAND ORAL NP PAatenolol oral Patenolol-chlorthalidone oral ADUCare Comprehensive FormularyEffective: November 1, 2019

31

Drug Tier Limits or Restrictionsatorvastatin oral P QL (60 per 30 days)AVALIDE ORAL NP PAAVAPRO ORAL NP PAAZOR ORAL NP PAbenazepril oral Pbenazepril-hydrochlorothiazide oral PBENICAR HCT ORAL NP PABENICAR ORAL NP PABETAPACE AF ORAL NP PABETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

betaxolol oral NP PABIDIL ORAL ADbisoprolol fumarate oral Pbisoprolol-hydrochlorothiazide oral ADbosentan oral NP PAbumetanide injection ADbumetanide oral ADBYSTOLIC ORAL NP PABYVALSON ORAL NP PACADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

NP PA

CALAN ORAL TABLET 120 MG NP PACALAN SR ORAL NP PAcandesartan oral NP PAcandesartan-hydrochlorothiazid oral NP PAcaptopril oral Pcaptopril-hydrochlorothiazide oral PCARDIZEM CD ORAL NP PACARDIZEM LA ORAL NP PACARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NP PA

CARDURA ORAL NP PACARDURA XL ORAL NP PACARTIA XT ORAL ADcarvedilol oral Pcarvedilol phosphate oral NP PAchlorothiazide oral ADUCare Comprehensive FormularyEffective: November 1, 201932

Drug Tier Limits or Restrictionschlorthalidone oral tablet 25 mg, 50 mg ADcholestyramine (with sugar) oral PCHOLESTYRAMINE LIGHT ORAL Pcilostazol oral ADclonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml) AD

clonidine hcl oral tablet ADclonidine transdermal AD QL (4 per 30 days)colesevelam oral NP PACOLESTID FLAVORED ORAL PACKET NP PACOLESTID ORAL NP PAcolestipol oral PCOREG CR ORAL NP PACOREG ORAL NP PACORGARD ORAL NP PACORLANOR ORAL AD PACORZIDE ORAL NP PACOZAAR ORAL NP PACRESTOR ORAL NP PADIGOX ORAL ADdigoxin injection ADdigoxin oral solution 50 mcg/ml (0.05 mg/ml) AD

digoxin oral tablet ADDILANTIN EXTENDED ORAL PDILANTIN INFATABS ORAL NP PADILANTIN ORAL PDILANTIN-125 ORAL NP PAdiltiazem hcl intravenous ADdiltiazem hcl oral PDILT-XR ORAL PDIOVAN HCT ORAL NP PADIOVAN ORAL NP PAdipyridamole intravenous ADdipyridamole oral Pdisopyramide phosphate oral capsule AD


33

Drug Tier Limits or Restrictionsdobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

AD

dobutamine intravenous ADdofetilide oral ADdopamine in 5 % dextrose intravenous ADdopamine intravenous solution ADdoxazosin oral tablet 1 mg, 2 mg, 4 mg P QL (30 per 30 days)doxazosin oral tablet 8 mg P QL (60 per 30 days)EDARBI ORAL NP PAEDARBYCLOR ORAL NP PAenalapril maleate oral Penalaprilat intravenous solution ADenalapril-hydrochlorothiazide oral PENTRESTO ORAL NP PAeplerenone oral ADepoprostenol (glycine) intravenous AD SPeprosartan oral NP PAEXFORGE HCT ORAL NP PAEXFORGE ORAL NP PAEZALLOR SPRINKLE ORAL NP PAezetimibe oral P QL (30 per 30 days)ezetimibe-simvastatin oral NP PAfelodipine oral Pfenofibrate micronized oral capsule 130 mg, 43 mg NP PA

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

fenofibrate nanocrystallized oral NP PAfenofibrate oral capsule NP PAfenofibrate oral tablet 120 mg, 160 mg, 40 mg NP PA

fenofibrate oral tablet 54 mg Pfenofibric acid (choline) oral NP PAfenofibric acid oral NP PAFENOGLIDE ORAL NP PAFIBRICOR ORAL NP PA


Drug Tier Limits or RestrictionsFISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG-180 MG- 60 MG-1,200 MG

AD

flecainide oral ADfluvastatin oral NP PAfosinopril oral Pfosinopril-hydrochlorothiazide oral Pfurosemide injection ADfurosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) AD

furosemide oral tablet ADgemfibrozil oral Pguanfacine oral tablet ADguanfacine oral tablet extended release 24 hr P

HEMANGEOL ORAL NP PAhydralazine injection ADhydralazine oral ADhydrochlorothiazide oral ADHYZAAR ORAL NP PAindapamide oral ADINDERAL LA ORAL NP PAINDERAL XL ORAL NP PAINNOPRAN XL ORAL NP PAINTUNIV ER ORAL NP PAirbesartan oral Pirbesartan-hydrochlorothiazide oral Pisosorbide dinitrate oral ADisosorbide mononitrate oral ADisradipine oral PJUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG NP PA

labetalol intravenous solution ADlabetalol intravenous syringe 20 mg/4 ml (5 mg/ml) AD

labetalol oral PLESCOL XL ORAL NP PALETAIRIS ORAL P PA; SPlidocaine (pf) intravenous AD


35

Drug Tier Limits or Restrictionslidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) AD

LIPITOR ORAL NP PALIPOFEN ORAL NP PAlisinopril oral Plisinopril-hydrochlorothiazide oral PLIVALO ORAL NP PALOPID ORAL NP PALOPRESSOR ORAL NP PAlosartan oral Plosartan-hydrochlorothiazide oral PLOTENSIN HCT ORAL NP PALOTENSIN ORAL TABLET 20 MG, 40 MG NP PALOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG NP PA

lovastatin oral tablet 10 mg P QL (30 per 30 days)lovastatin oral tablet 20 mg, 40 mg P QL (60 per 30 days)LOVAZA ORAL NP PAmagnesium sulfate in water intravenous ADmagnesium sulfate injection ADmannitol 10 % intravenous ADmannitol 20 % intravenous ADmannitol 25 % intravenous solution ADmannitol 5 % intravenous ADMATZIM LA ORAL Pmethyldopa oral ADmethyldopa-hydrochlorothiazide oral ADmethyldopate intravenous ADmetolazone oral ADmetoprolol succinate oral Pmetoprolol ta-hydrochlorothiaz oral ADmetoprolol tartrate intravenous ADmetoprolol tartrate oral Pmexiletine oral ADMICARDIS HCT ORAL NP PAMICARDIS ORAL NP PAmilrinone in 5 % dextrose intravenous ADmilrinone intravenous AD


Drug Tier Limits or Restrictionsminoxidil oral ADmoexipril oral Pmoexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg P

moexipril-hydrochlorothiazide oral tablet 7.5-12.5 mg AD

nadolol oral Pnadolol-bendroflumethiazide oral ADniacin oral capsule, extended release 250 mg, 500 mg P

niacin oral tablet 100 mg, 500 mg Pniacin oral tablet extended release 1,000 mg, 750 mg P

niacin oral tablet extended release 24 hr PNIACOR ORAL NP PANIASPAN EXTENDED-RELEASE ORAL Pnicardipine intravenous solution ADnicardipine oral Pnifedipine oral Pnimodipine oral NP PAnisoldipine oral NP PANITRO-BID TRANSDERMAL ADnitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 200 mg/500 ml (400 mcg/ml), 50 mg/250 ml (200 mcg/ml)

AD

nitroglycerin intravenous ADnitroglycerin sublingual ADnitroglycerin transdermal patch 24 hour ADnitroglycerin translingual spray,non-aerosol ADNITROMIST TRANSLINGUAL NP PANORVASC ORAL NP PANYMALIZE ORAL NP PAolmesartan oral NP PAolmesartan-amlodipin-hcthiazid oral NP PAolmesartan-hydrochlorothiazide oral NP PAomega-3 acid ethyl esters oral NP PAOPSUMIT ORAL NP PAORENITRAM ORAL NP PA


37

Drug Tier Limits or Restrictionspapaverine injection solution ADperindopril erbumine oral PPHENYTEK ORAL Pphenytoin oral suspension Pphenytoin oral tablet,chewable Pphenytoin sodium extended oral Pphenytoin sodium intravenous ADpindolol oral PPRALUENT PEN SUBCUTANEOUS NP PA; SPPRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG NP PA

pravastatin oral P QL (60 per 30 days)prazosin oral ADPRESTALIA ORAL NP PAPREVALITE ORAL PPRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG NP PA

procainamide injection ADPROCARDIA ORAL NP PAPROCARDIA XL ORAL NP PApropafenone oral tablet ADpropranolol intravenous ADpropranolol oral capsule,extended release 24 hr 120 mg, 160 mg NP PA


propranolol oral solution Ppropranolol oral tablet Ppropranolol-hydrochlorothiazid oral ADQBRELIS ORAL NP PAQUESTRAN LIGHT ORAL POWDER NP PAQUESTRAN ORAL NP PAquinapril oral Pquinapril-hydrochlorothiazide oral Pquinidine gluconate injection ADquinidine gluconate oral ADquinidine sulfate oral tablet ADramipril oral PRANEXA ORAL PUCare Comprehensive FormularyEffective: November 1, 201938

Drug Tier Limits or Restrictionsranolazine oral ADREPATHA PUSHTRONEX SUBCUTANEOUS NP PA; SPREPATHA SURECLICK SUBCUTANEOUS NP PA; SPREPATHA SYRINGE SUBCUTANEOUS NP PA; SPREVATIO ORAL NP PA; SProsuvastatin oral P QL (30 per 30 days)sildenafil (antihypertensive) intravenous AD PA; SPsildenafil (antihypertensive) oral suspension for reconstitution AD PA

sildenafil (antihypertensive) oral tablet P PA; SP; QLsimvastatin oral P QL (60 per 30 days)SORINE ORAL ADSOTALOL AF ORAL Psotalol oral PSOTYLIZE ORAL NP PAspironolactone oral ADspironolacton-hydrochlorothiaz oral ADSULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG NP PA

tadalafil (antihypertensive) oral NP PA; SP; QL (60 per 30 days)TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 2-180 MG, 2-240 MG, 4-240 MG NP PA

TAZTIA XT ORAL PTEKTURNA HCT ORAL PTEKTURNA ORAL NP PAtelmisartan oral NP PAtelmisartan-amlodipine oral NP PAtelmisartan-hydrochlorothiazid oral NP PATENORETIC 100 ORAL NP PATENORETIC 50 ORAL NP PATENORMIN ORAL NP PAterazosin oral capsule 1 mg, 2 mg, 5 mg P QL (30 per 30 days)terazosin oral capsule 10 mg P QL (60 per 30 days)THEOCHRON ORAL ADtheophylline oral elixir ADtheophylline oral solution ADtheophylline oral tablet extended release 12 hr AD


39

Drug Tier Limits or Restrictionstheophylline oral tablet extended release 24 hr AD

TIAZAC ORAL NP PAtimolol maleate oral NP PATOPROL XL ORAL NP PAtorsemide oral ADTRACLEER ORAL TABLET P PA; SPTRACLEER ORAL TABLET FOR SUSPENSION NP PA; SP; PAtrandolapril oral Ptriamterene-hydrochlorothiazid oral ADTRIBENZOR ORAL NP PATRICOR ORAL NP PATRIGLIDE ORAL TABLET 160 MG NP PATRILIPIX ORAL NP PATWYNSTA ORAL NP PATYVASO INHALATION NP PATYVASO INSTITUTIONAL START KIT INHALATION NP PA

TYVASO REFILL KIT INHALATION NP PATYVASO STARTER KIT INHALATION NP PAUPTRAVI ORAL NP PAvalsartan oral Pvalsartan-hydrochlorothiazide oral PVASCEPA ORAL NP PAVASERETIC ORAL NP PAVASOTEC ORAL NP PAVELETRI INTRAVENOUS AD SPVENTAVIS INHALATION NP PAverapamil intravenous ADverapamil oral PVERELAN ORAL NP PAVERELAN PM ORAL NP PAVYNDAMAX ORAL AD PAVYNDAQEL ORAL AD PAVYTORIN 10-10 ORAL NP PAVYTORIN 10-20 ORAL NP PAVYTORIN 10-40 ORAL NP PAVYTORIN 10-80 ORAL NP PA


Drug Tier Limits or RestrictionsWELCHOL ORAL TABLET NP PAZESTORETIC ORAL NP PAZESTRIL ORAL NP PAZETIA ORAL NP PAZIAC ORAL NP PAZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NP PA

ZYPITAMAG ORAL NP PACENTRAL NERVOUS SYSTEM AGENTSABILIFY MAINTENA INTRAMUSCULAR PABILIFY ORAL TABLET NP PAacamprosate oral ADacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

AD QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg AD QL (360 per 30 days)

acetaminophen-codeine oral tablet 300-60 mg AD QL (180 per 30 days)

ADDERALL XR ORAL NP PAADZENYS ER ORAL NP PAADZENYS XR-ODT ORAL NP PAAGGRENOX ORAL PAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML NP PA; QL (1 per 30 days)

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML NP PA; QL (2 per 30 days)

AJOVY SUBCUTANEOUS NP PAalmotriptan malate oral NP PAalprazolam oral tablet ADamantadine hcl oral ADAMBIEN CR ORAL NP PAAMBIEN ORAL NP PAAMERGE ORAL NP PAamitriptyline oral ADamitriptyline-chlordiazepoxide oral ADamoxapine oral ADamphetamine sulfate oral NP PAAPLENZIN ORAL NP PA


41

Drug Tier Limits or RestrictionsAPTENSIO XR ORAL NP PAAPTIOM ORAL NP PAaripiprazole oral solution Paripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg P QL (30 per 30 days)

aripiprazole oral tablet 5 mg P QL (60 per 30 days)aripiprazole oral tablet,disintegrating NP PA; QL (60 per 30 days)ARISTADA INITIO INTRAMUSCULAR NP PAARISTADA INTRAMUSCULAR NP PAarmodafinil oral NP PAARYMO ER ORAL NP PAASCOMP WITH CODEINE ORAL AD QL (180 per 30 days)aspirin-dipyridamole oral NP PAatomoxetine oral capsule 10 mg P QL (300 per 30 days)atomoxetine oral capsule 100 mg P QL (30 per 30 days)atomoxetine oral capsule 18 mg P QL (166 per 30 days)atomoxetine oral capsule 25 mg P QL (120 per 30 days)atomoxetine oral capsule 40 mg P QL (75 per 30 days)atomoxetine oral capsule 60 mg P QL (50 per 30 days)atomoxetine oral capsule 80 mg P QL (37 per 30 days)AUSTEDO ORAL AD PA; SPBANZEL ORAL NPBELBUCA BUCCAL NP PAbelladonna alkaloids-opium rectal suppository 16.2-60 mg AD QL (120 per 30 days)

BELSOMRA ORAL NP PAbenztropine injection ADbenztropine oral ADBRINTELLIX ORAL TABLET 20 MG NP PABRISDELLE ORAL NP PABRIVIACT ORAL NP PAbromocriptine oral tablet ADBUNAVAIL BUCCAL NP PAbuprenorphine hcl sublingual NP PA; QL (90 per 30 days)buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour

NP PA; QL (4 per 30 days)

buprenorphine transdermal patch weekly 7.5 mcg/hour NP PA


Drug Tier Limits or Restrictionsbuprenorphine-naloxone sublingual film 12-3 mg NP PA; QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg, 8-2 mg NP PA

buprenorphine-naloxone sublingual film 4-1 mg NP PA; QL (180 per 30 days)

buprenorphine-naloxone sublingual tablet 2-0.5 mg P QL (360 per 30 days)

buprenorphine-naloxone sublingual tablet 8-2 mg P QL (90 per 30 days)

bupropion hcl (smoking deter) oral P QL (60 per 30 days)bupropion hcl oral tablet Pbupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg P QL (30 per 30 days)

bupropion hcl oral tablet extended release 24 hr 450 mg P

bupropion hcl oral tablet sustained-release 12 hr P QL (60 per 30 days)

buspirone oral ADBUTALBITAL COMPOUND W/CODEINE ORAL AD QL (180 per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg AD QL (180 per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg AD QL (180 per 30 days)

butalbital-acetaminophen-caff oral capsule 50-325-40 mg AD QL (180 per 30 days)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg AD QL (180 per 30 days)

butalbital-aspirin-caffeine oral capsule ADBUTRANS TRANSDERMAL P PAcabergoline oral ADcaffeine citrate intravenous ADcaffeine citrate oral ADCAPITAL WITH CODEINE ORAL NP PAcarbamazepine oral capsule, er multiphase 12 hr NP PA

carbamazepine oral suspension 100 mg/5 ml P

carbamazepine oral tablet Pcarbamazepine oral tablet extended release 12 hr P


43

Drug Tier Limits or Restrictionscarbamazepine oral tablet,chewable PCARBATROL ORAL NP PAcarbidopa-levodopa oral Pcarbidopa-levodopa-entacapone oral ADcarisoprodol-asa-codeine oral NP PACELEBREX ORAL NP PAcelecoxib oral PCELEXA ORAL TABLET NP PACELONTIN ORAL CAPSULE 300 MG Pchlordiazepoxide hcl oral ADchlorpromazine injection ADchlorpromazine oral ADcholine,magnesium salicylate oral ADcitalopram oral solution Pcitalopram oral tablet P QL (30 per 30 days)clobazam oral suspension NP PAclobazam oral tablet Pclomipramine oral ADclonazepam oral ADclonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml) AD

clorazepate dipotassium oral ADclozapine oral PCLOZARIL ORAL NP PAcodeine sulfate oral tablet AD QL (180 per 30 days)COMPRO RECTAL ADCONCERTA ORAL NP PACOTEMPLA XR-ODT ORAL NP PACYMBALTA ORAL NP PADAYPRO ORAL NP PADAYTRANA TRANSDERMAL NP PADEPAKENE ORAL NP PADEPAKOTE ER ORAL NP PADEPAKOTE ORAL NP PADEPAKOTE SPRINKLES ORAL NP PAdesipramine oral ADdesvenlafaxine fumarate oral NP PA


Drug Tier Limits or Restrictionsdesvenlafaxine oral tablet extended release 24 hr NP PA

desvenlafaxine oral tablet extended release 24hr 50 mg NP PA

desvenlafaxine succinate oral NP PA; QL (30 per 30 days)DEXEDRINE SPANSULE ORAL NP PAdexmethylphenidate oral capsule,er biphasic 50-50 NP PA

dexmethylphenidate oral tablet 10 mg P QL; QL (60 per 30 days)dexmethylphenidate oral tablet 2.5 mg P QL; QL (240 per 30 days)dexmethylphenidate oral tablet 5 mg P QL; QL (120 per 30 days)dextroamphetamine oral capsule, extended release 10 mg P QL (180 per 30 days)

dextroamphetamine oral capsule, extended release 15 mg P QL (120 per 30 days)

dextroamphetamine oral capsule, extended release 5 mg P QL (360 per 30 days)

dextroamphetamine oral solution NP PAdextroamphetamine oral tablet 10 mg P QL (180 per 30 days)dextroamphetamine oral tablet 5 mg P QL (360 per 30 days)dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg P QL (180 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 15 mg P QL (120 per 30 days)





dextroamphetamine-amphetamine oral tablet 10 mg P QL (180 per 30 days)

dextroamphetamine-amphetamine oral tablet 12.5 mg P QL (144 per 30 days)





45

Drug Tier Limits or Restrictionsdextroamphetamine-amphetamine oral tablet 5 mg P QL (360 per 30 days)

dextroamphetamine-amphetamine oral tablet 7.5 mg P QL (240 per 30 days)

DIACOMIT ORAL NP PADIASTAT ACUDIAL RECTAL PDIASTAT RECTAL Pdiazepam injection ADDIAZEPAM INTENSOL ORAL ADdiazepam oral solution ADdiazepam oral tablet ADdiazepam rectal NP PAdiclofenac epolamine transdermal NP PAdiclofenac potassium oral ADdiclofenac sodium oral Pdiclofenac sodium topical gel 1 % NP PAdiflunisal oral ADdihydroergotamine injection ADDILANTIN EXTENDED ORAL PDILANTIN INFATABS ORAL NP PADILANTIN ORAL PDILANTIN-125 ORAL NP PADISKETS ORAL AD QL (30 per 30 days)divalproex oral Pdoxepin oral ADdroperidol injection solution ADDUEXIS ORAL NP PAduloxetine oral capsule,delayed release(dr/ec) 20 mg P QL (60 per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30 mg, 40 mg, 60 mg P QL (30 per 30 days)

DURAGESIC TRANSDERMAL NP PADYANAVEL XR ORAL NP PAEC-NAPROXEN ORAL PEDLUAR SUBLINGUAL NP PAEFFEXOR XR ORAL NP PAeletriptan oral NP PAEMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL NP PA


Drug Tier Limits or RestrictionsEMGALITY PEN SUBCUTANEOUS P PAEMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML P PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3) AD PA

ENDOCET ORAL TABLET 10-325 MG AD QL (180 per 30 days)ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG AD QL (360 per 30 days)

ENDOCET ORAL TABLET 7.5-325 MG AD QL (240 per 30 days)entacapone oral ADEPIDIOLEX ORAL NP SP; PAEPITOL ORAL Pescitalopram oxalate oral solution Pescitalopram oxalate oral tablet P QL (30 per 30 days)estazolam oral ADeszopiclone oral P QL (30 per 30 days)ethosuximide oral Petodolac oral ADEVEKEO ORAL NP PAEVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML AD

EXALGO ER ORAL NP PAFANAPT ORAL PFAZACLO ORAL NP PAfelbamate oral PFELBATOL ORAL SUSPENSION PFELBATOL ORAL TABLET NP PAfenoprofen oral capsule 400 mg NP PAfenoprofen oral tablet NP PAfentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

AD PA; QL (30 per 30 days)

fentanyl citrate buccal lozenge on a handle 200 mcg AD PA; QL (90 per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 75 mcg/hr NP PA; QL (10 per 30 days)

fentanyl transdermal patch 72 hour 25 mcg/hr, 50 mcg/hr P PA; QL (10 per 30 days)

fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour NP PA


47

Drug Tier Limits or RestrictionsFETZIMA ORAL NP PAFLECTOR TRANSDERMAL NP PAflumazenil intravenous ADfluoxetine oral capsule 10 mg P QL (30 per 30 days)fluoxetine oral capsule 20 mg Pfluoxetine oral capsule 40 mg P QL (60 per 30 days)fluoxetine oral capsule,delayed release(dr/ec) NP PA

fluoxetine oral solution Pfluoxetine oral tablet NP PAfluphenazine decanoate injection ADfluphenazine hcl injection ADfluphenazine hcl oral ADflurazepam oral ADflurbiprofen oral Pfluvoxamine oral capsule,extended release 24hr NP PA

fluvoxamine oral tablet 100 mg P QL (90 per 30 days)fluvoxamine oral tablet 25 mg P QL (30 per 30 days)fluvoxamine oral tablet 50 mg P QL (60 per 30 days)FOCALIN ORAL NP PAFOCALIN XR ORAL PFORFIVO XL ORAL NP PAfosphenytoin injection ADFROVA ORAL NP PAfrovatriptan oral NP PAFYCOMPA ORAL SUSPENSION NP PAFYCOMPA ORAL TABLET NPgabapentin oral capsule Pgabapentin oral solution 250 mg/5 ml (5 ml) AD

gabapentin oral solution 250 mg/5 ml, 300 mg/6 ml (6 ml) P

gabapentin oral tablet 600 mg, 800 mg PGABITRIL ORAL PGEODON INTRAMUSCULAR NP PAGEODON ORAL NP PAGOCOVRI ORAL NP PAGRALISE 30-DAY STARTER PACK ORAL NP PAUCare Comprehensive FormularyEffective: November 1, 201948

Drug Tier Limits or RestrictionsGRALISE ORAL NP PAguanfacine oral tablet ADguanfacine oral tablet extended release 24 hr P

haloperidol decanoate intramuscular ADhaloperidol lactate injection ADhaloperidol lactate oral ADhaloperidol oral ADHEMANGEOL ORAL NP PAHETLIOZ ORAL NP PAHORIZANT ORAL NP PAhydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml AD QL (5400 per 30 days)

hydrocodone-acetaminophen oral tablet 10-300 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

AD QL (360 per 30 days)

hydrocodone-acetaminophen oral tablet 10-325 mg AD QL (270 per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg AD QL (150 per 30 days)

hydromorphone oral liquid AD QL (675 per 30 days)hydromorphone oral tablet 2 mg AD QL (180 per 30 days)hydromorphone oral tablet 4 mg AD QL (150 per 30 days)hydromorphone oral tablet 8 mg AD QL (60 per 30 days)hydromorphone oral tablet extended release 24 hr NP PA

hydromorphone rectal AD QL (120 per 30 days)hydroxyzine hcl intramuscular solution 25 mg/ml AD

hydroxyzine hcl oral solution 10 mg/5 ml ADhydroxyzine hcl oral tablet ADhydroxyzine pamoate oral ADHYSINGLA ER ORAL NP PAibuprofen oral tablet 400 mg ADibuprofen oral tablet 600 mg, 800 mg NP PAimipramine hcl oral ADimipramine pamoate oral ADIMITREX NASAL NP PAIMITREX ORAL NP PAINBRIJA INHALATION NP PAUCare Comprehensive FormularyEffective: November 1, 2019

49

Drug Tier Limits or RestrictionsINDERAL LA ORAL NP PAINDERAL XL ORAL NP PAindomethacin oral capsule 25 mg Pindomethacin oral capsule 50 mg ADINNOPRAN XL ORAL NP PAINTERMEZZO SUBLINGUAL NP PAINTUNIV ER ORAL NP PAINVEGA ORAL NP PAINVEGA SUSTENNA INTRAMUSCULAR PINVEGA TRINZA INTRAMUSCULAR PKADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

NP PA

KEPPRA ORAL NP PAKEPPRA XR ORAL NP PAketoprofen oral capsule Pketoprofen oral capsule,ext rel. pellets 24 hr 200 mg AD

ketorolac injection cartridge ADketorolac injection solution ADketorolac intramuscular solution ADketorolac oral P QL (20 per 30 days)KHEDEZLA ORAL NP PALAMICTAL ODT ORAL NP PALAMICTAL ODT STARTER (BLUE) ORAL NP PALAMICTAL ODT STARTER (GREEN) ORAL NP PALAMICTAL ODT STARTER (ORANGE) ORAL NP PALAMICTAL ORAL TABLET NP PALAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG NP PA

LAMICTAL STARTER (BLUE) KIT ORAL NP PALAMICTAL STARTER (GREEN) KIT ORAL NP PALAMICTAL STARTER (ORANGE) KIT ORAL NP PALAMICTAL XR ORAL NP PALAMICTAL XR STARTER (BLUE) ORAL NP PALAMICTAL XR STARTER (GREEN) ORAL NP PALAMICTAL XR STARTER (ORANGE) ORAL NP PAlamotrigine oral tablet P


Drug Tier Limits or Restrictionslamotrigine oral tablet disintegrating, dose pk NP PA

lamotrigine oral tablet extended release 24hr P

lamotrigine oral tablet, chewable dispersible P

lamotrigine oral tablet,disintegrating NP PAlamotrigine oral tablets,dose pack PLATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG P QL (30 per 30 days)

LATUDA ORAL TABLET 80 MG P QL (60 per 30 days)LAZANDA NASAL NP PAlevetiracetam intravenous ADlevetiracetam oral Plevorphanol tartrate oral tablet 2 mg AD QL (120 per 30 days)LEXAPRO ORAL TABLET NP PAlithium carbonate oral ADlithium citrate oral solution 8 meq/5 ml ADlorazepam injection ADLORAZEPAM INTENSOL ORAL ADlorazepam oral ADLORCET (HYDROCODONE) ORAL AD QL (360 per 30 days)LORCET HD ORAL AD QL (360 per 30 days)loxapine succinate oral ADLUNESTA ORAL NP PALYRICA CR ORAL NP PALYRICA ORAL CAPSULE NP PA; QL (90 per 30 days)LYRICA ORAL SOLUTION NP PAmagnesium chloride injection ADmagnesium sulfate in water intravenous ADmagnesium sulfate injection ADmaprotiline oral ADMAXALT ORAL TABLET 10 MG NP PAMAXALT-MLT ORAL NP PAmeclofenamate oral ADmefenamic acid oral NP PAmeloxicam oral suspension ADmeloxicam oral tablet 15 mg Pmeloxicam oral tablet 7.5 mg P QL (30 per 30 days)UCare Comprehensive FormularyEffective: November 1, 2019

51

Drug Tier Limits or Restrictionsmemantine oral capsule,sprinkle,er 24hr NP PAmemantine oral solution NP PAmemantine oral tablet Pmemantine oral tablets,dose pack Pmeperidine oral solution AD QL (1200 per 30 days)meperidine oral tablet 100 mg AD QL (120 per 30 days)meperidine oral tablet 50 mg AD QL (240 per 30 days)meprobamate oral ADMETADATE ER ORAL AD QL; QL (90 per 30 days)methadone oral concentrate NP PA; QL (60 per 30 days)methadone oral solution 10 mg/5 ml NP PA; QL (300 per 30 days)methadone oral solution 5 mg/5 ml NP PA; QL (600 per 30 days)methadone oral tablet 10 mg NP PA; QL (60 per 30 days)methadone oral tablet 5 mg NP PA; QL (120 per 30 days)methadone oral tablet,soluble NP PA; QL (30 per 30 days)METHADOSE ORAL CONCENTRATE AD QL (60 per 30 days)METHADOSE ORAL TABLET,SOLUBLE AD QL (30 per 30 days)METHYLIN ORAL SOLUTION NP PA; QLmethylphenidate hcl oral capsule, er biphasic 30-70 10 mg P QL (180 per 30 days)

methylphenidate hcl oral capsule, er biphasic 30-70 20 mg P QL (90 per 30 days)





methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 60 mg NP PA

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg NP PA; QL

methylphenidate hcl oral solution 10 mg/5 ml NP PA; QL (180 per 30 days)

methylphenidate hcl oral solution 5 mg/5 ml NP PA; QL (360 per 30 days)

methylphenidate hcl oral tablet 10 mg P QL; QL (180 per 30 days)methylphenidate hcl oral tablet 20 mg P QL; QL (90 per 30 days)


Drug Tier Limits or Restrictionsmethylphenidate hcl oral tablet 5 mg P QL; QL (360 per 30 days)methylphenidate hcl oral tablet extended release 10 mg P QL (180 per 30 days)

methylphenidate hcl oral tablet extended release 20 mg P QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg P QL (120 per 30 days)




methylphenidate hcl oral tablet extended release 24hr 72 mg P

methylphenidate hcl oral tablet,chewable 10 mg P QL (180 per 30 days)

methylphenidate hcl oral tablet,chewable 2.5 mg P QL (720 per 30 days)

methylphenidate hcl oral tablet,chewable 5 mg P QL (360 per 30 days)

MIRAPEX ER ORAL NP PAMIRAPEX ORAL NP PAmirtazapine oral PMOBIC ORAL TABLET NP PAmodafinil oral NP PAMORPHABOND ER ORAL NP PAmorphine concentrate oral solution AD QL (135 per 30 days)morphine oral capsule, er multiphase 24 hr NP PAmorphine oral capsule,extend.release pellets NP PA

morphine oral solution 10 mg/5 ml AD QL (900 per 30 days)morphine oral solution 20 mg/5 ml (4 mg/ml) AD QL (675 per 30 days)

morphine oral tablet 15 mg AD PA; QL (180 per 30 days)morphine oral tablet 30 mg AD QL (90 per 30 days)morphine oral tablet extended release 100 mg, 200 mg, 60 mg P PA; QL (30 per 30 days)

morphine oral tablet extended release 15 mg P PA; QL (120 per 30 days)


53

Drug Tier Limits or Restrictionsmorphine oral tablet extended release 30 mg P PA; QL (90 per 30 days)

morphine rectal suppository 10 mg AD QL (270 per 30 days)morphine rectal suppository 20 mg AD QL (120 per 30 days)morphine rectal suppository 30 mg AD QL (90 per 30 days)morphine rectal suppository 5 mg AD QL (360 per 30 days)MS CONTIN ORAL NP PAMYDAYIS ORAL NP PAMYSOLINE ORAL NP PAnabumetone oral Pnalbuphine injection ADNALFON ORAL CAPSULE 400 MG NP PANALFON ORAL TABLET NP PAnaloxone injection Pnaltrexone oral ADNAMENDA ORAL TABLET NP PANAMENDA TITRATION PAK ORAL NP PANAMENDA XR ORAL NP PANAMZARIC ORAL NP PAnaproxen oral suspension ADnaproxen oral tablet Pnaproxen oral tablet,delayed release (dr/ec) P

naproxen sodium oral tablet 275 mg, 550 mg P

naratriptan oral NP PANARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION P

nefazodone oral PNEURONTIN ORAL NP PAnortriptyline oral ADNUCYNTA ER ORAL NP PANUCYNTA ORAL NP PANUEDEXTA ORAL AD PA; QL (60 per 30 days)NUPLAZID ORAL NP PAolanzapine intramuscular Polanzapine oral tablet P QL (30 per 30 days)olanzapine oral tablet,disintegrating NP PA; QL (30 per 30 days)olanzapine-fluoxetine oral NP PAUCare Comprehensive FormularyEffective: November 1, 201954

Drug Tier Limits or RestrictionsONFI ORAL SUSPENSION NP PAONFI ORAL TABLET 10 MG, 20 MG NP PAONZETRA XSAIL NASAL NP PAOPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR NP PA

oxaprozin oral NP PAoxazepam oral ADoxcarbazepine oral POXTELLAR XR ORAL NP PAoxycodone oral capsule AD QL (360 per 30 days)oxycodone oral concentrate AD QL (90 per 30 days)oxycodone oral solution AD QL (1200 per 30 days)oxycodone oral tablet 10 mg AD QL (180 per 30 days)oxycodone oral tablet 15 mg AD QL (120 per 30 days)oxycodone oral tablet 20 mg AD QL (90 per 30 days)oxycodone oral tablet 30 mg AD QL (60 per 30 days)oxycodone oral tablet 5 mg AD QL (360 per 30 days)OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG


OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG NP PA; QL (60 per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG


oxycodone-acetaminophen oral tablet 10-325 mg AD QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg AD QL (360 per 30 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg AD QL (240 per 30 days)

oxycodone-aspirin oral AD QL (360 per 30 days)OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG NP PA; QL (60 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG



55

Drug Tier Limits or Restrictionsoxymorphone oral tablet extended release 12 hr NP PA

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg NP PA; QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg NP PA; QL (60 per 30 days)

paroxetine hcl oral tablet 10 mg, 40 mg P QL (30 per 30 days)paroxetine hcl oral tablet 20 mg, 30 mg P QL (60 per 30 days)paroxetine hcl oral tablet extended release 24 hr NP PA; QL (60 per 30 days)

paroxetine mesylate(menop.sym) oral NP PAPAXIL CR ORAL NP PAPAXIL ORAL NP PAPEGANONE ORAL Ppentazocine-naloxone oral ADperphenazine oral ADperphenazine-amitriptyline oral ADPEXEVA ORAL NP PAphenelzine oral ADphenobarbital oral ADphenobarbital sodium injection solution ADPHENYTEK ORAL Pphenytoin oral suspension Pphenytoin oral tablet,chewable Pphenytoin sodium extended oral Pphenytoin sodium intravenous ADpiroxicam oral ADPOTIGA ORAL TABLET 200 MG, 400 MG, 50 MG NP PA

pramipexole oral tablet Ppramipexole oral tablet extended release 24 hr NP PA

primidone oral PPRISTIQ ORAL NP PAPROBUPHINE SUBDERMAL NP PAPROCENTRA ORAL NP PAprochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) AD

prochlorperazine maleate oral AD


Drug Tier Limits or Restrictionsprochlorperazine rectal ADpromethazine injection solution ADpromethazine oral ADpromethazine rectal suppository 12.5 mg, 25 mg AD

propranolol intravenous ADpropranolol oral capsule,extended release 24 hr 120 mg, 160 mg NP PA


propranolol oral solution Ppropranolol oral tablet Pprotriptyline oral ADPROVIGIL ORAL PPROZAC ORAL CAPSULE NP PAQUDEXY XR ORAL NP PAquetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg P QL (90 per 30 days)

quetiapine oral tablet 300 mg, 400 mg P QL (60 per 30 days)quetiapine oral tablet extended release 24 hr P QL (60 per 30 days)

QUILLICHEW ER ORAL NP PAQUILLIVANT XR ORAL NP PAramelteon oral AD QL (30 per 30 days)RELPAX ORAL PREMERON ORAL TABLET 15 MG, 30 MG NP PAREMERON SOLTAB ORAL NP PAREQUIP ORAL NP PAREQUIP XL ORAL NP PAREXULTI ORAL NP PAriluzole oral ADRISPERDAL CONSTA INTRAMUSCULAR PRISPERDAL ORAL NP PArisperidone oral solution Prisperidone oral tablet P QL (60 per 30 days)risperidone oral tablet,disintegrating P QL (60 per 30 days)RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 30 MG, 40 MG P

RITALIN ORAL NP PA


57

Drug Tier Limits or Restrictionsrizatriptan oral P QLropinirole oral tablet Propinirole oral tablet extended release 24 hr NP PA

ROWEEPRA ORAL PROWEEPRA XR ORAL PROZEREM ORAL P QL (30 per 30 days)RYTARY ORAL NP PASABRIL ORAL NP PAsalsalate oral ADSAPHRIS SUBLINGUAL PSARAFEM ORAL TABLET 10 MG, 20 MG NP PASAVELLA ORAL TABLET P QL (60 per 30 days)SAVELLA ORAL TABLETS,DOSE PACK P QL (55 per 30 days)SECONAL SODIUM ORAL ADselegiline hcl oral ADSEROQUEL ORAL NP PASEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR NP PA

sertraline oral concentrate Psertraline oral tablet 100 mg P QL (60 per 30 days)sertraline oral tablet 25 mg P QL (30 per 30 days)sertraline oral tablet 50 mg P QL; QL (60 per 30 days)SINEMET CR ORAL NP PASINEMET ORAL NP PASONATA ORAL NP PASPRAVATO NASAL AD PA; SPSPRITAM ORAL NP PASTRATTERA ORAL NP PASUBLOCADE SUBCUTANEOUS NP PASUBOXONE SUBLINGUAL FILM 12-3 MG P QL (60 per 30 days)SUBOXONE SUBLINGUAL FILM 2-0.5 MG P QL (360 per 30 days)SUBOXONE SUBLINGUAL FILM 4-1 MG P QL (180 per 30 days)SUBOXONE SUBLINGUAL FILM 8-2 MG P QL (90 per 30 days)sulindac oral Psumatriptan nasal spray,non-aerosol 20 mg/actuation P QL (18 per 30 days)

sumatriptan nasal spray,non-aerosol 5 mg/actuation P QL (36 per 30 days)


Drug Tier Limits or Restrictionssumatriptan succinate oral tablet 100 mg, 25 mg P QL (18 per 30 days)

sumatriptan succinate oral tablet 50 mg P QLsumatriptan succinate subcutaneous cartridge AD QL (8 per 30 days)

sumatriptan succinate subcutaneous pen injector AD QL (8 per 30 days)

sumatriptan succinate subcutaneous solution AD QL (8 per 30 days)

sumatriptan-naproxen oral NP PASYMBYAX ORAL NP PATEGRETOL ORAL SUSPENSION NP PATEGRETOL ORAL TABLET NP PATEGRETOL XR ORAL NP PAtemazepam oral ADtetrabenazine oral AD PA; SPthioridazine oral ADthiothixene oral ADtiagabine oral NP PAtimolol maleate oral NP PAtolmetin oral ADTOPAMAX ORAL NP PAtopiramate oral capsule, sprinkle Ptopiramate oral capsule,sprinkle,er 24hr NP PAtopiramate oral tablet Ptramadol oral tablet AD QL (240 per 30 days)tramadol-acetaminophen oral AD QL (240 per 30 days)tranylcypromine oral ADtrazodone oral PTREXIMET ORAL NP PAtriazolam oral ADtrifluoperazine oral ADtrihexyphenidyl oral ADTRILEPTAL ORAL NP PATRINTELLIX ORAL NP PA; QL (30 per 30 days)TROKENDI XR ORAL NP PAvalproate sodium intravenous ADvalproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml) AD


59

Drug Tier Limits or Restrictionsvalproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml) P

valproic acid oral Pvenlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg P QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 75 mg P QL

venlafaxine oral tablet P QL (90 per 30 days)venlafaxine oral tablet extended release 24hr NP PA

VERSACLOZ ORAL NP PAvigabatrin oral NP PAVIGADRONE ORAL NP PAVIIBRYD ORAL TABLET NP PA; QL (30 per 30 days)VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) NP PA; QL (30 per 30 days)

VIMOVO ORAL NP PAVIMPAT INTRAVENOUS ADVIMPAT ORAL NP PAVOLTAREN TOPICAL NP PAVRAYLAR ORAL NP PAVYVANSE ORAL CAPSULE 10 MG P QL (210 per 30 days)VYVANSE ORAL CAPSULE 20 MG P QL (105 per 30 days)VYVANSE ORAL CAPSULE 30 MG P QL (70 per 30 days)VYVANSE ORAL CAPSULE 40 MG P QL (52 per 30 days)VYVANSE ORAL CAPSULE 50 MG P QL (42 per 30 days)VYVANSE ORAL CAPSULE 60 MG P QL (35 per 30 days)VYVANSE ORAL CAPSULE 70 MG P QL (30 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 10 MG NP PA; QL (210 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 20 MG NP PA; QL (105 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 30 MG NP PA; QL (70 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 40 MG NP PA; QL (52 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 50 MG NP PA; QL (42 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 60 MG NP PA; QL (35 per 30 days)WELLBUTRIN SR ORAL NP PAWELLBUTRIN XL ORAL NP PAXADAGO ORAL NP PAXTAMPZA ER ORAL NP PAYOSPRALA ORAL NP PA


Drug Tier Limits or Restrictionszaleplon oral capsule 10 mg P QL (60 per 30 days)zaleplon oral capsule 5 mg P QL (30 per 30 days)ZARONTIN ORAL NP PAZEMBRACE SYMTOUCH SUBCUTANEOUS NP PAZENZEDI ORAL NP PAziprasidone hcl oral P QL (60 per 30 days)ZIPSOR ORAL NP PAZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR NP PA

zolmitriptan oral NP PA; QL (18 per 30 days)ZOLOFT ORAL NP PAzolpidem oral tablet P QL (30 per 30 days)zolpidem oral tablet,ext release multiphase NP PA; QL (30 per 30 days)zolpidem sublingual NP PAZOLPIMIST ORAL NP PAZOMIG NASAL NP PAZOMIG ORAL NP PAZOMIG ZMT ORAL NP PAzonisamide oral PZORVOLEX ORAL NP PAZUBSOLV SUBLINGUAL NP PAZYBAN ORAL NP PAZYPREXA INTRAMUSCULAR NP PAZYPREXA ORAL NP PAZYPREXA RELPREVV INTRAMUSCULAR NP PAZYPREXA ZYDIS ORAL NP PADEVICESACCU-CHEK AVIVA PLUS METER PACCU-CHEK GUIDE GLUCOSE METER PACCU-CHEK GUIDE ME GLUCOSE MTR PACCU-CHEK NANO PACE AEROSOL CLOUD ENHANCER ADCLEO 90 INFUSION SET 24" ADCOMFORT SHORT INFUSION SET 23" ADCONTOUR METER PCONTOUR NEXT EZ METER PCONTOUR NEXT METER PCONTOUR NEXT ONE METER P


61

Drug Tier Limits or RestrictionsDEXCOM G4 RECEIVER AD PADEXCOM G4 RECEIVER PEDIATRIC AD PADEXCOM G4 RECEIVER-SHARE (PED) AD PADEXCOM G4 RECEIVER-SHARE KIT AD PADEXCOM G4 TRANSMITTER AD PADEXCOM G5 RECEIVER AD PADEXCOM G5 TRANSMITTER AD PADEXCOM G5-G4 SENSOR AD PADEXCOM G6 RECEIVER AD PADEXCOM G6 SENSOR AD PADEXCOM G6 TRANSMITTER AD PADEXCOM RECEIVER AD PAECLIPSE SYRINGE SYRINGE 3 ML 21 GAUGE X 1" AD

FORA G20 KIT NP PAFREESTYLE FREEDOM LITE NP PAFREESTYLE INSULINX NP PAFREESTYLE LIBRE 10 DAY READER AD PAFREESTYLE LIBRE 10 DAY SENSOR AD PAFREESTYLE LIBRE 14 DAY READER AD PAFREESTYLE LIBRE 14 DAY SENSOR AD PAFREESTYLE LITE METER NP PAGLUCOCARD EXPRESSION NP PAGLUCOCARD EXPRESSION KIT NP PAGLUCOCARD SHINE METER NP PAGLUCOCARD SHINE METER KIT NP PAGLUCOCARD SHINE XL METER NP PAHEP FLUSH-10 (PF) INTRAVENOUS ADheparin (porcine) in nacl (pf) intravenous ADheparin flush(porcine)-0.9nacl intravenous ADheparin lock flush (porcine) intravenous syringe 100 unit/ml AD

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE AD

HEPARIN LOCK INTRAVENOUS ADHEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS AD

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml AD


Drug Tier Limits or RestrictionsMONOJECT MAGELLAN SYRINGE SYRINGE 3 ML 20 GAUGE X 1" AD

MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE AD

NORMAL SALINE FLUSH INJECTION ADONETOUCH ULTRA2 METER NP PAONETOUCH ULTRAMINI NP PAONETOUCH VERIO FLEX NP PAONETOUCH VERIO IQ METER NP PAONETOUCH VERIO SYSTEM NP PAPOLYFIN QR INFUSION SET ADPRECISION XTRA MONITOR NP PAPRODIGY POCKET METER NP PAPRODIGY VOICE GLUCOSE METER NP PAsodium chloride 0.9 % (flush) injection syringe AD

syringe with needle, safety syringe 1 ml 25 gauge x 5/8" AD

T:SLIM SUBCUTANEOUS ADTRUE METRIX AIR GLUCOSE METER NP PATRUE METRIX GLUCOSE METER NP PAWAVESENSE PRESTO NP PAWAVESENSE PRESTO KIT NP PADIAGNOSTIC AGENTSACCU-CHEK AVIVA PLUS TEST STRP PACCU-CHEK COMPACT PLUS TEST PACCU-CHEK GUIDE PACCU-CHEK SMARTVIEW TEST STRIP PCANDIN INTRADERMAL ADCONTOUR NEXT TEST STRIPS PCONTOUR TEST STRIPS Pcosyntropin injection ADcosyntropin intravenous ADE-Z-CAT DRY ORAL ADE-Z-HD BARIUM ORAL ADE-Z-PAQUE ORAL ADfluorescein-proparacaine ophthalmic (eye) ADFORA G20 STRIP NP PAFREESTYLE INSULINX STRIP NP PAUCare Comprehensive FormularyEffective: November 1, 2019

63

Drug Tier Limits or RestrictionsFREESTYLE INSULINX TEST STRIPS NP PAFREESTYLE LITE STRIPS NP PAFREESTYLE TEST NP PAGLUCAGEN DIAGNOSTIC KIT INJECTION ADGLUCAGON HCL INJECTION ADGLUCOCARD EXPRESSION STRIP NP PAGLUCOCARD SHINE TEST STRIPS NP PAISOVUE-300 INTRAVENOUS ADISOVUE-M 300 INTRATHECAL ADLIQUID E-Z PAQUE ORAL ADmannitol 10 % intravenous ADmannitol 20 % intravenous ADmannitol 25 % intravenous solution ADmannitol 5 % intravenous ADOMNIPAQUE 140 INTRAVENOUS ADOMNIPAQUE 240 INTRAVENOUS ADOMNIPAQUE 300 INTRAVENOUS ADONETOUCH ULTRA BLUE TEST STRIP NP PAONETOUCH VERIO NP PAPRECISION XTRA TEST NP PAPRODIGY NO CODING NP PAREADI-CAT 2 ORAL SUSPENSION 2.1 % (W/V), 2.0 % (W/W) AD

TAGITOL V ORAL ADthallous chloride tl-201 intravenous solution 37 mbq/ml (1 mci/ml) AD

THYROGEN INTRAMUSCULAR AD SPTRUE METRIX GLUCOSE TEST STRIP NP PAVARIBAR THIN HONEY ORAL ADVARIBAR THIN LIQUID ORAL ADVISIPAQUE INTRAVENOUS SOLUTION 270 MG IODINE/ML AD

VOLUMEN ORAL ADWAVESENSE PRESTO STRIP NP PAELECTROLYTIC, CALORIC, AND WATER BALANCEACCURETIC ORAL NP PAacetazolamide oral ADacetazolamide sodium injection ADUCare Comprehensive FormularyEffective: November 1, 201964

Drug Tier Limits or Restrictionsacetic acid irrigation ADamiloride-hydrochlorothiazide oral ADamlodipine-valsartan-hcthiazid oral Pammonium chloride intravenous ADATACAND HCT ORAL NP PAatenolol-chlorthalidone oral ADAURYXIA ORAL NP PAAVALIDE ORAL NP PABAL-CARE DHA ORAL ADBD PRE-FILLED NORMAL SALINE INJECTION AD

benazepril-hydrochlorothiazide oral PBENICAR HCT ORAL NP PAbisoprolol-hydrochlorothiazide oral ADbumetanide injection ADbumetanide oral ADcalcium acetate oral capsule Pcalcium acetate oral tablet 667 mg Pcalcium chloride intravenous ADcalcium gluconate intravenous ADcandesartan-hydrochlorothiazid oral NP PAcaptopril-hydrochlorothiazide oral PCARBAGLU ORAL AD SPchlorothiazide oral ADchlorthalidone oral tablet 25 mg, 50 mg ADchromium chloride intravenous ADCONSTULOSE ORAL ADCOPPER CHLORIDE INTRAVENOUS ADCORZIDE ORAL NP PACRYSVITA SUBCUTANEOUS AD PA; SPCYTRA K CRYSTALS ORAL ADCYTRA-2 ORAL ADCYTRA-3 ORAL ADCYTRA-K ORAL ADDELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL AD

DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL AD


65

Drug Tier Limits or RestrictionsDELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL AD

DELFLEX-SM WITH 1.5% DEXTROSE INTRAPERITONEAL AD

dextrose 5 % in ringer's intravenous ADdextrose 5 %-lactated ringers intravenous ADDIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL AD

DIANEAL PD-2 WITH 2.5 % DEX INTRAPERITONEAL AD

DIANEAL PD-2 WITH 4.25 % DEX INTRAPERITONEAL AD

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL AD

DIANEAL WITH 2.5 % DEXTROSE INTRAPERITONEAL AD

DIANEAL WITH 4.25 % DEXTROSE INTRAPERITONEAL AD

DIOVAN HCT ORAL NP PAEDARBYCLOR ORAL NP PAEFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ AD

electrolyte-48 in d5w intravenous ADELIPHOS ORAL ADenalapril-hydrochlorothiazide oral PENULOSE ORAL ADEXFORGE HCT ORAL NP PAfosinopril-hydrochlorothiazide oral PFOSRENOL ORAL NP PAfurosemide injection ADfurosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) AD

furosemide oral tablet ADGENERLAC ORAL ADglycine urologic solution irrigation ADhetastarch 6 % in 0.9 % nacl intravenous ADhydrochlorothiazide oral ADHYZAAR ORAL NP PAindapamide oral ADIONOSOL-B IN D5W INTRAVENOUS AD


Drug Tier Limits or RestrictionsIONOSOL-MB IN D5W INTRAVENOUS ADirbesartan-hydrochlorothiazide oral PISOLYTE S PH 7.4 INTRAVENOUS ADISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS AD

ISOLYTE-S INTRAVENOUS ADJYNARQUE ORAL AD PA; SPK-EFFERVESCENT ORAL ADKIONEX (WITH SORBITOL) ORAL ADKLOR-CON 10 ORAL ADKLOR-CON 8 ORAL ADKLOR-CON M10 ORAL ADKLOR-CON M15 ORAL ADKLOR-CON M20 ORAL ADKLOR-CON ORAL ADKLOR-CON/EF ORAL ADlactated ringers intravenous ADlactated ringers irrigation ADlactulose oral solution ADlanthanum oral NP PAlisinopril-hydrochlorothiazide oral Plosartan-hydrochlorothiazide oral PLOTENSIN HCT ORAL NP PAmanganese chloride intravenous ADmannitol 10 % intravenous ADmannitol 20 % intravenous ADmannitol 25 % intravenous solution ADmannitol 5 % intravenous ADmethyldopa-hydrochlorothiazide oral ADmetolazone oral ADmetoprolol ta-hydrochlorothiaz oral ADMICARDIS HCT ORAL NP PAmoexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg P

moexipril-hydrochlorothiazide oral tablet 7.5-12.5 mg AD

MYNATAL ADVANCE ORAL ADMYNATAL ORAL CAPSULE AD


67

Drug Tier Limits or RestrictionsMYNATAL PLUS ORAL ADMYNATAL-Z ORAL ADnadolol-bendroflumethiazide oral ADNORMAL SALINE FLUSH INJECTION ADNORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS AD

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS AD

NORMOSOL-R INTRAVENOUS ADNORMOSOL-R PH 7.4 INTRAVENOUS ADNUTRILYTE INTRAVENOUS ADolmesartan-amlodipin-hcthiazid oral NP PAolmesartan-hydrochlorothiazide oral NP PAPHOSLYRA ORAL PPHOSPHA 250 NEUTRAL ORAL ADPHYSIOLYTE IRRIGATION ADPHYSIOSOL IRRIGATION IRRIGATION ADPLASMA-LYTE 148 INTRAVENOUS ADPLASMA-LYTE A INTRAVENOUS ADPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA + DOCUSATE ORAL ADPNV-OMEGA ORAL ADpotassium acetate intravenous solution 2 meq/ml AD

potassium bicarb and chloride oral ADpotassium bicarb-citric acid oral ADpotassium chlorid-d5-0.45%nacl intravenous AD

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

AD

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

potassium chloride in lr-d5 intravenous ADpotassium chloride in water intravenous piggyback AD

potassium chloride intravenous ADpotassium chloride oral capsule, extended release AD


Drug Tier Limits or Restrictionspotassium chloride oral liquid ADpotassium chloride oral tablet extended release 10 meq, 8 meq AD

potassium chloride oral tablet,er particles/crystals AD

potassium chloride-0.45 % nacl intravenous AD

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

AD

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

potassium chloride-d5-0.9%nacl intravenous AD

potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

AD

potassium citrate-citric acid oral solution ADpotassium phosphate m-/d-basic intravenous AD

PR NATAL 400 EC ORAL ADPR NATAL 400 ORAL ADPR NATAL 430 EC ORAL ADPR NATAL 430 ORAL ADPRENAISSANCE ORAL ADPRENAISSANCE PLUS ORAL ADPRENATABS FA ORAL ADPRENATABS RX ORAL ADPRENATAL LOW IRON ORAL ADPRENATAL PLUS (CALCIUM CARB) ORAL ADPRENATAL PLUS ORAL ADprobenecid oral ADprobenecid-colchicine oral ADpropranolol-hydrochlorothiazid oral ADquinapril-hydrochlorothiazide oral PRAVICTI ORAL AD SPRENAGEL ORAL PRENVELA ORAL POWDER IN PACKET NP PAringer's intravenous ADringer's irrigation AD


69

Drug Tier Limits or Restrictionsselenium intravenous ADsevelamer carbonate oral NP PAsevelamer hcl oral NP PAsodium acetate intravenous ADsodium bicarbonate intravenous ADsodium chlor 0.9% bacteriostat injection ADsodium chloride 0.45 % intravenous ADsodium chloride 0.9 % (flush) injection syringe AD

sodium chloride 0.9 % injection ADsodium chloride 0.9 % intravenous ADsodium chloride 3 % intravenous ADsodium chloride 5 % intravenous ADsodium chloride intravenous ADsodium chloride irrigation ADsodium citrate-citric acid oral ADsodium lactate intravenous ADsodium phenylbutyrate oral ADsodium phosphate intravenous ADSODIUM POLYSTYRENE (SORB FREE) ORAL ADsodium polystyrene sulfonate oral powder ADsodium polystyrene sulfonate rectal enema 30 gram/120 ml AD

spironolactone oral ADspironolacton-hydrochlorothiaz oral ADSPS (WITH SORBITOL) ORAL ADSPS (WITH SORBITOL) RECTAL ADTEKTURNA HCT ORAL Ptelmisartan-hydrochlorothiazid oral NP PATENORETIC 100 ORAL NP PATENORETIC 50 ORAL NP PATHEOCHRON ORAL ADtheophylline oral elixir ADtheophylline oral solution ADtheophylline oral tablet extended release 12 hr AD

TL-SELECT ORAL ADtorsemide oral AD


Drug Tier Limits or RestrictionsTRIADVANCE ORAL ADtriamterene-hydrochlorothiazid oral ADTRIBENZOR ORAL NP PATRICITRATES ORAL ADTRINATAL RX 1 ORAL ADTRINATE ORAL ADTRIVEEN-DUO DHA ORAL ADTRIVEEN-ONE ORAL ADTRIVEEN-PRX RNF ORAL ADvalsartan-hydrochlorothiazide oral PVASERETIC ORAL NP PAVELPHORO ORAL NP PAVELTASSA ORAL AD SPVENA-BAL DHA ORAL ADVINACAL ORAL ADVINATE ONE ORAL ADVINATE ULTRA ORAL ADVIRT-PN PLUS ORAL ADVIRT-SELECT ORAL ADVITAFOL-OB ORAL ADwater for irrigation, sterile irrigation ADZATEAN-PN PLUS ORAL ADZESTORETIC ORAL NP PAZIAC ORAL NP PAzinc chloride intravenous ADzinc sulfate intravenous solution 5 mg/ml ADENZYMESCATHFLO ACTIVASE INTRA-CATHETER ADELELYSO INTRAVENOUS AD PA; SPFABRAZYME INTRAVENOUS AD PA; SPLUMIZYME INTRAVENOUS AD PA; SPPALYNZIQ SUBCUTANEOUS AD PA; SPPULMOZYME INHALATION AD SPREVCOVI INTRAMUSCULAR AD PA; SPSTRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML, 80 MG/0.8 ML AD PA

VIMIZIM INTRAVENOUS AD SPVPRIV INTRAVENOUS AD PA; SP


71

Drug Tier Limits or RestrictionsEYE, EAR, NOSE AND THROAT (EENT) PREPS.acetazolamide oral ADacetazolamide sodium injection ADacetic acid otic (ear) ADACULAR LS OPHTHALMIC (EYE) NP PAACULAR OPHTHALMIC (EYE) NP PAACUVAIL (PF) OPHTHALMIC (EYE) NP PAALAWAY OPHTHALMIC (EYE) PALOCRIL OPHTHALMIC (EYE) NP PAALOMIDE OPHTHALMIC (EYE) NP PAALPHAGAN P OPHTHALMIC (EYE) PALREX OPHTHALMIC (EYE) NP PAapraclonidine ophthalmic (eye) NP PAASTEPRO NASAL SPRAY,NON-AEROSOL NP PAatropine ophthalmic (eye) drops ADatropine ophthalmic (eye) ointment ADAZASITE OPHTHALMIC (EYE) NP PAazelastine nasal P QL (60 per 30 days)azelastine ophthalmic (eye) NP PAAZOPT OPHTHALMIC (EYE) NP PAbacitracin ophthalmic (eye) ADbacitracin-polymyxin b ophthalmic (eye) ADBACTROBAN NASAL NASAL ADBALANCED SALT INTRAOCULAR ADBECONASE AQ NASAL NP PABEPREVE OPHTHALMIC (EYE) NP PABESIVANCE OPHTHALMIC (EYE) NP PAbetaxolol ophthalmic (eye) PBETOPTIC S OPHTHALMIC (EYE) NP PAbimatoprost ophthalmic (eye) NP PABLEPHAMIDE OPHTHALMIC (EYE) ADBLEPHAMIDE S.O.P. OPHTHALMIC (EYE) ADbrimonidine ophthalmic (eye) drops 0.15 % NP PA

brimonidine ophthalmic (eye) drops 0.2 % Pbromfenac ophthalmic (eye) NP PABROMSITE OPHTHALMIC (EYE) NP PA


Drug Tier Limits or Restrictionsbudesonide nasal NP PAcarteolol ophthalmic (eye) NP PACHILDREN'S ALAWAY OPHTHALMIC (EYE) Pchlorhexidine gluconate mucous membrane ADCILOXAN OPHTHALMIC (EYE) NP PACIPRO HC OTIC (EAR) PCIPRODEX OTIC (EAR) Pciprofloxacin hcl ophthalmic (eye) Pciprofloxacin hcl otic (ear) NP PACOMBIGAN OPHTHALMIC (EYE) PCOSOPT (PF) OPHTHALMIC (EYE) NP PACOSOPT OPHTHALMIC (EYE) NP PAcromolyn ophthalmic (eye) Pcyclopentolate ophthalmic (eye) drops 1 %, 2 % AD

CYSTARAN OPHTHALMIC (EYE) AD SPdexamethasone sodium phosphate ophthalmic (eye) AD

diclofenac sodium ophthalmic (eye) Pdorzolamide ophthalmic (eye) Pdorzolamide-timolol (pf) ophthalmic (eye) dropperette NP PA

dorzolamide-timolol ophthalmic (eye) Pdoxycycline hyclate oral tablet 20 mg ADDYMISTA NASAL NP PAELESTAT OPHTHALMIC (EYE) NP PAEMADINE OPHTHALMIC (EYE) NP PAepinastine ophthalmic (eye) NP PAerythromycin ophthalmic (eye) ADEYE ITCH RELIEF OPHTHALMIC (EYE) Pflunisolide nasal spray,non-aerosol 25 mcg (0.025 %) NP PA; QL (50 per 30 days)

fluorescein-proparacaine ophthalmic (eye) ADfluorometholone ophthalmic (eye) ADflurbiprofen sodium ophthalmic (eye) NP PAgatifloxacin ophthalmic (eye) NP PAGENTAK OPHTHALMIC (EYE) OINTMENT ADgentamicin ophthalmic (eye) ADhydrocortisone-acetic acid otic (ear) ADUCare Comprehensive FormularyEffective: November 1, 2019

73

Drug Tier Limits or RestrictionsIOPIDINE OPHTHALMIC (EYE) NP PAipratropium bromide nasal P QL (30 per 30 days)ISTALOL OPHTHALMIC (EYE) NP PAketorolac ophthalmic (eye) Pketotifen fumarate ophthalmic (eye) PLASTACAFT OPHTHALMIC (EYE) NP PAlatanoprost ophthalmic (eye) Plevobunolol ophthalmic (eye) drops 0.5 % NP PAlevofloxacin ophthalmic (eye) NP PAlidocaine hcl mucous membrane jelly ADlidocaine hcl mucous membrane jelly in applicator AD

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

loteprednol etabonate ophthalmic (eye) ADLUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % NP PA

metipranolol ophthalmic (eye) ADmometasone nasal PMOXEZA OPHTHALMIC (EYE) NP PAmoxifloxacin ophthalmic (eye) NP PANASONEX NASAL NP PANATACYN OPHTHALMIC (EYE) ADneomycin-bacitracin-poly-hc ophthalmic (eye) AD

neomycin-bacitracin-polymyxin ophthalmic (eye) AD

neomycin-polymyxin b-dexameth ophthalmic (eye) AD

neomycin-polymyxin-gramicidin ophthalmic (eye) AD

neomycin-polymyxin-hc ophthalmic (eye) ADneomycin-polymyxin-hc otic (ear) PNEO-POLYCIN HC OPHTHALMIC (EYE) ADNEVANAC OPHTHALMIC (EYE) NP PAOCUFLOX OPHTHALMIC (EYE) NP PAofloxacin ophthalmic (eye) Pofloxacin otic (ear) ADolopatadine nasal NP PA


Drug Tier Limits or Restrictionsolopatadine ophthalmic (eye) POMNARIS NASAL NP PAOTIPRIO INTRATYMPANIC NP PAOTOVEL OTIC (EAR) NP PAOXERVATE OPHTHALMIC (EYE) AD PA; SPPATADAY OPHTHALMIC (EYE) NP PAPATANASE NASAL NP PAPATANOL OPHTHALMIC (EYE) NP PAPAZEO OPHTHALMIC (EYE) PPERIOGARD MUCOUS MEMBRANE ADphenylephrine hcl ophthalmic (eye) ADPHOSPHOLINE IODIDE OPHTHALMIC (EYE) ADpilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % AD

POLYCIN OPHTHALMIC (EYE) ADpolymyxin b sulf-trimethoprim ophthalmic (eye) AD

PRED MILD OPHTHALMIC (EYE) ADprednisolone acetate ophthalmic (eye) ADprednisolone sodium phosphate ophthalmic (eye) AD

PROLENSA OPHTHALMIC (EYE) NP PAproparacaine ophthalmic (eye) ADQNASL NASAL NP PARESTASIS MULTIDOSE OPHTHALMIC (EYE) AD PARESTASIS OPHTHALMIC (EYE) AD PA; QL (60 per 30 days)RHOPRESSA OPHTHALMIC (EYE) NP PAROCKLATAN OPHTHALMIC (EYE) NP PASIMBRINZA OPHTHALMIC (EYE) NP PASINUVA SINUS NP PAsulfacetamide sodium ophthalmic (eye) ADsulfacetamide-prednisolone ophthalmic (eye) AD

TETCAINE OPHTHALMIC (EYE) ADtetracaine hcl (pf) ophthalmic (eye) ADtetracaine hcl ophthalmic (eye) ADTICANASE NASAL NP PAtimolol maleate ophthalmic (eye) drops P


75

Drug Tier Limits or Restrictionstimolol maleate ophthalmic (eye) drops, once daily NP PA

timolol maleate ophthalmic (eye) gel forming solution P

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) NP PA

TIMOPTIC OPHTHALMIC (EYE) NP PATIMOPTIC-XE OPHTHALMIC (EYE) NP PATOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION P

tobramycin ophthalmic (eye) ADtobramycin-dexamethasone ophthalmic (eye) AD

TRAVATAN Z OPHTHALMIC (EYE) Ptropicamide ophthalmic (eye) ADTRUSOPT OPHTHALMIC (EYE) NP PAVERAMYST NASAL NP PAVIGAMOX OPHTHALMIC (EYE) PVYZULTA OPHTHALMIC (EYE) NP PAXALATAN OPHTHALMIC (EYE) NP PAXHANCE NASAL NP PAZADITOR OPHTHALMIC (EYE) NP PAZETONNA NASAL NP PAZIOPTAN (PF) OPHTHALMIC (EYE) NP PAZIRGAN OPHTHALMIC (EYE) ADZYLET OPHTHALMIC (EYE) ADZYMAXID OPHTHALMIC (EYE) NP PAGASTROINTESTINAL DRUGSACIPHEX ORAL NP PAACIPHEX SPRINKLE ORAL NP PAAKYNZEO (NETUPITANT) ORAL NP PAalosetron oral ADAMITIZA ORAL ADANZEMET ORAL NP PAaprepitant oral capsule 125 mg, 40 mg AD QL (1 per 30 days)aprepitant oral capsule 80 mg AD QL (2 per 30 days)aprepitant oral capsule,dose pack AD QL (3 per 30 days)APRISO ORAL NP PAASACOL HD ORAL NP PA


Drug Tier Limits or RestrictionsAZULFIDINE EN-TABS ORAL NP PAAZULFIDINE ORAL NP PAbalsalazide oral PCANASA RECTAL PCARAFATE ORAL SUSPENSION ADCESAMET ORAL NP PAcimetidine hcl oral NP PAcimetidine oral tablet 300 mg, 400 mg, 800 mg NP PA

CIMZIA POWDER FOR RECONST SUBCUTANEOUS NP SP; PA

CIMZIA STARTER KIT SUBCUTANEOUS NP SP; PACIMZIA SUBCUTANEOUS NP SP; PACOLAZAL ORAL NP PACOMPRO RECTAL ADCREON ORAL PDELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) P

DEXILANT ORAL NP PAdimenhydrinate injection solution ADDIPENTUM ORAL NP PAdiphenoxylate-atropine oral ADdronabinol oral ADDUEXIS ORAL NP PAENTYVIO INTRAVENOUS NP SP; PAesomeprazole magnesium oral NP PAesomeprazole strontium oral capsule,delayed release(dr/ec) 49.3 mg NP PA

famotidine (pf) intravenous ADfamotidine (pf)-nacl (iso-os) intravenous ADfamotidine intravenous solution ADfamotidine oral suspension Pfamotidine oral tablet 10 mg ADfamotidine oral tablet 20 mg, 40 mg PGAVILYTE-C ORAL ADGAVILYTE-G ORAL ADGAVILYTE-N ORAL ADGIAZO ORAL NP PAgranisetron (pf) intravenous ADUCare Comprehensive FormularyEffective: November 1, 2019

77

Drug Tier Limits or Restrictionsgranisetron hcl intravenous ADgranisetron hcl oral NP PA; QL (6 per 30 days)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS P PA; SP; QL (2 per 30 days)

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS P PA; SP; QL (2 per 30 days)

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS P PA; SP; QL (2 per 30 days)

HUMIRA PEN SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS P PA; SP; QL (3 per 30 days)

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS P PA; SP; QL (3 per 30 days)

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS P PA; SP; QL (3 per 30 days)

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML P PA; SP; QL (2 per 30 days)


HUMIRA(CF) SUBCUTANEOUS P PA; SP; QL (2 per 30 days)INFLECTRA INTRAVENOUS NP SP; PAlansoprazole oral capsule,delayed release(dr/ec) 15 mg NP PA

lansoprazole oral capsule,delayed release(dr/ec) 30 mg NP PA; QL (30 per 30 days)

lansoprazole oral tablet,disintegrat, delay rel NP PA

LIALDA ORAL NP PALINZESS ORAL ADmeclizine oral tablet 12.5 mg, 25 mg ADmeclizine oral tablet,chewable ADmesalamine oral NP PAmesalamine rectal enema Pmesalamine rectal suppository NP PAmesalamine with cleansing wipe rectal Pmetoclopramide hcl injection ADmetoclopramide hcl oral solution ADmetoclopramide hcl oral tablet ADmisoprostol oral AD


Drug Tier Limits or RestrictionsMOVANTIK ORAL AD PANEXIUM IV INTRAVENOUS RECON SOLN 40 MG NP PA

NEXIUM ORAL NP PANEXIUM PACKET ORAL Pnizatidine oral NP PAOCALIVA ORAL AD PA; SPomeprazole oral capsule,delayed release(dr/ec) 10 mg P QL (30 per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg P

omeprazole-sodium bicarbonate oral NP PAondansetron hcl (pf) injection ADondansetron hcl intravenous ADondansetron hcl oral solution Pondansetron hcl oral tablet 24 mg ADondansetron hcl oral tablet 4 mg Pondansetron hcl oral tablet 8 mg P QLondansetron oral P QLpalonosetron intravenous solution ADpalonosetron intravenous syringe NP PAPANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

NP PA

pantoprazole oral tablet,delayed release (dr/ec) 20 mg P QL (30 per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg P

peg 3350-electrolytes oral ADpeg-electrolyte soln oral ADPENTASA ORAL PPEPCID ORAL NP PAPERTZYE ORAL NP PAPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA + DOCUSATE ORAL ADPRENAISSANCE ORAL AD


79

Drug Tier Limits or RestrictionsPRENAISSANCE PLUS ORAL ADPREVACID ORAL NP PAPREVACID SOLUTAB ORAL NP PAPRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON NP PA

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) AD

prochlorperazine maleate oral ADprochlorperazine rectal ADPROTONIX ORAL NP PAPYLERA ORAL ADrabeprazole oral tablet,delayed release (dr/ec) NP PA

ranitidine hcl oral capsule Pranitidine hcl oral syrup Pranitidine hcl oral tablet 150 mg, 300 mg Pranitidine hcl oral tablet 75 mg ADREMICADE INTRAVENOUS NP SP; PARENFLEXIS INTRAVENOUS NP PAROWASA RECTAL NP PASANCUSO TRANSDERMAL NP PASE-NATAL 19 (WITH DOCUSATE) ORAL ADSFROWASA RECTAL NP PASIMPONI ARIA INTRAVENOUS NP SP; PASIMPONI SUBCUTANEOUS NP SP; PAsucralfate oral ADsulfasalazine oral PTARON-PREX PRENATAL-DHA ORAL ADTL-SELECT ORAL ADtrimethobenzamide oral ADTRIVEEN-PRX RNF ORAL ADursodiol oral ADVIBERZI ORAL ADVIMOVO ORAL NP PAVINACAL ORAL ADVINATE ULTRA ORAL ADVIOKACE ORAL NP PAVIRT-SELECT ORAL AD


Drug Tier Limits or RestrictionsXERMELO ORAL AD PAYOSPRALA ORAL NP PAZANTAC ORAL TABLET 300 MG NP PAZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

P

ZOFRAN ODT ORAL NP PAZOFRAN ORAL NP PAZUPLENZ ORAL NP PAHEAVY METAL ANTAGONISTSCHEMET ORAL ADdeferasirox oral AD PA; SPdeferoxamine injection ADFERRIPROX ORAL TABLET 1,000 MG AD PAFERRIPROX ORAL TABLET 500 MG AD PA; SPJADENU ORAL AD PA; SPJADENU SPRINKLE ORAL AD PApenicillamine oral ADHORMONES AND SYNTHETIC SUBSTITUTESacarbose oral PACTOPLUS MET XR ORAL NP PAADLYXIN SUBCUTANEOUS NP PAADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS NP PA

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS NP PA

ADVAIR DISKUS INHALATION NP PAADVAIR HFA INHALATION P QL (12 per 30 days)AEROSPAN INHALATION NP PAAFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90)

NP PA

AIRDUO RESPICLICK INHALATION NP PAalogliptin oral NP PAalogliptin-metformin oral NP PA


81

Drug Tier Limits or Restrictionsalogliptin-pioglitazone oral NP PAALTAVERA (28) ORAL ADALVESCO INHALATION NP PAALYACEN 1/35 (28) ORAL ADALYACEN 7/7/7 (28) ORAL ADAMARYL ORAL NP PAAMETHIA LO ORAL AD QLAMETHIA ORAL AD QLAMETHYST (28) ORAL ADanastrozole oral ADANDRODERM TRANSDERMAL P PAANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

P PA

ANDROGEL TRANSDERMAL GEL IN PACKET P PAAPIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS NP PA

APIDRA U-100 INSULIN SUBCUTANEOUS NP PAAPRI ORAL ADARANELLE (28) ORAL ADARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION

NP PA

ARMOUR THYROID ORAL TABLET 120 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

AD

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION

NP PA

ASMANEX HFA INHALATION NP PAASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)

P

AUBRA ORAL ADAVANDIA ORAL TABLET 2 MG, 4 MG NP PAAVIANE ORAL ADAXIRON TRANSDERMAL NP PAAZURETTE (28) ORAL AD


Drug Tier Limits or RestrictionsBALZIVA (28) ORAL ADBASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS NP PA

betamethasone acet,sod phos injection ADBLISOVI 24 FE ORAL ADBLISOVI FE 1.5/30 (28) ORAL ADBLISOVI FE 1/20 (28) ORAL ADBREO ELLIPTA INHALATION NP PABRIELLYN ORAL ADbudesonide inhalation Pbudesonide oral NP PABYDUREON BCISE SUBCUTANEOUS NP PABYDUREON SUBCUTANEOUS PEN INJECTOR P

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON P QL (4 per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML P QL (3 per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML P QL (2 per 30 days)

calcitonin (salmon) nasal PCAMILA ORAL ADCAMRESE LO ORAL AD QL (84 per 84 days)CAMRESE ORAL ADCAZIANT (28) ORAL ADCHATEAL (28) ORAL ADchlorpropamide oral ADcolesevelam oral tablet NP PAcortisone oral ADCRYSELLE (28) ORAL ADCYCLAFEM 1/35 (28) ORAL ADCYCLAFEM 7/7/7 (28) ORAL ADcyred oral ADdanazol oral ADDASETTA 1/35 (28) ORAL ADDASETTA 7/7/7 (28) ORAL ADDAYSEE ORAL ADDEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML AD


83

Drug Tier Limits or Restrictionsdesmopressin injection AD PAdesmopressin nasal spray,non-aerosol ADdesmopressin oral ADdesogestrel-ethinyl estradiol oral ADDEXAMETHASONE INTENSOL ORAL ADdexamethasone oral elixir ADdexamethasone oral solution ADdexamethasone oral tablet ADdexamethasone sodium phos (pf) injection ADdexamethasone sodium phosphate injection solution AD

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg AD

DUETACT ORAL NP PADULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION P QL (13 per 30 days)


ECONTRA EZ ORAL AD QL (1 Max Qty Per Fill Retail)ELINEST ORAL ADELLA ORAL AD QL (1 per 30 days)EMOQUETTE ORAL ADENPRESSE ORAL ADENSKYCE ORAL ADERRIN ORAL ADESTARYLLA ORAL ADestradiol oral ADestradiol transdermal patch semiweekly AD QL (8 per 28 days)estradiol vaginal cream ADestradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml AD

estradiol-norethindrone acet oral ADestropipate oral tablet 0.75 mg ADEVAMIST TRANSDERMAL AD QL (17 per 30 days)EVISTA ORAL NP PAexemestane oral ADFALMINA (28) ORAL ADFARXIGA ORAL PFEMHRT LOW DOSE ORAL AD


Drug Tier Limits or RestrictionsFEMYNOR ORAL ADFIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS NP PA

FIASP U-100 INSULIN SUBCUTANEOUS NP PAFLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

P QL (60 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION P QL (4 per 30 days)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION P QL (12 per 30 days)



fludrocortisone oral ADfluticasone propion-salmeterol inhalation NP PAFORTEO SUBCUTANEOUS PFORTESTA TRANSDERMAL NP PAGENOTROPIN MINIQUICK SUBCUTANEOUS NP PA; SPGENOTROPIN SUBCUTANEOUS NP PA; SPGIANVI (28) ORAL ADglimepiride oral tablet 1 mg P QL (240 per 30 days)glimepiride oral tablet 2 mg P QL (120 per 30 days)glimepiride oral tablet 4 mg P QL (60 per 30 days)glipizide oral tablet 10 mg P QL (180 per 30 days)glipizide oral tablet 5 mg P QLglipizide oral tablet extended release 24hr 10 mg, 5 mg P QL (60 per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg P QL (300 per 30 days)

glipizide-metformin oral tablet 2.5-250 mg AD QL (240 per 30 days)glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg AD QL (120 per 30 days)

GLUCAGEN DIAGNOSTIC KIT INJECTION ADGLUCAGEN HYPOKIT INJECTION ADGLUCAGON EMERGENCY KIT (HUMAN) INJECTION AD

GLUCAGON HCL INJECTION ADGLUCOTROL ORAL NP PA


85

Drug Tier Limits or RestrictionsGLUCOTROL XL ORAL NP PAglyburide micronized oral tablet 1.5 mg, 3 mg P QL

glyburide micronized oral tablet 6 mg P QL (60 per 30 days)glyburide oral P QLglyburide-metformin oral tablet 1.25-250 mg AD QL (240 per 30 days)

glyburide-metformin oral tablet 2.5-500 mg AD QL (180 per 30 days)

glyburide-metformin oral tablet 5-500 mg AD QL (120 per 30 days)GLYNASE ORAL NP PAGLYSET ORAL PGLYXAMBI ORAL NP PAHEATHER ORAL ADHUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS NP PA

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS NP PA

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS P

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS NP PA

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS NP PA

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS P

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE NP PA

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION P

HUMATROPE INJECTION NP PA; SPHUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS P

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS NP PA

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS NP PA

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS P

HUMULIN R REGULAR U-100 INSULN INJECTION P


Drug Tier Limits or RestrictionsHUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS P

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS NP PA

hydrocortisone oral ADhydroxyprogest(pf)(preg presv) intramuscular AD PA; SP

hydroxyprogesterone cap(ppres) intramuscular AD PA; SP

hydroxyprogesterone capr(bulk) AD PA; SPhydroxyprogesterone caproate intramuscular AD PA; SP

insulin lispro subcutaneous NP PAINTROVALE ORAL ADINVOKAMET ORAL NP PAINVOKAMET XR ORAL NP PAINVOKANA ORAL P QL (30 per 30 days)JANUMET ORAL P QL (60 per 30 days)JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG NP PA; QL (60 per 30 days)

JANUVIA ORAL P QL (30 per 30 days)JARDIANCE ORAL PJENCYCLA ORAL ADJENTADUETO ORAL PJENTADUETO XR ORAL NP PAJINTELI ORAL ADJOLESSA ORAL ADJOLIVETTE ORAL ADJULEBER ORAL ADJUNEL 1.5/30 (21) ORAL ADJUNEL 1/20 (21) ORAL ADJUNEL FE 1.5/30 (28) ORAL ADJUNEL FE 1/20 (28) ORAL ADJUNEL FE 24 ORAL ADKAITLIB FE ORAL ADKARIVA (28) ORAL ADKAZANO ORAL NP PAUCare Comprehensive FormularyEffective: November 1, 2019

87

Drug Tier Limits or RestrictionsKELNOR 1/35 (28) ORAL ADKISQALI FEMARA CO-PACK ORAL AD PA; SPKOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG P QL (60 per 30 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG P QL (30 per 30 days)

KURVELO (28) ORAL ADl norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

AD

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS P

LANTUS U-100 INSULIN SUBCUTANEOUS PLARIN 1.5/30 (21) ORAL ADLARIN 1/20 (21) ORAL ADLARIN 24 FE ORAL ADLARIN FE 1.5/30 (28) ORAL ADLARIN FE 1/20 (28) ORAL ADLARISSIA ORAL ADLAYOLIS FE ORAL ADLEENA 28 ORAL ADLESSINA ORAL ADletrozole oral ADleuprolide subcutaneous kit AD SPLEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS P

LEVEMIR U-100 INSULIN SUBCUTANEOUS PLEVONEST (28) ORAL ADlevonorgestrel oral tablet 1.5 mg AD QL (1 Max Qty Per Fill Retail)levonorgestrel-ethinyl estrad oral ADlevonorg-eth estrad triphasic oral ADLEVORA-28 ORAL ADlevothyroxine intravenous recon soln 200 mcg, 500 mcg AD

levothyroxine oral ADLEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

AD


Drug Tier Limits or RestrictionsLILETTA INTRAUTERINE ADliothyronine intravenous ADliothyronine oral ADLORYNA (28) ORAL ADLOW-OGESTREL (28) ORAL ADLUGOLS ORAL ADLUPRON DEPOT (3 MONTH) INTRAMUSCULAR AD PA; SP



LUPRON DEPOT INTRAMUSCULAR AD PA; SPLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR AD PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR AD PA; SPLUTERA (28) ORAL ADLYZA ORAL ADMARLISSA (28) ORAL ADmedroxyprogesterone intramuscular suspension AD

medroxyprogesterone intramuscular syringe AD QL (1 per 30 days)

medroxyprogesterone oral ADMEGACE ES ORAL NP PAmegestrol oral suspension 400 mg/10 ml (10 ml) NP PA; PA

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) P PA

megestrol oral suspension 625 mg/5 ml NP PAmegestrol oral tablet P PAmetformin oral tablet 1,000 mg ADmetformin oral tablet 500 mg AD QL (150 per 30 days)metformin oral tablet 850 mg AD QL (90 per 30 days)metformin oral tablet extended release 24 hr 500 mg AD QL (150 per 30 days)

metformin oral tablet extended release 24 hr 750 mg AD

metformin oral tablet extended release 24hr 500 mg AD QL (150 per 30 days)


89

Drug Tier Limits or Restrictionsmethimazole oral tablet 10 mg, 5 mg ADMETHITEST ORAL ADmethylprednisolone acetate injection ADmethylprednisolone oral ADmethylprednisolone sodium succ injection recon soln 125 mg, 40 mg AD

methylprednisolone sodium succ intravenous AD

MIACALCIN INJECTION PMICROGESTIN 1.5/30 (21) ORAL ADMICROGESTIN 1/20 (21) ORAL ADMICROGESTIN FE 1.5/30 (28) ORAL ADMICROGESTIN FE 1/20 (28) ORAL ADmiglitol oral NP PAMIMVEY ORAL ADMONO-LINYAH ORAL ADMONONESSA (28) ORAL ADMY WAY ORAL AD QL (1 Max Qty Per Fill Retail)MYALEPT SUBCUTANEOUS AD PAMYZILRA ORAL ADnateglinide oral PNATPARA SUBCUTANEOUS AD PANECON 0.5/35 (28) ORAL ADNESINA ORAL NP PANEXPLANON SUBDERMAL AD SPnikki (28) oral ADNORA-BE ORAL ADNORDITROPIN FLEXPRO SUBCUTANEOUS P PA; SPnoreth-ethinyl estradiol-iron oral ADnorethindrone (contraceptive) oral ADnorethindrone acetate oral ADnorethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-20 mg-mcg, 1-5 mg-mcg

AD

norethindrone-e.estradiol-iron oral tablet ADnorgestimate-ethinyl estradiol oral ADNORTREL 0.5/35 (28) ORAL ADNORTREL 1/35 (21) ORAL ADNORTREL 1/35 (28) ORAL ADUCare Comprehensive FormularyEffective: November 1, 201990

Drug Tier Limits or RestrictionsNORTREL 7/7/7 (28) ORAL ADNOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS P

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS NP PA

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS P

NOVOLIN R REGULAR U-100 INSULN INJECTION P

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS P

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS P

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS P

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS P

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS P

NP THYROID ORAL ADNUTROPIN AQ NUSPIN SUBCUTANEOUS P PA; SPNUVARING VAGINAL ADOCELLA ORAL ADoctreotide acetate injection AD SPOGESTREL (28) ORAL ADOMNITROPE SUBCUTANEOUS NP PA; SPONGLYZA ORAL P QL (30 per 30 days)OPCICON ONE-STEP ORAL AD QL (1 Max Qty Per Fill Retail)ORILISSA ORAL AD PA; SPORSYTHIA ORAL ADOSENI ORAL NP PAoxandrolone oral AD PAOZEMPIC SUBCUTANEOUS NP PAPHILITH ORAL ADPIMTREA (28) ORAL ADpioglitazone oral P QL (30 per 30 days)pioglitazone-glimepiride oral NP PApioglitazone-metformin oral NP PA; QL (90 per 30 days)PIRMELLA ORAL ADPORTIA 28 ORAL AD


91

Drug Tier Limits or RestrictionsPRANDIN ORAL PPRECOSE ORAL NP PAprednisolone oral solution 15 mg/5 ml ADprednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

AD

PREDNISONE INTENSOL ORAL ADprednisone oral ADPREMARIN INJECTION ADPREMARIN VAGINAL ADPREMPHASE ORAL ADPREMPRO ORAL ADPREVIFEM ORAL ADprogesterone intramuscular ADprogesterone micronized oral ADPROGLYCEM ORAL ADpropylthiouracil oral ADPULMICORT FLEXHALER INHALATION PPULMICORT INHALATION NP PAQTERN ORAL TABLET 10-5 MG NP PAQUASENSE ORAL ADQVAR REDIHALER INHALATION NP PAraloxifene oral PRECLIPSEN (28) ORAL ADrepaglinide oral Prepaglinide-metformin oral NP PA; QLSAIZEN SAIZENPREP SUBCUTANEOUS NP PASAIZEN SUBCUTANEOUS NP PA; SPSEGLUROMET ORAL NP PASEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG NP PA; SP

SETLAKIN ORAL ADSIGNIFOR SUBCUTANEOUS AD SPSOLIQUA 100/33 SUBCUTANEOUS NP PASOLU-CORTEF (PF) INJECTION ADSOLU-CORTEF INJECTION ADSOLU-MEDROL (PF) INJECTION ADSOLU-MEDROL (PF) INTRAVENOUS ADUCare Comprehensive FormularyEffective: November 1, 201992

Drug Tier Limits or RestrictionsSOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG AD

SOMATULINE DEPOT SUBCUTANEOUS AD SPSPRINTEC (28) ORAL ADSRONYX ORAL ADSTEGLATRO ORAL NP PASTEGLUJAN ORAL NP PASTRIANT BUCCAL NP PASTRONG IODINE ORAL ADSYEDA ORAL ADSYMBICORT INHALATION P QLSYMLINPEN 120 SUBCUTANEOUS PSYMLINPEN 60 SUBCUTANEOUS PSYNAREL NASAL ADSYNJARDY ORAL NP PASYNJARDY XR ORAL NP PAtamoxifen oral ADtarina fe 1/20 (28) oral ADTESTIM TRANSDERMAL NP PAtestosterone cypionate intramuscular ADtestosterone enanthate intramuscular ADTESTOSTERONE TRANSDERMAL GEL NP PAtestosterone transdermal gel in metered-dose pump NP PA

testosterone transdermal gel in packet NP PAtestosterone transdermal solution in metered pump w/app NP PA

THYROLAR-1 ORAL ADTHYROLAR-1/2 ORAL ADTHYROLAR-1/4 ORAL ADTHYROLAR-2 ORAL ADTHYROLAR-3 ORAL ADTILIA FE ORAL ADtolazamide oral tablet 250 mg AD QL (120 per 30 days)tolazamide oral tablet 500 mg AD QL (60 per 30 days)tolbutamide oral ADTOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS NP PA


93

Drug Tier Limits or RestrictionsTOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS NP PA

TRADJENTA ORAL PTRESIBA FLEXTOUCH U-100 SUBCUTANEOUS NP PA

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS NP PA

TRI-ESTARYLLA ORAL ADTRI-LEGEST FE ORAL ADTRI-LINYAH ORAL ADtri-lo-estarylla oral ADtri-lo-sprintec oral ADTRI-PREVIFEM (28) ORAL ADTRIPTODUR INTRAMUSCULAR AD PA; SPTRI-SPRINTEC (28) ORAL ADTRIVORA (28) ORAL ADTRULICITY SUBCUTANEOUS NP PATYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) NP SP; PA

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) NP PA; SP; PA

UCERIS ORAL NP PAUCERIS RECTAL NP PAUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

AD

unithroid oral tablet 137 mcg ADvasopressin injection ADVELIVET TRIPHASIC REGIMEN (28) ORAL ADVICTOZA 2-PAK SUBCUTANEOUS P QL (6 per 30 days)VICTOZA 3-PAK SUBCUTANEOUS P QL (9 per 30 days)VIENVA ORAL ADVIORELE (28) ORAL ADVOGELXO TRANSDERMAL NP PAWELCHOL ORAL NP PAWERA (28) ORAL ADWIXELA INHUB INHALATION P QL (60 per 30 days)WYMZYA FE ORAL ADXIGDUO XR ORAL NP PAUCare Comprehensive FormularyEffective: November 1, 201994

Drug Tier Limits or RestrictionsXULANE TRANSDERMAL ADXULTOPHY 100/3.6 SUBCUTANEOUS NP PAyuvafem vaginal ADZARAH ORAL ADZENCHENT (28) ORAL ADZOMACTON SUBCUTANEOUS NP PA; SPZORBTIVE SUBCUTANEOUS NP PA; SPZOVIA 1/35E (28) ORAL ADLOCAL ANESTHETICS (PARENTERAL)bupivacaine (pf) injection solution ADbupivacaine injection ADbupivacaine-dextrose-water(pf) injection ADbupivacaine-epinephrine (pf) injection ADbupivacaine-epinephrine injection ADlidocaine (pf) in d7.5w intrathecal ADlidocaine (pf) injection solution ADlidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) AD

lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

AD

MISCELLANEOUS THERAPEUTIC AGENTSacetylcysteine ADACTEMRA ACTPEN SUBCUTANEOUS AD PA; SPACTEMRA INTRAVENOUS NP SP; PAACTEMRA SUBCUTANEOUS AD PA; SPACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG NP PA

alendronate oral solution P QL (300 per 30 days)alendronate oral tablet 10 mg, 40 mg, 5 mg P QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg P QL (4 per 30 days)allopurinol oral ADamifostine crystalline intravenous ADAMPYRA ORAL NP PAASTAGRAF XL ORAL NP SP; PAATELVIA ORAL NP PAATGAM INTRAVENOUS AD SP


95

Drug Tier Limits or RestrictionsAUBAGIO ORAL P PA; SPAVODART ORAL NP PAAVONEX (WITH ALBUMIN) INTRAMUSCULAR P PA; SP; QL (4 per 30 days)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT P PA; SP; QL (4 per 30 days)

AVONEX INTRAMUSCULAR SYRINGE KIT P PA; SP; QL (4 per 30 days)AZASAN ORAL NP PAazathioprine oral PAZULFIDINE EN-TABS ORAL NP PAAZULFIDINE ORAL NP PABERINERT INTRAVENOUS KIT P PA; SPBERINERT INTRAVENOUS RECON SOLN P PABETASERON SUBCUTANEOUS KIT P PA; SP; QLBETASERON SUBCUTANEOUS RECON SOLN P PABINOSTO ORAL NP PABONIVA INTRAVENOUS NP SP; PABONIVA ORAL NP PAcalcitonin (salmon) nasal PCELLCEPT ORAL NP SP; PACERDELGA ORAL ADCHEMET ORAL ADCIMZIA POWDER FOR RECONST SUBCUTANEOUS NP SP; PA

CIMZIA STARTER KIT SUBCUTANEOUS NP SP; PACIMZIA SUBCUTANEOUS NP SP; PAcinacalcet oral ADCINRYZE INTRAVENOUS NP PA; SPcolchicine oral ADCOPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML P PA; SP

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA

cyclophosphamide intravenous ADCYCLOPHOSPHAMIDE ORAL CAPSULE ADcyclosporine intravenous ADcyclosporine modified oral P SPcyclosporine oral capsule PCYSTAGON ORAL AD SP


Drug Tier Limits or Restrictionsdalfampridine oral AD PA; SPdeferoxamine injection ADDENTA 5000 PLUS DENTAL ADDENTAGEL DENTAL ADdexrazoxane hcl intravenous ADdisulfiram oral ADdutasteride oral Pdutasteride-tamsulosin oral NP PAEC-NAPROXEN ORAL PELIDEL TOPICAL PELMIRON ORAL ADENBREL MINI SUBCUTANEOUS NP SP; PA; QL (4 per 30 days)ENBREL SUBCUTANEOUS RECON SOLN P PA; SP; QL (8 per 30 days)ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

ENBREL SURECLICK SUBCUTANEOUS P PA; SP; QL (4 per 30 days)ENTYVIO INTRAVENOUS NP SP; PAENVARSUS XR ORAL NP SP; PAetidronate disodium oral NP PAEVISTA ORAL NP PAEVOTAZ ORAL ADEVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML AD

EXTAVIA SUBCUTANEOUS KIT NP SP; PA; QLEXTAVIA SUBCUTANEOUS RECON SOLN NP SP; PAfinasteride oral tablet 5 mg P

FIRAZYR SUBCUTANEOUS NP PA; SP; QL (9 Max Qty Per Fill Retail)

FIRDAPSE ORAL AD PA; SPflumazenil intravenous ADfluoride (sodium) dental gel ADfluoride (sodium) oral drops ADfluoride (sodium) oral tablet,chewable ADFLUORITAB ORAL TABLET,CHEWABLE ADfomepizole intravenous ADFOSAMAX ORAL TABLET 70 MG NP PAFOSAMAX PLUS D ORAL NP PAUCare Comprehensive FormularyEffective: November 1, 2019

97

Drug Tier Limits or RestrictionsFOSRENOL ORAL NP PAGENGRAF ORAL CAPSULE 100 MG, 25 MG PGENGRAF ORAL SOLUTION PGILENYA ORAL CAPSULE 0.5 MG P PAglatiramer subcutaneous syringe 20 mg/ml NP SP; PA; QL (30 per 30 days)glatiramer subcutaneous syringe 40 mg/ml NP SP; PA; QL (12 per 30 days)GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML NP SP; PA; QL (30 per 30 days)

GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA; QL (12 per 30 days)

GLUCAGEN HYPOKIT INJECTION ADGLUCAGON EMERGENCY KIT (HUMAN) INJECTION AD

HAEGARDA SUBCUTANEOUS NP PAHUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS P PA; SP; QL (2 per 30 days)



HUMIRA PEN SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS P PA; SP; QL (3 per 30 days)





HUMIRA(CF) SUBCUTANEOUS P PA; SP; QL (2 per 30 days)hydroxychloroquine oral ADibandronate oral P PA; QL (1 per 30 days)icatibant subcutaneous NP PAIMURAN ORAL NP PAindomethacin oral capsule 25 mg Pindomethacin oral capsule 50 mg ADINFLECTRA INTRAVENOUS NP SP; PA


Drug Tier Limits or RestrictionsINTRON A INJECTION AD SPJALYN ORAL NP PAKALBITOR SUBCUTANEOUS NP PAKEVZARA SUBCUTANEOUS NP SP; PAKINERET SUBCUTANEOUS NP SP; PAKIONEX (WITH SORBITOL) ORAL ADKRYSTEXXA INTRAVENOUS AD PA; SPlanthanum oral NP PAleflunomide oral AD QL (30 per 30 days)LEMTRADA INTRAVENOUS AD PAleucovorin calcium injection recon soln AD SPleucovorin calcium oral AD SPlevocarnitine (with sugar) oral ADlevocarnitine oral tablet ADlevoleucovorin calcium intravenous recon soln 175 mg AD SP

LUDENT FLUORIDE ORAL ADLUGOLS ORAL ADmagnesium sulfate in water intravenous ADmagnesium sulfate injection ADMAVENCLAD (10 TABLET PACK) ORAL NP PAMAVENCLAD (4 TABLET PACK) ORAL NP PAMAVENCLAD (5 TABLET PACK) ORAL NP PAMAVENCLAD (6 TABLET PACK) ORAL NP PAMAVENCLAD (7 TABLET PACK) ORAL NP PAMAVENCLAD (8 TABLET PACK) ORAL NP PAMAVENCLAD (9 TABLET PACK) ORAL NP PAMAYZENT ORAL NP PAMAYZENT STARTER PACK ORAL NP PAmercaptopurine oral ADmesna intravenous ADMESNEX ORAL AD SPmethotrexate sodium (pf) injection ADmethotrexate sodium injection ADmethotrexate sodium oral ADmethylene blue (antidote) intravenous ADMIACALCIN INJECTION Pmiglustat oral AD SP


99

Drug Tier Limits or RestrictionsMITIGARE ORAL ADMULTIVITAMIN WITH FLUORIDE ORAL ADMULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE AD

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG AD

mycophenolate mofetil hcl intravenous AD SPmycophenolate mofetil oral capsule P SPmycophenolate mofetil oral suspension for reconstitution NP SP; PA

mycophenolate mofetil oral tablet P SPmycophenolate sodium oral NP SP; PAMYFORTIC ORAL NP SP; PAnaloxone injection Pnaltrexone oral ADnaproxen oral suspension ADnaproxen oral tablet Pnaproxen oral tablet,delayed release (dr/ec) P

naproxen sodium oral tablet 275 mg, 550 mg P

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION P

NATPARA SUBCUTANEOUS AD PANEORAL ORAL NP SP; PAOCREVUS INTRAVENOUS AD PAoctreotide acetate injection AD SPORENCIA (WITH MALTOSE) INTRAVENOUS NP SP; PAORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML NP PA

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML NP SP; PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML NP PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML NP SP; PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG AD SP

OTEZLA ORAL NP SP; PA; QL (60 per 30 days)OTEZLA STARTER ORAL NP SP; PA; QL (1 per 273 days)


Drug Tier Limits or RestrictionsOTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 MG/0.4 ML NP PA

pamidronate intravenous ADpenicillamine oral ADphysostigmine salicylate injection ADphytonadione (vitamin k1) oral tablet 5 mg ADpimecrolimus topical NP PAPLEGRIDY SUBCUTANEOUS NP SP; PAPOMALYST ORAL AD SPPREZCOBIX ORAL ADprobenecid oral ADprobenecid-colchicine oral ADPROGRAF ORAL CAPSULE NP SP; PAPROGRAF ORAL GRANULES IN PACKET 1 MG NP PA

PROLEUKIN INTRAVENOUS AD SPPROLIA SUBCUTANEOUS NP SP; PAPROSCAR ORAL NP PAraloxifene oral PRAPAMUNE ORAL NP SP; PAREBIF (WITH ALBUMIN) SUBCUTANEOUS P PA; SP; QL (6 per 30 days)REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML P PA; SP; QL (6 per 30 days)

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

P PA; SP; QL (5 per 30 days)

REBIF TITRATION PACK SUBCUTANEOUS P PA; SP; QL (5 per 30 days)REMICADE INTRAVENOUS NP SP; PARENAGEL ORAL PRENFLEXIS INTRAVENOUS NP PARENVELA ORAL POWDER IN PACKET NP PAREVLIMID ORAL AD PA; SPrisedronate oral NP PARUCONEST INTRAVENOUS NP PARUZURGI ORAL AD PASANDIMMUNE ORAL NP SP; PAsevelamer carbonate oral tablet NP PASF 5000 PLUS DENTAL ADSF DENTAL AD


101

Drug Tier Limits or RestrictionsSIMPONI ARIA INTRAVENOUS NP SP; PASIMPONI SUBCUTANEOUS NP SP; PAsirolimus oral NP PASODIUM POLYSTYRENE (SORB FREE) ORAL ADsodium polystyrene sulfonate oral powder ADsodium polystyrene sulfonate rectal enema 30 gram/120 ml AD

sodium thiosulfate intravenous solution 12.5 gram/50 ml (250 mg/ml) AD

SPS (WITH SORBITOL) ORAL ADSPS (WITH SORBITOL) RECTAL ADSTELARA INTRAVENOUS NP SP; PASTELARA SUBCUTANEOUS NP SP; PASTRONG IODINE ORAL ADsulfasalazine oral Ptacrolimus oral P SPTAKHZYRO SUBCUTANEOUS AD PA; SPTECFIDERA ORAL NP SP; PATHALOMID ORAL AD PA; SPTRI-VITAMIN WITH FLUORIDE ORAL ADTYMLOS SUBCUTANEOUS NP PA; SP; PAVISTOGARD ORAL ADVITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML AD

XELJANZ ORAL NP SP; PA; QL (60 per 30 days)XELJANZ XR ORAL NP SP; PA; QL (30 per 30 days)XGEVA SUBCUTANEOUS AD SPZORTRESS ORAL NP SP; PAOXYTOCICSmifepristone oral ADoxytocin injection solution ADPHARMACEUTICAL AIDSDILUENT FOR ACTHIB INTRAMUSCULAR ADDILUENT FOR IMOVAX INTRAMUSCULAR ADDILUENT FOR RABAVERT INTRAMUSCULAR ADDILUENT FOR ROTARIX ORAL ADSHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR AD


Drug Tier Limits or RestrictionsRESPIRATORY TRACT AGENTSACCOLATE ORAL NP PAacetylcysteine ADADCIRCA ORAL NP PA; SPADEMPAS ORAL NP PAADVAIR DISKUS INHALATION NP PAADVAIR HFA INHALATION P QL (12 per 30 days)AEROSPAN INHALATION NP PAAIRDUO RESPICLICK INHALATION NP PAalbuterol hfa 90 mcg inhaler NP PA; Tevaalbuterol hfa 90 mcg inhaler NP PA; Paralbuterol hfa 90 mcg inhaler P Prasco; QL (36 per 30 days)albuterol sulfate inhalation solution for nebulization P

albuterol sulfate oral syrup Palbuterol sulfate oral tablet NP PAalbuterol sulfate oral tablet extended release 12 hr NP PA

ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET P

ALL DAY ALLERGY-D ORAL PALLERGY AND CONGESTION RELIEF ORAL PALLERGY COMPLETE-D ORAL PALLERGY RELIEF (LORATADINE) ORAL PALLERGY RELIEF D-24HR ORAL PALLERGY RELIEF,NASAL DECONGEST ORAL PALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR P

ALLER-TEC ORAL PALOCRIL OPHTHALMIC (EYE) NP PAALVESCO INHALATION NP PAALYQ ORAL NP PAambrisentan oral NP PAaminophylline intravenous ADARCAPTA NEOHALER INHALATION NP PAARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION

NP PA


103

Drug Tier Limits or RestrictionsARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION

NP PA

ASMANEX HFA INHALATION NP PAASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)

P

atropine injection solution ADatropine injection syringe 0.05 mg/ml, 0.1 mg/ml AD

ATROVENT HFA INHALATION P QL (26 per 30 days)BECONASE AQ NASAL NP PABEVESPI AEROSPHERE INHALATION NP PAbosentan oral NP PABREO ELLIPTA INHALATION NP PAbrompheniramine-pseudoeph-dm oral syrup AD

BROVANA INHALATION NP PAbudesonide inhalation Pbudesonide nasal NP PAcarbinoxamine maleate oral liquid ADcarbinoxamine maleate oral tablet 4 mg ADcetirizine oral solution 1 mg/ml Pcetirizine oral tablet Pcetirizine oral tablet,chewable Pcetirizine-pseudoephedrine oral PCHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION P

CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE P

CHILD'S ALL DAY ALLERGY(CETIR) ORAL PCLARINEX ORAL SYRUP NP PACLARINEX ORAL TABLET NP PACLARINEX-D 12 HOUR ORAL NP PAclemastine oral tablet 2.68 mg ADcodeine sulfate oral tablet AD QL (180 per 30 days)COMBIVENT RESPIMAT INHALATION P QL (8 per 30 days)


Drug Tier Limits or Restrictionscromolyn ophthalmic (eye) Pcromolyn oral ADcyproheptadine oral ADDALIRESP ORAL NP PAdesloratadine oral NP PAdimenhydrinate injection solution ADdiphenhydramine hcl injection solution 50 mg/ml AD

diphenhydramine hcl injection syringe ADdiphenoxylate-atropine oral ADDULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION P QL (13 per 30 days)


DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML NP PA; SP

DYMISTA NASAL NP PAephedrine sulfate injection solution ADepinephrine injection auto-injector 0.15 mg/0.15 ml NP PA; Non-Mylan


epinephrine injection auto-injector 0.3 mg/0.3 ml NP PA; Non-Mylan


epinephrine injection solution ADepinephrine injection syringe 0.1 mg/ml ADEPIPEN 2-PAK INJECTION NP PA; QL (2 per 30 days)EPIPEN JR 2-PAK INJECTION NP PA; QL (2 per 30 days)epoprostenol (glycine) intravenous AD SPESBRIET ORAL CAPSULE AD PA; SP; QL (270 per 30 days)ESBRIET ORAL TABLET 267 MG AD PA; SP; QL (270 per 30 days)ESBRIET ORAL TABLET 801 MG AD PA; SP; QL (90 per 30 days)FASENRA SUBCUTANEOUS AD PA; SPFLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

P QL (60 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION P QL (4 per 30 days)


105

Drug Tier Limits or RestrictionsFLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION P QL (12 per 30 days)



flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) NP PA; QL (50 per 30 days)

fluticasone propionate nasal P QL (16 per 30 days)fluticasone propion-salmeterol inhalation NP PAGASTROCROM ORAL ADINCRUSE ELLIPTA INHALATION NP PAipratropium bromide inhalation Pipratropium-albuterol inhalation PKALYDECO ORAL TABLET AD PA; SPLETAIRIS ORAL P PA; SPlevalbuterol hcl inhalation NP PAlevalbuterol tartrate inhalation NP PAlevocetirizine oral PLORATA-DINE D ORAL Ploratadine oral solution Ploratadine oral tablet PLORATADINE-D ORAL PLUGOLS ORAL ADmetaproterenol oral syrup ADmetaproterenol oral tablet NP PAmometasone nasal Pmontelukast oral granules in packet NP PAmontelukast oral tablet Pmontelukast oral tablet,chewable PNASONEX NASAL NP PANON-DROWSY ALLERGY ORAL PNUCALA SUBCUTANEOUS AUTO-INJECTOR AD PA; SPNUCALA SUBCUTANEOUS RECON SOLN 100 MG AD PA

NUCALA SUBCUTANEOUS RECON SOLN 100 MG AD PA; SP

NUCALA SUBCUTANEOUS SYRINGE AD PA; SPNUEDEXTA ORAL AD PA; QL (60 per 30 days)


Drug Tier Limits or RestrictionsOFEV ORAL AD PA; SP; QL (60 per 30 days)OMNARIS NASAL NP PAOPSUMIT ORAL NP PAORENITRAM ORAL NP PAORKAMBI ORAL AD PA; SPPERFOROMIST INHALATION NP PAPROAIR HFA INHALATION P QL (17 per 30 days)PROAIR RESPICLICK INHALATION NP PAPROLASTIN-C INTRAVENOUS RECON SOLN AD SPPROLASTIN-C INTRAVENOUS SOLUTION ADpromethazine injection solution ADpromethazine oral ADPROVENTIL HFA INHALATION PPULMICORT FLEXHALER INHALATION PPULMICORT INHALATION NP PAPULMOZYME INHALATION AD SPQNASL NASAL NP PAQVAR REDIHALER INHALATION NP PAREVATIO ORAL NP PA; SPSEMPREX-D ORAL NP PASEREVENT DISKUS INHALATION Psildenafil (antihypertensive) intravenous AD PA; SPsildenafil (antihypertensive) oral tablet P PA; SP; QLSINGULAIR ORAL NP PASINUVA SINUS NP PASPIRIVA RESPIMAT INHALATION PSPIRIVA WITH HANDIHALER INHALATION P QL (90 per 30 days)STRIVERDI RESPIMAT INHALATION NP PASTRONG IODINE ORAL ADSYMBICORT INHALATION P QLSYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N) AD PA; SP

SYMJEPI INJECTION Ptadalafil (antihypertensive) oral NP PA; SP; QL (60 per 30 days)terbutaline oral ADterbutaline subcutaneous ADTHEOCHRON ORAL ADtheophylline oral elixir AD


107

Drug Tier Limits or Restrictionstheophylline oral solution ADtheophylline oral tablet extended release 12 hr AD

TICANASE NASAL NP PATRACLEER ORAL TABLET P SPTRACLEER ORAL TABLET FOR SUSPENSION NP PATRELEGY ELLIPTA INHALATION NP PATUDORZA PRESSAIR INHALATION P QL (1 per 30 days)TYVASO INHALATION NP PATYVASO INSTITUTIONAL START KIT INHALATION NP PA

TYVASO REFILL KIT INHALATION NP PATYVASO STARTER KIT INHALATION NP PAUPTRAVI ORAL NP PAUTIBRON NEOHALER INHALATION NP PAVELETRI INTRAVENOUS AD SPVENTAVIS INHALATION NP PAVENTOLIN HFA INHALATION NP PA; QL (36 per 30 days)VERAMYST NASAL NP PAWAL-ZYR (CETIRIZINE) ORAL TABLET PWIXELA INHUB INHALATION P QL (60 per 30 days)XHANCE NASAL NP PAXOLAIR SUBCUTANEOUS AD PA; SPXOPENEX CONCENTRATE INHALATION NP PAXOPENEX HFA INHALATION NP PAXOPENEX INHALATION NP PAzafirlukast oral P QLZETONNA NASAL NP PAzileuton oral NP PAZYFLO CR ORAL NP PAZYFLO ORAL NP PASKIN AND MUCOUS MEMBRANE AGENTSacitretin oral AD SPACNE MEDICATION TOPICAL GEL 5 % PACNE MEDICATION TOPICAL LOTION Pacyclovir topical cream NP PAacyclovir topical ointment P


Drug Tier Limits or Restrictionsadapalene topical cream NP PAadapalene topical gel NP PAadapalene topical gel with pump NP PAadapalene topical solution NP PAalclometasone topical ADAVAR-E LS TOPICAL NP PAAVITA TOPICAL NP PAazelaic acid topical ADAZELEX TOPICAL PBENZACLIN PUMP TOPICAL NP PABENZACLIN TOPICAL NP PABENZAMYCIN TOPICAL NP PAbenzoyl peroxide topical cleanser 10 %, 5 %, 6 % P

benzoyl peroxide topical foam Pbenzoyl peroxide topical gel 5 % Pbetamethasone dipropionate topical cream ADbetamethasone dipropionate topical lotion ADbetamethasone valerate topical cream ADbetamethasone valerate topical lotion ADbetamethasone valerate topical ointment ADbetamethasone, augmented topical ADBP 10-1 TOPICAL ADBPO TOPICAL GEL Pcalcipotriene topical cream ADCENTANY AT TOPICAL NP PACENTANY TOPICAL NP PAciclopirox topical cream ADciclopirox topical solution ADciclopirox topical suspension ADCLARAVIS ORAL ADCLEANSING WASH TOPICAL CLEANSER ADCLINDACIN ETZ TOPICAL SWAB ADCLINDACIN P TOPICAL ADclindamycin phosphate topical foam ADclindamycin phosphate topical gel ADclindamycin phosphate topical lotion ADclindamycin phosphate topical solution AD


109

Drug Tier Limits or Restrictionsclindamycin phosphate topical swab ADclindamycin phosphate vaginal ADclindamycin-benzoyl peroxide topical NP PAclindamycin-tretinoin topical NP PAclobetasol scalp ADclobetasol topical cream ADclobetasol topical foam ADclobetasol topical gel ADclobetasol topical ointment ADclobetasol-emollient topical ADclotrimazole mucous membrane ADclotrimazole-betamethasone topical cream ADCORMAX SCALP ADCOSENTYX (2 SYRINGES) SUBCUTANEOUS NP SP; PACOSENTYX PEN (2 PENS) SUBCUTANEOUS NP SP; PACOSENTYX PEN SUBCUTANEOUS NP SP; PACOSENTYX SUBCUTANEOUS NP SP; PACROTAN TOPICAL ADDENAVIR TOPICAL Pdesonide topical ADdiclofenac epolamine transdermal NP PAdiclofenac sodium topical gel 1 % NP PAdiclofenac sodium topical gel 3 % NP PADIFFERIN TOPICAL Pdiflorasone topical ADDOVONEX TOPICAL ADDUAC TOPICAL NP PADUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML NP PA; SP

econazole topical ADELIDEL TOPICAL PENBREL MINI SUBCUTANEOUS NP SP; PA; QL (4 per 30 days)ENBREL SUBCUTANEOUS RECON SOLN P PA; SP; QL (8 per 30 days)ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

ENBREL SURECLICK SUBCUTANEOUS P PA; SP; QL (4 per 30 days)


Drug Tier Limits or RestrictionsEPIDUO FORTE TOPICAL NP PAEPIDUO TOPICAL GEL WITH PUMP NP PAERY PADS TOPICAL ADerythromycin with ethanol topical ADethyl chloride topical ADEUCRISA TOPICAL NP PAEURAX TOPICAL CREAM ADFABIOR TOPICAL NP PAFEM PH VAGINAL ADfinasteride oral tablet 1 mg PFLECTOR TRANSDERMAL NP PAfluocinolone and shower cap scalp ADfluocinolone topical ADfluocinonide topical ADFLUOCINONIDE-E TOPICAL ADFLUOROPLEX TOPICAL ADfluorouracil topical cream 5 % ADfluorouracil topical solution ADfluticasone propionate topical cream ADfluticasone propionate topical ointment ADFORMADON TOPICAL ADgentamicin topical ADhalobetasol propionate topical cream ADhalobetasol propionate topical ointment ADHUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS P PA; SP; QL (2 per 30 days)



HUMIRA PEN SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA SUBCUTANEOUS P PA; SP; QL (2 per 30 days)HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

P PA; SP; QL (3 per 30 days)




111

Drug Tier Limits or RestrictionsHUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML P PA; SP; QL (2 per 30 days)


HUMIRA(CF) SUBCUTANEOUS P PA; SP; QL (2 per 30 days)hydrocortisone acetate rectal ADhydrocortisone rectal ADhydrocortisone topical cream 2.5 % ADhydrocortisone topical lotion 2.5 % ADhydrocortisone topical ointment 2.5 % ADimiquimod topical cream in packet ADINFLECTRA INTRAVENOUS NP SP; PAisotretinoin oral ADJUBLIA TOPICAL NP PAKEPIVANCE INTRAVENOUS ADketoconazole topical cream ADketoconazole topical shampoo ADLICE KILLING TOPICAL PLICE SOLUTION TOPICAL PLICE TREATMENT (PERMETHRIN) TOPICAL PLICE TREATMENT TOPICAL SHAMPOO Plidocaine hcl laryngotracheal ADlidocaine hcl topical cream 3 % ADlidocaine hcl topical lotion ADlidocaine hcl-hydrocortison ac rectal cream 3-0.5 % AD

lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3-1 % (7 gram) AD

lidocaine hcl-hydrocortison ac topical ADLIDOCAINE PAIN RELIEF TOPICAL ADlidocaine topical adhesive patch,medicated NP PAlidocaine topical ointment ADlidocaine-hydrocortisone-aloe rectal ADlidocaine-prilocaine topical ADLIDODERM TOPICAL NP PALIDOPURE PATCH TOPICAL NP PAlindane topical shampoo NP PALTA PRE-ATTACHED LARYNGOTRACHEAL ADmalathion topical NP PAUCare Comprehensive FormularyEffective: November 1, 2019112

Drug Tier Limits or Restrictionsmethoxsalen oral AD SPmetronidazole topical cream ADmetronidazole topical gel 0.75 % ADmetronidazole topical lotion ADmetronidazole vaginal ADMICONAZOLE-3 VAGINAL SUPPOSITORY AD QL (3 per 30 days)mometasone topical ADmupirocin calcium topical NP PAmupirocin topical PMYORISAN ORAL ADnaftifine topical cream NP PANAFTIN TOPICAL CREAM 2 % NP PANATROBA TOPICAL Pneomycin-polymyxin b gu irrigation ADNEUAC KIT TOPICAL NP PANEUAC TOPICAL NP PANYAMYC TOPICAL ADnystatin topical ADnystatin-triamcinolone topical ADNYSTOP TOPICAL ADONEXTON TOPICAL NP PAORAVIG BUCCAL NP PAOTEZLA ORAL NP SP; PA; QL (60 per 30 days)OTEZLA STARTER ORAL NP SP; PA; QL (1 per 273 days)OVIDE TOPICAL NP PAoxiconazole topical NP PAOXISTAT TOPICAL CREAM NP PApermethrin topical cream Pphenazopyridine oral tablet 100 mg, 200 mg AD

PICATO TOPICAL ADpimecrolimus topical NP PApodofilox topical ADprednicarbate topical ADPROCTOFOAM HC RECTAL ADPROCTO-PAK TOPICAL ADPROCTOZONE-HC TOPICAL ADPROTOPIC TOPICAL P


113

Drug Tier Limits or RestrictionsQUTENZA TOPICAL NP PARECTIV RECTAL ADREMICADE INTRAVENOUS NP SP; PARENFLEXIS INTRAVENOUS NP PARETIN-A MICRO PUMP TOPICAL NP PARETIN-A MICRO TOPICAL NP PARETIN-A TOPICAL NP PAROSADAN TOPICAL CREAM ADROSADAN TOPICAL GEL ADsalicylic acid er-ceramides topical kit,cleanser and cream er AD

salicylic acid topical cream ADsalicylic acid topical cream,extended release AD

salicylic acid topical gel ADsalicylic acid topical lotion ADsalicylic acid topical lotion,extended release ADsalicylic acid topical shampoo ADSANTYL TOPICAL AD PA; SP; QL (90 per 30 days)selenium sulfide topical shampoo 2.25 % ADSILIQ SUBCUTANEOUS NP SP; PAsilver nitrate topical ointment ADsilver nitrate topical solution 0.5 %, 25 %, 50 % AD

silver sulfadiazine topical ADSKLICE TOPICAL NP PAspinosad topical NP PASSD TOPICAL ADSSS 10-5 TOPICAL CREAM ADSTELARA INTRAVENOUS NP SP; PASTELARA SUBCUTANEOUS NP SP; PAsulfacetamide sodium (acne) topical ADsulfacetamide sodium topical cleanser ADsulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) AD

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

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w) AD


Drug Tier Limits or Restrictionssulfacetamide sodium-sulfur topical suspension 10-5 % AD

sulfacetamide sod-sulfur-urea topical cleanser AD

tacrolimus topical NP PATALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS NP SP; PA

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS NP SP; PA

TALTZ AUTOINJECTOR SUBCUTANEOUS NP SP; PATALTZ SYRINGE SUBCUTANEOUS NP SP; PATARGRETIN TOPICAL ADtazarotene topical NP PATAZORAC TOPICAL P PAterconazole vaginal cream AD QLterconazole vaginal suppository AD QL (3 per 30 days)TREMFYA SUBCUTANEOUS NP SP; PAtretinoin microspheres topical NP PAtretinoin topical cream Ptretinoin topical gel 0.01 %, 0.025 % Ptretinoin topical gel 0.05 % NP PAtriamcinolone acetonide topical cream ADtriamcinolone acetonide topical lotion ADtriamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % AD

UREA NAIL STICK TOPICAL ADurea topical cream 50 % ADurea topical lotion 40 % ADVALCHLOR TOPICAL AD SPVANDAZOLE VAGINAL ADVOLTAREN TOPICAL NP PAXERESE TOPICAL NP PAZENATANE ORAL ADZIANA TOPICAL NP PAZOVIRAX TOPICAL NP PAZYCLARA TOPICAL ADSMOOTH MUSCLE RELAXANTSaminophylline intravenous ADdarifenacin oral NP PA


115

Drug Tier Limits or RestrictionsDETROL LA ORAL NP PADETROL ORAL NP PADITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 5 MG NP PA

ENABLEX ORAL NP PAGELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

NP PA

GELNIQUE TRANSDERMAL GEL IN PACKET NP PAMYRBETRIQ ORAL NP PAoxybutynin chloride oral POXYTROL TRANSDERMAL Psolifenacin oral NP PATHEOCHRON ORAL ADtheophylline oral elixir ADtheophylline oral solution ADtheophylline oral tablet extended release 12 hr AD

tolterodine oral PTOVIAZ ORAL Ptrospium oral NP PAVESICARE ORAL PVITAMINSascorbic acid (vitamin c) injection ADB COMPLEX 100 INJECTION ADBAL-CARE DHA ORAL ADcalcitriol intravenous solution 1 mcg/ml ADcalcitriol oral ADCOMPLETE NATAL DHA ORAL ADCOMPLETENATE ORAL ADcyanocobalamin (vitamin b-12) injection ADELITE OB WITH DHA ORAL ADELITE-OB 400 ORAL ADergocalciferol (vitamin d2) oral capsule 50,000 unit AD

FOLBIC ORAL ADFOLBIC RF ORAL ADfolic acid injection ADFOLIVANE-OB ORAL AD


Drug Tier Limits or RestrictionsFOSAMAX PLUS D ORAL NP PAHECTOROL INTRAVENOUS SOLUTION 2 MCG/ML AD

hydroxocobalamin intramuscular ADM.V.I. ADULT INTRAVENOUS ADMULTIVITAMIN WITH FLUORIDE ORAL ADMULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE AD

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG AD

MYNATAL ADVANCE ORAL ADMYNATAL ORAL ADMYNATAL PLUS ORAL ADMYNATAL-Z ORAL ADMYNATE 90 PLUS ORAL ADMYNEPHROCAPS ORAL ADphytonadione (vitamin k1) oral tablet 5 mg ADPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA + DOCUSATE ORAL ADPNV-DHA ORAL ADPNV-OMEGA ORAL ADPNV-SELECT ORAL ADPR NATAL 400 EC ORAL ADPR NATAL 400 ORAL ADPR NATAL 430 EC ORAL ADPR NATAL 430 ORAL ADPRENAISSANCE ORAL ADPRENAISSANCE PLUS ORAL ADPRENATABS FA ORAL ADPRENATABS RX ORAL ADPRENATAL LOW IRON ORAL ADPRENATAL PLUS (CALCIUM CARB) ORAL ADPRENATAL PLUS ORAL ADPRENATAL-U ORAL ADpyridoxine (vitamin b6) injection ADRENAL CAPS ORAL ADRENA-VITE RX ORAL ADRENO CAPS ORAL ADUCare Comprehensive FormularyEffective: November 1, 2019

117

Drug Tier Limits or RestrictionsSE-NATAL 19 (WITH DOCUSATE) ORAL ADSE-NATAL 19 ORAL ADTARON-C DHA ORAL ADTARON-PREX PRENATAL-DHA ORAL ADTL-SELECT ORAL ADTRIADVANCE ORAL ADTRINATAL RX 1 ORAL ADTRINATE ORAL ADTRIVEEN-DUO DHA ORAL ADTRIVEEN-ONE ORAL ADTRIVEEN-PRX RNF ORAL ADTRI-VITAMIN WITH FLUORIDE ORAL ADVENA-BAL DHA ORAL ADVINACAL ORAL ADVINATE CARE ORAL ADVINATE GT ORAL ADVINATE II ORAL ADVINATE M ORAL ADVINATE ONE ORAL ADVINATE PN CARE ORAL ADVINATE ULTRA ORAL ADVIRT-PN DHA ORAL ADVIRT-PN ORAL ADVIRT-PN PLUS ORAL ADVIRT-SELECT ORAL ADVITAFOL-OB ORAL ADVITAMIN D2 ORAL ADVITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML AD

VOL-NATE ORAL ADVOL-TAB RX ORAL ADZATEAN-PN DHA ORAL ADZATEAN-PN PLUS ORAL AD


Indexabacavir............................ 2abacavir-lamivudine............ 2abacavir-lamivudine-zidovudine......................... 2ABILIFY............................41ABILIFY MAINTENA............41abiraterone.......................12acamprosate.....................41acarbose.......................... 81ACCOLATE...................... 103ACCU-CHEK AVIVA PLUS METER............................. 61ACCU-CHEK AVIVA PLUS TEST STRP....................... 63ACCU-CHEK COMPACT PLUS TEST....................... 63ACCU-CHEK GUIDE............63ACCU-CHEK GUIDE GLUCOSE METER...............61ACCU-CHEK GUIDE ME GLUCOSE MTR.................. 61ACCU-CHEK NANO.............61ACCU-CHEK SMARTVIEW TEST STRIP...................... 63ACCUPRIL........................ 31ACCURETIC.................31, 64ACE AEROSOL CLOUD ENHANCER....................... 61acebutolol...................20, 31acetaminophen-codeine..... 41acetazolamide........31, 64, 72acetazolamide sodium............................31, 64, 72acetic acid.................. 65, 72acetylcysteine............95, 103ACIPHEX.......................... 76ACIPHEX SPRINKLE........... 76acitretin......................... 108ACNE MEDICATION..........108ACTEMRA......................... 95ACTEMRA ACTPEN............. 95ACTHIB (PF)..................... 17ACTONEL......................... 95ACTOPLUS MET XR............ 81ACULAR........................... 72ACULAR LS.......................72ACUVAIL (PF)................... 72acyclovir.....................2, 108acyclovir sodium................. 2ADACEL(TDAP ADOLESN/ADULT)(PF)........17

ADALAT CC.......................31adapalene...................... 109ADCIRCA.................. 31, 103ADDERALL XR................... 41adefovir............................. 2ADEMPAS..................31, 103adenosine........................ 31adenosine (diagnostic)....... 31ADLYXIN.......................... 81ADMELOG SOLOSTAR U-100 INSULIN.................... 81ADMELOG U-100 INSULIN LISPRO............................ 81ADRUCIL..........................12ADVAIR DISKUS... 20, 81, 103ADVAIR HFA........ 20, 81, 103ADVATE........................... 26ADYNOVATE..................... 26ADZENYS ER.....................41ADZENYS XR-ODT............. 41AEMCOLO.......................... 2AEROSPAN................ 81, 103AFINITOR.........................12AFINITOR DISPERZ........... 12AFLURIA QD 2019-20(3YR UP)(PF)............................17AFLURIA QD 2019-20(6-35MO)(PF)....................... 17AFLURIA QUAD 2019-20(6MO UP)......................17AFREZZA..........................81AFSTYLA.......................... 26AGGRENOX............26, 31, 41AIMOVIG AUTOINJECTOR... 41AIRDUO RESPICLICK.......................... 20, 81, 103AJOVY..............................41AKYNZEO (NETUPITANT).... 76ALAWAY...........................72albendazole........................2albumin, human 25 %....... 26ALBURX (HUMAN) 25 %..... 26ALBUTEIN 25 %................ 26ALBUTEIN 5 %..................26albuterol sulfate.........20, 103alclometasone.................109ALECENSA........................12alendronate...................... 95alfuzosin.......................... 20ALIQOPA.......................... 12aliskiren...........................31

ALL DAY ALLERGY (CETIRIZINE).............. 1, 103ALL DAY ALLERGY-D............................1, 20, 103ALLERGY AND CONGESTION RELIEF............................1, 20, 103ALLERGY COMPLETE-D............................1, 20, 103ALLERGY RELIEF (LORATADINE)............ 1, 103ALLERGY RELIEF D-24HR............................1, 20, 103ALLERGY RELIEF,NASAL DECONGEST.......... 1, 20, 103ALLERGY-CONGESTION RELIEF-D.............. 1, 20, 103ALLER-TEC..................1, 103allopurinol........................ 95almotriptan malate............ 41ALOCRIL................... 72, 103alogliptin..........................81alogliptin-metformin.......... 81alogliptin-pioglitazone........ 82ALOMIDE......................... 72alosetron..........................76ALPHAGAN P.....................72ALPHANATE...................... 26ALPHANINE SD................. 26alprazolam....................... 41ALPROLIX.........................26alprostadil........................ 31ALREX............................. 72ALTACE............................31ALTAVERA (28)................. 82ALTOPREV........................ 31ALUNBRIG........................12ALVESCO.................. 82, 103ALYACEN 1/35 (28)........... 82ALYACEN 7/7/7 (28).......... 82ALYQ........................31, 103amantadine hcl............. 2, 41AMARYL........................... 82AMBIEN........................... 41AMBIEN CR.......................41ambrisentan.............. 31, 103AMERGE...........................41AMETHIA..........................82AMETHIA LO..................... 82AMETHYST (28)................ 82amifostine crystalline......... 95


119

amikacin............................2amiloride-hydrochlorothiazide......31, 65aminocaproic acid..............26aminophylline.......... 103, 115amiodarone...................... 31AMITIZA.......................... 76amitriptyline..................... 41amitriptyline-chlordiazepoxide............... 41amlodipine....................... 31amlodipine-atorvastatin..... 31amlodipine-benazepril........31amlodipine-olmesartan.......31amlodipine-valsartan......... 31amlodipine-valsartan-hcthiazid.....................31, 65ammonium chloride........... 65amoxapine....................... 41amoxicillin..........................2amoxicillin-pot clavulanate... 2amphetamine sulfate......... 41amphotericin b................... 3ampicillin........................... 3ampicillin sodium................ 3ampicillin-sulbactam............3AMPYRA........................... 95anagrelide........................ 26anastrozole................. 12, 82ANCOBON.......................... 3ANDRODERM.................... 82ANDROGEL.......................82ANORO ELLIPTA................ 20ANTARA........................... 31ANZEMET......................... 76APIDRA SOLOSTAR U-100 INSULIN...........................82APIDRA U-100 INSULIN......82APLENZIN........................ 41apraclonidine.................... 72aprepitant........................ 76APRI................................82APRISO............................76APTENSIO XR................... 42APTIOM............................42APTIVUS............................ 3ARANELLE (28)................. 82ARANESP (IN POLYSORBATE)................. 26ARCAPTA NEOHALER.. 20, 103ARICEPT.......................... 20ARIKAYCE.......................... 3

aripiprazole...................... 42ARISTADA........................ 42ARISTADA INITIO..............42ARIXTRA.......................... 26armodafinil.......................42ARMONAIR RESPICLICK............................... 82, 103ARMOUR THYROID............ 82ARNUITY ELLIPTA.......82, 104ARYMO ER........................42ASACOL HD...................... 76ASCOMP WITH CODEINE.... 42ascorbic acid (vitamin c)...116ASMANEX HFA........... 82, 104ASMANEX TWISTHALER............................... 82, 104aspirin-dipyridamole............................26, 31, 42ASTAGRAF XL................... 95ASTEPRO......................... 72ATACAND......................... 31ATACAND HCT.............31, 65atazanavir..........................3ATELVIA...........................95atenolol...................... 20, 31atenolol-chlorthalidone............................21, 31, 65ATGAM............................ 95atomoxetine..................... 42atorvastatin......................32atovaquone........................ 3atovaquone-proguanil..........3ATRIPLA............................ 3atropine.............. 21, 72, 104ATROVENT HFA............... 104AUBAGIO......................... 96AUBRA.............................82AUGMENTIN....................... 3AUGMENTIN XR.................. 3AURYXIA.......................... 65AUSTEDO.........................42AVALIDE.....................32, 65AVANDIA..........................82AVAPRO........................... 32AVAR-E LS......................109AVELOX............................. 3AVIANE............................82AVITA............................ 109AVODART.........................96AVONEX...........................96AVONEX (WITH ALBUMIN)..96AXIRON........................... 82

azacitidine........................12AZASAN........................... 96AZASITE.......................... 72azathioprine..................... 96azelaic acid.....................109azelastine.........................72AZELEX.......................... 109azithromycin...................... 3AZOPT............................. 72AZOR...............................32AZULFIDINE............ 3, 77, 96AZULFIDINE EN-TABS............................. 3, 77, 96AZURETTE (28).................82B COMPLEX 100.............. 116BACIIM..............................3bacitracin..................... 3, 72bacitracin-polymyxin b.......72baclofen...........................21BACTROBAN NASAL........... 72BALANCED SALT............... 72BAL-CARE DHA.....26, 65, 116balsalazide....................... 77BALVERSA........................12BALZIVA (28)................... 83BANZEL........................... 42BARACLUDE....................... 3BASAGLAR KWIKPEN U-100 INSULIN.................... 83BAVENCIO........................12BAXDELA........................... 3BD PRE-FILLED NORMAL SALINE............................ 65BECONASE AQ...........72, 104BELBUCA..........................42BELEODAQ....................... 12belladonna alkaloids-opium.42BELSOMRA....................... 42benazepril........................ 32benazepril-hydrochlorothiazide......32, 65BENEFIX.......................... 26BENICAR..........................32BENICAR HCT..............32, 65BENZACLIN.....................109BENZACLIN PUMP............ 109BENZAMYCIN.................. 109BENZNIDAZOLE.................. 3benzoyl peroxide............. 109benztropine.................21, 42BEPREVE..........................72BERINERT........................ 96


BESIVANCE...................... 72BESPONSA....................... 12betamethasone acet,sod phos................................83betamethasone dipropionate................... 109betamethasone valerate... 109betamethasone, augmented..................... 109BETAPACE...................21, 32BETAPACE AF.............. 21, 32BETASERON..................... 96betaxolol...............21, 32, 72bethanechol chloride..........21BETHKIS............................3BETOPTIC S......................72BEVESPI AEROSPHERE21, 104bexarotene.......................12BEXSERO......................... 17bicalutamide.....................12BIDIL...............................32BIKTARVY.......................... 3bimatoprost......................72BINOSTO......................... 96bisoprolol fumarate...... 21, 32bisoprolol-hydrochlorothiazide 21, 32, 65bleomycin........................ 12BLEPHAMIDE.................... 72BLEPHAMIDE S.O.P............72BLINCYTO........................ 12BLISOVI 24 FE.................. 83BLISOVI FE 1.5/30 (28)..... 83BLISOVI FE 1/20 (28)........ 83BONIVA........................... 96BOOSTRIX TDAP............... 17BORTEZOMIB....................12bosentan...................32, 104BOSULIF.......................... 12BP 10-1..........................109BPO............................... 109BRAFTOVI........................ 12BREO ELLIPTA......21, 83, 104BRIELLYN.........................83BRILINTA......................... 27brimonidine...................... 72BRINTELLIX......................42BRISDELLE.......................42BRIVIACT.........................42bromfenac........................72bromocriptine................... 42

brompheniramine-pseudoeph-dm...........21, 104BROMSITE........................72BROVANA..................21, 104budesonide.......... 73, 83, 104bumetanide.................32, 65BUNAVAIL........................ 42bupivacaine...................... 95bupivacaine (pf)................95bupivacaine-dextrose-water(pf)......................... 95bupivacaine-epinephrine................................. 21, 95bupivacaine-epinephrine (pf)............................21, 95buprenorphine.................. 42buprenorphine hcl............. 42buprenorphine-naloxone.....43bupropion hcl....................43bupropion hcl (smoking deter)..............................43buspirone.........................43BUTALBITAL COMPOUND W/CODEINE......................43butalbital-acetaminop-caf-cod..................................43butalbital-acetaminophen... 43butalbital-acetaminophen-caff................................. 43butalbital-aspirin-caffeine................................. 27, 43BUTRANS......................... 43BYDUREON.......................83BYDUREON BCISE............. 83BYETTA............................83BYSTOLIC................... 21, 32BYVALSON.................. 21, 32cabergoline.......................43CABLIVI........................... 27CABOMETYX..................... 13CADUET........................... 32caffeine citrate..................43CALAN............................. 32CALAN SR........................ 32calcipotriene................... 109calcitonin (salmon).......83, 96calcitriol......................... 116calcium acetate.................65calcium chloride................ 65calcium gluconate..............65CALQUENCE..................... 13CAMILA............................83

CAMRESE......................... 83CAMRESE LO.................... 83CANASA...........................77candesartan..................... 32candesartan-hydrochlorothiazid....... 32, 65CANDIN........................... 63capecitabine..................... 13CAPITAL WITH CODEINE.... 43CAPRELSA........................ 13captopril.......................... 32captopril-hydrochlorothiazide......32, 65CARAFATE........................77CARBAGLU....................... 65carbamazepine............ 43, 44CARBATROL......................44carbidopa-levodopa........... 44carbidopa-levodopa-entacapone...................... 44carbinoxamine maleate.1, 104carboplatin....................... 13CARDIZEM....................... 32CARDIZEM CD.................. 32CARDIZEM LA................... 32CARDURA................... 21, 32CARDURA XL............... 21, 32carisoprodol-asa-codeine................................. 21, 44carteolol...........................73CARTIA XT....................... 32carvedilol....................21, 32carvedilol phosphate.... 21, 32CATHFLO ACTIVASE..... 27, 71CAYSTON...........................3CAZIANT (28)................... 83cefaclor............................. 3cefadroxil...........................3cefazolin............................ 4cefazolin in dextrose (iso-os)....................................4cefdinir.............................. 4cefditoren pivoxil................ 4cefepime............................4cefepime in dextrose,iso-osm.................................. 4cefixime.............................4cefotaxime......................... 4cefotetan........................... 4cefoxitin............................ 4cefoxitin in dextrose, iso-osm.................................. 4


121

cefpodoxime.......................4cefprozil.............................4ceftazidime........................ 4ceftriaxone.........................4ceftriaxone in dextrose,iso-os..................................... 4cefuroxime axetil................ 4cefuroxime sodium..............4CELEBREX........................ 44celecoxib..........................44CELEXA............................44CELLCEPT.........................96CELONTIN........................ 44CENTANY........................109CENTANY AT................... 109cephalexin......................... 4CERDELGA....................... 96CESAMET......................... 77cetirizine.....................1, 104cetirizine-pseudoephedrine............................1, 21, 104cevimeline........................21CHANTIX..........................21CHANTIX CONTINUING MONTH BOX..................... 21CHANTIX STARTING MONTH BOX..................... 21CHATEAL (28)...................83CHEMET..................... 81, 96CHILDREN'S ALAWAY.........73CHILDREN'S ALLERGY RELIEF(LOR)............... 1, 104CHILDREN'S CETIRIZINE................................. 1, 104CHILD'S ALL DAY ALLERGY(CETIR)..........1, 104chloramphenicol sod succinate........................... 4chlordiazepoxide hcl.......... 44chlorhexidine gluconate......73chloroquine phosphate.........4chlorothiazide..............32, 65chlorpromazine................. 44chlorpropamide................. 83chlorthalidone............. 33, 65chlorzoxazone...................21cholestyramine (with sugar)............................. 33CHOLESTYRAMINE LIGHT... 33choline,magnesium salicylate..........................44chromium chloride.............65

ciclopirox........................109cilostazol.................... 27, 33CILOXAN..........................73CIMDUO............................ 4cimetidine........................ 77cimetidine hcl................... 77CIMZIA.......................77, 96CIMZIA POWDER FOR RECONST....................77, 96CIMZIA STARTER KIT... 77, 96cinacalcet.........................96CINRYZE.......................... 96CIPRO............................... 4CIPRO HC.........................73CIPRO XR...........................4CIPRODEX........................73ciprofloxacin.......................5ciprofloxacin (mixture).........4ciprofloxacin hcl............ 4, 73ciprofloxacin in 5 % dextrose............................ 4cisplatin........................... 13citalopram........................44cladribine......................... 13CLARAVIS.......................109CLARINEX...................1, 104CLARINEX-D 12 HOUR............................1, 21, 104clarithromycin.................... 5CLEANSING WASH...........109clemastine.................. 1, 104CLEO 90 INFUSION SET 24"..................................61CLINDACIN ETZ...............109CLINDACIN P.................. 109clindamycin hcl................... 5clindamycin palmitate hcl..... 5CLINDAMYCIN PEDIATRIC.... 5clindamycin phosphate.......................... 5, 109, 110clindamycin-benzoyl peroxide.........................110clindamycin-tretinoin....... 110clobazam......................... 44clobetasol.......................110clobetasol-emollient.........110clomipramine....................44clonazepam...................... 44clonidine.....................22, 33clonidine (pf)......... 21, 33, 44clonidine hcl................21, 33clopidogrel....................... 27

clorazepate dipotassium..... 44clotrimazole.................... 110clotrimazole-betamethasone............... 110clozapine..........................44CLOZARIL........................ 44COAGADEX.......................27COARTEM...........................5codeine sulfate.......... 44, 104COLAZAL..........................77colchicine......................... 96colesevelam................ 33, 83COLESTID........................ 33COLESTID FLAVORED........ 33colestipol......................... 33colistin (colistimethate na)... 5COMBIGAN.......................73COMBIVENT RESPIMAT............................... 22, 104COMBIVIR..........................5COMETRIQ....................... 13COMFORT SHORT INFUSION SET 23"............ 61COMPLERA......................... 5COMPLETE NATAL DHA.....116COMPLETENATE...............116COMPRO.....................44, 77CONCERTA....................... 44CONSTULOSE................... 65CONTOUR METER.............. 61CONTOUR NEXT EZ METER. 61CONTOUR NEXT METER......61CONTOUR NEXT ONE METER............................. 61CONTOUR NEXT TEST STRIPS............................ 63CONTOUR TEST STRIPS..... 63COPAXONE....................... 96COPIKTRA........................ 13COPPER CHLORIDE............65COREG....................... 22, 33COREG CR.................. 22, 33CORGARD...................22, 33CORIFACT........................ 27CORLANOR.......................33CORMAX.........................110cortisone..........................83CORZIDE...............22, 33, 65COSENTYX......................110COSENTYX (2 SYRINGES). 110COSENTYX PEN............... 110COSENTYX PEN (2 PENS)..110


COSOPT...........................73COSOPT (PF).................... 73cosyntropin...................... 63COTELLIC.........................13COTEMPLA XR-ODT............44COZAAR...........................33CREON.............................77CRESEMBA.........................5CRESTOR......................... 33CRIXIVAN.......................... 5cromolyn.................. 73, 105CROTAN......................... 110CRYSELLE (28)................. 83CRYSVITA........................ 65cyanocobalamin (vitamin b-12)............................. 116CYCLAFEM 1/35 (28)......... 83CYCLAFEM 7/7/7 (28)........ 83cyclobenzaprine................ 22cyclopentolate...................73cyclophosphamide........13, 96CYCLOPHOSPHAMIDE... 13, 96cyclosporine..................... 96cyclosporine modified.........96CYMBALTA........................44cyproheptadine............1, 105CYRAMZA.........................13cyred...............................83CYSTAGON....................... 96CYSTARAN....................... 73cytarabine........................ 13cytarabine (pf)..................13CYTRA K CRYSTALS........... 65CYTRA-2.......................... 65CYTRA-3.......................... 65CYTRA-K.......................... 65dacarbazine......................13DAKLINZA..........................5dalfampridine................... 97DALIRESP.......................105danazol............................83dantrolene........................22dapsone.............................5DAPTACEL (DTAP PEDIATRIC) (PF)............... 17daptomycin........................ 5DARAPRIM......................... 5darifenacin..................... 115DASETTA 1/35 (28)........... 83DASETTA 7/7/7 (28)..........83daunorubicin.....................13DAURISMO....................... 13

DAXBIA............................. 5DAYPRO........................... 44DAYSEE........................... 83DAYTRANA....................... 44deferasirox....................... 81deferoxamine.............. 81, 97DELFLEX-LC/1.5% DEXTROSE....................... 65DELFLEX-LC/2.5% DEXTROSE....................... 65DELFLEX-LC/4.25% DEXTROSE....................... 66DELFLEX-SM WITH 1.5% DEXTROSE....................... 66DELSTRIGO........................5DELZICOL........................ 77DENAVIR........................110DENTA 5000 PLUS.............97DENTAGEL........................97DEPAKENE........................44DEPAKOTE....................... 44DEPAKOTE ER...................44DEPAKOTE SPRINKLES.......44DEPO-PROVERA................ 83DESCOVY...........................5desipramine......................44desloratadine.............. 1, 105desmopressin.............. 27, 84desogestrel-ethinyl estradiol...........................84desonide........................ 110desvenlafaxine..................45desvenlafaxine fumarate.... 44desvenlafaxine succinate.... 45DETROL......................... 116DETROL LA..................... 116dexamethasone................ 84DEXAMETHASONE INTENSOL........................ 84dexamethasone sodium phos (pf)..........................84dexamethasone sodium phosphate...................73, 84DEXCOM G4 RECEIVER...... 62DEXCOM G4 RECEIVER PEDIATRIC....................... 62DEXCOM G4 RECEIVER-SHARE (PED).................... 62DEXCOM G4 RECEIVER-SHARE KIT....................... 62DEXCOM G4 TRANSMITTER.62DEXCOM G5 RECEIVER...... 62

DEXCOM G5 TRANSMITTER.62DEXCOM G5-G4 SENSOR....62DEXCOM G6 RECEIVER...... 62DEXCOM G6 SENSOR.........62DEXCOM G6 TRANSMITTER.62DEXCOM RECEIVER........... 62DEXEDRINE SPANSULE...... 45DEXILANT........................ 77dexmethylphenidate.......... 45dexrazoxane hcl................ 97dextroamphetamine...........45dextroamphetamine-amphetamine.............. 45, 46dextrose 5 % in ringer's..... 66dextrose 5 %-lactated ringers.............................66DIACOMIT........................ 46DIANEAL LOW CALCIUM/1.5% DEX.......... 66DIANEAL PD-2 WITH 2.5 % DEX.................................66DIANEAL PD-2 WITH 4.25 % DEX.............................66DIANEAL PD-2/1.5% DEXTROSE....................... 66DIANEAL WITH 2.5 % DEXTROSE....................... 66DIANEAL WITH 4.25 % DEXTROSE....................... 66DIASTAT.......................... 46DIASTAT ACUDIAL.............46diazepam......................... 46DIAZEPAM INTENSOL.........46diclofenac epolamine.. 46, 110diclofenac potassium..........46diclofenac sodium.................... 13, 46, 73, 110dicloxacillin........................ 5dicyclomine...................... 22didanosine......................... 5DIFFERIN....................... 110diflorasone..................... 110DIFLUCAN..........................5diflunisal.......................... 46DIGOX............................. 33digoxin............................ 33dihydroergotamine.......22, 46DILANTIN................... 33, 46DILANTIN EXTENDED... 33, 46DILANTIN INFATABS.... 33, 46DILANTIN-125.............33, 46diltiazem hcl..................... 33


123

DILT-XR...........................33DILUENT FOR ACTHIB...... 102DILUENT FOR IMOVAX..... 102DILUENT FOR RABAVERT.. 102DILUENT FOR ROTARIX.... 102dimenhydrinate......1, 77, 105DIOVAN........................... 33DIOVAN HCT............... 33, 66DIPENTUM........................77diphenhydramine hcl.... 1, 105diphenoxylate-atropine.......................... 22, 77, 105dipyridamole............... 27, 33DISKETS.......................... 46disopyramide phosphate.....33disulfiram.........................97DITROPAN XL..................116divalproex........................ 46dobutamine.................22, 34dobutamine in d5w...... 22, 34DOCETAXEL......................13dofetilide..........................34donepezil......................... 22dopamine................... 22, 34dopamine in 5 % dextrose................................. 22, 34dorzolamide......................73dorzolamide-timolol........... 73dorzolamide-timolol (pf).....73DOVATO............................ 5DOVONEX.......................110doxazosin................... 22, 34doxepin............................46doxorubicin...................... 13doxycycline hyclate........5, 73doxycycline monohydrate.....5dronabinol........................77droperidol........................ 46drospirenone-ethinyl estradiol...........................84DROXIA........................... 13DUAC.............................110DUETACT......................... 84DUEXIS...................... 46, 77DULERA...............22, 84, 105duloxetine........................ 46DUPIXENT............... 105, 110DURAGESIC......................46dutasteride.......................97dutasteride-tamsulosin.......97DYANAVEL XR...................46DYMISTA.................. 73, 105

E.E.S. 400..........................5E.E.S. GRANULES................5ECLIPSE SYRINGE............. 62EC-NAPROXEN.............46, 97econazole....................... 110ECONTRA EZ.................... 84EDARBI............................34EDARBYCLOR.............. 34, 66EDLUAR........................... 46ED-SPAZ.......................... 22EDURANT...........................5efavirenz........................... 5EFFER-K...........................66EFFEXOR XR..................... 46EFFIENT...........................27electrolyte-48 in d5w......... 66ELELYSO.......................... 71ELESTAT.......................... 73eletriptan......................... 46ELIDEL..................... 97, 110ELINEST...........................84ELIPHOS.......................... 66ELIQUIS...........................27ELITE OB WITH DHA........ 116ELITE-OB 400............27, 116ELLA................................84ELMIRON..........................97ELOCTATE........................ 27EMADINE......................... 73EMBEDA...........................46EMCYT............................. 13EMGALITY PEN..................47EMGALITY SYRINGE...........47EMOQUETTE..................... 84EMTRIVA............................5ENABLEX........................ 116enalapril maleate...............34enalaprilat........................34enalapril-hydrochlorothiazide......34, 66ENBREL.................... 97, 110ENBREL MINI.............97, 110ENBREL SURECLICK... 97, 110ENDOCET......................... 47ENGERIX-B (PF)................ 17ENGERIX-B PEDIATRIC (PF).................................17enoxaparin....................... 27ENPRESSE........................84ENSKYCE......................... 84entacapone...................... 47entecavir........................... 5

ENTRESTO........................34ENTYVIO.....................77, 97ENULOSE......................... 66ENVARSUS XR.................. 97EPCLUSA............................6ephedrine sulfate....... 22, 105EPIDIOLEX....................... 47EPIDUO..........................111EPIDUO FORTE................111epinastine........................ 73epinephrine......... 22, 23, 105EPIPEN............................ 23EPIPEN 2-PAK............23, 105EPIPEN JR........................ 23EPIPEN JR 2-PAK........23, 105epirubicin......................... 13EPITOL............................ 47EPIVIR...............................6EPIVIR HBV........................6eplerenone....................... 34EPOGEN...........................27epoprostenol (glycine) 34, 105eprosartan....................... 34ergocalciferol (vitamin d2) 116ergoloid........................... 23ERIVEDGE........................ 13ERLEADA..........................13erlotinib........................... 13ERRIN..............................84ertapenem......................... 6ERY PADS.......................111ERYPED 200....................... 6ERYPED 400....................... 6ERY-TAB............................ 6ERYTHROCIN (AS STEARATE)........................ 6erythromycin................ 6, 73erythromycin ethylsuccinate.................... 6erythromycin with ethanol 111ESBRIET.........................105escitalopram oxalate..........47esomeprazole magnesium.. 77esomeprazole strontium..... 77ESTARYLLA.......................84estazolam........................ 47estradiol...........................84estradiol valerate.............. 84estradiol-norethindrone acet.................................84estropipate.......................84eszopiclone.......................47


ethambutol........................ 6ethosuximide.................... 47ethyl chloride.................. 111etidronate disodium...........97etodolac...........................47etoposide......................... 13EUCRISA........................ 111EURAX........................... 111EVAMIST..........................84EVEKEO........................... 47EVISTA.......................84, 97EVOTAZ....................... 6, 97EVZIO........................ 47, 97EXALGO ER...................... 47EXELON........................... 23exemestane................ 13, 84EXFORGE......................... 34EXFORGE HCT............. 34, 66EXTAVIA.......................... 97EYE ITCH RELIEF...............73EZALLOR SPRINKLE........... 34E-Z-CAT DRY.................... 63ezetimibe......................... 34ezetimibe-simvastatin........ 34E-Z-HD BARIUM................ 63E-Z-PAQUE.......................63FABIOR.......................... 111FABRAZYME......................71FALMINA (28)................... 84famciclovir......................... 6famotidine........................77famotidine (pf)..................77famotidine (pf)-nacl (iso-os).................................. 77FANAPT............................47FARXIGA.......................... 84FARYDAK......................... 13FASENRA........................105FAZACLO..........................47FEIBA NF..........................27felbamate.........................47FELBATOL........................ 47felodipine......................... 34FEM PH.......................... 111FEMHRT LOW DOSE...........84FEMYNOR......................... 85fenofibrate....................... 34fenofibrate micronized....... 34fenofibrate nanocrystallized 34fenofibric acid................... 34fenofibric acid (choline)......34FENOGLIDE...................... 34

fenoprofen....................... 47fentanyl........................... 47fentanyl citrate................. 47FERRIPROX...................... 81FETZIMA.......................... 48FIASP FLEXTOUCH U-100 INSULIN...........................85FIASP U-100 INSULIN........ 85FIBRICOR.........................34finasteride.................97, 111FIRAZYR.......................... 97FIRDAPSE........................ 97FISH OIL..........................35flecainide......................... 35FLECTOR...................48, 111FLOMAX........................... 23FLOVENT DISKUS.......85, 105FLOVENT HFA............ 85, 106floxuridine........................13FLUAD 2019-2020 (65 YR UP)(PF)............................18FLUARIX QUAD 2019-2020 (PF).................................18FLUBLOK QUAD 2019-2020 (PF).................................18FLUCELVAX QUAD 2019-2020............................... 18FLUCELVAX QUAD 2019-2020 (PF).........................18fluconazole.........................6fluconazole in dextrose(iso-o)..................................... 6fluconazole in nacl (iso-osm)................................. 6flucytosine......................... 6fludrocortisone..................85FLULAVAL QUAD 2019-2020............................... 18FLULAVAL QUAD 2019-2020 (PF).........................18flumazenil...................48, 97FLUMIST QUAD 2019-2020.18flunisolide................. 73, 106fluocinolone.................... 111fluocinolone and shower cap................................111fluocinonide.................... 111FLUOCINONIDE-E............ 111fluorescein-proparacaine................................. 63, 73fluoride (sodium)...............97FLUORITAB.......................97

fluorometholone................73FLUOROPLEX............. 13, 111fluorouracil................14, 111fluoxetine.........................48fluphenazine decanoate......48fluphenazine hcl................ 48flurazepam....................... 48flurbiprofen...................... 48flurbiprofen sodium........... 73flutamide......................... 14fluticasone propionate..............................106, 111fluticasone propion-salmeterol........... 23, 85, 106fluvastatin........................35fluvoxamine......................48FLUZONE HIGH-DOSE 2018-19 (PF).................... 18FLUZONE QUAD 2018-2019 18FLUZONE QUAD 2018-2019 (PF).................................18FLUZONE QUAD PEDI 2019-20 (PF).................... 18FOCALIN.......................... 48FOCALIN XR..................... 48FOLBIC.......................... 116FOLBIC RF...................... 116folic acid.........................116FOLIVANE-OB............27, 116fomepizole....................... 97fondaparinux.................... 27FORA G20...................62, 63FORFIVO XL......................48FORMADON.................... 111FORTEO........................... 85FORTESTA........................85FOSAMAX.........................97FOSAMAX PLUS D...... 97, 117fosamprenavir.................... 6fosinopril..........................35fosinopril-hydrochlorothiazide......35, 66fosphenytoin.....................48FOSRENOL..................66, 98FRAGMIN......................... 27FREESTYLE FREEDOM LITE. 62FREESTYLE INSULINX...62, 63FREESTYLE INSULINX TEST STRIPS............................ 64FREESTYLE LIBRE 10 DAY READER........................... 62


125

FREESTYLE LIBRE 10 DAY SENSOR...........................62FREESTYLE LIBRE 14 DAY READER........................... 62FREESTYLE LIBRE 14 DAY SENSOR...........................62FREESTYLE LITE METER..... 62FREESTYLE LITE STRIPS.....64FREESTYLE TEST............... 64FROVA............................. 48frovatriptan...................... 48FULPHILA......................... 27fulvestrant....................... 14furosemide..................35, 66FUZEON.............................6FYCOMPA......................... 48gabapentin....................... 48GABITRIL......................... 48galantamine..................... 23GAMASTAN S/D................ 18GAMMAGARD LIQUID.........18GAMMAGARD S-D (IGA < 1 MCG/ML)..........................18GAMUNEX-C..................... 18GARDASIL 9 (PF).............. 18GASTROCROM.................106gatifloxacin.......................73GAVILYTE-C......................77GAVILYTE-G..................... 77GAVILYTE-N..................... 77GELNIQUE...................... 116gemfibrozil....................... 35GENERLAC....................... 66GENGRAF......................... 98GENOTROPIN....................85GENOTROPIN MINIQUICK...85GENTAK........................... 73gentamicin............ 6, 73, 111gentamicin in nacl (iso-osm)................................. 6gentamicin sulfate (ped) (pf)................................... 6gentamicin sulfate (pf).........6GENVOYA...........................6GEODON.......................... 48GIANVI (28)..................... 85GIAZO............................. 77GILENYA.......................... 98GILOTRIF......................... 14glatiramer........................ 98GLATOPA......................... 98GLEOSTINE...................... 14

glimepiride....................... 85glipizide........................... 85glipizide-metformin............85GLUCAGEN DIAGNOSTIC KIT............................ 64, 85GLUCAGEN HYPOKIT.... 85, 98GLUCAGON EMERGENCY KIT (HUMAN).............. 85, 98GLUCAGON HCL...........64, 85GLUCOCARD EXPRESSION................................. 62, 64GLUCOCARD SHINE METER.62GLUCOCARD SHINE METER KIT..................................62GLUCOCARD SHINE TEST STRIPS............................ 64GLUCOCARD SHINE XL METER............................. 62GLUCOTROL..................... 85GLUCOTROL XL................. 86glyburide..........................86glyburide micronized..........86glyburide-metformin.......... 86glycine urologic solution..... 66glycopyrrolate...................23GLYNASE......................... 86GLYSET............................86GLYXAMBI........................86GOCOVRI..................... 6, 48GRALISE.......................... 49GRALISE 30-DAY STARTER PACK............................... 48granisetron (pf)................ 77granisetron hcl..................78GRANIX........................... 27griseofulvin microsize.......... 6griseofulvin ultramicrosize....7GRIS-PEG (ULTRAMICROSIZE)............ 7guanfacine..................35, 49guanidine......................... 23HAEGARDA.......................98halobetasol propionate..... 111haloperidol....................... 49haloperidol decanoate........ 49haloperidol lactate.............49HARVONI........................... 7HAVRIX (PF).....................18HEATHER......................... 86HECTOROL..................... 117HELIXATE FS.................... 27HEMANGEOL..........23, 35, 49

HEMLIBRA........................27HEMOFIL M HIGH.............. 27HEMOFIL M LOW............... 27HEMOFIL M MID................ 27HEMOFIL M SUPER HIGH.... 27HEP FLUSH-10 (PF)...... 27, 62heparin (porcine).............. 28heparin (porcine) in 5 % dex................................. 28heparin (porcine) in nacl (pf)............................28, 62heparin flush(porcine)-0.9nacl.......................28, 62HEPARIN LOCK............ 28, 62HEPARIN LOCK FLUSH.. 28, 62heparin lock flush (porcine)................................. 28, 62HEPARIN LOCKFLUSH(PORCINE)(PF)................................. 28, 62heparin(porcine) in 0.45% nacl.................................28heparin, porcine (pf).... 28, 62HEPLISAV-B (PF)...............18HEPSERA........................... 7hetastarch 6 % in 0.9 % nacl.................................66HETLIOZ.......................... 49HIBERIX (PF)....................18HIZENTRA........................ 18HORIZANT........................49HUMALOG JUNIOR KWIKPEN U-100................86HUMALOG KWIKPEN INSULIN...........................86HUMALOG MIX 50-50 INSULN U-100.................. 86HUMALOG MIX 50-50 KWIKPEN......................... 86HUMALOG MIX 75-25 KWIKPEN......................... 86HUMALOG MIX 75-25(U-100)INSULN..................... 86HUMALOG U-100 INSULIN.. 86HUMATE-P........................28HUMATROPE..................... 86HUMIRA.............. 78, 98, 111HUMIRA PEDIATRIC CROHNS START....78, 98, 111HUMIRA PEN........ 78, 98, 111HUMIRA PEN CROHNS-UC-HS START............78, 98, 111


HUMIRA PEN PSOR-UVEITS-ADOL HS..78, 98, 111HUMIRA(CF)........ 78, 98, 112HUMIRA(CF) PEDI CROHNS STARTER............. 78, 98, 111HUMIRA(CF) PEN.. 78, 98, 112HUMIRA(CF) PEN CROHNS-UC-HS.................78, 98, 111HUMIRA(CF) PEN PSOR-UV-ADOL HS........ 78, 98, 111HUMULIN 70/30 U-100 INSULIN...........................86HUMULIN 70/30 U-100 KWIKPEN......................... 86HUMULIN N NPH INSULIN KWIKPEN......................... 86HUMULIN N NPH U-100 INSULIN...........................86HUMULIN R REGULAR U-100 INSULN..................... 86HUMULIN R U-500 (CONC) INSULIN...........................87HUMULIN R U-500 (CONC) KWIKPEN......................... 87hydralazine.......................35hydrochlorothiazide......35, 66hydrocodone-acetaminophen................. 49hydrocodone-ibuprofen...... 49hydrocortisone...........87, 112hydrocortisone acetate..... 112hydrocortisone-acetic acid.. 73hydromorphone................ 49hydroxocobalamin........... 117hydroxychloroquine....... 7, 98hydroxyprogest(pf)(preg presv)..............................87hydroxyprogesterone cap(ppres)....................... 87hydroxyprogesterone capr(bulk)........................ 87hydroxyprogesterone caproate.......................... 87hydroxyurea..................... 14hydroxyzine hcl............. 1, 49hydroxyzine pamoate.....1, 49HYOPHEN...........................7hyoscyamine sulfate.......... 23HYPERHEP B S/D...............18HYPERHEP B S-D NEONATAL....................... 18HYPERRAB S/D (PF)...........18

HYPERRHO S/D................. 19HYSINGLA ER................... 49HYZAAR......................35, 66ibandronate......................98IBRANCE..........................14ibuprofen......................... 49icatibant...........................98ICLUSIG...........................14idarubicin......................... 14IDELVION.........................28IDHIFA............................ 14ifosfamide........................ 14ifosfamide-mesna..............14imatinib........................... 14IMBRUVICA...................... 14IMFINZI........................... 14imipramine hcl.................. 49imipramine pamoate..........49imiquimod...................... 112IMITREX...........................49IMOVAX RABIES VACCINE (PF).................................19IMURAN........................... 98INBRIJA........................... 49INCRUSE ELLIPTA...... 23, 106indapamide................. 35, 66INDERAL LA...........23, 35, 50INDERAL XL...........23, 35, 50indomethacin.............. 50, 98INFANRIX (DTAP) (PF)....... 19INFED..............................28INFLECTRA.......... 78, 98, 112INLYTA............................ 14INNOPRAN XL........ 23, 35, 50insulin lispro..................... 87INTELENCE.........................7INTERMEZZO....................50INTRON A............... 7, 14, 99INTROVALE...................... 87INTUNIV ER................ 35, 50INVEGA............................50INVEGA SUSTENNA........... 50INVEGA TRINZA................ 50INVIRASE.......................... 7INVOKAMET......................87INVOKAMET XR.................87INVOKANA....................... 87IONOSOL-B IN D5W.......... 66IONOSOL-MB IN D5W........ 67IOPIDINE......................... 74IPOL................................19

ipratropium bromide.......................... 23, 74, 106ipratropium-albuterol..23, 106irbesartan........................ 35irbesartan-hydrochlorothiazide......35, 67IRESSA............................ 14irinotecan.........................14ISENTRESS........................ 7ISENTRESS HD................... 7ISOLYTE S PH 7.4..............67ISOLYTE-P IN 5 % DEXTROSE....................... 67ISOLYTE-S....................... 67isoniazid............................ 7isosorbide dinitrate............35isosorbide mononitrate.......35isotretinoin..................... 112ISOVUE-300..................... 64ISOVUE-M 300..................64isradipine......................... 35ISTALOL...........................74itraconazole....................... 7ivermectin..........................7IXIARO (PF)......................19IXINITY............................28JADENU........................... 81JADENU SPRINKLE.............81JAKAFI.............................14JALYN.........................23, 99JANTOVEN........................28JANUMET......................... 87JANUMET XR.....................87JANUVIA.......................... 87JARDIANCE...................... 87JENCYCLA........................ 87JENTADUETO.................... 87JENTADUETO XR............... 87JINTELI............................87JIVI................................. 28JOLESSA.......................... 87JOLIVETTE........................87JUBLIA........................... 112JULEBER.......................... 87JULUCA..............................7JUNEL 1.5/30 (21).............87JUNEL 1/20 (21)............... 87JUNEL FE 1.5/30 (28)........ 87JUNEL FE 1/20 (28)........... 87JUNEL FE 24..................... 87JUXTAPID.........................35JYNARQUE........................67


127

KADCYLA......................... 14KADIAN........................... 50KAITLIB FE.......................87KALBITOR........................ 99KALETRA............................7KALYDECO......................106KARIVA (28).....................87KAZANO...........................87K-EFFERVESCENT..............67KEFLEX..............................7KELNOR 1/35 (28).............88KEPIVANCE.....................112KEPPRA............................50KEPPRA XR.......................50ketoconazole............... 7, 112ketoprofen....................... 50ketorolac.................... 50, 74ketotifen fumarate.............74KEVZARA......................... 99KHEDEZLA........................50KINERET.......................... 99KINRIX (PF)......................19KIONEX (WITH SORBITOL)................................. 67, 99KISQALI...........................14KISQALI FEMARA CO-PACK................................. 14, 88KITABIS PAK...................... 7KLOR-CON....................... 67KLOR-CON 10................... 67KLOR-CON 8.....................67KLOR-CON M10.................67KLOR-CON M15.................67KLOR-CON M20.................67KLOR-CON/EF................... 67KOATE............................. 28KOGENATE FS...................28KOMBIGLYZE XR............... 88KOVALTRY........................28KRYSTEXXA...................... 99KURVELO (28).................. 88l norgest/e.estradiol-e.estrad........................... 88labetalol..................... 23, 35lactated ringers.................67lactulose.......................... 67LAMICTAL........................ 50LAMICTAL ODT..................50LAMICTAL ODT STARTER (BLUE).............................50LAMICTAL ODT STARTER (GREEN).......................... 50

LAMICTAL ODT STARTER (ORANGE)........................ 50LAMICTAL STARTER (BLUE) KIT..................................50LAMICTAL STARTER (GREEN) KIT.....................50LAMICTAL STARTER (ORANGE) KIT.................. 50LAMICTAL XR....................50LAMICTAL XR STARTER (BLUE).............................50LAMICTAL XR STARTER (GREEN).......................... 50LAMICTAL XR STARTER (ORANGE)........................ 50lamivudine......................... 7lamivudine-zidovudine......... 7lamotrigine................. 50, 51lansoprazole..................... 78lanthanum.................. 67, 99LANTUS SOLOSTAR U-100 INSULIN...........................88LANTUS U-100 INSULIN..... 88LARIN 1.5/30 (21).............88LARIN 1/20 (21)............... 88LARIN 24 FE..................... 88LARIN FE 1.5/30 (28)........ 88LARIN FE 1/20 (28)........... 88LARISSIA......................... 88LASTACAFT...................... 74latanoprost.......................74LATUDA........................... 51LAYOLIS FE...................... 88LAZANDA......................... 51ledipasvir-sofosbuvir............7LEENA 28......................... 88leflunomide...................... 99LEMTRADA....................... 99LENVIMA..........................14LESCOL XL....................... 35LESSINA.......................... 88LETAIRIS.................. 35, 106letrozole..................... 15, 88leucovorin calcium.............99LEUKERAN........................15LEUKINE.......................... 28leuprolide................... 15, 88levalbuterol hcl.......... 23, 106levalbuterol tartrate... 23, 106LEVAQUIN..........................7LEVEMIR FLEXTOUCH U-100 INSULN..................... 88

LEVEMIR U-100 INSULIN....88levetiracetam....................51levobunolol.......................74levocarnitine.....................99levocarnitine (with sugar)...99levocetirizine...............1, 106levofloxacin.................. 7, 74levoleucovorin calcium....... 99LEVONEST (28).................88levonorgestrel...................88levonorgestrel-ethinyl estrad..............................88levonorg-eth estrad triphasic...........................88LEVORA-28.......................88levorphanol tartrate...........51levothyroxine....................88LEVOXYL.......................... 88LEXAPRO..........................51LEXIVA.............................. 7LIALDA............................ 78LICE KILLING..................112LICE SOLUTION...............112LICE TREATMENT.............112LICE TREATMENT (PERMETHRIN)................112lidocaine.........................112lidocaine (pf) in d7.5w...... 95lidocaine (pf)...............35, 95lidocaine hcl.........74, 95, 112lidocaine hcl-hydrocortison ac..................................112lidocaine in 5 % dextrose (pf)................................. 36LIDOCAINE PAIN RELIEF...112lidocaine-epinephrine... 23, 95lidocaine-hydrocortisone-aloe............................... 112lidocaine-prilocaine.......... 112LIDODERM......................112LIDOPURE PATCH............ 112LILETTA........................... 89lindane...........................112linezolid............................. 7linezolid in dextrose 5%.......7linezolid-0.9% sodium chloride............................. 7LINZESS.......................... 78liothyronine...................... 89LIPITOR........................... 36LIPOFEN...........................36LIQUID E-Z PAQUE............ 64


lisinopril...........................36lisinopril-hydrochlorothiazide......36, 67lithium carbonate.............. 51lithium citrate................... 51LIVALO............................ 36LONHALA MAGNAIR REFILL.23LONHALA MAGNAIR STARTER..........................23LONSURF......................... 15LOPID..............................36lopinavir-ritonavir............... 7LOPRESSOR................ 24, 36loratadine................... 2, 106LORATA-DINE D..... 1, 24, 106LORATADINE-D...... 2, 24, 106lorazepam........................ 51LORAZEPAM INTENSOL...... 51LORBRENA....................... 15LORCET (HYDROCODONE)..51LORCET HD...................... 51LORYNA (28).................... 89losartan........................... 36losartan-hydrochlorothiazide......36, 67LOTENSIN........................ 36LOTENSIN HCT............ 36, 67loteprednol etabonate........ 74LOTREL............................36lovastatin......................... 36LOVAZA........................... 36LOVENOX......................... 28LOW-OGESTREL (28)......... 89loxapine succinate............. 51LTA PRE-ATTACHED......... 112LUDENT FLUORIDE............ 99LUGOLS...........7, 89, 99, 106LUMIGAN......................... 74LUMIZYME........................71LUNESTA..........................51LUPRON DEPOT........... 15, 89LUPRON DEPOT (3 MONTH)................................. 15, 89LUPRON DEPOT (4 MONTH)................................. 15, 89LUPRON DEPOT (6 MONTH)................................. 15, 89LUPRON DEPOT-PED.....15, 89LUPRON DEPOT-PED (3 MONTH)..................... 15, 89LUTERA (28).....................89LYNPARZA........................15

LYRICA............................ 51LYRICA CR........................51LYZA............................... 89M.V.I. ADULT.................. 117magnesium chloride...........51magnesium sulfate. 36, 51, 99magnesium sulfate in water....................36, 51, 99malathion....................... 112manganese chloride...........67mannitol 10 %....... 36, 64, 67mannitol 20 %....... 36, 64, 67mannitol 25 %....... 36, 64, 67mannitol 5 %.........36, 64, 67maprotiline.......................51MARLISSA (28)................. 89MATULANE....................... 15MATZIM LA.......................36MAVENCLAD (10 TABLET PACK)..............................99MAVENCLAD (4 TABLET PACK)..............................99MAVENCLAD (5 TABLET PACK)..............................99MAVENCLAD (6 TABLET PACK)..............................99MAVENCLAD (7 TABLET PACK)..............................99MAVENCLAD (8 TABLET PACK)..............................99MAVENCLAD (9 TABLET PACK)..............................99MAVYRET........................... 7MAXALT........................... 51MAXALT-MLT.................... 51MAYZENT......................... 99MAYZENT STARTER PACK... 99meclizine......................2, 78meclofenamate................. 51medroxyprogesterone........ 89mefenamic acid.................51mefloquine.........................7MEGACE ES.................15, 89megestrol................... 15, 89MEKINIST........................ 15MEKTOVI..........................15meloxicam........................51melphalan hcl................... 15memantine.......................52MENACTRA (PF)................ 19MENVEO A-C-Y-W-135-DIP (PF).................................19

MENVEO MENA COMPONENT (PF).............. 19MENVEO MENCYW-135 COMPNT (PF)....................19meperidine....................... 52meprobamate................... 52mercaptopurine........... 15, 99meropenem........................7mesalamine......................78mesalamine with cleansing wipe................................ 78mesna............................. 99MESNEX...........................99METADATE ER...................52metaproterenol..........24, 106metaxalone...................... 24metformin........................ 89methadone.......................52METHADOSE.....................52methenamine hippurate....... 7methenamine mandelate......7methimazole.....................90METHITEST...................... 90methocarbamol.................24methotrexate sodium... 15, 99methotrexate sodium (pf)................................. 15, 99methoxsalen................... 113methscopolamine.............. 24methyldopa.................24, 36methyldopa-hydrochlorothiazide 24, 36, 67methyldopate.............. 24, 36methylene blue (antidote).. 99METHYLIN........................ 52methylphenidate hcl.....52, 53methylprednisolone........... 90methylprednisolone acetate 90methylprednisolone sodium succ................................ 90metipranolol..................... 74metoclopramide hcl........... 78metolazone................. 36, 67metoprolol succinate.... 24, 36metoprolol ta-hydrochlorothiaz.... 24, 36, 67metoprolol tartrate.......24, 36metronidazole............. 8, 113metronidazole in nacl (iso-os)....................................8mexiletine........................ 36MIACALCIN................. 90, 99


129

MICARDIS........................ 36MICARDIS HCT............ 36, 67MICONAZOLE-3...............113MICROGESTIN 1.5/30 (21). 90MICROGESTIN 1/20 (21)....90MICROGESTIN FE 1.5/30 (28)................................ 90MICROGESTIN FE 1/20 (28)................................ 90midodrine.........................24mifepristone................... 102miglitol............................ 90miglustat..........................99milrinone......................... 36milrinone in 5 % dextrose.. 36MIMVEY........................... 90minocycline........................ 8minoxidil.......................... 37MIRAPEX..........................53MIRAPEX ER..................... 53mirtazapine...................... 53misoprostol...................... 78MITIGARE.......................100mitomycin........................ 15mitoxantrone....................15M-M-R II (PF)................... 19MOBIC............................. 53modafinil..........................53MODERIBA DOSE PACK........8moexipril..........................37moexipril-hydrochlorothiazide......37, 67mometasone...... 74, 106, 113MONOCLATE-P.................. 28MONOJECT MAGELLAN SYRINGE..........................63MONOJECT SYRINGE..........63MONO-LINYAH.................. 90MONONESSA (28)............. 90MONONINE.......................28montelukast....................106MORPHABOND ER..............53morphine....................53, 54morphine concentrate........ 53MOVANTIK....................... 79MOXEZA...........................74moxifloxacin................. 8, 74MOZOBIL......................... 28MS CONTIN...................... 54MULTIVITAMIN WITH FLUORIDE............... 100, 117

MULTI-VITAMIN WITH FLUORIDE............... 100, 117MULTIVITAMINS WITH FLUORIDE............... 100, 117mupirocin....................... 113mupirocin calcium............113MY WAY........................... 90MYALEPT..........................90MYCAMINE......................... 8mycophenolate mofetil..... 100mycophenolate mofetil hcl 100mycophenolate sodium.....100MYDAYIS..........................54MYFORTIC...................... 100MYLERAN......................... 15MYNATAL.............28, 67, 117MYNATAL ADVANCE.......................... 28, 67, 117MYNATAL PLUS.....28, 68, 117MYNATAL-Z..........29, 68, 117MYNATE 90 PLUS.............117MYNEPHROCAPS..............117MYORISAN......................113MYRBETRIQ.................... 116MYSOLINE........................54MYZILRA.......................... 90nabumetone..................... 54nadolol....................... 24, 37nadolol-bendroflumethiazide24, 37, 68nafcillin..............................8nafcillin in dextrose iso-osm.................................. 8naftifine......................... 113NAFTIN.......................... 113nalbuphine....................... 54NALFON........................... 54naloxone...................54, 100naltrexone................ 54, 100NAMENDA........................ 54NAMENDA TITRATION PAK..54NAMENDA XR....................54NAMZARIC.................. 24, 54naproxen.................. 54, 100naproxen sodium....... 54, 100naratriptan....................... 54NARCAN................... 54, 100NASONEX..................74, 106NATACYN......................... 74nateglinide....................... 90NATPARA.................. 90, 100NATROBA....................... 113

NEBUPENT......................... 8NECON 0.5/35 (28)........... 90nefazodone.......................54neomycin...........................8neomycin-bacitracin-poly-hc................................... 74neomycin-bacitracin-polymyxin........................ 74neomycin-polymyxin b gu.113neomycin-polymyxin b-dexameth.........................74neomycin-polymyxin-gramicidin........................ 74neomycin-polymyxin-hc..... 74NEO-POLYCIN HC.............. 74NEORAL......................... 100NERLYNX..........................15NESINA............................90NEUAC........................... 113NEUAC KIT..................... 113NEULASTA........................29NEUPOGEN.......................29NEURONTIN......................54NEVANAC......................... 74nevirapine..........................8NEXAVAR......................... 15NEXIUM........................... 79NEXIUM IV....................... 79NEXIUM PACKET............... 79NEXPLANON..................... 90niacin.............................. 37NIACOR........................... 37NIASPAN EXTENDED-RELEASE.......................... 37nicardipine....................... 37NICODERM CQ.................. 24NICORELIEF..................... 24NICORETTE...................... 24nicotine............................24nicotine (polacrilex)........... 24NICOTROL........................24NICOTROL NS...................24nifedipine......................... 37nikki (28)......................... 90nilutamide........................15nimodipine....................... 37NINLARO..........................15nisoldipine........................37NITRO-BID....................... 37nitrofurantoin..................... 8nitrofurantoin macrocrystal.. 8


nitrofurantoin monohyd/m-cryst................................. 8nitroglycerin..................... 37nitroglycerin in 5 % dextrose.......................... 37NITROMIST...................... 37NIVESTYM........................ 29nizatidine......................... 79NON-DROWSY ALLERGY2, 106NORA-BE..........................90NORDITROPIN FLEXPRO..... 90norepinephrine bitartrate....24noreth-ethinyl estradiol-iron................................. 90norethindrone (contraceptive)................. 90norethindrone acetate........90norethindrone ac-eth estradiol...........................90norethindrone-e.estradiol-iron................................. 90norgestimate-ethinyl estradiol...........................90NORMAL SALINE FLUSH 63, 68NORMOSOL-M IN 5 % DEXTROSE....................... 68NORMOSOL-R................... 68NORMOSOL-R IN 5 % DEXTROSE....................... 68NORMOSOL-R PH 7.4.........68NORTREL 0.5/35 (28)........ 90NORTREL 1/35 (21)........... 90NORTREL 1/35 (28)........... 90NORTREL 7/7/7 (28)..........91nortriptyline..................... 54NORVASC.........................37NORVIR............................. 8NOVOEIGHT..................... 29NOVOLIN 70/30 U-100 INSULIN...........................91NOVOLIN 70-30 FLEXPEN U-100..............................91NOVOLIN N NPH U-100 INSULIN...........................91NOVOLIN R REGULAR U-100 INSULN..................... 91NOVOLOG FLEXPEN U-100 INSULIN...........................91NOVOLOG MIX 70-30 U-100 INSULN..................... 91NOVOLOG MIX 70-30FLEXPEN U-100............. 91

NOVOLOG PENFILL U-100 INSULIN...........................91NOVOLOG U-100 INSULIN ASPART........................... 91NOVOSEVEN RT................ 29NOXAFIL............................8NP THYROID.....................91NUCALA......................... 106NUCYNTA......................... 54NUCYNTA ER.................... 54NUEDEXTA................ 54, 106NUPLAZID........................ 54NUTRILYTE.......................68NUTROPIN AQ NUSPIN.......91NUVARING....................... 91NUWIQ............................ 29NUZYRA.............................8NYAMYC......................... 113NYMALIZE........................ 37nystatin......................8, 113nystatin-triamcinolone......113NYSTOP......................... 113OBIZUR........................... 29OCALIVA.......................... 79OCELLA............................91OCREVUS....................... 100octreotide acetate...... 91, 100OCUFLOX......................... 74ODEFSEY........................... 8OFEV............................. 107ofloxacin...................... 8, 74OGESTREL (28).................91olanzapine........................54olanzapine-fluoxetine.........54olmesartan....................... 37olmesartan-amlodipin-hcthiazid.....................37, 68olmesartan-hydrochlorothiazide......37, 68olopatadine.................74, 75omega-3 acid ethyl esters.. 37omeprazole...................... 79omeprazole-sodium bicarbonate...................... 79OMNARIS..................75, 107OMNIPAQUE 140............... 64OMNIPAQUE 240............... 64OMNIPAQUE 300............... 64OMNITROPE......................91ondansetron..................... 79ondansetron hcl................ 79ondansetron hcl (pf).......... 79

ONETOUCH ULTRA BLUE TEST STRIP...................... 64ONETOUCH ULTRA2 METER 63ONETOUCH ULTRAMINI......63ONETOUCH VERIO.............64ONETOUCH VERIO FLEX..... 63ONETOUCH VERIO IQ METER............................. 63ONETOUCH VERIO SYSTEM.63ONEXTON.......................113ONFI............................... 55ONGLYZA......................... 91ONMEL.............................. 8ONZETRA XSAIL................55OPANA ER........................ 55OPCICON ONE-STEP.......... 91OPSUMIT.................. 37, 107ORAVIG..........................113ORENCIA........................100ORENCIA (WITH MALTOSE).....................................100ORENCIA CLICKJECT........100ORENITRAM.............. 37, 107ORFADIN........................100ORILISSA.........................91ORKAMBI....................... 107orphenadrine citrate.......... 24ORSYTHIA........................ 91oseltamivir......................... 8OSENI............................. 91OTEZLA...................100, 113OTEZLA STARTER.....100, 113OTIPRIO.......................... 75OTOVEL........................... 75OTREXUP (PF)........... 15, 101OVIDE............................113oxacillin............................. 8oxacillin in dextrose(iso-osm)................................. 8oxaliplatin........................ 16oxandrolone..................... 91oxaprozin......................... 55oxazepam........................ 55oxcarbazepine...................55OXERVATE........................75oxiconazole.....................113OXISTAT........................ 113OXTELLAR XR................... 55oxybutynin chloride......... 116oxycodone........................55OXYCODONE.................... 55oxycodone-acetaminophen. 55


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oxycodone-aspirin............. 55OXYCONTIN......................55oxymorphone................... 56oxytocin......................... 102OXYTROL........................116OZEMPIC..........................91paclitaxel......................... 16paliperidone..................... 56palonosetron.................... 79PALYNZIQ........................ 71pamidronate................... 101PANCREAZE......................79pantoprazole.................... 79papaverine....................... 38paromomycin..................... 8paroxetine hcl...................56paroxetine mesylate(menop.sym)....... 56PATADAY..........................75PATANASE........................75PATANOL..........................75PAXIL.............................. 56PAXIL CR......................... 56PAZEO............................. 75PCE...................................9PEDIARIX (PF).................. 19PEDVAX HIB (PF).............. 19peg 3350-electrolytes........ 79PEGANONE....................... 56PEGASYS........................... 9PEGASYS PROCLICK............ 9peg-electrolyte soln........... 79PEGINTRON........................9penicillamine............. 81, 101penicillin g potassium.......... 9penicillin g procaine.............9penicillin g sodium.............. 9penicillin v potassium.......... 9PENTACEL (PF)................. 19PENTACEL ACTHIB COMPONENT (PF).............. 19PENTACEL DTAP-IPV COMPNT (PF)....................19PENTASA..........................79pentazocine-naloxone........ 56pentoxifylline.................... 29PEPCID............................ 79PERFOROMIST........... 24, 107perindopril erbumine..........38PERIOGARD......................75permethrin..................... 113perphenazine....................56

perphenazine-amitriptyline. 56PERTZYE.......................... 79PEXEVA............................56phenazopyridine.............. 113phenelzine........................56phenobarbital................... 56phenobarbital sodium........ 56phenylephrine hcl........ 24, 75PHENYTEK.................. 38, 56phenytoin................... 38, 56phenytoin sodium........ 38, 56phenytoin sodium extended.................... 38, 56PHILITH........................... 91PHOSLYRA........................68PHOSPHA 250 NEUTRAL..... 68PHOSPHOLINE IODIDE.......75PHYSIOLYTE..................... 68PHYSIOSOL IRRIGATION.... 68physostigmine salicylate............................... 24, 101phytonadione (vitamin k1)..............................101, 117PICATO.....................16, 113PIFELTRO...........................9pilocarpine hcl............. 24, 75pimecrolimus........... 101, 113PIMTREA (28)................... 91pindolol...................... 24, 38pioglitazone......................91pioglitazone-glimepiride..... 91pioglitazone-metformin...... 91piperacillin-tazobactam........ 9PIQRAY............................ 16PIRMELLA.........................91piroxicam......................... 56PLASMA-LYTE 148............. 68PLASMA-LYTE A................ 68PLAVIX............................ 29PLEGRIDY.......................101PNEUMOVAX 23................ 19PNV OB+DHA. 29, 68, 79, 117PNV-DHA.................. 29, 117PNV-DHA + DOCUSATE.................... 29, 68, 79, 117PNV-OMEGA.........29, 68, 117PNV-SELECT..............29, 117podofilox........................ 113POLYCIN.......................... 75POLYFIN QR INFUSION SET 63polymyxin b sulfate............. 9

polymyxin b sulf-trimethoprim.................... 75POMALYST................ 16, 101PORTIA 28....................... 91potassium acetate............. 68potassium bicarb and chloride............................68potassium bicarb-citric acid 68potassium chlorid-d5-0.45%nacl........................68potassium chloride....... 68, 69potassium chloride in 0.9%nacl......................... 68potassium chloride in 5 % dex................................. 68potassium chloride in lr-d5. 68potassium chloride in water 68potassium chloride-0.45 % nacl.................................69potassium chloride-d5-0.2%nacl......................... 69potassium chloride-d5-0.3%nacl......................... 69potassium chloride-d5-0.9%nacl......................... 69potassium citrate.............. 69potassium citrate-citric acid 69potassium phosphate m-/d-basic........................... 69POTELIGEO...................... 16POTIGA............................56PR NATAL 400...... 29, 69, 117PR NATAL 400 EC. 29, 69, 117PR NATAL 430...... 29, 69, 117PR NATAL 430 EC. 29, 69, 117PRADAXA......................... 29PRALUENT PEN................. 38pramipexole..................... 56PRANDIN..........................92prasugrel......................... 29PRAVACHOL......................38pravastatin.......................38praziquantel....................... 9prazosin..................... 24, 38PRECISION XTRA MONITOR 63PRECISION XTRA TEST...... 64PRECOSE......................... 92PRED MILD.......................75prednicarbate..................113prednisolone.....................92prednisolone acetate..........75


prednisolone sodium phosphate...................75, 92prednisone....................... 92PREDNISONE INTENSOL.....92PREMARIN........................92PREMPHASE......................92PREMPRO......................... 92PRENAISSANCE.................... 29, 69, 79, 117PRENAISSANCE PLUS.................... 29, 69, 80, 117PRENATABS FA.....29, 69, 117PRENATABS RX.... 29, 69, 117PRENATAL LOW IRON.......................... 29, 69, 117PRENATAL PLUS... 29, 69, 117PRENATAL PLUS (CALCIUM CARB).................29, 69, 117PRENATAL-U................... 117PRESTALIA....................... 38PREVACID........................ 80PREVACID SOLUTAB.......... 80PREVALITE....................... 38PREVIFEM........................ 92PREVNAR 13 (PF).............. 19PREVYMIS..........................9PREZCOBIX.................9, 101PREZISTA.......................... 9PRIFTIN............................. 9PRILOSEC........................ 80primidone.........................56PRINIVIL..........................38PRISTIQ...........................56PRIVIGEN.........................19PROAIR HFA.............. 24, 107PROAIR RESPICLICK...24, 107probenecid................ 69, 101probenecid-colchicine. 69, 101PROBUPHINE.................... 56procainamide....................38PROCARDIA......................38PROCARDIA XL................. 38PROCENTRA..................... 56prochlorperazine..........57, 80prochlorperazine edisylate................................. 56, 80prochlorperazine maleate................................. 56, 80PROCRIT.......................... 29PROCTOFOAM HC............ 113PROCTO-PAK.................. 113PROCTOZONE-HC............ 113

PRODIGY NO CODING........64PRODIGY POCKET METER... 63PRODIGY VOICE GLUCOSE METER............................. 63PROFILNINE..................... 29progesterone.................... 92progesterone micronized.... 92PROGLYCEM..................... 92PROGRAF....................... 101PROLASTIN-C..................107PROLENSA........................75PROLEUKIN............... 16, 101PROLIA.......................... 101PROMACTA....................... 29promethazine.........2, 57, 107propafenone..................... 38propantheline................... 25proparacaine.................... 75propranolol............25, 38, 57propranolol-hydrochlorothiazid.. 25, 38, 69propylthiouracil................. 92PROQUAD (PF)..................19PROSCAR....................... 101PROTONIX........................80PROTOPIC...................... 113protriptyline......................57PROVENTIL HFA.........25, 107PROVIGIL.........................57PROZAC........................... 57PULMICORT...............92, 107PULMICORT FLEXHALER............................... 92, 107PULMOZYME..............71, 107PYLERA........................ 9, 80pyrazinamide......................9pyridostigmine bromide......25pyridoxine (vitamin b6).... 117QBRELIS.......................... 38QNASL......................75, 107QTERN.............................92QUADRACEL (PF)...............19QUASENSE....................... 92QUDEXY XR...................... 57QUESTRAN....................... 38QUESTRAN LIGHT..............38quetiapine........................ 57QUILLICHEW ER................57QUILLIVANT XR.................57quinapril.......................... 38quinapril-hydrochlorothiazide......38, 69

quinidine gluconate........9, 38quinidine sulfate............9, 38quinine sulfate....................9QUTENZA....................... 114QVAR REDIHALER...... 92, 107RABAVERT (PF)................. 19rabeprazole...................... 80raloxifene..................92, 101ramelteon........................ 57ramipril............................38RANEXA........................... 38ranitidine hcl.................... 80ranolazine........................ 39RAPAFLO..........................25RAPAMUNE..................... 101RAVICTI...........................69RAZADYNE....................... 25RAZADYNE ER...................25READI-CAT 2.................... 64REBETOL........................... 9REBIF (WITH ALBUMIN)... 101REBIF REBIDOSE.............101REBIF TITRATION PACK....101REBINYN..........................29RECLIPSEN (28)................92RECOMBINATE.................. 29RECOMBIVAX HB (PF)........ 19RECTIV.......................... 114RELENZA DISKHALER.......... 9RELPAX............................57REMERON.........................57REMERON SOLTAB.............57REMICADE......... 80, 101, 114RENAGEL.................. 69, 101RENAL CAPS................... 117RENA-VITE RX.................117RENFLEXIS........ 80, 101, 114RENO CAPS.................... 117RENVELA.................. 69, 101repaglinide....................... 92repaglinide-metformin........92REPATHA PUSHTRONEX......39REPATHA SURECLICK.........39REPATHA SYRINGE............ 39REQUIP............................57REQUIP XL....................... 57RESCRIPTOR...................... 9RESTASIS........................ 75RESTASIS MULTIDOSE.......75RETACRIT........................ 29RETIN-A......................... 114RETIN-A MICRO...............114


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RETIN-A MICRO PUMP...... 114RETROVIR..........................9REVATIO...................39, 107REVCOVI..........................71REVLIMID................. 16, 101REVONTO.........................25REXULTI.......................... 57RHOPRESSA..................... 75RIBASPHERE...................... 9RIBASPHERE RIBAPAK....... 10ribavirin........................... 10rifabutin...........................10rifampin........................... 10RIFATER...........................10riluzole............................ 57rimantadine......................10ringer's............................ 69risedronate..................... 101RISPERDAL.......................57RISPERDAL CONSTA.......... 57risperidone....................... 57RITALIN........................... 57RITALIN LA.......................57ritonavir...........................10RITUXAN HYCELA.............. 16rivastigmine..................... 25rivastigmine tartrate..........25RIXUBIS.......................... 29rizatriptan........................ 58ROCKLATAN..................... 75ropinirole......................... 58ROSADAN.......................114rosuvastatin..................... 39ROTARIX..........................19ROTATEQ VACCINE............19ROWASA.......................... 80ROWEEPRA.......................58ROWEEPRA XR..................58ROZEREM.........................58RUBRACA......................... 16RUCONEST..................... 101RUZURGI........................101RYDAPT........................... 16RYTARY............................58SABRIL............................ 58SAIZEN............................92SAIZEN SAIZENPREP......... 92salicylic acid....................114salicylic acid er-ceramides 114salsalate.......................... 58SANCUSO.........................80SANDIMMUNE................. 101

SANTYL..........................114SAPHRIS.......................... 58SARAFEM......................... 58SAVAYSA......................... 29SAVELLA.......................... 58SECONAL SODIUM.............58SEEBRI NEOHALER............ 25SEGLUROMET................... 92selegiline hcl.....................58selenium.......................... 70selenium sulfide.............. 114SELZENTRY...................... 10SEMPREX-D........... 2, 25, 107SE-NATAL 19.............30, 118SE-NATAL 19 (WITH DOCUSATE)......... 30, 80, 118SEREVENT DISKUS.....25, 107SEROQUEL....................... 58SEROQUEL XR.................. 58SEROSTIM........................92sertraline......................... 58SETLAKIN.........................92sevelamer carbonate.. 70, 101sevelamer hcl................... 70SF................................. 101SF 5000 PLUS................. 101SFROWASA...................... 80SHINGRIX (PF)................. 19SHINGRIX ADJUVANT COMPONENT-PF.............. 102SHINGRIX GE ANTIGEN COMPONENT.....................19SIGNIFOR........................ 92SIKLOS............................16sildenafil (antihypertensive)......39, 107SILIQ.............................114silodosin.......................... 25silver nitrate................... 114silver sulfadiazine............ 114SIMBRINZA...................... 75SIMPONI...................80, 102SIMPONI ARIA........... 80, 102simvastatin.......................39SINEMET..........................58SINEMET CR..................... 58SINGULAIR..................... 107SINUVA.................... 75, 107sirolimus........................ 102SIRTURO..........................10SITAVIG...........................10SKLICE...........................114

sodium acetate................. 70sodium bicarbonate........... 70sodium chlor 0.9% bacteriostat...................... 70sodium chloride.................70sodium chloride 0.45 %..... 70sodium chloride 0.9 %....... 70sodium chloride 0.9 % (flush)........................63, 70sodium chloride 3 %.......... 70sodium chloride 5 %.......... 70sodium citrate-citric acid.... 70sodium lactate.................. 70sodium phenylbutyrate.......70sodium phosphate............. 70SODIUM POLYSTYRENE (SORB FREE).............70, 102sodium polystyrene sulfonate...................70, 102sodium thiosulfate........... 102sofosbuvir-velpatasvir........10solifenacin...................... 116SOLIQUA 100/33...............92SOLOSEC......................... 10SOLU-CORTEF...................92SOLU-CORTEF (PF)............92SOLU-MEDROL..................93SOLU-MEDROL (PF)........... 92SOMATULINE DEPOT..........93SONATA...........................58SORINE...................... 25, 39sotalol........................25, 39SOTALOL AF................25, 39SOTYLIZE................... 25, 39SOVALDI..........................10spinosad.........................114SPIRIVA RESPIMAT.... 25, 107SPIRIVA WITH HANDIHALER.............25, 107spironolactone.............39, 70spironolacton-hydrochlorothiaz..........39, 70SPORANOX.......................10SPRAVATO....................... 58SPRINTEC (28)................. 93SPRITAM..........................58SPRYCEL.......................... 16SPS (WITH SORBITOL)70, 102SRONYX...........................93SSD...............................114SSS 10-5........................114STAMARIL (PF)................. 19


stavudine......................... 10STEGLATRO......................93STEGLUJAN...................... 93STELARA................. 102, 114STIOLTO RESPIMAT...........25STIVARGA........................ 16STRATTERA...................... 58STRENSIQ........................71STRIANT.......................... 93STRIBILD......................... 10STRIVERDI RESPIMAT.25, 107STRONG IODINE...................10, 93, 102, 107SUBLOCADE..................... 58SUBOXONE.......................58sucralfate.........................80SULAR............................. 39sulfacetamide sodium. 75, 114sulfacetamide sodium (acne)............................114sulfacetamide sodium-sulfur......................114, 115sulfacetamide sod-sulfur-urea.............................. 115sulfacetamide-prednisolone 75sulfadiazine...................... 10sulfamethoxazole-trimethoprim.................... 10sulfasalazine........ 10, 80, 102sulindac........................... 58sumatriptan......................58sumatriptan succinate........59sumatriptan-naproxen....... 59SUPRAX........................... 10SUTENT........................... 16SYEDA............................. 93SYLATRON.................. 10, 16SYLVANT..........................16SYMBICORT......... 25, 93, 107SYMBYAX......................... 59SYMDEKO.......................107SYMFI..............................10SYMFI LO......................... 10SYMJEPI................... 25, 107SYMLINPEN 120................ 93SYMLINPEN 60..................93SYMTUZA......................... 10SYNAGIS..........................10SYNAREL..........................93SYNJARDY........................93SYNJARDY XR................... 93syringe with needle, safety. 63

T:SLIM.............................63TABLOID.......................... 16tacrolimus............... 102, 115tadalafil (antihypertensive)............................... 39, 107TAFINLAR.........................16TAGITOL V....................... 64TAGRISSO........................16TAKHZYRO..................... 102TALTZ AUTOINJECTOR..... 115TALTZ AUTOINJECTOR (2 PACK)............................ 115TALTZ AUTOINJECTOR (3 PACK)............................ 115TALTZ SYRINGE.............. 115TALZENNA........................16TAMIFLU.......................... 10tamoxifen................... 16, 93tamsulosin....................... 25TARGRETIN............... 16, 115tarina fe 1/20 (28)............ 93TARKA............................. 39TARON-C DHA........... 30, 118TARON-PREX PRENATAL-DHA....................30, 80, 118TASIGNA..........................16tazarotene......................115TAZORAC....................... 115TAZTIA XT........................39TECENTRIQ...................... 16TECFIDERA.....................102TECHNIVIE....................... 11TEGRETOL........................59TEGRETOL XR................... 59TEKTURNA....................... 39TEKTURNA HCT........... 39, 70telmisartan.......................39telmisartan-amlodipine...... 39telmisartan-hydrochlorothiazid....... 39, 70temazepam...................... 59TEMODAR.........................16temozolomide................... 16TENIVAC (PF)................... 19tenofovir disoproxil fumarate..........................11TENORETIC 100..... 25, 39, 70TENORETIC 50....... 25, 39, 70TENORMIN..................25, 39terazosin.................... 25, 39terbinafine hcl...................11terbutaline...........25, 26, 107

terconazole.....................115TESTIM............................93TESTOSTERONE................ 93testosterone..................... 93testosterone cypionate.......93testosterone enanthate...... 93tetanus,diphtheria tox ped(pf)............................ 19tetanus-diphtheria toxoids-td....................................20TETCAINE.........................75tetrabenazine................... 59tetracaine hcl....................75tetracaine hcl (pf)..............75tetracycline...................... 11thallous chloride tl-201...... 64THALOMID......................102THEOCHRON.39, 70, 107, 116theophylline...... 39, 40, 70, 107, 108, 116thioridazine...................... 59thiothixene....................... 59THYROGEN....................... 64THYROLAR-1.....................93THYROLAR-1/2..................93THYROLAR-1/4..................93THYROLAR-2.....................93THYROLAR-3.....................93tiagabine..........................59TIAZAC............................ 40TIBSOVO..........................16TICANASE................. 75, 108TICE BCG....................16, 20TILIA FE...........................93timolol maleate.................26, 40, 59, 75, 76TIMOPTIC.........................76TIMOPTIC OCUDOSE (PF)... 76TIMOPTIC-XE....................76tinidazole......................... 11TIVICAY........................... 11tizanidine......................... 26TL-SELECT..... 30, 70, 80, 118TOBI............................... 11TOBI PODHALER............... 11TOBRADEX....................... 76tobramycin.......................76tobramycin in 0.225 % nacl.................................11tobramycin in 0.9 % nacl... 11tobramycin sulfate.............11


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tobramycin-dexamethasone................ 76tolazamide....................... 93tolbutamide...................... 93tolmetin........................... 59TOLSURA......................... 11tolterodine......................116TOPAMAX.........................59topiramate....................... 59TOPOSAR......................... 16TOPROL XL................. 26, 40toremifene....................... 16torsemide................... 40, 70TOUJEO MAX U-300 SOLOSTAR....................... 93TOUJEO SOLOSTAR U-300 INSULIN...........................94TOVIAZ.......................... 116TRACLEER.................40, 108TRADJENTA...................... 94tramadol.......................... 59tramadol-acetaminophen....59trandolapril.......................40tranexamic acid................ 30tranylcypromine................ 59TRAVATAN Z.....................76trazodone.........................59TRELEGY ELLIPTA.......26, 108TREMFYA........................115TRESIBA FLEXTOUCH U-100................................. 94TRESIBA FLEXTOUCH U-200................................. 94tretinoin......................... 115tretinoin (chemotherapy)....16tretinoin microspheres......115TRETTEN..........................30TREXIMET........................ 59TRIADVANCE....... 30, 71, 118triamcinolone acetonide....115triamterene-hydrochlorothiazid....... 40, 71triazolam..........................59TRIBENZOR.................40, 71TRICITRATES....................71TRICOR............................40TRI-ESTARYLLA.................94trifluoperazine.................. 59TRIGLIDE......................... 40trihexyphenidyl............26, 59TRI-LEGEST FE................. 94TRILEPTAL........................59

TRI-LINYAH...................... 94TRILIPIX.......................... 40tri-lo-estarylla...................94tri-lo-sprintec................... 94trimethobenzamide............80trimethoprim.................... 11TRINATAL RX 1.... 30, 71, 118TRINATE..............30, 71, 118TRINTELLIX...................... 59TRI-PREVIFEM (28)........... 94TRIPTODUR...................... 94TRI-SPRINTEC (28)........... 94TRIUMEQ......................... 11TRIVEEN-DUO DHA.......................... 30, 71, 118TRIVEEN-ONE...... 30, 71, 118TRIVEEN-PRX RNF.................... 30, 71, 80, 118TRI-VITAMIN WITH FLUORIDE............... 102, 118TRIVORA (28)...................94TROGARZO.......................11TROKENDI XR...................59tropicamide...................... 76trospium........................ 116TRUE METRIX AIR GLUCOSE METER...............63TRUE METRIX GLUCOSE METER............................. 63TRUE METRIX GLUCOSE TEST STRIP...................... 64TRULICITY........................94TRUMENBA.......................20TRUSOPT......................... 76TRUVADA......................... 11TUDORZA PRESSAIR........ 108TWINRIX (PF)................... 20TWYNSTA.........................40TYKERB............................16TYMLOS....................94, 102TYVASO.................... 40, 108TYVASO INSTITUTIONAL START KIT................ 40, 108TYVASO REFILL KIT....40, 108TYVASO STARTER KIT.40, 108UCERIS............................94UDENYCA......................... 30UNITHROID...................... 94unithroid.......................... 94UNITUXIN........................ 16UPTRAVI................... 40, 108UR N-C............................ 11

urea.............................. 115UREA NAIL STICK............ 115URIMAR-T........................ 11UROGESIC-BLUE............... 11ursodiol........................... 80UTIBRON NEOHALER.. 26, 108valacyclovir...................... 11VALCHLOR................ 16, 115valganciclovir....................11valproate sodium.............. 59valproic acid..................... 60valproic acid (as sodium salt)...........................59, 60valsartan..........................40valsartan-hydrochlorothiazide......40, 71VALTREX..........................11VANCOCIN....................... 11vancomycin...................... 11vancomycin in dextrose 5 %................................... 11VANDAZOLE....................115VAQTA (PF)...................... 20VARIBAR THIN HONEY....... 64VARIBAR THIN LIQUID.......64VARIVAX (PF)................... 20VARIZIG.......................... 20VASCEPA..........................40VASERETIC................. 40, 71vasopressin...................... 94VASOTEC......................... 40VAXCHORA VACCINE......... 20VECTIBIX......................... 16VELCADE..........................16VELETRI....................40, 108VELIVET TRIPHASIC REGIMEN (28).................. 94VELPHORO....................... 71VELTASSA........................ 71VEMLIDY.......................... 11VENA-BAL DHA.....30, 71, 118VENCLEXTA...................... 16VENCLEXTA STARTING PACK............................... 17venlafaxine.......................60VENOFER......................... 30VENTAVIS................. 40, 108VENTOLIN HFA.......... 26, 108VERAMYST................ 76, 108verapamil.........................40VERELAN..........................40VERELAN PM.....................40


VERSACLOZ......................60VERZENIO........................17VESICARE.......................116VFEND............................. 11VIBERZI...........................80VICTOZA 2-PAK................ 94VICTOZA 3-PAK................ 94VIDEX 2 GRAM PEDIATRIC..11VIEKIRA PAK.................... 11VIENVA............................94vigabatrin.........................60VIGADRONE..................... 60VIGAMOX......................... 76VIIBRYD...........................60VIMIZIM...........................71VIMOVO..................... 60, 80VIMPAT............................60VINACAL........ 30, 71, 80, 118VINATE CARE............ 30, 118VINATE GT................ 30, 118VINATE II....................... 118VINATE M................. 30, 118VINATE ONE........ 30, 71, 118VINATE PN CARE............. 118VINATE ULTRA 30, 71, 80, 118vinblastine........................17VINCASAR PFS..................17vincristine........................ 17vinorelbine....................... 17VIOKACE..........................80VIORELE (28)................... 94VIRACEPT.........................11VIREAD............................11VIRT-PN....................30, 118VIRT-PN DHA.............30, 118VIRT-PN PLUS...... 30, 71, 118VIRT-SELECT..30, 71, 80, 118VISIPAQUE.......................64VISTOGARD....................102VITAFOL-OB.........30, 71, 118VITAMIN D2....................118VITAMINS A,C,D AND FLUORIDE............... 102, 118VITRAKVI......................... 17VIVOTIF...........................20VIZIMPRO........................ 17VOGELXO.........................94VOL-NATE................. 30, 118VOL-TAB RX.............. 30, 118VOLTAREN................ 60, 115VOLUMEN.........................64VONVENDI....................... 30

voriconazole................11, 12VOSEVI............................12VOTRIENT........................ 17VPRIV..............................71VRAYLAR..........................60VYNDAMAX.......................40VYNDAQEL....................... 40VYTORIN 10-10.................40VYTORIN 10-20.................40VYTORIN 10-40.................40VYTORIN 10-80.................40VYVANSE......................... 60VYZULTA..........................76WAL-ZYR (CETIRIZINE) 2, 108warfarin........................... 30water for irrigation, sterile.. 71WAVESENSE PRESTO... 63, 64WELCHOL................... 41, 94WELLBUTRIN SR............... 60WELLBUTRIN XL................60WERA (28)....................... 94WILATE............................30WINRHO SDF....................20WIXELA INHUB.....26, 94, 108WYMZYA FE...................... 94XADAGO.......................... 60XALATAN..........................76XALKORI.......................... 17XARELTO..........................30XELJANZ........................ 102XELJANZ XR....................102XERESE..........................115XERMELO......................... 81XGEVA........................... 102XHANCE....................76, 108XIFAXAN.......................... 12XIGDUO XR...................... 94XOFLUZA......................... 12XOLAIR.......................... 108XOPENEX.................. 26, 108XOPENEX CONCENTRATE............................... 26, 108XOPENEX HFA............26, 108XOSPATA......................... 17XPOVIO........................... 17XTAMPZA ER.....................60XTANDI............................17XULANE........................... 95XULTOPHY 100/3.6............95XYNTHA........................... 30XYNTHA SOLOFUSE........... 30YF-VAX (PF)......................20

YONDELIS........................ 17YOSPRALA.............31, 60, 81YUPELRI...........................26yuvafem.......................... 95ZADITOR..........................76zafirlukast...................... 108zaleplon........................... 61ZANTAC........................... 81ZARAH.............................95ZARONTIN........................61ZARXIO............................31ZATEAN-PN DHA........ 31, 118ZATEAN-PN PLUS..31, 71, 118ZEJULA............................ 17ZELBORAF........................17ZEMBRACE SYMTOUCH...... 61ZENATANE......................115ZENCHENT (28)................ 95ZENPEP............................81ZENZEDI..........................61ZEPATIER.........................12ZESTORETIC............... 41, 71ZESTRIL...........................41ZETIA.............................. 41ZETONNA..................76, 108ZIAC.....................26, 41, 71ZIANA............................115zidovudine........................12zileuton..........................108zinc chloride..................... 71zinc sulfate.......................71ZIOPTAN (PF)................... 76ziprasidone hcl..................61ZIPSOR............................61ZIRGAN........................... 76ZITHROMAX..................... 12ZITHROMAX TRI-PAK......... 12ZOCOR............................ 41ZOFRAN........................... 81ZOFRAN ODT.................... 81ZOHYDRO ER....................61ZOLINZA..........................17zolmitriptan......................61ZOLOFT........................... 61zolpidem.......................... 61ZOLPIMIST....................... 61ZOMACTON...................... 95ZOMIG.............................61ZOMIG ZMT......................61zonisamide....................... 61ZONTIVITY....................... 31ZORBTIVE........................ 95


137

ZORTRESS......................102ZORVOLEX....................... 61ZOSTAVAX (PF).................20ZOVIA 1/35E (28)............. 95ZOVIRAX.................. 12, 115ZUBSOLV......................... 61ZUPLENZ..........................81ZYBAN............................. 61ZYCLARA........................ 115ZYDELIG.......................... 17ZYFLO............................108ZYFLO CR....................... 108ZYKADIA..........................17ZYLET..............................76ZYMAXID......................... 76ZYPITAMAG...................... 41ZYPREXA..........................61ZYPREXA RELPREVV...........61ZYPREXA ZYDIS................ 61ZYTIGA............................ 17


Over-the-Counter (OTC) Drug List

The following list of over-the-counter (OTC) drugs are covered by UCare for State Public Program members. The list only includes the generic version of products. Some brand products are listed in parentheses for reference purposes only. This list is subject to change.

ANALGESICS AND ANTI-INFLAMMATORY DRUGS acetaminophen (TYLENOL) acetaminophen / pyrilamine / caffeine aspirin (BAYER) aspirin / acetaminophen/ caffeine (EXCEDRIN) aspirin / buffers (BUFFERIN) ibuprofen (MOTRIN) naproxen (ALEVE)

COUGH AND COLD MEDICATIONS ANTIHISTAMINES cetirizine (ZYRTEC) chlorpheniramine (CHLOR-TRIMETON) diphenhydramine (BENADRYL) loratadine (CLARITIN)

DECONGESTANTS phenylephrine (SUDAFED PE) pseudoephedrine (SUDAFED)

ANTIHISTAMINE / DECONGESTANT COMBINATIONS brompheniramine / pseudoephedrine brompheniramine / phenylephrine cetirizine / pseudoephedrine (ZYRTEC - D) chlorpheniramine / phenylephrine chlorpheniramine / phenylephrine / acetaminophen chlorpheniramine / phenylephrine / dextromethorphan / acetaminophen chlorpheniramine / pseudoephedrine chlorpheniramine / pseudoephedrine / acetaminophen chlorpheniramine / pseudoephedrine / dextrometorphah / acetaminophen diphenhyydramine / pseudoephedrine / acetaminophen diphenydramine / pseudoephedrine loratadine / pseudoephedrine (CLARITIN - D) phenylephrine / acetaminophen phenylephrine / guaifenesin pseudoephedrine / ibuprofen psueodoephedrine / acetaminophen

ANTITUSSIVES AND EXPECTORANT DRUGS dextromethorphan (ROBITUSSIN) dextromethorphan / chlorpheniramine dextromethorphan / phenylephrine

Over-the-Counter (OTC) Drug List ANTITUSSIVES AND EXPECTORANT DRUGS (continued) dextromethorphan / phenylephrine / acetaminophen dextromethorphan / pseudoephedrine dextromethorphan / pseudoephedrine / acetaminophen dextromethorphan / pseudoephedrine / brompheniramine dextromethorphan / pseudoephedrine / chlorpheniramine guaifenesin (MUCINEX) guaifenesin / dextromethorphan (MUCINEX DM) guaifenesin / dextromethorphan / phenylephrine guaifenesin / dextromethorphan / pseudoephedrine guaifenesin / dextromethorphan / pseudoephedrine / acetaminophen guaifenesin / phenylephrine guaifenesin / pseudoephedrine

DERMATOLOGICAL DRUGS ANTIACNE DRUGS benzoyl peroxide benzoyl peroxide / aloe vera

KEROLYTIC DRUGS salicylic acid salicylic acid / acetic acid (COMPOUND W) SCABICIDES permethrin (NIX) piperonyl / pyrethrins (RID) TOPICAL ANESTHETICS pramoxine (PROCTO-FOAM) TOPICAL ANTIBACTERIAL DRUGS bacitracin bacitracin / polymyxin b (POLYSPORIN) chlorhexidine neomycin / bacitracin / polymixin (NEOSPORIN) neomycin / bacitracin / polymixin / pramoxine (NEOSPORIN PLUS)

TOPICAL ANTIFUNGALS clotrimazole (LOTRIMIN) miconazole (MICATIN) terbinafine (LAMISIL) tolnaftate (TINACTIN)

TOPICAL CORTICOSTEROIDS hydrocortisone / aloe vera hydrocortisone

Over-the-Counter (OTC) Drug List OTHER TOPICAL DERMATOLOGICAL DRUGS ammonium lactate (AMLACTIN) calamine calamine / zinc oxide capsaicin (ZOSTRIX) chloroxylenol OTHER TOPICAL DERMATOLOGICAL DRUGS (continued) Diphenhydramine diphenhydramine / calamine diphenhydramine / zinc glyceryl / dimethicone / petrolatum (CETAPHIL) hydrogen peroxide methyl salicylate / menthol / camphor (BENGAY) salonpas mineral oil / petrolatum (AQUAPHOR, EUCERIN) petrolatum (VASELINE) pramoxine / calamine povidone-iodine (BETADINE) trolamine salicylate (MYOFLEX) urea (CARMOL) zinc oxide (DESITIN)

EAR / NOSE / THROAT MEDICATIONS DRUGS AFFECTING THE EAR carbamide peroxide (DEBROX) DRUGS AFFECTING THE NOSE cromolyn (NASALCROM) Nasacort AQ 24hr oxymetazoline (AFRIN) phenylephrine (NEO-SYNEPHRINE) sodium chloride

DRUGS AFFECTING THE THROAT zinc

GASTROINTESTINAL DRUGS ANTACIDS aluminum hydroxide (ALTERNAGEL) calcium carbonate (TUMS) calcium carbonate / magnesium hydroxide (MYLANTA SUPREME) magnesium carbonate / aluminum hydroxide (GAVISCON) magnesium hydroxide / aluminum hydroxide / simethicone (MYLANTA) magnesium hydroxide / aluminum hydroxide (MAALOX) magnesium oxide (URO-MAG) sodium bicarbonate

ANTIDIARRHEAL DRUGS bismuth subsalicylate (PEPTO-BISMOL) loperamide (IMMODIUM)

Over-the-Counter (OTC) Drug List ANTIULCER DRUGS famotidine (PEPCID) lansoprazole (PREVACID) ranitidine (ZANTAC) omeprazole (PRILOSEC)

LAXATIVES AND CATHARTICS bisacodyl (DULCOLAX) docusate calcium (SURFAK) docusate sodium (COLACE) glycerin magnesium citrate (CITROMA) magnesium hydroxide (PHILLIPS' MOM) methylcellulose (CITRUCEL) mineral oil polycarbophil polyethylene glycol 3350 (MIRALAX) psyllium (METAMUCIL) senna / docusate sodium (PERI-COLACE) sennosides / calcium (EX-LAX)

OTHER GI DRUGS hamamelis leaf / glycerin (TUCKS) lactase (LACTAID) phenylephrine phenylephrine / shark liver / petrolatum (PREPARATION H) simethicone (MYLICON) sorbitol witch hazel

MISCELLANEOUS (OTHER) PRODUCTS dimenhydrinate (DRAMAMINE) levorgestestrel (PLAN B) meclizine phenazopyridine (AZO)

OPHTHALMIC DRUGS propylene glycol PEGS (SYSTANE ULTRA) sodium chloride sodium chloride / petrolatum / mineral oil (REFRESH PM) tetrahydrazoline drops (VISINE)

SEDATIVE / HYPNOTIC DRUGS

acetaminophen / diphenhydramine (TYLENOL PM) doxylamine (UNISOM)


SMOKING CESSATION PRODUCTS nicotine (NICODERM) nicotine gum nicotine polacrilex (COMMIT)

VAGINAL ANTIFUNGALS clotrimazole (GYNE-LOTRIMIN) miconazole (MONISTAT)

VITAMINS AND RELATED PRODUCTS MINERALS/ELECTROLYTES calcium carbonate calcium citrate calcium glubionate calcium gluconate calcium lactate calcium / magnesium calcium / magnesium / zinc chromium electrolyte solution (pediatric) ferrous gluconate ferrous sulfate magnesium chloride magnesium gluconate magnesium oxide potassium chloride potassium gluconate selenium sodium chloride zinc gluconate zinc sulfate

MISCELLANEOUS NUTRIENTS beta-carotene biotin glucose VITAMINS cyanocobalmin (vitamin b12) folic acid niacin niacinamide pantothenic acid pyridoxine (vitamin b6) riboflavin (vitamin b2) thiamine (vitamin b1) vitamin a vitamin c vitamin d vitamin e


VITAMIN COMBINATION PRODUCTS beta carotene / vitamin c / vitamin e / minerals calcium carbonate / vitamin d calcium carbonate / vitamin d / minerals folic acid / vitamin b complex / vitamin c multivitamins multivitamins / iron multivitamins / minerals multivitamins / minerals / iron prenatal vitamin vitamin a / vitamin c / vitamin d vitamin a / vitamin d vitamin b complex vitamin b complex / folic acid vitamin b complex / minerals vitamin b complex / vitamin c vitamin b complex / vitamin c / vitamin e / zinc vitamin c / vitamin e

U3984 (12/2019)

PO Box 52 Minneapolis, MN 55440-0052

612-676-3200 1-800-203-7225 toll free

TTY/Hearing impaired 612-676-6810

1-800-688-2534 toll free

8 am to 5 pm Monday – Friday

ucare.org

Documents

Medicaid List of Covered Drugs (Formulary) 2019Medicaid List of Covered Drugs (Formulary) 2019 UCare Connect (SNBC) Families and Children (Prepaid Medical Assistance Program (PMAP))