2018 Cigna-HealthSpring COMPREHENSIVE DRUG …...the drugs covered by Cigna-HealthSpring, please...

Plan coveredCigna-HealthSpring Achieve (HMO SNP)

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

2018 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 18085, Version 16 Y0036_18_55624a_Final_2k Populated Template 08042017

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What is the Cigna-HealthSpring Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna-HealthSpring in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2018 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic equivalent of the drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money on the generic equivalent or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a

60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2018. To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 51. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Achieve (HMO SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

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What are generic drugs?Cigna-HealthSpring covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

• Prior Authorization: Cigna-HealthSpring requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna-HealthSpring before you fill your prescriptions. If you don’t get approval, Cigna-HealthSpring may not cover the drug.

• Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover. For example, Cigna-HealthSpring allows for 1 tablet per day for BYSTOLIC 10MG. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna-HealthSpring requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna-HealthSpring will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring Drug List?” on this page for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to

coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna-HealthSpring. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.

• You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Cigna-HealthSpring Drug List?You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

• You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the

right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 51. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 7 along with the amount dispensed per the days supplied. (For example: BYSTOLIC 10MG QL 30/30; this means the drug BYSTOLIC 10MG is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

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What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. You will receive a Pharmacy Directory in your Welcome Kit after you enroll, or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Tier 6 is for Cigna-HealthSpring plans only and is referred to as Select Diabetic Drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna-HealthSpring is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and

some generic medications may be in Tier 3, Tier 4, Tier 5 or Tier 6. Keep in mind that the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

For more information

For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit www.CignaHealthSpring.com for information on which stores with preferred cost-shares are near you.

Service Area: Mid-Atlantic

H2108-029Cigna-HealthSpring Achieve (HMO SNP) District of Columbia, Montgomery and Prince George’s, Maryland; Kent, New Castle and Sussex, Delaware

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30/60/90 Days 30/60/90 Days 30/60/90 Days

Tier 1: Preferred Generic Drugs $4 / $8 / $8 $9 / $18 / $18 $9 / $18 / $18

Tier 2: Generic Drugs $15 / $30 / $30 $20 / $40 / $40 $20 / $40 / $40

Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $47 / $94 / $141

Tier 4: Non-Preferred Drugs $90 / $180 / $270 $95 / $190 / $285 $95 / $190 / $285

Tier 5: Specialty Tier 27% (30-day supply only)

27% (30-day supply only)


Tier 6: Select Diabetic Drugs Tier $5 / $10 / $10 $6 / $12 / $12 $6 / $12 / $12

Service Area: Maryland

H2108-030Cigna-HealthSpring Achieve (HMO SNP) Anne Arundel, Baltimore, Baltimore City and Harford, Maryland




30/60/90 Days 30/60/90 Days 30/60/90 Days









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My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. - 8 p.m. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring

Generic Available?

Generic Cost-Share

Service Area: Pennsylvania

H3949-024Cigna-HealthSpring Achieve (HMO SNP) Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania




30/60/90 Days 30/60/90 Days 30/60/90 Days









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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen/caffeine caps

3 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

3 PA QL(180/30)

butalbital/aspirin/caffeine caps 3 PA QL(180/30)esgic caps 3 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

3 PA QL(180/30)

Nonsteroidal Anti-inflammatory Drugscelecoxib caps 400mg 2 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

2 QL(60/30)

diclofenac potassium 2diclofenac sodium dr tbec 25mg, 50mg

2

diclofenac sodium dr tbec 75mg 1diclofenac sodium er 2diflunisal 2etodolac 2etodolac er 2fenoprofen calcium caps 400mg

2

fenoprofen calcium tabs 2flurbiprofen 2ibu tabs 600mg, 800mg 1ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

meclofenamate sodium 2meloxicam 1 QL(30/30)nabumetone 2naproxen dr 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

naproxen sodium tabs 275mg, 550mg

2

naproxen susp 2naproxen tabs 250mg 2naproxen tabs 375mg, 500mg 1oxaprozin 2piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingbuprenorphine hcl inj 4 QL(150/30)DURAMORPH 4 QL(180/30)fentanyl 4 QL(10/30)INFUMORPH 200 4 QL(200/30)INFUMORPH 500 4 QL(200/30)levorphanol tartrate 5 QL(120/30)methadone hcl conc 2 QL(500/30)methadone hcl inj 4 QL(150/30)methadone hcl intensol 2 QL(500/30)methadone hcl oral soln 10mg/5ml

2 QL(450/30)

methadone hcl oral soln 5mg/5ml

2 QL(600/30)

methadone hcl tabs 10mg 2 QL(120/30)methadone hcl tabs 5mg 2 QL(180/30)mitigo 4 QL(200/30)morphine sulfate er tbcr 3 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

4 QL(180/30)

XTAMPZA ER 3 QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine oral soln

2 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ibudone tabs 5mg; 200mg 3 QL

9



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hcl sr 3 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(336/365)

NICOTROL INHALER 4 QL(1008/90)NICOTROL NS 4 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 2gentamicin sulfate inj 4gentamicin sulfate oint 2gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2neomycin/polymyxin b sulfates 4paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

TOBREX OINT 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tramadol hcl 2 QL(240/30)tramadol hydrochloride/acetaminophen

3 QL(240/30)

vicodin es tabs 300mg; 7.5mg 3 QL(180/30)vicodin hp tabs 300mg; 10mg 3 QL(180/30)vicodin tabs 300mg; 5mg 3 QL(360/30)

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2lidocaine hcl gel 2lidocaine hcl inj 4lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 1lidocaine hcl viscous 1lidocaine oint 4 QL(120/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 4

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2Opioid Dependence Treatmentsbuprenorphine hcl subl 4 PA QL(90/30)buprenorphine hcl/naloxone hcl 3 PA QL(90/30)naltrexone hcl 2SUBOXONE 3 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 PA QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 PA QL(90/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metronidazole vaginal 2mupirocin crea 4mupirocin oint 2neo-polycin 2neo-polycin hc 2neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

nitrofurantoin 4nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

rosadan 2silver sulfadiazine 3ssd 3SYNERCID 5tigecycline 5trimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5vancomycin 4vancomycin hcl caps 125mg 4 QL(40/10)vancomycin hcl caps 250mg 4 QL(80/10)vancomycin hcl in dextrose 4vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg

4

VANCOMYCIN HYDROCHLORIDE INJ 250MG

4

vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZYLET 3Antibacterials, Otheralcohol prep pads 1baciim 4bacitracin inj 4bacitracin ophthalmic oint 2bacitracin/polymyxin b 2BACTROBAN NASAL 3chloramphenicol sodium succinate

1

clindacin etz pledgets 2clindacin-p 2clindamycin 4clindamycin hcl 2clindamycin hydrochloride 2clindamycin phosphate crea 2clindamycin phosphate external soln

2

clindamycin phosphate gel 2clindamycin phosphate in d5w 4clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

4

clindamycin phosphate lotn 2clindamycin phosphate swab 2clindamycin/sodium chloride 4colistimethate sodium 4daptomycin inj 500mg 5 B/D PAlincomycin hcl 4linezolid inj 4linezolid susr 5 QL(1800/30)linezolid tabs 5 QL(60/30)methenamine hippurate 2metronidazole crea 2metronidazole gel 2metronidazole in nacl 0.79% 4metronidazole inj 500mg/100ml; 0.79%, 5mg/ml

4

metronidazole lotn 2metronidazole tabs 1

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, OtherAZACTAM 4AZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam inj 1gm 4AZTREONAM INJ 2GM 5cefotetan 4ertapenem 4ertapenem sodium 4imipenem/cilastatin inj 500mg; 500mg

4

imipenem/cilastatin inj 250mg; 250mg

2

INVANZ 4meropenem 4meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

2

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

3

BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium inj 10gm, 1gm, 2gm

4

nafcillin sodium inj 2gm 5oxacillin sodium 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vandazole 2XIFAXAN TABS 550MG 5 PA QL(90/30)XIFAXAN TABS 200MG 4 PA QL(9/30)Beta-lactam, Cephalosporinscefaclor caps 2cefaclor er 2cefaclor susr 3cefadroxil 2CEFAZOLIN 4cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 2cefepime 4cefepime/dextrose 4cefixime 4cefotaxime sodium 4cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 2cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

4

cefuroxime axetil 2cefuroxime sodium 4cephalexin caps 250mg, 500mg 1cephalexin susr 2cephalexin tabs 2SUPRAX SUSR 500MG/5ML 3tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

QuinolonesAVELOX INJ 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er tb24 500mg; 0 2 QL(3/3)ciprofloxacin er tb24 1000mg; 0 2 QL(14/14)ciprofloxacin hcl ophthalmic soln

2

ciprofloxacin hcl tabs 100mg, 750mg

2

ciprofloxacin hcl tabs 250mg 1ciprofloxacin hydrochloride 1ciprofloxacin i.v.-in d5w 4ciprofloxacin susr 2levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl inj 4moxifloxacin hcl tabs 2 QL(30/30)moxifloxacin hydrochloride ophthalmic soln

3

ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 3BLEPHAMIDE S.O.P. 3sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 2sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

penicillin g potassium 4penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

pfizerpen inj 20mu, 5000000unit

4

piperacillin sodium/tazobactam sodium

4

piperacillin/tazobactam 4ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

4

MacrolidesAZASITE 3azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 2 QL(75/30)azithromycin susr 100mg/5ml 2 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2 QL(60/30)clarithromycin susr 2clarithromycin tabs 2 QL(42/14)e.e.s. 400 3ery 2ERY-TAB 3ERYPED 400 5ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2erythromycin base 4erythromycin ethylsuccinate 3erythromycin external soln 2erythromycin gel 2erythromycin oint 2erythromycin pads 2

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)FYCOMPA SUSP 4 QL(720/30)FYCOMPA TABS 4 QL(30/30)levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2magnesium sulfate in d5w 4 B/D PAroweepra 2roweepra xr tb24 750mg 2 QL(120/30)roweepra xr tb24 500mg 2 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

2 QL(90/30)

clonazepam odt tbdp 1mg 2 QL(120/30)clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

sulfatrim pediatric 1Tetracyclinesdemeclocycline hcl 2doxy 100 4doxycycline hyclate caps 1doxycycline hyclate tabs 100mg 1doxycycline hyclate tabs 20mg 2doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate caps 75mg

3 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2mondoxyne nl 2 QL(60/30)morgidox 1x100mg caps 1morgidox 1x50mg 1morgidox 2x100mg caps 1tetracycline hydrochloride 1

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 QL(30/30)

APTIOM TABS 600MG 5 QL(60/30)BRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lamotrigine odt 2topiramate 2TROKENDI XR CP24 100MG, 25MG, 50MG

4 QL(30/30)

TROKENDI XR CP24 200MG 5 QL(60/30)Sodium Channel AgentsBANZEL SUSP 5 PA QL(2400/30)BANZEL TABS 200MG 5 PA QL(60/30)BANZEL TABS 400MG 5 PA QL(240/30)carbamazepine 2carbamazepine er 2DILANTIN CAPS 30MG 3epitol 2fosphenytoin sodium 4oxcarbazepine 2PEGANONE 3phenytoin 2phenytoin infatabs 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PANAMZARIC C4PK 3 QL(56/365)NAMZARIC CP24 3 QL(30/30)Cholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

galantamine hydrobromide er 4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)diazepam rectal gel gel 20mg 3 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)GABITRIL TABS 16MG 4 QL(90/30)GABITRIL TABS 12MG 4 QL(120/30)ONFI SUSP 5 QL(480/30)ONFI TABS 20MG 5 QL(60/30)ONFI TABS 10MG 3 QL(60/30)phenobarbital elix 2 QL(1500/30)phenobarbital tabs 2 QL(120/30)primidone 2SABRIL PACK 5 PA QL(200/30)SABRIL TABS 5 PA QL(180/30)tiagabine hydrochloride tabs 4mg

4

tiagabine hydrochloride tabs 16mg

4 QL(90/30)


4 QL(120/30)


4 QL(240/30)

valproate sodium 4valproic acid 2vigabatrin 5 PA QL(200/30)Glutamate Reducing Agentsfelbamate susp 5felbamate tabs 4lamotrigine 2lamotrigine er 2

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Monoamine Oxidase InhibitorsEMSAM 5 QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 2tranylcypromine sulfate 2SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 10mg

1


1 QL(30/30)


1 QL(60/30)

desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine caps 10mg 2 QL(30/30)fluoxetine caps 20mg 2 QL(120/30)fluoxetine dr 2 QL(4/28)fluoxetine hcl caps 10mg 2 QL(30/30)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hcl oral soln 2 QL(600/30)fluoxetine hydrochloride tabs 10mg

2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 4 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 PA QL(60/30)memantine hcl tabs 5mg 2 PA QL(90/30)memantine hcl titration pak 2 PA QL(49/28)memantine hydrochloride er 3 PA QL(30/30)memantine hydrochloride oral soln

2 PA QL(300/30)

NAMENDA XR 3 PA QL(30/30)NAMENDA XR TITRATION PACK

3 PA QL(56/365)

Antidepressants

Antidepressants, Otherbupropion hcl er tb12 100mg, 200mg

3 QL(60/30)

bupropion hcl sr 3 QL(60/30)bupropion hcl tabs 100mg 3 QL(120/30)bupropion hcl xl 3 QL(30/30)bupropion hydrochloride tabs 75mg

3 QL(180/30)

maprotiline hcl 4 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 3 QL(60/30)nefazodone hydrochloride 3 QL(60/30)trazodone hydrochloride tabs 300mg

2

trazodone hydrochloride tabs 100mg, 150mg, 50mg

1

TRINTELLIX 4 QL(30/30) ST

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiemetics

Antiemetics, Othermeclizine hcl tabs 2phenadoz 2promethazine hcl supp 2promethazine hcl syrp 2 PApromethazine hcl tabs 2 PApromethazine hydrochloride tabs 50mg

2 PA

promethegan 2scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy AdjunctsALOXI 5 B/D PAaprepitant caps 40mg 3 B/D PA QL(1/30)aprepitant caps 125mg 3 B/D PA QL(2/28)aprepitant caps 80mg 3 B/D PA QL(4/28)aprepitant caps 3 B/D PA QL(6/28)dronabinol 4 PA QL(60/30)EMEND SUSR 3 B/D PA QL(6/28)granisetron hcl inj 4 B/D PAgranisetron hcl tabs 2 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

4

ondansetron hcl oral soln 2 B/D PA QL(450/30)ondansetron hcl tabs 24mg 1 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(90/30)ondansetron odt 1 B/D PA QL(90/30)PALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML

5 B/D PA

palonosetron hydrochloride inj 0.25mg/5ml

5 B/D PA

SANCUSO 5 QL(4/28)

Antifungals

AntifungalsABELCET 5 PAAMBISOME 5 PAamphotericin b 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluoxetine hydrochloride tabs 20mg

2 QL(120/30)

fluvoxamine maleate er 2 QL(60/30)fluvoxamine maleate tabs 25mg, 50mg

2 QL(30/30)

fluvoxamine maleate tabs 100mg

2 QL(90/30)

olanzapine/fluoxetine 4 QL(30/30)paroxetine hcl er tb24 12.5mg 2 QL(30/30)paroxetine hcl er tb24 25mg, 37.5mg

2 QL(60/30)

paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hcl tabs 20mg 1 QL(90/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

PAXIL SUSP 3 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)sertraline hcl tabs 50mg 2 QL(120/30)venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er cp24 75mg 2 QL(90/30)VIIBRYD 4 QL(30/30) STVIIBRYD STARTER PACK 4 QL(30/30) STTricyclicsamitriptyline hcl 3 PAamoxapine 2clomipramine hcl 3 PAdesipramine hcl 2imipramine hcl tabs 25mg, 50mg

3 PA

imipramine hydrochloride 3 PAnortriptyline hcl 2perphenazine/amitriptyline 4 PAprotriptyline hcl 2trimipramine maleate 3 PA

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nystop 2SPORANOX ORAL SOLN 5 PAterbinafine hcl tabs 1 QL(90/365)terconazole 2voriconazole inj 5 PAvoriconazole susr 5 PA QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4colchicine caps 3 QL(60/30)colchicine tabs 3 QL(120/30)MITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)ergotamine tartrate/caffeine 2 QL(40/28)migergot 5 QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2 QL(9/30)rizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 3 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

2 QL(4/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CANCIDAS 5 PAcaspofungin acetate 5 PAciclodan 2ciclopirox nail lacquer 2ciclopirox olamine 2ciclopirox sham 2ciclopirox susp 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole lozg 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 2fluconazole in nacl 4fluconazole susr 2fluconazole tabs 100mg, 200mg, 50mg

2

fluconazole tabs 150mg 1flucytosine 5griseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PAketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 2naftifine hydrochloride 2NAFTIN GEL 3NATACYN 3NOXAFIL SUSP 5 PA QL(600/30)NOXAFIL TBEC 5 PA QL(96/30)nyamyc 2nystatin 2nystatin/triamcinolone 4

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cyclophosphamide inj 1gm, 500mg

4 B/D PA

cyclophosphamide inj 2gm 5 B/D PAdacarbazine 4 B/D PAEVOMELA 5 PAGLEOSTINE 3HEXALEN 5ifosfamide inj 1gm, 3gm 4 B/D PAKISQALI FEMARA 200 DOSE 5 PA QL(49/28)KISQALI FEMARA 400 DOSE 5 PA QL(70/28)KISQALI FEMARA 600 DOSE 5 PA QL(91/28)LEUKERAN 3MATULANE 5melphalan hydrochloride 5 B/D PAMUSTARGEN 4 B/D PAthiotepa 4 PATREANDA INJ 100MG 5 B/D PATREANDA INJ 25MG 5 B/D PA QL(8/21)VALCHLOR 5 PA QL(60/30)YONDELIS 5 PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 2 QL(30/30)ERLEADA 5 PA QL(120/30)flutamide 2nilutamide 5 QL(60/30)XTANDI 5 PA QL(120/30)YONSA 5 PA QL(120/30)ZYTIGA TABS 500MG 5 PA QL(60/30)ZYTIGA TABS 250MG 5 PA QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA QL(28/28)

THALOMID CAPS 200MG 5 PA QL(56/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sumatriptan succinate refill inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide 2pyridostigmine bromide er 3REGONOL 4

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 3AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 2isoniazid inj 4isoniazid syrp 2isoniazid tabs 100mg 2isoniazid tabs 300mg 1PASER 3PRIFTIN 4pyrazinamide 2rifampin caps 2rifampin inj 4RIFATER 3SIRTURO 4 PA QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PABUSULFEX 5 B/D PAcarmustine 2 B/D PAcyclophosphamide caps 3 B/D PA

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antineoplastics, OtherABRAXANE 5 PAadriamycin inj 2mg/ml 2 B/D PAazacitidine 5 B/D PABELEODAQ 5 PAbleomycin sulfate 4 B/D PABORTEZOMIB 5 PA QL(14/21)BRAFTOVI 5 PA QL(180/30)carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

4 B/D PA

cisplatin 4 B/D PACOSMEGEN 5 B/D PAdactinomycin 5 B/D PAdaunorubicin hcl 4 B/D PAdaunorubicin hydrochloride 4 B/D PAdecitabine 5dexrazoxane 4 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl 2 B/D PAdoxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml 4 B/D PAERWINAZE 5 B/D PA QL(60/28)ETHYOL 5 B/D PAfludarabine phosphate inj 50mg 4 B/D PAFUSILEV 5HALAVEN 5 PAidarubicin hcl inj 10mg/10ml 5 B/D PAirinotecan 4 B/D PAirinotecan hcl 4 B/D PAirinotecan hydrochloride inj 40mg/2ml

4 B/D PA

ISTODAX (OVERFILL) 5 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiestrogens/ModifiersEMCYT 3FARESTON 5 QL(30/30)FASLODEX 5 B/D PA QL(30/30)SOLTAMOX 5tamoxifen citrate 2Antimetabolitesadrucil 4 B/D PAALIMTA 5 PAARRANON 4cladribine 4 B/D PAclofarabine 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 3ELITEK 5 B/D PAfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PAgemcitabine 4 B/D PAgemcitabine hcl inj 200mg, 2gm 4 B/D PAgemcitabine hcl inj 1gm 5 B/D PAgemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA

hydroxyurea 2LONSURF TABS 8.19MG; 20MG

5 PA QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA QL(100/28)

mercaptopurine 2NIPENT 5 B/D PAPURIXAN 5 PA QL(300/30)TABLOID 3VYXEOS 5 B/D PA

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VERZENIO 5 PA QL(60/30)vinblastine sulfate 4 B/D PAvincasar pfs 4 B/D PAvincristine sulfate 4 B/D PAvinorelbine tartrate inj 50mg/5ml

4 B/D PA

ZEJULA 5 PA QL(90/30)ZOLINZA 5 QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 2 QL(60/30)letrozole 2 QL(30/30)Enzyme Inhibitorsetoposide inj 3 B/D PAKYPROLIS 5 B/D PAtoposar 3 B/D PAtopotecan hcl inj 4mg 5Molecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 PA QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA QL(28/28)

AFINITOR TABS 10MG 5 PA QL(56/28)ALECENSA 5 PA QL(240/30)ALIQOPA 5 PA QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA QL(30/30)

ALUNBRIG TABS 30MG 5 PA QL(180/30)ALUNBRIG TBPK 5 PA QL(60/365)BOSULIF TABS 400MG, 500MG

5 PA QL(30/30)

BOSULIF TABS 100MG 5 PA QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CALQUENCE 5 PA QL(60/30)CAPRELSA TABS 300MG 5 PA QL(30/30)CAPRELSA TABS 100MG 5 PA QL(60/30)COMETRIQ KIT 5 PA QL(56/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JEVTANA 5 PAKISQALI 5 PA QL(63/28)LARTRUVO 5 PAleucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4

leucovorin calcium tabs 2levoleucovorin calcium inj 175mg/17.5ml

5

levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

5

lipodox 50 5 B/D PALYNPARZA TABS 5 PA QL(120/30)MEKTOVI 5 PA QL(180/30)mesna 2 B/D PAMESNEX TABS 5mitomycin inj 40mg 5 B/D PAmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 2 B/D PANERLYNX 5 PA QL(180/30)NINLARO 5 PA QL(3/28)ODOMZO 5 PA QL(30/30)oxaliplatin inj 100mg 5 B/D PAoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml

4 B/D PA

PORTRAZZA 5 PA QL(100/21)PROLEUKIN 5 B/D PAromidepsin 5 PARUBRACA 5 PA QL(120/30)RYDAPT 5 PA QL(224/28)SYLATRON 5 PA QL(4/28)SYNRIBO 5 PA QL(28/28)TRISENOX 4 B/D PAVELCADE 5 PA QL(14/21)VENCLEXTA STARTING PACK 5 PA QL(84/365)VENCLEXTA TABS 100MG 5 PA QL(120/30)VENCLEXTA TABS 50MG 4 PA QL(30/30)VENCLEXTA TABS 10MG 4 PA QL(60/30)

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TARCEVA TABS 100MG, 150MG

5 PA QL(30/30)

TARCEVA TABS 25MG 5 PA QL(60/30)TASIGNA CAPS 150MG, 200MG

5 PA QL(112/28)

TASIGNA CAPS 50MG 5 PA QL(420/30)temsirolimus 5 B/D PA QL(4/28)TIBSOVO 5 PA QL(60/30)TYKERB 5 PA QL(180/30)VOTRIENT 5 PA QL(120/30)XALKORI 5 PA QL(60/30)ZALTRAP 5 PA QL(40/28)ZELBORAF 5 PA QL(240/30)ZYDELIG 5 PA QL(60/30)ZYKADIA 5 PA QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PABAVENCIO 5 PABESPONSA 5 PACYRAMZA 5 PADARZALEX 5 PAEMPLICITI 5 PAERBITUX 5 PAGAZYVA 5 PAHERCEPTIN INJ 440MG 5 PAHERCEPTIN INJ 150MG 5 B/D PAIMFINZI 5 PAKADCYLA 5 PAKEYTRUDA 5 PAMYLOTARG 5 PAOPDIVO INJ 240MG/24ML 5 PA QL(48/28)OPDIVO INJ 100MG/10ML, 40MG/4ML

5 PA QL(80/28)

PERJETA 5 PAPOTELIGEO 5 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ KIT 20MG 5 PA QL(84/28)COMETRIQ KIT 5 PA QL(112/28)COTELLIC 5 PA QL(63/28)ERIVEDGE 5 PA QL(28/28)FARYDAK 5 PA QL(6/21)GILOTRIF 5 PA QL(30/30)IBRANCE 5 PA QL(21/28)ICLUSIG TABS 45MG 5 PA QL(30/30)ICLUSIG TABS 15MG 5 PA QL(60/30)IDHIFA 5 PA QL(30/30)imatinib mesylate 5 PA QL(60/30)IMBRUVICA CAPS 70MG 5 PA QL(30/30)IMBRUVICA CAPS 140MG 5 PA QL(120/30)IMBRUVICA TABS 5 PA QL(30/30)INLYTA 5 PA QL(120/30)IRESSA 5 PA QL(30/30)JAKAFI 5 PA QL(60/30)LENVIMA 10 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 12MG DAILY DOSE 5 PA QL(90/30)LENVIMA 14 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 4 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 8 MG DAILY DOSE 5 PA QL(60/30)LYNPARZA CAPS 5 PA QL(448/28)MEKINIST TABS 2MG 5 PA QL(30/30)MEKINIST TABS 0.5MG 5 PA QL(90/30)NEXAVAR 5 PA QL(120/30)SPRYCEL 5 PA QL(30/30)STIVARGA 5 PASUTENT 5 PA QL(28/28)TAFINLAR 5 PA QL(120/30)TAGRISSO 5 PA QL(30/30)

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otheramantadine hcl 2entacapone 4 QL(240/30)tolcapone 5Dopamine AgonistsAPOKYN 5 PA QL(60/30)bromocriptine mesylate 2NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole hcl 2Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 2carbidopa/levodopa 2carbidopa/levodopa er 2carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

3

RYTARY 4 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 3 QL(30/30)selegiline hcl 2

Antipsychotics

1st Generation/Typicalchlorpromazine hcl inj 4chlorpromazine hcl tabs 2compro 2fluphenazine decanoate 4fluphenazine hcl conc 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RITUXAN 5 PARITUXAN HYCELA 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 PAVECTIBIX 5 PAYERVOY INJ 50MG/10ML 5 PAYERVOY INJ 200MG/40ML 5 PA QL(80/21)Retinoidsbexarotene 5PANRETIN 5TARGRETIN GEL 5 QL(60/30)tretinoin caps 5

Antiparasitics

AnthelminticsALBENZA 4BILTRICIDE 4ivermectin 2praziquantel 4AntiprotozoalsALINIA SUSR 3 QL(150/30)ALINIA TABS 5 QL(20/30)atovaquone 4atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 3 QL(24/30)DARAPRIM 5 QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3PRIMAQUINE PHOSPHATE 3quinine sulfate 4 QL(42/7)Pediculicides/Scabicideslindane 2malathion 4permethrin 2

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/60)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 QL(0.5/28)


5 QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 QL(30/30) ST

LATUDA TABS 80MG 5 QL(60/30) STNUPLAZID CAPS 5 PA QL(30/30)NUPLAZID TABS 10MG 5 PA QL(30/30)NUPLAZID TABS 17MG 5 PA QL(60/30)olanzapine inj 4 QL(30/30)olanzapine odt 3 QL(30/30)olanzapine tabs 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluphenazine hcl elix 2fluphenazine hcl inj 4fluphenazine hcl tabs 1mg 1fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2

haloperidol conc 2haloperidol decanoate 4haloperidol lactate 4haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1

haloperidol tabs 10mg, 20mg 2loxapine caps 25mg, 50mg 2loxapine caps 10mg, 5mg 2 QL(120/30)loxapine succinate caps 25mg, 50mg

2

loxapine succinate caps 10mg, 5mg

2 QL(120/30)

perphenazine 2pimozide 2prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate tabs 10mg

1

prochlorperazine maleate tabs 5mg

2

thioridazine hcl 2thiothixene caps 10mg, 1mg, 5mg

2

thiothixene caps 2mg 1trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA 5 QL(1/28)aripiprazole odt 5 QL(60/30)aripiprazole oral soln 3 QL(900/30)aripiprazole tabs 3 QL(30/30)ARISTADA INITIO 5 QL(4.8/365)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 10mg 1baclofen tabs 20mg, 5mg 2dantrolene sodium 2tizanidine hcl 2

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5FOSCAVIR 4ganciclovir inj 500mg, 500mg/10ml

4 B/D PA

valganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 3Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5 QL(30/30)BARACLUDE ORAL SOLN 3 QL(630/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 18MU, 6000000UNIT/ML

4

INTRON A INJ 10MU, 10MU/ML, 50MU

5

lamivudine tabs 100mg 2Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA QL(28/28)HARVONI 5 PA QL(28/28)VOSEVI 5 PA QL(30/30)Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA QL(2/28)PEGASYS INJ 180MCG/ML 5 PA QL(4/28)PEGASYS PROCLICK 5 PA QL(2/28)ribavirin caps 4 QL(168/28)ribavirin tabs 4 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 QL(30/30)GENVOYA 5 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

paliperidone er tb24 1.5mg, 3mg

2 QL(30/30) ST

paliperidone er tb24 6mg 2 QL(60/30) STpaliperidone er tb24 9mg 5 QL(30/30) STquetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

3 QL(60/30)

REXULTI 5 QL(30/30)RISPERDAL CONSTA INJ 50MG

5 QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone m-tab 3 QL(60/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

3 QL(60/30)

risperidone odt tbdp 4mg 3 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 3 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

4

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine odt tbdp 200mg 5 QL(120/30)clozapine tabs 25mg, 50mg 3clozapine tabs 200mg 3 QL(120/30)clozapine tabs 100mg 3 QL(270/30)VERSACLOZ 4 QL(540/30)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

abacavir tabs 4 QL(60/30)abacavir/lamivudine 5 QL(30/30)CIMDUO 5 QL(30/30)DESCOVY 5 QL(30/30)didanosine 2 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)tenofovir disoproxil fumarate 5 QL(30/30)TRIUMEQ 5 QL(30/30)TRUVADA 5 QL(30/30)VIDEX EC CPDR 125MG 4 QL(30/30)VIDEX PEDIATRIC 3 QL(1200/30)VIREAD POWD 5 QL(240/30)VIREAD TABS 5 QL(30/30)ZERIT ORAL SOLN 3 QL(2400/30)ZIAGEN ORAL SOLN 3 QL(960/30)zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 QL(30/30)FUZEON 5 QL(60/30)ISENTRESS HD 5 QL(60/30)SELZENTRY ORAL SOLN 5 QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 QL(60/30)

SELZENTRY TABS 300MG 5 QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ISENTRESS CHEW 100MG 5 QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS PACK 5 QL(180/30)ISENTRESS TABS 5 QL(60/30)JULUCA 5 QL(30/30)TIVICAY TABS 50MG 5 QL(60/30)TIVICAY TABS 10MG, 25MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 QL(30/30)EDURANT 5 QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 QL(30/30)INTELENCE TABS 100MG, 200MG

5 QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 2 QL(30/30)nevirapine er tb24 100mg 2 QL(90/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 QL(30/30)RESCRIPTOR TABS 200MG 3 QL(180/30)RESCRIPTOR TABS 100MG 3 QL(270/30)STRIBILD 5 QL(30/30)SUSTIVA CAPS 200MG 5 QL(60/30)SUSTIVA CAPS 50MG 3 QL(90/30)SUSTIVA TABS 5 QL(30/30)SYMFI 5 QL(30/30)SYMFI LO 5 QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine/zidovudine

5 QL(60/30)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIRACEPT TABS 625MG 5 QL(120/30)VIRACEPT TABS 250MG 5 QL(270/30)Anti-influenza Agentsoseltamivir phosphate caps 45mg, 75mg

3 QL(56/365)

oseltamivir phosphate caps 30mg

3 QL(112/365)

oseltamivir phosphate susr 3 QL(700/365)rimantadine hcl 2TAMIFLU CAPS 45MG, 75MG 4 QL(56/365)TAMIFLU CAPS 30MG 4 QL(112/365)TAMIFLU SUSR 3 QL(700/365)Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 4 B/D PAacyclovir susp 2acyclovir tabs 2DENAVIR 5 QL(5/30)famciclovir 2 QL(60/30)trifluridine 2valacyclovir hcl 2 QL(30/30)valacyclovir hydrochloride 2 QL(30/30)ZOVIRAX CREA 4 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl tabs 10mg, 5mg 1buspirone hcl tabs 15mg, 30mg, 7.5mg

2

doxepin hcl 3 PABenzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam odt tbdp 2mg 2 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TROGARZO 5 B/D PATYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 QL(120/30)APTIVUS ORAL SOLN 5 QL(285/28)atazanavir caps 300mg 5 QL(30/30)atazanavir caps 200mg 5 QL(60/30)atazanavir sulfate caps 300mg 5 QL(30/30)atazanavir sulfate caps 200mg 5 QL(60/30)atazanavir sulfate caps 150mg 4 QL(30/30)CRIXIVAN CAPS 400MG 3 QL(180/30)CRIXIVAN CAPS 200MG 3 QL(270/30)EVOTAZ 5 QL(30/30)fosamprenavir calcium 5 QL(120/30)INVIRASE CAPS 5 QL(300/30)INVIRASE TABS 5 QL(120/30)KALETRA ORAL SOLN 4 QL(480/30)KALETRA TABS 100MG; 25MG

4 QL(300/30)

KALETRA TABS 200MG; 50MG

5 QL(120/30)

LEXIVA SUSP 4 QL(1575/28)LEXIVA TABS 5 QL(120/30)lopinavir/ritonavir 4 QL(480/30)NORVIR CAPS 4 QL(360/30)NORVIR ORAL SOLN 4 QL(480/30)NORVIR PACK 4 QL(360/30)NORVIR TABS 4 QL(360/30)PREZCOBIX 5 QL(30/30)PREZISTA SUSP 5 QL(400/30)PREZISTA TABS 800MG 5 QL(30/30)PREZISTA TABS 600MG 5 QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ CAPS 150MG, 300MG

5 QL(30/30)

REYATAZ CAPS 200MG 5 QL(60/30)REYATAZ PACK 5 QL(180/30)ritonavir 4 QL(360/30)SYMTUZA 5 QL(30/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide er tb24 2.5mg 6 QL(240/30)glipizide tabs 5mg 6 QL(60/30)glipizide tabs 10mg 6 QL(120/30)glipizide xl tb24 10mg 6 QL(60/30)glipizide xl tb24 5mg 6 QL(120/30)glipizide xl tb24 2.5mg 6 QL(240/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

6 QL(120/30)

glipizide/metformin hcl tabs 2.5mg; 250mg

6 QL(240/30)

GLYXAMBI 4 QL(30/30)INVOKAMET 6 QL(60/30)INVOKAMET XR 6 QL(60/30)INVOKANA 6 QL(30/30)JANUMET 6 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

6 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

6 QL(60/30)

JANUVIA 6 QL(30/30)JARDIANCE 4 QL(30/30)JENTADUETO 6 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

6 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

6 QL(60/30)

metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet)

6 QL(60/30)

metformin hcl er tb24 750mg (generic for Glucophage XR)

6 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

6 QL(120/30)

metformin hcl tabs 1000mg 6 QL(60/30)metformin hcl tabs 850mg 6 QL(90/30)metformin hydrochloride oral soln

6 QL(750/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam inj 5mg/ml 2diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate caps 300mg 1lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 6 QL(90/30)BYDUREON 6 QL(4/28)BYDUREON BCISE 6 QL(4/28)BYDUREON PEN 6 QL(4/28)BYETTA INJ 5MCG/0.02ML 6 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 6 QL(2.4/30)CYCLOSET 4 QL(180/30)FARXIGA 6 QL(30/30)glimepiride tabs 4mg 6 QL(60/30)glimepiride tabs 2mg 6 QL(120/30)glimepiride tabs 1mg 6 QL(240/30)glipizide er tb24 10mg 6 QL(60/30)glipizide er tb24 5mg 6 QL(120/30)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN 70/30 KWIKPEN 6HUMULIN N 6HUMULIN N KWIKPEN 6HUMULIN R 6HUMULIN R U-500 (CONCENTRATED)

6

HUMULIN R U-500 KWIKPEN 6LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3SOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 4 QL(74/30)ELIQUIS TABS 2.5MG 4 QL(60/30)ELIQUIS TABS 5MG 4 QL(74/30)enoxaparin sodium inj 30mg/0.3ml

4 QL(9/90)

enoxaparin sodium inj 40mg/0.4ml

4 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

4 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

4 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

4 QL(30/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/90)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metformin hydrochloride tabs 500mg

6 QL(150/30)

miglitol 6 QL(90/30)nateglinide 6 QL(90/30)OZEMPIC 6 QL(3/28)pioglitazone hcl 6 QL(30/30)pioglitazone hcl/metformin hcl 6 QL(90/30)repaglinide tabs 0.5mg, 1mg 6 QL(120/30)repaglinide tabs 2mg 6 QL(240/30)RIOMET 6 QL(750/30)SYMLINPEN 120 5 PA QL(10.8/28)SYMLINPEN 60 6 PA QL(6/30)SYNJARDY 4 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

4 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

4 QL(60/30)

TRADJENTA 6 QL(30/30)TRULICITY 6 QL(2/28)VICTOZA 6 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

6 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

6 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 6HUMALOG JUNIOR KWIKPEN 6HUMALOG KWIKPEN 6HUMALOG MIX 50/50 6HUMALOG MIX 50/50 KWIKPEN

6

HUMALOG MIX 75/25 6HUMALOG MIX 75/25 KWIKPEN

6

HUMULIN 70/30 6

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARANESP ALBUMIN FREE INJ 300MCG/0.6ML

5 PA QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA QL(4/28)

LEUKINE INJ 250MCG 5 PAMOZOBIL 5 QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

PROMACTA 5 PA QL(30/30)ZARXIO 5 PAHemostasis Agentstranexamic acid inj 2tranexamic acid tabs 2 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 4 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)prasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 0.3mg 2clonidine hcl tabs 0.1mg, 0.2mg 1midodrine hcl 2Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

5

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

4

heparin sodium/d5w 4heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

heparin sodium/sodium chloride 0.9% premix

4

jantoven 1PRADAXA 3 QL(60/30)SAVAYSA 4 QL(30/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 20MG 3 QL(30/30)XARELTO TABS 15MG 3 QL(60/30)XARELTO TABS 10MG 3 QL(90/90)Blood Formation Modifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)


4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA QL(1/21)


5 PA QL(1.2/28)


5 PA QL(1.6/28)


5 PA QL(2/28)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enalapril maleate/hydrochlorothiazide

2 QL(60/30)

fosinopril sodium 2 QL(60/30)fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 2moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

2 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

2 QL(60/30)

perindopril erbumine 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 2 QL(30/30)trandolapril tabs 2mg, 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 4amiodarone hcl tabs 2dofetilide 3 QL(60/30)flecainide acetate 2lidocaine hcl inj 4mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2propafenone hcl 2propafenone hcl er cp12 225mg, 325mg

4

propafenone hydrochloride er cp12 425mg

4

quinidine sulfate 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prazosin hcl 2Angiotensin II Receptor AntagonistsBENICAR 4 QL(30/30) STBENICAR HCT 4 QL(30/30) STcandesartan cilexetil 2 QL(30/30)candesartan cilexetil/hydrochlorothiazide

2 QL(30/30)

EDARBI 4 STEDARBYCLOR 4 STENTRESTO 3 QL(60/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg 1 QL(30/30)losartan potassium tabs 25mg, 50mg

1 QL(60/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 4 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

4 QL(30/30)

telmisartan 2 QL(30/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide 2 QL(30/30)valsartan 2 QL(30/30)valsartan/hydrochlorothiazide 2 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

2 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

2 QL(60/30)

captopril tabs 100mg, 50mg 2captopril tabs 12.5mg, 25mg 2 QL(90/30)captopril/hydrochlorothiazide 2enalapril maleate 2 QL(60/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propranolol hcl tabs 60mg 2propranolol hcl tabs 10mg, 20mg, 40mg, 80mg

1

propranolol hydrochloride tabs 60mg

2

propranolol/hydrochlorothiazide 2timolol maleate tabs 4Calcium Channel Blocking Agentsafeditab cr 3 QL(60/30)amlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

2 QL(60/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/olmesartan medoxomil

4 QL(30/30)

amlodipine/valsartan/hctz 2 QL(30/30)AZOR 4 QL(30/30) STcartia xt 2dilt-xr 2diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg

2

diltiazem hcl er tb24 2diltiazem hcl inj 4diltiazem hcl tabs 2felodipine er 2 QL(60/30)isradipine 2matzim la 2nicardipine hcl caps 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sorine 2sotalol hcl 2sotalol hcl (af) 2sotalol hcl af 2sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride tabs 120mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 1atenolol/chlorthalidone 1betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)BYVALSON 3 QL(30/30)carvedilol 1carvedilol phosphate 3 QL(30/30)COREG CR 3 QL(30/30)labetalol hcl inj 4labetalol hcl tabs 2metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 3nadolol/bendroflumethiazide 3 QL(30/30)pindolol 1propranolol hcl er 3propranolol hcl inj 4propranolol hcl oral soln 2

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide inj 4bumetanide tabs 0.5mg, 1mg 1bumetanide tabs 2mg 2ethacrynate sodium 4furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 1spironolactone tabs 25mg 1spironolactone tabs 100mg, 50mg

2

spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 2hydrochlorothiazide 1indapamide 1metolazone 2Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

2 QL(30/30)

fenofibrate micronized caps 67mg

2 QL(60/30)

fenofibrate tabs 145mg, 160mg 4 QL(30/30)fenofibrate tabs 48mg, 54mg 4 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nicardipine hcl inj 4nifedipine er tb24 90mg 3 QL(30/30)nifedipine er tb24 30mg, 60mg 3 QL(60/30)nimodipine 4nisoldipine er tb24 20mg, 30mg, 40mg

2

nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg

2 QL(30/30)

taztia xt cp24 120mg, 180mg, 240mg, 300mg

2

verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl inj 4verapamil hcl sr cp24 360mg 2 QL(30/30)verapamil hcl tabs 40mg 2verapamil hcl tabs 120mg, 80mg

1

Cardiovascular Agents, Otheratropine sulfate inj 0.5mg/5ml 4CORLANOR 4 PA QL(60/30)DEMSER 5digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 4 PAdigoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PANORTHERA CAPS 100MG 5 PA QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA QL(180/30)

pentoxifylline er 2PRALUENT 5 PARANEXA 3 QL(60/30)TEKTURNA 3 QL(30/30)TEKTURNA HCT 3 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2nitroglycerin transdermal 2 QL(30/30)

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

3 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

3 QL(60/30)

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 4 QL(30/30) STLIVALO 3 QL(30/30) STlovastatin tabs 40mg 2 QL(60/30)lovastatin tabs 10mg, 20mg 1 QL(30/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 2 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 2ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 4 QL(120/30)prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)WELCHOL 3ZETIA 4 QL(30/30) STVasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 3 QL(180/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYRICA CR TB24 165MG, 82.5MG

3 QL(90/30)

Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AVONEX 5 PA QL(4/28)AVONEX PEN 5 PA QL(4/28)BETASERON 5 PA QL(14/28)COPAXONE INJ 40MG/ML 5 PA QL(12/28)COPAXONE INJ 20MG/ML 5 PA QL(30/30)GILENYA 5 PA QL(30/30)REBIF 5 PA QL(6/28)REBIF REBIDOSE 5 PA QL(6/28)REBIF REBIDOSE TITRATION PACK

5 PA QL(4.2/28)

REBIF TITRATION PACK 5 PA QL(4.2/28)TECFIDERA CPDR 120MG 5 PA QL(14/30)TECFIDERA CPDR 240MG 5 PA QL(60/30)TECFIDERA STARTER PACK 5 PA QL(120/365)TYSABRI 5 PA QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 2paroex 1periogard 1pilocarpine hcl tabs 2pilocarpine hydrochloride 2triamcinolone acetonide dental paste

2

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 2avita 2 PA QL(45/30)calcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)calcipotriene oint 4 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


2 QL(90/30)


2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

2 QL(60/30)

dextroamphetamine sulfate tabs 10mg

2 QL(180/30)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl 2 QL(60/30)metadate er 3 QL(90/30)methylphenidate hydrochloride er tb24 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

3 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

3 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tbcr 36mg

3 QL(60/30)


3 QL(90/30)


3 QL(120/30)

methylphenidate hydrochloride tabs

3 QL(90/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)NUEDEXTA 3 QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA QL(90/30)tetrabenazine tabs 25mg 5 PA QL(120/30)Fibromyalgia AgentsLYRICA CR TB24 330MG 3 QL(60/30)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZYCLARA PUMP CREA 2.5% 5 QL(15/30)ZYCLARA PUMP CREA 3.75% 5 QL(56/30)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN 4 B/D PAAMINOSYN 7%/ELECTROLYTES

4 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN II 4 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN M 4 B/D PAAMINOSYN-HBC 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PAAMINOSYN-RF 4 B/D PACARBAGLU 5 PACLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)claravis 2curity gauze pads 2”x2” 2diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium transdermal soln

4 QL(1050/30)

doxepin hydrochloride 2ELIDEL 3 QL(100/90)erythromycin/benzoyl peroxide 2fluorouracil crea 5% 3fluorouracil crea 0.5% 5fluorouracil external soln 2imiquimod 2 QL(12/30)imiquimod pump 5 QL(56/30)isotretinoin 2methoxsalen 5myorisan 2PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)podofilox 2REGRANEX 5 PA QL(15/30)SANTYL 3selenium sulfide lotn 1tacrolimus oint 2 QL(100/90)tazarotene 4 QL(120/30)TAZORAC CREA 4 QL(120/30)TAZORAC GEL 4 QL(100/30)tretinoin crea 2 PA QL(45/30)tretinoin gel 2 PA QL(45/30)tretinoin microsphere 4 PAtretinoin microsphere pump gel 0.1%

4 PA

zenatane 2ZYCLARA 5 QL(56/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAkcl 0.075%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.2% 4 B/D PAkcl 0.15%/d5w/nacl 0.225% 4 B/D PAkcl 0.15%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.9% 4 B/D PAkcl 0.3%/d5w/nacl 0.45% 4 B/D PAkcl 0.3%/d5w/nacl 0.9% 4 B/D PAklor-con 2klor-con 10 1klor-con 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML

4 B/D PA

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

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PApotassium chloride cr 1potassium chloride er cpcr 2potassium chloride er tbcr 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX E 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX E 5%/DEXTROSE 25%

4 B/D PA

CLINIMIX N14G30E 4 B/D PACLINIMIX N9G15E 4 B/D PACLINISOL SF 15% 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PAdextrose 10%/nacl 0.2% 4 B/D PAdextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4dextrose 5%/lactated ringers 4 B/D PAdextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml

4 B/D PA

PROCALAMINE 4 B/D PAPROSOL 4 B/D PAringers injection 4 B/D PAsodium bicarbonate inj 4sodium bicarbonate partial fill 4sodium chloride 0.45% 4sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4

sodium fluoride chew 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAElectrolyte/Mineral/Metal ModifiersCHEMET 5CUPRIMINE 5DEPEN TITRATABS 5JADENU 5JADENU SPRINKLE 5kionex 3SAMSCA TABS 15MG 5 PA QL(30/30)SAMSCA TABS 30MG 5 PA QL(60/30)sodium polystyrene sulfonate powd

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 2potassium chloride sr 1potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

4 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L

4 B/D PA

potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 2PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Gastrointestinal Agents, Othercromolyn sodium conc 2diphenoxylate/atropine 2GATTEX 5 PA QL(30/30)loperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 2OSMOPREP 3RELISTOR INJ 8MG/0.4ML 5 PA QL(11.2/28)RELISTOR INJ 12MG/0.6ML 5 PA QL(16.8/28)TRULANCE 4 QL(30/30)ursodiol 3Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 4famotidine premixed 4famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl caps 2ranitidine hcl inj 4ranitidine hcl syrp 2ranitidine hcl tabs 1Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

alosetron hydrochloride tabs 1mg

5 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

3

sps 3SYPRINE 5trientine hydrochloride 5VELTASSA 3Phosphate BindersAURYXIA 4 QL(360/30)calcium acetate caps 2calcium acetate tabs 667mg 2PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl caps 1dicyclomine hcl oral soln 2dicyclomine hydrochloride 1ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NAGLAZYME 5 PAORFADIN 5sodium phenylbutyrate 5 PAVPRIV 5 PAZAVESCA 5 QL(90/30)ZENPEP 3

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 4 QL(30/30)ENABLEX 4 QL(30/30) STflavoxate hcl 2MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

2 QL(30/30)

oxybutynin chloride er tb24 15mg

2 QL(60/30)

oxybutynin chloride syrp 1 QL(600/30)oxybutynin chloride tabs 1 QL(120/30)tolterodine tartrate 3 QL(60/30)tolterodine tartrate er 3 QL(30/30)VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)doxazosin mesylate tabs 1mg, 2mg, 4mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

finasteride tabs 5mg 2 QL(30/30)tamsulosin hcl 2 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

1

terazosin hcl caps 10mg 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lactulose oral soln 2MOVIPREP 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 powd 2SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3sucralfate 2Proton Pump Inhibitorsesomeprazole magnesium 3 QL(60/30)esomeprazole sodium 4omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 1 QL(60/30)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN 5 PAALDURAZYME 5 PABUPHENYL TABS 5 PACEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5 PAFABRAZYME 5 B/D PAKUVAN 5 PALUMIZYME 5 PAmiglustat 5 QL(90/30)

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dexamethasone oral soln 2dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

fludrocortisone acetate 2fluocinolone acetonide body 2fluocinolone acetonide crea 2fluocinolone acetonide external soln

1

fluocinolone acetonide oint 2fluocinolone acetonide scalp 2fluocinonide crea 0.05% 2fluocinonide crea 0.1% 4fluocinonide external soln 2fluocinonide gel 2fluocinonide oint 2fluticasone propionate crea 2fluticasone propionate oint 2halobetasol propionate 2hydrocortisone butyrate (lipid) 2hydrocortisone butyrate (lipophilic)

2

hydrocortisone butyrate crea 2hydrocortisone butyrate external soln

2

hydrocortisone butyrate oint 2hydrocortisone external crea 1hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 1hydrocortisone tabs 2hydrocortisone valerate 2MEDROL TABS 2MG 3methylprednisolone acetate inj 40mg/ml, 80mg/ml

4

methylprednisolone dose pack 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Genitourinary Agents, Otherbethanechol chloride 2ELMIRON 4phenazopyridine hydrochloride 2phenazopyridine hydrocholride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ala-cort crea 1% 1alclometasone dipropionate 2augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone valerate crea 2betamethasone valerate foam 3betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate emollient crea

2

clobetasol propionate emollient foam

4

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate oint 2clobetasol propionate sham 2clodan 2cortisone acetate 4DEPO-MEDROL INJ 20MG/ML 4desonide lotn 2desonide oint 2desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone elix 2dexamethasone intensol 2

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 4 PAdesmopressin acetate inj 4desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2GENOTROPIN 5 PAGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

INCRELEX 4 PANOVAREL 4 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL

4 PA

STIMATE 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PAoxandrolone tabs 10mg 5 PA QL(60/30)oxandrolone tabs 2.5mg 3 PA QL(120/30)Androgensdanazol caps 100mg, 200mg 4danazol caps 50mg 3testosterone cypionate 4testosterone enanthate 4 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump 4 PA QL(300/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methylprednisolone sodiumsuccinate inj 125mg, 40mg

4

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone 2prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisone intensol 2prednisone oral soln 2prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 1procto-med hc 1procto-pak 1proctosol hc 1proctozone-hc 1SOLU-CORTEF 4texacort 3triamcinolone acetonide crea 0.025%, 0.5%

2

triamcinolone acetonide crea 0.1%

1

triamcinolone acetonide inj 40mg/ml

2

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2trianex 5triderm crea 0.1% 1TRIPTODUR 5 PA QL(1/168)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

estradiol pttw 2 PA QL(8/28)estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol valerate 4ESTRING 3 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2FEMRING 3 QL(1/90)femynor 2fyavolv tabs 2.5mcg; 0.5mg 3 PAintrovale 2 QL(91/91)isibloom 2jevantique lo 3 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2kariva 2kelnor 1/35 2kelnor 1/50 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EstrogensALORA 3 PA QL(8/28)altavera 2alyacen 1/35 2alyacen 7/7/7 2amethia 2 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 2ashlyna 2 QL(91/91)aubra 2aviane 2balziva 2bekyree 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2cesia 2chateal 2cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2dasetta 1/35 2dasetta 7/7/7 2daysee 2 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 2DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol 2elinest 2emoquette 2enpresse-28 2enskyce 2estarylla 2estradiol crea 4

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 3 PA QL(30/30)previfem 2quasense 2 QL(91/91)reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2trinessa 2trivora-28 2tydemy 2velivet 2vienva 2viorele 2vyfemla 2vylibra 2wera 2yuvafem 4 QL(18/28)zenchent 2zovia 1/35e 2Progesterone Agonists/AntagonistsELLA 3MAKENA 5 PAProgestinscamila 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levora 0.15/30-28 2low-ogestrel 2lutera 2marlissa 2melodetta 24 fe 2MENEST 3 PAMENOSTAR 3 PA QL(4/28)mibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mili 2MINIVELLE 3 PA QL(8/28)mono-linyah 2myzilra 2necon 0.5/35-28 2necon 7/7/7 2norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

3 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2ogestrel 2orsythia 2philith 2pimtrea 2pirmella 1/35 2pirmella 7/7/7 2portia-28 2

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID 3

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2 QL(16/28)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA QL(4/365)leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate inj 500mcg/ml

5 PA

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA

SANDOSTATIN LAR DEPOT 5 PASIGNIFOR 5 PA QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA QL(0.5/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 2hydroxyprogesterone caproate 5 PAincassia 2jencycla 2jolivette 2lyza 2MAKENA 5 PAmedroxyprogesterone acetate inj 150mg/ml

4 QL(1/90)

medroxyprogesterone acetate inj 150mg/ml

2 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

3 PA

megestrol acetate tabs 3 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone caps 2sharobel 2Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG

3

levoxyl tabs 100mcg, 112mcg, 175mcg

3

liothyronine sodium inj 4liothyronine sodium tabs 2SYNTHROID 3

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

5 PA QL(2/28)

HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML

5 PA QL(4/28)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ

5 PA QL(4/365)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN 5 PA QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML

5 PA QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

5 PA QL(6/365)

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML

5 PA QL(8/365)

KINERET 5 PA QL(20.1/30)methotrexate sodium 4methotrexate tabs 2mycophenolate mofetil caps 2 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PAmycophenolate mofetil tabs 2 PAmycophenolic acid dr 2 PANULOJIX 5 PA QL(150/30)PROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PAREMICADE 5 PARENFLEXIS 5 PASANDIMMUNE ORAL SOLN 4 PAsirolimus 4 PAtacrolimus caps 2 PATORISEL 5 B/D PA QL(4/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SOMAVERT 5 PA QL(30/30)SYNAREL 5 PATRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

Immunological Agents

Angioedema AgentsCINRYZE 5 PA QL(100/30)FIRAZYR 5 PA QL(18/30)RUCONEST 5 PA QL(8/30)Immune SuppressantsASTAGRAF XL CP24 5MG 5 PAASTAGRAF XL CP24 0.5MG, 1MG

4 PA

AZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PAcyclosporine 4 PAcyclosporine modified 4 PAENBREL INJ 25MG/0.5ML 5 PA QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA QL(8/28)ENBREL MINI 5 PA QL(8/28)ENBREL SURECLICK 5 PA QL(8/28)ENVARSUS XR TB24 4MG 5 PAENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 4 PA

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GARDASIL 9 4 QL(1.5/365)HAVRIX 4HEPLISAV-B 4 B/D PA QL(3/365)HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4 B/D PAINFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4 B/D PARECOMBIVAX HB 4 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 4 QL(2/999)STAMARIL 4 QL(1/999)TENIVAC 4 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

4

TRUMENBA 4TWINRIX 4TYPHIM VI 4VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 2LIALDA 3 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XATMEP 4 PAZORTRESS TABS 0.25MG, 0.75MG

5 PA QL(60/30)

ZORTRESS TABS 0.5MG 5 PA QL(120/30)Immunizing Agents, PassiveATGAM 4 PAGAMMAKED INJ 1GM/10ML 4 B/D PAGAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA INJ 162MG/0.9ML 5 PA QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA QL(40/28)

ACTIMMUNE 5 PAARCALYST 5 PABENLYSTA INJ 400MG 5 PA QL(9/28)BENLYSTA INJ 120MG 5 PA QL(30/28)ILARIS 5 PA QL(2/28)leflunomide 2 QL(30/30)RIDAURA 4SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BCG VACCINE 4BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)XGEVA 5 PA QL(1.7/28)zoledronic acid inj 4mg/5ml 4 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 4 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 2 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16”

2 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16”

2 QL(200/30)

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

bd safetyglide 27g x 5/8” 2 QL(200/30)CARNITOR INJ 4 B/D PAFERRIPROX 5 PAfomepizole 5INTRALIPID 4 B/D PAKORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA QL(2/28)novofine 31 2 QL(200/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mesalamine 4Glucocorticoidsbudesonide cpep 4colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

BINOSTO 4calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 1mcg 4 QL(240/30)doxercalciferol caps 2.5mcg 5 QL(120/30)doxercalciferol inj 4etidronate disodium 2FORTEO 5 PA QL(2.4/28)ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5pamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 2 QL(90/30)PROLIA 4 QL(1/180)risedronate sodium tabs 150mg 3 QL(1/30)risedronate sodium tabs 35mg 3 QL(4/28)risedronate sodium tabs 30mg, 5mg

3 QL(30/30)

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RESTASIS 3 QL(60/30)tropicamide 2Ophthalmic Anti-allergy AgentsALOCRIL 3azelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

epinastine hcl 2olopatadine hcl ophthalmic soln 2 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

2 QL(2.5/30)

PAZEO 3 QL(2.5/30)Ophthalmic Anti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3fluorometholone 3flurbiprofen sodium 2ILEVRO 3ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4neomycin/polymyxin/dexamethasone

2

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 3TOBRADEX OINT 3tobramycin/dexamethasone 3Ophthalmic Antiglaucoma Agentsacetazolamide er 2apraclonidine 2AZOPT 3betaxolol hcl 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

novofine 32gx6mm 2 QL(200/30)novofine autocover 30gx8mm 2 QL(200/30)novotwist 32gx5mm 2 QL(200/30)NUTRILIPID 4 B/D PAOMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD DASH SYSTEM 3 QL(1/365)OMNIPOD STARTER KIT 3 QL(1/365)PHYSIOLYTE 4physiosol irrigation 4RINGERS IRRIGATION 4sodium chloride0.9% 4sodium chloride 0.9% 4sterile water irrigation 4sterile water irrigation plastic bottle

4

techlite pen needles/31g x 6 mm

2 QL(200/30)

techlite pen needles/31g x 8mm 2 QL(200/30)techlite pen needles/32g x 4mm 2 QL(200/30)techlite pen needles/32g x 6mm 2 QL(200/30)techlite pen needles/32g x 8mm 2 QL(200/30)TIS-U-SOL 4V-GO 20 3V-GO 30 3V-GO 40 3

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 2CYSTARAN 5 PA QL(60/28)LACRISERT 3proparacaine hcl 2

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 2 QL(16/30)mometasone furoate susp 2 QL(34/30)NASONEX 4 QL(34/30) STAntihistaminesazelastine hcl nasal soln 2 QL(30/25)desloratadine 2 QL(30/30)diphenhydramine hcl inj 4levocetirizine dihydrochloride oral soln

2 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

Antileukotrienesmontelukast sodium 2 QL(30/30)zafirlukast 2 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 3 QL(25.8/30)COMBIVENT RESPIMAT 3 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 2albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

brimonidine tartrate ophthalmic soln 0.2%

2

brimonidine tartrate ophthalmic soln 0.15%

3

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)levobunolol hcl 1metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic soln 3SIMBRINZA 4timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetic acid 2COLY-MYCIN S 4fluocinolone acetonide oil 4hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide susp 4 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sildenafil tabs 20mg 3 PA QL(90/30)TRACLEER 5 PA QL(60/30)VENTAVIS 5 PA QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA QL(270/30)ESBRIET TABS 801MG 5 PA QL(90/30)ESBRIET TABS 267MG 5 PA QL(270/30)OFEV 5 PA QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP 4 B/D PAPROLASTIN-C 5 B/D PAribavirin inhalation soln 5 B/D PATRELEGY ELLIPTA 3 QL(60/30)XOLAIR 5 PA QL(6/28)ZEMAIRA 5 B/D PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

3 PA QL(90/30)

methocarbamol tabs 2 PAorphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(60/365)zaleplon 2 QL(30/30)zolpidem tartrate tabs 3 PA QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 4 PA QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

albuterol sulfate tabs 1ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml

4

epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)levalbuterol tartrate hfa 3 QL(30/30)metaproterenol sulfate 2PERFOROMIST 3 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 4VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 PA QL(84/56)KALYDECO 5 PA QL(60/30)ORKAMBI PACK 5 PA QL(56/28)ORKAMBI TABS 5 PA QL(120/30)PULMOZYME 5 B/D PA QL(150/30)TOBI PODHALER 5 QL(1568/365)tobramycin nebu 5 B/D PA QL(280/56)Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 4 PA QL(30/30)DALIRESP TABS 250MCG 4 PA QL(60/365)THEO-24 3theophylline cr 2theophylline er tb12 300mg, 450mg

2

theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA QL(90/30)LETAIRIS 5 PA QL(30/30)OPSUMIT 5 PA QL(30/30)REMODULIN 5 B/D PA

51

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 25abacavir oral soln . . . . . . . . . . . . . . . . . 25abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 25abacavir tabs . . . . . . . . . . . . . . . . . . . . . 25ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 16ABILIFY MAINTENA . . . . . . . . . . . . . . . 23ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 19acamprosate calcium dr . . . . . . . . . . . . . 9acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 27acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 31acetaminophen/codeine oral soln . . . . 7acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . . 8acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . . 7acetazolamide . . . . . . . . . . . . . . . . . . . . . 32acetazolamide er . . . . . . . . . . . . . . . . . . 48acetazolamide sodium . . . . . . . . . . . . . 32acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 49acetylcysteine inhalation soln . . . . . . 50acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ACTEMRA INJ 162MG/0.9ML . . . . . . 46ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 46ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 46acyclovir caps . . . . . . . . . . . . . . . . . . . . 26acyclovir oint . . . . . . . . . . . . . . . . . . . . . 26acyclovir sodium . . . . . . . . . . . . . . . . . . . 26acyclovir susp . . . . . . . . . . . . . . . . . . . . 26acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 26ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 46ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 39adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 24ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 50adriamycin inj 2mg/ml . . . . . . . . . . . . . . 19adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 49

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 49afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . 31AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 20AFINITOR DISPERZ TBSO 5MG . . . 20AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 20AFINITOR TABS 10MG . . . . . . . . . . . . 20ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 40ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 22albuterol sulfate er . . . . . . . . . . . . . . . . . 49albuterol sulfate nebu 0.5% . . . . . . . . 49albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 49albuterol sulfate syrp . . . . . . . . . . . . . . 49albuterol sulfate tabs . . . . . . . . . . . . . . 50alclometasone dipropionate . . . . . . . . 40alcohol prep pads . . . . . . . . . . . . . . . . . 10ALDURAZYME . . . . . . . . . . . . . . . . . . . . 39ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 20alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 47alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 47alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 39ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 22ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 22ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 20allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 17allopurinol sodium . . . . . . . . . . . . . . . . . 17ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 48ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 42alosetron hydrochloride tabs 0.5mg . . 38alosetron hydrochloride tabs 1mg . . . 38ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 26alprazolam odt tbdp 2mg . . . . . . . . . . . 26alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 26

alprazolam tabs 2mg . . . . . . . . . . . . . . 26altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ALUNBRIG TABS 30MG . . . . . . . . . . . 20ALUNBRIG TABS 180MG, 90MG . . . 20ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 20alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 42alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 42amantadine hcl . . . . . . . . . . . . . . . . . . . . 22AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 16a-methapred . . . . . . . . . . . . . . . . . . . . . . 40amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 42amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 42amikacin sulfate . . . . . . . . . . . . . . . . . . . . 9amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 32amiloride/hydrochlorothiazide . . . . . . 32aminophylline . . . . . . . . . . . . . . . . . . . . . 50AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 35AMINOSYN 7%/ELECTROLYTES . . 35AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 35AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 35AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 35AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 35AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 35AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 35AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 35AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 35amiodarone hcl inj . . . . . . . . . . . . . . . . 30amiodarone hcl tabs . . . . . . . . . . . . . . 30AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 38amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 16amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 31amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 31amlodipine besylate tabs 2.5mg . . . . 31amlodipine besylate tabs 5mg . . . . . . 31

52


Covered Drugs Index

ARISTADA INJ 662MG/2.4ML . . . . . . 23ARISTADA INJ 882MG/3.2ML . . . . . . 23ARISTADA INJ 1064MG/3.9ML . . . . . 23armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 50ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 49ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 19ascomp/codeine . . . . . . . . . . . . . . . . . . . . 8ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 42aspirin/dipyridamole . . . . . . . . . . . . . . . 29ASTAGRAF XL CP24 0.5MG, 1MG . . 45ASTAGRAF XL CP24 5MG . . . . . . . . . 45atazanavir caps 200mg . . . . . . . . . . . . 26atazanavir caps 300mg . . . . . . . . . . . . 26atazanavir sulfate caps 150mg . . . . . 26atazanavir sulfate caps 200mg . . . . . 26atazanavir sulfate caps 300mg . . . . . 26atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 31atenolol/chlorthalidone . . . . . . . . . . . . . 31ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 46atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 34atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 34atorvastatin calcium . . . . . . . . . . . . . . . 33atovaquone . . . . . . . . . . . . . . . . . . . . . . . 22atovaquone/proguanil hcl . . . . . . . . . . 22ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 25atropine sulfate inj 0.5mg/5ml . . . . . . 32atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . . . . . . . . . . . . . . 38atropine sulfate ophthalmic soln . . . . 48ATROVENT HFA . . . . . . . . . . . . . . . . . . 49aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 40AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 11AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 38AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 21AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 12aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 22apraclonidine . . . . . . . . . . . . . . . . . . . . . . 48aprepitant caps . . . . . . . . . . . . . . . . . . . 16aprepitant caps 40mg . . . . . . . . . . . . . . 16aprepitant caps 80mg . . . . . . . . . . . . . . 16aprepitant caps 125mg . . . . . . . . . . . . . 16apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 46APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 13APTIOM TABS 600MG . . . . . . . . . . . . . 13APTIVUS CAPS . . . . . . . . . . . . . . . . . . 26APTIVUS ORAL SOLN . . . . . . . . . . . . 26ARALAST NP . . . . . . . . . . . . . . . . . . . . . 50aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 29ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 29ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 29ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 46aripiprazole odt . . . . . . . . . . . . . . . . . . . . 23aripiprazole oral soln . . . . . . . . . . . . . . 23aripiprazole tabs . . . . . . . . . . . . . . . . . . 23ARISTADA INITIO . . . . . . . . . . . . . . . . . 23ARISTADA INJ 441MG/1.6ML . . . . . . 23

amlodipine besylate tabs 10mg . . . . . 31amlodipine besylate/valsartan . . . . . . 31amlodipine/olmesartan medoxomil . . 31amlodipine/valsartan/hctz . . . . . . . . . . 31ammonium lactate . . . . . . . . . . . . . . . . . 34amnesteem . . . . . . . . . . . . . . . . . . . . . . . 34amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 16amoxicillin caps . . . . . . . . . . . . . . . . . . . 11amoxicillin chew . . . . . . . . . . . . . . . . . . 11amoxicillin/clavulanate potassium . . . 11amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 11amoxicillin susr . . . . . . . . . . . . . . . . . . . 11amoxicillin tabs . . . . . . . . . . . . . . . . . . . 11amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 33amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 33amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 33amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 33amphotericin b . . . . . . . . . . . . . . . . . . . . 16ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 11ampicillin sodium . . . . . . . . . . . . . . . . . . 11ampicillin-sulbactam . . . . . . . . . . . . . . . 11AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 34ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 41anagrelide hydrochloride . . . . . . . . . . . 29anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 38anastrozole . . . . . . . . . . . . . . . . . . . . . . . 20ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 50

53


Covered Drugs Index

betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 48bethanechol chloride . . . . . . . . . . . . . . . 40bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 22BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 46bicalutamide . . . . . . . . . . . . . . . . . . . . . . 18BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 11BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 24BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 22bimatoprost ophthalmic soln . . . . . . . 48BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 47bisoprolol fumarate . . . . . . . . . . . . . . . . 31bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 31bleomycin sulfate . . . . . . . . . . . . . . . . . . 19BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 12BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 12blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 42blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 42BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 46BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 19BOSULIF TABS 100MG . . . . . . . . . . . . 20BOSULIF TABS 400MG, 500MG . . . 20BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 19BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 49briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 29brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 49brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 49BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 13BRIVIACT ORAL SOLN . . . . . . . . . . . 13BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 13BRIVIACT TABS 100MG . . . . . . . . . . . 13bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 48bromocriptine mesylate . . . . . . . . . . . . 22budesonide cpep . . . . . . . . . . . . . . . . . 47

BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 12BCG VACCINE . . . . . . . . . . . . . . . . . . . . 46bd eclipse syringe/1ml/30gx1/2” . . . . 47bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 47bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 47bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 47bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 47bd pen needle/mini/ultrafine/ 31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . . 47bd pen needle/nano/ultra fine/ 32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . . 47bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 47bd safetyglide 27g x 5/8” . . . . . . . . . . . 47bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 42BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 19benazepril hcl . . . . . . . . . . . . . . . . . . . . . 30benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 30benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 30BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 18BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 30BENICAR HCT . . . . . . . . . . . . . . . . . . . . 30BENLYSTA INJ 120MG . . . . . . . . . . . . 46BENLYSTA INJ 400MG . . . . . . . . . . . . 46benztropine mesylate inj . . . . . . . . . . . 22benztropine mesylate tabs . . . . . . . . . 22BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 12BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 21betamethasone dipropionate . . . . . . . 40betamethasone valerate crea . . . . . . 40betamethasone valerate foam . . . . . 40betamethasone valerate lotn . . . . . . . 40betamethasone valerate oint . . . . . . . 40BETASERON . . . . . . . . . . . . . . . . . . . . . 34betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 31

avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 34AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 34azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 19AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 11AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 11AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 45AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 12azathioprine inj . . . . . . . . . . . . . . . . . . . 45azathioprine tabs . . . . . . . . . . . . . . . . . 45azelastine hcl nasal soln . . . . . . . . . . . 49azelastine hcl ophthalmic soln . . . . . 48azithromycin inj . . . . . . . . . . . . . . . . . . . 12azithromycin pack . . . . . . . . . . . . . . . . . 12azithromycin susr 100mg/5ml . . . . . . 12azithromycin susr 200mg/5ml . . . . . . 12azithromycin tabs 250mg, 500mg . . . 12azithromycin tabs 600mg . . . . . . . . . . . 12AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 48AZOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31aztreonam inj 1gm . . . . . . . . . . . . . . . . . 11AZTREONAM INJ 2GM . . . . . . . . . . . . 11

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 10bacitracin ophthalmic oint . . . . . . . . . . 10bacitracin/polymyxin b . . . . . . . . . . . . . 10baclofen tabs 10mg . . . . . . . . . . . . . . . . 24baclofen tabs 20mg, 5mg . . . . . . . . . . 24BACTROBAN NASAL . . . . . . . . . . . . . 10balsalazide disodium . . . . . . . . . . . . . . 46balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42BANZEL SUSP . . . . . . . . . . . . . . . . . . . 14BANZEL TABS 200MG . . . . . . . . . . . . 14BANZEL TABS 400MG . . . . . . . . . . . . 14BARACLUDE ORAL SOLN . . . . . . . . 24BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 21

54


Covered Drugs Index

carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 19carmustine . . . . . . . . . . . . . . . . . . . . . . . . 18CARNITOR INJ . . . . . . . . . . . . . . . . . . . 47carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 49cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 31carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 31carvedilol phosphate . . . . . . . . . . . . . . . 31caspofungin acetate . . . . . . . . . . . . . . . 17CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 50caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42cefaclor caps . . . . . . . . . . . . . . . . . . . . . 11cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 11cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 11cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 11CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 11cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 11cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 11cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime/dextrose . . . . . . . . . . . . . . . . . 11cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefotaxime sodium . . . . . . . . . . . . . . . . . 11cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 11cefpodoxime proxetil . . . . . . . . . . . . . . . 11cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime/dextrose . . . . . . . . . . . . . . . 11ceftriaxone in iso-osmotic dextrose . . 11ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 11cefuroxime axetil . . . . . . . . . . . . . . . . . . 11cefuroxime sodium . . . . . . . . . . . . . . . . 11celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . . 7celecoxib caps 400mg . . . . . . . . . . . . . . 7CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 13

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 44CABOMETYX TABS 20MG, 60MG . . . 20CABOMETYX TABS 40MG . . . . . . . . 20calcipotriene crea . . . . . . . . . . . . . . . . . 34calcipotriene external soln . . . . . . . . . 34calcipotriene oint . . . . . . . . . . . . . . . . . . 34calcitonin-salmon . . . . . . . . . . . . . . . . . . 47calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 35calcitriol caps . . . . . . . . . . . . . . . . . . . . . 47calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 47calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 35calcitriol oral soln . . . . . . . . . . . . . . . . . 47calcium acetate caps . . . . . . . . . . . . . . 38calcium acetate tabs 667mg . . . . . . . . 38CALQUENCE . . . . . . . . . . . . . . . . . . . . . 20camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 42camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 42CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 17candesartan cilexetil . . . . . . . . . . . . . . . 30candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 30CAPASTAT SULFATE . . . . . . . . . . . . . . 18CAPRELSA TABS 100MG . . . . . . . . . 20CAPRELSA TABS 300MG . . . . . . . . . 20captopril/hydrochlorothiazide . . . . . . . 30captopril tabs 12.5mg, 25mg . . . . . . . 30captopril tabs 100mg, 50mg . . . . . . . . 30CARAFATE SUSP . . . . . . . . . . . . . . . . 39CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 35carbamazepine . . . . . . . . . . . . . . . . . . . . 14carbamazepine er . . . . . . . . . . . . . . . . . 14carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 22carbidopa/levodopa . . . . . . . . . . . . . . . . 22carbidopa/levodopa/entacapone . . . . 22carbidopa/levodopa er . . . . . . . . . . . . . 22carbidopa/levodopa odt . . . . . . . . . . . . 22

budesonide susp . . . . . . . . . . . . . . . . . . 49bumetanide inj . . . . . . . . . . . . . . . . . . . . 32bumetanide tabs 0.5mg, 1mg . . . . . . . 32bumetanide tabs 2mg . . . . . . . . . . . . . . 32BUPHENYL TABS . . . . . . . . . . . . . . . . 39buprenorphine hcl inj . . . . . . . . . . . . . . . 7buprenorphine hcl/naloxone hcl . . . . . . 9buprenorphine hcl subl . . . . . . . . . . . . . 9bupropion hcl er tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 15bupropion hcl sr . . . . . . . . . . . . . . . . . . . . 9bupropion hcl sr . . . . . . . . . . . . . . . . . . . 15bupropion hcl tabs 100mg . . . . . . . . . . 15bupropion hcl xl . . . . . . . . . . . . . . . . . . . 15bupropion hydrochloride tabs 75mg . . . . . . . . . . . . . . . . . . . . . . . . 15buspirone hcl tabs 10mg, 5mg . . . . . . 26buspirone hcl tabs 15mg, 30mg, 7.5mg . . . . . . . . . . . . . . . 26busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 18BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 18butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . . 7butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . . 8butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . . 7butalbital/aspirin/caffeine caps . . . . . . 7butalbital/aspirin/caffeine/codeine . . . . 8butorphanol tartrate inj 1mg/ml . . . . . . 8butorphanol tartrate inj 2mg/ml . . . . . . 8butorphanol tartrate nasal soln . . . . . . 8BYDUREON . . . . . . . . . . . . . . . . . . . . . . 27BYDUREON BCISE . . . . . . . . . . . . . . . 27BYDUREON PEN . . . . . . . . . . . . . . . . . 27BYETTA INJ 5MCG/0.02ML . . . . . . . . 27BYETTA INJ 10MCG/0.04ML . . . . . . . 27BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 31BYSTOLIC TABS 20MG . . . . . . . . . . . 31BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 31

55


Covered Drugs Index

CLINIMIX 5%/DEXTROSE 15% . . . . 35CLINIMIX 5%/DEXTROSE 20% . . . . 35CLINIMIX 5%/DEXTROSE 25% . . . . 35CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 35CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 35CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 36CLINIMIX E 5%/DEXTROSE 25% . . . 36CLINIMIX N9G15E . . . . . . . . . . . . . . . . 36CLINIMIX N14G30E . . . . . . . . . . . . . . . 36CLINISOL SF 15% . . . . . . . . . . . . . . . . 36clobetasol propionate crea . . . . . . . . . 40clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 40clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 40clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 40clobetasol propionate foam . . . . . . . . 40clobetasol propionate gel . . . . . . . . . . 40clobetasol propionate oint . . . . . . . . . 40clobetasol propionate sham . . . . . . . . 40clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 19clomipramine hcl . . . . . . . . . . . . . . . . . . 16clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 13clonazepam odt tbdp 1mg . . . . . . . . . . 13clonazepam odt tbdp 2mg . . . . . . . . . . 13clonazepam tabs 0.5mg . . . . . . . . . . . . 13clonazepam tabs 1mg . . . . . . . . . . . . . 13clonazepam tabs 2mg . . . . . . . . . . . . . 13clonidine hcl er . . . . . . . . . . . . . . . . . . . . 34clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 29clonidine hcl ptwk 0.3mg/24hr . . . . . . 29clonidine hcl tabs 0.1mg, 0.2mg . . . . 29clonidine hcl tabs 0.3mg . . . . . . . . . . . 29clopidogrel tabs 75mg . . . . . . . . . . . . . 29

ciprofloxacin hcl tabs 100mg, 750mg . . . . . . . . . . . . . . . . . . . . 12ciprofloxacin hcl tabs 250mg . . . . . . . 12ciprofloxacin hydrochloride . . . . . . . . . 12ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 12ciprofloxacin susr . . . . . . . . . . . . . . . . . 12CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 12cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 19citalopram hydrobromide oral soln . . . 15citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 15cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 19claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 35clarithromycin er . . . . . . . . . . . . . . . . . . . 12clarithromycin susr . . . . . . . . . . . . . . . . 12clarithromycin tabs . . . . . . . . . . . . . . . . 12clindacin etz pledgets . . . . . . . . . . . . . . 10clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin hcl . . . . . . . . . . . . . . . . . . . . 10clindamycin hydrochloride . . . . . . . . . . 10clindamycin phosphate crea . . . . . . . 10clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 10clindamycin phosphate gel . . . . . . . . 10clindamycin phosphate in d5w . . . . . . 10clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 10clindamycin phosphate lotn . . . . . . . . 10clindamycin phosphate swab . . . . . . 10clindamycin/sodium chloride . . . . . . . . 10CLINIMIX 2.75%/DEXTROSE 5% . . 35CLINIMIX 4.25%/DEXTROSE 5% . . 35CLINIMIX 4.25%/DEXTROSE 10% . . 35CLINIMIX 4.25%/DEXTROSE 20% . . 35CLINIMIX 4.25%/DEXTROSE 25% . . 35

cephalexin caps 250mg, 500mg . . . . 11cephalexin susr . . . . . . . . . . . . . . . . . . . 11cephalexin tabs . . . . . . . . . . . . . . . . . . . 11CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 39cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 37chloramphenicol sodium succinate . . 10chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 34chloroquine phosphate . . . . . . . . . . . . . 22chlorothiazide . . . . . . . . . . . . . . . . . . . . . 32chlorothiazide sodium . . . . . . . . . . . . . . 32chlorpromazine hcl inj . . . . . . . . . . . . . 22chlorpromazine hcl tabs . . . . . . . . . . . 22chlorthalidone . . . . . . . . . . . . . . . . . . . . . 32cholestyramine . . . . . . . . . . . . . . . . . . . . 33cholestyramine light . . . . . . . . . . . . . . . 33chorionic gonadotropin . . . . . . . . . . . . . 41ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 17ciclopirox nail lacquer . . . . . . . . . . . . . . 17ciclopirox olamine . . . . . . . . . . . . . . . . . 17ciclopirox sham . . . . . . . . . . . . . . . . . . . 17ciclopirox susp . . . . . . . . . . . . . . . . . . . . 17cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 24cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 29CILOXAN OINT . . . . . . . . . . . . . . . . . . . 12CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 25cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 38cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 38CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 45CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 12ciprofloxacin er tb24 500mg; 0 . . . . . . 12ciprofloxacin er tb24 1000mg; 0 . . . . 12ciprofloxacin hcl ophthalmic soln . . . 12

56


Covered Drugs Index

daptomycin inj 500mg . . . . . . . . . . . . . . 10DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 22darifenacin hydrobromide er . . . . . . . . 39DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 21dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 42dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 42daunorubicin hcl . . . . . . . . . . . . . . . . . . . 19daunorubicin hydrochloride . . . . . . . . . 19daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 44decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 19DELESTROGEN INJ 10MG/ML . . . . 42delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42demeclocycline hcl . . . . . . . . . . . . . . . . 13DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 32DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 26DEPEN TITRATABS . . . . . . . . . . . . . . . 37DEPO-ESTRADIOL . . . . . . . . . . . . . . . 42DEPO-MEDROL INJ 20MG/ML . . . . . 40DEPO-PROVERA . . . . . . . . . . . . . . . . . 44DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 25desipramine hcl . . . . . . . . . . . . . . . . . . . 16desloratadine . . . . . . . . . . . . . . . . . . . . . . 49desmopressin acetate inj . . . . . . . . . . 41desmopressin acetate nasal soln . . . 41desmopressin acetate tabs . . . . . . . . 41desogestrel/ethinyl estradiol . . . . . . . . 42desonide lotn . . . . . . . . . . . . . . . . . . . . . 40desonide oint . . . . . . . . . . . . . . . . . . . . . 40desoximetasone crea . . . . . . . . . . . . . 40desoximetasone gel . . . . . . . . . . . . . . . 40desoximetasone oint . . . . . . . . . . . . . . 40desvenlafaxine er . . . . . . . . . . . . . . . . . . 15dexamethasone elix . . . . . . . . . . . . . . . 40dexamethasone intensol . . . . . . . . . . . 40dexamethasone oral soln . . . . . . . . . . 40dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 40

CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 39CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 33CRIXIVAN CAPS 200MG . . . . . . . . . . 26CRIXIVAN CAPS 400MG . . . . . . . . . . 26cromolyn sodium conc . . . . . . . . . . . . 38cromolyn sodium nebu . . . . . . . . . . . . 50cromolyn sodium ophthalmic soln . . . 48cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 42CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 37curity gauze pads 2”x2” . . . . . . . . . . . . 35cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 42cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 42cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 50cyclophosphamide caps . . . . . . . . . . . 18cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 18cyclophosphamide inj 2gm . . . . . . . . . 18cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 18CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 27cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 45cyclosporine modified . . . . . . . . . . . . . . 45CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 21cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CYSTADANE . . . . . . . . . . . . . . . . . . . . . 39CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 39CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 48cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 19cytarabine aqueous . . . . . . . . . . . . . . . . 19

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 18dactinomycin . . . . . . . . . . . . . . . . . . . . . . 19DALIRESP TABS 250MCG . . . . . . . . . 50DALIRESP TABS 500MCG . . . . . . . . . 50danazol caps 50mg . . . . . . . . . . . . . . . . 41danazol caps 100mg, 200mg . . . . . . . 41dantrolene sodium . . . . . . . . . . . . . . . . . 24dapsone tabs . . . . . . . . . . . . . . . . . . . . . 18DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 46

clopidogrel tabs 300mg . . . . . . . . . . . . 29clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 26clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 27clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 17clotrimazole external crea . . . . . . . . . 17clotrimazole external soln . . . . . . . . . . 17clotrimazole lozg . . . . . . . . . . . . . . . . . . 17clozapine odt tbdp 12.5mg, 25mg . . . 24clozapine odt tbdp 100mg . . . . . . . . . . 24clozapine odt tbdp 150mg . . . . . . . . . . 24clozapine odt tbdp 200mg . . . . . . . . . . 24clozapine tabs 25mg, 50mg . . . . . . . . 24clozapine tabs 100mg . . . . . . . . . . . . . . 24clozapine tabs 200mg . . . . . . . . . . . . . . 24COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 22colchicine caps . . . . . . . . . . . . . . . . . . . 17colchicine tabs . . . . . . . . . . . . . . . . . . . . 17colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 33colistimethate sodium . . . . . . . . . . . . . . 10colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 47COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 49COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 48COMBIVENT RESPIMAT . . . . . . . . . . 49COMETRIQ KIT . . . . . . . . . . . . . . . . . . 20COMETRIQ KIT . . . . . . . . . . . . . . . . . . 21COMETRIQ KIT 20MG . . . . . . . . . . . . 21COMPLERA . . . . . . . . . . . . . . . . . . . . . . 25compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 22constulose . . . . . . . . . . . . . . . . . . . . . . . . 38COPAXONE INJ 20MG/ML . . . . . . . . . 34COPAXONE INJ 40MG/ML . . . . . . . . . 34COREG CR . . . . . . . . . . . . . . . . . . . . . . . 31CORLANOR . . . . . . . . . . . . . . . . . . . . . . 32cortisone acetate . . . . . . . . . . . . . . . . . . 40COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 19COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 21COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 28

57


Covered Drugs Index

DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . 46disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . 9divalproex sodium . . . . . . . . . . . . . . . . . 14divalproex sodium dr . . . . . . . . . . . . . . . 14divalproex sodium er . . . . . . . . . . . . . . . 14docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 19DOCETAXEL INJ 200MG/10ML . . . . 19dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 30donepezil hcl tabs 10mg . . . . . . . . . . . 14donepezil hcl tabs 23mg, 5mg . . . . . . 14donepezil hcl tbdp 5mg . . . . . . . . . . . . 14donepezil hcl tbdp 10mg . . . . . . . . . . . 14donepezil hydrochloride tabs 5mg . . 14donepezil hydrochloride tabs 10mg . . 14dorzolamide hcl . . . . . . . . . . . . . . . . . . . 49dorzolamide hcl/timolol maleate . . . . 49doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 39doxazosin mesylate tabs 8mg . . . . . . 39doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 26doxepin hydrochloride . . . . . . . . . . . . . 35doxercalciferol caps 0.5mcg . . . . . . . . 47doxercalciferol caps 1mcg . . . . . . . . . . 47doxercalciferol caps 2.5mcg . . . . . . . . 47doxercalciferol inj . . . . . . . . . . . . . . . . . 47doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 19doxorubicin hcl liposome . . . . . . . . . . . 19doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline hyclate caps . . . . . . . . . . 13doxycycline hyclate tabs 20mg . . . . . 13doxycycline hyclate tabs 100mg . . . . 13doxycycline monohydrate caps 75mg . . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 13doxycycline monohydrate tabs . . . . . 13doxycycline susr . . . . . . . . . . . . . . . . . . 13

diazepam inj 5mg/ml . . . . . . . . . . . . . . . 27diazepam oral soln . . . . . . . . . . . . . . . . 27diazepam rectal gel gel 2.5mg . . . . . . 14diazepam rectal gel gel 10mg . . . . . . 14diazepam rectal gel gel 20mg . . . . . . 14diazepam tabs . . . . . . . . . . . . . . . . . . . . 27diclofenac potassium . . . . . . . . . . . . . . . 7diclofenac sodium dr tbec 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . . 7diclofenac sodium dr tbec 75mg . . . . . 7diclofenac sodium er . . . . . . . . . . . . . . . . 7diclofenac sodium gel 1% . . . . . . . . . . 35diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 48diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 35dicloxacillin sodium . . . . . . . . . . . . . . . . 11dicyclomine hcl caps . . . . . . . . . . . . . . 38dicyclomine hcl oral soln . . . . . . . . . . . 38dicyclomine hydrochloride . . . . . . . . . . 38didanosine . . . . . . . . . . . . . . . . . . . . . . . . 25diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . 7digitek tabs 0.25mg . . . . . . . . . . . . . . . . 32digitek tabs 0.125mg . . . . . . . . . . . . . . . 32digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 32digoxin tabs 125mcg . . . . . . . . . . . . . . . 32digoxin tabs 250mcg . . . . . . . . . . . . . . . 32digox tabs 125mcg . . . . . . . . . . . . . . . . 32digox tabs 250mcg . . . . . . . . . . . . . . . . 32dihydroergotamine mesylate inj . . . . 17DILANTIN CAPS 30MG . . . . . . . . . . . . 14diltiazem hcl er cp12 . . . . . . . . . . . . . . 31diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg . . . . . 31diltiazem hcl er tb24 . . . . . . . . . . . . . . . 31diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 31diltiazem hcl tabs . . . . . . . . . . . . . . . . . 31dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31diphenhydramine hcl inj . . . . . . . . . . . 49diphenoxylate/atropine . . . . . . . . . . . . . 38

dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 48dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 40dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 40dexmethylphenidate hcl . . . . . . . . . . . . 34dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 19dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 34dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 34dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 34dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 34dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 34dextrose 2.5%/nacl 0.45% . . . . . . . . . 36DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 36dextrose5% /electrolyte #48 viaflex . . 36dextrose 5%/lactated ringers . . . . . . . 36dextrose 5%/nacl 0.2% . . . . . . . . . . . . 36DEXTROSE 5%/NACL 0.3% . . . . . . . 36dextrose 5%/nacl 0.9% . . . . . . . . . . . . 36dextrose 5%/nacl 0.33% . . . . . . . . . . . 36dextrose 5%/nacl 0.45% . . . . . . . . . . . 36dextrose 5%/nacl 0.225% . . . . . . . . . . 36DEXTROSE 10% . . . . . . . . . . . . . . . . . . 36dextrose 10%/nacl 0.2% . . . . . . . . . . . 36dextrose10%/nacl 0.45% . . . . . . . . . . . 36DEXTROSE 20% . . . . . . . . . . . . . . . . . . 36DEXTROSE 25% . . . . . . . . . . . . . . . . . . 36DEXTROSE 30% . . . . . . . . . . . . . . . . . . 36DEXTROSE 40% . . . . . . . . . . . . . . . . . . 36DEXTROSE 50% . . . . . . . . . . . . . . . . . . 36DEXTROSE 70% . . . . . . . . . . . . . . . . . . 36DIASTAT ACUDIAL GEL 10MG . . . . . 13DIASTAT ACUDIAL GEL 20MG . . . . . 14DIASTAT PEDIATRIC . . . . . . . . . . . . . . 14

58


Covered Drugs Index

epirubicin hcl inj 200mg/100ml . . . . . 19epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14EPIVIR HBV ORAL SOLN . . . . . . . . . 24ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 21ergoloid mesylates . . . . . . . . . . . . . . . . . 14ergotamine tartrate/caffeine . . . . . . . . 17ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 21ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 18errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 11ertapenem sodium . . . . . . . . . . . . . . . . . 11ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 19ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 12ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYTHROCIN LACTOBIONATE . . . 12erythrocin stearate . . . . . . . . . . . . . . . . . 12erythromycin base . . . . . . . . . . . . . . . . . 12erythromycin/benzoyl peroxide . . . . . 35erythromycin ethylsuccinate . . . . . . . . 12erythromycin external soln . . . . . . . . . 12erythromycin gel . . . . . . . . . . . . . . . . . . 12erythromycin oint . . . . . . . . . . . . . . . . . 12erythromycin pads . . . . . . . . . . . . . . . . 12ESBRIET CAPS . . . . . . . . . . . . . . . . . . 50ESBRIET TABS 267MG . . . . . . . . . . . . 50ESBRIET TABS 801MG . . . . . . . . . . . . 50escitalopram oxalate oral soln . . . . . 15escitalopram oxalate tabs 5mg . . . . . 15escitalopram oxalate tabs 10mg . . . . 15escitalopram oxalate tabs 20mg . . . . 15esgic caps . . . . . . . . . . . . . . . . . . . . . . . . . 7esomeprazole magnesium . . . . . . . . . 39esomeprazole sodium . . . . . . . . . . . . . 39estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 42estradiol crea . . . . . . . . . . . . . . . . . . . . . 42estradiol pttw . . . . . . . . . . . . . . . . . . . . . 42estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 42estradiol tabs 0.5mg, 1mg, 2mg . . . . 42estradiol tabs 10mcg . . . . . . . . . . . . . . . 42

EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 15EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 25EMTRIVA ORAL SOLN . . . . . . . . . . . . 25ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . 39enalapril maleate . . . . . . . . . . . . . . . . . . 30enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 30ENBREL INJ 25MG/0.5ML . . . . . . . . . 45ENBREL INJ 25MG, 50MG/ML . . . . . 45ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 45ENBREL SURECLICK . . . . . . . . . . . . . 45endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . . 8endocet tabs 325mg; 7.5mg . . . . . . . . . 8endocet tabs 325mg; 10mg . . . . . . . . . 8ENGERIX-B INJ 10MCG/0.5ML . . . . 46ENGERIX-B INJ 20MCG/ML . . . . . . . 46enoxaparin sodium inj 30mg/0.3ml . . 28enoxaparin sodium inj 40mg/0.4ml . . 28enoxaparin sodium inj 60mg/0.6ml . . 28enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . 28enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 28enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 42enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 42entacapone . . . . . . . . . . . . . . . . . . . . . . . 22entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 24ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 30enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 45ENVARSUS XR TB24 4MG . . . . . . . . 45EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 24epinastine hcl . . . . . . . . . . . . . . . . . . . . . 48epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml . . . . . 50epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . 50EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 50EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 50

dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 16DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 19duloxetine hcl cpep 20mg . . . . . . . . . . 15duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 15duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 15DURAMORPH . . . . . . . . . . . . . . . . . . . . . 7DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 48dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 39dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 39

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 17EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 30EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 30ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 38EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 25e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 12efavirenz caps 50mg . . . . . . . . . . . . . . . 25efavirenz caps 200mg . . . . . . . . . . . . . 25efavirenz tabs . . . . . . . . . . . . . . . . . . . . 25ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 39ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 44ELIGARD INJ 22.5MG . . . . . . . . . . . . . 44ELIGARD INJ 30MG . . . . . . . . . . . . . . . 44ELIGARD INJ 45MG . . . . . . . . . . . . . . . 44elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ELIQUIS STARTER PACK . . . . . . . . . 28ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 28ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 28ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 40EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 19EMEND SUSR . . . . . . . . . . . . . . . . . . . . 16emoquette . . . . . . . . . . . . . . . . . . . . . . . . 42EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 21

59


Covered Drugs Index

fludarabine phosphate inj 50mg . . . . 19fludrocortisone acetate . . . . . . . . . . . . . 40flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 49fluocinolone acetonide body . . . . . . . . 40fluocinolone acetonide crea . . . . . . . . 40fluocinolone acetonide external soln . . . . . . . . . . . . . . . . . . . . . . 40fluocinolone acetonide oil . . . . . . . . . . 49fluocinolone acetonide oint . . . . . . . . 40fluocinolone acetonide scalp . . . . . . . 40fluocinonide crea 0.1% . . . . . . . . . . . . . 40fluocinonide crea 0.05% . . . . . . . . . . . 40fluocinonide external soln . . . . . . . . . . 40fluocinonide gel . . . . . . . . . . . . . . . . . . . 40fluocinonide oint . . . . . . . . . . . . . . . . . . 40fluoride chew 0.25mg . . . . . . . . . . . . . . 36fluoritab chew 0.5mg, 1mg . . . . . . . . . 36fluorometholone . . . . . . . . . . . . . . . . . . . 48fluorouracil crea 0.5% . . . . . . . . . . . . . . 35fluorouracil crea 5% . . . . . . . . . . . . . . . 35fluorouracil external soln . . . . . . . . . . . 35fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 19fluoxetine caps 10mg . . . . . . . . . . . . . . 15fluoxetine caps 20mg . . . . . . . . . . . . . . 15fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 15fluoxetine hcl caps 10mg . . . . . . . . . . . 15fluoxetine hcl caps 20mg . . . . . . . . . . . 15fluoxetine hcl caps 40mg . . . . . . . . . . . 15fluoxetine hcl oral soln . . . . . . . . . . . . . 15fluoxetine hydrochloride tabs 10mg . . 15fluoxetine hydrochloride tabs 20mg . . 16fluphenazine decanoate . . . . . . . . . . . . 22fluphenazine hcl conc . . . . . . . . . . . . . 22fluphenazine hcl elix . . . . . . . . . . . . . . 23fluphenazine hcl inj . . . . . . . . . . . . . . . . 23fluphenazine hcl tabs 1mg . . . . . . . . . 23fluphenazine hcl tabs 10mg, 2.5mg, 5mg . . . . . . . . . . . . . . . . . 23flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7flurbiprofen sodium . . . . . . . . . . . . . . . . 48

fenofibrate micronized caps 67mg . . 32fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 32fenofibrate tabs 48mg, 54mg . . . . . . . 32fenofibrate tabs 145mg, 160mg . . . . . 32fenofibric acid dr cpdr 45mg . . . . . . . . 32fenofibric acid dr cpdr 135mg . . . . . . . 32fenoprofen calcium caps 400mg . . . . . 7fenoprofen calcium tabs . . . . . . . . . . . . 7fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . . 8fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . . 8fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . . 8FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 47FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 15FETZIMA TITRATION PACK . . . . . . . 15finasteride tabs 5mg . . . . . . . . . . . . . . . 39FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 45FIRMAGON INJ 80MG . . . . . . . . . . . . . 44FIRMAGON INJ 120MG . . . . . . . . . . . 44flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 39flecainide acetate . . . . . . . . . . . . . . . . . . 30FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 49FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 49FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 49FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 49FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 49fluconazole in nacl . . . . . . . . . . . . . . . . . 17fluconazole susr . . . . . . . . . . . . . . . . . . 17fluconazole tabs 100mg, 200mg, 50mg . . . . . . . . . . . . . . 17fluconazole tabs 150mg . . . . . . . . . . . . 17flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 17

estradiol valerate . . . . . . . . . . . . . . . . . . 42ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 42ethacrynate sodium . . . . . . . . . . . . . . . . 32ethambutol hcl . . . . . . . . . . . . . . . . . . . . 18ethosuximide . . . . . . . . . . . . . . . . . . . . . . 13ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 42ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 19etidronate disodium . . . . . . . . . . . . . . . . 47etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . 7etoposide inj . . . . . . . . . . . . . . . . . . . . . . 20EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 18EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 26exemestane . . . . . . . . . . . . . . . . . . . . . . . 20ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 33ezetimibe/simvastatin . . . . . . . . . . . . . . 33

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 39falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 26famotidine inj . . . . . . . . . . . . . . . . . . . . . 38famotidine premixed . . . . . . . . . . . . . . . 38famotidine tabs 20mg, 40mg . . . . . . . 38FANAPT TABS 1MG, 2MG, 4MG . . . 23FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 23FANAPT TITRATION PACK . . . . . . . . 23FARESTON . . . . . . . . . . . . . . . . . . . . . . . 19FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 27FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 21FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 19felbamate susp . . . . . . . . . . . . . . . . . . . 14felbamate tabs . . . . . . . . . . . . . . . . . . . . 14felodipine er . . . . . . . . . . . . . . . . . . . . . . . 31FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 42femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 42fenofibrate caps 43mg, 50mg . . . . . . . 32fenofibrate caps 130mg, 150mg . . . . 32

60


Covered Drugs Index

GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 41GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 41gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . . 9gentamicin sulfate crea . . . . . . . . . . . . . 9gentamicin sulfate inj . . . . . . . . . . . . . . . 9gentamicin sulfate oint . . . . . . . . . . . . . 9gentamicin sulfate ophthalmic soln . . . 9gentamicin sulfate pediatric . . . . . . . . . 9GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 24GEODON INJ . . . . . . . . . . . . . . . . . . . . 23GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 34GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 21GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 18glimepiride tabs 1mg . . . . . . . . . . . . . . . 27glimepiride tabs 2mg . . . . . . . . . . . . . . . 27glimepiride tabs 4mg . . . . . . . . . . . . . . . 27glipizide er tb24 2.5mg . . . . . . . . . . . . . 27glipizide er tb24 5mg . . . . . . . . . . . . . . . 27glipizide er tb24 10mg . . . . . . . . . . . . . 27glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 27glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 27glipizide tabs 5mg . . . . . . . . . . . . . . . . . 27glipizide tabs 10mg . . . . . . . . . . . . . . . . 27glipizide xl tb24 2.5mg . . . . . . . . . . . . . 27glipizide xl tb24 5mg . . . . . . . . . . . . . . . 27glipizide xl tb24 10mg . . . . . . . . . . . . . . 27GLUCAGEN HYPOKIT . . . . . . . . . . . . 28GLUCAGON EMERGENCY KIT . . . . 28glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 38glycopyrrolate tabs . . . . . . . . . . . . . . . . 38glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 27granisetron hcl inj . . . . . . . . . . . . . . . . . 16

FYCOMPA SUSP . . . . . . . . . . . . . . . . . 13FYCOMPA TABS . . . . . . . . . . . . . . . . . 13

Ggabapentin caps 100mg . . . . . . . . . . . 14gabapentin caps 300mg, 400mg . . . . 14gabapentin oral soln . . . . . . . . . . . . . . 14gabapentin tabs 600mg . . . . . . . . . . . . 14gabapentin tabs 800mg . . . . . . . . . . . . 14GABITRIL TABS 12MG . . . . . . . . . . . . 14GABITRIL TABS 16MG . . . . . . . . . . . . 14galantamine hydrobromide er . . . . . . 14galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 15galantamine hydrobromide tabs . . . . 15GAMMAKED INJ 1GM/10ML . . . . . . . 46GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 46GAMUNEX-C INJ 1GM/10ML . . . . . . 46GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 46ganciclovir inj 500mg, 500mg/10ml . . . . . . . . . . . . . . . 24GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 46GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 38gavilyte-n/flavor pack . . . . . . . . . . . . . . 38GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 21gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 19gemcitabine hcl inj 1gm . . . . . . . . . . . . 19gemcitabine hcl inj 200mg, 2gm . . . . 19gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 19gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 32generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 38gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 45GENOTROPIN . . . . . . . . . . . . . . . . . . . . 41

flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 18fluticasone propionate crea . . . . . . . . 40fluticasone propionate oint . . . . . . . . . 40fluticasone propionate susp . . . . . . . . 49fluvoxamine maleate er . . . . . . . . . . . . 16fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 16fluvoxamine maleate tabs 100mg . . . 16FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 19fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 47fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 28FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 47fosamprenavir calcium . . . . . . . . . . . . . 26FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . 24fosinopril sodium . . . . . . . . . . . . . . . . . . 30fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 30fosphenytoin sodium . . . . . . . . . . . . . . . 14FREAMINE HBC 6.9% . . . . . . . . . . . . . 36FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 36furosemide inj . . . . . . . . . . . . . . . . . . . . 32furosemide oral soln . . . . . . . . . . . . . . 32furosemide tabs . . . . . . . . . . . . . . . . . . . 32FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 19FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 25fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 42

61


Covered Drugs Index

hydrocodone/ibuprofen . . . . . . . . . . . . . 8hydrocortisone/acetic acid . . . . . . . . . . 49hydrocortisone butyrate crea . . . . . . . 40hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 40hydrocortisone butyrate (lipid) . . . . . . 40hydrocortisone butyrate (lipophilic) . . 40hydrocortisone butyrate oint . . . . . . . 40hydrocortisone enem . . . . . . . . . . . . . . 47hydrocortisone external crea . . . . . . . 40hydrocortisone lotn 2.5% . . . . . . . . . . . 40hydrocortisone oint 1%, 2.5% . . . . . . 40hydrocortisone rectal crea . . . . . . . . . 40hydrocortisone tabs . . . . . . . . . . . . . . . 40hydrocortisone valerate . . . . . . . . . . . . 40hydromorphone hcl dosette . . . . . . . . . 8hydromorphone hcl inj . . . . . . . . . . . . . . 8hydromorphone hcl liqd . . . . . . . . . . . . 8hydromorphone hcl tabs 2mg, 4mg . . 8hydromorphone hcl tabs 8mg . . . . . . . . 8hydroxychloroquine sulfate . . . . . . . . . 22hydroxyprogesterone caproate . . . . . 44hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 19hyoscyamine sulfate elix . . . . . . . . . . . 38hyoscyamine sulfate odt . . . . . . . . . . . 38hyoscyamine sulfate subl . . . . . . . . . . 38hyoscyamine sulfate tabs . . . . . . . . . . 38hyoscyamine sulfate tbdp . . . . . . . . . . 38

Iibandronate sodium tabs . . . . . . . . . . 47IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 21ibudone tabs 5mg; 200mg . . . . . . . . . . . 8ibuprofen susp . . . . . . . . . . . . . . . . . . . . . 7ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . . 7ibu tabs 600mg, 800mg . . . . . . . . . . . . . 7ICLUSIG TABS 15MG . . . . . . . . . . . . . 21ICLUSIG TABS 45MG . . . . . . . . . . . . . 21idarubicin hcl inj 10mg/10ml . . . . . . . . 19

HUMALOG MIX 75/25 KWIKPEN . . . 28HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 45HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 45HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ . . . . 45HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML . . . . . . . . 45HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 45HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 45HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 45HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 45HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 45HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 28HUMULIN 70/30 KWIKPEN . . . . . . . . 28HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 28HUMULIN N KWIKPEN . . . . . . . . . . . . 28HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 28HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 28HUMULIN R U-500 KWIKPEN. . . . . . 28hydralazine hcl inj . . . . . . . . . . . . . . . . . 33hydralazine hcl tabs . . . . . . . . . . . . . . . 33hydrochlorothiazide . . . . . . . . . . . . . . . . 32hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . . 8hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . . 8hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg . . . . . . . . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . . . . . . . . . . 8

granisetron hcl tabs . . . . . . . . . . . . . . . 16griseofulvin microsize . . . . . . . . . . . . . . 17griseofulvin ultramicrosize . . . . . . . . . . 17GUANIDINE HCL . . . . . . . . . . . . . . . . . . 18

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 19halobetasol propionate . . . . . . . . . . . . . 40haloperidol conc . . . . . . . . . . . . . . . . . . 23haloperidol decanoate . . . . . . . . . . . . . 23haloperidol lactate . . . . . . . . . . . . . . . . . 23haloperidol tabs 0.5mg, 1mg, 2mg, 5mg . . . . . . . . . . . . 23haloperidol tabs 10mg, 20mg . . . . . . . 23HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 24HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 46heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 44heparin sodium/d5w . . . . . . . . . . . . . . . 29heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 29heparin sodium/nacl 0.9% . . . . . . . . . . 29heparin sodium/ nacl 0.45% inj 50unit/ml; 0.45% . . . . 29heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 29heparin sodium/ sodium chloride 0.9% premix . . . . . . . 29HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 36HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 46HERCEPTIN INJ 150MG . . . . . . . . . . . 21HERCEPTIN INJ 440MG . . . . . . . . . . . 21HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 34HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 18HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 46HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 28HUMALOG JUNIOR KWIKPEN . . . . 28HUMALOG KWIKPEN . . . . . . . . . . . . . 28HUMALOG MIX 50/50 . . . . . . . . . . . . . 28HUMALOG MIX 50/50 KWIKPEN . . . 28HUMALOG MIX 75/25 . . . . . . . . . . . . . 28

62


Covered Drugs Index

isosorbide dinitrate er . . . . . . . . . . . . . . 33isosorbide dinitrate tabs . . . . . . . . . . . 33isosorbide mononitrate . . . . . . . . . . . . . 33isosorbide mononitrate er . . . . . . . . . . 33isotonic gentamicin . . . . . . . . . . . . . . . . . 9isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 35isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 31ISTODAX (OVERFILL) . . . . . . . . . . . . . 19itraconazole caps . . . . . . . . . . . . . . . . . 17itraconazole oral soln . . . . . . . . . . . . . . 17ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 22IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 37JADENU SPRINKLE . . . . . . . . . . . . . . . 37JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 21jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 29JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 27JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 27JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 27JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 27JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 27jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 44JENTADUETO . . . . . . . . . . . . . . . . . . . . 27JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 27JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 27jevantique lo . . . . . . . . . . . . . . . . . . . . . . 42JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 20jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 44juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 25junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 42junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 42junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 42

INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 23INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 23INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 23INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 23INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 23INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 23INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 23INVIRASE CAPS . . . . . . . . . . . . . . . . . 26INVIRASE TABS . . . . . . . . . . . . . . . . . . 26INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 27INVOKAMET XR . . . . . . . . . . . . . . . . . . 27INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 27IPOL INACTIVATED IPV . . . . . . . . . . . 46ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 49ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 49ipratropium bromide nasal soln . . . . . 49irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 30irbesartan/hydrochlorothiazide . . . . . . 30IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 21irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 19irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 19irinotecan hydrochloride inj 40mg/2ml . . . . . . . . . . . . . . . . . . . . . . . . . 19ISENTRESS CHEW 25MG . . . . . . . . . 25ISENTRESS CHEW 100MG . . . . . . . 25ISENTRESS HD . . . . . . . . . . . . . . . . . . . 25ISENTRESS PACK . . . . . . . . . . . . . . . 25ISENTRESS TABS . . . . . . . . . . . . . . . . 25isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 42isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 18isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 18isoniazid tabs 100mg . . . . . . . . . . . . . . 18isoniazid tabs 300mg . . . . . . . . . . . . . . 18

IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 18ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 48imatinib mesylate . . . . . . . . . . . . . . . . . . 21IMBRUVICA CAPS 70MG . . . . . . . . . . 21IMBRUVICA CAPS 140MG. . . . . . . . . 21IMBRUVICA TABS . . . . . . . . . . . . . . . . 21IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 21imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 11imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 11imipramine hcl tabs 25mg, 50mg . . . 16imipramine hydrochloride . . . . . . . . . . 16imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 35imiquimod pump . . . . . . . . . . . . . . . . . . . 35IMOVAX RABIES (H.D.C.V.) . . . . . . . 46incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 44INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 41INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 49indapamide . . . . . . . . . . . . . . . . . . . . . . . 32INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 46INFUMORPH 200 . . . . . . . . . . . . . . . . . . 7INFUMORPH 500 . . . . . . . . . . . . . . . . . . 7INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 21INTELENCE TABS 25MG . . . . . . . . . . 25INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 25INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 47INTRON A INJ 10MU, 10MU/ML, 50MU . . . . . . . . . . . 24INTRON A INJ 18MU, 6000000UNIT/ML . . . . . . . . . . . 24introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 42INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 11INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 23INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 23

63


Covered Drugs Index

LENVIMA 12MG DAILY DOSE . . . . . 21LENVIMA 14 MG DAILY DOSE . . . . . 21LENVIMA 18 MG DAILY DOSE . . . . . 21LENVIMA 20 MG DAILY DOSE . . . . . 21LENVIMA 24 MG DAILY DOSE . . . . . 21lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 50letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 20leucovorin calcium inj 100mg, 350mg, 500mg, 50mg . . . . . . 20leucovorin calcium tabs . . . . . . . . . . . 20LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 18LEUKINE INJ 250MCG . . . . . . . . . . . . 29leuprolide acetate . . . . . . . . . . . . . . . . . 44levalbuterol tartrate hfa . . . . . . . . . . . . 50LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 28LEVEMIR FLEXTOUCH . . . . . . . . . . . 28levetiracetam er tb24 500mg . . . . . . . 13levetiracetam er tb24 750mg . . . . . . . 13levetiracetam inj . . . . . . . . . . . . . . . . . . 13levetiracetam oral soln . . . . . . . . . . . . 13levetiracetam tabs . . . . . . . . . . . . . . . . 13levobunolol hcl . . . . . . . . . . . . . . . . . . . . 49levocarnitine . . . . . . . . . . . . . . . . . . . . . . 47levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 49levocetirizine dihydrochloride tabs . . 49levofloxacin in d5w . . . . . . . . . . . . . . . . 12levofloxacin inj . . . . . . . . . . . . . . . . . . . . 12levofloxacin oral soln . . . . . . . . . . . . . . 12levofloxacin tabs . . . . . . . . . . . . . . . . . . 12levoleucovorin calcium inj 175mg/17.5ml . . . . . . . . . . . . . . . . . . . . . 20levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . . . . . . . . . . . . . . . 20levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 42levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 42levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 42

KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 47kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 39KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 20

Llabetalol hcl inj . . . . . . . . . . . . . . . . . . . . 31labetalol hcl tabs . . . . . . . . . . . . . . . . . . 31LACRISERT . . . . . . . . . . . . . . . . . . . . . . 48LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 36LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 47LACTATED RINGERS VIAFLEX . . . . 36lactulose oral soln . . . . . . . . . . . . . . . . . 39lamivudine oral soln . . . . . . . . . . . . . . . 25lamivudine tabs 100mg . . . . . . . . . . . . 24lamivudine tabs 150mg . . . . . . . . . . . . 25lamivudine tabs 300mg . . . . . . . . . . . . 25lamivudine/zidovudine . . . . . . . . . . . . . 25lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 14lamotrigine er . . . . . . . . . . . . . . . . . . . . . 14lamotrigine odt . . . . . . . . . . . . . . . . . . . . 14LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 28LANTUS SOLOSTAR . . . . . . . . . . . . . . 28larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 42larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 42larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 42larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 42larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 20latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 48LATUDA TABS 80MG . . . . . . . . . . . . . . 23LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 23leflunomide . . . . . . . . . . . . . . . . . . . . . . . 46LENVIMA 4 MG DAILY DOSE . . . . . . 21LENVIMA 8 MG DAILY DOSE . . . . . . 21LENVIMA 10 MG DAILY DOSE . . . . . 21

junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 42

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 36KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 21KALETRA ORAL SOLN . . . . . . . . . . . 26KALETRA TABS 100MG; 25MG . . . . 26KALETRA TABS 200MG; 50MG . . . . 26KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 50kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . . 36kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 36kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . . . 36kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 36kcl 0.15%/d5w/nacl 0.45% . . . . . . . . . 36kcl 0.15%/d5w/nacl 0.225% . . . . . . . . 36kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 36kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 42kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 42ketoconazole crea . . . . . . . . . . . . . . . . 17ketoconazole sham . . . . . . . . . . . . . . . 17ketoconazole tabs . . . . . . . . . . . . . . . . . 17ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 48KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 21kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 42KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 45KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 46kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 20KISQALI FEMARA 200 DOSE . . . . . . 18KISQALI FEMARA 400 DOSE . . . . . . 18KISQALI FEMARA 600 DOSE . . . . . . 18klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 36klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 36klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 36klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 36klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 36klor-con sprinkle . . . . . . . . . . . . . . . . . . . 36

64


Covered Drugs Index

LUPRON DEPOT (3-MONTH) . . . . . . 44LUPRON DEPOT (4-MONTH) . . . . . . 44LUPRON DEPOT (6-MONTH) . . . . . . 44LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 44LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 44lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43LYNPARZA CAPS . . . . . . . . . . . . . . . . 21LYNPARZA TABS . . . . . . . . . . . . . . . . . 20LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 13LYRICA CAPS 225MG, 300MG . . . . . 13LYRICA CR TB24 165MG, 82.5MG . . 34LYRICA CR TB24 330MG . . . . . . . . . . 34LYRICA ORAL SOLN . . . . . . . . . . . . . . 13LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 44lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Mmagnesium sulfate in d5w . . . . . . . . . . 13MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML . . . . . . . . . . . . . . . . . . . . . . . . 36magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 36MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 43MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 44malathion . . . . . . . . . . . . . . . . . . . . . . . . . 22maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 15marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 43MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 15MATULANE . . . . . . . . . . . . . . . . . . . . . . . 18matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 31meclizine hcl tabs . . . . . . . . . . . . . . . . . 16meclofenamate sodium . . . . . . . . . . . . . 7MEDROL TABS 2MG . . . . . . . . . . . . . . 40

lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 27lithium carbonate caps 300mg . . . . . . 27lithium carbonate er . . . . . . . . . . . . . . . . 27lithium carbonate tabs . . . . . . . . . . . . . 27LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 33LONSURF TABS 6.14MG; 15MG . . . 19LONSURF TABS 8.19MG; 20MG . . . 19loperamide hcl caps . . . . . . . . . . . . . . . 38lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 26lorazepam conc . . . . . . . . . . . . . . . . . . . 27lorazepam inj 2mg/ml, 4mg/ml . . . . . . 27lorazepam intensol . . . . . . . . . . . . . . . . 27lorazepam tabs 0.5mg, 1mg . . . . . . . . 27lorazepam tabs 2mg . . . . . . . . . . . . . . . 27lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet plus tabs 325mg; 7.5mg . . . . . . . 8losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 30losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 30losartan potassium tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 30losartan potassium tabs 100mg . . . . . 30LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 48lovastatin tabs 10mg, 20mg . . . . . . . . 33lovastatin tabs 40mg . . . . . . . . . . . . . . . 33low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 43loxapine caps 10mg, 5mg . . . . . . . . . . 23loxapine caps 25mg, 50mg . . . . . . . . . 23loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 23loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 23ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 48LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 39LUPRON DEPOT (1-MONTH) . . . . . . 44

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 42levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 43levorphanol tartrate . . . . . . . . . . . . . . . . . 7levothyroxine sodium tabs . . . . . . . . . 44levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 44LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . . 44LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 26LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 26LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46lidocaine hcl external soln . . . . . . . . . . 9lidocaine hcl gel . . . . . . . . . . . . . . . . . . . . 9lidocaine hcl inj . . . . . . . . . . . . . . . . . . . . 9lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 30lidocaine hcl jelly . . . . . . . . . . . . . . . . . . . 9lidocaine hcl mouth/throat soln . . . . . . 9lidocaine hcl viscous . . . . . . . . . . . . . . . . 9lidocaine oint . . . . . . . . . . . . . . . . . . . . . . 9lidocaine/prilocaine crea . . . . . . . . . . . . 9lidocaine ptch . . . . . . . . . . . . . . . . . . . . . . 9lidocaine viscous . . . . . . . . . . . . . . . . . . . 9lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 10lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 10linezolid susr . . . . . . . . . . . . . . . . . . . . . 10linezolid tabs . . . . . . . . . . . . . . . . . . . . . 10LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 38liothyronine sodium inj . . . . . . . . . . . . . 44liothyronine sodium tabs . . . . . . . . . . . 44lipodox 50 . . . . . . . . . . . . . . . . . . . . . . . . . 20LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 47lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 30lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 30lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 30

65


Covered Drugs Index

metoclopramide hcl tabs . . . . . . . . . . . 38metolazone . . . . . . . . . . . . . . . . . . . . . . . 32metoprolol/hydrochlorothiazide . . . . . 31metoprolol succinate er . . . . . . . . . . . . 31metoprolol tartrate inj . . . . . . . . . . . . . . 31metoprolol tartrate tabs . . . . . . . . . . . . 31metronidazole crea . . . . . . . . . . . . . . . . 10metronidazole gel . . . . . . . . . . . . . . . . . 10metronidazole inj 500mg/100ml; 0.79%, 5mg/ml . . . . . . 10metronidazole in nacl 0.79% . . . . . . . 10metronidazole lotn . . . . . . . . . . . . . . . . 10metronidazole tabs . . . . . . . . . . . . . . . . 10metronidazole vaginal . . . . . . . . . . . . . . 10mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 30MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 47mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 43microgestin 1.5/30 . . . . . . . . . . . . . . . . . 43microgestin 1/20 . . . . . . . . . . . . . . . . . . . 43microgestin fe . . . . . . . . . . . . . . . . . . . . . 43microgestin fe 1.5/30 . . . . . . . . . . . . . . 43midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 29migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 17miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 39mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 33MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 43minocycline hcl . . . . . . . . . . . . . . . . . . . . 13minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 33mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 15mirtazapine odt . . . . . . . . . . . . . . . . . . . . 15misoprostol . . . . . . . . . . . . . . . . . . . . . . . 39MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 17mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7mitomycin inj 20mg, 5mg . . . . . . . . . . . 20mitomycin inj 40mg . . . . . . . . . . . . . . . . 20mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 20M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 46modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 50

metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 28methadone hcl conc . . . . . . . . . . . . . . . . 7methadone hcl inj . . . . . . . . . . . . . . . . . . 7methadone hcl intensol . . . . . . . . . . . . . 7methadone hcl oral soln 5mg/5ml . . . . 7methadone hcl oral soln 10mg/5ml . . . 7methadone hcl tabs 5mg . . . . . . . . . . . . 7methadone hcl tabs 10mg . . . . . . . . . . . 7methazolamide . . . . . . . . . . . . . . . . . . . . 32methenamine hippurate . . . . . . . . . . . . 10methimazole . . . . . . . . . . . . . . . . . . . . . . 45methocarbamol tabs . . . . . . . . . . . . . . 50methotrexate sodium . . . . . . . . . . . . . . 45methotrexate tabs . . . . . . . . . . . . . . . . . 45methoxsalen . . . . . . . . . . . . . . . . . . . . . . 35methscopolamine bromide . . . . . . . . . 38methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 34methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 34methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 34methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg . . . . . . . . . 34methylphenidate hydrochloride er tbcr 18mg . . . . . . . . . . . . . . . . . . . . . . 34methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 34methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 34methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 34methylprednisolone acetate inj 40mg/ml, 80mg/ml . . . . . . . . . . . . . . 40methylprednisolone dose pack . . . . . 40methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 41methylprednisolone tabs . . . . . . . . . . . 41metipranolol . . . . . . . . . . . . . . . . . . . . . . . 49metoclopramide hcl inj . . . . . . . . . . . . 38metoclopramide hcl oral soln . . . . . . 38

medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . . . . . . . . 44medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . . . . . . . . 44medroxyprogesterone acetate tabs . . 44mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 22megestrol acetate susp 40mg/ml . . . 44megestrol acetate tabs . . . . . . . . . . . . 44MEKINIST TABS 0.5MG . . . . . . . . . . . 21MEKINIST TABS 2MG . . . . . . . . . . . . . 21MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 20melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 43meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . 7melphalan hydrochloride . . . . . . . . . . . 18memantine hcl tabs 5mg . . . . . . . . . . . 15memantine hcl tabs 10mg . . . . . . . . . . 15memantine hcl titration pak . . . . . . . . . 15memantine hydrochloride er . . . . . . . . 15memantine hydrochloride oral soln . . 15MENACTRA . . . . . . . . . . . . . . . . . . . . . . 46MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 43MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 43MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 46mercaptopurine . . . . . . . . . . . . . . . . . . . . 19meropenem . . . . . . . . . . . . . . . . . . . . . . . 11meropenem/sodium chloride . . . . . . . 11mesalamine . . . . . . . . . . . . . . . . . . . . . . . 47mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20MESNEX TABS . . . . . . . . . . . . . . . . . . . 20metadate er . . . . . . . . . . . . . . . . . . . . . . . 34metaproterenol sulfate . . . . . . . . . . . . . 50metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 27metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 27metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet) . . . . . . 27metformin hcl tabs 850mg . . . . . . . . . . 27metformin hcl tabs 1000mg . . . . . . . . 27metformin hydrochloride oral soln . . 27

66


Covered Drugs Index

naproxen susp . . . . . . . . . . . . . . . . . . . . . 7naproxen tabs 250mg . . . . . . . . . . . . . . . 7naproxen tabs 375mg, 500mg . . . . . . . 7naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 17NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . . 9NASONEX . . . . . . . . . . . . . . . . . . . . . . . . 49NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 17nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 28NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 47NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 22necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 43necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 43nefazodone hcl . . . . . . . . . . . . . . . . . . . . 15nefazodone hydrochloride . . . . . . . . . . 15neomycin/bacitracin/polymyxin . . . . . 10neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 10neomycin/polymyxin b sulfates . . . . . . 9neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 48neomycin/polymyxin/gramicidin . . . . . 10neomycin/polymyxin/hc . . . . . . . . . . . . 49neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 10neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 49neomycin sulfate . . . . . . . . . . . . . . . . . . . 9neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 10neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 10NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 36NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 20NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 22nevirapine er tb24 100mg . . . . . . . . . . 25nevirapine er tb24 400mg . . . . . . . . . . 25nevirapine tabs . . . . . . . . . . . . . . . . . . . 25NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 21niacin er tbcr 500mg . . . . . . . . . . . . . . . 33niacin er tbcr 1000mg, 750mg . . . . . . 33niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33nicardipine hcl caps . . . . . . . . . . . . . . . 31

moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 12MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 29MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 30multivitamin with fluoride chew . . . . . 38mupirocin crea . . . . . . . . . . . . . . . . . . . . 10mupirocin oint . . . . . . . . . . . . . . . . . . . . 10MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 18mycophenolate mofetil caps . . . . . . . 45mycophenolate mofetil inj . . . . . . . . . . 45mycophenolate mofetil susr . . . . . . . . 45mycophenolate mofetil tabs . . . . . . . . 45mycophenolic acid dr . . . . . . . . . . . . . . 45MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 21myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 35MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 39myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . . 7nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31nadolol/bendroflumethiazide . . . . . . . . 31nafcillin sodium inj 2gm . . . . . . . . . . . . 11nafcillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 11naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 17naftifine hydrochloride . . . . . . . . . . . . . 17NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 17NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 39nalbuphine hcl inj 10mg/ml . . . . . . . . . . 8nalbuphine hcl inj 20mg/ml . . . . . . . . . . 8naloxone hcl . . . . . . . . . . . . . . . . . . . . . . . 9naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . 9NAMENDA XR . . . . . . . . . . . . . . . . . . . . 15NAMENDA XR TITRATION PACK . . 15NAMZARIC C4PK . . . . . . . . . . . . . . . . 14NAMZARIC CP24 . . . . . . . . . . . . . . . . . 14naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . . 7

moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 30moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . . . . . . 30moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . . . . . . 30mometasone furoate crea . . . . . . . . . 41mometasone furoate external soln . 41mometasone furoate oint . . . . . . . . . . 41mometasone furoate susp . . . . . . . . . 49mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 13mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 43montelukast sodium . . . . . . . . . . . . . . . 49morgidox 1x50mg . . . . . . . . . . . . . . . . . 13morgidox 1x100mg caps . . . . . . . . . . 13morgidox 2x100mg caps . . . . . . . . . . 13morphine sulfate er tbcr . . . . . . . . . . . . 7morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . . 7MORPHINE SULFATE INJ 1MG/ML . . . 8MORPHINE SULFATE INJ 2MG/ML . . . 8MORPHINE SULFATE INJ 4MG/ML . . . 8morphine sulfate inj 5mg/ml . . . . . . . . . 8MORPHINE SULFATE INJ 8MG/ML . . . 8morphine sulfate inj 8mg/ml . . . . . . . . . 8MORPHINE SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 8morphine sulfate inj 10mg/ml . . . . . . . . 8MORPHINE SULFATE INJ 150MG/30ML, 50MG/ML . . . . . . . . . . . . 8morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . . 8MORPHINE SULFATE TABS . . . . . . . 8MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 39moxifloxacin hcl inj . . . . . . . . . . . . . . . . 12moxifloxacin hcl tabs . . . . . . . . . . . . . . 12moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 12

67


Covered Drugs Index

olanzapine tabs . . . . . . . . . . . . . . . . . . . 23olmesartan medoxomil . . . . . . . . . . . . . 30olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 30olopatadine hcl ophthalmic soln . . . . 48olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 48omega-3-acid ethyl esters . . . . . . . . . . 33omeprazole cpdr . . . . . . . . . . . . . . . . . . 39OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 48OMNIPOD DASH 5 PACK. . . . . . . . . . 48OMNIPOD DASH SYSTEM . . . . . . . . 48OMNIPOD STARTER KIT . . . . . . . . . . 48ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 16ondansetron hcl oral soln . . . . . . . . . . 16ondansetron hcl tabs 4mg, 8mg . . . . 16ondansetron hcl tabs 24mg . . . . . . . . 16ondansetron odt . . . . . . . . . . . . . . . . . . . 16ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 14ONFI TABS 10MG . . . . . . . . . . . . . . . . . 14ONFI TABS 20MG . . . . . . . . . . . . . . . . . 14OPDIVO INJ 100MG/10ML, 40MG/4ML . . . . . . . . . . 21OPDIVO INJ 240MG/24ML . . . . . . . . . 21OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 50oralone dental paste . . . . . . . . . . . . . . . 34ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 39ORKAMBI PACK . . . . . . . . . . . . . . . . . . 50ORKAMBI TABS . . . . . . . . . . . . . . . . . . 50orphenadrine citrate er . . . . . . . . . . . . . 50orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 43oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 38oseltamivir phosphate caps 30mg . . 26oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 26oseltamivir phosphate susr . . . . . . . . 26OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 38oxacillin sodium . . . . . . . . . . . . . . . . . . . 11oxaliplatin inj 100mg . . . . . . . . . . . . . . . 20

nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 43nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 43nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 43nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 16NORVIR CAPS . . . . . . . . . . . . . . . . . . . 26NORVIR ORAL SOLN . . . . . . . . . . . . . 26NORVIR PACK . . . . . . . . . . . . . . . . . . . 26NORVIR TABS . . . . . . . . . . . . . . . . . . . . 26NOVAREL . . . . . . . . . . . . . . . . . . . . . . . . 41novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 47novofine 32gx6mm . . . . . . . . . . . . . . . . 48novofine autocover 30gx8mm . . . . . . 48novotwist 32gx5mm . . . . . . . . . . . . . . . 48NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 17NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 17NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 34nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 45NUPLAZID CAPS . . . . . . . . . . . . . . . . . 23NUPLAZID TABS 10MG . . . . . . . . . . . 23NUPLAZID TABS 17MG . . . . . . . . . . . 23NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 48nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 17nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 17nystatin/triamcinolone . . . . . . . . . . . . . . 17nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Ooctreotide acetate inj 500mcg/ml . . . 44octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 44ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 25ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 20OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 12ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 43olanzapine/fluoxetine . . . . . . . . . . . . . . 16olanzapine inj . . . . . . . . . . . . . . . . . . . . . 23olanzapine odt . . . . . . . . . . . . . . . . . . . . 23

nicardipine hcl inj . . . . . . . . . . . . . . . . . 32NICOTROL INHALER. . . . . . . . . . . . . . . 9NICOTROL NS . . . . . . . . . . . . . . . . . . . . . 9nifedipine er tb24 30mg, 60mg . . . . . 32nifedipine er tb24 90mg . . . . . . . . . . . . 32nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 18nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 32NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 20NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 19nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg . . . . . . . 32nisoldipine er tb24 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 32nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 10nitrofurantoin macrocrystals . . . . . . . . 10nitrofurantoin monohydrate . . . . . . . . . 10nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 10nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 33nitroglycerin lingual . . . . . . . . . . . . . . . . 33nitroglycerin subl . . . . . . . . . . . . . . . . . . 33nitroglycerin transdermal . . . . . . . . . . . 33nizatidine caps . . . . . . . . . . . . . . . . . . . . 38nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 44norethindrone . . . . . . . . . . . . . . . . . . . . . 44norethindrone acetate . . . . . . . . . . . . . . 44norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 43norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 43norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 43norgestimate/ethinyl estradiol . . . . . . 43norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 44NORMOSOL-M IN D5W . . . . . . . . . . . 36NORMOSOL -R . . . . . . . . . . . . . . . . . . . 36NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 36NORMOSOL-R IN D5W. . . . . . . . . . . . 36NORTHERA CAPS 100MG . . . . . . . . 32NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 32

68


Covered Drugs Index

phenazopyridine hydrochloride . . . . . 40phenazopyridine hydrocholride . . . . . 40phenelzine sulfate . . . . . . . . . . . . . . . . . 15phenobarbital elix . . . . . . . . . . . . . . . . . 14phenobarbital tabs . . . . . . . . . . . . . . . . 14phenoxybenzamine hydrochloride . . 29phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 14phenytoin infatabs . . . . . . . . . . . . . . . . . 14phenytoin sodium . . . . . . . . . . . . . . . . . . 14phenytoin sodium extended . . . . . . . . 14philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 38PHOSPHOLINE IODIDE . . . . . . . . . . . 49PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 48physiosol irrigation . . . . . . . . . . . . . . . . . 48PICATO GEL 0.05% . . . . . . . . . . . . . . . 35PICATO GEL 0.015% . . . . . . . . . . . . . . 35pilocarpine hcl ophthalmic soln . . . . . 49pilocarpine hcl tabs . . . . . . . . . . . . . . . 34pilocarpine hydrochloride . . . . . . . . . . . 34pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 23pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 43pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 31pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 28pioglitazone hcl/metformin hcl . . . . . . 28piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 12piperacillin/tazobactam . . . . . . . . . . . . . 12pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 43pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 43piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . . 7PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 36podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 35polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10polyethylene glycol 3350 powd . . . . . 39polymyxin b sulfate . . . . . . . . . . . . . . . . 10polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 10POMALYST . . . . . . . . . . . . . . . . . . . . . . . 18portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 43

PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 22pantoprazole sodium tbec . . . . . . . . . 39paricalcitol caps 1mcg, 2mcg . . . . . . . 47paricalcitol caps 4mcg . . . . . . . . . . . . . 47paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34paromomycin sulfate . . . . . . . . . . . . . . . . 9paroxetine hcl er tb24 12.5mg . . . . . . 16paroxetine hcl er tb24 25mg, 37.5mg . . . . . . . . . . . . . . . . . . . . . 16paroxetine hcl tabs 10mg . . . . . . . . . . 16paroxetine hcl tabs 20mg . . . . . . . . . . 16paroxetine hcl tabs 30mg, 40mg . . . . 16PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 16PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 48PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 46PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 46peg 3350/electrolytes . . . . . . . . . . . . . . 39peg-3350/electrolytes . . . . . . . . . . . . . . 39peg-3350/nacl/na bicarbonate/kcl . . . 39PEGANONE . . . . . . . . . . . . . . . . . . . . . . 14PEGASYS INJ 180MCG/0.5ML . . . . . 24PEGASYS INJ 180MCG/ML . . . . . . . . 24PEGASYS PROCLICK . . . . . . . . . . . . . 24penicillin g potassium . . . . . . . . . . . . . . 12penicillin v potassium oral soln . . . . . 12penicillin v potassium tabs 250mg . . 12penicillin v potassium tabs 500mg . . 12PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 22pentoxifylline er . . . . . . . . . . . . . . . . . . . . 32PERFOROMIST . . . . . . . . . . . . . . . . . . . 50PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 36perindopril erbumine . . . . . . . . . . . . . . . 30periogard . . . . . . . . . . . . . . . . . . . . . . . . . 34PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 21permethrin . . . . . . . . . . . . . . . . . . . . . . . . 22perphenazine . . . . . . . . . . . . . . . . . . . . . 23perphenazine/amitriptyline . . . . . . . . . 16pfizerpen inj 20mu, 5000000unit . . . . 12phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 16

oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 20oxandrolone tabs 2.5mg . . . . . . . . . . . 41oxandrolone tabs 10mg . . . . . . . . . . . . 41oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . . 7oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 27oxcarbazepine . . . . . . . . . . . . . . . . . . . . 14oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 39oxybutynin chloride er tb24 15mg . . . 39oxybutynin chloride syrp . . . . . . . . . . . 39oxybutynin chloride tabs . . . . . . . . . . . 39oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . . 8oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . . 8oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . . 8oxycodone/aspirin . . . . . . . . . . . . . . . . . . 8oxycodone hcl caps . . . . . . . . . . . . . . . . 8oxycodone hcl conc . . . . . . . . . . . . . . . . 8oxycodone hcl oral soln . . . . . . . . . . . . 8oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . . 8oxycodone hcl tabs 30mg . . . . . . . . . . . 8oxycodone/ibuprofen . . . . . . . . . . . . . . . 8OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 28

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 30paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 20paliperidone er tb24 1.5mg, 3mg . . . 24paliperidone er tb24 6mg . . . . . . . . . . . 24paliperidone er tb24 9mg . . . . . . . . . . . 24PALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML . . . . . . . . . . . . . . . . . . . . . . 16palonosetron hydrochloride inj 0.25mg/5ml . . . . . . . . . . . . . . . . . . . . . . . 16pamidronate disodium . . . . . . . . . . . . . 47

69


Covered Drugs Index

PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 18PRIMAQUINE PHOSPHATE . . . . . . . 22primidone . . . . . . . . . . . . . . . . . . . . . . . . . 14PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 16PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 50PROAIR RESPICLICK . . . . . . . . . . . . . 50probenecid . . . . . . . . . . . . . . . . . . . . . . . . 17probenecid/colchicine . . . . . . . . . . . . . . 17PROCALAMINE . . . . . . . . . . . . . . . . . . . 37prochlorperazine . . . . . . . . . . . . . . . . . . 23prochlorperazine edisylate . . . . . . . . . 23prochlorperazine maleate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 23prochlorperazine maleate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 23PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 29PROCRIT INJ 20000UNIT/ML . . . . . . 29PROCRIT INJ 40000UNIT/ML . . . . . . 29procto-med hc . . . . . . . . . . . . . . . . . . . . . 41procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 41proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 41proctozone-hc . . . . . . . . . . . . . . . . . . . . . 41progesterone caps . . . . . . . . . . . . . . . . 44PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 28PROGRAF INJ . . . . . . . . . . . . . . . . . . . 45PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 50PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 48PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 20PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 47PROMACTA . . . . . . . . . . . . . . . . . . . . . . 29promethazine hcl supp . . . . . . . . . . . . 16promethazine hcl syrp . . . . . . . . . . . . . 16promethazine hcl tabs . . . . . . . . . . . . . 16promethazine hydrochloride tabs 50mg . . . . . . . . . . . . . . . . . . . . . . . . 16promethegan . . . . . . . . . . . . . . . . . . . . . . 16propafenone hcl . . . . . . . . . . . . . . . . . . . 30propafenone hcl er cp12 225mg, 325mg . . . . . . . . . . . . . . . . . . . . 30

prednisolone sodium phosphate ophthalmic soln . . . . . . . . 48prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 41prednisone intensol . . . . . . . . . . . . . . . . 41prednisone oral soln . . . . . . . . . . . . . . 41prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 41prednisone tabs 50mg . . . . . . . . . . . . . 41prednisone tbpk . . . . . . . . . . . . . . . . . . . 41PREGNYL W/DILUENT BENZYL ALCOHOL/NACL . . . . . . . . . 41PREMARIN CREA . . . . . . . . . . . . . . . . 43PREMARIN INJ . . . . . . . . . . . . . . . . . . . 43PREMARIN TABS . . . . . . . . . . . . . . . . 43PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . 37premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml . . . . . . . 37prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 33previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 43PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 26PREZISTA SUSP . . . . . . . . . . . . . . . . . 26PREZISTA TABS 75MG . . . . . . . . . . . . 26PREZISTA TABS 150MG . . . . . . . . . . . 26PREZISTA TABS 600MG . . . . . . . . . . . 26PREZISTA TABS 800MG . . . . . . . . . . . 26

PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 20potassium chloride cr . . . . . . . . . . . . . . 36potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . . . 37potassium chloride/dextrose/ lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l . . . . . . . . . . . . . . . . . 37POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L . . . . 37potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 37potassium chloride er cpcr . . . . . . . . . 36potassium chloride er tbcr . . . . . . . . . 36potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 37potassium chloride oral soln . . . . . . . 37potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 37potassium chloride sr . . . . . . . . . . . . . . 37potassium citrate er . . . . . . . . . . . . . . . . 37POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 21PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 29PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 32pramipexole dihydrochloride . . . . . . . . 22pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 22pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 22prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 29pravastatin sodium . . . . . . . . . . . . . . . . 33praziquantel . . . . . . . . . . . . . . . . . . . . . . . 22prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 30PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 48PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 48PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 48prednicarbate oint . . . . . . . . . . . . . . . . . 41prednisolone . . . . . . . . . . . . . . . . . . . . . . 41prednisolone acetate . . . . . . . . . . . . . . 48

70


Covered Drugs Index

REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 18REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 24REYATAZ CAPS 150MG, 300MG . . . 26REYATAZ CAPS 200MG . . . . . . . . . . . 26REYATAZ PACK . . . . . . . . . . . . . . . . . . 26ribavirin caps . . . . . . . . . . . . . . . . . . . . . 24ribavirin inhalation soln . . . . . . . . . . . . 50ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 24RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 46rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 18rifampin caps . . . . . . . . . . . . . . . . . . . . . 18rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 18RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 18riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34rimantadine hcl . . . . . . . . . . . . . . . . . . . . 26ringers injection . . . . . . . . . . . . . . . . . . . 37RINGERS IRRIGATION . . . . . . . . . . . . 48RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 28risedronate sodium tabs 30mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 47risedronate sodium tabs 35mg . . . . . 47risedronate sodium tabs 150mg . . . . 47RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 24RISPERDAL CONSTA INJ 50MG . . . 24risperidone m-tab . . . . . . . . . . . . . . . . . . 24risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 24risperidone odt tbdp 4mg . . . . . . . . . . . 24risperidone oral soln . . . . . . . . . . . . . . 24risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 24risperidone tabs 4mg . . . . . . . . . . . . . . 24ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 26RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 22RITUXAN HYCELA . . . . . . . . . . . . . . . . 22rivastigmine tartrate . . . . . . . . . . . . . . . . 15rivastigmine transdermal system . . . . 15rizatriptan benzoate . . . . . . . . . . . . . . . . 17rizatriptan benzoate odt . . . . . . . . . . . . 17

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 46raloxifene hydrochloride . . . . . . . . . . . . 44ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 30RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 32ranitidine hcl caps . . . . . . . . . . . . . . . . . 38ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 38ranitidine hcl syrp . . . . . . . . . . . . . . . . . 38ranitidine hcl tabs . . . . . . . . . . . . . . . . . 38RAPAMUNE ORAL SOLN . . . . . . . . . 45rasagiline mesylate . . . . . . . . . . . . . . . . 22REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REBIF REBIDOSE . . . . . . . . . . . . . . . . 34REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 34REBIF TITRATION PACK . . . . . . . . . . 34reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 43RECOMBIVAX HB . . . . . . . . . . . . . . . . . 46REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 18REGRANEX . . . . . . . . . . . . . . . . . . . . . . 35RELISTOR INJ 8MG/0.4ML . . . . . . . . 38RELISTOR INJ 12MG/0.6ML . . . . . . . 38REMICADE . . . . . . . . . . . . . . . . . . . . . . . 45REMODULIN . . . . . . . . . . . . . . . . . . . . . . 50RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 45RENVELA PACK . . . . . . . . . . . . . . . . . . 38RENVELA TABS . . . . . . . . . . . . . . . . . . 38repaglinide tabs 0.5mg, 1mg . . . . . . . 28repaglinide tabs 2mg . . . . . . . . . . . . . . 28REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 33REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 33REPATHA SURECLICK . . . . . . . . . . . . 33RESCRIPTOR TABS 100MG . . . . . . . 25RESCRIPTOR TABS 200MG . . . . . . . 25RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 48RETROVIR IV INFUSION . . . . . . . . . . 25REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 18

propafenone hydrochloride er cp12 425mg . . . . . . . . . . . . . . . . . . . . 30propantheline bromide . . . . . . . . . . . . . 38proparacaine hcl . . . . . . . . . . . . . . . . . . . 48propranolol hcl er . . . . . . . . . . . . . . . . . . 31propranolol hcl inj . . . . . . . . . . . . . . . . . 31propranolol hcl oral soln . . . . . . . . . . . 31propranolol hcl tabs 10mg, 20mg, 40mg, 80mg . . . . . . . . . 31propranolol hcl tabs 60mg . . . . . . . . . . 31propranolol hydrochloride tabs 60mg . . . . . . . . . . . . . . . . . . . . . . . . 31propranolol/hydrochlorothiazide . . . . 31propylthiouracil . . . . . . . . . . . . . . . . . . . . 45PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 46PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 37protriptyline hcl . . . . . . . . . . . . . . . . . . . . 16PULMOZYME . . . . . . . . . . . . . . . . . . . . . 50PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 19pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 18pyridostigmine bromide . . . . . . . . . . . . 18pyridostigmine bromide er . . . . . . . . . . 18

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 46quasense . . . . . . . . . . . . . . . . . . . . . . . . . 43quetiapine fumarate . . . . . . . . . . . . . . . 24quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 24quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 24quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 30quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 30quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 30quinidine sulfate . . . . . . . . . . . . . . . . . . . 30quinine sulfate . . . . . . . . . . . . . . . . . . . . . 22

71


Covered Drugs Index

sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 31sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 31sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 31sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 31sotalol hydrochloride tabs 120mg . . . 31spironolactone/hydrochlorothiazide . . 32spironolactone tabs 25mg . . . . . . . . . . 32spironolactone tabs 100mg, 50mg . . 32SPORANOX ORAL SOLN . . . . . . . . . 17sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 43SPRITAM TB3D 750MG . . . . . . . . . . . 13SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 13SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 21sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 46stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 25sterile water irrigation . . . . . . . . . . . . . . 48sterile water irrigation plastic bottle . . 48STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 41STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 21streptomycin sulfate . . . . . . . . . . . . . . . . 9STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 25SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . 9sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 39sulfacetamide sodium lotn . . . . . . . . . 12sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 12sulfacetamide sodium/ prednisolone sodium phosphate . . . . 12sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 12sulfamethoxazole/trimethoprim ds . . 13sulfamethoxazole/trimethoprim inj . . 13sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 13sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 13

sertraline hcl tabs 25mg . . . . . . . . . . . . 16sertraline hcl tabs 50mg . . . . . . . . . . . . 16sertraline hcl tabs 100mg . . . . . . . . . . 16setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 43sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 44SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 46SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 44sildenafil tabs 20mg . . . . . . . . . . . . . . . 50SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 50silver sulfadiazine . . . . . . . . . . . . . . . . . 10SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 49SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 46simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 33sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 45SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 18sodium bicarbonate inj . . . . . . . . . . . . 37sodium bicarbonate partial fill . . . . . . . 37sodium chloride 0.9% . . . . . . . . . . . . . . 48sodium chloride0.9% . . . . . . . . . . . . . . 48sodium chloride 0.45% . . . . . . . . . . . . . 37sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 37sodium fluoride chew 0.5mg, 1mg . . 37SODIUM LACTATE INJ 5MEQ/ML . . 37sodium phenylbutyrate . . . . . . . . . . . . . 39sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 37sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 38sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 12SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 28SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 19SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 41SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 44SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 44SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 44SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 45

romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 20ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 22rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 10rosuvastatin calcium . . . . . . . . . . . . . . . 33ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 46ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 46roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 13roweepra xr tb24 500mg . . . . . . . . . . . 13roweepra xr tb24 750mg . . . . . . . . . . . 13ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 50RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 20RUCONEST . . . . . . . . . . . . . . . . . . . . . . 45RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 20RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 22

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 14SABRIL TABS . . . . . . . . . . . . . . . . . . . . 14salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . 7SAMSCA TABS 15MG . . . . . . . . . . . . . 37SAMSCA TABS 30MG . . . . . . . . . . . . . 37SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 16SANDIMMUNE ORAL SOLN . . . . . . 45SANDOSTATIN LAR DEPOT . . . . . . . 44SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 35SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 24SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 29scopolamine . . . . . . . . . . . . . . . . . . . . . . 16selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 22selenium sulfide lotn . . . . . . . . . . . . . . 35SELZENTRY ORAL SOLN . . . . . . . . 25SELZENTRY TABS 25MG . . . . . . . . . 25SELZENTRY TABS 150MG, 75MG . . 25SELZENTRY TABS 300MG . . . . . . . . 25SENSIPAR TABS 30MG . . . . . . . . . . . 47SENSIPAR TABS 60MG . . . . . . . . . . . 47SENSIPAR TABS 90MG . . . . . . . . . . . 47SEREVENT DISKUS . . . . . . . . . . . . . . 50sertraline hcl conc . . . . . . . . . . . . . . . . . 16

72


Covered Drugs Index

terbinafine hcl tabs . . . . . . . . . . . . . . . . 17terbutaline sulfate . . . . . . . . . . . . . . . . . 50terconazole . . . . . . . . . . . . . . . . . . . . . . . 17testosterone cypionate . . . . . . . . . . . . . 41testosterone enanthate . . . . . . . . . . . . 41testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 41testosterone pump . . . . . . . . . . . . . . . . . 41TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 46tetrabenazine tabs 12.5mg . . . . . . . . . 34tetrabenazine tabs 25mg . . . . . . . . . . . 34tetracycline hydrochloride . . . . . . . . . . 13texacort . . . . . . . . . . . . . . . . . . . . . . . . . . . 41THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 18THALOMID CAPS 200MG . . . . . . . . . 18THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 50theophylline cr . . . . . . . . . . . . . . . . . . . . . 50theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 50theophylline er tb24 . . . . . . . . . . . . . . . 50thioridazine hcl . . . . . . . . . . . . . . . . . . . . 23thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 18thiothixene caps 2mg . . . . . . . . . . . . . . 23thiothixene caps 10mg, 1mg, 5mg . . 23THYMOGLOBULIN . . . . . . . . . . . . . . . . 46THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 44THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 44THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 44THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 44THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 44tiagabine hydrochloride tabs 2mg . . . 14tiagabine hydrochloride tabs 4mg . . . 14tiagabine hydrochloride tabs 12mg . . 14tiagabine hydrochloride tabs 16mg . . 14TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 21tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 10timolol maleate ophthalmic soln . . . . 49timolol maleate tabs . . . . . . . . . . . . . . . 31

TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 21TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 21TAMIFLU CAPS 30MG . . . . . . . . . . . . 26TAMIFLU CAPS 45MG, 75MG . . . . . 26TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 26tamoxifen citrate . . . . . . . . . . . . . . . . . . . 19tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 39TARCEVA TABS 25MG . . . . . . . . . . . . 21TARCEVA TABS 100MG, 150MG . . . 21TARGRETIN GEL . . . . . . . . . . . . . . . . . 22tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 43TASIGNA CAPS 50MG . . . . . . . . . . . . 21TASIGNA CAPS 150MG, 200MG . . . 21tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 35tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 11TAZORAC CREA . . . . . . . . . . . . . . . . . 35TAZORAC GEL . . . . . . . . . . . . . . . . . . . 35taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 32TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 22TECFIDERA CPDR 120MG . . . . . . . . 34TECFIDERA CPDR 240MG . . . . . . . . 34TECFIDERA STARTER PACK . . . . . . 34techlite pen needles/31g x 6 mm . . . 48techlite pen needles/31g x 8mm . . . . 48techlite pen needles/32g x 4mm . . . . 48techlite pen needles/32g x 6mm . . . . 48techlite pen needles/32g x 8mm . . . . 48TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 11TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 32TEKTURNA HCT . . . . . . . . . . . . . . . . . . 32telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 30telmisartan/amlodipine . . . . . . . . . . . . . 30telmisartan/hydrochlorothiazide . . . . . 30temazepam . . . . . . . . . . . . . . . . . . . . . . . 50temsirolimus . . . . . . . . . . . . . . . . . . . . . . 21TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 46tenofovir disoproxil fumarate . . . . . . . 25terazosin hcl caps 1mg, 2mg, 5mg . . 39terazosin hcl caps 10mg . . . . . . . . . . . 39

sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 47sulfatrim pediatric . . . . . . . . . . . . . . . . . . 13sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 18sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 17sumatriptan succinate tabs . . . . . . . . 18SUPRAX SUSR 500MG/5ML . . . . . . . 11SUPREP BOWEL PREP KIT . . . . . . . 39SUSTIVA CAPS 50MG . . . . . . . . . . . . . 25SUSTIVA CAPS 200MG . . . . . . . . . . . 25SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 25SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 21SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 20SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 25SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 28SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 28SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 26SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 46SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 45SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 10SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 28SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 28SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 28SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 20SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 44SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 38

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 19tacrolimus caps . . . . . . . . . . . . . . . . . . . 45tacrolimus oint . . . . . . . . . . . . . . . . . . . . 35

73


Covered Drugs Index

trimipramine maleate . . . . . . . . . . . . . . 16trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 43TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 15tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 43TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 41TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 20tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 43TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 25trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 43tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 43TROGARZO . . . . . . . . . . . . . . . . . . . . . . 26TROKENDI XR CP24 100MG, 25MG, 50MG . . . . . . . . . . . . . 14TROKENDI XR CP24 200MG . . . . . . 14TROPHAMINE . . . . . . . . . . . . . . . . . . . . 37tropicamide . . . . . . . . . . . . . . . . . . . . . . . 48TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 38TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 28TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 46TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 25TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 46TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 26tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 10TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 21TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 46TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 34

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 17UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 44UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 22ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 26valacyclovir hydrochloride . . . . . . . . . . 26VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 18valganciclovir . . . . . . . . . . . . . . . . . . . . . . 24

trazodone hydrochloride tabs 300mg . . . . . . . . . . . . . . . . . . . . . . . 15TREANDA INJ 25MG . . . . . . . . . . . . . . 18TREANDA INJ 100MG . . . . . . . . . . . . . 18TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 18TRELEGY ELLIPTA . . . . . . . . . . . . . . . 50TRELSTAR MIXJECT INJ 3.75MG . . 45TRELSTAR MIXJECT INJ 11.25MG . . 45TRELSTAR MIXJECT INJ 22.5MG . . 45TRESIBA FLEXTOUCH . . . . . . . . . . . . 28tretinoin caps . . . . . . . . . . . . . . . . . . . . . 22tretinoin crea . . . . . . . . . . . . . . . . . . . . . 35tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 35tretinoin microsphere . . . . . . . . . . . . . . 35tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 35triamcinolone acetonide crea 0.1% . . . . . . . . . . . . . . . . . . . . . . . . . 41triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 41triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 34triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 41triamcinolone acetonide lotn . . . . . . . 41triamcinolone acetonide oint . . . . . . . 41triamterene/hydrochlorothiazide . . . . 32trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41triderm crea 0.1% . . . . . . . . . . . . . . . . . 41trientine hydrochloride . . . . . . . . . . . . . 38tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 43trifluoperazine hcl . . . . . . . . . . . . . . . . . . 23trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 26trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 22tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 43tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 43trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 10trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 10tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 48TIVICAY TABS 10MG, 25MG . . . . . . . 25TIVICAY TABS 50MG . . . . . . . . . . . . . . 25tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 24TOBI PODHALER . . . . . . . . . . . . . . . . . 50TOBRADEX OINT . . . . . . . . . . . . . . . . 48tobramycin/dexamethasone . . . . . . . . 48tobramycin nebu . . . . . . . . . . . . . . . . . . 50tobramycin ophthalmic soln . . . . . . . . . 9tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . . 9tobramycin sulfate ophthalmic soln . . 9TOBREX OINT . . . . . . . . . . . . . . . . . . . . 9tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 22tolmetin sodium . . . . . . . . . . . . . . . . . . . . 7tolterodine tartrate . . . . . . . . . . . . . . . . . 39tolterodine tartrate er . . . . . . . . . . . . . . 39topiramate . . . . . . . . . . . . . . . . . . . . . . . . 14toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 20topotecan hcl inj 4mg . . . . . . . . . . . . . . 20TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 45torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 32TOUJEO MAX SOLOSTAR . . . . . . . . 28TOUJEO SOLOSTAR . . . . . . . . . . . . . . 28TPN ELECTROLYTES . . . . . . . . . . . . . 37TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 50TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 28tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . . 9tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . . 9trandolapril tabs 1mg . . . . . . . . . . . . . . 30trandolapril tabs 2mg, 4mg . . . . . . . . . 30tranexamic acid inj . . . . . . . . . . . . . . . . 29tranexamic acid tabs . . . . . . . . . . . . . . 29TRANSDERM-SCOP . . . . . . . . . . . . . . 16tranylcypromine sulfate . . . . . . . . . . . . 15TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 37TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 48trazodone hydrochloride tabs 100mg, 150mg, 50mg . . . . . . . . . . . . . . 15

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Covered Drugs Index

VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 24VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 21VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 38VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 24VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 24vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 43vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 29WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 33wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 21XARELTO STARTER PACK . . . . . . . . 29XARELTO TABS 10MG . . . . . . . . . . . . 29XARELTO TABS 15MG . . . . . . . . . . . . 29XARELTO TABS 20MG . . . . . . . . . . . . 29XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 46XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 47XIFAXAN TABS 200MG . . . . . . . . . . . . 11XIFAXAN TABS 550MG . . . . . . . . . . . . 11XIGDUO XR TB24 5MG; 1000MG . . 28XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 28XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 50XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . . 7XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 18XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 28XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

YYERVOY INJ 50MG/10ML . . . . . . . . . 22YERVOY INJ 200MG/40ML . . . . . . . . 22YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

verapamil hcl er cp24 200mg . . . . . . . 32verapamil hcl er tbcr . . . . . . . . . . . . . . 32verapamil hcl inj . . . . . . . . . . . . . . . . . . 32verapamil hcl sr cp24 360mg . . . . . . . 32verapamil hcl tabs 40mg . . . . . . . . . . . 32verapamil hcl tabs 120mg, 80mg . . . 32VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 24VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 20VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 39V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 48V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 48VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 38vicodin es tabs 300mg; 7.5mg . . . . . . . 9vicodin hp tabs 300mg; 10mg . . . . . . . 9vicodin tabs 300mg; 5mg . . . . . . . . . . . . 9VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 28VIDEX EC CPDR 125MG . . . . . . . . . . 25VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 25vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 14VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 12VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 16VIIBRYD STARTER PACK . . . . . . . . . 16VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 14VIMPAT ORAL SOLN . . . . . . . . . . . . . 14VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 14vinblastine sulfate . . . . . . . . . . . . . . . . . 20vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 20vincristine sulfate . . . . . . . . . . . . . . . . . . 20vinorelbine tartrate inj 50mg/5ml . . . . 20viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43VIRACEPT TABS 250MG . . . . . . . . . . 26VIRACEPT TABS 625MG . . . . . . . . . . 26VIRAMUNE SUSP . . . . . . . . . . . . . . . . 25VIREAD POWD . . . . . . . . . . . . . . . . . . . 25VIREAD TABS . . . . . . . . . . . . . . . . . . . . 25voriconazole inj . . . . . . . . . . . . . . . . . . . 17voriconazole susr . . . . . . . . . . . . . . . . . 17voriconazole tabs . . . . . . . . . . . . . . . . . 17

valganciclovir hydrochlorde . . . . . . . . 24valproate sodium . . . . . . . . . . . . . . . . . . 14valproic acid . . . . . . . . . . . . . . . . . . . . . . . 14valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 30valsartan/hydrochlorothiazide . . . . . . 30vancomycin . . . . . . . . . . . . . . . . . . . . . . . 10vancomycin hcl caps 125mg . . . . . . . 10vancomycin hcl caps 250mg . . . . . . . 10vancomycin hcl in dextrose . . . . . . . . . 10vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg . . . . . . . . . 10VANCOMYCIN HYDROCHLORIDE INJ 250MG . . . . 10vancomycin hydrochloride/ sodium chloride inj 0.9%; 750mg/150ml . . . . . . . . . . . . . . . . . . . . . 10vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 11VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 46VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 46VASCEPA CAPS 0.5GM . . . . . . . . . . . 33VASCEPA CAPS 1GM . . . . . . . . . . . . . 33VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 46VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 22VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 20velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 38VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 38VENCLEXTA STARTING PACK . . . . 20VENCLEXTA TABS 10MG . . . . . . . . . 20VENCLEXTA TABS 50MG . . . . . . . . . 20VENCLEXTA TABS 100MG . . . . . . . . 20venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 16venlafaxine hcl er cp24 37.5mg . . . . . 16venlafaxine hcl er cp24 75mg . . . . . . 16venlafaxine hcl er cp24 150mg . . . . . 16VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 50VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 50verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 32

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Covered Drugs Index

zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 43ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 26ZUBSOLV SUBL 0.7MG; 0.18MG . . . 9ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . . 9ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 35ZYCLARA PUMP CREA 2.5% . . . . . . 35ZYCLARA PUMP CREA 3.75% . . . . . 35ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 21ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 21ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ZYTIGA TABS 250MG . . . . . . . . . . . . . 18ZYTIGA TABS 500MG . . . . . . . . . . . . . 18

YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 18YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 18yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 49zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 50ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 21ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 18ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 39zebutal caps 325mg; 50mg; 40mg . . . 7ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 20ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 21ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 50zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 35zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 43ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 39ZERIT ORAL SOLN . . . . . . . . . . . . . . . 25ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZIAGEN ORAL SOLN . . . . . . . . . . . . . 25zidovudine caps . . . . . . . . . . . . . . . . . . 25zidovudine syrp . . . . . . . . . . . . . . . . . . . 25zidovudine tabs . . . . . . . . . . . . . . . . . . . 25ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 48ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 24ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 24zoledronic acid inj 4mg/5ml . . . . . . . . 47zoledronic acid inj 5mg/100ml . . . . . . 47ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 20zolpidem tartrate tabs . . . . . . . . . . . . . 50zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 13ZORTRESS TABS 0.5MG . . . . . . . . . . 46ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 46ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 46ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 12

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Notes

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-668-3813 (TTY 711), 7 days a week, 8 a.m. - 8 p.m. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711). 注意：如果您使用繁體/中文，您可以免費獲得語言援助服務請致電 1-800-668-3813 (TTY 711). Cigna-HealthSpring complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna-HealthSpring cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna

1-800-668-3813 (TTY 711) October 1 – February 14, 8 a.m. – 8 p.m. local time, 7 days a week. From February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m. local time, Saturday, 8 a.m. – 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

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2018 Cigna-HealthSpring COMPREHENSIVE DRUG …...the drugs covered by Cigna-HealthSpring, please...

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