excellus 3 tier (commercial)
TRANSCRIPT
A nonprofit independent licensee of the Blue Cross Blue Shield Association
3-TIER FORMULARY GUIDEIncludes generic and brand-name medications
ExcellusBCBS.comB-1354 Y18 / 12291-18FLRX
August 2019
Dear Member,
The prescription drug benefit is one of the most important and frequently
utilized elements of health plan coverage. To help you identify which
medications are covered under your plan, we are pleased to provide the
3-Tier Formulary Guide. This booklet provides you with easy to understand
information about your prescription drug coverage including descriptions of
prescription drug safety and cost-saving programs.
The 3-Tier Formulary Guide lists commonly prescribed medications and their
tier classifications. The medications listed have been approved by the Food
and Drug Administration (FDA) as safe and effective and were selected in
consultation with a team of health care professionals because they meet our
criteria for safety, quality and value. We continually review and update
our formulary.
The drugs listed in the formulary and program descriptions may not apply to all plans.
This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.
The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.
If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.
How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.
How do I use the Formulary?There are two ways to find your drug within the formulary:
Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.
Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.
3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.
• Tier One drugs are typically generics and have the lowest copayment amount.
• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.
• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.
The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.
Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.
Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.
Generics Are Real MedicineGeneric drugs: safe, effective, affordable!
To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.
In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.
Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.
Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.
Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com
Mail Service PharmacyGet your prescriptions delivered right to your door!
When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer
opay savings for ordering prescriptions cthrough Express Scripts Home Delivery PharmacySM
or Wegmans® Home Delivery Pharmacy.
Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com
Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.
If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.
Coverage requirements or limits may include:
Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based
on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.
Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work, we will then cover Drug B.
Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.
Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com
Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.
Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.
Key:
UPPERCASE – Brand name medicationlowercase – generic medication
PA = Prior Authorization required
QL = Quantity Limit applies
ST = Step Therapy required
S = Specialty Drugs
MS = Drug must be purchased at a participating network specialty pharmacy for coverage
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
ANAPROX 3
ANAPROX DS 3
ARTHROTEC 50 3 QL
ARTHROTEC 75 3 QL
butalbital/aspirin/caffeine 50-325-40 capsule 1 QL
butalbital/aspirin/caffeine 50-325-40 tablet 1
CAMBIA 3
QL
ST
CELEBREX (50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE, 400MG CAPSULE)
3 QL
celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL
choline salicylate/magnesium salicylate 1
DAYPRO 3 QL
DICLOFENAC EPOLAMINE 3
QL
PA
diclofenac potassium 1
diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)
1
diclofenac sodium/misoprostol 1 QL
DICLOPR 3
QL
PA
diflunisal 1
DISALCID 3
DITHOL 3
QL
PA
DUEXIS 3
QL
PA
EC-NAPROSYN 3
PAGE 5 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet,500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h)
1
FELDENE 3
FENOPROFEN CALCIUM (200 MG CAPSULE, 400 MG CAPSULE) 3 PA
fenoprofen calcium 600 mg tablet 1 PA
FENORTHO 3 PA
FIORINAL 3 QL
FLECTOR 3
QL
PA
flurbiprofen 1
ibu 1
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1
INDOCIN (25 MG/5 ML SUSPENSION, 50 MG SUPPOSITORY) 3
indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) 1
ketoprofen 1
ketorolac tromethamine 10 mg tablet 1 QL
LODINE 3
MECLOFENAMATE SODIUM 3
mefenamic acid 1
meloxicam (7.5 mg tablet, 15 mg tablet) 1
MELOXICAM 7.5 MG/5ML ORAL SUSP 3
MOBIC (7.5 MG TABLET, 7.5 MG/5 ML SUSPENSION, 15 MG TABLET) 3
nabumetone (500 mg tablet, 750 mg tablet) 1 QL
NALFON 3 PA
NAPRELAN 3 PA
NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500MG TABLET)
3
naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500mg tablet dr)
1
NAPROXEN 125 MG/5ML ORAL SUSP 3
naproxen sodium (275 mg tablet, 550 mg tablet) 1
naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 1 PA
NUDROXIPAK 3
QL
PA
PAGE 6 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
oxaprozin 600 mg tablet 1 QL
PENNSAID 2% PUMP 3
QL
PA
piroxicam 1
PONSTEL 3
profeno 1 PA
QMIIZ ODT (ODT 7.5 MG TABLET, ODT 15 MG TABLET) 3
QL
PA
salsalate 1
SPRIX 3
QL
PA
S
sulindac 1
TIVORBEX 3
QL
PA
tolmetin sodium 1
VIMOVO 3
QL
PA
VIVLODEX 3 PA
VOLTAREN-XR 3
ZIPSOR 3
QL
PA
ZORVOLEX 3
QL
PA
OPIOID ANALGESICS, LONG-ACTING
ARYMO ER 3 PA
AVINZA 3 PA
BELBUCA 3 PA
BUPRENORPHINE 7.5 MCG/HR PATCH TDWK 3 PA
buprenorphine patch 1 PA
PAGE 7 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
BUTRANS 3 PA
CONZIP 3 PA
DOLOPHINE HCL 3
DURAGESIC 3 PA
EMBEDA 3 PA
EXALGO 3 PA
fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)
1 PA
fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr patch td72, 87.5mcg/hr patchtd72)
1 PA
hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32mg tab er 24h)
1 PA
HYSINGLA ER 3 PA
KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE,ER 50 MG CAPSULE, ER 60 MG CAPSULE, ER 100 MG CAPSULE)
3 PA
KADIAN (ER 40 MG CAPSULE, ER 200 MG CAPSULE) 3 PA
KADIAN ER 80 MG CAPSULE 3
PA
ST
levorphanol tartrate 2 mg tablet 1 PA
LEVORPHANOL TARTRATE 3 MG TABLET 3 PA
methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mg tablet sol)
1 PA
methadone intensol 1 PA
METHADOSE 10 MG/ML ORAL CONC 3 PA
methadose 40 mg tablet dispr 1 PA
MORPHABOND ER 3 PA
PAGE 8 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg cpmp 24hr, 30 mg tablet er, 40 mg cap er pel, 45 mg cpmp24hr, 50 mg cap er pel, 60 mg cap er pel, 60 mg cpmp 24hr, 60 mg tablet er, 75mg cpmp 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 100 mg cap er pel, 100 mgtablet er, 120 mg cpmp 24hr, 200 mg tablet er)
1 PA
MS CONTIN 3 PA
NUCYNTA ER 2 PA
OXYCODONE HCL (10 MG TAB ER 12H, 15 MG TAB ER 12H, 20 MG TAB ER12H, 30 MG TAB ER 12H, 40 MG TAB ER 12H, 60 MG TAB ER 12H, 80 MGTAB ER 12H)
3 PA
OXYCONTIN 3 PA
oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mgtab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h)
1 PA
TRAMADOL ER CAPS 3 PA
tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200mg tbmp 24hr, 300 mg tab er 24h, 300 mg tbmp 24hr)
1 PA
ULTRAM ER 3 PA
XTAMPZA ER 2 PA
ZOHYDRO ER 3 PA
OPIOID ANALGESICS, SHORT-ACTING
ABSTRAL 3
QL
PA
acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)
1
acetaminophen/caff/dihydrocod 320.5-30mg capsule 1
ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 TABLET 3
ACTIQ 3
QL
PA
APADAZ 3
ascomp with codeine 1
aspirin/caffeine/dihydrocodeine bitartrate 1
butalbital/acetaminophen/caffeine/codeine phosphate(butalbit/acetamin/caff/codeine 50-300-30 capsule,butalbit/acetamin/caff/codeine 50-325-30 capsule)
1 QL
butorphanol tartrate 10 mg/ml spray 1 QL
CAPITAL W-CODEINE 3
carisoprodol/aspirin/codeine phosphate 1
codeine phosphate/butalbital/aspirin/caffeine 1
PAGE 9 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
codeine sulfate 1
DEMEROL (50 MG TABLET, 100 MG TABLET) 3
DILAUDID (2 MG TABLET, 4 MG TABLET, 5 MG/5 ML ORAL LIQUID, 8 MGTABLET)
3
endocet 1
FENTANYL CITRATE (100 MCG TABLET EFF, 200 MCG TABLET EFF, 400MCG TABLET EFF, 600 MCG TABLET EFF, 800 MCG TABLET EFF)
3
QL
PA
fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozengehd, 800 mcg lozenge hd, 1200 mcg lozenge hd, 1600 mcg lozenge hd)
1
QL
PA
FENTORA 3
QL
PA
FIORICET WITH CODEINE 3 QL
FIORINAL WITH CODEINE #3 3
HYCET 3
hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)
1
hydrocodone/ibuprofen 1
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)
1
IBUDONE 3
ibuprofen/oxycodone hcl 1
LAZANDA 3
QL
PA
lorcet 1
lorcet hd 1
lorcet plus 1
lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325 mg tablet) 1
LORTAB 10 MG-300 MG/15 ML ELXR 3
meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1
MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2
PAGE 10 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)
1
NALOCET 3
NORCO 3
NUCYNTA 2
OPANA (5 MG TABLET, 10 MG TABLET) 3
opium/belladonna alkaloids 1
OXAYDO 3
OXECTA 3
OXYCODONE 10MG/0.5ML ORAL SYRINGE 3
oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)
1
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)
1
oxycodone hcl/aspirin 1
oxymorphone hcl (5 mg tablet, 10 mg tablet) 1
PANLOR 3 QL
pentazocine hcl/naloxone hcl 1
PERCOCET 3
PRIMLEV 3
ROXICODONE 3
ROXYBOND 3
SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)
3
QL
PA
SYNALGOS-DC 3
tramadol hcl 50 mg tablet 1
tramadol hcl/acetaminophen 1
TREZIX 3
TYLENOL-CODEINE NO.3 3
TYLENOL-CODEINE NO.4 3
ULTRACET 3
ULTRAM 3
verdrocet 1
vicodin 1
PAGE 11 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
vicodin es 1
vicodin hp 1
XARTEMIS XR 3 PA
XODOL 10-300 3
XODOL 5-300 3
XODOL 7.5-300 3
xylon 10 1
ZAMICET 3
ANESTHETICS
LOCAL ANESTHETICS
ANACAINE 3
ANASTIA 3
ANODYNE LPT 3
QL
PA
APRIZIO PAK 3
QL
PA
DERMACINRX EMPRICAINE 3 PA
dermacinrx prizopak 1
QL
PA
DOLOTRANZ 3
QL
PA
EMLA 3
glydo 1
lido-k 1
LIDO-PRILO CAINE PACK 3
QL
PA
lidocaine (5 % adh. patch, 5 % oint. (g)) 1
lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)
1
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5kit)
1
LIDODERM 3
LIDOPAC 3
QL
PA
PAGE 12 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
lidopin 3% cream 1
LIDOPIN 3.25% CREAM 3
LIDOPRIL 3
QL
PA
LIDOPRIL XR 3
QL
PA
LIDOTRANS 5 PAK 3
QL
PA
LIPROZONEPAK 3 PA
MEDOLOR PAK 3 PA
NEURCAINE 3
QL
PA
NUMBONEX 3
NUVAKAAN 3
QL
PA
PAINGO KFT 3
QL
PA
PRILOLID 3 PA
RELADOR PAK 3
QL
PA
SOLUPAK 3
QL
PA
ZTLIDO 3 QL
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 1 QL
ANTABUSE 3
disulfiram 1
naltrexone hcl 1
REVIA 3
PAGE 13 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OPIOID DEPENDENCE TREATMENTS
BUNAVAIL 3
buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1
buprenorphine hcl/naloxone hcl 1
LUCEMYRA 3 QL
SUBOXONE 2
ZUBSOLV 2
OPIOID REVERSAL AGENTS
naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1 mg/ml syringe) 1
NARCAN 2
SMOKING CESSATION AGENTS
buproban 1
bupropion hcl 150 mg tab er 12h 1
CHANTIX 3 QL
NICOTROL 3 QL
NICOTROL NS 3 QL
ZYBAN 3
ANTIBACTERIALS
AMINOGLYCOSIDES
ARIKAYCE 3
QL
PA
S
gentak 1
gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))
1
neomycin sulfate 1
paromomycin sulfate 1
tobramycin 1
TOBREX (DROP, OINTMENT) 3
ANTIBACTERIALS, OTHER
AEMCOLO 3
AKTIPAK 3
QL
ST
PAGE 14 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ALTABAX 3
bacitracin 500 unit/g oint. (g) 1
BACTROBAN (CREAM, OINTMENT) 3
BACTROBAN NASAL 3
BENZAMYCIN 3
CENTANY 3
CENTANY AT 3
QL
PA
CLEOCIN (2% CREAM, 100 MG OVULE) 3
CLEOCIN HCL 3
CLEOCIN PALMITATE 3
CLEOCIN T (T GEL, T LOTION, T PLEDGETS, T SOLUTION) 3 ST
clindacin etz 1% pledget 1
CLINDACIN ETZ KIT 3
QL
PA
clindacin p 1
CLINDACIN PAC 3
QL
PA
CLINDAGEL 3 ST
clindamycin hcl 1
clindamycin palmitate hcl 1
clindamycin phosphate (1 % foam, 1 % gel (gram), 1 % lotion, 1 % med. swab,1 % solution, 2 % cream/appl)
1
CLINDAMYCIN PHOSPHATE 1 % GEL DAILY 3 ST
CLINDESSE 3
erythromycin base/benzoyl peroxide 1
EVOCLIN 3 ST
FIRVANQ 2
FLAGYL 3
FLAGYL ER 3
FURADANTIN 3
HIPREX 3
PAGE 15 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
hyophen 1
linezolid 100 mg/5ml susp recon 1
linezolid 600 mg tablet 1 QL
MACROBID 3
MACRODANTIN 3
methenamine hippurate 1
methenamine mandelate 1
methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1
METROGEL-VAGINAL 3
metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)
1
MONUROL 3
mupirocin 1
mupirocin calcium 1
nitrofurantoin 1
nitrofurantoin macrocrystal 1
nitrofurantoin monohydrate/macrocrystals 1
NUVESSA 3 QL
phosphasal 1
PRIMSOL 3
SIVEXTRO 200 MG TABLET 3 PA
SOLOSEC 3
SULFAMYLON (8.5% CREAM, POWDER PACKET) 3
TINDAMAX 3
tinidazole 1
trimethoprim 1
TRIMPEX 3
ur n-c 1
URELLE 3
uretron d-s 1
URIBEL 3
urimar-t 1
urin d.s. 1
PAGE 16 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
uro-458 1
uro-mp 1
urogesic-blue 1
uryl 1
utira-c 1
VANCOCIN HCL 3
vancomycin hcl (125 mg capsule, 250 mg capsule) 1
vandazole 1
ZYVOX 100 MG/5 ML SUSPENSION 3
ZYVOX 600 MG TABLET 3 QL
BETA-LACTAM, CEPHALOSPORINS
CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3
cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)
1
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5mlsusp recon)
1
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1
cefditoren pivoxil 1
cefixime (100 mg/5ml susp recon, 200 mg/5ml susp recon, 400 mg capsule) 1
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)
1
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500mg tablet)
1
CEFTIBUTEN 3
CEFTIN (250 MG TABLET, 500 MG TABLET) 3
cefuroxime axetil 1
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule)
1
DAXBIA 3
KEFLEX 3
SPECTRACEF 3
SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 ML SUSPENSION, 200MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 400 MG CAPSULE,500 MG/5 ML SUSPENSION)
3
PAGE 17 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
BETA-LACTAM, PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susprecon, 500 mg capsule, 500 mg tablet, 875 mg tablet)
1
AMOXICILLIN 775 MG TBMP 24HR 3
amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)
1
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susprecon, 500 mg capsule)
1
AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET)
3
AUGMENTIN ES-600 3
AUGMENTIN XR 3
dicloxacillin sodium 1
MOXATAG 3 PA
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)
1
MACROLIDES
AZASITE 3
azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)
1
BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3
clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)
1
DIFICID 3 ST
E.E.S. 200 3
E.E.S. 400 3
ery 1
ery-tab 1
ERYGEL 3
ERYPED 200 3
ERYPED 400 3
erythrocin stearate 1
erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)
1
erythromycin base in ethanol (in 2 % gel (gram), in 2 % med. swab, in 2 %solution)
1
PAGE 18 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet, 400mg/5ml susp recon)
1
ILOTYCIN 3
PCE 3
ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MGTABLET)
3
ZITHROMAX TRI-PAK 3
ZMAX 3
QUINOLONES
AVELOX 3
AVELOX ABC PACK 3
BAXDELA 450 MG TABLET 3 QL
BESIVANCE 3
CETRAXAL 3 QL
CILOXAN (EYE DROPS, OINTMENT) 3
CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG TABLET, 500 MGTABLET)
3
CIPRO XR 3
ciprofloxacin 1
ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)
1
ciprofloxacin hcl 0.2 % droperette 1 QL
ciprofloxacin/ciprofloxacin hcl 1
FACTIVE 3
FLOXIN 3
gatifloxacin 1
LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET, 500 MG TABLET, 750MG TABLET)
3
levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)
1
MOXEZA 2
moxifloxacin hcl 1
OCUFLOX 3
ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1
OTIPRIO 3
VIGAMOX 3
ZYMAXID 3
PAGE 19 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SULFONAMIDES
AVC 3
BACTRIM 3
BACTRIM DS 3
BLEPH-10 3
KLARON 3
SILVADENE 3
silver sulfadiazine 1
ssd 1
sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1
sulfadiazine 1
sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oralsusp, sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)
1
sulfatrim 1
thermazene 1
TETRACYCLINES
ACTICLATE 3 PA
ADOXA 3
avidoxy 1
demeclocycline hcl 1
DORYX 3 ST
DORYX MPC 3 ST
doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet, 50 mg tablet dr,75 mg tablet dr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tabletdr, 200 mg tablet dr)
1
doxycycline hyclate (75 mg tablet, 150 mg tablet) 1
QL
PA
doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mgtablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mgcapsule, 150 mg tablet)
1
DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3
QL
ST
MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3
PAGE 20 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 80 mg tab er 24h, 90 mgtab er 24h, 105 mg tab er 24h, 115mg tab er 24h, 135 mg tab er 24h)
1
QL
PA
minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100mg capsule, 100 mg tablet)
1
MINOCYCLINE HCL 55 MG TAB ER 24H 3
QL
PA
MINOLIRA ER 3
QL
PA
mondoxyne nl 1
MONODOX 3
MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3
QL
PA
morgidox (50 mg capsule, 100 mg capsule) 1
NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150 MG-7 DAY WITHLOAD)
3 PA
ORACEA 3
QL
ST
SEYSARA 3
QL
PA
SOLODYN 3
QL
PA
TARGADOX 3
tetracycline hcl 1
VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3
XIMINO 3
QL
PA
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET, 100 MG TABLET)
3
QL
PA
DIACOMIT 3
QL
PA
S
PAGE 21 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
EPIDIOLEX 3
QL
PA
S
MS
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET)
3
KEPPRA XR (500 MG TABLET, 750 MG TABLET) 3 QL
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)
1
levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL
POTIGA 3
roweepra 1
roweepra xr 500 mg tablet 1
roweepra xr 750 mg tablet 1 QL
SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)
3
QL
PA
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 3
ethosuximide (250 mg capsule, 250 mg/5ml solution) 1
ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3
ZONEGRAN 3
zonisamide 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
clobazam (10 mg tablet, 20 mg tablet) 1 QL
clobazam 2.5 mg/ml oral susp 1
DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3
DEPAKOTE 3
DEPAKOTE ER 3
DEPAKOTE SPRINKLE 3
DIASTAT 3 QL
DIASTAT ACUDIAL 3 QL
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1
PAGE 22 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250 mg tab er 24h,250 mg tablet dr, 500 mg tab er 24h, 500 mg tablet dr)
1
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)
1
GABITRIL 3
GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
GRALISE 30-DAY STARTER PACK 3 PA
MYSOLINE 3
NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE,400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET)
3
ONFI (10 MG TABLET, 20 MG TABLET) 3 QL
ONFI 2.5 MG/ML SUSPENSION 3
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
1
primidone 1
SABRIL 3
QL
PA
S
MS
SYMPAZAN 3
QL
ST
tiagabine hcl 1
valproic acid 1
valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution,500mg/10ml solution)
1
vigabatrin 1
QL
PA
S
MS
GLUTAMATE REDUCING AGENTS
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1
FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)
3 QL
LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)
3
LAMICTAL (BLUE) 3
PAGE 23 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LAMICTAL (GREEN) 3
LAMICTAL (ORANGE) 3
LAMICTAL ODT 3 QL
LAMICTAL XR 3
lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)
1 QL
lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)
1
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)
3
QL
PA
TOPAMAX 3
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)
1
TOPIRAMATE ER CAPS 3
QL
PA
TROKENDI XR 3
QL
PA
SODIUM CHANNEL AGENTS
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)
3
QL
PA
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)
1
CARBATROL 3
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2
DILANTIN-125 2
epitol 1
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mgtablet)
1
OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3
QL
PA
PEGANONE 3
PHENYTEK 2
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1
phenytoin sodium extended 1
PAGE 24 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3
TEGRETOL XR 3
TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600MG TABLET)
3
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)
2
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1
CHOLINESTERASE INHIBITORS
ARICEPT 3
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 23mg tablet)
1
EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 13.3 MG/24HRPATCH)
3
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)
1
NAMZARIC 3
QL
PA
RAZADYNE 3
RAZADYNE ER 3
rivastigmine 1
rivastigmine tartrate 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)
1
memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)
1 QL
NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK,10 MG TABLET)
3
NAMENDA XR 3 QL
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
amitriptyline hcl/chlordiazepoxide 1
APLENZIN 3
QL
ST
bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL
bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)
1
PAGE 25 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
BUPROPION HCL 450 MG TAB ER 24H 3
QL
ST
FORFIVO XL 3
QL
ST
mirtazapine 1
olanzapine/fluoxetine hcl 1
perphenazine/amitriptyline hcl 1
REMERON 3
SYMBYAX 3
WELLBUTRIN 3
WELLBUTRIN SR 3
WELLBUTRIN XL (150 MG TABLET, 300 MG TABLET) 3 QL
MONOAMINE OXIDASE INHIBITORS
EMSAM 3
QL
ST
MARPLAN 3
NARDIL 3
PARNATE 3
phenelzine sulfate 1
tranylcypromine sulfate 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)
BRISDELLE 3
QL
PA
CELEXA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL
citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
citalopram hydrobromide 10 mg/5 ml solution 1
DESVENLAFAXINE ER 3 QL
DESVENLAFAXINE FUMARATE 3
QL
ST
desvenlafaxine succinate 1 QL
EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE, 150 MG CAPSULE) 3 QL
PAGE 26 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mgtablet)
1
FETZIMA 3 QL
fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)
1
fluoxetine hcl 90 mg capsule dr 1 QL
fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1
KHEDEZLA 3
QL
ST
LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10 MG TABLET, 20 MGTABLET)
3
maprotiline hcl 1
nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1
nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL
OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3
QL
ST
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1
paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL
paroxetine mesylate 1
QL
PA
PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET)
3
PAXIL CR 3 QL
PEXEVA 3
QL
ST
PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET, ER 100 MG TABLET) 3 QL
PROZAC (10 MG, 40 MG) 3 QL
PROZAC 20 MG PULVULE 3
PROZAC WEEKLY 3 QL
SARAFEM 3
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
trazodone hcl 1
TRINTELLIX 3 QL
PAGE 27 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)
3
QL
ST
venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)
1
venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL
VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)
3 QL
VIIBRYD 10-20 MG STARTER PACK 3
ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET)
3
TRICYCLICS
amitriptyline hcl 1
amoxapine 1
ANAFRANIL 3
clomipramine hcl 1
desipramine hcl 1
doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)
1
imipramine hcl 1
imipramine pamoate 1
NORPRAMIN 3
nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1
NORTRIPTYLINE HCL (10 MG/5 ML SOLUTION, 20 MG/10ML SOLUTION) 3
QL
PA
PAMELOR 3
protriptyline hcl 1
SURMONTIL 3
TOFRANIL 3
TOFRANIL-PM 3
trimipramine maleate 1
ANTIEMETICS
ANTIEMETICS, OTHER
BONJESTA 3
QL
PA
COMPAZINE (5 MG TABLET, 10 MG TABLET) 3
PAGE 28 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
compazine 25 mg suppository 1
compro 1
DICLEGIS 3
QL
PA
doxylamine succinate/pyridoxine hcl (b6) 1
QL
PA
meclizine hcl (12.5 mg tablet, 25 mg tablet) 1
metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1 QL
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)
1
METOZOLV ODT 3 QL
MOTEGRITY 3
QL
ST
perphenazine 1
phenadoz 1
phenergan (12.5 mg, 25 mg, 50 mg) 1
prochlorperazine 1
prochlorperazine maleate 1
promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)
1
promethegan 1
REGLAN 3
scopolamine 1
TIGAN 300 MG CAPSULE 3
TRANSDERM-SCOP 3
trimethobenzamide hcl 1
EMETOGENIC THERAPY ADJUNCTS
AKYNZEO 300-0.5 MG CAPSULE 3 QL
ANZEMET (50 MG TABLET, 100 MG TABLET) 3
QL
ST
aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)
1 QL
CESAMET 3
dronabinol 1
PAGE 29 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE, 125 MGPOWDER PACKET, TRIPACK)
3 QL
granisetron hcl 1 mg tablet 1 QL
MARINOL 3
ondansetron 1
ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1
SANCUSO 3
QL
ST
SUSTOL 3
SYNDROS 3 PA
VARUBI 90 MG TABLET 3
ZOFRAN (4 MG TABLET, 4 MG/5 ML ORAL SOLN, 8 MG TABLET) 3
ZOFRAN ODT 3
ZUPLENZ 3
QL
ST
ANTIFUNGALS
ANCOBON 3
ciclodan 0.77% cream 1
ciclodan 8% solution 1 QL
ciclopirox (0.77 % gel (gram), 1 % shampoo) 1
ciclopirox 8 % solution 1 QL
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1
clotrimazole (1 % cream (g), 10 mg troche) 1
CRESEMBA 186 MG CAPSULE 3
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)
3
econazole nitrate 1
ECOZA 3
QL
ST
ERTACZO 3 ST
EXELDERM (CREAM, SOLUTION) 3
EXTINA 3 ST
PAGE 30 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mgtablet, 150 mg tablet, 200 mg tablet)
1
flucytosine 1
GRIFULVIN V 3
GRIS-PEG 3
griseofulvin ultramicrosize 1
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1
GYNAZOLE 1 3
itraconazole (10 mg/ml solution, 100 mg capsule) 1
JUBLIA 3
QL
PA
KERYDIN 3 PA
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1
ketodan (foam, foam kit) 1
LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3
QL
PA
LAMISIL 250 MG TABLET 3
LOPROX (0.77% CREAM, 0.77% TOPICAL SUSP, 1% SHAMPOO) 3
LOPROX (CREAM KIT, SUSPENSION KIT) 3
QL
PA
LULICONAZOLE 3 QL
LUZU 3
QL
ST
MENTAX 3 ST
miconazole nitrate 200 mg supp.vag 1
MICONAZOLE NITRATE/ZINC OXIDE/PETROLATUM,WHITE 3
naftifine hcl (1 % cream (g), 1 % gel (gram)) 1
naftifine hcl 2 % cream (g) 1 QL
NAFTIN (1% GEL, 2% GEL) 3 ST
NAFTIN 2% CREAM 3 QL
NATACYN 3
NIZORAL 3
PAGE 31 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3
nyamyc 1
NYATA 3
nystatin (500k unit tablet, 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)
1
nystatin/triamcinolone acetonide 1
nystop 1
ONMEL 3
QL
PA
ORAVIG 3 PA
oxiconazole nitrate 1
OXISTAT 1% CREAM 3
OXISTAT 1% LOTION 3 ST
PENLAC 3 QL
SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3
TERAZOL 3 3
TERAZOL 7 3
terbinafine hcl 250 mg tablet 1
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1
TOLSURA 3
QL
PA
VFEND (40 MG/ML SUSPENSION, 50 MG TABLET) 3
VFEND 200 MG TABLET 3 QL
voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1
voriconazole 200 mg tablet 1 QL
VUSION 3
XOLEGEL 3 ST
ANTIGOUT AGENTS
allopurinol 1
COLCHICINE 3 QL
COLCRYS 2 QL
MITIGARE 3 QL
PAGE 32 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
probenecid 1
probenecid/colchicine 1
ULORIC 2
QL
ST
ZYLOPRIM 3
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS, OTHER
AIMOVIG AUTOINJECTOR 2
QL
PA
AIMOVIG AUTOINJECTOR (2 PACK) 2
QL
PA
AJOVY 2
QL
PA
EMGALITY PEN 2
QL
PA
EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 120 MG/ML SYRINGE, 300MG (100 MG X3SYR))
2
QL
PA
ERGOT ALKALOIDS
CAFERGOT 3
D.H.E.45 3
dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1
DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL
ERGOMAR 3
ergotamine tartrate/caffeine 1
MIGERGOT 3
MIGRANAL 3 QL
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate 1 QL
AMERGE 3 QL
AXERT 3 QL
eletriptan hydrobromide 1 QL
PAGE 33 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
FROVA 3 QL
frovatriptan succinate 1 QL
IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 5 MGNASAL SPRAY, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6MG/0.5 ML VIAL, 20 MG NASAL SPRAY, 25 MG TABLET, 50 MG TABLET,100 MG TABLET)
3 QL
MAXALT 3 QL
MAXALT MLT 3 QL
naratriptan hcl 1 QL
ONZETRA XSAIL 3
QL
ST
RELPAX 3 QL
rizatriptan benzoate 1 QL
sumatriptan (5 mg spray, 20 mg spray) 1 QL
sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)
1 QL
sumatriptan succinate/naproxen sodium 1 QL
SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3
QL
ST
TREXIMET 3 QL
ZEMBRACE SYMTOUCH 3
QL
ST
zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet) 1 QL
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3
QL
ST
ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL
ZOMIG ZMT 3 QL
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
GUANIDINE HCL 3
MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG TIMESPAN) 3
pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1
PAGE 34 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
PYRIDOSTIGMINE BROMIDE 30 MG TABLET 3
pyridostigmine bromide 60 mg/5 ml syrup 1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (25 mg tablet, 100 mg tablet) 1
MYCOBUTIN 3
rifabutin 1
ANTITUBERCULARS
cycloserine 1
ethambutol hcl 1
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1
MYAMBUTOL 3
PASER 3
PRIFTIN 3
pyrazinamide 1
RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3
RIFAMATE 3
rifampin (150 mg capsule, 300 mg capsule) 1
RIFATER 3
SIRTURO 3
TRECATOR 3
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLET 3
cyclophosphamide (25 mg capsule, 50 mg capsule) 1
GLEOSTINE 3
HEXALEN 3
LEUKERAN 2
lomustine 1
MATULANE 2 S
melphalan 1
MYLERAN 2
PAGE 35 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MGCAPSULE, 180 MG CAPSULE, 250 MG CAPSULE)
3
S
MS
temozolomide 1
S
MS
VALCHLOR 3
QL
PA
S
MS
ANTIANDROGENS
abiraterone acetate 1
QL
S
MS
bicalutamide 1
CASODEX 3
ERLEADA 3
QL
PA
S
MS
flutamide 1
NILANDRON 3
nilutamide 1
XTANDI 2
QL
PA
S
MS
YONSA 3
QL
PA
S
MS
ZYTIGA (250 MG TABLET, 500 MG TABLET) 2
QL
PA
S
MS
PAGE 36 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANTIANGIOGENIC AGENTS
POMALYST 3
QL
PA
S
MS
REVLIMID 2
QL
PA
S
MS
THALOMID 3
QL
S
MS
ANTIESTROGENS/MODIFIERS
EMCYT 3
FARESTON 2
SOLTAMOX 3
QL
PA
tamoxifen citrate 1
toremifene citrate 1
ANTIMETABOLITES
capecitabine 1
S
MS
DROXIA 3
EFUDEX 3
fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1
HYDREA 3
hydroxyurea 1
mercaptopurine 1
PURIXAN 3
QL
PA
S
SIKLOS (100 MG TABLET, 1,000 MG TABLET) 3 PA
PAGE 37 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
TABLOID 2
XELODA 3
S
MS
ANTINEOPLASTICS, OTHER
ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)
3
QL
PA
S
MS
BALVERSA (3 MG TABLET, 4 MG TABLET, 5 MG TABLET) 3
QL
PA
S
COPIKTRA 15 MG CAPSULE 3
QL
PA
S
COPIKTRA 25 MG CAPSULE 3
QL
PA
HEMANGEOL 3 S
IDHIFA 3
QL
PA
S
MS
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1
LONSURF 3
PA
S
MS
LYSODREN 2
NINLARO 3
PA
S
MS
RUBRACA (200 MG TABLET, 250 MG TABLET, 300 MG TABLET) 3
QL
PA
S
PAGE 38 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RYDAPT 3
QL
PA
S
MS
SYLATRON 3
PA
S
MS
TIBSOVO 3
QL
PA
VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100 MG CAPSULE) 3
QL
PA
S
MS
VIZIMPRO 3
QL
PA
S
MS
XOSPATA 3
QL
PA
S
MS
ZOLINZA 3
QL
PA
S
MS
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1
ARIMIDEX 3
AROMASIN 3
exemestane 1
FEMARA 3
letrozole 1
PAGE 39 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ENZYME INHIBITORS
etoposide 50 mg capsule 1
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2
QL
PA
S
MS
LORBRENA (25 MG TABLET, 100 MG TABLET) 3
QL
PA
S
MS
PIQRAY (200 MG DAILY, 250 MG DAILY, 300 MG DAILY) 3
QL
PA
S
MS
MOLECULAR TARGET INHIBITORS
AFINITOR 2
QL
PA
S
MS
ALECENSA 3
PA
S
MS
BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3
QL
PA
S
MS
BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
S
CABOMETYX 3
QL
PA
S
MS
PAGE 40 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
CALQUENCE 3
QL
PA
S
CAPRELSA (100 MG TABLET, 300 MG TABLET) 2
QL
PA
S
COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2
QL
PA
S
COTELLIC 3
PA
S
MS
DAURISMO (25 MG TABLET, 100 MG TABLET) 3
QL
PA
S
MS
ERIVEDGE 3
QL
PA
S
MS
erlotinib hcl 1
QL
S
MS
FARYDAK 3
QL
PA
S
MS
GILOTRIF 3
QL
PA
S
MS
PAGE 41 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
GLEEVEC (100 MG TABLET, 400 MG TABLET) 3
QL
ST
S
MS
IBRANCE 2
QL
PA
S
MS
ICLUSIG (15 MG TABLET, 45 MG TABLET) 3
QL
PA
S
imatinib mesylate (100 mg tablet, 400 mg tablet) 1
QL
S
MS
IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)
3
QL
PA
S
INLYTA (1 MG TABLET, 5 MG TABLET) 3
QL
PA
S
MS
IRESSA 3
QL
PA
S
MS
JAKAFI 2
QL
PA
S
MS
KISQALI 3
QL
PA
S
MS
PAGE 42 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3
QL
PA
S
MS
LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)
3
QL
PA
S
MS
LYNPARZA (100 MG TABLET, 150 MG TABLET) 3
QL
PA
S
MS
LYNPARZA 50 MG CAPSULE 3
PA
S
MS
MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3
QL
PA
S
MS
MEKTOVI 3
QL
PA
S
MS
NERLYNX 3
QL
PA
S
MS
NEXAVAR 2
QL
PA
S
MS
ODOMZO 3
PA
S
MS
PAGE 43 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)
2
QL
PA
S
MS
STIVARGA 2
QL
PA
S
MS
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)
2
QL
PA
S
MS
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
S
MS
TAGRISSO 3
PA
S
MS
TALZENNA (0.25 MG CAPSULE, 1 MG CAPSULE) 3
QL
PA
S
MS
TARCEVA 3
QL
PA
S
MS
TASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) 3
QL
PA
S
MS
PAGE 44 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
TYKERB 2
QL
PA
S
MS
VENCLEXTA 3
QL
PA
S
VERZENIO 2
QL
PA
MS
VOTRIENT 2
QL
PA
S
MS
XALKORI 3
QL
PA
S
MS
ZEJULA 3
QL
PA
ZELBORAF 2
QL
PA
S
MS
ZYDELIG 3
QL
PA
S
MS
ZYKADIA (150 MG CAPSULE, 150 MG TABLET) 3
QL
PA
S
MS
PAGE 45 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RETINOIDS
bexarotene 1
QL
PA
S
MS
PANRETIN 3
TARGRETIN 1% GEL 3
PA
S
MS
TARGRETIN 75 MG CAPSULE 3
QL
PA
S
MS
tretinoin 10 mg capsule 1
TREATMENT ADJUNCTS
MESNEX 400 MG TABLET 3
ANTIPARASITICS
ANTIHELMINTHICS
albendazole 1
ALBENZA 3
BENZNIDAZOLE (12.5 MG TABLET, 100 MG TABLET) 3 QL
BILTRICIDE 3
EMVERM 3
QL
PA
ivermectin 1
praziquantel 1
SKLICE 3 QL
STROMECTOL 3
ANTIPROTOZOALS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3
ARAKODA 3
atovaquone 1
PAGE 46 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 3
DARAPRIM 3 S
hydroxychloroquine sulfate 1
IMPAVIDO 3
QL
PA
KRINTAFEL 2
MALARONE 3
mefloquine hcl 1
MEPRON 3
NEBUPENT 3
PLAQUENIL 3
PRIMAQUINE PHOSPHATE 3
QUALAQUIN 3 PA
quinine sulfate 1 PA
PEDICULICIDES/SCABICIDES
crotan 1 QL
ELIMITE 3
EURAX 3 QL
lindane 1 QL
malathion 1
OVIDE 3
permethrin 5 % cream (g) 1
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1
carbidopa/levodopa/entacapone 1
PAGE 47 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
COMTAN 3
entacapone 1
GOCOVRI 3
QL
PA
OSMOLEX ER 3
QL
PA
STALEVO 3
TASMAR 3
tolcapone 1
DOPAMINE AGONISTS
APOKYN 3
S
MS
bromocriptine mesylate 1
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3
QL
PA
PARLODEL 3
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.375 mg tab er 24h, 0.5mg tablet, 0.75 mg tab er 24h, 0.75 mg tablet, 1 mg tablet, 1.5 mg tab er 24h,1.5 mg tablet, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg tab er 24h, 4.5 mgtab er 24h)
1
REQUIP 3
REQUIP XL 3 QL
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet)
1
ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er24h, 12 mg tab er 24h)
1 QL
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 1
PAGE 48 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis,carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tabrapdis, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis,carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg-200mgtablet er)
1
LODOSYN 3
RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)
3
QL
PA
SINEMET 10-100 3
SINEMET 25-100 3
SINEMET 25-250 3
SINEMET CR 3
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
AZILECT 3 QL
ELDEPRYL 3
rasagiline mesylate 1 QL
selegiline hcl 1
XADAGO (50 MG TABLET, 100 MG TABLET) 3
QL
ST
ZELAPAR 3
QL
PA
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
ADASUVE 3
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet,200 mg tablet)
1
fluphenazine decanoate 1
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5mg/ml oral conc, 10 mg tablet)
1
haloperidol 1
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1
loxapine succinate 1
molindone hcl 1
ORAP 3
pimozide 1
thioridazine hcl 1
PAGE 49 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
thiothixene 1
trifluoperazine hcl 1
2ND GENERATION/ATYPICAL
ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20MG TABLET, 30 MG TABLET)
3 QL
ABILIFY DISCMELT 3 QL
ABILIFY MYCITE 3
QL
PA
aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mg tablet)
1 QL
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)
3
QL
ST
FANAPT TITRATION PACK 3 ST
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE)
3
INVEGA 3 QL
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)
3
QL
ST
NUPLAZID (10 MG TABLET, 17 MG TABLET, 34 MG CAPSULE) 3
QL
PA
S
MS
olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet, 7.5 mg tablet, 10 mgtab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tab rapdis, 20mg tablet)
1
paliperidone 1 QL
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)
1
quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)
1 QL
REXULTI 3
QL
ST
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 1 MG/MLSOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)
3
RISPERDAL M-TAB 3
PAGE 50 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mgtablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mgtablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
1
SAPHRIS 3
QL
ST
SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET, 300 MG TABLET)
3
SEROQUEL 400 MG TABLET 3 QL
SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MGTABLET, 400 MG TABLET)
3 QL
VRAYLAR 3
QL
ST
ziprasidone hcl 1
ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MGTABLET, 15 MG TABLET, 20 MG TABLET)
3
ZYPREXA ZYDIS 3
TREATMENT-RESISTANT
clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 25 mg tablet, 50 mg tablet,100 mg tab rapdis, 100 mg tablet, 150 mg tab rapdis, 200 mg tab rapdis, 200mg tablet)
1
CLOZARIL 3
FAZACLO 3
VERSACLOZ 3
ANTISPASTICITY AGENTS
baclofen (10 mg tablet, 20 mg tablet) 1
baclofen 5 mg tablet 1
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3
dantrolene sodium 1
tizanidine hcl 1
ZANAFLEX 3
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
PREVYMIS (240 MG TABLET, 480 MG TABLET) 3
VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3
valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1
ZIRGAN 3
PAGE 51 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 1
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL
entecavir 1 QL
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3
HEPSERA 3
lamivudine 100 mg tablet 1
TYZEKA 3 QL
VEMLIDY 3
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS
DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3
QL
PA
ST
S
MS
EPCLUSA 3
QL
PA
S
MS
HARVONI 3
QL
PA
S
MS
LEDIPASVIR/SOFOSBUVIR 3
QL
PA
S
MS
MAVYRET 3
QL
PA
S
MS
PAGE 52 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OLYSIO 3
QL
PA
ST
S
MS
SOFOSBUVIR/VELPATASVIR 3
QL
PA
S
MS
SOVALDI 3
QL
PA
S
MS
TECHNIVIE 3
QL
PA
ST
S
MS
VIEKIRA PAK 3
QL
PA
ST
S
MS
VIEKIRA XR 3
QL
PA
ST
S
MS
VOSEVI 3
QL
PA
S
MS
PAGE 53 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ZEPATIER 3
QL
PA
ST
S
MS
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
COPEGUS 3
PA
S
MS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLIONUNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)
3
S
MS
moderiba 1
PA
S
MS
PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 3
QL
PA
S
MS
PEGASYS PROCLICK 3
QL
PA
S
MS
PEGINTRON 3
QL
PA
S
MS
PEGINTRON REDIPEN 3
QL
PA
S
MS
REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3
PA
S
MS
PAGE 54 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ribasphere (200 mg capsule, 200 mg tablet) 1
PA
S
MS
RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3
PA
S
MS
RIBASPHERE RIBAPAK 3
PA
S
MS
RIBATAB 3
PA
MS
ribavirin (200 mg capsule, 200 mg tablet) 1
PA
S
MS
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVY 2 S
GENVOYA 2 S
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 MGTABLET)
2
QL
S
ISENTRESS 100 MG POWDER PACKET 2 S
ISENTRESS HD 2
QL
S
STRIBILD 3
QL
S
TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3 S
VITEKTA 150 MG TABLET 3
QL
S
VITEKTA 85 MG TABLET 3 S
PAGE 55 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA 3
QL
ST
S
COMPLERA 3 S
DELSTRIGO 3
QL
S
EDURANT 3 S
efavirenz 1 S
INTELENCE 2 S
nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1 S
NEVIRAPINE 50 MG/5 ML ORAL SUSP 2 S
ODEFSEY 3 S
PIFELTRO 3
QL
S
RESCRIPTOR 2 S
SUSTIVA 3 S
SYMFI 2
QL
S
SYMFI LO 2
QL
S
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3 S
VIRAMUNE XR 3 S
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mg/ml solution 1
abacavir sulfate 300 mg tablet 1 S
abacavir sulfate/lamivudine 1 S
abacavir sulfate/lamivudine/zidovudine 1 S
CIMDUO 2
QL
S
PAGE 56 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
COMBIVIR 3 S
didanosine 1 S
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3 S
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3 S
EPZICOM 3 S
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1 S
lamivudine/zidovudine 1 S
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3 S
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule,40 mg capsule)
1 S
tenofovir disoproxil fumarate 1 S
TRIZIVIR 3 S
TRUVADA 2 S
VIDEX 2 S
VIDEX EC 3 S
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)
3 S
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE)
3 S
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3 S
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1 S
ANTI-HIV AGENTS, OTHER
DESCOVY 2 S
DOVATO 3
JULUCA 3 S
SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)
2 S
SELZENTRY 20 MG/ML ORAL SOLN 2 S
TRIUMEQ 3 S
TYBOST 2
QL
S
PAGE 57 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3 S
atazanavir sulfate 1 S
CRIXIVAN 3 S
EVOTAZ 3
QL
S
INVIRASE 3 S
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MGTABLET)
3 S
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3 S
lopinavir/ritonavir 1 S
NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)
3 S
PREZCOBIX 3 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET,400 MG TABLET, 600 MG TABLET, 800 MG TABLET)
3 S
REYATAZ 3 S
ritonavir 1 S
SYMTUZA 3 QL
VIRACEPT 3 S
ANTI-INFLUENZA AGENTS
FLUMADINE 3
oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)
1 QL
RELENZA 3 QL
rimantadine hcl 1
TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75MG CAPSULE)
3 QL
ANTIHERPETIC AGENTS
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1
acyclovir (5 % cream (g), 5 % oint. (g)) 1 QL
ALFERON N 3
DENAVIR 3 QL
famciclovir (125 mg tablet, 250 mg tablet) 1
PAGE 58 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
famciclovir 500 mg tablet 1 QL
FAMVIR (125 MG TABLET, 250 MG TABLET) 3
FAMVIR 500 MG TABLET 3 QL
SITAVIG 3 PA
trifluridine 1
valacyclovir hcl 1
VALTREX 3
VIROPTIC 3
XERESE 3 PA
ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800MG TABLET)
3
ZOVIRAX (CREAM, OINTMENT) 3 QL
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl 1
meprobamate 1
midazolam hcl 2 mg/ml syrup 1
BENZODIAZEPINES
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)
1
alprazolam intensol 1
ATIVAN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3
chlordiazepoxide hcl 1
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)
1
clorazepate dipotassium 1
diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10mg tablet)
1
KLONOPIN 3
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1
lorazepam intensol 1
oxazepam 1
TRANXENE T-TAB 3
VALIUM 3
XANAX 3
PAGE 59 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
XANAX XR 3
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETRO 3
lithium carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mgtablet er, 450 mg tablet er, 600 mg capsule)
1
lithium citrate 1
LITHOBID 3
BLOOD GLUCOSE REGULATORS
DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:
ANTIDIABETIC AGENTS
acarbose 1
ACTOPLUS MET 3
ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL
ACTOS 3
ADLYXIN 3 QL
ALOGLIPTIN BENZOATE 3
QL
ST
ALOGLIPTIN BENZOATE/METFORMIN HCL 3
QL
ST
ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3
QL
ST
AMARYL 3
AVANDIA 3
BYDUREON 2 QL
BYDUREON BCISE 2 QL
BYDUREON PEN 2 QL
BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL
CHLORPROPAMIDE 3
CYCLOSET 3 QL
DIABETA 3
PAGE 60 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
DUETACT 3 QL
FARXIGA 2
FORTAMET 3 ST
glimepiride 1
glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)
1
glipizide/metformin hcl 1
GLUCOPHAGE 3
GLUCOPHAGE XR 3
GLUCOTROL 3
GLUCOTROL XL 3
GLUCOVANCE 3
GLUMETZA 3 ST
glyburide 1
glyburide,micronized 1
glyburide/metformin hcl 1
GLYNASE 3
GLYSET 3
GLYXAMBI 3 QL
INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)
2
INVOKAMET 50-500 MG TABLET 2 QL
INVOKAMET XR 2
INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL
JANUMET 2 QL
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)
2 QL
JANUVIA 2 QL
JARDIANCE 10 MG TABLET 3 QL
JARDIANCE 25 MG TABLET 3
JENTADUETO 2 QL
JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL
PAGE 61 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
KAZANO 3
QL
ST
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3
QL
ST
metformin er 500mg & 1000mg tab (generic version of glumetza) 1 ST
metformin hcl (500 mg tab er 24, 1000 mg tab er 24) 1 ST
metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)
1
METFORMIN HCL 500 MG/5ML SOLUTION 3
miglitol 1
nateglinide 1
NESINA 3
QL
ST
ONGLYZA 3
QL
ST
OSENI 3
QL
ST
OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL
pioglitazone hcl 1
pioglitazone hcl/glimepiride 1 QL
pioglitazone hcl/metformin hcl 1
PRANDIN 3
PRECOSE 3
QTERN 10 MG-5 MG TABLET 3 QL
QTERN 5 MG-5 MG TABLET 3
repaglinide 1
REPAGLINIDE/METFORMIN 3
RIOMET 3
SEGLUROMET 2 QL
STARLIX 3
STEGLATRO 2 QL
PAGE 62 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
STEGLUJAN 3 QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 3
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)
3 QL
TANZEUM 30 MG PEN INJECT 3 QL
TANZEUM 50 MG PEN INJECT 3
tolazamide 1
tolbutamide 1
TRADJENTA 2 QL
TRULICITY 2 QL
VICTOZA 2-PAK 2 QL
VICTOZA 3-PAK 2 QL
XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)
2 QL
BLOOD GLUCOSE SUPPLIES
Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.
FREESTYLE FREEDOM LITE METER 2
FREESTYLE INSULINX GLUCOSE SYS 2
FREESTYLE INSULINX TEST STRIPS 2 QL
FREESTYLE LITE METER 2
FREESTYLE LITE TEST STRIPS 2 QL
FREESTYLE PREC NEO TEST STRIPS 2 QL
FREESTYLE PRECISION NEO METER 2
FREESTYLE TEST STRIPS 2 QL
ONETOUCH ULTRA BLUE STRIPS 2 QL
ONETOUCH ULTRA2 GLUCOSE SYST 2
ONETOUCH ULTRAMINI METER 2
ONETOUCH VERIO FLEX SYSTEM KIT 2
ONETOUCH VERIO IQ SYSTEM KIT 2
ONETOUCH VERIO METER SYSTEM 2
PAGE 63 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ONETOUCH VERIO SYNC SYST KIT 2
ONETOUCH VERIO TEST STRIP 2 QL
PRECISION XTRA MONITOR 2
PRECISION XTRA TEST STRIPS 2 QL
GLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKIT 2
GLUCAGON EMERGENCY KIT 2 QL
PROGLYCEM 3
INSULINS
ADMELOG 3
ADMELOG SOLOSTAR 3
AFREZZA 3
APIDRA 3
APIDRA SOLOSTAR 3
BASAGLAR KWIKPEN U-100 3
FIASP 3
FIASP FLEXTOUCH 3
HUMALOG 2
HUMALOG JUNIOR KWIKPEN 2
HUMALOG KWIKPEN U-100 2
HUMALOG KWIKPEN U-200 2
HUMALOG MIX 50-50 2
HUMALOG MIX 50-50 KWIKPEN 2
HUMALOG MIX 75-25 2
HUMALOG MIX 75-25 KWIKPEN 2
HUMULIN 70-30 2
HUMULIN 70/30 KWIKPEN 2
HUMULIN N 2
HUMULIN N KWIKPEN 2
HUMULIN R 2
HUMULIN R U-500 2
HUMULIN R U-500 KWIKPEN 2
PAGE 64 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
INSULIN LISPRO (100/ML INSULN PEN, 100/ML VIAL) 2
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70-30 2
NOVOLIN 70-30 FLEXPEN 2
NOVOLIN N 2
NOVOLIN R 2
NOVOLOG 2
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70-30 2
NOVOLOG MIX 70-30 FLEXPEN 2
SOLIQUA 100-33 3 QL
TOUJEO MAX SOLOSTAR 2
TOUJEO SOLOSTAR 2
TRESIBA 2
TRESIBA FLEXTOUCH U-100 2
TRESIBA FLEXTOUCH U-200 2
XULTOPHY 100-3.6 3 QL
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ARIXTRA 3 S
BEVYXXA 3 QL
COUMADIN 2
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL
ELIQUIS 5 MG STARTER PACK 2 QL
enoxaparin sodium 1 S
fondaparinux sodium 1 S
FRAGMIN 3 S
IPRIVASK 3 S
PAGE 65 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
jantoven 1
LOVENOX 3 S
PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 3
QL
ST
PRADAXA 110 MG CAPSULE 3 ST
SAVAYSA 3
QL
ST
warfarin sodium 1
XARELTO (2.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MGTABLET)
2 QL
XARELTO STARTER PACK 2
ZONTIVITY 3
QL
PA
BLOOD FORMATION MODIFIERS
AGRYLIN 3
anagrelide hcl 1
ARANESP 2
S
MS
CABLIVI 11 MG KIT 3
QL
PA
S
DOPTELET ((10 TAB 20 MG TAB, (15 TAB 20 MG TAB) 3
QL
PA
S
MS
EPOGEN 2
S
MS
FULPHILA 3
QL
S
MS
GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML SYRINGE, 300MCG/ML VIAL, 480 MCG/0.8 ML SAFE SYR, 480 MCG/0.8 ML SYRINGE, 480MCG/1.6 ML VIAL)
3
QL
PA
S
MS
PAGE 66 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LEUKINE 3
QL
S
MS
MOZOBIL 3
QL
PA
S
MS
MULPLETA 3
QL
PA
S
MS
NEULASTA 3
QL
S
MS
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYR, 480 MCG/1.6 ML VIAL)
3
QL
PA
S
MS
NIVESTYM (300 MCG/0.5 ML SYRING, 480 MCG/0.8 ML SYRING) 3
PA
S
MS
PROCRIT 2
S
MS
PROMACTA 3
QL
PA
S
MS
RETACRIT 3
S
MS
TAVALISSE 3
QL
PA
S
PAGE 67 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
UDENYCA 3
QL
S
MS
ZARXIO 2
S
MS
HEMOSTASIS AGENTS
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3
aminocaproic acid (250 mg/ml solution, 500 mg tablet, 1000 mg tablet) 1
LYSTEDA 3 QL
MEPHYTON 3
phytonadione (vit k1) 5 mg tablet 1
tranexamic acid 650 mg tablet 1 QL
PLATELET MODIFYING AGENTS
AGGRENOX 3
aspirin/dipyridamole 1
BRILINTA 60 MG TABLET 2
BRILINTA 90 MG TABLET 2 QL
cilostazol 1
clopidogrel bisulfate 300 mg tablet 1
clopidogrel bisulfate 75 mg tablet 1 QL
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1
EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL
PERSANTINE 3
PLAVIX 300 MG TABLET 3
PLAVIX 75 MG TABLET 3 QL
PLETAL 3
prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL
ticlopidine hcl 1
PAGE 68 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CATAPRES 3
CATAPRES-TTS 3 QL
clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)
1 QL
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1
guanfacine hcl (1 mg tablet, 2 mg tablet) 1
methyldopa 1
midodrine hcl 1
NORTHERA 3
QL
PA
S
MS
TENEX 3
ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA 3
DIBENZYLINE 3
doxazosin mesylate 1
MINIPRESS 3
phenoxybenzamine hcl 1
prazosin hcl 1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND 3
AVAPRO 3
BENICAR 3
candesartan cilexetil 1
COZAAR 3
DIOVAN 3
EDARBI 3 ST
eprosartan mesylate 1
irbesartan 1
PAGE 69 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
losartan potassium 1
MICARDIS 3
olmesartan medoxomil 1
telmisartan 1
valsartan 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
ACCUPRIL 3
ACEON 3
ALTACE 3
benazepril hcl 1
captopril 1
enalapril maleate 1
EPANDED SOLUTION 3 PA
fosinopril sodium 1
lisinopril 1
LOTENSIN 3
MAVIK 3
moexipril hcl 1
perindopril erbumine 1
PRINIVIL 3
QBRELIS 3
QL
PA
quinapril hcl 1
ramipril 1
trandolapril 1
VASOTEC 3
ZESTRIL 3
ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1
BETAPACE 3
BETAPACE AF 3
CORDARONE 3
PAGE 70 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
disopyramide phosphate 1
dofetilide 1
flecainide acetate 1
mexiletine hcl 1
MULTAQ 2 QL
NORPACE 3
NORPACE CR 3
pacerone 1
propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mgtablet, 325 mg cap er 12h, 425 mg cap er 12h)
1
quinidine gluconate 324 mg tablet er 1
quinidine sulfate 1
RYTHMOL 3
RYTHMOL SR 3
sorine 1
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1
SOTYLIZE 3 PA
TIKOSYN 3
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl 1
atenolol 1
betaxolol hcl (10 mg tablet, 20 mg tablet) 1
bisoprolol fumarate 1
BYSTOLIC 3
carvedilol 1
carvedilol phosphate 1 QL
COREG 3
COREG CR 3 QL
CORGARD 3
INDERAL LA 3
INDERAL XL 3
INNOPRAN XL 3
KAPSPARGO SPRINKLE 3
PAGE 71 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
LEVATOL 3
LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3
metoprolol succinate 1
metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)
1
nadolol 1
pindolol 1
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mgtablet, 120 mg cap sa 24h, 160 mg cap sa 24h)
1
SECTRAL 3
TENORMIN 3
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
TOPROL XL 3
ZEBETA 3
CALCIUM CHANNEL BLOCKING AGENTS
ADALAT CC 3
afeditab cr 1
amlodipine besylate 1
CALAN 3
CALAN SR 3
CARDIZEM 3
CARDIZEM CD 3
CARDIZEM LA 3
cartia xt 1
dilt-xr 1
PAGE 72 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)
1
felodipine 1
isradipine 1
matzim la 1
nicardipine hcl (20 mg capsule, 30 mg capsule) 1
nifedical xl 1
nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30 mg tablet er, 60mg tab er 24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er)
1
nimodipine 1
nisoldipine 1 QL
NORVASC 3
NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 ML SOLUTION) 3 QL
PROCARDIA 3
PROCARDIA XL 3
SULAR 3 QL
taztia xt 1
TIAZAC 3
verapamil hcl (40 mg tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg cap24hpel, 120 mg tablet, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360mg cap24h pel)
1
VERELAN 3
VERELAN PM 3
CARDIOVASCULAR AGENTS, OTHER
ACCURETIC 3
ALDACTAZIDE 3
aliskiren hemifumarate 1 QL
amiloride hcl/hydrochlorothiazide 1
amlodipine besylate/atorvastatin calcium 1 QL
amlodipine besylate/benazepril hcl 1
amlodipine besylate/olmesartan medoxomil 1 QL
PAGE 73 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
amlodipine besylate/valsartan 1
QL
PA
amlodipine besylate/valsartan/hydrochlorothiazide 1
QL
PA
ATACAND HCT 3
atenolol/chlorthalidone 1
AVALIDE 3
AZOR 3 QL
benazepril hcl/hydrochlorothiazide 1
BENICAR HCT 3
BIDIL 3 QL
bisoprolol fumarate/hydrochlorothiazide 1
BYVALSON 3 QL
CADUET 3 QL
candesartan cilexetil/hydrochlorothiazide 1
captopril/hydrochlorothiazide 1
CORLANOR 3 QL
CORZIDE 3
DEMSER 3
digitek 1
digox 1
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1
DIOVAN HCT 3
DUTOPROL 3 QL
DYAZIDE 3
EDARBYCLOR 3 ST
enalapril maleate/hydrochlorothiazide 1
ENTRESTO 3
QL
ST
EXFORGE 3 QL
EXFORGE HCT 3 QL
PAGE 74 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
fosinopril sodium/hydrochlorothiazide 1
HYZAAR 3
irbesartan/hydrochlorothiazide 1
isoxsuprine hcl 1
LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250MCG TABLET)
2
lisinopril/hydrochlorothiazide 1
LOPRESSOR HCT 3
losartan potassium/hydrochlorothiazide 1
LOTENSIN HCT 3
LOTREL 3
MAXZIDE 3
MAXZIDE-25 MG 3
methyldopa/hydrochlorothiazide 1
METOPROLOL SUCCINATE/HYDROCHLOROTHIAZIDE 3 QL
metoprolol tartrate/hydrochlorothiazide 1
MICARDIS HCT 3
moexipril hcl/hydrochlorothiazide 1
nadolol/bendroflumethiazide 1
olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL
olmesartan medoxomil/hydrochlorothiazide 1
pentoxifylline 1
PRESTALIA (7 MG-5 MG TABLET, 14 MG-10 MG TABLET) 3 QL
PRESTALIA 3.5 MG-2.5 MG TABLET 3
propranolol hcl/hydrochlorothiazide 1
quinapril hcl/hydrochlorothiazide 1
RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL
RESERPINE 3
spironolactone/hydrochlorothiazide 1
TARKA 3 QL
TEKTURNA 3 QL
TEKTURNA HCT 3 QL
PAGE 75 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
telmisartan/amlodipine besylate 1 QL
telmisartan/hydrochlorothiazide 1
TENORETIC 100 3
TENORETIC 50 3
trandolapril/verapamil hcl 1 QL
triamterene/hydrochlorothiazide 1
TRIBENZOR 3 QL
TWYNSTA 3 QL
valsartan/hydrochlorothiazide 1
VASERETIC 3
VECAMYL 3
VYNDAQEL 3
QL
PA
S
MS
ZESTORETIC 3
ZIAC 3
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (125 mg tablet, 250 mg tablet, 500 mg capsule er) 1
DIAMOX SEQUELS 3
KEVEYIS 3
PA
S
DIURETICS, LOOP
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
DEMADEX 3
EDECRIN 3
ethacrynic acid 1
furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,80 mg tablet)
1
LASIX 3
torsemide 1
PAGE 76 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
DIURETICS, POTASSIUM-SPARING
ALDACTONE 3
amiloride hcl 1
CAROSPIR 3 QL
DYRENIUM 3
eplerenone 1
INSPRA 3
spironolactone 1
DIURETICS, THIAZIDE
chlorothiazide 1
chlorthalidone 1
DIURIL 3
hydrochlorothiazide 1
indapamide 1
methyclothiazide 1
metolazone 1
MICROZIDE 3
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
ANTARA 3
fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL
fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1
fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL
FENOFIBRATE NANOCRYSTALLIZED 160 MG TABLET 3 QL
fenofibrate,micronized 1
fenofibric acid 1
fenofibric acid (choline) 1 QL
FENOGLIDE 3 QL
FIBRICOR 3
gemfibrozil 1
LIPOCHOL PLUS 3
LIPOFEN 3
PAGE 77 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 200 MG CAPSULE) 3
LOFIBRA 160 MG TABLET 3 QL
LOFIBRA 54 MG TABLET 3
LOPID 3
TRICOR (48 MG TABLET, 145 MG TABLET) 3 QL
TRIGLIDE 3 QL
TRILIPIX 3 QL
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ALTOPREV 3 QL
atorvastatin calcium 1
CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL
EZALLOR SPRINKLE 3
FLOLIPID 3
fluvastatin sodium (20 mg capsule, 40 mg capsule, 80 mg tab er 24h) 1 QL
LESCOL 3 QL
LESCOL XL 3 QL
LIPITOR 3
LIVALO 3
QL
ST
lovastatin (10 mg tablet, 20 mg tablet) 1
lovastatin 40 mg tablet 1 QL
PRAVACHOL 3
pravastatin sodium 1
rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL
ZOCOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET, 80MG TABLET)
3 QL
ZYPITAMAG 3 ST
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1
PAGE 78 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)
1
colesevelam hcl 1
COLESTID (1 GM TABLET, FLAVORED GRANULES, GRANULES,GRANULES PACKET)
3
colestipol hcl 1
ezetimibe 1
ezetimibe/simvastatin 1
JUXTAPID 3
QL
PA
S
KYNAMRO 3
PA
S
LOVAZA 3 QL
niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL
NIACOR 3
NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL
omega-3 acid ethyl esters 1 QL
PRALUENT 2
QL
PA
prevalite (packet, powder) 1
QUESTRAN (PACKET, POWDER) 3
QUESTRAN LIGHT 3
REPATHA 2
QL
PA
VASCEPA 0.5 GM CAPSULE 3
VASCEPA 1 GM CAPSULE 3 QL
VYTORIN 3
WELCHOL 3
ZETIA 3
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
minoxidil (2.5 mg tablet, 10 mg tablet) 1
PAGE 79 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
DILATRATE-SR 3
GONITRO 3 PA
ISORDIL 3
ISORDIL TITRADOSE 3
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40mg tablet er)
1
isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1
isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)
1
minitran 1
NITRO-BID 3
NITRO-DUR 3
nitro-time 1
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)
1
nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1
nitroglycerin 400mcg/spr spray 1
QL
PA
NITROLINGUAL 3 QL
NITROMIST 3
QL
PA
NITROSTAT 3
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADDERALL 3
ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE)
3 QL
ADZENYS ER 3
QL
PA
ADZENYS XR-ODT 3
QL
PA
amphetamine sulfate 1
DESOXYN 3 PA
DEXEDRINE (SPANSULE 5 MG, SPANSULE 10 MG, SPANSULE 15 MG) 3
PAGE 80 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
dexedrine 10 mg tablet 1
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h)
1 QL
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)
1
dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)
1
DYANAVEL XR 3
QL
PA
EVEKEO 3
EVEKEO ODT 3 QL
methamphetamine hcl 1 PA
MYDAYIS 3
QL
PA
PROCENTRA 3
VYVANSE 2 QL
ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 30 MG TABLET)
3
zenzedi (5 mg tablet, 10 mg tablet) 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
ADHANSIA XR (25 MG CAPSULE, 35 MG CAPSULE, 45 MG CAPSULE, 55MG CAPSULE, 70 MG CAPSULE, 85 MG CAPSULE)
3
QL
PA
APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)
3
QL
PA
atomoxetine hcl 1
clonidine hcl 0.1 mg tab er 12h 1 QL
CONCERTA 3 QL
COTEMPLA XR-ODT 3
QL
PA
PAGE 81 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
DAYTRANA 3
QL
PA
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)
1 QL
FOCALIN 3
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MGCAPSULE)
3 QL
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er24h)
1 QL
INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3 MG TABLET, ER 4 MGTABLET)
3 QL
JORNAY PM (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE, 100 MG CAPSULE)
3
QL
PA
KAPVAY 3 QL
METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)
3 QL
metadate er 1
METHYLIN (2.5 MG CHEWABLE TAB, 5 MG CHEWABLE TABLET, 5 MG/5ML SOLUTION, 10 MG CHEWABLE TABLET, 10 MG/5 ML SOLUTION)
3
methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70,20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 40 mg cpbp 30-70,40 mg cpbp 50-50)
1 QL
methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)
1 QL
methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)
1
METHYLPHENIDATE HCL 72 MG TAB ER 24 3 QL
QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)
3
QL
PA
QUILLIVANT XR 3
QL
PA
RELEXXII 3 QL
RITALIN 3
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE)
3 QL
STRATTERA 3
CENTRAL NERVOUS SYSTEM, OTHER
ADIPEX-P 3
PAGE 82 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ALLZITAL 3
AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3
QL
PA
S
MS
BELVIQ 3
QL
PA
BELVIQ XR 3
QL
PA
benzphetamine hcl 1
BONTRIL PDM 3
BUPAP 3 QL
butalbital/acetaminophen (butalbital/acetaminophen capsule,butalbital/acetaminophen tablet)
1 QL
butalbital/acetaminophen 50mg-325mg tablet 1
butalbital/acetaminophen/caffeine 1
CONTRAVE 3
QL
PA
diethylpropion hcl (25 mg tablet, 75 mg tablet er) 1
ESGIC 50-325-40 MG TABLET 3
esgic capsule 1
FIORICET 3
HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
INGREZZA 3
QL
PA
S
INGREZZA INITIATION PACK 3
QL
PA
S
LOMAIRA 3
marten-tab 1
NUEDEXTA 3
QL
PA
PAGE 83 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
phendimetrazine tartrate (35 mg tablet, 105 mg capsule er) 1
phentermine hcl 1
QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)
3
QL
PA
REGIMEX 3
RILUTEK 3
riluzole 1
SUPRENZA ODT 3
QL
PA
TEGSEDI 3
QL
PA
S
MS
TENCON 3
tetrabenazine (12.5 mg tablet, 25 mg tablet) 1
QL
PA
S
MS
TIGLUTIK 3 QL
VANATOL LQ 3
XENAZINE (12.5 MG TABLET, 25 MG TABLET) 3
QL
S
MS
zebutal 1
FIBROMYALGIA AGENTS
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60 MG CAPSULE) 3 QL
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL
duloxetine hcl 40 mg capsule dr 1
IRENKA 3
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)
2
LYRICA 20 MG/ML ORAL SOLUTION 2 QL
PAGE 84 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)
3
QL
PA
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET, TITRATION PACK)
3
QL
ST
MULTIPLE SCLEROSIS AGENTS
AMPYRA 3
QL
S
MS
AUBAGIO 3
QL
ST
S
MS
AVONEX 2
QL
S
MS
BETASERON 3
QL
ST
S
MS
COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2
QL
S
MS
dalfampridine 1
QL
S
MS
EXTAVIA 3
PA
S
MS
FIRDAPSE 3
QL
PA
S
GILENYA 0.5 MG CAPSULE 2
QL
S
MS
PAGE 85 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
glatiramer acetate (20 mg/ml syringe, 40 mg/ml syringe) 1
QL
S
MS
glatopa 20 mg/ml syringe 1
QL
ST
S
MS
glatopa 40 mg/ml syringe 1
QL
S
MS
MAVENCLAD 3
QL
PA
S
MS
MAYZENT (0.25 MG TABLET, 2 MG TABLET) 3
QL
PA
S
MS
PLEGRIDY 2
QL
S
MS
PLEGRIDY PEN 2
QL
S
MS
REBIF 2
QL
S
MS
TECFIDERA 2
QL
S
MS
ZINBRYTA 3
QL
ST
S
PAGE 86 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
DENTAL AND ORAL AGENTS
cevimeline hcl 1
chlorhexidine gluconate 0.12 % mouthwash 1
EVOXAC 3
oralone 1
paroex 1
PERIDEX 3
periogard 1
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1
SALAGEN 3
triamcinolone acetonide 0.1 % paste (g) 1
DERMATOLOGICAL AGENTS
8-MOP 3
ABSORICA 3 PA
ACANYA 3
QL
PA
acitretin 1 QL
ACZONE 3
QL
ST
adapalene (0.1 % cream (g), 0.1 % gel (gram), 0.3 % gel (gram), 0.3 % gelw/pump)
1
adapalene (0.1 % med. swab, 0.1 % solution) 1
QL
ST
ADAPALENE 0.1 % LOTION 3 ST
adapalene/benzoyl peroxide 1 QL
ALDARA 3
ALEVICYN PLUS 3
ALTRENO 3 QL
AMELUZ 3
ammonium lactate 1
amnesteem 1
ANA-LEX 3
PAGE 87 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE,2.5%-1% LOTION)
3
ATRALIN 3
ATRAPRO DERMAL SPRAY 3
avar cleanser 1
AVAR-E 3
AVAR-E GREEN 3
avita 1
azelaic acid 1
AZELEX 3
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 QL
benzepro 6% foaming cloths 1 QL
benzepro 7% creamy wash 1
benzoyl peroxide 7 % cleanser 1
benzoyl peroxide microspheres 1
bpo (4% gel, 8% gel) 1
bpo 6% foaming cloths 1 QL
calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1
calcipotriene/betamethasone dipropionate 1
calcitrene 1
CALCITRIOL 3 MCG/G OINT. (G) 3
CAPSFENAC PAK 3
QL
PA
CARAC 3 PA
claravis 1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1
QL
PA
clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram),phos/benzoyl 1 % gel w/pump)
1 QL
clindamycin phosphate/tretinoin 1 PA
clotrimazole/betamethasone dipropionate (clotrimazole/betamethasone 1 %cream (g), clotrimazole/betamethasone 1 % lotion)
1
CONDYLOX (GEL, TOPICAL SOLN) 3
CORTISPORIN (CREAM, OINTMENT) 3
PAGE 88 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
COSENTYX 2
QL
PA
ST
S
MS
dapsone 5 % gel (gram) 1 QL
DERMACINRX CLORHEXACIN 3
QL
PA
DERMACINRX LEXITRAL 3
QL
PA
DERMACINRX SURGICAL PHARMAPAK 3
QL
PA
DERMACINRX THERAZOLE PAK 3
QL
PA
DICLO GEL 3
QL
PA
DICLO GEL-XRYLIX SHEET 3
QL
PA
diclofenac sodium 1 % gel (gram) 1 QL
diclofenac sodium 3 % gel (gram) 1 PA
DICLOFEX DC 3
QL
PA
DICLOZOR 3
QL
PA
DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL PUMP) 3
DIFFERIN 0.1% LOTION 3 ST
DOVONEX 3
DOXEPIN HCL 5 % CREAM (G) 3
DRITHOCREME HP 3
DRYSOL 3
DUAC 3
PAGE 89 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
DUOBRII 3
QL
PA
DUPIXENT 200 MG/1.14 ML SYRING 3
QL
PA
S
MS
ELIDEL 3 QL
ENSTILAR 3
QL
PA
EPIDUO 3 QL
EPIDUO FORTE 3 QL
EPIFOAM 3
EUCRISA 3
QL
ST
FABIOR 3
QL
PA
FINACEA 3
FLUOROPLEX 3
FLUOROURACIL 0.5% CREAM 3 PA
GORDON'S UREA 3
hydrocortisone acetate/iodoquinol/aloe vera 1
hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)
1
hydrocortisone acetate/pramoxine hcl 1
hydroquinone microspheres 1
IMIQUIMOD 3.75 % CRM MD PMP 3
imiquimod 5 % cream pack 1
LEVULAN 3
LEXIXRYL 3
QL
PA
PAGE 90 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)
1
LOTRISONE 3
methoxsalen 10 mg cap lq rap 1
METROCREAM 3
METROGEL 3
METROLOTION 3
metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)
1
MICORT HC 2.5% CREAM 3
MICROCYN 3
MICROCYN HYDROGEL 3
myorisan 1
NATROBA 3
NEO-SYNALAR 0.5%-0.025% CREAM 3
neuac gel 1
NORITATE 3 ST
NOVACORT 3
NUDICLO SOLUPAK 3
QL
PA
NUOX 3
ONEXTON GEL PUMP 3
QL
PA
OVACE 3
OVACE PLUS (9.8% FOAM, 10% CREAM, 10% SHAMPOO, 10% WASH) 3
OVACE PLUS WASH 3
OXSORALEN-ULTRA 3
PACNEX 3
PACNEX HP 3
PACNEX LP 3
PICATO (0.015% GEL, 0.05% GEL) 2 QL
pimecrolimus 1 QL
PAGE 91 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
PLEXION (CLNSING CLOTH, CREAM, LOTION) 3
PLIXDA 3
QL
ST
podofilox 1
PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1%CREAM, 2.5%-1% LOTION, 2.5%-1% OINTMENT)
3
PRAMOSONE E 3
PROCORT 3
PROCTOFOAM-HC 3
PROTOPIC 3 QL
PRUDOXIN 3
QBREXZA 3 QL
RECTIV 3 QL
REGRANEX 3 QL
RETIN-A 3
RETIN-A MICRO 3
RETIN-A MICRO PUMP 3
ROSADAN (CREAM KIT, GEL KIT) 3
QL
PA
rosadan (cream, gel) 1
ROSANIL 3
ROSULA 10%-5% CLOTHS 3
SANTYL 3
seb-prev 1
selenium sulfide 1
SELRX 3
SILIQ 3
QL
PA
ST
S
MS
silver nitrate/potassium nitrate 1
PAGE 92 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SKYRIZI 2
QL
PA
S
MS
SOLARAZE 3 PA
SOOLANTRA 3
QL
ST
SORIATANE 3 QL
SORILUX 3
QL
PA
SPINOSAD 3
sss 10-5 cream 1
STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2
QL
PA
S
MS
STELARA 45 MG/0.5 ML VIAL 2
PA
S
MS
sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1
sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)
1
TACLONEX 0.005%-0.064% SUSPENS 3
QL
PA
TACLONEX OINTMENT 3
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL
TALTZ 3
QL
PA
ST
S
MS
tazarotene 1
PAGE 93 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
TAZORAC 3
TOLAK 2
TREMFYA 2
QL
PA
S
MS
TRETIN-X (0.025% CREAM COMB PCK, 0.05% COMBO PACK, 0.1%COMBO PACK)
3
TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3
QL
PA
tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.05 % gel (gram), 0.1 % cream (g))
1
tretinoin microspheres 1
tretinoin/emollient base 1 PA
tri-chlor 1
ULESFIA 3
VECTICAL 3
VELTIN 3 PA
VEREGEN 3
VOLTAREN 3 QL
VYTONE 3
XELITRAL 3
QL
PA
XEPI 3 QL
XRYLIX 3
QL
PA
zenatane 1
ZEYOCAINE 3
QL
PA
ZIANA 3 PA
ZONALON 3
ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75% CREAM PUMP) 3
ZYPRAM 3
PAGE 94 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
CARBAGLU 3
PA
S
MS
CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3
CARNITOR SF 3
clinpro 5000 1
cytra-k crystals packet 1
denta 5000 plus 1
dentagel 1
EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3
effer-k 25 meq tablet eff 1
ENDARI 3
QL
PA
ICAR-C PLUS 3
k effervescent 1
K-TAB ER 3
klor-con 10 1
klor-con 20 meq packet 1
KLOR-CON 25 MEQ PACKET 3
klor-con 8 1
klor-con m10 1
klor-con m15 1
klor-con m20 1
klor-con sprinkle 1
klor-con-ef 1
levocarnitine (with sugar) 1
levocarnitine 330 mg tablet 1
NESTABS ONE 3
NUTRESTORE 3 PA
ORACIT 3
PAGE 95 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
potassium bicarbonate/citric acid 1
potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meqtablet er, 20meq/15ml liquid, 40meq/15ml liquid)
1
potassium chloride/potassium bicarbonate/citric acid 1
potassium citrate 1
potassium citrate/citric acid 3300-1002 packet 1
prevident (0.2%, dental) 1
PREVIDENT (1.1% GEL, 5000 BOOSTER PLUS) 3
PREVIDENT 5000 3
PREVIDENT 5000 ENAMEL PROTECT 3
PREVIDENT 5000 PLUS 3
PREVIDENT 5000 SENSITIVE 3
sf 1
sf 5000 plus 1
tl g-fol os 1
UROCIT-K 3
ELECTROLYTE/MINERAL/METAL MODIFIERS
CHEMET 3
CUPRIMINE 3
QL
PA
deferasirox 1
S
MS
EXJADE 3
S
MS
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3 S
GALZIN 3
JADENU 3
S
MS
JYNARQUE (15 MG TABLET, 30 MG TABLET, 45 MG-15 MG TABLET, 60MG-30 MG TABLET, 90 MG-30 MG TABLET)
3
QL
PA
S
KAYEXALATE 3
PAGE 96 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
kionex (15 gm/60 ml suspension, powder) 1
penicillamine 1
QL
PA
RADIOGARDASE 3
SAMSCA 3
QL
S
MS
sodium polystyrene sulfonate 1
sps 1
SYPRINE 3 PA
trientine hcl 1 PA
DEPEN 2
PHOSPHATE BINDERS
AURYXIA 3 QL
calcium acetate 1
eliphos 1
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MGTABLET CHEW)
3 QL
FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3
lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL
PHOSLO 3
PHOSLYRA 3
RENAGEL 3
RENVELA 3
sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1
sevelamer carbonate 0.8 g powd pack 1 QL
sevelamer hcl 1
VELPHORO 3 QL
VELTASSA 3 ST
VITAMINS
BRAND RX PRENATAL VITAMINS ARE T3 AND GENERIC RX PRENATALVITAMINS ARE T1
3
cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1
PAGE 97 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.
3 PA
folic acid 1 mg tablet 1
NASCOBAL 3
OB COMPLETE PETITE 3
POTABA 3
XURIDEN 3
QL
PA
S
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ANASPAZ 3
BENTYL (10 MG CAPSULE, 20 MG TABLET) 3
chlordiazepoxide/clidinium bromide 1
CUVPOSA 3
QL
PA
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1
ed-spaz 1
GLYCATE 3
QL
PA
glycopyrrolate (1 mg tablet, 2 mg tablet) 1
glycopyrrolate 1.5 mg tablet 1
QL
PA
hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet,0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir)
1
hyosyne 1
LEVBID 3
LEVSIN 0.125 MG TABLET 3
LEVSIN-SL 3
LIBRAX 3
methscopolamine bromide 1
nulev 1
oscimin 1
oscimin sl 1
PAGE 98 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
oscimin sr 1
propantheline bromide 1
ROBINUL 1 MG TABLET 3
ROBINUL FORTE 3
symax 1
SYMAX DUOTAB 3
symax-sl 1
symax-sr 1
GASTROINTESTINAL AGENTS, OTHER
ACTIGALL 3
CHENODAL 3 S
cromolyn sodium 20 mg/ml oral conc 1
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)
1
ENTEREG 3
FULYZAQ 3
QL
PA
GASTROCROM 3
GATTEX 3
QL
PA
S
MS
lansoprazole/amoxicillin trihydrate/clarithromycin 1
LOMOTIL 3
loperamide hcl 2 mg capsule 1
MOTOFEN 3
MOVANTIK 2 QL
MYALEPT 3
PA
S
MS
MYTESI 3
QL
PA
OMECLAMOX-PAK 3
QL
PA
PAGE 99 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
opium tincture 1
paregoric 1
PREVPAC 3
PYLERA 3
RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL, 150 MG TABLET)
3
SYMPROIC 3
QL
ST
URSO 3
URSO FORTE 3
ursodiol 1
XENICAL 3 PA
XIFAXAN 200 MG TABLET 3
XIFAXAN 550 MG TABLET 3 QL
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine 1
cimetidine hcl 1
famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1
nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) 1
PEPCID (40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg capsule,300 mg tablet)
1
ZANTAC 300 MG TABLET 3
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl 1 QL
AMITIZA 3
QL
ST
LINZESS 2 QL
LOTRONEX 3 QL
TRULANCE 3
QL
ST
VIBERZI 3
PAGE 100 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LAXATIVES
CLENPIQ 3
COLYTE WITH FLAVOR PACKETS 3
constulose 1
enulose 1
gavilyte-c 1
gavilyte-g 1
gavilyte-n 1
generlac 1
GIALAX 3
GOLYTELY (PACKET, SOLUTION) 3
KRISTALOSE 3 PA
lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1
lactulose 10 g packet 1
QL
PA
MOVIPREP 3 QL
NULYTELY WITH FLAVOR PACKS 3
OSMOPREP 3
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride (peg3350/sodsulf,bicarb,cl/kcl 236-22.74g soln recon, peg3350/sod sulf,bicarb,cl/kcl 240-22.72g soln recon)
1
peg-prep 1
PLENVU 3
PREPOPIK 2
sodium chloride/sodium bicarbonate/potassium chloride/peg 1
SUPREP 2
trilyte with flavor packets 1
PROTECTANTS
CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3
CYTOTEC 3
misoprostol 1
sucralfate 1
PAGE 101 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
PROTON PUMP INHIBITORS
ACIPHEX 3 QL
ACIPHEX SPRINKLE 3
QL
PA
DEXILANT 3
QL
ST
ESOMEP-EZS 3
QL
PA
esomeprazole magnesium 1 QL
ESOMEPRAZOLE STRONTIUM 3 PA
lansoprazole (15 mg capsule dr, 15 mg tab rap dr, 30 mg capsule dr, 30 mg tabrap dr)
1 QL
NEXIUM 3
QL
ST
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) 1 QL
omeprazole/sodium bicarbonate 1
QL
ST
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 QL
PREVACID (15 MG SOLUTAB, 30 MG SOLUTAB, DR 30 MG CAPSULE) 3 QL
PRILOSEC 3 QL
PROTONIX 3 QL
rabeprazole sodium 20 mg tablet dr 1 QL
ZEGERID (20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) 3
QL
ST
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
BUPHENYL (500 MG TABLET, POWDER) 3
CERDELGA 3
PA
S
MS
CHOLBAM 3
PA
S
PAGE 102 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
CREON 2
CYSTADANE 3 S
CYSTAGON 2 S
GALAFOLD 3
QL
PA
S
MS
KUVAN 3
PA
S
MS
miglustat 1
QL
PA
S
MS
NITYR 3
PA
S
OCALIVA 3
QL
PA
S
MS
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG CAPSULE, 10MG CAPSULE, 20 MG CAPSULE)
3
PA
S
PALYNZIQ 3
PA
S
MS
PANCREAZE 3
pancrelipase 5,000 1
PERTZYE 3
PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3
QL
PA
S
MS
PAGE 103 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RAVICTI 3
QL
PA
S
MS
sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1
STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)
3
QL
PA
S
SUCRAID 3
PA
S
ULTRESA 3
VIOKACE 3
ZAVESCA 3
QL
PA
S
MS
ZENPEP 2
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
darifenacin hydrobromide 1 QL
DETROL 3 QL
DETROL LA 3 QL
DITROPAN XL 3
ENABLEX 3 QL
flavoxate hcl 1
GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)
3
QL
ST
MYRBETRIQ 2 QL
oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)
1
OXYTROL 3 ST
solifenacin succinate 1 QL
PAGE 104 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL
TOVIAZ 2 QL
trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL
VESICARE 2 QL
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 1 QL
AVODART 3 QL
CARDURA XL 3
CIALIS (2.5 MG TABLET, 5 MG TABLET) 3 QL
dutasteride 1 QL
dutasteride/tamsulosin hcl 1 QL
finasteride 5 mg tablet 1
FLOMAX 3 QL
JALYN 3 QL
PROSCAR 3
RAPAFLO 3 QL
silodosin 1 QL
tadalafil (2.5 mg tablet, 5 mg tablet) 1 QL
tamsulosin hcl 1 QL
UROXATRAL 3 QL
GENITOURINARY AGENTS, OTHER
ADDYI 3 PA
bethanechol chloride 1
CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT,40 MCG VIAL)
3 QL
CIALIS (10 MG TABLET, 20 MG TABLET) 3 QL
conceptrol 0 C Covered in full
EDEX 3 QL
ELMIRON 3
PAGE 105 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
FEM PH 3
gynol ii 0 C Covered in full
K-PHOS NO.2 3
K-PHOS ORIGINAL 3
LEVITRA 3 QL
LITHOSTAT 3
MUSE 3 QL
phenazopyridine hcl 1
PYRIDIUM 3
RELAGARD 3
RIMSO-50 3
sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL
STAXYN 3 QL
STENDRA 3 QL
tadalafil 10 mg tablet 1 QL
tadalafil 20 mg tablet (generic version of Adcirca) 1
QL
PA
S
MS
THIOLA 3
QL
S
THIOLA EC (EC 100 MG TABLET, EC 300 MG TABLET) 3
QL
S
today contraceptive sponge 0 C Covered in full
URECHOLINE 3
UROQID-ACID NO.2 3
vardenafil hcl 1 QL
vcf (film, foam, gel) 0 C Covered in full
VIAGRA 3 QL
PAGE 106 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
ACTHAR 3
QL
PA
S
MS
ala-cort 1
ALA-SCALP 3
alclometasone dipropionate 1
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1
anucort-hc 1
ANUSOL-HC 25 MG SUPPOSITORY 3
APEXICON E 3
BESER KIT 3
QL
PA
betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))
1
betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05% cream (g), betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))
1
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 %foam)
1
BRYHALI 3
QL
ST
CAPEX SHAMPOO 3
clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05% lotion, 0.05 % oint. (g), 0.05 % shampoo, 0.05 % solution, 0.05 % spray)
1
clobetasol propionate/emollient base 1
CLOBEX 3
CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST
CLODAN 0.05% KIT 3
QL
PA
clodan 0.05% shampoo 1
CLODERM 3 ST
CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION, 0.05%OINTMENT)
3 ST
CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL
cormax 1
PAGE 107 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
CORTEF 3
cortisone acetate 1
CUTIVATE (CREAM, LOTION) 3
decadron 0.5 mg/5 ml elixir 1
deltasone 1
DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3
DERMACINRX CINLONE-I CPI 3
QL
PA
DERMACINRX SILAPAK 3
QL
PA
DERMACINRX SILAZONE 3
QL
PA
DERMATOP 3
DERMAZONE 3
QL
PA
DESONATE 3 ST
desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
DESOWEN (CREAM, LOTION) 3
desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 %cream (g), 0.25 % oint. (g), 0.25 % spray)
1
dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1
QL
PA
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mgtablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)
1
DEXAMETHASONE INTENSOL 3
DIFLORASONE DIACETATE 3
DIPROLENE (LOTION, OINTMENT) 3
DIPROLENE AF 3
DXEVO 3
QL
PA
ELLZIA PAK 3
QL
PA
ELOCON (CREAM, LOTION, OINTMENT) 3
PAGE 108 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 30MG TABLET, 36 MG TABLET)
3
QL
PA
S
MS
fludrocortisone acetate 1
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 %cream (g), 0.025 % oint. (g))
1
fluocinolone acetonide/shower cap 1
fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 %solution, 0.1 % cream (g))
1
fluocinonide/emollient base 1
flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1
halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 1
HALOBETASOL PROPIONATE 0.05 % FOAM 3
QL
ST
HALOG 3 ST
hemmorex-hc 1
hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g),2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mgtablet)
1
hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1
hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
hydrocortisone butyrate 0.1 % lotion 1 ST
hydrocortisone butyrate/emoll 0.1 % cream (g) 1
hydrocortisone valerate 1
hydrocortisone/mineral oil/petrolatum,white 1
IMPOYZ 3 ST
KENALOG 3
QL
ST
KORLYM 3
QL
PA
S
LEXETTE 3
QL
ST
PAGE 109 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 ST
LOCOID LIPOCREAM 3 ST
LUXIQ 3
MEDROL 3
methylprednisolone 1
MICORT-HC 2.5% CREAM 3
MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3
MILLIPRED DP 3
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
nolix 0.05% cream 1
NUCORT 3
NUTRIARX 3
QL
PA
OLUX 3
OLUX-E 3
ORAPRED ODT 3
PANDEL 3 ST
PEDIADERM HC 3
QL
PA
PEDIAPRED 3
prednicarbate 1
prednisolone 15 mg/5 ml solution 1
prednisolone sodium phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5ml solution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25mg/5 ml solution, 30 mg tab rapdis)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)
1
prednisone intensol 1
procto-med hc 1
procto-pak 1
PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3
proctosol-hc 1
proctozone-hc 1
PSORCON 3
PAGE 110 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RAYOS 3 PA
SANADERMRX 3
QL
PA
scalacort 1
SERNIVO 3
QL
ST
SILALITE PAK 3
QL
PA
SILAZONE-II 3
QL
PA
SYNALAR (0.01% SOLUTION, 0.025% CREAM, 0.025% OINTMENT) 3
SYNALAR TS 3
QL
PA
TAPERDEX 3
QL
PA
TEMOVATE 3
TEXACORT 3
TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM,0.25% OINTMENT, 0.25% SPRAY)
3
TRI-SILA 3
QL
PA
triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g))
1
triamcinolone acetonide 0.147mg/g aerosol 1 QL
TRIANEX 3
triderm 1
TRIDESILON 3
ULTRAVATE (CREAM, OINTMENT) 3
ULTRAVATE 0.05% LOTION 3
QL
ST
ULTRAVATE X 3
QL
PA
VANOS 3 ST
PAGE 111 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
VERDESO 3 ST
VERIPRED 20 3
WHYTEDERM TRILASIL PAK 3
QL
PA
ZODEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 3
QL
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
BRAVELLE 3
QL
PA
S
MS
chorionic gonadotropin, human 10000 unit vial 1
QL
PA
S
MS
DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3
S
MS
DDAVP 0.01% NASAL SPRAY 3
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet,10/spray spray/pump)
1
desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1
S
MS
desmopressin acetate (non-refrigerated) 1
EGRIFTA (1 MG VIAL, 2 MG VIAL) 3
QL
PA
S
FOLLISTIM AQ 3
QL
PA
ST
S
MS
PAGE 112 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
GENOTROPIN 3
PA
ST
S
MS
GONAL-F 2
QL
PA
S
MS
HUMATROPE 3
PA
ST
S
MS
INCRELEX 3
PA
S
MS
MENOPUR 3
PA
S
MS
NOCDURNA 3 QL
NOCTIVA 3
QL
S
NORDITROPIN FLEXPRO 3
PA
ST
S
MS
novarel 10,000 units vial 1
QL
PA
S
MS
NUTROPIN AQ 3
PA
ST
S
MS
PAGE 113 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2
PA
S
MS
OVIDREL 3
PA
S
MS
pregnyl 1
QL
PA
S
MS
SAIZEN 3
QL
PA
ST
S
MS
SEROSTIM 3
QL
PA
S
MS
STIMATE 3 S
ZOMACTON 3
QL
PA
S
MS
ZORBTIVE 3
QL
PA
S
MS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 3
OXANDRIN 3
oxandrolone 1
PAGE 114 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ANDROGENS
ANDRODERM 2 PA
ANDROGEL 2 PA
ANDROID 3 PA
androxy 1 PA
AXIRON 3 PA
danazol 1
DEPO-TESTOSTERONE 3
FORTESTA 3 PA
methitest 1 PA
methyltestosterone 1 PA
NATESTO 3
QL
PA
STRIANT 3 PA
TESTIM 3 PA
testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel packet, 20.25/1.25 gel mdpmp, 25mg(1%) gel packet, 30mg/1.5ml sol md pmp)
1 PA
testosterone (10 mg (2%) gel md pmp, 12.5/1.25g gel md pmp, 50 mg (1%) gel(gram)
1 PA
TESTOSTERONE (50 MG (1%) GEL PACKET AND 12.5/1.25G PUMP). SOMEMANUFACTURERS ARE T3 AND OTHERS T1
3 PA
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1
testosterone enanthate 200 mg/ml vial 1
TESTRED 3 PA
VOGELXO 3 PA
XYOSTED 3
QL
PA
ESTROGENS
ACTIVELLA 3
aftera 0 C Covered in full
ALORA 3
altavera 0 C Covered in full
PAGE 115 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
alyacen 0 C Covered in full
amabelz 1
amethia 0 C Covered in full
amethia lo 0 C Covered in full
amethyst 0 C Covered in full
ANGELIQ 3
apri 0 C Covered in full
aranelle 0 C Covered in full
ashlyna 0 C Covered in full
aubra 0 C Covered in full
aubra eq 0 C Covered in full
aurovela 1 mg-20 mcg tablet 1
aurovela 24 fe 1
aviane 0 C Covered in full
azurette 0 C Covered in full
balcoltra 0 C Covered in full
balziva 0 C Covered in full
bekyree 0 C Covered in full
BEYAZ 3
BIJUVA 3
blisovi 24 fe 0 C Covered in full
blisovi fe 0 C Covered in full
BREVICON 3
briellyn 0 C Covered in full
camrese 0 C Covered in full
camrese lo 0 C Covered in full
caziant 0 C Covered in full
chateal 0 C Covered in full
PAGE 116 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
chateal eq 0 C Covered in full
CLIMARA 3 QL
CLIMARA PRO 2
COMBIPATCH 3
covaryx 1
covaryx h.s. 1
cryselle 0 C Covered in full
cyclafem 0 C Covered in full
CYCLESSA 3
cyred 0 C Covered in full
dasetta 0 C Covered in full
daysee 0 C Covered in full
DELESTROGEN 3
delyla 0 C Covered in full
DEPO-ESTRADIOL 3
desogestrel-ethinyl estradiol 0 C Covered in full
desogestrel-ethinyl estradiol/ethinyl estradiol 0 C Covered in full
DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75 MG GELPACKET, 1 MG GEL PACKET)
3
drospirenone/ethinyl estradiol/levomefolate calcium 0 C Covered in full
econtra one-step 0 C Covered in full
eemt 1
eemt h.s. 1
ELESTRIN 3
elinest 0 C Covered in full
emoquette 0 C Covered in full
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)
3 QL
enpresse 0 C Covered in full
enskyce 0 C Covered in full
estarylla 0 C Covered in full
PAGE 117 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3
ESTRACE 0.01% CREAM 2
estradiol (.025mg/24h patch tdwk, .0375mg/24 patch tdwk, 0.05mg/24h patchtdwk, 0.06mg/24h patch tdwk, .075mg/24h patch tdwk, 0.1mg/24hr patch tdwk)
1 QL
estradiol (0.01 % cream/appl, .025mg/24h patch tdsw, .0375mg/24 patch tdsw,0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hr patch tdsw, 0.5mg tablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet)
1
estradiol valerate 1
estradiol/norethindrone acetate 1
ESTRING 3
ESTROGEL 3
estrogens,esterified/methyltestosterone 1
estropipate 1
ESTROSTEP FE 3
ethinyl estradiol/drospirenone 0 C Covered in full
ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 0 C Covered in full
ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 0 C Covered in full
EVAMIST 3
falmina 0 C Covered in full
fayosim 0 C Covered in full
FEMHRT 3
FEMRING 3
femynor 0 C Covered in full
fyavolv 1
GENERESS FE 3
gianvi 0 C Covered in full
gildagia 0 C Covered in full
gildess 24 fe 0 C Covered in full
IMVEXXY 3
introvale 0 C Covered in full
isibloom 0 C Covered in full
jevantique lo 1
jinteli 1
PAGE 118 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
jolessa 0 C Covered in full
juleber 0 C Covered in full
junel 0 C Covered in full
junel fe 0 C Covered in full
junel fe 24 0 C Covered in full
kaitlib fe 0 C Covered in full
kariva 0 C Covered in full
kelnor 1-35 0 C Covered in full
kelnor 1-50 0 C Covered in full
kimidess 0 C Covered in full
kurvelo 0 C Covered in full
l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 0 C Covered in full
larin 0 C Covered in full
larin 24 fe 0 C Covered in full
larin fe 0 C Covered in full
larissia 0 C Covered in full
layolis fe 0 C Covered in full
leena 0 C Covered in full
lessina 0 C Covered in full
levonest 0 C Covered in full
levonorgestrel 0 C Covered in full
levonorgestrel-ethinyl estradiol 0 C Covered in full
levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)
0 C Covered in full
levora-28 0 C Covered in full
lillow 0 C Covered in full
lo loestrin fe 0 C Covered in full
LOESTRIN 3
PAGE 119 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
LOESTRIN FE 3
lomedia 24 fe 0 C Covered in full
lopreeza 1
loryna 0 C Covered in full
LOSEASONIQUE 3
low-ogestrel 0 C Covered in full
lutera 0 C Covered in full
marlissa 0 C Covered in full
melodetta 24 fe 0 C Covered in full
MENEST 3
MENOSTAR 3 QL
mibelas 24 fe 0 C Covered in full
microgestin 0 C Covered in full
microgestin 24 fe 0 C Covered in full
microgestin fe 0 C Covered in full
mili 0 C Covered in full
mimvey 1
mimvey lo 1
MINASTRIN 24 FE 3
MINIVELLE 3
MIRCETTE 3
mono-linyah 0 C Covered in full
mononessa 0 C Covered in full
my choice 0 C Covered in full
my way 0 C Covered in full
myzilra 0 C Covered in full
natazia 0 C Covered in full
necon (0.5-35-28 tablet, 1-50-28 tablet, 7-7-7-28 tablet) 0 C Covered in full
new day 0 C Covered in full
PAGE 120 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
nikki 0 C Covered in full
norethindrone ac-eth estradiol 1mg-20mcg tablet 0 C Covered in full
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 1
norethindrone acetate-ethinyl estradiol/ferrous fumarate 0 C Covered in full
norethindrone-ethinyl estradiol/ferrous fumarate 0 C Covered in full
norgestimate-ethinyl estradiol 0 C Covered in full
nortrel 0 C Covered in full
nuvaring 0 C Covered in full
ocella 0 C Covered in full
ogestrel 0 C Covered in full
orsythia 0 C Covered in full
ORTHO TRI-CYCLEN 3
ORTHO TRI-CYCLEN LO 3
ORTHO-CYCLEN 3
ORTHO-NOVUM 3
philith 0 C Covered in full
pimtrea 0 C Covered in full
pirmella 0 C Covered in full
plan b one-step 0 C Covered in full
portia 0 C Covered in full
PREFEST 3
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)
2
PREMPHASE 2
PREMPRO 2
previfem 0 C Covered in full
QUARTETTE 3
quasense 0 C Covered in full
rajani 0 C Covered in full
reclipsen 0 C Covered in full
PAGE 121 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
rivelsa 0 C Covered in full
SAFYRAL 3
SEASONIQUE 3
setlakin 0 C Covered in full
sprintec 0 C Covered in full
sronyx 0 C Covered in full
syeda 0 C Covered in full
take action 0 C Covered in full
tarina 24 fe 1
tarina fe 0 C Covered in full
taytulla 0 C Covered in full
tilia fe 0 C Covered in full
tri femynor 0 C Covered in full
tri-estarylla 0 C Covered in full
tri-legest fe 0 C Covered in full
tri-linyah 0 C Covered in full
tri-lo-estarylla 0 C Covered in full
tri-lo-marzia 0 C Covered in full
tri-lo-sprintec 0 C Covered in full
tri-mili 0 C Covered in full
TRI-NORINYL 3
tri-previfem 0 C Covered in full
tri-sprintec 0 C Covered in full
tri-vylibra 0 C Covered in full
tri-vylibra lo 1
trinessa 0 C Covered in full
trinessa lo 0 C Covered in full
trivora-28 0 C Covered in full
PAGE 122 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
tydemy 0 C Covered in full
VAGIFEM 3
velivet 0 C Covered in full
vestura 0 C Covered in full
vienva 0 C Covered in full
viorele 0 C Covered in full
VIVELLE-DOT 3
vyfemla 0 C Covered in full
vylibra 0 C Covered in full
wera 0 C Covered in full
wymzya fe 0 C Covered in full
xulane 0 C Covered in full
YASMIN 28 3
YAZ 3
yuvafem 1
zarah 0 C Covered in full
zenchent 0 C Covered in full
zenchent fe 0 C Covered in full
zovia 1-35e 0 C Covered in full
zovia 1-50e 0 C Covered in full
PROGESTERONE AGONISTS/ANTAGONISTS
ella 0 C Covered in full
PROGESTINS
AYGESTIN 3
camila 0 C Covered in full
CRINONE 4% GEL 3
CRINONE 8% GEL 3 S
deblitane 0 C Covered in full
depo-subq provera 104 0 C Covered in full
PAGE 123 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
econtra ez 0 C Covered in full
ENDOMETRIN 3
PA
S
errin 0 C Covered in full
fallback solo 0 C Covered in full
heather 0 C Covered in full
incassia 0 C Covered in full
jencycla 0 C Covered in full
jolivette 0 C Covered in full
kyleena 0 C Covered in full as medicalbenefit
liletta 0 C Covered in full as medicalbenefit
lyza 0 C Covered in full
medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 0 C Covered in full
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
MEGACE 3
MEGACE ES 3
megestrol acetate (20 mg tablet, 40 mg tablet) 1
megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1
mirena 0 C Covered in full as medicalbenefit
nexplanon 0 C Covered in full as medicalbenefit
next choice one dose 0 C Covered in full
NOR-Q-D 3
nora-be 0 C Covered in full
norethindrone 0 C Covered in full
norethindrone acetate 1
norlyda 0 C Covered in full
norlyroc 0 C Covered in full
opcicon one-step 0 C Covered in full
PAGE 124 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
option 2 0 C Covered in full
ORTHO MICRONOR 3
progesterone 1
S
MS
progesterone, micronized 1
PROMETRIUM 3
PROVERA 3
sharobel 0 C Covered in full
skyla 0 C Covered in full as medicalbenefit
SLYND 3
tulana 0 C Covered in full
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
clomiphene citrate 1
DUAVEE 2
EVISTA 3
OSPHENA 3 ST
raloxifene hcl 1
serophene 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID 3
CYTOMEL 3
levo-t 1
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet)
1
levoxyl 1
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1
NATURE-THROID 3
np thyroid 1
SYNTHROID 3
THYROLAR-1 3
THYROLAR-1/2 3
THYROLAR-1/4 3
PAGE 125 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
THYROLAR-2 3
THYROLAR-3 3
TIROSINT 3
TIROSINT-SOL 3
unithroid 1
WESTHROID 3
WP THYROID 3
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 1
CETROTIDE 3
PA
S
MS
GANIRELIX ACETATE 3
PA
S
MS
leuprolide acetate 1
PA
S
LUPANETA PACK 3
S
MS
octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)
1
S
MS
ORILISSA (150 MG TABLET, 200 MG TABLET) 3
QL
PA
SANDOSTATIN 3
S
MS
SANDOSTATIN LAR 3
S
MS
SANDOSTATIN LAR DEPOT 3
S
MS
SIGNIFOR 3
PA
S
MS
PAGE 126 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SOMATULINE DEPOT 3
QL
S
MS
SOMAVERT 3
PA
S
MS
SYNAREL 3
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 1
propylthiouracil 1
SSKI 3
TAPAZOLE 3
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
BERINERT 500 UNIT KIT 3
QL
PA
S
MS
CINRYZE 3
QL
PA
S
MS
FIRAZYR 3
QL
PA
S
MS
HAEGARDA 2
QL
PA
S
MS
PAGE 127 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RUCONEST 3
QL
PA
S
MS
TAKHZYRO 2
QL
PA
S
MS
IMMUNE SUPPRESSANTS
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3
QL
PA
S
AZASAN 3
ST
S
azathioprine 1 S
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 3 S
CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) 3
QL
PA
ST
S
MS
cyclosporine (25 mg capsule, 100 mg capsule) 1 S
cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100mg/ml solution)
1 S
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2
QL
PA
S
MS
ENBREL MINI 2
QL
PA
S
MS
PAGE 128 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
ENBREL SURECLICK 2
QL
PA
S
MS
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3
QL
PA
S
gengraf (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) 1 S
HUMIRA 2
QL
PA
S
MS
IMURAN 3 S
KINERET 3
QL
PA
ST
S
methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1
mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1 S
mycophenolate sodium 1 S
MYFORTIC 3 S
NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100MG/ML SOLUTION)
3 S
OLUMIANT 3
QL
PA
S
MS
ORENCIA 3
QL
PA
ST
S
MS
PAGE 129 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OTREXUP 3 PA
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3 S
PROGRAF 0.2 MG GRANULE PACKET 3 ST
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)
3 S
RASUVO 3 PA
RHEUMATREX 3
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLN) 3 S
SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/MLPEN INJECTOR, 100 MG/ML SYRINGE)
3
QL
PA
ST
S
MS
sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2 mg tablet) 1 S
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1 S
TREXALL 3
XATMEP 3 PA
XELJANZ 10 MG TABLET 2
QL
PA
S
MS
XELJANZ 5 MG TABLET 2
PA
S
MS
XELJANZ XR 2
QL
PA
S
MS
ZORTRESS 3 S
PAGE 130 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGE 2
QL
PA
S
MS
ACTEMRA ACTPEN 2
QL
PA
S
MS
ACTIMMUNE 3
PA
S
MS
ARAVA 3
ARCALYST 3
PA
S
MS
BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3
QL
PA
S
MS
DUPIXENT 300 MG/2 ML SYRINGE 3
QL
PA
S
MS
GRASTEK 3 QL
KEVZARA 3
QL
PA
ST
S
MS
leflunomide 1
ORALAIR 3
QL
S
PAGE 131 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OTEZLA 2
QL
PA
S
MS
RAGWITEK 3 QL
RIDAURA 3
VACCINES
XOFLUZA 3 QL
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO 3 QL
ASACOL HD 3
balsalazide disodium 1
CANASA 3
COLAZAL 3
DELZICOL 2
DIPENTUM 3
GIAZO 3
QL
PA
LIALDA 3
mesalamine (1.2 g tablet dr, 4 g/60 ml enema, 400 mg cap(drtab), 1000 mgsupp.rect)
1
mesalamine 800 mg tablet dr 1
mesalamine with cleansing wipes 1
QL
PA
PENTASA 2
ROWASA 4 GM/60 ML ENEMA KIT 3
QL
PA
SFROWASA 3
GLUCOCORTICOIDS
budesonide 3 mg capdr - er 1
budesonide 9 mg tabdr - er 1 QL
PAGE 132 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
colocort 1
CORTENEMA 3
CORTIFOAM 3
ENTOCORT EC 3
hydrocortisone 100mg/60ml enema 1
UCERIS 2 MG RECTAL FOAM 3
QL
PA
UCERIS 9 MG ER TABLET 3 QL
SULFONAMIDES
AZULFIDINE 3
sulfasalazine (500 mg tablet, 500 mg tablet dr) 1
METABOLIC BONE DISEASE AGENTS
ACTONEL (5 MG TABLET, 30 MG TABLET, 35 MG TABLET, 150 MGTABLET)
3 QL
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70mg tablet)
1 QL
alendronate sodium 70 mg/75ml solution 1
ATELVIA 3 QL
BINOSTO 3 QL
BONIVA 150 MG TABLET 3 QL
calcitonin,salmon,synthetic 1
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1
cinacalcet hcl 1
DICLOVIX 3
QL
PA
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1
DRISDOL 3
ergocalciferol (vitamin d2) 50000 unit capsule 1
etidronate disodium 1
FORTEO 3
PA
S
MS
FORTICAL 3
PAGE 133 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
FOSAMAX 3 QL
FOSAMAX PLUS D 3 QL
HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 3
ibandronate sodium 150 mg tablet 1 QL
MIACALCIN 200 UNIT NASAL SPRAY 3
NATPARA 3
QL
PA
S
MS
paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1
RAYALDEE 3
risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)
1 QL
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORALSOLN)
3
SENSIPAR 3
TRIXYLITRAL 3
QL
PA
TYMLOS 2
QL
PA
S
MS
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3
MISCELLANEOUS THERAPEUTIC AGENTS
BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2
cervical cap 0 C Covered in full
CETYLEV 3
COMFORT PAC-MELOXICAM 3
QL
PA
COMFORT PAC-NAPROXEN 3
QL
PA
condoms, female 0 C Covered in full
diaphragms, contoured 0 C Covered in full
PAGE 134 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
diaphragms, wide seal 0 C Covered in full
FLEXIPAK 3
QL
PA
FOAM/GAUZE BANDAGE/LIDOCAINE/CHLORHEXIDINE/ISOPROPYLALCOHOL
3
QL
PA
INBRIJA 3
QL
PA
S
MS
INFLAMMACIN 3
QL
PA
INTRAROSA 3 QL
isometheptene mucate/dichloralphenazone/acetaminophen 1
LOKELMA (5 POWDER PACKET, 10 POWDER PACKET) 2 QL
methergine 1 QL
methylergonovine maleate 0.2 mg tablet 1 QL
nodolor 1
NUDICLO TABPAK 3
QL
PA
NUDROXIPAK DSDR-50 3
QL
PA
NUDROXIPAK DSDR-75 3
QL
PA
NUDROXIPAK E-400 3
QL
PA
NUDROXIPAK I-800 3
QL
PA
NUDROXIPAK N-500 3
QL
PA
ODACTRA 3 QL
paragard t 380-a 0 C Covered in full as medicalbenefit
PAGE 135 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RUZURGI 3
QL
PA
S
SAXENDA 3
QL
PA
SILVER/BANDAGE/FOAM/GAUZE/LIDOCAINE/CHLORHEXIDIN/ISOPROPANOL
3
QL
PA
SYRINGE, INSULIN U-500 WITH NEEDLE, DISPOSABLE, 0.5 ML 3
XENAFLAMM 3
QL
PA
XERMELO 3
QL
PA
MODIFIED SOLID FOODS
All modified solid foods are covered as brands with Prior Authorization
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AKTEN 3
ALCAINE 3
atropine sulfate (1 % drops, 1 % oint. (g)) 1
bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
CEQUA 3 QL
cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1
CYSTARAN 3
PA
S
ISOPTO ATROPINE 3
LACRISERT 3
MAXITROL (DROPS, OINTMENT) 3
MITOSOL 3
NAPHAZOLINE 0.1% 3
neo-polycin 1
PAGE 136 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
neo-polycin hc 1
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1
neomycin sulfate/bacitracin/polymyxin b 1
neomycin sulfate/polymyxin b sulfate/gramicidin d 1
neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))
1
neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1
OXERVATE 3
QL
PA
S
MS
PAREMYD 3
phenylephrine hcl (2.5 % drops, 10 % drops) 1
polycin 1
polymyxin b sulfate/trimethoprim 1
POLYTRIM 3
PRED-G (1% DROPS, S.O.P. OINTMENT) 3
proparacaine hcl 1
RESTASIS 2 QL
RESTASIS MULTIDOSE 2 QL
sulfacetamide sodium/prednisolone sodium phosphate 1
TETRAVISC 3
TETRAVISC FORTE 3
TOBRADEX (DROPS, OINTMENT) 3
TOBRADEX ST 3
tobramycin/dexamethasone 1
tropicamide (0.5 % drops, 1 % drops) 1
XIIDRA 2 QL
ZYLET 3
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL 3
ALOMIDE 3
PAGE 137 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
azelastine hcl 0.05 % drops 1
BEPREVE 3
cromolyn sodium 4 % drops 1
ELESTAT 3
EMADINE 3
epinastine hcl 1
LASTACAFT 3
olopatadine hcl (0.1 % drops, 0.2 % drops) 1
PATADAY 3
PATANOL 3
PAZEO 3
OPHTHALMIC ANTI-INFLAMMATORIES
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ALREX 3
bromfenac sodium 1
BROMSITE 3 QL
dexamethasone sodium phosphate 0.1 % drops 1
diclofenac sodium 0.1 % drops 1
DUREZOL 3
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 3
FML FORTE 3
FML S.O.P. 3
ILEVRO 3
INVELTYS 3
ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1
LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2
loteprednol etabonate 1
PAGE 138 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
MAXIDEX 3
NEVANAC 3
OCUFEN 3
OMNIPRED 3
PRED FORTE 3
PRED MILD 3
prednisolone acetate 1
prednisolone sodium phosphate 1 % drops 1
PROLENSA 3 QL
VEXOL 3
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 2
apraclonidine hcl 1
AZOPT 3
BETAGAN 3
betaxolol hcl 0.5 % drops 1
BETIMOL 3
BETOPTIC S 3
brimonidine tartrate 1
carteolol hcl 1
COMBIGAN 2 QL
COSOPT 3
COSOPT PF 3 QL
dorzolamide hcl 1
dorzolamide hcl/timolol maleate 1
dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL
IOPIDINE (0.5% DROPS, 1% DROPS) 3
ISOPTO CARPINE 3
ISTALOL 3
levobunolol hcl 1
methazolamide 1
metipranolol 1
PAGE 139 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
NEPTAZANE 3
PHOSPHOLINE IODIDE 3
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1
RESCULA 3
RHOPRESSA 3
QL
ST
ROCKLATAN 3
QL
ST
SIMBRINZA 3 QL
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drop daily, 0.5 % drops,0.5 % sol-gel)
1
TIMOPTIC (0.25% DROP, 0.5% DROP) 3
TIMOPTIC (0.25% DROPS, 0.5% DROPS) 3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE (0.25% EYE GEL-SOLN, 0.5% GEL-SOLUTION) 3
TIMOPTIC-XE (0.25% SOLN, 0.5% SOLN) 3
TRUSOPT 3
VYZULTA 3 ST
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2
latanoprost 1 QL
LUMIGAN 2
TRAVATAN Z 2
XALATAN 3 QL
XELPROS 3
QL
ST
ZIOPTAN 3
QL
ST
OTIC AGENTS
acetasol hc 1
acetic acid 2 % solution 1
acetic acid/aluminum acetate 1
PAGE 140 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
CORTISPORIN-TC 3
DERMOTIC 3
fluocinolone acetonide oil 1
hydrocortisone/acetic acid 1
neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)
1
OTOVEL 3 QL
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN 3
QL
ST
ALVESCO (80 MCG INHALER, 160 MCG INHALER) 3
QL
ST
ARMONAIR RESPICLICK 2 QL
ARNUITY ELLIPTA 2 QL
ASMANEX 2 QL
ASMANEX HFA 2 QL
BECONASE AQ 3 QL
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)
1 QL
FLOVENT DISKUS 2 QL
FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)
2 QL
flunisolide 1 QL
fluticasone propionate 50 mcg spray susp 1
mometasone furoate 50 mcg spray/pump 1
NASONEX 3
OMNARIS 3 QL
PULMICORT 3 QL
PAGE 141 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
PULMICORT FLEXHALER (90 MCG, 180 MCG) 3
QL
ST
QNASL 2 QL
QNASL CHILDREN 2 QL
QVAR 2 QL
QVAR REDIHALER 2 QL
RHINOCORT AQUA 3
TICANASE 3
QL
PA
TICASPRAY 3
QL
PA
triamcinolone acetonide 55 mcg spray 1
VERAMYST 3 QL
XHANCE 3 QL
ZETONNA 3 QL
ANTIHISTAMINES
arbinoxa 1
ASTEPRO 3 QL
azelastine hcl 137 mcg spray/pump 1
azelastine hcl 205.5 mcg spray/pump 1 QL
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1
carbinoxamine maleate 6 mg tablet 1
QL
PA
cetirizine hcl 1 mg/ml solution 1
CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET) 3
clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1
cyproheptadine hcl 1
QL
PA
desloratadine 1
diphenhydramine hcl 12.5mg/5ml elixir 1
PAGE 142 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)
1
hydroxyzine pamoate 1
KARBINAL ER 3 QL
levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL
levocetirizine dihydrochloride 5 mg tablet 1
olopatadine hcl 0.6 % spray/pump 1 QL
PATANASE 3 QL
promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1
RYCLORA 3 QL
RYVENT 3
QL
PA
VISTARIL 3
XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET) 3
ANTILEUKOTRIENES
ACCOLATE 3
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)
1 QL
SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG TABLET CHEW,10 MG TABLET)
3 QL
zafirlukast 1
zileuton 1 QL
ZYFLO 3 QL
ZYFLO CR 3 QL
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT 3
ATROVENT HFA 2
INCRUSE ELLIPTA 3 QL
ipratropium bromide 1
LONHALA MAGNAIR REFILL 3
QL
ST
LONHALA MAGNAIR STARTER 3
QL
ST
PAGE 143 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SEEBRI NEOHALER 3
SPIRIVA 2
SPIRIVA RESPIMAT 2
TUDORZA PRESSAIR 3 QL
YUPELRI 3
QL
ST
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENACLICK 3 QL
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)
1
ALBUTEROL SULFATE 90 MCG HFA AER AD (Alternative to Ventolin HFA and Proair HFA only) 2 QL
ARCAPTA NEOHALER 3 QL
AUVI-Q (0.15 MG, 0.3 MG) 3 QLPA
BROVANA 3
epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1
epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1 QL
EPIPEN 2 QL
EPIPEN 2-PAK 2 QL
EPIPEN JR 2-PAK 2 QL
FORADIL 2 QL
levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)
1
levalbuterol tartrate 1
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1
PERFOROMIST 3 QL
PROAIR HFA 2 QL
PROAIR RESPICLICK 2 QL
PROVENTIL HFA 3 QL
SEREVENT DISKUS 2
STRIVERDI RESPIMAT 2 QL
PAGE 144 LAST UPDATED 08/2019
3 QLALBUTEROL SULFATE 90 MCG HFA AER AD (Alternative to Proventil HFA only)
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
SYMJEPI 3 QL
terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1
VENTOLIN HFA 2 QL
VOSPIRE ER 3
XOPENEX 3
XOPENEX CONCENTRATE 3
XOPENEX HFA 3
CYSTIC FIBROSIS AGENTS
BETHKIS 3
QL
S
MS
CAYSTON 3
S
MS
KALYDECO 3
QL
PA
S
MS
KITABIS PAK 3
S
MS
ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)
3
QL
PA
S
MS
PULMOZYME 3
S
MS
SYMDEKO 3
QL
PA
S
MS
TOBI PODHALER 3
QL
S
MS
PAGE 145 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
tobramycin/nebulizer 1
S
MS
MAST CELL STABILIZERS
cromolyn sodium 20 mg/2 ml ampul-neb 1
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine citrate 60 mg/3 ml solution 1
DALIRESP (250 MCG TABLET, 500 MCG TABLET) 3
QL
ST
ELIXOPHYLLIN 3
THEO-24 3
theochron 1
theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)
1
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 3
QL
PA
S
MS
ADEMPAS 3
QL
PA
S
MS
ambrisentan 1
QL
PA
S
MS
bosentan 1
QL
PA
S
MS
LETAIRIS 3
QL
PA
S
MS
PAGE 146 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OPSUMIT 3
QL
PA
S
MS
ORENITRAM ER 3
PA
S
MS
REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3
QL
PA
S
MS
sildenafil citrate (10 mg/ml susp recon, 20 mg tablet) 1
QL
PA
S
MS
TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3
PA
S
MS
TRACLEER 32 MG TABLET FOR SUSP 3
QL
PA
S
MS
TYVASO 3
QL
PA
S
MS
UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400 MCG TABLET,600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
3
QL
PA
S
PULMONARY FIBROSIS AGENTS
ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2
QL
PA
S
MS
PAGE 147 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
OFEV 2
QL
PA
S
MS
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1
ADVAIR DISKUS 2 QL
ADVAIR HFA 2 QL
AIRDUO RESPICLICK 3
QL
ST
ANORO ELLIPTA 2 QL
benzonatate 1
BEVESPI AEROSPHERE 2 QL
BREO ELLIPTA 100-25 MCG INH 2 QL
BREO ELLIPTA 200-25 MCG INH 2
bromfed dm 1
brompheniramine maleate/pseudoephedrine hcl/dextromethorphan 1
centergy dm 1
CLARINEX-D 12 HOUR 3
COMBIVENT RESPIMAT 2 QL
CUROSURF 3
DULERA 3 QL
DYMISTA 3
QL
PA
FLOWTUSS 3 QL
fluticasone propionate/salmeterol xinafoate (propion/salmeterol 100-50 mcg blstw/dev, propion/salmeterol 250-50 mcg blst w/dev, propion/salmeterol 500-50mcg blst w/dev)
1 QL
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE(PROPION/SALMETEROL 55-14 MCG AER POW BA,PROPION/SALMETEROL 113-14 MCG AER POW BA,PROPION/SALMETEROL 232-14 MCG AER POW BA)
2 QL
GUAIFENESIN/HYDROCODONE BITARTRATE 3
QL
PA
PAGE 148 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
HYCOFENIX 3
hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1
hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)
1
hydrocodone polistirex/chlorpheniramine polistirex 1 QL
hydromet 1
ipratropium bromide/albuterol sulfate 1
nebusal 3% vial 1
NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/ML SYRINGE) 3
QL
PA
S
MS
OBREDON 3 QL
phenylephrine hcl/promethazine hcl 1
promethazine hcl/codeine 1
promethazine/dextromethorphan 6.25-15/5 syrup 1
promethazine/phenylephrine hcl/codeine 1
REZIRA 3
ribavirin 6 g vial-neb 1 MS
SEMPREX-D 3
sodium chloride for inhalation 1
STIOLTO RESPIMAT 2 QL
SYMBICORT 2 QL
TESSALON PERLE 3
TICALAST 3
QL
PA
TOBI 3
S
MS
tobramycin in 0.225 % sodium chloride 1 S
TRELEGY ELLIPTA 3
QL
ST
TUSSICAPS 3
PAGE 149 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
tussigon 1
TUSSIONEX 3
QL
ST
TUZISTRA XR 3
TYZINE 3
UTIBRON NEOHALER 2
VIRAZOLE 3
VITUZ 3 QL
wixela inhub 1 QL
ZUTRIPRO 3
SKELETAL MUSCLE RELAXANTS
AMRIX 3
QL
PA
carisoprodol 250 mg tablet 1
QL
PA
carisoprodol 350 mg tablet 1
carisoprodol/aspirin 1
chlorzoxazone (250 mg tablet, 375 mg tablet, 750 mg tablet) 1
QL
PA
chlorzoxazone 500 mg tablet 1 QL
COMFORT PAC-CYCLOBENZAPRINE 3
QL
PA
COMFORT PAC-TIZANIDINE 3
QL
PA
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1
cyclobenzaprine hcl 7.5 mg tablet 1
QL
PA
FEXMID 3
QL
PA
LORZONE 3
QL
PA
PAGE 150 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
metaxall 1 QL
metaxalone 400 mg tablet 1
metaxalone 800 mg tablet 1 QL
methocarbamol (500 mg tablet, 750 mg tablet) 1
NORGESIC FORTE 3
QL
ST
orphenadrine citrate 100 mg tablet er 1
orphengesic forte 1
QL
ST
PARAFON FORTE DSC 3 QL
ROBAXIN 500 MG TABLET 3
ROBAXIN-750 3
SKELAXIN 3 QL
SOMA 250 MG TABLET 3
QL
PA
SOMA 350 MG TABLET 3
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
AMBIEN (5 MG TABLET, 10 MG TABLET) 3 QL
AMBIEN CR 3 QL
DORAL 3
EDLUAR 3
QL
ST
estazolam 1
eszopiclone 1 QL
flurazepam hcl 1
HALCION 3
INTERMEZZO 3
QL
ST
LUNESTA 3 QL
PAGE 151 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
RESTORIL 3
SONATA (5 MG CAPSULE, 10 MG CAPSULE) 3 QL
temazepam 1
triazolam 1
zaleplon (5 mg capsule, 10 mg capsule) 1 QL
zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)
1 QL
ZOLPIMIST 3
QL
ST
SLEEP DISORDERS, OTHER
armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL
BELSOMRA 3
QL
ST
BUTISOL SODIUM 3
HETLIOZ 3
QL
PA
S
MS
modafinil 1 QL
NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 250 MGTABLET)
3 QL
PROVIGIL 3 QL
ROZEREM 3
QL
ST
SECONAL SODIUM 3
SILENOR 3
QL
ST
SUNOSI 3
QL
PA
XYREM 3
QL
PA
S
PAGE 152 LAST UPDATED 08/2019
PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES
Uncategorized
Unclassified
citalopram hydrobromide 20 mg/10ml solution 1
SKYRIZI (2 SYRINGES) KIT 2
QL
PA
S
MS
PAGE 153 LAST UPDATED 08/2019
Index of covered drugs
88-MOP 87
Aabacavir sulfate 56
abacavir sulfate/lamivudine 56
abacavir sulfate/lamivudine/zidovudine 56
ABILIFY 50
ABILIFY DISCMELT 50
ABILIFY MYCITE 50
abiraterone acetate 36
ABSORICA 87
ABSTRAL 9
acamprosate calcium 13
ACANYA 87
acarbose 60
ACCOLATE 143
ACCUPRIL 70
ACCURETIC 73
acebutolol hcl 71
ACEON 70
acetaminophen with codeine phosphate 9
acetaminophen/caff/dihydrocod 325-30-16
tablet 9
acetaminophen/caffeine/dihydrocodeine
bitartrate 9
ACETASOL HC 140
acetazolamide 76
acetic acid 140
acetic acid/aluminum acetate 140
acetylcysteine 148
ACIPHEX 102
ACIPHEX SPRINKLE 102
acitretin 87
ACTEMRA 131
ACTEMRA ACTPEN 131
ACTHAR 107
ACTICLATE 20
ACTIGALL 99
ACTIMMUNE 131
ACTIQ 9
ACTIVELLA 115
ACTONEL 133
ACTOPLUS MET 60
ACTOPLUS MET XR 60
ACTOS 60
ACULAR 138
ACULAR LS 138
ACUVAIL 138
acyclovir 58
ACZONE 87
ADALAT CC 72
adapalene 87
adapalene/benzoyl peroxide 87
ADASUVE 49
ADCIRCA 146
ADDERALL 80
ADDERALL XR 80
ADDYI 105
adefovir dipivoxil 52
ADEMPAS 146
ADHANSIA XR 81
ADIPEX-P 82
ADLYXIN 60
ADMELOG 64
ADMELOG SOLOSTAR 64
ADOXA 20
ADRENACLICK 144
ADVAIR DISKUS 148
ADVAIR HFA 148
ADZENYS ER 80
ADZENYS XR-ODT 80
AEMCOLO 14
AEROSPAN 141
AFEDITAB CR 72
AFINITOR 40
AFREZZA 64
AFTERA 115
AGGRENOX 68
AGRYLIN 66
AIMOVIG AUTOINJECTOR 33
AIMOVIG AUTOINJECTOR (2 PACK) 33
AIRDUO RESPICLICK 148
AJOVY 33
AKTEN 136
AKTIPAK 14
AKYNZEO 29
ALA-CORT 107
ALA-SCALP 107
albendazole 46
ALBENZA 46
albuterol sulfate 144
ALCAINE 136
alclometasone dipropionate 107
ALDACTAZIDE 73
ALDACTONE 77
ALDARA 87
ALECENSA 40
alendronate sodium 133
ALEVICYN PLUS 87
ALFERON N 58
alfuzosin hcl 105
ALINIA 46
aliskiren hemifumarate 73
ALKERAN 35
allopurinol 32
ALLZITAL 83
almotriptan malate 33
ALOCRIL 137
alogliptin benzoate 60
alogliptin benzoate/metformin hcl 60
alogliptin benzoate/pioglitazone hcl 60
ALOMIDE 137
ALORA 115
alosetron hcl 100
ALPHAGAN P 139
alprazolam 59
ALPRAZOLAM INTENSOL 59
ALREX 138
ALTABAX 15
ALTACE 70
ALTAVERA 115
PAGE 154 LAST UPDATED 08/2019
ALTOPREV 78
ALTRENO 87
ALUNBRIG 38
ALVESCO 141
ALYACEN 116
AMABELZ 116
amantadine hcl 47
AMARYL 60
AMBIEN 151
AMBIEN CR 151
ambrisentan 146
amcinonide 107
AMELUZ 87
AMERGE 33
AMETHIA 116
AMETHIA LO 116
AMETHYST 116
AMICAR 68
amiloride hcl 77
amiloride hcl/hydrochlorothiazide 73
aminocaproic acid 68
amiodarone hcl 70
AMITIZA 100
amitriptyline hcl 28
amitriptyline hcl/chlordiazepoxide 25
amlodipine besylate 72
amlodipine besylate/atorvastatin calcium 73
amlodipine besylate/benazepril hcl 73
amlodipine besylate/olmesartan medoxomil 73
amlodipine besylate/valsartan 74
amlodipine
besylate/valsartan/hydrochlorothiazide 74
ammonium lactate 87
AMNESTEEM 87
amoxapine 28
amoxicillin 18
amoxicillin/potassium clavulanate 18
amphetamine sulfate 80
ampicillin trihydrate 18
AMPYRA 85
AMRIX 150
ANA-LEX 87
ANACAINE 12
ANADROL-50 114
ANAFRANIL 28
anagrelide hcl 66
ANALPRAM HC 88
ANAPROX 5
ANAPROX DS 5
ANASPAZ 98
ANASTIA 12
anastrozole 39
ANCOBON 30
ANDRODERM 115
ANDROGEL 115
ANDROID 115
ANDROXY 115
ANGELIQ 116
ANODYNE LPT 12
ANORO ELLIPTA 148
ANTABUSE 13
ANTARA 77
ANUCORT-HC 107
ANUSOL-HC 107
ANZEMET 29
APADAZ 9
APEXICON E 107
APIDRA 64
APIDRA SOLOSTAR 64
APLENZIN 25
APOKYN 48
apraclonidine hcl 139
aprepitant 29
APRI 116
APRISO 132
APRIZIO PAK 12
APTENSIO XR 81
APTIOM 24
APTIVUS 58
ARAKODA 46
ARANELLE 116
ARANESP 66
ARAVA 131
ARBINOXA 142
ARCALYST 131
ARCAPTA NEOHALER 144
ARICEPT 25
ARIKAYCE 14
ARIMIDEX 39
aripiprazole 50
ARIXTRA 65
armodafinil 152
ARMONAIR RESPICLICK 141
ARMOUR THYROID 125
ARNUITY ELLIPTA 141
AROMASIN 39
ARTHROTEC 50 5
ARTHROTEC 75 5
ARYMO ER 7
ASACOL HD 132
ASCOMP WITH CODEINE 9
ASHLYNA 116
ASMANEX 141
ASMANEX HFA 141
aspirin/caffeine/dihydrocodeine bitartrate 9
aspirin/dipyridamole 68
ASTAGRAF XL 128
ASTEPRO 142
ATACAND 69
ATACAND HCT 74
atazanavir sulfate 58
ATELVIA 133
atenolol 71
atenolol/chlorthalidone 74
ATIVAN 59
atomoxetine hcl 81
atorvastatin calcium 78
atovaquone 46
atovaquone/proguanil hcl 47
ATRALIN 88
ATRAPRO DERMAL SPRAY 88
ATRIPLA 56
atropine sulfate 136
PAGE 155 LAST UPDATED 08/2019
ATROVENT 143
ATROVENT HFA 143
AUBAGIO 85
AUBRA 116
AUBRA EQ 116
AUGMENTIN 18
AUGMENTIN ES-600 18
AUGMENTIN XR 18
AUROVELA 116
AUROVELA 24 FE 116
AURYXIA 97
AUSTEDO 83
AUVI-Q 144
AVALIDE 74
AVANDIA 60
AVAPRO 69
AVAR 88
AVAR-E 88
AVAR-E GREEN 88
AVC 20
AVELOX 19
AVELOX ABC PACK 19
AVIANE 116
AVIDOXY 20
AVINZA 7
AVITA 88
AVODART 105
Avonex 85
AXERT 33
AXIRON 115
AYGESTIN 123
AZASAN 128
AZASITE 18
azathioprine 128
azelaic acid 88
azelastine hcl 138,142
AZELEX 88
AZILECT 49
azithromycin 18
AZOPT 139
AZOR 74
AZULFIDINE 133
AZURETTE 116
Bbacitracin 15
bacitracin/polymyxin b sulfate 136
baclofen 51
BACTRIM 20
BACTRIM DS 20
BACTROBAN 15
BACTROBAN NASAL 15
BALCOLTRA 116
balsalazide disodium 132
BALVERSA 38
BALZIVA 116
BANZEL 24
BARACLUDE 52
BASAGLAR KWIKPEN U-100 64
BAXDELA 19
bd pen needles t2. all other manufacturers
t3. 134
BECONASE AQ 141
BEKYREE 116
BELBUCA 7
BELSOMRA 152
BELVIQ 83
BELVIQ XR 83
benazepril hcl 70
benazepril hcl/hydrochlorothiazide 74
BENICAR 69
BENICAR HCT 74
BENLYSTA 131
BENTYL 98
BENZACLIN 88
BENZAMYCIN 15
BENZEPRO 88
benznidazole 46
benzonatate 148
benzoyl peroxide 88
benzoyl peroxide microspheres 88
benzphetamine hcl 83
benztropine mesylate 47
BEPREVE 138
BERINERT 127
BESER KIT 107
BESIVANCE 19
BETAGAN 139
betamethasone dipropionate 107
betamethasone dipropionate/propylene
glycol 107
betamethasone valerate 107
BETAPACE 70
BETAPACE AF 70
BETASERON 85
betaxolol hcl 71,139
bethanechol chloride 105
BETHKIS 145
BETIMOL 139
BETOPTIC S 139
BEVESPI AEROSPHERE 148
BEVYXXA 65
bexarotene 46
BEYAZ 116
BIAXIN 18
bicalutamide 36
BIDIL 74
BIJUVA 116
BIKTARVY 55
BILTRICIDE 46
bimatoprost 0.03 % drops (into the eye for
glaucoma) 140
BINOSTO 133
bisoprolol fumarate 71
bisoprolol fumarate/hydrochlorothiazide 74
BLEPH-10 20
BLEPHAMIDE 136
BLEPHAMIDE S.O.P. 136
BLISOVI 24 FE 116
BLISOVI FE 116
BONIVA 133
BONJESTA 28
BONTRIL PDM 83
PAGE 156 LAST UPDATED 08/2019
bosentan 146
BOSULIF 40
BPO 88
BRAFTOVI 40
BRAND RX PRENATAL VITAMINS ARE T3
AND GENERIC RX PRENATAL VITAMINS
ARE T1 97
BRAVELLE 112
BREO ELLIPTA 148
BREVICON 116
BRIELLYN 116
BRILINTA 68
brimonidine tartrate 139
BRISDELLE 26
BRIVIACT 21
BROMFED DM 148
bromfenac sodium 138
bromocriptine mesylate 48
brompheniramine maleate/pseudoephedrine
hcl/dextromethorphan 148
BROMSITE 138
BROVANA 144
BRYHALI 107
budesonide 132,141
bumetanide 76
BUNAVAIL 14
BUPAP 83
BUPHENYL 102
buprenorphine 7
buprenorphine hcl 14
buprenorphine hcl/naloxone hcl 14
buprenorphine patch 7
BUPROBAN 14
bupropion hcl 14,25,26
buspirone hcl 59
butalbital/acetaminophen 83
butalbital/acetaminophen/caffeine 83
butalbital/acetaminophen/caffeine/codeine
phosphate 9
butalbital/aspirin/caffeine 5
BUTISOL SODIUM 152
butorphanol tartrate 9
BUTRANS 8
BYDUREON 60
BYDUREON BCISE 60
BYDUREON PEN 60
BYETTA 60
BYSTOLIC 71
BYVALSON 74
Ccabergoline 126
CABLIVI 66
CABOMETYX 40
CADUET 74
CAFERGOT 33
caffeine citrate 146
CALAN 72
CALAN SR 72
calcipotriene 88
calcipotriene/betamethasone dipropionate 88
calcitonin,salmon,synthetic 133
CALCITRENE 88
calcitriol 88,133
calcium acetate 97
CALQUENCE 41
CAMBIA 5
CAMILA 123
CAMRESE 116
CAMRESE LO 116
CANASA 132
candesartan cilexetil 69
candesartan cilexetil/hydrochlorothiazide 74
capecitabine 37
CAPEX SHAMPOO 107
CAPITAL W-CODEINE 9
CAPRELSA 41
CAPSFENAC PAK 88
captopril 70
captopril/hydrochlorothiazide 74
CARAC 88
CARAFATE 101
CARBAGLU 95
carbamazepine 24
CARBATROL 24
carbidopa 48
carbidopa/levodopa 49
carbidopa/levodopa/entacapone 47
carbinoxamine maleate 142
CARDIZEM 72
CARDIZEM CD 72
CARDIZEM LA 72
CARDURA 69
CARDURA XL 105
carisoprodol 150
carisoprodol/aspirin 150
carisoprodol/aspirin/codeine phosphate 9
CARNITOR 95
CARNITOR SF 95
CAROSPIR 77
carteolol hcl 139
CARTIA XT 72
carvedilol 71
carvedilol phosphate 71
CASODEX 36
CATAPRES 69
CATAPRES-TTS 69
CAVERJECT 105
CAYSTON 145
CAZIANT 116
CEDAX 17
cefaclor 17
cefadroxil 17
cefdinir 17
cefditoren pivoxil 17
cefixime 17
cefpodoxime proxetil 17
cefprozil 17
ceftibuten 17
CEFTIN 17
cefuroxime axetil 17
CELEBREX 5
celecoxib 5
PAGE 157 LAST UPDATED 08/2019
CELEXA 26
CELLCEPT 128
CELONTIN 22
CENTANY 15
CENTANY AT 15
CENTERGY DM 148
cephalexin 17
CEQUA 136
CERDELGA 102
cervical cap 134
CESAMET 29
cetirizine hcl 142
CETRAXAL 19
CETROTIDE 126
CETYLEV 134
cevimeline hcl 87
CHANTIX 14
CHATEAL 116
CHATEAL EQ 117
CHEMET 96
CHENODAL 99
chlordiazepoxide hcl 59
chlordiazepoxide/clidinium bromide 98
chlorhexidine gluconate 87
chloroquine phosphate 47
chlorothiazide 77
chlorpromazine hcl 49
chlorpropamide 60
chlorthalidone 77
chlorzoxazone 150
CHOLBAM 102
cholestyramine (with sugar) 78
cholestyramine/aspartame 79
choline salicylate/magnesium salicylate 5
chorionic gonadotropin, human 112
CIALIS 105
CICLODAN 30
ciclopirox 30
ciclopirox olamine 30
cilostazol 68
CILOXAN 19
CIMDUO 56
cimetidine 100
cimetidine hcl 100
CIMZIA 128
cinacalcet hcl 133
CINRYZE 127
CIPRO 19
CIPRO HC 141
CIPRO XR 19
CIPRODEX 141
ciprofloxacin 19
ciprofloxacin hcl 19
ciprofloxacin/ciprofloxacin hcl 19
citalopram hydrobromide 26,153
CLARAVIS 88
CLARINEX 142
CLARINEX-D 12 HOUR 148
clarithromycin 18
clemastine fumarate 142
CLENPIQ 101
CLEOCIN 15
CLEOCIN HCL 15
CLEOCIN PALMITATE 15
CLEOCIN T 15
CLIMARA 117
CLIMARA PRO 117
CLINDACIN ETZ 15
CLINDACIN P 15
CLINDACIN PAC 15
CLINDAGEL 15
clindamycin hcl 15
clindamycin palmitate hcl 15
clindamycin phosphate 15
clindamycin phosphate/benzoyl peroxide 88
clindamycin phosphate/tretinoin 88
CLINDESSE 15
CLINPRO 5000 95
clobazam 22
clobetasol propionate 107
clobetasol propionate/emollient base 107
CLOBEX 107
clocortolone pivalate 0.1 % cream(g) 107
CLODAN 107
CLODERM 107
clomiphene citrate 125
clomipramine hcl 28
clonazepam 59
clonidine 69
clonidine hcl 69,81
clopidogrel bisulfate 68
clorazepate dipotassium 59
clotrimazole 30
clotrimazole/betamethasone dipropionate 88
clozapine 51
CLOZARIL 51
COARTEM 47
codeine phosphate/butalbital/aspirin/caffeine 9
codeine sulfate 10
COLAZAL 132
colchicine 32
COLCRYS 32
colesevelam hcl 79
COLESTID 79
colestipol hcl 79
COLOCORT 133
COLY-MYCIN S 141
COLYTE WITH FLAVOR PACKETS 101
COMBIGAN 139
COMBIPATCH 117
COMBIVENT RESPIMAT 148
COMBIVIR 57
COMETRIQ 41
COMFORT PAC-CYCLOBENZAPRINE 150
COMFORT PAC-MELOXICAM 134
COMFORT PAC-NAPROXEN 134
COMFORT PAC-TIZANIDINE 150
COMPAZINE 28,29
COMPLERA 56
COMPRO 29
COMTAN 48
CONCEPTROL 105
CONCERTA 81
PAGE 158 LAST UPDATED 08/2019
condoms, female 134
CONDYLOX 88
CONSTULOSE 101
CONTRAVE 83
CONZIP 8
COPAXONE 85
COPEGUS 54
COPIKTRA 38
CORDARONE 70
CORDRAN 107
COREG 71
COREG CR 71
CORGARD 71
CORLANOR 74
CORMAX 107
CORTEF 108
CORTENEMA 133
CORTIFOAM 133
cortisone acetate 108
CORTISPORIN 88
CORTISPORIN-TC 141
CORZIDE 74
COSENTYX 89
COSOPT 139
COSOPT PF 139
COTELLIC 41
COTEMPLA XR-ODT 81
COUMADIN 65
COVARYX 117
COVARYX H.S. 117
COZAAR 69
CREON 103
CRESEMBA 30
CRESTOR 78
CRINONE 123
CRIXIVAN 58
cromolyn sodium 99,138,146
CROTAN 47
CRYSELLE 117
CUPRIMINE 96
CUROSURF 148
CUTIVATE 108
CUVPOSA 98
cyanocobalamin (vitamin b-12) 97
CYCLAFEM 117
CYCLESSA 117
cyclobenzaprine hcl 150
cyclopentolate hcl 136
cyclophosphamide (25 mg capsule, 50 mg
capsule) 35
cycloserine 35
CYCLOSET 60
cyclosporine 128
cyclosporine, modified 128
CYMBALTA 84
cyproheptadine hcl 142
CYRED 117
CYSTADANE 103
CYSTAGON 103
CYSTARAN 136
CYTOMEL 125
CYTOTEC 101
CYTRA-K 95
DD.H.E.45 33
DAKLINZA 52
dalfampridine 85
DALIRESP 146
danazol 115
DANTRIUM 51
dantrolene sodium 51
dapsone 35,89
DARAPRIM 47
darifenacin hydrobromide 104
DASETTA 117
DAURISMO 41
DAXBIA 17
DAYPRO 5
DAYSEE 117
DAYTRANA 82
DDAVP 112
DEBLITANE 123
DECADRON 108
deferasirox 96
DELESTROGEN 117
DELSTRIGO 56
DELTASONE 108
DELYLA 117
DELZICOL 132
DEMADEX 76
demeclocycline hcl 20
DEMEROL 10
DEMSER 74
DENAVIR 58
DENTA 5000 PLUS 95
DENTAGEL 95
DEPAKENE 22
DEPAKOTE 22
DEPAKOTE ER 22
DEPAKOTE SPRINKLE 22
DEPEN 97
DEPO-ESTRADIOL 117
DEPO-SUBQ PROVERA 104 123
DEPO-TESTOSTERONE 115
DERMA-SMOOTHE-FS 108
DERMACINRX CINLONE-I CPI 108
DERMACINRX CLORHEXACIN 89
DERMACINRX EMPRICAINE 12
DERMACINRX LEXITRAL 89
DERMACINRX PRIZOPAK 12
DERMACINRX SILAPAK 108
DERMACINRX SILAZONE 108
DERMACINRX SURGICAL PHARMAPAK 89
DERMACINRX THERAZOLE PAK 89
DERMATOP 108
DERMAZONE 108
DERMOTIC 141
DESCOVY 57
desipramine hcl 28
desloratadine 142
desmopressin acetate 112
desmopressin acetate (non-refrigerated) 112
PAGE 159 LAST UPDATED 08/2019
desogestrel-ethinyl estradiol 117
desogestrel-ethinyl estradiol/ethinyl
estradiol 117
DESONATE 108
desonide 108
DESOWEN 108
desoximetasone 108
DESOXYN 80
desvenlafaxine er 26
desvenlafaxine fumarate 26
desvenlafaxine succinate 26
DETROL 104
DETROL LA 104
dexamethasone 108
DEXAMETHASONE INTENSOL 108
dexamethasone sodium phosphate 138
DEXEDRINE 80,81
DEXILANT 102
dexmethylphenidate hcl 82
dextroamphetamine sulf-
saccharate/amphetamine sulf-aspartate 81
dextroamphetamine sulfate 81
DIABETA 60
DIACOMIT 21
DIAMOX SEQUELS 76
diaphragms, contoured 134
diaphragms, wide seal 135
DIASTAT 22
DIASTAT ACUDIAL 22
diazepam 22,59
DIBENZYLINE 69
DICLEGIS 29
DICLO GEL 89
DICLO GEL-XRYLIX SHEET 89
diclofenac epolamine 5
diclofenac potassium 5
diclofenac sodium 5,89,138
diclofenac sodium/misoprostol 5
DICLOFEX DC 89
DICLOPR 5
DICLOVIX 133
dicloxacillin sodium 18
DICLOZOR 89
dicyclomine hcl 98
didanosine 57
diethylpropion hcl 83
DIFFERIN 89
DIFICID 18
diflorasone diacetate 108
DIFLUCAN 30
diflunisal 5
DIGITEK 74
DIGOX 74
digoxin 74
dihydroergotamine mesylate 33
dihydroergotamine mesylate 0.5mg/spry
spray/pump 33
DILANTIN 24
DILANTIN-125 24
DILATRATE-SR 80
DILAUDID 10
DILT-XR 72
diltiazem hcl 73
DIOVAN 69
DIOVAN HCT 74
DIPENTUM 132
diphenhydramine hcl 142
diphenoxylate hcl/atropine sulfate 99
DIPROLENE 108
DIPROLENE AF 108
dipyridamole 68
DISALCID 5
disopyramide phosphate 71
disulfiram 13
DITHOL 5
DITROPAN XL 104
DIURIL 77
divalproex sodium 23
DIVIGEL 117
dofetilide 71
DOLOPHINE HCL 8
DOLOTRANZ 12
donepezil hcl 25
DOPTELET 66
DORAL 151
DORYX 20
DORYX MPC 20
dorzolamide hcl 139
dorzolamide hcl/timolol maleate 139
dorzolamide hcl/timolol maleate/pf 139
DOVATO 57
DOVONEX 89
doxazosin mesylate 69
doxepin hcl 28
doxepin hcl 5 % cream (g) 89
doxercalciferol 133
doxycycline hyclate 20
doxycycline monohydrate 20
doxycycline monohydrate 40 mg cap ir dr 20
doxylamine succinate/pyridoxine hcl (b6) 29
DRISDOL 133
DRITHOCREME HP 89
dronabinol 29
drospirenone/ethinyl estradiol/levomefolate
calcium 117
DROXIA 37
DRYSOL 89
DUAC 89
DUAVEE 125
DUETACT 61
DUEXIS 5
DULERA 148
duloxetine hcl 84
DUOBRII 90
DUPIXENT 90,131
DURAGESIC 8
DUREZOL 138
dutasteride 105
dutasteride/tamsulosin hcl 105
DUTOPROL 74
DXEVO 108
DYANAVEL XR 81
DYAZIDE 74
PAGE 160 LAST UPDATED 08/2019
DYMISTA 148
DYRENIUM 77
EE.E.S. 200 18
E.E.S. 400 18
EC-NAPROSYN 5
econazole nitrate 30
ECONTRA EZ 124
ECONTRA ONE-STEP 117
ECOZA 30
ED-SPAZ 98
EDARBI 69
EDARBYCLOR 74
EDECRIN 76
EDEX 105
EDLUAR 151
EDURANT 56
EEMT 117
EEMT H.S. 117
efavirenz 56
EFFER-K 95
EFFEXOR XR 26
EFFIENT 68
EFUDEX 37
EGRIFTA 112
ELDEPRYL 49
ELESTAT 138
ELESTRIN 117
eletriptan hydrobromide 33
ELIDEL 90
ELIMITE 47
ELINEST 117
ELIPHOS 97
ELIQUIS 65
ELIXOPHYLLIN 146
ELLA 123
ELLZIA PAK 108
ELMIRON 105
ELOCON 108
EMADINE 138
EMBEDA 8
EMCYT 37
EMEND 30
EMFLAZA 109
EMGALITY PEN 33
EMGALITY SYRINGE 33
EMLA 12
EMOQUETTE 117
EMSAM 26
EMTRIVA 57
EMVERM 46
ENABLEX 104
enalapril maleate 70
enalapril maleate/hydrochlorothiazide 74
ENBREL 128
ENBREL MINI 128
ENBREL SURECLICK 129
ENDARI 95
ENDOCET 10
ENDOMETRIN 124
ENJUVIA 117
enoxaparin sodium 65
ENPRESSE 117
ENSKYCE 117
ENSTILAR 90
entacapone 48
entecavir 52
Enteral Formula Requires Prior Authorization.
Brands are Tier 3 & generics are Tier 1. 98
ENTEREG 99
ENTOCORT EC 133
ENTRESTO 74
ENULOSE 101
ENVARSUS XR 129
EPANDED SOLUTION 70
EPCLUSA 52
EPIDIOLEX 22
EPIDUO 90
EPIDUO FORTE 90
EPIFOAM 90
epinastine hcl 138
epinephrine 144
EPIPEN 144
EPIPEN 2-PAK 144
EPIPEN JR 2-PAK 144
EPITOL 24
EPIVIR 57
EPIVIR HBV 52
eplerenone 77
EPOGEN 66
eprosartan mesylate 69
EPZICOM 57
EQUETRO 60
ergocalciferol (vitamin d2) 133
ergoloid mesylates 25
ERGOMAR 33
ergotamine tartrate/caffeine 33
ERIVEDGE 41
ERLEADA 36
erlotinib hcl 41
ERRIN 124
ERTACZO 30
ERY 18
ERY-TAB 18
ERYGEL 18
ERYPED 200 18
ERYPED 400 18
ERYTHROCIN STEARATE 18
erythromycin base 18
erythromycin base in ethanol 18
erythromycin base/benzoyl peroxide 15
erythromycin ethylsuccinate 19
ESBRIET 147
escitalopram oxalate 27
ESGIC 83
ESOMEP-EZS 102
esomeprazole magnesium 102
esomeprazole strontium 102
ESTARYLLA 117
estazolam 151
ESTRACE 118
estradiol 118
PAGE 161 LAST UPDATED 08/2019
estradiol valerate 118
estradiol/norethindrone acetate 118
ESTRING 118
ESTROGEL 118
estrogens,esterified/methyltestosterone 118
estropipate 118
ESTROSTEP FE 118
eszopiclone 151
ethacrynic acid 76
ethambutol hcl 35
ethinyl estradiol/drospirenone 118
ethosuximide 22
ethynodiol diacetate-ethinyl estradiol 118
etidronate disodium 133
etodolac 6
etoposide 40
EUCRISA 90
EURAX 47
EVAMIST 118
EVEKEO 81
EVEKEO ODT 81
EVISTA 125
EVOCLIN 15
EVOTAZ 58
EVOXAC 87
EXALGO 8
EXELDERM 30
EXELON 25
exemestane 39
EXFORGE 74
EXFORGE HCT 74
EXJADE 96
EXTAVIA 85
EXTINA 30
EZALLOR SPRINKLE 78
ezetimibe 79
ezetimibe/simvastatin 79
FFABIOR 90
FACTIVE 19
FALLBACK SOLO 124
FALMINA 118
famciclovir 58,59
famotidine 100
FAMVIR 59
FANAPT 50
FARESTON 37
FARXIGA 61
FARYDAK 41
FAYOSIM 118
FAZACLO 51
felbamate 23
FELBATOL 23
FELDENE 6
felodipine 73
FEM PH 106
FEMARA 39
FEMHRT 118
FEMRING 118
FEMYNOR 118
fenofibrate 77
fenofibrate nanocrystallized 77
fenofibrate,micronized 77
fenofibric acid 77
fenofibric acid (choline) 77
FENOGLIDE 77
fenoprofen calcium 6
fenoprofen calcium (200 mg capsule, 400 mg
capsule) 6
FENORTHO 6
fentanyl 8
fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr
patch td72, 87.5mcg/hr patch td72) 8
fentanyl citrate 10
FENTORA 10
FERRIPROX 96
FETZIMA 27
FEXMID 150
FIASP 64
FIASP FLEXTOUCH 64
FIBRICOR 77
FINACEA 90
finasteride 105
FIORICET 83
FIORICET WITH CODEINE 10
FIORINAL 6
FIORINAL WITH CODEINE #3 10
FIRAZYR 127
FIRDAPSE 85
FIRVANQ 15
FLAGYL 15
FLAGYL ER 15
FLAREX 138
flavoxate hcl 104
flecainide acetate 71
FLECTOR 6
FLEXIPAK 135
FLOLIPID 78
FLOMAX 105
FLOVENT DISKUS 141
FLOVENT HFA 141
FLOWTUSS 148
FLOXIN 19
fluconazole 31
flucytosine 31
fludrocortisone acetate 109
FLUMADINE 58
flunisolide 141
fluocinolone acetonide 109
fluocinolone acetonide oil 141
fluocinolone acetonide/shower cap 109
fluocinonide 109
fluocinonide/emollient base 109
fluorometholone 138
FLUOROPLEX 90
fluorouracil 37
fluorouracil 0.5% cream 90
fluoxetine hcl 27
fluphenazine decanoate 49
fluphenazine hcl 49
flurandrenolide 109
flurazepam hcl 151
PAGE 162 LAST UPDATED 08/2019
flurbiprofen 6
flurbiprofen sodium 138
flutamide 36
fluticasone propionate 109,141
fluticasone propionate/salmeterol xinafoate 148
fluvastatin sodium 78
fluvoxamine maleate 27
FML 138
FML FORTE 138
FML S.O.P. 138
foam/gauze
bandage/lidocaine/chlorhexidine/isopropyl
alcohol 135
FOCALIN 82
FOCALIN XR 82
folic acid 98
FOLLISTIM AQ 112
fondaparinux sodium 65
FORADIL 144
FORFIVO XL 26
FORTAMET 61
FORTEO 133
FORTESTA 115
FORTICAL 133
FOSAMAX 134
FOSAMAX PLUS D 134
fosinopril sodium 70
fosinopril sodium/hydrochlorothiazide 75
FOSRENOL 97
FRAGMIN 65
freestyle freedom lite meter 63
freestyle insulinx glucose sys 63
freestyle insulinx test strips 63
freestyle lite meter 63
freestyle lite test strips 63
freestyle prec neo test strips 63
freestyle precision neo meter 63
freestyle test strips 63
FROVA 34
frovatriptan succinate 34
FULPHILA 66
FULYZAQ 99
FURADANTIN 15
furosemide 76
FYAVOLV 118
FYCOMPA 23
Ggabapentin 23
GABITRIL 23
GALAFOLD 103
galantamine hbr 25
GALZIN 96
ganirelix acetate 126
GASTROCROM 99
gatifloxacin 19
GATTEX 99
GAVILYTE-C 101
GAVILYTE-G 101
GAVILYTE-N 101
GELNIQUE 104
gemfibrozil 77
GENERESS FE 118
GENERLAC 101
GENGRAF 129
GENOTROPIN 113
GENTAK 14
gentamicin sulfate 14
GENVOYA 55
GEODON 50
GIALAX 101
GIANVI 118
GIAZO 132
GILDAGIA 118
GILDESS 24 FE 118
GILENYA 85
GILOTRIF 41
glatiramer acetate 86
GLATOPA 86
GLEEVEC 42
GLEOSTINE 35
glimepiride 61
glipizide 61
glipizide/metformin hcl 61
GLUCAGEN 64
GLUCAGON EMERGENCY KIT 64
GLUCOPHAGE 61
GLUCOPHAGE XR 61
GLUCOTROL 61
GLUCOTROL XL 61
GLUCOVANCE 61
GLUMETZA 61
glyburide 61
glyburide,micronized 61
glyburide/metformin hcl 61
GLYCATE 98
glycopyrrolate 98
GLYDO 12
GLYNASE 61
GLYSET 61
GLYXAMBI 61
GOCOVRI 48
GOLYTELY 101
Gonal-f 113
GONITRO 80
GORDON'S UREA 90
GRALISE 23
granisetron hcl 30
GRANIX 66
GRASTEK 131
GRIFULVIN V 31
GRIS-PEG 31
griseofulvin ultramicrosize 31
griseofulvin, microsize 31
guaifenesin/hydrocodone bitartrate 148
guanfacine hcl 69,82
guanidine hcl 34
GYNAZOLE 1 31
GYNOL II 106
HHAEGARDA 127
HALCION 151
PAGE 163 LAST UPDATED 08/2019
halobetasol propionate 109
HALOG 109
haloperidol 49
haloperidol lactate 49
HARVONI 52
HEATHER 124
HECTOROL 134
HEMANGEOL 38
HEMMOREX-HC 109
HEPSERA 52
HETLIOZ 152
HEXALEN 35
HIPREX 15
HORIZANT 83
HUMALOG 64
HUMALOG JUNIOR KWIKPEN 64
HUMALOG KWIKPEN U-100 64
HUMALOG KWIKPEN U-200 64
HUMALOG MIX 50-50 64
HUMALOG MIX 50-50 KWIKPEN 64
HUMALOG MIX 75-25 64
HUMALOG MIX 75-25 KWIKPEN 64
HUMATROPE 113
Humira 129
HUMULIN 70-30 64
HUMULIN 70/30 KWIKPEN 64
HUMULIN N 64
HUMULIN N KWIKPEN 64
HUMULIN R 64
HUMULIN R U-500 64
HUMULIN R U-500 KWIKPEN 64
HYCAMTIN 40
HYCET 10
HYCOFENIX 149
hydralazine hcl 79
HYDREA 37
hydrochlorothiazide 77
hydrocodone bitart/chlorpheniramine
maleate/pseudoephedrine 149
hydrocodone bitartrate/acetaminophen 10
hydrocodone bitartrate/homatropine
methylbromide 149
hydrocodone polistirex/chlorpheniramine
polistirex 149
hydrocodone/ibuprofen 10
hydrocortisone 109,133
hydrocortisone acetate 109
hydrocortisone acetate/iodoquinol/aloe vera 90
hydrocortisone acetate/lidocaine hcl/aloe
vera 90
hydrocortisone acetate/pramoxine hcl 90
hydrocortisone butyrate 109
hydrocortisone butyrate/emollient base 109
hydrocortisone valerate 109
hydrocortisone/acetic acid 141
hydrocortisone/mineral oil/petrolatum,white 109
HYDROMET 149
hydromorphone hcl 8,10
hydroquinone microspheres 90
hydroxychloroquine sulfate 47
hydroxyurea 37
hydroxyzine hcl 143
hydroxyzine pamoate 143
HYOPHEN 16
hyoscyamine sulfate 98
HYOSYNE 98
HYSINGLA ER 8
HYZAAR 75
Iibandronate sodium 134
IBRANCE 42
IBU 6
IBUDONE 10
ibuprofen 6
ibuprofen/oxycodone hcl 10
ICAR-C PLUS 95
ICLUSIG 42
IDHIFA 38
ILEVRO 138
ILOTYCIN 19
imatinib mesylate 42
IMBRUVICA 42
imipramine hcl 28
imipramine pamoate 28
imiquimod 90
IMITREX 34
IMPAVIDO 47
IMPOYZ 109
IMURAN 129
IMVEXXY 118
INBRIJA 135
INCASSIA 124
INCRELEX 113
INCRUSE ELLIPTA 143
indapamide 77
INDERAL LA 71
INDERAL XL 71
INDOCIN 6
indomethacin 6
INFLAMMACIN 135
INGREZZA 83
INGREZZA INITIATION PACK 83
INLYTA 42
INNOPRAN XL 71
INSPRA 77
insulin lispro 65
INTELENCE 56
INTERMEZZO 151
INTRAROSA 135
INTRON A 54
INTROVALE 118
INTUNIV 82
INVEGA 50
INVELTYS 138
INVIRASE 58
INVOKAMET 61
INVOKAMET XR 61
INVOKANA 61
IOPIDINE 139
ipratropium bromide 143
ipratropium bromide/albuterol sulfate 149
PAGE 164 LAST UPDATED 08/2019
IPRIVASK 65
irbesartan 69
irbesartan/hydrochlorothiazide 75
IRENKA 84
IRESSA 42
ISENTRESS 55
ISENTRESS HD 55
ISIBLOOM 118
isometheptene
mucate/dichloralphenazone/acetaminophen 135
isoniazid 35
ISOPTO ATROPINE 136
ISOPTO CARPINE 139
ISORDIL 80
ISORDIL TITRADOSE 80
isosorbide dinitrate 80
isosorbide mononitrate 80
isoxsuprine hcl 75
isradipine 73
ISTALOL 139
itraconazole 31
ivermectin 46
JJadenu 96
JAKAFI 42
JALYN 105
JANTOVEN 66
JANUMET 61
JANUMET XR 61
JANUVIA 61
JARDIANCE 61
JENCYCLA 124
JENTADUETO 61
JENTADUETO XR 61
JEVANTIQUE LO 118
JINTELI 118
JOLESSA 119
JOLIVETTE 124
JORNAY PM 82
JUBLIA 31
JULEBER 119
JULUCA 57
JUNEL 119
JUNEL FE 119
JUNEL FE 24 119
JUXTAPID 79
JYNARQUE 96
KK EFFERVESCENT 95
K-PHOS NO.2 106
K-PHOS ORIGINAL 106
K-TAB ER 95
KADIAN 8
KAITLIB FE 119
KALETRA 58
KALYDECO 145
KAPSPARGO SPRINKLE 71
KAPVAY 82
KARBINAL ER 143
KARIVA 119
KAYEXALATE 96
KAZANO 62
KEFLEX 17
KELNOR 1-35 119
KELNOR 1-50 119
KENALOG 109
KEPPRA 22
KEPPRA XR 22
KERYDIN 31
ketoconazole 31
KETODAN 31
ketoprofen 6
ketorolac tromethamine 6,138
KEVEYIS 76
KEVZARA 131
KHEDEZLA 27
KIMIDESS 119
KINERET 129
KIONEX 97
KISQALI 42
KISQALI FEMARA CO-PACK 43
KITABIS PAK 145
KLARON 20
KLONOPIN 59
KLOR-CON 95
KLOR-CON 10 95
KLOR-CON 8 95
KLOR-CON M10 95
KLOR-CON M15 95
KLOR-CON M20 95
KLOR-CON SPRINKLE 95
KLOR-CON-EF 95
KOMBIGLYZE XR 62
KORLYM 109
KRINTAFEL 47
KRISTALOSE 101
KURVELO 119
KUVAN 103
KYLEENA 124
KYNAMRO 79
Llabetalol hcl 72
LACRISERT 136
lactulose 101
LAMICTAL 23
LAMICTAL (BLUE) 23
LAMICTAL (GREEN) 24
LAMICTAL (ORANGE) 24
LAMICTAL ODT 24
LAMICTAL XR 24
LAMISIL 31
lamivudine 52,57
lamivudine/zidovudine 57
lamotrigine 24
LANOXIN 75
lansoprazole 102
lansoprazole/amoxicillin
trihydrate/clarithromycin 99
lanthanum carbonate 97
LANTUS 65
PAGE 165 LAST UPDATED 08/2019
LANTUS SOLOSTAR 65
LARIN 119
LARIN 24 FE 119
LARIN FE 119
LARISSIA 119
LASIX 76
LASTACAFT 138
latanoprost 140
LATUDA 50
LAYOLIS FE 119
LAZANDA 10
ledipasvir/sofosbuvir 52
LEENA 119
leflunomide 131
LENVIMA 43
LESCOL 78
LESCOL XL 78
LESSINA 119
LETAIRIS 146
letrozole 39
leucovorin calcium 38
LEUKERAN 35
LEUKINE 67
leuprolide acetate 126
levalbuterol hcl 144
levalbuterol tartrate 144
LEVAQUIN 19
LEVATOL 72
LEVBID 98
LEVEMIR 65
LEVEMIR FLEXTOUCH 65
levetiracetam 22
LEVITRA 106
LEVO-T 125
levobunolol hcl 139
levocarnitine 95
levocarnitine (with sugar) 95
levocetirizine dihydrochloride 143
levofloxacin 19
LEVONEST 119
levonorgestrel 119
levonorgestrel-ethinyl estradiol 119
levonorgestrel/ethinyl estradiol and ethinyl
estradiol 119
LEVORA-28 119
levorphanol tartrate 8
levothyroxine sodium 125
LEVOXYL 125
LEVSIN 98
LEVSIN-SL 98
LEVULAN 90
LEXAPRO 27
LEXETTE 109
LEXIVA 58
LEXIXRYL 90
LIALDA 132
LIBRAX 98
LIDO-K 12
LIDO-PRILO CAINE PACK 12
lidocaine 12
lidocaine hcl 12
lidocaine hcl/hydrocortisone acetate 91
lidocaine/prilocaine 12
LIDODERM 12
LIDOPAC 12
LIDOPIN 13
LIDOPRIL 13
LIDOPRIL XR 13
LIDOTRANS 5 PAK 13
LILETTA 124
LILLOW 119
lindane 47
linezolid 16
LINZESS 100
liothyronine sodium 125
LIPITOR 78
LIPOCHOL PLUS 77
LIPOFEN 77
LIPROZONEPAK 13
lisinopril 70
lisinopril/hydrochlorothiazide 75
lithium carbonate 60
lithium citrate 60
LITHOBID 60
LITHOSTAT 106
LIVALO 78
LO LOESTRIN FE 119
LOCOID 110
LOCOID LIPOCREAM 110
LODINE 6
LODOSYN 49
LOESTRIN 119
LOESTRIN FE 120
LOFIBRA 78
LOKELMA 135
LOMAIRA 83
LOMEDIA 24 FE 120
LOMOTIL 99
lomustine 35
LONHALA MAGNAIR REFILL 143
LONHALA MAGNAIR STARTER 143
LONSURF 38
loperamide hcl 99
LOPID 78
lopinavir/ritonavir 58
LOPREEZA 120
LOPRESSOR 72
LOPRESSOR HCT 75
LOPROX 31
lorazepam 59
LORAZEPAM INTENSOL 59
LORBRENA 40
LORCET 10
LORCET HD 10
LORCET PLUS 10
LORTAB 10
LORYNA 120
LORZONE 150
losartan potassium 70
losartan potassium/hydrochlorothiazide 75
LOSEASONIQUE 120
LOTEMAX 138
LOTENSIN 70
PAGE 166 LAST UPDATED 08/2019
LOTENSIN HCT 75
loteprednol etabonate 138
LOTREL 75
LOTRISONE 91
LOTRONEX 100
lovastatin 78
LOVAZA 79
LOVENOX 66
LOW-OGESTREL 120
loxapine succinate 49
LUCEMYRA 14
luliconazole 31
LUMIGAN 140
LUNESTA 151
LUPANETA PACK 126
LUTERA 120
LUXIQ 110
LUZU 31
LYNPARZA 43
LYRICA 84
LYRICA CR 85
LYSODREN 38
LYSTEDA 68
LYZA 124
MMACROBID 16
MACRODANTIN 16
MALARONE 47
malathion 47
maprotiline hcl 27
MARINOL 30
MARLISSA 120
MARPLAN 26
MARTEN-TAB 83
MATULANE 35
MATZIM LA 73
MAVENCLAD 86
MAVIK 70
MAVYRET 52
MAXALT 34
MAXALT MLT 34
MAXIDEX 139
MAXITROL 136
MAXZIDE 75
MAXZIDE-25 MG 75
MAYZENT 86
meclizine hcl 29
meclofenamate sodium 6
MEDOLOR PAK 13
MEDROL 110
medroxyprogesterone acetate 124
mefenamic acid 6
mefloquine hcl 47
MEGACE 124
MEGACE ES 124
megestrol acetate 124
MEKINIST 43
MEKTOVI 43
MELODETTA 24 FE 120
meloxicam 6
melphalan 35
memantine hcl 25
MENEST 120
MENOPUR 113
MENOSTAR 120
MENTAX 31
meperidine hcl 10
MEPHYTON 68
meprobamate 59
MEPRON 47
mercaptopurine 37
mesalamine 132
mesalamine 800 mg tablet dr 132
mesalamine with cleansing wipes 132
MESNEX 46
MESTINON 34
METADATE CD 82
METADATE ER 82
metaproterenol sulfate 144
METAXALL 151
metaxalone 151
metformin er 500mg & 1000mg tab (generic
version of glumetza) 62
metformin hcl 62
methadone hcl 8
METHADONE INTENSOL 8
METHADOSE 8
methamphetamine hcl 81
methazolamide 139
methenamine hippurate 16
methenamine mandelate 16
methenamine/sod
phosph,monobasic/methylene
blue/hyoscyamine 16
METHERGINE 135
methimazole 127
METHITEST 115
methocarbamol 151
methotrexate sodium 129
methotrexate sodium/pf 129
methoxsalen 91
methscopolamine bromide 98
methyclothiazide 77
methyldopa 69
methyldopa/hydrochlorothiazide 75
methylergonovine maleate 135
METHYLIN 82
methylphenidate hcl 82
methylprednisolone 110
methyltestosterone 115
metipranolol 139
metoclopramide hcl 29
metolazone 77
metoprolol succinate 72
metoprolol succinate/hydrochlorothiazide 75
metoprolol tartrate 72
metoprolol tartrate/hydrochlorothiazide 75
METOZOLV ODT 29
METROCREAM 91
METROGEL 91
METROGEL-VAGINAL 16
METROLOTION 91
PAGE 167 LAST UPDATED 08/2019
metronidazole 16,91
mexiletine hcl 71
MIACALCIN 134
MIBELAS 24 FE 120
MICARDIS 70
MICARDIS HCT 75
miconazole nitrate 31
miconazole nitrate/zinc
oxide/petrolatum,white 31
MICORT-HC 91,110
MICROCYN 91
MICROCYN HYDROGEL 91
MICROGESTIN 120
MICROGESTIN 24 FE 120
MICROGESTIN FE 120
MICROZIDE 77
midazolam hcl 59
midodrine hcl 69
MIGERGOT 33
miglitol 62
miglustat 103
MIGRANAL 33
MILI 120
MILLIPRED 110
MILLIPRED DP 110
MIMVEY 120
MIMVEY LO 120
MINASTRIN 24 FE 120
MINIPRESS 69
MINITRAN 80
MINIVELLE 120
MINOCIN 20
minocycline hcl 21
MINOLIRA ER 21
minoxidil 79
MIRAPEX 48
MIRAPEX ER 48
MIRCETTE 120
MIRENA 124
mirtazapine 26
misoprostol 101
MITIGARE 32
MITOSOL 136
MOBIC 6
modafinil 152
MODERIBA 54
moexipril hcl 70
moexipril hcl/hydrochlorothiazide 75
molindone hcl 49
mometasone furoate 110,141
MONDOXYNE NL 21
MONO-LINYAH 120
MONODOX 21
MONONESSA 120
montelukast sodium 143
MONUROL 16
MORGIDOX 21
MORPHABOND ER 8
morphine sulfate 9,11
morphine sulfate (15 mg tablet, 30 mg tablet)
10
MOTEGRITY 29
MOTOFEN 99
MOVANTIK 99
MOVIPREP 101
MOXATAG 18
MOXEZA 19
moxifloxacin hcl 19
MOZOBIL 67
MS CONTIN 9
MULPLETA 67
MULTAQ 71
mupirocin 16
mupirocin calcium 16
MUSE 106
MY CHOICE 120
MY WAY 120
MYALEPT 99
MYAMBUTOL 35
MYCOBUTIN 35
mycophenolate mofetil 129
mycophenolate sodium 129
MYDAYIS 81
MYFORTIC 129
MYLERAN 35
MYORISAN 91
MYRBETRIQ 104
MYSOLINE 23
MYTESI 99
MYZILRA 120
Nnabumetone 6
nadolol 72
nadolol/bendroflumethiazide 75
naftifine hcl 31
NAFTIN 31
NALFON 6
NALOCET 11
naloxone hcl 14
naltrexone hcl 13
NAMENDA 25
NAMENDA XR 25
NAMZARIC 25
naphazoline 0.1% 136
NAPRELAN 6
NAPROSYN 6
naproxen 6
naproxen sodium 6
naratriptan hcl 34
NARCAN 14
NARDIL 26
NASCOBAL 98
NASONEX 141
NATACYN 31
NATAZIA 120
nateglinide 62
NATESTO 115
NATPARA 134
NATROBA 91
NATURE-THROID 125
NEBUPENT 47
NEBUSAL 149
PAGE 168 LAST UPDATED 08/2019
NECON 120
nefazodone hcl 27
NEO-POLYCIN 136
NEO-POLYCIN HC 137
NEO-SYNALAR 91
neomycin sulfate 14
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone 137
neomycin sulfate/bacitracin/polymyxin b 137
neomycin sulfate/polymyxin b sulfate/gramicidin
d 137
neomycin sulfate/polymyxin b
sulfate/hydrocortisone 137,141
neomycin/polymyxin b
sulfate/dexamethasone 137
NEORAL 129
NEPTAZANE 140
NERLYNX 43
NESINA 62
NESTABS ONE 95
NEUAC 91
NEULASTA 67
NEUPOGEN 67
NEUPRO 48
NEURCAINE 13
NEURONTIN 23
NEVANAC 139
nevirapine 56
nevirapine 50 mg/5 ml oral susp 56
NEW DAY 120
NEXAVAR 43
NEXIUM 102
NEXPLANON 124
NEXT CHOICE ONE DOSE 124
niacin 79
NIACOR 79
NIASPAN 79
nicardipine hcl 73
NICOTROL 14
NICOTROL NS 14
NIFEDICAL XL 73
nifedipine 73
NIKKI 121
NILANDRON 36
nilutamide 36
nimodipine 73
NINLARO 38
nisoldipine 73
NITRO-BID 80
NITRO-DUR 80
NITRO-TIME 80
nitrofurantoin 16
nitrofurantoin macrocrystal 16
nitrofurantoin monohydrate/macrocrystals 16
nitroglycerin 80
NITROLINGUAL 80
NITROMIST 80
NITROSTAT 80
NITYR 103
NIVESTYM 67
nizatidine 100
NIZORAL 31
NOCDURNA 113
NOCTIVA 113
NODOLOR 135
NOLIX 110
NOR-Q-D 124
NORA-BE 124
NORCO 11
NORDITROPIN FLEXPRO 113
norethindrone 124
norethindrone acetate 124
norethindrone acetate-ethinyl estradiol 121
norethindrone acetate-ethinyl estradiol/ferrous
fumarate 121
norethindrone-ethinyl estradiol/ferrous
fumarate 121
NORGESIC FORTE 151
norgestimate-ethinyl estradiol 121
NORITATE 91
NORLYDA 124
NORLYROC 124
NORPACE 71
NORPACE CR 71
NORPRAMIN 28
NORTHERA 69
NORTREL 121
nortriptyline hcl 28
NORVASC 73
NORVIR 58
NOVACORT 91
NOVAREL 113
NOVOLIN 70-30 65
NOVOLIN 70-30 FLEXPEN 65
NOVOLIN N 65
NOVOLIN R 65
NOVOLOG 65
NOVOLOG FLEXPEN 65
NOVOLOG MIX 70-30 65
NOVOLOG MIX 70-30 FLEXPEN 65
NOXAFIL 32
NP THYROID 125
NUCALA 149
NUCORT 110
NUCYNTA 11
NUCYNTA ER 9
NUDICLO 91,135
NUDROXIPAK 6
NUDROXIPAK DSDR-50 135
NUDROXIPAK DSDR-75 135
NUDROXIPAK E-400 135
NUDROXIPAK I-800 135
NUDROXIPAK N-500 135
NUEDEXTA 83
NULEV 98
NULYTELY WITH FLAVOR PACKS 101
NUMBONEX 13
NUOX 91
NUPLAZID 50
NUTRESTORE 95
NUTRIARX 110
NUTROPIN AQ 113
NUVAKAAN 13
PAGE 169 LAST UPDATED 08/2019
NUVARING 121
NUVESSA 16
NUVIGIL 152
NUZYRA 21
NYAMYC 32
NYATA 32
NYMALIZE 73
nystatin 32
nystatin/triamcinolone acetonide 32
NYSTOP 32
OOB COMPLETE PETITE 98
OBREDON 149
OCALIVA 103
OCELLA 121
octreotide acetate 126
OCUFEN 139
OCUFLOX 19
ODACTRA 135
ODEFSEY 56
ODOMZO 43
OFEV 148
ofloxacin 19
OGESTREL 121
olanzapine 50
olanzapine/fluoxetine hcl 26
OLEPTRO ER 27
olmesartan medoxomil 70
olmesartan medoxomil/amlodipine
besylate/hydrochlorothiazide 75
olmesartan medoxomil/hydrochlorothiazide 75
olopatadine hcl 138,143
OLUMIANT 129
OLUX 110
OLUX-E 110
OLYSIO 53
OMECLAMOX-PAK 99
omega-3 acid ethyl esters 79
omeprazole 102
omeprazole/sodium bicarbonate 102
OMNARIS 141
OMNIPRED 139
OMNITROPE 114
ondansetron 30
ondansetron hcl 30
onetouch ultra blue strips 63
onetouch ultra2 glucose syst 63
onetouch ultramini meter 63
onetouch verio flex system kit 63
onetouch verio iq system kit 63
onetouch verio meter system 63
onetouch verio sync syst kit 64
onetouch verio test strip 64
ONEXTON 91
ONFI 23
ONGLYZA 62
ONMEL 32
ONZETRA XSAIL 34
OPANA 11
OPCICON ONE-STEP 124
opium tincture 100
opium/belladonna alkaloids 11
OPSUMIT 147
OPTION 2 125
ORACEA 21
ORACIT 95
Oralair 131
ORALONE 87
ORAP 49
ORAPRED ODT 110
ORAVIG 32
ORENCIA 129
ORENITRAM ER 147
ORFADIN 103
ORILISSA 126
ORKAMBI 145
orphenadrine citrate 151
ORPHENGESIC FORTE 151
ORSYTHIA 121
ORTHO MICRONOR 125
ORTHO TRI-CYCLEN 121
ORTHO TRI-CYCLEN LO 121
ORTHO-CYCLEN 121
ORTHO-NOVUM 121
OSCIMIN 98
OSCIMIN SL 98
OSCIMIN SR 99
oseltamivir phosphate 58
OSENI 62
OSMOLEX ER 48
OSMOPREP 101
OSPHENA 125
OTEZLA 132
OTIPRIO 19
OTOVEL 141
OTREXUP 130
OVACE 91
OVACE PLUS 91
OVACE PLUS WASH 91
OVIDE 47
OVIDREL 114
OXANDRIN 114
oxandrolone 114
oxaprozin 7
OXAYDO 11
oxazepam 59
oxcarbazepine 24
OXECTA 11
OXERVATE 137
oxiconazole nitrate 32
OXISTAT 32
OXSORALEN-ULTRA 91
OXTELLAR XR 24
oxybutynin chloride 104
oxycodone 10mg/0.5ml oral syringe 11
oxycodone hcl 9,11
oxycodone hcl/acetaminophen 11
oxycodone hcl/aspirin 11
OXYCONTIN 9
oxymorphone hcl 9,11
OXYTROL 104
OZEMPIC 62
PAGE 170 LAST UPDATED 08/2019
PPACERONE 71
PACNEX 91
PACNEX HP 91
PACNEX LP 91
PAINGO KFT 13
paliperidone 50
PALYNZIQ 103
PAMELOR 28
PANCREAZE 103
PANCRELIPASE 5,000 103
PANDEL 110
PANLOR 11
PANRETIN 46
pantoprazole sodium 102
PARAFON FORTE DSC 151
PARAGARD T 380-A 135
paregoric 100
PAREMYD 137
paricalcitol 134
PARLODEL 48
PARNATE 26
PAROEX 87
paromomycin sulfate 14
paroxetine hcl 27
paroxetine mesylate 27
PASER 35
PATADAY 138
PATANASE 143
PATANOL 138
PAXIL 27
PAXIL CR 27
PAZEO 138
PCE 19
PEDIADERM HC 110
PEDIAPRED 110
peg 3350/sod sulf/sod bicarb/sod
chloride/potassium chloride 101
PEG-PREP 101
PEGANONE 24
PEGASYS 54
PEGASYS PROCLICK 54
PEGINTRON 54
PEGINTRON REDIPEN 54
penicillamine 97
penicillin v potassium 18
PENLAC 32
PENNSAID 7
PENTASA 132
pentazocine hcl/naloxone hcl 11
pentoxifylline 75
PEPCID 100
PERCOCET 11
PERFOROMIST 144
PERIDEX 87
perindopril erbumine 70
PERIOGARD 87
permethrin 47
perphenazine 29
perphenazine/amitriptyline hcl 26
PERSANTINE 68
PERTZYE 103
PEXEVA 27
PHENADOZ 29
phenazopyridine hcl 106
phendimetrazine tartrate 84
phenelzine sulfate 26
PHENERGAN 29
phenobarbital 23
phenoxybenzamine hcl 69
phentermine hcl 84
phenylephrine hcl 137
phenylephrine hcl/promethazine hcl 149
PHENYTEK 24
phenytoin 24
phenytoin sodium extended 24
PHILITH 121
PHOSLO 97
PHOSLYRA 97
PHOSPHASAL 16
PHOSPHOLINE IODIDE 140
phytonadione (vit k1) 68
PICATO 91
PIFELTRO 56
pilocarpine hcl 87,140
pimecrolimus 91
pimozide 49
PIMTREA 121
pindolol 72
pioglitazone hcl 62
pioglitazone hcl/glimepiride 62
pioglitazone hcl/metformin hcl 62
PIQRAY 40
PIRMELLA 121
piroxicam 7
PLAN B ONE-STEP 121
PLAQUENIL 47
PLAVIX 68
PLEGRIDY 86
PLEGRIDY PEN 86
PLENVU 101
PLETAL 68
PLEXION 92
PLIXDA 92
podofilox 92
POLYCIN 137
polymyxin b sulfate/trimethoprim 137
POLYTRIM 137
POMALYST 37
PONSTEL 7
PORTIA 121
POTABA 98
potassium bicarbonate/citric acid 96
potassium chloride 96
potassium chloride/potassium
bicarbonate/citric acid 96
potassium citrate 96
potassium citrate/citric acid 96
POTIGA 22
PRADAXA 66
PRALUENT 79
pramipexole di-hcl 48
PAGE 171 LAST UPDATED 08/2019
PRAMOSONE 92
PRAMOSONE E 92
PRANDIN 62
prasugrel hcl 68
PRAVACHOL 78
pravastatin sodium 78
praziquantel 46
prazosin hcl 69
precision xtra monitor 64
precision xtra test strips 64
PRECOSE 62
PRED FORTE 139
PRED MILD 139
PRED-G 137
prednicarbate 110
prednisolone 110
prednisolone acetate 139
prednisolone sodium phosphate 110,139
prednisone 110
PREDNISONE INTENSOL 110
PREFEST 121
PREGNYL 114
PREMARIN 121
PREMPHASE 121
PREMPRO 121
PREPOPIK 101
PRESTALIA 75
PREVACID 102
PREVALITE 79
PREVIDENT 96
PREVIDENT 5000 96
PREVIDENT 5000 ENAMEL PROTECT 96
PREVIDENT 5000 PLUS 96
PREVIDENT 5000 SENSITIVE 96
PREVIFEM 121
PREVPAC 100
PREVYMIS 51
PREZCOBIX 58
PREZISTA 58
PRIFTIN 35
PRILOLID 13
PRILOSEC 102
primaquine phosphate 47
primidone 23
PRIMLEV 11
PRIMSOL 16
PRINIVIL 70
PRISTIQ 27
PROAIR HFA 144
PROAIR RESPICLICK 144
probenecid 33
probenecid/colchicine 33
PROCARDIA 73
PROCARDIA XL 73
PROCENTRA 81
prochlorperazine 29
prochlorperazine maleate 29
PROCORT 92
PROCRIT 67
PROCTO-MED HC 110
PROCTO-PAK 110
PROCTOCORT 110
PROCTOFOAM-HC 92
PROCTOSOL-HC 110
PROCTOZONE-HC 110
PROCYSBI 103
PROFENO 7
progesterone 125
progesterone, micronized 125
PROGLYCEM 64
PROGRAF 130
PROLENSA 139
PROMACTA 67
promethazine hcl 29,143
promethazine hcl/codeine 149
promethazine hcl/dextromethorphan hbr 149
promethazine/phenylephrine hcl/codeine 149
PROMETHEGAN 29
PROMETRIUM 125
propafenone hcl 71
propantheline bromide 99
proparacaine hcl 137
propranolol hcl 72
propranolol hcl/hydrochlorothiazide 75
propylthiouracil 127
PROSCAR 105
PROTONIX 102
PROTOPIC 92
protriptyline hcl 28
PROVENTIL HFA 144
PROVERA 125
PROVIGIL 152
PROZAC 27
PROZAC WEEKLY 27
PRUDOXIN 92
PSORCON 110
PULMICORT 141
PULMICORT FLEXHALER 142
PULMOZYME 145
PURIXAN 37
PYLERA 100
pyrazinamide 35
PYRIDIUM 106
pyridostigmine bromide 34,35
QQBRELIS 70
QBREXZA 92
QMIIZ ODT 7
QNASL 142
QNASL CHILDREN 142
QSYMIA 84
QTERN 62
QUALAQUIN 47
QUARTETTE 121
QUASENSE 121
QUDEXY XR 24
QUESTRAN 79
QUESTRAN LIGHT 79
quetiapine fumarate 50
QUILLICHEW ER 82
QUILLIVANT XR 82
quinapril hcl 70
PAGE 172 LAST UPDATED 08/2019
quinapril hcl/hydrochlorothiazide 75
quinidine gluconate 71
quinidine sulfate 71
quinine sulfate 47
QVAR 142
QVAR REDIHALER 142
Rrabeprazole sodium 102
RADIOGARDASE 97
RAGWITEK 132
RAJANI 121
raloxifene hcl 125
ramipril 70
RANEXA 75
ranitidine hcl 100
RAPAFLO 105
RAPAMUNE 130
rasagiline mesylate 49
RASUVO 130
RAVICTI 104
RAYALDEE 134
RAYOS 111
RAZADYNE 25
RAZADYNE ER 25
REBETOL 54
Rebif 86
RECLIPSEN 121
RECTIV 92
REGIMEX 84
REGLAN 29
REGRANEX 92
RELADOR PAK 13
RELAGARD 106
RELENZA 58
RELEXXII 82
RELISTOR 100
RELPAX 34
REMERON 26
RENAGEL 97
RENVELA 97
repaglinide 62
repaglinide/metformin 62
REPATHA 79
REQUIP 48
REQUIP XL 48
RESCRIPTOR 56
RESCULA 140
reserpine 75
RESTASIS 137
RESTASIS MULTIDOSE 137
RESTORIL 152
RETACRIT 67
RETIN-A 92
RETIN-A MICRO 92
RETIN-A MICRO PUMP 92
RETROVIR 57
REVATIO 147
REVIA 13
REVLIMID 37
REXULTI 50
REYATAZ 58
REZIRA 149
RHEUMATREX 130
RHINOCORT AQUA 142
RHOPRESSA 140
RIBASPHERE 55
RIBASPHERE RIBAPAK 55
RIBATAB 55
ribavirin 55,149
RIDAURA 132
rifabutin 35
RIFADIN 35
RIFAMATE 35
rifampin 35
RIFATER 35
RILUTEK 84
riluzole 84
rimantadine hcl 58
RIMSO-50 106
RIOMET 62
risedronate sodium 134
RISPERDAL 50
RISPERDAL M-TAB 50
risperidone 51
RITALIN 82
RITALIN LA 82
ritonavir 58
rivastigmine 25
rivastigmine tartrate 25
RIVELSA 122
rizatriptan benzoate 34
ROBAXIN 151
ROBAXIN-750 151
ROBINUL 99
ROBINUL FORTE 99
ROCALTROL 134
ROCKLATAN 140
ropinirole hcl 48
ROSADAN 92
ROSANIL 92
ROSULA 92
rosuvastatin calcium 78
ROWASA 132
ROWEEPRA 22
ROWEEPRA XR 22
ROXICODONE 11
ROXYBOND 11
ROZEREM 152
RUBRACA 38
RUCONEST 128
RUZURGI 136
RYCLORA 143
RYDAPT 39
RYTARY 49
RYTHMOL 71
RYTHMOL SR 71
RYVENT 143
SSABRIL 23
SAFYRAL 122
SAIZEN 114
PAGE 173 LAST UPDATED 08/2019
SALAGEN 87
salsalate 7
SAMSCA 97
SANADERMRX 111
SANCUSO 30
SANDIMMUNE 130
SANDOSTATIN 126
SANDOSTATIN LAR 126
SANDOSTATIN LAR DEPOT 126
SANTYL 92
SAPHRIS 51
SARAFEM 27
SAVAYSA 66
SAVELLA 85
SAXENDA 136
SCALACORT 111
scopolamine 29
SEASONIQUE 122
SEB-PREV 92
SECONAL SODIUM 152
SECTRAL 72
SEEBRI NEOHALER 144
SEGLUROMET 62
selegiline hcl 49
selenium sulfide 92
SELRX 92
SELZENTRY 57
SEMPREX-D 149
SENSIPAR 134
SEREVENT DISKUS 144
SERNIVO 111
SEROPHENE 125
SEROQUEL 51
SEROQUEL XR 51
SEROSTIM 114
sertraline hcl 27
SETLAKIN 122
sevelamer carbonate 97
sevelamer hcl 97
SEYSARA 21
SF 96
SF 5000 PLUS 96
SFROWASA 132
SHAROBEL 125
SIGNIFOR 126
SIKLOS 37
SILALITE PAK 111
SILAZONE-II 111
sildenafil citrate 106,147
SILENOR 152
SILIQ 92
silodosin 105
SILVADENE 20
silver nitrate/potassium nitrate 92
silver sulfadiazine 20
silver/bandage/foam/gauze/lidocaine/chlorhexid
in/isopropanol 136
SIMBRINZA 140
SIMPONI 130
simvastatin 78
SINEMET 10-100 49
SINEMET 25-100 49
SINEMET 25-250 49
SINEMET CR 49
SINGULAIR 143
sirolimus 130
SIRTURO 35
SITAVIG 59
SIVEXTRO 16
SKELAXIN 151
SKLICE 46
SKYLA 125
SKYRIZI 93
SKYRIZI (2 SYRINGES) KIT 153
SLYND 125
sodium chloride for inhalation 149
sodium chloride/sodium bicarbonate/potassium
chloride/peg 101
sodium phenylbutyrate 104
sodium polystyrene sulfonate 97
sofosbuvir/velpatasvir 53
SOLARAZE 93
solifenacin succinate 104
SOLIQUA 100-33 65
SOLODYN 21
SOLOSEC 16
SOLTAMOX 37
SOLUPAK 13
SOMA 151
SOMATULINE DEPOT 127
SOMAVERT 127
SONATA 152
SOOLANTRA 93
SORIATANE 93
SORILUX 93
SORINE 71
sotalol hcl 71
SOTYLIZE 71
SOVALDI 53
SPECTRACEF 17
spinosad 93
SPIRIVA 144
SPIRIVA RESPIMAT 144
spironolactone 77
spironolactone/hydrochlorothiazide 75
SPORANOX 32
SPRINTEC 122
SPRITAM 22
SPRIX 7
SPRYCEL 44
SPS 97
SRONYX 122
SSD 20
SSKI 127
SSS 10-5 93
STALEVO 48
STARLIX 62
stavudine 57
STAXYN 106
STEGLATRO 62
STEGLUJAN 63
STELARA 93
STENDRA 106
PAGE 174 LAST UPDATED 08/2019
STIMATE 114
STIOLTO RESPIMAT 149
STIVARGA 44
STRATTERA 82
STRENSIQ 104
STRIANT 115
STRIBILD 55
STRIVERDI RESPIMAT 144
STROMECTOL 46
SUBOXONE 14
SUBSYS 11
SUCRAID 104
sucralfate 101
SULAR 73
sulfacetamide sodium 20,93
sulfacetamide sodium/prednisolone sodium
phosphate 137
sulfacetamide sodium/sulfur 93
sulfadiazine 20
sulfamethoxazole/trimethoprim 20
SULFAMYLON 16
sulfasalazine 133
SULFATRIM 20
sulindac 7
sumatriptan 34
sumatriptan succinate 34
sumatriptan succinate/naproxen sodium 34
SUMAVEL DOSEPRO 34
SUNOSI 152
SUPRAX 17
SUPRENZA ODT 84
SUPREP 101
SURMONTIL 28
SUSTIVA 56
SUSTOL 30
SUTENT 44
SYEDA 122
SYLATRON 39
SYMAX 99
SYMAX DUOTAB 99
SYMAX-SL 99
SYMAX-SR 99
SYMBICORT 149
SYMBYAX 26
SYMDEKO 145
SYMFI 56
SYMFI LO 56
SYMJEPI 145
SYMLINPEN 120 63
SYMLINPEN 60 63
SYMPAZAN 23
SYMPROIC 100
SYMTUZA 58
SYNALAR 111
SYNALAR TS 111
SYNALGOS-DC 11
SYNAREL 127
SYNDROS 30
SYNJARDY 63
SYNJARDY XR 63
SYNTHROID 125
SYPRINE 97
syringe, insulin u-500 with needle, disposable,
0.5 ml 136
TTABLOID 38
TACLONEX 93
tacrolimus 93,130
tadalafil 105,106
TAFINLAR 44
TAGRISSO 44
TAKE ACTION 122
TAKHZYRO 128
Taltz 93
TALZENNA 44
TAMIFLU 58
tamoxifen citrate 37
tamsulosin hcl 105
TANZEUM 63
TAPAZOLE 127
TAPERDEX 111
TARCEVA 44
TARGADOX 21
TARGRETIN 46
TARINA 24 FE 122
TARINA FE 122
TARKA 75
TASIGNA 44
TASMAR 48
TAVALISSE 67
TAYTULLA 122
tazarotene 93
TAZORAC 94
TAZTIA XT 73
TECFIDERA 86
TECHNIVIE 53
TEGRETOL 25
TEGRETOL XR 25
TEGSEDI 84
TEKTURNA 75
TEKTURNA HCT 75
telmisartan 70
telmisartan/amlodipine besylate 76
telmisartan/hydrochlorothiazide 76
temazepam 152
TEMODAR 36
TEMOVATE 111
temozolomide 36
TENCON 84
TENEX 69
tenofovir disoproxil fumarate 57
TENORETIC 100 76
TENORETIC 50 76
TENORMIN 72
TERAZOL 3 32
TERAZOL 7 32
terazosin hcl 69
terbinafine hcl 32
terbutaline sulfate 145
terconazole 32
TESSALON PERLE 149
TESTIM 115
PAGE 175 LAST UPDATED 08/2019
testosterone 115
testosterone (10 mg (2%) gel md pmp,
12.5/1.25g gel md pmp, 50 mg (1%) gel
(gram) 115
testosterone (50 mg (1%) gel packet and
12.5/1.25g pump). some manufacturers are t3
and others t1 115
testosterone cypionate 115
testosterone enanthate 115
TESTRED 115
tetrabenazine 84
tetracycline hcl 21
TETRAVISC 137
TETRAVISC FORTE 137
TEXACORT 111
THALOMID 37
THEO-24 146
THEOCHRON 146
theophylline anhydrous 146
THERMAZENE 20
THIOLA 106
THIOLA EC 106
thioridazine hcl 49
thiothixene 50
THYROLAR-1 125
THYROLAR-1/2 125
THYROLAR-1/4 125
THYROLAR-2 126
THYROLAR-3 126
tiagabine hcl 23
TIAZAC 73
TIBSOVO 39
TICALAST 149
TICANASE 142
TICASPRAY 142
ticlopidine hcl 68
TIGAN 29
TIGLUTIK 84
TIKOSYN 71
TILIA FE 122
timolol maleate 72,140
TIMOPTIC 140
TIMOPTIC OCUDOSE 140
TIMOPTIC-XE 140
TINDAMAX 16
tinidazole 16
TIROSINT 126
TIROSINT-SOL 126
TIVICAY 55
TIVORBEX 7
tizanidine hcl 51
TL G-FOL OS 96
TOBI 149
TOBI PODHALER 145
TOBRADEX 137
TOBRADEX ST 137
tobramycin 14
tobramycin in 0.225 % sodium chloride 149
tobramycin/dexamethasone 137
tobramycin/nebulizer 146
TOBREX 14
TODAY CONTRACEPTIVE SPONGE 106
TOFRANIL 28
TOFRANIL-PM 28
TOLAK 94
tolazamide 63
tolbutamide 63
tolcapone 48
tolmetin sodium 7
TOLSURA 32
tolterodine tartrate 105
TOPAMAX 24
TOPICORT 111
topiramate 24
topiramate er caps 24
TOPROL XL 72
toremifene citrate 37
torsemide 76
TOUJEO MAX SOLOSTAR 65
TOUJEO SOLOSTAR 65
TOVIAZ 105
TRACLEER 147
TRADJENTA 63
tramadol er caps 9
tramadol hcl 9,11
tramadol hcl/acetaminophen 11
trandolapril 70
trandolapril/verapamil hcl 76
tranexamic acid 68
TRANSDERM-SCOP 29
TRANXENE T-TAB 59
tranylcypromine sulfate 26
TRAVATAN Z 140
trazodone hcl 27
TRECATOR 35
TRELEGY ELLIPTA 149
TREMFYA 94
TRESIBA 65
TRESIBA FLEXTOUCH U-100 65
TRESIBA FLEXTOUCH U-200 65
TRETIN-X 94
tretinoin 46,94
tretinoin microspheres 94
tretinoin/emollient base 94
TREXALL 130
TREXIMET 34
TREZIX 11
TRI FEMYNOR 122
TRI-CHLOR 94
TRI-ESTARYLLA 122
TRI-LEGEST FE 122
TRI-LINYAH 122
TRI-LO-ESTARYLLA 122
TRI-LO-MARZIA 122
TRI-LO-SPRINTEC 122
TRI-MILI 122
TRI-NORINYL 122
TRI-PREVIFEM 122
TRI-SILA 111
TRI-SPRINTEC 122
TRI-VYLIBRA 122
TRI-VYLIBRA LO 122
triamcinolone acetonide 87,111,142
PAGE 176 LAST UPDATED 08/2019
triamterene/hydrochlorothiazide 76
TRIANEX 111
triazolam 152
TRIBENZOR 76
TRICOR 78
TRIDERM 111
TRIDESILON 111
trientine hcl 97
trifluoperazine hcl 50
trifluridine 59
TRIGLIDE 78
trihexyphenidyl hcl 47
TRILEPTAL 25
TRILIPIX 78
TRILYTE WITH FLAVOR PACKETS 101
trimethobenzamide hcl 29
trimethoprim 16
trimipramine maleate 28
TRIMPEX 16
TRINESSA 122
TRINESSA LO 122
TRINTELLIX 27
TRIUMEQ 57
TRIVORA-28 122
TRIXYLITRAL 134
TRIZIVIR 57
TROKENDI XR 24
tropicamide 137
trospium chloride 105
TRULANCE 100
TRULICITY 63
TRUSOPT 140
TRUVADA 57
TUDORZA PRESSAIR 144
TULANA 125
TUSSICAPS 149
TUSSIGON 150
TUSSIONEX 150
TUZISTRA XR 150
TWYNSTA 76
TYBOST 57
TYDEMY 123
TYKERB 45
TYLENOL-CODEINE NO.3 11
TYLENOL-CODEINE NO.4 11
TYMLOS 134
Tyvaso 147
TYZEKA 52
TYZINE 150
UUCERIS 133
UDENYCA 68
ULESFIA 94
ULORIC 33
ULTRACET 11
ULTRAM 11
ULTRAM ER 9
ULTRAVATE 111
ULTRAVATE X 111
ULTRESA 104
UNITHROID 126
UPTRAVI 147
UR N-C 16
URECHOLINE 106
URELLE 16
URETRON D-S 16
URIBEL 16
URIMAR-T 16
URIN D.S. 16
URO-458 17
URO-MP 17
UROCIT-K 96
UROGESIC-BLUE 17
UROQID-ACID NO.2 106
UROXATRAL 105
URSO 100
URSO FORTE 100
ursodiol 100
URYL 17
UTIBRON NEOHALER 150
UTIRA-C 17
VVAGIFEM 123
valacyclovir hcl 59
VALCHLOR 36
VALCYTE 51
valganciclovir hcl 51
VALIUM 59
valproic acid 23
valproic acid (as sodium salt) (valproate
sodium) 23
valsartan 70
valsartan/hydrochlorothiazide 76
VALTREX 59
VANATOL LQ 84
VANCOCIN HCL 17
vancomycin hcl 17
VANDAZOLE 17
VANOS 111
vardenafil hcl 106
VARUBI 30
VASCEPA 79
VASERETIC 76
VASOTEC 70
VCF 106
VECAMYL 76
VECTICAL 94
VELIVET 123
VELPHORO 97
VELTASSA 97
VELTIN 94
VEMLIDY 52
VENCLEXTA 45
venlafaxine er tab (tier dependent on
manufacturer. ucb t3, others t1) 28
venlafaxine hcl 28
VENTOLIN HFA 145
VERAMYST 142
verapamil hcl 73
VERDESO 112
VERDROCET 11
PAGE 177 LAST UPDATED 08/2019
VEREGEN 94
VERELAN 73
VERELAN PM 73
VERIPRED 20 112
VERSACLOZ 51
VERZENIO 45
VESICARE 105
VESTURA 123
VEXOL 139
VFEND 32
VIAGRA 106
VIBERZI 100
VIBRAMYCIN 21
VICODIN 11
VICODIN ES 12
VICODIN HP 12
VICTOZA 2-PAK 63
VICTOZA 3-PAK 63
VIDEX 57
VIDEX EC 57
VIEKIRA PAK 53
VIEKIRA XR 53
VIENVA 123
vigabatrin 23
VIGAMOX 19
VIIBRYD 28
VIMOVO 7
VIMPAT 25
VIOKACE 104
VIORELE 123
VIRACEPT 58
VIRAMUNE 56
VIRAMUNE XR 56
VIRAZOLE 150
VIREAD 57
VIROPTIC 59
VISTARIL 143
VITEKTA 55
VITRAKVI 39
VITUZ 150
VIVELLE-DOT 123
VIVLODEX 7
VIZIMPRO 39
VOGELXO 115
VOLTAREN 94
VOLTAREN-XR 7
voriconazole 32
VOSEVI 53
VOSPIRE ER 145
VOTRIENT 45
VRAYLAR 51
VUSION 32
VYFEMLA 123
VYLIBRA 123
VYNDAQEL 76
VYTONE 94
VYTORIN 79
VYVANSE 81
VYZULTA 140
Wwarfarin sodium 66
WELCHOL 79
WELLBUTRIN 26
WELLBUTRIN SR 26
WELLBUTRIN XL 26
WERA 123
WESTHROID 126
WHYTEDERM TRILASIL PAK 112
WIXELA INHUB 150
WP THYROID 126
WYMZYA FE 123
XXADAGO 49
XALATAN 140
XALKORI 45
XANAX 59
XANAX XR 60
XARELTO 66
XARTEMIS XR 12
XATMEP 130
XELITRAL 94
XELJANZ 130
XELJANZ XR 130
XELODA 38
XELPROS 140
XENAFLAMM 136
XENAZINE 84
XENICAL 100
XEPI 94
XERESE 59
XERMELO 136
XHANCE 142
XIFAXAN 100
XIGDUO XR 63
XIIDRA 137
XIMINO 21
XODOL 10-300 12
XODOL 5-300 12
XODOL 7.5-300 12
XOFLUZA 132
XOLEGEL 32
XOPENEX 145
XOPENEX CONCENTRATE 145
XOPENEX HFA 145
XOSPATA 39
XRYLIX 94
XTAMPZA ER 9
XTANDI 36
XULANE 123
XULTOPHY 100-3.6 65
XURIDEN 98
XYLON 10 12
XYOSTED 115
XYREM 152
XYZAL 143
YYASMIN 28 123
YAZ 123
YONSA 36
YUPELRI 144
PAGE 178 LAST UPDATED 08/2019
YUVAFEM 123
Zzafirlukast 143
zaleplon 152
ZAMICET 12
ZANAFLEX 51
ZANTAC 100
ZARAH 123
ZARONTIN 22
ZARXIO 68
ZAVESCA 104
ZEBETA 72
ZEBUTAL 84
ZEGERID 102
ZEJULA 45
ZELAPAR 49
ZELBORAF 45
ZEMBRACE SYMTOUCH 34
ZEMPLAR 134
ZENATANE 94
ZENCHENT 123
ZENCHENT FE 123
ZENPEP 104
ZENZEDI 81
ZEPATIER 54
ZERIT 57
ZESTORETIC 76
ZESTRIL 70
ZETIA 79
ZETONNA 142
ZEYOCAINE 94
ZIAC 76
ZIAGEN 57
ZIANA 94
zidovudine 57
zileuton 143
ZINBRYTA 86
ZIOPTAN 140
ziprasidone hcl 51
ZIPSOR 7
ZIRGAN 51
ZITHROMAX 19
ZITHROMAX TRI-PAK 19
ZMAX 19
ZOCOR 78
ZODEX 112
ZOFRAN 30
ZOFRAN ODT 30
ZOHYDRO ER 9
ZOLINZA 39
zolmitriptan 34
ZOLOFT 28
zolpidem tartrate 152
ZOLPIMIST 152
ZOMACTON 114
ZOMIG 34
ZOMIG ZMT 34
ZONALON 94
ZONEGRAN 22
zonisamide 22
ZONTIVITY 66
ZORBTIVE 114
ZORTRESS 130
ZORVOLEX 7
ZOVIA 1-35E 123
ZOVIA 1-50E 123
ZOVIRAX 59
ZTLIDO 13
ZUBSOLV 14
ZUPLENZ 30
ZUTRIPRO 150
ZYBAN 14
ZYCLARA 94
ZYDELIG 45
ZYFLO 143
ZYFLO CR 143
ZYKADIA 45
ZYLET 137
ZYLOPRIM 33
ZYMAXID 19
ZYPITAMAG 78
ZYPRAM 94
ZYPREXA 51
ZYPREXA ZYDIS 51
ZYTIGA 36
ZYVOX 17
PAGE 179 LAST UPDATED 08/2019