2020 comprehensive formulary august...taking a drug on our 2020 formulary that was covered at the...

2020 Comprehensive Formulary (List of Covered Drugs)UMHA DUAL (HMO-SNP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Formulary File Submission ID: 20344, 13

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact us at 1-844-789-6762, for TTY users, 711, 24 hours a day, 7 days a week, or visit www.UMMedicareAdvantage.org.

H8854_20_DRS_2019_OE_C DRS: 08/30/2019

H8854_20_DRS_2019_OE_C DRS: 08/30/2019

University of Maryland Health Advantage Dual Prime (HMO SNP)

2020 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID: 20344, 13 This formulary was updated on 08/01/2020. For a complete listing or other questions, please contact us at 1-844-786-6762 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit www.UMMedicareAdvantage.org Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means University of Maryland Health Advantage Dual Prime (HMO SNP). When it refers to “plan” or “our plan,” it means UMHA Dual Prime (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 08/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

http://www.ummedicareadvantage.org/

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What is the University of Maryland Health Advantage Formulary? A formulary is a list of covered drugs selected by University of Maryland Health Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. University of Maryland Health Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a University of Maryland Health Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the University of Maryland Health Advantage Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

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o If we make these other changes, you or your prescriber can ask us to make an

exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the University of Maryland Health Advantage’s Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of 08/01/2020. To get updated information about the drugs covered by University of Maryland Health Advantage, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page number 8. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 63. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? University of Maryland Health Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage?

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Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: University of Maryland Health Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from University of Maryland Health Advantage before you fill your prescriptions. If you don’t get approval, University of Maryland Health Advantage may not cover the drug.

• Quantity Limits: For certain drugs, University of Maryland Health Advantage limits the

amount of the drug that University of Maryland Health Advantage will cover. For example, University of Maryland Health Advantage provides 30 tablets per day per prescription for Januvia. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, University of Maryland Health Advantage requires you to

first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, University of Maryland Health Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, University of Maryland Health Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restriction. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask University of Maryland Health Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the University of Maryland Health Advantage’s formulary?” on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that University of Maryland Health Advantage does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by University of Maryland Health Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by University of Maryland Health Advantage.

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• You can ask University of Maryland Health Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the University of Maryland Health Advantage’s Formulary? You can ask University of Maryland Health Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for

certain drugs, University of Maryland Health Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, University of Maryland Health Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow

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refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90-days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90-days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. If you experience a change in your level of care (such as a move from a hospital to a home setting) and need a drug that is not on our formulary or your ability to get your drugs is limited, we may cover a one-time temporary supply. The temporary one-time supply must be for a 30-day supply (or a 31-day supply if you reside in a long-term care facility) unless your prescription is for a fewer day supply. You must have drug(s) filled at a network pharmacy. You should use the plan's exception process if you wish to have continued coverage of the drug after the temporary supply is finished. For more information For more detailed information about your University of Maryland Health Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about University of Maryland Health Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. University of Maryland Health Advantage’s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by University of Maryland Health Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 63. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADMELOG SOLOSTAR) and generic drugs are listed in lower-case italics (e.g., lamotrigine). The information in the Requirements/Limits column tells you if University of Maryland Health Advantage has any special requirements for coverage of your drug. The following abbreviations are used in the University of Maryland Health Advantage Formulary: B/D – Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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HR – High Risk Drug. According to medical experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available. LA – Limited Access. These prescriptions may be available only at certain pharmacies. For more information consult your Provider & Pharmacy Directory or call Member Services, at 1-844-786-6762, 24 hours a day, 7 days a week. TTY users please call 711. NM – No Mail Order. For certain drugs, you will not be able to use the CVS Mail Order Pharmacy. These are drugs that are generally not taken on a regular basis (chronic or long-term medical condition). PA – Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL – Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets every 30 days per prescription for Januvia. ST – Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition, before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. For generic drugs (including brand drugs treated as generic):

University of Maryland Health Advantage DUAL PRIME (HMO SNP)

Retail/Mail Order: 30-day Long-Term Care: 31-day Out of Network: 10-day

Based on your level of “extra help” you pay either: $0, $1.30, or $3.60 copay depending on your income and institutional status. Long-Term Care and Out-of-network 90-day supplies are not covered.

For all other drugs: University of Maryland Health Advantage DUAL PRIME (HMO SNP)

Retail/Mail Order: 90-day Long-Term Care: 31-day Out of Network: 10-day

Based on your level of “extra help” you pay either: $0, $3.90, or $8.95 copay depending on your income and institutional status. Long-Term Care and Out-of-network 90-day supplies are not covered.

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Comprehensive Formulary Drug Name Requirements/Limits ANALGESICS GOUT allopurinol tab colchicine w/ probenecid COLCRYS QL (120 tabs / 30 days) MITIGARE QL (60 caps / 30 days) probenecid NSAIDS celecoxib CAPS 50mg QL (240 caps / 30 days) celecoxib CAPS 100mg QL (120 caps / 30 days) celecoxib CAPS 200mg QL (60 caps / 30 days) celecoxib CAPS 400mg QL (30 caps / 30 days) diclofenac potassium QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC diflunisal TABS etodolac flurbiprofen TABS 100mg ibu tab 600mg ibu tab 800mg ibuprofen SUSP ibuprofen TABS 400mg, 600mg, 800mg meloxicam TABS nabumetone TABS naproxen TABS 250mg, 375mg, 500mg naproxen dr naproxen sodium TABS 275mg, 550mg piroxicam CAPS sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg QL (400 tabs / 30 days) acetaminophen w/ codeine 300-30mg QL (360 tabs / 30 days) acetaminophen w/ codeine 300-60mg QL (180 tabs / 30 days) acetaminophen w/ codeine soln QL (2700 mL / 30 days) butorphanol tartrate SOLN 1mg/ml, 2mg/ml nalbuphine hcl SOLN tramadol hcl tab 50 mg QL (240 tabs / 30 days) tramadol-acetaminophen QL (240 tabs / 30 days) OPIOID ANALGESICS, CII endocet 2.5-325mg QL (360 tabs / 30 days) endocet 5-325mg QL (360 tabs / 30 days) endocet 7.5-325mg QL (240 tabs / 30 days) endocet 10-325mg QL (180 tabs / 30 days)

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Drug Name Requirements/Limits fentanyl citrate LPOP QL (120 lozenges / 30

days), PA fentanyl patch 12 mcg/hr QL (10 patches / 30 days),

PA fentanyl patch 25 mcg/hr QL (10 patches / 30 days),




PA hydroco/apap tab 5-325mg QL (240 tabs / 30 days) hydroco/apap tab 7.5-325 QL (180 tabs / 30 days) hydroco/apap tab 10-325mg QL (180 tabs / 30 days) hydrocodone-acetaminophen 7.5-325 mg/15ml QL (2700 mL / 30 days) hydrocodone-ibuprofen tab 7.5-200 mg QL (150 tabs / 30 days) hydromorphone hcl LIQD QL (600 mL / 30 days) hydromorphone hcl SOLN 10mg/ml, 50mg/5ml,

500mg/50ml B/D

hydromorphone hcl TABS QL (180 tabs / 30 days) HYSINGLA ER QL (30 tabs / 30 days), PA lorcet hd tab 10-325mg QL (180 tabs / 30 days) lorcet plus tab 7.5-325 QL (180 tabs / 30 days) lorcet tab 5-325mg QL (240 tabs / 30 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (450 mL / 30 days), PA methadone hcl 5mg QL (90 tabs / 30 days), PA methadone hcl 10mg QL (90 tabs / 30 days), PA methadone hcl intensol QL (90 mL / 30 days), PA morphine ext-rel tab QL (90 tabs / 30 days), PA morphine sul inj 1mg/ml B/D MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml,

5mg/ml, 8mg/ml, 10mg/ml B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml B/D morphine sulfate TABS QL (180 tabs / 30 days) morphine sulfate oral soln 10mg/5ml QL (900 mL / 30 days) morphine sulfate oral soln 20mg/5ml QL (900 mL / 30 days) morphine sulfate oral soln 100mg/5ml QL (180 mL / 30 days) NUCYNTA ER QL (60 tabs / 30 days), PA oxycodone hcl CAPS QL (180 caps / 30 days) oxycodone hcl CONC QL (180 mL / 30 days) oxycodone hcl SOLN QL (900 mL / 30 days) oxycodone hcl TABS QL (180 tabs / 30 days) oxycodone w/ acetaminophen 2.5-325mg QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-325mg QL (360 tabs / 30 days)

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Drug Name Requirements/Limits oxycodone w/ acetaminophen 7.5-325mg QL (240 tabs / 30 days) oxycodone w/ acetaminophen 10-325mg QL (180 tabs / 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D lidocaine inj 0.5% B/D lidocaine inj 1% B/D lidocaine inj 1.5% preservative free (pf) B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR SULFADIAZINE TABS tobramycin NEBU NM, PA tobramycin inj 1.2 gm/30ml tobramycin inj 1.2gm tobramycin inj 10mg/ml tobramycin inj 80mg/2ml tobramycin sulfate SOLN ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS ALINIA atovaquone SUSP aztreonam CAYSTON NM, LA, PA clindamycin cap 75mg clindamycin cap 300 mg clindamycin hcl cap 150 mg clindamycin phosphate in d5w CLINDAMYCIN PHOSPHATE IN NACL clindamycin phosphate inj clindamycin soln 75mg/5ml colistimethate sodium SOLR dapsone TABS daptomycin EMVERM QL (12 tabs / 365 days) ertapenem sodium imipenem-cilastatin ivermectin TABS linezolid in sodium chloride

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Drug Name Requirements/Limits linezolid inj linezolid susp linezolid tab 600mg meropenem methenamine hippurate metronidazole TABS metronidazole in nacl nitrofurantoin macrocrystal 50mg, 100mg nitrofurantoin monohyd macro pentamidine isethionate inh B/D pentamidine isethionate inj praziquantel TABS SIVEXTRO sulfamethoxazole-trimethop ds sulfamethoxazole-trimethoprim inj sulfamethoxazole-trimethoprim susp sulfamethoxazole-trimethoprim tab 400-80mg SYNERCID tigecycline trimethoprim TABS vancomycin hcl CAPS 125mg QL (120 caps / 30 days) vancomycin hcl CAPS 250mg QL (240 caps / 30 days) vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg,

750mg

VANCOMYCIN IN NACL ANTIFUNGALS ABELCET B/D AMBISOME B/D amphotericin b SOLR B/D caspofungin acetate fluconazole SUSR; TABS fluconazole inj nacl 200 fluconazole inj nacl 400 flucytosine CAPS griseofulvin microsize griseofulvin ultramicrosize itraconazole CAPS PA ketoconazole TABS PA micafungin sodium MYCAMINE NOXAFIL SUSP QL (630 mL / 30 days) nystatin TABS posaconazole QL (93 tabs / 30 days) terbinafine hcl TABS QL (90 tabs / year)

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Drug Name Requirements/Limits voriconazole SOLR; SUSR PA voriconazole TABS ANTIMALARIALS atovaquone-proguanil hcl chloroquine phosphate TABS COARTEM mefloquine hcl primaquine phosphate 26.3mg PRIMAQUINE PHOSPHATE 26.3mg quinine sulfate CAPS PA ANTIRETROVIRAL AGENTS abacavir sulfate NM APTIVUS NM atazanavir sulfate NM CRIXIVAN NM didanosine NM EDURANT NM efavirenz NM EMTRIVA NM fosamprenavir tab 700 mg NM FUZEON NM INTELENCE NM INVIRASE NM ISENTRESS NM ISENTRESS HD NM lamivudine NM LEXIVA SUSP NM nevirapine susp 50 mg/5ml NM nevirapine tab 100mg er NM nevirapine tab 200mg NM nevirapine tab 400mg er NM NORVIR PACK NM NORVIR SOLN NM PIFELTRO NM PREZISTA SUSP QL (400 mL / 30 days), NM PREZISTA TABS 75mg QL (480 tabs / 30 days), NM PREZISTA TABS 150mg QL (240 tabs / 30 days), NM PREZISTA TABS 600mg QL (60 tabs / 30 days), NM PREZISTA TABS 800mg QL (30 tabs / 30 days), NM REYATAZ PACK NM ritonavir NM SELZENTRY NM stavudine NM tenofovir disoproxil fumarate NM

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Drug Name Requirements/Limits TIVICAY NM TROGARZO NM, LA TYBOST NM VIRACEPT NM VIREAD POWD NM VIREAD TABS 150mg, 200mg, 250mg NM zidovudine cap 100mg NM zidovudine syp 50mg/5ml NM zidovudine tab 300mg NM ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine NM abacavir sulfate-lamivudine-zidovudine NM ATRIPLA NM BIKTARVY NM CIMDUO NM COMPLERA NM DELSTRIGO NM DESCOVY NM DOVATO NM EVOTAZ NM GENVOYA NM JULUCA NM KALETRA TAB 100-25MG NM KALETRA TAB 200-50MG NM lamivudine-zidovudine NM lopinavir-ritonavir NM ODEFSEY NM PREZCOBIX NM STRIBILD NM SYMFI NM SYMFI LO NM SYMTUZA NM TEMIXYS NM TRIUMEQ NM TRUVADA TAB 100-150 QL (30 tabs / 30 days), NM TRUVADA TAB 133-200 QL (30 tabs / 30 days), NM TRUVADA TAB 167-250 QL (30 tabs / 30 days), NM TRUVADA TAB 200-300 QL (30 tabs / 30 days), NM ANTITUBERCULAR AGENTS cycloserine CAPS ethambutol hcl TABS isoniazid TABS isoniazid syp 50mg/5ml PASER D/R

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Drug Name Requirements/Limits PRIFTIN pyrazinamide TABS rifabutin rifampin CAPS; SOLR RIFATER SIRTURO 100mg LA, PA TRECATOR ANTIVIRALS acyclovir CAPS; SUSP; TABS acyclovir sodium B/D adefovir dipivoxil NM BARACLUDE SOLN NM entecavir NM EPCLUSA NM, PA EPIVIR HBV SOLN NM famciclovir TABS ganciclovir sodium B/D HARVONI NM, PA lamivudine (hbv) NM MAVYRET NM, PA oseltamivir phosphate CAPS 30mg QL (168 caps / year) oseltamivir phosphate CAPS 45mg, 75mg QL (84 caps / year) oseltamivir phosphate SUSR QL (1080 mL / year) PEGASYS NM, PA PEGASYS PROCLICK NM, PA RELENZA DISKHALER QL (6 inhalers / year) ribavirin cap 200mg NM ribavirin tab 200mg NM rimantadine hydrochloride valacyclovir hcl TABS valganciclovir hcl VEMLIDY NM VOSEVI NM, PA CEPHALOSPORINS cefaclor CEFACLOR ER TAB 500MG cefadroxil CEFAZOLIN IN DEXTROSE 2GM/100ML-4% cefazolin inj cefazolin sodium SOLR 1gm CEFAZOLIN SODIUM 1 GM/50ML cefdinir cefepime for inj cefixime SUSR

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Drug Name Requirements/Limits cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE ceftriaxone sodium SOLR 1gm, 2gm, 10gm,

250mg, 500mg

cefuroxime axetil cefuroxime sodium cephalexin CAPS 250mg, 500mg cephalexin SUSR tazicef SOLR TEFLARO ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR; TABS clarithromycin TABS clarithromycin er clarithromycin for susp DIFICID e.e.s. 400 ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate TABS erythromycin tab ec FLUOROQUINOLONES CIPRO SUSR 500mg/5ml ciprofloxacin hcl tab ciprofloxacin in d5w levofloxacin TABS levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml moxifloxacin hcl TABS PENICILLINS amoxicillin amoxicillin & pot clavulanate 200-28.5 chw tabs amoxicillin & pot clavulanate 200/5ml susr amoxicillin & pot clavulanate 250-125 tabs amoxicillin & pot clavulanate 250/5ml susr amoxicillin & pot clavulanate 400-57 chw tabs amoxicillin & pot clavulanate 400/5ml susr

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Drug Name Requirements/Limits amoxicillin & pot clavulanate 500-125 tabs amoxicillin & pot clavulanate 600/5ml susr amoxicillin & pot clavulanate 875-125 tabs amoxicillin & pot clavulanate er 12hr 1000-62.5

tabs

ampicillin & sulbactam sodium ampicillin cap 500mg ampicillin inj ampicillin sodium BICILLIN L-A dicloxacillin sodium nafcillin sodium for inj NAFCILLIN SODIUM FOR INJ 10GM oxacillin sodium SOLR PENICILLIN G POT IN DEXTROSE 2MU PENICILLIN G POT IN DEXTROSE 3MU PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium penicilln gk inj 5mu penicilln gk inj 20mu pfizerpen-g inj 5mu pfizerpen-g inj 20mu piper/tazoba inj 2-0.25gm piper/tazoba inj 3-0.375gm piper/tazoba inj 4-0.5gm piper/tazoba inj 12-1.5gm piper/tazoba inj 36-4.5gm TETRACYCLINES doxy 100 doxycycline (monohydrate) CAPS 50mg, 100mg doxycycline (monohydrate) TABS 50mg, 75mg,

100mg

doxycycline hyclate CAPS; SOLR doxycycline hyclate 20 mg doxycycline hyclate 100 mg minocycline hcl CAPS mondoxyne nl cap 100mg tetracycline hcl CAPS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA B/D, NM cyclophosphamide CAPS; SOLR B/D EMCYT

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Drug Name Requirements/Limits GLEOSTINE LEUKERAN ANTHRACYCLINES adriamycin SOLN B/D doxorubicin hcl B/D doxorubicin hcl liposomal B/D epirubicin hcl B/D ANTIMETABOLITES adrucil inj B/D ALIMTA B/D azacitidine B/D, NM cytarabine 20mg/ml B/D fluorouracil SOLN B/D gemcitabine inj soln B/D gemcitabine inj solr B/D mercaptopurine TABS methotrexate sodium inj soln B/D methotrexate sodium inj solr B/D PURIXAN NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE B/D docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml B/D DOCETAXEL CONC 80mg/4ml, 160mg/8ml,

200mg/10ml B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

B/D

paclitaxel B/D TAXOTERE B/D ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate B/D vinorelbine tartrate B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN NM, LA, PA BORTEZOMIB NM, PA DAURISMO NM, LA, PA ERIVEDGE NM, LA, PA FARYDAK NM, LA, PA HERCEPTIN NM, PA HERCEPTIN HYLECTA NM, PA HERZUMA NM, PA

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Drug Name Requirements/Limits IBRANCE CAPS QL (21 caps / 28 days), NM,

LA, PA IBRANCE TABS QL (21 tabs / 28 days), NM,

LA, PA IDHIFA QL (30 tabs / 30 days), NM,

LA, PA KADCYLA B/D, NM KANJINTI NM, PA KEYTRUDA NM, PA KISQALI NM, PA KISQALI FEMARA 200 DOSE NM, PA KISQALI FEMARA 400 DOSE NM, PA KISQALI FEMARA 600 DOSE NM, PA LYNPARZA NM, LA, PA MVASI NM, LA, PA NINLARO NM, PA ODOMZO NM, LA, PA OGIVRI NM, PA ONTRUZANT NM, PA RITUXAN NM, LA, PA RITUXAN HYCELA NM, LA, PA RUBRACA NM, LA, PA RUXIENCE NM, PA TALZENNA NM, LA, PA TECENTRIQ NM, LA, PA TIBSOVO NM, LA, PA TRAZIMERA NM, PA TRUXIMA NM, PA VELCADE NM, PA VENCLEXTA NM, LA, PA VENCLEXTA STARTING PACK NM, LA, PA VERZENIO NM, LA, PA ZEJULA NM, LA, PA ZIRABEV NM, PA ZOLINZA NM, PA HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate NM, PA anastrozole TABS bicalutamide DEPO-PROVERA INJ 400/ML B/D ERLEADA NM, LA, PA exemestane flutamide fulvestrant B/D letrozole TABS

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Drug Name Requirements/Limits leuprolide inj 1mg/0.2 NM, PA LUPRON DEPOT (1-MONTH) 3.75mg NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) NM, PA LYSODREN megestrol ac sus 40mg/ml megestrol ac tab 20mg megestrol ac tab 40mg megestrol sus 625mg/5ml PA nilutamide NUBEQA NM, LA, PA SOLTAMOX tamoxifen citrate TABS toremifene citrate TRELSTAR DEP INJ 3.75MG NM, PA TRELSTAR LA INJ 11.25MG NM, PA XTANDI NM, LA, PA ZYTIGA 500mg NM, LA, PA IMMUNOMODULATORS POMALYST 1mg, 2mg QL (21 caps / 21 days), NM,

LA, PA POMALYST 3mg, 4mg QL (21 caps / 28 days), NM,

LA, PA REVLIMID QL (28 caps / 28 days), NM,

LA, PA THALOMID 50mg, 100mg QL (28 caps / 28 days), NM,

PA THALOMID 150mg, 200mg QL (56 caps / 28 days), NM,

PA KINASE INHIBITORS AFINITOR 10mg QL (30 tabs / 30 days), NM,

PA AFINITOR DISPERZ 2mg QL (150 tabs / 30 days),

NM, PA AFINITOR DISPERZ 3mg QL (90 tabs / 30 days), NM,

PA AFINITOR DISPERZ 5mg QL (60 tabs / 30 days), NM,

PA ALECENSA NM, LA, PA ALUNBRIG NM, LA, PA AYVAKIT QL (30 tabs / 30 days), NM,

LA, PA BALVERSA NM, LA, PA BOSULIF NM, PA BRAFTOVI NM, LA, PA BRUKINSA NM, LA, PA

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Drug Name Requirements/Limits CABOMETYX QL (30 tabs / 30 days), NM,

LA, PA CALQUENCE NM, LA, PA CAPRELSA NM, LA, PA COMETRIQ NM, LA, PA COPIKTRA NM, LA, PA COTELLIC NM, LA, PA erlotinib hcl 25mg QL (90 tabs / 30 days), NM,

PA erlotinib hcl 100mg, 150mg QL (30 tabs / 30 days), NM,

PA everolimus QL (30 tabs / 30 days), NM,

PA GILOTRIF TAB 20MG NM, LA, PA GILOTRIF TAB 30MG NM, LA, PA GILOTRIF TAB 40MG NM, LA, PA ICLUSIG NM, LA, PA imatinib mesylate 100mg QL (90 tabs / 30 days), NM,

PA imatinib mesylate 400mg QL (60 tabs / 30 days), NM,

PA IMBRUVICA NM, LA, PA INLYTA 1mg QL (180 tabs / 30 days),

NM, LA, PA INLYTA 5mg QL (120 tabs / 30 days),

NM, LA, PA INREBIC NM, LA, PA IRESSA NM, LA, PA JAKAFI QL (60 tabs / 30 days), NM,

LA, PA LENVIMA 4 MG DAILY DOSE NM, LA, PA LENVIMA 8 MG DAILY DOSE NM, LA, PA LENVIMA 10 MG DAILY DOSE NM, LA, PA LENVIMA 12MG DAILY DOSE NM, LA, PA LENVIMA 14 MG DAILY DOSE NM, LA, PA LENVIMA 18 MG DAILY DOSE NM, LA, PA LENVIMA 20 MG DAILY DOSE NM, LA, PA LENVIMA 24 MG DAILY DOSE NM, LA, PA LORBRENA NM, LA, PA MEKINIST NM, LA, PA MEKTOVI NM, LA, PA NERLYNX NM, LA, PA NEXAVAR NM, LA, PA PEMAZYRE NM, LA, PA PIQRAY 200MG DAILY DOSE NM, PA

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Drug Name Requirements/Limits PIQRAY 250MG DAILY DOSE NM, PA PIQRAY 300MG DAILY DOSE NM, PA ROZLYTREK NM, LA, PA RYDAPT NM, PA SPRYCEL NM, PA STIVARGA NM, LA, PA SUTENT QL (30 caps / 30 days), NM,

PA TAFINLAR NM, LA, PA TAGRISSO QL (30 tabs / 30 days), NM,

LA, PA TASIGNA NM, PA TUKYSA NM, LA, PA TURALIO NM, LA, PA TYKERB NM, LA, PA VITRAKVI NM, LA, PA VIZIMPRO NM, LA, PA VOTRIENT NM, LA, PA XALKORI NM, LA, PA XOSPATA NM, LA, PA ZELBORAF NM, LA, PA ZYDELIG NM, LA, PA ZYKADIA NM, LA, PA MISCELLANEOUS bexarotene NM, PA hydroxyurea CAPS LONSURF NM, PA MATULANE LA SYLATRON NM, PA SYNRIBO NM, PA TAZVERIK NM, LA, PA tretinoin (chemotherapy) XPOVIO 60 MG ONCE WEEKLY NM, LA, PA XPOVIO 80 MG ONCE WEEKLY NM, LA, PA XPOVIO 80 MG TWICE WEEKLY NM, LA, PA XPOVIO 100 MG ONCE WEEKLY NM, LA, PA PLATINUM-BASED AGENTS carboplatin B/D cisplatin SOLN B/D oxaliplatin inj 50mg B/D oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg B/D oxaliplatin inj 100mg/20ml B/D

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Drug Name Requirements/Limits PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml B/D leucovorin calcium SOLR B/D leucovorin calcium TABS MESNEX TABS TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl B/D toposar B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap 10-20 mg amlodipine besylate-benazepril hcl cap 10-40 mg benazepril & hydrochlorothiazide captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide quinapril-hydrochlorothiazide ACE INHIBITORS benazepril hcl TABS captopril TABS enalapril maleate TABS fosinopril sodium lisinopril TABS moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone TABS ALPHA BLOCKERS doxazosin mesylate TABS prazosin hcl terazosin hcl ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

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Drug Name Requirements/Limits amlodipine besylate-valsartan tab amlodipine-valsartan-hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide ENTRESTO irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide olmesartan medoxomil-amlodipine-

hydrochlorothiazide

olmesartan medoxomil-hydrochlorothiazide telmisartan-amlodipine telmisartan-hydrochlorothiazide valsartan-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil irbesartan losartan potassium TABS olmesartan medoxomil TABS telmisartan valsartan ANTIARRHYTHMICS amiodarone hcl soln amiodarone tab 100mg amiodarone tab 200mg amiodarone tab 400mg disopyramide phosphate dofetilide NM flecainide acetate MULTAQ NORPACE CR pacerone propafenone hcl propafenone hcl 12hr quinidine sulfate sorine sotalol hcl sotalol hcl (afib/afl) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS lovastatin pravastatin sodium rosuvastatin calcium QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg simvastatin TABS 80mg QL (30 tabs / 30 days)

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Drug Name Requirements/Limits ANTILIPEMICS, MISCELLANEOUS cholestyramine cholestyramine light pack cholestyramine light powd colesevelam hcl colestipol hcl gran colestipol hcl pack colestipol hcl tabs ezetimibe ezetimibe-simvastatin fenofibrate TABS 48mg, 54mg, 145mg, 160mg fenofibrate micronized 67mg, 134mg, 200mg gemfibrozil TABS JUXTAPID NM, LA, PA niacin (antihyperlipidemic) niacin er (antihyperlipidemic) 500mg QL (60 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg niacor PRALUENT NM, PA prevalite VASCEPA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol TABS betaxolol hcl bisoprolol fumarate BYSTOLIC 2.5mg, 5mg, 10mg QL (30 tabs / 30 days) BYSTOLIC 20mg QL (60 tabs / 30 days) carvedilol labetalol hcl TABS metoprolol succinate metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 25mg, 50mg, 100mg nadolol TABS pindolol propranolol cap er propranolol hcl TABS propranolol oral sol

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Drug Name Requirements/Limits timolol maleate TABS CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS cartia xt dilt-xr cap diltiazem cap 240mg cd diltiazem cap 360mg cd diltiazem cap er/12hr diltiazem hcl TABS diltiazem hcl coated beads CP24 diltiazem hcl coated beads cap sr 24hr diltiazem hcl extended release beads cap sr diltiazem inj felodipine isradipine nicardipine hcl CAPS nifedipine TB24 nifedipine er nimodipine CAPS NYMALIZE taztia xt tiadylt er verapamil cap er verapamil hcl SOLN; TABS; TBCR verapamil tab er DIGITALIS GLYCOSIDES digitek .25mg PA; PA if 70 years and older digitek .125mg QL (30 tabs / 30 days) digox 125mcg QL (30 tabs / 30 days) digox 250mcg PA; PA if 70 years and older digoxin TABS 125mcg QL (30 tabs / 30 days) digoxin TABS 250mcg PA; PA if 70 years and older digoxin inj digoxin sol 50mcg/ml PA; PA if 70 years and older DIURETICS acetazolamide CP12; TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide inj 0.25/ml bumetanide tab chlorothiazide TABS chlorthalidone furosemide SOLN; TABS furosemide inj

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Drug Name Requirements/Limits hydrochlorothiazide CAPS; TABS indapamide methazolamide TABS metolazone spironolactone & hydrochlorothiazide torsemide tabs triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide tabs MISCELLANEOUS aliskiren fumarate clonidine hcl TABS clonidine hcl ptwk CORLANOR DEMSER PA hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS NORTHERA 100mg QL (90 caps / 30 days), NM,

LA, PA NORTHERA 200mg, 300mg QL (180 caps / 30 days),

NM, LA, PA ranolazine NITRATES isosorb mononitrate tab isosorbide dinitrate 5mg, 10mg, 20mg, 30mg isosorbide mononitrate er minitran NITRO-BID NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin SOLN .4mg/spray nitroglycerin SUBL nitroglycerin td patch PULMONARY ARTERIAL HYPERTENSION ADEMPAS QL (90 tabs / 30 days), NM,

LA, PA ambrisentan QL (30 tabs / 30 days), NM,

LA, PA bosentan 62.5mg QL (120 tabs / 30 days),

NM, LA, PA bosentan 125mg QL (60 tabs / 30 days), NM,

LA, PA OPSUMIT QL (30 tabs / 30 days), NM,

LA, PA

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Drug Name Requirements/Limits sildenafil citrate tab 20 mg (pulmonary

hypertension) QL (90 tabs / 30 days), NM, PA

treprostinil NM, LA, PA VENTAVIS NM, PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg QL (150 tabs / 30 days) alprazolam tab 0.25mg QL (150 tabs / 30 days) alprazolam tab 1mg QL (150 tabs / 30 days) alprazolam tab 2 mg QL (150 tabs / 30 days) buspirone hcl TABS fluvoxamine maleate TABS lorazepam SOLN lorazepam TABS QL (150 tabs / 30 days) lorazepam intensol QL (150 mL / 30 days) ANTICONVULSANTS APTIOM QL (60 tabs / 30 days) BANZEL SUS 40MG/ML PA BANZEL TAB 200MG PA BANZEL TAB 400MG PA BRIVIACT INJ 50MG/5ML PA BRIVIACT SOL 10MG/ML PA BRIVIACT TAB 10MG PA BRIVIACT TAB 25MG PA BRIVIACT TAB 50MG PA BRIVIACT TAB 75MG PA BRIVIACT TAB 100MG PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 CELONTIN clobazam PA clonazepam TABS 2mg QL (300 tabs / 30 days) clonazepam TABS .5mg, 1mg QL (90 tabs / 30 days) clonazepam TBDP 2mg QL (300 tabs / 30 days) clonazepam TBDP .125mg, .25mg, .5mg, 1mg QL (90 tabs / 30 days) clorazepate dipotassium QL (180 tabs / 30 days),

PA; PA if 65 years and older DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam TABS QL (120 tabs / 30 days),

PA; PA if 65 years and older diazepam gel diazepam inj diazepam intensol QL (240 mL / 30 days), PA;

PA if 65 years and older

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Drug Name Requirements/Limits diazepam oral soln 1 mg/ml QL (1200 mL / 30 days),

PA; PA if 65 years and older DILANTIN CAP 30MG DILANTIN CAP 100MG DILANTIN CHEW TAB 50MG DILANTIN-125 SUSP divalproex sodium CSDR; TB24; TBEC EPIDIOLEX QL (600 mL / 30 days), NM,

LA, PA epitol ethosuximide CAPS; SOLN felbamate FYCOMPA SUSP QL (720 mL / 30 days), PA FYCOMPA TABS 2mg, 4mg, 6mg QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg QL (30 tabs / 30 days), PA gabapentin CAPS 100mg QL (1080 caps / 30 days) gabapentin CAPS 300mg QL (360 caps / 30 days) gabapentin CAPS 400mg QL (270 caps / 30 days) gabapentin SOLN QL (2160 mL / 30 days) gabapentin TABS 600mg QL (180 tabs / 30 days) gabapentin TABS 800mg QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 levetiracetam SOLN; TABS; TB24 levetiracetam in sodium chloride levetiracetam oral soln 100 mg/ml NAYZILAM oxcarbazepine PEGANONE phenobarbital ELIX; TABS PA; PA if 70 years and older phenobarbital sodium SOLN PA; PA if 70 years and older PHENYTEK phenytoin CHEW; SUSP phenytoin sodium extended phenytoin sodium inj 50mg/ml pregabalin CAPS 25mg, 50mg, 75mg, 100mg,

150mg QL (120 caps / 30 days), PA

pregabalin CAPS 200mg QL (90 caps / 30 days), PA pregabalin CAPS 225mg, 300mg QL (60 caps / 30 days), PA pregabalin SOLN QL (900 mL / 30 days), PA primidone TABS roweepra roweepra xr SPRITAM subvenite tab SYMPAZAN PA

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Drug Name Requirements/Limits tiagabine hcl topiramate CPSP; TABS valproate sodium SOLN valproate sodium oral soln valproic acid CAPS VALTOCO vigabatrin powd pack 500mg QL (180 packets / 30 days),

NM, LA, PA vigabatrin tab 500mg QL (180 tabs / 30 days),

NM, LA, PA vigadrone QL (180 packets / 30 days),

NM, LA, PA VIMPAT 50mg QL (120 tabs / 30 days) VIMPAT 100mg, 150mg, 200mg QL (60 tabs / 30 days) VIMPAT INJ 200MG/20ML VIMPAT SOL 10MG/ML QL (1200 mL / 30 days) XCOPRI MAINTENANCE PAK 150-200MG QL (56 tabs / 28 days) XCOPRI PAK 12.5-25MG QL (28 tabs / 28 days) XCOPRI PAK 50-100MG QL (28 tabs / 28 days) XCOPRI PAK 50-200MG QL (56 tabs / 28 days) XCOPRI TABS 50mg QL (90 tabs / 30 days) XCOPRI TABS 100mg, 150mg, 200mg QL (60 tabs / 30 days) XCOPRI TITRATION PAK 150-200MG QL (28 tabs / 28 days) zonisamide CAPS ANTIDEMENTIA donepezil hydrochloride TABS 5mg QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg donepezil hydrochloride TBDP 5mg QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg galantamine hydrobromide SOLN galantamine hydrobromide TABS QL (60 tabs / 30 days) galantamine hydrobromide er QL (30 caps / 30 days) memantine hcl cp24 PA; PA if < 30 yrs memantine soln PA; PA if < 30 yrs memantine tabs PA; PA if < 30 yrs memantine titration pak PA; PA if < 30 yrs NAMZARIC rivastigmine tartrate 1.5mg, 3mg QL (90 caps / 30 days) rivastigmine tartrate 4.5mg, 6mg QL (60 caps / 30 days) rivastigmine td patch 24hr 4.6 mg/24hr QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr QL (30 patches / 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS

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Drug Name Requirements/Limits amoxapine bupropion hcl TABS bupropion hcl TB12 bupropion hcl TB24 150mg, 300mg citalopram hydrobromide clomipramine hcl CAPS PA desipramine hcl TABS desvenlafaxine succinate QL (30 tabs / 30 days), PA doxepin hcl CAPS; CONC DRIZALMA SPRINKLE 20mg, 30mg, 60mg QL (60 caps / 30 days), PA DRIZALMA SPRINKLE 40mg QL (90 caps / 30 days), PA duloxetine hcl CPEP 20mg, 30mg, 60mg QL (60 caps / 30 days) EMSAM QL (30 patches / 30 days),

PA escitalopram oxalate FETZIMA 20mg, 40mg QL (60 caps / 30 days), PA FETZIMA 80mg, 120mg QL (30 caps / 30 days), PA FETZIMA TITRATION PACK PA fluoxetine cap 10mg fluoxetine cap 20mg fluoxetine cap 40mg fluoxetine hcl SOLN imipramine hcl TABS maprotiline hcl MARPLAN TAB 10MG QL (180 tabs / 30 days) mirtazapine TABS; TBDP nefazodone hcl nortriptyline hcl CAPS; SOLN paroxetine hcl tabs PAXIL SUSP QL (900 mL / 30 days) phenelzine sulfate TABS protriptyline hcl sertraline hcl CONC; TABS tranylcypromine sulfate trazodone hcl TABS 50mg, 100mg, 150mg trimipramine maleate CAPS 25mg QL (240 caps / 30 days) trimipramine maleate CAPS 50mg QL (120 caps / 30 days) trimipramine maleate CAPS 100mg QL (60 caps / 30 days) TRINTELLIX 5mg QL (120 tabs / 30 days) TRINTELLIX 10mg QL (60 tabs / 30 days) TRINTELLIX 20mg QL (30 tabs / 30 days) venlafaxine hcl CP24; TABS VIIBRYD STARTER PACK VIIBRYD TAB QL (30 tabs / 30 days)

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Drug Name Requirements/Limits ANTIPARKINSONIAN AGENTS amantadine hcl CAPS QL (120 caps / 30 days) amantadine hcl SYRP; TABS APOKYN QL (20 cartridges / 30

days), NM, LA, PA benztropine mesylate inj benztropine mesylate tab 0.5mg PA; PA if 70 years and older benztropine mesylate tab 1mg PA; PA if 70 years and older benztropine mesylate tab 2mg PA; PA if 70 years and older bromocriptine mesylate CAPS; TABS carbidopa-levodopa carbidopa/levodopa/entacapone entacapone NEUPRO pramipexole tab 0.5mg pramipexole tab 0.25mg pramipexole tab 0.75mg pramipexole tab 0.125mg pramipexole tab 1.5mg pramipexole tab 1mg rasagiline mesylate TABS ropinirole tab 0.5mg ropinirole tab 0.25mg ropinirole tab 1mg ropinirole tab 2mg ropinirole tab 3mg ropinirole tab 4mg ropinirole tab 5mg selegiline hcl CAPS; TABS trihexyphenidyl hcl PA; PA if 70 years and older ANTIPSYCHOTICS ABILIFY MAINTENA QL (1 injection / 28 days) aripiprazole odt QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml QL (900 mL / 30 days) aripiprazole tab QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml,

882mg/3.2ml QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days) ARISTADA INITIO CAPLYTA QL (30 caps / 30 days) chlorpromazine hcl TABS CHLORPROMAZINE INJ clozapine odt 12.5mg, 25mg PA clozapine odt 100mg QL (270 tabs / 30 days), PA

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Drug Name Requirements/Limits clozapine odt 150mg QL (180 tabs / 30 days), PA clozapine odt 200mg QL (135 tabs / 30 days), PA clozapine tab 25mg clozapine tab 50mg clozapine tab 100mg QL (270 tabs / 30 days) clozapine tab 200mg QL (135 tabs / 30 days) FANAPT QL (60 tabs / 30 days), PA FANAPT TITRATION PACK PA fluphenazine decanoate SOLN fluphenazine hcl GEODON SOLR QL (6 mL / 3 days) haloperidol TABS haloperidol conc 2mg/ml haloperidol decanoate SOLN haloperidol lactate inj 5mg/ml INVEGA SUST INJ 39 MG/0.25 ML QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML QL (1 injection / 28 days) INVEGA TRINZA QL (1 injection / 90 days) LATUDA 20mg, 40mg, 60mg, 120mg QL (30 tabs / 30 days) LATUDA 80mg QL (60 tabs / 30 days) loxapine succinate molindone hcl NUPLAZID CAPS QL (30 caps / 30 days), NM,

LA, PA NUPLAZID TABS 10MG QL (30 tabs / 30 days), NM,

LA, PA olanzapine SOLR QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 10mg QL (60 tabs / 30 days) olanzapine TABS 7.5mg, 15mg, 20mg QL (30 tabs / 30 days) olanzapine TBDP 5mg, 15mg, 20mg QL (30 tabs / 30 days) olanzapine TBDP 10mg QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg QL (30 tabs / 30 days) paliperidone 6mg QL (60 tabs / 30 days) perphenazine TABS PERSERIS QL (1 injection / 30 days) pimozide quetiapine fumarate TABS quetiapine fumarate TB24 50mg, 300mg, 400mg QL (60 tabs / 30 days), PA quetiapine fumarate TB24 150mg, 200mg QL (30 tabs / 30 days), PA REXULTI 3mg, 4mg QL (30 tabs / 30 days) REXULTI .25mg, .5mg, 1mg, 2mg QL (60 tabs / 30 days) RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

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Drug Name Requirements/Limits RISPERDAL INJ 25MG QL (2 injections / 28 days) RISPERDAL INJ 37.5MG QL (2 injections / 28 days) RISPERDAL INJ 50MG QL (2 injections / 28 days) risperidone SOLN QL (240 mL / 30 days) risperidone TABS risperidone TBDP 1mg, 2mg, 3mg, 4mg QL (60 tabs / 30 days) risperidone TBDP .25mg, .5mg QL (90 tabs / 30 days) SAPHRIS QL (60 tabs / 30 days) SECUADO QL (30 patches / 30 days) thioridazine hcl TABS thiothixene trifluoperazine hcl VERSACLOZ QL (600 mL / 30 days), PA VRAYLAR 1.5mg QL (60 caps / 30 days), PA VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK PA ziprasidone hcl QL (60 caps / 30 days) ziprasidone mesylate QL (6 injections / 3 days) ZYPREXA RELPREVV 300mg QL (2 vials / 28 days), PA ZYPREXA RELPREVV 405mg QL (1 vial / 28 days), PA ZYPREXA RELPREVV INJ 210MG QL (2 vials / 28 days), PA ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5

mg QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 10 mg

QL (90 caps / 30 days)









amphetamine-dextroamphetamine tab 5 mg QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 mg QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 10 mg QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 mg QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 15 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 20 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 30 mg QL (60 tabs / 30 days) atomoxetine hcl 10mg, 18mg, 25mg QL (120 caps / 30 days) atomoxetine hcl 40mg QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 100mg QL (30 caps / 30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg QL (120 tabs / 30 days)

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Drug Name Requirements/Limits dexmethylphenidate hcl TABS 10mg QL (60 tabs / 30 days) guanfacine er (adhd) PA; PA if 70 years and older metadate er tab 20mg QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml QL (1800 mL / 30 days) methylphenidate hcl oral soln 10mg/5ml QL (900 mL / 30 days) methylphenidate hcl tbcr 10 mg QL (90 tabs / 30 days) methylphenidate hcl tbcr 20mg QL (90 tabs / 30 days) HYPNOTICS BELSOMRA QL (30 tabs / 30 days) doxepin hcl (sleep) QL (30 tabs / 30 days) eszopiclone QL (30 tabs / 30 days), PA;

PA applies if 70 years and older after a 90 day supply in a calendar year

HETLIOZ NM, LA, PA temazepam 7.5mg QL (30 caps / 30 days), PA;

PA applies if 65 years and older after a 90 day supply in a calendar year

temazepam 15mg QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

zaleplon QL (60 caps / 30 days), PA; PA applies if 70 years and older after a 90 day supply in a calendar year

zolpidem tartrate TABS QL (30 tabs / 30 days), PA; PA applies if 70 years and older after a 90 day supply in a calendar year

MIGRAINE AIMOVIG QL (1 pen / 30 days), NM,

PA dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spr 4 mg/ml QL (8 mL / 30 days), PA eletriptan hydrobromide QL (12 tabs / 30 days) EMGALITY SOAJ QL (2 pens / 30 days), NM,

PA EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days),

NM, PA ergotamine w/ caffeine TABS naratriptan hcl QL (12 tabs / 30 days) rizatriptan benzoate QL (18 tabs / 30 days)

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Drug Name Requirements/Limits rizatriptan benzoate odt QL (18 tabs / 30 days) sumatriptan SOLN 5mg/act QL (24 inhalers / 30 days) sumatriptan SOLN 20mg/act QL (12 inhalers / 30 days) sumatriptan inj 4mg/0.5ml QL (18 injections / 30 days) sumatriptan inj 6mg/0.5ml QL (12 injections / 30 days) sumatriptan succinate TABS QL (12 tabs / 30 days) zolmitriptan TABS QL (12 tabs / 30 days) zolmitriptan odt QL (12 tabs / 30 days) MISCELLANEOUS AUSTEDO 6mg QL (60 tabs / 30 days), NM,

PA AUSTEDO 9mg, 12mg QL (120 tabs / 30 days),

NM, PA INGREZZA CAPS QL (30 caps / 30 days), NM,

PA INGREZZA CPPK QL (28 caps / 28 days), NM,

PA lithium carbonate CAPS; TABS lithium carbonate er LITHIUM SOLN 8MEQ/5ML LYRICA CR QL (60 tabs / 30 days), PA NUEDEXTA QL (60 caps / 30 days), PA pyridostigmine tab 60mg riluzole tetrabenazine 12.5mg QL (240 tabs / 30 days),

NM, PA tetrabenazine 25mg QL (120 tabs / 30 days),

NM, PA MULTIPLE SCLEROSIS AGENTS BETASERON QL (14 syringes / 28 days),

NM, PA dalfampridine TB12 NM, PA GILENYA QL (28 caps / 28 days), NM,

PA glatiramer acetate 20mg/ml QL (30 syringes / 30 days),

NM, PA glatiramer acetate 40mg/ml QL (12 syringes / 28 days),

NM, PA glatopa 20mg/ml QL (30 syringes / 30 days),

NM, PA glatopa 40mg/ml QL (12 syringes / 28 days),

NM, PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg

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Drug Name Requirements/Limits carisoprodol TABS 350mg QL (120 tabs / 30 days),

PA; PA if 70 years and older cyclobenzaprine hcl TABS 5mg, 10mg PA; PA if 70 years and older dantrolene sodium CAPS methocarbamol TABS PA; PA if 70 years and older tizanidine hcl TABS NARCOLEPSY/CATAPLEXY armodafinil 50mg QL (90 tabs / 30 days), PA armodafinil 150mg, 200mg, 250mg QL (30 tabs / 30 days), PA XYREM QL (540 mL / 30 days), NM,

LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium buprenorphine hcl SUBL QL (90 tabs / 30 days), PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg QL (90 films / 30 days) buprenorphine hcl-naloxone hcl dihydrate 4-1mg QL (90 films / 30 days) buprenorphine hcl-naloxone hcl dihydrate 8-2mg QL (90 films / 30 days) buprenorphine hcl-naloxone hcl dihydrate 12-3mg QL (60 films / 30 days) buprenorphine hcl-naloxone hcl sl QL (90 tabs / 30 days) bupropion hcl (smoking deterrent) CHANTIX PA CHANTIX CONTINUING MONTH PA CHANTIX STARTER PACK PA disulfiram TABS naloxone inj 0.4mg/ml naloxone inj 1mg/ml naltrexone hcl TABS NARCAN NICOTROL INHALER NICOTROL NS VIVITROL NM ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 PA ANDRODERM QL (30 patches / 30 days),

PA oxandrolone tab 2.5mg PA oxandrolone tab 10mg PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm QL (300 grams / 30 days),

PA testosterone cypionate SOLN PA testosterone enanthate SOLN PA ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN

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Drug Name Requirements/Limits BD ALCOHOL SWABS BD ULTRAFINE INSULIN SYRINGE BD ULTRAFINE/NANO PEN NEEDLES BYDUREON BCISE QL (4 pens / 28 days) BYDUREON PEN QL (4 pens / 28 days) BYETTA QL (1 pen / 30 days) FIASP FIASP FLEXTOUCH FIASP PENFILL GAUZE PADS 2" X 2" HUMULIN R INJ U-500 B/D HUMULIN R U-500 KWIKPEN INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LEVEMIR LEVEMIR FLEXTOUCH NOVOLIN 70/30 (brand RELION not covered) NOVOLIN 70/30 FLEXPEN (brand RELION not covered) NOVOLIN N (brand RELION not covered) NOVOLIN N FLEXPEN (brand RELION not covered) NOVOLIN R (brand RELION not covered) NOVOLIN R FLEXPEN (brand RELION not covered) NOVOLOG NOVOLOG 70/30 FLEXPEN NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG PENFILL OZEMPIC INJ 0.25 OR 0.5MG/DOSE QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days) SOLIQUA 100/33 QL (10 pens / 30 days) TRESIBA FLEXTOUCH TRESIBA INJ TRULICITY QL (4 pens / 28 days) VICTOZA QL (3 pens / 30 days) XULTOPHY 100/3.6 QL (5 pens / 30 days) ANTIDIABETICS, ORAL acarbose TABS FARXIGA QL (30 tabs / 30 days) glimepiride 1mg, 2mg QL (90 tabs / 30 days) glimepiride 4mg QL (60 tabs / 30 days) glip/metform tab 2.5-250mg QL (240 tabs / 30 days) glip/metform tab 2.5-500mg QL (120 tabs / 30 days) glip/metform tab 5-500mg QL (120 tabs / 30 days)

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Drug Name Requirements/Limits glipizide TABS 5mg QL (240 tabs / 30 days) glipizide TABS 10mg QL (120 tabs / 30 days) glipizide TB24 2.5mg, 5mg QL (90 tabs / 30 days) glipizide TB24 10mg QL (60 tabs / 30 days) glipizide xl 2.5mg, 5mg QL (90 tabs / 30 days) glipizide xl 10mg QL (60 tabs / 30 days) glyburide TABS 1.25mg QL (480 tabs / 30 days),

PA; PA if 70 years and older glyburide TABS 2.5mg QL (240 tabs / 30 days),

PA; PA if 70 years and older glyburide TABS 5mg QL (120 tabs / 30 days),

PA; PA if 70 years and older glyburide micronized 1.5mg QL (240 tabs / 30 days),

PA; PA if 70 years and older glyburide micronized 3mg QL (120 tabs / 30 days),

PA; PA if 70 years and older glyburide micronized 6mg QL (60 tabs / 30 days), PA;

PA if 70 years and older glyburide-metformin tab 1.25-250 mg QL (240 tabs / 30 days),

PA; PA if 70 years and older glyburide-metformin tab 2.5-500 mg QL (120 tabs / 30 days),

PA; PA if 70 years and older glyburide-metformin tab 5-500mg QL (120 tabs / 30 days),

PA; PA if 70 years and older GLYXAMBI QL (30 tabs / 30 days) JANUMET QL (60 tabs / 30 days) JANUMET XR TAB 50-500MG QL (60 tabs / 30 days) JANUMET XR TAB 50-1000 QL (60 tabs / 30 days) JANUMET XR TAB 100-1000 QL (30 tabs / 30 days) JANUVIA QL (30 tabs / 30 days) JARDIANCE 10mg QL (60 tabs / 30 days) JARDIANCE 25mg QL (30 tabs / 30 days) JENTADUETO QL (60 tabs / 30 days) JENTADUETO TAB XR 2.5-1000 MG QL (60 tabs / 30 days) JENTADUETO TAB XR 5-1000 MG QL (30 tabs / 30 days) metformin er 500mg QL (120 tabs / 30 days);

(generic of GLUCOPHAGE XR)

metformin er 750mg QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin hcl TABS 500mg QL (150 tabs / 30 days) metformin hcl TABS 850mg QL (90 tabs / 30 days) metformin hcl TABS 1000mg QL (75 tabs / 30 days) nateglinide QL (90 tabs / 30 days) pioglitazone hcl QL (30 tabs / 30 days)

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Drug Name Requirements/Limits repaglinide 2mg QL (240 tabs / 30 days) repaglinide .5mg, 1mg QL (120 tabs / 30 days) RYBELSUS QL (30 tabs / 30 days) SYNJARDY TAB 5-500MG QL (120 tabs / 30 days) SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days) SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days) SYNJARDY TAB 12.5-1000MG QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000MG QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5-1000MG QL (60 tabs / 30 days) SYNJARDY XR TAB 25-1000MG QL (30 tabs / 30 days) TRADJENTA QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 5-2.5-1000MG QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 10-5-1000 MG QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 25-5-1000 MG QL (30 tabs / 30 days) XIGDUO XR TAB 2.5-1000MG QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days) XIGDUO XR TAB 5-1000MG QL (60 tabs / 30 days) XIGDUO XR TAB 10-500MG QL (30 tabs / 30 days) XIGDUO XR TAB 10-1000MG QL (30 tabs / 30 days) BISPHOSPHONATES alendronate sodium soln 70mg/75ml alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 70 mg ibandronate sodium tabs B/D PAMIDRONATE DISODIUM 6mg/ml B/D pamidronate disodium 30mg/10ml, 90mg/10ml B/D pamidronate inj 30mg B/D pamidronate inj 90mg B/D risedronate sodium TABS 5mg, 35mg, 150mg risedronate sodium TBEC zoledronic acid inj 4mg/100ml B/D, NM zoledronic acid inj 5mg/100ml B/D, NM zoledronic inj 4mg/5ml B/D, NM CHELATING AGENTS CHEMET clovique PA deferasirox tab NM, PA JADENU 180mg NM, LA, PA JADENU SPRINKLE NM, LA, PA

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Drug Name Requirements/Limits kionex sus 15gm/60ml LOKELMA penicillamine TABS sodium polystyrene sulfonate powder sodium polystyrene sulfonate susp sps susp 15gm/60ml trientine hcl PA VELTASSA LA, PA CONTRACEPTIVES altavera tab alyacen 1/35 amethia amethia lo apri aranelle ashlyna aubra aviane balziva bekyree blisovi 24 fe blisovi fe 1.5/30 briellyn camila camrese lo caziant pak cryselle-28 cyclafem 1/35 cyclafem 7/7/7 cyred tab dasetta 1/35 dasetta 7/7/7 deblitane desogestrel & ethinyl estradiol desogestrel-ethinyl estradiol (biphasic) drospirenone-ethinyl estradiol drospirenone-ethinyl estradiol-levomefolate calcium ELLA eluryng emoquette enpresse-28 enskyce errin estarylla tab 0.25-35

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Drug Name Requirements/Limits ethynodiol diacet & eth estrad ethynodiol tab 1-50 etonogestrel-ethinyl estradiol falmina fayosim femynor gianvi tab 3-0.02mg hailey 24 fe heather incassia introvale isibloom jasmiel jolessa tab 0.15-0.03 mg jolivette juleber junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 kaitlib fe kariva kelnor 1/35 kelnor 1/50 kurvelo larin 1.5/30 larin 1/20 larin fe 1.5/30 larin fe 1/20 larissia tab layolis fe leena tab lessina levonest levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth

est 0.01mg

levonor/ethi tab levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

levonorgestrel & eth estradiol levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-

day)

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Drug Name Requirements/Limits levora 0.15/30-28 loryna low-ogestrel lutera lyza marlissa medroxyprogesterone acetate (contraceptive) melodetta 24 fe mibelas 24 fe microgestin 1.5/30 microgestin 1/20 microgestin fe 1.5/30 microgestin fe 1/20 mili mono-linyah tab 0.25-35 necon 0.5/35-28 nikki nora-be tab 0.35mg nore/eth/fer chw 0.4mg-35 noreth/ethin chw fe norethin acet & estrad-fe norethindrone (contraceptive) norethindrone acet & eth estra norgest/ethi tab 0.25/35 norgestimate-ethinyl estradiol (triphasic) 0.18-

25/0.215-25/0.25-25 mg-mcg

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

nortrel 0.5/35 (28) nortrel 1/35 nortrel 7/7/7 ocella tab 3-0.03mg orsythia philith pimtrea pirmella 1/35 portia-28 previfem reclipsen rivelsa setlakin tab sharobel sprintec 28 sronyx syeda

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Drug Name Requirements/Limits tarina 24 fe tarina fe 1/20 tilia fe tri-estarylla tri-legest fe tri-linyah tri-lo marzia tri-lo-estarylla tri-lo-sprintec tri-mili tri-previfem tri-sprintec tri-vylibra tri-vylibra lo trivora-28 tulana tydemy velivet vienva viorele vyfemla vylibra wymzya fe xulane dis 150-35 zarah zovia 1/35e ENDOMETRIOSIS danazol CAPS SYNAREL ENZYME REPLACEMENTS ALDURAZYME NM, LA, PA CARBAGLU NM, LA, PA CERDELGA NM, PA CEREZYME NM, LA, PA CYSTADANE NM, LA CYSTAGON NM, LA, PA FABRAZYME NM, LA, PA KUVAN NM, LA, PA levocarnitine (metabolic modifiers) B/D LUMIZYME NM, LA, PA miglustat NM, PA NAGLAZYME NM, LA, PA nitisinone NM, PA NITYR NM, LA, PA

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Drug Name Requirements/Limits ORFADIN NM, LA, PA sodium phenylbutyrate NM, PA ESTROGENS DELESTROGEN 10mg/ml estradiol PTWK; TABS estradiol vaginal cream estradiol vaginal tab estradiol valerate inj fyavolv jinteli norethindrone acetate-ethinyl estradiol yuvafem vaginal tablet 10 mcg GLUCOCORTICOIDS cortisone acetate TABS DEXAMETHASONE CONC dexamethasone ELIX; SOLN; TABS dexamethasone sodium phosphate fludrocortisone acetate TABS hydrocortisone TABS methylpr ss inj B/D methylpred pak 4mg methylpred tab 4mg B/D methylpred tab 8mg B/D methylpred tab 16mg B/D methylpred tab 32mg B/D methylprednisolone acetate B/D pred sod pho sol 5mg/5ml B/D prednisolone sodium phosphate SOLN 15mg/5ml B/D prednisolone sol 15mg/5ml B/D prednisolone sol 25mg/5ml B/D PREDNISONE CON 5MG/ML B/D prednisone pak 5mg prednisone pak 10mg prednisone sol 5mg/5ml B/D prednisone tab 1mg B/D prednisone tab 2.5mg B/D prednisone tab 5mg B/D prednisone tab 10mg B/D prednisone tab 20mg B/D prednisone tab 50mg B/D SOLU-CORTEF GLUCOSE ELEVATING AGENTS diazoxide SUSP GLUCAGEN HYPOKIT

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Drug Name Requirements/Limits GLUCAGON EMERGENCY KIT GVOKE HYPOPEN 2-PACK GVOKE PFS PROGLYCEM SUS 50MG/ML MISCELLANEOUS cabergoline calcitonin (salmon) B/D cinacalcet hcl 30mg, 90mg B/D, QL (120 tabs / 30

days), NM cinacalcet hcl 60mg B/D, QL (60 tabs / 30 days),

NM FORTEO NM, PA GENOTROPIN NM, PA GENOTROPIN MINIQUICK NM, PA INCRELEX NM, LA, PA KORLYM NM, LA, PA LUPRON DEP-PED INJ 7.5MG NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH) NM, PA LUPRON DEPOT-PED (1-MONTH NM, PA LUPRON DEPOT-PED (3-MONTH NM, PA NATPARA NM, PA octreotide acetate NM, PA OSPHENA PA PROLIA QL (1 injection / 180 days),

NM raloxifene tab 60mg SIGNIFOR NM, LA, PA SOMATULINE DEPOT NM, PA SOMAVERT NM, LA, PA TYMLOS NM, PA XGEVA NM, PA PHOSPHATE BINDER AGENTS AURYXIA QL (360 tabs / 30 days), PA calcium acetate (phosphate binder) CAPS QL (360 caps / 30 days) calcium acetate (phosphate binder) TABS QL (360 tabs / 30 days) sevelamer carbonate PACK 2.4gm QL (180 packets / 30 days) sevelamer carbonate PACK .8gm QL (540 packets / 30 days) sevelamer carbonate TABS QL (540 tabs / 30 days) PROGESTINS medroxyprogesterone acetate tab norethindrone acetate TABS THYROID AGENTS euthyrox levo-t

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Drug Name Requirements/Limits levothyroxine sodium TABS levoxyl liothyronine sodium TABS methimazole TABS propylthiouracil TABS SYNTHROID unithroid VASOPRESSINS desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml STIMATE NM GASTROINTESTINAL ANTIEMETICS aprepitant B/D aprepitant pak 80mg & 125mg B/D compro supp dronabinol B/D, QL (60 caps / 30 days) EMEND SUSR B/D granisetron hcl SOLN granisetron hcl TABS B/D meclizine hcl TABS metoclopramide hcl SOLN; TABS metoclopramide hcl inj ondansetron hcl TABS B/D ondansetron hcl inj ondansetron hcl oral soln B/D ondansetron odt B/D prochlorperazine inj prochlorperazine maleate TABS prochlorperazine supp promethazine hcl SYRP; TABS PA; PA if 70 years and older promethazine hcl inj PA; PA if 70 years and older scopolamine QL (10 patches / 30 days),

PA; PA if 70 years and older ANTISPASMODICS dicyclomine hcl cap 10mg dicyclomine hcl soln 10mg/5ml dicyclomine hcl tab 20mg glycopyrrolate tab 1mg glycopyrrolate tab 2mg H2-RECEPTOR ANTAGONISTS famotidine SUSR

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Drug Name Requirements/Limits famotidine TABS 20mg, 40mg famotidine in nacl famotidine inj nizatidine CAPS INFLAMMATORY BOWEL DISEASE balsalazide disodium budesonide ec colocort hydrocortisone (enema) mesalamine CPDR mesalamine ENEM mesalamine SUPP mesalamine TBEC 1.2gm mesalamine w/ cleanser sulfasalazine TABS sulfasalazine ec LAXATIVES constulose enulose gavilyte-c gavilyte-g gavilyte-n/flavor pack generlac GOLYTELY lactulose SOLN lactulose (encephalopathy) NULYTELY/FLAVOR PACKS peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350-potassium chloride-sod bicarbonate-sod

chloride

PLENVU SUPREP BOWEL PREP KIT trilyte MISCELLANEOUS alosetron hcl PA AMITIZA CAP 8MCG QL (180 caps / 30 days) AMITIZA CAP 24MCG QL (60 caps / 30 days) cromolyn sodium (mastocytosis) diphenoxylate w/ atropine GATTEX NM, LA, PA LINZESS QL (30 caps / 30 days) loperamide hcl CAPS misoprostol TABS MOVANTIK 12.5mg QL (60 tabs / 30 days)

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Drug Name Requirements/Limits MOVANTIK 25mg QL (30 tabs / 30 days) RELISTOR SOLN PA sucralfate TABS ursodiol CAPS; TABS XIFAXAN 550mg PA PANCREATIC ENZYMES CREON ZENPEP PROTON PUMP INHIBITORS DEXILANT QL (30 caps / 30 days) esomeprazole magnesium CPDR QL (30 caps / 30 days), ST lansoprazole CPDR QL (30 caps / 30 days) omeprazole cap 10mg omeprazole cap 20mg omeprazole cap 40mg pantoprazole sodium SOLR pantoprazole sodium tbec rabeprazole sodium QL (30 tabs / 30 days) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl QL (30 tabs / 30 days) dutasteride CAPS QL (30 caps / 30 days) dutasteride-tamsulosin hcl QL (30 caps / 30 days) finasteride TABS 5mg tamsulosin hcl MISCELLANEOUS bethanechol chloride TABS potassium citrate (alkalinizer) er tabs URINARY ANTISPASMODICS MYRBETRIQ QL (30 tabs / 30 days) oxybutynin chloride SYRP oxybutynin chloride TABS oxybutynin chloride TB24 5mg QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg QL (60 tabs / 30 days) tolterodine tartrate CP24 QL (30 caps / 30 days), ST tolterodine tartrate TABS ST TOVIAZ QL (30 tabs / 30 days) trospium chloride TABS QL (60 tabs / 30 days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal metronidazole vaginal terconazole vaginal vandazole

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Drug Name Requirements/Limits HEMATOLOGIC ANTICOAGULANTS COUMADIN ELIQUIS 2.5mg QL (60 tabs / 30 days) ELIQUIS 5mg QL (74 tabs / 30 days) ELIQUIS STARTER PACK QL (74 tabs / 30 days) enoxaparin sodium fondaparinux sodium heparin sod (porcine) in d5w heparin sod inj 1000/ml B/D heparin sod inj 5000/ml B/D heparin sod inj 10000/ml B/D heparin sod inj 20000/ml B/D HEPARIN SODIUM/NACL 0.45% jantoven PRADAXA QL (60 caps / 30 days) warfarin sodium XARELTO 2.5mg QL (60 tabs / 30 days) XARELTO 10mg, 15mg, 20mg QL (30 tabs / 30 days) XARELTO STARTER PACK QL (51 tabs / 30 days) HEMATOPOIETIC GROWTH FACTORS PROCRIT NM, PA ZARXIO NM, PA MISCELLANEOUS anagrelide hcl BERINERT QL (24 boxes / 30 days),

NM, LA, PA cilostazol DROXIA ENDARI NM, LA, PA HAEGARDA 2000unit QL (30 vials / 30 days), NM,

LA, PA HAEGARDA 3000unit QL (20 vials / 30 days), NM,

LA, PA icatibant acetate QL (9 syringes / 30 days),

NM, PA pentoxifylline TBCR PROMACTA PACK 12.5mg QL (360 packets / 30 days),

NM, LA, PA PROMACTA PACK 25mg QL (180 packets / 30 days),

NM, LA, PA PROMACTA TABS 12.5mg, 25mg QL (30 tabs / 30 days), NM,

LA, PA PROMACTA TABS 50mg, 75mg QL (60 tabs / 30 days), NM,

LA, PA

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Drug Name Requirements/Limits tranexamic acid SOLN; TABS PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole BRILINTA clopidogrel tab 75mg prasugrel hcl IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ENBREL SOLR QL (16 vials / 28 days), NM,

PA ENBREL SOSY 25mg/0.5ml QL (16 syringes / 28 days),

NM, PA ENBREL SOSY 50mg/ml QL (8 syringes / 28 days),

NM, PA ENBREL MINI QL (8 injections / 28 days),

NM, PA ENBREL SURECLICK QL (8 injections / 28 days),

NM, PA HUMIRA 10mg/0.1ml, 20mg/0.2ml QL (2 injections / 28 days),

NM, PA HUMIRA 40mg/0.4ml QL (6 injections / 28 days),

NM, PA HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days),

NM, PA HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days),

NM, PA HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days),

NM, PA HUMIRA PEDIATRIC CROHNS DISEASE NM, PA HUMIRA PEN QL (6 pens / 28 days), NM,

PA HUMIRA PEN CD/UC/HS STARTER NM, PA HUMIRA PEN INJ CD/UC/HS STARTER NM, PA HUMIRA PEN INJ PS/UV STARTER NM, PA HUMIRA PEN-PS/UV STARTER NM, PA hydroxychloroquine sulfate leflunomide TABS QL (30 tabs / 30 days) methotrexate sodium tabs REMICADE NM, PA RENFLEXIS NM, LA, PA RINVOQ QL (30 tabs / 30 days), NM,

PA SKYRIZI QL (7 kits / year), NM, PA STELARA SOLN 45mg/0.5ml QL (1 vial / 28 days), NM,

LA, PA

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Drug Name Requirements/Limits STELARA SOSY QL (1 syringe / 28 days),

NM, PA XATMEP B/D XELJANZ QL (60 tabs / 30 days), NM,

PA XELJANZ XR QL (30 tabs / 30 days), NM,

PA IMMUNOGLOBULINS BIVIGAM NM, PA GAMASTAN S/D B/D, NM GAMMAGARD LIQUID NM, PA GAMMAGARD S/D NM, PA GAMMAKED NM, PA GAMMAPLEX NM, PA GAMMAPLEX 10GM/100ML NM, PA GAMUNEX-C NM, PA OCTAGAM NM, PA PANZYGA NM, PA PRIVIGEN NM, PA IMMUNOMODULATORS ACTIMMUNE NM, LA, PA ARCALYST NM, PA INTRON-A INJ 10MU B/D, NM INTRON-A INJ 18MU B/D, NM INTRON-A INJ 25MU B/D, NM INTRON-A INJ 50MU B/D, NM IMMUNOSUPPRESSANTS azathioprine TABS B/D BENLYSTA NM, PA cyclosporine CAPS; SOLN B/D, NM cyclosporine modified (for microemulsion) B/D, NM everolimus (immunosuppressant) B/D, NM gengraf B/D, NM mycophenolate mofetil CAPS; SUSR; TABS B/D, NM mycophenolate sodium tbec B/D, NM NULOJIX B/D, NM PROGRAF PACK B/D, NM SANDIMMUNE SOLN 100mg/ml B/D, NM sirolimus SOLN; TABS B/D, NM tacrolimus CAPS B/D, NM ZORTRESS TAB 0.5MG B/D, NM ZORTRESS TAB 0.25MG B/D, NM ZORTRESS TAB 0.75MG B/D, NM ZORTRESS TAB 1MG B/D, NM

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Drug Name Requirements/Limits VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX DAPTACEL DIPHTHERIA/TETANUS TOXOID B/D ENGERIX-B SUSP B/D GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) B/D INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX M-M-R II MENACTRA MENVEO PEDIARIX PEDVAX HIB PENTACEL PROQUAD QUADRACEL RABAVERT B/D RECOMBIVAX HB B/D ROTARIX ROTATEQ SHINGRIX QL (2 vials per lifetime) TDVAX B/D TENIVAC B/D TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 klor-con 10 klor-con m10

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Drug Name Requirements/Limits klor-con m15 klor-con m20 klor-con pak 20meq klor-con spr cap 8meq klor-con spr cap 10meq MAGNESIUM SULFATE SOLN 2gm/50ml,

4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

MAGNESIUM SULFATE IN D5W magnesium sulfate in dextrose magnesium sulfate inj 50% potassium chloride CPCR potassium chloride PACK potassium chloride SOLN 10%, 20% potassium chloride TBCR potassium chloride microencapsulated crystals er sodium chloride SOLN 2.5meq/ml sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln TPN ELECTROLYTES B/D IV NUTRITION AMINOSYN II INJ 10% B/D AMINOSYN-PF 7% B/D CLINIMIX 4.25%/DEXTROSE 5% B/D CLINIMIX 5%/DEXTROSE 15% B/D CLINIMIX 5%/DEXTROSE 20% B/D CLINIMIX INJ 4.25/D10 B/D clinisol sf 15% B/D CLINOLIPID B/D FREAMINE HBC 6.9% B/D FREAMINE III B/D hepatamine B/D INTRALIPID 30% B/D INTRALIPID INJ 20% B/D NEPHRAMINE B/D NUTRILIPID INJ 20% B/D plenamine B/D PREMASOL 10% B/D PROCALAMINE B/D PROSOL B/D TRAVASOL B/D TROPHAMINE INJ 10% B/D

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Drug Name Requirements/Limits IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% dextrose 5% DEXTROSE 5% /ELECTROLYTE dextrose 5%/nacl 0.2% DEXTROSE 5%/NACL 0.3% dextrose 5%/nacl 0.9% dextrose 5%/nacl 0.45% dextrose 5%/nacl 0.225% dextrose 5%/potassium chl dextrose 10% flex contain DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% dextrose 10%/nacl 0.45% dextrose 50% dextrose in lactated ringers dextrose inj 70% ISOLYTE P ISOLYTE S kcl0.15%/d5w/nacl0.2% KCL 0.3%/D5W/NACL 0.9% kcl 0.3%/d5w/nacl 0.45% kcl 0.15%/d5w/nacl 0.9% KCL 0.15%/D5W/NACL 0.225% kcl 0.075%/d5w/nacl 0.45% kcl/d5w inj 0.3% kcl/d5w/nacl inj 0.22%/0.45% kcl/d5w/nacl inj .15/.45% kcl/nacl inj 0.3-0.9 kcl/nacl inj 0.15%-0.9% lactated ringer's NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W PLASMA-LYTE A PLASMA-LYTE-148 pot chloride inj 2meq/ml potassium chloride SOLN 2meq/ml POTASSIUM CHLORIDE SOLN .4meq/ml,

10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

potassium chloride in nacl sodium chloride SOLN 3%, 5% sodium chloride 0.45% sodium chloride inj 0.9%

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Drug Name Requirements/Limits VITAMINS calcitriol CAPS B/D calcitriol inj B/D calcitriol oral soln 1 mcg/ml B/D M-NATAL PLUS paricalcitol CAPS B/D PNV FOLIC ACID + IRON MUL PRENATAL PRENATAL PLUS PRENATAL PLUS LOW IRON RAYALDEE TRICARE OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc BLEPHAMIDE OINT neomycin-polymy-dexameth neomycin-polymyxin-hc (ophth) sulfacetamide sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone ZYLET ANTI-INFECTIVES AZASITE bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE CILOXAN OINT ciprofloxacin hcl (ophth) erythromycin (ophth) gatifloxacin (ophth) gentak gentamicin sulfate soln (ophth) MOXEZA moxifloxacin hcl (ophth) NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidin ofloxacin (ophth) polymyxin b-trimethoprim sulfacetamide sodium (ophth) tobramycin (ophth) trifluridine

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Drug Name Requirements/Limits ZIRGAN ANTI-INFLAMMATORIES ALREX bromfenac sodium (ophth) BROMSITE dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL FLAREX fluorometholone flurbiprofen sodium ILEVRO ketorolac tromethamine (ophth) LOTEMAX GEL; OINT loteprednol etabonate prednisolone acetate (ophth) PREDNISOLONE SODIUM PHOSPHATE (OPHTH) PROLENSA ANTIALLERGICS azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) LASTACAFT olopatadine hcl 0.2% PAZEO ZERVIATE ANTIGLAUCOMA ALPHAGAN P SOL 0.1% AZOPT betaxolol hcl (ophth) BETOPTIC-S brimonidine sol 0.2% brimonidine sol 0.15% carteolol hcl (ophth) COMBIGAN dorzolamide hcl dorzolamide hcl-timolol maleate latanoprost SOLN levobunolol hcl LUMIGAN PHOSPHOLINE IODIDE pilocarpine hcl SOLN RHOPRESSA SIMBRINZA

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Drug Name Requirements/Limits timolol maleate (ophth) soln timolol maleate gel timolol maleate ophth soln 0.5% (once-daily) travoprost MISCELLANEOUS ATROPINE SULFATE SOLN 1% CYSTARAN NM, LA, PA proparacaine hcl SOLN RESTASIS QL (60 single use vials / 30

days) RESTASIS MULTIDOSE QL (1 bottle / 30 days) RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA QL (60 blisters / 30 days) BEVESPI AEROSPHERE QL (1 inhaler / 30 days) COMBIVENT RESPIMAT QL (2 inhalers / 30 days) ipratropium-albuterol nebu B/D TRELEGY ELLIPTA QL (60 blisters / 30 days) ANTICHOLINERGICS ATROVENT HFA QL (2 inhalers / 30 days) INCRUSE ELLIPTA QL (30 blisters / 30 days) ipratropium bromide SOLN B/D ipratropium bromide (nasal) ANTIHISTAMINES azelastine spr 0.1% azelastine spr 0.15% cetirizine syrup cyproheptadine hcl SYRP; TABS PA; PA if 70 years and older diphenhydramine hcl inj 50mg/ml hydroxyzine hcl SYRP; TABS PA; PA if 70 years and older hydroxyzine hcl inj PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg PA; PA if 70 years and older levocetirizine dihydrochloride BETA AGONISTS albuterol sulfate AERS 108mcg/act QL (2 inhalers / 30 days);

(generic of Proair HFA) albuterol sulfate AERS 108mcg/act QL (2 inhalers / 30 days);

(generic of Ventolin HFA) albuterol sulfate NEBU B/D albuterol sulfate SYRP albuterol sulfate TABS albuterol sulfate TB12 levalbuterol hcl NEBU B/D levalbuterol hcl soln nebu conc 1.25 mg/0.5ml B/D

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Drug Name Requirements/Limits levalbuterol tartrate hfa QL (2 inhalers / 30 days) SEREVENT DISKUS QL (60 inhalations / 30

days) terbutaline sulfate TABS VENTOLIN HFA QL (2 inhalers / 30 days) LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS zafirlukast MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% B/D ARALAST NP NM, LA, PA DALIRESP epinephrine (anaphylaxis) .15mg/0.3ml,

.3mg/0.3ml (generic of EpiPen)

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

ESBRIET NM, PA FASENRA NM, LA, PA FASENRA PEN NM, LA, PA KALYDECO NM, PA NUCALA NM, LA, PA OFEV NM, PA ORKAMBI NM, PA PROLASTIN-C NM, LA, PA PULMOZYME NM, PA SYMDEKO NM, LA, PA SYMJEPI THEO-24 theophylline theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab sr 24hr TRIKAFTA NM, LA, PA XOLAIR NM, LA, PA ZEMAIRA NM, LA, PA NASAL STEROIDS flunisolide (nasal) QL (3 bottles / 30 days) fluticasone propionate (nasal) QL (1 bottle / 30 days) STEROID INHALANTS ARNUITY ELLIPTA QL (30 inhalations / 30

days) budesonide (inhalation) .25mg/2ml, .5mg/2ml B/D

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Drug Name Requirements/Limits FLOVENT DISKUS 50mcg/blist, 100mcg/blist QL (120 inhalations / 30

days) FLOVENT DISKUS 250mcg/blist QL (240 inhalations / 30

days) FLOVENT HFA QL (2 inhalers / 30 days) PULMICORT FLEXHALER QL (2 inhalers / 30 days) STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS QL (60 inhalations / 30

days) ADVAIR HFA QL (1 inhaler / 30 days) BREO ELLIPTA QL (60 blisters / 30 days) SYMBICORT QL (1 inhaler / 30 days) TOPICAL DERMATOLOGY, ACNE amnesteem PA avita QL (45 grams / 30 days), PA benzoyl peroxide-erythromycin claravis PA clindamycin phosphate (topical) GEL QL (75 grams / 30 days) clindamycin phosphate (topical) LOTN clindamycin phosphate (topical) SOLN QL (60 mL / 30 days) ery pad 2% erythromycin (acne aid) isotretinoin CAPS PA myorisan PA sulfacetamide sodium (acne) tretinoin CREA QL (45 grams / 30 days), PA tretinoin GEL .01%, .025% QL (45 grams / 30 days), PA zenatane PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) mupirocin OINT QL (220 grams / 30 days) silver sulfadiazine CREA ssd SULFAMYLON CREA DERMATOLOGY, ANTIFUNGALS ciclopirox CREA QL (90 grams / 30 days) ciclopirox SUSP QL (60 mL / 30 days) clotrimazole (topical) CREA clotrimazole (topical) SOLN QL (30 mL / 30 days) clotrimazole w/ betamethasone CREA ketoconazole cream QL (60 grams / 30 days) nyamyc QL (60 grams / 30 days) nystatin (topical) CREA; OINT

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Drug Name Requirements/Limits nystatin (topical) POWD QL (60 grams / 30 days) nystop QL (60 grams / 30 days) DERMATOLOGY, ANTIPSORIATICS acitretin PA calcipotriene CREA; OINT QL (120 grams / 30 days),

PA calcipotriene SOLN QL (120 mL / 30 days), PA calcitrene QL (120 grams / 30 days),

PA tazarotene CREA QL (60 grams / 30 days), PA TAZORAC CREA .05% QL (60 grams / 30 days), PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo selenium sulfide LOTN DERMATOLOGY, CORTICOSTEROIDS ala-cort alclometasone dipropionate betamethasone dipropionate (topical) betamethasone dipropionate augmented betamethasone valerate CREA; LOTN; OINT ENSTILAR QL (120 grams / 30 days),

PA fluocinolone acetonide CREA; OIL; OINT fluocinolone acetonide SOLN QL (90 mL / 30 days) fluocinolone acetonide oil body fluocinonide CREA .05% QL (120 grams / 30 days) fluocinonide GEL QL (60 grams / 30 days) fluocinonide OINT QL (60 grams / 30 days) fluocinonide SOLN QL (60 mL / 30 days) fluocinonide emulsified base QL (120 grams / 30 days) fluticasone propionate CREA; OINT halobetasol propionate CREA; OINT QL (50 grams / 30 days) hydrocortisone (topical) cream 1% hydrocortisone (topical) cream 2.5% hydrocortisone (topical) lotion 2.5% hydrocortisone (topical) oint 2.5% hydrocortisone butyrate cream 0.1% QL (45 grams / 30 days) hydrocortisone butyrate oint 0.1% QL (45 grams / 30 days) mometasone furoate CREA; OINT; SOLN TEXACORT SOLN 2.5% triamcinolone acetonide (topical) CREA .1% QL (454 grams / 30 days) triamcinolone acetonide (topical) CREA .025%,

.5%

triamcinolone acetonide (topical) LOTN

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Drug Name Requirements/Limits triamcinolone acetonide (topical) OINT .025%,

.1%, .5%

DERMATOLOGY, LOCAL ANESTHETICS glydo QL (30 mL / 30 days), PA lidocaine PTCH 5% QL (3 patches / 1 day), PA lidocaine hcl GEL QL (30 mL / 30 days), PA lidocaine hcl SOLN 4% QL (50 mL / 30 days), PA lidocaine oint 5% QL (50 grams / 30 days), PA lidocaine-prilocaine QL (30 grams / 30 days), PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN diclofenac sodium (topical) 1% gel QL (1000 grams / 30 days),

PA fluorouracil (topical) CREA 5% QL (40 grams / 30 days) fluorouracil (topical) SOLN QL (10 mL / 30 days) imiquimod CREA 5% QL (24 packets / 30 days) metronidazole (topical) CREA; LOTN metronidazole gel 0.75% PANRETIN QL (60 grams / 30 days) PICATO .05% QL (2 tubes / 30 days) PICATO .015% QL (3 tubes / 30 days) podofilox SOLN procto-med hc procto-pak proctosol hc cre 2.5% proctozone-hc RECTIV QL (30 grams / 30 days) rosadan cre 0.75% tacrolimus (topical) QL (100 grams / 30 days) TARGRETIN GEL QL (60 grams / 30 days),

NM, PA VALCHLOR QL (60 grams / 30 days),

NM, LA, PA DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion permethrin cre 5% DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% REGRANEX QL (30 grams / 30 days), PA SANTYL sodium chlor sol 0.9% irr water for irrigation, sterile MOUTH/THROAT/DENTAL AGENTS cevimeline hcl

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Drug Name Requirements/Limits chlorhexidine gluconate (mouth-throat) clotrimazole LOZG lidocaine hcl (mouth-throat) nystatin (mouth-throat) paroex sol 0.12% periogard pilocarpine hcl (oral) triamcinolone acetonide (mouth) OTIC acetic acid (otic) CIPRODEX flac fluocinolone acetonide (otic) neomycin-polymyxin-hc (otic) ofloxacin (otic)

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Index

A abacavir sulfate .............................. 12 abacavir sulfate-lamivudine .............. 13 abacavir sulfate-lamivudine-zidovudine .................................................... 13 ABELCET ....................................... 11 ABILIFY MAINTENA ......................... 31 abiraterone acetate ......................... 18 ABRAXANE ..................................... 17 acamprosate calcium ....................... 36 acarbose ....................................... 37 acebutolol hcl ................................. 24 acetaminophen w/ codeine 300-15mg 8 acetaminophen w/ codeine 300-30mg 8 acetaminophen w/ codeine 300-60mg 8 acetaminophen w/ codeine soln ......... 8 acetazolamide ................................ 25 acetic acid ..................................... 61 acetic acid (otic) ............................. 62 acetylcysteine ................................ 58 acitretin ........................................ 60 ACTHIB ......................................... 52 ACTIMMUNE ................................... 51 acyclovir ........................................ 14 acyclovir sodium ............................. 14 ADACEL ......................................... 52 adefovir dipivoxil ............................ 14 ADEMPAS ...................................... 26 adriamycin ..................................... 17 adrucil inj ...................................... 17 ADVAIR DISKUS ............................. 59 ADVAIR HFA .................................. 59 AFINITOR ...................................... 19 AFINITOR DISPERZ ......................... 19 AIMOVIG ....................................... 34 ala-cort ......................................... 60 albendazole ................................... 10 albuterol sulfate ............................. 57 alclometasone dipropionate .............. 60 ALDURAZYME ................................. 43 ALECENSA ..................................... 19 alendronate sodium soln 70mg/75ml . 39 alendronate sodium tab 10 mg ......... 39 alendronate sodium tab 35 mg ......... 39

alendronate sodium tab 40 mg ......... 39 alendronate sodium tab 5 mg ........... 39 alendronate sodium tab 70 mg ......... 39 alfuzosin hcl ................................... 48 ALIMTA ......................................... 17 ALINIA .......................................... 10 aliskiren fumarate ........................... 26 allopurinol tab .................................. 8 alosetron hcl .................................. 47 ALPHAGAN P SOL 0.1% ................... 56 alprazolam tab 0.25mg ................... 27 alprazolam tab 0.5mg ..................... 27 alprazolam tab 1mg ........................ 27 alprazolam tab 2 mg ....................... 27 ALREX ........................................... 56 altavera tab ................................... 40 ALUNBRIG ..................................... 19 alyacen 1/35 .................................. 40 amantadine hcl .............................. 31 AMBISOME .................................... 11 ambrisentan .................................. 26 amethia ........................................ 40 amethia lo ..................................... 40 amikacin sulfate ............................. 10 amiloride & hydrochlorothiazide ........ 25 amiloride hcl .................................. 25 AMINOSYN II INJ 10% .................... 53 AMINOSYN-PF 7% .......................... 53 amiodarone hcl soln ........................ 23 amiodarone tab 100mg ................... 23 amiodarone tab 200mg ................... 23 amiodarone tab 400mg ................... 23 AMITIZA CAP 24MCG ...................... 47 AMITIZA CAP 8MCG ........................ 47 amitriptyline hcl ............................. 29 amlodipine besylate ........................ 25 amlodipine besylate-benazepril hcl cap 10-20 mg ...................................... 22 amlodipine besylate-benazepril hcl cap 10-40 mg ...................................... 22 amlodipine besylate-benazepril hcl cap 2.5-10 mg ..................................... 22 amlodipine besylate-benazepril hcl cap 5-10 mg ........................................ 22

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amlodipine besylate-benazepril hcl cap 5-20 mg ........................................ 22 amlodipine besylate-benazepril hcl cap 5-40 mg ........................................ 22 amlodipine besylate-olmesartan medoxomil ..................................... 22 amlodipine besylate-valsartan tab ..... 23 amlodipine-valsartan-hydrochlorothiazide tab ................... 23 ammonium lactate .......................... 61 amnesteem .................................... 59 amoxapine ..................................... 30 amoxicillin ..................................... 15 amoxicillin & pot clavulanate 200/5ml susr .............................................. 15 amoxicillin & pot clavulanate 200-28.5 chw tabs ....................................... 15 amoxicillin & pot clavulanate 250/5ml susr .............................................. 15 amoxicillin & pot clavulanate 250-125 tabs .............................................. 15 amoxicillin & pot clavulanate 400/5ml susr .............................................. 15 amoxicillin & pot clavulanate 400-57 chw tabs ....................................... 15 amoxicillin & pot clavulanate 500-125 tabs .............................................. 16 amoxicillin & pot clavulanate 600/5ml susr .............................................. 16 amoxicillin & pot clavulanate 875-125 tabs .............................................. 16 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs .............................. 16 amphetamine-dextroamphetamine cap sr 24hr 10 mg ................................ 33 amphetamine-dextroamphetamine cap sr 24hr 15 mg ................................ 33 amphetamine-dextroamphetamine cap sr 24hr 20 mg ................................ 33 amphetamine-dextroamphetamine cap sr 24hr 25 mg ................................ 33 amphetamine-dextroamphetamine cap sr 24hr 30 mg ................................ 33 amphetamine-dextroamphetamine cap sr 24hr 5 mg .................................. 33

amphetamine-dextroamphetamine tab 10 mg ........................................... 33 amphetamine-dextroamphetamine tab 12.5 mg ........................................ 33 amphetamine-dextroamphetamine tab 15 mg ........................................... 33 amphetamine-dextroamphetamine tab 20 mg ........................................... 33 amphetamine-dextroamphetamine tab 30 mg ........................................... 33 amphetamine-dextroamphetamine tab 5 mg ............................................ 33 amphetamine-dextroamphetamine tab 7.5 mg .......................................... 33 amphotericin b ............................... 11 ampicillin & sulbactam sodium .......... 16 ampicillin cap 500mg ...................... 16 ampicillin inj .................................. 16 ampicillin sodium ............................ 16 ANADROL-50 ................................. 36 anagrelide hcl ................................ 49 anastrozole .................................... 18 ANDRODERM ................................. 36 ANORO ELLIPTA ............................. 57 APOKYN ........................................ 31 aprepitant ..................................... 46 aprepitant pak 80mg & 125mg ......... 46 apri .............................................. 40 APTIOM ......................................... 27 APTIVUS ....................................... 12 ARALAST NP .................................. 58 aranelle ......................................... 40 ARCALYST ..................................... 51 aripiprazole odt .............................. 31 aripiprazole oral solution 1 mg/ml ..... 31 aripiprazole tab .............................. 31 ARISTADA ..................................... 31 ARISTADA INITIO ........................... 31 armodafinil .................................... 36 ARNUITY ELLIPTA ........................... 58 ashlyna ......................................... 40 aspirin-dipyridamole ....................... 50 atazanavir sulfate ........................... 12 atenolol ......................................... 24 atenolol & chlorthalidone ................. 24

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atomoxetine hcl .............................. 33 atorvastatin calcium ........................ 23 atovaquone .................................... 10 atovaquone-proguanil hcl ................. 12 ATRIPLA ........................................ 13 ATROPINE SULFATE ........................ 57 ATROVENT HFA .............................. 57 aubra ............................................ 40 AURYXIA ....................................... 45 AUSTEDO ...................................... 35 AVASTIN ....................................... 17 aviane ........................................... 40 avita ............................................. 59 AYVAKIT ........................................ 19 azacitidine ..................................... 17 AZASITE ........................................ 55 azathioprine ................................... 51 azelastine drop 0.05% ..................... 56 azelastine spr 0.1% ........................ 57 azelastine spr 0.15%....................... 57 azithromycin .................................. 15 AZOPT .......................................... 56 aztreonam ..................................... 10 B bacitracin (ophthalmic) .................... 55 bacitracin-polymyxin b (ophth) ......... 55 bacitracin-poly-neomycin-hc ............ 55 baclofen ........................................ 35 balsalazide disodium ....................... 47 BALVERSA ..................................... 19 balziva .......................................... 40 BANZEL SUS 40MG/ML .................... 27 BANZEL TAB 200MG ........................ 27 BANZEL TAB 400MG ........................ 27 BARACLUDE ................................... 14 BASAGLAR KWIKPEN ....................... 36 BCG VACCINE ................................ 52 BD ALCOHOL SWABS ...................... 37 BD ULTRAFINE INSULIN SYRINGE ..... 37 BD ULTRAFINE/NANO PEN NEEDLES .. 37 bekyree ......................................... 40 BELSOMRA .................................... 34 benazepril & hydrochlorothiazide ....... 22 benazepril hcl ................................. 22 BENDEKA ...................................... 16

BENLYSTA ..................................... 51 benzoyl peroxide-erythromycin ......... 59 benztropine mesylate inj ................. 31 benztropine mesylate tab 0.5mg ....... 31 benztropine mesylate tab 1mg ......... 31 benztropine mesylate tab 2mg ......... 31 BEPREVE ....................................... 56 BERINERT ..................................... 49 BESIVANCE ................................... 55 betamethasone dipropionate (topical) 60 betamethasone dipropionate augmented .................................... 60 betamethasone valerate .................. 60 BETASERON ................................... 35 betaxolol hcl .................................. 24 betaxolol hcl (ophth) ....................... 56 bethanechol chloride ....................... 48 BETOPTIC-S ................................... 56 BEVESPI AEROSPHERE .................... 57 bexarotene .................................... 21 BEXSERO ...................................... 52 bicalutamide .................................. 18 BICILLIN L-A .................................. 16 BIKTARVY ...................................... 13 bisoprolol & hydrochlorothiazide ....... 24 bisoprolol fumarate ......................... 24 BIVIGAM ....................................... 51 BLEPHAMIDE.................................. 55 blisovi 24 fe ................................... 40 blisovi fe 1.5/30 ............................. 40 BOOSTRIX ..................................... 52 BORTEZOMIB ................................. 17 bosentan ....................................... 26 BOSULIF ....................................... 19 BRAFTOVI ..................................... 19 BREO ELLIPTA ................................ 59 briellyn ......................................... 40 BRILINTA ...................................... 50 brimonidine sol 0.15% .................... 56 brimonidine sol 0.2% ...................... 56 BRIVIACT INJ 50MG/5ML ................. 27 BRIVIACT SOL 10MG/ML .................. 27 BRIVIACT TAB 100MG ..................... 27 BRIVIACT TAB 10MG ....................... 27 BRIVIACT TAB 25MG ....................... 27

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BRIVIACT TAB 50MG ....................... 27 BRIVIACT TAB 75MG ....................... 27 bromfenac sodium (ophth) ............... 56 bromocriptine mesylate ................... 31 BROMSITE ..................................... 56 BRUKINSA ..................................... 19 budesonide (inhalation) ................... 58 budesonide ec ................................ 47 bumetanide inj 0.25/ml ................... 25 bumetanide tab .............................. 25 buprenorphine hcl ........................... 36 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........................... 36 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg .......................... 36 buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................. 36 buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................. 36 buprenorphine hcl-naloxone hcl sl ..... 36 bupropion hcl ................................. 30 bupropion hcl (smoking deterrent) .... 36 buspirone hcl ................................. 27 butorphanol tartrate ......................... 8 BYDUREON BCISE ........................... 37 BYDUREON PEN .............................. 37 BYETTA ......................................... 37 BYSTOLIC ...................................... 24 C cabergoline .................................... 45 CABOMETYX ................................... 20 calcipotriene .................................. 60 calcitonin (salmon) ......................... 45 calcitrene ...................................... 60 calcitriol ........................................ 55 calcitriol inj .................................... 55 calcitriol oral soln 1 mcg/ml ............. 55 calcium acetate (phosphate binder) ... 45 CALQUENCE ................................... 20 camila ........................................... 40 camrese lo ..................................... 40 candesartan cilexetil ....................... 23 candesartan cilexetil-hydrochlorothiazide ......................... 23 CAPLYTA ....................................... 31

CAPRELSA ..................................... 20 captopril ........................................ 22 captopril & hydrochlorothiazide ......... 22 CARBAGLU .................................... 43 carbamazepine ............................... 27 carbidopa/levodopa/entacapone ....... 31 carbidopa-levodopa ........................ 31 carboplatin .................................... 21 carisoprodol ................................... 36 carteolol hcl (ophth) ........................ 56 cartia xt ........................................ 25 carvedilol ...................................... 24 caspofungin acetate ........................ 11 CAYSTON ...................................... 10 caziant pak .................................... 40 cefaclor ......................................... 14 CEFACLOR ER TAB 500MG ............... 14 cefadroxil ...................................... 14 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ............................................... 14 cefazolin inj ................................... 14 cefazolin sodium ............................. 14 CEFAZOLIN SODIUM 1 GM/50ML ...... 14 cefdinir ......................................... 14 cefepime for inj .............................. 14 cefixime ........................................ 14 cefoxitin for inj ............................... 15 cefpodoxime proxetil ....................... 15 cefprozil ........................................ 15 ceftazidime .................................... 15 CEFTAZIDIME/DEXTROSE ................ 15 ceftriaxone sodium ......................... 15 cefuroxime axetil ............................ 15 cefuroxime sodium ......................... 15 celecoxib ......................................... 8 CELONTIN ..................................... 27 cephalexin ..................................... 15 CERDELGA ..................................... 43 CEREZYME ..................................... 43 cetirizine syrup ............................... 57 cevimeline hcl ................................ 61 CHANTIX ....................................... 36 CHANTIX CONTINUING MONTH ........ 36 CHANTIX STARTER PACK ................. 36 CHEMET ........................................ 39

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chlorhexidine gluconate (mouth-throat) .................................................... 62 chloroquine phosphate .................... 12 chlorothiazide ................................ 25 chlorpromazine hcl .......................... 31 CHLORPROMAZINE INJ .................... 31 chlorthalidone ................................ 25 cholestyramine ............................... 24 cholestyramine light pack ................ 24 cholestyramine light powd ............... 24 ciclopirox ....................................... 59 cilostazol ....................................... 49 CILOXAN ....................................... 55 CIMDUO ........................................ 13 cinacalcet hcl ................................. 45 CIPRO ........................................... 15 CIPRODEX ..................................... 62 ciprofloxacin hcl (ophth) .................. 55 ciprofloxacin hcl tab ........................ 15 ciprofloxacin in d5w ........................ 15 cisplatin ........................................ 21 citalopram hydrobromide ................. 30 claravis ......................................... 59 clarithromycin ................................ 15 clarithromycin er ............................ 15 clarithromycin for susp .................... 15 clindamycin cap 300 mg .................. 10 clindamycin cap 75mg ..................... 10 clindamycin hcl cap 150 mg ............. 10 clindamycin phosphate (topical) ........ 59 clindamycin phosphate in d5w .......... 10 CLINDAMYCIN PHOSPHATE IN NACL .. 10 clindamycin phosphate inj ................ 10 clindamycin phosphate vaginal ......... 48 clindamycin soln 75mg/5ml .............. 10 CLINIMIX 4.25%/DEXTROSE 5% ...... 53 CLINIMIX 5%/DEXTROSE 15% ......... 53 CLINIMIX 5%/DEXTROSE 20% ......... 53 CLINIMIX INJ 4.25/D10 ................... 53 clinisol sf 15% ................................ 53 CLINOLIPID ................................... 53 clobazam ....................................... 27 clomipramine hcl ............................ 30 clonazepam ................................... 27 clonidine hcl ................................... 26

clonidine hcl ptwk ........................... 26 clopidogrel tab 75mg ...................... 50 clorazepate dipotassium .................. 27 clotrimazole ................................... 62 clotrimazole (topical) ...................... 59 clotrimazole w/ betamethasone ........ 59 clovique ........................................ 39 clozapine odt ........................... 31, 32 clozapine tab 100mg ....................... 32 clozapine tab 200mg ....................... 32 clozapine tab 25mg ......................... 32 clozapine tab 50mg ......................... 32 COARTEM ...................................... 12 colchicine w/ probenecid .................... 8 COLCRYS ......................................... 8 colesevelam hcl .............................. 24 colestipol hcl gran ........................... 24 colestipol hcl pack .......................... 24 colestipol hcl tabs ........................... 24 colistimethate sodium ..................... 10 colocort ......................................... 47 COMBIGAN .................................... 56 COMBIVENT RESPIMAT .................... 57 COMETRIQ ..................................... 20 COMPLERA .................................... 13 compro supp .................................. 46 constulose ..................................... 47 COPIKTRA ..................................... 20 CORLANOR .................................... 26 cortisone acetate ............................ 44 COTELLIC ...................................... 20 COUMADIN .................................... 49 CREON .......................................... 48 CRIXIVAN ...................................... 12 cromolyn sod neb 20mg/2ml ............ 58 cromolyn sodium (mastocytosis) ....... 47 cromolyn sodium (ophth) ................. 56 cryselle-28 .................................... 40 cyclafem 1/35 ................................ 40 cyclafem 7/7/7 ............................... 40 cyclobenzaprine hcl ......................... 36 cyclophosphamide .......................... 16 cycloserine .................................... 13 cyclosporine ................................... 51 cyclosporine modified (for

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microemulsion) .............................. 51 cyproheptadine hcl .......................... 57 cyred tab ....................................... 40 CYSTADANE ................................... 43 CYSTAGON .................................... 43 CYSTARAN ..................................... 57 cytarabine ..................................... 17 D dalfampridine ................................. 35 DALIRESP ...................................... 58 danazol ......................................... 43 dantrolene sodium .......................... 36 dapsone ........................................ 10 DAPTACEL ..................................... 52 daptomycin .................................... 10 dasetta 1/35 .................................. 40 dasetta 7/7/7 ................................. 40 DAURISMO .................................... 17 deblitane ....................................... 40 deferasirox tab ............................... 39 DELESTROGEN ............................... 44 DELSTRIGO ................................... 13 DEMSER ........................................ 26 DEPO-PROVERA INJ 400/ML ............. 18 DESCOVY ...................................... 13 desipramine hcl .............................. 30 desmopressin acetate spray ............. 46 desmopressin acetate spray refrigerated .................................................... 46 desmopressin acetate tabs ............... 46 desmopressin inj 4mcg/ml ............... 46 desogestrel & ethinyl estradiol .......... 40 desogestrel-ethinyl estradiol (biphasic) .................................................... 40 desvenlafaxine succinate ................. 30 dexamethasone .............................. 44 DEXAMETHASONE ........................... 44 dexamethasone sodium phosphate .... 44 dexamethasone sodium phosphate (ophth) ......................................... 56 DEXILANT ...................................... 48 dexmethylphenidate hcl ............. 33, 34 dextrose 10% flex contain ............... 54 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ............................................ 54

dextrose 10%/nacl 0.45% ............... 54 dextrose 2.5%/nacl 0.45% .............. 54 dextrose 5% .................................. 54 DEXTROSE 5% /ELECTROLYTE ......... 54 dextrose 5%/nacl 0.2% ................... 54 dextrose 5%/nacl 0.225% ............... 54 DEXTROSE 5%/NACL 0.3% .............. 54 dextrose 5%/nacl 0.45% ................. 54 dextrose 5%/nacl 0.9% ................... 54 dextrose 5%/potassium chl .............. 54 dextrose 50% ................................ 54 dextrose in lactated ringers .............. 54 dextrose inj 70% ............................ 54 DIASTAT ACUDIAL .......................... 27 DIASTAT PEDIATRIC ....................... 27 diazepam ...................................... 27 diazepam gel ................................. 27 diazepam inj .................................. 27 diazepam intensol ........................... 27 diazepam oral soln 1 mg/ml ............. 28 diazoxide ....................................... 44 diclofenac potassium ......................... 8 diclofenac sodium ............................. 8 diclofenac sodium (ophth) ................ 56 diclofenac sodium (topical) 1% gel .... 61 dicloxacillin sodium ......................... 16 dicyclomine hcl cap 10mg ................ 46 dicyclomine hcl soln 10mg/5ml ......... 46 dicyclomine hcl tab 20mg ................ 46 didanosine ..................................... 12 DIFICID ........................................ 15 diflunisal ......................................... 8 digitek .......................................... 25 digox ............................................ 25 digoxin .......................................... 25 digoxin inj ..................................... 25 digoxin sol 50mcg/ml ...................... 25 dihydroergotamine mesylate inj 1 mg/ml........................................... 34 dihydroergotamine mesylate nasal spr 4 mg/ml........................................... 34 DILANTIN CAP 100MG ..................... 28 DILANTIN CAP 30MG ....................... 28 DILANTIN CHEW TAB 50MG ............. 28 DILANTIN-125 SUSP ....................... 28

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diltiazem cap 240mg cd ................... 25 diltiazem cap 360mg cd ................... 25 diltiazem cap er/12hr ...................... 25 diltiazem hcl .................................. 25 diltiazem hcl coated beads ............... 25 diltiazem hcl coated beads cap sr 24hr .................................................... 25 diltiazem hcl extended release beads cap sr ........................................... 25 diltiazem inj ................................... 25 dilt-xr cap ...................................... 25 diphenhydramine hcl inj 50mg/ml ..... 57 diphenoxylate w/ atropine ................ 47 DIPHTHERIA/TETANUS TOXOID ........ 52 disopyramide phosphate .................. 23 disulfiram ...................................... 36 divalproex sodium .......................... 28 docetaxel ...................................... 17 DOCETAXEL ................................... 17 dofetilide ....................................... 23 donepezil hydrochloride ................... 29 dorzolamide hcl .............................. 56 dorzolamide hcl-timolol maleate ....... 56 DOVATO ........................................ 13 doxazosin mesylate ......................... 22 doxepin hcl .................................... 30 doxepin hcl (sleep) ......................... 34 doxorubicin hcl ............................... 17 doxorubicin hcl liposomal ................. 17 doxy 100 ....................................... 16 doxycycline (monohydrate) .............. 16 doxycycline hyclate ......................... 16 doxycycline hyclate 100 mg ............. 16 doxycycline hyclate 20 mg ............... 16 DRIZALMA SPRINKLE ...................... 30 dronabinol ..................................... 46 drospirenone-ethinyl estradiol .......... 40 drospirenone-ethinyl estradiol-levomefolate calcium ....................... 40 DROXIA ......................................... 49 duloxetine hcl ................................ 30 DUREZOL ...................................... 56 dutasteride .................................... 48 dutasteride-tamsulosin hcl ............... 48

E e.e.s. 400 ...................................... 15 EDURANT ...................................... 12 efavirenz ....................................... 12 eletriptan hydrobromide .................. 34 ELIQUIS ........................................ 49 ELIQUIS STARTER PACK .................. 49 ELLA ............................................. 40 eluryng ......................................... 40 EMCYT .......................................... 16 EMEND .......................................... 46 EMGALITY ..................................... 34 emoquette ..................................... 40 EMSAM ......................................... 30 EMTRIVA ....................................... 12 EMVERM ........................................ 10 enalapril maleate ............................ 22 enalapril maleate & hydrochlorothiazide .................................................... 22 ENBREL ......................................... 50 ENBREL MINI ................................. 50 ENBREL SURECLICK ........................ 50 ENDARI ......................................... 49 endocet 10-325mg ........................... 8 endocet 2.5-325mg .......................... 8 endocet 5-325mg ............................. 8 endocet 7.5-325mg .......................... 8 ENGERIX-B .................................... 52 enoxaparin sodium ......................... 49 enpresse-28 .................................. 40 enskyce ........................................ 40 ENSTILAR ...................................... 60 entacapone .................................... 31 entecavir ....................................... 14 ENTRESTO ..................................... 23 enulose ......................................... 47 EPCLUSA ....................................... 14 EPIDIOLEX .................................... 28 epinephrine (anaphylaxis) ................ 58 epirubicin hcl ................................. 17 epitol ............................................ 28 EPIVIR HBV ................................... 14 eplerenone .................................... 22 ergotamine w/ caffeine .................... 34 ERIVEDGE ..................................... 17

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ERLEADA ....................................... 18 erlotinib hcl .................................... 20 errin ............................................. 40 ertapenem sodium .......................... 10 ery pad 2% .................................... 59 ery-tab .......................................... 15 ERYTHROCIN LACTOBIONATE ........... 15 erythrocin stearate ......................... 15 erythromycin (acne aid) .................. 59 erythromycin (ophth) ...................... 55 erythromycin base .......................... 15 erythromycin cap 250mg ec ............. 15 erythromycin ethylsuccinate ............. 15 erythromycin tab ec ........................ 15 ESBRIET ........................................ 58 escitalopram oxalate ....................... 30 esomeprazole magnesium ................ 48 estarylla tab 0.25-35 ....................... 40 estradiol ........................................ 44 estradiol vaginal cream ................... 44 estradiol vaginal tab ........................ 44 estradiol valerate inj ....................... 44 eszopiclone .................................... 34 ethambutol hcl ............................... 13 ethosuximide ................................. 28 ethynodiol diacet & eth estrad .......... 41 ethynodiol tab 1-50 ........................ 41 etodolac ......................................... 8 etonogestrel-ethinyl estradiol ........... 41 etoposide ...................................... 22 euthyrox ....................................... 45 everolimus ..................................... 20 everolimus (immunosuppressant) ..... 51 EVOTAZ ........................................ 13 exemestane ................................... 18 ezetimibe ...................................... 24 ezetimibe-simvastatin ..................... 24 F FABRAZYME ................................... 43 falmina ......................................... 41 famciclovir ..................................... 14 famotidine ............................... 46, 47 famotidine in nacl ........................... 47 famotidine inj ................................. 47 FANAPT ......................................... 32

FANAPT TITRATION PACK ................ 32 FARXIGA ....................................... 37 FARYDAK ....................................... 17 FASENRA ....................................... 58 FASENRA PEN ................................ 58 fayosim ......................................... 41 felbamate ...................................... 28 felodipine ...................................... 25 femynor ........................................ 41 fenofibrate ..................................... 24 fenofibrate micronized ..................... 24 fentanyl citrate ................................. 9 fentanyl patch 100 mcg/hr ................. 9 fentanyl patch 12 mcg/hr .................. 9 fentanyl patch 25 mcg/hr .................. 9 fentanyl patch 50 mcg/hr .................. 9 fentanyl patch 75 mcg/hr .................. 9 FETZIMA ....................................... 30 FETZIMA TITRATION PACK ............... 30 FIASP ........................................... 37 FIASP FLEXTOUCH .......................... 37 FIASP PENFILL ............................... 37 finasteride ..................................... 48 flac ............................................... 62 FLAREX ......................................... 56 flecainide acetate ........................... 23 FLOVENT DISKUS ........................... 59 FLOVENT HFA ................................ 59 fluconazole .................................... 11 fluconazole inj nacl 200 ................... 11 fluconazole inj nacl 400 ................... 11 flucytosine ..................................... 11 fludrocortisone acetate .................... 44 flunisolide (nasal) ........................... 58 fluocinolone acetonide ..................... 60 fluocinolone acetonide (otic) ............ 62 fluocinolone acetonide oil body ......... 60 fluocinonide ................................... 60 fluocinonide emulsified base ............. 60 fluorometholone ............................. 56 fluorouracil .................................... 17 fluorouracil (topical) ........................ 61 fluoxetine cap 10mg ....................... 30 fluoxetine cap 20mg ....................... 30 fluoxetine cap 40mg ....................... 30

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fluoxetine hcl ................................. 30 fluphenazine decanoate ................... 32 fluphenazine hcl ............................. 32 flurbiprofen ..................................... 8 flurbiprofen sodium ......................... 56 flutamide ....................................... 18 fluticasone propionate ..................... 60 fluticasone propionate (nasal) .......... 58 fluvoxamine maleate ....................... 27 fondaparinux sodium ....................... 49 FORTEO ........................................ 45 fosamprenavir tab 700 mg ............... 12 fosinopril sodium ............................ 22 fosinopril sodium & hydrochlorothiazide .................................................... 22 FREAMINE HBC 6.9% ...................... 53 FREAMINE III ................................. 53 fulvestrant ..................................... 18 furosemide .................................... 25 furosemide inj ................................ 25 FUZEON ........................................ 12 fyavolv .......................................... 44 FYCOMPA ...................................... 28 G gabapentin .................................... 28 galantamine hydrobromide............... 29 galantamine hydrobromide er ........... 29 GAMASTAN S/D .............................. 51 GAMMAGARD LIQUID ...................... 51 GAMMAGARD S/D ........................... 51 GAMMAKED ................................... 51 GAMMAPLEX .................................. 51 GAMMAPLEX 10GM/100ML ............... 51 GAMUNEX-C ................................... 51 ganciclovir sodium .......................... 14 GARDASIL 9 .................................. 52 gatifloxacin (ophth) ......................... 55 GATTEX ......................................... 47 GAUZE PADS 2 ............................... 37 gavilyte-c ...................................... 47 gavilyte-g ...................................... 47 gavilyte-n/flavor pack ..................... 47 gemcitabine inj soln ........................ 17 gemcitabine inj solr ......................... 17 gemfibrozil .................................... 24

generlac ........................................ 47 gengraf ......................................... 51 GENOTROPIN ................................. 45 GENOTROPIN MINIQUICK ................ 45 gentak .......................................... 55 gentamicin in saline ........................ 10 gentamicin sulfate .......................... 10 gentamicin sulfate (topical) .............. 59 gentamicin sulfate soln (ophth) ........ 55 GENVOYA ...................................... 13 GEODON ....................................... 32 gianvi tab 3-0.02mg ....................... 41 GILENYA ....................................... 35 GILOTRIF TAB 20MG ....................... 20 GILOTRIF TAB 30MG ....................... 20 GILOTRIF TAB 40MG ....................... 20 glatiramer acetate 20mg/ml ............. 35 glatiramer acetate 40mg/ml ............. 35 glatopa ......................................... 35 GLEOSTINE.................................... 17 glimepiride .................................... 37 glip/metform tab 2.5-250mg ............ 37 glip/metform tab 2.5-500mg ............ 37 glip/metform tab 5-500mg ............... 37 glipizide ........................................ 38 glipizide xl ..................................... 38 GLUCAGEN HYPOKIT ....................... 44 GLUCAGON EMERGENCY KIT ............ 45 glyburide ....................................... 38 glyburide micronized ....................... 38 glyburide-metformin tab 1.25-250 mg .................................................... 38 glyburide-metformin tab 2.5-500 mg . 38 glyburide-metformin tab 5-500mg .... 38 glycopyrrolate tab 1mg ................... 46 glycopyrrolate tab 2mg ................... 46 glydo ............................................ 61 GLYXAMBI ..................................... 38 GOLYTELY ..................................... 47 granisetron hcl ............................... 46 griseofulvin microsize ...................... 11 griseofulvin ultramicrosize ............... 11 guanfacine er (adhd) ....................... 34 GVOKE HYPOPEN 2-PACK ................. 45 GVOKE PFS .................................... 45

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H HAEGARDA .................................... 49 hailey 24 fe.................................... 41 halobetasol propionate .................... 60 haloperidol .................................... 32 haloperidol conc 2mg/ml .................. 32 haloperidol decanoate ..................... 32 haloperidol lactate inj 5mg/ml .......... 32 HARVONI ....................................... 14 HAVRIX ......................................... 52 heather ......................................... 41 heparin sod (porcine) in d5w ............ 49 heparin sod inj 1000/ml ................... 49 heparin sod inj 10000/ml ................. 49 heparin sod inj 20000/ml ................. 49 heparin sod inj 5000/ml ................... 49 HEPARIN SODIUM/NACL 0.45% ........ 49 hepatamine ................................... 53 HERCEPTIN .................................... 17 HERCEPTIN HYLECTA ...................... 17 HERZUMA ...................................... 17 HETLIOZ ....................................... 34 HIBERIX ........................................ 52 HUMIRA ........................................ 50 HUMIRA INJ 10MG/0.2ML ................ 50 HUMIRA KIT 20MG/0.4ML ................ 50 HUMIRA KIT 40MG/0.8ML ................ 50 HUMIRA PEDIATRIC CROHNS DISEASE .................................................... 50 HUMIRA PEN .................................. 50 HUMIRA PEN CD/UC/HS STARTER ..... 50 HUMIRA PEN INJ CD/UC/HS STARTER 50 HUMIRA PEN INJ PS/UV STARTER ..... 50 HUMIRA PEN-PS/UV STARTER .......... 50 HUMULIN R INJ U-500 ..................... 37 HUMULIN R U-500 KWIKPEN ............ 37 hydralazine hcl ............................... 26 hydrochlorothiazide ......................... 26 hydroco/apap tab 10-325mg ............. 9 hydroco/apap tab 5-325mg ............... 9 hydroco/apap tab 7.5-325 ................ 9 hydrocodone-acetaminophen 7.5-325 mg/15ml ........................................ 9 hydrocodone-ibuprofen tab 7.5-200 mg ..................................................... 9

hydrocortisone ............................... 44 hydrocortisone (enema) .................. 47 hydrocortisone (topical) cream 1% ... 60 hydrocortisone (topical) cream 2.5% . 60 hydrocortisone (topical) lotion 2.5% .. 60 hydrocortisone (topical) oint 2.5% .... 60 hydrocortisone butyrate cream 0.1% . 60 hydrocortisone butyrate oint 0.1% .... 60 hydromorphone hcl ........................... 9 hydroxychloroquine sulfate .............. 50 hydroxyurea .................................. 21 hydroxyzine hcl .............................. 57 hydroxyzine hcl inj .......................... 57 hydroxyzine pamoate ...................... 57 HYSINGLA ER ................................... 9 I ibandronate sodium tabs ................. 39 IBRANCE ....................................... 18 ibu tab 600mg ................................. 8 ibu tab 800mg ................................. 8 ibuprofen ........................................ 8 icatibant acetate ............................. 49 ICLUSIG ........................................ 20 IDHIFA .......................................... 18 ILEVRO ......................................... 56 imatinib mesylate ........................... 20 IMBRUVICA ................................... 20 imipenem-cilastatin ........................ 10 imipramine hcl ............................... 30 imiquimod ..................................... 61 IMOVAX RABIES (H.D.C.V.) .............. 52 incassia ......................................... 41 INCRELEX ...................................... 45 INCRUSE ELLIPTA ........................... 57 indapamide .................................... 26 INFANRIX ...................................... 52 INGREZZA ..................................... 35 INLYTA .......................................... 20 INREBIC ........................................ 20 INSULIN PEN NEEDLE ..................... 37 INSULIN SAFETY NEEDLES ............... 37 INSULIN SYRINGE .......................... 37 INTELENCE .................................... 12 INTRALIPID 30% ............................ 53 INTRALIPID INJ 20% ...................... 53

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INTRON-A INJ 10MU ....................... 51 INTRON-A INJ 18MU ....................... 51 INTRON-A INJ 25MU ....................... 51 INTRON-A INJ 50MU ....................... 51 introvale ........................................ 41 INVEGA SUST INJ 117 MG/0.75 ML ... 32 INVEGA SUST INJ 156MG/ML ........... 32 INVEGA SUST INJ 234 MG/1.5 ML ..... 32 INVEGA SUST INJ 39 MG/0.25 ML ..... 32 INVEGA SUST INJ 78 MG/0.5 ML ....... 32 INVEGA TRINZA ............................. 32 INVIRASE ...................................... 12 IPOL INACTIVATED IPV ................... 52 ipratropium bromide ....................... 57 ipratropium bromide (nasal) ............. 57 ipratropium-albuterol nebu .............. 57 irbesartan ...................................... 23 irbesartan-hydrochlorothiazide ......... 23 IRESSA ......................................... 20 irinotecan hcl ................................. 22 ISENTRESS .................................... 12 ISENTRESS HD ............................... 12 isibloom ........................................ 41 ISOLYTE P ..................................... 54 ISOLYTE S ..................................... 54 isoniazid ........................................ 13 isoniazid syp 50mg/5ml ................... 13 isosorb mononitrate tab ................... 26 isosorbide dinitrate ......................... 26 isosorbide mononitrate er ................ 26 isotretinoin .................................... 59 isradipine ...................................... 25 itraconazole ................................... 11 ivermectin ..................................... 10 IXIARO .......................................... 52 J JADENU ......................................... 39 JADENU SPRINKLE .......................... 39 JAKAFI .......................................... 20 jantoven ........................................ 49 JANUMET ....................................... 38 JANUMET XR TAB 100-1000 ............. 38 JANUMET XR TAB 50-1000 ............... 38 JANUMET XR TAB 50-500MG ............ 38 JANUVIA ........................................ 38

JARDIANCE .................................... 38 jasmiel .......................................... 41 JENTADUETO ................................. 38 JENTADUETO TAB XR 2.5-1000 MG ... 38 JENTADUETO TAB XR 5-1000 MG ...... 38 jinteli ............................................ 44 jolessa tab 0.15-0.03 mg ................. 41 jolivette ........................................ 41 juleber .......................................... 41 JULUCA ......................................... 13 junel 1.5/30 ................................... 41 junel 1/20 ..................................... 41 junel fe 1.5/30 ............................... 41 junel fe 1/20 .................................. 41 junel fe 24 ..................................... 41 JUXTAPID ...................................... 24 K KADCYLA ....................................... 18 kaitlib fe ........................................ 41 KALETRA TAB 100-25MG ................. 13 KALETRA TAB 200-50MG ................. 13 KALYDECO ..................................... 58 KANJINTI ...................................... 18 kariva ........................................... 41 kcl 0.075%/d5w/nacl 0.45% ............ 54 KCL 0.15%/D5W/NACL 0.225% ........ 54 kcl 0.15%/d5w/nacl 0.9% ............... 54 kcl 0.3%/d5w/nacl 0.45% ............... 54 KCL 0.3%/D5W/NACL 0.9% ............. 54 kcl/d5w inj 0.3% ............................ 54 kcl/d5w/nacl inj .15/.45%................ 54 kcl/d5w/nacl inj 0.22%/0.45% ......... 54 kcl/nacl inj 0.15%-0.9% .................. 54 kcl/nacl inj 0.3-0.9 ......................... 54 kcl0.15%/d5w/nacl0.2% ................. 54 kelnor 1/35 .................................... 41 kelnor 1/50 .................................... 41 ketoconazole .................................. 11 ketoconazole cream ........................ 59 ketoconazole shampoo .................... 60 ketorolac tromethamine (ophth) ....... 56 KEYTRUDA ..................................... 18 KINRIX ......................................... 52 kionex sus 15gm/60ml .................... 40 KISQALI ........................................ 18

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KISQALI FEMARA 200 DOSE ............. 18 KISQALI FEMARA 400 DOSE ............. 18 KISQALI FEMARA 600 DOSE ............. 18 klor-con 10 .................................... 52 klor-con 8 ...................................... 52 klor-con m10 ................................. 52 klor-con m15 ................................. 53 klor-con m20 ................................. 53 klor-con pak 20meq ........................ 53 klor-con spr cap 10meq ................... 53 klor-con spr cap 8meq ..................... 53 KORLYM ........................................ 45 kurvelo ......................................... 41 KUVAN .......................................... 43 L labetalol hcl ................................... 24 lactated ringer's ............................. 54 lactulose ........................................ 47 lactulose (encephalopathy) .............. 47 lamivudine ..................................... 12 lamivudine (hbv) ............................ 14 lamivudine-zidovudine ..................... 13 lamotrigine .................................... 28 lansoprazole .................................. 48 larin 1.5/30 ................................... 41 larin 1/20 ...................................... 41 larin fe 1.5/30 ................................ 41 larin fe 1/20 ................................... 41 larissia tab ..................................... 41 LASTACAFT .................................... 56 latanoprost .................................... 56 LATUDA ......................................... 32 layolis fe ....................................... 41 leena tab ....................................... 41 leflunomide .................................... 50 LENVIMA 10 MG DAILY DOSE ........... 20 LENVIMA 12MG DAILY DOSE ............ 20 LENVIMA 14 MG DAILY DOSE ........... 20 LENVIMA 18 MG DAILY DOSE ........... 20 LENVIMA 20 MG DAILY DOSE ........... 20 LENVIMA 24 MG DAILY DOSE ........... 20 LENVIMA 4 MG DAILY DOSE ............. 20 LENVIMA 8 MG DAILY DOSE ............. 20 lessina .......................................... 41 letrozole ........................................ 18

leucovorin calcium .......................... 22 LEUKERAN ..................................... 17 leuprolide inj 1mg/0.2 ..................... 19 levalbuterol hcl ............................... 57 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...................................... 57 levalbuterol tartrate hfa ................... 58 LEVEMIR ....................................... 37 LEVEMIR FLEXTOUCH ...................... 37 levetiracetam ................................. 28 levetiracetam in sodium chloride ....... 28 levetiracetam oral soln 100 mg/ml .... 28 levobunolol hcl ............................... 56 levocarnitine (metabolic modifiers) ... 43 levocetirizine dihydrochloride ........... 57 levofloxacin ................................... 15 levofloxacin in d5w ......................... 15 levofloxacin inj 25mg/ml ................. 15 levofloxacin oral soln 25 mg/ml ........ 15 levonest ........................................ 41 levonor/ethi tab ............................. 41 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg 41 levonorgestrel & eth estradiol ........... 41 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) ............................ 41 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ..................... 41 levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7) .................. 41 levora 0.15/30-28 .......................... 42 levo-t ............................................ 45 levothyroxine sodium ...................... 46 levoxyl .......................................... 46 LEXIVA.......................................... 12 lidocaine ....................................... 61 lidocaine hcl ................................... 61 lidocaine hcl (local anesth.) .............. 10 lidocaine hcl (mouth-throat) ............. 62 lidocaine inj 0.5% ........................... 10 lidocaine inj 1% ............................. 10 lidocaine inj 1.5% preservative free (pf) .................................................... 10 lidocaine oint 5% ............................ 61 lidocaine-prilocaine ......................... 61

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linezolid in sodium chloride .............. 10 linezolid inj .................................... 11 linezolid susp ................................. 11 linezolid tab 600mg ......................... 11 LINZESS ........................................ 47 liothyronine sodium ........................ 46 lisinopril ........................................ 22 lisinopril & hydrochlorothiazide ......... 22 lithium carbonate............................ 35 lithium carbonate er ........................ 35 LITHIUM SOLN 8MEQ/5ML ............... 35 LOKELMA ....................................... 40 LONSURF ....................................... 21 loperamide hcl ............................... 47 lopinavir-ritonavir ........................... 13 lorazepam ..................................... 27 lorazepam intensol .......................... 27 LORBRENA ..................................... 20 lorcet hd tab 10-325mg .................... 9 lorcet plus tab 7.5-325 ..................... 9 lorcet tab 5-325mg .......................... 9 loryna ........................................... 42 losartan potassium ......................... 23 losartan-hydrochlorothiazide ............ 23 LOTEMAX ...................................... 56 loteprednol etabonate ..................... 56 lovastatin ...................................... 23 low-ogestrel ................................... 42 loxapine succinate .......................... 32 LUMIGAN ....................................... 56 LUMIZYME ..................................... 43 LUPRON DEPOT (1-MONTH) ............. 19 LUPRON DEPOT INJ 11.25MG (3-MONTH) ........................................ 19 LUPRON DEPOT-PED (1-MONTH ........ 45 LUPRON DEPOT-PED (3-MONTH ........ 45 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ........................................ 45 LUPRON DEP-PED INJ 7.5MG ............ 45 lutera ............................................ 42 LYNPARZA ..................................... 18 LYRICA CR ..................................... 35 LYSODREN ..................................... 19 lyza .............................................. 42

M magnesium sulfate ......................... 53 MAGNESIUM SULFATE ..................... 53 MAGNESIUM SULFATE IN D5W ......... 53 magnesium sulfate in dextrose ......... 53 magnesium sulfate inj 50% .............. 53 malathion ...................................... 61 maprotiline hcl ............................... 30 marlissa ........................................ 42 MARPLAN TAB 10MG ....................... 30 MATULANE .................................... 21 MAVYRET ...................................... 14 meclizine hcl .................................. 46 medroxyprogesterone acetate (contraceptive) .............................. 42 medroxyprogesterone acetate tab ..... 45 mefloquine hcl ............................... 12 megestrol ac sus 40mg/ml ............... 19 megestrol ac tab 20mg .................... 19 megestrol ac tab 40mg .................... 19 megestrol sus 625mg/5ml ............... 19 MEKINIST ...................................... 20 MEKTOVI ....................................... 20 melodetta 24 fe .............................. 42 meloxicam ....................................... 8 memantine hcl cp24 ........................ 29 memantine soln ............................. 29 memantine tabs ............................. 29 memantine titration pak .................. 29 MENACTRA .................................... 52 MENVEO ........................................ 52 mercaptopurine .............................. 17 meropenem ................................... 11 mesalamine ................................... 47 mesalamine w/ cleanser .................. 47 MESNEX ........................................ 22 metadate er tab 20mg .................... 34 metformin er ................................. 38 metformin hcl ................................ 38 methadone hcl ................................. 9 methadone hcl 10mg ........................ 9 methadone hcl 5mg .......................... 9 methadone hcl intensol ..................... 9 methazolamide ............................... 26 methenamine hippurate................... 11

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methimazole .................................. 46 methocarbamol .............................. 36 methotrexate sodium inj soln ........... 17 methotrexate sodium inj solr ............ 17 methotrexate sodium tabs ............... 50 methylphenidate hcl ........................ 34 methylphenidate hcl oral soln ........... 34 methylphenidate hcl tbcr 10 mg ........ 34 methylphenidate hcl tbcr 20mg......... 34 methylpr ss inj ............................... 44 methylpred pak 4mg ....................... 44 methylpred tab 16mg ...................... 44 methylpred tab 32mg ...................... 44 methylpred tab 4mg ....................... 44 methylpred tab 8mg ....................... 44 methylprednisolone acetate ............. 44 metoclopramide hcl ......................... 46 metoclopramide hcl inj .................... 46 metolazone .................................... 26 metoprolol & hydrochlorothiazide ...... 24 metoprolol succinate ....................... 24 metoprolol tartrate ......................... 24 metronidazole ................................ 11 metronidazole (topical) .................... 61 metronidazole gel 0.75% ................. 61 metronidazole in nacl ...................... 11 metronidazole vaginal ..................... 48 mibelas 24 fe ................................. 42 micafungin sodium .......................... 11 microgestin 1.5/30 ......................... 42 microgestin 1/20 ............................ 42 microgestin fe 1.5/30 ...................... 42 microgestin fe 1/20 ......................... 42 midodrine hcl ................................. 26 miglustat ....................................... 43 mili ............................................... 42 minitran ........................................ 26 minocycline hcl ............................... 16 minoxidil ....................................... 26 mirtazapine ................................... 30 misoprostol .................................... 47 MITIGARE ....................................... 8 M-M-R II ....................................... 52 M-NATAL PLUS ............................... 55 moexipril hcl .................................. 22

molindone hcl ................................ 32 mometasone furoate ....................... 60 mondoxyne nl cap 100mg ................ 16 mono-linyah tab 0.25-35 ................. 42 montelukast sodium ........................ 58 morphine ext-rel tab ......................... 9 morphine sul inj 1mg/ml ................... 9 morphine sulfate .............................. 9 MORPHINE SULFATE ......................... 9 morphine sulfate oral soln 100mg/5ml . 9 morphine sulfate oral soln 10mg/5ml .. 9 morphine sulfate oral soln 20mg/5ml .. 9 MOVANTIK ............................... 47, 48 MOXEZA ........................................ 55 moxifloxacin hcl ............................. 15 moxifloxacin hcl (ophth) .................. 55 MULTAQ ........................................ 23 mupirocin ...................................... 59 MVASI .......................................... 18 MYCAMINE ..................................... 11 mycophenolate mofetil .................... 51 mycophenolate sodium tbec ............. 51 myorisan ....................................... 59 MYRBETRIQ ................................... 48 N nabumetone .................................... 8 nadolol .......................................... 24 nafcillin sodium for inj ..................... 16 NAFCILLIN SODIUM FOR INJ 10GM ... 16 NAGLAZYME .................................. 43 nalbuphine hcl .................................. 8 naloxone inj 0.4mg/ml .................... 36 naloxone inj 1mg/ml ....................... 36 naltrexone hcl ................................ 36 NAMZARIC ..................................... 29 naproxen ......................................... 8 naproxen dr ..................................... 8 naproxen sodium .............................. 8 naratriptan hcl ............................... 34 NARCAN ........................................ 36 NATACYN ...................................... 55 nateglinide .................................... 38 NATPARA ....................................... 45 NAYZILAM ..................................... 28 necon 0.5/35-28 ............................ 42

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nefazodone hcl ............................... 30 neomycin sulfate ............................ 10 neomycin-bacitracin zn-polymyxin .... 55 neomycin-polymy-dexameth ............ 55 neomycin-polymyxin-gramicidin ....... 55 neomycin-polymyxin-hc (ophth) ....... 55 neomycin-polymyxin-hc (otic) .......... 62 NEPHRAMINE ................................. 53 NERLYNX ....................................... 20 NEUPRO ........................................ 31 nevirapine susp 50 mg/5ml .............. 12 nevirapine tab 100mg er .................. 12 nevirapine tab 200mg ..................... 12 nevirapine tab 400mg er .................. 12 NEXAVAR ...................................... 20 niacin (antihyperlipidemic) ............... 24 niacin er (antihyperlipidemic) ........... 24 niacor ........................................... 24 nicardipine hcl ................................ 25 NICOTROL INHALER ........................ 36 NICOTROL NS ................................ 36 nifedipine ...................................... 25 nifedipine er................................... 25 nikki ............................................. 42 nilutamide ..................................... 19 nimodipine ..................................... 25 NINLARO ....................................... 18 nitisinone ...................................... 43 NITRO-BID .................................... 26 NITRO-DUR DIS 0.3MG/HR .............. 26 NITRO-DUR DIS 0.8MG/HR .............. 26 nitrofurantoin macrocrystal .............. 11 nitrofurantoin monohyd macro ......... 11 nitroglycerin .................................. 26 nitroglycerin td patch ...................... 26 NITYR ........................................... 43 nizatidine ...................................... 47 nora-be tab 0.35mg ........................ 42 nore/eth/fer chw 0.4mg-35 .............. 42 noreth/ethin chw fe ......................... 42 norethin acet & estrad-fe ................. 42 norethindrone (contraceptive) .......... 42 norethindrone acet & eth estra ......... 42 norethindrone acetate ..................... 45 norethindrone acetate-ethinyl estradiol

.................................................... 44 norgest/ethi tab 0.25/35 ................. 42 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ........................................ 42 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ........................................ 42 NORMOSOL-M IN D5W .................... 54 NORMOSOL-R ................................ 54 NORMOSOL-R IN D5W ..................... 54 NORPACE CR ................................. 23 NORTHERA .................................... 26 nortrel 0.5/35 (28) ......................... 42 nortrel 1/35 ................................... 42 nortrel 7/7/7 .................................. 42 nortriptyline hcl .............................. 30 NORVIR PACK ................................ 12 NORVIR SOLN ................................ 12 NOVOLIN 70/30 ............................. 37 NOVOLIN 70/30 FLEXPEN ................ 37 NOVOLIN N .................................... 37 NOVOLIN N FLEXPEN ...................... 37 NOVOLIN R .................................... 37 NOVOLIN R FLEXPEN ....................... 37 NOVOLOG ..................................... 37 NOVOLOG 70/30 FLEXPEN ............... 37 NOVOLOG FLEXPEN ........................ 37 NOVOLOG MIX 70/30 ...................... 37 NOVOLOG PENFILL ......................... 37 NOXAFIL ....................................... 11 NUBEQA ........................................ 19 NUCALA ........................................ 58 NUCYNTA ER .................................... 9 NUEDEXTA .................................... 35 NULOJIX ........................................ 51 NULYTELY/FLAVOR PACKS ............... 47 NUPLAZID CAPS ............................. 32 NUPLAZID TABS 10MG .................... 32 NUTRILIPID INJ 20% ...................... 53 nyamyc ......................................... 59 NYMALIZE ..................................... 25 nystatin ........................................ 11 nystatin (mouth-throat) ................... 62 nystatin (topical) ...................... 59, 60

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nystop .......................................... 60 O ocella tab 3-0.03mg ........................ 42 OCTAGAM ...................................... 51 octreotide acetate ........................... 45 ODEFSEY ....................................... 13 ODOMZO ....................................... 18 OFEV ............................................ 58 ofloxacin (ophth) ............................ 55 ofloxacin (otic) ............................... 62 OGIVRI ......................................... 18 olanzapine ..................................... 32 olmesartan medoxomil .................... 23 olmesartan medoxomil-amlodipine-hydrochlorothiazide ......................... 23 olmesartan medoxomil-hydrochlorothiazide ......................... 23 olopatadine hcl 0.2% ...................... 56 omeprazole cap 10mg ..................... 48 omeprazole cap 20mg ..................... 48 omeprazole cap 40mg ..................... 48 ondansetron hcl .............................. 46 ondansetron hcl inj ......................... 46 ondansetron hcl oral soln ................. 46 ondansetron odt ............................. 46 ONTRUZANT .................................. 18 OPSUMIT ....................................... 26 ORFADIN ....................................... 44 ORKAMBI ...................................... 58 orsythia ......................................... 42 oseltamivir phosphate ..................... 14 OSPHENA ...................................... 45 oxacillin sodium .............................. 16 oxaliplatin inj 100mg ....................... 21 oxaliplatin inj 100mg/20ml .............. 21 oxaliplatin inj 50mg ........................ 21 oxaliplatin inj 50mg/10ml ................ 21 oxandrolone tab 10mg .................... 36 oxandrolone tab 2.5mg ................... 36 oxcarbazepine ................................ 28 oxybutynin chloride ......................... 48 oxycodone hcl ................................. 9 oxycodone w/ acetaminophen 10-325mg .......................................... 10 oxycodone w/ acetaminophen 2.5-

325mg ............................................ 9 oxycodone w/ acetaminophen 5-325mg ...................................................... 9 oxycodone w/ acetaminophen 7.5-325mg .......................................... 10 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .. 37 OZEMPIC INJ 1MG/DOSE ................. 37 P pacerone ....................................... 23 paclitaxel ....................................... 17 paliperidone ................................... 32 pamidronate disodium ..................... 39 PAMIDRONATE DISODIUM ............... 39 pamidronate inj 30mg ..................... 39 pamidronate inj 90mg ..................... 39 PANRETIN ..................................... 61 pantoprazole sodium ....................... 48 pantoprazole sodium tbec ................ 48 PANZYGA ...................................... 51 paricalcitol ..................................... 55 paroex sol 0.12% ........................... 62 paromomycin sulfate ....................... 10 paroxetine hcl tabs ......................... 30 PASER D/R .................................... 13 PAXIL ........................................... 30 PAZEO .......................................... 56 PEDIARIX ...................................... 52 PEDVAX HIB .................................. 52 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ..................................... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride .................. 47 PEGANONE .................................... 28 PEGASYS ....................................... 14 PEGASYS PROCLICK ........................ 14 PEMAZYRE ..................................... 20 penicillamine .................................. 40 PENICILLIN G POT IN DEXTROSE 2MU .................................................... 16 PENICILLIN G POT IN DEXTROSE 3MU .................................................... 16 PENICILLIN G PROCAINE ................. 16 penicillin g sodium .......................... 16 penicillin v potassium ...................... 16 penicilln gk inj 20mu ....................... 16

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penicilln gk inj 5mu ......................... 16 PENTACEL ..................................... 52 pentamidine isethionate inh ............. 11 pentamidine isethionate inj .............. 11 pentoxifylline ................................. 49 perindopril erbumine ....................... 22 periogard ...................................... 62 permethrin cre 5% .......................... 61 perphenazine ................................. 32 PERSERIS ...................................... 32 pfizerpen-g inj 20mu ....................... 16 pfizerpen-g inj 5mu ........................ 16 phenelzine sulfate ........................... 30 phenobarbital ................................. 28 phenobarbital sodium ...................... 28 PHENYTEK ..................................... 28 phenytoin ...................................... 28 phenytoin sodium extended ............. 28 phenytoin sodium inj 50mg/ml ......... 28 philith ........................................... 42 PHOSPHOLINE IODIDE .................... 56 PICATO ......................................... 61 PIFELTRO ...................................... 12 pilocarpine hcl ................................ 56 pilocarpine hcl (oral) ....................... 62 pimozide ....................................... 32 pimtrea ......................................... 42 pindolol ......................................... 24 pioglitazone hcl .............................. 38 piper/tazoba inj 12-1.5gm ............... 16 piper/tazoba inj 2-0.25gm ............... 16 piper/tazoba inj 3-0.375gm .............. 16 piper/tazoba inj 36-4.5gm ............... 16 piper/tazoba inj 4-0.5gm ................. 16 PIQRAY 200MG DAILY DOSE ............ 20 PIQRAY 250MG DAILY DOSE ............ 21 PIQRAY 300MG DAILY DOSE ............ 21 pirmella 1/35 ................................. 42 piroxicam ....................................... 8 PLASMA-LYTE A .............................. 54 PLASMA-LYTE-148 .......................... 54 plenamine ..................................... 53 PLENVU ......................................... 47 PNV FOLIC ACID + IRON MUL ........... 55 podofilox ....................................... 61

polymyxin b-trimethoprim ............... 55 POMALYST ..................................... 19 portia-28 ....................................... 42 posaconazole ................................. 11 pot chloride inj 2meq/ml .................. 54 potassium chloride .................... 53, 54 POTASSIUM CHLORIDE ................... 54 potassium chloride in nacl ................ 54 potassium chloride microencapsulated crystals er ..................................... 53 potassium citrate (alkalinizer) er tabs 48 PRADAXA ...................................... 49 PRALUENT ..................................... 24 pramipexole tab 0.125mg ................ 31 pramipexole tab 0.25mg .................. 31 pramipexole tab 0.5mg ................... 31 pramipexole tab 0.75mg .................. 31 pramipexole tab 1.5mg ................... 31 pramipexole tab 1mg ...................... 31 prasugrel hcl .................................. 50 pravastatin sodium ......................... 23 praziquantel ................................... 11 prazosin hcl ................................... 22 pred sod pho sol 5mg/5ml ............... 44 prednisolone acetate (ophth) ........... 56 prednisolone sodium phosphate ........ 44 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) ....................................... 56 prednisolone sol 15mg/5ml .............. 44 prednisolone sol 25mg/5ml .............. 44 PREDNISONE CON 5MG/ML .............. 44 prednisone pak 10mg ...................... 44 prednisone pak 5mg ....................... 44 prednisone sol 5mg/5ml .................. 44 prednisone tab 10mg ...................... 44 prednisone tab 1mg ........................ 44 prednisone tab 2.5mg ..................... 44 prednisone tab 20mg ...................... 44 prednisone tab 50mg ...................... 44 prednisone tab 5mg ........................ 44 pregabalin ..................................... 28 PREMASOL 10% ............................. 53 PRENATAL ..................................... 55 PRENATAL PLUS ............................. 55 PRENATAL PLUS LOW IRON .............. 55

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prevalite ........................................ 24 previfem........................................ 42 PREZCOBIX.................................... 13 PREZISTA ...................................... 12 PRIFTIN ........................................ 14 primaquine phosphate ..................... 12 PRIMAQUINE PHOSPHATE ................ 12 primidone ...................................... 28 PRIVIGEN ...................................... 51 probenecid...................................... 8 PROCALAMINE................................ 53 prochlorperazine inj ........................ 46 prochlorperazine maleate ................. 46 prochlorperazine supp ..................... 46 PROCRIT ....................................... 49 procto-med hc ................................ 61 procto-pak ..................................... 61 proctosol hc cre 2.5% ..................... 61 proctozone-hc ................................ 61 PROGLYCEM SUS 50MG/ML .............. 45 PROGRAF ...................................... 51 PROLASTIN-C ................................. 58 PROLENSA ..................................... 56 PROLIA ......................................... 45 PROMACTA .................................... 49 promethazine hcl ............................ 46 promethazine hcl inj ........................ 46 propafenone hcl .............................. 23 propafenone hcl 12hr ...................... 23 proparacaine hcl ............................. 57 propranolol & hydrochlorothiazide ..... 24 propranolol cap er ........................... 24 propranolol hcl ............................... 24 propranolol oral sol ......................... 24 propylthiouracil .............................. 46 PROQUAD ...................................... 52 PROSOL ........................................ 53 protriptyline hcl .............................. 30 PULMICORT FLEXHALER ................... 59 PULMOZYME .................................. 58 PURIXAN ....................................... 17 pyrazinamide ................................. 14 pyridostigmine tab 60mg ................. 35 Q QUADRACEL ................................... 52

quetiapine fumarate ........................ 32 quinapril hcl ................................... 22 quinapril-hydrochlorothiazide ........... 22 quinidine sulfate ............................. 23 quinine sulfate ............................... 12 R RABAVERT ..................................... 52 rabeprazole sodium ........................ 48 raloxifene tab 60mg ........................ 45 ramipril ......................................... 22 ranolazine ..................................... 26 rasagiline mesylate ......................... 31 RAYALDEE ..................................... 55 reclipsen ....................................... 42 RECOMBIVAX HB ............................ 52 RECTIV ......................................... 61 REGRANEX .................................... 61 RELENZA DISKHALER ...................... 14 RELISTOR ...................................... 48 REMICADE ..................................... 50 RENFLEXIS .................................... 50 repaglinide .................................... 39 RESTASIS ...................................... 57 RESTASIS MULTIDOSE .................... 57 REVLIMID ...................................... 19 REXULTI ........................................ 32 REYATAZ ....................................... 12 RHOPRESSA................................... 56 ribavirin cap 200mg ........................ 14 ribavirin tab 200mg ........................ 14 rifabutin ........................................ 14 rifampin ........................................ 14 RIFATER ........................................ 14 riluzole .......................................... 35 rimantadine hydrochloride ............... 14 RINVOQ ........................................ 50 risedronate sodium ......................... 39 RISPERDAL INJ 12.5MG ................... 32 RISPERDAL INJ 25MG...................... 33 RISPERDAL INJ 37.5MG ................... 33 RISPERDAL INJ 50MG...................... 33 risperidone .................................... 33 ritonavir ........................................ 12 RITUXAN ....................................... 18 RITUXAN HYCELA ........................... 18

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rivastigmine tartrate ....................... 29 rivastigmine td patch 24hr 13.3 mg/24hr ........................................ 29 rivastigmine td patch 24hr 4.6 mg/24hr .................................................... 29 rivastigmine td patch 24hr 9.5 mg/24hr .................................................... 29 rivelsa ........................................... 42 rizatriptan benzoate ........................ 34 rizatriptan benzoate odt ................... 35 ropinirole tab 0.25mg ...................... 31 ropinirole tab 0.5mg ....................... 31 ropinirole tab 1mg .......................... 31 ropinirole tab 2mg .......................... 31 ropinirole tab 3mg .......................... 31 ropinirole tab 4mg .......................... 31 ropinirole tab 5mg .......................... 31 rosadan cre 0.75% ......................... 61 rosuvastatin calcium ....................... 23 ROTARIX ....................................... 52 ROTATEQ ...................................... 52 roweepra ....................................... 28 roweepra xr ................................... 28 ROZLYTREK ................................... 21 RUBRACA ...................................... 18 RUXIENCE ..................................... 18 RYBELSUS ..................................... 39 RYDAPT ......................................... 21 S SANDIMMUNE ................................ 51 SANTYL ......................................... 61 SAPHRIS ....................................... 33 scopolamine ................................... 46 SECUADO ...................................... 33 selegiline hcl .................................. 31 selenium sulfide ............................. 60 SELZENTRY .................................... 12 SEREVENT DISKUS ......................... 58 sertraline hcl .................................. 30 setlakin tab .................................... 42 sevelamer carbonate ....................... 45 sharobel ........................................ 42 SHINGRIX ..................................... 52 SIGNIFOR ...................................... 45 sildenafil citrate tab 20 mg (pulmonary

hypertension) ................................ 27 silver sulfadiazine ........................... 59 SIMBRINZA ................................... 56 simvastatin .................................... 23 sirolimus ....................................... 51 SIRTURO ....................................... 14 SIVEXTRO ..................................... 11 SKYRIZI ........................................ 50 sodium chlor sol 0.9% irr ................. 61 sodium chloride ........................ 53, 54 sodium chloride 0.45% .................... 54 sodium chloride inj 0.9% ................. 54 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln .................................... 53 sodium phenylbutyrate .................... 44 sodium polystyrene sulfonate powder 40 sodium polystyrene sulfonate susp .... 40 SOLIQUA 100/33 ............................ 37 SOLTAMOX .................................... 19 SOLU-CORTEF ................................ 44 SOMATULINE DEPOT ....................... 45 SOMAVERT .................................... 45 sorine ........................................... 23 sotalol hcl ...................................... 23 sotalol hcl (afib/afl) ......................... 23 spironolactone ............................... 22 spironolactone & hydrochlorothiazide . 26 sprintec 28 .................................... 42 SPRITAM ....................................... 28 SPRYCEL ....................................... 21 sps susp 15gm/60ml ....................... 40 sronyx .......................................... 42 ssd ............................................... 59 stavudine ...................................... 12 STELARA ................................. 50, 51 STIMATE ....................................... 46 STIVARGA ..................................... 21 streptomycin sulfate ....................... 10 STRIBILD ...................................... 13 subvenite tab ................................. 28 sucralfate ...................................... 48 sulfacetamide sodium (acne) ............ 59 sulfacetamide sodium (ophth) .......... 55 sulfacetamide sod-prednisolone ........ 55 SULFADIAZINE ............................... 10

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sulfamethoxazole-trimethop ds ......... 11 sulfamethoxazole-trimethoprim inj .... 11 sulfamethoxazole-trimethoprim susp . 11 sulfamethoxazole-trimethoprim tab 400-80mg ..................................... 11 SULFAMYLON ................................. 59 sulfasalazine .................................. 47 sulfasalazine ec .............................. 47 sulindac ......................................... 8 sumatriptan ................................... 35 sumatriptan inj 4mg/0.5ml .............. 35 sumatriptan inj 6mg/0.5ml .............. 35 sumatriptan succinate ..................... 35 SUPREP BOWEL PREP KIT ................ 47 SUTENT ......................................... 21 syeda ............................................ 42 SYLATRON ..................................... 21 SYMBICORT ................................... 59 SYMDEKO ...................................... 58 SYMFI ........................................... 13 SYMFI LO ...................................... 13 SYMJEPI ........................................ 58 SYMPAZAN .................................... 28 SYMTUZA ...................................... 13 SYNAREL ....................................... 43 SYNERCID ..................................... 11 SYNJARDY TAB 12.5-1000MG ........... 39 SYNJARDY TAB 12.5-500MG ............. 39 SYNJARDY TAB 5-1000MG ............... 39 SYNJARDY TAB 5-500MG ................. 39 SYNJARDY XR TAB 10-1000MG ......... 39 SYNJARDY XR TAB 12.5-1000MG ...... 39 SYNJARDY XR TAB 25-1000MG ......... 39 SYNJARDY XR TAB 5-1000MG ........... 39 SYNRIBO ....................................... 21 SYNTHROID ................................... 46 T TABLOID ....................................... 17 tacrolimus ..................................... 51 tacrolimus (topical) ......................... 61 TAFINLAR ...................................... 21 TAGRISSO ..................................... 21 TALZENNA ..................................... 18 tamoxifen citrate ............................ 19 tamsulosin hcl ................................ 48

TARGRETIN ................................... 61 tarina 24 fe.................................... 43 tarina fe 1/20 ................................. 43 TASIGNA ....................................... 21 TAXOTERE ..................................... 17 tazarotene ..................................... 60 tazicef ........................................... 15 TAZORAC ...................................... 60 taztia xt ........................................ 25 TAZVERIK ...................................... 21 TDVAX .......................................... 52 TECENTRIQ .................................... 18 TEFLARO ....................................... 15 telmisartan .................................... 23 telmisartan-amlodipine .................... 23 telmisartan-hydrochlorothiazide ........ 23 temazepam ................................... 34 TEMIXYS ....................................... 13 TENIVAC ....................................... 52 tenofovir disoproxil fumarate ............ 12 terazosin hcl .................................. 22 terbinafine hcl ................................ 11 terbutaline sulfate .......................... 58 terconazole vaginal ......................... 48 testosterone .................................. 36 testosterone cypionate .................... 36 testosterone enanthate ................... 36 tetrabenazine ................................. 35 tetracycline hcl ............................... 16 TEXACORT SOLN 2.5% .................... 60 THALOMID ..................................... 19 THEO-24 ....................................... 58 theophylline ................................... 58 theophylline tab er 12hr 300 mg ....... 58 theophylline tab er 12hr 450 mg ....... 58 theophylline tab sr 24hr .................. 58 thioridazine hcl ............................... 33 thiothixene .................................... 33 tiadylt er ....................................... 25 tiagabine hcl .................................. 29 TIBSOVO ....................................... 18 tigecycline ..................................... 11 tilia fe ........................................... 43 timolol maleate .............................. 25 timolol maleate (ophth) soln ............ 57

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timolol maleate gel ......................... 57 timolol maleate ophth soln 0.5% (once-daily) ............................................ 57 TIVICAY ........................................ 13 tizanidine hcl .................................. 36 TOBRADEX .................................... 55 TOBRADEX ST ................................ 55 tobramycin .................................... 10 tobramycin (ophth) ......................... 55 tobramycin inj 1.2 gm/30ml ............. 10 tobramycin inj 1.2gm ...................... 10 tobramycin inj 10mg/ml .................. 10 tobramycin inj 80mg/2ml ................. 10 tobramycin sulfate .......................... 10 tobramycin-dexamethasone ............. 55 tolterodine tartrate ......................... 48 topiramate ..................................... 29 toposar ......................................... 22 toremifene citrate ........................... 19 torsemide tabs ............................... 26 TOVIAZ ......................................... 48 TPN ELECTROLYTES ........................ 53 TRADJENTA ................................... 39 tramadol hcl tab 50 mg .................... 8 tramadol-acetaminophen .................. 8 trandolapril .................................... 22 tranexamic acid .............................. 50 tranylcypromine sulfate ................... 30 TRAVASOL ..................................... 53 travoprost ..................................... 57 TRAZIMERA ................................... 18 trazodone hcl ................................. 30 TRECATOR ..................................... 14 TRELEGY ELLIPTA ........................... 57 TRELSTAR DEP INJ 3.75MG .............. 19 TRELSTAR LA INJ 11.25MG .............. 19 treprostinil ..................................... 27 TRESIBA FLEXTOUCH ...................... 37 TRESIBA INJ .................................. 37 tretinoin ........................................ 59 tretinoin (chemotherapy) ................. 21 triamcinolone acetonide (mouth) ...... 62 triamcinolone acetonide (topical) 60, 61 triamterene & hydrochlorothiazide cap 37.5-25 mg ................................... 26

triamterene & hydrochlorothiazide tabs .................................................... 26 TRICARE ....................................... 55 trientine hcl ................................... 40 tri-estarylla .................................... 43 trifluoperazine hcl ........................... 33 trifluridine ..................................... 55 trihexyphenidyl hcl ......................... 31 TRIJARDY XR TAB ER 24HR 10-5-1000 MG ............................................... 39 TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG ........................................ 39 TRIJARDY XR TAB ER 24HR 25-5-1000 MG ............................................... 39 TRIJARDY XR TAB ER 24HR 5-2.5-1000MG ........................................ 39 TRIKAFTA ...................................... 58 tri-legest fe.................................... 43 tri-linyah ....................................... 43 tri-lo marzia ................................... 43 tri-lo-estarylla ................................ 43 tri-lo-sprintec ................................. 43 trilyte ........................................... 47 trimethoprim ................................. 11 tri-mili .......................................... 43 trimipramine maleate ...................... 30 TRINTELLIX ................................... 30 tri-previfem ................................... 43 tri-sprintec .................................... 43 TRIUMEQ ....................................... 13 trivora-28 ...................................... 43 tri-vylibra ...................................... 43 tri-vylibra lo ................................... 43 TROGARZO .................................... 13 TROPHAMINE INJ 10% .................... 53 trospium chloride ............................ 48 TRULICITY ..................................... 37 TRUMENBA .................................... 52 TRUVADA TAB 100-150 ................... 13 TRUVADA TAB 133-200 ................... 13 TRUVADA TAB 167-250 ................... 13 TRUVADA TAB 200-300 ................... 13 TRUXIMA ....................................... 18 TUKYSA......................................... 21 tulana ........................................... 43

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TURALIO ....................................... 21 TWINRIX INJ .................................. 52 TYBOST ......................................... 13 tydemy ......................................... 43 TYKERB ......................................... 21 TYMLOS ........................................ 45 TYPHIM VI ..................................... 52 U unithroid ....................................... 46 ursodiol ......................................... 48 V valacyclovir hcl ............................... 14 VALCHLOR ..................................... 61 valganciclovir hcl ............................ 14 valproate sodium ............................ 29 valproate sodium oral soln ............... 29 valproic acid .................................. 29 valsartan ....................................... 23 valsartan-hydrochlorothiazide ........... 23 VALTOCO ...................................... 29 vancomycin hcl .............................. 11 VANCOMYCIN IN NACL .................... 11 vandazole ...................................... 48 VAQTA .......................................... 52 VARIVAX ....................................... 52 VASCEPA ....................................... 24 VELCADE ....................................... 18 velivet ........................................... 43 VELTASSA ..................................... 40 VEMLIDY ....................................... 14 VENCLEXTA ................................... 18 VENCLEXTA STARTING PACK ............ 18 venlafaxine hcl ............................... 30 VENTAVIS ...................................... 27 VENTOLIN HFA ............................... 58 verapamil cap er ............................. 25 verapamil hcl ................................. 25 verapamil tab er ............................. 25 VERSACLOZ ................................... 33 VERZENIO ..................................... 18 VICTOZA ....................................... 37 vienva ........................................... 43 vigabatrin powd pack 500mg ............ 29 vigabatrin tab 500mg ...................... 29 vigadrone ...................................... 29

VIIBRYD STARTER PACK .................. 30 VIIBRYD TAB ................................. 30 VIMPAT ......................................... 29 VIMPAT INJ 200MG/20ML ................ 29 VIMPAT SOL 10MG/ML..................... 29 vincristine sulfate ........................... 17 vinorelbine tartrate ......................... 17 viorele .......................................... 43 VIRACEPT ...................................... 13 VIREAD ......................................... 13 VITRAKVI ...................................... 21 VIVITROL ...................................... 36 VIZIMPRO ..................................... 21 voriconazole .................................. 12 VOSEVI ......................................... 14 VOTRIENT ..................................... 21 VRAYLAR ....................................... 33 VRAYLAR THERAPY PACK ................. 33 vyfemla ......................................... 43 vylibra .......................................... 43 W warfarin sodium ............................. 49 water for irrigation, sterile .............. 61 wymzya fe ..................................... 43 X XALKORI ....................................... 21 XARELTO ....................................... 49 XARELTO STARTER PACK ................. 49 XATMEP ........................................ 51 XCOPRI MAINTENANCE PAK 150-200MG .................................................... 29 XCOPRI PAK 12.5-25MG .................. 29 XCOPRI PAK 50-100MG ................... 29 XCOPRI PAK 50-200MG ................... 29 XCOPRI TABS ................................. 29 XCOPRI TITRATION PAK 150-200MG . 29 XELJANZ ....................................... 51 XELJANZ XR ................................... 51 XGEVA .......................................... 45 XIFAXAN ....................................... 48 XIGDUO XR TAB 10-1000MG ............ 39 XIGDUO XR TAB 10-500MG .............. 39 XIGDUO XR TAB 2.5-1000MG ........... 39 XIGDUO XR TAB 5-1000MG .............. 39 XIGDUO XR TAB 5-500MG ............... 39

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XOLAIR ......................................... 58 XOSPATA ....................................... 21 XPOVIO 100 MG ONCE WEEKLY ........ 21 XPOVIO 60 MG ONCE WEEKLY .......... 21 XPOVIO 80 MG ONCE WEEKLY .......... 21 XPOVIO 80 MG TWICE WEEKLY ......... 21 XTANDI ......................................... 19 xulane dis 150-35 ........................... 43 XULTOPHY 100/3.6 ......................... 37 XYREM .......................................... 36 Y YF-VAX .......................................... 52 yuvafem vaginal tablet 10 mcg ......... 44 Z zafirlukast ..................................... 58 zaleplon ........................................ 34 zarah ............................................ 43 ZARXIO ......................................... 49 ZEJULA ......................................... 18 ZELBORAF ..................................... 21 ZEMAIRA ....................................... 58 zenatane ....................................... 59 ZENPEP ......................................... 48 ZERVIATE ...................................... 56 zidovudine cap 100mg ..................... 13 zidovudine syp 50mg/5ml ................ 13

zidovudine tab 300mg ..................... 13 ziprasidone hcl ............................... 33 ziprasidone mesylate ...................... 33 ZIRABEV ....................................... 18 ZIRGAN ......................................... 56 zoledronic acid inj 4mg/100ml .......... 39 zoledronic acid inj 5mg/100ml .......... 39 zoledronic inj 4mg/5ml .................... 39 ZOLINZA ....................................... 18 zolmitriptan ................................... 35 zolmitriptan odt .............................. 35 zolpidem tartrate ............................ 34 zonisamide .................................... 29 ZORTRESS TAB 0.25MG................... 51 ZORTRESS TAB 0.5MG .................... 51 ZORTRESS TAB 0.75MG................... 51 ZORTRESS TAB 1MG ....................... 51 ZOSTAVAX .................................... 52 zovia 1/35e ................................... 43 ZYDELIG ....................................... 21 ZYKADIA ....................................... 21 ZYLET ........................................... 55 ZYPREXA RELPREVV ........................ 33 ZYPREXA RELPREVV INJ 210MG ........ 33 ZYTIGA ......................................... 19

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact us, University of Maryland Health Advantage Member Services, at 1-844-786-6762 or for TTY users, 711, 24 hours a day, 7 days a week, or visit www.UMMedicareAdvantage.org.

• UMHA Dual Prime is an HMO SNP with a Medicare contract and a State of Maryland Medicaid contract. Enrollment in UMHA Dual Prime depends on contract renewal.

The Formulary may change at any time. You will receive notice when necessary. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. For the University of Maryland Health Advantage Dual Prime Plan members premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This information is available for free in other languages. Please call our Member Services number at 1-844-786-6762 or, for TTY users, 711, 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for non‑English speakers. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

2020 comprehensive formulary august...taking a drug on our 2020 formulary that was covered at the...

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