list of covered over-the-counter medications
TRANSCRIPT
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
ADULT ASPIRIN REGIMENaspirin
BRAND 1
ASPIR 81aspirin
BRAND 1
ASPIR-LOWaspirin
BRAND 1
ASPIRIN (600 MG SUPPOSITORY, GS 81 MGCHEWABLE TAB, 325 MG TABLET, SM 81MG CHEWABLE TAB, QC 81 MG CHEWABLETAB, HM 325 MG TABLET, HM 81 MGCHEWABLE TAB, 300 MG SUPPOSITORY,SM 325 MG TABLET, GS 325 MG TABLET, 81MG CHEWABLE TABLET, QC 325 MGTABLET)
generic 1
ASPIRIN EC (SM 81 MG, 500 MG, SM 325MG, 81 MG, HM 81 MG, HM 325 MG, QC 81MG, QC 325 MG, 325 MG)
generic 1
CHILDREN'S ASPIRIN (SM 81 MG CHW, 81MG CHEW)
generic 1
ECPIRINaspirin
BRAND 1
ANESTHETICS
LOCAL ANESTHETICS
lidocaine 3% cream generic 1
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
NICORETTE (2 MG, 4 MG)nicotine polacrilex
BRAND 1 AL At least 18 yrs old
NICOTINE GUM (HM 4 MG, 2 MG, 4 MG, SM2 MG, SM 4 MG, HM 2 MG)
generic 1 AL At least 18 yrs old
NICOTINE LOZENGE (2 MG MINI, 4 MG MINI,SM 2 MG, HM 2 MG MINI, GS 2 MG MINI, GS4 MG MINI, 4 MG, GS 4 MG, 2 MG, HM 2 MG,SM 4 MG, HM 4 MG)
generic 1 AL At least 18 yrs old
NICOTINE PATCH (HM 7 MG/24HR PATCH, 7 generic 1 AL At least 18 yrs old
PAGE 1 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
MG/24HR PATCH, TRANSDERMAL SYSTEM,SM 7 MG/24HR PATCH, HM 14 MG/24HRPATCH, SM 14 MG/24HR PATCH, SM 21MG/24HR PATCH, HM 21 MG/24HR PATCH,14 MG/24HR PATCH, 21 MG/24HR PATCH)
ANTIFUNGALS
3 DAY VAGINALmiconazole nitrate
BRAND 1
3-DAY VAGINAL CREAM (SM, )clotrimazole
BRAND 1
CLOTRIMAZOLE (SM VAG, VAGINAL) generic 1
clotrimazole-3 2% cream generic 1
miconazole 1 combination pack generic 1
MICONAZOLE 3 4% CREAMmiconazole nitrate
BRAND 1
MICONAZOLE 7 (SM 7 100 MG VAG SUP, SM7 CREAM, 7 100 MG VAG SUPP, 7 CREAM)
generic 1
MICONAZOLE NITRATE (VAGINAL, SMVAGINAL, TOPICAL)
generic 1
qc miconazole-7 cream generic 1
BLOOD GLUCOSE REGULATORS
INSULINS
HUMULIN 70-30insulin nph human isophane/insulin regular,human
BRAND 1
HUMULIN 70/30 KWIKPENinsulin nph human isophane/insulin regular,human
BRAND 1
HUMULIN Ninsulin nph human isophane
BRAND 1
HUMULIN N KWIKPENinsulin nph human isophane
BRAND 1
HUMULIN Rinsulin regular, human
BRAND 1
NOVOLIN Ninsulin nph human isophane
BRAND 1
NOVOLIN Rinsulin regular, human
BRAND 1
PAGE 2 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
8 HOUR ACETAMINOPHEN ER 650 MGacetaminophen
BRAND 1
SM 8 HOUR PAIN RELIEF 650 MGacetaminophen
BRAND 1
8HR ARTHRITIS PAINacetaminophen
BRAND 1
8HR MUSCLE ACHE-PAIN ER 650 MGacetaminophen
BRAND 1
acetaminophen 160 mg/5 ml liq generic 1 AL Up to 6 yrs old
acetaminophen er 650 mg caplet generic 1
acetaminophen er 650 mg tablet generic 1
GS ARTHRITIS PAIN ER 650 MGacetaminophen
BRAND 1
ARTHRITIS PAIN RELIEF (RELF ER 650 MG,SM ER 650 MG, QC ER 650 MG)acetaminophen
BRAND 1
ARTHRITIS PAIN RELIEF (SM ARTHRIT RLFER 650 MG, ARTHRITIS ER 650 MG CAPLT,HM ARTHRITIS ER 650 MG, HM ARTHRITRLF ER 650 MG)acetaminophen
BRAND 1
CHILDREN'S ACETAMINOPHEN (HM CHILD160 MG, CHLD 160 MG/5 ML, CHILD 160 MG)
generic 1 AL Up to 6 yrs old
CHILD'S MAPAP 160 MG TAB CHEWacetaminophen
BRAND 1 AL Up to 6 yrs old
CHILDREN'S PAIN RELIEF (160 ML SUS, QC160 ML)acetaminophen
BRAND 1 AL Up to 6 yrs old
CHILD'S PAIN RELIEVER SUSPacetaminophen
BRAND 1 AL Up to 6 yrs old
CHILDREN'S PAIN-FEVER (GS CHLD 160ML, SM CHLD 160 ML, HM CHLD 160 ML,CHILD 160 ML)acetaminophen
BRAND 1 AL Up to 6 yrs old
CHILDREN'S SILAPAPacetaminophen
BRAND 1 AL Up to 6 yrs old
ED-APAPacetaminophen
BRAND 1 AL Up to 6 yrs old
1
PAGE 3 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
INFANT PAIN-FEVER 160 MG/5 MLacetaminophen
BRAND AL Up to 6 yrs old
inf acetaminophen 160 mg/5 ml generic 1 AL Up to 6 yrs old
INFANT PAIN RELIEF 160 MG/5 MLacetaminophen
BRAND 1 AL Up to 6 yrs old
QC INFANT PAIN RLF 160 MG/5 MLacetaminophen
BRAND 1 AL Up to 6 yrs old
INFANTS' PAIN-FEVER (INFANTS 160 ML,GS INFANT 160, SM INFANT 160, HMINFANT 160)acetaminophen
BRAND 1 AL Up to 6 yrs old
JR. STR NON-ASPIRIN PAINacetaminophen
BRAND 1 AL Up to 6 yrs old
M-PAPacetaminophen
BRAND 1 AL Up to 6 yrs old
MAPAP ARTHRITIS PAINacetaminophen
BRAND 1
PAIN RELIEF ER 650 MG CAPLETacetaminophen
BRAND 1
PAIN RELIEVER JUNIOR STRENGTHacetaminophen
BRAND 1 AL Up to 6 yrs old
DERMATOLOGICAL AGENTS
VANALICEpiperonyl butoxide/pyrethrins
BRAND 1
ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
CALCITRATEcalcium citrate
BRAND 1
calcium 600 mg tablet generic 1
calcium carb 1,250 mg/5 ml sus generic 1
children's ferrous sulfate generic 1
FEOSOL (65 MG TABLET, 45 MG CAPLET)ferrous sulfate
BRAND 1
FER-IN-SOLferrous sulfate
BRAND 1
FERATEferrous gluconate
BRAND 1
FEROSUL 325 MG TABLET BRAND 1
PAGE 4 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
ferrous sulfate
FERRIMIN 150ferrous fumarate
BRAND 1
FERRO-TIMEferrous sulfate
BRAND 1
ferrous fumarate 324 mg tab generic 1
ferrous gluconate 324 mg tab generic 1
FERROUS SULFATE (SULF 300 MG/5 MLLIQ, SULFATE 325 MG TABLET, SULF EC325 MG TABLET, SULF 220 MG/5 ML ELIX,SULF 44 MG IRON/5ML LQ, SULF EC 324 MGTABLET, SULF 15 MG IRON/ML DRP)
generic 1
FERROUSULferrous sulfate
BRAND 1
HEMOCYTEferrous fumarate
BRAND 1
IRON (45 MG, 65 MG) generic 1
OYSCO-500calcium carbonate
BRAND 1
oyster shell calcium generic 1
hm slow release iron tablet generic 1
PHOSPHATE BINDERS
calcium acetate 668 mg tablet generic 1
VITAMINS
AQUADEKS PEDIATRIC LIQUIDpediatric multivitamin no.40/phytonadione (vitk1)
BRAND 1QL
AL Up to 3 yrs old
AQUADEKS CHEWABLE TABLETmultivitamin, minerals no.51/folic acid/vitk1/ubidecarenone
BRAND 1 AL At least 4 yrs old
CORVITAfolic acid/multivitamin,ther andminerals/lycopene/lutein
BRAND 1
POLY-VI-FLOR (0.25 MG DROPS, 0.5 MGTAB CHEW, 0.25 MG TAB CHEW, 1 MG TABCHEW)pediatric multivitamin no.33 with sodiumfluoride
BRAND 1 AL Up to 12 yrs old
POLY-VI-FLOR WITH IRON (0.25 MG, 0.5MG)pediatric multivitamin no.33/sodium fluoride/iron
BRAND 1 AL Up to 12 yrs old
PAGE 5 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
carbonyl
TRI-VI-FLORpediatric multivitamin a,c,and d3 no.38 withsodium fluoride
BRAND 1 AL Up to 12 yrs old
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
ANTACID (500 MG CHEW TABLET, GS 500MG CHEWABLE TAB, HM 500 MG CHEWTABLET)calcium carbonate
BRAND 1
ANTACID CALCIUMcalcium carbonate
BRAND 1
ANTACID EXTRA STRENGTH (HM EX-STR750 MG CHWTB, XTRA STRENGTH CHEWTAB, EX-STR 750 MG TAB CHEW)calcium carbonate
BRAND 1
ANTACID ULTRA STR 1,000 MG CHWcalcium carbonate
BRAND 1
CAL-GESTcalcium carbonate
BRAND 1
CALCIUM ANTACID (CALCIUM 750 MG TBCHEW, EX-STR TABLET CHEW, HM CAL1000 MG CHEW TB, SM CAL 500 MG CHEWTAB, CALCIUM EX-STR TABLET, CALCIUM500 MG CHW TAB, CALCIUM 1,000 MG TAB,GS CAL 500 MG CHEW TAB, HM CAL 750MG CHEW TAB)calcium carbonate
BRAND 1
calcium carbonate 648 mg tab generic 1
TUMS (TABLET CHEWABLE, E-X TABLETCHEWABLE, KIDS 300 MG (750) CHEWTAB)calcium carbonate
BRAND 1
TUMS FRESHERScalcium carbonate
BRAND 1
TUMS SMOOTHIEScalcium carbonate
BRAND 1
TUMS ULTRAcalcium carbonate
BRAND 1
TUMS ULTRA STRENGTHcalcium carbonate
BRAND 1
TUMS X-STRcalcium carbonate
BRAND 1
PAGE 6 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
SM CALCIUM ANTACID TAB CHEWcalcium carbonate
BRAND 1
LAXATIVES
CLEARLAX POWDERpolyethylene glycol 3350
BRAND 1
ENEMEEZ (, PLUS)docusate sodium
BRAND 1 AL At least 12 yrs old
polyethylene glycol 3350 generic 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
AFTERAlevonorgestrel
BRAND 1 AL At least 12 yrs old
ECONTRA EZlevonorgestrel
BRAND 1 AL At least 12 yrs old
ECONTRA ONE-STEPlevonorgestrel
BRAND 1 AL At least 12 yrs old
levonorgestrel generic 1 AL At least 12 yrs old
MY CHOICElevonorgestrel
BRAND 1 AL At least 12 yrs old
MY WAYlevonorgestrel
BRAND 1 AL At least 12 yrs old
NEW DAYlevonorgestrel
BRAND 1 AL At least 12 yrs old
OPCICON ONE-STEPlevonorgestrel
BRAND 1 AL At least 12 yrs old
PLAN B ONE-STEPlevonorgestrel
BRAND 1 AL At least 12 yrs old
TAKE ACTIONlevonorgestrel
BRAND 1 AL At least 12 yrs old
MISCELLANEOUS THERAPEUTIC AGENTS
ANTACID 750 MG CHEWABLE TABLETcalcium carbonate
BRAND 1
RESPIRATORY TRACT/PULMONARY AGENTS
ANTIHISTAMINES
ALL DAY ALLERGY (10 MG TABLET, QC 10MG TAB, SM 10 MG TAB, HM 10 MG TAB)cetirizine hcl
BRAND 1
PAGE 7 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
ALLERGY (LORATADINE) 10 MG TABloratadine
BRAND 1 QL
ALLERGY RELIEF 5 MG/5 ML SOLNloratadine
BRAND 1 AL Up to 11 yrs old
ALLERGY RELIEF (10 MG, GS 10 MG)loratadine
BRAND 1 QL
ALLERGY RELIEF (SM RELIEF 10 MG ODT,RELIEF 10 MG ODT, RLF (CETRZN) 10 MGTAB)loratadine
BRAND 1
cetirizine hcl 1 mg/ml soln generic 1 AL Up to 11 yrs old
CETIRIZINE HCL (5 MG, 10 MG) generic 1
CHILDREN'S ALL DAY ALLERGY (SM ER 1MG/ML, GS ER 1 MG/ML, ERGY 1 MG/ML)cetirizine hcl
BRAND 1 AL Up to 11 yrs old
HM CHILD ALL DAY ALLER 1 MG/MLcetirizine hcl
BRAND 1 AL Up to 11 yrs old
CHILDREN'S ALLERGY (CHILD 5 MG/5 MLSOLN, QC CHILDREN'S 1 MG/ML)loratadine
BRAND 1 AL Up to 11 yrs old
SM CHILD ALLERGY 5 MG/5 ML SOLloratadine
BRAND 1 AL Up to 11 yrs old
CHILD ALLERGY RELIEF 1 MG/MLcetirizine hcl
BRAND 1 AL Up to 11 yrs old
CHILDREN'S CETIRIZINE HCL (HCL 1MG/ML, HM 1 MG/ML)
generic 1 AL Up to 11 yrs old
CHILDREN'S LORATADINE (HM 5 ML, 5 MLSYR, SM 5 ML, 5 ML SOL)
generic 1 AL Up to 11 yrs old
LORATADINE (5 ML, SM 5 ML) generic 1 AL Up to 11 yrs old
LORATADINE (HM 10 MG, SM 10 MG) generic 1
LORATADINE (QC 10 MG, 10 MG) generic 1 QL
loratadine allergy generic 1 AL Up to 11 yrs old
RESPIRATORY TRACT AGENTS, OTHER
ADULT TUSSIN CHEST CONGESTIONguaifenesin
BRAND 1
ADULT TUSSIN COUGH CONGEST DMguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
ALL DAY ALLERGY-D (, GNP, SM)cetirizine hcl/pseudoephedrine hcl
BRAND 1
PAGE 8 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
ALLERGY COMPLETE-Dcetirizine hcl/pseudoephedrine hcl
BRAND 1
ALLERGY RELIEF D-24HR TABLETloratadine/pseudoephedrine sulfate
BRAND 1
ALLERGY RELIEF-NASAL DECONGESTloratadine/pseudoephedrine sulfate
BRAND 1
ALLERGY-CONGESTION 12HRloratadine/pseudoephedrine sulfate
BRAND 1
ALLERGY-CONGES RELF ER TABLETloratadine/pseudoephedrine sulfate
BRAND 1
cetirizine-pseudoephedrine er generic 1
CHEST CONGESTION RELIEF (HMCONGEST RLF 400 MG TB, CONGEST RLF400 MG TAB, SM CONGESTION RELIEFCAP)guaifenesin
BRAND 1
CHILD MUCINEX CHEST MINI-MELTSguaifenesin
BRAND 1
CHILD MUCINEX COUGH MINI-MELTSguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
CHILD MUCUS-COUGH RELIEFguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
CHILDREN'S MUCUS RELIEFguaifenesin
BRAND 1
COUGH DMguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
GUAIFENESIN (200 MG/10 ML, 300 MG/15ML, 100 MG/5 ML)
generic 1
GUAIFENESIN-DEXTROMETHORPHAN(GUAIFENESIN-DM 200-20 MG/10 ML,GUAIFENESIN-DM 100-10 MG/5 ML,GUAIFENESIN DM SYRUP)
generic 1 AL Up to 20 yrs old
guaifenesin-dm er generic 1 AL Up to 20 yrs old
LIQUITUSS GGguaifenesin
BRAND 1
LORATA-DINE Dloratadine/pseudoephedrine sulfate
BRAND 1
LORATADINE-D (24HR, SM 12 HOUR, QC24HR, 12 HOUR)loratadine/pseudoephedrine sulfate
BRAND 1
MUCINEX BRAND 1
PAGE 9 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
guaifenesin
MUCINEX DM ER 600-30 MG TABLETguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCOSAguaifenesin
BRAND 1
MUCUS DM MAX ER 1,200-60 MG TBguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCUS ER 600 MG TABLETguaifenesin
BRAND 1
MUCUS RELIEF (QC 400 MG CAPLET, 400MG TABLET)guaifenesin
BRAND 1
MUCUS RELIEF CHEST CONGESTIONguaifenesin
BRAND 1
MUCUS RELIEF DM COUGHguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCUS RLF DM ER 600-30 MG TABguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCUS RELIEF DM MAX LIQUIDguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCUS RELIEF DM MAX ERguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
MUCUS RELIEF ER (ER 600 MG TABLET, ER1,200 MG TAB, QC ER 600 MG TAB, SM ER600 MG TAB, QC ER 1,200 MG TB)guaifenesin
BRAND 1
MUCUS-CHEST CONGESTIONguaifenesin
BRAND 1
MUCUS-ER MAX (MG TABLET, SM MG TAB)guaifenesin
BRAND 1
ROBAFEN 200 MG/10 ML SYRUPguaifenesin
BRAND 1
ROBAFEN DM COUGHguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
ROBAFEN DM PEAK COLDguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
SILTUSSIN SAguaifenesin
BRAND 1
TUSSIN (100 MG/5 ML SYRUP, 400 MGTABLET)guaifenesin
BRAND 1
PAGE 10 LAST UPDATED 04/2020
DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS
TUSSIN CHEST CONGESTION LIQUIDguaifenesin
BRAND 1
TUSSIN DM (400-20 MG/20 ML LIQ, SM 400-20 MG/20 ML, LIQUID)guaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
HM TUSSIN DM MAX LIQUIDguaifenesin/dextromethorphan hbr
BRAND 1 AL Up to 20 yrs old
TUSSIN HONEYguaifenesin
BRAND 1
TUSSIN MUCUS-CHEST CONGESTION (GS200 MG/10, GS 100 MG/5, 200 MG/10, SM 200MG/10, QC 200 MG/10)guaifenesin
BRAND 1
PAGE 11 LAST UPDATED 04/2020
LIST OF COVERED PRESCRIPTION MEDICATIONS DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalb-aspirin-caffe 50-325-40 generic 1
celecoxib generic 1
DICLOFENAC SODIUM (DR 50 MG, DR 25MG, DR 75 MG, EC 50 MG, EC 25 MG, EC 75MG)
generic 1
ec-naproxen generic 1
IBUibuprofen
BRAND 1
IBUPROFEN (400 MG TABLET, 600 MGTABLET, 800 MG TABLET, 100 MG/5 MLSUSP)
generic 1
INDOMETHACIN (25 MG, 50 MG) generic 1
KETOROLAC TROMETHAMINE (30 MG/MLVIAL, 10 MG TABLET, 60 MG/2 ML SYRINGE,15 MG/ML SYRINGE, 60 MG/2 MLCARPUJECT, 60 MG/2 ML VIAL, 30 MG/MLSYRINGE, 15 MG/ML VIAL, 30 MG/MLCARPUJECT)
generic 1 AL At least 17 yrs old
meloxicam generic 1
nabumetone generic 1
NAPROXEN (250 MG, DR 375 MG, 375 MG,500 MG, DR 500 MG)
generic 1
salsalate generic 1
OPIOID ANALGESICS, LONG-ACTING
ARYMO ERmorphine sulfate
BRAND 1PA
AL At least 18 yrs old
FENTANYL (12, 25, 75, 50, 100) generic 1 AL At least 18 yrs old
HYSINGLA ERhydrocodone bitartrate
BRAND 1PA
AL At least 18 yrs old
MORPHABOND ERmorphine sulfate
BRAND 1PA
AL At least 18 yrs old
morphine sulf er 30 mg tablet generic 1 AL At least 18 yrs old
PAGE 12 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
MORPHINE SULFATE ER (ER 200 MG, ER 60MG, ER 100 MG, ER 15 MG)
generic 1 AL At least 18 yrs old
SUBLOCADEbuprenorphine
BRAND 1PA
AL At least 18 yrs old
XTAMPZA ERoxycodone myristate
BRAND 1PA
AL At least 18 yrs old
OPIOID ANALGESICS, SHORT-ACTING
ACETAMINOPHEN-CODEINE(ACETAMINOPHEN-COD #4 TABLET,ACETAMINOPHEN-COD #3 TABLET,ACETAMINOPHEN-COD #2 TABLET,ACETAMIN-CODEIN 300-30 MG/12.5,ACETAMINOP-CODEINE 120-12 MG/5)
generic 1 AL At least 12 yrs old
belladonna-opium generic 1
butalb-caff-acetaminoph-codein generic 1 AL At least 12 yrs old
butalbital-asa-caffeine cap generic 1
codeine sulfate generic 1 AL At least 12 yrs old
HYDROCODONE-ACETAMINOPHEN(HYDROCODONE-ACETAMIN 5-217/10,HYDROCODONE-ACETAMIN 7.5-325,HYDROCODONE-ACETAMIN 10-325 MG,HYDROCODONE-ACETAMIN 2.5-108/5,HYDROCODONE-ACETAMIN 5-300 MG,HYDROCODONE-ACETAMIN 5-325 MG,HYDROCODONE-ACETAMN 7.5-325/15,HYDROCODONE-ACETAMIN 7.5-300,HYDROCODONE-ACETAMIN 10-300 MG)
generic 1
hydrocodone-ibuprofen generic 1
HYDROMORPHONE HCL (2 MG TABLET, 8MG TABLET, 4 MG TABLET, 0.5 MG/0.5 ML)
generic 1
MORPHINE SULFATE (SULFATE IR 30 MGTAB, SULF 100 MG/5 ML CONC, SULF 10MG/5 ML SOLN, SULFATE IR 15 MG TAB,SULF 20 MG/5 ML SOLN)
generic 1
OXYCODONE HCL (5 MG/5 ML SOLN, 10 MGTABLET, 20 MG TABLET, 5 MG TABLET, 30MG TABLET, 15 MG TABLET)
generic 1
OXYCODONE-ACETAMINOPHEN(OXYCODON-ACETAMINOPHEN 2.5-325,OXYCODONE-ACETAMINOPHEN 10-325,OXYCODONE-ACETAMINOPHEN 5-325,OXYCODON-ACETAMINOPHEN 7.5-325)
generic 1
PAGE 13 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
tramadol hcl 50 mg tablet generic 1 AL At least 12 yrs old
VICODIN HPhydrocodone bitartrate/acetaminophen
BRAND 1
ANESTHETICS
LOCAL ANESTHETICS
BUPIVACAINE HCL (0.25% VIAL, 0.5% (5MG/ML) AMP, 0.75% VIAL, 0.25% (2.5MG/ML), 0.5% VIAL, 0.75% AMPUL)
generic 1
bupivacaine hcl-epinephrine generic 1
lidocaine 5% patch generic 1 PA
lidocaine 5% ointment generic 1
LIDOCAINE HCL (HCL 4% SOLUTION, HCL2% JEL UROJET AC, HCL 2% JELLY URO-JET, HCL 1% 20 MG/2 ML VL, HCL 1.5%AMPUL, 3% CREAM, HCL 2% AMPUL, HCL2% 40 MG/2 ML, HCL 1% VIAL, HCL 0.5%VIAL, HCL 1% 50 MG/5 ML, HCL 2% 100MG/5 ML, HCL 2% 40 MG/2 ML VL, HCL 1%20 MG/2 ML, HCL 1% 50 MG/5 ML VL, HCL1% AMPUL, HCL 1% 300 MG/30 ML, HCL 4%AMPUL, HCL 2% VIAL, HCL 2% JELLY)
generic 1
lidocaine hcl in 7.5% dextrose generic 1
lidocaine hcl viscous generic 1
lidocaine hcl-epinephrine generic 1
lidocaine-epinephrine generic 1
lidocaine-prilocaine generic 1 QL
ZTLIDOlidocaine
BRAND 1 PA
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium generic 1
disulfiram generic 1
naltrexone hcl generic 1
VIVITROLnaltrexone microspheres
BRAND 1PA
AL At least 18 yrs old
OPIOID DEPENDENCE TREATMENTS
PAGE 14 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
BUPRENORPHINE HCL (2 MG, 8 MG) generic 1PA
AL At least 16 yrs old
BUPRENORPHINE-NALOXONE(BUPRENORPHIN-NALOXON 8-2 MG,BUPRENORPHN-NALOXN 2-0.5 MG)
generic 1PA
AL At least 16 yrs old
SUBOXONEbuprenorphine hcl/naloxone hcl
BRAND 1PA
AL At least 16 yrs old
ZUBSOLVbuprenorphine hcl/naloxone hcl
BRAND 1PA
AL At least 16 yrs old
OPIOID REVERSAL AGENTS
NALOXONE HCL (2 MG/2 ML SYRINGE, 0.4MG/ML CARPUJECT, 0.4 MG/ML VIAL, 4MG/10 ML VIAL)
generic 1
NARCANnaloxone hcl
BRAND 1
SMOKING CESSATION AGENTS
bupropion hcl sr 150 mg tablet generic 1 AL At least 6 yrs old
CHANTIX (1 MG CONT MONTH BOX, 0.5 MGTABLET, 1 MG TABLET, STARTING MONTHBOX)varenicline tartrate
BRAND 1 AL At least 18 yrs old
ANTIBACTERIALS
AMINOGLYCOSIDES
GENTAMICIN SULFATE (20 MG/2 ML VIAL,80 MG/2 ML VIAL, 800 MG/20 ML VIAL, 3MG/ML EYE DROP, 0.1% CREAM, 40 MG/MLVIAL, 0.3% EYE DROP)
generic 1
GENTAMICIN SULFATE IN NS (ISOTON 80MG/100 ML, 70 MG/NS 50 ML PB, ISO 120MG/100 ML, ISOTON 60 MG/50 ML, ISOTON80 MG/50 ML, ISOTON 100 MG/50 ML, ISO100 MG/100 ML)
generic 1
neomycin sulfate generic 1
tobramycin 0.3% eye drop generic 1
TOBRAMYCIN SULFATE (10 MG/ML, 80 MG/2ML, 40 MG/ML)
generic 1
ANTIBACTERIALS, OTHER
PAGE 15 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
acetic acid 0.25% irrig soln generic 1
CLEOCIN 100 MG VAGINAL OVULEclindamycin phosphate
BRAND 1
CLEOCIN PHOSPHATE (300 MG/2 ML, 900MG/6 ML, 600 MG/4 ML)clindamycin phosphate
BRAND 1
clindamycin hcl generic 1
clindamycin palmitate hcl generic 1 AL Up to 11 yrs old
clindamycin pediatric generic 1 AL Up to 11 yrs old
CLINDAMYCIN PHOSPHATE (PHOSPLEDGET, PH SOLUTION)
generic 1 AL At least 12 yrs old
CLINDAMYCIN PHOSPHATE (9 G/60 MLVIAL, 600 MG/4 ML VL, 300 MG/2 ML VL, 900MG/6 ML VL)
generic 1
CLINDESSEclindamycin phosphate
BRAND 1
colistimethate generic 1
FIRVANQvancomycin hcl
BRAND 1
lincomycin hcl generic 1
linezolid 600 mg tablet generic 1
methenamine hippurate generic 1
methenamine mandelate generic 1
METRONIDAZOLE (250 MG TABLET, 500MG/100 ML, VAGINAL 0.75% GL, 500 MGTABLET)
generic 1
mupirocin 2% ointment generic 1
NEOMYCIN-POLYMYXIN B (40 MG/ML AMP,40 MG/ML VL)
generic 1
NITROFURANTOIN (25 MG/5 ML SUSP, MCR25 MG CAP, MCR 50 MG CAP, MCR 100 MGCAP)
generic 1
nitrofurantoin mono-macro generic 1
polymyxin b sulfate generic 1
tinidazole generic 1
trimethoprim generic 1
VANCOMYCIN HCL (1 GM VIAL, 500 MG A-VVIAL, HCL 250 MG CAPSULE, 1 GM ADD- generic 1
PAGE 16 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
VAN VIAL, HCL 1.5 GRAM VIAL, 500 MGVIAL, HCL 125 MG CAPSULE, HCL 250 MGVIAL, HCL 5 GM VIAL, HCL 10 GM VIAL, HCL750 MG VIAL, HCL 1.25 GRAM VIAL)
VANCOMYCIN HCL-0.9% NACL (VANCO 500MG/100 ML-0.9%, VANCO 750 MG/150 ML-0.9%, VANCOMYCIN 1 G/200ML-0.9%)
generic 1
vancomycin-d5w 500 mg/100 ml generic 1
BETA-LACTAM, CEPHALOSPORINS
CEFACLOR (500 MG, 250 MG) generic 1
cefadroxil 500 mg capsule generic 1
CEFAZOLIN SODIUM (1 GM ADD-VAN, 20GM BULK, 1 GM, 500 MG, 10 GM)
generic 1
CEFDINIR (250 MG/5 ML SUSP, 300 MGCAPSULE, 125 MG/5 ML SUSP)
generic 1
CEFEPIME HCL (2 GRAM, 1 GM) generic 1
cefixime 400 mg capsule generic 1
cefotaxime sodium 1 gm vial generic 1
cefotetan generic 1
cefotetan & dextrose generic 1
cefoxitin generic 1
cefoxitin sodium generic 1
CEFPROZIL (250 MG/5 ML SUSP, 125 MG/5ML SUSP, 250 MG TABLET, 500 MG TABLET)
generic 1
CEFTRIAXONE (1 GM-D5W BAG, 1 GM ADD-VANT VIAL, 1 GM PIGGYBACK, 250 MG VIAL,2 GM PIGGYBACK, 2 GM-D5W BAG, 2 GMADD VIAL)
generic 1
CEFTRIAXONE (500 MG, 10 GM, 1 GM, 2GM)
generic 1
cefuroxime generic 1
cefuroxime sodium generic 1
CEPHALEXIN (125 MG/5 ML SUSP, 250 MGCAPSULE, 750 MG CAPSULE, 250 MG/5 MLSUSP, 500 MG CAPSULE)
generic 1
BETA-LACTAM, OTHER
AZACTAMaztreonam
BRAND 1
PAGE 17 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
imipenem-cilastatin sodium generic 1
meropenem generic 1
meropenem-0.9% nacl generic 1
BETA-LACTAM, PENICILLINS
AMOXICILLIN (250 MG CAPSULE, 500 MGTABLET, 500 MG CAPSULE, 125 MG/5 MLSUSP, 200 MG/5 ML SUSP, 875 MG TABLET,250 MG/5 ML SUSP, 400 MG/5 ML SUSP)
generic 1
AMOXICILLIN (125 MG, 250 MG) generic 1
AMOXICILLIN-CLAVULANATE POTASS (600-42.9 MG/5 ML SUS, 875-125 MG TABLET,400-57 MG/5 ML SUSP, 500-125 MG TABLET,250-62.5 MG/5 ML SUS, 250-125 MG TABLET,200-28.5 MG/5 ML SUS)
generic 1
AMPICILLIN SODIUM (10 GM VIAL, 2 GMADD-VANTAGE VL, 500 MG VIAL, 250 MGVIAL, 1 GM ADD-VANTAGE VL, 10 GMBOTTLE, 125 MG VIAL, 2 GM VIAL, 1 GMVIAL)
generic 1
ampicillin 500 mg capsule generic 1
AMPICILLIN-SULBACTAM (AMPICILLIN-SULB3 GM ADD VIAL, AMPICILLIN-SULB 1.5 GADD VIAL, AMPICILLIN-SULBACTAM 15 GMVL, AMPICILLIN-SULBACTAM 3 GM VIAL,AMPICILLIN-SULBACTAM 1.5 GM VL)
generic 1
BICILLIN C-R 1.2 MILLION UNITpenicillin g benzathine/penicillin g procaine
BRAND 1
BICILLIN C-R 900-300 SYRINGEpenicillin g benzathine/penicillin g procaine
BRAND 1
BICILLIN L-A (600,000 UNIT/ML, 1,200,000UNITS)penicillin g benzathine
BRAND 1
BICILLIN L-A 2,400,000 UNITSpenicillin g benzathine
BRAND 1
dicloxacillin sodium generic 1
pen g 1.2 million unit/2 ml generic 1
penicillin g 600,000 unit/1 ml generic 1
penicillin g sodium generic 1
PENICILLIN V POTASSIUM (250 MG TABLET,250 MG/5 ML SOLN, 125 MG/5 ML SOLN, 500MG TABLET)
generic 1
PAGE 18 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PIPERACILLIN-TAZOBACTAM (PIPERACIL-TAZOBACT 2.25 GM VL, PIPERACIL-TAZO3.375 GM ADD VL, PIPERACIL-TAZOBACT4.5 GM VIAL, PIPERACIL-TAZO 4.5 GM ADDVIAL, PIPERACIL-TAZOBACT 3.375 GM VL,PIPERACIL-TAZOBACT 13.5 GM VL,PIPERACIL-TAZOBACT 40.5 GRAM,PIPERACIL-TAZO 2.25 GM ADD VL)
generic 1
MACROLIDES
AZITHROMYCIN (200 MG/5 ML SUSP, I.V.500 MG VIAL, 100 MG/5 ML SUSP)
generic 1
AZITHROMYCIN (500 MG ADD-VAN VL, 500MG TABLET, 600 MG TABLET, 1 GM PWDPACKET, 250 MG TABLET)
generic 1
CLARITHROMYCIN (125 ML, 250 ML) generic 1 AL Up to 11 yrs old
CLARITHROMYCIN (500 MG, 250 MG) generic 1
clarithromycin er generic 1
E.E.S. 200erythromycin ethylsuccinate
BRAND 1
erythromycin 0.5% eye ointment generic 1
QUINOLONES
CIPRO (5%, 10%)ciprofloxacin
BRAND 1 AL Up to 11 yrs old
ciprofloxacin 0.3% eye drop generic 1
CIPROFLOXACIN HCL (500 MG, 100 MG, 750MG, 250 MG)
generic 1 AL At least 12 yrs old
ciprofloxacin-d5w generic 1
LEVOFLOXACIN (500 MG, 750 MG, 250 MG) generic 1 AL At least 12 yrs old
levofloxacin-d5w generic 1
moxifloxacin 0.5% eye drops generic 1
OFLOXACIN (EYE, EAR) generic 1
SULFONAMIDES
silver sulfadiazine generic 1
SULFAMETHOXAZOLE-TRIMETHOPRIM (SSTABLET, SUSP, DS TABLET)
generic 1
TETRACYCLINES
PAGE 19 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
DOXYCYCLINE HYCLATE (75 MG TAB, 50MG CAP, 100 MG TAB, 150 MG TAB, 100 MGCAP)
generic 1
doxycycline hyclate 20 mg tab generic 1
MINOCYCLINE HCL (100 MG, 50 MG, 75 MG) generic 1
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT (50 MG TABLET, 10 MG/ML ORALSOLN, 100 MG TABLET, 25 MG TABLET, 10MG TABLET, 75 MG TABLET)brivaracetam
BRAND 1PA
AL At least 4 yrs old
BRIVIACT 50 MG/5 ML VIALbrivaracetam
BRAND 1PA
AL At least 16 yrs old
KEPPRA (750 MG TABLET, 250 MG TABLET,100 MG/ML ORAL SOLN, 1,000 MG TABLET,500 MG TABLET)levetiracetam
BRAND 1 PA
KEPPRA XRlevetiracetam
BRAND 1 PA
LEVETIRACETAM (100 MG/ML SOLN, 500MG/5 ML VIAL, 500 MG TABLET, 750 MGTABLET, 250 MG TABLET, 1,000 MGTABLET, 500 MG/5 ML SOLN)
generic 1
levetiracetam er generic 1
ROWEEPRAlevetiracetam
BRAND 1 PA
CALCIUM CHANNEL MODIFYING AGENTS
ETHOSUXIMIDE (250 MG/5 ML SOLN, 250MG CAPSULE)
generic 1
ZARONTIN 250 MG CAPSULEethosuximide
BRAND 1 PA
zonisamide generic 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
CLOBAZAM (10 MG TABLET, 2.5 MG/MLSUSPENSION, 20 MG TABLET)
generic 1 AL At least 2 yrs old
DEPAKOTEdivalproex sodium
BRAND 1 PA
DEPAKOTE ERdivalproex sodium
BRAND 1 PA
PAGE 20 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
DEPAKOTE SPRINKLEdivalproex sodium
BRAND 1 PA
DIASTATdiazepam
BRAND 1PA
AL Up to 18 yrs old
DIASTAT ACUDIALdiazepam
BRAND 1PA
AL Up to 18 yrs old
DIAZEPAM (2.5 MG SYS, 20 MG SYST, 10MG SYST)
generic 1 AL Up to 18 yrs old
DIVALPROEX SODIUM (SOD 250 MG TAB,SOD 500 MG TAB, 125 MG CAP SPRNK, SOD125 MG TAB)
generic 1
divalproex sodium er generic 1
GABAPENTIN (300 MG/6 ML SOLN, 250 MG/5ML SOLN, 800 MG TABLET, 100 MGCAPSULE, 300 MG CAPSULE, 600 MGTABLET, 400 MG CAPSULE)
generic 1
GABITRILtiagabine hcl
BRAND 1 PA
MYSOLINEprimidone
BRAND 1 PA
NEURONTIN (800 MG TABLET, 100 MGCAPSULE, 300 MG CAPSULE, 400 MGCAPSULE, 600 MG TABLET, 250 MG/5 MLSOLUTION)gabapentin
BRAND 1 PA
ONFI (2.5 MG/ML SUSPENSION, 20 MGTABLET, 10 MG TABLET)clobazam
BRAND 1PA
AL At least 2 yrs old
PHENOBARBITAL (60 MG TABLET, 97.2 MGTABLET, 100 MG TABLET, 15 MG TABLET,64.8 MG TABLET, 20 MG/5 ML SOLN, 30 MGTABLET, 16.2 MG TABLET, 20 MG/5 ML ELIX,32.4 MG TABLET)
generic 1
primidone generic 1
SABRIL (500 MG TABLET, 500 MG POWDERPACKET)vigabatrin
BRAND 1 PA
SYMPAZANclobazam
BRAND 1PA
AL At least 2 yrs old
tiagabine hcl generic 1
1
PAGE 21 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
VALPROIC ACID (500 MG/10 ML SOL, 250MG CAPSULE, 250 MG/5 ML SOLN)
generic
VIGABATRIN (500 MG POWDER PACKT, 500MG TABLET)
generic 1
VIGADRONEvigabatrin
BRAND 1 PA
GLUTAMATE REDUCING AGENTS
FELBAMATE (400 MG TABLET, 600 MGTABLET, 600 MG/5 ML SUSP)
generic 1
FELBATOL (400 MG TABLET, 600 MGTABLET, 600 MG/5 ML SUSP)felbamate
BRAND 1 PA
FYCOMPA (10 MG TABLET, 6 MG TABLET,12 MG TABLET, 2 MG TABLET, 8 MGTABLET, 0.5 MG/ML ORAL SUSP, 4 MGTABLET)perampanel
BRAND 1PA
AL At least 4 yrs old
LAMICTAL (200 MG, 25 MG DISPER, 5 MGDISPER, 150 MG, 100 MG, 25 MG)lamotrigine
BRAND 1 PA
LAMICTAL (BLUE)lamotrigine
BRAND 1
LAMICTAL (GREEN)lamotrigine
BRAND 1
LAMICTAL (ORANGE)lamotrigine
BRAND 1
LAMICTAL ODTlamotrigine
BRAND 1
LAMICTAL ODT (BLUE)lamotrigine
BRAND 1 PA
LAMICTAL ODT (GREEN)lamotrigine
BRAND 1 PA
LAMICTAL ODT (ORANGE)lamotrigine
BRAND 1 PA
LAMICTAL XRlamotrigine
BRAND 1PA
AL At least 13 yrs old
LAMICTAL XR (BLUE)lamotrigine
BRAND 1PA
AL At least 13 yrs old
LAMICTAL XR (GREEN)lamotrigine
BRAND 1PA
AL At least 13 yrs old
PAGE 22 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
LAMICTAL XR (ORANGE)lamotrigine
BRAND 1PA
AL At least 13 yrs old
LAMOTRIGINE (5 MG DISPER TABLET, 200MG TABLET, 150 MG TABLET, 25 MGDISPER TAB, 100 MG TABLET, 25 MGTABLET)
generic 1
lamotrigine (blue) generic 1 PA
lamotrigine (green) generic 1 PA
lamotrigine (orange) generic 1 PA
lamotrigine er generic 1 AL At least 13 yrs old
lamotrigine odt generic 1 PA
lamotrigine odt (blue) generic 1
lamotrigine odt (green) generic 1
lamotrigine odt (orange) generic 1
QUDEXY XRtopiramate
BRAND 1 PA
SUBVENITElamotrigine
BRAND 1 PA
SUBVENITE (BLUE)lamotrigine
BRAND 1 PA
SUBVENITE (GREEN)lamotrigine
BRAND 1 PA
SUBVENITE (ORANGE)lamotrigine
BRAND 1 PA
TOPAMAX (100 MG TABLET, 50 MG TABLET,25 MG SPRINKLE CAP, 25 MG TABLET, 200MG TABLET, 15 MG SPRINKLE CAP)topiramate
BRAND 1 PA
TOPIRAMATE (25 MG SPRINKLE CAP, 15MG SPRINKLE CAP, 200 MG TABLET, 50 MGTABLET, 25 MG TABLET, 100 MG TABLET)
generic 1
topiramate er generic 1
TROKENDI XRtopiramate
BRAND 1PA
AL At least 6 yrs old
SODIUM CHANNEL AGENTS
PAGE 23 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
APTIOMeslicarbazepine acetate
BRAND 1PA
AL At least 4 yrs old
BANZEL (400 MG TABLET, 40 MG/MLSUSPENSION, 200 MG TABLET)rufinamide
BRAND 1PA
AL At least 1 yrs old
CARBAMAZEPINE (200 MG TABLET, 100 MGTAB CHEW, 100 MG/5 ML SUSP)
generic 1
CARBAMAZEPINE ER (ER 100 MG CAP, ER400 MG TABLET, ER 300 MG CAP, ER 200MG TABLET, ER 200 MG CAP, ER 100 MGTABLET)
generic 1
CARBATROLcarbamazepine
BRAND 1 PA
DILANTIN (30 MG, 100 MG)phenytoin sodium extended
BRAND 1 PA
DILANTIN-125phenytoin
BRAND 1 PA
EPITOLcarbamazepine
BRAND 1 PA
OXCARBAZEPINE (150 MG TABLET, 300MG/5 ML SUSP, 300 MG TABLET, 600 MGTABLET)
generic 1
OXTELLAR XRoxcarbazepine
BRAND 1PA
AL At least 6 yrs old
PHENYTOIN (125 MG/5 ML SUSP, 50 MGINFATAB, 50 MG TABLET CHEW, 100 MG/4ML SUSP)
generic 1
phenytoin sodium extended generic 1
TEGRETOL (200 MG TABLET, 100 MG/5 MLSUSP)carbamazepine
BRAND 1 PA
TEGRETOL XRcarbamazepine
BRAND 1 PA
TRILEPTAL (600 MG TABLET, 300 MG/5 MLSUSP, 300 MG TABLET, 150 MG TABLET)oxcarbazepine
BRAND 1 PA
VIMPAT (10 MG/ML SOLUTION, 150 MGTABLET, 100 MG TABLET, 200 MG TABLET,50 MG TABLET, STARTER KIT)lacosamide
BRAND 1 PA
ANTIDEMENTIA AGENTS
PAGE 24 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
CHOLINESTERASE INHIBITORS
DONEPEZIL HCL (10 MG, 5 MG) generic 1 AL At least 18 yrs old
donepezil hcl odt generic 1 AL At least 18 yrs old
EXELONrivastigmine
BRAND 1 AL At least 18 yrs old
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
MEMANTINE HCL (10 MG, 5 MG) generic 1 AL At least 18 yrs old
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl generic 1 AL At least 6 yrs old
BUPROPION HCL SR (200 MG, 100 MG) generic 1 AL At least 6 yrs old
bupropion hcl xl 450 mg tablet generic 1 AL At least 18 yrs old
BUPROPION XL (300 MG, 150 MG) generic 1 AL At least 6 yrs old
chlordiazepoxide-amitriptyline generic 1 AL At least 18 yrs old
MIRTAZAPINE (15 MG TABLET, 45 MGTABLET, 45 MG ODT, 7.5 MG TABLET, 30MG TABLET, 15 MG ODT, 30 MG ODT)
generic 1 AL At least 6 yrs old
perphenazine-amitriptyline generic 1 AL At least 18 yrs old
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR)
CITALOPRAM HBR (10 MG/5 ML SOLN, 20MG/10 ML SOL)
generic 1 AL 6.0 to 11.0 yrs old
CITALOPRAM HBR (20 MG, 10 MG, 40 MG) generic 1 AL At least 6 yrs old
desvenlafaxine succinate er generic 1 AL At least 18 yrs old
ESCITALOPRAM OXALATE (10 MG, 5 MG, 20MG)
generic 1 AL At least 6 yrs old
FLUOXETINE HCL (40 MG, 10 MG, 20 MG) generic 1 AL At least 6 yrs old
fluoxetine 20 mg/5 ml solution generic 1 AL 6.0 to 11.0 yrs old
fluvoxamine maleate generic 1 AL At least 6 yrs old
paroxetine hcl generic 1 AL At least 6 yrs old
sertraline 20 mg/ml oral conc generic 1 AL 6.0 to 11.0 yrs old
PAGE 25 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
SERTRALINE HCL (50 MG, 25 MG, 100 MG) generic 1 AL At least 6 yrs old
trazodone hcl generic 1 AL At least 6 yrs old
TRINTELLIXvortioxetine hydrobromide
BRAND 1PA
AL At least 18 yrs old
venlafaxine hcl generic 1 AL At least 6 yrs old
VENLAFAXINE HCL ER (ER 37.5 MG, ER 75MG, ER 150 MG)
generic 1 AL At least 6 yrs old
VIIBRYD (10 MG, 20 MG, 40 MG)vilazodone hcl
BRAND 1 AL At least 18 yrs old
TRICYCLICS
amitriptyline hcl generic 1 AL At least 12 yrs old
amoxapine generic 1 AL At least 16 yrs old
clomipramine hcl generic 1PA
AL At least 10 yrs old
desipramine hcl generic 1 AL At least 13 yrs old
DOXEPIN HCL (25 MG CAPSULE, 150 MGCAPSULE, 10 MG/ML ORAL CONC, 100 MGCAPSULE, 50 MG CAPSULE, 10 MGCAPSULE, 75 MG CAPSULE)
generic 1 AL At least 12 yrs old
imipramine hcl generic 1 AL At least 6 yrs old
NORTRIPTYLINE HCL (HCL 75 MG CAP, HCL10 MG CAP, HCL 25 MG CAP, HCL 50 MGCAP, 10 MG/5 ML SOLN)
generic 1 AL At least 13 yrs old
ANTIEMETICS
ANTIEMETICS, OTHER
DICLEGISdoxylamine succinate/pyridoxine hcl (b6)
BRAND 1 AL At least 18 yrs old
meclizine hcl generic 1
METOCLOPRAMIDE HCL (10 MG TABLET, 5MG TABLET, 10 MG/10 ML SOL, 5 MG/5 MLSOLN)
generic 1
perphenazine generic 1 AL At least 6 yrs old
prochlorperazine maleate generic 1
PROMETHAZINE HCL (25 MG generic 1
PAGE 26 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
SUPPOSITORY, 12.5 MG TABLET, 12.5 MGSUPPOS, 50 MG TABLET, 25 MG TABLET)
PROMETHEGANpromethazine hcl
BRAND 1
TRANSDERM-SCOPscopolamine
BRAND 1PA
AL At least 18 yrs old
EMETOGENIC THERAPY ADJUNCTS
APREPITANT (125 MG, 40 MG, 80 MG) generic 1
GRANISETRON HCL (1 MG TABLET, 0.1MG/ML VIAL, 1 MG/ML VIAL)
generic 1
ONDANSETRON HCL (4 MG/5 MLSOLUTION, HCL 4 MG/2 ML VIAL, HCL 8 MGTABLET, HCL 4 MG TABLET, 40 MG/20 MLVIAL, HCL 4 MG/2 ML SYR)
generic 1
ondansetron odt generic 1
ANTIFUNGALS
amphotericin b generic 1
CICLOPIROX (0.77% CREAM, 0.77%TOPICAL SUSP, 8% SOLUTION)
generic 1
CLOTRIMAZOLE (1% SOLUTION, 10 MGTROCHE, 1% TOPICAL CREAM)
generic 1
econazole nitrate generic 1
ERAXIS (WATER DILUENT)anidulafungin
BRAND 1
FLUCONAZOLE (150 MG TABLET, 40 MG/MLSUSP, 10 MG/ML SUSP)
generic 1
FLUCONAZOLE (50 MG, 200 MG, 100 MG) generic 1
FLUCONAZOLE-NACL (200 MG/100 ML, 400MG/200 ML)
generic 1
GRISEOFULVIN (125 MG/5 ML SUSP, MICRO500 MG TAB)
generic 1
GYNAZOLE 1butoconazole nitrate
BRAND 1
KETOCONAZOLE (SHAMPOO, CREAM) generic 1
miconazole 3 generic 1
NYSTATIN (100,000 UNIT/GM CREAM,500,000 UNIT ORAL TAB, 500,000 UNIT/5 MLSUS, 100,000 UNIT/ML SUSP, 100,000
generic 1
PAGE 27 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
UNIT/GM OINT, 100,000 UNIT/GM POWD)
NYSTATIN-TRIAMCINOLONE (CREAM,OINTM)
generic 1
terbinafine hcl generic 1
terconazole 0.4% cream generic 1 QL
terconazole 0.8% cream generic 1 QL
ANTIGOUT AGENTS
allopurinol generic 1
colchicine 0.6 mg capsule generic 1 AL At least 18 yrs old
colchicine 0.6 mg tablet generic 1 AL At least 4 yrs old
probenecid generic 1
probenecid-colchicine generic 1
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS, OTHER
EMGALITY PENgalcanezumab-gnlm
BRAND 1 AL At least 18 yrs old
EMGALITY SYRINGEgalcanezumab-gnlm
BRAND 1 AL At least 18 yrs old
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
RIZATRIPTAN (10 MG ODT, 10 MG TABLET,5 MG TABLET, 5 MG ODT)
generic 1 AL At least 6 yrs old
sumatriptan generic 1 AL At least 18 yrs old
SUMATRIPTAN SUCCINATE (SUCC 50 MGTABLET, 6 MG/0.5 ML VIAL, SUCC 25 MGTABLET, SUCC 100 MG TABLET)
generic 1 AL At least 18 yrs old
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine hcl generic 1
MESTINON 60 MG/5 ML SYRUPpyridostigmine bromide
BRAND 1
PYRIDOSTIGMINE BROMIDE (BR 30 MGTABLET, BR 60 MG TABLET, 60 MG/5 MLSOLN)
generic 1
1
PAGE 28 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
pyridostigmine bromide er generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
DAPSONE (100 MG, 25 MG) generic 1
rifabutin generic 1
ANTITUBERCULARS
ethambutol hcl generic 1
ISONIAZID (50 MG/5 ML SOLUTION, 300 MGTABLET, 100 MG TABLET)
generic 1
pyrazinamide generic 1
RIFAMPIN (150 MG CAPSULE, IV 600 MGVIAL, 300 MG CAPSULE)
generic 1
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLETmelphalan
BRAND 1 AL At least 18 yrs old
BICNUcarmustine
BRAND 1
cisplatin 50 mg vial generic 1
CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50MG CAPSULE, 1 GM VIAL, 500 MG VIAL, 2GM VIAL)
generic 1
ifosfamide generic 1
LEUKERANchlorambucil
BRAND 1
MATULANEprocarbazine hcl
BRAND 1
melphalan hcl generic 1
MYLERANbusulfan
BRAND 1
TEMODAR 100 MG VIALtemozolomide
BRAND 1
temozolomide generic 1
thiotepa 100 mg vial generic 1
TREANDAbendamustine hcl
BRAND 1
PAGE 29 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ANTIANDROGENS
bicalutamide generic 1 AL At least 18 yrs old
flutamide generic 1 AL At least 18 yrs old
XTANDIenzalutamide
BRAND 1 AL At least 18 yrs old
ZYTIGAabiraterone acetate
BRAND 1 AL At least 18 yrs old
ANTIANGIOGENIC AGENTS
POMALYSTpomalidomide
BRAND 1 AL At least 18 yrs old
REVLIMIDlenalidomide
BRAND 1 AL At least 18 yrs old
ANTIESTROGENS/MODIFIERS
tamoxifen citrate generic 1 AL At least 18 yrs old
ANTIMETABOLITES
ALIMTApemetrexed disodium
BRAND 1
cladribine generic 1
cytarabine generic 1
floxuridine generic 1
FLUOROURACIL (5,000 MG/100 ML, 2.5GM/50 ML BTL, 2.5 GM/50 ML VIAL, 500MG/10 ML VIAL, 2,500 MG/50 ML VL, 2%TOPICAL SOLN, 5% CREAM, 5 GM/100 MLBTL, 5 GM/100 ML VIAL, 1,000 MG/20 ML VL,5% TOPICAL SOLN)
generic 1
gemcitabine hcl generic 1
hydroxyurea generic 1
mercaptopurine generic 1
XELODAcapecitabine
BRAND 1 AL At least 18 yrs old
ANTINEOPLASTICS, OTHER
azacitidine generic 1
bleomycin sulfate generic 1
bortezomib generic 1
CARBOPLATIN (150 MG/15 ML, 50 MG/5 ML, generic 1
PAGE 30 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
450 MG/45 ML, 600 MG/60 ML)
CISPLATIN (100 MG/100 ML, 50 MG/50 ML,200 MG/200 ML)
generic 1
dacarbazine generic 1
daunorubicin hcl generic 1
decitabine generic 1
dexrazoxane generic 1 AL At least 18 yrs old
docetaxel generic 1 AL At least 18 yrs old
DOXORUBICIN HCL (50 MG, 150 MG/75 ML,20 MG/10 ML, 10 MG/5 ML, 50 MG/25 ML, 200MG/100 ML)
generic 1
doxorubicin hcl liposome generic 1
EPIRUBICIN HCL (HCL 200 MG, 200 MG/100ML, 50 MG/25 ML)
generic 1
fludarabine phosphate generic 1
idarubicin hcl generic 1
IRINOTECAN HCL (100 MG/5 ML VL, 40 MG/2ML VIAL, 500 MG/25 ML VL)
generic 1
LEUCOVORIN CALCIUM (CALCIUM 100 MGVIAL, CALCIUM 10 MG TAB, CALCIUM 5 MGTAB, CALCIUM 25 MG TAB, CALCIUM 200MG VIAL, CALCIUM 50 MG VIAL, CALCIUM350 MG VIAL, CALCIUM 15 MG TAB,CALCIUM 500 MG VL, CAL 100 MG/10 ML VL,CAL 500 MG/50 ML VL)
generic 1
mitomycin generic 1
mitoxantrone hcl generic 1 AL At least 18 yrs old
MUTAMYCINmitomycin
BRAND 1
ONCASPARpegaspargase
BRAND 1
oxaliplatin generic 1
paclitaxel generic 1
PARAPLATINcarboplatin
BRAND 1
thiotepa 15 mg vial generic 1
VALSTARvalrubicin
BRAND 1
PAGE 31 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
vinblastine sulfate generic 1
vincristine sulfate generic 1
vinorelbine tartrate generic 1
ZOLADEXgoserelin acetate
BRAND 1PA
AL At least 18 yrs old
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole generic 1 AL At least 18 yrs old
exemestane generic 1 AL At least 18 yrs old
letrozole generic 1 AL At least 18 yrs old
ENZYME INHIBITORS
ETOPOSIDE (1,000 MG/50 ML, 500 MG/25ML, 100 MG/5 ML)
generic 1
topotecan hcl 4 mg vial generic 1 AL At least 6 yrs old
topotecan hcl 4 mg/4 ml vial generic 1
MOLECULAR TARGET INHIBITORS
imatinib mesylate generic 1 AL At least 1 yrs old
IRESSAgefitinib
BRAND 1 AL At least 18 yrs old
SUTENTsunitinib malate
BRAND 1 AL At least 18 yrs old
VOTRIENTpazopanib hcl
BRAND 1 AL At least 18 yrs old
MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE
ARZERRAofatumumab
BRAND 1
CAMPATHalemtuzumab
BRAND 1
RITUXANrituximab
BRAND 1
RETINOIDS
PANRETINalitretinoin
BRAND 1 PA
tretinoin 10 mg capsule generic 1 AL At least 1 yrs old
TREATMENT ADJUNCTS
PAGE 32 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
mesna generic 1
ANTIPARASITICS
ANTIHELMINTHICS
albendazole generic 1
BILTRICIDEpraziquantel
BRAND 1
ivermectin 3 mg tablet generic 1
ANTIPROTOZOALS
atovaquone generic 1
chloroquine phosphate generic 1
hydroxychloroquine sulfate generic 1
mefloquine hcl generic 1
NEBUPENTpentamidine isethionate
BRAND 1
primaquine generic 1
PEDICULICIDES/SCABICIDES
permethrin generic 1
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
BENZTROPINE MESYLATE (1 MG TABLET, 2MG TABLET, 0.5 MG TAB)
generic 1 AL At least 3 yrs old
TRIHEXYPHENIDYL HCL (5 MG TABLET, 2MG TABLET, 2 MG/5 ML ELX)
generic 1 AL At least 18 yrs old
ANTIPARKINSON AGENTS, OTHER
AMANTADINE (50 MG/5 ML SOLUTION, 100MG TABLET, 100 MG/10 ML SOLN, 100 MGCAPSULE)
generic 1 AL At least 1 yrs old
carbidopa-levodopa-entacapone generic 1 AL At least 18 yrs old
DOPAMINE AGONISTS
pramipexole dihydrochloride generic 1 AL At least 18 yrs old
ropinirole hcl generic 1 AL At least 18 yrs old
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
PAGE 33 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
CARBIDOPA-LEVODOPA (25-250, 10-100, 25-100)
generic 1 AL At least 18 yrs old
carbidopa-levodopa er generic 1 AL At least 18 yrs old
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
SELEGILINE HCL (5 MG TABLET, 5 MGCAPSULE)
generic 1 AL At least 18 yrs old
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine 25 mg/ml amp generic 1 AL At least 18 yrs old
CHLORPROMAZINE HCL (50 MG, 200 MG,100 MG, 10 MG, 25 MG)
generic 1 AL At least 18 yrs old
DROPERIDOL (2.5 MG/ML AMPUL, 5 MG/2ML VIAL)
generic 1 AL At least 18 yrs old
fluphenazine decanoate generic 1 AL At least 18 yrs old
FLUPHENAZINE HCL (10 MG TABLET, 5MG/ML CONC, 5 MG TABLET, 2.5 MG/5 MLELIX, 2.5 MG TABLET, 1 MG TABLET)
generic 1 AL At least 6 yrs old
fluphenazine 2.5 mg/ml vial generic 1 AL At least 18 yrs old
haloperidol generic 1 AL At least 6 yrs old
HALOPERIDOL DECANOATE (DECAN 50MG/ML AMP, DEC 50 MG/ML VIAL, DEC 500MG/5 ML VL, DEC 100 MG/ML VIAL, DEC 250MG/5 ML VL, DEC 100 MG/ML AMP)
generic 1 AL At least 18 yrs old
haloperidol decanoate 100 generic 1 AL At least 18 yrs old
HALOPERIDOL LACTATE (50 MG/10 ML VL,5 MG/ML AMPUL, 5 MG/ML VIAL)
generic 1 AL At least 18 yrs old
haloperidol lac 2 mg/ml conc generic 1 AL At least 6 yrs old
loxapine generic 1 AL At least 18 yrs old
pimozide generic 1 AL At least 18 yrs old
thioridazine hcl generic 1 AL At least 18 yrs old
thiothixene generic 1 AL At least 18 yrs old
trifluoperazine hcl generic 1 AL At least 18 yrs old
2ND GENERATION/ATYPICAL
PAGE 34 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ABILIFY MAINTENA (ER 300 MG SYR, ER300 MG VL, ER 400 MG VL, ER 400 MG SYR)aripiprazole
BRAND 1PA
AL At least 18 yrs old
ARIPIPRAZOLE (15 MG TABLET, 1 MG/MLSOLUTION, 10 MG TABLET, 30 MG TABLET,5 MG TABLET, 20 MG TABLET, 2 MGTABLET)
generic 1 AL At least 6 yrs old
ARISTADAaripiprazole lauroxil
BRAND 1PA
AL At least 18 yrs old
ARISTADA INITIOaripiprazole lauroxil, submicronized
BRAND 1PA
AL At least 18 yrs old
FANAPT (10 MG, 1 MG, 2 MG, 6 MG, 8 MG, 4MG, 12 MG)iloperidone
BRAND 1 AL At least 18 yrs old
INVEGA SUSTENNApaliperidone palmitate
BRAND 1PA
AL At least 18 yrs old
INVEGA TRINZApaliperidone palmitate
BRAND 1PA
AL At least 18 yrs old
LATUDAlurasidone hcl
BRAND 1 AL At least 10 yrs old
OLANZAPINE (20 MG, 10 MG, 5 MG, 2.5 MG,7.5 MG, 15 MG)
generic 1 AL At least 6 yrs old
olanzapine odt generic 1 AL At least 6 yrs old
PERSERISrisperidone
BRAND 1PA
AL At least 18 yrs old
quetiapine fumarate generic 1 AL At least 6 yrs old
quetiapine fumarate er generic 1 AL At least 6 yrs old
RISPERDAL CONSTArisperidone microspheres
BRAND 1PA
AL At least 18 yrs old
RISPERIDONE (2 MG TABLET, 4 MGTABLET, 0.25 MG TABLET, 1 MG/MLSOLUTION, 1 MG TABLET, 3 MG TABLET,0.5 MG TABLET)
generic 1 AL At least 6 yrs old
risperidone odt generic 1 AL At least 6 yrs old
ziprasidone hcl generic 1 AL At least 6 yrs old
PAGE 35 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TREATMENT-RESISTANT
clozapine generic 1 AL At least 6 yrs old
CLOZARILclozapine
BRAND 1 AL At least 6 yrs old
ANTISPASTICITY AGENTS
BACLOFEN (10 MG, 20 MG, 5 MG) generic 1
TIZANIDINE HCL (4 MG, 2 MG) generic 1
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
ganciclovir sodium generic 1
VALGANCICLOVIR HCL (450 MG TABLET,HCL 50 MG/ML)
generic 1
ANTI-HEPATITIS B (HBV) AGENTS
entecavir generic 1
EPIVIR HBV 25 MG/5 ML SOLNlamivudine
BRAND 1 AL Up to 11 yrs old
lamivudine hbv generic 1
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS
MAVYRETglecaprevir/pibrentasvir
BRAND 1PA
AL At least 12 yrs old
sofosbuvir-velpatasvir generic 1PA
AL At least 18 yrs old
VOSEVIsofosbuvir/velpatasvir/voxilaprevir
BRAND 1PA
AL At least 18 yrs old
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
INTRON Ainterferon alfa-2b,recomb.
BRAND 1
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5ML SYRINGE)peginterferon alfa-2a
BRAND 1PA
AL At least 3 yrs old
PEGINTRONpeginterferon alfa-2b
BRAND 1PA
AL At least 3 yrs old
RIBAVIRIN (200 MG CAPSULE, 200 MG generic 1 PA
PAGE 36 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TABLET) AL At least 5 yrs old
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVYbictegravir sodium/emtricitabine/tenofoviralafenamide fumar
BRAND 1PA
AL At least 6 yrs old
GENVOYAelvitegravir/cobicistat/emtricitabine/tenofoviralafenamide
BRAND 1PA
AL At least 12 yrs old
ISENTRESS (100 MG POWDER PACKET, 25MG TABLET CHEW, 400 MG TABLET, 100MG TABLET CHEW)raltegravir potassium
BRAND 1 PA
ISENTRESS HDraltegravir potassium
BRAND 1 PA
STRIBILDelvitegravir/cobicistat/emtricitabine/tenofovirdisoproxil
BRAND 1PA
AL At least 12 yrs old
TIVICAYdolutegravir sodium
BRAND 1 PA
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLAefavirenz/emtricitabine/tenofovir disoproxilfumarate
BRAND 1PA
AL At least 12 yrs old
COMPLERAemtricitabine/rilpivirine hcl/tenofovir disoproxilfumarate
BRAND 1PA
AL At least 12 yrs old
DELSTRIGOdoravirine/lamivudine/tenofovir disoproxilfumarate
BRAND 1PA
AL At least 18 yrs old
EDURANTrilpivirine hcl
BRAND 1PA
AL At least 12 yrs old
INTELENCEetravirine
BRAND 1 PA
NEVIRAPINE (50 MG/5 ML SUSP, 200 MGTABLET)
generic 1 PA
nevirapine er generic 1 PA
ODEFSEYemtricitabine/rilpivirine hcl/tenofoviralafenamide fumarate
BRAND 1PA
AL At least 12 yrs old
PIFELTRO BRAND 1 PA
PAGE 37 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
doravirine AL At least 18 yrs old
SUSTIVA (200 MG CAPSULE, 600 MGTABLET, 50 MG CAPSULE)efavirenz
BRAND 1 PA
SYMFIefavirenz/lamivudine/tenofovir disoproxilfumarate
BRAND 1 PA
SYMFI LOefavirenz/lamivudine/tenofovir disoproxilfumarate
BRAND 1 PA
VIRAMUNE 50 MG/5 ML SUSPnevirapine
BRAND 1 PA
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir 300 mg tablet generic 1 PA
abacavir-lamivudine generic 1 PA
CIMDUOlamivudine/tenofovir disoproxil fumarate
BRAND 1 PA
DIDANOSINE (400 MG, 250 MG) generic 1 PA
EMTRIVA (10 MG/ML SOLUTION, 200 MGCAPSULE)emtricitabine
BRAND 1 PA
EPIVIR 10 MG/ML ORAL SOLNlamivudine
BRAND 1 PA
LAMIVUDINE (300 MG TABLET, 150 MGTABLET, 10 MG/ML ORAL SOLN)
generic 1 PA
lamivudine-zidovudine generic 1 PA
RETROVIR 200 MG/20 ML VIALzidovudine
BRAND 1 PA
stavudine generic 1 PA
TEMIXYSlamivudine/tenofovir disoproxil fumarate
BRAND 1 PA
tenofovir disoproxil fumarate generic 1
TRIZIVIRabacavir sulfate/lamivudine/zidovudine
BRAND 1 PA
TRUVADAemtricitabine/tenofovir disoproxil fumarate
BRAND 1 PA
VIDEX 2 GM PEDIATRIC SOLNdidanosine
BRAND 1 PA
PAGE 38 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
VIREAD (POWDER, 200 MG TABLET, 150 MGTABLET, 250 MG TABLET)tenofovir disoproxil fumarate
BRAND 1
ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate
BRAND 1 PA
ZIDOVUDINE (50 MG/5 ML SYRUP, 300 MGTABLET, 100 MG CAPSULE)
generic 1 PA
ANTI-HIV AGENTS, OTHER
DESCOVYemtricitabine/tenofovir alafenamide fumarate
BRAND 1 PA
DOVATOdolutegravir sodium/lamivudine
BRAND 1PA
AL At least 18 yrs old
FUZEONenfuvirtide
BRAND 1PA
AL At least 6 yrs old
JULUCAdolutegravir sodium/rilpivirine hcl
BRAND 1PA
AL At least 18 yrs old
SELZENTRY (20 MG/ML ORAL SOLN, 300MG TABLET, 25 MG TABLET, 150 MGTABLET, 75 MG TABLET)maraviroc
BRAND 1PA
AL At least 16 yrs old
TRIUMEQabacavir sulfate/dolutegravir sodium/lamivudine
BRAND 1PA
AL At least 18 yrs old
TROGARZOibalizumab-uiyk
BRAND 1PA
AL At least 18 yrs old
TYBOSTcobicistat
BRAND 1PA
AL At least 12 yrs old
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MGCAPSULE)tipranavir/vitamin e tpgs
BRAND 1 PA
CRIXIVANindinavir sulfate
BRAND 1 PA
EVOTAZatazanavir sulfate/cobicistat
BRAND 1PA
AL At least 18 yrs old
INVIRASE 500 MG TABLETsaquinavir mesylate
BRAND 1 PA
1
PAGE 39 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
KALETRA (100-25 MG TABLET, 80 MG-20MG/ML SOLN, 200-50 MG TABLET)lopinavir/ritonavir
BRAND PA
LEXIVA (50 MG/ML SUSPENSION, 700 MGTABLET)fosamprenavir calcium
BRAND 1 PA
NORVIR (80 MG/ML SOLUTION, 100 MGTABLET, 100 MG POWDER PACKET)ritonavir
BRAND 1 PA
PREZCOBIXdarunavir ethanolate/cobicistat
BRAND 1PA
AL At least 18 yrs old
PREZISTA (600 MG TABLET, 100 MG/MLSUSPENSION, 150 MG TABLET, 75 MGTABLET, 800 MG TABLET)darunavir ethanolate
BRAND 1 PA
REYATAZ (200 MG CAPSULE, 50 MGPOWDER PACKET, 300 MG CAPSULE, 150MG CAPSULE)atazanavir sulfate
BRAND 1 PA
SYMTUZAdarunavir eth/cobicistat/emtricitabine/tenofoviralafenamide
BRAND 1 PA
VIRACEPTnelfinavir mesylate
BRAND 1 PA
ANTI-INFLUENZA AGENTS
OSELTAMIVIR PHOSPHATE (30 MG, 75 MG,45 MG)
generic 1
oseltamivir 6 mg/ml suspension generic 1 AL Up to 12 yrs old
ANTIHERPETIC AGENTS
acyclovir 200 mg/5 ml susp generic 1 AL Up to 17 yrs old
ACYCLOVIR (200 MG CAPSULE, 400 MGTABLET, 800 MG TABLET)
generic 1
DENAVIRpenciclovir
BRAND 1
trifluridine generic 1
valacyclovir generic 1
ZOVIRAX (OINTMENT, CREAM)acyclovir
BRAND 1 AL At least 12 yrs old
ANXIOLYTICS
PAGE 40 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ANXIOLYTICS, OTHER
buspirone hcl generic 1
BENZODIAZEPINES
alprazolam generic 1 AL At least 7 yrs old
chlordiazepoxide hcl generic 1 AL At least 6 yrs old
CLONAZEPAM (0.5 MG DIS TABLET, 0.25MG ODT, 0.5 MG TABLET, 0.5 MG ODT, 2 MGODT, 0.125 MG ODT, 1 MG ODT, 1 MGTABLET, 1 MG DIS TABLET, 2 MG TABLET,0.125 MG DIS TAB)
generic 1
clorazepate dipotassium generic 1 AL At least 9 yrs old
DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5MG/5 ML SOLUTION, 5 MG TABLET)
generic 1
KLONOPINclonazepam
BRAND 1 PA
lisinopril 5 mg tablet generic 1
LORAZEPAM (4 MG/ML CARPUJECT, 2MG/ML ORAL CONCENT, 0.5 MG TABLET, 4MG/ML VIAL, 2 MG/ML VIAL, 1 MG TABLET, 2MG/ML CARPUJECT, 20 MG/10 ML VIAL, 2MG TABLET)
generic 1
LORAZEPAM INTENSOLlorazepam
BRAND 1
oxazepam generic 1 AL At least 6 yrs old
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETROcarbamazepine
BRAND 1PA
AL At least 6 yrs old
LITHIUM CARBONATE (300 MG TAB, 600 MGCAP, 150 MG CAP, 300 MG CAP)
generic 1 AL At least 6 yrs old
lithium carbonate er generic 1 AL At least 6 yrs old
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose generic 1
BYDUREON PEN BRAND 1
PAGE 41 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
exenatide microspheres
BYETTAexenatide
BRAND 1
FARXIGAdapagliflozin propanediol
BRAND 1
FORTAMETmetformin hcl
BRAND 1
glimepiride generic 1
glipizide generic 1
glipizide er generic 1
glipizide xl generic 1
glipizide-metformin generic 1
GLUMETZAmetformin hcl
BRAND 1
glyburide generic 1
glyburide micronized generic 1
glyburide-metformin hcl generic 1
GLYSETmiglitol
BRAND 1
GLYXAMBIempagliflozin/linagliptin
BRAND 1 AL At least 18 yrs old
INVOKAMETcanagliflozin/metformin hcl
BRAND 1
INVOKANAcanagliflozin
BRAND 1
JANUMETsitagliptin phosphate/metformin hcl
BRAND 1 AL At least 18 yrs old
JANUMET XRsitagliptin phosphate/metformin hcl
BRAND 1 AL At least 18 yrs old
JANUVIAsitagliptin phosphate
BRAND 1 AL At least 18 yrs old
JARDIANCEempagliflozin
BRAND 1
JENTADUETOlinagliptin/metformin hcl
BRAND 1 AL At least 18 yrs old
KOMBIGLYZE XRsaxagliptin hcl/metformin hcl
BRAND 1 AL At least 18 yrs old
metformin er gastric generic 1
PAGE 42 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
metformin er osmotic generic 1
METFORMIN HCL (1,000 MG, 850 MG, 500MG)
generic 1
metformin hcl er generic 1
ONGLYZAsaxagliptin hcl
BRAND 1 AL At least 18 yrs old
pioglitazone hcl generic 1
repaglinide generic 1
TRADJENTAlinagliptin
BRAND 1 AL At least 18 yrs old
GLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKITglucagon,human recombinant
BRAND 1 QL
GLUCAGEN DIAGNOSTIC 1 MG VIALglucagon,human recombinant
BRAND 1
GLUCAGON EMERGENCY KITglucagon hcl
BRAND 1
glucagon hcl generic 1
PROGLYCEMdiazoxide
BRAND 1
INSULINS
BASAGLAR KWIKPEN U-100insulin glargine,human recombinant analog
BRAND 1
HUMALOG (100 UNITS/ML CARTRIDGE, 100UNIT/ML VIAL)insulin lispro
BRAND 1
HUMALOG KWIKPEN U-100insulin lispro
BRAND 1
HUMALOG MIX 50-50insulin lispro protamine and insulin lispro
BRAND 1
HUMALOG MIX 50-50 KWIKPENinsulin lispro protamine and insulin lispro
BRAND 1
HUMALOG MIX 75-25insulin lispro protamine and insulin lispro
BRAND 1
HUMALOG MIX 75-25 KWIKPENinsulin lispro protamine and insulin lispro
BRAND 1
LANTUSinsulin glargine,human recombinant analog
BRAND 1
LANTUS SOLOSTAR BRAND 1
PAGE 43 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
insulin glargine,human recombinant analog
LEVEMIRinsulin detemir
BRAND 1
LEVEMIR FLEXTOUCHinsulin detemir
BRAND 1
NOVOLOG (100 CARTRIDGE, 100 VIAL)insulin aspart
BRAND 1
NOVOLOG FLEXPENinsulin aspart
BRAND 1
NOVOLOG MIX 70-30insulin aspart protamine human/insulin aspart
BRAND 1
NOVOLOG MIX 70-30 FLEXPENinsulin aspart protamine human/insulin aspart
BRAND 1
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
CATHFLO ACTIVASEalteplase
BRAND 1
COUMADINwarfarin sodium
BRAND 1
ELIQUIS (5 MG TABLET, 2.5 MG TABLET,DVT-PE TREAT START 5MG)apixaban
BRAND 1 AL At least 18 yrs old
ENOXAPARIN SODIUM (150 MG/MLSYRINGE, 80 MG/0.8 ML SYR, 300 MG/3 MLVIAL, 120 MG/0.8 ML SYR, 30 MG/0.3 MLSYR, 60 MG/0.6 ML SYR, 100 MG/MLSYRINGE, 40 MG/0.4 ML SYR)
generic 1
heparin 500 unit/5 ml (100/ml) generic 1
HEPARIN SODIUM (SOD 5,000 UNIT/0.5 ML,2,000 UNIT/2 ML VIAL, 5,000 UNIT/MLCARPUJCT, SOD 1,000 UNIT/ML VIAL, SOD10,000 UNIT/ML VL, SOD 5,000 UNIT/MLVIAL, SOD 5,000 UNIT/ML SYRG, SOD 20,000UNIT/ML VL, SOD 5,000 UNIT/ 0.5 ML)
generic 1
heparin 1,000 unit/500 ml-ns generic 1
JANTOVENwarfarin sodium
BRAND 1
PRADAXAdabigatran etexilate mesylate
BRAND 1 AL At least 18 yrs old
warfarin sodium generic 1
1
PAGE 44 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
XARELTO (2.5 MG TABLET, 15 MG TABLET,20 MG TABLET, STARTER PACK, 10 MGTABLET)rivaroxaban
BRAND AL At least 18 yrs old
BLOOD FORMATION MODIFIERS
anagrelide hcl generic 1
ARANESP (500 MCG/1 ML SYRINGE, 150MCG/0.3 ML SYRINGE, 100 MCG/ML VIAL, 60MCG/0.3 ML SYRINGE, 25 MCG/ML VIAL, 40MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 300MCG/0.6 ML SYRINGE, 10 MCG/0.4 MLSYRINGE, 300 MCG/ML VIAL, 200 MCG/0.4ML SYRINGE, 100 MCG/0.5 ML SYRINGE, 25MCG/0.42 ML SYRING, 200 MCG/ML VIAL, 60MCG/ML VIAL)darbepoetin alfa in polysorbate 80
BRAND 1 PA
GRANIX (300 MCG/ML VIAL, 300 MCG/0.5 MLSYRINGE, 300 MCG/0.5 ML SAFE SYR, 480MCG/0.8 ML SYRINGE, 480 MCG/0.8 MLSAFE SYR, 480 MCG/1.6 ML VIAL)tbo-filgrastim
BRAND 1 PA
LEUKINEsargramostim
BRAND 1 PA
NEULASTA (6 ML SYRINGE, ONPRO 6 MLKIT)pegfilgrastim
BRAND 1 PA
NEUPOGEN (300 MCG/ML VIAL, 300MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480MCG/0.8 ML SYR)filgrastim
BRAND 1 PA
PROCRITepoetin alfa
BRAND 1 PA
HEMOSTASIS AGENTS
ADVATEantihemophilic factor (fviii) recombinant,fulllength
BRAND 1
ADYNOVATEantihemophilic factor (fviii) recombinant, fulllength, peg
BRAND 1
AFSTYLAantihemophilic factor viii recomb,single-chn,b-dom truncated
BRAND 1
ALPHANATEantihemophilic factor, human/von willebrandfactor,human
BRAND 1
PAGE 45 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ALPHANINE SDfactor ix
BRAND 1
ALPROLIXfactor ix recombinant, fc fusion protein
BRAND 1
AMICAR (500 MG TABLET, 1,000 MGTABLET, 0.25 GRAM/ML ORAL SOLN)aminocaproic acid
BRAND 1
aminocaproic acid 5 g/20 ml vl generic 1
BENEFIXfactor ix human recombinant
BRAND 1
COAGADEXcoagulation factor x
BRAND 1
CORIFACTfactor xiii
BRAND 1
ELOCTATEantihemophilic factor (fviii) recombinant, fcfusion protein
BRAND 1
ESPEROCTantihemophilic factor (fviii) rec, b-dom truncatedpeg-exei
BRAND 1
FEIBA NFanti-inhibitor coagulant complex
BRAND 1
HEMLIBRAemicizumab-kxwh
BRAND 1
HEMOFIL Mantihemophilic factor, human
BRAND 1
HUMATE-Pantihemophilic factor, human/von willebrandfactor,human
BRAND 1
IDELVIONfactor ix recombinant,albumin fusion protein
BRAND 1
IXINITY (3,000, 2,000, 250)factor ix human recombinant, threonine 148
BRAND 1
JIVIantihemophilic factor (fviii) rec, b-domaindeleted peg-aucl
BRAND 1 AL At least 12 yrs old
KOATEantihemophilic factor, human
BRAND 1
KOGENATE FSantihemophilic factor (fviii) recombinant,fulllength
BRAND 1
KOVALTRY BRAND 1
PAGE 46 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
antihemophilic factor (fviii) recombinant,fulllength
MEPHYTONphytonadione (vit k1)
BRAND 1
MONONINEfactor ix
BRAND 1
NOVOEIGHTantihemophilic factor viii recombinant, b-domaintruncated
BRAND 1
NOVOSEVEN RTcoagulation factor viia (recombinant)
BRAND 1
NUWIQantihemophilic factor viii rec hek cell, b-domaindeleted
BRAND 1
OBIZURantihemophilic factor viii, recombinant porcinesequence
BRAND 1
PHYTONADIONE (1 MG/0.5 ML SYR, 10MG/ML AMPUL)
generic 1
PROFILNINEfactor ix complex, prothrombin cplx conc(pcc)no.4, 3-factor
BRAND 1
REBINYNfactor ix (human) recombinant, pegylated
BRAND 1
RECOMBINATEantihemophilic factor viii, human recombinant
BRAND 1
RIXUBISfactor ix human recombinant
BRAND 1
TRANEXAMIC ACID (650 MG TABLET, 1,000MG/10 ML)
generic 1
tranexamic acid-nacl generic 1
TRETTENfactor xiii a-subunit, recombinant
BRAND 1
vitamin k1 generic 1
VONVENDIvon willebrand factor (recombinant)
BRAND 1
WILATE (500-500, 1,000-1,000)antihemophilic factor, human/von willebrandfactor,human
BRAND 1
XYNTHAantihemophilic factor (factor viii) recomb,b-domain deleted
BRAND 1
PAGE 47 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
XYNTHA SOLOFUSEantihemophilic factor (factor viii) recomb,b-domain deleted
BRAND 1
PLATELET MODIFYING AGENTS
AGGRENOXaspirin/dipyridamole
BRAND 1
BRILINTAticagrelor
BRAND 1
cilostazol generic 1
clopidogrel 75 mg tablet generic 1
DIPYRIDAMOLE (75 MG, 25 MG, 50 MG) generic 1
prasugrel hcl generic 1
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CATAPRES-TTS 1clonidine
BRAND 1
CATAPRES-TTS 2clonidine
BRAND 1
CATAPRES-TTS 3clonidine
BRAND 1
CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG) generic 1
guanfacine hcl generic 1
methyldopa generic 1
midodrine hcl generic 1
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate generic 1
prazosin hcl generic 1
terazosin hcl generic 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan generic 1
losartan potassium generic 1
olmesartan medoxomil generic 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl generic 1
1
PAGE 48 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
enalapril maleate generic
fosinopril sodium generic 1
LISINOPRIL (10 MG, 30 MG, 40 MG, 2.5 MG,20 MG)
generic 1
quinapril hcl generic 1
ramipril generic 1
ANTIARRHYTHMICS
AMIODARONE HCL (200 MG, 100 MG) generic 1
flecainide acetate generic 1
mexiletine hcl generic 1
propafenone hcl generic 1
quinidine sulfate generic 1
sotalol generic 1
sotalol af generic 1
TIKOSYNdofetilide
BRAND 1
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl generic 1
atenolol generic 1
bisoprolol fumarate generic 1
carvedilol generic 1
LABETALOL HCL (100 MG, 200 MG, 300 MG) generic 1
metoprolol succinate generic 1
METOPROLOL TARTRATE (50 MG, 100 MG,25 MG)
generic 1
PROPRANOLOL HCL (20 MG/5 ML SOLN, 40MG TABLET, 10 MG TABLET, 20 MGTABLET, 40 MG/5 ML SOLN, 60 MG TABLET,80 MG TABLET)
generic 1
propranolol hcl er generic 1
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate generic 1
diltiazem 12hr er generic 1
diltiazem 24hr er generic 1
1
PAGE 49 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
diltiazem 24hr er (cd) generic
DILTIAZEM HCL (90 MG, 30 MG, 60 MG, 120MG)
generic 1
felodipine er generic 1
nifedipine generic 1
nifedipine er generic 1
nimodipine generic 1 AL At least 18 yrs old
VERAPAMIL ER (ER 240 MG CAPSULE, ER240 MG TABLET, ER 120 MG CAPSULE, ER120 MG TABLET, ER 180 MG TABLET, ER180 MG CAPSULE)
generic 1
VERAPAMIL HCL (80 MG TABLET, 40 MGTABLET, 360 MG CAP PELLET, 120 MGTABLET)
generic 1
verapamil sr generic 1
CARDIOVASCULAR AGENTS, OTHER
amiloride-hydrochlorothiazide generic 1
amlodipine besylate-benazepril generic 1
amlodipine-olmesartan generic 1
amlodipine-valsartan generic 1
atenolol-chlorthalidone generic 1
bisoprolol-hydrochlorothiazide generic 1
DIGOXIN (0.05 MG/ML SOLUTION, 125 MCGTABLET, 0.125 MG TABLET, 250 MCGTABLET, 0.25 MG TABLET)
generic 1
dobutamine 250 mg/20 ml vial generic 1
dobutamine hcl in dextrose generic 1
enalapril-hydrochlorothiazide generic 1
ENTRESTOsacubitril/valsartan
BRAND 1
fosinopril-hydrochlorothiazide generic 1
lisinopril-hydrochlorothiazide generic 1
losartan-hydrochlorothiazide generic 1
milrinone in 5% dextrose generic 1
milrinone lactate generic 1
pentoxifylline generic 1
PAGE 50 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
quinapril-hydrochlorothiazide generic 1
RANEXAranolazine
BRAND 1
spironolactone-hctz generic 1
TRIAMTERENE-HYDROCHLOROTHIAZID(75-50 MG TAB, 37.5-25 MG CP, 37.5-25 MGTB)
generic 1
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide generic 1
acetazolamide er generic 1
DIURETICS, LOOP
BUMETANIDE (1 MG/4 ML VIAL, 1 MGTABLET, 0.5 MG TABLET, 2.5 MG/10 MLVIAL, 2 MG TABLET)
generic 1
FUROSEMIDE (100 MG/10 ML SYRING, 80MG TABLET, 20 MG TABLET, 40 MG/4 MLVIAL, 40 MG/4 ML SYRINGE, 40 MG/5 MLSOLN, 10 MG/ML SOLUTION, 40 MGTABLET, 100 MG/10 ML VIAL, 20 MG/2 MLVIAL)
generic 1
torsemide generic 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl generic 1
eplerenone generic 1
spironolactone generic 1
DIURETICS, THIAZIDE
chlorthalidone generic 1
DIURILchlorothiazide
BRAND 1 AL Up to 11 yrs old
HYDROCHLOROTHIAZIDE (12.5 MG TB, 50MG TAB, 12.5 MG CP, 25 MG TAB)
generic 1
indapamide generic 1
metolazone generic 1
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
FENOFIBRATE (145 MG, 48 MG) generic 1
gemfibrozil generic 1
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
PAGE 51 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
atorvastatin calcium generic 1
lovastatin generic 1
pravastatin sodium generic 1
rosuvastatin calcium generic 1
SIMVASTATIN (20 MG, 40 MG, 5 MG, 80 MG,10 MG)
generic 1
DYSLIPIDEMICS, OTHER
CHOLESTYRAMINE (POWDER, PACKET) generic 1
CHOLESTYRAMINE LIGHT (POWDER,PACKET)
generic 1
COLESTID (PACKET, FLAVORED, )colestipol hcl
BRAND 1
COLESTIPOL HCL (HCL GRANULES,MICRONIZED 1 GM TAB, HCL GRANULESPACKET, HCL 1 GM TABLET)
generic 1
ezetimibe generic 1 AL At least 10 yrs old
niacin er generic 1
VASODILATORS, DIRECT-ACTING ARTERIAL
HYDRALAZINE HCL (25 MG, 10 MG, 100 MG,50 MG)
generic 1
minoxidil generic 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitrate generic 1
isosorbide mononitrate generic 1
isosorbide mononitrate er generic 1
NITROGLYCERIN (0.6 MG, 0.3 MG, 0.4 MG) generic 1
nitroglycerin patch generic 1
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
DEXTROAMPHETAMINE SULFATE (10 MG, 5MG)
generic 1
dextroamphetamine-amphet er generic 1 AL At least 6 yrs old
dextroamphetamine-amphetamine generic 1 AL At least 3 yrs old
DYANAVEL XR BRAND 1 AL At least 6 yrs old
PAGE 52 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
amphetamine
VYVANSE (10 MG CHEWABLE TABLET, 60MG CAPSULE, 60 MG CHEWABLE TABLET,20 MG CAPSULE, 50 MG CAPSULE, 30 MGCAPSULE, 20 MG CHEWABLE TABLET, 10MG CAPSULE, 30 MG CHEWABLE TABLET,40 MG CHEWABLE TABLET, 70 MGCAPSULE, 40 MG CAPSULE, 50 MGCHEWABLE TABLET)lisdexamfetamine dimesylate
BRAND 1 AL At least 6 yrs old
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
APTENSIO XRmethylphenidate hcl
BRAND 1 AL At least 6 yrs old
atomoxetine hcl generic 1 AL At least 6 yrs old
DAYTRANAmethylphenidate
BRAND 1 AL At least 6 yrs old
dexmethylphenidate hcl generic 1
FOCALIN XRdexmethylphenidate hcl
BRAND 1 AL At least 6 yrs old
guanfacine hcl er generic 1
METHYLPHENIDATE ER (ER 20 MG, ER 10MG)
generic 1 AL At least 6 yrs old
METHYLPHENIDATE HCL (5 MG, 20 MG, 10MG)
generic 1
methylphenidate hcl cd generic 1 AL At least 6 yrs old
methylphenidate hcl er (cd) generic 1 AL At least 6 yrs old
QUILLICHEW ERmethylphenidate hcl
BRAND 1 AL At least 6 yrs old
QUILLIVANT XRmethylphenidate hcl
BRAND 1 AL At least 6 yrs old
CENTRAL NERVOUS SYSTEM, OTHER
AUSTEDOdeutetrabenazine
BRAND 1PA
AL At least 18 yrs old
BUTALBITAL-ACETAMINOPHEN (50-325, 50-300)
generic 1
butalbital-acetaminophen-caffe generic 1
INGREZZAvalbenazine tosylate
BRAND 1PA
AL At least 18 yrs old
PAGE 53 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
NUEDEXTAdextromethorphan hbr/quinidine sulfate
BRAND 1 AL At least 18 yrs old
riluzole generic 1
tetrabenazine generic 1PA
AL At least 18 yrs old
FIBROMYALGIA AGENTS
duloxetine hcl generic 1 AL At least 6 yrs old
PREGABALIN (200 MG, 100 MG, 225 MG, 75MG, 25 MG, 150 MG, 50 MG, 300 MG)
generic 1
MULTIPLE SCLEROSIS AGENTS
AUBAGIOteriflunomide
BRAND 1 AL At least 18 yrs old
AVONEX PREFILLED SYR 30 MCG KTinterferon beta-1a
BRAND 1 AL At least 18 yrs old
AVONEX PENinterferon beta-1a
BRAND 1 AL At least 18 yrs old
BETASERON (0.3 MG VIAL, 0.3 MG KIT)interferon beta-1b
BRAND 1 AL At least 18 yrs old
COPAXONE 20 MG/ML SYRINGEglatiramer acetate
BRAND 1 AL At least 18 yrs old
dalfampridine er generic 1 AL At least 18 yrs old
GILENYAfingolimod hcl
BRAND 1 AL At least 10 yrs old
REBIFinterferon beta-1a/albumin human
BRAND 1
REBIF REBIDOSEinterferon beta-1a/albumin human
BRAND 1
TECFIDERAdimethyl fumarate
BRAND 1 AL At least 18 yrs old
DENTAL AND ORAL AGENTS
chlorhexidine gluconate generic 1
PILOCARPINE HCL (7.5 MG, 5 MG) generic 1
sodium fluoride 1.1% gel generic 1
triamcinolone 0.1% paste generic 1
DERMATOLOGICAL AGENTS
PAGE 54 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
acitretin generic 1
ALA-QUINclioquinol/hydrocortisone
BRAND 1
AMMONIUM LACTATE (CREAM, LOTION) generic 1
AMNESTEEMisotretinoin
BRAND 1 AL At least 12 yrs old
AVITA 0.025% CREAMtretinoin
BRAND 1 AL At least 12 yrs old
CALCIPOTRIENE (CREAM, OINTMENT) generic 1PA
AL At least 18 yrs old
calcitriol 3 mcg/g ointment generic 1
CLARAVISisotretinoin
BRAND 1 AL At least 12 yrs old
clinda-benzoyl perox 1-5% pump generic 1 AL At least 12 yrs old
clotrimazole-betamethasone crm generic 1
CORTISPORIN (CREAM, OINTMENT)neomycin/bacitracin/polymyxinb/hydrocortisone
BRAND 1
COSENTYX (2 SYRINGES)secukinumab
BRAND 1PA
AL At least 18 yrs old
COSENTYX PENsecukinumab
BRAND 1PA
AL At least 18 yrs old
COSENTYX PEN (2 PENS)secukinumab
BRAND 1PA
AL At least 18 yrs old
COSENTYX SYRINGEsecukinumab
BRAND 1PA
AL At least 18 yrs old
diclofenac sodium 1% gel generic 1
diclofenac sodium 3% gel generic 1PA
AL At least 18 yrs old
DIFFERIN (LOTION, CREAM)adapalene
BRAND 1 AL At least 12 yrs old
doxepin 5% cream generic 1PA
AL At least 18 yrs old
ELIDELpimecrolimus
BRAND 1
PAGE 55 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
EUCRISAcrisaborole
BRAND 1 AL At least 2 yrs old
FINACEA 15% GELazelaic acid
BRAND 1
imiquimod 5% cream packet generic 1 AL At least 12 yrs old
isotretinoin generic 1 AL At least 12 yrs old
LIDOCAINE-HYDROCORTISONE (2.8-0.55%GEL, 3-0.5% CREAM)
generic 1
lidocaine-hc 3-2.5% gel kit generic 1 QL
METRONIDAZOLE (0.75% CREAM, TOPICAL0.75% GL, TOPICAL 1% GEL, TOP 1% GELPUMP)
generic 1
MYORISANisotretinoin
BRAND 1 AL At least 12 yrs old
NATROBAspinosad
BRAND 1
podofilox generic 1
PROCTOFOAM-HChydrocortisone acetate/pramoxine hcl
BRAND 1
PROTOPIC 0.03% OINTMENTtacrolimus
BRAND 1
PROTOPIC 0.1% OINTMENTtacrolimus
BRAND 1 AL At least 16 yrs old
RETIN-A (0.025%, 0.05%, 0.1%)tretinoin
BRAND 1 AL At least 12 yrs old
salicylic acid 6% cream generic 1
SANTYLcollagenase clostridium histolyticum
BRAND 1
SELENIUM SULFIDE (2.25% SHAMPOO,2.5% LOTION)
generic 1
silver nitrate 0.5% soln generic 1
UREA (CREAM, LOTION) generic 1
ZENATANEisotretinoin
BRAND 1 AL At least 12 yrs old
ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
PAGE 56 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
AMINOSYN (8.5%, 10%)parenteral amino acid 10 % combination no.2
BRAND 1
AMINOSYN II (15%, 7%, 8.5%, 10%)parenteral amino acid 7 % combination no.2
BRAND 1
AMINOSYN II WITH ELECTROLYTESamino acids 8.5 %/electrolyte-tpn soln
BRAND 1
AMINOSYN Mamino acids 3.5 %/electrolyte-m solution
BRAND 1
AMINOSYN WITH ELECTROLYTES (8.5%-ELECTROLYTES, 7%-ELECTROLYTE)amino acids 8.5 %/electrolyte-tpn soln
BRAND 1
AMINOSYN-HBCamino acids 7 %
BRAND 1
AMINOSYN-PF (10%, 7%)parenteral amino acid 7 % combination no.1(pediatric)
BRAND 1
AMINOSYN-RFparenteral amino acid 5.2 % combination no.1(renal)
BRAND 1
calcium chloride 10% vial generic 1
CALCIUM GLUCONATE (10,000 MG/100 ML,5,000 MG/50 ML VL, 1,000 MG/10 ML VL)
generic 1
CENTRATEXferrous fumarate/folic acid/multivitamin-minerals no.15
BRAND 1
chromium generic 1
CLINIMIX (5%-20%, 4.25%-5%, 4.25%-10%,5%-15%)amino acids 4.25 %/dextrose 10 % in water
BRAND 1
CLINIMIX E (5%-15%, 4.25%-10%, 2.75%-5%,4.25%-5%, 5%-20%)amino acids 5 %/calcium/electrolyte-tpnsoln/dextrose 20 %
BRAND 1
CLINISOLparenteral amino acid 15% combination no.5
BRAND 1
copper chloride generic 1
DELFLEX WITH 1.5% DEXTROSEperitoneal dialysis solution no.19 and dextrose1.5 %
BRAND 1
dextrose 10%-0.2% nacl generic 1
dextrose 10%-0.45% nacl generic 1
PAGE 57 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
dextrose 2.5%-0.45% nacl generic 1
dextrose 5%-0.2% nacl generic 1
dextrose 5%-0.2% nacl-kcl generic 1
dextrose 5%-0.225% nacl generic 1
dextrose 5%-0.225% nacl-kcl generic 1
dextrose 5%-0.3% nacl generic 1
dextrose 5%-0.3% nacl-kcl generic 1
dextrose 5%-0.33% nacl generic 1
dextrose 5%-0.45% nacl generic 1
dextrose 5%-0.45% nacl-kcl generic 1
dextrose 5%-0.9% nacl generic 1
dextrose 5%-1/2ns-kcl generic 1
dextrose 5%-1/4ns-kcl generic 1
dextrose 5%-electrolyte #48 generic 1
dextrose 5%-ns-kcl generic 1
dextrose 5%-potassium chloride generic 1
dextrose in lactated ringers generic 1
DEXTROSE IN WATER (10%-WATER IVSOLUTION, 20%-WATER IV SOLN, 70%-WATER IV SOLN, 5%-WATER VIAL, 50%-WATER IV SOLN, 50%-WATER ABBOJECT,50%-WATER VIAL, 50%-WATER SYRINGE,40%-WATER IV SOLN, 5%-WATER 50 ML,25%-WATER SYRINGE, 5%-WATER 100 ML,30%-WATER IV SOLN, 5%-WATER IV SOLN)
generic 1
EFFER-Kpotassium bicarbonate/citric acid
BRAND 1
fluoride generic 1
FREAMINE IIIparenteral amino acid 10 % combination no.4
BRAND 1
FUSION PLUSiron fum,polysac comp/folic acid/vit b compcno.18/l. casei
BRAND 1
glucose in water generic 1
HEMATOGEN FAferrous fumarate/ascorbicacid/cyanocobalamin/folic acid
BRAND 1
HEMOCYTE PLUS BRAND 1
PAGE 58 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ferrous fumarate/folic acid/multivitamin-minerals no.15
HEMOCYTE-Fferrous fumarate/folic acid
BRAND 1
HEPATAMINEamino acids 8 %
BRAND 1
HYPERLYTE CRsodium/potassium/magnesium/calcium/chloride/acetate
BRAND 1
IFEREX 150 FORTEiron polysaccharidecomplex/cyanocobalamin/folic acid
BRAND 1
INTEGRA Firon fumarate,polysac comp/folic acid/vitaminc/niacinamide
BRAND 1
INTEGRA PLUSiron fumarate,polysac cplex/folic acid/vitb compwith c no.9
BRAND 1
INTRALIPIDfat emulsions
BRAND 1
IODOPENsodium iodide
BRAND 1
IONOSOL B WITH DEXTROSE 5%electrolyte-b solution/dextrose 5 % in water
BRAND 1
IONOSOL MB-DEXTROSE 5%electrolyte-mb solution/dextrose 5 % in water
BRAND 1
ISOLYTE P WITH DEXTROSEelectrolyte-p solution/dextrose 5 % in water
BRAND 1
ISOLYTE S (OLUTION-EXCEL, OLN PH7.4)electrolyte-s solution
BRAND 1
KLOR-CONpotassium chloride
BRAND 1
KLOR-CON 10potassium chloride
BRAND 1
KLOR-CON 8potassium chloride
BRAND 1
KLOR-CON M10potassium chloride
BRAND 1
KLOR-CON M15potassium chloride
BRAND 1
KLOR-CON M20potassium chloride
BRAND 1
PAGE 59 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
KLOR-CON-EFpotassium bicarbonate/citric acid
BRAND 1
LACTATED RINGERS (IRRIGATION,INJECTION)
generic 1
LEVOCARNITINE (1 G/10 ML SOLN, 330 MGTABLET)
generic 1
magnesium chloride generic 1
MAGNESIUM SULFATE (SULF 2 G/50 MLBAG, SULF 40 G/1,000 ML, SULF 4 G/100 MLBAG, SULFATE 50% VIAL, SULF 4 G/50 MLBAG, SULF 20 G/500 ML BAG)
generic 1
manganese chloride generic 1
manganese sulfate generic 1
MULTITRACE-4zinc sulfate/cupric sulfate/manganesesulf/chromic chloride
BRAND 1
MULTITRACE-5zinc sulfate/coppersulfate/manganese/chromium/selenium
BRAND 1
NEPHRAMINEamino acids 5.4 %
BRAND 1
NORMOSOL-M AND DEXTROSEelectrolyte-m solution/dextrose 5 % in water
BRAND 1
NORMOSOL-Relectrolyte-r solution
BRAND 1
NORMOSOL-R AND DEXTROSEelectrolyte-r solution/dextrose 5 % in water
BRAND 1
NORMOSOL-R PH 7.4electrolyte-r (ph 7.4)
BRAND 1
NUTRILIPIDfat emulsions
BRAND 1
PLASMA-LYTE 148electrolyte-148 solution
BRAND 1
PLASMA-LYTE A PH 7.4electrolyte-a solution
BRAND 1
PLENAMINEparenteral amino acid 15% combination no.1
BRAND 1
potassium acetate generic 1
potassium chl-normal saline generic 1
POTASSIUM CHLORIDE (ER 10 MEQ generic 1
PAGE 60 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TABLET, 20 MEQ PACKET, 40 MEQ/20 MLCONC, 60 MEQ/30 ML CONC, 10% (20MEQ/15ML), 20 MEQ/10 ML CONC, 10MEQ/50 ML SOL, ER 8 MEQ CAPSULE, 20MEQ/50 ML SOL, ER 8 MEQ TABLET, 10MEQ/100 ML SOL, ER 10 MEQ CAPSULE, 2MEQ/ML CONC, 20% (40 MEQ/15ML), 30MEQ/100 ML SOL, 10% (40 MEQ/30ML), 40MEQ/100 ML SOL, 10 MEQ/5 ML CONC, ER20 MEQ TABLET, 20 MEQ/100 ML SOL)
potassium chloride in d5lr generic 1
potassium chloride-nacl generic 1
potassium phosp 45 mmol/15 ml generic 1
potassium phosphates generic 1
PREMASOL 10% IV SOLUTIONparenteral amino acid 10% combination no.7
BRAND 1
PROCALAMINEamino acids 3 %/electrolyte-tpn soln/glycerin
BRAND 1
PROSOLparenteral amino acid 20 % combination no.1
BRAND 1
PUREVIT DUALFE PLUSiron fumarate-iron polysacch cplex/folicacid/multivit no.18
BRAND 1
ringers injection generic 1
ringers irrigation generic 1
SE-TAN PLUSiron fumarate-iron polysacch cplex/folicacid/multivit no.18
BRAND 1
SODIUM ACETATE (400 MEQ/100 ML, 200MEQ/100 ML, 100 MEQ/50 ML, 40 MEQ/20 MLVL)
generic 1
sodium bicarbonate 4.2% vial generic 1
SODIUM CHLORIDE (SODIUM CHLORIDE5% IV SOLN, SODIUM CHLORIDE 0.9% 50ML, SODIUM CHLORIDE 0.9% IRRIG.,SODIUM CHLORIDE 4 MEQ/ML VL, SODIUMCHLORIDE 3% IV SOLN, SODIUM CHLORIDE0.9% PRCSS SOL, SODIUM CHLORIDE 50MEQ/20 ML, SALINE 0.45% SOLN-EXCELCON, SODIUM CHLORIDE 0.9% SOLN,SODIUM CHLORIDE 0.9% 500 ML, SODIUMCHLORIDE 0.9% 1,000 ML, SODIUMCHLORIDE 0.9% SOL-EXCEL, SODIUMCHLORIDE 0.9% VIAL, SODIUM CHLORIDE
generic 1
PAGE 61 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
0.9% SOLUTION, SODIUM CHLORIDE 0.45%SOLN, SODIUM CHLORIDE 0.9% IRRIG,SODIUM CHLORIDE 100 MEQ/40 ML,SODIUM CHLORIDE 0.9% 100 ML)
sodium fluoride 0.5 mg/ml drop generic 1
sodium phosphate generic 1
SYNTHAMIN 17 WITHOUT ELTYEparenteral amino acid 10 % combination no.6
BRAND 1
TANDEM PLUSiron fumarate-iron polysacch cplex/folicacid/multivit no.18
BRAND 1
TIS-U-SOL PENTALYTEsodium chloride/pot chloride/mag sul/sodphos,db/pot phos,mb
BRAND 1
TPN ELECTROLYTESsodium/potassium/magnesium/calcium/chloride/acetate
BRAND 1
TPN ELECTROLYTES IIsodium/potassium/magnesium/calcium/chloride/acetate
BRAND 1
TRAVASOLparenteral amino acid 10 % combination no.6
BRAND 1
TRICONferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND 1
TROPHAMINE 10% IV SOLUTIONamino acids 10 %
BRAND 1
zinc chloride generic 1
ZINC SULFATE (30 MG/10 ML, 25 MG/5 ML) generic 1
ELECTROLYTE/MINERAL/METAL MODIFIERS
deferoxamine mesylate generic 1
SODIUM POLYSTYRENE SULFONATE(SODIUM POLYSTYRENE POWDER, SODPOLYSTYREN 15 G/60 ML)
generic 1
SPS (15 GM/60 ML SUSPENSION, 30 GM/120ML ENEMA SUSP)sodium polystyrene sulfonate/sorbitol solution
BRAND 1
PHOSPHATE BINDERS
CALCIUM ACETATE (667 MG CAPSULE, 667MG GELCAP)
generic 1
RENVELA (0.8, 2.4)sevelamer carbonate
BRAND 1 AL Up to 11 yrs old
PAGE 62 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
sevelamer hcl generic 1
VITAMINS
ascorbic acid generic 1
BACMINmultivitamin with minerals no.20/iron/folic acid
BRAND 1
CITRANATAL B-CALMprenatal vitaminno.48/iron,carbonyl,gluconate/folic acid/b6
BRAND 1 AL At least 12 yrs old
COMPLETE NATAL DHAprenatal vit no.2/iron bg chel,succ-prot/folicacid/omega-3
BRAND 1 AL At least 12 yrs old
CONCEPT DHAmv-min 75/ferrous fum/iron ps cplx/folicac/omega-3/dha/epa
BRAND 1 AL At least 12 yrs old
CONCEPT OBmv-mins no.74/ferrous fumarate/iron pscplx/folic acid
BRAND 1 AL At least 12 yrs old
cyanocobalamin injection generic 1
DIALYVITEfolic acid/vitamin b complex and vitamin c
BRAND 1
DIALYVITE 3000folic acid/vitamin b comp andc/selenium/minerals/zinc
BRAND 1
DIALYVITE 5000multivitamins with minerals no.11/folic acid
BRAND 1
DIALYVITE SUPREME Dmultivitamin-minerals no.25/folic acid/vitamind3
BRAND 1
DIALYVITE ZINCvitamin b complex no.11/folic acid/vitc/biotin/zinc oxide
BRAND 1
FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET) generic 1
FOLIVANE-OBmv-mins no.74/ferrous fumarate/iron pscplx/folic acid
BRAND 1 AL At least 12 yrs old
FOLTRATEcyanocobalamin/folic acid
BRAND 1
INFUVITE ADULT VIALmultivitamin infusion, adult no.4 with vitamin k
BRAND 1
INFUVITE PEDIATRICmultivitamin infusion, pediatric no.1 with vitamin BRAND 1
PAGE 63 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
k
KABIVENamino acid 3.31 % no.1/d9.8w/fatemulsions/electrolyte no.10
BRAND 1
M-NATAL PLUSprenatal vits with calcium no.72/ferrousfumarate/folic acid
BRAND 1 AL At least 12 yrs old
M.V.I. ADULTmultivitamin infusion, adult no.1 with witamin k
BRAND 1
M.V.I. PEDIATRICmultivitamin infusion, pediatric no.2 with vitamink
BRAND 1
MULTIVITAMIN WITH FLUORIDE (MULTIVIT-FLUOR 0.25 MG CHW, MULTIVIT-FLUOR 0.5MG CHEW, MULTIVIT-FLUORIDE 1 MGCHW)
generic 1 AL Up to 12 yrs old
NEPHPLEX RXvit b complex no.3/folic acid/ascorbicacid/biotin/zinc oxid
BRAND 1
NEPHRO-VITE RXvitamin b complex no.3/folic acid/ascorbicacid(vitc)/biotin
BRAND 1
PERIKABIVENamino acid 2.36 % no.1/d6.8w/fatemulsions/electrolytes no.9
BRAND 1
PNV 29-1prenatal vitamin with calciumno.76/iron,carbonyl/folic acid
BRAND 1 AL At least 12 yrs old
prenatal vitamin plus low iron generic 1 AL At least 12 yrs old
PREPLUSprenatal vits with calcium no.72/ferrousfumarate/folic acid
BRAND 1 AL At least 12 yrs old
pyridoxine hcl generic 1
SE-NATAL 19prenatal vits with calcium 118/ferrousfumarate/folic acid
BRAND 1 AL At least 12 yrs old
SELECT-OBprenatal vit no.128/iron polysaccharidecomplex/folic acid
BRAND 1 AL At least 12 yrs old
SELECT-OB + DHAprenatal vitamins no.33/iron polysachcomplex/folic acid/dha
BRAND 1 AL At least 12 yrs old
STROVITE ONE BRAND 1
PAGE 64 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
multivit with mins10/folic acid/vit d3/a lipoicacid/lutein
TARON-C DHAmv-min 75/ferrous fum/iron ps cplx/folicac/omega-3/dha/epa
BRAND 1 AL At least 12 yrs old
thiamine hcl generic 1
THRIVITE RXprenatal vitamin with calciumno.76/iron,carbonyl/folic acid
BRAND 1 AL At least 12 yrs old
TRINATAL RX 1prenatal vitamin 27 with calcium/ferrousfumarate/folic acid
BRAND 1 AL At least 12 yrs old
TRIVEEN-DUO DHAprenatal vit with calcium 53/iron bis,s-p/folicacid/omega-3
BRAND 1 AL At least 12 yrs old
TRUST NATAL DHAprenatal vit no.2/iron bg chel,succ-prot/folicacid/omega-3
BRAND 1 AL At least 12 yrs old
VIRT-C DHAmv-min 75/ferrous fum/iron ps cplx/folicac/omega-3/dha/epa
BRAND 1 AL At least 12 yrs old
VIRT-FEFA PLUSiron fumarate,polysac cplex/folic acid/vitb compwith c no.9
BRAND 1
VITAFOL GUMMIESprenatal vit no.112/iron phosph/folicacid/omega-3s/dha/epa
BRAND 1 AL At least 12 yrs old
VITAFOL ULTRAprenatal vit no.67/iron polysaccharides/folatecomb.no.1/dha
BRAND 1 AL At least 12 yrs old
VITAFOL-OBprenatal vits with calcium no.10/ferrousfumarate/folic acid
BRAND 1 AL At least 12 yrs old
VITAFOL-OB+DHAprenatal vits with calcium no.10/ferrousfum/folic acid/dha
BRAND 1 AL At least 12 yrs old
VITAFOL-ONEprenatal vits no.26/iron polysaccharidecplex/folic acid/dha
BRAND 1 AL At least 12 yrs old
VITAL-D RXvit b complex no.4/vit d3/ascorbic acid/folicacid/zinc oxid
BRAND 1
VP-VITE RXvitamin b complex no.3/folic acid/ascorbic BRAND 1
PAGE 65 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
acid(vitc)/biotin
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
belladonna-phenobarbital generic 1
DICYCLOMINE HCL (20 MG TABLET, 10 MGCAPSULE, 10 MG/5 ML SOLN)
generic 1
GLYCOPYRROLATE (1 MG, 2 MG) generic 1
GLYRX-PFglycopyrrolate/pf
BRAND 1
HYOSCYAMINE SULFATE (0.125 MG ODT,SULF 0.125 MG TAB, 0.125 MG TAB SL,0.125 MG/5 ML ELIX, 0.125 MG/ML DROP)
generic 1
hyoscyamine sulfate er generic 1
propantheline bromide generic 1
GASTROINTESTINAL AGENTS, OTHER
cromolyn 100 mg/5 ml oral conc generic 1
diphenoxylate-atrop 2.5-0.025 generic 1
loperamide generic 1
MOVANTIKnaloxegol oxalate
BRAND 1 PA
PYLERAcolloidal bismuthsubcitrate/metronidazole/tetracycline hcl
BRAND 1
URSODIOL (250 MG TABLET, 300 MGCAPSULE, 500 MG TABLET)
generic 1
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
FAMOTIDINE (40 MG/4 ML VIAL, 20 MGTABLET, 20 MG PIGGYBACK, 40 MGTABLET, 20 MG/2 ML VIAL)
generic 1
famotidine 200 mg/20 ml vial generic 1
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl generic 1
LINZESSlinaclotide
BRAND 1PA
AL At least 18 yrs old
LOTRONEXalosetron hcl
BRAND 1
PAGE 66 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
LAXATIVES
CLENPIQsodium picosulfate/magnesium oxide/citric acid
BRAND 1 AL At least 9 yrs old
GOLYTELY PACKETpeg 3350/sod sulf/sod bicarb/sodchloride/potassium chloride
BRAND 1 QL
GOLYTELY SOLUTIONpeg 3350/sod sulf/sod bicarb/sodchloride/potassium chloride
BRAND 1 QL
LACTULOSE (20 GM/30 ML, 10 GM/15 ML) generic 1
peg 3350-electrolyte solution generic 1
peg-3350 and electrolytes generic 1
TRILYTE WITH FLAVOR PACKETSsodium chloride/sodium bicarbonate/potassiumchloride/peg
BRAND 1
PROTECTANTS
misoprostol generic 1
SUCRALFATE (1 GM TABLET, 1 GM/10 MLSUSP)
generic 1
PROTON PUMP INHIBITORS
NEXIUM (20 MG, 2.5 MG, 10 MG, 40 MG, 5MG)esomeprazole magnesium
BRAND 1 AL Up to 11 yrs old
omeprazole generic 1 AL At least 1 yrs old
PANTOPRAZOLE SODIUM (40 MG, 20 MG) generic 1 AL At least 5 yrs old
PREVACID (30 MG, 15 MG)lansoprazole
BRAND 1 AL 1.0 to 11.0 yrs old
PROTONIX 40 MG SUSPENSIONpantoprazole sodium
BRAND 1 AL 5.0 to 11.0 yrs old
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
ARALAST NPalpha-1-proteinase inhibitor
BRAND 1PA
AL At least 18 yrs old
CREONlipase/protease/amylase
BRAND 1 PA
CYSTADANEbetaine
BRAND 1
CYSTAGON BRAND 1
PAGE 67 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
cysteamine bitartrate
ELELYSOtaliglucerase alfa
BRAND 1PA
AL At least 4 yrs old
FABRAZYMEagalsidase beta
BRAND 1PA
AL At least 8 yrs old
GLASSIAalpha-1-proteinase inhibitor
BRAND 1PA
AL At least 18 yrs old
PANCREAZElipase/protease/amylase
BRAND 1 PA
PERTZYE (4,000, 8,000, 16,000)lipase/protease/amylase
BRAND 1 PA
PERTZYE DR 24,000 UNIT CAPSULElipase/protease/amylase
BRAND 1 PA
PROLASTIN Calpha-1-proteinase inhibitor
BRAND 1PA
AL At least 18 yrs old
VIOKACElipase/protease/amylase
BRAND 1PA
AL At least 18 yrs old
ZAVESCAmiglustat
BRAND 1PA
AL At least 18 yrs old
ZEMAIRAalpha-1-proteinase inhibitor
BRAND 1PA
AL At least 18 yrs old
ZENPEP (10,000, 20,000, 25,000, 5,000)lipase/protease/amylase
BRAND 1 PA
ZENPEP (15,000, 3,000, 40,000)lipase/protease/amylase
BRAND 1 PA
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
OXYBUTYNIN CHLORIDE (5 MG/5 MLSYRUP, 5 MG TABLET)
generic 1
oxybutynin chloride er generic 1
solifenacin succinate generic 1 AL At least 18 yrs old
TOVIAZfesoterodine fumarate
BRAND 1 AL At least 18 yrs old
BENIGN PROSTATIC HYPERTROPHY AGENTS
PAGE 68 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
alfuzosin hcl er generic 1
dutasteride generic 1
finasteride 5 mg tablet generic 1
tamsulosin hcl generic 1
GENITOURINARY AGENTS, OTHER
bethanechol chloride generic 1
K-PHOS NEUTRALsodium phosphate,dibasic/pot phos,monob/sodphosphate mono
BRAND 1
K-PHOS NO.2sodium phosphate,monobasic/potassiumphosphate,monobasic
BRAND 1
K-PHOS ORIGINALpotassium phosphate,monobasic
BRAND 1
ORACITcitric acid/sodium citrate
BRAND 1
phenazopyridine hcl generic 1
PHOSPHA 250 NEUTRALsodium phosphate,dibasic/pot phos,monob/sodphosphate mono
BRAND 1
potass cit-sod cit-citric acid generic 1
potassium citrate er generic 1
potassium citrate-citric acid generic 1
RENACIDINcitric acid/gluconolactone/magnesiumcarbonate
BRAND 1
sodium citrate-citric acid generic 1
THIOLAtiopronin
BRAND 1
TRICITRATESsodium/potassium/potassium citrate/sodiumcitrate/cit ac
BRAND 1
VIRT-PHOS 250 NEUTRALsodium phosphate,dibasic/pot phos,monob/sodphosphate mono
BRAND 1
VIRTRATE-3sodium/potassium/potassium citrate/sodiumcitrate/cit ac
BRAND 1
VIRTRATE-K BRAND 1
PAGE 69 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
potassium citrate/citric acid
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
ACTHARcorticotropin
BRAND 1 PA
betamethasone dp aug 0.05% crm generic 1
betamethasone sod phos-acetate generic 1
betamethasone va 0.1% cream generic 1
CELESTONEbetamethasone acetate/betamethasone sodiumphosphate
BRAND 1
clobetasol emollient 0.05% crm generic 1
CLOBETASOL PROPIONATE (OINTMENT,GEL, CREAM, SOLUTION)
generic 1
DERMA-SMOOTHE-FS (SCALP, BODY)fluocinolone acetonide
BRAND 1
DEXAMETHASONE (6 MG TABLET, 0.5 MGTABLET, 2 MG TABLET, 0.75 MG TABLET,0.5 MG/5 ML ELX, 4 MG TABLET, 1.5 MGTABLET, 1 MG TABLET, 0.5 MG/5 ML LIQ)
generic 1
DEXAMETHASONE SODIUM PHOSPHATE(10 MG/ML SYRING, 4 MG/ML VIAL, 120MG/30 ML VL, 20 MG/5 ML VIAL, 10 MG/MLVIAL, 100 MG/10 ML VL, 4 MG/ML SYRINGE)
generic 1
fludrocortisone acetate generic 1
FLUTICASONE PROPIONATE (0.05%CREAM, 0.005% OINT)
generic 1
HALOBETASOL PROPIONATE (CREAM,OINTMNT)
generic 1
HYDROCORTISONE (5 MG TABLET, 1%OINTMENT, 10 MG TABLET, 2.5% CREAM,20 MG TABLET, 1% CREAM, 2.5%OINTMENT)
generic 1
METHYLPREDNISOLONE (4 MG TABLET, 32MG TAB, 4 MG DOSEPK, 8 MG TAB)
generic 1
METHYLPREDNISOLONE ACETATE (40MG/ML, 80 MG/ML)
generic 1
methylprednisolone sodium succ generic 1
MOMETASONE FUROATE (OINT, CREAM,SOLN)
generic 1
prednisolone 15 mg/5 ml soln generic 1
PAGE 70 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
prednisolone sodium phos odt generic 1 AL Up to 11 yrs old
PREDNISOLONE SODIUM PHOSPHATE(SOD PH 25 ML, 5 ML SOLN)
generic 1
PREDNISONE (5 MG TAB DOSE PACK, 2.5MG TABLET, 1 MG TABLET, 10 MG TABDOSE PACK, 5 MG TABLET, 50 MG TABLET,5 MG/5 ML SOLUTION, 20 MG TABLET, 10MG TABLET)
generic 1
SOLU-CORTEF (100 MG ACT-O-VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 100MG VIAL, 1,000 MG ACT-O-VL)hydrocortisone sodium succinate/pf
BRAND 1
TRIAMCINOLONE ACETONIDE (0.025%OINT, 0.1% OINTMENT, 0.5% OINTMENT,0.1% CREAM, 0.5% CREAM, 0.025% CREAM,0.05% OINTMENT)
generic 1
TRIDERM 0.1% CREAMtriamcinolone acetonide
BRAND 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
DESMOPRESSIN ACETATE (ACETATE 0.2MG TB, AC 4 MCG/ML VIAL, 40 MCG/10 MLVIAL, ACETATE 0.1 MG TB, 10 MCG/0.1 MLSPR, AC 4 MCG/ML AMPUL)
generic 1
GENOTROPIN (MINIQUICK 2 MG, 5 MGCARTRIDGE, MINIQUICK 1.6 MG, MINIQUICK1.2 MG, MINIQUICK 0.4 MG, MINIQUICK 1.8MG, MINIQUICK 0.6 MG, MINIQUICK 1 MG,MINIQUICK 0.8 MG, MINIQUICK 1.4 MG, 12MG CARTRIDGE, MINIQUICK 0.2 MG)somatropin
BRAND 1PA
AL Up to 16 yrs old
NORDITROPIN FLEXPROsomatropin
BRAND 1PA
AL Up to 16 yrs old
STIMATEdesmopressin acetate
BRAND 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERMtestosterone
BRAND 1PA
AL At least 18 yrs old
ANDROGEL (1.62%(1.25G) PCKT, 1.62%PUMP, 1.62%(2.5G) PCKT, 1%(5G) PACKET,1%(2.5G) PACKET)
BRAND 1PA
AL At least 18 yrs old
PAGE 71 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
testosterone
danazol generic 1
TESTOSTERONE CYPIONATE(TESTOSTERON 2,000 MG/10 ML,TESTOSTERONE 100 MG/ML,TESTOSTERONE 200 MG/ML,TESTOSTERON 1,000 MG/10 ML)
generic 1
testosterone enanthate generic 1
ESTROGENS
AFIRMELLElevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ALTAVERAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ALYACENnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AMETHIAlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
AMETHIA LOlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
AMETHYSTlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ANNOVERAsegesterone acetate/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
APRIdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ARANELLEnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ASHLYNAlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
AUBRAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AUBRA EQlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AUROVELAnorethindrone acetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AUROVELA 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
PAGE 72 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
AUROVELA FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
AVIANElevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AYUNAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
AZURETTEdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
BALCOLTRAlevonorgestrel/ethinyl estradiol/ferrousbisglycinate
BRAND 1 AL At least 12 yrs old
BALZIVAnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
BEKYREEdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
BEYAZdrospirenone/ethinyl estradiol/levomefolatecalcium
BRAND 1 AL At least 12 yrs old
BLISOVI 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
BLISOVI FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
BRIELLYNnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CAMRESElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
CAMRESE LOlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
CAZIANTdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CHATEALlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CHATEAL EQlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CLIMARA PROestradiol/levonorgestrel
BRAND 1
COMBIPATCH BRAND 1
PAGE 73 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
estradiol/norethindrone acetate
CRYSELLEnorgestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CYCLAFEMnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CYREDdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
CYRED EQdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
DASETTAnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
DAYSEElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
desogestr-eth estrad eth estra generic 1 AL At least 12 yrs old
desogestrel-ethinyl estradiol generic 1 AL At least 12 yrs old
drospirenone-eth estra-levomef generic 1 AL At least 12 yrs old
drospirenone-ethinyl estradiol generic 1 AL At least 12 yrs old
ELINESTnorgestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ELURYNGetonogestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
EMOQUETTEdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ENPRESSElevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ENSKYCEdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ESTARYLLAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ESTRADIOL (TDS 0.075 MG/DAY, 0.5 MGTABLET, 0.0375 MG/DAY PATCH, TDS0.0375 MG/DAY, 0.06 MG/DAY PATCH, 1 MGTABLET, TDS 0.05 MG/DAY, 0.075 MG/DAYPATCH, 2 MG TABLET, TDS 0.06 MG/DAY,TDS 0.025 MG/DAY, TDS 0.1 MG/DAY)
generic 1
estradiol valerate generic 1
estradiol-norethindrone acetat generic 1 AL At least 18 yrs old
ESTRING BRAND 1
PAGE 74 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
estradiol
estrogen-methyltestosterone generic 1
ESTROSTEP FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
ethynodiol-ethinyl estradiol generic 1 AL At least 12 yrs old
etonogestrel-ethinyl estradiol generic 1 AL At least 12 yrs old
FALMINAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
FAYOSIMlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
FEMHRTnorethindrone acetate-ethinyl estradiol
BRAND 1
FEMYNORnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
GENERESS FEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND 1 AL At least 12 yrs old
GIANVIethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
HAILEYnorethindrone acetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
HAILEY 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
INTROVALElevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ISIBLOOMdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
JAIMIESSlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
JASMIELethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
JOLESSAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
JULEBERdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
JUNELnorethindrone acetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PAGE 75 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
JUNEL FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
JUNEL FE 24norethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
KAITLIB FEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND 1 AL At least 12 yrs old
KALLIGAdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
KARIVAdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
KELNOR 1-35ethynodiol diacetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
KELNOR 1-50ethynodiol diacetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
KURVELOlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LARINnorethindrone acetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LARIN 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
LARIN FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
LARISSIAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LAYOLIS FEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND 1 AL At least 12 yrs old
LEENAnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LESSINAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LEVONESTlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
levonorg-eth estrad eth estrad generic 1 AL At least 12 yrs old
levonorgestrel-eth estradiol generic 1 AL At least 12 yrs old
LEVORA-28levonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
1
PAGE 76 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
LILLOWlevonorgestrel/ethinyl estradiol
BRAND AL At least 12 yrs old
LO LOESTRIN FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
LO-ZUMANDIMINEethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
LOESTRINnorethindrone acetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LOESTRIN FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
LOJAIMIESSlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
LORYNAethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
LOSEASONIQUElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
LOW-OGESTRELnorgestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
LUTERAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
MARLISSAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
MELODETTA 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
MIBELAS 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
MICROGESTIN FE 1.5-30 TABnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
MILInorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
MINASTRIN 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
MIRCETTEdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
1
PAGE 77 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
MONO-LINYAHnorgestimate-ethinyl estradiol
BRAND AL At least 12 yrs old
NATAZIAestradiol valerate/dienogest
BRAND 1 AL At least 12 yrs old
NECON 0.5-35-28 TABLETnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
NIKKIethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
NORETHIN-ETH ESTRA-FERROUS FUM(NORET-ESTR-FE 0.4-0.035(21)-75,NORETH-ESTRAD-FE 1-0.02(21)-75,NORETH-ESTRAD-FE 1-0.02(24)-75,NORETHIN-ESTRA-FE 0.8-0.025 MG)
generic 1 AL At least 12 yrs old
NORETHINDRON-ETHINYL ESTRADIOL(NORETHIN-ETH 1 MG-5 MCG, NORETHIND-ETH 0.5-2.5)
generic 1
NORETHINDRON-ETHINYL ESTRADIOL(NORETHIND-ETH ESTRAD 1-0.02 MG,NORETHIN-EE 1.5-0.03 MG(21) TB)
generic 1 AL At least 12 yrs old
norethindrone-eth estradiol-fe generic 1 AL At least 12 yrs old
norgestimate-ethinyl estradiol generic 1 AL At least 12 yrs old
NORTRELnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
NUVARINGetonogestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
OCELLAethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
OGESTRELnorgestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ORSYTHIAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ORTHO TRI-CYCLENnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ORTHO-NOVUMnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PHILITHnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PIMTREAdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PIRMELLA (7-7-7-28, 1-35 28)norethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PAGE 78 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PORTIAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PREMARIN VAGINAL CREAM-APPLestrogens, conjugated
BRAND 1
PREMARIN (1.25 MG, 0.3 MG, 0.45 MG, 0.625MG, 0.9 MG)estrogens, conjugated
BRAND 1
PREMPHASEestrogens, conjugated/medroxyprogesteroneacetate
BRAND 1
PREMPROestrogens, conjugated/medroxyprogesteroneacetate
BRAND 1
PREVIFEMnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
QUARTETTElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
RECLIPSENdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
RIVELSAlevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
SAFYRALdrospirenone/ethinyl estradiol/levomefolatecalcium
BRAND 1 AL At least 12 yrs old
SEASONIQUElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
SETLAKINlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
SIMLIYAdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
SIMPESSElevonorgestrel/ethinyl estradiol and ethinylestradiol
BRAND 1 AL At least 12 yrs old
SPRINTECnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
SRONYXlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
SYEDAethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
1
PAGE 79 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TARINA 24 FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND AL At least 12 yrs old
TARINA FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
TARINA FE 1-20 EQnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
TAYTULLAnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
TILIA FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
TRI FEMYNORnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-ESTARYLLAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-LEGEST FEnorethindrone acetate-ethinyl estradiol/ferrousfumarate
BRAND 1 AL At least 12 yrs old
TRI-LINYAHnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-LO-ESTARYLLAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-LO-MARZIAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-LO-MILInorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-LO-SPRINTECnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-MILInorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-PREVIFEMnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-SPRINTECnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-VYLIBRAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TRI-VYLIBRA LOnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
PAGE 80 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TRIVORA-28levonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
TYDEMYdrospirenone/ethinyl estradiol/levomefolatecalcium
BRAND 1 AL At least 12 yrs old
VAGIFEMestradiol
BRAND 1 QL
VELIVETdesogestrel-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
VIENVAlevonorgestrel/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
VIORELEdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
VOLNEAdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
VYFEMLAnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
VYLIBRAnorgestimate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
WERAnorethindrone-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
WYMZYA FEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND 1 AL At least 12 yrs old
XULANEnorelgestromin/ethinyl estradiol
BRAND 1 AL At least 12 yrs old
YASMIN 28ethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
YAZethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
ZARAHethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
ZOVIA 1-35Eethynodiol diacetate-ethinyl estradiol
BRAND 1 AL At least 12 yrs old
ZUMANDIMINEethinyl estradiol/drospirenone
BRAND 1 AL At least 12 yrs old
PROGESTERONE AGONISTS/ANTAGONISTS
ELLAulipristal acetate
BRAND 1 AL At least 12 yrs old
PROGESTINS
PAGE 81 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
CAMILAnorethindrone
BRAND 1 AL At least 12 yrs old
DEBLITANEnorethindrone
BRAND 1 AL At least 12 yrs old
DEPO-PROVERA (150 MG/ML SYRINGE, 150MG/ML VIAL)medroxyprogesterone acetate
BRAND 1 AL At least 12 yrs old
DEPO-SUBQ PROVERA 104medroxyprogesterone acetate
BRAND 1 AL At least 12 yrs old
ERRINnorethindrone
BRAND 1 AL At least 12 yrs old
HEATHERnorethindrone
BRAND 1 AL At least 12 yrs old
hydroxyprogest 250 mg/ml vial generic 1PA
AL At least 16 yrs old
INCASSIAnorethindrone
BRAND 1 AL At least 12 yrs old
JENCYCLAnorethindrone
BRAND 1 AL At least 12 yrs old
KYLEENAlevonorgestrel
BRAND 1 QL
LILETTAlevonorgestrel
BRAND 1 QL
LYZAnorethindrone
BRAND 1 AL At least 12 yrs old
MAKENA (275 MG/1.1 ML AUTOINJCT, 250MG/ML VIAL)hydroxyprogesterone caproate/pf
BRAND 1PA
AL At least 16 yrs old
medroxyprogesterone 150 mg/ml generic 1 AL At least 12 yrs old
MEDROXYPROGESTERONE ACETATE (2.5MG, 10 MG, 5 MG)
generic 1
MEGESTROL ACETATE (ACET 40 MG/MLSUSP, 40 MG TABLET, 625 MG/5 ML SUSP,ACET 400 MG/10 ML, 20 MG TABLET)
generic 1
MIRENAlevonorgestrel
BRAND 1 QL
NEXPLANONetonogestrel
BRAND 1 QL
NORA-BEnorethindrone
BRAND 1 AL At least 12 yrs old
PAGE 82 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
norethindrone generic 1 AL At least 12 yrs old
norethindrone ac (lupaneta) generic 1PA
AL At least 18 yrs old
norethindrone acetate generic 1
NORLYDAnorethindrone
BRAND 1 AL At least 12 yrs old
ORTHO MICRONORnorethindrone
BRAND 1 AL At least 12 yrs old
PROGESTERONE (500 MG/10 ML VIAL, 200MG CAPSULE, 100 MG CAPSULE)
generic 1
PROMETRIUMprogesterone, micronized
BRAND 1
SHAROBELnorethindrone
BRAND 1 AL At least 12 yrs old
SKYLAlevonorgestrel
BRAND 1 QL
SLYNDdrospirenone
BRAND 1 AL At least 12 yrs old
TULANAnorethindrone
BRAND 1 AL At least 12 yrs old
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROIDthyroid,pork
BRAND 1
LEVOTHYROXINE SODIUM (150 MCGTABLET, 200 MCG TABLET, 500 MCG/5 MLVL, 112 MCG TABLET, 200 MCG/5 ML VL,300 MCG TABLET, 125 MCG TABLET, 50MCG TABLET, 88 MCG TABLET, 175 MCGTABLET, 100 MCG/5 ML VL, 100 MCGTABLET, 25 MCG TABLET, 75 MCG TABLET,137 MCG TABLET)
generic 1
LEVOXYLlevothyroxine sodium
BRAND 1
LIOTHYRONINE SODIUM (50 MCG, 5 MCG,25 MCG)
generic 1
NP THYROIDthyroid,pork
BRAND 1
THYROID (30 MG, 15 MG, 90 MG, 120 MG, 60MG)thyroid,pork
BRAND 1
PAGE 83 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
THYROLAR-1liotrix
BRAND 1
THYROLAR-1/2liotrix
BRAND 1
THYROLAR-1/4liotrix
BRAND 1
THYROLAR-2liotrix
BRAND 1
THYROLAR-3liotrix
BRAND 1
UNITHROIDlevothyroxine sodium
BRAND 1
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline generic 1
LEUPROLIDE ACETATE (14 MG/2.8 ML VL, 1MG/0.2 ML KIT, 14 MG/2.8 ML KT)
generic 1 PA
LUPANETA PACKleuprolide acetate/norethindrone acetate
BRAND 1PA
AL At least 18 yrs old
LUPRON DEPOTleuprolide acetate
BRAND 1PA
AL At least 18 yrs old
LUPRON DEPOT (LUPANETA)leuprolide acetate
BRAND 1PA
AL At least 18 yrs old
LUPRON DEPOT-PED (11.25 MG 3MO, 30MG 3MO KIT, 7.5 MG KIT, 11.25 MG KIT, 15MG KIT)leuprolide acetate
BRAND 1PA
AL 2.0 to 12.0 yrs old
OCTREOTIDE ACETATE (ACET 0.05 MG/MLVL, ACET 50 MCG/ML AMP, 1,000 MCG/5 MLVIAL, 5,000 MCG/5 ML VIAL, ACET 100MCG/ML AMP, ACET 500 MCG/ML AMP,1,000 MCG/ML VIAL, ACET 50 MCG/ML SYR,ACET 100 MCG/ML VL, ACET 500 MCG/MLSYR, ACET 500 MCG/ML VL, ACET 50MCG/ML VIAL, ACET 200 MCG/ML VL, ACET100 MCG/ML SYR)
generic 1
ORILISSAelagolix sodium
BRAND 1 PA
SYNARELnafarelin acetate
BRAND 1 PA
TRIPTODUR BRAND 1 PA
PAGE 84 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
triptorelin pamoateAL 2.0 to 12.0 yrs old
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole generic 1
propylthiouracil generic 1
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
BERINERT (500 VIAL, 500 KIT)c1 esterase inhibitor
BRAND 1PA
AL At least 12 yrs old
FIRAZYRicatibant acetate
BRAND 1PA
AL At least 18 yrs old
IMMUNE SUPPRESSANTS
azathioprine generic 1
CELLCEPT 200 MG/ML ORAL SUSPmycophenolate mofetil
BRAND 1 AL Up to 11 yrs old
CELLCEPT 500 MG VIALmycophenolate mofetil hcl
BRAND 1
cyclosporine 250 mg/5 ml ampul generic 1
CYCLOSPORINE MODIFIED (50 MG, 25 MG,100 MG)
generic 1
cyclosporine modified 100mg/ml generic 1 AL Up to 11 yrs old
ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 25MG/0.5 ML SYRINGE)etanercept
BRAND 1PA
AL At least 2 yrs old
ENBREL MINIetanercept
BRAND 1PA
AL At least 2 yrs old
ENBREL SURECLICKetanercept
BRAND 1PA
AL At least 2 yrs old
HUMIRAadalimumab
BRAND 1 PA
HUMIRA PENadalimumab
BRAND 1 PA
1
PAGE 85 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
HUMIRA PEN CROHN'S-UC-HSadalimumab
BRAND PA
HUMIRA PEN PSOR-UVEITS-ADOL HSadalimumab
BRAND 1 PA
HUMIRA(CF)adalimumab
BRAND 1 PA
HUMIRA(CF) PEDIATRIC CROHN'Sadalimumab
BRAND 1 PA
HUMIRA(CF) PENadalimumab
BRAND 1 PA
HUMIRA(CF) PEN CROHN'S-UC-HSadalimumab
BRAND 1 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HSadalimumab
BRAND 1 PA
METHOTREXATE (250 MG/10 ML VIAL, 50MG/2 ML VIAL, 2.5 MG TABLET, 1 GM VIAL)
generic 1
methotrexate sodium generic 1
MYCOPHENOLATE MOFETIL (500 MG VIAL,250 MG CAPSULE, 500 MG TABLET)
generic 1
RAPAMUNE 1 MG/ML ORAL SOLNsirolimus
BRAND 1
SANDIMMUNE 50 MG/ML AMPULcyclosporine
BRAND 1
SIROLIMUS (1 MG, 2 MG, 0.5 MG) generic 1
TACROLIMUS (1 MG, 5 MG, 0.5 MG) generic 1
XELJANZtofacitinib citrate
BRAND 1PA
AL At least 18 yrs old
IMMUNIZING AGENTS, PASSIVE
BIVIGAM 10% VIALimmune globulin,gamm(igg)/glycine/iga greaterthan 50 mcg/ml
BRAND 1 PA
GAMMAGARD S-Dimmune globulin,gamm(igg)/glycine/glucose/iga0 to 50 mcg/ml
BRAND 1 PA
HYPERRHO S-Drho(d) immune globulin
BRAND 1
IMMUNOMODULATORS
ACTIMMUNEinterferon gamma-1b,recomb.
BRAND 1
PAGE 86 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
leflunomide generic 1
VACCINES
ADACEL TDAP (VIAL, SYRINGE)diphtheria,pertussis(acellular),tetanusvaccine/pf
BRAND 1
BOOSTRIX TDAP (VIAL, SYRINGE)diphtheria,pertussis(acellular),tetanus vaccine
BRAND 1
DAPTACEL DTAPdiphtheria, pertussis (acell), tetanus pediatricvaccine/pf
BRAND 1
HAVRIX (1,440 UNITS/ML VIAL, 720UNITS/0.5 ML VIAL, 720 UNIT/0.5 MLSYRINGE, 1,440 UNITS/ML SYRINGE)hepatitis a virus vaccine/pf
BRAND 1 AL At least 21 yrs old
INFANRIX DTAP (SYRINGE, VIAL)diphtheria, pertussis (acell), tetanus pediatricvaccine/pf
BRAND 1
SHINGRIXvaricella-zoster virus glycoprotein e,rec/as01badjuvant/pf
BRAND 1 AL At least 50 yrs old
SHINGRIX ADJUVANT COMPONENTvaccine adjuvant system, as01b/pf, componentvial 1 of 2
BRAND 1 AL At least 50 yrs old
SHINGRIX GE ANTIGEN COMPONENTvaricella-zoster virus glycoproteine,rec,component 2 of 2
BRAND 1 AL At least 50 yrs old
VAQTA (50 UNITS/ML SYRINGE, 25UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML VIAL)hepatitis a virus vaccine/pf
BRAND 1 AL At least 21 yrs old
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISOmesalamine
BRAND 1
balsalazide disodium generic 1
mesalamine 1,000 mg supp generic 1
mesalamine dr generic 1
GLUCOCORTICOIDS
ANUSOL-HC 2.5% CREAMhydrocortisone
BRAND 1
PAGE 87 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
budesonide ec generic 1
hydrocortisone 100 mg/60 ml generic 1
PROCTO-MED HChydrocortisone
BRAND 1
PROCTOSOL-HChydrocortisone
BRAND 1
PROCTOZONE-HChydrocortisone
BRAND 1
SULFONAMIDES
sulfasalazine generic 1
sulfasalazine dr generic 1
METABOLIC BONE DISEASE AGENTS
ALENDRONATE SODIUM (10 MG TAB, 70MG TAB, 35 MG TAB, 5 MG TABLET)
generic 1
calcitonin-salmon generic 1 AL At least 18 yrs old
CALCITRIOL (1 MCG/ML SOLUTION, 0.5MCG CAPSULE, 0.25 MCG CAPSULE, 1MCG/ML AMPUL)
generic 1
DOXERCALCIFEROL (1 MCG CAPSULE, 4MCG/2 ML VL, 0.5 MCG CAP, 2.5 MCG CAP)
generic 1
pamidronate disodium generic 1
PARICALCITOL (2 MCG/ML VIAL, 2 MCGCAPSULE, 5 MCG/ML VIAL, 10 MCG/2 MLVIAL, 4 MCG CAPSULE, 1 MCG CAPSULE)
generic 1
vitamin d2 generic 1
ZOLEDRONIC ACID (4 MG/5 ML VIAL, 4 MGVIAL, 4 MG/100 ML, 5 MG/100 ML)
generic 1
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine 6 gram/30 ml vl generic 1
methylergonovine 0.2 mg tablet generic 1
PARAGARD T 380-Acopper
BRAND 1 QL
bacteriostatic saline vial generic 1
sorbitol generic 1
sorbitol-mannitol generic 1
STERILE WATER FOR IC-GREEN BRAND 1
PAGE 88 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
water for injection,sterile
STERILE WATER FOR KCENTRAwater for injection,sterile
BRAND 1
sterile water for irrigation generic 1
WATER (FOR INJECTION VIAL, STERILEFOR INJECTION, BACTERIOSTATIC VIAL)
generic 1
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AK-POLY-BACbacitracin/polymyxin b sulfate
BRAND 1
ATROPINE SULFATE (DROPS, OINTMENT) generic 1
bacitracin-polymyxin generic 1
balanced salt generic 1
CYCLOPENTOLATE HCL (0.5% EYE, 1%EYE, HCL 2%)
generic 1
CYSTARANcysteamine hcl
BRAND 1
neomycin-bacitracin-poly-hc generic 1
neomycin-bacitracin-polymyxin generic 1
NEOMYCIN-POLYMYXIN-DEXAMETH(NEOMYC-POLYM-DEXAMETH DROP,NEOMYC-POLYM-DEXAMET OINTM)
generic 1
PHENYLEPHRINE HCL (10% DROPS, 2.5%DROP)
generic 1
POLYCINbacitracin/polymyxin b sulfate
BRAND 1
polymyxin b sul-trimethoprim generic 1
RESTASIScyclosporine
BRAND 1
RESTASIS MULTIDOSEcyclosporine
BRAND 1
sulfacetamide-prednisolone generic 1
TOBRADEX (DROPS, OINTMENT)tobramycin/dexamethasone
BRAND 1
ZYLETtobramycin/loteprednol etabonate
BRAND 1
OPHTHALMIC ANTI-ALLERGY AGENTS
PAGE 89 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
cromolyn 4% eye drops generic 1
olopatadine hcl 0.1% eye drops generic 1
PAZEOolopatadine hcl
BRAND 1
OPHTHALMIC ANTI-INFLAMMATORIES
ALREXloteprednol etabonate
BRAND 1
dexamethasone 0.1% eye drop generic 1
diclofenac 0.1% eye drops generic 1
DUREZOLdifluprednate
BRAND 1
FLAREXfluorometholone acetate
BRAND 1
FML FORTEfluorometholone
BRAND 1
FML S.O.P.fluorometholone
BRAND 1
ILEVROnepafenac
BRAND 1
ketorolac 0.5% ophth solution generic 1
LOTEMAX 0.5% EYE DROPSloteprednol etabonate
BRAND 1
MAXIDEXdexamethasone
BRAND 1
prednisolone ac 1% eye drop generic 1
OPHTHALMIC ANTIGLAUCOMA AGENTS
brimonidine 0.2% eye drop generic 1
carteolol hcl generic 1
COMBIGANbrimonidine tartrate/timolol maleate
BRAND 1
dorzolamide hcl generic 1
dorzolamide-timolol eye drops generic 1
levobunolol hcl generic 1
methazolamide generic 1
RHOPRESSAnetarsudil mesylate
BRAND 1 AL At least 18 yrs old
ROCKLATAN BRAND 1 AL At least 18 yrs old
PAGE 90 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
netarsudil mesylate/latanoprost
TIMOLOL MALEATE (0.25% GFS GEL-SOLUTION, 0.5% EYE DROP, 0.5% GFSGEL-SOLUTION, 0.5% GEL-SOLUTION,MALEATE 0.5% EYE DROPS, 0.25% GEL-SOLUTION, MALEATE 0.25% EYE DROP)
generic 1
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost 0.005% eye drops generic 1
TRAVATAN Ztravoprost
BRAND 1
OTIC AGENTS
acetic acid 2% ear solution generic 1
CIPRODEXciprofloxacin hcl/dexamethasone
BRAND 1
DERMOTICfluocinolone acetonide oil
BRAND 1
neomycin-polymyxin-hc ear susp generic 1
neomycin-polymyxin-hydrocort generic 1
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ASMANEX (TWISTHALER 220 MCG #60,TWISTHALER 110 MCG #30, TWISTHALER220 MCG #14, TWISTHALR 220 MCG #120,TWISTHALER 220 MCG #30)mometasone furoate
BRAND 1 AL At least 4 yrs old
budesonide generic 1 AL 1.0 to 8.0 yrs old
FLOVENT HFAfluticasone propionate
BRAND 1
fluticasone prop 50 mcg spray generic 1
ANTIHISTAMINES
AZELASTINE HCL (0.1% (137 MCG) SPRY,0.15% NASAL SPRAY)
generic 1
CARBINOXAMINE MALEATE (4 MG/5 MLLIQUID, MALEATE 4 MG TAB)
generic 1
cetirizine hcl generic 1 AL Up to 11 yrs old
clemastine fumarate generic 1
1
PAGE 91 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
CYPROHEPTADINE HCL (2 MG/5 ML SYRUP,4 MG TABLET, 2 MG/5 ML SOLN, 4 MG/10 MLSYRP)
generic
DIPHENHYDRAMINE HCL (50 MG/MLSYRNG, 50 MG/ML VIAL, 50 MG/ML CRPJT,25 MG/10 ML, 12.5 MG/5 ML)
generic 1
HYDROXYZINE HCL (HCL 10 MG TABLET, 50MG/ML VIAL, 10 MG/5 ML SYRUP, 100 MG/2ML VIAL, HCL 50 MG TABLET, 10 MG/5 MLSOLN, 25 MG/ML VIAL, HCL 25 MG TABLET)
generic 1
hydroxyzine pamoate generic 1
levocetirizine 5 mg tablet generic 1
PROMETHAZINE HCL (50 MG/ML VIAL, 50MG/ML AMPUL, 6.25 MG/5 ML SYRP, 25MG/ML VIAL, 6.25 MG/5 ML SOLN, 25 MG/MLAMPUL)
generic 1
ANTILEUKOTRIENES
MONTELUKAST SODIUM (4 MG TAB CHEW,10 MG TABLET, 5 MG TAB CHEW)
generic 1
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFAipratropium bromide
BRAND 1
ipratropium br 0.02% soln generic 1
SPIRIVAtiotropium bromide
BRAND 1 AL At least 18 yrs old
BRONCHODILATORS, SYMPATHOMIMETIC
ALBUTEROL SULFATE (SUL 1.25 MG/3 MLSOL, SULF 2 MG/5 ML SYRUP, 5 MG/MLSOLUTION)
generic 1
ALBUTEROL SULFATE (SUL 0.63 MG/3 MLSOL, SUL 2.5 MG/3 ML SOLN, 2.5 MG/0.5 MLSOL)
generic 1
EPINEPHRINE (0.15 MG AUTO-INJCT, 0.3MG AUTO-INJECT)
generic 1
PROAIR HFAalbuterol sulfate
BRAND 1
PROVENTIL HFAalbuterol sulfate
BRAND 1
SEREVENT DISKUSsalmeterol xinafoate
BRAND 1QL
AL At least 4 yrs old
PAGE 92 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
terbutaline sulf 1 mg/ml vial generic 1
CYSTIC FIBROSIS AGENTS
BETHKIStobramycin
BRAND 1 PA
KITABIS PAKtobramycin/nebulizer
BRAND 1 PA
PULMOZYMEdornase alfa
BRAND 1
QL
PA
AL Up to 65 yrs old
MAST CELL STABILIZERS
cromolyn 20 mg/2 ml neb soln generic 1
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
CAFFEINE CITRATE (60 ML VIAL, 60 MLORAL)
generic 1
ELIXOPHYLLINtheophylline anhydrous
BRAND 1
THEO-24theophylline anhydrous
BRAND 1
THEOPHYLLINE (80 MG/15 ML SOLN, ER400 MG TABLET, ER 600 MG TABLET)
generic 1
THEOPHYLLINE ANHYDROUS (ER 450 MGTAB, ER 300 MG TAB, ER 100 MG TABLET)
generic 1
theophylline er 200 mg tablet generic 1
PULMONARY ANTIHYPERTENSIVES
epoprostenol sodium generic 1
LETAIRISambrisentan
BRAND 1 PA
SILDENAFIL CITRATE (20 MG TABLET, 10MG/ML ORAL SUSP)
generic 1 PA
tadalafil 20 mg tablet generic 1 PA
TRACLEER (125 MG, 62.5 MG)bosentan
BRAND 1 PA
VENTAVISiloprost tromethamine
BRAND 1 PA
RESPIRATORY TRACT AGENTS, OTHER
ACETYLCYSTEINE (20%, 10%) generic 1
PAGE 93 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ADVAIR DISKUSfluticasone propionate/salmeterol xinafoate
BRAND 1QL
AL At least 4 yrs old
ADVAIR HFAfluticasone propionate/salmeterol xinafoate
BRAND 1QL
AL At least 5 yrs old
benzonatate generic 1 AL Up to 20 yrs old
BEVESPI AEROSPHEREglycopyrrolate/formoterol fumarate
BRAND 1
brompheniramine-pseudoephed-dm generic 1 AL Up to 20 yrs old
COMBIVENT RESPIMATipratropium bromide/albuterol sulfate
BRAND 1
DULERA (200 MCG, 100 MCG)mometasone furoate/formoterol fumarate
BRAND 1QL
AL At least 5 yrs old
DULERA 50 MCG-5 MCG INHALERmometasone furoate/formoterol fumarate
BRAND 1 AL At least 5 yrs old
HYDROCODONE-HOMATROPINE MBR(SOLN, SYRUP)
generic 1 AL 18.0 to 20.0 yrs old
ipratropium-albuterol generic 1
promethazine-dm generic 1 AL Up to 20 yrs old
promethazine-phenylephrine generic 1 AL Up to 20 yrs old
ribavirin 6 gm inhalation vial generic 1PA
AL At least 5 yrs old
sodium chloride 0.9% inhal vl generic 1
sodium chloride 10% vial generic 1 PA
STIOLTO RESPIMATtiotropium bromide/olodaterol hcl
BRAND 1
SYMBICORT 160-4.5 MCG INHALERbudesonide/formoterol fumarate
BRAND 1QL
AL At least 5 yrs old
SYMBICORT 80-4.5 MCG INHALERbudesonide/formoterol fumarate
BRAND 1QL
AL At least 5 yrs old
UTIBRON NEOHALERindacaterol maleate/glycopyrrolate
BRAND 1
SKELETAL MUSCLE RELAXANTS
chlorzoxazone 500 mg tablet generic 1
PAGE 94 LAST UPDATED 04/2020
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
CYCLOBENZAPRINE HCL (10 MG, 5 MG) generic 1
METHOCARBAMOL (750 MG, 500 MG) generic 1
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
TEMAZEPAM (15 MG, 30 MG) generic 1 AL At least 18 yrs old
zaleplon generic 1 AL At least 18 yrs old
zolpidem tartrate 10 mg tablet generic 1PA
AL At least 18 yrs old
zolpidem tartrate 5 mg tablet generic 1 AL At least 18 yrs old
SLEEP DISORDERS, OTHER
modafinil generic 1PA
AL At least 18 yrs old
ROZEREMramelteon
BRAND 1 AL At least 65 yrs old
PAGE 95 LAST UPDATED 04/2020
Index of covered drugs33 DAY VAGINAL 2
3-DAY VAGINAL CREAM 2
88 HOUR ACETAMINOPHEN 2
8 HOUR PAIN RELIEF 3
8HR ARTHRITIS PAIN 3
8HR MUSCLE ACHES-PAIN 3
AABACAVIR SULFATE 39
ABACAVIR SULFATE/DOLUTEGRAVIR
SODIUM/LAMIVUDINE 39
ABACAVIR SULFATE/LAMIVUDINE 38
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 38
ABILIFY MAINTENA 34
ABIRATERONE ACETATE 30
ACAMPROSATE CALCIUM 14
ACARBOSE 41
ACEBUTOLOL HCL 49
ACETAMINOPHEN 4
ACETAMINOPHEN WITH CODEINE PHOSPHATE 13
ACETAZOLAMIDE 51
ACETIC ACID 91
ACETYLCYSTEINE 93
ACITRETIN 54
ACTHAR 70
ACTIMMUNE 86
ACYCLOVIR 40
ADACEL TDAP 87
ADALIMUMAB 86
ADAPALENE 55
ADULT ASPIRIN REGIMEN 1
ADULT TUSSIN CHEST CONGESTION 8
ADULT TUSSIN COUGH CONGEST DM 8
ADVAIR DISKUS 93
ADVAIR HFA 94
ADVATE 45
ADYNOVATE 45
AFIRMELLE 72
AFSTYLA 45
AFTERA 7
AGALSIDASE BETA 68
AGGRENOX 48
AK-POLY-BAC 89
ALA-QUIN 55
ALBENDAZOLE 33
ALBUTEROL SULFATE 92
ALEMTUZUMAB 32
ALENDRONATE SODIUM 88
ALFUZOSIN HCL 68
ALIMTA 30
ALITRETINOIN 32
ALKERAN 29
ALL DAY ALLERGY 7
ALL DAY ALLERGY-D 8
ALLERGY 7
ALLERGY COMPLETE-D 8
ALLERGY RELIEF 8
ALLERGY RELIEF D-24HR 9
ALLERGY RELIEF-NASAL DECONGEST 9
ALLERGY-CONGESTION 12HR 9
ALLERGY-CONGESTION RELIEF 9
ALLOPURINOL 28
ALOSETRON HCL 66
ALPHA-1-PROTEINASE INHIBITOR 68
ALPHANATE 45
ALPHANINE SD 45
ALPRAZOLAM 41
ALPROLIX 46
ALREX 90
ALTAVERA 72
ALTEPLASE 44
ALYACEN 72
AMANTADINE HCL 33
AMBRISENTAN 93
AMETHIA 72
AMETHIA LO 72
AMETHYST 72
AMICAR 46
PAGE 96 LAST UPDATED 04/2020
AMILORIDE HCL 51
AMILORIDE HCL/HYDROCHLOROTHIAZIDE 50
AMINO ACID 2.36 % NO.1/D6.8W/FAT
EMULSIONS/ELECTROLYTES NO.9 64
AMINO ACID 3.31 % NO.1/D9.8W/FAT
EMULSIONS/ELECTROLYTE NO.10 64
AMINO ACIDS 10 % 62
AMINO ACIDS 3 %/ELECTROLYTE-TPN
SOLN/GLYCERIN 61
AMINO ACIDS 3.5 %/ELECTROLYTE-M
SOLUTION 57
AMINO ACIDS 4.25 %/DEXTROSE 10 % IN
WATER 57
AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN
SOLN/DEXTROSE 20 % 57
AMINO ACIDS 5.4 % 60
AMINO ACIDS 7 % 57
AMINO ACIDS 8 % 59
AMINO ACIDS 8.5 %/ELECTROLYTE-TPN SOLN 57
AMINOCAPROIC ACID 46
AMINOSYN 56
AMINOSYN II 57
AMINOSYN II WITH ELECTROLYTES 57
AMINOSYN M 57
AMINOSYN WITH ELECTROLYTES 57
AMINOSYN-HBC 57
AMINOSYN-PF 57
AMINOSYN-RF 57
AMIODARONE HCL 49
AMITRIPTYLINE HCL 26
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 25
AMLODIPINE BESYLATE 49
AMLODIPINE BESYLATE/BENAZEPRIL HCL 50
AMLODIPINE BESYLATE/OLMESARTAN
MEDOXOMIL 50
AMLODIPINE BESYLATE/VALSARTAN 50
AMMONIUM LACTATE 55
AMNESTEEM 55
AMOXAPINE 26
AMOXICILLIN 18
AMOXICILLIN/POTASSIUM CLAVULANATE 18
AMPHETAMINE 52
AMPHOTERICIN B 27
AMPICILLIN SODIUM 18
AMPICILLIN SODIUM/SULBACTAM SODIUM 18
AMPICILLIN TRIHYDRATE 18
ANAGRELIDE HCL 45
ANASTROZOLE 32
ANDRODERM 71
ANDROGEL 71
ANIDULAFUNGIN 27
ANNOVERA 72
ANTACID 7
ANTACID CALCIUM 6
ANTACID EXTRA STRENGTH 6
ANTACID ULTRA STRENGTH 6
ANTI-INHIBITOR COAGULANT COMPLEX 46
ANTIHEMOPHILIC FACTOR (FACTOR VIII)
RECOMB,B-DOMAIN DELETED 47
ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOM
TRUNCATED PEG-EXEI 46
ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOMAIN
DELETED PEG-AUCL 46
ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,
FC FUSION PROTEIN 46
ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,
FULL LENGTH, PEG 45
ANTIHEMOPHILIC FACTOR (FVIII)
RECOMBINANT,FULL LENGTH 46
ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-
DOMAIN DELETED 47
ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE-
CHN,B-DOM TRUNCATED 45
ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-
DOMAIN TRUNCATED 47
ANTIHEMOPHILIC FACTOR VIII, HUMAN
RECOMBINANT 47
ANTIHEMOPHILIC FACTOR VIII, RECOMBINANT
PORCINE SEQUENCE 47
ANTIHEMOPHILIC FACTOR, HUMAN 46
ANTIHEMOPHILIC FACTOR, HUMAN/VON
WILLEBRAND FACTOR,HUMAN 47
PAGE 97 LAST UPDATED 04/2020
ANUSOL-HC 87
APIXABAN 44
APREPITANT 27
APRI 72
APRISO 87
APTENSIO XR 53
APTIOM 23
APTIVUS 39
AQUADEKS 5
ARALAST NP 67
ARANELLE 72
ARANESP 45
ARIPIPRAZOLE 35
ARIPIPRAZOLE LAUROXIL 35
ARIPIPRAZOLE LAUROXIL, SUBMICRONIZED 35
ARISTADA 35
ARISTADA INITIO 35
ARMOUR THYROID 83
ARTHRITIS PAIN 3
ARTHRITIS PAIN RELIEF 3
ARYMO ER 12
ARZERRA 32
ASCORBIC ACID 63
ASHLYNA 72
ASMANEX 91
ASPIR 81 1
ASPIR-LOW 1
ASPIRIN 1
ASPIRIN/DIPYRIDAMOLE 48
ATAZANAVIR SULFATE 40
ATAZANAVIR SULFATE/COBICISTAT 39
ATENOLOL 49
ATENOLOL/CHLORTHALIDONE 50
ATOMOXETINE HCL 53
ATORVASTATIN CALCIUM 51
ATOVAQUONE 33
ATRIPLA 37
ATROPINE SULFATE 89
ATROVENT HFA 92
AUBAGIO 54
AUBRA 72
AUBRA EQ 72
AUROVELA 72
AUROVELA 24 FE 72
AUROVELA FE 72
AUSTEDO 53
AVIANE 73
AVITA 55
AVONEX 54
AVONEX PEN 54
AYUNA 73
AZACITIDINE 30
AZACTAM 17
AZATHIOPRINE 85
AZELAIC ACID 56
AZELASTINE HCL 91
AZITHROMYCIN 19
AZTREONAM 17
AZURETTE 73
BBACITRACIN/POLYMYXIN B SULFATE 89
BACLOFEN 36
BACMIN 63
BACTERIOSTATIC SODIUM CHLORIDE 88
BALANCED SALT IRRIG SOLN NO.2 89
BALCOLTRA 73
BALSALAZIDE DISODIUM 87
BALZIVA 73
BANZEL 24
BASAGLAR KWIKPEN U-100 43
BEKYREE 73
BENAZEPRIL HCL 48
BENDAMUSTINE HCL 29
BENEFIX 46
BENZONATATE 94
BENZTROPINE MESYLATE 33
BERINERT 85
BETAINE 67
BETAMETHASONE ACETATE/BETAMETHASONE
SODIUM PHOSPHATE 70
PAGE 98 LAST UPDATED 04/2020
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL 70
BETAMETHASONE VALERATE 70
BETASERON 54
BETHANECHOL CHLORIDE 69
BETHKIS 93
BEVESPI AEROSPHERE 94
BEYAZ 73
BICALUTAMIDE 29
BICILLIN C-R 18
BICILLIN L-A 18
BICNU 29
BICTEGRAVIR
SODIUM/EMTRICITABINE/TENOFOVIR
ALAFENAMIDE FUMAR 37
BIKTARVY 37
BILTRICIDE 33
BISOPROLOL FUMARATE 49
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE 50
BIVIGAM 86
BLEOMYCIN SULFATE 30
BLISOVI 24 FE 73
BLISOVI FE 73
BOOSTRIX TDAP 87
BORTEZOMIB 30
BOSENTAN 93
BRIELLYN 73
BRILINTA 48
BRIMONIDINE TARTRATE 90
BRIMONIDINE TARTRATE/TIMOLOL MALEATE 90
BRIVARACETAM 20
BRIVIACT 20
BROMPHENIRAMINE
MALEATE/PSEUDOEPHEDRINE
HCL/DEXTROMETHORPHAN 94
BUDESONIDE 91
BUDESONIDE/FORMOTEROL FUMARATE 94
BUMETANIDE 51
BUPIVACAINE HCL/EPINEPHRINE 14
BUPIVACAINE HCL/PF 14
BUPRENORPHINE 13
BUPRENORPHINE HCL 14
BUPRENORPHINE HCL/NALOXONE HCL 15
BUPROPION HCL 25
BUSPIRONE HCL 40
BUSULFAN 29
BUTALBITAL/ACETAMINOPHEN 53
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 53
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
E PHOSPHATE 13
BUTALBITAL/ASPIRIN/CAFFEINE 13
BUTOCONAZOLE NITRATE 27
BYDUREON PEN 41
BYETTA 42
CC1 ESTERASE INHIBITOR 85
CABERGOLINE 84
CAFFEINE CITRATE 93
CAL-GEST 6
CALCIPOTRIENE 55
CALCITONIN,SALMON,SYNTHETIC 88
CALCITRATE 4
CALCITRIOL 88
CALCIUM ACETATE 62
CALCIUM ANTACID 6
CALCIUM CARBONATE 7
CALCIUM CHLORIDE 57
CALCIUM CITRATE 4
CALCIUM GLUCONATE 57
CAMILA 81
CAMPATH 32
CAMRESE 73
CAMRESE LO 73
CANAGLIFLOZIN 42
CANAGLIFLOZIN/METFORMIN HCL 42
CAPECITABINE 30
CARBAMAZEPINE 41
CARBATROL 24
CARBIDOPA/LEVODOPA 34
CARBIDOPA/LEVODOPA/ENTACAPONE 33
PAGE 99 LAST UPDATED 04/2020
CARBINOXAMINE MALEATE 91
CARBOPLATIN 31
CARMUSTINE 29
CARTEOLOL HCL 90
CARVEDILOL 49
CATAPRES-TTS 1 48
CATAPRES-TTS 2 48
CATAPRES-TTS 3 48
CATHFLO ACTIVASE 44
CAZIANT 73
CEFACLOR 17
CEFADROXIL 17
CEFAZOLIN SODIUM 17
CEFDINIR 17
CEFEPIME HCL 17
CEFIXIME 17
CEFOTAXIME SODIUM 17
CEFOTETAN DISODIUM 17
CEFOTETAN DISODIUM IN ISO-OSMOTIC
DEXTROSE 17
CEFOXITIN SODIUM 17
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC 17
CEFPROZIL 17
CEFTRIAXONE SODIUM 17
CEFTRIAXONE SODIUM IN ISO-OSMOTIC
DEXTROSE 17
CEFUROXIME AXETIL 17
CEFUROXIME SODIUM 17
CELECOXIB 12
CELESTONE 70
CELLCEPT 85
CENTRATEX 57
CEPHALEXIN 17
CETIRIZINE HCL 91
CETIRIZINE HCL/PSEUDOEPHEDRINE HCL 9
CHANTIX 15
CHATEAL 73
CHATEAL EQ 73
CHEST CONGESTION RELIEF 9
CHILD MUCINEX CHEST MINI-MELTS 9
CHILD MUCINEX COUGH MINI-MELTS 9
CHILD MUCUS-COUGH RELIEF 9
CHILDREN'S ALL DAY ALLERGY 8
CHILDREN'S ALLERGY 8
CHILDREN'S ALLERGY RELIEF 8
CHILDREN'S MAPAP 3
CHILDREN'S MUCUS RELIEF 9
CHILDREN'S PAIN RELIEF 3
CHILDREN'S PAIN RELIEVER 3
CHILDREN'S PAIN-FEVER 3
CHILDREN'S SILAPAP 3
CHLORAMBUCIL 29
CHLORDIAZEPOXIDE HCL 41
CHLORHEXIDINE GLUCONATE 54
CHLOROQUINE PHOSPHATE 33
CHLOROTHIAZIDE 51
CHLORPROMAZINE HCL 34
CHLORTHALIDONE 51
CHLORZOXAZONE 94
CHOLESTYRAMINE (WITH SUGAR) 52
CHOLESTYRAMINE/ASPARTAME 52
CHROMIC CHLORIDE 57
CICLOPIROX 27
CILOSTAZOL 48
CIMDUO 38
CIPRO 19
CIPRODEX 91
CIPROFLOXACIN 19
CIPROFLOXACIN HCL 19
CIPROFLOXACIN HCL/DEXAMETHASONE 91
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN
WATER 19
CISPLATIN 31
CITALOPRAM HYDROBROMIDE 25
CITRANATAL B-CALM 63
CITRIC ACID/GLUCONOLACTONE/MAGNESIUM
CARBONATE 69
CITRIC ACID/SODIUM CITRATE 69
CLADRIBINE 30
CLARAVIS 55
CLARITHROMYCIN 19
CLEARLAX 7
PAGE 100 LAST UPDATED 04/2020
CLEMASTINE FUMARATE 91
CLENPIQ 66
CLEOCIN 16
CLEOCIN PHOSPHATE 16
CLIMARA PRO 73
CLINDAMYCIN HCL 16
CLINDAMYCIN PALMITATE HCL 16
CLINDAMYCIN PHOSPHATE 16
CLINDAMYCIN PHOSPHATE/BENZOYL
PEROXIDE 55
CLINDESSE 16
CLINIMIX 57
CLINIMIX E 57
CLINISOL 57
CLIOQUINOL/HYDROCORTISONE 55
CLOBAZAM 21
CLOBETASOL PROPIONATE 70
CLOBETASOL PROPIONATE/EMOLLIENT BASE 70
CLOMIPRAMINE HCL 26
CLONAZEPAM 41
CLONIDINE 48
CLONIDINE HCL 48
CLOPIDOGREL BISULFATE 48
CLORAZEPATE DIPOTASSIUM 41
CLOTRIMAZOLE 27
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE 55
CLOZAPINE 36
CLOZARIL 36
COAGADEX 46
COAGULATION FACTOR VIIA (RECOMBINANT) 47
COAGULATION FACTOR X 46
COBICISTAT 39
CODEINE SULFATE 13
COLCHICINE 28
COLESTID 52
COLESTIPOL HCL 52
COLISTIN (AS COLISTIMETHATE SODIUM) 16
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 56
COLLOIDAL BISMUTH
SUBCITRATE/METRONIDAZOLE/TETRACYCLINE
HCL 66
COMBIGAN 90
COMBIPATCH 73
COMBIVENT RESPIMAT 94
COMPLERA 37
COMPLETE NATAL DHA 63
CONCEPT DHA 63
CONCEPT OB 63
COPAXONE 54
COPPER 88
CORIFACT 46
CORTICOTROPIN 70
CORTISPORIN 55
CORVITA 5
COSENTYX (2 SYRINGES) 55
COSENTYX PEN 55
COSENTYX PEN (2 PENS) 55
COSENTYX SYRINGE 55
COUGH DM 9
COUMADIN 44
CREON 67
CRISABOROLE 55
CRIXIVAN 39
CROMOLYN SODIUM 93
CRYSELLE 74
CUPRIC CHLORIDE 57
CYANOCOBALAMIN (VITAMIN B-12) 63
CYANOCOBALAMIN/FOLIC ACID 63
CYCLAFEM 74
CYCLOBENZAPRINE HCL 94
CYCLOPENTOLATE HCL 89
CYCLOPHOSPHAMIDE 29
CYCLOSPORINE 89
CYCLOSPORINE, MODIFIED 85
CYPROHEPTADINE HCL 91
CYRED 74
CYRED EQ 74
CYSTADANE 67
CYSTAGON 67
PAGE 101 LAST UPDATED 04/2020
CYSTARAN 89
CYSTEAMINE BITARTRATE 67
CYSTEAMINE HCL 89
CYTARABINE/PF 30
DDABIGATRAN ETEXILATE MESYLATE 44
DACARBAZINE 31
DALFAMPRIDINE 54
DANAZOL 72
DAPAGLIFLOZIN PROPANEDIOL 42
DAPSONE 29
DAPTACEL DTAP 87
DARBEPOETIN ALFA IN POLYSORBATE 80 45
DARUNAVIR
ETH/COBICISTAT/EMTRICITABINE/TENOFOVIR
ALAFENAMIDE 40
DARUNAVIR ETHANOLATE 40
DARUNAVIR ETHANOLATE/COBICISTAT 40
DASETTA 74
DAUNORUBICIN HCL 31
DAYSEE 74
DAYTRANA 53
DEBLITANE 82
DECITABINE 31
DEFEROXAMINE MESYLATE 62
DELFLEX WITH 1.5% DEXTROSE 57
DELSTRIGO 37
DENAVIR 40
DEPAKOTE 20
DEPAKOTE ER 20
DEPAKOTE SPRINKLE 20
DEPO-PROVERA 82
DEPO-SUBQ PROVERA 104 82
DERMA-SMOOTHE-FS 70
DERMOTIC 91
DESCOVY 39
DESIPRAMINE HCL 26
DESMOPRESSIN ACETATE 71
DESOGESTREL-ETHINYL ESTRADIOL 81
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
ESTRADIOL 81
DESVENLAFAXINE SUCCINATE 25
DEUTETRABENAZINE 53
DEXAMETHASONE 90
DEXAMETHASONE SODIUM PHOSPHATE 90
DEXMETHYLPHENIDATE HCL 53
DEXRAZOXANE HCL 31
DEXTROAMPHETAMINE SULF-
SACCHARATE/AMPHETAMINE SULF-
ASPARTATE 52
DEXTROAMPHETAMINE SULFATE 52
DEXTROMETHORPHAN HBR/QUINIDINE
SULFATE 53
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE 57
DEXTROSE 10 % AND 0.45 % SODIUM
CHLORIDE 57
DEXTROSE 2.5 % AND 0.45 % SODIUM
CHLORIDE 57
DEXTROSE 30 % IN WATER 58
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE 58
DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE 58
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE 58
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 58
DEXTROSE 5 % IN LACTATED RINGERS 58
DEXTROSE 5 % IN WATER 58
DIALYVITE 63
DIALYVITE 3000 63
DIALYVITE 5000 63
DIALYVITE SUPREME D 63
DIALYVITE ZINC 63
DIASTAT 21
DIASTAT ACUDIAL 21
DIAZEPAM 41
DIAZOXIDE 43
DICLEGIS 26
DICLOFENAC SODIUM 90
DICLOXACILLIN SODIUM 18
DICYCLOMINE HCL 66
DIDANOSINE 38
DIFFERIN 55
PAGE 102 LAST UPDATED 04/2020
DIFLUPREDNATE 90
DIGOXIN 50
DILANTIN 24
DILANTIN-125 24
DILTIAZEM HCL 50
DIMETHYL FUMARATE 54
DIPHENHYDRAMINE HCL 92
DIPHENOXYLATE HCL/ATROPINE SULFATE 66
DIPHTHERIA, PERTUSSIS (ACELL), TETANUS
PEDIATRIC VACCINE/PF 87
DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS
VACCINE 87
DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS
VACCINE/PF 87
DIPYRIDAMOLE 48
DISULFIRAM 14
DIURIL 51
DIVALPROEX SODIUM 21
DOBUTAMINE HCL 50
DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER 50
DOCETAXEL 31
DOCUSATE SODIUM 7
DOFETILIDE 49
DOLUTEGRAVIR SODIUM 37
DOLUTEGRAVIR SODIUM/LAMIVUDINE 39
DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL 39
DONEPEZIL HCL 25
DORAVIRINE 37
DORAVIRINE/LAMIVUDINE/TENOFOVIR
DISOPROXIL FUMARATE 37
DORNASE ALFA 93
DORZOLAMIDE HCL 90
DORZOLAMIDE HCL/TIMOLOL MALEATE 90
DOVATO 39
DOXAZOSIN MESYLATE 48
DOXEPIN HCL 55
DOXERCALCIFEROL 88
DOXORUBICIN HCL 31
DOXORUBICIN HCL PEGYLATED LIPOSOMAL 31
DOXYCYCLINE HYCLATE 20
DOXYLAMINE SUCCINATE/PYRIDOXINE HCL
(B6) 26
DROPERIDOL 34
DROSPIRENONE 83
DROSPIRENONE/ETHINYL
ESTRADIOL/LEVOMEFOLATE CALCIUM 81
DULERA 94
DULOXETINE HCL 54
DUREZOL 90
DUTASTERIDE 69
DYANAVEL XR 52
EE.E.S. 200 19
ECONAZOLE NITRATE 27
ECONTRA EZ 7
ECONTRA ONE-STEP 7
ECPIRIN 1
ED-APAP 3
EDURANT 37
EFAVIRENZ 38
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE 37
EFAVIRENZ/LAMIVUDINE/TENOFOVIR
DISOPROXIL FUMARATE 38
EFFER-K 58
ELAGOLIX SODIUM 84
ELECTROLYTE-148 SOLUTION 60
ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN
WATER 58
ELECTROLYTE-A SOLUTION 60
ELECTROLYTE-B SOLUTION/DEXTROSE 5 % IN
WATER 59
ELECTROLYTE-M SOLUTION/DEXTROSE 5 % IN
WATER 60
ELECTROLYTE-MB SOLUTION/DEXTROSE 5 % IN
WATER 59
ELECTROLYTE-P SOLUTION/DEXTROSE 5 % IN
WATER 59
ELECTROLYTE-R (PH 7.4) 60
ELECTROLYTE-R SOLUTION 60
PAGE 103 LAST UPDATED 04/2020
ELECTROLYTE-R SOLUTION/DEXTROSE 5 % IN
WATER 60
ELECTROLYTE-S SOLUTION 59
ELELYSO 68
ELIDEL 55
ELINEST 74
ELIQUIS 44
ELIXOPHYLLIN 93
ELLA 81
ELOCTATE 46
ELURYNG 74
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR ALAFENAMIDE 37
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR DISOPROXIL 37
EMGALITY PEN 28
EMGALITY SYRINGE 28
EMICIZUMAB-KXWH 46
EMOQUETTE 74
EMPAGLIFLOZIN 42
EMPAGLIFLOZIN/LINAGLIPTIN 42
EMTRICITABINE 38
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
ALAFENAMIDE FUMARATE 37
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE 37
EMTRICITABINE/TENOFOVIR ALAFENAMIDE
FUMARATE 39
EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE 38
EMTRIVA 38
ENALAPRIL MALEATE 48
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 50
ENBREL 85
ENBREL MINI 85
ENBREL SURECLICK 85
ENEMEEZ 7
ENFUVIRTIDE 39
ENOXAPARIN SODIUM 44
ENPRESSE 74
ENSKYCE 74
ENTECAVIR 36
ENTRESTO 50
ENZALUTAMIDE 30
EPINEPHRINE 92
EPIRUBICIN HCL 31
EPITOL 24
EPIVIR 38
EPIVIR HBV 36
EPLERENONE 51
EPOETIN ALFA 45
EPOPROSTENOL SODIUM (GLYCINE) 93
EQUETRO 41
ERAXIS (WATER DILUENT) 27
ERGOCALCIFEROL (VITAMIN D2) 88
ERRIN 82
ERYTHROMYCIN BASE 19
ERYTHROMYCIN ETHYLSUCCINATE 19
ESCITALOPRAM OXALATE 25
ESLICARBAZEPINE ACETATE 23
ESOMEPRAZOLE MAGNESIUM 67
ESPEROCT 46
ESTARYLLA 74
ESTRADIOL 81
ESTRADIOL VALERATE 74
ESTRADIOL VALERATE/DIENOGEST 78
ESTRADIOL/LEVONORGESTREL 73
ESTRADIOL/NORETHINDRONE ACETATE 74
ESTRING 74
ESTROGENS, CONJUGATED 79
ESTROGENS,
CONJUGATED/MEDROXYPROGESTERONE
ACETATE 79
ESTROGENS,ESTERIFIED/METHYLTESTOSTERON
E 75
ESTROSTEP FE 75
ETANERCEPT 85
ETHAMBUTOL HCL 29
ETHINYL ESTRADIOL/DROSPIRENONE 81
ETHOSUXIMIDE 20
ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 81
ETONOGESTREL 82
PAGE 104 LAST UPDATED 04/2020
ETONOGESTREL/ETHINYL ESTRADIOL 78
ETOPOSIDE 32
ETRAVIRINE 37
EUCRISA 55
EVOTAZ 39
EXELON 25
EXEMESTANE 32
EXENATIDE 42
EXENATIDE MICROSPHERES 41
EZETIMIBE 52
FFABRAZYME 68
FACTOR IX 47
FACTOR IX (HUMAN) RECOMBINANT,
PEGYLATED 47
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.4, 3-FACTOR 47
FACTOR IX HUMAN RECOMBINANT 47
FACTOR IX HUMAN RECOMBINANT, THREONINE
148 46
FACTOR IX RECOMBINANT, FC FUSION
PROTEIN 46
FACTOR IX RECOMBINANT,ALBUMIN FUSION
PROTEIN 46
FACTOR XIII 46
FACTOR XIII A-SUBUNIT, RECOMBINANT 47
FALMINA 75
FAMOTIDINE 66
FAMOTIDINE/PF 66
FANAPT 35
FARXIGA 42
FAT EMULSIONS 60
FAYOSIM 75
FEIBA NF 46
FELBAMATE 22
FELBATOL 22
FELODIPINE 50
FEMHRT 75
FEMYNOR 75
FENOFIBRATE NANOCRYSTALLIZED 51
FENTANYL 12
FEOSOL 4
FER-IN-SOL 4
FERATE 4
FEROSUL 4
FERRIMIN 150 5
FERRO-TIME 5
FERROUS FUMARATE 5
FERROUS FUMARATE/ASCORBIC ACID/B12-
IF/FOLIC ACID 62
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID 58
FERROUS FUMARATE/FOLIC ACID 59
FERROUS FUMARATE/FOLIC ACID/MULTIVITAMIN-
MINERALS NO.15 58
FERROUS GLUCONATE 5
FERROUS SULFATE 5
FERROUSUL 5
FESOTERODINE FUMARATE 68
FILGRASTIM 45
FINACEA 56
FINASTERIDE 69
FINGOLIMOD HCL 54
FIRAZYR 85
FIRVANQ 16
FLAREX 90
FLECAINIDE ACETATE 49
FLOVENT HFA 91
FLOXURIDINE 30
FLUCONAZOLE 27
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-
OSMOTIC 27
FLUDARABINE PHOSPHATE 31
FLUDROCORTISONE ACETATE 70
FLUOCINOLONE ACETONIDE 70
FLUOCINOLONE ACETONIDE OIL 91
FLUORIDE (SODIUM) 62
FLUOROMETHOLONE 90
FLUOROMETHOLONE ACETATE 90
FLUOROURACIL 30
FLUOXETINE HCL 25
PAGE 105 LAST UPDATED 04/2020
FLUPHENAZINE DECANOATE 34
FLUPHENAZINE HCL 34
FLUTAMIDE 30
FLUTICASONE PROPIONATE 91
FLUTICASONE PROPIONATE/SALMETEROL
XINAFOATE 94
FLUVOXAMINE MALEATE 25
FML FORTE 90
FML S.O.P. 90
FOCALIN XR 53
FOLIC ACID 63
FOLIC ACID/MULTIVITAMIN,THER AND
MINERALS/LYCOPENE/LUTEIN 5
FOLIC ACID/VITAMIN B COMP AND
C/SELENIUM/MINERALS/ZINC 63
FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN
C 63
FOLIVANE-OB 63
FOLTRATE 63
FORTAMET 42
FOSAMPRENAVIR CALCIUM 40
FOSINOPRIL SODIUM 49
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 50
FREAMINE III 58
FUROSEMIDE 51
FUSION PLUS 58
FUZEON 39
FYCOMPA 22
GGABAPENTIN 21
GABITRIL 21
GALCANEZUMAB-GNLM 28
GAMMAGARD S-D 86
GANCICLOVIR SODIUM 36
GEFITINIB 32
GEMCITABINE HCL 30
GEMFIBROZIL 51
GENERESS FE 75
GENOTROPIN 71
GENTAMICIN SULFATE 15
GENTAMICIN SULFATE IN SODIUM CHLORIDE,
ISO-OSMOTIC 15
GENVOYA 37
GIANVI 75
GILENYA 54
GLASSIA 68
GLATIRAMER ACETATE 54
GLECAPREVIR/PIBRENTASVIR 36
GLIMEPIRIDE 42
GLIPIZIDE 42
GLIPIZIDE/METFORMIN HCL 42
GLUCAGEN 43
GLUCAGON EMERGENCY KIT 43
GLUCAGON HCL 43
GLUCAGON,HUMAN RECOMBINANT 43
GLUMETZA 42
GLYBURIDE 42
GLYBURIDE,MICRONIZED 42
GLYBURIDE/METFORMIN HCL 42
GLYCOPYRROLATE 66
GLYCOPYRROLATE/FORMOTEROL FUMARATE 94
GLYCOPYRROLATE/PF 66
GLYRX-PF 66
GLYSET 42
GLYXAMBI 42
GOLYTELY 67
GOSERELIN ACETATE 32
GRANISETRON HCL/PF 27
GRANIX 45
GRISEOFULVIN, MICROSIZE 27
GUAIFENESIN 11
GUAIFENESIN/DEXTROMETHORPHAN HBR 11
GUANFACINE HCL 53
GUANIDINE HCL 28
GYNAZOLE 1 27
HHAILEY 75
HAILEY 24 FE 75
HALOBETASOL PROPIONATE 70
HALOPERIDOL 34
PAGE 106 LAST UPDATED 04/2020
HALOPERIDOL DECANOATE 34
HALOPERIDOL LACTATE 34
HAVRIX 87
HEATHER 82
HEMATOGEN FA 58
HEMLIBRA 46
HEMOCYTE 5
HEMOCYTE PLUS 58
HEMOCYTE-F 59
HEMOFIL M 46
HEPARIN SODIUM,PORCINE 44
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE/PF 44
HEPARIN SODIUM,PORCINE/PF 44
HEPATAMINE 59
HEPATITIS A VIRUS VACCINE/PF 87
HUMALOG 43
HUMALOG KWIKPEN U-100 43
HUMALOG MIX 50-50 43
HUMALOG MIX 50-50 KWIKPEN 43
HUMALOG MIX 75-25 43
HUMALOG MIX 75-25 KWIKPEN 43
HUMATE-P 46
HUMIRA 85
HUMIRA PEN 85
HUMIRA PEN CROHN'S-UC-HS 85
HUMIRA PEN PSOR-UVEITS-ADOL HS 86
HUMIRA(CF) 86
HUMIRA(CF) PEDIATRIC CROHN'S 86
HUMIRA(CF) PEN 86
HUMIRA(CF) PEN CROHN'S-UC-HS 86
HUMIRA(CF) PEN PSOR-UV-ADOL HS 86
HUMULIN 70-30 2
HUMULIN 70/30 KWIKPEN 2
HUMULIN N 2
HUMULIN N KWIKPEN 2
HUMULIN R 2
HYDRALAZINE HCL 52
HYDROCHLOROTHIAZIDE 51
HYDROCODONE BITARTRATE 12
HYDROCODONE
BITARTRATE/ACETAMINOPHEN 14
HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE 94
HYDROCODONE/IBUPROFEN 13
HYDROCORTISONE 88
HYDROCORTISONE ACETATE/LIDOCAINE
HCL/ALOE VERA 56
HYDROCORTISONE ACETATE/PRAMOXINE HCL 56
HYDROCORTISONE SODIUM SUCCINATE/PF 71
HYDROMORPHONE HCL 13
HYDROXYCHLOROQUINE SULFATE 33
HYDROXYPROGESTERONE CAPROATE/PF 82
HYDROXYUREA 30
HYDROXYZINE HCL 92
HYDROXYZINE PAMOATE 92
HYOSCYAMINE SULFATE 66
HYPERLYTE CR 59
HYPERRHO S-D 86
HYSINGLA ER 12
IIBALIZUMAB-UIYK 39
IBU 12
IBUPROFEN 12
ICATIBANT ACETATE 85
IDARUBICIN HCL 31
IDELVION 46
IFEREX 150 FORTE 59
IFOSFAMIDE 29
ILEVRO 90
ILOPERIDONE 35
ILOPROST TROMETHAMINE 93
IMATINIB MESYLATE 32
IMIPENEM/CILASTATIN SODIUM 17
IMIPRAMINE HCL 26
IMIQUIMOD 56
IMMUNE
GLOBULIN,GAMM(IGG)/GLYCINE/GLUCOSE/IGA 0
TO 50 MCG/ML 86
PAGE 107 LAST UPDATED 04/2020
IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA
GREATER THAN 50 MCG/ML 86
INCASSIA 82
INDACATEROL MALEATE/GLYCOPYRROLATE 94
INDAPAMIDE 51
INDINAVIR SULFATE 39
INDOMETHACIN 12
INFANRIX DTAP 87
INFANT PAIN-FEVER 3
INFANTS' PAIN RELIEF 4
INFANTS' PAIN-FEVER 4
INFUVITE ADULT 63
INFUVITE PEDIATRIC 63
INGREZZA 53
INSULIN ASPART 44
INSULIN ASPART PROTAMINE HUMAN/INSULIN
ASPART 44
INSULIN DETEMIR 44
INSULIN GLARGINE,HUMAN RECOMBINANT
ANALOG 43
INSULIN LISPRO 43
INSULIN LISPRO PROTAMINE AND INSULIN
LISPRO 43
INSULIN NPH HUMAN ISOPHANE 2
INSULIN NPH HUMAN ISOPHANE/INSULIN
REGULAR, HUMAN 2
INSULIN REGULAR, HUMAN 2
INTEGRA F 59
INTEGRA PLUS 59
INTELENCE 37
INTERFERON ALFA-2B,RECOMB. 36
INTERFERON BETA-1A 54
INTERFERON BETA-1A/ALBUMIN HUMAN 54
INTERFERON BETA-1B 54
INTERFERON GAMMA-1B,RECOMB. 86
INTRALIPID 59
INTRON A 36
INTROVALE 75
INVEGA SUSTENNA 35
INVEGA TRINZA 35
INVIRASE 39
INVOKAMET 42
INVOKANA 42
IODOPEN 59
IONOSOL B WITH DEXTROSE 5% 59
IONOSOL MB-DEXTROSE 5% 59
IPRATROPIUM BROMIDE 92
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 94
IRBESARTAN 48
IRESSA 32
IRINOTECAN HCL 31
IRON FUM,POLYSAC COMP/FOLIC ACID/VIT B
COMPC NO.18/L. CASEI 58
IRON FUMARATE,POLYSAC COMP/FOLIC
ACID/VITAMIN C/NIACINAMIDE 59
IRON FUMARATE,POLYSAC CPLEX/FOLIC
ACID/VITB COMP WITH C NO.9 65
IRON FUMARATE-IRON POLYSACCH CPLEX/FOLIC
ACID/MULTIVIT NO.18 62
IRON POLYSACCHARIDE
COMPLEX/CYANOCOBALAMIN/FOLIC ACID 59
ISENTRESS 37
ISENTRESS HD 37
ISIBLOOM 75
ISOLYTE P WITH DEXTROSE 59
ISOLYTE S 59
ISONIAZID 29
ISOSORBIDE DINITRATE 52
ISOSORBIDE MONONITRATE 52
ISOTRETINOIN 56
IVERMECTIN 33
IXINITY 46
JJAIMIESS 75
JANTOVEN 44
JANUMET 42
JANUMET XR 42
JANUVIA 42
JARDIANCE 42
JASMIEL 75
JENCYCLA 82
PAGE 108 LAST UPDATED 04/2020
JENTADUETO 42
JIVI 46
JOLESSA 75
JR. STR NON-ASPIRIN PAIN 4
JULEBER 75
JULUCA 39
JUNEL 75
JUNEL FE 75
JUNEL FE 24 76
KK-PHOS NEUTRAL 69
K-PHOS NO.2 69
K-PHOS ORIGINAL 69
KABIVEN 64
KAITLIB FE 76
KALETRA 39
KALLIGA 76
KARIVA 76
KELNOR 1-35 76
KELNOR 1-50 76
KEPPRA 20
KEPPRA XR 20
KETOCONAZOLE 27
KETOROLAC TROMETHAMINE 90
KITABIS PAK 93
KLONOPIN 41
KLOR-CON 59
KLOR-CON 10 59
KLOR-CON 8 59
KLOR-CON M10 59
KLOR-CON M15 59
KLOR-CON M20 59
KLOR-CON-EF 59
KOATE 46
KOGENATE FS 46
KOMBIGLYZE XR 42
KOVALTRY 46
KURVELO 76
KYLEENA 82
LLABETALOL HCL 49
LACOSAMIDE 24
LACTULOSE 67
LAMICTAL 22
LAMICTAL (BLUE) 22
LAMICTAL (GREEN) 22
LAMICTAL (ORANGE) 22
LAMICTAL ODT 22
LAMICTAL ODT (BLUE) 22
LAMICTAL ODT (GREEN) 22
LAMICTAL ODT (ORANGE) 22
LAMICTAL XR 22
LAMICTAL XR (BLUE) 22
LAMICTAL XR (GREEN) 22
LAMICTAL XR (ORANGE) 22
LAMIVUDINE 38
LAMIVUDINE/TENOFOVIR DISOPROXIL
FUMARATE 38
LAMIVUDINE/ZIDOVUDINE 38
LAMOTRIGINE 23
LANSOPRAZOLE 67
LANTUS 43
LANTUS SOLOSTAR 43
LARIN 76
LARIN 24 FE 76
LARIN FE 76
LARISSIA 76
LATANOPROST 91
LATUDA 35
LAYOLIS FE 76
LEENA 76
LEFLUNOMIDE 86
LENALIDOMIDE 30
LESSINA 76
LETAIRIS 93
LETROZOLE 32
LEUCOVORIN CALCIUM 31
LEUKERAN 29
LEUKINE 45
PAGE 109 LAST UPDATED 04/2020
LEUPROLIDE ACETATE 84
LEUPROLIDE ACETATE/NORETHINDRONE
ACETATE 84
LEVEMIR 44
LEVEMIR FLEXTOUCH 44
LEVETIRACETAM 20
LEVOBUNOLOL HCL 90
LEVOCARNITINE (WITH SUGAR) 60
LEVOCETIRIZINE DIHYDROCHLORIDE 92
LEVOFLOXACIN 19
LEVOFLOXACIN/DEXTROSE 5 % IN WATER 19
LEVONEST 76
LEVONORGESTREL 83
LEVONORGESTREL/ETHINYL ESTRADIOL 81
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL 79
LEVONORGESTREL/ETHINYL
ESTRADIOL/FERROUS BISGLYCINATE 73
LEVORA-28 76
LEVOTHYROXINE SODIUM 84
LEVOXYL 83
LEXIVA 40
LIDOCAINE 14
LIDOCAINE HCL 14
LIDOCAINE HCL IN DEXTROSE 7.5 % IN
WATER/PF 14
LIDOCAINE HCL/EPINEPHRINE 14
LIDOCAINE HCL/EPINEPHRINE BITARTRATE 14
LIDOCAINE HCL/PF 14
LIDOCAINE/PRILOCAINE 14
LILETTA 82
LILLOW 76
LINACLOTIDE 66
LINAGLIPTIN 43
LINAGLIPTIN/METFORMIN HCL 42
LINCOMYCIN HCL 16
LINEZOLID 16
LINZESS 66
LIOTHYRONINE SODIUM 83
LIOTRIX 84
LIPASE/PROTEASE/AMYLASE 68
LIQUITUSS GG 9
LISDEXAMFETAMINE DIMESYLATE 53
LISINOPRIL 49
LISINOPRIL/HYDROCHLOROTHIAZIDE 50
LITHIUM CARBONATE 41
LO LOESTRIN FE 77
LO-ZUMANDIMINE 77
LOESTRIN 77
LOESTRIN FE 77
LOJAIMIESS 77
LOPERAMIDE HCL 66
LOPINAVIR/RITONAVIR 39
LORATA-DINE D 9
LORATADINE 8
LORATADINE-D 9
LORATADINE/PSEUDOEPHEDRINE SULFATE 9
LORAZEPAM 41
LORAZEPAM INTENSOL 41
LORYNA 77
LOSARTAN POTASSIUM 48
LOSARTAN
POTASSIUM/HYDROCHLOROTHIAZIDE 50
LOSEASONIQUE 77
LOTEMAX 90
LOTEPREDNOL ETABONATE 90
LOTRONEX 66
LOVASTATIN 52
LOW-OGESTREL 77
LOXAPINE SUCCINATE 34
LUPANETA PACK 84
LUPRON DEPOT 84
LUPRON DEPOT (LUPANETA) 84
LUPRON DEPOT-PED 84
LURASIDONE HCL 35
LUTERA 77
LYZA 82
MM-NATAL PLUS 64
M-PAP 4
M.V.I. ADULT 64
PAGE 110 LAST UPDATED 04/2020
M.V.I. PEDIATRIC 64
MAGNESIUM CHLORIDE 60
MAGNESIUM SULFATE IN STERILE WATER 60
MAKENA 82
MANGANESE CHLORIDE 60
MANGANESE SULFATE 60
MANNITOL/SORBITOL SOLUTION 88
MAPAP ARTHRITIS PAIN 4
MARAVIROC 39
MARLISSA 77
MATULANE 29
MAVYRET 36
MAXIDEX 90
MECLIZINE HCL 26
MEDROXYPROGESTERONE ACETATE 82
MEFLOQUINE HCL 33
MEGESTROL ACETATE 82
MELODETTA 24 FE 77
MELOXICAM 12
MELPHALAN 29
MELPHALAN HCL 29
MEMANTINE HCL 25
MEPHYTON 47
MERCAPTOPURINE 30
MEROPENEM 18
MEROPENEM IN 0.9 % SODIUM CHLORIDE 18
MESALAMINE 87
MESNA 32
MESTINON 28
METFORMIN HCL 43
METHAZOLAMIDE 90
METHENAMINE HIPPURATE 16
METHENAMINE MANDELATE 16
METHIMAZOLE 85
METHOCARBAMOL 95
METHOTREXATE SODIUM 86
METHOTREXATE SODIUM/PF 86
METHYLDOPA 48
METHYLERGONOVINE MALEATE 88
METHYLPHENIDATE 53
METHYLPHENIDATE HCL 53
METHYLPREDNISOLONE 70
METHYLPREDNISOLONE ACETATE 70
METHYLPREDNISOLONE SODIUM SUCCINATE 70
METOCLOPRAMIDE HCL 26
METOLAZONE 51
METOPROLOL SUCCINATE 49
METOPROLOL TARTRATE 49
METRONIDAZOLE 56
METRONIDAZOLE IN SODIUM CHLORIDE 16
MEXILETINE HCL 49
MIBELAS 24 FE 77
MICONAZOLE 3 2
MICONAZOLE NITRATE 27
MICROGESTIN FE 77
MIDODRINE HCL 48
MIGLITOL 42
MIGLUSTAT 68
MILI 77
MILRINONE LACTATE 50
MILRINONE LACTATE/DEXTROSE 5 % IN WATER50
MINASTRIN 24 FE 77
MINOCYCLINE HCL 20
MINOXIDIL 52
MIRCETTE 77
MIRENA 82
MIRTAZAPINE 25
MISOPROSTOL 67
MITOMYCIN 31
MITOXANTRONE HCL 31
MODAFINIL 95
MOMETASONE FUROATE 91
MOMETASONE FUROATE/FORMOTEROL
FUMARATE 94
MONO-LINYAH 77
MONONINE 47
MONTELUKAST SODIUM 92
MORPHABOND ER 12
MORPHINE SULFATE 13
MOVANTIK 66
MOXIFLOXACIN HCL 19
MUCINEX 9
PAGE 111 LAST UPDATED 04/2020
MUCINEX DM 10
MUCOSA 10
MUCUS DM MAX ER 10
MUCUS ER 10
MUCUS RELIEF 10
MUCUS RELIEF CHEST CONGESTION 10
MUCUS RELIEF DM COUGH 10
MUCUS RELIEF DM ER 10
MUCUS RELIEF DM MAX 10
MUCUS RELIEF DM MAX ER 10
MUCUS RELIEF ER 10
MUCUS-CHEST CONGESTION 10
MUCUS-ER MAX 10
MULTITRACE-4 60
MULTITRACE-5 60
MULTIVIT WITH MINS10/FOLIC ACID/VIT D3/A
LIPOIC ACID/LUTEIN 64
MULTIVITAMIN INFUSION, ADULT NO.1 WITH
WITAMIN K 64
MULTIVITAMIN INFUSION, ADULT NO.4 WITH
VITAMIN K 63
MULTIVITAMIN INFUSION, PEDIATRIC NO.1 WITH
VITAMIN K 63
MULTIVITAMIN INFUSION, PEDIATRIC NO.2 WITH
VITAMIN K 64
MULTIVITAMIN WITH MINERALS NO.20/IRON/FOLIC
ACID 63
MULTIVITAMIN, MINERALS NO.51/FOLIC ACID/VIT
K1/UBIDECARENONE 5
MULTIVITAMIN-MINERALS NO.25/FOLIC
ACID/VITAMIN D3 63
MULTIVITAMINS WITH MINERALS NO.11/FOLIC
ACID 63
MUPIROCIN 16
MUTAMYCIN 31
MV-MIN 75/FERROUS FUM/IRON PS CPLX/FOLIC
AC/OMEGA-3/DHA/EPA 65
MV-MINS NO.74/FERROUS FUMARATE/IRON PS
CPLX/FOLIC ACID 63
MY CHOICE 7
MY WAY 7
MYCOPHENOLATE MOFETIL 86
MYCOPHENOLATE MOFETIL HCL 85
MYLERAN 29
MYORISAN 56
MYSOLINE 21
NNABUMETONE 12
NAFARELIN ACETATE 84
NALOXEGOL OXALATE 66
NALOXONE HCL 15
NALTREXONE HCL 14
NALTREXONE MICROSPHERES 14
NAPROXEN 12
NARCAN 15
NATAZIA 78
NATROBA 56
NEBUPENT 33
NECON 78
NELFINAVIR MESYLATE 40
NEOMYCIN SULFATE 15
NEOMYCIN SULFATE/BACITRACIN
ZINC/POLYMYXIN B/HYDROCORTISONE 89
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
B 89
NEOMYCIN SULFATE/POLYMYXIN B SULFATE 16
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE 91
NEOMYCIN/BACITRACIN/POLYMYXIN
B/HYDROCORTISONE 55
NEOMYCIN/POLYMYXIN B
SULFATE/DEXAMETHASONE 89
NEPAFENAC 90
NEPHPLEX RX 64
NEPHRAMINE 60
NEPHRO-VITE RX 64
NETARSUDIL MESYLATE 90
NETARSUDIL MESYLATE/LATANOPROST 90
NEULASTA 45
NEUPOGEN 45
NEURONTIN 21
PAGE 112 LAST UPDATED 04/2020
NEVIRAPINE 38
NEW DAY 7
NEXIUM 67
NEXPLANON 82
NIACIN 52
NICORETTE 1
NICOTINE 1
NICOTINE POLACRILEX 1
NIFEDIPINE 50
NIKKI 78
NIMODIPINE 50
NITROFURANTOIN MACROCRYSTAL 16
NITROFURANTOIN
MONOHYDRATE/MACROCRYSTALS 16
NITROGLYCERIN 52
NORA-BE 82
NORDITROPIN FLEXPRO 71
NORELGESTROMIN/ETHINYL ESTRADIOL 81
NORETHINDRONE 83
NORETHINDRONE ACETATE 83
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL 78
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 80
NORETHINDRONE-ETHINYL ESTRADIOL 81
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 81
NORGESTIMATE-ETHINYL ESTRADIOL 81
NORGESTREL-ETHINYL ESTRADIOL 78
NORLYDA 83
NORMOSOL-M AND DEXTROSE 60
NORMOSOL-R 60
NORMOSOL-R AND DEXTROSE 60
NORMOSOL-R PH 7.4 60
NORTREL 78
NORTRIPTYLINE HCL 26
NORVIR 40
NOVOEIGHT 47
NOVOLIN N 2
NOVOLIN R 2
NOVOLOG 44
NOVOLOG FLEXPEN 44
NOVOLOG MIX 70-30 44
NOVOLOG MIX 70-30 FLEXPEN 44
NOVOSEVEN RT 47
NP THYROID 83
NUEDEXTA 53
NUTRILIPID 60
NUVARING 78
NUWIQ 47
NYSTATIN 27
NYSTATIN/TRIAMCINOLONE ACETONIDE 28
OOBIZUR 47
OCELLA 78
OCTREOTIDE ACETATE 84
ODEFSEY 37
OFATUMUMAB 32
OFLOXACIN 19
OGESTREL 78
OLANZAPINE 35
OLMESARTAN MEDOXOMIL 48
OLOPATADINE HCL 90
OMEPRAZOLE 67
ONCASPAR 31
ONDANSETRON 27
ONDANSETRON HCL 27
ONFI 21
ONGLYZA 43
OPCICON ONE-STEP 7
OPIUM/BELLADONNA ALKALOIDS 13
ORACIT 69
ORILISSA 84
ORSYTHIA 78
ORTHO MICRONOR 83
ORTHO TRI-CYCLEN 78
ORTHO-NOVUM 78
OSELTAMIVIR PHOSPHATE 40
OXALIPLATIN 31
OXAZEPAM 41
OXCARBAZEPINE 24
PAGE 113 LAST UPDATED 04/2020
OXTELLAR XR 24
OXYBUTYNIN CHLORIDE 68
OXYCODONE HCL 13
OXYCODONE HCL/ACETAMINOPHEN 13
OXYCODONE MYRISTATE 13
OYSCO-500 5
PPACLITAXEL 31
PAIN RELIEF 4
PAIN RELIEVER JUNIOR STRENGTH 4
PALIPERIDONE PALMITATE 35
PAMIDRONATE DISODIUM 88
PANCREAZE 68
PANRETIN 32
PANTOPRAZOLE SODIUM 67
PARAGARD T 380-A 88
PARAPLATIN 31
PARENTERAL AMINO ACID 10 % COMBINATION
NO.2 56
PARENTERAL AMINO ACID 10 % COMBINATION
NO.4 58
PARENTERAL AMINO ACID 10 % COMBINATION
NO.6 62
PARENTERAL AMINO ACID 10% COMBINATION
NO.7 61
PARENTERAL AMINO ACID 15% COMBINATION
NO.1 60
PARENTERAL AMINO ACID 15% COMBINATION
NO.5 57
PARENTERAL AMINO ACID 20 % COMBINATION
NO.1 61
PARENTERAL AMINO ACID 5.2 % COMBINATION
NO.1 (RENAL) 57
PARENTERAL AMINO ACID 7 % COMBINATION
NO.1 (PEDIATRIC) 57
PARENTERAL AMINO ACID 7 % COMBINATION
NO.2 57
PARICALCITOL 88
PAROXETINE HCL 25
PAZEO 90
PAZOPANIB HCL 32
PEDIATRIC MULTIVITAMIN A,C,AND D3 NO.38
WITH SODIUM FLUORIDE 6
PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM
FLUORIDE 5
PEDIATRIC MULTIVITAMIN NO.33/SODIUM
FLUORIDE/IRON CARBONYL 5
PEDIATRIC MULTIVITAMIN NO.40/PHYTONADIONE
(VIT K1) 5
PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM
FLUORIDE 64
PEG 3350/SOD SULF/SOD BICARB/SOD
CHLORIDE/POTASSIUM CHLORIDE 67
PEGASPARGASE 31
PEGASYS 36
PEGFILGRASTIM 45
PEGINTERFERON ALFA-2A 36
PEGINTERFERON ALFA-2B 36
PEGINTRON 36
PEMETREXED DISODIUM 30
PENCICLOVIR 40
PENICILLIN G BENZATHINE 18
PENICILLIN G BENZATHINE/PENICILLIN G
PROCAINE 18
PENICILLIN G PROCAINE 18
PENICILLIN G SODIUM 18
PENICILLIN V POTASSIUM 18
PENTAMIDINE ISETHIONATE 33
PENTOXIFYLLINE 50
PERAMPANEL 22
PERIKABIVEN 64
PERITONEAL DIALYSIS SOLUTION NO.19 AND
DEXTROSE 1.5 % 57
PERMETHRIN 33
PERPHENAZINE 26
PERPHENAZINE/AMITRIPTYLINE HCL 25
PERSERIS 35
PERTZYE 68
PHENAZOPYRIDINE HCL 69
PHENOBARBITAL 21
PAGE 114 LAST UPDATED 04/2020
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE
SULF/SCOPOLAMINE HB 66
PHENYLEPHRINE HCL 89
PHENYLEPHRINE HCL/PROMETHAZINE HCL 94
PHENYTOIN 24
PHENYTOIN SODIUM EXTENDED 24
PHILITH 78
PHOSPHA 250 NEUTRAL 69
PHYTONADIONE (VIT K1) 47
PIFELTRO 37
PILOCARPINE HCL 54
PIMECROLIMUS 55
PIMOZIDE 34
PIMTREA 78
PIOGLITAZONE HCL 43
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 18
PIPERONYL BUTOXIDE/PYRETHRINS 4
PIRMELLA 78
PLAN B ONE-STEP 7
PLASMA-LYTE 148 60
PLASMA-LYTE A PH 7.4 60
PLENAMINE 60
PNV 29-1 64
PODOFILOX 56
POLY-VI-FLOR 5
POLY-VI-FLOR WITH IRON 5
POLYCIN 89
POLYETHYLENE GLYCOL 3350 7
POLYMYXIN B SULFATE 16
POLYMYXIN B SULFATE/TRIMETHOPRIM 89
POMALIDOMIDE 30
POMALYST 30
PORTIA 78
POTASSIUM ACETATE 60
POTASSIUM BICARBONATE/CITRIC ACID 59
POTASSIUM CHLORIDE 59
POTASSIUM CHLORIDE IN 0.45 % SODIUM
CHLORIDE 61
POTASSIUM CHLORIDE IN 0.9 % SODIUM
CHLORIDE 60
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN
WATER 58
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9
% SODIUM CHLORIDE 58
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %
SODIUM CHLORIDE 58
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %
SODIUM CHLORIDE 58
POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3
% SODIUM CHLORIDE 58
POTASSIUM CHLORIDE IN LACTATED RINGERS
AND 5 % DEXTROSE 61
POTASSIUM CHLORIDE IN WATER FOR
INJECTION, STERILE 60
POTASSIUM CITRATE 69
POTASSIUM CITRATE/CITRIC ACID 69
POTASSIUM PHOSPHATE,MONOBASIC 69
POTASSIUM PHOSPHATE,MONOBASIC-DIBASIC 61
PRADAXA 44
PRAMIPEXOLE DI-HCL 33
PRASUGREL HCL 48
PRAVASTATIN SODIUM 52
PRAZIQUANTEL 33
PRAZOSIN HCL 48
PREDNISOLONE 70
PREDNISOLONE ACETATE 90
PREDNISOLONE SODIUM PHOSPHATE 71
PREDNISONE 71
PREGABALIN 54
PREMARIN 79
PREMASOL 61
PREMPHASE 79
PREMPRO 79
PRENATAL VIT NO.112/IRON PHOSPH/FOLIC
ACID/OMEGA-3S/DHA/EPA 65
PRENATAL VIT NO.128/IRON POLYSACCHARIDE
COMPLEX/FOLIC ACID 64
PRENATAL VIT NO.2/IRON BG CHEL,SUCC-
PROT/FOLIC ACID/OMEGA-3 65
PRENATAL VIT NO.67/IRON
POLYSACCHARIDES/FOLATE COMB.NO.1/DHA 65
PAGE 115 LAST UPDATED 04/2020
PRENATAL VIT WITH CALCIUM 53/IRON BIS,S-
P/FOLIC ACID/OMEGA-3 65
PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS
FUMARATE/FOLIC ACID 65
PRENATAL VITAMIN
NO.48/IRON,CARBONYL,GLUCONATE/FOLIC
ACID/B6 63
PRENATAL VITAMIN WITH CALCIUM
NO.76/IRON,CARBONYL/FOLIC ACID 65
PRENATAL VITAMINS NO.33/IRON POLYSACH
COMPLEX/FOLIC ACID/DHA 64
PRENATAL VITS NO.26/IRON POLYSACCHARIDE
CPLEX/FOLIC ACID/DHA 65
PRENATAL VITS WITH CALCIUM 118/FERROUS
FUMARATE/FOLIC ACID 64
PRENATAL VITS WITH CALCIUM NO.10/FERROUS
FUM/FOLIC ACID/DHA 65
PRENATAL VITS WITH CALCIUM NO.10/FERROUS
FUMARATE/FOLIC ACID 65
PRENATAL VITS WITH CALCIUM NO.72/FERROUS
FUMARATE/FOLIC ACID 64
PREPLUS 64
PREVACID 67
PREVIFEM 79
PREZCOBIX 40
PREZISTA 40
PRIMAQUINE PHOSPHATE 33
PRIMIDONE 21
PROAIR HFA 92
PROBENECID 28
PROBENECID/COLCHICINE 28
PROCALAMINE 61
PROCARBAZINE HCL 29
PROCHLORPERAZINE MALEATE 26
PROCRIT 45
PROCTO-MED HC 88
PROCTOFOAM-HC 56
PROCTOSOL-HC 88
PROCTOZONE-HC 88
PROFILNINE 47
PROGESTERONE 83
PROGESTERONE, MICRONIZED 83
PROGLYCEM 43
PROLASTIN C 68
PROMETHAZINE HCL 92
PROMETHAZINE HCL/DEXTROMETHORPHAN
HBR 94
PROMETHEGAN 27
PROMETRIUM 83
PROPAFENONE HCL 49
PROPANTHELINE BROMIDE 66
PROPRANOLOL HCL 49
PROPYLTHIOURACIL 85
PROSOL 61
PROTONIX 67
PROTOPIC 56
PROVENTIL HFA 92
PULMOZYME 93
PUREVIT DUALFE PLUS 61
PYLERA 66
PYRAZINAMIDE 29
PYRIDOSTIGMINE BROMIDE 28
PYRIDOXINE HCL (VITAMIN B6) 64
QQUARTETTE 79
QUDEXY XR 23
QUETIAPINE FUMARATE 35
QUILLICHEW ER 53
QUILLIVANT XR 53
QUINAPRIL HCL 49
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 50
QUINIDINE SULFATE 49
RRALTEGRAVIR POTASSIUM 37
RAMELTEON 95
RAMIPRIL 49
RANEXA 51
RANOLAZINE 51
RAPAMUNE 86
REBIF 54
PAGE 116 LAST UPDATED 04/2020
REBIF REBIDOSE 54
REBINYN 47
RECLIPSEN 79
RECOMBINATE 47
RENACIDIN 69
RENVELA 62
REPAGLINIDE 43
RESTASIS 89
RESTASIS MULTIDOSE 89
RETIN-A 56
RETROVIR 38
REVLIMID 30
REYATAZ 40
RHO(D) IMMUNE GLOBULIN 86
RHOPRESSA 90
RIBAVIRIN 94
RIFABUTIN 29
RIFAMPIN 29
RILPIVIRINE HCL 37
RILUZOLE 54
RINGER'S SOLUTION 61
RINGER'S SOLUTION,LACTATED 60
RISPERDAL CONSTA 35
RISPERIDONE 35
RISPERIDONE MICROSPHERES 35
RITONAVIR 40
RITUXAN 32
RITUXIMAB 32
RIVAROXABAN 44
RIVASTIGMINE 25
RIVELSA 79
RIXUBIS 47
RIZATRIPTAN BENZOATE 28
ROBAFEN 10
ROBAFEN DM COUGH 10
ROBAFEN DM PEAK COLD 10
ROCKLATAN 90
ROPINIROLE HCL 33
ROSUVASTATIN CALCIUM 52
ROWEEPRA 20
ROZEREM 95
RUFINAMIDE 24
SSABRIL 21
SACUBITRIL/VALSARTAN 50
SAFYRAL 79
SALICYLIC ACID 56
SALMETEROL XINAFOATE 92
SALSALATE 12
SANDIMMUNE 86
SANTYL 56
SAQUINAVIR MESYLATE 39
SARGRAMOSTIM 45
SAXAGLIPTIN HCL 43
SAXAGLIPTIN HCL/METFORMIN HCL 42
SCOPOLAMINE 27
SE-NATAL 19 64
SE-TAN PLUS 61
SEASONIQUE 79
SECUKINUMAB 55
SEGESTERONE ACETATE/ETHINYL ESTRADIOL 72
SELECT-OB 64
SELECT-OB + DHA 64
SELEGILINE HCL 34
SELENIUM SULFIDE 56
SELZENTRY 39
SEREVENT DISKUS 92
SERTRALINE HCL 25
SETLAKIN 79
SEVELAMER CARBONATE 62
SEVELAMER HCL 62
SHAROBEL 83
SHINGRIX 87
SHINGRIX ADJUVANT COMPONENT 87
SHINGRIX GE ANTIGEN COMPONENT 87
SILDENAFIL CITRATE 93
SILTUSSIN SA 10
SILVER NITRATE 56
SILVER SULFADIAZINE 19
SIMLIYA 79
SIMPESSE 79
PAGE 117 LAST UPDATED 04/2020
SIMVASTATIN 52
SIROLIMUS 86
SITAGLIPTIN PHOSPHATE 42
SITAGLIPTIN PHOSPHATE/METFORMIN HCL 42
SKYLA 83
SLYND 83
SODIUM ACETATE 61
SODIUM BICARBONATE 61
SODIUM CHLORIDE 0.45 % 61
SODIUM CHLORIDE FOR INHALATION 94
SODIUM CHLORIDE/POT CHLORIDE/MAG SUL/SOD
PHOS,DB/POT PHOS,MB 62
SODIUM CHLORIDE/SODIUM
BICARBONATE/POTASSIUM CHLORIDE/PEG 67
SODIUM IODIDE 59
SODIUM PHOSPHATE,DIBASIC/POT
PHOS,MONOB/SOD PHOSPHATE MONO 69
SODIUM PHOSPHATE,MONOBASIC-DIBASIC 62
SODIUM PHOSPHATE,MONOBASIC/POTASSIUM
PHOSPHATE,MONOBASIC 69
SODIUM PICOSULFATE/MAGNESIUM
OXIDE/CITRIC ACID 66
SODIUM POLYSTYRENE SULFONATE 62
SODIUM POLYSTYRENE SULFONATE/SORBITOL
SOLUTION 62
SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO
RIDE/ACETATE 62
SODIUM/POTASSIUM/POTASSIUM
CITRATE/SODIUM CITRATE/CIT AC 69
SOFOSBUVIR/VELPATASVIR 36
SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR 36
SOLIFENACIN SUCCINATE 68
SOLU-CORTEF 71
SOMATROPIN 71
SORBITOL SOLUTION 88
SOTALOL HCL 49
SPINOSAD 56
SPIRIVA 92
SPIRONOLACTONE 51
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 51
SPRINTEC 79
SPS 62
SRONYX 79
STAVUDINE 38
STERILE WATER FOR IC-GREEN 88
STERILE WATER FOR KCENTRA 89
STIMATE 71
STIOLTO RESPIMAT 94
STRIBILD 37
STROVITE ONE 64
SUBLOCADE 13
SUBOXONE 15
SUBVENITE 23
SUBVENITE (BLUE) 23
SUBVENITE (GREEN) 23
SUBVENITE (ORANGE) 23
SUCRALFATE 67
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE 89
SULFAMETHOXAZOLE/TRIMETHOPRIM 19
SULFASALAZINE 88
SUMATRIPTAN 28
SUMATRIPTAN SUCCINATE 28
SUNITINIB MALATE 32
SUSTIVA 38
SUTENT 32
SYEDA 79
SYMBICORT 94
SYMFI 38
SYMFI LO 38
SYMPAZAN 21
SYMTUZA 40
SYNAREL 84
SYNTHAMIN 17 WITHOUT ELTYE 62
TTACROLIMUS 86
TADALAFIL 93
TAKE ACTION 7
TALIGLUCERASE ALFA 68
TAMOXIFEN CITRATE 30
TAMSULOSIN HCL 69
PAGE 118 LAST UPDATED 04/2020
TANDEM PLUS 62
TARINA 24 FE 79
TARINA FE 80
TARINA FE 1-20 EQ 80
TARON-C DHA 65
TAYTULLA 80
TBO-FILGRASTIM 45
TECFIDERA 54
TEGRETOL 24
TEGRETOL XR 24
TEMAZEPAM 95
TEMIXYS 38
TEMODAR 29
TEMOZOLOMIDE 29
TENOFOVIR DISOPROXIL FUMARATE 38
TERAZOSIN HCL 48
TERBINAFINE HCL 28
TERBUTALINE SULFATE 92
TERCONAZOLE 28
TERIFLUNOMIDE 54
TESTOSTERONE 71
TESTOSTERONE CYPIONATE 72
TESTOSTERONE ENANTHATE 72
TETRABENAZINE 54
THEO-24 93
THEOPHYLLINE ANHYDROUS 93
THIAMINE HCL 65
THIOLA 69
THIORIDAZINE HCL 34
THIOTEPA 31
THIOTHIXENE 34
THRIVITE RX 65
THYROID 83
THYROID,PORK 83
THYROLAR-1 83
THYROLAR-1/2 84
THYROLAR-1/4 84
THYROLAR-2 84
THYROLAR-3 84
TIAGABINE HCL 21
TICAGRELOR 48
TIKOSYN 49
TILIA FE 80
TIMOLOL MALEATE 91
TINIDAZOLE 16
TIOPRONIN 69
TIOTROPIUM BROMIDE 92
TIOTROPIUM BROMIDE/OLODATEROL HCL 94
TIPRANAVIR/VITAMIN E TPGS 39
TIS-U-SOL PENTALYTE 62
TIVICAY 37
TIZANIDINE HCL 36
TOBRADEX 89
TOBRAMYCIN 93
TOBRAMYCIN SULFATE 15
TOBRAMYCIN/DEXAMETHASONE 89
TOBRAMYCIN/LOTEPREDNOL ETABONATE 89
TOBRAMYCIN/NEBULIZER 93
TOFACITINIB CITRATE 86
TOPAMAX 23
TOPIRAMATE 23
TOPOTECAN HCL 32
TORSEMIDE 51
TOVIAZ 68
TPN ELECTROLYTES 62
TPN ELECTROLYTES II 62
TRACLEER 93
TRADJENTA 43
TRAMADOL HCL 13
TRANEXAMIC ACID 47
TRANEXAMIC ACID IN SODIUM CHLORIDE,ISO-
OSMOTIC 47
TRANSDERM-SCOP 27
TRAVASOL 62
TRAVATAN Z 91
TRAVOPROST 91
TRAZODONE HCL 26
TREANDA 29
TRETINOIN 56
TRETTEN 47
TRI FEMYNOR 80
TRI-ESTARYLLA 80
PAGE 119 LAST UPDATED 04/2020
TRI-LEGEST FE 80
TRI-LINYAH 80
TRI-LO-ESTARYLLA 80
TRI-LO-MARZIA 80
TRI-LO-MILI 80
TRI-LO-SPRINTEC 80
TRI-MILI 80
TRI-PREVIFEM 80
TRI-SPRINTEC 80
TRI-VI-FLOR 6
TRI-VYLIBRA 80
TRI-VYLIBRA LO 80
TRIAMCINOLONE ACETONIDE 71
TRIAMTERENE/HYDROCHLOROTHIAZIDE 51
TRICITRATES 69
TRICON 62
TRIDERM 71
TRIFLUOPERAZINE HCL 34
TRIFLURIDINE 40
TRIHEXYPHENIDYL HCL 33
TRILEPTAL 24
TRILYTE WITH FLAVOR PACKETS 67
TRIMETHOPRIM 16
TRINATAL RX 1 65
TRINTELLIX 26
TRIPTODUR 84
TRIPTORELIN PAMOATE 84
TRIUMEQ 39
TRIVEEN-DUO DHA 65
TRIVORA-28 80
TRIZIVIR 38
TROGARZO 39
TROKENDI XR 23
TROPHAMINE 62
TRUST NATAL DHA 65
TRUVADA 38
TULANA 83
TUMS 6
TUMS FRESHERS 6
TUMS SMOOTHIES 6
TUMS ULTRA 6
TUMS ULTRA STRENGTH 6
TUMS X-STR 6
TUSSIN 10
TUSSIN CHEST CONGESTION 10
TUSSIN DM 11
TUSSIN DM MAX 11
TUSSIN HONEY 11
TUSSIN MUCUS-CHEST CONGESTION 11
TYBOST 39
TYDEMY 81
UULIPRISTAL ACETATE 81
ULTRA STRENGTH ANTACID 6
UNITHROID 84
UREA 56
URSODIOL 66
UTIBRON NEOHALER 94
VVACCINE ADJUVANT SYSTEM, AS01B/PF,
COMPONENT VIAL 1 OF 2 87
VAGIFEM 81
VALACYCLOVIR HCL 40
VALBENAZINE TOSYLATE 53
VALGANCICLOVIR HCL 36
VALPROIC ACID 21
VALRUBICIN 31
VALSTAR 31
VANALICE 4
VANCOMYCIN HCL 16
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE 17
VANCOMYCIN IN 5 % DEXTROSE IN WATER 17
VAQTA 87
VARENICLINE TARTRATE 15
VARICELLA-ZOSTER VIRUS GLYCOPROTEIN
E,REC,COMPONENT 2 OF 2 87
VARICELLA-ZOSTER VIRUS GLYCOPROTEIN
E,REC/AS01B ADJUVANT/PF 87
VELIVET 81
VENLAFAXINE HCL 26
PAGE 120 LAST UPDATED 04/2020
VENTAVIS 93
VERAPAMIL HCL 50
VICODIN HP 14
VIDEX 38
VIENVA 81
VIGABATRIN 22
VIGADRONE 22
VIIBRYD 26
VILAZODONE HCL 26
VIMPAT 24
VINBLASTINE SULFATE 31
VINCRISTINE SULFATE 32
VINORELBINE TARTRATE 32
VIOKACE 68
VIORELE 81
VIRACEPT 40
VIRAMUNE 38
VIREAD 38
VIRT-C DHA 65
VIRT-FEFA PLUS 65
VIRT-PHOS 250 NEUTRAL 69
VIRTRATE-3 69
VIRTRATE-K 69
VIT B COMPLEX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN/ZINC OXID 64
VIT B COMPLEX NO.4/VIT D3/ASCORBIC
ACID/FOLIC ACID/ZINC OXID 65
VITAFOL GUMMIES 65
VITAFOL ULTRA 65
VITAFOL-OB 65
VITAFOL-OB+DHA 65
VITAFOL-ONE 65
VITAL-D RX 65
VITAMIN B COMPLEX NO.11/FOLIC ACID/VIT
C/BIOTIN/ZINC OXIDE 63
VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC
ACID(VITC)/BIOTIN 65
VIVITROL 14
VOLNEA 81
VON WILLEBRAND FACTOR (RECOMBINANT) 47
VONVENDI 47
VORTIOXETINE HYDROBROMIDE 26
VOSEVI 36
VOTRIENT 32
VP-VITE RX 65
VYFEMLA 81
VYLIBRA 81
VYVANSE 53
WWARFARIN SODIUM 44
WATER FOR INJECTION,STERILE 89
WATER FOR IRRIGATION,STERILE 89
WERA 81
WILATE 47
WYMZYA FE 81
XXARELTO 44
XELJANZ 86
XELODA 30
XTAMPZA ER 13
XTANDI 30
XULANE 81
XYNTHA 47
XYNTHA SOLOFUSE 47
YYASMIN 28 81
YAZ 81
ZZALEPLON 95
ZARAH 81
ZARONTIN 20
ZAVESCA 68
ZEMAIRA 68
ZENATANE 56
ZENPEP 68
ZIAGEN 39
ZIDOVUDINE 39
ZINC CHLORIDE 62
PAGE 121 LAST UPDATED 04/2020
ZINC SULFATE 62
ZINC SULFATE/COPPER
SULFATE/MANGANESE/CHROMIUM/SELENIUM 60
ZINC SULFATE/CUPRIC SULFATE/MANGANESE
SULF/CHROMIC CHLORIDE 60
ZIPRASIDONE HCL 35
ZOLADEX 32
ZOLEDRONIC ACID IN MANNITOL AND WATER
FOR INJECTION 88
ZOLPIDEM TARTRATE 95
ZONISAMIDE 20
ZOVIA 1-35E 81
ZOVIRAX 40
ZTLIDO 14
ZUBSOLV 15
ZUMANDIMINE 81
ZYLET 89
ZYTIGA 30
PAGE 122 LAST UPDATED 04/2020