2022 formulary (list of covered drugs)

Blue Cross MedicareRx Choice (PDP)SM

2022 Formulary(List of Covered Drugs)

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

HPMS Approved Formulary File ID: 00022279, Version 07

This formulary was updated on 12/07/2021. For more recent information or other questions, please contactBlue Cross MedicareRxSM Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m.,local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (forexample, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

Y0096_ILCOMPC22_C 243165.122112/07/2021

www.getblueil.com/pdp/druglist

Blue Cross MedicareRx

2022 Formulary(List of Covered Drugs)

Note to existing members: This formulary has changed since last year. Please review this documentto make sure it still contains the drugs you take.

When this drug list (formulary) refers to "we", "us", or "our", it means, HCSC Insurance ServicesCompany (HISC). When it refers to "plan" or "our plan," it means Blue Cross MedicareRx.

This document includes a list of the drugs (formulary) for our plan which is current as ofDecember 2021. For an updated formulary, please contact us. Our contact information, along withthe 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, 2022,and from time to time during the year.

12/07/2021 i

What is the Blue Cross MedicareRx Formulary?A formulary is a list of covered drugs selected by Blue Cross MedicareRx in consultation with a team ofhealth care providers, which represents the prescription therapies believed to be a necessary part of aquality treatment program. Blue Cross MedicareRx will generally cover the drugs listed in our formulary aslong as the drug is medically necessary, the prescription is filled at a Blue Cross MedicareRx networkpharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, pleasereview your Evidence of Coverage.

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but "we" or Blue Cross MedicareRx may add or removedrugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.We must follow the Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changesduring the year:

New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacingit with a new generic drug that will appear on the same or lower cost sharing tier and with the same orfewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drugon our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If youare 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.

If we make such a change, you or your prescriber can ask us to make an exception and continue tocover the brand name drug for you. The notice we provide you will also include information on howto request an exception, and you can find information in the section below titled "How do I requestan exception to the Blue Cross MedicareRx's Formulary?"

Drugs removed from the market. If the Food and Drug Administration deems a drug on our formularyto be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately removethe 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 generic drug that is not new to market to replace a brand name drug currently on theformulary; or add new restrictions to the brand name drug or move it to a differentcost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugsfrom our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drugor move a drug to a higher cost-sharing tier, we must notify affected members of the change at least30 days before the change becomes effective, or at the time the member requests a refill of the drug, atwhich time the member will receive a 30-day supply of the drug.

If we make these other changes, you or your prescriber can ask us to make an exception and continueto cover the brand name drug for you. The notice we provide you will also include information onhow to request an exception, and you can also find information in the section below entitled "Howdo I request an exception to the Blue Cross MedicareRx's Formulary?"

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drugon our 2022 formulary that was covered at the beginning of the year, we will not discontinue or reducecoverage of the drug during the 2022 coverage year except as described above. This means these drugswill remain available at the same cost sharing and with no new restrictions for those members taking themfor the remainder of the coverage year. You will not get direct notice this year about changes that do notaffect you. However, on January 1 of the next year, such changes would affect you, and it is important tocheck the Drug List for the new benefit year for any changes to drugs.

12/07/2021 ii

The enclosed formulary is current as of 12/07/2021. To get updated information about the drugs coveredby Blue Cross MedicareRx, please contact us. Our contact information appears on the front and back coverpages. Formulary publications are updated and posted online on a monthly basis with applicable changes,including negative changes. The web address is located on the front and back cover of this formulary.

How do I use the Formulary?There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending onthe type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, Cardiovascular Agents. If you know what your drug is used for,look for the category name in the list that begins on page 1. Then look under the category name for yourdrug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that beginson page 64. The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Nextto your drug, you will see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Blue Cross MedicareRx covers both brand name drugs and generic drugs. A generic drug is approved bythe FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost lessthan brand name drugs.

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

Prior Authorization:Blue Cross MedicareRx requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from Blue Cross MedicareRx before youfill your prescriptions. If you don’t get approval, Blue Cross MedicareRx may not cover the drug.

Quantity Limits: For certain drugs, Blue Cross MedicareRx limits the amount of the drug that Blue CrossMedicareRx will cover. For example, Blue Cross MedicareRx provides 60 tablets per 30-day prescriptionfor Losartan 25 mg. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Blue Cross MedicareRx requires you to first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, Blue Cross MedicareRx may not cover Drug B unless you try Drug Afirst. If Drug A does not work for you, Blue Cross MedicareRx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covered drugsby visiting our Website. We have posted online documents that explain our prior authorization and steptherapy restrictions. You may also ask us to send you a copy. Our contact information, along with the datewe last updated the formulary, appears on the front and back cover pages.

You can ask Blue Cross MedicareRx 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 theBlue Cross MedicareRx's formulary?" on page iv for information about how to request an exception.

12/07/2021 iii

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 Customer Serviceand ask if your drug is covered.

If you learn that Blue Cross MedicareRx does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Blue Cross MedicareRx. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby Blue Cross MedicareRx.

You can ask Blue Cross MedicareRx to make an exception and cover your drug. See below for informationabout how to request an exception.

How do I request an exception to the Blue Cross MedicareRx's Formulary?You can ask Blue Cross MedicareRx to make an exception to our coverage rules. There are several types ofexceptions 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 coveredat a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at alower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level, unless the drug is on the specialtytier. If approved, this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueCross MedicareRx limits the amount of the drug that we will cover. If your drug has a quantity limit, youcan ask us to waive the limit and cover a greater amount.

Generally, Blue Cross MedicareRx will only approve your request for an exception if the alternative drugsincluded on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would notbe 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, tier, or utilization restrictionexception. When you request a formulary, tier, or utilization restriction exception you should submita statement from your prescriber or physician supporting your request. Generally, we must make ourdecision 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 to72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than24 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 orrequesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may needa prior authorization from us before you can fill your prescription. You should talk to your doctor to decideif you should switch to an appropriate drug that we cover or request a formulary exception so that we willcover the drug you take. While you talk to your doctor to determine the right course of action for you, wemay 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 covera temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up toa maximum of a 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.

12/07/2021 iv

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug while you pursue a formulary exception.

You may have changes that take you from one treatment setting to another. During this level of care change,drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must useyour plan’s exception and appeals processes. However, when you are admitted to, or discharged from, along-term care setting, you may not have access to the drugs you were previously given. You may get a refillupon admission or discharge to prevent a gap in care.

For more informationFor more detailed information about your Blue Cross MedicareRx prescription drug coverage, please reviewyour Evidence of Coverage and other plan materials.

If you have questions about Blue Cross MedicareRx, please contact us. Our contact information, along withthe 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 at1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,visit https://www.medicare.gov.

12/07/2021 v

https://www.medicare.gov

Blue Cross MedicareRx's FormularyThe formulary below provides coverage information about the drugs covered by Blue Cross MedicareRx. Ifyou have trouble finding your drug in the list, turn to the Index that begins on page 64.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) andgeneric drugs are listed in lower-case italics (e.g., metformin).

The information in the Requirements/Limits column tells you if Blue Cross MedicareRx has any specialrequirements for coverage of your drug.

Most drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contactinformation appears on the front and back cover pages.

KEYTier 1 = Preferred Generic

Tier 2 = Generic

Tier 3 = Preferred Brand

Tier 4 = Non-Preferred Drug

Tier 5 = Specialty Tier

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. Thesedrugs require prior authorization to determine coverage under Part B or Part D. Information may need tobe provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For moreinformation consult your Pharmacy Directory or call Customer Service at 1-888-285-2249, 8:00 a.m. – 8:00p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies(for example, voicemail) will be used on weekends and holidays. TTY users should call 711.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Ourformulary does include coverage for some of these drugs, but alternatives may be found in lower co-paytiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriatefor you to use.

Copayment and Coinsurance Amounts:For more information on Copayment and Coinsurance, please review your Evidence of Coverage.

Preferred Generic: Tier 1 copay/coinsurance-Generic drugs covered under your Medicare plan at the lowestcopay/coinsurance

Generic: Tier 2 copay/coinsurance-Generic drugs and some brand drugs other than those consideredPreferred Generic drugs covered under your Medicare prescription drug plan at the highest generic copay/coinsurance

Preferred Brand: Tier 3 copay/coinsurance-Brand drugs covered under your Medicare prescription drugplan at the lowest brand copay/coinsurance

Non-Preferred Drug: Tier 4 copay/coinsurance-Brand drugs and certain generic drugs other than thoseconsidered preferred Brand drugs that are covered under your Medicare prescription drug plan at thehighest brand copay/coinsurance

12/07/2021 vi

Specialty Tier: Tier 5 copay/coinsurance medications are usually high cost therapies that can be used totreat chronic conditions such as rheumatoid arthritis, cancer, multiple sclerosis or rare and complex diseases.They frequently require special handling, administration, and storage, as well as close clinic monitoring andmanagement.

2022 DOSAGE FORM ABBREVIATION KEY

adsorbedadactuationact

aerosol powder blisteraepbadjuvantadjuv

atrial fibrillation/atrial flutterafib/aflaerosolaer, aero

breath activatedba, br act,breath act,breath activ

applicatorapp

capsulescap, capsbioequivalent allergy unitbau

continuous deliverycdcartridgecart

controlled release capsulecpcrchewable tabletschew tab

conjugate, conjugatedconjconcentrateconc

crystalscryscreamcrm

disintegratingdisint,disintegr

deterrentdeter

enteric coatedecdelayed-releasedr

emulsionemulenzyme-linked immunosorbentassay

el, elu

extractextextended releaseer, extended,extended rel,xr

genitourinarygugramgm

immunoglobulinighourhr

inhalationinh, inhalintramuscularim

index of reactivityirinjectioninj

literlintravenousiv

lipophiliclipolong actingla

liquidliq, liqdflocculation unitslf, lfu

milliequivalentmeqmicrogrammcg

milligrammgmiscellaneousmisc

million unitsmumilliliterml

oral contraceptiveocnebulesnebu

outer membrane vesiclesomvointmentoin, oint

osmoticosmophthalmicop, ophth

12/07/2021 vii

2022 DOSAGE FORM ABBREVIATION KEY

packpakpulmonary arterialhypertension

pah

plaque forming unitspfupreservative-freepf

premenstrual dysphoric disorderpmddpowderpow, powd

patch twice weeklypttwprefilledpref, prefill

recombinantrecombpatch weeklyptwk

sublingualslrefrigeraterefrig

square centimetersqcmsolutionsol, soln

suspensionsus, suspsuppositoriessupp, suppos

tabletstab, tabssyringesyr

dispersible tablettbdpcontrolled release tablettbcr

tablet packtbpkenteric coated tablettbec

therapythertransdermaltd

unitunttranslingualtl

vaccinevacvaginalva

12/07/2021 viii

2022

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

1

Drug Name Drug Tier Requirements/LimitsAnalgesicsacetaminophen w/ codeine soln 120-12 mg/5ml 3 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg, 300-30 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 3 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 3 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 3 QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 4butorphanol tartrate inj 2 mg/ml 4celecoxib cap 50 mg, 100 mg, 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 3 QL (30 capsules/30 days)diclofenac potassium tab 50 mg 3 QL (120 tablets/30 days)diclofenac sodium gel 1% 3 PAdiclofenac sodium tab delayed release 25 mg 3 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 3 QL (60 tablets/30 days)etodolac cap 200 mg 3 QL (150 capsules/30 days)etodolac cap 300 mg 3 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg, 500 mg 3 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg 3 QL (30 tablets/30 days)etodolac tab 400 mg, 500 mg 3 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg, 400 mcg, 600 mcg 4 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg, 1200 mcg, 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/

hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr, 100 mcg/hr4 PA, QL (15 patches/30 days)

hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (2700 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg, 7.5-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 3 QL (240 tablets/30 days)hydromorphone hcl inj 2 mg/ml 4 BDhydromorphone hcl liqd 1 mg/ml 4 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml, 10 mg/ml 4 BDhydromorphone hcl tab 2 mg, 4 mg, 8 mg 3 QL (180 tablets/30 days)ibuprofen tab 400 mg 1 QL (240 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)meloxicam tab 7.5 mg 1 QL (60 tablets/30 days)meloxicam tab 15 mg 1 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)

2022

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsmorphine sulfate inj pf 0.5 mg/ml, 1 mg/ml 4 BDmorphine sulfate tab er 15 mg, 30 mg, 60 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg, 200 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 4 QL (360 tablets/30 days)morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg 3 QL (150 tablets/30 days)naproxen sodium tab 550 mg 3 QL (90 tablets/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (180 tablets/30 days)naproxen tab 375 mg 1 QL (120 tablets/30 days)naproxen tab 500 mg 1 QL (90 tablets/30 days)oxaprozin tab 600 mg 4 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 3 QL (360 tablets/30 days)oxycodone hcl tab 10 mg, 15 mg, 20 mg, 30 mg 3 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 3 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)piroxicam cap 10 mg 2 QL (60 capsules/30 days)piroxicam cap 20 mg 2 QL (30 capsules/30 days)sulindac tab 150 mg, 200 mg 2 QL (60 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)AnestheticsLIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4% 3LIDOCAINE HCL JELLY - lidocaine hcl urethral/mucosal gel 2% 3 PA, QL (150 mls/30 days)lidocaine hcl local inj 1% 4lidocaine hcl local preservative free inj 1% 4lidocaine hcl soln 4% 3 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 3 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 2lidocaine patch 5% 4 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 4 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 4APO-VARENICLINE - varenicline tartrate tab 0.5 mg, 1 mg 4buprenorphine hcl sl tab 2 mg, 8 mg 3 QL (90 tablets/30 days)

2022


3

Drug Name Drug Tier Requirements/Limitsbuprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg, 8-2 mg, 12-3 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 3CHANTIX STARTING MONTH PACK - varenicline tartrate tab

0.5 mg x 11 & tab 1 mg x 42 pack4

disulfiram tab 250 mg 3disulfiram tab 500 mg 4KLOXXADO - naloxone hcl nasal spray 8 mg/0.1ml 4NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 2naloxone hcl inj 0.4 mg/ml, 4 mg/10ml 2naloxone hcl soln prefilled syringe 2 mg/2ml 2naltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 3NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBLOCADE - buprenorphine extended release soln pref syr

100 mg/0.5ml, 300 mg/1.5ml5

varenicline tartrate tab 0.5 mg 4varenicline tartrate tab 1 mg 4Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml), 1 gm/4ml (250 mg/ml) 4amoxicillin (trihydrate) cap 250 mg, 500 mg 2amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml,

250 mg/5ml, 400 mg/5ml2

amoxicillin (trihydrate) tab 500 mg, 875 mg 2amoxicillin & k clavulanate for susp 400-57 mg/5ml 2amoxicillin & k clavulanate tab 250-125 mg 3amoxicillin & k clavulanate tab 500-125 mg, 875-125 mg 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

4

AMPICILLIN - ampicillin cap 500 mg 4ampicillin & sulbactam sodium for inj 3 (2-1) gm 4AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 4ampicillin sodium for inj 250 mg, 500 mg, 1 gm, 2 gm 4ampicillin sodium for iv soln 2 gm 4

2022


Drug Name Drug Tier Requirements/LimitsAMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm4

azithromycin for susp 100 mg/5ml, 200 mg/5ml 4azithromycin iv for soln 500 mg 4azithromycin tab 250 mg, 500 mg, 600 mg 2aztreonam for inj 1 gm, 2 gm 4BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml, 1200000 unit/2ml, 2400000 unit/4ml4

CEFACLOR - cefaclor cap 250 mg, 500 mg 3cefadroxil cap 500 mg 2CEFAZOLIN SODIUM - cefazolin sodium for iv soln 1 gm 4CEFAZOLIN SODIUM - cefazolin sodium-dextrose iv solution

1 gm/50ml-4%4

cefazolin sodium for inj 500 mg, 1 gm 4CEFAZOLIN SODIUM/DEXTROSE - cefazolin sodium for iv soln

1 gm and dextrose 4% (50 ml)4

cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml, 250 mg/5ml 3CEFEPIME - cefepime hcl iv soln 1 gm/50ml, 2 gm/100ml 4cefepime hcl for inj 1 gm, 2 gm 4CEFEPIME/DEXTROSE - cefepime hcl for iv soln 1 gm and

dextrose 5% (50 ml), 2 gm and dextrose 5% (50 ml)4

cefixime cap 400 mg 4CEFOXITIN SODIUM - cefoxitin sodium iv for soln 1 gm and

dextrose 4% (50 ml), 2 gm and dextrose 2.2% (50 ml)4

cefoxitin sodium for iv soln 1 gm, 2 gm 4cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml 4cefpodoxime proxetil tab 100 mg, 200 mg 4cefprozil tab 250 mg, 500 mg 3ceftazidime for inj 1 gm, 6 gm 4ceftazidime for iv soln 2 gm 4CEFTAZIDIME/DEXTROSE - ceftazidime for iv soln 1 gm and

dextrose 5% (50ml), 2 gm and dextrose 5% (50ml)4

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 20 mg/ml, 40 mg/ml

4

CEFTRIAXONE SODIUM - ceftriaxone sodium (bulk) for inj 100 gm 4ceftriaxone sodium for inj 250 mg, 500 mg, 1 gm, 2 gm, 10 gm 4ceftriaxone sodium for iv soln 1 gm, 2 gm 4CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74% 50 ml, 2 gm and dextrose 2.22% 50 ml4

cefuroxime axetil tab 250 mg, 500 mg 2

2022


5

Drug Name Drug Tier Requirements/Limitscefuroxime sodium for inj 750 mg 4cefuroxime sodium for iv soln 1.5 gm 4cephalexin cap 250 mg, 500 mg 1cephalexin cap 750 mg 4cephalexin for susp 125 mg/5ml, 250 mg/5ml 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm4

CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab 250 mg, 500 mg, 750 mg 2ciprofloxacin 200 mg/100ml in d5w 4ciprofloxacin 400 mg/200ml in d5w 4CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml,

250 mg/5ml4

clarithromycin tab 250 mg, 500 mg 4clindamycin hcl cap 75 mg, 150 mg, 300 mg 2clindamycin phosphate inj 300 mg/2ml, 600 mg/4ml, 900 mg/6ml,

9 gm/60ml4

clindamycin phosphate swab 1% 4clindamycin phosphate vaginal cream 2% 3colistimethate sod for inj 150 mg 4daptomycin for iv soln 500 mg 5dicloxacillin sodium cap 250 mg 2dicloxacillin sodium cap 500 mg 3doxycycline hyclate cap 50 mg, 100 mg 2doxycycline hyclate for inj 100 mg 4doxycycline hyclate tab 20 mg, 100 mg 2doxycycline monohydrate cap 150 mg 4doxycycline monohydrate tab 150 mg 4ertapenem sodium for inj 1 gm 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

erythromycin soln 2% 2erythromycin tab delayed release 250 mg, 333 mg, 500 mg 4erythromycin tab 250 mg, 500 mg 4gentamicin in saline inj 1.2 mg/ml 4gentamicin sulfate inj 40 mg/ml 4GENTAMICIN SULFATE PEDIATRIC - gentamicin sulfate inj 10 mg/

ml4

GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin insaline inj 1 mg/ml, 1.6 mg/ml

4

2022


Drug Name Drug Tier Requirements/Limitsimipenem-cilastatin intravenous for soln 500 mg 4IMIPENEM/CILASTATIN - imipenem-cilastatin intravenous for soln

250 mg4

IMPAVIDO - miltefosine cap 50 mg 5ISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 4levofloxacin in d5w iv soln 250 mg/50ml, 500 mg/100ml,

750 mg/150ml4

levofloxacin iv soln 25 mg/ml 4levofloxacin oral soln 25 mg/ml 4levofloxacin tab 250 mg, 500 mg, 750 mg 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%4

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 4 PAmeropenem iv for soln 500 mg, 1 gm 4MEROPENEM/SODIUM CHLORIDE - meropenem & sodium

chloride 0.9% for iv soln 500 mg/50ml, 1 gm/50ml4

methenamine hippurate tab 1 gm 3metronidazole in nacl 0.74% iv soln 500 mg/100ml 4metronidazole in nacl 0.79% iv soln 500 mg/100ml 4metronidazole tab 250 mg, 500 mg 2metronidazole vaginal gel 0.75% 3minocycline hcl cap 50 mg, 75 mg, 100 mg 2minocycline hcl tab 50 mg, 75 mg, 100 mg 4moxifloxacin hcl tab 400 mg 3MOXIFLOXACIN HYDROCHLORIDE - moxifloxacin hcl iv solution

400 mg/250ml4

MOXIFLOXACIN HYDROCHLORIDE - moxifloxacin hcl400 mg/250ml in sodium chloride 0.8% inj

4

NAFCILLIN - nafcillin sodium in dextrose inj 1 gm/50ml,2 gm/100ml

4

NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm, 2 gm 4nafcillin sodium for inj 1 gm, 2 gm 4nafcillin sodium for iv soln 10 gm 4neomycin sulfate tab 500 mg 2nitrofurantoin macrocrystalline cap 50 mg, 100 mg# 2nitrofurantoin monohydrate macrocrystalline cap 100 mg# 2ofloxacin tab 400 mg 3paromomycin sulfate cap 250 mg 4

2022


7

Drug Name Drug Tier Requirements/Limitspenicillin g potassium for inj 5000000 unit, 20000000 unit 4PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose, 40000 unit/ml indextrose, 60000 unit/ml in dextrose

4

PENICILLIN V POTASSIUM - penicillin v potassium for soln125 mg/5ml, 250 mg/5ml

4

penicillin v potassium tab 250 mg, 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 4piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm), 4.5 gm

(4-0.5 gm)4

SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 4SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 4sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 4sulfamethoxazole-trimethoprim tab 400-80 mg, 800-160 mg 2SUPRAX - cefixime chew tab 100 mg, 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm, 6 gm 4TEFLARO - ceftaroline fosamil for iv soln 400 mg, 600 mg 5tetracycline hcl cap 250 mg, 500 mg 4tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml,

2 gm/50ml (40 mg/ml)4

tobramycin sulfate for inj 1.2 gm 4tobramycin sulfate inj 80 mg/2ml (40 mg/ml), 1.2 gm/30ml (40 mg/

ml)4

trimethoprim tab 100 mg 2VANCOMYCIN - vancomycin hcl iv soln 2000 mg/400ml 4VANCOMYCIN - vancomycin hcl-sodium chloride iv soln

500 mg/100ml-0.9%, 750 mg/150ml-0.9%4

VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm 4VANCOMYCIN HCL - vancomycin hcl-sodium chloride iv soln

1 gm/200ml-0.9%4

vancomycin hcl cap 125 mg 4 QL (120 capsules/30 days)vancomycin hcl cap 250 mg 4 QL (240 capsules/30 days)vancomycin hcl for iv soln 1.5 gm 4vancomycin hcl for iv soln 500 mg, 750 mg, 1 gm, 5 gm, 10 gm 4VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln

250 mg, 1.25 gm4

2022


Drug Name Drug Tier Requirements/LimitsVANCOMYCIN HYDROCHLORIDE - vancomycin hcl iv soln

500 mg/100ml, 750 mg/150ml, 1000 mg/200ml, 1250 mg/250ml,1500 mg/300ml, 1750 mg/350ml

4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycinhcl-dextrose iv soln 500 mg/100ml-5%, 750 mg/150ml-5%,1 gm/200ml-5%

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg,

800 mg5

BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 5carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg 4carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 4carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg 4carbamazepine tab 200 mg 3CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg, 20 mg 4 PA, QL (60 tablets/30 days)DIACOMIT - stiripentol cap 250 mg, 500 mg* 5DIACOMIT - stiripentol packet 250 mg, 500 mg* 5DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg,

20 mg4 QL (5 twin pack(s)/30 days)

DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg, 10 mg, 20 mg4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 4divalproex sodium cap delayed release sprinkle 125 mg 3divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg 2divalproex sodium tab er 24 hr 250 mg, 500 mg 3EPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PAethosuximide cap 250 mg 3ethosuximide soln 250 mg/5ml 4felbamate susp 600 mg/5ml 5felbamate tab 400 mg, 600 mg 4FINTEPLA - fenfluramine hcl oral soln 2.2 mg/ml 5 PA, QL (360 mls/30 days)fosphenytoin sodium inj 100 mg/2ml, 500 mg/10ml 4FYCOMPA - perampanel susp 0.5 mg/ml 4FYCOMPA - perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg,

12 mg4

2022


9

Drug Name Drug Tier Requirements/Limitsgabapentin cap 100 mg 2 QL (1080 capsules/30 days)gabapentin cap 300 mg 2 QL (360 capsules/30 days)gabapentin cap 400 mg 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 4 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg, 25 mg 4lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg 2levetiracetam inj 500 mg/5ml (100 mg/ml) 4levetiracetam oral soln 100 mg/ml 4levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg 2NAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 4 QL (10 bottles/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4oxcarbazepine tab 150 mg, 300 mg, 600 mg 3phenobarbital elixir 20 mg/5ml# 4phenobarbital sodium inj 65 mg/ml, 130 mg/ml# 4phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg,

64.8 mg, 97.2 mg, 100 mg#2

phenytoin chew tab 50 mg 4phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg, 300 mg 3phenytoin susp 125 mg/5ml 4pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg, 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 4 QL (900 mls/30 days)primidone tab 50 mg, 250 mg 2rufinamide susp 40 mg/ml 5rufinamide tab 200 mg 4rufinamide tab 400 mg 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg,

500 mg, 750 mg, 1000 mg4

SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg, 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg 4topiramate sprinkle cap 15 mg, 25 mg 2topiramate tab 25 mg, 50 mg, 100 mg, 200 mg 2valproate sodium inj 100 mg/ml 4valproate sodium oral soln 250 mg/5ml 4valproic acid cap 250 mg 2

2022


Drug Name Drug Tier Requirements/LimitsVALTOCO - diazepam nasal spray ther pack 2 x 7.5 mg/0.1ml

(15 mg dose), 2 x 10 mg/0.1ml (20 mg dose)4 QL (5 twin pack(s)/30 days)

VALTOCO - diazepam nasal spray 5 mg/0.1 ml, 10 mg/0.1 ml 4 QL (5 twin pack(s)/30 days)vigabatrin powd pack 500 mg* 5 QL (180 packets/30 days)vigabatrin tab 500 mg* 5 QL (180 tablets/30 days)VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 4VIMPAT - lacosamide oral solution 10 mg/ml 4VIMPAT - lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg 4XCOPRI - cenobamate tab pack 100 mg & 150 mg tabs (250 mg

daily dose)5

XCOPRI - cenobamate tab pack 150 mg & 200 mg tabs (350 mgdaily dose)

5

XCOPRI - cenobamate tab titration pack 14 x 12.5 mg & 14 x25 mg

4

XCOPRI - cenobamate tab titration pack 14 x 50 mg & 14 x100 mg, 14 x 150 mg & 14 x 200 mg

5

XCOPRI - cenobamate tab 50 mg, 100 mg, 150 mg, 200 mg 5zonisamide cap 25 mg, 50 mg, 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg, 10 mg 4donepezil hydrochloride tab 5 mg, 10 mg 2donepezil hydrochloride tab 23 mg 3GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg 4galantamine hydrobromide tab 4 mg, 8 mg, 12 mg 4memantine hcl oral solution 2 mg/ml 4 PA (<=29 yr)memantine hcl tab 5 mg, 10 mg 2 PA (<=29 yr)memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack 4 PA (<=29 yr)rivastigmine tartrate cap 1.5 mg, 3 mg, 4.5 mg, 6 mg 4rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr, 13.3 mg/24hr 4Antidepressantsamitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg# 2AMOXAPINE - amoxapine tab 25 mg, 50 mg, 100 mg, 150 mg# 4bupropion hcl tab er 12hr 100 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg, 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 3 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 3 QL (30 tablets/30 days)bupropion hcl tab 75 mg 3 QL (60 tablets/30 days)bupropion hcl tab 100 mg 3 QL (120 tablets/30 days)

2022


11

Drug Name Drug Tier Requirements/Limitscitalopram hydrobromide oral soln 10 mg/5ml 4 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg, 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg, 50 mg, 75 mg# 4desipramine hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg,

150 mg#4

desvenlafaxine succinate tab er 24hr 25 mg, 50 mg, 100 mg 4 QL (30 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 150 mg# 4doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg# 4doxepin hcl conc 10 mg/ml# 4DRIZALMA SPRINKLE - duloxetine hcl cap delayed release

sprinkle 20 mg, 40 mg, 60 mg4 QL (60 capsules/30 days)

DRIZALMA SPRINKLE - duloxetine hcl cap delayed releasesprinkle 30 mg

4 QL (90 capsules/30 days)

duloxetine hcl enteric coated pellets cap 20 mg, 60 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 2 QL (90 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr, 9 mg/24hr,

12 mg/24hr5

escitalopram oxalate soln 5 mg/5ml 4 QL (600 mls/30 days)escitalopram oxalate tab 5 mg, 10 mg 2 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 2 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg, 40 mg, 80 mg,

120 mg4 QL (30 capsules/30 days)

FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &40 mg therapy pack

4 QL (28 capsules/28 days)

fluoxetine hcl cap 10 mg 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 4 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 3 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg, 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg, 25 mg, 50 mg# 4MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg, 30 mg, 45 mg 4 QL (30 tablets/30 days)mirtazapine tab 7.5 mg, 30 mg, 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 15 mg 2 QL (45 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg, 150 mg 4

2022


Drug Name Drug Tier Requirements/LimitsNEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 50 mg,

200 mg, 250 mg4

NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 4nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg# 2paroxetine hcl oral susp 10 mg/5ml# 4 PA (>=65 yr), QL

(900 mls/30 days)paroxetine hcl tab 10 mg, 40 mg# 2 PA (>=65 yr), QL (45

tablets/30 days)paroxetine hcl tab 20 mg# 2 PA (>=65 yr), QL (30

tablets/30 days)paroxetine hcl tab 30 mg# 2 PA (>=65 yr), QL (60

tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA (>=65 yr), QL

(900 mls/30 days)phenelzine sulfate tab 15 mg 3protriptyline hcl tab 5 mg, 10 mg# 4sertraline hcl oral concentrate for solution 20 mg/ml 4 QL (300 mls/30 days)sertraline hcl tab 25 mg, 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

x 2 (56 mg dose pack)5 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln 28 mg/devicex 3 (84 mg dose pack)

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 4trazodone hcl tab 50 mg, 100 mg, 150 mg 2trazodone hcl tab 300 mg 4trimipramine maleate cap 25 mg, 50 mg, 100 mg# 4TRINTELLIX - vortioxetine hbr tab 5 mg, 10 mg, 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg, 20 mg, 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 4 BDaprepitant capsule 40 mg, 80 mg, 125 mg 4 BDchlorpromazine hcl inj 25 mg/ml 4 PA (>=65 yr)chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg 4 PA (>=65 yr)

2022


13

Drug Name Drug Tier Requirements/LimitsCHLORPROMAZINE HYDROCHLORIDE - chlorpromazine hcl

conc 30 mg/ml, 100 mg/ml4 PA (>=65 yr)

CHLORPROMAZINE HYDROCHLORIDE - chlorpromazine hcl inj50 mg/2ml

4 PA (>=65 yr)

dronabinol cap 2.5 mg, 5 mg, 10 mg 4 BDfosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml, 4 mg/4ml (1 mg/ml) 4meclizine hcl tab 12.5 mg# 2ONDANSETRON HCL - ondansetron hcl tab 24 mg 4 BDondansetron hcl inj 4 mg/2ml (2 mg/ml), 40 mg/20ml (2 mg/ml) 4ondansetron hcl oral soln 4 mg/5ml 3 BDondansetron hcl tab 4 mg, 8 mg 2 BDondansetron orally disintegrating tab 4 mg, 8 mg 4 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg 4 PA (>=65 yr)PROCHLORPERAZINE EDISYLATE - prochlorperazine edisylate

inj 50 mg/10ml4

prochlorperazine edisylate inj 10 mg/2ml 4prochlorperazine maleate tab 5 mg, 10 mg 2prochlorperazine suppos 25 mg 4promethazine hcl syrup 6.25 mg/5ml# 4 PA (>=65 yr)promethazine hcl tab 12.5 mg, 25 mg, 50 mg# 2 PA (>=65 yr)AntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 4 BDcaspofungin acetate for iv soln 50 mg, 70 mg 4ciclopirox solution 8% 2 QL (6.6 mls/30 days)clotrimazole troche 10 mg 3CRESEMBA - isavuconazonium sulf for iv sol 372 mg

(isavuconazole 200mg)5 PA

CRESEMBA - isavuconazonium sulfate cap 186 mg (isavuconazole100 mg)

5 PA

econazole nitrate cream 1% 3fluconazole for susp 10 mg/ml, 40 mg/ml 4fluconazole in nacl 0.9% inj 200 mg/100ml, 400 mg/200ml 4fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg 2flucytosine cap 250 mg, 500 mg 5

2022


Drug Name Drug Tier Requirements/Limitsgriseofulvin microsize susp 125 mg/5ml 4itraconazole cap 100 mg 4 QL (120 capsules/30 days)ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2micafungin sodium for iv soln 50 mg 4micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin topical powder 100000 unit/gm 2posaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg 2 QL (30 tablets/30 days)terconazole vaginal cream 0.4% 3terconazole vaginal cream 0.8% 2voriconazole for inj 200 mg 4 PAvoriconazole for susp 40 mg/ml 4 PAvoriconazole tab 50 mg, 200 mg 4 PAAntigout Agentsallopurinol tab 100 mg, 300 mg 1colchicine tab 0.6 mg 3colchicine w/ probenecid tab 0.5-500 mg 3probenecid tab 500 mg 3Antimigraine Agentsdihydroergotamine mesylate nasal spray 4 mg/ml 5 QL (8 mls/28 days)EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector

120 mg/ml3 PA, QL (2 pens/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr100 mg/ml

3 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr120 mg/ml

3 PA, QL (2 syringes/30 days)

ergotamine w/ caffeine tab 1-100 mg 3naratriptan hcl tab 1 mg, 2.5 mg 3 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg, 10 mg 4 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg, 10 mg 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act, 20 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan succinate inj 6 mg/0.5ml 3 QL (10 doses/30 days)

2022


15

Drug Name Drug Tier Requirements/Limitssumatriptan succinate solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml 3 QL (12 doses/30 days)sumatriptan succinate solution cartridge 4 mg/0.5ml, 6 mg/0.5ml 3 QL (12 doses/30 days)sumatriptan succinate tab 25 mg, 50 mg, 100 mg 2 QL (18 tablets/30 days)Antimyasthenic Agentspyridostigmine bromide tab er 180 mg 4pyridostigmine bromide tab 60 mg 3AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4dapsone tab 25 mg, 100 mg 3ethambutol hcl tab 100 mg, 400 mg 3ISONIAZID - isoniazid inj 100 mg/ml 4isoniazid tab 100 mg 2isoniazid tab 300 mg 2PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 4rifabutin cap 150 mg 4rifampin cap 150 mg, 300 mg 4rifampin for inj 600 mg 4SIRTURO - bedaquiline fumarate tab 20 mg, 100 mg* 5TRECATOR - ethionamide tab 250 mg 4Antineoplasticsabiraterone acetate tab 250 mg 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAADCETRIS - brentuximab vedotin for iv soln 50 mg 5 PAADRIAMYCIN - doxorubicin hcl for inj 10 mg, 50 mg 4 BDALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg, 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg, 180 mg* 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 2ARRANON - nelarabine iv soln 5 mg/ml 5 PAarsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 4arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml,

1000 mg/50ml*5 PA

2022


Drug Name Drug Tier Requirements/LimitsASPARLAS - calaspargase pegol-mknl iv soln 3750 unit/5ml (750

unit/ml)*5

AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion),400 mg/16ml (for infusion)*

5 PA

AYVAKIT - avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg 5 PA, QL (30 tablets/30 days)azacitidine for inj 100 mg 5BALVERSA - erdafitinib tab 3 mg 5 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg 5 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg 5 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/

ml)*5 PA

BELEODAQ - belinostat for iv inj 500 mg 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg 5 PAbicalutamide tab 50 mg 3BLENREP - belantamab mafodotin-blmf for iv soln 100 mg 5 PAbleomycin sulfate for inj 15 unit, 30 unit 4 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg, 500 mg 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 75 mg* 5 PA, QL (180 capsules/30 days)BRUKINSA - zanubrutinib cap 80 mg 5 PA, QL (120 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg, 40 mg, 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg* 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml, 150 mg/15ml, 450 mg/45ml,

600 mg/60ml4

carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 4cisplatin inj 50 mg/50ml (1 mg/ml), 100 mg/100ml (1 mg/ml) 4cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 PA, QL (112 capsules/28 days)

2022


17

Drug Name Drug Tier Requirements/LimitsCOMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)

kit*5 PA, QL (84 capsules/28 days)

COPIKTRA - duvelisib cap 15 mg, 25 mg* 5 PA, QL (56 capsules/28 days)COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)CYCLOPHOSPHAMIDE - cyclophosphamide iv soln 500 mg/2.5ml

(200 mg/ml), 1 gm/5ml (200 mg/ml)5

CYCLOPHOSPHAMIDE - cyclophosphamide tab 25 mg, 50 mg 4 BDcyclophosphamide cap 25 mg 3 BDcyclophosphamide cap 50 mg 3 BDcyclophosphamide for inj 500 mg, 1 gm, 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion),

500 mg/50ml (for infusion)*5 PA

CYTARABINE - cytarabine inj 20 mg/ml 4 BDcytarabine inj pf 20 mg/ml, 100 mg/ml 4 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 4dactinomycin for inj 0.5 mg 5DANYELZA - naxitamab-gqgk iv soln 40 mg/10ml (4 mg/ml) 5 PADARZALEX - daratumumab iv soln 100 mg/5ml, 400 mg/20ml* 5 PADARZALEX FASPRO - daratumumab-hyaluronidase-fihj inj

1800-30000 mg-unit/15ml*5 PA

daunorubicin hcl iv soln 20 mg/4ml 4DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml4

DAURISMO - glasdegib maleate tab 25 mg 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane hcl for inj 250 mg, 500 mg 5docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/ml), 160 mg/8ml

(20 mg/ml)5

docetaxel soln for iv infusion 20 mg/2ml, 80 mg/8ml, 160 mg/16ml 5doxorubicin hcl inj 2 mg/ml 4 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PADOXORUBICIN HYDROCHLORIDE - doxorubicin hcl for inj 10 mg 4 BDELITEK - rasburicase for iv soln 1.5 mg, 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg, 400 mg 5 PAENHERTU - fam-trastuzumab deruxtecan-nxki for iv soln 100 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml), 200 mg/100ml (2 mg/

ml)4

2022


Drug Name Drug Tier Requirements/LimitsERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml),

200 mg/100ml (2 mg/ml)5 PA

ERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg, 150 mg 5 PA, QL (30 tablets/30 days)ERWINASE - asparaginase erwinia chrysanthemi for inj 10000 unit* 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml), 500 mg/25ml (20 mg/ml),

1 gm/50ml (20 mg/ml)4

everolimus tab for oral susp 2 mg, 5 mg 5 PA, QL (60 tablets/30 days)everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)everolimus tab 2.5 mg, 7.5 mg, 10 mg 5 PA, QL (30 tablets/30 days)everolimus tab 5 mg 5 PA, QL (60 tablets/30 days)EVOMELA - melphalan hcl for inj 50 mg (propylene glycol (pg) free) 5exemestane tab 25 mg 4EXKIVITY - mobocertinib succinate cap 40 mg 5 PA, QL (120 capsules/30 days)FARYDAK - panobinostat lactate cap 10 mg, 15 mg, 20 mg* 5 PA, QL (6 capsules/21 days)fludarabine phosphate for inj 50 mg 4fludarabine phosphate inj 25 mg/ml 4fluorouracil iv soln 500 mg/10ml (50 mg/ml), 1 gm/20ml (50 mg/ml),

2.5 gm/50ml (50 mg/ml), 5 gm/100ml (50 mg/ml)4 BD

flutamide cap 125 mg 4FOLOTYN - pralatrexate iv inj 20 mg/ml, 40 mg/2ml 5 PAFOTIVDA - tivozanib hcl cap 890 mcg, 1340 mcg 5 PA, QL (21 capsules/28 days)fulvestrant inj 250 mg/5ml 5 PAGAVRETO - pralsetinib cap 100 mg 5 PA, QL (120 capsules/30 days)GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg, 1 gm, 2 gm 4gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml), 1 gm/26.3ml (38 mg/

ml), 2 gm/52.6ml (38 mg/ml)4

GILOTRIF - afatinib dimaleate tab 20 mg, 30 mg, 40 mg* 5 PA, QL (30 tablets/30 days)HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk inj

600-10000 mg-unit/5ml*5 PA

HERZUMA - trastuzumab-pkrb for iv soln 150 mg, 420 mg 5 PAhydroxyurea cap 500 mg 2IBRANCE - palbociclib cap 75 mg, 100 mg, 125 mg* 5 PA, QL (21 capsules/28 days)

2022


19

Drug Name Drug Tier Requirements/LimitsIBRANCE - palbociclib tab 75 mg, 100 mg, 125 mg* 5 PA, QL (21 tablets/28 days)ICLUSIG - ponatinib hcl tab 10 mg, 15 mg, 30 mg, 45 mg* 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml), 10 mg/10ml (1 mg/ml),

20 mg/20ml (1 mg/ml)5

IDHIFA - enasidenib mesylate tab 50 mg, 100 mg* 5 PA, QL (30 tablets/30 days)IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 4imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg* 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg* 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 420 mg, 560 mg* 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml),

500 mg/10ml (50 mg/ml)5 PA

IMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/ml

4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)INQOVI - decitabine-cedazuridine tab 35-100 mg 5 PA, QL (5 tablets/28 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 4irinotecan hcl inj 40 mg/2ml (20 mg/ml), 100 mg/5ml (20 mg/ml) 4ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg, 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg, 10 mg, 15 mg, 20 mg,

25 mg*5 PA, QL (60 tablets/30 days)

JEMPERLI - dostarlimab-gxly iv soln 500 mg/10ml (50 mg/ml) 5 PAJEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg,

160 mg5 PA

KANJINTI - trastuzumab-anns for iv soln 150 mg, 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml) 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (42 tablets/28 days)

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mgtab)

5 PA, QL (63 tablets/28 days)

2022


Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk5 PA, QL (49 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KOSELUGO - selumetinib sulfate cap 10 mg 5 PA, QL (240 capsules/30 days)KOSELUGO - selumetinib sulfate cap 25 mg 5 PA, QL (120 capsules/30 days)KYPROLIS - carfilzomib for inj 10 mg, 30 mg, 60 mg 5 PAlapatinib ditosylate tab 250 mg 5 PA, QL (180 tablets/30 days)LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack

10 mg*5 PA, QL (30 capsules/30 days)

LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 3 x4 mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap ther pack 10 mg &2 x 4 mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 2 x10 mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap ther pack 2 x 10 mg& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 2 x

4 mg*5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg 2LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)4

leucovorin calcium for inj 50 mg, 100 mg, 200 mg, 350 mg, 500 mg 4leucovorin calcium inj 500 mg/50ml (10 mg/ml) 4leucovorin calcium tab 5 mg 2leucovorin calcium tab 10 mg, 15 mg, 25 mg 4LEUKERAN - chlorambucil tab 2 mg 4LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml)* 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMAKRAS - sotorasib tab 120 mg 5 PA, QL (240 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PALYNPARZA - olaparib tab 100 mg, 150 mg* 5 PA, QL (120 tablets/30 days)

2022


21

Drug Name Drug Tier Requirements/LimitsMARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg* 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 3mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg, 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml), 25 mg/12.5ml

(2 mg/ml), 30 mg/15ml (2 mg/ml)4

MONJUVI - tafasitamab-cxix for iv soln 200 mg 5 PAMVASI - bevacizumab-awwb iv soln 100 mg/4ml (for infusion),

400 mg/16ml (for infusion)5 PA

MYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg* 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg, 3 mg, 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5NUBEQA - darolutamide tab 300 mg 5 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)OGIVRI - trastuzumab-dkst for iv soln 150 mg, 420 mg 5 PAONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAONTRUZANT - trastuzumab-dttb for iv soln 150 mg, 420 mg 5 PAONUREG - azacitidine tab 200 mg, 300 mg 5 PA, QL (14 tablets/28 days)OPDIVO - nivolumab iv soln 40 mg/4ml, 100 mg/10ml,

120 mg/12ml, 240 mg/24ml5 PA

OXALIPLATIN - oxaliplatin iv soln 200 mg/40ml 5oxaliplatin for iv inj 50 mg, 100 mg 5oxaliplatin iv soln 50 mg/10ml, 100 mg/20ml 5PACLITAXEL - paclitaxel iv conc 100 mg/16.67ml (6 mg/ml),

150 mg/25ml (6 mg/ml)4

paclitaxel iv conc 30 mg/5ml (6 mg/ml), 100 mg/16.7ml (6 mg/ml),300 mg/50ml (6 mg/ml)

4

PADCEV - enfortumab vedotin-ejfv for iv soln 20 mg, 30 mg 5 PA

2022


Drug Name Drug Tier Requirements/LimitsPARAPLATIN - carboplatin iv soln 1000 mg/100ml 4PEMAZYRE - pemigatinib tab 4.5 mg, 9 mg, 13.5 mg 5 PA, QL (14 tablets/21 days)PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

PHESGO - pertuzumab-trastuz-hyaluron-zzxf inj60 mg-60 mg-2000 unt/ml, 80 mg-40 mg-2000 unt/ml

5 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mgdaily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg dailydose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 30 mg, 140 mg 5 PAPOMALYST - pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PAPURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5QINLOCK - ripretinib tab 50 mg 5 PA, QL (90 tablets/30 days)RETEVMO - selpercatinib cap 40 mg 5 PA, QL (180 capsules/30 days)RETEVMO - selpercatinib cap 80 mg 5 PA, QL (120 capsules/30 days)REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg, 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg, 20 mg, 25 mg* 5 PA, QL (21 capsules/28 days)RIABNI - rituximab-arrx iv soln 100 mg/10ml (10 mg/ml),

500 mg/50ml (10 mg/ml)5 PA

RITUXAN - rituximab iv soln 100 mg/10ml, 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml, 1600-26800 mg-unit/13.4ml*5 PA

ROMIDEPSIN - romidepsin iv soln 27.5 mg/5.5ml (5 mg/ml) 5 PAROZLYTREK - entrectinib cap 100 mg 5 PA, QL (150 capsules/30 days)ROZLYTREK - entrectinib cap 200 mg 5 PA, QL (90 capsules/30 days)RUBRACA - rucaparib camsylate tab 200 mg, 250 mg, 300 mg* 5 PA, QL (120 tablets/30 days)RUXIENCE - rituximab-pvvr iv soln 100 mg/10ml (10 mg/ml),

500 mg/50ml (10 mg/ml)5 PA

RYBREVANT - amivantamab-vmjw iv soln 350 mg/7ml 5 PARYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)RYLAZE - asparaginase erwinia chrys (recomb)-rywn im soln

10 mg/0.5ml5

SARCLISA - isatuximab-irfc iv soln 100 mg/5ml, 500 mg/25ml 5 PASCEMBLIX - asciminib hcl tab 20 mg 5 PA, QL (60 tablets/30 days)SCEMBLIX - asciminib hcl tab 40 mg 5 PA, QL (300 tablets/30 days)

2022


23

Drug Name Drug Tier Requirements/LimitsSOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)sunitinib malate cap 25 mg, 37.5 mg, 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TABRECTA - capmatinib hcl tab 150 mg, 200 mg 5 PA, QL (120 tablets/30 days)TAFINLAR - dabrafenib mesylate cap 50 mg, 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg, 80 mg* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg* 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg* 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg, 20 mg 2TARGRETIN - bexarotene gel 1% 5 PATASIGNA - nilotinib hcl cap 50 mg, 150 mg, 200 mg 5 PA, QL (120 capsules/30 days)TAZVERIK - tazemetostat hbr tab 200 mg 5 PA, QL (240 tablets/30 days)TECENTRIQ - atezolizumab iv soln 840 mg/14ml, 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5TEPMETKO - tepotinib hcl tab 225 mg 5 PA, QL (60 tablets/30 days)THALOMID - thalidomide cap 50 mg, 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg, 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg, 100 mg 5TIBSOVO - ivosidenib tab 250 mg* 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 4toremifene citrate tab 60 mg 5TRAZIMERA - trastuzumab-qyyp for iv soln 150 mg, 420 mg 5 PATREANDA - bendamustine hcl for iv soln 25 mg, 100 mg 5tretinoin cap 10 mg 5 PATRODELVY - sacituzumab govitecan-hziy for iv soln 180 mg 5 PATRUSELTIQ - infigratinib phos cap pack 100 & 25 mg (125 mg daily

dose)5 PA, QL (42 capsules/28 days)

TRUSELTIQ - infigratinib phos cap ther pack 2 x 25 mg (50 mgdaily dose)


TRUSELTIQ - infigratinib phos cap ther pack 3 x 25 mg (75 mgdaily dose)


TRUSELTIQ - infigratinib phos cap ther pack 100 mg (100 mg dailydose)


2022


Drug Name Drug Tier Requirements/LimitsTRUXIMA - rituximab-abbs iv soln 100 mg/10ml (10 mg/ml),

500 mg/50ml (10 mg/ml)5 PA

TUKYSA - tucatinib tab 50 mg 5 PA, QL (300 tablets/30 days)TUKYSA - tucatinib tab 150 mg 5 PA, QL (120 tablets/30 days)TURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)UKONIQ - umbralisib tosylate tab 200 mg 5 PA, QL (120 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml, 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mg* 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 4 BDVINCRISTINE SULFATE - vincristine sulfate iv soln 1 mg/ml 4 BDvinorelbine tartrate inj 10 mg/ml, 50 mg/5ml (10 mg/ml) 4VITRAKVI - larotrectinib sulfate cap 25 mg* 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg* 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml* 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg, 30 mg, 45 mg* 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAWELIREG - belzutifan tab 40 mg 5 PA, QL (90 tablets/30 days)XALKORI - crizotinib cap 200 mg, 250 mg* 5 PA, QL (120 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XPOVIO - selinexor tab therapy pack 40 mg (40 mg once weekly),

40 mg (40 mg twice weekly), 40 mg (80 mg once weekly), 50 mg(100 mg once weekly), 60 mg (60 mg once weekly)

5 PA, QL (1 box/28 days)

XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack20 mg




XPOVIO 40 MG TWICE WEEKLY - selinexor tab therapy pack20 mg






2022


25

Drug Name Drug Tier Requirements/LimitsXPOVIO 80 MG ONCE WEEKLY - selinexor tab therapy pack

20 mg5 PA, QL (1 box/28 days)



XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)XTANDI - enzalutamide tab 40 mg* 5 PA, QL (120 tablets/30 days)XTANDI - enzalutamide tab 80 mg* 5 PA, QL (60 tablets/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml),

200 mg/40ml (5 mg/ml)*5 PA

YONDELIS - trabectedin for inj 1 mg 5 PAZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion),


ZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg* 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZEPZELCA - lurbinectedin for iv soln 4 mg 5 PAZIRABEV - bevacizumab-bvzr iv soln 100 mg/4ml (for infusion),


ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg, 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib tab 150 mg* 5 PA, QL (90 tablets/30 days)ZYNLONTA - loncastuximab tesirine-lpyl for iv soln 10 mg 5 PAAntiparasiticsalbendazole tab 200 mg 4atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg 3BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mg 4chloroquine phosphate tab 250 mg 4chloroquine phosphate tab 500 mg 2COARTEM - artemether-lumefantrine tab 20-120 mg 4hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2mefloquine hcl tab 250 mg 4nitazoxanide tab 500 mg 5 QL (20 tablets/30 days)pentamidine isethionate for nebulization soln 300 mg 4 BDpentamidine isethionate for soln 300 mg 4praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg (15 mg base) 4pyrimethamine tab 25 mg 5

2022


Drug Name Drug Tier Requirements/LimitsAntiparkinson Agentsamantadine hcl cap 100 mg 3amantadine hcl soln 50 mg/5ml 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg, 1 mg, 2 mg# 2 PA (>=65 yr)bromocriptine mesylate tab 2.5 mg 4carbidopa & levodopa orally disintegrating tab 10-100 mg,

25-100 mg, 25-250 mg4

carbidopa & levodopa tab er 25-100 mg, 50-200 mg 3carbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250 mg 2entacapone tab 200 mg 4INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg, 0.25 mg, 0.5 mg,

0.75 mg, 1 mg, 1.5 mg2

rasagiline mesylate tab 0.5 mg, 1 mg 4ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,

4 mg, 5 mg2

SELEGILINE HCL - selegiline hcl tab 5 mg 4selegiline hcl cap 5 mg 3AntipsychoticsABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

300 mg, 400 mg4 QL (1 syringe/28 days)

ABILIFY MAINTENA - aripiprazole im for extended release susp300 mg, 400 mg

4 QL (1 vial/28 days)

aripiprazole oral solution 1 mg/ml 4 PA (>=65 yr), QL(750 mls/30 days)

aripiprazole orally disintegrating tab 10 mg, 15 mg 5 PA (>=65 yr), QL (60tablets/30 days)

aripiprazole tab 2 mg, 5 mg 4 PA (>=65 yr), QL (45tablets/30 days)

aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg 4 PA (>=65 yr), QL (30tablets/30 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml, 662 mg/2.4ml, 882 mg/3.2ml

4 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml


ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml


asenapine maleate sl tab 2.5 mg, 5 mg, 10 mg 4 PA (>=65 yr), QL (60tablets/30 days)

CAPLYTA - lumateperone tosylate cap 42 mg 5 PA (>=65 yr), QL (30capsules/30 days)

2022


27

Drug Name Drug Tier Requirements/LimitsCLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg 4 PA (>=65 yr), QL (90

tablets/30 days)clozapine orally disintegrating tab 25 mg, 100 mg 4 PA (>=65 yr), QL (270

tablets/30 days)clozapine tab 25 mg, 50 mg 3 PA (>=65 yr), QL (90

tablets/30 days)clozapine tab 100 mg 4 PA (>=65 yr), QL (270

tablets/30 days)clozapine tab 200 mg 4 PA (>=65 yr), QL (120

tablets/30 days)FANAPT - iloperidone tab 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg,

12 mg4 PA (>=65 yr), QL (60

tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA (>=65 yr), QL (7 packs

(56 tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 4 PA (>=65 yr)FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PA (>=65 yr)FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 4 PA (>=65 yr)fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg 4 PA (>=65 yr)FLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml4 PA (>=65 yr)

haloperidol decanoate im soln 50 mg/ml, 100 mg/ml 4 PA (>=65 yr)haloperidol lactate inj 5 mg/ml 4 PA (>=65 yr)haloperidol lactate oral conc 2 mg/ml 4 PA (>=65 yr)haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg 2 PA (>=65 yr)haloperidol tab 20 mg 3 PA (>=65 yr)INVEGA HAFYERA - paliperidone palmitate er susp pref syr

1,092 mg/3.5ml, 1,560 mg/5ml4 QL (1 kit/180 days)

INVEGA SUSTENNA - paliperidone palmitate er susp prefsyr 39 mg/0.25ml, 78 mg/0.5ml, 117 mg/0.75ml, 156 mg/ml,234 mg/1.5ml

4 QL (1 kit/28 days)

INVEGA TRINZA - paliperidone palmitate er susp prefsyr 273 mg/0.875ml, 410 mg/1.315ml, 546 mg/1.75ml,819 mg/2.625ml

4 QL (1 kit/90 days)

LATUDA - lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg 4 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 4 QL (60 tablets/30 days)loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg 3 PA (>=65 yr)LYBALVI - olanzapine-samidorphan l-malate tab 5-10 mg,

10-10 mg, 15-10 mg, 20-10 mg5 PA (>=65 yr), QL (30

tablets/30 days)MOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg, 10 mg,

25 mg4 PA (>=65 yr)

NUPLAZID - pimavanserin tartrate cap 34 mg* 4 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 4 PA, QL (30 tablets/30 days)

2022


Drug Name Drug Tier Requirements/Limitsolanzapine for im inj 10 mg 4 PA (>=65 yr), QL

(90 vials/30 days)olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg 4 PA (>=65 yr), QL (30

tablets/30 days)olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg 2 PA (>=65 yr), QL (45

tablets/30 days)olanzapine tab 15 mg, 20 mg 2 PA (>=65 yr), QL (30

tablets/30 days)paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg 4 PA (>=65 yr), QL (30

tablets/30 days)paliperidone tab er 24hr 6 mg 4 PA (>=65 yr), QL (60

tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg, 120 mg5 QL (1 syringe/30 days)

PIMOZIDE - pimozide tab 1 mg, 2 mg 4quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg 4 PA (>=65 yr), QL (60

tablets/30 days)quetiapine fumarate tab er 24hr 150 mg, 200 mg 4 PA (>=65 yr), QL (30

tablets/30 days)quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg 2 PA (>=65 yr), QL (120

tablets/30 days)quetiapine fumarate tab 300 mg, 400 mg 2 PA (>=65 yr), QL (60

tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,

4 mg4 PA (>=65 yr), QL (30

tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for im extended

rel susp 12.5 mg, 25 mg, 37.5 mg, 50 mg4 QL (2 vials/28 days)

RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 4 PA (>=65 yr), QL (60tablets/30 days)

risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg 4 PA (>=65 yr), QL (60tablets/30 days)

risperidone orally disintegrating tab 4 mg 4 PA (>=65 yr), QL (120tablets/30 days)

risperidone soln 1 mg/ml 4 PA (>=65 yr), QL(480 mls/30 days)

risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 2 PA (>=65 yr), QL (60tablets/30 days)

risperidone tab 4 mg 2 PA (>=65 yr), QL (120tablets/30 days)

SECUADO - asenapine td patch 24 hr 3.8 mg/24hr, 5.7 mg/24hr,7.6 mg/24hr

5 PA (>=65 yr), QL (30patches/30 days)

thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg 4 PA (>=65 yr)thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg 4 PA (>=65 yr)

2022


29

Drug Name Drug Tier Requirements/Limitstrifluoperazine hcl tab 1 mg, 2 mg, 5 mg, 10 mg 3 PA (>=65 yr)VERSACLOZ - clozapine susp 50 mg/ml 5 PA (>=65 yr), QL

(540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg, 3 mg, 4.5 mg, 6 mg 4 QL (30 capsules/30 days)ziprasidone hcl cap 20 mg, 40 mg 4 QL (90 capsules/30 days)ziprasidone hcl cap 60 mg, 80 mg 4 QL (60 capsules/30 days)ziprasidone mesylate for inj 20 mg 4 PA (>=65 yr), QL

(60 vials/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg4 PA (>=65 yr), QL


susp 300 mg5 PA (>=65 yr), QL


susp 405 mg5 PA (>=65 yr), QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg, 20 mg 2tizanidine hcl tab 2 mg, 4 mg 2Antiviralsabacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)abacavir sulfate tab 300 mg 4 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 4 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir sodium iv soln 50 mg/ml 4 BDacyclovir susp 200 mg/5ml 4acyclovir tab 400 mg, 800 mg 2adefovir dipivoxil tab 10 mg 4APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)atazanavir sulfate cap 150 mg, 300 mg 4 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 4 QL (60 capsules/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)CABENUVA - cabotegravir 400 mg/2ml & rilpivirine 600 mg/2ml im

susp er*5 QL (4 mls/30 days)

CABENUVA - cabotegravir 600 mg/3ml & rilpivirine 900 mg/3ml imsusp er*

5 QL (6 mls/30 days)

CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

DELSTRIGO - doravirine-lamivudine-tenofovir df tab100-300-300 mg

5 QL (30 tablets/30 days)

2022


Drug Name Drug Tier Requirements/LimitsDESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 4 QL (90 capsules/30 days)efavirenz cap 200 mg 4 QL (120 capsules/30 days)efavirenz tab 600 mg 4 QL (30 tablets/30 days)efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)efavirenz-lamivudine-tenofovir df tab 400-300-300 mg,

600-300-300 mg5 QL (30 tablets/30 days)

emtricitabine caps 200 mg 4 QL (30 capsules/30 days)emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg,

133-200 mg, 167-250 mg, 200-300 mg5 QL (30 tablets/30 days)

EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg, 1 mg 4EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 4etravirine tab 100 mg 4 QL (60 tablets/30 days)etravirine tab 200 mg 5 QL (60 tablets/30 days)EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)fosamprenavir calcium tab 700 mg 4 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 4 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir pellet pack 33.75-150 mg,45-200 mg

5 PA

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg, 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)lamivudine oral soln 10 mg/ml 4 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg 3 QL (60 tablets/30 days)lamivudine tab 300 mg 4 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 4 QL (60 tablets/30 days)

2022


31

Drug Name Drug Tier Requirements/LimitsLEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 4 QL (480 mls/30 days)lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)NEVIRAPINE ER - nevirapine tab er 24hr 100 mg 4 QL (90 tablets/30 days)nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)nevirapine tab er 24hr 400 mg 4 QL (30 tablets/30 days)nevirapine tab 200 mg 3 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg 2 QL (168 capsules/365 days)oseltamivir phosphate cap 45 mg, 75 mg 2 QL (84 capsules/365 days)oseltamivir phosphate for susp 6 mg/ml 4 QL (1080 mls/365 days)PIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg, 480 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4 QL (6 boxes/365 days)

RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)ribavirin cap 200 mg 3ribavirin tab 200 mg 3ritonavir tab 100 mg 3 QL (360 tablets/30 days)RUKOBIA - fostemsavir tromethamine tab er 12hr 600 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg, 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir pellet pack 150 mg, 200 mg 5 PASOVALDI - sofosbuvir tab 200 mg, 400 mg 5 PASTAVUDINE - stavudine cap 15 mg, 20 mg, 30 mg, 40 mg 4 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


2022


Drug Name Drug Tier Requirements/LimitsSYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


TEMIXYS - lamivudine-tenofovir disoproxil fumarate tab300-300 mg


tenofovir disoproxil fumarate tab 300 mg 4 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (240 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg, 50 mg 5 QL (60 tablets/30 days)TIVICAY PD - dolutegravir sodium tab for oral susp 5 mg 5 QL (360 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml)* 5 QL (14 vials/28 days)TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg, 1 gm 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 3VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 4 QL (120 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg, 200 mg,

250 mg5 QL (30 tablets/30 days)

VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAXOFLUZA - baloxavir marboxil tab therapy pack 2 x 20 mg (40 mg

dose), 2 x 40 mg (80 mg dose), 1 x 40 mg (40 mg dose)4 QL (4 tablets/365 days)

XOFLUZA - baloxavir marboxil tab therapy pack 1 x 80 mg (80 mgdose)


ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAzidovudine cap 100 mg 4 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 4 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsalprazolam tab 0.25 mg, 0.5 mg, 1 mg 2 QL (120 tablets/30 days)alprazolam tab 2 mg 2 QL (150 tablets/30 days)buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg 2clonazepam orally disintegrating tab 0.125 mg, 0.25 mg, 0.5 mg,

1 mg4 QL (90 tablets/30 days)

clonazepam orally disintegrating tab 2 mg 4 QL (300 tablets/30 days)clonazepam tab 0.5 mg, 1 mg 2 QL (120 tablets/30 days)clonazepam tab 2 mg 2 QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 4 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 4 PA, QL (360 tablets/30 days)

2022


33

Drug Name Drug Tier Requirements/Limitsclorazepate dipotassium tab 15 mg 4 PA, QL (180 tablets/30 days)diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam tab 2 mg, 5 mg, 10 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 0.5 mg, 1 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 2 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 4lithium carbonate cap 600 mg 3lithium carbonate cap 150 mg 3lithium carbonate cap 300 mg 2lithium carbonate tab er 300 mg, 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days), ST

BYETTA - exenatide soln pen-injector 5 mcg/0.02ml 4 QL (2 pens/30 days), STBYETTA - exenatide soln pen-injector 10 mcg/0.04ml 4 QL (1 pen/30 days), STdiazoxide susp 50 mg/ml 4GAUZE PADS 2" X 2" 3glimepiride tab 1 mg# 1 QL (240 tablets/30 days)glimepiride tab 2 mg# 1 QL (120 tablets/30 days)glimepiride tab 4 mg# 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 2 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 2 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 2 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg, 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3 QL (4 kits/30 days)glyburide micronized tab 1.5 mg# 2 QL (240 tablets/30 days)glyburide micronized tab 3 mg# 2 QL (120 tablets/30 days)glyburide micronized tab 6 mg# 2 QL (60 tablets/30 days)glyburide tab 1.25 mg# 2 QL (480 tablets/30 days)glyburide tab 2.5 mg# 2 QL (240 tablets/30 days)

2022


Drug Name Drug Tier Requirements/Limitsglyburide tab 5 mg# 2 QL (120 tablets/30 days)glyburide-metformin tab 1.25-250 mg# 2 QL (240 tablets/30 days)glyburide-metformin tab 2.5-500 mg, 5-500 mg# 2 QL (120 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg, 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 3 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml(1 unit dial), 200 unit/ml

3 QL (20 pens/30 days)

HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100unit/ml (50-50)

3 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)


HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)

3 QL (6 vials/30 days)

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml3 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml5 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)


HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN SYRINGE/NEEDLE 3JANUMET - sitagliptin-metformin hcl tab 50-500 mg, 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg,


JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)

2022


35

Drug Name Drug Tier Requirements/Limitsmetformin hcl tab er 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)nateglinide tab 60 mg 3 QL (180 tablets/30 days)nateglinide tab 120 mg 3 QL (90 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml), 1 mg/dose (4 mg/3ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg 2 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg, 45 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg# 4 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg 3 QL (90 tablets/30 days)repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)RYBELSUS - semaglutide tab 3 mg, 7 mg, 14 mg 3 QL (30 tablets/30 days), STSYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg,

12.5-500 mg, 12.5-1000 mg3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr5-1000 mg, 10-1000 mg, 12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300unit/ml (2 unit dial)


TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit dial)


VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products and Modifiersanagrelide hcl cap 0.5 mg 3anagrelide hcl cap 1 mg 4aspirin-dipyridamole cap er 12hr 25-200 mg 4BRILINTA - ticagrelor tab 60 mg, 90 mg 4CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5cilostazol tab 50 mg, 100 mg 2

2022


Drug Name Drug Tier Requirements/Limitsclopidogrel bisulfate tab 75 mg 1enoxaparin sodium inj 30 mg/0.3ml, 40 mg/0.4ml, 100 mg/ml,

120 mg/0.8ml, 150 mg/ml4 QL (30 syringes/90 days)

enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)enoxaparin sodium subcutaneous soln 60 mg/0.6ml, 80 mg/0.8ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml, 7.5 mg/0.6ml,

10 mg/0.8ml5 QL (30 syringes/90 days)

GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml,480 mcg/0.8ml

5 PA

GRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml,480 mcg/1.6ml (300 mcg/ml)

5 PA

HEPARIN SODIUM - heparin sodium (porcine) inj soln pref syr5000 unit/0.5ml

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml, 10000 unit/

ml, 20000 unit/ml3

heparin sodium (porcine) pf inj 5000 unit/0.5ml 3HEPARIN SODIUM/D5W - heparin sodium (porcine)-dextrose iv sol

20000 unit/500ml-5%4

LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PAMOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5PRADAXA - dabigatran etexilate mesylate cap 75 mg, 150 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)prasugrel hcl tab 5 mg, 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml,

10000 unit/ml4 PA

PROCRIT - epoetin alfa inj 20000 unit/ml, 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 25 mg,

12.5 mg*5 PA

PROMACTA - eltrombopag olamine tab 12.5 mg, 25 mg, 50 mg,75 mg*

5 PA

RETACRIT - epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ml, 4000unit/ml, 10000 unit/ml, 20000 unit/ml, 40000 unit/ml

4 PA

tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 4tranexamic acid tab 650 mg 3warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,

7.5 mg, 10 mg1

XARELTO - rivaroxaban tab 2.5 mg, 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg, 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

2022


37

Drug Name Drug Tier Requirements/LimitsCardiovascular Agentsacetazolamide cap er 12hr 500 mg 3acetazolamide tab 125 mg, 250 mg 3aliskiren fumarate tab 150 mg, 300 mg 4 QL (30 tablets/30 days)amiloride hcl tab 5 mg 2amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 4amlodipine besylate tab 2.5 mg, 5 mg, 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg, 2.5-20 mg,

2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg, 10-10 mg,10-20 mg, 10-40 mg, 10-80 mg

4

amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10 mg,5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg

2

amlodipine besylate-olmesartan medoxomil tab 5-20 mg, 5-40 mg,10-20 mg, 10-40 mg


amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg, 10-160 mg,10-320 mg


amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg,5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg


atenolol & chlorthalidone tab 50-25 mg, 100-25 mg 1atenolol tab 25 mg, 50 mg, 100 mg 1atorvastatin calcium tab 10 mg, 20 mg, 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg, 10-12.5 mg,

20-12.5 mg, 20-25 mg2

benazepril hcl tab 5 mg, 10 mg, 20 mg, 40 mg 1bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg,

10-6.25 mg1

bisoprolol fumarate tab 5 mg, 10 mg 2bumetanide inj 0.25 mg/ml 4bumetanide tab 0.5 mg, 1 mg 2bumetanide tab 2 mg 3candesartan cilexetil tab 4 mg, 8 mg, 16 mg 3 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 3 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg,

32-12.5 mg, 32-25 mg3 QL (30 tablets/30 days)

captopril tab 12.5 mg 2captopril tab 25 mg, 50 mg, 100 mg 3carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg 1chlorthalidone tab 25 mg, 50 mg 2cholestyramine light powder packets 4 gm 4

2022


Drug Name Drug Tier Requirements/Limitscholestyramine light powder 4 gm/dose 4cholestyramine powder packets 4 gm 4cholestyramine powder 4 gm/dose 4clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg 1clonidine td patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 4colestipol hcl granule packets 5 gm 4colestipol hcl granules 5 gm 4colestipol hcl tab 1 gm 3CORLANOR - ivabradine hcl oral soln 5 mg/5ml 4 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg, 7.5 mg 4 PA, QL (60 tablets/30 days)digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg)# 2 QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg 4diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg 2diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg,

300 mg, 360 mg2

diltiazem hcl coated beads tab er 24hr 180 mg, 240 mg, 300 mg,360 mg, 420 mg

3

diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg,240 mg, 300 mg, 360 mg, 420 mg

2

diltiazem hcl tab 30 mg, 60 mg, 90 mg, 120 mg 2dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg

(0.5 mg)4

doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg 2 QL (60 tablets/30 days)droxidopa cap 100 mg, 200 mg, 300 mg 5 PAenalapril maleate & hydrochlorothiazide tab 5-12.5 mg, 10-25 mg 2enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg 2ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (180 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg, 97-103 mg 3 QL (60 tablets/30 days)ezetimibe tab 10 mg 3 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg,


felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg 2fenofibrate micronized cap 67 mg, 134 mg, 200 mg 3 QL (30 capsules/30 days)fenofibrate tab 48 mg, 54 mg 3 QL (60 tablets/30 days)fenofibrate tab 145 mg, 160 mg 3 QL (30 tablets/30 days)flecainide acetate tab 50 mg, 100 mg, 150 mg 2fluvastatin sodium cap 20 mg, 40 mg 4 QL (60 capsules/30 days)fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg2

2022


39

Drug Name Drug Tier Requirements/Limitsfosinopril sodium tab 10 mg, 20 mg, 40 mg 2furosemide inj 10 mg/ml 4furosemide oral soln 10 mg/ml 4furosemide tab 20 mg, 40 mg, 80 mg 1gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg 2hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg 1icosapent ethyl cap 1 gm 3irbesartan tab 75 mg, 150 mg, 300 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg 2 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg, 10 mg, 20 mg, 30 mg 3isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mg 2isradipine cap 2.5 mg, 5 mg 3labetalol hcl tab 100 mg, 200 mg, 300 mg 2lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,

20-25 mg1

lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg,


losartan potassium tab 25 mg, 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)lovastatin tab 10 mg, 20 mg, 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg, 50 mg 4metoprolol & hydrochlorothiazide tab 50-25 mg, 100-25 mg 2metoprolol succinate tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg 2metoprolol tartrate tab 25 mg, 50 mg, 100 mg 1metyrosine cap 250 mg 5mexiletine hcl cap 150 mg 3mexiletine hcl cap 200 mg, 250 mg 4midodrine hcl tab 2.5 mg, 5 mg, 10 mg 4minoxidil tab 2.5 mg, 10 mg 2moexipril hcl tab 7.5 mg, 15 mg 2MULTAQ - dronedarone hcl tab 400 mg 4nadolol tab 20 mg, 40 mg 3nadolol tab 80 mg 4nebivolol hcl tab 2.5 mg, 5 mg, 10 mg, 20 mg 4niacin tab er 500 mg 4 QL (30 tablets/30 days)niacin tab er 750 mg, 1000 mg 4 QL (60 tablets/30 days)

2022


Drug Name Drug Tier Requirements/Limitsnicardipine hcl cap 20 mg, 30 mg 4nifedipine tab er 24hr 30 mg, 60 mg, 90 mg 3nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg 3nimodipine cap 30 mg 4NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 4nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg 4NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/

hr2

NORTHERA - droxidopa cap 100 mg, 200 mg, 300 mg* 5 PAolmesartan medoxomil tab 5 mg 2 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg, 40 mg 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg,


olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg,40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25 mg


omega-3-acid ethyl esters cap 1 gm 3pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg, 4 mg, 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 3pravastatin sodium tab 10 mg, 20 mg, 40 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg, 2 mg, 5 mg 2propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg 4propafenone hcl tab 150 mg, 225 mg 2propafenone hcl tab 300 mg 3propranolol hcl inj 1 mg/ml 4propranolol hcl tab 10 mg, 20 mg, 40 mg, 80 mg 2quinapril hcl tab 5 mg 2quinapril hcl tab 10 mg, 20 mg, 40 mg 1quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,

20-25 mg2

QUINIDINE SULFATE - quinidine sulfate tab 200 mg, 300 mg 3ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg 1ranolazine tab er 12hr 500 mg, 1000 mg 4 QL (60 tablets/30 days)RECTIV - nitroglycerin oint 0.4% 4

2022


41

Drug Name Drug Tier Requirements/LimitsREPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml4 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

4 PA, QL (2 systems/28 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

4 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg, 10 mg, 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)simvastatin tab 5 mg, 10 mg, 40 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg 2sotalol hcl tab 80 mg, 120 mg, 160 mg, 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg, 50 mg, 100 mg 1telmisartan tab 20 mg, 40 mg, 80 mg 2 QL (30 tablets/30 days)telmisartan-amlodipine tab 40-5 mg, 40-10 mg, 80-5 mg, 80-10 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg, 80-25 mg 3 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 3 QL (60 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg, 5 mg, 10 mg 1 QL (60 capsules/30 days)trandolapril tab 1 mg, 2 mg, 4 mg 1trandolapril-verapamil hcl tab er 2-180 mg, 2-240 mg, 4-240 mg 3TRANDOLAPRIL/VERAPAMIL HCL - trandolapril-verapamil hcl tab

er 1-240 mg2

triamterene & hydrochlorothiazide cap 37.5-25 mg 1triamterene & hydrochlorothiazide tab 37.5-25 mg, 75-50 mg 1valsartan tab 40 mg, 80 mg, 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg,

160-25 mg, 320-12.5 mg, 320-25 mg2 QL (30 tablets/30 days)

VASCEPA - icosapent ethyl cap 0.5 gm, 1 gm 3verapamil hcl tab er 120 mg, 180 mg, 240 mg 2verapamil hcl tab 40 mg, 80 mg, 120 mg 1Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg,

15 mg, 20 mg, 25 mg, 30 mg4 QL (30 capsules/30 days)

amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10 mg,12.5 mg, 15 mg, 30 mg


amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)atomoxetine hcl cap 10 mg, 18 mg, 25 mg, 40 mg 4 QL (60 capsules/30 days)

2022


Drug Name Drug Tier Requirements/Limitsatomoxetine hcl cap 60 mg, 80 mg, 100 mg 4 QL (30 capsules/30 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 4 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dalfampridine tab er 12hr 10 mg 3 PAdexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg 3 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)dimethyl fumarate capsule delayed release 120 mg, 240 mg 5 PA, QL (60 capsules/30 days)dimethyl fumarate capsule dr starter pack 120 mg & 240 mg 5 PA, QL (60 capsules/30 days)GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)MAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)MAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (12)

starter pack5 PA, QL (1 pack/28 days)

methylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg, 10 mg, 20 mg 4 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

riluzole tab 50 mg 4tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAVUMERITY - diroximel fumarate capsule delayed release 231 mg 5 PA, QL (120 capsules/30 days)VUMERITY - diroximel fumarate capsule dr starter bottle 231 mg 5 PA, QL (106 capsules/30 days)Dental and Oral Agentschlorhexidine gluconate soln 0.12% 2KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg, 7.5 mg 4Dermatological Agentsacitretin cap 10 mg, 17.5 mg, 25 mg 4AUGMENTED BETAMETHASONE DIPROPIONATE -

betamethasone dipropionate augmented gel 0.05%4 QL (200 grams/28 days)

azelaic acid gel 15% 4benzoyl peroxide-erythromycin gel 5-3% 4betamethasone dipropionate augmented cream 0.05% 4 QL (200 grams/28 days)

2022


43

Drug Name Drug Tier Requirements/Limitsbetamethasone dipropionate augmented lotion 0.05% 4 QL (210 mls/30 days)betamethasone dipropionate augmented oint 0.05% 4 QL (200 grams/28 days)calcipotriene cream 0.005% 4 QL (120 grams/30 days)calcipotriene oint 0.005% 4 QL (120 grams/30 days)calcipotriene soln 0.005% (50 mcg/ml) 4 QL (120 mls/30 days)CARAC - fluorouracil cream 0.5% 5clobetasol propionate cream 0.05% 4 QL (210 grams/28 days)clobetasol propionate emollient base cream 0.05% 4 QL (210 grams/28 days)clobetasol propionate gel 0.05% 4 QL (210 grams/28 days)clobetasol propionate oint 0.05% 4 QL (210 grams/28 days)clobetasol propionate soln 0.05% 4 QL (200 mls/28 days)clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 4desonide cream 0.05% 4 QL (120 grams/30 days)desonide lotion 0.05% 4 QL (118 mls/30 days)desonide oint 0.05% 4 QL (120 grams/30 days)desoximetasone cream 0.05%, 0.25% 4 QL (120 grams/30 days)desoximetasone gel 0.05% 4 QL (120 grams/30 days)desoximetasone oint 0.25% 4 QL (120 grams/30 days)FINACEA - azelaic acid foam 15% 3fluocinolone acetonide cream 0.01% 4 QL (120 grams/30 days)fluocinonide cream 0.05% 3 QL (120 grams/30 days)fluocinonide emulsified base cream 0.05% 3 QL (120 grams/30 days)fluocinonide gel 0.05% 4 QL (120 grams/30 days)fluocinonide oint 0.05% 4 QL (120 grams/30 days)fluocinonide soln 0.05% 4 QL (120 mls/30 days)FLUOROURACIL - fluorouracil cream 0.5% 5fluorouracil cream 5% 4fluticasone propionate cream 0.05% 2 QL (120 grams/30 days)fluticasone propionate oint 0.005% 2 QL (120 grams/30 days)gentamicin sulfate cream 0.1% 3gentamicin sulfate oint 0.1% 3halobetasol propionate cream 0.05% 4 QL (200 grams/28 days)halobetasol propionate oint 0.05% 4 QL (200 grams/28 days)hydrocortisone butyrate cream 0.1% 4 QL (135 grams/30 days)hydrocortisone butyrate hydrophilic lipo base cream 0.1% 4 QL (120 grams/30 days)hydrocortisone butyrate oint 0.1% 3 QL (135 grams/30 days)hydrocortisone butyrate soln 0.1% 4 QL (120 mls/30 days)

2022


Drug Name Drug Tier Requirements/Limitshydrocortisone cream 1% 2hydrocortisone cream 2.5% 3 QL (454 grams/30 days)hydrocortisone lotion 2.5% 2 QL (118 mls/30 days)hydrocortisone oint 1% 2hydrocortisone oint 2.5% 2 QL (454 grams/30 days)hydrocortisone valerate cream 0.2% 4 QL (120 grams/30 days)hydrocortisone valerate oint 0.2% 3 QL (120 grams/30 days)imiquimod cream 5% 3 PAisotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg 4lactic acid (ammonium lactate) cream 12% 2lactic acid (ammonium lactate) lotion 12% 3malathion lotion 0.5% 4metronidazole cream 0.75% 4metronidazole gel 0.75% 3metronidazole lotion 0.75% 4mometasone furoate cream 0.1% 2 QL (135 grams/30 days)mometasone furoate oint 0.1% 2 QL (135 grams/30 days)mometasone furoate solution 0.1% (lotion) 2 QL (120 mls/30 days)mupirocin oint 2% 2 QL (30 grams/30 days)nystatin-triamcinolone cream 100000-0.1 unit/gm-% 4nystatin-triamcinolone oint 100000-0.1 unit/gm-% 4permethrin cream 5% 3pimecrolimus cream 1% 4 PApodofilox soln 0.5% 4SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 2SOOLANTRA - ivermectin cream 1% 3sulfacetamide sodium lotion 10% 4tacrolimus oint 0.03%, 0.1% 4 PAtazarotene cream 0.1% 3 PATAZORAC - tazarotene cream 0.05% 4 PATAZORAC - tazarotene gel 0.05%, 0.1% 4 PAtretinoin cream 0.025%, 0.05%, 0.1% 4 PAtretinoin gel 0.01%, 0.025% 4 PAtriamcinolone acetonide cream 0.025%, 0.1%, 0.5% 3 QL (454 grams/30 days)triamcinolone acetonide oint 0.025%, 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.5% 2 QL (120 grams/30 days)

2022


45

Drug Name Drug Tier Requirements/LimitsElectrolytes/Minerals/Metals/Vitaminscalcium acetate cap 667 mg (169 mg ca) 3calcium acetate tab 667 mg 3CARBAGLU - carglumic acid tab 200 mg* 5 PACHEMET - succimer cap 100 mg 5deferasirox granules packet 90 mg, 180 mg, 360 mg 5 PAdeferasirox tab for oral susp 125 mg, 250 mg, 500 mg 5 PAdeferasirox tab 90 mg, 180 mg, 360 mg 5 PAdextrose inj 5%, 10% 4dextrose 2.5% w/ sodium chloride 0.45% 4dextrose 5% in lactated ringers 4dextrose 5% w/ sodium chloride 0.2%, 0.33%, 0.45%, 0.9% 4FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)HEPATAMINE - amino acid infusion 8% 4 BDINTRALIPID - fat emulsion plant based (soy) iv emulsion 20% 4 BDkcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 4kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 4kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 4lactated ringer's solution 4magnesium sulfate inj 50% 4NUTRILIPID - fat emulsion plant based (soy) iv emulsion 20% 4 BDpotassium chloride cap er 8 meq, 10 meq 2potassium chloride inj 2 meq/ml 4potassium chloride microencapsulated crys er tab 10 meq, 15 meq,

20 meq2

potassium chloride oral soln 10% (20 meq/15ml) 4potassium chloride tab er 8 meq (600 mg) 3potassium chloride tab er 10 meq, 20 meq (1500 mg) 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 4POTASSIUM CHLORIDE/SODIUM CHLORIDE - kcl 20 meq/l

(0.15%) in nacl 0.45% inj4

potassium citrate tab er 5 meq (540 mg), 10 meq (1080 mg), 15meq (1620 mg)

4

SAMSCA - tolvaptan tab 15 mg 5 PAsevelamer carbonate packet 0.8 gm 4 QL (270 packets/30 days)sevelamer carbonate packet 2.4 gm 4 QL (90 packets/30 days)

2022


Drug Name Drug Tier Requirements/Limitssevelamer carbonate tab 800 mg 4 QL (270 tablets/30 days)sodium chloride iv soln 0.45%, 0.9% 4sodium chloride preservative free inj 0.9% 4sodium polystyrene sulfonate oral susp 15 gm/60ml 3sodium polystyrene sulfonate powder 4tolvaptan tab 30 mg 5 PATRAVASOL - amino acid infusion 10% 4 BDtrientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)TROPHAMINE - amino acid infusion 10% 4 BDVELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm,

16.8 gm, 25.2 gm3

water for irrigation, sterile irrigation soln 3Gastrointestinal Agentsalosetron hcl tab 0.5 mg 4 PA, QL (60 tablets/30 days)alosetron hcl tab 1 mg 5 PA, QL (60 tablets/30 days)CHENODAL - chenodiol tab 250 mg* 5 PADEXILANT - dexlansoprazole cap delayed release 30 mg, 60 mg 4 QL (30 capsules/30 days)dicyclomine hcl cap 10 mg# 2 PA (>=65 yr)dicyclomine hcl tab 20 mg# 2 PA (>=65 yr)esomeprazole magnesium cap delayed release 20 mg, 40 mg 3 QL (30 capsules/30 days)esomeprazole sodium for intravenous soln 40 mg 4famotidine for susp 40 mg/5ml 4famotidine inj 20 mg/2ml, 40 mg/4ml, 200 mg/20ml 4famotidine tab 20 mg, 40 mg 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAGAVILYTE-C - peg 3350-kcl-na bicarb-nacl-na sulfate for soln

240 gm4

glycopyrrolate tab 1 mg, 2 mg 2lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg, 30 mg 3 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg, 145 mcg, 290 mcg 3 QL (30 capsules/30 days)loperamide hcl cap 2 mg 2LUBIPROSTONE - lubiprostone cap 8 mcg 4 QL (120 capsules/30 days)LUBIPROSTONE - lubiprostone cap 24 mcg 4 QL (60 capsules/30 days)metoclopramide hcl inj 5 mg/ml 4metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 4metoclopramide hcl tab 5 mg, 10 mg 1misoprostol tab 100 mcg, 200 mcg 3

2022


47

Drug Name Drug Tier Requirements/LimitsMOVANTIK - naloxegol oxalate tab 12.5 mg, 25 mg 3 PAMYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANIZATIDINE - nizatidine cap 150 mg 4nizatidine cap 300 mg 3OCALIVA - obeticholic acid tab 5 mg, 10 mg* 5 PA, QL (30 tablets/30 days)omeprazole cap delayed release 10 mg 1 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg, 40 mg 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 4peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm 2rabeprazole sodium ec tab 20 mg 3 QL (30 tablets/30 days)sucralfate tab 1 gm 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

SUTAB - sod sulfate-mg sulfate-pot chloride tab 1479-225-188 mg 4ursodiol cap 300 mg 4ursodiol tab 250 mg 3ursodiol tab 500 mg 4XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

CEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000

unit, 6000-19000-30000 unit, 12000-38000-60000 unit,24000-76000-120000 unit, 36000-114000-180000 unit

3

cromolyn sodium oral conc 100 mg/5ml 4CRYSVITA - burosumab-twza inj 10 mg/ml, 20 mg/ml, 30 mg/ml 5 PACYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml) 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg, 35 mg* 5levocarnitine oral soln 1 gm/10ml (10%) 4levocarnitine tab 330 mg 4LUMIZYME - alglucosidase alfa for iv soln 50 mg* 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5

2022


Drug Name Drug Tier Requirements/Limitsnitisinone cap 2 mg, 5 mg, 10 mg 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml, 10 mg/0.5ml, 20 mg/ml5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5sapropterin dihydrochloride powder packet 100 mg, 500 mg 5 PAsapropterin dihydrochloride tab 100 mg 5 PAsodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml,

28 mg/0.7ml, 40 mg/ml, 80 mg/0.8ml*5 PA

VPRIV - velaglucerase alfa for inj 400 unit 5 PAVYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit, 5000-17000-24000 unit, 10000-32000-42000 unit,15000-47000-63000 unit, 20000-63000-84000 unit,25000-79000-105000 unit, 40000-126000-168000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50 mg 3dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 2 QL (30 tablets/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron granules for oral extended release susp

8 mg/ml3 QL (3 bottles/28 days)

MYRBETRIQ - mirabegron tab er 24 hr 25 mg, 50 mg 3 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml 4 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 3 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 3 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 3 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)penicillamine tab 250 mg 5tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg, 4 mg 4 QL (30 capsules/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg, 8 mg 3 QL (30 tablets/30 days)trospium chloride tab 20 mg 3 QL (60 tablets/30 days)

2022


49

Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Adrenal)DEXAMETHASONE - dexamethasone soln 0.5 mg/5ml 4dexamethasone elixir 0.5 mg/5ml 4dexamethasone sodium phosphate inj 4 mg/ml, 20 mg/5ml,

120 mg/30ml4

dexamethasone tab therapy pack 1.5 mg (21) 3dexamethasone tab therapy pack 1.5 mg (35) 3dexamethasone tab therapy pack 1.5 mg (51) 3dexamethasone tab 0.5 mg, 0.75 mg, 4 mg, 6 mg 2dexamethasone tab 1.5 mg 3fludrocortisone acetate tab 0.1 mg 2HEMADY - dexamethasone tab 20 mg 4hydrocortisone tab 5 mg, 10 mg, 20 mg 2methylprednisolone sod succ for inj 40 mg, 125 mg, 500 mg,

1000 mg4

methylprednisolone tab therapy pack 4 mg (21) 2methylprednisolone tab 4 mg, 8 mg, 32 mg 2methylprednisolone tab 16 mg 3PREDNISOLONE - prednisolone syrup 15 mg/5ml 4prednisolone sod phosphate oral soln 15 mg/5ml 4PREDNISONE - prednisone oral soln 5 mg/5ml 4prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21),

10 mg (48)2

prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg 2prednisone tab 50 mg 3Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit4 PA

desmopressin acetate inj 4 mcg/ml 4desmopressin acetate nasal spray soln 0.01% (refrigerated), 0.01% 4desmopressin acetate preservative free inj 4 mcg/ml 4desmopressin acetate tab 0.1 mg, 0.2 mg 3EGRIFTA SV - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin solution cartridge 5 mg/1.5ml,

10 mg/1.5ml5 PA

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL -chorionic gonadotropin for im inj 10000 unit

4 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 4

2022


Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANDRODERM - testosterone td patch 24hr 2 mg/24hr, 4 mg/24hr 3 PA, QL (30 patches/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day, 0.05-0.25 mg/day#4

danazol cap 50 mg, 100 mg, 200 mg 4 PAdesogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 4desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 4desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 4DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm

(0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%),1.25 mg/1.25gm (0.1%)#

4

drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 4drospirenone-ethinyl estradiol tab 3-0.02 mg, 3-0.03 mg 4DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 1-0.5 mg# 4estradiol tab 0.5 mg, 1 mg, 2 mg# 2estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr,

0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr#3

estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr(37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr,0.1 mg/24hr#

3

estradiol vaginal cream 0.1 mg/gm 3estradiol vaginal tab 10 mcg 4ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg,

1 mg-50 mcg4

HYDROXYPROGESTERONE CAPROATE - hydroxyprogesteronecaproate im in oil 1.25 gm/5ml

5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 4levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 4levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg4

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 4medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 4medroxyprogesterone acetate im susp 150 mg/ml 4medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg 2megestrol acetate susp 40 mg/ml# 4 PA (>=65 yr)megestrol acetate tab 20 mg, 40 mg# 2 PA (>=65 yr)MENEST - esterified estrogens tab 0.3 mg, 0.625 mg, 1.25 mg# 4norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,

0.5 mg-35 mcg, 1 mg-35 mcg4

2022


51

Drug Name Drug Tier Requirements/Limitsnorethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 4norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 4norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg,

1.5 mg-30 mcg4

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg,1.5 mg-30 mcg

4

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 4norethindrone acetate tab 5 mg 3norethindrone tab 0.35 mg 4norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg,

0.5-35/1-35/0.5-35 mg-mcg4

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 4norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg,

0.18-35/0.215-35/0.25-35 mg-mcg4

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 4oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 4 PAPREMARIN - estrogens, conjugated tab 0.3 mg, 0.45 mg,

0.625 mg, 0.9 mg, 1.25 mg#3

PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg, 0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg#

3

progesterone cap 100 mg, 200 mg 2raloxifene hcl tab 60 mg 3testosterone cypionate im inj in oil 100 mg/ml, 200 mg/ml 3 PAtestosterone td gel 25 mg/2.5gm (1%) 4 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 4 PA, QL (60 units/30 days)testosterone td gel 12.5 mg/act (1%) 4 PA, QL (4 pump bottles/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 4 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 4 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 4 PA, QL (2 pump bottles/30 days)TYBLUME - levonorgestrel & ethinyl estradiol chew tab

0.1 mg-20 mcg4

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (euthyrox, levo-t, levoxyl,

unithroid)1

levothyroxine sodium tab 50 mcg (euthyrox, levo-t, levoxyl,unithroid)

1


1

2022


Drug Name Drug Tier Requirements/Limitslevothyroxine sodium tab 88 mcg (euthyrox, levo-t, levoxyl,

unithroid)1


1


1


1


1


1


1


1

levothyroxine sodium tab 300 mcg (levo-t, unithroid) 1liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg 2Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 5Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 3ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4 PA

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4 PA

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4 PA

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4 PAFIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg/vial (240 mg dose) 5leuprolide acetate inj kit 5 mg/ml 5 PALUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg, 7.5 mg5 PA

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 11.25 mg, 22.5 mg

5 PA

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5 PA

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5 PA

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg, 11.25 mg, 15 mg

5 PA

2022


53

Drug Name Drug Tier Requirements/LimitsLUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)

for inj pediatric kit 11.25 mg, 30 mg5 PA

OCTREOTIDE ACETATE - octreotide acetate subcutaneous solnpref syr 50 mcg/ml, 100 mcg/ml, 500 mcg/ml

4 PA

octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml (0.1 mg/ml), 200 mcg/ml (0.2 mg/ml), 500 mcg/ml (0.5 mg/ml), 1000 mcg/ml (1 mg/ml)

4 PA

ORGOVYX - relugolix tab 120 mg 5 PA, QL (90 tablets/30 days)SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml, 0.6 mg/ml,

0.9 mg/ml*5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj60 mg/0.2ml, 90 mg/0.3ml, 120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg, 15 mg, 20 mg, 25 mg,30 mg*

5 PA

SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg,

11.25 mg, 22.5 mg4 PA

Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg, 10 mg 1propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 3ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg, 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

3

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

BOOSTRIX - tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-mcg/0.5ml

3

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)*5 PA

2022


Drug Name Drug Tier Requirements/LimitsCOSENTYX - secukinumab subcutaneous soln prefilled syringe

75 mg/0.5ml5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneousauto-inj 150 mg/ml (300 mg dose)*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

cyclosporine cap 25 mg, 100 mg 4 BDcyclosporine iv soln 50 mg/ml 4 BDcyclosporine modified cap 25 mg, 50 mg, 100 mg 4 BDcyclosporine modified oral soln 100 mg/ml 4 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC -

diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln pen-injector200 mg/1.14ml, 300 mg/2ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml, 300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous inj 25 mg/0.5ml 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml, 50 mg/ml5 PA

ENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/ml

5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp10 mcg/0.5ml, 20 mcg/ml

3 BD

everolimus tab 0.25 mg, 0.5 mg, 0.75 mg 5 BDGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml, 2.5 gm/25ml, 5 gm/50ml, 10 gm/100ml, 20 gm/200ml,40 gm/400ml

5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

3

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

3

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit*

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit*

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml, 1440 elunit/ml

3

2022


55

Drug Name Drug Tier Requirements/LimitsHIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg3

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml,20 mg/0.2ml, 40 mg/0.8ml, 40 mg/0.4ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml, 80 mg/0.8ml &40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml,40 mg/0.4ml, 80 mg/0.8ml

5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit40 mg/0.8ml, 80 mg/0.8ml

5 PA

HUMIRA PEN-PEDIATRIC UC STARTER PACK - adalimumabpen-injector kit 80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml, 80 mg/0.8ml & 40 mg/0.4ml

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3INTRON A - interferon alfa-2b inj 6000000 unit/ml 4INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 3INTRON A - interferon alfa-2b for inj 18000000 unit 4INTRON A - interferon alfa-2b for inj 50000000 unit 5IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 3IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 3KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 3KINRIX - diph-tetanus-acell pert-polio, ipv vacc susp pref syr 0.5 ml 3leflunomide tab 10 mg 4leflunomide tab 20 mg 3M-M-R II - measles-mumps-rubella virus vaccines for inj soln 3MENACTRA - meningococcal (a, c, y, and w-135) diphth conjugate

vaccine3

MENQUADFI - meningococcal (a, c, y, and w-135) tetanusconjugate vaccine

3

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 3METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)3

methotrexate sodium for inj 1 gm 3methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml

(25 mg/ml), 1000 mg/40ml (25 mg/ml)3

methotrexate sodium inj 50 mg/2ml (25 mg/ml) 3

2022


Drug Name Drug Tier Requirements/Limitsmethotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 3 BDmycophenolate mofetil for oral susp 200 mg/ml 4 BDmycophenolate mofetil hcl for iv soln 500 mg 4 BDmycophenolate mofetil tab 500 mg 3 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 3PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml3

PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml 5 PAPENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for

im susp3

PROGRAF - tacrolimus packet for susp 0.2 mg, 1 mg 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp3

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

3

RABAVERT - rabies vaccine, pcec for inj 3 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml, 10 mcg/ml, 40 mcg/ml3 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARINVOQ - upadacitinib tab er 24hr 15 mg 5 PAROTARIX - rotavirus vaccine, live for oral susp 3ROTATEQ - rotavirus vaccine, live oral pentavalent soln 3SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

sirolimus oral soln 1 mg/ml 4 BDsirolimus tab 0.5 mg, 1 mg, 2 mg 4 BDSKYRIZI - risankizumab-rzaa sol prefilled syringe 2 x 75 mg/0.83ml

kit5 PA

SKYRIZI - risankizumab-rzaa soln prefilled syringe 150 mg/ml 5 PASKYRIZI PEN - risankizumab-rzaa soln auto-injector 150 mg/ml 5 PASTAMARIL - yellow fever vaccine for inj suspension 3STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml, 90 mg/ml

5 PA

SYNAGIS - palivizumab im soln 50 mg/0.5ml, 100 mg/ml* 5

2022


57

Drug Name Drug Tier Requirements/Limitstacrolimus cap 0.5 mg, 1 mg, 5 mg 4 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3 BDTHYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

3

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 3TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml3

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml, 50 unit/ml 3VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml3

XATMEP - methotrexate oral soln 2.5 mg/ml 4 BDXELJANZ - tofacitinib citrate oral soln 1 mg/ml 5 PAXELJANZ - tofacitinib citrate tab 5 mg, 10 mg 5 PAXELJANZ XR - tofacitinib citrate tab er 24hr 11 mg, 22 mg 5 PAXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml, 150 mg/ml*5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 3ZORTRESS - everolimus tab 1 mg 5 BDInflammatory Bowel Disease Agentsbalsalazide disodium cap 750 mg 4budesonide delayed release particles cap 3 mg 4 QL (90 capsules/30 days)budesonide tab er 24hr 9 mg 5 QL (30 tablets/30 days)DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml 4hydrocortisone perianal cream 1% 2hydrocortisone perianal cream 2.5% 3 QL (454 grams/30 days)mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)mesalamine enema 4 gm 4mesalamine rectal enema 4 gm & cleanser wipe kit 4mesalamine suppos 1000 mg 4mesalamine tab delayed release 800 mg 4 QL (180 tablets/30 days)mesalamine tab delayed release 1.2 gm 4 QL (120 tablets/30 days)sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg, 70 mg 1 QL (4 tablets/28 days)

2022


Drug Name Drug Tier Requirements/Limitscalcitonin (salmon) inj 200 unit/ml 5calcitonin (salmon) nasal soln 200 unit/act 3CALCITRIOL - calcitriol inj 1 mcg/ml 4calcitriol cap 0.25 mcg, 0.5 mcg 2calcitriol oral soln 1 mcg/ml 4cinacalcet hcl tab 30 mg 4 PAcinacalcet hcl tab 60 mg, 90 mg 5 PAFORTEO - teriparatide (recombinant) soln pen-inj 620 mcg/2.48ml 5 PAibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg, 50 mcg, 75 mcg, 100 mcg*5 PA, QL (2 cartridges/28 days)

paricalcitol cap 1 mcg, 2 mcg, 4 mcg 4paricalcitol iv soln 2 mcg/ml, 5 mcg/ml 4PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 4 QL (4 tablets/28 days)risedronate sodium tab 5 mg, 30 mg 4 QL (30 tablets/30 days)risedronate sodium tab 35 mg 3 QL (4 tablets/28 days)risedronate sodium tab 150 mg 4 QL (1 tablet/28 days)TYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1%, 0.15% 3azelastine hcl ophth soln 0.05% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 4BESIVANCE - besifloxacin hcl ophth susp 0.6% 3betaxolol hcl ophth soln 0.5% 2bimatoprost ophth soln 0.03% 4 QL (15 mls/75 days)brimonidine tartrate ophth soln 0.15% 4brimonidine tartrate ophth soln 0.2% 2CARTEOLOL HCL - carteolol hcl ophth soln 1% 4ciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 2CYSTADROPS - cysteamine hcl ophth soln 0.37%* 5 PA

2022


59

Drug Name Drug Tier Requirements/LimitsCYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PADEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

difluprednate ophth emulsion 0.05% 3dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 3FLURBIPROFEN SODIUM - flurbiprofen sodium ophth soln 0.03% 4GENTAK - gentamicin sulfate ophth oint 0.3% 4gentamicin sulfate ophth soln 0.3% 2ketorolac tromethamine ophth soln 0.4% 3ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 1 QL (15 mls/75 days)LUMIGAN - bimatoprost ophth soln 0.01% 3 QL (15 mls/75 days)moxifloxacin hcl ophth soln 0.5% (generic for Vigamox) 2moxifloxacin hcl ophth soln 0.5% (2 times daily) (generic for

Moxeza)2

NATACYN - natamycin ophth susp 5% 4neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml4

ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1%, 0.2% 3pilocarpine hcl ophth soln 1%, 2%, 4% 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 2PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 3RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 PAROCKLATAN - netarsudil dimesylate-latanoprost ophth soln

0.02-0.005%3 PA

SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM

PHOSPHATE - sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%

4

2022


Drug Name Drug Tier Requirements/Limitstimolol maleate ophth gel forming soln 0.25%, 0.5% 4timolol maleate ophth soln 0.25%, 0.5% 1tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 3travoprost ophth soln 0.004% 3 QL (15 mls/75 days)TRIFLURIDINE - trifluridine ophth soln 1% 3Otic Agentsfluocinolone acetonide (otic) oil 0.01% 4hydrocortisone w/ acetic acid otic soln 1-2% 4neomycin-polymyxin-hc otic soln 1% 3neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 3ofloxacin otic soln 0.3% 3Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10%, 20% 3 BDADEMPAS - riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg* 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act,115-21 mcg/act, 230-21 mcg/act

3 QL (1 canister/30 days)

albuterol sulfate inhal aero 108 mcg/act (generics for ProAir HFAand Proventil HFA)

3 QL (36 grams/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml), 0.63 mg/3ml,

1.25 mg/3ml3 BD

albuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab 2 mg, 4 mg 4ambrisentan tab 5 mg, 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act, 100 mcg/act, 200 mcg/act

3 QL (30 blisters/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension50 mcg/act, 100 mcg/act, 200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh




ASMANEX TWISTHALER 30 METERED DOSES - mometasonefuroate inhal powd 110 mcg/inh, 220 mcg/inh




2022


61

Drug Name Drug Tier Requirements/LimitsASMANEX TWISTHALER 7 METERED DOSES - mometasone

furoate inhal powd 110 mcg/inh3 QL (1 canister/30 days)

ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 3 QL (2 bottles/30 days)bosentan tab 62.5 mg, 125 mg* 5 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh, 200-25 mcg/inh3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml 4 BDcaffeine citrate oral soln 60 mg/3ml 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PA (>=65 yr)COMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 4 BDDALIRESP - roflumilast tab 250 mcg, 500 mcg 4 PA, QL (30 tablets/30 days)diphenhydramine hcl inj 50 mg/ml 4epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (generic

for EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister, 100 mcg/blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)

3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act, 113-14 mcg/act,232-14 mcg/act

3 QL (1 inhaler/30 days)

INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh

3 QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)

2022


Drug Name Drug Tier Requirements/LimitsKALYDECO - ivacaftor packet 25 mg, 50 mg, 75 mg* 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg* 5 PA, QL (60 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 2mometasone furoate nasal susp 50 mcg/act 4 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg, 5 mg 2montelukast sodium oral granules packet 4 mg 4montelukast sodium tab 10 mg 2OFEV - nintedanib esylate cap 100 mg, 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 4 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg,

150-188 mg*5 PA, QL (60 packets/30 days)

ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg, 200-125 mg* 5 PA, QL (120 tablets/30 days)PULMOZYME - dornase alfa inhal soln 2.5 mg/2.5ml 5 BDSEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 3 PA, QL (90 tablets/30 days)SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab

tbpk5 PA, QL (60 tablets/30 days)

SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg, 5 mg 4THEOPHYLLINE ER - theophylline tab er 12hr 300 mg, 450 mg 4theophylline tab er 24hr 400 mg, 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BD, PATRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh, 200-62.5-25 mcg/inh3 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml), 50 mg/20ml (2.5 mg/ml),100 mg/20ml (5 mg/ml), 200 mg/20ml (10 mg/ml)*

5 BD

TRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor75 mg tbpk


TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor150 mg tbpk


VENTAVIS - iloprost inhalation solution 10 mcg/ml, 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)zafirlukast tab 10 mg, 20 mg 4Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg, 10 mg# 2 PA

2022


63

Drug Name Drug Tier Requirements/Limitsmethocarbamol tab 500 mg, 750 mg# 2Sleep Disorder Agentsarmodafinil tab 50 mg, 150 mg, 200 mg, 250 mg 3 PA, QL (30 tablets/30 days)doxepin hcl (sleep) tab 3 mg, 6 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg, 200 mg 3 PA, QL (30 tablets/30 days)ramelteon tab 8 mg 4 QL (30 tablets/30 days)temazepam cap 15 mg, 30 mg 2 QL (30 capsules/30 days)WAKIX - pitolisant hcl tab 4.45 mg, 17.8 mg 5 PA, QL (60 tablets/30 days)XYWAV - calcium, mag, potassium, & sod oxybates oral soln

500 mg/ml*5 PA, QL (540 mls/30 days)

zaleplon cap 5 mg# 2 QL (30 capsules/30 days)zaleplon cap 10 mg# 2 QL (60 capsules/30 days)zolpidem tartrate tab 5 mg, 10 mg# 2 QL (30 tablets/30 days)

2022

64

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................29abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................29abacavir sulfate soln 20 mg/ml.................................. 29abacavir sulfate tab 300 mg.......................................29ABILIFY MAINTENA....................................................26ABILIFY MAINTENA....................................................26abiraterone acetate tab 250 mg.................................15ABRAXANE...................................................................15acamprosate calcium tab delayed release 333

mg..................................................................................2acarbose tab 100 mg.................................................. 33acarbose tab 25 mg.................................................... 33acarbose tab 50 mg.................................................... 33acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15 mg, 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................37acetazolamide tab 125 mg, 250 mg.......................... 37acetylcysteine inhal soln 10%, 20%.......................... 60acitretin cap 10 mg, 17.5 mg, 25 mg.........................42ACTHIB..........................................................................53ACTIMMUNE................................................................ 53acyclovir cap 200 mg.................................................. 29acyclovir sodium iv soln 50 mg/ml.............................29acyclovir susp 200 mg/5ml......................................... 29acyclovir tab 400 mg, 800 mg....................................29ADACEL........................................................................ 53ADCETRIS.................................................................... 15adefovir dipivoxil tab 10 mg........................................29ADEMPAS..................................................................... 60ADRIAMYCIN............................................................... 15ADVAIR DISKUS..........................................................60ADVAIR HFA.................................................................60albendazole tab 200 mg............................................. 25albuterol sulfate inhal aero 108 mcg/act (generics for

ProAir HFA and Proventil HFA)...............................60albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................60albuterol sulfate soln nebu 0.5% (5 mg/ml), 0.63

mg/3ml, 1.25 mg/3ml................................................60albuterol sulfate syrup 2 mg/5ml................................60albuterol sulfate tab 2 mg, 4 mg................................ 60ALCOHOL SWABS......................................................33

ALDURAZYME............................................................. 47ALECENSA................................................................... 15alendronate sodium tab 10 mg.................................. 57alendronate sodium tab 35 mg, 70 mg..................... 57alfuzosin hcl tab er 24hr 10 mg................................. 48ALIMTA.......................................................................... 15ALIQOPA....................................................................... 15aliskiren fumarate tab 150 mg, 300 mg.....................37allopurinol tab 100 mg, 300 mg................................. 14alosetron hcl tab 0.5 mg............................................. 46alosetron hcl tab 1 mg................................................ 46ALPHAGAN P...............................................................58alprazolam tab 0.25 mg, 0.5 mg, 1 mg..................... 32alprazolam tab 2 mg....................................................32ALUNBRIG....................................................................15ALUNBRIG....................................................................15ALUNBRIG....................................................................15amantadine hcl cap 100 mg.......................................26amantadine hcl soln 50 mg/5ml.................................26AMBISOME...................................................................13ambrisentan tab 5 mg, 10 mg.................................... 60amikacin sulfate inj 500 mg/2ml (250 mg/ml), 1

gm/4ml (250 mg/ml)................................................... 3amiloride hcl tab 5 mg.................................................37amiodarone hcl tab 200 mg........................................37amiodarone hcl tab 400 mg........................................37amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg,

100 mg, 150 mg........................................................10amlodipine besylate-atorvastatin calcium tab 2.5-10

mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40mg, 5-80 mg, 10-10 mg, 10-20 mg, 10-40 mg,10-80 mg....................................................................37

amlodipine besylate-benazepril hcl cap 2.5-10 mg,5-10 mg, 5-20 mg, 5-40 mg, 10-20 mg, 10-40mg................................................................................37

amlodipine besylate-olmesartan medoxomil tab 5-20mg, 5-40 mg, 10-20 mg, 10-40 mg.........................37

amlodipine besylate tab 2.5 mg, 5 mg, 10mg................................................................................37

amlodipine besylate-valsartan tab 5-160 mg, 5-320mg, 10-160 mg, 10-320 mg.....................................37

amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,10-160-25 mg, 10-320-25 mg................................. 37

AMOXAPINE.................................................................10AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 3AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 3amoxicillin (trihydrate) cap 250 mg, 500

mg..................................................................................3

2022

65

amoxicillin (trihydrate) for susp 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400 mg/5ml............................ 3

amoxicillin (trihydrate) tab 500 mg, 875mg..................................................................................3

amoxicillin & k clavulanate for susp 400-57mg/5ml.......................................................................... 3

amoxicillin & k clavulanate tab 250-125mg..................................................................................3

amoxicillin & k clavulanate tab 500-125 mg, 875-125mg..................................................................................3

amphetamine-dextroamphetamine cap er 24hr 5 mg,10 mg, 15 mg, 20 mg, 25 mg, 30 mg.....................41

amphetamine-dextroamphetamine tab 20mg................................................................................41

amphetamine-dextroamphetamine tab 5 mg, 7.5 mg,10 mg, 12.5 mg, 15 mg, 30 mg.............................. 41

AMPHOTERICIN B......................................................13AMPICILLIN.................................................................... 3ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................3AMPICILLIN SODIUM................................................... 3ampicillin sodium for inj 250 mg, 500 mg, 1 gm, 2

gm..................................................................................3ampicillin sodium for iv soln 2 gm................................3AMPICILLIN-SULBACTAM........................................... 4anagrelide hcl cap 0.5 mg.......................................... 35anagrelide hcl cap 1 mg............................................. 35anastrozole tab 1 mg...................................................15ANDRODERM.............................................................. 50ANORO ELLIPTA.........................................................60APOKYN........................................................................26APO-VARENICLINE.......................................................2aprepitant capsule 40 mg, 80 mg, 125

mg................................................................................12aprepitant capsule therapy pack 80 & 125

mg................................................................................12APTIOM........................................................................... 8APTIVUS....................................................................... 29ARCALYST....................................................................53aripiprazole orally disintegrating tab 10 mg, 15

mg................................................................................26aripiprazole oral solution 1 mg/ml..............................26aripiprazole tab 10 mg, 15 mg, 20 mg, 30

mg................................................................................26aripiprazole tab 2 mg, 5 mg....................................... 26ARISTADA.....................................................................26ARISTADA.....................................................................26ARISTADA INITIO........................................................26armodafinil tab 50 mg, 150 mg, 200 mg, 250

mg................................................................................63ARNUITY ELLIPTA......................................................60ARRANON.................................................................... 15

arsenic trioxide iv soln 10 mg/10ml (1 mg/ml)................................................................................15

arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)................................................................................15

ARZERRA..................................................................... 15asenapine maleate sl tab 2.5 mg, 5 mg, 10

mg................................................................................26ASMANEX HFA............................................................60ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 60ASMANEX TWISTHALER 14 METERED




DOSES....................................................................... 61ASPARLAS....................................................................16aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................35atazanavir sulfate cap 150 mg, 300

mg................................................................................29atazanavir sulfate cap 200 mg...................................29atenolol & chlorthalidone tab 50-25 mg, 100-25

mg................................................................................37atenolol tab 25 mg, 50 mg, 100 mg...........................37atomoxetine hcl cap 10 mg, 18 mg, 25 mg, 40

mg................................................................................41atomoxetine hcl cap 60 mg, 80 mg, 100

mg................................................................................42atorvastatin calcium tab 10 mg, 20 mg, 40

mg................................................................................37atorvastatin calcium tab 80 mg.................................. 37atovaquone-proguanil hcl tab 62.5-25 mg, 250-100

mg................................................................................25atovaquone susp 750 mg/5ml....................................25ATROVENT HFA..........................................................61AUGMENTED BETAMETHASONE

DIPROPIONATE....................................................... 42AVASTIN........................................................................16AYVAKIT........................................................................ 16azacitidine for inj 100 mg............................................16AZATHIOPRINE........................................................... 53azathioprine tab 50 mg............................................... 53azelaic acid gel 15%................................................... 42azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................61azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................61azelastine hcl ophth soln 0.05%................................ 58

2022

66

azithromycin for susp 100 mg/5ml, 200mg/5ml.......................................................................... 4

azithromycin iv for soln 500 mg................................... 4azithromycin tab 250 mg, 500 mg, 600

mg..................................................................................4aztreonam for inj 1 gm, 2 gm....................................... 4BBACITRACIN................................................................ 58baclofen tab 10 mg, 20 mg........................................ 29balsalazide disodium cap 750 mg............................. 57BALVERSA....................................................................16BALVERSA....................................................................16BALVERSA....................................................................16BARACLUDE................................................................ 29BAVENCIO.................................................................... 16BCG VACCINE.............................................................53BELEODAQ.................................................................. 16benazepril & hydrochlorothiazide tab 5-6.25 mg,

10-12.5 mg, 20-12.5 mg, 20-25 mg........................37benazepril hcl tab 5 mg, 10 mg, 20 mg, 40

mg................................................................................37BENDEKA..................................................................... 16BENLYSTA.................................................................... 53BENLYSTA.................................................................... 53BENLYSTA.................................................................... 53BENZNIDAZOLE..........................................................25benzoyl peroxide-erythromycin gel

5-3%............................................................................42benztropine mesylate tab 0.5 mg, 1 mg, 2

mg................................................................................26BESIVANCE..................................................................58BESPONSA.................................................................. 16betamethasone dipropionate augmented cream

0.05%..........................................................................42betamethasone dipropionate augmented lotion

0.05%..........................................................................43betamethasone dipropionate augmented oint

0.05%..........................................................................43BETASERON................................................................ 42betaxolol hcl ophth soln 0.5%.................................... 58bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50

mg................................................................................48bexarotene cap 75 mg................................................ 16BEXSERO..................................................................... 53bicalutamide tab 50 mg...............................................16BICILLIN L-A...................................................................4BIKTARVY..................................................................... 29bimatoprost ophth soln 0.03%................................... 58bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,

5-6.25 mg, 10-6.25 mg............................................ 37bisoprolol fumarate tab 5 mg, 10 mg.........................37

BLENREP......................................................................16bleomycin sulfate for inj 15 unit, 30

unit...............................................................................16BLINCYTO.....................................................................16BOOSTRIX....................................................................53BOOSTRIX....................................................................53bosentan tab 62.5 mg, 125 mg..................................61BOSULIF....................................................................... 16BOSULIF....................................................................... 16BRAFTOVI.....................................................................16BREO ELLIPTA............................................................ 61BRILINTA.......................................................................35brimonidine tartrate ophth soln 0.15%...................... 58brimonidine tartrate ophth soln 0.2%........................ 58BRIVIACT........................................................................ 8BRIVIACT........................................................................ 8BRIVIACT........................................................................ 8bromocriptine mesylate tab 2.5 mg........................... 26BRUKINSA....................................................................16budesonide delayed release particles cap 3

mg................................................................................57budesonide inhalation susp 0.25 mg/2ml, 0.5

mg/2ml, 1 mg/2ml.....................................................61budesonide tab er 24hr 9 mg.....................................57bumetanide inj 0.25 mg/ml......................................... 37bumetanide tab 0.5 mg, 1 mg.................................... 37bumetanide tab 2 mg.................................................. 37buprenorphine hcl-naloxone hcl sl film 2-0.5

mg..................................................................................3buprenorphine hcl-naloxone hcl sl film 4-1 mg, 8-2

mg, 12-3 mg................................................................ 3buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................3buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................3buprenorphine hcl sl tab 2 mg, 8 mg...........................2bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................3bupropion hcl tab 100 mg...........................................10bupropion hcl tab 75 mg.............................................10bupropion hcl tab er 12hr 100 mg............................. 10bupropion hcl tab er 12hr 150 mg, 200

mg................................................................................10bupropion hcl tab er 24hr 150 mg............................. 10bupropion hcl tab er 24hr 300 mg............................. 10buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30

mg................................................................................32busulfan inj 6 mg/ml.................................................... 16butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1

2022

67

BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1BYDUREON BCISE.....................................................33BYETTA......................................................................... 33BYETTA......................................................................... 33CCABENUVA...................................................................29CABENUVA...................................................................29cabergoline tab 0.5 mg............................................... 52CABLIVI......................................................................... 35CABOMETYX............................................................... 16caffeine citrate oral soln 60 mg/3ml...........................61calcipotriene cream 0.005%.......................................43calcipotriene oint 0.005%............................................43calcipotriene soln 0.005% (50 mcg/ml).....................43calcitonin (salmon) inj 200 unit/ml............................. 58calcitonin (salmon) nasal soln 200 unit/

act................................................................................58CALCITRIOL.................................................................58calcitriol cap 0.25 mcg, 0.5 mcg................................ 58calcitriol oral soln 1 mcg/ml........................................58calcium acetate cap 667 mg (169 mg

ca)................................................................................45calcium acetate tab 667 mg....................................... 45CALQUENCE................................................................16candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg, 32-12.5 mg, 32-25 mg......................................37candesartan cilexetil tab 32 mg................................. 37candesartan cilexetil tab 4 mg, 8 mg, 16

mg................................................................................37CAPASTAT SULFATE..................................................15CAPLYTA.......................................................................26CAPRELSA................................................................... 16CAPRELSA................................................................... 16captopril tab 12.5 mg...................................................37captopril tab 25 mg, 50 mg, 100 mg..........................37CARAC.......................................................................... 43CARBAGLU.................................................................. 45carbamazepine cap er 12hr 100 mg, 200 mg, 300

mg..................................................................................8carbamazepine chew tab 100 mg................................8carbamazepine susp 100 mg/5ml................................8carbamazepine tab 200 mg..........................................8carbamazepine tab er 12hr 100 mg, 200 mg, 400

mg..................................................................................8carbidopa & levodopa orally disintegrating tab

10-100 mg, 25-100 mg, 25-250 mg........................26carbidopa & levodopa tab 10-100 mg, 25-100 mg,

25-250 mg..................................................................26carbidopa & levodopa tab er 25-100 mg, 50-200

mg................................................................................26

carboplatin iv soln 50 mg/5ml, 150 mg/15ml, 450mg/45ml, 600 mg/60ml............................................ 16

carmustine for inj 100 mg...........................................16CARTEOLOL HCL.......................................................58carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25

mg................................................................................37caspofungin acetate for iv soln 50 mg, 70

mg................................................................................13CEFACLOR..................................................................... 4cefadroxil cap 500 mg...................................................4CEFAZOLIN SODIUM................................................... 4CEFAZOLIN SODIUM................................................... 4CEFAZOLIN SODIUM/DEXTROSE............................ 4cefazolin sodium for inj 500 mg, 1 gm.........................4cefdinir cap 300 mg....................................................... 4cefdinir for susp 125 mg/5ml, 250

mg/5ml.......................................................................... 4CEFEPIME...................................................................... 4CEFEPIME/DEXTROSE............................................... 4cefepime hcl for inj 1 gm, 2 gm....................................4cefixime cap 400 mg..................................................... 4CEFOXITIN SODIUM.................................................... 4cefoxitin sodium for iv soln 1 gm, 2 gm.......................4cefpodoxime proxetil for susp 50 mg/5ml, 100

mg/5ml.......................................................................... 4cefpodoxime proxetil tab 100 mg, 200

mg..................................................................................4cefprozil tab 250 mg, 500 mg.......................................4CEFTAZIDIME/DEXTROSE......................................... 4ceftazidime for inj 1 gm, 6 gm......................................4ceftazidime for iv soln 2 gm..........................................4CEFTRIAXONE/DEXTROSE....................................... 4CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 4CEFTRIAXONE SODIUM............................................. 4ceftriaxone sodium for inj 250 mg, 500 mg, 1 gm, 2

gm, 10 gm....................................................................4ceftriaxone sodium for iv soln 1 gm, 2

gm..................................................................................4cefuroxime axetil tab 250 mg, 500 mg........................ 4cefuroxime sodium for inj 750 mg................................5cefuroxime sodium for iv soln 1.5 gm..........................5celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg, 100 mg, 200 mg....................... 1CELONTIN...................................................................... 8cephalexin cap 250 mg, 500 mg..................................5cephalexin cap 750 mg.................................................5cephalexin for susp 125 mg/5ml, 250

mg/5ml.......................................................................... 5CEREZYME.................................................................. 47CHANTIX STARTING MONTH PACK.........................3CHEMET........................................................................45

2022

68

CHENODAL.................................................................. 46CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................5chlorhexidine gluconate soln 0.12%..........................42chloroquine phosphate tab 250 mg...........................25chloroquine phosphate tab 500 mg...........................25chlorpromazine hcl inj 25 mg/ml................................ 12chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100

mg, 200 mg............................................................... 12CHLORPROMAZINE

HYDROCHLORIDE.................................................. 13CHLORPROMAZINE

HYDROCHLORIDE.................................................. 13chlorthalidone tab 25 mg, 50 mg............................... 37cholestyramine light powder 4 gm/

dose............................................................................ 38cholestyramine light powder packets 4

gm................................................................................37cholestyramine powder 4 gm/dose............................38cholestyramine powder packets 4 gm.......................38CHORIONIC GONADOTROPIN................................49ciclopirox solution 8%..................................................13cilostazol tab 50 mg, 100 mg..................................... 35CIMDUO........................................................................ 29cinacalcet hcl tab 30 mg.............................................58cinacalcet hcl tab 60 mg, 90 mg................................58CINRYZE.......................................................................53ciprofloxacin 200 mg/100ml in d5w............................. 5ciprofloxacin 400 mg/200ml in d5w............................. 5CIPROFLOXACIN HCL.................................................5ciprofloxacin hcl ophth soln 0.3%.............................. 58ciprofloxacin hcl tab 250 mg, 500 mg, 750

mg..................................................................................5CISPLATIN.................................................................... 16cisplatin inj 50 mg/50ml (1 mg/ml), 100 mg/100ml (1

mg/ml).........................................................................16citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 11citalopram hydrobromide tab 10 mg, 20

mg................................................................................11citalopram hydrobromide tab 40 mg..........................11cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................16CLARITHROMYCIN.......................................................5clarithromycin tab 250 mg, 500 mg............................. 5CLEMASTINE FUMARATE........................................ 61clindamycin hcl cap 75 mg, 150 mg, 300

mg..................................................................................5clindamycin phosphate inj 300 mg/2ml, 600 mg/4ml,

900 mg/6ml, 9 gm/60ml............................................. 5clindamycin phosphate swab 1%.................................5

clindamycin phosphate vaginal cream2%..................................................................................5

clobazam suspension 2.5 mg/ml................................. 8clobazam tab 10 mg, 20 mg.........................................8clobetasol propionate cream 0.05%..........................43clobetasol propionate emollient base cream

0.05%..........................................................................43clobetasol propionate gel 0.05%................................43clobetasol propionate oint 0.05%.............................. 43clobetasol propionate soln 0.05%..............................43clofarabine iv soln 1 mg/ml.........................................16clomipramine hcl cap 25 mg, 50 mg, 75

mg................................................................................11clonazepam orally disintegrating tab 0.125 mg, 0.25

mg, 0.5 mg, 1 mg..................................................... 32clonazepam orally disintegrating tab 2

mg................................................................................32clonazepam tab 0.5 mg, 1 mg................................... 32clonazepam tab 2 mg..................................................32clonidine hcl tab 0.1 mg, 0.2 mg, 0.3

mg................................................................................38clonidine hcl tab er 12hr 0.1 mg................................ 42clonidine td patch weekly 0.1 mg/24hr, 0.2 mg/24hr,

0.3 mg/24hr................................................................38clopidogrel bisulfate tab 75 mg..................................36clorazepate dipotassium tab 15 mg...........................33clorazepate dipotassium tab 3.75 mg....................... 32clorazepate dipotassium tab 7.5 mg......................... 32clotrimazole troche 10 mg.......................................... 13clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 43clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 43CLOZAPINE ODT........................................................ 27clozapine orally disintegrating tab 25 mg, 100

mg................................................................................27clozapine tab 100 mg..................................................27clozapine tab 200 mg..................................................27clozapine tab 25 mg, 50 mg.......................................27COARTEM.....................................................................25colchicine tab 0.6 mg.................................................. 14colchicine w/ probenecid tab 0.5-500

mg................................................................................14colestipol hcl granule packets 5 gm.......................... 38colestipol hcl granules 5 gm.......................................38colestipol hcl tab 1 gm................................................ 38colistimethate sod for inj 150 mg................................. 5COMBIGAN...................................................................58COMBIPATCH.............................................................. 50COMBIVENT RESPIMAT........................................... 61COMETRIQ...................................................................16COMETRIQ...................................................................16

2022

69

COMETRIQ...................................................................17COMPLERA.................................................................. 29COPAXONE.................................................................. 42COPAXONE.................................................................. 42COPIKTRA....................................................................17CORLANOR..................................................................38CORLANOR..................................................................38COSENTYX.................................................................. 53COSENTYX.................................................................. 54COSENTYX.................................................................. 54COSENTYX SENSOREADY PEN............................ 54COSENTYX SENSOREADY PEN............................ 54COTELLIC.....................................................................17CREON..........................................................................47CRESEMBA.................................................................. 13CRESEMBA.................................................................. 13cromolyn sodium ophth soln 4%................................58cromolyn sodium oral conc 100

mg/5ml........................................................................ 47cromolyn sodium soln nebu 20 mg/2ml.................... 61CRYSVITA.....................................................................47cyclobenzaprine hcl tab 5 mg, 10 mg....................... 62CYCLOPHOSPHAMIDE............................................. 17CYCLOPHOSPHAMIDE............................................. 17cyclophosphamide cap 25 mg................................... 17cyclophosphamide cap 50 mg................................... 17cyclophosphamide for inj 500 mg, 1 gm, 2

gm................................................................................17cyclosporine cap 25 mg, 100 mg...............................54cyclosporine iv soln 50 mg/ml....................................54cyclosporine modified cap 25 mg, 50 mg, 100

mg................................................................................54cyclosporine modified oral soln 100 mg/

ml.................................................................................54CYRAMZA.....................................................................17CYSTADANE................................................................ 47CYSTADROPS............................................................. 58CYSTAGON.................................................................. 47CYSTARAN...................................................................59CYTARABINE............................................................... 17cytarabine inj pf 20 mg/ml, 100 mg/ml...................... 17DDACARBAZINE............................................................ 17dacarbazine for inj 200 mg.........................................17dactinomycin for inj 0.5 mg........................................ 17dalfampridine tab er 12hr 10 mg................................42DALIRESP.....................................................................61danazol cap 50 mg, 100 mg, 200 mg........................50DANYELZA................................................................... 17dapsone tab 25 mg, 100 mg...................................... 15DAPTACEL....................................................................54

daptomycin for iv soln 500 mg..................................... 5DARZALEX................................................................... 17DARZALEX FASPRO..................................................17daunorubicin hcl iv soln 20 mg/4ml........................... 17DAUNORUBICIN HYDROCHLORIDE......................17DAURISMO...................................................................17DAURISMO...................................................................17decitabine for inj 50 mg.............................................. 17deferasirox granules packet 90 mg, 180 mg, 360

mg................................................................................45deferasirox tab 90 mg, 180 mg, 360

mg................................................................................45deferasirox tab for oral susp 125 mg, 250 mg, 500

mg................................................................................45DELSTRIGO................................................................. 29DESCOVY.....................................................................30desipramine hcl tab 10 mg, 25 mg, 50 mg, 75 mg,

100 mg, 150 mg........................................................11desmopressin acetate inj 4 mcg/ml...........................49desmopressin acetate nasal spray soln 0.01%

(refrigerated), 0.01%................................................ 49desmopressin acetate preservative free inj 4 mcg/

ml.................................................................................49desmopressin acetate tab 0.1 mg, 0.2

mg................................................................................49desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 50desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................50

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................50

desonide cream 0.05%............................................... 43desonide lotion 0.05%.................................................43desonide oint 0.05%....................................................43desoximetasone cream 0.05%, 0.25%..................... 43desoximetasone gel 0.05%........................................ 43desoximetasone oint 0.25%....................................... 43desvenlafaxine succinate tab er 24hr 25 mg, 50 mg,

100 mg....................................................................... 11DEXAMETHASONE.................................................... 49dexamethasone elixir 0.5 mg/5ml..............................49DEXAMETHASONE SODIUM

PHOSPHATE.............................................................59dexamethasone sodium phosphate inj 4 mg/ml, 20

mg/5ml, 120 mg/30ml.............................................. 49dexamethasone tab 0.5 mg, 0.75 mg, 4 mg, 6

mg................................................................................49dexamethasone tab 1.5 mg........................................49dexamethasone tab therapy pack 1.5 mg

(21)..............................................................................49

2022

70

dexamethasone tab therapy pack 1.5 mg(35)..............................................................................49

dexamethasone tab therapy pack 1.5 mg(51)..............................................................................49

DEXILANT.....................................................................46dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10

mg................................................................................42dexrazoxane hcl for inj 250 mg, 500

mg................................................................................17dextroamphetamine sulfate cap er 24hr 10 mg, 15

mg................................................................................42dextroamphetamine sulfate cap er 24hr 5

mg................................................................................42dextroamphetamine sulfate tab 10 mg......................42dextroamphetamine sulfate tab 5 mg........................42dextrose 2.5% w/ sodium chloride

0.45%..........................................................................45dextrose 5% in lactated ringers................................. 45dextrose 5% w/ sodium chloride 0.2%, 0.33%,

0.45%, 0.9%.............................................................. 45dextrose inj 5%, 10%.................................................. 45DIACOMIT....................................................................... 8DIACOMIT....................................................................... 8DIASTAT ACUDIAL........................................................8DIASTAT PEDIATRIC.................................................... 8diazepam oral soln 1 mg/ml....................................... 33DIAZEPAM RECTAL GEL.............................................8diazepam tab 2 mg, 5 mg, 10 mg..............................33diazoxide susp 50 mg/ml............................................ 33diclofenac potassium tab 50 mg.................................. 1diclofenac sodium gel 1%.............................................1diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1dicloxacillin sodium cap 250 mg.................................. 5dicloxacillin sodium cap 500 mg.................................. 5dicyclomine hcl cap 10 mg......................................... 46dicyclomine hcl tab 20 mg..........................................46difluprednate ophth emulsion 0.05%.........................59digoxin oral soln 0.05 mg/ml...................................... 38digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25

mg).............................................................................. 38dihydroergotamine mesylate nasal spray 4 mg/

ml.................................................................................14DILANTIN........................................................................ 8diltiazem hcl cap er 12hr 60 mg, 90 mg, 120

mg................................................................................38

diltiazem hcl cap er 24hr 120 mg, 180 mg, 240mg................................................................................38

diltiazem hcl coated beads cap er 24hr 120 mg, 180mg, 240 mg, 300 mg, 360 mg.................................38

diltiazem hcl coated beads tab er 24hr 180 mg, 240mg, 300 mg, 360 mg, 420 mg.................................38

diltiazem hcl extended release beads cap er 24hr120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420mg................................................................................38

diltiazem hcl tab 30 mg, 60 mg, 90 mg, 120mg................................................................................38

dimethyl fumarate capsule delayed release 120 mg,240 mg....................................................................... 42

dimethyl fumarate capsule dr starter pack 120 mg &240 mg....................................................................... 42

DIPENTUM....................................................................57diphenhydramine hcl inj 50 mg/ml.............................61DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC................................................................ 54disulfiram tab 250 mg....................................................3disulfiram tab 500 mg....................................................3divalproex sodium cap delayed release sprinkle 125

mg..................................................................................8divalproex sodium tab delayed release 125 mg, 250

mg, 500 mg..................................................................8divalproex sodium tab er 24 hr 250 mg, 500

mg..................................................................................8DIVIGEL.........................................................................50docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/

ml), 160 mg/8ml (20 mg/ml)....................................17docetaxel soln for iv infusion 20 mg/2ml, 80 mg/8ml,

160 mg/16ml..............................................................17dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25

mg), 500 mcg (0.5 mg)............................................ 38donepezil hydrochloride orally disintegrating tab 5

mg, 10 mg..................................................................10donepezil hydrochloride tab 23 mg........................... 10donepezil hydrochloride tab 5 mg, 10

mg................................................................................10dorzolamide hcl ophth soln 2%..................................59dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml.......................................................................... 59DOVATO........................................................................ 30doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8

mg................................................................................38DOXEPIN HCL............................................................. 11doxepin hcl (sleep) tab 3 mg, 6 mg...........................63doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100

mg................................................................................11doxepin hcl conc 10 mg/ml.........................................11doxorubicin hcl inj 2 mg/ml.........................................17

2022

71

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml.................................................................................17

DOXORUBICIN HYDROCHLORIDE........................ 17doxycycline hyclate cap 50 mg, 100 mg..................... 5doxycycline hyclate for inj 100 mg...............................5doxycycline hyclate tab 20 mg, 100 mg......................5doxycycline monohydrate cap 150 mg........................5doxycycline monohydrate tab 150 mg.........................5DRIZALMA SPRINKLE............................................... 11DRIZALMA SPRINKLE............................................... 11dronabinol cap 2.5 mg, 5 mg, 10 mg.........................13drospirenone-ethinyl estradiol tab 3-0.02 mg, 3-0.03

mg................................................................................50drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................50droxidopa cap 100 mg, 200 mg, 300

mg................................................................................38DUAVEE........................................................................ 50duloxetine hcl enteric coated pellets cap 20 mg, 60

mg................................................................................11duloxetine hcl enteric coated pellets cap 30

mg................................................................................11DUPIXENT.................................................................... 54DUPIXENT.................................................................... 54dutasteride cap 0.5 mg............................................... 48Eeconazole nitrate cream 1%.......................................13EDURANT..................................................................... 30efavirenz cap 200 mg..................................................30efavirenz cap 50 mg....................................................30efavirenz-emtricitabine-tenofovir df tab 600-200-300

mg................................................................................30efavirenz-lamivudine-tenofovir df tab 400-300-300

mg, 600-300-300 mg................................................30efavirenz tab 600 mg...................................................30EGRIFTA SV.................................................................49ELAPRASE................................................................... 47ELELYSO.......................................................................47ELIGARD.......................................................................52ELIGARD.......................................................................52ELIGARD.......................................................................52ELIGARD.......................................................................52ELITEK...........................................................................17ELLA...............................................................................50EMCYT.......................................................................... 17EMGALITY.................................................................... 14EMGALITY.................................................................... 14EMGALITY.................................................................... 14EMPLICITI.....................................................................17EMSAM..........................................................................11emtricitabine caps 200 mg......................................... 30

emtricitabine-tenofovir disoproxil fumarate tab100-150 mg, 133-200 mg, 167-250 mg, 200-300mg................................................................................30

EMTRIVA.......................................................................30enalapril maleate & hydrochlorothiazide tab 5-12.5

mg, 10-25 mg............................................................38enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20

mg................................................................................38ENBREL........................................................................ 54ENBREL........................................................................ 54ENBREL........................................................................ 54ENBREL MINI...............................................................54ENBREL SURECLICK................................................ 54ENGERIX-B.................................................................. 54ENHERTU..................................................................... 17enoxaparin sodium inj 300 mg/3ml............................36enoxaparin sodium inj 30 mg/0.3ml, 40

mg/0.4ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml.................................................................................36

enoxaparin sodium subcutaneous soln 60 mg/0.6ml,80 mg/0.8ml...............................................................36

entacapone tab 200 mg..............................................26entecavir tab 0.5 mg, 1 mg.........................................30ENTRESTO...................................................................38ENTRESTO...................................................................38EPCLUSA......................................................................30EPIDIOLEX......................................................................8epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000)...................................................................... 61epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak)...................... 61epirubicin hcl iv soln 50 mg/25ml (2 mg/ml), 200

mg/100ml (2 mg/ml)................................................. 17EPIVIR HBV..................................................................30ERBITUX....................................................................... 18ergotamine w/ caffeine tab 1-100 mg........................14ERIVEDGE....................................................................18ERLEADA......................................................................18erlotinib hcl tab 100 mg, 150 mg............................... 18erlotinib hcl tab 25 mg.................................................18ertapenem sodium for inj 1 gm.................................... 5ERWINASE................................................................... 18ERYTHROCIN LACTOBIONATE.................................5erythromycin ophth oint 5 mg/gm.............................. 59erythromycin soln 2%.................................................... 5erythromycin tab 250 mg, 500 mg...............................5erythromycin tab delayed release 250 mg, 333 mg,

500 mg..........................................................................5ESBRIET....................................................................... 61ESBRIET....................................................................... 61ESBRIET....................................................................... 61escitalopram oxalate soln 5 mg/5ml..........................11

2022

72

escitalopram oxalate tab 20 mg.................................11escitalopram oxalate tab 5 mg, 10 mg......................11esomeprazole magnesium cap delayed release 20

mg, 40 mg..................................................................46esomeprazole sodium for intravenous soln 40

mg................................................................................46estradiol & norethindrone acetate tab 1-0.5

mg................................................................................50estradiol tab 0.5 mg, 1 mg, 2 mg...............................50estradiol td patch twice weekly 0.025 mg/24hr,

0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr...................................................................... 50

estradiol td patch weekly 0.025 mg/24hr,0.0375 mg/24hr (37.5 mcg/24hr), 0.05mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr...................................................................... 50

estradiol vaginal cream 0.1 mg/gm........................... 50estradiol vaginal tab 10 mcg...................................... 50ethambutol hcl tab 100 mg, 400 mg..........................15ethosuximide cap 250 mg.............................................8ethosuximide soln 250 mg/5ml.....................................8ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg, 1 mg-50 mcg................................................... 50etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg, 500 mg...................................... 1etodolac tab er 24hr 400 mg, 500 mg......................... 1etodolac tab er 24hr 600 mg........................................ 1ETOPOPHOS............................................................... 18etoposide inj 100 mg/5ml (20 mg/ml), 500 mg/25ml

(20 mg/ml), 1 gm/50ml (20 mg/ml)......................... 18etravirine tab 100 mg.................................................. 30etravirine tab 200 mg.................................................. 30everolimus tab 0.25 mg, 0.5 mg, 0.75

mg................................................................................54everolimus tab 2.5 mg, 7.5 mg, 10 mg......................18everolimus tab 5 mg....................................................18everolimus tab for oral susp 2 mg, 5

mg................................................................................18everolimus tab for oral susp 3 mg............................. 18EVOMELA..................................................................... 18EVOTAZ.........................................................................30exemestane tab 25 mg............................................... 18EXKIVITY...................................................................... 18ezetimibe-simvastatin tab 10-10 mg, 10-20 mg,

10-40 mg, 10-80 mg.................................................38ezetimibe tab 10 mg....................................................38FFABRAZYME................................................................ 47famotidine for susp 40 mg/5ml...................................46

famotidine inj 20 mg/2ml, 40 mg/4ml, 200mg/20ml......................................................................46

famotidine tab 20 mg, 40 mg..................................... 46FANAPT.........................................................................27FANAPT TITRATION PACK....................................... 27FARYDAK......................................................................18felbamate susp 600 mg/5ml......................................... 8felbamate tab 400 mg, 600 mg.................................... 8felodipine tab er 24hr 2.5 mg, 5 mg, 10

mg................................................................................38fenofibrate micronized cap 67 mg, 134 mg, 200

mg................................................................................38fenofibrate tab 145 mg, 160 mg.................................38fenofibrate tab 48 mg, 54 mg.....................................38fentanyl citrate lozenge on a handle 200 mcg, 400

mcg, 600 mcg..............................................................1fentanyl citrate lozenge on a handle 800 mcg, 1200

mcg, 1600 mcg........................................................... 1fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 37.5

mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5mcg/hr, 100 mcg/hr.....................................................1

FETZIMA....................................................................... 11FETZIMA TITRATION PACK......................................11FINACEA....................................................................... 43finasteride tab 5 mg.....................................................48FINTEPLA........................................................................8FIRMAGON...................................................................52FIRMAGON...................................................................52flecainide acetate tab 50 mg, 100 mg, 150

mg................................................................................38FLOVENT DISKUS......................................................61FLOVENT DISKUS......................................................61FLOVENT HFA.............................................................61FLOVENT HFA.............................................................61FLOVENT HFA.............................................................61fluconazole for susp 10 mg/ml, 40 mg/

ml.................................................................................13fluconazole in nacl 0.9% inj 200 mg/100ml, 400

mg/200ml....................................................................13fluconazole tab 50 mg, 100 mg, 150 mg, 200

mg................................................................................13flucytosine cap 250 mg, 500 mg................................13fludarabine phosphate for inj 50 mg..........................18fludarabine phosphate inj 25 mg/ml.......................... 18fludrocortisone acetate tab 0.1 mg............................ 49fluocinolone acetonide (otic) oil 0.01%..................... 60fluocinolone acetonide cream 0.01%........................ 43fluocinonide cream 0.05%.......................................... 43fluocinonide emulsified base cream

0.05%..........................................................................43fluocinonide gel 0.05%................................................43fluocinonide oint 0.05%...............................................43

2022

73

fluocinonide soln 0.05%..............................................43fluorometholone ophth susp 0.1%.............................59FLUOROURACIL......................................................... 43fluorouracil cream 5%................................................. 43fluorouracil iv soln 500 mg/10ml (50 mg/ml), 1

gm/20ml (50 mg/ml), 2.5 gm/50ml (50 mg/ml), 5gm/100ml (50 mg/ml)............................................... 18

fluoxetine hcl cap 10 mg.............................................11fluoxetine hcl cap 20 mg.............................................11fluoxetine hcl cap 40 mg.............................................11fluoxetine hcl solution 20 mg/5ml.............................. 11fluoxetine hcl tab 10 mg..............................................11fluoxetine hcl tab 20 mg..............................................11fluphenazine decanoate inj 25 mg/ml........................27FLUPHENAZINE HCL.................................................27FLUPHENAZINE HCL.................................................27fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10

mg................................................................................27FLUPHENAZINE HYDROCHLORIDE...................... 27FLURBIPROFEN SODIUM.........................................59flutamide cap 125 mg..................................................18FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 61fluticasone propionate cream 0.05%.........................43fluticasone propionate nasal susp 50 mcg/

act................................................................................61fluticasone propionate oint 0.005%........................... 43fluvastatin sodium cap 20 mg, 40 mg....................... 38fluvoxamine maleate tab 100 mg...............................11fluvoxamine maleate tab 25 mg, 50

mg................................................................................11FOLOTYN......................................................................18fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................36fondaparinux sodium subcutaneous inj 5 mg/0.4ml,

7.5 mg/0.6ml, 10 mg/0.8ml......................................36FORTEO........................................................................58fosamprenavir calcium tab 700 mg........................... 30fosaprepitant dimeglumine for iv infusion 150

mg................................................................................13fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg.........................................................38fosinopril sodium tab 10 mg, 20 mg, 40

mg................................................................................39fosphenytoin sodium inj 100 mg/2ml, 500

mg/10ml........................................................................ 8FOSRENOL.................................................................. 45FOSRENOL.................................................................. 45FOTIVDA....................................................................... 18fulvestrant inj 250 mg/5ml...........................................18furosemide inj 10 mg/ml..............................................39furosemide oral soln 10 mg/ml...................................39

furosemide tab 20 mg, 40 mg, 80 mg....................... 39FUZEON........................................................................30FYCOMPA....................................................................... 8FYCOMPA....................................................................... 8Ggabapentin cap 100 mg................................................ 9gabapentin cap 300 mg................................................ 9gabapentin cap 400 mg................................................ 9gabapentin oral soln 250 mg/5ml.................................9gabapentin tab 600 mg................................................. 9gabapentin tab 800 mg................................................. 9GALANTAMINE HYDROBROMIDE.......................... 10galantamine hydrobromide cap er 24hr 8 mg, 16 mg,

24 mg..........................................................................10galantamine hydrobromide tab 4 mg, 8 mg, 12

mg................................................................................10GAMUNEX-C................................................................ 54ganciclovir sodium for inj 500 mg.............................. 30GARDASIL 9.................................................................54GARDASIL 9.................................................................54GATTEX.........................................................................46GAUZE PADS 2" X 2".................................................33GAVILYTE-C................................................................. 46GAVRETO..................................................................... 18GAZYVA.........................................................................18gemcitabine hcl for inj 200 mg, 1 gm, 2

gm................................................................................18gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml),

1 gm/26.3ml (38 mg/ml), 2 gm/52.6ml (38 mg/ml)................................................................................18

gemfibrozil tab 600 mg............................................... 39GENTAK........................................................................ 59gentamicin in saline inj 1.2 mg/ml................................5GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE...................................................................5gentamicin sulfate cream 0.1%..................................43gentamicin sulfate inj 40 mg/ml....................................5gentamicin sulfate oint 0.1%...................................... 43gentamicin sulfate ophth soln 0.3%...........................59GENTAMICIN SULFATE PEDIATRIC......................... 5GENVOYA.....................................................................30GILENYA....................................................................... 42GILOTRIF......................................................................18glimepiride tab 1 mg....................................................33glimepiride tab 2 mg....................................................33glimepiride tab 4 mg....................................................33glipizide-metformin hcl tab 2.5-250 mg.....................33glipizide-metformin hcl tab 2.5-500 mg, 5-500

mg................................................................................33glipizide tab 10 mg...................................................... 33glipizide tab 5 mg.........................................................33

2022

74

glipizide tab er 24hr 10 mg.........................................33glipizide tab er 24hr 2.5 mg........................................33glipizide tab er 24hr 5 mg...........................................33GLUCAGEN HYPOKIT............................................... 33glyburide-metformin tab 1.25-250 mg....................... 34glyburide-metformin tab 2.5-500 mg, 5-500

mg................................................................................34glyburide micronized tab 1.5 mg................................33glyburide micronized tab 3 mg...................................33glyburide micronized tab 6 mg...................................33glyburide tab 1.25 mg................................................. 33glyburide tab 2.5 mg....................................................33glyburide tab 5 mg.......................................................34glycopyrrolate tab 1 mg, 2 mg................................... 46GLYXAMBI.................................................................... 34granisetron hcl inj 1 mg/ml, 4 mg/4ml (1 mg/

ml)................................................................................13GRANIX......................................................................... 36GRANIX......................................................................... 36griseofulvin microsize susp 125

mg/5ml........................................................................ 14HHAEGARDA.................................................................. 54HAEGARDA.................................................................. 54HALAVEN...................................................................... 18halobetasol propionate cream 0.05%........................43halobetasol propionate oint 0.05%............................ 43haloperidol decanoate im soln 50 mg/ml, 100 mg/

ml.................................................................................27haloperidol lactate inj 5 mg/ml................................... 27haloperidol lactate oral conc 2 mg/ml........................27haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10

mg................................................................................27haloperidol tab 20 mg................................................. 27HARVONI...................................................................... 30HARVONI...................................................................... 30HAVRIX..........................................................................54HEMADY....................................................................... 49HEPARIN SODIUM......................................................36HEPARIN SODIUM......................................................36HEPARIN SODIUM/D5W............................................36heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/

ml, 10000 unit/ml, 20000 unit/ml.............................36heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................36HEPATAMINE............................................................... 45HERCEPTIN................................................................. 18HERCEPTIN HYLECTA.............................................. 18HERZUMA.....................................................................18HETLIOZ........................................................................63HIBERIX........................................................................ 55

HUMALOG.................................................................... 34HUMALOG.................................................................... 34HUMALOG JUNIOR KWIKPEN.................................34HUMALOG KWIKPEN.................................................34HUMALOG MIX 50/50.................................................34HUMALOG MIX 50/50 KWIKPEN............................. 34HUMALOG MIX 75/25.................................................34HUMALOG MIX 75/25 KWIKPEN............................. 34HUMIRA.........................................................................55HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................55HUMIRA PEN............................................................... 55HUMIRA PEN-CD/UC/HS STARTER........................55HUMIRA PEN-PEDIATRIC UC STARTER

PACK...........................................................................55HUMIRA PEN-PS/UV STARTER...............................55HUMULIN 70/30...........................................................34HUMULIN 70/30 KWIKPEN....................................... 34HUMULIN N..................................................................34HUMULIN N KWIKPEN.............................................. 34HUMULIN R..................................................................34HUMULIN R U-500 (CONCENTRATE).....................34HUMULIN R U-500 KWIKPEN...................................34hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100

mg................................................................................39hydrochlorothiazide cap 12.5 mg...............................39hydrochlorothiazide tab 12.5 mg, 25 mg, 50

mg................................................................................39hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 1hydrocodone-acetaminophen tab 10-325 mg,

7.5-325 mg...................................................................1hydrocodone-acetaminophen tab 5-325

mg..................................................................................1hydrocortisone butyrate cream 0.1%........................ 43hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................43hydrocortisone butyrate oint 0.1%.............................43hydrocortisone butyrate soln 0.1%............................ 43hydrocortisone cream 1%...........................................44hydrocortisone cream 2.5%........................................44hydrocortisone enema 100 mg/60ml.........................57hydrocortisone lotion 2.5%......................................... 44hydrocortisone oint 1%............................................... 44hydrocortisone oint 2.5%............................................ 44hydrocortisone perianal cream 1%............................57hydrocortisone perianal cream 2.5%.........................57hydrocortisone tab 5 mg, 10 mg, 20

mg................................................................................49hydrocortisone valerate cream 0.2%.........................44hydrocortisone valerate oint 0.2%............................. 44

2022

75

hydrocortisone w/ acetic acid otic soln1-2%............................................................................60

hydromorphone hcl inj 2 mg/ml....................................1hydromorphone hcl liqd 1 mg/ml..................................1hydromorphone hcl preservative free inj 2 mg/ml, 10

mg/ml............................................................................ 1hydromorphone hcl tab 2 mg, 4 mg, 8

mg..................................................................................1hydroxychloroquine sulfate tab 200 mg.................... 25HYDROXYPROGESTERONE

CAPROATE................................................................50hydroxyurea cap 500 mg............................................ 18Iibandronate sodium tab 150 mg................................ 58IBRANCE.......................................................................18IBRANCE.......................................................................19ibuprofen tab 400 mg.................................................... 1ibuprofen tab 600 mg.................................................... 1ibuprofen tab 800 mg.................................................... 1icatibant acetate inj 30 mg/3ml.................................. 55ICLUSIG........................................................................ 19icosapent ethyl cap 1 gm............................................39idarubicin hcl iv inj 5 mg/5ml (1 mg/ml), 10 mg/10ml

(1 mg/ml), 20 mg/20ml (1 mg/ml)........................... 19IDHIFA............................................................................19IFOSFAMIDE................................................................ 19ifosfamide for inj 1 gm.................................................19ILARIS............................................................................55imatinib mesylate tab 100 mg.................................... 19imatinib mesylate tab 400 mg.................................... 19IMBRUVICA.................................................................. 19IMBRUVICA.................................................................. 19IMBRUVICA.................................................................. 19IMFINZI..........................................................................19IMIPENEM/CILASTATIN............................................... 6imipenem-cilastatin intravenous for soln 500

mg..................................................................................6imipramine hcl tab 10 mg, 25 mg, 50

mg................................................................................11imiquimod cream 5%...................................................44IMLYGIC........................................................................ 19IMLYGIC........................................................................ 19IMOVAX RABIES (H.D.C.V.)...................................... 55IMPAVIDO........................................................................6INBRIJA......................................................................... 26INCRELEX.................................................................... 49INCRUSE ELLIPTA..................................................... 61INFANRIX......................................................................55INLYTA...........................................................................19INLYTA...........................................................................19INQOVI.......................................................................... 19

INREBIC........................................................................ 19INSULIN SYRINGE/NEEDLE.....................................34INTELENCE.................................................................. 30INTRALIPID.................................................................. 45INTRON A.....................................................................55INTRON A.....................................................................55INTRON A.....................................................................55INTRON A.....................................................................55INTRON A.....................................................................55INVEGA HAFYERA..................................................... 27INVEGA SUSTENNA.................................................. 27INVEGA TRINZA..........................................................27INVIRASE......................................................................30IPOL INACTIVATED IPV.............................................55ipratropium bromide inhal soln 0.02%.......................61ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................61ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................61irbesartan-hydrochlorothiazide tab 150-12.5 mg,

300-12.5 mg.............................................................. 39irbesartan tab 75 mg, 150 mg, 300 mg.....................39IRESSA..........................................................................19IRINOTECAN................................................................19irinotecan hcl inj 40 mg/2ml (20 mg/ml), 100 mg/5ml

(20 mg/ml)..................................................................19ISENTRESS..................................................................30ISENTRESS..................................................................30ISENTRESS..................................................................30ISENTRESS HD...........................................................30ISONIAZID.................................................................... 15isoniazid tab 100 mg................................................... 15isoniazid tab 300 mg................................................... 15isosorbide dinitrate tab 5 mg, 10 mg, 20 mg, 30

mg................................................................................39isosorbide mononitrate tab er 24hr 30 mg, 60 mg,

120 mg....................................................................... 39ISOTONIC GENTAMICIN............................................. 6isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg,

40 mg..........................................................................44isradipine cap 2.5 mg, 5 mg.......................................39ISTODAX (OVERFILL)................................................19itraconazole cap 100 mg............................................ 14ivermectin tab 3 mg.....................................................25IXEMPRA KIT...............................................................19IXIARO...........................................................................55JJAKAFI...........................................................................19JANUMET......................................................................34JANUMET XR...............................................................34JANUMET XR...............................................................34JANUVIA........................................................................34

2022

76

JANUVIA........................................................................34JANUVIA........................................................................34JARDIANCE..................................................................34JARDIANCE..................................................................34JEMPERLI.....................................................................19JEVTANA.......................................................................19JULUCA.........................................................................30KKADCYLA......................................................................19KALYDECO...................................................................62KALYDECO...................................................................62KANJINTI.......................................................................19kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 45kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%




inj................................................................................. 45KEPIVANCE..................................................................42ketoconazole cream 2%..............................................14ketoconazole shampoo 2%........................................ 14ketoconazole tab 200 mg........................................... 14ketorolac tromethamine ophth soln

0.4%............................................................................59ketorolac tromethamine ophth soln

0.5%............................................................................59KEYTRUDA...................................................................19KINRIX........................................................................... 55KINRIX........................................................................... 55KISQALI.........................................................................19KISQALI.........................................................................19KISQALI.........................................................................19KISQALI FEMARA 200 DOSE...................................20KISQALI FEMARA 400 DOSE...................................20KISQALI FEMARA 600 DOSE...................................20KLOXXADO.....................................................................3KORLYM........................................................................52KOSELUGO.................................................................. 20KOSELUGO.................................................................. 20KYPROLIS.................................................................... 20Llabetalol hcl tab 100 mg, 200 mg, 300

mg................................................................................39LACRISERT.................................................................. 59lactated ringer's solution............................................. 45lactic acid (ammonium lactate) cream

12%............................................................................. 44

lactic acid (ammonium lactate) lotion12%............................................................................. 44

lactulose (encephalopathy) solution 10gm/15ml......................................................................46

lactulose solution 10 gm/15ml....................................46lamivudine oral soln 10 mg/ml................................... 30lamivudine tab 100 mg (hbv)......................................30lamivudine tab 150 mg................................................30lamivudine tab 300 mg................................................30lamivudine-zidovudine tab 150-300 mg.................... 30lamotrigine tab 25 mg, 100 mg, 150 mg, 200

mg..................................................................................9lamotrigine tab chewable dispersible 5 mg, 25

mg..................................................................................9lansoprazole cap delayed release 15 mg, 30

mg................................................................................46LANTUS.........................................................................34LANTUS SOLOSTAR..................................................34lapatinib ditosylate tab 250 mg.................................. 20latanoprost ophth soln 0.005%.................................. 59LATUDA.........................................................................27LATUDA.........................................................................27leflunomide tab 10 mg.................................................55leflunomide tab 20 mg.................................................55LENVIMA 10 MG DAILY DOSE.................................20LENVIMA 12MG DAILY DOSE..................................20LENVIMA 14 MG DAILY DOSE.................................20LENVIMA 18 MG DAILY DOSE.................................20LENVIMA 20 MG DAILY DOSE.................................20LENVIMA 24 MG DAILY DOSE.................................20LENVIMA 4 MG DAILY DOSE...................................20LENVIMA 8 MG DAILY DOSE...................................20letrozole tab 2.5 mg.....................................................20LEUCOVORIN CALCIUM...........................................20leucovorin calcium for inj 50 mg, 100 mg, 200 mg,

350 mg, 500 mg........................................................20leucovorin calcium inj 500 mg/50ml (10 mg/

ml)................................................................................20leucovorin calcium tab 10 mg, 15 mg, 25

mg................................................................................20leucovorin calcium tab 5 mg.......................................20LEUKERAN...................................................................20LEUKINE....................................................................... 36leuprolide acetate inj kit 5 mg/ml............................... 52levetiracetam inj 500 mg/5ml (100 mg/

ml)..................................................................................9levetiracetam oral soln 100 mg/ml...............................9levetiracetam tab 250 mg, 500 mg, 750 mg, 1000

mg..................................................................................9levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 47levocarnitine tab 330 mg............................................ 47

2022

77

levocetirizine dihydrochloride tab 5 mg.....................62levofloxacin in d5w iv soln 250 mg/50ml, 500

mg/100ml, 750 mg/150ml.......................................... 6levofloxacin iv soln 25 mg/ml....................................... 6levofloxacin oral soln 25 mg/ml....................................6levofloxacin tab 250 mg, 500 mg, 750

mg..................................................................................6levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 50levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg........................................................50levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................50levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................50levothyroxine sodium tab 100 mcg (euthyrox, levo-t,

levoxyl, unithroid)......................................................52levothyroxine sodium tab 112 mcg (euthyrox, levo-t,







levoxyl, unithroid)......................................................51levothyroxine sodium tab 300 mcg (levo-t,

unithroid).....................................................................52levothyroxine sodium tab 50 mcg (euthyrox, levo-t,



levoxyl, unithroid)......................................................52LEXIVA...........................................................................31LIBTAYO........................................................................ 20LIDOCAINE HCL............................................................2LIDOCAINE HCL JELLY............................................... 2lidocaine hcl local inj 1%...............................................2lidocaine hcl local preservative free inj

1%..................................................................................2lidocaine hcl soln 4%.....................................................2lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................2lidocaine hcl viscous soln 2%.......................................2lidocaine patch 5%.........................................................2lidocaine-prilocaine cream 2.5-2.5%........................... 2

LINEZOLID......................................................................6linezolid for susp 100 mg/5ml.......................................6linezolid iv soln 600 mg/300ml (2 mg/

ml)..................................................................................6linezolid tab 600 mg...................................................... 6LINZESS........................................................................46liothyronine sodium tab 5 mcg, 25 mcg, 50

mcg..............................................................................52lisinopril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg............................................. 39lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40

mg................................................................................39LITHIUM........................................................................ 33lithium carbonate cap 150 mg....................................33lithium carbonate cap 300 mg....................................33lithium carbonate cap 600 mg....................................33lithium carbonate tab 300 mg.....................................33lithium carbonate tab er 300 mg, 450

mg................................................................................33LONSURF..................................................................... 20LONSURF..................................................................... 20loperamide hcl cap 2 mg............................................ 46lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................31lopinavir-ritonavir tab 100-25 mg............................... 31lopinavir-ritonavir tab 200-50 mg............................... 31lorazepam tab 0.5 mg, 1 mg...................................... 33lorazepam tab 2 mg.................................................... 33LORBRENA.................................................................. 20LORBRENA.................................................................. 20losartan potassium & hydrochlorothiazide

tab 50-12.5 mg, 100-12.5 mg, 100-25mg................................................................................39

losartan potassium tab 100 mg..................................39losartan potassium tab 25 mg, 50 mg.......................39lovastatin tab 10 mg, 20 mg, 40 mg..........................39loxapine succinate cap 5 mg, 10 mg, 25 mg, 50

mg................................................................................27LUBIPROSTONE......................................................... 46LUBIPROSTONE......................................................... 46LUMAKRAS.................................................................. 20LUMIGAN...................................................................... 59LUMIZYME....................................................................47LUMOXITI......................................................................20LUPRON DEPOT (1-MONTH)...................................52LUPRON DEPOT (3-MONTH)...................................52LUPRON DEPOT (4-MONTH)...................................52LUPRON DEPOT (6-MONTH)...................................52LUPRON DEPOT-PED (1-MONTH)..........................52LUPRON DEPOT-PED (3-MONTH)..........................53LYBALVI.........................................................................27LYNPARZA....................................................................20

2022

78

LYSODREN...................................................................52Mmagnesium sulfate inj 50%........................................ 45malathion lotion 0.5%..................................................44MARPLAN..................................................................... 11MARQIBO......................................................................21MATULANE...................................................................21MAYZENT......................................................................42MAYZENT......................................................................42MAYZENT STARTER PACK...................................... 42meclizine hcl tab 12.5 mg...........................................13medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................50medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 50medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10

mg................................................................................50mefloquine hcl tab 250 mg......................................... 25megestrol acetate susp 40 mg/ml..............................50megestrol acetate tab 20 mg, 40 mg.........................50MEKINIST......................................................................21MEKINIST......................................................................21MEKTOVI.......................................................................21meloxicam tab 15 mg....................................................1meloxicam tab 7.5 mg...................................................1melphalan hcl for inj 50 mg........................................ 21memantine hcl oral solution 2 mg/ml.........................10memantine hcl tab 28 x 5 mg & 21 x 10 mg titration

pack.............................................................................10memantine hcl tab 5 mg, 10 mg................................ 10MENACTRA.................................................................. 55MENEST........................................................................50MENQUADFI................................................................ 55MENVEO....................................................................... 55mercaptopurine tab 50 mg......................................... 21MEROPENEM/SODIUM CHLORIDE..........................6meropenem iv for soln 500 mg, 1 gm..........................6mesalamine cap er 24hr 0.375 gm............................57mesalamine enema 4 gm........................................... 57mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 57mesalamine suppos 1000 mg.................................... 57mesalamine tab delayed release 1.2

gm................................................................................57mesalamine tab delayed release 800

mg................................................................................57mesna inj 100 mg/ml...................................................21MESNEX........................................................................21metformin hcl tab 1000 mg.........................................35metformin hcl tab 500 mg...........................................35metformin hcl tab 850 mg...........................................35

metformin hcl tab er 24hr 500 mg............................. 35metformin hcl tab er 24hr 750 mg............................. 35methadone hcl tab 10 mg.............................................1methadone hcl tab 5 mg............................................... 1methazolamide tab 25 mg, 50 mg............................. 39methenamine hippurate tab 1 gm................................6methimazole tab 5 mg, 10 mg................................... 53methocarbamol tab 500 mg, 750 mg........................ 63METHOTREXATE SODIUM.......................................55methotrexate sodium for inj 1 gm.............................. 55methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................55methotrexate sodium inj pf 50 mg/2ml (25 mg/ml),

250 mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/ml)................................................................................55

methotrexate sodium tab 2.5 mg............................... 56methylergonovine maleate tab 0.2 mg......................48methylphenidate hcl tab 5 mg, 10 mg, 20

mg................................................................................42methylphenidate hcl tab er 20 mg............................. 42methylprednisolone sod succ for inj 40 mg, 125 mg,

500 mg, 1000 mg..................................................... 49methylprednisolone tab 16 mg...................................49methylprednisolone tab 4 mg, 8 mg, 32

mg................................................................................49methylprednisolone tab therapy pack 4 mg

(21)..............................................................................49metoclopramide hcl inj 5 mg/ml................................. 46metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................46metoclopramide hcl tab 5 mg, 10 mg........................46metoprolol & hydrochlorothiazide tab 50-25 mg,

100-25 mg..................................................................39metoprolol succinate tab er 24hr 25 mg, 50 mg, 100

mg, 200 mg............................................................... 39metoprolol tartrate tab 25 mg, 50 mg, 100

mg................................................................................39metronidazole cream 0.75%.......................................44metronidazole gel 0.75%............................................ 44metronidazole in nacl 0.74% iv soln 500

mg/100ml......................................................................6metronidazole in nacl 0.79% iv soln 500

mg/100ml......................................................................6metronidazole lotion 0.75%........................................ 44metronidazole tab 250 mg, 500 mg.............................6metronidazole vaginal gel 0.75%.................................6metyrosine cap 250 mg.............................................. 39mexiletine hcl cap 150 mg..........................................39mexiletine hcl cap 200 mg, 250 mg...........................39MIACALCIN...................................................................58micafungin sodium for iv soln 100 mg.......................14micafungin sodium for iv soln 50 mg.........................14

2022

79

midodrine hcl tab 2.5 mg, 5 mg, 10 mg.....................39miglustat cap 100 mg..................................................47minocycline hcl cap 50 mg, 75 mg, 100

mg..................................................................................6minocycline hcl tab 50 mg, 75 mg, 100

mg..................................................................................6minoxidil tab 2.5 mg, 10 mg.......................................39mirtazapine orally disintegrating tab 15 mg, 30 mg,

45 mg..........................................................................11mirtazapine tab 15 mg................................................ 11mirtazapine tab 7.5 mg, 30 mg, 45 mg..................... 11misoprostol tab 100 mcg, 200 mcg........................... 46mitomycin for iv soln 20 mg, 40 mg...........................21mitomycin for iv soln 5 mg..........................................21mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml),

25 mg/12.5ml (2 mg/ml), 30 mg/15ml (2 mg/ml)................................................................................21

M-M-R II........................................................................ 55modafinil tab 100 mg, 200 mg................................... 63moexipril hcl tab 7.5 mg, 15 mg.................................39MOLINDONE HYDROCHLORIDE............................ 27mometasone furoate cream 0.1%............................. 44mometasone furoate nasal susp 50 mcg/

act................................................................................62mometasone furoate oint 0.1%..................................44mometasone furoate solution 0.1%

(lotion).........................................................................44MONJUVI...................................................................... 21montelukast sodium chew tab 4 mg, 5

mg................................................................................62montelukast sodium oral granules packet 4

mg................................................................................62montelukast sodium tab 10 mg..................................62morphine sulfate inj pf 0.5 mg/ml, 1 mg/

ml................................................................................... 2morphine sulfate tab 15 mg..........................................2morphine sulfate tab 30 mg..........................................2morphine sulfate tab er 100 mg, 200 mg.................... 2morphine sulfate tab er 15 mg, 30 mg, 60

mg..................................................................................2MOVANTIK....................................................................47moxifloxacin hcl ophth soln 0.5% (2 times daily)

(generic for Moxeza)................................................ 59moxifloxacin hcl ophth soln 0.5% (generic for

Vigamox).................................................................... 59moxifloxacin hcl tab 400 mg.........................................6MOXIFLOXACIN HYDROCHLORIDE.........................6MOXIFLOXACIN HYDROCHLORIDE.........................6MOZOBIL...................................................................... 36MULTAQ........................................................................ 39mupirocin oint 2%........................................................ 44MVASI............................................................................ 21

MYALEPT...................................................................... 47mycophenolate mofetil cap 250 mg...........................56mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................56mycophenolate mofetil hcl for iv soln 500

mg................................................................................56mycophenolate mofetil tab 500 mg........................... 56MYLOTARG.................................................................. 21MYRBETRIQ.................................................................48MYRBETRIQ.................................................................48Nnabumetone tab 500 mg...............................................2nabumetone tab 750 mg...............................................2nadolol tab 20 mg, 40 mg...........................................39nadolol tab 80 mg........................................................39NAFCILLIN...................................................................... 6NAFCILLIN SODIUM.....................................................6nafcillin sodium for inj 1 gm, 2 gm...............................6nafcillin sodium for iv soln 10 gm.................................6NAGLAZYME................................................................47NALOXONE HCL........................................................... 3naloxone hcl inj 0.4 mg/ml, 4 mg/10ml........................3naloxone hcl soln prefilled syringe 2

mg/2ml.......................................................................... 3naltrexone hcl tab 50 mg.............................................. 3naproxen sodium tab 275 mg.......................................2naproxen sodium tab 550 mg.......................................2naproxen tab 250 mg.................................................... 2naproxen tab 375 mg.................................................... 2naproxen tab 500 mg.................................................... 2naproxen tab ec 375 mg...............................................2naproxen tab ec 500 mg...............................................2naratriptan hcl tab 1 mg, 2.5 mg................................14NARCAN..........................................................................3NATACYN......................................................................59nateglinide tab 120 mg............................................... 35nateglinide tab 60 mg..................................................35NATPARA...................................................................... 58NAYZILAM.......................................................................9nebivolol hcl tab 2.5 mg, 5 mg, 10 mg, 20

mg................................................................................39NEFAZODONE HCL....................................................11NEFAZODONE HYDROCHLORIDE.........................12NEOMYCIN/POLYMYXIN/

GRAMICIDIN............................................................. 59neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................59neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................59neomycin-polymyxin-hc otic soln 1%........................ 60

2022

80

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.................................................................. 60

neomycin sulfate tab 500 mg....................................... 6NERLYNX......................................................................21NEVIRAPINE ER......................................................... 31nevirapine susp 50 mg/5ml........................................ 31nevirapine tab 200 mg................................................ 31nevirapine tab er 24hr 400 mg...................................31NEXAVAR......................................................................21niacin tab er 500 mg................................................... 39niacin tab er 750 mg, 1000 mg..................................39nicardipine hcl cap 20 mg, 30 mg..............................40NICOTROL INHALER................................................... 3NICOTROL NS............................................................... 3nifedipine tab er 24hr 30 mg, 60 mg, 90

mg................................................................................40nifedipine tab er 24hr osmotic release 30 mg, 60 mg,

90 mg..........................................................................40nilutamide tab 150 mg.................................................21nimodipine cap 30 mg.................................................40NINLARO.......................................................................21NIPENT..........................................................................21NISOLDIPINE ER........................................................ 40nisoldipine tab er 24hr 8.5 mg, 17 mg, 34

mg................................................................................40nitazoxanide tab 500 mg............................................ 25nitisinone cap 2 mg, 5 mg, 10 mg............................. 48NITRO-BID....................................................................40nitrofurantoin macrocrystalline cap 50 mg, 100

mg..................................................................................6nitrofurantoin monohydrate macrocrystalline cap 100

mg..................................................................................6nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6

mg................................................................................40nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4

mg/hr, 0.6 mg/hr........................................................40NIZATIDINE...................................................................47nizatidine cap 300 mg.................................................47norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................51norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,

0.5 mg-35 mcg, 1 mg-35 mcg.................................50norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg, 1.5 mg-30 mcg................................................ 51norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg, 1.5 mg-30 mcg................................................ 51norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................51norethindrone acetate tab 5 mg.................................51norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................51

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35mg-mcg, 0.5-35/1-35/0.5-35 mg-mcg.................... 51

norethindrone tab 0.35 mg......................................... 51norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................51norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg,0.18-35/0.215-35/0.25-35 mg-mcg.........................51

norgestrel & ethinyl estradiol tab 0.3 mg-30mcg..............................................................................51

NORTHERA.................................................................. 40NORTRIPTYLINE HCL............................................... 12nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75

mg................................................................................12NORVIR.........................................................................31NORVIR.........................................................................31NOXAFIL....................................................................... 14NOXAFIL....................................................................... 14NUBEQA........................................................................21NUEDEXTA...................................................................42NULOJIX........................................................................56NUPLAZID.....................................................................27NUPLAZID.....................................................................27NUTRILIPID.................................................................. 45nystatin cream 100000 unit/gm..................................14nystatin oint 100000 unit/gm...................................... 14nystatin susp 100000 unit/ml......................................14nystatin topical powder 100000 unit/

gm................................................................................14nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................44nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................44OOCALIVA....................................................................... 47OCTREOTIDE ACETATE........................................... 53octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100

mcg/ml (0.1 mg/ml), 200 mcg/ml (0.2 mg/ml),500 mcg/ml (0.5 mg/ml), 1000 mcg/ml (1 mg/ml)................................................................................53

ODEFSEY..................................................................... 31ODOMZO...................................................................... 21OFEV............................................................................. 62ofloxacin ophth soln 0.3%...........................................59ofloxacin otic soln 0.3%.............................................. 60ofloxacin tab 400 mg..................................................... 6OGIVRI.......................................................................... 21olanzapine for im inj 10 mg........................................ 28olanzapine orally disintegrating tab 5 mg, 10 mg, 15

mg, 20 mg..................................................................28olanzapine tab 15 mg, 20 mg.................................... 28

2022

81

olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10mg................................................................................28

olmesartan-amlodipine-hydrochlorothiazide tab20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg,40-10-12.5 mg, 40-10-25 mg.................................. 40

olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg, 40-12.5 mg, 40-25 mg........................40

olmesartan medoxomil tab 20 mg, 40mg................................................................................40

olmesartan medoxomil tab 5 mg............................... 40olopatadine hcl nasal soln 0.6%................................ 62olopatadine hcl ophth soln 0.1%, 0.2%.....................59omega-3-acid ethyl esters cap 1 gm.........................40omeprazole cap delayed release 10

mg................................................................................47omeprazole cap delayed release 20 mg, 40

mg................................................................................47OMNITROPE................................................................ 49OMNITROPE................................................................ 49ONCASPAR.................................................................. 21ONDANSETRON HCL................................................ 13ondansetron hcl inj 4 mg/2ml (2 mg/ml), 40 mg/20ml

(2 mg/ml)....................................................................13ondansetron hcl oral soln 4 mg/5ml.......................... 13ondansetron hcl tab 4 mg, 8 mg................................13ondansetron orally disintegrating tab 4 mg, 8

mg................................................................................13ONIVYDE...................................................................... 21ONTRUZANT................................................................21ONUREG.......................................................................21OPDIVO.........................................................................21OPSUMIT...................................................................... 62ORALAIR.......................................................................62ORFADIN.......................................................................48ORFADIN.......................................................................48ORGOVYX.................................................................... 53ORKAMBI......................................................................62ORKAMBI......................................................................62oseltamivir phosphate cap 30 mg..............................31oseltamivir phosphate cap 45 mg, 75

mg................................................................................31oseltamivir phosphate for susp 6 mg/

ml.................................................................................31OXALIPLATIN...............................................................21oxaliplatin for iv inj 50 mg, 100 mg............................21oxaliplatin iv soln 50 mg/10ml, 100

mg/20ml......................................................................21oxandrolone tab 10 mg............................................... 51oxandrolone tab 2.5 mg..............................................51oxaprozin tab 600 mg....................................................2oxcarbazepine susp 300 mg/5ml (60 mg/

ml)..................................................................................9

oxcarbazepine tab 150 mg, 300 mg, 600mg..................................................................................9

oxybutynin chloride syrup 5 mg/5ml..........................48oxybutynin chloride tab 5 mg..................................... 48oxybutynin chloride tab er 24hr 10 mg......................48oxybutynin chloride tab er 24hr 15 mg......................48oxybutynin chloride tab er 24hr 5 mg........................48oxycodone hcl tab 10 mg, 15 mg, 20 mg, 30

mg..................................................................................2oxycodone hcl tab 5 mg................................................2oxycodone w/ acetaminophen tab 10-325

mg..................................................................................2oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................2oxycodone w/ acetaminophen tab 5-325

mg..................................................................................2oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................2OZEMPIC...................................................................... 35OZEMPIC...................................................................... 35PPACLITAXEL.................................................................21paclitaxel iv conc 30 mg/5ml (6 mg/ml), 100

mg/16.7ml (6 mg/ml), 300 mg/50ml (6 mg/ml)................................................................................21

PADCEV........................................................................ 21paliperidone tab er 24hr 1.5 mg, 3 mg, 9

mg................................................................................28paliperidone tab er 24hr 6 mg....................................28palonosetron hcl iv soln 0.25 mg/5ml........................13palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 13PALONOSETRON

HYDROCHLORIDE.................................................. 13PALYNZIQ..................................................................... 48pantoprazole sodium ec tab 20 mg........................... 47pantoprazole sodium ec tab 40 mg........................... 47pantoprazole sodium for iv soln 40 mg..................... 47PARAPLATIN................................................................ 22paricalcitol cap 1 mcg, 2 mcg, 4 mcg........................58paricalcitol iv soln 2 mcg/ml, 5 mcg/ml......................58paromomycin sulfate cap 250 mg................................6paroxetine hcl oral susp 10 mg/5ml.......................... 12paroxetine hcl tab 10 mg, 40 mg............................... 12paroxetine hcl tab 20 mg............................................ 12paroxetine hcl tab 30 mg............................................ 12PASER........................................................................... 15PAXIL............................................................................. 12PEDIARIX......................................................................56PEDVAX HIB................................................................ 56

2022

82

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm................................................................................47

peg 3350-kcl-sod bicarb-nacl for soln 420gm................................................................................47

PEGASYS..................................................................... 56PEGASYS..................................................................... 56PEMAZYRE.................................................................. 22penicillamine tab 250 mg............................................48penicillin g potassium for inj 5000000 unit, 20000000

unit.................................................................................7PENICILLIN G POTASSIUM IN

DEXTROSE................................................................. 7PENICILLIN V POTASSIUM.........................................7penicillin v potassium tab 250 mg, 500

mg..................................................................................7PENTACEL....................................................................56pentamidine isethionate for nebulization soln 300

mg................................................................................25pentamidine isethionate for soln 300

mg................................................................................25pentoxifylline tab er 400 mg....................................... 40perindopril erbumine tab 2 mg, 4 mg, 8

mg................................................................................40PERJETA.......................................................................22permethrin cream 5%..................................................44perphenazine tab 2 mg, 4 mg, 8 mg, 16

mg................................................................................13PERSERIS.................................................................... 28phenelzine sulfate tab 15 mg.....................................12phenobarbital elixir 20 mg/5ml..................................... 9phenobarbital sodium inj 65 mg/ml, 130 mg/

ml................................................................................... 9phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg,

60 mg, 64.8 mg, 97.2 mg, 100 mg........................... 9phenoxybenzamine hcl cap 10 mg............................40phenytoin chew tab 50 mg........................................... 9phenytoin sodium extended cap 100 mg.................... 9phenytoin sodium extended cap 200 mg, 300

mg..................................................................................9phenytoin susp 125 mg/5ml......................................... 9PHESGO....................................................................... 22PIFELTRO..................................................................... 31pilocarpine hcl ophth soln 1%, 2%, 4%.....................59pilocarpine hcl tab 5 mg, 7.5 mg................................42pimecrolimus cream 1%..............................................44PIMOZIDE..................................................................... 28pindolol tab 10 mg....................................................... 40pindolol tab 5 mg......................................................... 40pioglitazone hcl-glimepiride tab 30-2 mg, 30-4

mg................................................................................35pioglitazone hcl-metformin hcl tab 15-500 mg,

15-850 mg..................................................................35

pioglitazone hcl tab 15 mg..........................................35pioglitazone hcl tab 30 mg, 45 mg.............................35piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)................................................................ 7piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm), 4.5 gm (4-0.5 gm).................................7PIQRAY 200MG DAILY DOSE...................................22PIQRAY 250MG DAILY DOSE...................................22PIQRAY 300MG DAILY DOSE...................................22piroxicam cap 10 mg..................................................... 2piroxicam cap 20 mg..................................................... 2podofilox soln 0.5%..................................................... 44POLIVY..........................................................................22polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 59POMALYST...................................................................22PORTRAZZA................................................................ 22posaconazole tab delayed release 100

mg................................................................................14POTASSIUM CHLORIDE/SODIUM

CHLORIDE.................................................................45potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 45potassium chloride cap er 8 meq, 10

meq............................................................................. 45potassium chloride inj 2 meq/ml................................ 45potassium chloride microencapsulated crys er tab 10

meq, 15 meq, 20 meq..............................................45potassium chloride oral soln 10% (20

meq/15ml).................................................................. 45potassium chloride tab er 10 meq, 20 meq (1500

mg).............................................................................. 45potassium chloride tab er 8 meq (600

mg).............................................................................. 45potassium citrate tab er 5 meq (540 mg), 10 meq

(1080 mg), 15 meq (1620 mg)................................45POTELIGEO................................................................. 22PRADAXA..................................................................... 36PRADAXA..................................................................... 36pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1 mg, 1.5 mg.............................. 26prasugrel hcl tab 5 mg, 10 mg................................... 36pravastatin sodium tab 10 mg, 20 mg, 40

mg................................................................................40pravastatin sodium tab 80 mg....................................40praziquantel tab 600 mg............................................. 25prazosin hcl cap 1 mg, 2 mg, 5 mg........................... 40PREDNISOLONE.........................................................49PREDNISOLONE ACETATE......................................59prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 49PREDNISONE.............................................................. 49

2022

83

prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20mg................................................................................49

prednisone tab 50 mg................................................. 49prednisone tab therapy pack 5 mg (21), 5 mg (48),

10 mg (21), 10 mg (48)............................................49pregabalin cap 225 mg, 300 mg.................................. 9pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150

mg, 200 mg..................................................................9pregabalin soln 20 mg/ml..............................................9PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 49PREMARIN................................................................... 51PREMARIN................................................................... 51PREMPHASE............................................................... 51PREMPRO.................................................................... 51PREVYMIS....................................................................31PREZCOBIX................................................................. 31PREZISTA..................................................................... 31PREZISTA..................................................................... 31PREZISTA..................................................................... 31PREZISTA..................................................................... 31PREZISTA..................................................................... 31PRIFTIN.........................................................................15primaquine phosphate tab 26.3 mg (15 mg

base)........................................................................... 25primidone tab 50 mg, 250 mg...................................... 9probenecid tab 500 mg............................................... 14PROCHLORPERAZINE EDISYLATE....................... 13prochlorperazine edisylate inj 10

mg/2ml........................................................................ 13prochlorperazine maleate tab 5 mg, 10

mg................................................................................13prochlorperazine suppos 25 mg................................ 13PROCRIT...................................................................... 36PROCRIT...................................................................... 36progesterone cap 100 mg, 200 mg........................... 51PROGRAF.....................................................................56PROLASTIN-C..............................................................48PROLASTIN-C..............................................................48PROLENSA...................................................................59PROLIA..........................................................................58PROMACTA.................................................................. 36PROMACTA.................................................................. 36promethazine hcl syrup 6.25 mg/5ml........................ 13promethazine hcl tab 12.5 mg, 25 mg, 50

mg................................................................................13propafenone hcl cap er 12hr 225 mg, 325 mg, 425

mg................................................................................40propafenone hcl tab 150 mg, 225 mg....................... 40propafenone hcl tab 300 mg...................................... 40propranolol hcl inj 1 mg/ml......................................... 40

propranolol hcl tab 10 mg, 20 mg, 40 mg, 80mg................................................................................40

propylthiouracil tab 50 mg.......................................... 53PROQUAD.................................................................... 56protriptyline hcl tab 5 mg, 10 mg............................... 12PULMOZYME............................................................... 62PURIXAN.......................................................................22pyrazinamide tab 500 mg........................................... 15pyridostigmine bromide tab 60 mg............................ 15pyridostigmine bromide tab er 180 mg......................15pyrimethamine tab 25 mg...........................................25QQINLOCK...................................................................... 22QUADRACEL................................................................56quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200

mg................................................................................28quetiapine fumarate tab 300 mg, 400

mg................................................................................28quetiapine fumarate tab er 24hr 150 mg, 200

mg................................................................................28quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400

mg................................................................................28quinapril hcl tab 10 mg, 20 mg, 40 mg......................40quinapril hcl tab 5 mg..................................................40quinapril-hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg............................................. 40QUINIDINE SULFATE................................................. 40RRABAVERT................................................................... 56rabeprazole sodium ec tab 20 mg............................. 47raloxifene hcl tab 60 mg............................................. 51ramelteon tab 8 mg..................................................... 63ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10

mg................................................................................40ranolazine tab er 12hr 500 mg, 1000

mg................................................................................40rasagiline mesylate tab 0.5 mg, 1 mg....................... 26RECOMBIVAX HB....................................................... 56RECTIV..........................................................................40RELENZA DISKHALER.............................................. 31RENFLEXIS.................................................................. 56repaglinide tab 0.5 mg................................................ 35repaglinide tab 1 mg....................................................35repaglinide tab 2 mg....................................................35REPATHA...................................................................... 41REPATHA PUSHTRONEX SYSTEM........................41REPATHA SURECLICK.............................................. 41RESTASIS.....................................................................59RESTASIS MULTIDOSE.............................................59RETACRIT.....................................................................36RETEVMO.....................................................................22

2022

84

RETEVMO.....................................................................22RETROVIR IV INFUSION...........................................31REVCOVI...................................................................... 48REVLIMID......................................................................22REVLIMID......................................................................22REVLIMID......................................................................22REXULTI........................................................................28REYATAZ.......................................................................31RHOPRESSA............................................................... 59RIABNI........................................................................... 22ribavirin cap 200 mg....................................................31ribavirin tab 200 mg.....................................................31rifabutin cap 150 mg....................................................15rifampin cap 150 mg, 300 mg.................................... 15rifampin for inj 600 mg................................................ 15riluzole tab 50 mg........................................................ 42RINVOQ.........................................................................56risedronate sodium tab 150 mg................................. 58risedronate sodium tab 35 mg................................... 58risedronate sodium tab 5 mg, 30 mg.........................58risedronate sodium tab delayed release 35

mg................................................................................58RISPERDAL CONSTA................................................ 28RISPERIDONE ODT................................................... 28risperidone orally disintegrating tab 0.5 mg, 1 mg, 2

mg, 3 mg....................................................................28risperidone orally disintegrating tab 4

mg................................................................................28risperidone soln 1 mg/ml............................................ 28risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3

mg................................................................................28risperidone tab 4 mg................................................... 28ritonavir tab 100 mg.................................................... 31RITUXAN.......................................................................22RITUXAN HYCELA......................................................22rivastigmine tartrate cap 1.5 mg, 3 mg, 4.5 mg, 6

mg................................................................................10rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,

13.3 mg/24hr............................................................. 10rizatriptan benzoate oral disintegrating tab 5 mg, 10

mg................................................................................14rizatriptan benzoate tab 5 mg, 10 mg....................... 14ROCKLATAN.................................................................59ROMIDEPSIN............................................................... 22ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg, 5 mg............................................. 26rosuvastatin calcium tab 40 mg................................. 41rosuvastatin calcium tab 5 mg, 10 mg, 20

mg................................................................................41ROTARIX.......................................................................56ROTATEQ......................................................................56ROZLYTREK.................................................................22

ROZLYTREK.................................................................22RUBRACA.....................................................................22rufinamide susp 40 mg/ml............................................ 9rufinamide tab 200 mg.................................................. 9rufinamide tab 400 mg.................................................. 9RUKOBIA...................................................................... 31RUXIENCE....................................................................22RYBELSUS................................................................... 35RYBREVANT................................................................ 22RYDAPT........................................................................ 22RYLAZE.........................................................................22SSAMSCA........................................................................45SANDIMMUNE............................................................. 56SANTYL.........................................................................44sapropterin dihydrochloride powder packet 100 mg,

500 mg....................................................................... 48sapropterin dihydrochloride tab 100

mg................................................................................48SARCLISA.....................................................................22SCEMBLIX.................................................................... 22SCEMBLIX.................................................................... 22SECUADO.....................................................................28SELEGILINE HCL........................................................26selegiline hcl cap 5 mg............................................... 26selenium sulfide lotion 2.5%.......................................44SELZENTRY.................................................................31SELZENTRY.................................................................31SELZENTRY.................................................................31SELZENTRY.................................................................31SEREVENT DISKUS...................................................62sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................12sertraline hcl tab 100 mg............................................ 12sertraline hcl tab 25 mg, 50 mg................................. 12sevelamer carbonate packet 0.8 gm......................... 45sevelamer carbonate packet 2.4 gm......................... 45sevelamer carbonate tab 800 mg..............................46SHINGRIX..................................................................... 56SIGNIFOR..................................................................... 53sildenafil citrate tab 20 mg..........................................62silver sulfadiazine cream 1%......................................44SIMBRINZA...................................................................59simvastatin tab 20 mg.................................................41simvastatin tab 5 mg, 10 mg, 40 mg......................... 41simvastatin tab 80 mg.................................................41sirolimus oral soln 1 mg/ml.........................................56sirolimus tab 0.5 mg, 1 mg, 2 mg.............................. 56SIRTURO.......................................................................15SIVEXTRO...................................................................... 7SIVEXTRO...................................................................... 7

2022

85

SKYRIZI.........................................................................56SKYRIZI.........................................................................56SKYRIZI PEN............................................................... 56sodium chloride iv soln 0.45%, 0.9%........................ 46sodium chloride preservative free inj

0.9%............................................................................46sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................48sodium phenylbutyrate tab 500 mg........................... 48sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................46sodium polystyrene sulfonate powder.......................46SOLTAMOX...................................................................23SOMATULINE DEPOT................................................53SOMAVERT.................................................................. 53SOOLANTRA................................................................44sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160

mg................................................................................41sotalol hcl tab 80 mg, 120 mg, 160 mg, 240

mg................................................................................41SOVALDI....................................................................... 31SOVALDI....................................................................... 31spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................41spironolactone tab 25 mg, 50 mg, 100

mg................................................................................41SPRAVATO 56MG DOSE........................................... 12SPRAVATO 84MG DOSE........................................... 12SPRITAM......................................................................... 9SPRYCEL......................................................................23SPRYCEL......................................................................23STAMARIL.....................................................................56STAVUDINE.................................................................. 31STELARA...................................................................... 56STELARA...................................................................... 56STELARA...................................................................... 56STIMATE....................................................................... 49STIVARGA.....................................................................23STRENSIQ....................................................................48STREPTOMYCIN SULFATE........................................ 7STRIBILD...................................................................... 31SUBLOCADE.................................................................. 3sucralfate tab 1 gm......................................................47SULFACETAMIDE SODIUM/PREDNISOLONE

SODIUM PHOSPHATE............................................59sulfacetamide sodium lotion 10%.............................. 44sulfacetamide sodium ophth soln 10%..................... 59SULFADIAZINE.............................................................. 7sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml.......................................................................... 7sulfamethoxazole-trimethoprim susp 200-40

mg/5ml.......................................................................... 7

sulfamethoxazole-trimethoprim tab 400-80 mg,800-160 mg..................................................................7

sulfasalazine tab 500 mg............................................57sulindac tab 150 mg, 200 mg.......................................2sumatriptan nasal spray 5 mg/act, 20 mg/

act................................................................................14sumatriptan succinate inj 6 mg/0.5ml........................14sumatriptan succinate solution auto-injector 4

mg/0.5ml, 6 mg/0.5ml.............................................. 15sumatriptan succinate solution cartridge 4 mg/0.5ml,

6 mg/0.5ml................................................................. 15sumatriptan succinate tab 25 mg, 50 mg, 100

mg................................................................................15sunitinib malate cap 12.5 mg..................................... 23sunitinib malate cap 25 mg, 37.5 mg, 50

mg................................................................................23SUPRAX.......................................................................... 7SUPREP BOWEL PREP KIT.....................................47SUTAB........................................................................... 47SYMDEKO.................................................................... 62SYMDEKO.................................................................... 62SYMLINPEN 120......................................................... 35SYMLINPEN 60............................................................35SYMPAZAN.....................................................................9SYMPAZAN.....................................................................9SYMTUZA..................................................................... 32SYNAGIS.......................................................................56SYNAREL......................................................................53SYNERCID......................................................................7SYNJARDY................................................................... 35SYNJARDY................................................................... 35SYNJARDY XR............................................................ 35SYNJARDY XR............................................................ 35SYNRIBO...................................................................... 23TTABLOID........................................................................23TABRECTA....................................................................23tacrolimus cap 0.5 mg, 1 mg, 5 mg........................... 57tacrolimus oint 0.03%, 0.1%.......................................44tadalafil tab 20 mg (pah).............................................62TAFINLAR..................................................................... 23TAGRISSO.................................................................... 23TALZENNA....................................................................23TALZENNA....................................................................23tamoxifen citrate tab 10 mg, 20 mg...........................23tamsulosin hcl cap 0.4 mg..........................................48TARGRETIN..................................................................23TASIGNA....................................................................... 23tazarotene cream 0.1%...............................................44TAZICEF.......................................................................... 7TAZORAC......................................................................44TAZORAC......................................................................44

2022

86

TAZVERIK..................................................................... 23TDVAX........................................................................... 57TECENTRIQ................................................................. 23TEFLARO........................................................................ 7telmisartan-amlodipine tab 40-5 mg, 40-10 mg, 80-5

mg, 80-10 mg............................................................41telmisartan-hydrochlorothiazide tab 40-12.5 mg,

80-25 mg....................................................................41telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................41telmisartan tab 20 mg, 40 mg, 80 mg....................... 41temazepam cap 15 mg, 30 mg.................................. 63TEMIXYS.......................................................................32TEMODAR.................................................................... 23temsirolimus soln for iv infusion 25 mg/

ml.................................................................................23TENIVAC....................................................................... 57tenofovir disoproxil fumarate tab 300

mg................................................................................32TEPMETKO.................................................................. 23terazosin hcl cap 1 mg................................................41terazosin hcl cap 2 mg, 5 mg, 10 mg........................ 41terbinafine hcl tab 250 mg..........................................14terbutaline sulfate tab 2.5 mg, 5 mg..........................62terconazole vaginal cream 0.4%................................14terconazole vaginal cream 0.8%................................14testosterone cypionate im inj in oil 100 mg/ml, 200

mg/ml.......................................................................... 51testosterone td gel 12.5 mg/act (1%)........................ 51testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 51testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 51testosterone td gel 25 mg/2.5gm (1%)......................51testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 51testosterone td gel 50 mg/5gm (1%).........................51tetrabenazine tab 12.5 mg..........................................42tetrabenazine tab 25 mg.............................................42tetracycline hcl cap 250 mg, 500 mg...........................7THALOMID....................................................................23THALOMID....................................................................23THEOPHYLLINE ER................................................... 62theophylline tab er 24hr 400 mg, 600

mg................................................................................62thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100

mg................................................................................28thiotepa for inj 15 mg, 100 mg................................... 23thiothixene cap 1 mg, 2 mg, 5 mg, 10

mg................................................................................28THYMOGLOBULIN......................................................57

tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16mg..................................................................................9

TIBSOVO.......................................................................23tigecycline for iv soln 50 mg.........................................7timolol maleate ophth gel forming soln 0.25%,

0.5%............................................................................60timolol maleate ophth soln 0.25%,

0.5%............................................................................60TIVICAY......................................................................... 32TIVICAY......................................................................... 32TIVICAY PD.................................................................. 32tizanidine hcl tab 2 mg, 4 mg.....................................29tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 60tobramycin nebu soln 300 mg/5ml............................ 62tobramycin ophth soln 0.3%.......................................60TOBRAMYCIN SULFATE............................................. 7tobramycin sulfate for inj 1.2 gm..................................7tobramycin sulfate inj 80 mg/2ml (40 mg/ml), 1.2

gm/30ml (40 mg/ml)................................................... 7tolterodine tartrate cap er 24hr 2 mg, 4

mg................................................................................48tolvaptan tab 30 mg.....................................................46topiramate sprinkle cap 15 mg, 25 mg........................9topiramate tab 25 mg, 50 mg, 100 mg, 200

mg..................................................................................9topotecan hcl for inj 4 mg........................................... 23toremifene citrate tab 60 mg...................................... 23TOUJEO MAX SOLOSTAR........................................35TOUJEO SOLOSTAR..................................................35TOVIAZ.......................................................................... 48TRACLEER................................................................... 62tramadol hcl tab 50 mg................................................. 2TRANDOLAPRIL/VERAPAMIL HCL......................... 41trandolapril tab 1 mg, 2 mg, 4 mg..............................41trandolapril-verapamil hcl tab er 2-180 mg, 2-240

mg, 4-240 mg............................................................41tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................36tranexamic acid tab 650 mg.......................................36tranylcypromine sulfate tab 10 mg............................ 12TRAVASOL....................................................................46travoprost ophth soln 0.004%.................................... 60TRAZIMERA................................................................. 23trazodone hcl tab 300 mg...........................................12trazodone hcl tab 50 mg, 100 mg, 150

mg................................................................................12TREANDA..................................................................... 23TRECATOR...................................................................15TRELEGY ELLIPTA.....................................................62TRELSTAR MIXJECT..................................................53

2022

87

treprostinil inj soln 20 mg/20ml (1 mg/ml), 50mg/20ml (2.5 mg/ml), 100 mg/20ml (5 mg/ml), 200mg/20ml (10 mg/ml)................................................. 62

tretinoin cap 10 mg......................................................23tretinoin cream 0.025%, 0.05%, 0.1%.......................44tretinoin gel 0.01%, 0.025%....................................... 44triamcinolone acetonide cream 0.025%, 0.1%,

0.5%............................................................................44triamcinolone acetonide oint 0.025%,

0.1%............................................................................44triamcinolone acetonide oint 0.5%.............................44triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................41triamterene & hydrochlorothiazide tab 37.5-25 mg,

75-50 mg....................................................................41trientine hcl cap 250 mg............................................. 46trifluoperazine hcl tab 1 mg, 2 mg, 5 mg, 10

mg................................................................................29TRIFLURIDINE.............................................................60TRIKAFTA..................................................................... 62TRIKAFTA..................................................................... 62trimethoprim tab 100 mg...............................................7trimipramine maleate cap 25 mg, 50 mg, 100

mg................................................................................12TRINTELLIX..................................................................12TRIUMEQ......................................................................32TRODELVY................................................................... 23TROGARZO..................................................................32TROPHAMINE..............................................................46trospium chloride tab 20 mg.......................................48TRUMENBA.................................................................. 57TRUSELTIQ.................................................................. 23TRUSELTIQ.................................................................. 23TRUSELTIQ.................................................................. 23TRUSELTIQ.................................................................. 23TRUXIMA...................................................................... 24TUKYSA........................................................................ 24TUKYSA........................................................................ 24TURALIO....................................................................... 24TWINRIX........................................................................57TYBLUME......................................................................51TYBOST........................................................................ 32TYMLOS........................................................................58TYPHIM VI.................................................................... 57TYSABRI....................................................................... 42UUKONIQ.........................................................................24UNITUXIN......................................................................24ursodiol cap 300 mg....................................................47ursodiol tab 250 mg.....................................................47ursodiol tab 500 mg.....................................................47

Vvalacyclovir hcl tab 500 mg, 1 gm............................. 32VALCHLOR................................................................... 24valganciclovir hcl for soln 50 mg/ml.......................... 32valganciclovir hcl tab 450 mg.....................................32valproate sodium inj 100 mg/ml................................... 9valproate sodium oral soln 250 mg/5ml...................... 9valproic acid cap 250 mg..............................................9valsartan-hydrochlorothiazide tab 80-12.5 mg,

160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25mg................................................................................41

valsartan tab 320 mg...................................................41valsartan tab 40 mg, 80 mg, 160 mg.........................41VALTOCO......................................................................10VALTOCO......................................................................10VANCOMYCIN................................................................7VANCOMYCIN................................................................7VANCOMYCIN HCL.......................................................7VANCOMYCIN HCL.......................................................7vancomycin hcl cap 125 mg.........................................7vancomycin hcl cap 250 mg.........................................7vancomycin hcl for iv soln 1.5 gm................................7vancomycin hcl for iv soln 500 mg, 750 mg, 1 gm, 5

gm, 10 gm....................................................................7VANCOMYCIN HYDROCHLORIDE............................7VANCOMYCIN HYDROCHLORIDE............................8VANCOMYCIN HYDROCHLORIDE/

DEXTROSE................................................................. 8VAQTA........................................................................... 57varenicline tartrate tab 0.5 mg..................................... 3varenicline tartrate tab 1 mg.........................................3VARIVAX........................................................................57VASCEPA...................................................................... 41VECTIBIX...................................................................... 24VELCADE......................................................................24VELTASSA.................................................................... 46VENCLEXTA.................................................................24VENCLEXTA.................................................................24VENCLEXTA.................................................................24VENCLEXTA STARTING PACK................................ 24venlafaxine hcl cap er 24hr 150 mg.......................... 12venlafaxine hcl cap er 24hr 37.5 mg......................... 12venlafaxine hcl cap er 24hr 75 mg............................ 12venlafaxine hcl tab 25 mg, 37.5 mg, 50 mg, 75 mg,

100 mg....................................................................... 12VENTAVIS..................................................................... 62VENTOLIN HFA........................................................... 62verapamil hcl tab 40 mg, 80 mg, 120

mg................................................................................41verapamil hcl tab er 120 mg, 180 mg, 240

mg................................................................................41

2022

88

VERSACLOZ................................................................ 29VERZENIO....................................................................24VICTOZA....................................................................... 35VIEKIRA PAK................................................................32vigabatrin powd pack 500 mg.................................... 10vigabatrin tab 500 mg................................................. 10VIIBRYD.........................................................................12VIIBRYD STARTER PACK......................................... 12VIMPAT.......................................................................... 10VIMPAT.......................................................................... 10VIMPAT.......................................................................... 10VINBLASTINE SULFATE............................................24VINCRISTINE SULFATE.............................................24vinorelbine tartrate inj 10 mg/ml, 50 mg/5ml (10 mg/

ml)................................................................................24VIRACEPT.................................................................... 32VIRACEPT.................................................................... 32VIREAD..........................................................................32VIREAD..........................................................................32VITRAKVI...................................................................... 24VITRAKVI...................................................................... 24VITRAKVI...................................................................... 24VIZIMPRO..................................................................... 24voriconazole for inj 200 mg........................................ 14voriconazole for susp 40 mg/ml.................................14voriconazole tab 50 mg, 200 mg............................... 14VOSEVI..........................................................................32VOTRIENT.................................................................... 24VPRIV............................................................................ 48VRAYLAR...................................................................... 29VUMERITY....................................................................42VUMERITY....................................................................42VYNDAQEL...................................................................48VYXEOS........................................................................24WWAKIX............................................................................63warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg,

5 mg, 6 mg, 7.5 mg, 10 mg.....................................36water for irrigation, sterile irrigation

soln..............................................................................46WELIREG......................................................................24XXALKORI....................................................................... 24XARELTO...................................................................... 36XARELTO...................................................................... 36XARELTO STARTER PACK.......................................36XATMEP........................................................................ 57XCOPRI......................................................................... 10XCOPRI......................................................................... 10XCOPRI......................................................................... 10XCOPRI......................................................................... 10

XCOPRI......................................................................... 10XELJANZ.......................................................................57XELJANZ.......................................................................57XELJANZ XR................................................................57XGEVA...........................................................................58XIFAXAN........................................................................47XOFLUZA......................................................................32XOFLUZA......................................................................32XOLAIR..........................................................................57XOLAIR..........................................................................57XOSPATA...................................................................... 24XPOVIO......................................................................... 24XPOVIO 100 MG ONCE WEEKLY............................24XPOVIO 40 MG ONCE WEEKLY..............................24XPOVIO 40 MG TWICE WEEKLY.............................24XPOVIO 60 MG ONCE WEEKLY..............................24XPOVIO 60 MG TWICE WEEKLY.............................24XPOVIO 80 MG ONCE WEEKLY..............................25XPOVIO 80 MG TWICE WEEKLY.............................25XTANDI.......................................................................... 25XTANDI.......................................................................... 25XTANDI.......................................................................... 25XYWAV.......................................................................... 63YYERVOY........................................................................25YF-VAX.......................................................................... 57YONDELIS.................................................................... 25Zzafirlukast tab 10 mg, 20 mg......................................62zaleplon cap 10 mg..................................................... 63zaleplon cap 5 mg....................................................... 63ZALTRAP.......................................................................25ZANOSAR..................................................................... 25ZEJULA..........................................................................25ZELBORAF................................................................... 25ZENPEP........................................................................ 48ZEPATIER..................................................................... 32ZEPZELCA....................................................................25zidovudine cap 100 mg...............................................32zidovudine syrup 10 mg/ml.........................................32zidovudine tab 300 mg................................................32ziprasidone hcl cap 20 mg, 40 mg.............................29ziprasidone hcl cap 60 mg, 80 mg.............................29ziprasidone mesylate for inj 20 mg............................29ZIRABEV....................................................................... 25zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 58zoledronic acid iv soln 5 mg/100ml........................... 58ZOLINZA........................................................................25zolpidem tartrate tab 5 mg, 10 mg.............................63

2022

89

zonisamide cap 25 mg, 50 mg, 100mg................................................................................10

ZORTRESS...................................................................57ZYDELIG....................................................................... 25ZYKADIA....................................................................... 25ZYNLONTA................................................................... 25ZYPREXA RELPREVV............................................... 29ZYPREXA RELPREVV............................................... 29ZYPREXA RELPREVV............................................... 29

Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield ofIllinois does not exclude people or treat them differently because of race, color, national origin, age, disability,or sex.

Blue Cross and Blue Shield of Illinois:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact Civil Rights Coordinator.

If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminatedin another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievancewith: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago,Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil RightsCoordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office forCivil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SW

Room 509F, HHH BuildingWashington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licenseeof the Blue Cross and Blue Shield Association

Y0096_ILCOMPC22_C 243165.1221

mailto:[email protected]

mailto:[email protected]

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

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

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

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call1-888-285-2249 (TTY/TDD: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al1-888-285-2249 (TTY/TDD: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer1-888-285-2249 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-285-2249（TTY/TDD：711）。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-285-2249 (TTY/TDD:711) 번으로 전화해 주십시오

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nangwalang bayad. Tumawag sa 1-888-285-2249 (TTY/TDD: 711).

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-888-285-2249 (رقم هاتف الصم والبكم: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните1-888-285-2249 (телетайп: 711).

સુચના: જો તમ ેગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટ ેઉપલબ્ધ છે. ફોન કરો 1-888-285-2249 (TTY: 711).

1-888-285-2249 (TTY: 711). خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-285-2249(TTY/TDD: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-285-2249 (TTY/TDD: 711).

ध्यान दें: यदि आप हिंदी बोलत ेहै ंतो आपक ेलिए मुफ्त मे ंभाषा सहायता सेवाए ंउपलब्ध हैं। 1-888-285-2249 (TTY/TDD: 711) परकॉल करें।

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelezle 1-888-285-2249 (ATS : 711).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίεςπαρέχονται δωρεάν. Καλέστε 1-888-285-2249 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-285-2249 (TTY/TDD: 711).

This formulary was updated on 12/07/2021. For more recent information or other questions, please contactBlue Cross MedicareRx Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m.,local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (forexample, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

Prescription drug plans provided by HCSC Insurance Services Company (HISC), an Independent Licensee ofthe Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plansdepends on contract renewal.

www.getblueil.com/pdp/druglist

2022 formulary (list of covered drugs)

Documents