Your 2021 Premium Standard Formulary - Culinary Health Fund

Your 2021 Premium Standard Formulary

For the most current list of covered medications or if you have questions:

Call the number on your member ID card.

Visit your plan’s website on your member ID card to:

• Find a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

Effective January 1, 2021

Culinary Health Fund Formulary

2

Understanding your formulary

What is a formulary?A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

To create the list, OptumRx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

About this formulary Where differences between this formulary and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.

How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equal becomes available.

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID card.

3

Medication tips

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.

Over-the-counter medicationsAn over-the-counter (OTC) medication may be the right treatment option for some conditions. Talk to your doctor about OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

What if I am taking a specialty medication?Specialty medications are used to treat complex conditions. These high-cost medications may be injected, infused or taken by mouth. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and have your prescriptions delivered right to your home or doctor’s office.

4

Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).

Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost generics and some brand name

Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2 $$ Mid-range cost preferred brand name

Use Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket costs.

Tier 3 $$$ Highest-cost non-preferred

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier E Excluded May not be covered or need prior authorization. Lower-cost options are available and covered.

Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity.

SP Specialty Medication – Medication is designated as specialty.

ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

Table of Contents

Analgesics - Drugs for Pain.............................. 6Analgesics - Drugs for Pain and Inflammation. 6Anesthetics.......................................................7Anti-Addiction / Substance Abuse Treatment

Agents............................................................ 7Antibacterials....................................................7Anticoagulants..................................................8Anticonvulsants - Drugs for Seizures............... 8Antidementia Agents - Drugs for Alzheimer's

Disease and Dementia...................................9Antidepressants................................................9Antiemetics - Drugs for Nausea and Vomiting..9Antifungals......................................................10Antigout Agents.............................................. 10Antimigraine Agents....................................... 10Antineoplastics - Drugs for Cancer.................10Antiparasitics.................................................. 11Antiparkinson Agents......................................11Antiplatelets....................................................11Antipsychotics - Drugs for Mood Disorders.... 11Antivirals.........................................................12Anxiolytics - Drugs for Anxiety........................12Bipolar Agents - Drugs for Mood Disorders....12Blood Products and Modifiers - Drugs for

Blood Disorders............................................12Cardiovascular Agents - Drugs for Heart and

Circulation Conditions.................................. 13Central Nervous System Agents - Drugs for

Attention Deficit Disorder..............................15Central Nervous System Agents - Drugs for

Multiple Sclerosis......................................... 16Central Nervous System Agents -

Miscellaneous...............................................16Dental and Oral Agents - Drugs for Mouth

and Throat Conditions..................................16Dermatological Agents - Drugs for Skin

Conditions.................................................... 16Diabetes - Antidiabetic Agents....................... 18Diabetes - Glucose Monitoring....................... 19Diabetes - Glycemic Agents........................... 21Diabetes - Insulins..........................................21Electrolytes / Minerals / Metals / Vitamins...... 23Gastrointestinal Agents - Drugs for Acid

Reflux and Ulcer...........................................23Gastrointestinal Agents - Drugs for Bowel,

Intestine and Stomach Conditions................24Genetic or Enzyme Disorder - Drugs for

Replacement, Modification, Treatment.........24Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions.....................24

Genitourinary Agents - Drugs for Prostate Conditions.................................................... 25

Hormonal Agents - Adrenal............................ 25Hormonal Agents - Men's Health....................25Hormonal Agents - Osteoporosis................... 25Hormonal Agents - Pituitary............................26Hormonal Agents - Sex Hormones and Birth

Control..........................................................26Hormonal Agents - Thyroid.............................27Immunological Agents - Drugs for Immune

System Stimulation or Suppression............. 28Inflammatory Bowel Disease Agents..............29Metabolic Bone Disease Agents - Drugs for

Osteoporosis................................................ 29Metabolic Bone Disease Agents - Other........ 29Miscellaneous Therapeutic Agents.................29Ophthalmic Agents - Drugs for Eye Allergy,

Infection and Inflammation........................... 30Ophthalmic Agents - Drugs for Glaucoma......30Ophthalmic Agents - Drugs for Miscellaneous

Eye Conditions............................................. 30Otic Agents - Drugs for Ear Conditions.......... 31Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold..................31Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions 31

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.............................. 33

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.............. 33

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...............................33

Sleep Disorder Agents....................................33Index of Drugs................................................ 34

5

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain

acetaminophen-codeine #2

TIER 1 QL


TIER 1 QL


TIER 1 QL

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

TIER 1 QL

APADAZ E QL

apap-caff-dihydrocodeine oral capsule

TIER 1 QL

BELBUCA TIER 2 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

E QL

butalbital-apap-caffeine TIER 1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR

E PA; QL

CONZIP E PA; QL

DILAUDID ORAL E QL

DURAGESIC-100 E PA; QL





fentanyl TIER 1 PA; QL

FENTANYL CITRATE BUCCAL TABLET

E PA; QL

FENTORA E PA; QL

FIORICET E

FIORICET/CODEINE E

hydrocodone-acetaminophen oral tablet

TIER 1 QL

hydromorphone hcl oral tablet

TIER 1 QL

HYSINGLA ER TIER 2 PA; QL

Drug NameDrug Tier

Notes

LAZANDA E PA; QL

morphine sulfate er oral tablet extended release

TIER 1 PA; QL

MS CONTIN E PA; QL

NUCYNTA E QL

NUCYNTA ER E PA; QL

OXYCODONE HCL ER E PA; QL

oxycodone hcl oral tablet TIER 1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

TIER 1 QL

OXYCONTIN TIER 2 PA; QL

PERCOCET E QL

ROXICODONE E QL

SUBSYS E PA; QL

tramadol hcl oral tablet 50 mg

TIER 1 QL

TREZIX TIER 3 QL

ULTRACET E QL

ULTRAM E QL

XTAMPZA ER TIER 2 PA; QL

ZOHYDRO ER E PA; QL

Analgesics - Drugs for Pain and Inflammation

ARTHROTEC E

CAMBIA E

CELEBREX E QL

celecoxib oral TIER 1 QL

DICLOFENAC E

diclofenac sodium oral TIER 1

DUEXIS TIER 3 QL

etodolac oral tablet TIER 1

FLECTOR E QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

TIER 1

indomethacin oral capsule 25 mg, 50 mg

TIER 1

6

Drug NameDrug Tier

Notes

KETOROLAC TROMETHAMINE NASAL

E QL

ketorolac tromethamine oral

TIER 1 QL

meloxicam oral tablet TIER 1

MOBIC E

nabumetone oral TIER 1

NALFON E

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

TIER 3

naproxen oral tablet TIER 1

PENNSAID E

QMIIZ ODT E

RELAFEN E

RELAFEN DS E

SPRIX E QL

VIMOVO E QL

VOLTAREN E QL

ZIPSOR E

ZORVOLEX E

Anesthetics

lidocaine external patch 5 %

TIER 1

lidocaine-prilocaine external cream

TIER 1

LIDODERM E

ZTLIDO E

Anti-Addiction / Substance Abuse Treatment Agents

BUNAVAIL TIER 3 QL

buprenorphine hcl sublingual

TIER 1 QL

buprenorphine hcl-naloxone hcl

TIER 1 QL

CHANTIX TIER 3 QL

CHANTIX CONTINUING MONTH PAK

TIER 3 QL

Drug NameDrug Tier

Notes

CHANTIX STARTING MONTH PAK

TIER 3 QL

naltrexone hcl oral TIER 1

NARCAN TIER 2

SUBOXONE E QL

ZUBSOLV TIER 2 QL

Antibacterials

ACTICLATE E

amoxicillin oral capsule TIER 1

amoxicillin oral suspension reconstituted

TIER 1

amoxicillin oral tablet TIER 1

amoxicillin-potassium clavulanate oral suspension reconstituted

TIER 1

amoxicillin-potassium clavulanate oral tablet

TIER 1

azithromycin oral suspension reconstituted

TIER 1

azithromycin oral tablet TIER 1

cefdinir TIER 1

cefuroxime axetil TIER 1

cephalexin oral capsule TIER 1

cephalexin oral suspension reconstituted

TIER 1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

TIER 1

clarithromycin oral tablet TIER 1

clindamycin hcl oral TIER 1

CLINDESSE TIER 3

DIFICID ORAL TABLET TIER 3

DORYX E

DORYX MPC E

doxycycline hyclate oral capsule

TIER 1

doxycycline hyclate oral tablet

TIER 1

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

E

7

Drug NameDrug Tier

Notes

doxycycline monohydrate oral capsule

TIER 1

doxycycline monohydrate oral tablet

TIER 1

levofloxacin oral tablet TIER 1

metronidazole oral tablet TIER 1

metronidazole vaginal TIER 1

minocycline hcl oral capsule

TIER 1

MINOLIRA E

mupirocin external TIER 1

nitrofurantoin macrocrystal oral

TIER 1

nitrofurantoin monohydrate macrocrystals

TIER 1

NUZYRA ORAL TIER 3

penicillin v potassium oral tablet

TIER 1

SEYSARA TIER 3 ST

SILVADENE E

SOLODYN E

SOLOSEC TIER 3

sulfamethoxazole-trimethoprim oral tablet

TIER 1

TARGADOX E

XENLETA TIER 3

XEPI TIER 3

XIMINO TIER 3

Anticoagulants

ELIQUIS TIER 2

enoxaparin sodium TIER 1 SP; QL

PRADAXA TIER 2

warfarin sodium oral TIER 1

XARELTO TIER 2

XARELTO STARTER PACK

TIER 2

Anticonvulsants - Drugs for Seizures

BRIVIACT INTRAVENOUS

TIER 3

Drug NameDrug Tier

Notes

BRIVIACT ORAL TIER 3 ST

carbamazepine oral tablet

TIER 1

CARBATROL E

DEPAKOTE E

DEPAKOTE ER E

DEPAKOTE SPRINKLES E

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL SUSPENSION

E

divalproex sodium er TIER 1

divalproex sodium oral tablet delayed release

TIER 1

EPIDIOLEX TIER 3 PA; SP

FYCOMPA TIER 3

gabapentin oral capsule TIER 1

gabapentin oral tablet TIER 1

KEPPRA ORAL E

KEPPRA XR E

LAMICTAL E

LAMICTAL ODT E

LAMICTAL STARTER E

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR

E

lamotrigine er TIER 1

lamotrigine oral tablet TIER 1

levetiracetam oral tablet TIER 1

NAYZILAM TIER 3

NEURONTIN E

ONFI E

oxcarbazepine oral tablet TIER 1

OXTELLAR XR E

QUDEXY XR E

SABRIL E PA; SP

SYMPAZAN TIER 3

TEGRETOL E

TEGRETOL-XR E

8

Drug NameDrug Tier

Notes

TOPAMAX E

TOPAMAX SPRINKLE E

topiramate oral tablet TIER 1

TRILEPTAL E

TROKENDI XR TIER 3 ST

VALTOCO 10 MG DOSE TIER 3




VIMPAT TIER 3

XCOPRI TIER 3 ST

XCOPRI (250 MG DAILY DOSE)

TIER 3 ST

XCOPRI (350 MG DAILY DOSE)

TIER 3 ST

ZONEGRAN E

zonisamide oral TIER 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

donepezil hcl oral tablet 10 mg, 23 mg

TIER 1

memantine hcl oral tablet 10 mg, 5 mg

TIER 1

NAMZARIC TIER 2 QL

Antidepressants

amitriptyline hcl oral TIER 1

BRISDELLE E QL

bupropion hcl er (sr) TIER 1 QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

TIER 1 QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

E QL

bupropion hcl oral TIER 1

CELEXA E

citalopram hydrobromide oral tablet

TIER 1

CYMBALTA E QL

Drug NameDrug Tier

Notes

desvenlafaxine succinate er

TIER 1 QL

doxepin hcl oral capsule TIER 1

duloxetine hcl oral TIER 1 QL

EFFEXOR XR E

escitalopram oxalate oral tablet

TIER 1

fluoxetine hcl oral capsule

TIER 1

fluoxetine hcl oral tablet TIER 1

fluvoxamine maleate TIER 1

FORFIVO XL E QL

LEXAPRO E

mirtazapine oral tablet TIER 1

nortriptyline hcl oral capsule

TIER 1

paroxetine hcl TIER 1

PAXIL CR E

PAXIL ORAL TABLET E

PRISTIQ E QL

PROZAC E

sertraline hcl oral tablet TIER 1

trazodone hcl oral TIER 1

TRINTELLIX TIER 3 ST; QL

venlafaxine hcl TIER 1

venlafaxine hcl er TIER 1

VIIBRYD TIER 3 QL

VIIBRYD STARTER PACK

TIER 3 QL

WELLBUTRIN SR E QL

WELLBUTRIN XL E QL

ZOLOFT E

Antiemetics - Drugs for Nausea and Vomiting

meclizine hcl oral tablet 12.5 mg, 25 mg

TIER 1

metoclopramide hcl oral tablet 10 mg

TIER 1

ondansetron hcl oral tablet 4 mg, 8 mg

TIER 1

ondansetron odt TIER 1

9

Drug NameDrug Tier

Notes

prochlorperazine maleate oral

TIER 1

SANCUSO E QL

scopolamine TIER 1

VARUBI (180 MG DOSE) TIER 3 QL

Antifungals

ciclopirox external solution

TIER 1

clotrimazole external cream

TIER 1

clotrimazole-betamethasone external cream

TIER 1

CRESEMBA ORAL TIER 3

fluconazole oral tablet TIER 1

GYNAZOLE-1 TIER 3

JUBLIA E PA

KERYDIN TIER 3 PA

ketoconazole external cream

TIER 1

ketoconazole external shampoo

TIER 1

nystatin external cream TIER 1

nystatin mouth/throat TIER 1

terbinafine hcl oral TIER 1

terconazole vaginal cream

TIER 1

TOLSURA E PA

Antigout Agents

allopurinol oral TIER 1

COLCHICINE ORAL CAPSULE

E

colchicine oral tablet TIER 1

COLCRYS E

febuxostat TIER 1 ST

GLOPERBA E

MITIGARE E

Antimigraine Agents

AIMOVIG TIER 2 PA; QL

AJOVY E PA; QL

eletriptan hydrobromide TIER 1 QL

Drug NameDrug Tier

Notes

EMGALITY TIER 2 PA; QL

EMGALITY (300 MG DOSE)

TIER 2 PA; QL

IMITREX E QL

IMITREX STATDOSE REFILL

E QL

IMITREX STATDOSE SYSTEM

E QL

MAXALT E QL

MAXALT-MLT E QL

NURTEC TIER 2 PA; QL

ONZETRA XSAIL E QL

RELPAX E QL

REYVOW E PA; QL

rizatriptan benzoate TIER 1 QL

sumatriptan succinate oral

TIER 1 QL

TOSYMRA E QL

TREXIMET E QL

UBRELVY TIER 2 PA; QL

ZEMBRACE SYMTOUCH

E QL

ZOMIG ORAL E QL

ZOMIG ZMT E QL

Antineoplastics - Drugs for Cancer

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG

E PA; SP; QL

anastrozole oral TIER 1

ARIMIDEX E

BELRAPZO E PA; SP

CABOMETYX TIER 2 PA; SP

capecitabine TIER 1 PA; SP

DARZALEX FASPRO E PA; SP

ERLEADA E PA; SP

GLEEVEC E PA; SP

HERZUMA E PA; SP

IBRANCE ORAL CAPSULE

TIER 3 PA; SP

IDHIFA TIER 3 PA; SP; QL

10

Drug NameDrug Tier

Notes

imatinib mesylate TIER 1 PA; SP

IMBRUVICA ORAL TABLET

TIER 3 PA; SP

KANJINTI TIER 2 PA; SP

letrozole oral TIER 1

LYNPARZA TIER 2 PA; SP

MVASI TIER 2 PA; SP

NUBEQA TIER 3 PA; SP

OGIVRI E PA; SP

ONTRUZANT E PA; SP

REVLIMID TIER 2 PA; SP

RUBRACA TIER 2 PA; SP

RUXIENCE TIER 2 PA; SP

SPRYCEL TIER 2 PA; SP

TABRECTA E PA; SP

tamoxifen citrate oral TIER 1

TARGRETIN EXTERNAL TIER 3 PA; SP

TARGRETIN ORAL E PA; SP

TAZVERIK E PA; SP

temozolomide TIER 1 PA; SP

TRAZIMERA TIER 2 PA; SP

TREANDA E PA; SP

TRUXIMA E PA; SP

XTANDI TIER 3 PA; SP

YONSA E PA; SP

ZEJULA TIER 2 PA; SP

ZIRABEV TIER 2 PA; SP

ZYTIGA E PA; SP

Antiparasitics

ARAKODA TIER 3

EMVERM TIER 2

hydroxychloroquine sulfate oral

TIER 1

NATROBA E

PLAQUENIL E

Antiparkinson Agents

benztropine mesylate oral

TIER 1

Drug NameDrug Tier

Notes

carbidopa-levodopa oral tablet

TIER 1

GOCOVRI E PA

INBRIJA TIER 3 PA; SP

NOURIANZ TIER 3 PA

OSMOLEX ER E PA

pramipexole dihydrochloride

TIER 1

ropinirole hcl TIER 1

RYTARY TIER 3 ST

Antiplatelets

ASPIRIN-OMEPRAZOLE E QL

BRILINTA TIER 2

clopidogrel bisulfate oral TIER 1

PLAVIX E

prasugrel hcl TIER 1

YOSPRALA E QL

Antipsychotics - Drugs for Mood Disorders

ABILIFY E QL

aripiprazole oral tablet TIER 1 QL

ARISTADA TIER 3

ARISTADA INITIO TIER 3

INVEGA SUSTENNA TIER 3

INVEGA TRINZA TIER 3

LATUDA TIER 3 QL

olanzapine oral tablet TIER 1 QL

PERSERIS TIER 3

quetiapine fumarate TIER 1 QL

quetiapine fumarate er TIER 1 QL

REXULTI TIER 3 QL

RISPERDAL E QL

risperidone oral tablet TIER 1 QL

SAPHRIS TIER 3 QL

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR

E QL

11

Drug NameDrug Tier

Notes

SECUADO TRANSDERMAL PATCH 24 HOUR 5.7 MG/24HR, 7.6 MG/24HR

E

SEROQUEL E QL

SEROQUEL XR E QL

VRAYLAR TIER 3 ST; QL

ziprasidone hcl TIER 1 QL

ZYPREXA INTRAMUSCULAR

E

ZYPREXA ORAL E QL

Antivirals

acyclovir oral capsule TIER 1

acyclovir oral tablet TIER 1

ATRIPLA E

BARACLUDE ORAL TABLET

E SP; QL

BIKTARVY TIER 3

CIMDUO TIER 2

DESCOVY E

DOVATO TIER 2

entecavir TIER 1 SP; QL

EPCLUSA ORAL TABLET 400-100 MG

TIER 2 PA; SP; QL

GENVOYA TIER 3

HARVONI TIER 2 PA; SP; QL

JULUCA TIER 2

LEDIPASVIR-SOFOSBUVIR

E PA; SP; QL

MAVYRET TIER 2 PA; SP; QL

ODEFSEY TIER 3

oseltamivir phosphate oral

TIER 1 QL

PREZCOBIX TIER 2

SOFOSBUVIR-VELPATASVIR

E PA; SP; QL

SYMFI TIER 2

SYMFI LO TIER 2

TAMIFLU E QL

TEMIXYS E

TIVICAY TIER 2

Drug NameDrug Tier

Notes

TRIUMEQ TIER 2

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

TIER 2

TRUVADA ORAL TABLET 200-300 MG

E

valacyclovir hcl oral TIER 1

VALTREX E

VEMLIDY TIER 3 SP

VOSEVI TIER 2 PA; SP; QL

XOFLUZA (40 MG DOSE)

TIER 3 QL

XOFLUZA (80 MG DOSE)

TIER 3 QL

ZOVIRAX E

Anxiolytics - Drugs for Anxiety

alprazolam oral tablet TIER 1

ATIVAN ORAL E

buspirone hcl oral TIER 1

clonazepam oral tablet TIER 1

diazepam oral tablet TIER 1

hydroxyzine hcl oral tablet

TIER 1

hydroxyzine pamoate oral

TIER 1

KLONOPIN E

lorazepam oral tablet TIER 1

triazolam TIER 1 QL

VALIUM E

XANAX E

XANAX XR E

Bipolar Agents - Drugs for Mood Disorders

lithium carbonate er TIER 1

lithium carbonate oral capsule

TIER 1

Blood Products and Modifiers - Drugs for Blood Disorders

ADYNOVATE TIER 3 SP

12

Drug NameDrug Tier

Notes

AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

TIER 3 SP

ARANESP (ALBUMIN FREE)

TIER 2 PA; SP

ELOCTATE TIER 3 SP

EPOGEN E PA; SP

ESPEROCT E SP

FULPHILA E PA; SP

GRANIX E PA; SP

JIVI TIER 3 SP

MULPLETA TIER 2 PA; SP

NEULASTA TIER 3 PA; SP

NEULASTA ONPRO TIER 3 PA; SP

NEUPOGEN E PA; SP

NIVESTYM TIER 2 PA; SP

NOVOEIGHT TIER 2 SP

NUWIQ TIER 2 SP

PROCRIT E PA; SP

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

TIER 2 PA; SP

UDENYCA E PA; SP

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML

TIER 3 PA; SP

ZARXIO TIER 2 PA; SP

ZIEXTENZO TIER 3 PA; SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ALTACE E

amiodarone hcl oral TIER 1

amlodipine besylate oral TIER 1

amlodipine besylate-benazepril hcl

TIER 1

Drug NameDrug Tier

Notes

amlodipine besylate-valsartan

TIER 1

amlodipine-olmesartan TIER 1

ATACAND E

atenolol oral TIER 1

atenolol-chlorthalidone TIER 1

atorvastatin calcium oral TIER 1

AVAPRO E

AZOR E

benazepril hcl oral TIER 1

BENICAR E

BENICAR HCT E

bisoprolol fumarate TIER 1

bisoprolol-hydrochlorothiazide

TIER 1

bumetanide oral TIER 1

BYSTOLIC TIER 2

candesartan cilexetil TIER 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

E

cartia xt TIER 1

carvedilol TIER 1

CATAPRES-TTS-1 E

CATAPRES-TTS-2 E

CATAPRES-TTS-3 E

chlorthalidone TIER 1

clonidine hcl oral TIER 1

COLESTID E

COLESTID FLAVORED E

CONSENSI ORAL TABLET 10-200 MG, 5-200 MG

E

CONSENSI ORAL TABLET 2.5-200 MG

E QL

COREG E

COREG CR E

CORLANOR TIER 3

13

Drug NameDrug Tier

Notes

COZAAR E

CRESTOR E

digoxin oral tablet TIER 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

TIER 1

dilt-xr TIER 1

DIOVAN E

DIOVAN HCT E

doxazosin mesylate oral TIER 1

EDARBI TIER 3 ST

EDARBYCLOR TIER 3 ST

enalapril maleate oral TIER 1

ENTRESTO TIER 2

EXFORGE E

EXFORGE HCT E

ezetimibe TIER 1

ezetimibe-simvastatin TIER 1

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

TIER 1

fenofibrate oral tablet TIER 1

fenofibric acid oral capsule delayed release

TIER 1

flecainide acetate TIER 1

furosemide oral tablet TIER 1

gemfibrozil oral TIER 1

guanfacine hcl TIER 1

HEMANGEOL TIER 3

hydralazine hcl oral TIER 1

hydrochlorothiazide oral TIER 1

HYZAAR E

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

irbesartan TIER 1

irbesartan-hydrochlorothiazide

TIER 1

isosorbide mononitrate er TIER 1

Drug NameDrug Tier

Notes

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral TIER 1

LASIX E

LESCOL XL E

LIPITOR E

lisinopril oral TIER 1

lisinopril-hydrochlorothiazide

TIER 1

LIVALO E ST

losartan potassium oral TIER 1

losartan potassium-hctz TIER 1

LOTREL E

lovastatin TIER 1

LOVAZA E

metoprolol succinate er TIER 1

metoprolol tartrate oral TIER 1

MICARDIS E

MICARDIS HCT E

MULTAQ TIER 3

nadolol oral TIER 1

NEXLETOL TIER 2 PA; QL

NEXLIZET TIER 2 PA; QL

NIASPAN E

nifedipine er TIER 1

nifedipine er osmotic release

TIER 1

nitroglycerin sublingual TIER 1

NITROSTAT E

NORVASC E

olmesartan medoxomil oral

TIER 1

olmesartan medoxomil-hctz

TIER 1

olmesartan-amlodipine-hctz

TIER 1

omega-3-acid ethyl esters

TIER 1

PRALUENT TIER 3 PA; QL

14

Drug NameDrug Tier

Notes

PRAVACHOL E

pravastatin sodium TIER 1

prazosin hcl oral TIER 1

PRINIVIL E

propranolol hcl er TIER 1

propranolol hcl oral tablet TIER 1

QUESTRAN E

QUESTRAN LIGHT E

ramipril TIER 1

RANEXA E

ranolazine er TIER 1

REPATHA TIER 3 PA; QL

REPATHA PUSHTRONEX SYSTEM

TIER 3 PA; QL

REPATHA SURECLICK TIER 3 PA; QL

rosuvastatin calcium TIER 1

simvastatin oral TIER 1

sotalol hcl oral TIER 1

spironolactone oral TIER 1

TEKTURNA TIER 2

TEKTURNA HCT TIER 2 ST

telmisartan TIER 1

telmisartan-hctz TIER 1

TENORMIN E

TIKOSYN E

TOPROL XL E

torsemide TIER 1

triamterene-hctz TIER 1

TRIBENZOR E

TRICOR E

valsartan TIER 1

valsartan-hydrochlorothiazide

TIER 1

VASCEPA TIER 2

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

TIER 1

verapamil hcl er oral tablet extended release

TIER 1

Drug NameDrug Tier

Notes

VYTORIN E

WELCHOL E

ZESTRIL E

ZETIA E

ZOCOR E

ZYPITAMAG E

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL E PA; QL

ADDERALL XR E PA; QL

ADHANSIA XR E PA; QL

amphetamine-dextroamphetamine

TIER 1 PA; QL

amphetamine-dextroamphetamine er

TIER 1 PA; QL

atomoxetine hcl TIER 1 QL

CONCERTA E PA; QL

dexmethylphenidate hcl er

TIER 1 PA; QL

dexmethylphenidate hcl oral tablet 10 mg, 5 mg

TIER 1 PA; QL

EVEKEO E PA; QL

EVEKEO ODT TIER 3 PA; QL

FOCALIN E PA; QL

FOCALIN XR E PA; QL

guanfacine hcl er TIER 1

INTUNIV E

JORNAY PM TIER 3 PA; QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg

TIER 1 PA; QL

methylphenidate hcl er (xr)

TIER 1 PA; QL

methylphenidate hcl er oral tablet extended release

TIER 1 PA; QL

methylphenidate hcl oral tablet

TIER 1 PA; QL

15

Drug NameDrug Tier

Notes

RITALIN E PA; QL

RITALIN LA E PA; QL

STRATTERA E QL

VYVANSE TIER 2 PA; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA TIER 3 PA; SP; QL

AUBAGIO TIER 3 PA; SP; QL

AVONEX PEN TIER 2 PA; SP; QL

AVONEX PREFILLED TIER 2 PA; SP; QL

BAFIERTAM TIER 2 PA; SP; QL

BETASERON TIER 2 PA; SP; QL

COPAXONE TIER 2 PA; SP; QL

EXTAVIA E PA; SP; QL

GILENYA TIER 3 PA; SP; QL

glatiramer acetate TIER 1 PA; SP; QL

MAVENCLAD (10 TABS) TIER 3 PA; SP







MAYZENT TIER 3 PA; SP; QL

PLEGRIDY E PA; SP; QL

PLEGRIDY STARTER PACK

E PA; SP; QL

REBIF E PA; SP; QL

REBIF REBIDOSE E PA; SP; QL

REBIF REBIDOSE TITRATION PACK

E PA; SP; QL

REBIF TITRATION PACK

E PA; SP; QL

TECFIDERA TIER 2 PA; SP; QL

VUMERITY TIER 2 PA; SP; QL

Central Nervous System Agents - Miscellaneous

ADDYI TIER 3 PA; QL

Drug NameDrug Tier

Notes

ADIPEX-P E

AUSTEDO TIER 3 PA; SP; QL

CONTRAVE E

HORIZANT TIER 3

LYRICA E

pregabalin oral capsule TIER 1

TEGSEDI TIER 3 PA; SP

TIGLUTIK TIER 3 SP

VYLEESI TIER 3 PA; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat

TIER 1

lidocaine viscous hcl TIER 1

Dermatological Agents - Drugs for Skin Conditions

ABSORICA LD TIER 3 PA

ACANYA E

ACZONE EXTERNAL GEL 7.5 %

TIER 2

AKLIEF E PA

ALA SCALP E

AMZEEQ TIER 3

APEXICON E E

ARAZLO E

AVITA E PA

BENZACLIN E

BENZACLIN WITH PUMP

E

BENZAMYCIN E

betamethasone dipropionate external cream

TIER 1

CALCIPOTRIENE EXTERNAL FOAM

E

CAPEX E

claravis TIER 1 PA

CLINDAGEL E

16

Drug NameDrug Tier

Notes

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

TIER 1

clindamycin phosphate external lotion

TIER 1

clindamycin phosphate external solution

TIER 1

clindamycin phosphate external swab

TIER 1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

E

clindamycin phosphate gel 1 % external

TIER 1

clobetasol propionate external cream

TIER 1

clobetasol propionate external ointment

TIER 1

clobetasol propionate external solution

TIER 1

CLOBEX E

CLOBEX SPRAY E

CLODERM E

CORDRAN EXTERNAL TAPE

E

DAPSONE EXTERNAL GEL 7.5 %

E

DESONATE E

DIFFERIN EXTERNAL CREAM

E PA

DIFFERIN EXTERNAL GEL 0.3 %

E PA

DIFFERIN EXTERNAL LOTION

E PA

DUOBRII E

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

TIER 2 PA; SP; QL

ELIDEL E

EPIDUO E

EPIDUO FORTE TIER 3

EUCRISA TIER 2 ST

Drug NameDrug Tier

Notes

FINACEA TIER 3

fluocinonide external cream

TIER 1

FLUOROPLEX TIER 3

HALOBETASOL PROPIONATE EXTERNAL FOAM

E

HALOG EXTERNAL CREAM

E

HALOG EXTERNAL OINTMENT

E

hydrocortisone external cream 1 %, 2.5 %

TIER 1

hydrocortisone external ointment 1 %, 2.5 %

TIER 1

IMIQUIMOD PUMP E

IMPOYZ E

KENALOG EXTERNAL E

LEXETTE E

METROGEL E

metronidazole external cream

TIER 1

metronidazole external gel

TIER 1

MIRVASO TIER 3

mometasone furoate external cream

TIER 1

NORITATE E

ONEXTON TIER 3

ORACEA E

PANDEL E

PROPECIA E

PSORCON E

QBREXZA TIER 3 QL

RETIN-A E PA

RETIN-A MICRO GEL 0.04 %, 0.1 %

E PA

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

E PA

17

Drug NameDrug Tier

Notes

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

TIER 2 PA

RHOFADE TIER 3

SERNIVO TIER 3

SOOLANTRA TIER 3

SORILUX E

TACLONEX EXTERNAL OINTMENT

E QL

TACLONEX EXTERNAL SUSPENSION

TIER 3 QL

tacrolimus external ointment

TIER 1

TAZORAC EXTERNAL CREAM 0.1 %

E PA

TOPICORT SPRAY E

tretinoin external cream TIER 1 PA

triamcinolone acetonide external cream

TIER 1

triamcinolone acetonide external ointment

TIER 1

TRIANEX E

ULTRAVATE E

VECTICAL E

VELTIN E

VERDESO E

ZIANA E

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

ADLYXIN E QL

ADLYXIN STARTER PACK

E QL

ALOGLIPTIN BENZOATE

E

ALOGLIPTIN-METFORMIN HCL

E

ALOGLIPTIN-PIOGLITAZONE

E

BYDUREON TIER 2 ST; QL

Drug NameDrug Tier

Notes

BYDUREON BCISE AUTOINJECTOR

TIER 2 ST; QL

BYETTA 10 MCG PEN TIER 2 ST; QL

BYETTA 5 MCG PEN TIER 2 ST; QL

FARXIGA TIER 2 ST

FORTAMET E

glimepiride TIER 1

glipizide er TIER 1

glipizide ir TIER 1

GLUMETZA E PA

glyburide oral TIER 1

GLYXAMBI TIER 2 ST

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET TIER 2 ST

JANUMET XR TIER 2 ST

JANUVIA TIER 2 ST

JARDIANCE TIER 2 ST

JENTADUETO TIER 2 ST

JENTADUETO XR TIER 2 ST

KAZANO E

KOMBIGLYZE XR E

metformin hcl er TIER 1

metformin hcl er (mod) E PA

metformin hcl er (osm) E

metformin hcl oral tablet TIER 1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC TIER 2 ST; QL

pioglitazone hcl TIER 1

QTERN E

RYBELSUS TIER 2 ST; QL

SEGLUROMET E

SOLIQUA TIER 2 ST; QL

STEGLATRO E

STEGLUJAN E

18

Drug NameDrug Tier

Notes

SYMLINPEN 120 TIER 3 PA

SYMLINPEN 60 TIER 3 PA

SYNJARDY TIER 2 ST

SYNJARDY XR TIER 2 ST

TRADJENTA TIER 2 ST

TRIJARDY XR TIER 2 ST

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

TIER 2 ST; QL

VICTOZA TIER 2 ST; QL

XIGDUO XR TIER 2 ST

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA DEVICE

E QL

ACCU-CHEK AVIVA CONNECT KIT W/DEVICE

E QL

ACCU-CHEK AVIVA IN VITRO

E

ACCU-CHEK AVIVA PLUS KIT W/DEVICE

E QL

ACCU-CHEK COMPACT PLUS CARE KIT

E QL

ACCU-CHEK COMPACT PLUS CONTROL

E

ACCU-CHEK COMPACT PLUS TEST STRIPS

E QL

ACCU-CHEK FASTCLIX LANCET KIT

$0 COPAY

ACCU-CHEK GUIDE KIT W/DEVICE

E QL

ACCU-CHEK GUIDE CONTROL

E

ACCU-CHEK GUIDE KIT W/DEVICE

E QL

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

E QL

ACCU-CHEK SMARTVIEW CONTROL

E

Drug NameDrug Tier

Notes

ACCU-CHEK SMARTVIEW TEST STRIPS

E QL

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

$0 COPAY

AGAMATRIX CONTROL LEVEL 2

E

AGAMATRIX CONTROL LEVEL 4

E

AGAMATRIX PRESTO TEST

E QL

ASSURE PLATINUM E QL

BIOTEL CARE BLOOD GLUCOSE SYST

E QL

BLOOD GLUCOSE TEST

E QL

CARETOUCH CONTROL SOL LEVEL 2

E

CARETOUCH TEST E QL

CONTOUR CONTROL$0

COPAY

CONTOUR NEXT CONTROL

$0 COPAY

CONTOUR NEXT MONITOR

$0 COPAY

QL

CONTOUR NEXT TEST$0

COPAYQL

CONTOUR TEST$0

COPAYQL

DIATHRIVE BLOOD GLUCOSE METER

E QL

DIATHRIVE BLOOD GLUCOSE TEST

E QL

DIATHRIVE GLUCOSE CONTROL SOLN

E

DIATHRIVE GLUCOSE TEST

E QL

DIATHRIVE+ GLUCOSE MONITOR

E QL

DIATHRIVE+ GLUCOSE TEST

E QL

EASY TRAK II BLOOD GLUCOSE SYS

E QL

19

Drug NameDrug Tier

Notes

EASY TRAK II CONTROL

E

EASY TRAK II GLUCOSE TEST

E QL

EASYMAX 15 LEVEL 2-3 CONTROL

E

EASYMAX CONTROL E

EASYMAX CONTROL NORMAL/HIGH

E

EMBRACE TALK BLOOD GLUCOSE

E QL

EMBRACE TALK GLUCOSE CONTROL

E

EMBRACE TALK GLUCOSE TEST

E QL

EMBRACE TALK MONITORING SYSTEM

E QL

EVENCARE PROVIEW GLUCOSE TEST

E QL

FORA 6 CONNECT E QL

FORA GTEL BLOOD GLUCOSE SYSTEM

E QL

FORA GTEL BLOOD GLUCOSE TEST

E QL

FORTISCARE CONTROL

E

FORTISCARE GLUCOSE SYSTEM DEVICE

E QL

FORTISCARE T1 GLUCOSE SYSTEM

E QL

FREESTYLE FREEDOM LITE

E QL

FREESTYLE INSULINX SYSTEM

E QL

FREESTYLE INSULINX TEST

E QL

FREESTYLE LIBRE 14 DAY READER

E

FREESTYLE LIBRE 14 DAY SENSOR

E

FREESTYLE LIBRE 2 READER SYSTM DEVICE

E

Drug NameDrug Tier

Notes

FREESTYLE LIBRE 2 SENSOR SYSTM

E

FREESTYLE LIBRE READER

E

FREESTYLE LIBRE SENSOR SYSTEM

E

FREESTYLE LITE TEST E QL

FREESTYLE PRECISION NEO TEST

E QL

FREESTYLE TEST E QL

GLUCOCARD 01 SENSOR PLUS

E QL

GLUCOCARD EXPRESSION TEST

E QL

GLUCOCARD SHINE CONNEX

E QL

GLUCOCARD SHINE EXPRESS

E QL

GLUCOCARD SHINE TEST

E QL

GLUCOCARD VITAL TEST

E QL

GOJJI BLOOD GLUCOSE TEST

E QL

GOJJI BLOOD TEST STRIP/LANCETS

E QL

GOJJI CONTROL E

HARMONY BLOOD GLUCOSE TEST

E QL

HW EMBRACE PRO GLUCOSE METER

E QL

HW EMBRACE PRO GLUCOSE TEST

E QL

HW EMBRACE TALK BLOOD GLUCOSE

E QL

HW EMBRACE TALK GLUCOSE TEST

E QL

INFINITY BLOOD GLUCOSE TEST

E QL

KROGER HEALTHPRO GLUCOSE TEST

E QL

MICRODOT TEST E QL

20

Drug NameDrug Tier

Notes

ONE DROP BLOOD GLUCOSE MONITOR

E QL

ONE DROP TEST E QL

ONETOUCH ULTRA E QL

ONETOUCH ULTRA 2 KIT W/DEVICE

E QL

ONETOUCH ULTRA MINI KIT W/DEVICE

E QL

ONETOUCH VERIO KIT W/DEVICE

E QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

E QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

E

ONETOUCH VERIO TEST STRIPS

E QL

ONETOUCH VERIO IQ SYSTEM

E QL

ONETOUCH VERIO REFLECT

E QL

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

E QL

PRECISION LINK E QL

PRECISION PCX PLUS TEST

E QL

PRECISION QID MONITOR

E QL

PRECISION QID TEST E QL

PRECISION SOF-TACT MONITOR

E QL

PRECISION SOF-TACT TEST

E QL

PRECISION XTRA BLOOD GLUCOSE

E QL

PRECISION XTRA DEVICE

E QL

PRECISION XTRA KIT E QL

PRECISION XTRA MONITOR

E QL

PRODIGY NO CODING BLOOD GLUC

E QL

Drug NameDrug Tier

Notes

RELION BLOOD GLUCOSE TEST

E QL

RELION PREMIER CLASSIC

E QL

RELION PREMIER TEST

E QL

RELION ULTIMA TEST E QL

SURESTEP PRO HIGH GLUCOSE

E

SURESTEP PRO LOW GLUCOSE

E

SURESTEP PRO NORMAL GLUCOSE

E

TRUE FOCUS BLOOD GLUCOSE METER

E QL

TRUE METRIX BLOOD GLUCOSE TEST

E QL

TRUE METRIX PRO BLOOD GLUCOSE

E QL

UNISTRIP CONTROL IN VITRO SOLUTION LOW

E

VIVAGUARD INO CONTROL SOLUTION

E

VIVAGUARD INO GLUCOSE METER

E QL

VIVAGUARD INO TEST STRIPS

E QL

Diabetes - Glycemic Agents

BAQSIMI ONE PACK TIER 2

BAQSIMI TWO PACK TIER 2

GLUCAGON EMERGENCY KIT

TIER 2

GVOKE PFS TIER 2

Diabetes - Insulins

ADMELOG E

ADMELOG SOLOSTAR E

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

BD AUTOSHIELD DUO PEN NEEDLES

$0 COPAY

21

Drug NameDrug Tier

Notes

BD ULTRA-FINE INSULIN SYRINGES

$0 COPAY

BD ULTRA-FINE PEN NEEDLES

$0 COPAY

BD VEO INSULIN SYR U/F 1/2UNIT

$0 COPAY

FIASP E

FIASP FLEXTOUCH E

FIASP PENFILL E

HUMALOG KWIKPEN TIER 2

HUMALOG MIX 50/50 KWIKPEN

TIER 2

HUMALOG MIX 50/50 VIAL

TIER 2

HUMALOG MIX 75/25 KWIKPEN

TIER 2

HUMALOG MIX 75/25 VIAL

TIER 2

HUMALOG U-100 JUNIOR KWIKPEN

TIER 2

HUMALOG VIAL TIER 2

HUMULIN 70/30 KWIKPEN

TIER 2

HUMULIN 70/30 VIAL TIER 2

HUMULIN N KWIKPEN TIER 2

HUMULIN N VIAL TIER 2

HUMULIN R U-500 KWIKPEN

TIER 2

HUMULIN R U-500 VIAL TIER 2

HUMULIN R VIAL TIER 2

INSULIN ASP PROT & ASP FLEXPEN

E

INSULIN ASPART E

INSULIN ASPART FLEXPEN

E

INSULIN ASPART PENFILL

E

INSULIN ASPART PROT & ASPART

E

INSULIN LISPRO E

INSULIN LISPRO (1 UNIT DIAL)

E

Drug NameDrug Tier

Notes

INSULIN LISPRO JUNIOR KWIKPEN

E

INSULIN LISPRO PROT & LISPRO

E

LANTUS SOLOSTAR TIER 2

LANTUS U-100 VIAL TIER 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

NOVOFINE AUTOCOVER PEN NEEDLE

$0 COPAY

NOVOFINE PEN NEEDLE

$0 COPAY

NOVOFINE PLUS PEN NEEDLE

$0 COPAY

NOVOLIN 70/30 FLEXPEN

E

NOVOLIN 70/30 FLEXPEN RELION

E

NOVOLIN 70/30 RELION E

NOVOLIN 70/30 VIAL E

NOVOLIN N FLEXPEN E

NOVOLIN N FLEXPEN RELION

E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R FLEXPEN E

NOVOLIN R FLEXPEN RELION

E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG FLEXPEN E

NOVOLOG MIX 70/30 FLEXPEN

E

NOVOLOG MIX 70/30 VIAL

E

NOVOLOG PENFILL E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE

$0 COPAY

22

Drug NameDrug Tier

Notes

TOUJEO MAX SOLOSTAR

TIER 2

TOUJEO SOLOSTAR TIER 2

TRESIBA E

TRESIBA FLEXTOUCH E

Electrolytes / Minerals / Metals / Vitamins

AZESCHEW PRENATAL/POSTNATAL

E

AZESCO E

CARNITOR ORAL E

CARNITOR SF E

CITRANATAL BLOOM E

cyanocobalamin injection solution 1000 mcg/ml

TIER 1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

TIER 3

ENBRACE HR E

ergocalciferol oral capsule

TIER 1

folic acid oral tablet 1 mg TIER 1

klor-con m20 TIER 1

K-TAB E

LOKELMA TIER 3

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

TIER 1

NASCOBAL TIER 3

NESTABS ONE E

potassium chloride crys er

TIER 1

potassium chloride er TIER 1

potassium citrate er TIER 1

PREGENNA E

PRENARA E

PRENATE E

PRENATE DHA E

PRENATE ELITE E

PRENATE ENHANCE E

Drug NameDrug Tier

Notes

PRENATE ESSENTIAL E

PRENATE MINI E

PRENATE PIXIE E

PRENATE RESTORE E

PRENATVITE COMPLETE

E

PRIMACARE E

sodium fluoride oral tablet chewable

TIER 1

TRINAZ E

TRISTART ONE E

VELTASSA TIER 3

VITAFOL FE+ E

VITAFOL-OB+DHA E

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

TIER 1

VITATHELY WITH GINGER

E

WESTGEL DHA E

ZALVIT E

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX E QL

CARAFATE ORAL TABLET

E

DEXILANT TIER 2 QL

esomeprazole magnesium oral capsule delayed release

TIER 1 QL

famotidine oral tablet 20 mg, 40 mg

TIER 1

lansoprazole oral capsule delayed release

TIER 1 QL

NEXIUM ORAL CAPSULE DELAYED RELEASE

E QL

omeprazole oral capsule delayed release

TIER 1 QL

omeprazole-sodium bicarbonate

E QL

23

Drug NameDrug Tier

Notes

pantoprazole sodium oral tablet delayed release

TIER 1 QL

PREVACID E QL

PREVACID SOLUTAB E QL

PROTONIX ORAL TABLET DELAYED RELEASE

E QL

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E QL

rabeprazole sodium oral tablet delayed release

TIER 1 QL

sucralfate oral tablet TIER 1

ZEGERID E QL

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

AMITIZA E QL

CLENPIQ TIER 3

dicyclomine hcl oral capsule

TIER 1

dicyclomine hcl oral tablet

TIER 1

diphenoxylate-atropine oral tablet

TIER 1

gavilyte-g TIER 1

glycopyrrolate oral tablet 1 mg, 2 mg

TIER 1

GOLYTELY E

hyoscyamine sulfate sl TIER 1

hyoscyamine sulfate sublingual

TIER 1

lactulose oral solution TIER 1

LINZESS TIER 2 ST; QL

MOTEGRITY TIER 3 ST; QL

MOTOFEN E

MOVANTIK E QL

MOVIPREP E

NULYTELY LEMON-LIME

E

Drug NameDrug Tier

Notes

NULYTELY WITH FLAVOR PACKS

E

OMECLAMOX-PAK TIER 2

OSMOPREP E

PLENVU E

PYLERA TIER 2

RELISTOR E QL

SUPREP BOWEL PREP KIT

TIER 3

SYMPROIC TIER 2 QL

TRULANCE E QL

VIBERZI TIER 3

ZELNORM TIER 3 PA; QL

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA TIER 3 PA; SP

CREON TIER 2

EXONDYS 51 E PA; SP

NITYR TIER 3 PA; SP

PANCREAZE E

PERTZYE E

STRENSIQ SUBCUTANEOUS SOLUTION 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

TIER 2 PA; SP

VIOKACE E

VYONDYS 53 E PA; SP

ZENPEP TIER 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA TIER 3

CIALIS ORAL TABLET 10 MG, 20 MG

E QL

CIALIS ORAL TABLET 2.5 MG, 5 MG

E PA; QL

DEPEN TITRATABS TIER 2 SP

LEVITRA E QL

24

Drug NameDrug Tier

Notes

MYRBETRIQ TIER 2

oxybutynin chloride er TIER 1

oxybutynin chloride oral tablet

TIER 1

phenazopyridine hcl oral tablet 100 mg, 200 mg

TIER 1

RENAGEL E

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

TIER 1 QL

solifenacin succinate TIER 1

STAXYN E QL

STENDRA E QL

tadalafil oral tablet 10 mg, 20 mg

TIER 1 QL

tadalafil oral tablet 2.5 mg, 5 mg

TIER 1 PA; QL

tolterodine tartrate er TIER 1

TOVIAZ TIER 3

VELPHORO TIER 3

VESICARE E

VIAGRA E QL

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er TIER 1

AVODART E

dutasteride oral TIER 1

finasteride oral tablet 5 mg

TIER 1

FLOMAX E

tamsulosin hcl TIER 1

terazosin hcl oral capsule 1 mg, 10 mg, 5 mg

TIER 1

Hormonal Agents - Adrenal

CORTEF E

dexamethasone oral tablet

TIER 1

hydrocortisone oral TIER 1

Drug NameDrug Tier

Notes

KENALOG INJECTION SUSPENSION 40 MG/ML

E

methylprednisolone oral TIER 1

prednisolone oral solution

TIER 1

prednisolone sodium phosphate oral solution

TIER 1

prednisone oral tablet TIER 1

prednisone oral tablet therapy pack

TIER 1

RAYOS E

Hormonal Agents - Men's Health

ANDRODERM TIER 2 PA

ANDROGEL E PA

ANDROGEL PUMP E PA

AVEED E PA

DEPO-TESTOSTERONE E PA

FORTESTA E PA

JATENZO E PA

NATESTO E PA

TESTIM E PA

TESTOPEL E PA

testosterone cypionate intramuscular

TIER 1 PA

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

TIER 1 PA

VOGELXO E PA

VOGELXO PUMP E PA

XYOSTED TIER 3 PA

Hormonal Agents - Osteoporosis

OSPHENA TIER 3

25

Drug NameDrug Tier

Notes

Hormonal Agents - Pituitary

ACTHAR TIER 2 PA; SP

BYNFEZIA PEN E PA; SP

cabergoline TIER 1

CETROTIDE E PA; SP

GENOTROPIN E PA; SP

GENOTROPIN MINIQUICK

E PA; SP

GONAL-F E PA; SP

GONAL-F RFF E PA; SP

GONAL-F RFF REDIJECT

E PA; SP

HUMATROPE E PA; SP

ISTURISA E PA; SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

TIER 2 PA; SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

TIER 2 PA; SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

TIER 2 PA; SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

TIER 2 PA; SP

NOCDURNA TIER 3

OMNITROPE E PA; SP

ORILISSA TIER 2

SAIZEN E PA; SP

SAIZENPREP E PA; SP

SANDOSTATIN E PA; SP

ZOMACTON E PA; SP

ZOMACTON (FOR ZOMA-JET 10)

E PA; SP

Drug NameDrug Tier

Notes

Hormonal Agents - Sex Hormones and Birth Control

ANNOVERA E QL

apri TIER 1

aviane TIER 1

BEYAZ E

BIJUVA TIER 3

blisovi 24 fe TIER 1

blisovi fe 1.5/30 TIER 1

blisovi fe 1/20 TIER 1

CLIMARA E

CLIMARA PRO TIER 2

cryselle-28 TIER 1

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

E

DIVIGEL TIER 3

dotti TIER 1

drospirenone-ethinyl estradiol

TIER 1

DUAVEE TIER 2

ELESTRIN TIER 3

ENDOMETRIN TIER 2

enskyce TIER 1

estarylla TIER 1

ESTRACE E

estradiol oral TIER 1

estradiol transdermal TIER 1

estradiol vaginal TIER 1

ESTROGEL TIER 3

EVAMIST TIER 3

femynor TIER 1

GENERESS FE E

gianvi TIER 1

IMVEXXY MAINTENANCE PACK

TIER 3

IMVEXXY STARTER PACK

TIER 3

isibloom TIER 1

26

Drug NameDrug Tier

Notes

junel 1.5/30 TIER 1

junel 1/20 TIER 1

junel fe 1.5/30 TIER 1

junel fe 1/20 TIER 1

junel fe 24 TIER 1

kariva TIER 1

kurvelo TIER 1

larin fe 1/20 TIER 1

larissia TIER 1

lessina TIER 1

levonorgest-eth est & eth est

TIER 1 QL

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg, 0.15-0.03 mg

TIER 1 QL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

TIER 1

LO LOESTRIN FE TIER 3

LOESTRIN 1.5/30 (21) E

LOESTRIN 1/20 (21) E

LOESTRIN FE 1.5/30 E

LOESTRIN FE 1/20 E

low-ogestrel TIER 1

MAKENA TIER 2 PA; SP

medroxyprogesterone acetate oral

TIER 1

microgestin fe 1/20 TIER 1

MINASTRIN 24 FE E

mono-linyah TIER 1

NATAZIA TIER 2

nikki TIER 1

norethindrone acetate oral

TIER 1

norethindrone acet-ethinyl est

TIER 1

norethindrone oral TIER 1

norgestimate-ethinyl estradiol triphasic

TIER 1

Drug NameDrug Tier

Notes

nortrel 1/35 (21) TIER 1

nortrel 1/35 (28) TIER 1

NUVARING TIER 3

ORTHO MICRONOR E

PREMARIN ORAL TIER 2

PREMARIN VAGINAL TIER 2

PREMPHASE TIER 2

PREMPRO TIER 2

progesterone micronized oral

TIER 1

PROMETRIUM E

SAFYRAL E

SEASONIQUE E QL

SLYND E

sprintec 28 TIER 1

sronyx TIER 1

syeda TIER 1

TAYTULLA TIER 3

tri femynor TIER 1

tri-lo-marzia TIER 1

tri-lo-sprintec TIER 1

tri-previfem TIER 1

tri-sprintec TIER 1

TWIRLA E

VAGIFEM E

vienva TIER 1

viorele TIER 1

VIVELLE-DOT E

YASMIN 28 E

YAZ E

Hormonal Agents - Thyroid

ARMOUR THYROID TIER 3

CYTOMEL E

euthyrox TIER 1

LEVOTHYROXINE SODIUM ORAL CAPSULE

E

levothyroxine sodium oral tablet

TIER 1

27

Drug NameDrug Tier

Notes

levoxyl TIER 1

liothyronine sodium oral TIER 1

methimazole oral TIER 1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

TIER 3

np thyroid oral tablet 60 mg

TIER 1

SYNTHROID TIER 3

TIROSINT E

TIROSINT-SOL E

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN TIER 3 PA; SP

ACTEMRA SUBCUTANEOUS

TIER 3 PA; SP

ASCENIV E PA; SP

azathioprine oral TIER 1

CIMZIA TIER 2 PA; SP

CIMZIA PREFILLED KIT TIER 2 PA; SP

CIMZIA STARTER KIT TIER 2 PA; SP

COSENTYX (300 MG DOSE)

E PA; SP

COSENTYX 150 MG/ML E PA; SP

COSENTYX SENSOREADY (300 MG)

E PA; SP

COSENTYX SENSOREADY PEN

E PA; SP

CUTAQUIG E PA; SP

cyclosporine modified oral capsule

TIER 1 SP

ENBREL MINI TIER 3 PA; SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

TIER 3 PA; SP

Drug NameDrug Tier

Notes

ENBREL SURECLICK TIER 3 PA; SP

FIRAZYR TIER 3 PA; SP; QL

HAEGARDA TIER 3 PA; SP

HUMIRA TIER 2 PA; SP

HUMIRA PEDIATRIC CROHNS START

TIER 2 PA; SP

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

TIER 2 PA; SP

HUMIRA PEN-CD/UC/HS STARTER

TIER 2 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START

TIER 2 PA; SP

INFLECTRA TIER 2 PA; SP

leflunomide oral TIER 1

methotrexate oral TIER 1

methotrexate sodium oral TIER 1

mycophenolate mofetil oral capsule

TIER 1 SP

mycophenolate mofetil oral tablet

TIER 1 SP

mycophenolate sodium TIER 1 SP

OLUMIANT E PA; SP

ORENCIA CLICKJECT TIER 3 PA; SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML

TIER 3 PA; SP

OTEZLA TIER 2 PA; SP

PANZYGA E PA; SP

PROGRAF ORAL CAPSULE

TIER 3 SP

RASUVO TIER 2

REMICADE E PA; SP

RENFLEXIS TIER 2 PA; SP

RINVOQ TIER 2 PA; SP

RUCONEST TIER 3 PA; SP; QL

SIMPONI TIER 2 PA; SP

SIMPONI ARIA TIER 2 PA; SP

sirolimus oral tablet TIER 1 SP

28

Drug NameDrug Tier

Notes

SKYRIZI (150 MG DOSE)

TIER 2 PA; SP

STELARA INTRAVENOUS

TIER 2 PA; SP

STELARA SUBCUTANEOUS

TIER 2 PA; SP; QL

tacrolimus oral TIER 1 SP

TAKHZYRO TIER 3 PA; SP

TALTZ TIER 3 PA; SP

TREMFYA TIER 2 PA; SP

XELJANZ TIER 2 PA; SP

XELJANZ XR TIER 2 PA; SP

XEMBIFY TIER 3 PA; SP

Inflammatory Bowel Disease Agents

APRISO TIER 2

ASACOL HD E

CANASA E

DELZICOL E

DIPENTUM E

LIALDA E

mesalamine oral tablet delayed release

TIER 1

PENTASA TIER 3

PROCTOFOAM HC TIER 2

sulfasalazine oral tablet TIER 1

UCERIS ORAL E

UCERIS RECTAL TIER 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium oral tablet

TIER 1

BINOSTO TIER 3

FORTEO TIER 2 PA; SP

ibandronate sodium oral TIER 1

PROLIA TIER 2 PA; SP; QL

RAYALDEE TIER 3

TYMLOS TIER 2 PA; SP

Drug NameDrug Tier

Notes

Metabolic Bone Disease Agents - Other

calcitriol oral capsule TIER 1

SENSIPAR E

Miscellaneous Therapeutic Agents

BOTOX TIER 2 PA; SP

DUROLANE TIER 2 PA; SP

ENDARI TIER 3 PA

EUFLEXXA TIER 2 PA; SP

FIRDAPSE E PA; SP

GEL-ONE E PA; SP

GELSYN-3 TIER 2 PA; SP

GENVISC 850 E PA; SP

HYALGAN E PA; SP

HYMOVIS E PA; SP

MONOVISC E PA; SP

ORTHOVISC E PA; SP

OXBRYTA E PA; SP; QL

PALFORZIA (12 MG DAILY DOSE)

E PA; SP


E PA; SP


E PA; SP


E PA; SP


E PA; SP


E PA; SP


E PA; SP

PALFORZIA (300 MG MAINTENANCE)

E PA; SP

PALFORZIA (300 MG TITRATION)

E PA; SP


E PA; SP


E PA; SP

29

Drug NameDrug Tier

Notes


E PA; SP

PALFORZIA INITIAL ESCALATION

E PA; SP

SODIUM HYALURONATE INTRA-ARTICULAR

E PA; SP

SUPARTZ FX E PA; SP

SYNVISC E PA; SP

SYNVISC ONE E PA; SP

TRILURON E PA; SP

TRIVISC E PA; SP

VISCO-3 E PA; SP

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

AZASITE TIER 3

BESIVANCE TIER 3

BROMSITE E

ciprofloxacin hcl ophthalmic

TIER 1

erythromycin ophthalmic TIER 1

ILEVRO E

INVELTYS TIER 3

ketorolac tromethamine ophthalmic

TIER 1

LOTEMAX OPHTHALMIC SUSPENSION

E

LOTEMAX SM TIER 3

MOXEZA TIER 2

moxifloxacin hcl (2x day) TIER 1

moxifloxacin hcl ophthalmic solution

TIER 1

NEVANAC E

ofloxacin ophthalmic TIER 1

olopatadine hcl ophthalmic

TIER 1

PRED FORTE E

prednisolone acetate ophthalmic

TIER 1

Drug NameDrug Tier

Notes

PROLENSA TIER 2

VIGAMOX E

ZERVIATE E

Ophthalmic Agents - Drugs for Glaucoma

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

TIER 2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

E

AZOPT TIER 2

BETIMOL TIER 3

brimonidine tartrate ophthalmic

TIER 1

COMBIGAN TIER 2

COSOPT E

COSOPT PF E

dorzolamide hcl-timolol mal

TIER 1

latanoprost ophthalmic TIER 1

LUMIGAN TIER 2

RHOPRESSA TIER 3

ROCKLATAN TIER 3

SIMBRINZA TIER 2

timolol maleate ophthalmic solution

TIER 1

TIMOPTIC E

TIMOPTIC OCUDOSE E

TIMOPTIC-XE E

VYZULTA E

XALATAN E

ZIOPTAN E

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

BEOVU E PA; SP

CEQUA E PA

LATISSE E

polymyxin b-trimethoprim TIER 1

30

Drug NameDrug Tier

Notes

RESTASIS TIER 2 PA

RESTASIS MULTIDOSE TIER 2 PA

TOBRADEX OPHTHALMIC SUSPENSION

E

tobramycin-dexamethasone

TIER 1

XIIDRA TIER 2 PA

Otic Agents - Drugs for Ear Conditions

CIPRODEX TIER 2

neomycin-polymyxin-hc otic suspension

TIER 1

ofloxacin otic TIER 1

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal TIER 1 QL

benzonatate TIER 1

cetirizine hcl oral solution TIER 1

CLARINEX E

CLARINEX-D 12 HOUR E

cyproheptadine hcl oral tablet

TIER 1

DYMISTA TIER 2 QL

FASENRA TIER 2 PA; SP

FASENRA PEN TIER 2 PA; SP

fluticasone propionate nasal

TIER 1

hydrocodone polst-chlorphen polst er susp

TIER 1 PA; QL

ipratropium bromide nasal

TIER 1

levocetirizine dihydrochloride oral tablet

TIER 1

mometasone furoate nasal

TIER 1 QL

NASONEX E QL

NUCALA TIER 2 PA; SP; QL

OMNARIS TIER 3 QL

Drug NameDrug Tier

Notes

promethazine hcl oral tablet

TIER 1

promethazine-codeine TIER 1 PA; QL

promethazine-dm TIER 1

pseudoephedrine-bromphen-dm

TIER 1

QNASL TIER 3 QL

QNASL CHILDRENS TIER 3 QL

XHANCE E QL

XOLAIR TIER 2 PA; SP

ZETONNA TIER 3 QL

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ADVAIR DISKUS TIER 2 QL

ADVAIR HFA TIER 2 QL

AIRDUO DIGIHALER E QL

AIRDUO RESPICLICK 113/14

E QL


E QL


E QL

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

TIER 1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

E QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml

TIER 1 QL

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml

TIER 1

ALVESCO E QL

ANORO ELLIPTA TIER 2 QL

ARMONAIR DIGIHALER E QL

31

Drug NameDrug Tier

Notes

ARNUITY ELLIPTA TIER 2 QL

ASMANEX (120 METERED DOSES)

E QL


E QL


E QL


E QL


E QL

ASMANEX HFA E QL

ATROVENT HFA TIER 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML

E

BEVESPI AEROSPHERE

E QL

BREO ELLIPTA TIER 2 QL

budesonide inhalation TIER 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E QL

COMBIVENT RESPIMAT TIER 2 QL

DUAKLIR PRESSAIR E QL

DULERA E QL

epinephrine injection solution auto-injector

TIER 1

EPIPEN 2-PAK TIER 3 ST

EPIPEN JR 2-PAK E

FLOVENT DISKUS TIER 2 QL

FLOVENT HFA TIER 2 QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

TIER 1 QL

INCRUSE ELLIPTA E QL

ipratropium-albuterol TIER 1 QL

Drug NameDrug Tier

Notes

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

E QL

LONHALA MAGNAIR REFILL KIT

TIER 3 QL

LONHALA MAGNAIR STARTER KIT

TIER 3 QL

montelukast sodium oral tablet

TIER 1

montelukast sodium oral tablet chewable

TIER 1

PERFOROMIST TIER 3 QL

PROAIR DIGIHALER E QL

PROAIR HFA TIER 2 QL

PROAIR RESPICLICK TIER 2 QL

PROVENTIL HFA E QL

PULMICORT FLEXHALER

TIER 2 QL

PULMICORT SUSPENSION

E QL

QVAR REDIHALER E QL

SEEBRI NEOHALER E QL

SEREVENT DISKUS TIER 2 QL

SINGULAIR E

SPIRIVA HANDIHALER TIER 2 QL

SPIRIVA RESPIMAT TIER 2 QL

STIOLTO RESPIMAT TIER 2 QL

STRIVERDI RESPIMAT TIER 2 QL

SYMBICORT TIER 2 QL

SYMJEPI TIER 3

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

TIER 2 QL

TUDORZA PRESSAIR E QL

UTIBRON NEOHALER E QL

VENTOLIN HFA TIER 2 QL

wixela inhub TIER 1 QL

XOPENEX HFA E QL

YUPELRI TIER 3 QL

32

Drug NameDrug Tier

Notes

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS TIER 2 SP

KITABIS PAK E SP

PULMOZYME TIER 2 PA; SP

TOBI NEBULIZER E SP

TOBI PODHALER TIER 3 SP; QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

E SP

TRIKAFTA TIER 3 PA; SP; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA E PA; SP; QL

ADEMPAS TIER 2 PA; SP; QL

LETAIRIS E PA; SP; QL

OPSUMIT TIER 2 PA; SP; QL

ORENITRAM TIER 3 PA; SP

REMODULIN E PA; SP

sildenafil citrate oral tablet 20 mg

TIER 1 PA; SP; QL

TRACLEER 62.5 MG, 125 MG

E PA; SP; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

baclofen oral TIER 1

carisoprodol oral TIER 1

cyclobenzaprine hcl oral TIER 1

LORZONE TIER 3

metaxalone TIER 1

methocarbamol oral TIER 1

NORGESIC FORTE E

ORPHENGESIC FORTE E

OZOBAX E

Drug NameDrug Tier

Notes

SKELAXIN E

SOMA E

tizanidine hcl oral tablet TIER 1

VANADOM E

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E QL

AMBIEN CR E QL

armodafinil TIER 1 PA; QL

eszopiclone TIER 1 QL

LUNESTA E QL

modafinil TIER 1 PA; QL

NUVIGIL E PA; QL

PROVIGIL E PA; QL

RESTORIL E QL

SILENOR TIER 3 QL

SUNOSI TIER 3 PA; QL

temazepam TIER 1 QL

WAKIX TIER 3 PA; SP; QL

XYREM TIER 3 PA; SP; QL

zolpidem tartrate er TIER 1 QL

zolpidem tartrate oral TIER 1 QL

33

Index of Drugs

ABILIFY.............................. 11ABSORICA LD....................16ACANYA............................. 16ACCU-CHEK AVIVA CONNECT KIT W/DEVICE.19ACCU-CHEK AVIVA DEVICE.............................. 19ACCU-CHEK AVIVA PLUS KIT W/DEVICE................... 19ACCU-CHEK COMPACT PLUS CARE KIT.................19ACCU-CHEK COMPACT PLUS CONTROL................19ACCU-CHEK COMPACT PLUS TEST STRIPS.......... 19ACCU-CHEK FASTCLIX LANCET KIT....................... 19ACCU-CHEK GUIDE CONTROL.......................... 19ACCU-CHEK GUIDE KIT W/DEVICE.......................... 19ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE.......................... 19ACCU-CHEK SMARTVIEW CONTROL... 19ACCU-CHEK SMARTVIEW TEST STRIPS...............................19ACCU-CHEK SOFTCLIX LANCET DEVICE KIT.........19acetaminophen-codeine....... 6acetaminophen-codeine #2.. 6acetaminophen-codeine #3.. 6acetaminophen-codeine #4.. 6ACIPHEX............................ 23ACTEMRA.......................... 28ACTEMRA ACTPEN...........28ACTHAR............................. 26ACTICLATE.......................... 7acyclovir..............................12ACZONE.............................16ADCIRCA............................33ADDERALL.........................15ADDERALL XR...................15ADDYI.................................16ADEMPAS.......................... 33ADHANSIA XR................... 15ADIPEX-P........................... 16ADLYXIN............................ 18ADLYXIN STARTER PACK.................................. 18ADMELOG..........................21

ADMELOG SOLOSTAR..... 21ADVAIR DISKUS................ 31ADVAIR HFA...................... 31ADYNOVATE......................12AFINITOR........................... 10AFSTYLA............................13AGAMATRIX CONTROL LEVEL 2..............................19AGAMATRIX CONTROL LEVEL 4..............................19AGAMATRIX PRESTO TEST...................................19AIMOVIG............................ 10AIRDUO DIGIHALER......... 31AIRDUO RESPICLICK 113/14.................................31AIRDUO RESPICLICK 232/14.................................31AIRDUO RESPICLICK 55/14...................................31AJOVY................................ 10AKLIEF............................... 16ALA SCALP........................ 16albuterol sulfate.................. 31albuterol sulfate hfa............ 31ALBUTEROL SULFATE HFA.....................................31alendronate sodium............ 29alfuzosin hcl er....................25allopurinol........................... 10ALOGLIPTIN BENZOATE.. 18ALOGLIPTIN-METFORMIN HCL..............18ALOGLIPTIN-PIOGLITAZONE................. 18ALPHAGAN P.....................30alprazolam.......................... 12ALTACE..............................13ALVESCO...........................31AMBIEN.............................. 33AMBIEN CR........................33amiodarone hcl................... 13AMITIZA..............................24amitriptyline hcl..................... 9amlodipine besylate............ 13amlodipine besylate-benazepril hcl......................13amlodipine besylate-valsartan............................. 13amlodipine-olmesartan....... 13amoxicillin............................. 7amoxicillin-potassium clavulanate............................7

amphetamine-dextroamphetamine............ 15amphetamine-dextroamphetamine er........15AMPYRA.............................16AMRIX................................ 33AMZEEQ.............................16anastrozole......................... 10ANDRODERM.................... 25ANDROGEL........................25ANDROGEL PUMP............ 25ANNOVERA........................26ANORO ELLIPTA............... 31APADAZ............................... 6apap-caff-dihydrocodeine..... 6APEXICON E......................16APIDRA SOLOSTAR..........21APIDRA VIAL......................21apri......................................26APRISO.............................. 29ARAKODA.......................... 11ARANESP (ALBUMIN FREE)................................. 13ARAZLO............................. 16ARIMIDEX.......................... 10aripiprazole......................... 11ARISTADA..........................11ARISTADA INITIO.............. 11armodafinil .......................... 33ARMONAIR DIGIHALER.... 31ARMOUR THYROID...........27ARNUITY ELLIPTA.............32ARTHROTEC....................... 6ASACOL HD....................... 29ASCENIV............................ 28ASMANEX (120 METERED DOSES)........... 32ASMANEX (14 METERED DOSES).............................. 32ASMANEX (30 METERED DOSES).............................. 32ASMANEX (60 METERED DOSES).............................. 32ASMANEX (7 METERED DOSES).............................. 32ASMANEX HFA.................. 32ASPIRIN-OMEPRAZOLE... 11ASSURE PLATINUM..........19ATACAND...........................13atenolol............................... 13atenolol-chlorthalidone........13ATIVAN...............................12atomoxetine hcl...................15

34

atorvastatin calcium............ 13ATRIPLA.............................12ATROVENT HFA................ 32AUBAGIO........................... 16AURYXIA............................ 24AUSTEDO.......................... 16AUVI-Q............................... 32AVAPRO.............................13AVEED................................25aviane................................. 26AVITA................................. 16AVODART.......................... 25AVONEX PEN.................... 16AVONEX PREFILLED........ 16AZASITE.............................30azathioprine........................ 28azelastine hcl...................... 31AZESCHEW PRENATAL/POSTNATAL.. 23AZESCO............................. 23azithromycin..........................7AZOPT................................30AZOR..................................13baclofen.............................. 33BAFIERTAM....................... 16BAQSIMI ONE PACK......... 21BAQSIMI TWO PACK.........21BARACLUDE......................12BASAGLAR KWIKPEN.......21BD AUTOSHIELD DUO PEN NEEDLES...................21BD ULTRA-FINE INSULIN SYRINGES......................... 22BD ULTRA-FINE PEN NEEDLES........................... 22BD VEO INSULIN SYR U/F 1/2UNIT........................22BELBUCA............................. 6BELRAPZO.........................10benazepril hcl......................13BENICAR............................13BENICAR HCT................... 13BENZACLIN........................16BENZACLIN WITH PUMP.. 16BENZAMYCIN.................... 16BENZHYDROCODONE-ACETAMINOPHEN.............. 6benzonatate........................ 31benztropine mesylate..........11BEOVU............................... 30BESIVANCE....................... 30betamethasone dipropionate........................ 16

BETASERON......................16BETHKIS............................ 33BETIMOL............................ 30BEVESPI AEROSPHERE.. 32BEYAZ................................ 26BIJUVA............................... 26BIKTARVY.......................... 12BINOSTO............................29BIOTEL CARE BLOOD GLUCOSE SYST................19bisoprolol fumarate............. 13bisoprolol-hydrochlorothiazide.............13blisovi 24 fe.........................26blisovi fe 1.5/30...................26blisovi fe 1/20......................26BLOOD GLUCOSE TEST.. 19BOTOX............................... 29BREO ELLIPTA.................. 32BRILINTA............................11brimonidine tartrate.............30BRISDELLE.......................... 9BRIVIACT............................. 8BROMSITE......................... 30budesonide......................... 32BUDESONIDE-FORMOTEROL FUMARATE........................ 32bumetanide......................... 13BUNAVAIL............................ 7buprenorphine hcl................. 7buprenorphine hcl-naloxone hcl..........................7bupropion hcl........................ 9bupropion hcl er (sr)..............9bupropion hcl er (xl).............. 9BUPROPION HCL ER (XL).. 9buspirone hcl...................... 12butalbital-apap-caffeine........ 6BUTRANS.............................6BYDUREON....................... 18BYDUREON BCISE AUTOINJECTOR................18BYETTA 10 MCG PEN....... 18BYETTA 5 MCG PEN......... 18BYNFEZIA PEN..................26BYSTOLIC.......................... 13cabergoline......................... 26CABOMETYX..................... 10CALCIPOTRIENE...............16calcitriol...............................29CAMBIA................................ 6CANASA............................. 29

candesartan cilexetil ........... 13capecitabine........................10CAPEX................................16CARAFATE.........................23carbamazepine..................... 8CARBATROL........................8carbidopa-levodopa............ 11CARDIZEM LA....................13CARETOUCH CONTROL SOL LEVEL 2..................... 19CARETOUCH TEST...........19carisoprodol........................ 33CARNITOR......................... 23CARNITOR SF................... 23cartia xt............................... 13carvedilol.............................13CATAPRES-TTS-1............. 13CATAPRES-TTS-2............. 13CATAPRES-TTS-3............. 13cefdinir.................................. 7cefuroxime axetil ...................7CELEBREX...........................6celecoxib...............................6CELEXA................................9cephalexin.............................7CEQUA............................... 30CERDELGA........................ 24cetirizine hcl........................ 31CETROTIDE....................... 26CHANTIX.............................. 7CHANTIX CONTINUING MONTH PAK........................ 7CHANTIX STARTING MONTH PAK........................ 7chlorhexidine gluconate...... 16chlorthalidone..................... 13CIALIS................................ 24ciclopirox.............................10CIMDUO............................. 12CIMZIA................................28CIMZIA PREFILLED KIT.... 28CIMZIA STARTER KIT....... 28CIPRODEX......................... 31ciprofloxacin hcl.............. 7, 30citalopram hydrobromide...... 9CITRANATAL BLOOM....... 23claravis................................16CLARINEX..........................31CLARINEX-D 12 HOUR..... 31clarithromycin........................7CLENPIQ............................ 24CLIMARA............................26CLIMARA PRO................... 26

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CLINDAGEL....................... 16clindamycin hcl..................... 7clindamycin phosphate....... 17CLINDAMYCIN PHOSPHATE......................17clindamycin phosphate-benzoyl peroxide.................17CLINDESSE......................... 7clobetasol propionate..........17CLOBEX............................. 17CLOBEX SPRAY................ 17CLODERM..........................17clonazepam........................ 12clonidine hcl........................ 13clopidogrel bisulfate............ 11clotrimazole.........................10clotrimazole-betamethasone................... 10COLCHICINE......................10colchicine............................ 10COLCRYS.......................... 10COLESTID..........................13COLESTID FLAVORED..... 13COMBIGAN........................ 30COMBIVENT RESPIMAT... 32CONCERTA........................15CONSENSI......................... 13CONTOUR CONTROL....... 19CONTOUR NEXT CONTROL.......................... 19CONTOUR NEXT MONITOR...........................19CONTOUR NEXT TEST.....19CONTOUR TEST............... 19CONTRAVE........................16CONZIP................................ 6COPAXONE....................... 16CORDRAN..........................17COREG...............................13COREG CR........................ 13CORLANOR....................... 13CORTEF............................. 25COSENTYX (300 MG DOSE)................................ 28COSENTYX 150 MG/ML.... 28COSENTYX SENSOREADY (300 MG)...28COSENTYX SENSOREADY PEN.......... 28COSOPT.............................30COSOPT PF....................... 30COZAAR.............................14CREON...............................24

CRESEMBA........................10CRESTOR.......................... 14cryselle-28.......................... 26CUTAQUIG.........................28cyanocobalamin..................23CYANOCOBALAMIN..........23cyclobenzaprine hcl............ 33cyclosporine modified......... 28CYMBALTA.......................... 9cyproheptadine hcl..............31CYTOMEL.......................... 27DAPSONE.......................... 17DARZALEX FASPRO......... 10DELESTROGEN.................26DELZICOL.......................... 29DEPAKOTE.......................... 8DEPAKOTE ER.................... 8DEPAKOTE SPRINKLES..... 8DEPEN TITRATABS...........24DEPO-TESTOSTERONE... 25DESCOVY.......................... 12DESONATE........................ 17desvenlafaxine succinate er...........................................9dexamethasone.................. 25DEXILANT.......................... 23dexmethylphenidate hcl...... 15dexmethylphenidate hcl er..15DIATHRIVE BLOOD GLUCOSE METER.............19DIATHRIVE BLOOD GLUCOSE TEST................ 19DIATHRIVE GLUCOSE CONTROL SOLN............... 19DIATHRIVE GLUCOSE TEST...................................19DIATHRIVE+ GLUCOSE MONITOR...........................19DIATHRIVE+ GLUCOSE TEST...................................19diazepam............................ 12DICLOFENAC.......................6diclofenac sodium................. 6dicyclomine hcl................... 24DIFFERIN........................... 17DIFICID.................................7digoxin................................ 14DILANTIN............................. 8DILANTIN INFATABS...........8DILAUDID............................. 6diltiazem hcl er coated beads.................................. 14dilt-xr................................... 14

DIOVAN.............................. 14DIOVAN HCT......................14DIPENTUM......................... 29diphenoxylate-atropine....... 24divalproex sodium.................8divalproex sodium er.............8DIVIGEL..............................26donepezil hcl.........................9DORYX................................. 7DORYX MPC........................ 7dorzolamide hcl-timolol mal 30dotti ..................................... 26DOVATO.............................12doxazosin mesylate............ 14doxepin hcl............................9doxycycline hyclate...............7DOXYCYCLINE HYCLATE.. 7doxycycline monohydrate..... 8drospirenone-ethinyl estradiol.............................. 26DUAKLIR PRESSAIR......... 32DUAVEE............................. 26DUEXIS................................ 6DULERA............................. 32duloxetine hcl........................9DUOBRII.............................17DUPIXENT..........................17DURAGESIC-100................. 6DURAGESIC-12................... 6DURAGESIC-25................... 6DURAGESIC-50................... 6DURAGESIC-75................... 6DUROLANE........................29dutasteride.......................... 25DYMISTA............................31EASY TRAK II BLOOD GLUCOSE SYS.................. 19EASY TRAK II CONTROL.. 20EASY TRAK II GLUCOSE TEST...................................20EASYMAX 15 LEVEL 2-3 CONTROL.......................... 20EASYMAX CONTROL........20EASYMAX CONTROL NORMAL/HIGH.................. 20EDARBI.............................. 14EDARBYCLOR................... 14EFFEXOR XR.......................9ELESTRIN.......................... 26eletriptan hydrobromide...... 10ELIDEL............................... 17ELIQUIS................................8ELOCTATE.........................13

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EMBRACE TALK BLOOD GLUCOSE.......................... 20EMBRACE TALK GLUCOSE CONTROL........20EMBRACE TALK GLUCOSE TEST................ 20EMBRACE TALK MONITORING SYSTEM.....20EMGALITY..........................10EMGALITY (300 MG DOSE)................................ 10EMVERM............................ 11enalapril maleate................ 14ENBRACE HR.................... 23ENBREL............................. 28ENBREL MINI.....................28ENBREL SURECLICK........28ENDARI.............................. 29ENDOMETRIN....................26enoxaparin sodium............... 8enskyce...............................26entecavir............................. 12ENTRESTO........................ 14EPCLUSA........................... 12EPIDIOLEX...........................8EPIDUO.............................. 17EPIDUO FORTE.................17epinephrine......................... 32EPIPEN 2-PAK................... 32EPIPEN JR 2-PAK..............32EPOGEN............................ 13ergocalciferol...................... 23ERLEADA........................... 10erythromycin....................... 30escitalopram oxalate.............9esomeprazole magnesium..23ESPEROCT........................ 13estarylla.............................. 26ESTRACE...........................26estradiol.............................. 26ESTROGEL........................ 26eszopiclone.........................33etodolac................................ 6EUCRISA............................17EUFLEXXA......................... 29euthyrox.............................. 27EVAMIST............................ 26EVEKEO............................. 15EVEKEO ODT.................... 15EVENCARE PROVIEW GLUCOSE TEST................ 20EXFORGE.......................... 14EXFORGE HCT..................14

EXONDYS 51..................... 24EXTAVIA.............................16ezetimibe............................ 14ezetimibe-simvastatin......... 14famotidine........................... 23FARXIGA............................ 18FASENRA...........................31FASENRA PEN.................. 31febuxostat........................... 10femynor...............................26fenofibrate...........................14fenofibrate micronized........ 14fenofibric acid......................14fentanyl................................. 6FENTANYL CITRATE...........6FENTORA.............................6FIASP................................. 22FIASP FLEXTOUCH...........22FIASP PENFILL..................22FINACEA............................ 17finasteride........................... 25FIORICET............................. 6FIORICET/CODEINE............6FIRAZYR............................ 28FIRDAPSE..........................29flecainide acetate................14FLECTOR............................. 6FLOMAX............................. 25FLOVENT DISKUS.............32FLOVENT HFA................... 32fluconazole..........................10fluocinonide.........................17FLUOROPLEX....................17fluoxetine hcl.........................9fluticasone propionate.........31fluticasone-salmeterol.........32fluvoxamine maleate.............9FOCALIN............................ 15FOCALIN XR...................... 15folic acid..............................23FORA 6 CONNECT............ 20FORA GTEL BLOOD GLUCOSE SYSTEM.......... 20FORA GTEL BLOOD GLUCOSE TEST................ 20FORFIVO XL........................ 9FORTAMET........................ 18FORTEO.............................29FORTESTA.........................25FORTISCARE CONTROL.. 20FORTISCARE GLUCOSE SYSTEM............................. 20

FORTISCARE T1 GLUCOSE SYSTEM.......... 20FREESTYLE FREEDOM LITE.................................... 20FREESTYLE INSULINX SYSTEM............................. 20FREESTYLE INSULINX TEST...................................20FREESTYLE LIBRE 14 DAY READER.................... 20FREESTYLE LIBRE 14 DAY SENSOR.................... 20FREESTYLE LIBRE 2 READER SYSTM............... 20FREESTYLE LIBRE 2 SENSOR SYSTM............... 20FREESTYLE LIBRE READER.............................20FREESTYLE LIBRE SENSOR SYSTEM.............20FREESTYLE LITE TEST.... 20FREESTYLE PRECISION NEO TEST..........................20FREESTYLE TEST.............20FULPHILA...........................13furosemide.......................... 14FYCOMPA............................ 8gabapentin............................ 8gavilyte-g............................ 24GEL-ONE............................29GELSYN-3.......................... 29gemfibrozil .......................... 14GENERESS FE.................. 26GENOTROPIN....................26GENOTROPIN MINIQUICK.........................26GENVISC 850.....................29GENVOYA.......................... 12gianvi.................................. 26GILENYA............................ 16glatiramer acetate............... 16GLEEVEC...........................10glimepiride.......................... 18glipizide er...........................18glipizide ir............................18GLOPERBA........................ 10GLUCAGON EMERGENCY KIT.............. 21GLUCOCARD 01 SENSOR PLUS.................. 20GLUCOCARD EXPRESSION TEST.......... 20

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GLUCOCARD SHINE CONNEX............................ 20GLUCOCARD SHINE EXPRESS...........................20GLUCOCARD SHINE TEST...................................20GLUCOCARD VITAL TEST...................................20GLUMETZA........................ 18glyburide............................. 18glycopyrrolate..................... 24GLYXAMBI......................... 18GOCOVRI...........................11GOJJI BLOOD GLUCOSE TEST...................................20GOJJI BLOOD TEST STRIP/LANCETS................20GOJJI CONTROL............... 20GOLYTELY.........................24GONAL-F............................26GONAL-F RFF....................26GONAL-F RFF REDIJECT. 26GRANIX.............................. 13guanfacine hcl.....................14guanfacine hcl er................ 15GVOKE PFS....................... 21GYNAZOLE-1..................... 10HAEGARDA........................28HALOBETASOL PROPIONATE.................... 17HALOG............................... 17HARMONY BLOOD GLUCOSE TEST................ 20HARVONI........................... 12HEMANGEOL.....................14HERZUMA.......................... 10HORIZANT......................... 16HUMALOG KWIKPEN........ 22HUMALOG MIX 50/50 KWIKPEN........................... 22HUMALOG MIX 50/50 VIAL.................................... 22HUMALOG MIX 75/25 KWIKPEN........................... 22HUMALOG MIX 75/25 VIAL.................................... 22HUMALOG U-100 JUNIOR KWIKPEN........................... 22HUMALOG VIAL.................22HUMATROPE.....................26HUMIRA..............................28HUMIRA PEDIATRIC CROHNS START............... 28

HUMIRA PEN..................... 28HUMIRA PEN-CD/UC/HS STARTER........................... 28HUMIRA PEN-PS/UV/ADOL HS START... 28HUMULIN 70/30 KWIKPEN........................... 22HUMULIN 70/30 VIAL.........22HUMULIN N KWIKPEN...... 22HUMULIN N VIAL............... 22HUMULIN R U-500 KWIKPEN........................... 22HUMULIN R U-500 VIAL.... 22HUMULIN R VIAL............... 22HW EMBRACE PRO GLUCOSE METER.............20HW EMBRACE PRO GLUCOSE TEST................ 20HW EMBRACE TALK BLOOD GLUCOSE.............20HW EMBRACE TALK GLUCOSE TEST................ 20HYALGAN...........................29hydralazine hcl....................14hydrochlorothiazide.............14hydrocodone polst-chlorphen polst er susp.......31hydrocodone-acetaminophen..................... 6hydrocortisone.............. 17, 25hydromorphone hcl............... 6hydroxychloroquine sulfate. 11hydroxyzine hcl................... 12hydroxyzine pamoate..........12HYMOVIS........................... 29hyoscyamine sulfate........... 24hyoscyamine sulfate sl........24HYSINGLA ER......................6HYZAAR............................. 14ibandronate sodium............ 29IBRANCE............................10ibuprofen...............................6IDHIFA................................ 10ILEVRO...............................30imatinib mesylate................ 11IMBRUVICA........................11IMIQUIMOD PUMP.............17IMITREX............................. 10IMITREX STATDOSE REFILL................................10IMITREX STATDOSE SYSTEM............................. 10IMPOYZ.............................. 17

IMVEXXY MAINTENANCE PACK.................................. 26IMVEXXY STARTER PACK.................................. 26INBRIJA.............................. 11INCRUSE ELLIPTA............ 32INDERAL LA.......................14INDERAL XL.......................14indomethacin........................ 6INFINITY BLOOD GLUCOSE TEST................ 20INFLECTRA........................28INNOPRAN XL................... 14INSULIN ASP PROT & ASP FLEXPEN................... 22INSULIN ASPART.............. 22INSULIN ASPART FLEXPEN........................... 22INSULIN ASPART PENFILL............................. 22INSULIN ASPART PROT & ASPART.......................... 22INSULIN LISPRO............... 22INSULIN LISPRO (1 UNIT DIAL)...................................22INSULIN LISPRO JUNIOR KWIKPEN........................... 22INSULIN LISPRO PROT & LISPRO...............................22INTUNIV............................. 15INVEGA SUSTENNA..........11INVEGA TRINZA................ 11INVELTYS.......................... 30INVOKAMET.......................18INVOKAMET XR.................18INVOKANA......................... 18ipratropium bromide............31ipratropium-albuterol...........32irbesartan............................14irbesartan-hydrochlorothiazide.............14isibloom...............................26isosorbide mononitrate er... 14ISTURISA........................... 26JANUMET...........................18JANUMET XR.....................18JANUVIA.............................18JARDIANCE....................... 18JATENZO........................... 25JENTADUETO....................18JENTADUETO XR..............18JIVI......................................13JORNAY PM.......................15

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JUBLIA................................10JULUCA..............................12junel 1.5/30......................... 27junel 1/20............................ 27junel fe 1.5/30..................... 27junel fe 1/20........................ 27junel fe 24........................... 27KANJINTI............................11KAPSPARGO SPRINKLE.. 14kariva.................................. 27KATERZIA.......................... 14KAZANO............................. 18KENALOG.................... 17, 25KEPPRA............................... 8KEPPRA XR......................... 8KERYDIN............................10ketoconazole.......................10KETOROLAC TROMETHAMINE.................7ketorolac tromethamine.. 7, 30KITABIS PAK......................33KLONOPIN......................... 12klor-con m20....................... 23KOMBIGLYZE XR.............. 18KROGER HEALTHPRO GLUCOSE TEST................ 20K-TAB................................. 23kurvelo................................ 27labetalol hcl.........................14lactulose..............................24LAMICTAL............................ 8LAMICTAL ODT....................8LAMICTAL STARTER.......... 8LAMICTAL XR...................... 8lamotrigine............................ 8lamotrigine er........................ 8lansoprazole....................... 23LANTUS SOLOSTAR......... 22LANTUS U-100 VIAL.......... 22larin fe 1/20......................... 27larissia.................................27LASIX..................................14latanoprost.......................... 30LATISSE............................. 30LATUDA..............................11LAZANDA............................. 6LEDIPASVIR-SOFOSBUVIR.................... 12leflunomide......................... 28LESCOL XL........................ 14lessina.................................27LETAIRIS............................33letrozole.............................. 11

LEVALBUTEROL HFA....... 32LEVEMIR U-100 FLEXTOUCH...................... 22LEVEMIR U-100 VIAL........ 22levetiracetam........................ 8LEVITRA.............................24levocetirizine dihydrochloride................... 31levofloxacin........................... 8levonorgest-eth est & eth est....................................... 27levonorgest-eth estrad 91-day...................................... 27levonorgestrel-ethinyl estrad..................................27LEVOTHYROXINE SODIUM............................. 27levothyroxine sodium.......... 27levoxyl.................................28LEXAPRO.............................9LEXETTE............................17LIALDA............................... 29lidocaine................................7lidocaine viscous hcl........... 16lidocaine-prilocaine............... 7LIDODERM...........................7LINZESS.............................24liothyronine sodium.............28LIPITOR..............................14lisinopril ...............................14lisinopril-hydrochlorothiazide.............14lithium carbonate................ 12lithium carbonate er............ 12LIVALO............................... 14LO LOESTRIN FE.............. 27LOESTRIN 1.5/30 (21)....... 27LOESTRIN 1/20 (21).......... 27LOESTRIN FE 1.5/30......... 27LOESTRIN FE 1/20............ 27LOKELMA...........................23LONHALA MAGNAIR REFILL KIT......................... 32LONHALA MAGNAIR STARTER KIT.................... 32lorazepam........................... 12LORZONE.......................... 33losartan potassium..............14losartan potassium-hctz......14LOTEMAX...........................30LOTEMAX SM.................... 30LOTREL..............................14lovastatin.............................14

LOVAZA..............................14low-ogestrel........................ 27LUMIGAN........................... 30LUNESTA........................... 33LUPRON DEPOT (1-MONTH)............................. 26LUPRON DEPOT (3-MONTH)............................. 26LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG.................................. 26LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG.................................. 26LYNPARZA.........................11LYRICA...............................16MAKENA.............................27MAVENCLAD (10 TABS)....16MAVENCLAD (4 TABS)......16MAVENCLAD (5 TABS)......16MAVENCLAD (6 TABS)......16MAVENCLAD (7 TABS)......16MAVENCLAD (8 TABS)......16MAVENCLAD (9 TABS)......16MAVYRET.......................... 12MAXALT............................. 10MAXALT-MLT..................... 10MAYZENT...........................16meclizine hcl......................... 9medroxyprogesterone acetate................................ 27meloxicam.............................7memantine hcl...................... 9mesalamine........................ 29metaxalone......................... 33metformin hcl er.................. 18metformin hcl er (mod)........18metformin hcl er (osm)........18metformin hcl ir ................... 18methimazole....................... 28methocarbamol................... 33methotrexate.......................28methotrexate sodium.......... 28methylphenidate hcl............15methylphenidate hcl er........15methylphenidate hcl er (la). 15methylphenidate hcl er (xr). 15methylprednisolone.............25metoclopramide hcl...............9metoprolol succinate er.......14metoprolol tartrate...............14

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METROGEL........................17metronidazole................. 8, 17MICARDIS.......................... 14MICARDIS HCT..................14MICRODOT TEST.............. 20microgestin fe 1/20............. 27MINASTRIN 24 FE............. 27minocycline hcl..................... 8MINOLIRA............................ 8mirtazapine........................... 9MIRVASO........................... 17MITIGARE.......................... 10MOBIC.................................. 7modafinil ............................. 33mometasone furoate.....17, 31mono-linyah........................ 27MONOVISC........................ 29montelukast sodium............32morphine sulfate er............... 6MOTEGRITY...................... 24MOTOFEN..........................24MOVANTIK......................... 24MOVIPREP.........................24MOXEZA.............................30moxifloxacin hcl.................. 30moxifloxacin hcl (2x day).... 30MS CONTIN..........................6MULPLETA.........................13MULTAQ.............................14multivitamin/fluoride............ 23mupirocin.............................. 8MVASI.................................11mycophenolate mofetil ........28mycophenolate sodium.......28MYRBETRIQ...................... 25nabumetone..........................7nadolol................................ 14NALFON............................... 7naltrexone hcl....................... 7NAMZARIC........................... 9NAPRELAN.......................... 7naproxen...............................7NARCAN...............................7NASCOBAL........................ 23NASONEX.......................... 31NATAZIA.............................27NATESTO...........................25NATROBA.......................... 11NATURE-THROID.............. 28NAYZILAM............................8neomycin-polymyxin-hc...... 31NESINA.............................. 18NESTABS ONE.................. 23

NEULASTA.........................13NEULASTA ONPRO...........13NEUPOGEN....................... 13NEURONTIN........................ 8NEVANAC.......................... 30NEXIUM..............................23NEXLETOL......................... 14NEXLIZET...........................14NIASPAN............................ 14nifedipine er........................ 14nifedipine er osmotic release................................ 14nikki.....................................27nitrofurantoin macrocrystal... 8nitrofurantoin monohydrate macrocrystals........................8nitroglycerin........................ 14NITROSTAT....................... 14NITYR................................. 24NIVESTYM......................... 13NOCDURNA....................... 26norethindrone......................27norethindrone acetate.........27norethindrone acet-ethinyl est....................................... 27NORGESIC FORTE........... 33norgestimate-ethinyl estradiol triphasic................27NORITATE..........................17nortrel 1/35 (21).................. 27nortrel 1/35 (28).................. 27nortriptyline hcl......................9NORVASC.......................... 14NOURIANZ......................... 11NOVOEIGHT...................... 13NOVOFINE AUTOCOVER PEN NEEDLE..................... 22NOVOFINE PEN NEEDLE. 22NOVOFINE PLUS PEN NEEDLE............................. 22NOVOLIN 70/30 FLEXPEN 22NOVOLIN 70/30 FLEXPEN RELION.............................. 22NOVOLIN 70/30 RELION... 22NOVOLIN 70/30 VIAL.........22NOVOLIN N FLEXPEN.......22NOVOLIN N FLEXPEN RELION.............................. 22NOVOLIN N RELION..........22NOVOLIN N VIAL............... 22NOVOLIN R FLEXPEN.......22NOVOLIN R FLEXPEN RELION.............................. 22

NOVOLIN R RELION..........22NOVOLIN R VIAL............... 22NOVOLOG FLEXPEN........ 22NOVOLOG MIX 70/30 FLEXPEN........................... 22NOVOLOG MIX 70/30 VIAL.................................... 22NOVOLOG PENFILL.......... 22NOVOLOG U-100 VIAL...... 22NOVOTWIST PEN NEEDLE............................. 22np thyroid............................ 28NUBEQA.............................11NUCALA............................. 31NUCYNTA............................ 6NUCYNTA ER...................... 6NULYTELY LEMON-LIME..24NULYTELY WITH FLAVOR PACKS................ 24NURTEC.............................10NUVARING.........................27NUVIGIL............................. 33NUWIQ............................... 13NUZYRA............................... 8nystatin............................... 10ODEFSEY...........................12ofloxacin........................30, 31OGIVRI............................... 11olanzapine.......................... 11olmesartan medoxomil........14olmesartan medoxomil-hctz..................................... 14olmesartan-amlodipine-hctz..................................... 14olopatadine hcl....................30OLUMIANT......................... 28OMECLAMOX-PAK............ 24omega-3-acid ethyl esters.. 14omeprazole......................... 23omeprazole-sodium bicarbonate......................... 23OMNARIS........................... 31OMNITROPE...................... 26ondansetron hcl.................... 9ondansetron odt....................9ONE DROP BLOOD GLUCOSE MONITOR........ 21ONE DROP TEST.............. 21ONETOUCH ULTRA.......... 21ONETOUCH ULTRA 2 KIT W/DEVICE.......................... 21ONETOUCH ULTRA MINI KIT W/DEVICE................... 21

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ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE....21ONETOUCH VERIO IQ SYSTEM............................. 21ONETOUCH VERIO KIT W/DEVICE.......................... 21ONETOUCH VERIO REFLECT........................... 21ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE.......................... 21ONEXTON.......................... 17ONFI..................................... 8ONGLYZA...........................18ONTRUZANT......................11ONZETRA XSAIL............... 10OPSUMIT........................... 33ORACEA.............................17ORENCIA........................... 28ORENCIA CLICKJECT.......28ORENITRAM...................... 33ORILISSA........................... 26ORPHENGESIC FORTE.... 33ORTHO MICRONOR..........27ORTHOVISC...................... 29oseltamivir phosphate.........12OSENI.................................18OSMOLEX ER.................... 11OSMOPREP....................... 24OSPHENA.......................... 25OTEZLA..............................28OXBRYTA...........................29oxcarbazepine...................... 8OXTELLAR XR..................... 8oxybutynin chloride............. 25oxybutynin chloride er.........25oxycodone hcl.......................6OXYCODONE HCL ER........ 6oxycodone-acetaminophen...6OXYCONTIN........................ 6OZEMPIC........................... 18OZOBAX.............................33PALFORZIA (12 MG DAILY DOSE)..................... 29PALFORZIA (120 MG DAILY DOSE)..................... 29PALFORZIA (160 MG DAILY DOSE)..................... 29PALFORZIA (20 MG DAILY DOSE)..................... 29PALFORZIA (200 MG DAILY DOSE)..................... 29

PALFORZIA (240 MG DAILY DOSE)..................... 29PALFORZIA (3 MG DAILY DOSE)................................ 29PALFORZIA (300 MG MAINTENANCE)................ 29PALFORZIA (300 MG TITRATION)........................29PALFORZIA (40 MG DAILY DOSE)..................... 29PALFORZIA (6 MG DAILY DOSE)................................ 29PALFORZIA (80 MG DAILY DOSE)..................... 30PALFORZIA INITIAL ESCALATION..................... 30PANCREAZE......................24PANDEL............................. 17pantoprazole sodium.......... 24PANZYGA...........................28paroxetine hcl....................... 9PAXIL....................................9PAXIL CR............................. 9penicillin v potassium............8PENNSAID........................... 7PENTASA........................... 29PERCOCET..........................6PERFOROMIST................. 32PERSERIS..........................11PERTZYE........................... 24phenazopyridine hcl............25pioglitazone hcl................... 18PLAQUENIL........................11PLAVIX............................... 11PLEGRIDY..........................16PLEGRIDY STARTER PACK.................................. 16PLENVU............................. 24polymyxin b-trimethoprim....30potassium chloride crys er.. 23potassium chloride er..........23potassium citrate er............ 23PRADAXA.............................8PRALUENT.........................14pramipexole dihydrochloride................... 11prasugrel hcl....................... 11PRAVACHOL......................15pravastatin sodium..............15prazosin hcl.........................15PRECISION LINK............... 21PRECISION PCX PLUS TEST...................................21

PRECISION QID MONITOR...........................21PRECISION QID TEST...... 21PRECISION SOF-TACT MONITOR...........................21PRECISION SOF-TACT TEST...................................21PRECISION XTRA............. 21PRECISION XTRA BLOOD GLUCOSE.............21PRECISION XTRA MONITOR...........................21PRED FORTE.....................30prednisolone....................... 25prednisolone acetate.......... 30prednisolone sodium phosphate........................... 25prednisone.......................... 25pregabalin........................... 16PREGENNA........................23PREMARIN.........................27PREMPHASE..................... 27PREMPRO..........................27PRENARA.......................... 23PRENATE...........................23PRENATE DHA.................. 23PRENATE ELITE................23PRENATE ENHANCE........ 23PRENATE ESSENTIAL...... 23PRENATE MINI.................. 23PRENATE PIXIE.................23PRENATE RESTORE........ 23PRENATVITE COMPLETE 23PREVACID......................... 24PREVACID SOLUTAB........24PREZCOBIX....................... 12PRIMACARE...................... 23PRINIVIL.............................15PRISTIQ............................... 9PROAIR DIGIHALER..........32PROAIR HFA......................32PROAIR RESPICLICK........32prochlorperazine maleate... 10PROCRIT............................13PROCTOFOAM HC............29PRODIGY NO CODING BLOOD GLUC.................... 21progesterone micronized.... 27PROGRAF.......................... 28PROLENSA........................ 30PROLIA...............................29promethazine hcl................ 31promethazine-codeine........ 31

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promethazine-dm................31PROMETRIUM................... 27PROPECIA......................... 17propranolol hcl.................... 15propranolol hcl er................ 15PROTONIX......................... 24PROVENTIL HFA............... 32PROVIGIL...........................33PROZAC...............................9pseudoephedrine-bromphen-dm..................... 31PSORCON..........................17PULMICORT FLEXHALER.32PULMICORT SUSPENSION.................... 32PULMOZYME..................... 33PYLERA..............................24QBREXZA...........................17QMIIZ ODT........................... 7QNASL................................31QNASL CHILDRENS..........31QTERN............................... 18QUDEXY XR.........................8QUESTRAN........................15QUESTRAN LIGHT............ 15quetiapine fumarate............ 11quetiapine fumarate er........11QVAR REDIHALER............ 32RABEPRAZOLE SODIUM..24rabeprazole sodium............ 24ramipril ................................ 15RANEXA............................. 15ranolazine er....................... 15RASUVO.............................28RAYALDEE.........................29RAYOS............................... 25REBIF................................. 16REBIF REBIDOSE..............16REBIF REBIDOSE TITRATION PACK.............. 16REBIF TITRATION PACK.. 16RELAFEN............................. 7RELAFEN DS....................... 7RELION BLOOD GLUCOSE TEST................ 21RELION PREMIER CLASSIC............................ 21RELION PREMIER TEST...21RELION ULTIMA TEST...... 21RELISTOR..........................24RELPAX..............................10REMICADE.........................28REMODULIN...................... 33

RENAGEL...........................25RENFLEXIS........................28REPATHA...........................15REPATHA PUSHTRONEX SYSTEM............................. 15REPATHA SURECLICK..... 15RESTASIS.......................... 31RESTASIS MULTIDOSE.... 31RESTORIL..........................33RETACRIT..........................13RETIN-A............................. 17RETIN-A MICRO GEL 0.04 %, 0.1 %............................. 17RETIN-A MICRO PUMP...................................... 17, 18REVLIMID...........................11REXULTI.............................11REYVOW............................10RHOFADE.......................... 18RHOPRESSA..................... 30RINVOQ..............................28RISPERDAL....................... 11risperidone.......................... 11RITALIN.............................. 16RITALIN LA.........................16rizatriptan benzoate............ 10ROCKLATAN......................30ropinirole hcl....................... 11rosuvastatin calcium........... 15ROXICODONE..................... 6RUBRACA.......................... 11RUCONEST........................28RUXIENCE......................... 11RYBELSUS.........................18RYTARY............................. 11SABRIL................................. 8SAFYRAL........................... 27SAIZEN...............................26SAIZENPREP..................... 26SANCUSO.......................... 10SANDOSTATIN.................. 26SAPHRIS............................ 11scopolamine........................10SEASONIQUE.................... 27SECUADO.................... 11, 12SEEBRI NEOHALER..........32SEGLUROMET...................18SENSIPAR..........................29SEREVENT DISKUS.......... 32SERNIVO............................18SEROQUEL........................12SEROQUEL XR..................12sertraline hcl......................... 9

SEYSARA.............................8sildenafil citrate............. 25, 33SILENOR............................ 33SILVADENE..........................8SIMBRINZA........................ 30SIMPONI.............................28SIMPONI ARIA................... 28simvastatin..........................15SINGULAIR........................ 32sirolimus..............................28SKELAXIN.......................... 33SKYRIZI (150 MG DOSE).. 29SLYND................................27sodium fluoride................... 23SODIUM HYALURONATE. 30SOFOSBUVIR-VELPATASVIR................... 12solifenacin succinate...........25SOLIQUA............................18SOLODYN............................ 8SOLOSEC............................ 8SOMA................................. 33SOOLANTRA......................18SORILUX............................ 18sotalol hcl............................15SPIRIVA HANDIHALER..... 32SPIRIVA RESPIMAT.......... 32spironolactone.................... 15sprintec 28.......................... 27SPRIX................................... 7SPRYCEL........................... 11sronyx................................. 27STAXYN............................. 25STEGLATRO...................... 18STEGLUJAN.......................18STELARA........................... 29STENDRA...........................25STIOLTO RESPIMAT......... 32STRATTERA...................... 16STRENSIQ......................... 24STRIVERDI RESPIMAT..... 32SUBOXONE......................... 7SUBSYS............................... 6sucralfate............................ 24sulfamethoxazole-trimethoprim..........................8sulfasalazine....................... 29sumatriptan succinate.........10SUNOSI.............................. 33SUPARTZ FX..................... 30SUPREP BOWEL PREP KIT...................................... 24

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SURESTEP PRO HIGH GLUCOSE.......................... 21SURESTEP PRO LOW GLUCOSE.......................... 21SURESTEP PRO NORMAL GLUCOSE..........21syeda.................................. 27SYMBICORT...................... 32SYMFI.................................12SYMFI LO........................... 12SYMJEPI............................ 32SYMLINPEN 120................ 19SYMLINPEN 60.................. 19SYMPAZAN.......................... 8SYMPROIC.........................24SYNJARDY.........................19SYNJARDY XR...................19SYNTHROID.......................28SYNVISC............................ 30SYNVISC ONE................... 30TABRECTA.........................11TACLONEX........................ 18tacrolimus..................... 18, 29tadalafil ............................... 25TAKHZYRO........................ 29TALTZ.................................29TAMIFLU............................ 12tamoxifen citrate................. 11tamsulosin hcl..................... 25TARGADOX..........................8TARGRETIN....................... 11TAYTULLA..........................27TAZORAC...........................18TAZVERIK.......................... 11TECFIDERA....................... 16TEGRETOL.......................... 8TEGRETOL-XR.................... 8TEGSEDI............................ 16TEKTURNA........................ 15TEKTURNA HCT................ 15telmisartan.......................... 15telmisartan-hctz.................. 15temazepam......................... 33TEMIXYS............................ 12temozolomide..................... 11TENORMIN.........................15terazosin hcl........................25terbinafine hcl..................... 10terconazole......................... 10TESTIM...............................25TESTOPEL......................... 25testosterone........................ 25testosterone cypionate........25

TIGLUTIK............................16TIKOSYN............................ 15timolol maleate....................30TIMOPTIC...........................30TIMOPTIC OCUDOSE....... 30TIMOPTIC-XE.....................30TIROSINT........................... 28TIROSINT-SOL...................28TIVICAY..............................12tizanidine hcl....................... 33TOBI NEBULIZER.............. 33TOBI PODHALER...............33TOBRADEX........................ 31TOBRAMYCIN....................33tobramycin-dexamethasone.................. 31TOLSURA...........................10tolterodine tartrate er.......... 25TOPAMAX............................ 9TOPAMAX SPRINKLE......... 9TOPICORT SPRAY............ 18topiramate.............................9TOPROL XL........................15torsemide............................ 15TOSYMRA.......................... 10TOUJEO MAX SOLOSTAR........................ 23TOUJEO SOLOSTAR.........23TOVIAZ...............................25TRACLEER.........................33TRADJENTA.......................19tramadol hcl ir ....................... 6TRAZIMERA....................... 11trazodone hcl........................ 9TREANDA...........................11TRELEGY ELLIPTA............32TREMFYA...........................29TRESIBA............................ 23TRESIBA FLEXTOUCH......23tretinoin............................... 18TREXIMET..........................10TREZIX................................. 6tri femynor...........................27triamcinolone acetonide......18triamterene-hctz..................15TRIANEX............................ 18triazolam............................. 12TRIBENZOR....................... 15TRICOR.............................. 15TRIJARDY XR.................... 19TRIKAFTA.......................... 33TRILEPTAL...........................9tri-lo-marzia.........................27

tri-lo-sprintec....................... 27TRILURON......................... 30TRINAZ...............................23TRINTELLIX......................... 9tri-previfem..........................27tri-sprintec........................... 27TRISTART ONE................. 23TRIUMEQ........................... 12TRIVISC..............................30TROKENDI XR..................... 9TRUE FOCUS BLOOD GLUCOSE METER.............21TRUE METRIX BLOOD GLUCOSE TEST................ 21TRUE METRIX PRO BLOOD GLUCOSE.............21TRULANCE........................ 24TRULICITY......................... 19TRUVADA...........................12TRUXIMA............................11TUDORZA PRESSAIR....... 32TWIRLA.............................. 27TYMLOS............................. 29UBRELVY........................... 10UCERIS.............................. 29UDENYCA.......................... 13ULTOMIRIS........................ 13ULTRACET...........................6ULTRAM............................... 6ULTRAVATE.......................18UNISTRIP CONTROL........ 21UTIBRON NEOHALER.......32VAGIFEM............................27valacyclovir hcl....................12VALIUM.............................. 12valsartan............................. 15valsartan-hydrochlorothiazide.............15VALTOCO 10 MG DOSE......9VALTOCO 15 MG DOSE......9VALTOCO 20 MG DOSE......9VALTOCO 5 MG DOSE........9VALTREX........................... 12VANADOM..........................33VARUBI (180 MG DOSE)... 10VASCEPA...........................15VECTICAL.......................... 18VELPHORO........................25VELTASSA......................... 23VELTIN............................... 18VEMLIDY............................ 12venlafaxine hcl...................... 9venlafaxine hcl er..................9

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VENTOLIN HFA..................32verapamil hcl er.................. 15VERDESO.......................... 18VESICARE..........................25VIAGRA.............................. 25VIBERZI..............................24VICTOZA............................ 19vienva................................. 27VIGAMOX........................... 30VIIBRYD............................... 9VIIBRYD STARTER PACK...9VIMOVO............................... 7VIMPAT................................ 9VIOKACE............................24viorele................................. 27VISCO-3............................. 30VITAFOL FE+..................... 23VITAFOL-OB+DHA.............23vitamin d (ergocalciferol).....23VITATHELY WITH GINGER..............................23VIVAGUARD INO CONTROL SOLUTION.......21VIVAGUARD INO GLUCOSE METER.............21VIVAGUARD INO TEST STRIPS...............................21VIVELLE-DOT.................... 27VOGELXO.......................... 25VOGELXO PUMP...............25VOLTAREN.......................... 7VOSEVI.............................. 12VRAYLAR........................... 12VUMERITY......................... 16VYLEESI.............................16VYONDYS 53..................... 24VYTORIN............................15VYVANSE...........................16VYZULTA............................30WAKIX................................ 33warfarin sodium.................... 8WELCHOL.......................... 15WELLBUTRIN SR.................9WELLBUTRIN XL................. 9WESTGEL DHA..................23wixela inhub........................ 32XALATAN........................... 30XANAX................................12XANAX XR..........................12XARELTO............................. 8XARELTO STARTER PACK.................................... 8XCOPRI................................ 9

XCOPRI (250 MG DAILY DOSE).................................. 9XCOPRI (350 MG DAILY DOSE).................................. 9XELJANZ............................ 29XELJANZ XR...................... 29XEMBIFY............................ 29XENLETA............................. 8XEPI......................................8XHANCE.............................31XIGDUO XR........................19XIIDRA................................31XIMINO................................. 8XOFLUZA (40 MG DOSE)..12XOFLUZA (80 MG DOSE)..12XOLAIR...............................31XOPENEX HFA.................. 32XTAMPZA ER.......................6XTANDI...............................11XYOSTED...........................25XYREM............................... 33YASMIN 28......................... 27YAZ.....................................27YONSA............................... 11YOSPRALA........................ 11YUPELRI............................ 32ZALVIT................................23ZANAFLEX......................... 33ZARXIO.............................. 13ZEGERID............................24ZEJULA.............................. 11ZELNORM.......................... 24ZEMBRACE SYMTOUCH.. 10ZENPEP............................. 24ZERVIATE.......................... 30ZESTRIL............................. 15ZETIA..................................15ZETONNA...........................31ZIANA................................. 18ZIEXTENZO........................13ZIOPTAN............................ 30ziprasidone hcl....................12ZIPSOR................................ 7ZIRABEV............................ 11ZOCOR...............................15ZOHYDRO ER......................6ZOLOFT................................9zolpidem tartrate................. 33zolpidem tartrate er.............33ZOMACTON....................... 26ZOMACTON (FOR ZOMA-JET 10)............................... 26ZOMIG................................ 10

ZOMIG ZMT........................10ZONEGRAN......................... 9zonisamide............................9ZORVOLEX.......................... 7ZOVIRAX............................ 12ZTLIDO................................. 7ZUBSOLV............................. 7ZYCLARA........................... 18ZYCLARA PUMP................18ZYPITAMAG....................... 15ZYPREXA........................... 12ZYTIGA...............................11

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Nondiscrimination notice and access to communication services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

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If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

mailto:Optum_Civil_Rights%40Optum.com?subject=

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

Multi-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

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CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ

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ស់អ្នក។

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DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih.

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